A midwife crisis

Midwives, in fact, are desperately needed to help carry the load by facilitating as many low-risk pregnancies as possible, to help create a more efficient system. Advocates point out that among midwifery clients, about 25 per cent give birth at home, with no hospital stay or additional costs to the health care system. Those who do give birth in hospital usually stay on half as long as the average patient attended by an MD. “One of the stated huge advantages of midwifery care is that if everything is fine with mother and baby, they are discharged within three to six hours after their birth,” says Lynch. The subsequent home visits help keep them out of the emergency rooms.

Midwifery care is proven safe, too. According to the Canadian Institute of Health Information, those who use midwives are less likely to be hospitalized prenatally, to undergo a Caesarean, to give birth prematurely, to have labour induced and to have an episiotomy. Also, they are significantly more satisfied with the care they received. A 2007 study by Statistics Canada found that 71 per cent of women who used midwives described their experience as “very positive,” compared to only 53 per cent who gave birth with the help of an obstetrician, nurse or family doctor.

But with only 700 registered midwives in Canada, there aren’t nearly enough to make even a dent in the load of over 350,000 births a year. (By comparison, Britain employs 28,000, who attend over 70 per cent of all births.) Across the country, access to midwives remains spotty. This year, New Brunswick, Saskatchewan and, most recently, Alberta announced plans to introduce regulated, publicly funded midwifery services. In Quebec, the Ministry of Health and Social Services aims to have midwives delivering 10 per cent of the province’s babies in birthing centres by 2016. In Vancouver, midwives are just beginning to see waiting lists, although they’re not nearly as long as those in Toronto. “I think that supply and demand is sort of matched now,” says Elahar, who co-founded Pomegranate Midwives, a community-oriented clinic with yoga, massage and acupuncture services, in 2006. “But I do think that in the coming years the demand is going to be greater. We are walking into that.”

Unfortunately, right now, the profession is growing too slowly to avoid the crunch. For one thing, funding is only available for a small number of spots in the six midwifery education programs in universities across the country. Even if more spots were added, at the moment there aren’t enough placements to absorb more student practitioners.

Equally significant, each province caps the number of births a midwife can take on each year—usually somewhere around 40. Beyond that, midwives feel they can’t provide the quality of care and individual attention necessary. The SOGC wants to see the caps lifted. “They should be able to take more than 40 deliveries in a year,” says Lalonde. “The average right now for OB/GYN is over 250 deliveries per year because we don’t have the choice. If 20 women come into the hospital with no doctors, we still have to deliver them. Midwives in the U.S. and in Europe do about 120 deliveries a year. With 350,000 deliveries in Canada, it will take a lot of midwives at this rate. No wonder midwives have a waiting list.”

The ideal model, according to Lalonde, would involve a collective of four or five midwives—each delivering two to three times the number of babies the current caps allow for—and one obstetrician to back them up. This, he says, is an arrangement that might reasonably appeal to an OB/GYN offered a rural posting. “What we’re worried about,” says Lalonde, “is in five to 10 years [small and medium-sized] communities will not have an obstetrician within a reasonable distance to do a surgery, if the need arises. Then you’ll see maternal mortality go even higher. We have a very small window of opportunity.”

Across the country, initiatives designed to quickly and safely bolster the number of midwives are springing up—programs designed to speed up accreditation for internationally trained midwives, or offer advanced standing to nurses who want to transition into midwifery. “One thing our college is working on is increasing midwives’ scope of care,” says Elahar, “giving us more training so we can do things like, for example, a vacuum delivery. Especially for those in rural areas. It’s not great science, it’s just something that we need training for.”

Jacyk’s delivery, in a Toronto hospital, is a perfect example of the type of collaborative care Lalonde envisions. Her midwife was on hand through 16 hours of early labour and 11 hours of arduous active labour. When it became clear that complications had arisen, Jacyk’s care was transferred to an OB/GYN, who ultimately performed a C-section, with the midwife standing by to care for the baby when he arrived. “They were so willing to work around each other,” she says. “My hope was to have a natural birth, but having gone through all that, the care I got before and after was amazing. It was pretty seamless.”

Unfortunately, the resources to provide this sort of one-on-one care are available to almost no one. “Ninety-eight per cent of women have to deal with maybe one nurse part-time to follow you during labour and delivery,” says Lalonde. “We have to offer every woman the same level of care. We have to be careful we don’t create two groups of women, one with midwives and the rest can just take care of themselves.”