Desperately Seeking Midwife

WHY AREN'T THERE ENOUGH IN CANADA?

by Alex Roslin

TODAY'S PARENT

Spring 2009

Moiya Callahan’s first prenatal visit to the hospital didn’t go quite as she had imagined. A nurse and intern came into the room for a quick checkup, then the obstetrician dropped by “for literally a minute,” she says. “She came in, asked if I had any questions and left.” There was no time to build a relationship with the person who would bring her little one into this world. That’s not how she had thought it would happen.

Callahan, a music composer in Montreal, turned to the Internet, and that’s where she heard about midwives and their natural approach to pregnancy and childbirth. Still a little unclear on what that meant, she made an appointment. The experience was another eye-opener as she learned about midwives’ philosophy of birth as a healthy normal process that usually doesn’t require a doctor or even a hospital setting. “Your whole world changes. It’s a different perspective on pregnancy. I had never thought like that before.”

Opting for midwifery care

Callahan is part of a fast-growing trend of Canadian parents who are opting for midwifery care, as research shows they offer a safe, low-intervention alternative for the 80 to 90 percent of births that are considered low risk. But in much of Canada, parents are lucky to get in the door. While 24 percent of Quebec parents say they’d like to have their baby in a birthing centre or at home with a midwife, only 1.6 percent actually do. Two-thirds of moms who call for a spot with a midwife are turned away because of a lack of places. That’s largely because the province has just 90 practitioners, instead of the 500 that midwives estimate are needed to meet the demand.

That same story is being repeated across Canada. One of the last industrialized countries to officially recognize and regulate midwifery (beginning with Ontario in 1994), Canada is suddenly seeing a scramble to keep up with the exploding demand for midwives.

In Ontario, the province that leads the way in terms of the proportion of women giving birth with midwives (eight percent), demand is fast outstripping supply. A 2005 Ontario government study found that only 57 percent of women who wanted a midwife’s services in 2003/04 actually got to see one, compared to 80 percent in 1999/2000. According to a 2006 study, some 16,000 women seek a midwife each year, and 6,000 can’t get a spot. Last year, the Ontario government announced a $2.3 million plan to increase by 50 percent the number of enrolments for the four-year midwifery undergraduate program. The aim is to have an additional 1,200 women give birth with a midwife each year. But that will still mean 4,800 women will be out of luck.

While midwifery struggled for recognition as recently as the 1990s, health officials and doctors are quickly coming around, largely for the most pragmatic reason: Midwives can save the cash-strapped health system oodles of money because their natural delivery method costs about 30 percent less than the conventional hospital approach.

Officials also say midwives have a critical role to play in helping Canada’s health care system cope with a yawning lack of maternity care providers, a situation that’s reached crisis proportions and is poised to get a whole lot worse as boomer-aged doctors start to retire.

But despite this, midwifery still faces major obstacles in Canada. Don’t expect anything soon like New Zealand’s quick progress since it officially recognized midwifery in 1990; there, 78 percent of women today give birth with a midwife. In Canada, by contrast, midwives say that while many doctors and nurses support their profession, expansion is still happening at a glacial pace due to resistance from some in the medical community and inertia in the health care bureaucracy. Progress is also slow because of the same delays in turning out new graduates that the medical profession faces: a mishmash of differing approaches in each province and territory, and always tight health budgets.

The maternity case crisis

Callers to Corinne Leclercq’s medical clinic in Victoriaville, Que., got a stark awakening last summer about the crisis hitting the field of obstetrics and gynaecology. A phone message said the clinic had no spaces open for gynaecological exams for the following four months due to a shortage of doctors that would persist for nearly a year.

Gynaecologists’ offices have been inundated by a mini baby boom. Leclercq says a lack of maternity care doctors in the province has meant 20 unfilled hospital positions for OB/GYNs. “It will just get worse,” she says, noting that 30 to 40 percent of OB/GYNs in the province are aged 50 and up and will soon retire. In Ontario, the number of family doctors and obstetricians attending births has already dropped from 3,100 in 1984 to less than 1,300 in 2004. Across Canada, 36 percent of obstetricians and gynaecologists expect to retire within five years, according to a report from the Society of Obstetricians and Gynaecologists of Canada (SOGC). (Leclercq sits on the society’s board.)

These shortages are a key reason that Canada slipped from sixth to 21st place in national infant mortality rates between 1990 and 2002, and from second place to 11th for rates of maternal complications during labour, says the SOGC report.

“Midwives can help in part with this lack of professionals,” Leclercq said.

But Leclercq’s support comes with an important caveat: She thinks midwives should all work in hospitals and not deliver babies in homes or Quebec’s unique network of midwife-run birthing centres. “The risk is certainly higher at home or in birthing centres,” she said.

It’s a controversial argument that midwives vehemently reject, saying they’ve got not only a proven safety record, but also much lower rates of medical interventions than doctors.

In Wolfville, NS, midwife Louise McDonald is also turning clients away. She is one of just six midwives serving the entire province, where, like her counterparts in the other Atlantic provinces, the Yukon and Nunavut, midwives are not yet regulated by provincial law. This means their services aren’t covered by provincial health plans, and parents must pay $1,200 to $2,400 (McDonald uses a sliding scale depending on family income) for a full course of care at her clinic. It also means she has no malpractice insurance, rights to prescribe medications or hospital privileges, and risks being charged with practising medicine without a licence.

McDonald says midwifery in Atlantic Canada has progressed slowly because of squeezed health budgets — meaning no money for start-up costs for a midwifery program — and an erosion of awareness that most births can happen safely, without any need for medical interventions. “A lot of that is because of the lack of midwives. We can educate women on normal births. We are the specialists in normal births.”

Nova Scotia is now developing regulations to govern midwives and hopes to license and fund them by early 2009. New Brunswick has said it will also license and fund midwives this year. Maria Kuttner, former director of primary health care at the Nova Scotia Department of Health, says the use of midwives for normal birth will free up doctors to deal with cases involving complications. “It’s going to alleviate some of the wait times,” she says.

Kuttner agrees with McDonald that lack of awareness about midwifery in the medical community has contributed to the province’s slowness to license midwives. “They may not appreciate that midwives do more than deliver babies. They take care of families from the beginning of pregnancy,” she says.

The midwifery experience

In Alberta, where the province does regulate midwives, but their service isn’t included in the health plan, Heather Cook was willing to lay down the $3,000 fee to have her second baby in a natural, low-stress setting.

Cook, a Calgary writer, speaks in glowing terms about her experience. “I loved, loved, loved my midwife. I talk about her all the time. The care was so wonderful. I said afterward, ‘I want to do that again!’”

That’s not quite what she was saying after her previous baby was born. Prenatal appointments with her doctor had lasted less than 10 minutes. During labour, nurses did frequent manual checks on her progress that she says were quite uncomfortable. Nurses also advised her to start pushing before she was ready, which left her prematurely exhausted; then “the doctor popped in for the last 15 minutes,” she said.

With her midwife, by contrast, prenatal appointments lasted an hour or more; her midwife visited her at home before and after the birth; and during labour the two midwives who attended were reassuring and unobtrusive, checking her progress manually as little as possible. Cook said their confidence in her helped her trust her body and have a more comfortable labour.

She believes the contrast between the two experiences — both lasting the same nine hours — was the main reason for the large difference in her recovery time. “After my first child, it felt like I had been kicked in the crotch for an hour or two and I stayed in bed for 24 hours,” says Cook. “With my second birth, there was way less swelling and pain, and I was able to walk out of the hospital four hours after having my daughter.”

Leclercq acknowledges that OB/GYNs can’t give pregnant women the same attention as midwives because of vast differences in client loads. She has 200 to 225 maternity care clients per year, while midwives’ professional standards limit their patient load to 40. Leclercq also agrees that rates of medical interventions like C-sections are too high in hospitals, a trend she attributes in part to doctors not wanting to take chances due to the threat of lawsuits: “There are doctors who do too many C-sections.”

On the horizon

Back in Quebec, a radical expansion of midwifery is reportedly in the works at the provincial health ministry.

In June 2008, Minister of Health Philippe Couillard announced the creation, by 2014, of 13 new stand-alone birthing centres where midwives will be based, and a goal to have midwives delivering 10 percent of the province’s 80,000 annual births by 2018. That would mean a need for 2,000 midwives — more than 20 times the current number. Quebec midwives welcome the news. But like their counterparts across the country, they also worry that a fast expansion of midwifery in Canada will come with strings attached, like integration into the hospital system and having doctors train midwives. These are changes that midwives say would imperil their vision of birth as being, in most cases, a healthy normal event best left free of the risk-based approach of the medical model.

Also, despite the province’s support, midwives say that previous expansion plans have stalled due to resistance from a foot-dragging health bureaucracy, which wants control over the birthing centres, as well as from doctors fearing that midwives will take away their jobs. Case in point: In the Laurentians north of Montreal, advocates first proposed a regional birthing centre in 1992; the OK finally came two years ago, 15 years later — and only after the local mayor, who is married to a midwife, agreed to kick in city funds to build it. “The resistance coming from the medical community slowed the birthing centre for years,” said Céline Lemay, president of the Quebec Midwives Association.

For Moiya Callahan in Montreal, any expansion comes a little too late. Activists have lobbied for a birthing centre to serve the eastern and central part of the city, where she lives, for 10 years without much progress, and as she doesn’t have a vehicle, she had to rent cars or take the subway and bus to make her prenatal appointments at the West Island’s Maison de naissance Lac Saint-Louis — a 60 kilometre round trip. Still, the long treks didn’t stop her from having all three of her kids there. “I couldn’t imagine doing it any other way.”

Midwifery basics

Midwifery varies a little in each province and territory, but there are some common basics. Midwives believe moms with low-risk pregnancies can deliver with minimal medical intervention.

“Physicians and nurses are trained to look for illness in the body, whereas midwives tend to look at pregnancy and childbirth as a healthy process,” says Gisela Becker, a practitioner in Fort Smith, NT, who has a master’s degree in midwifery and is vice-president of the Canadian Association of Midwives.

A midwife will usually follow her client through pregnancy, labour, birth and for six weeks postpartum. “When women have one-on-one care, research shows there are better outcomes,” Becker says.

While she takes pains to point out that many doctors and nurses also provide excellent maternity care, Becker says that because midwives offer continuity of care by a single provider and spend more time with clients, they often have more chance to build trust, ease fears about birth and help women go into labour with more self-confidence. “Ninety percent of what we do is preventive care, and if we do that well, hardly any interventions will occur,” she explains.

Prenatal visits usually take place in a clinic or birthing centre and often last an hour or more, while births may happen in hospital or at home. In Quebec, clients deliver in a midwife-led birthing centre.

Looking for a midwife? Most of the provinces and territories have an association of midwives that can give you a referral. A starting place to learn more is the website of the Canadian Association of Midwives: canadianmidwives.org.

Midwifery safe, inexpensive

The research is clear: Midwife-assisted births are safe, lead to fewer medical interventions, such as Caesarean section and episiotomy, and cost less than births with a doctor.

A 2004 study by Quebec midwife Sinclair Harris, of 8,429 midwife-assisted births in birthing centres, found a perinatal mortality rate of 4.7 per 1,000 births from 1995 to 2002, compared to a Quebec average of 6.7 for low-risk deliveries in 1998.

A 2005 study led by Kenneth Johnson, an epidemiologist with the Public Health Agency of Canada, found dramatically lower rates of medical interventions among 5,418 midwife-assisted home births in Canada and the US, as compared to the same type of low-risk births in hospital. Interventions were less frequent for:

• episiotomy (2.1% vs. 33%)
• Caesarean section (3.7% vs. 19%)
• electronic fetal monitoring (9.6% vs. 84.3%)
• vacuum extraction (0.6% vs. 5.5%)

A 1997 study of midwifery for the Quebec government found midwife-assisted clients in the province had fewer premature babies than low-risk-pregnancy moms followed by doctors (2.9% vs. 5.7%) and a lower hospitalization rate during pregnancy (3.3% vs. 10.3%). The study also found midwife-assisted birth in hospital costs less than conventional birth in hospital ($2,062 vs. $3,016).

A 2002 Quebec government report found that 98% of midwife-assisted clients breastfed at birth compared to a provincial average of 72%.

Centres of Controversy: Hospitals Vs. Midwives

There are only two birthing centres in Montreal, which must turn away many eager parents. Midwives say resistance from the medical community is hindering their practice from growing in Quebec.

by ALEX ROSLIN

Special to The Gazette
The Montreal Gazette
Saturday, September 29, 2007

There’s a fine line between relaxed and sleepy, and Renelde Napoli strikes it perfectly. She is in her seventh month of pregnancy and a little tired out, but still in good spirits as she juggles caring for first-born Olivia, 4, and preparing to exhibit her jewellery at an upcoming art show.

She hopes to have her baby at the CLSC Lac St. Louis Birthing Centre in Pointe Claire with the help of midwives. While many expecting parents opt for hospitals because they feel safer there, Napoli feels the opposite.

“The birthing centre feels like a more comfortable and safer environment. It feels more like home—not threatening, with machines everywhere.”

Napoli has experienced both settings. She had planned to give birth to Olivia in the Pointe Claire birthing centre, but her first baby arrived just days too early—36 weeks into her pregnancy.

The cutoff for births there at the time was 36 weeks, five days. (It has since been reduced to 34 weeks.) So Olivia was born at the LaSalle General Hospital with the assistance of Napoli’s midwife.

Napoli said the hospital’s staff were “really nice,” but that she far prefers the extra care and natural philosophy of a midwife. So when it came time for baby No. 2, she immediately signed up again at Pointe Claire despite the fact she doesn’t have a car and needs to borrow or rent wheels to make the 30-minute trip from her Plateau home.

“The birthing centre seems so much more natural,” Napoli said. “I love that they take time to talk to you. Each appointment is an hour, and if it’s longer, it’s no big deal.”

Napoli is part of a growing movement of Quebec parents seeking an alternative to the hospital birthing experience.

Waiting lists at Montreal’s two birthing centres (the second is in Côte des Neiges) are long, with only 30 per cent of expecting parents able to get a spot. Parents who don’t sign up within a few weeks of becoming pregnant probably won’t get a spot.

A 2005 poll for Quebec’s Health Ministry found 15 per cent of Quebec women would like to give birth at a birthing centre, while another nine per cent would like to do so at home with the help of a midwife.

Yet only about 1.5 per cent of the province’s 80,000 annual births are currently assisted by midwives. The reason: Quebec has only 90 midwives working at eight birthing centres, well short of the 500 practitioners and 40 birthing centres that midwives say are needed to meet the demand.

Advocates say birthing centres are more natural for the 80- to 90 per cent of pregnancies that are low-risk and don’t require medical intervention, and that they can ease the burden on Quebec’s overworked obstetricians, who typically have a caseload of 200 to 300 births per year, compared with 80 for each team of two midwives.

Yet plans to expand the number of birthing centres in the province have stalled. A new birthing centre scheduled to open next year in the Laurentians got off the ground only after 14 years of campaigning by community groups and funding from the city of Blainville to construct the building.

In Montreal, midwives and community groups have campaigned for 10 years to create a birthing centre in the Plateau. With the Health Ministry refusing to finance a third birthing centre on the island, the local health board that includes the Plateau said it is hiring four midwives this fall to work out of the Ste. Justine Hospital.

Activists are negotiating with a private foundation to finance the construction of a building in the Plateau that they hope the Health Ministry would rent for use as a birthing centre.

Such a centre nearby would have come in handy for Moiya Callahan, a Mile End resident expecting her third baby in April. Like Napoli, she must rent a vehicle to attend prenatal appointments with her midwife at the Pointe Claire birthing centre, where she had her first two kids. Because of the distance, she is considering a home birth the third time around.

When Callahan learned she was pregnant with her first son, she went to a hospital for her first prenatal checkup, but said quickly got turned off. “I saw the doctor for about three minutes. It was not a very nurturing environment.”

She learned about midwives on the Internet and was won over by their philosophy of natural childbirth and self-empowerment. “You can spend an hour with them at appointments. Then, you really have that trust. Having that trust in them makes you trust yourself more.”

***

So why the delay in creating new birthing centres? A big part of the reason, midwives say, is resistance from the medical community in a country that was one of the last in the industrial world in which authorities started to legalize midwifery.

Quebec let some midwives practice in a pilot project starting in 1995, but midwifery was legalized only in 1999, while midwife-assisted home births were allowed just in 2005. Midwifery remains illegal in Newfoundland and Labrador, New Brunswick, Prince Edward Island and Yukon and the Northwest Territories.

Indeed, if gynecologist Corinne Leclerc has her way, parents like Napoli and Callahan won’t be able to give birth outside hospitals. Leclerc heads a committee on midwifery issues at the Quebec Association of Obstetricians and Gynecologists.

“We are firmly against birthing centres and homebirths because of the security of the newborn and mother. We would like to work with (midwives), but in hospitals,” she said.

As an example of what can go wrong, Leclerc cited the case of a stillborn baby in a Montreal home birth attended by two midwives in Nov. 2006.

Quebec coroner Paul Dionne issued a report in August saying the death was preventable. He recommended the Quebec Order of Midwives, the professional body that regulates midwifery, change a number of its practices.

Midwives called the death tragic, but several said the coroner’s report was biased against midwives and has fostered misconceptions about the safety of their work.

“I thought the coroner was biased, not having done his homework,” said Gisela Becker, vice-president of the Canadian Association of Midwives.

“Many places in Canada and the world have demonstrated that home births are safe. When a death happens in a hospital, you hardly ever hear about the details.”

Sinclair Harris did a wide-ranging examination of Quebec birthing centre data as part of a study she presented at an international midwifery conference in 2004. Harris is a clinical instructor of midwife students who has worked for 14 years as a midwife in Quebec and Britain and 20 years as an obstetrical nurse in the high-risk-delivery room at the Royal Victoria Hospital.

Harris compared data on all 8,400 midwife-assisted births in Quebec between 1995 and 2002 and publicly available figures on 76,000 hospital births.

The number of perinatal deaths (those in which the fetus dies in the latter months of pregnancy, is stillborn or dies in the first weeks of birth) was 57-per-cent higher in hospital births, according to the data.

Harris cautioned the lower rate of interventions in birthing centres is partly because they accept only mothers with low-risk pregnancies. But, she said, the figures show midwifery is safe.

Harris criticized Dionne’s report, saying it suggests a lack of knowledge about midwifery protocol. “His recommendations are reasonable, but most are already in place,” she said.

For example, Dionne recommended that midwives get regular skills retraining and create guidelines to measure a labour’s progress and what to do in emergencies. Harris said retraining is already done and the guidelines already exist.

Another recommendation in the report falls into “grey zone,” she said—that midwives should transfer the mother to a hospital if they spot the presence of baby stool, known as meconium, in the amniotic fluid. In the case of the stillborn baby, Dionne said the fetus died as a result of swallowing meconium. The attending midwives later told police investigating the incident they had noticed some light meconium when they ruptured the mother’s water during labour on the night of Nov. 21, 2006.

Harris said the presence of meconium doesn’t necessarily mean the fetus is in danger and is not in itself a reason for a hospital transfer if the fetus is showing no other signs of distress.

Leclerc, the gynecologist, agreed meconium isn’t by itself normally considered a reason for a hospital transfer.

“Probably if the baby wasn’t suffering, the doctor would have said (to the midwives) it’s okay to continue what they’re doing,” she said.

Indeed, the Quebec Midwives Act requires only that midwives do a phone consultation with a doctor if “thick or unusual” meconium is noticed.

In the case of the stillborn baby, his heartbeat remained healthy for more than four hours after the discovery of meconium, slowing only during the final stages of pushing. The coroner’s report said the baby probably died about 15 minutes before it was born at 8:21 a.m.

Harris also criticized Dionne for failing to include a key fact in the two-page summary of his report published on the coroner’s website. The complete 10-page report, which the coroner’s office provided by email, notes an indirect cause of the fetus’ death was that it had a severely underdeveloped brain, which had a gestational age of only 23 to 25 weeks.

“The baby would have been completely incompetent neurologically and would probably have died within a few weeks (of birth),” Dionne told The Gazette this week.

But he said that doesn’t change his opinion that the midwives made mistakes. For example, he said, they should have called 911 immediately when pushing seemed to have stalled.

He also stood by his recommendation that a mother should be immediately transferred to a hospital if any meconium is detected. When told Leclerc’s differing opinion, he said: “I don’t give a damn. There should be an automatic transfer, period.”

As for the midwives’ criticism that he was biased and that his recommendations are already part of midwifery protocol, he said: “It’s not my business to answer them. Yes, I did some recommendations (for practices) I knew they were already doing. But it’s on paper, and their members didn’t do it. They were lax.”

The mother of the stillborn baby refused to comment: “We’re trying to turn the page.”

The Quebec health ministry, for its part, doesn’t plan to change rules governing midwives, and is leaving any reforms up to the Quebec Order of Midwives, which is studying Dionne’s report.

Back in the Plateau, Napoli said the death was “absolutely awful,” but that she believes midwifery has been unfairly maligned in the outcry over the case. “What about all the babies who die in the hospital? Doctors make mistakes, too.”

Midwifery Facts

Midwife-assisted births that involve a Caesarean: 6.2%

Hospital births that involve a Caeserean: 18.5%

Midwife-assisted births that involve an episiotomy (a cut to widen vagina to help baby emerge): 1.9%

Hospital births that involve an episiotomy: 30%

Perinatal deaths per 1,000 among midwife-assisted births: 4.7

Perinatal deaths per 1,000 among hospital births: 7.4

Fetal deaths per 1,000 among midwife-assisted births: 4.2

Fetal deaths per 1,000 among hospital births: 4.3

Cost of a midwife-assisted birth in 1997: $2,062

Cost of a hospital birth: $3,016

Percent of midwifery clients requiring hospitalization during pregnancy: 3.3

Percent among hospital clients: 10.3

Percent of midwifery clients who breastfeed at birth: 98

Quebec average for breastfeeding at birth: 72 percent

Sources: Public Health Agency of Canada, Evaluation Study of Quebec Birthing Centre Pilot Projects, Institut de la statistique du Québec, Quebec College of Physicians, Quebec Order of Midwives, Quebec Association of Midwives

For More Information

World Health Organization midwifery webpage
International Confederation of Midwives
American College of Nurse-Midwives
Canadian Association of Midwives
Regroupement Naissance-Renaissance (Quebec-based, French language)
Groupe Maman (Quebec-based, English & French)
La Leche League
Hypnobirthing.com: an alternative approach to pregnancy and birth