The Destruction of Canadian Midwifery during the 20th Century
Throughout most of the 20th century, Canada was the only western industrialized country with no legal provisions for the practice and the profession of midwifery. Prior to the Second World War, many births were attended by lay midwives; Canada’s indigenous peoples had a strong tradition of midwifery and there were thousands of trained midwives from other countries living in Canada. Nonetheless, Canada and the United States developed a medical monopoly of childbirth early in the century which was enforced fiercely. In both countries, midwives were discussed by the medical profession, government and media as “the midwife problem”, and endured the non-recognition of their profession, humiliation, harassment, legal action, and imprisonment. In the United States, certified nurse midwives were permitted to practice in very limited settings, serving about 4% of the population throughout this century. In Canada, the profession and practice of midwifery was eliminated as medicine claimed sole professional rights to provide primary maternity care.
The only exception to this was a small number of trained (usually British) midwives employed by the government as nurses in remote nursing stations in parts of Canada where physicians did not wish to practice. In the rest of Canada, to practice as a midwife until the 1990’s has meant to risk legal action such as the charge of practicing medicine without a licence, criminal negligence charges, and the quasi-legal process of inquests.
The Childbirth Movement Helps Midwifery to Re-Emerge in Canada
In the 1970’s and 1980’s, the social activism of the Canadian and international childbirth movements defined a period of public dissatisfaction with increasing intervention in childbirth. This activism in Canada protested the lack of respect and lack of choices for women, and the impersonalized, sometimes degrading care by physicians and obstetric nurses.
In Canada, the childbirth movement has been a coalition of grass roots women’s organizations and individuals seeking change. Although these have had differing backgrounds, they have shared the view that birth is an event with great social meaning and that the interventions of medicine should be used judiciously. They defined goals for improving maternity care for women and their babies, promoting women centered care, normal or “natural” birth, access to midwives and choices in birthplace and services. This social movement has often been intertwined with midwifery. Against considerable odds, in many Canadian provinces its work has been successful, creating legislative changes, influencing liberalizing changes in hospital policies, promoting information and support for childbearing women, choice of birth place, choice of care giver, and specifically bringing back the profession of midwifery.
Despite the risks of practicing midwifery prior to legislation, some women felt drawn to offer women choices and to provide care which honoured normal birth. By the late 1970’s, women and their families were showing a new willingness to take childbirth back into their own hands. They wanted midwives to assist them at home or to advocate for them in hospital. Some midwives were formally trained as midwives or nurses, while some created their own apprenticeship educations, supported by a few radical physicians, other midwives, the women they cared for, and support from the international midwifery community. They formed organizations to promote legalization and education for midwives. In Canada, the number of known practicing midwives increased from approximately 50 in 1980 to approximately 150 in 1990. By the time midwifery was legalized in Ontario, 1% of all births were attended by midwives, half of these in the home setting.
Legal Recognition for Canadian Midwives
During the 1990’s, with considerable struggle ongoing in some parts of Canada, midwifery has been recognized legally as part of the health care system, in five of the ten Canadian provinces: Ontario, Alberta, British Columbia, Quebec and Manitoba. Public funding has been provided in all of these provinces except Alberta, and a 4 year baccalaureate midwifery education program has operated in Ontario since 1993; a similar program is planned for British Columbia in 2001. Canadian midwifery has been defined as an autonomous profession, clearly separate from the profession of nursing in education, administration and care provision. The 1990’s were a decade of rapid change in the state of midwifery in many Canadian provinces. Ontario, in its eighth year of integration into the health care system has the longest experience of legislated midwifery and provides a window into the progress of Canadian midwifery.
Assessing the Progress of Canadian Midwifery
In Ontario, the population of 65 midwives registered in 1994 has grown to 220 in the year 2000, and is increasing at approximately 30 per year. The demand for midwifery services continues in most settings to be greater than the supply. Midwives now care for 4% of the birthing population, and expect to be accessible to 10% of Ontario’s childbearing women in another 4 years. Now is an appropriate time to review the founding principles of Canadian midwifery in this province and assess whether midwives have been successful in responding to the concerns of the childbirth movement, and specifically, in normalizing birth. Canadian midwifery care principles are summarized by the following 6 practices: facilitating informed choice, enabling choice of birthplace, spending adequate time with the woman, maintaining continuity of care with a small group of known caregivers, developing a personalized, egalitarian relationship with the woman, appropriate use of technology.
The Philosophy of Midwifery Care
The College of Midwives of Ontario (regulatory body) has since 1992 defined the philosophy of midwifery in the following statements:
Midwifery care is based on a respect for pregnancy as a state of health and childbirth as a normal physiologic process.
It respects the diversity of women’s needs and the variety of personal and cultural meanings which women, families and communities bring to the pregnancy, birth and early parenting experience.
The maintenance and promotion of health throughout the childbearing cycle are central.
Midwives focus on preventive care and the appropriate use of technology.
Care is continuous, personalized and non-authoritarian. It responds to a woman’s social, emotional and cultural as well as physical needs.
Midwives respect the woman’s right to choice of caregiver and place of birth in accordance with the Standards of Practice of the College of Midwives.
They are willing to attend births in a variety of settings, including birth at home.
They encourage the woman to actively participate in her care throughout pregnancy, birth and the postpartum period and to make choices about the manner in which her care is provided.
Midwifery care includes education and counselling, enabling a woman to make informed choices.
Midwives promote decision making as a shared responsibility between the woman, her family and her caregivers. The mother is recognized as the primary decision-maker.
Fundamental to midwifery care is the understanding that a woman’s caregivers respect and support her so that she may give birth safely, with power and dignity.
Has Midwifery Helped to Normalize Birth in the Health Care System?
With the legal recognition of midwifery in 1994, the profession of midwifery in Ontario promised to protect the model of practice and improve accessibility to women through public funding. The model of practice was carefully developed to embody the central values of midwifery and the childbirth movement of the 1980’s. The experience of witnessing fragmented midwifery models and the loss of protection for key vulnerable practices and values in many international jurisdictions led midwifery to take great care in defining the details of how midwives in Ontario are allowed to practice. The midwifery principles, models and approaches to enacting them are very similar, though not identical, in the other Canadian provinces where legislated midwifery has developed more recently.
There is currently only one sanctioned model of midwifery practice in Ontario, and it is defined in detail by regulatory documents and strictly put into regulated practice. Probably more than in any other jurisdiction in the world, Ontario midwives are required to enact value themes and guiding principles by providing care in clearly defined and regulated modes of practice. Part of what makes the Ontario experience interesting for observers is that a group of practitioners decided to limit their professional freedom in order to enact a model of care which was both desirable to women and vulnerable in terms of surviving the rigours of health care system organization.
There is now increasing evidence to support midwifery’s contribution to normalizing birth in Canada, and to providing care which is personalized and responsive to women and their families.
If we begin with medical interventions at the time of birth, the following data (widely available in hospital, government and professional organization reports) is instructive:
Quality of care, health promotion, and adherence to model of practice principles can be assessed in part by examining the following data:
Breastfeeding at 6 weeks:
Challenges for the New Canadian Midwifery
Overall, the re-emergence of midwifery in Canada has been successful in terms of providing the choice of less interventive, more personalized care to women. However, there are challenges to be noted:
The small population size of the midwifery profession and the women they care for make it difficult for health policy analysts to make clear conclusions about the comparative value of midwifery care. It will be important for midwifery to expand considerably before the real implications of midwifery care for the larger population of Canadian women can be determined. It is still possible that many midwifery clients are self selected for aspects of midwifery services and don’t reflect the general population.
All midwifery-physician comparative data needs to be examined in the context of midwives being mandated to care for women with low risk pregnancies. We do not yet have carefully matched population cohorts to provide the most meaningful comparisons.
The emergence of evidence-based practice as critical in the 1990’s has meant that midwives, like physicians have accepted research as an important guide for practice. Sometimes, available research has supported less intervention, and sometimes more, with effects on midwifery practice.(i.e. fewer episiotomies supported by research, vaginal breech birth and expectant management at 42 weeks not supported by research)
The values of childbearing women in Canada, and their desires for different kinds of care provision are evolving. Midwifery is firmly rooted in the childbirth movement values of the 1980’s. To date, that has been a strength rather than a weakness, and demand for services reflects this. However, the trend for women to selectively choose parts of “the midwifery package” and reject others can pose challenges to midwifery which is also rooted in the value theme expressed as: “Follow the woman.”
Finally, the Ontario midwifery model can be demanding over time on practitioners, if not enough attention is paid to creative ways for midwives to control their on-call hours, and support them in their workplaces. It will be important to monitor the concerns of midwives re: quality of life and be responsive, as the midwifery profession is only as viable as its midwives.
In conclusion, the re-emergence of midwifery, against considerable odds, and the acheivements of midwives working together with women to improve childbirth care in Canada have been inspirational, and a great triumph for those who value normalizing and honouring birth.
Now, however, the present moment is historically new, and a new phase of integration into the health care system and responding to a new group of women is taking place. Social childbirth values, and practices in both medicine and midwifery are changing. Midwifery in Ontario has been very successful, and will need to be responsive and able to evolve, keeping the childbearing woman at the center, to maintain that success.