A midwife crisis - Macleans.ca

A midwife crisis

Not enough doctors, not enough midwives: it’s a bad time to have a baby in Canada

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A midwife crisis

Joanne Jacyk, a 31-year-old Toronto-based environmental engineer, was all of five weeks pregnant with her first child when she picked up the phone to call a midwife—only to find that she was too late. “They were already full for my due date,” she says. “I thought, ‘I just got my blood test!’ I basically called as fast as I could.” Anxious, Jacyk got online, found a list of every midwifery clinic in the Greater Toronto Area, and phoned them all. “When I started getting calls back saying, ‘We can’t take you,’ I got really upset,” she says. “I didn’t realize how badly I wanted a midwife until I thought the option wasn’t there.”

There’s a joke circulating among the new-mommy set in Ontario, one of seven provinces where midwifery services are now or will soon be publicly funded: if you think you might be pregnant, first you call the midwife, then you pee on the stick. Jacyk, now the mother of a healthy three-month-old boy, was one of the lucky ones. Eventually, persistence and fortuitous planetary alignment landed her a placement. But last year in Ontario, 40 per cent of pregnant women who sought out midwifery care—roughly 6,000 of them—were turned away. Demand has so outstripped supply that in some parts of the province, finding a midwife is harder than securing the kid a spot in a decent daycare.

For many people, the word “midwife” still evokes patchouli incense and homemade yogourt. But midwives’ growing popularity, fuelled almost entirely by word of mouth, reflects the mainstream’s rapidly changing perception of their profession. “We generally have waiting lists every month,” says Andrea Lennox, a registered practitioner at Kensington Midwives in Toronto and vice-president of the College of Midwives of Ontario.

Because there are only 400 registered midwives to serve the entire province, savvy mothers-to-be have taken to “strategizing” to secure a coveted spot, says Raquel Parra, the clinic’s office administrator. For instance, if they don’t live within the clinic’s catchment area, they’ll lie about their address. They’ll lie about their intention to have a home birth (which well-informed women know places them higher up on the waiting list). And from time to time, they’ll fudge their due dates. “There are months in the year that you’re more likely to get a midwife,” says Parra. “December is really difficult because of the holidays. They know this so they’ll call me and give me a date several weeks earlier, and we’ll find out later when they do an ultrasound.” For midwives themselves, the impossibility of helping everyone who wants help can be stressful. “I know some midwives, when they’re going to parties, they lie and say they do something else for a living,” says Lennox, “because they just get bombarded.”

More than anything, midwife-mania is the product of deeply rooted problems within the larger maternity care system. With each passing year, the shortage of maternity care providers in Canada is becoming more pronounced. According to the Society of Obstetricians and Gynaecologists of Canada, there are currently only 1,650 OB/GYNs practising in this country, an estimated 500 of whom have shifted their practices away from deliveries, choosing instead to focus on gynecology, fertility and family planning. Moreover, roughly 34 per cent of the OB/GYNs now working are set to retire in the next five years.

At the same time, fewer family physicians are delivering babies—13 per cent in 2004, down from 36 per cent in 1990. In five years, reports estimate that up to 10,000 women in Ontario alone will not find access to a maternity care provider of any kind—not a midwife, not a physician, not anyone, until the day they find themselves doubled over with contractions in an emergency ward.

Compared with what is currently available in traditional medicine, midwifery is felt by many to be infinitely more personal. Instead of five-minute appointments with an obstetrician, clients get roughly 45 minutes with their midwife during each visit. Midwives have a policy of placing mothers-to-be at the heart of the decision-making process. They care for their clients through the entire labour process, and after the birth make home visits for the first 10 days to help families adjust to nursing and life with an infant.

In part, midwives say the surge in demand is a rejection of the “too-posh-to-push” school of maternity, whereby childbirth can be pencilled in like a reiki appointment—and tied to a broader social trend toward pared-down, natural living. Women who seek out the service are generally those with low-risk pregnancies who are looking for a de-medicalized experience—whether via a natural birth (midwives can’t administer epidurals, for instance) or, increasingly, a home birth—though midwifery offers, in many cases, the best of both worlds: approximately 75 per cent of midwife-assisted births in Ontario take place in a hospital so that, in case of an emergency, care can be swiftly transferred to an MD.

This emphasis on one-on-one care is something that Canada’s wildly overburdened obstetricians are simply unable to provide. Already they have an unusually demanding lifestyle. “Time-wise, they have to be on call on weekends and at night,” says Dr. André Lalonde, executive vice-president of the society, “whereas in family medicine they have fewer emergencies.” Moreover, in the last five years, he says, the society has witnessed a “feminization” of the specialty. “Now 80 to 85 per cent of new graduates in obstetrics are women,” he says, “and, rightly so, they want to have children of their own and family life, so they’re not going to do 250 to 300 deliveries a year. We have some people doing 450 or 500 deliveries a year. That’s not going to happen. They want to work reasonable hours.”

It doesn’t help that the governing body for OB/GYNs is having trouble attracting young medical students to the specialty. The hours aside, one deterrent to practising obstetrics is an emerging fear of litigation. It is said that the record number of women undergoing Caesarean sections (one in four) is due in part to a belief among doctors that the procedure is safer, and less apt to result in a lawsuit, than a potentially complicated vaginal birth. “The liability piece is big,” says Bridget Lynch, a Toronto-based midwife and president of the International Confederation of Midwives. “The self-protection that goes on in terms of not only do I not want to be sued, but I don’t want the personal grief that accompanies a loss for one of my patients.”

Another deterrent is the pay, which is deemed inadequate compared with other, less taxing specialties. If a patient goes into labour in the middle of the day, an obstetrician has to cancel all of her appointments, and lose those billings. Meanwhile, the amount she can bill for the delivery is fixed, no matter how long or complicated the labour. “There is better payment now at night—30 per cent more after midnight, 40 per cent in some places,” says Lalonde, “but that has been slow in coming.” Compared with the billings a physician can rack up in a walk-in clinic, where she might see dozens of people a day, it’s not a great deal. “You may only deliver one woman in a whole night,” he says, “but you’re going to be a lot more stressed than someone seeing all these people with a common cold or earaches.”

With obstetricians spread so thin, and midwives eager for greater representation, one might think they’d be eager to help each other out. First, however, they need to overcome what remains of a long-standing culture clash. Traditionally, midwives and medical doctors have looked at each other with suspicion: midwives are critical of the medicalization of childbirth, while the medical community has been dismissive of midwives’ touchy-feely approach and perceived lack of expertise.

In some communities, doctors are still reluctant to grant them hospital privileges, which would give them the right to practise alongside medical doctors. In Squamish, B.C., says Lehe Elahar, a Vancouver-based practitioner, midwives have been working for years, with support from the public and local health authorities, to get privileges at the hospital, to no avail. “The hospital is putting obstacles in place and we really can only assume that it’s for political reasons,” she says. “There are women that are travelling perilous journeys, driving through the mountains to get to Vancouver to get care, when really they should be getting care in their communities.” As recently as 10 years ago, Lalonde says, obstetricians didn’t see the need for midwives. “Physicians were doing more deliveries,” he says. “Now, faced with an inhuman workload, they’re saying we need to find a solution.”

That solution, he says, is the implementation of the SOGC’s “National Birthing Strategy,” a plan that demands that doctors, nurses and midwives learn to play well together, and ideally work in collectives, to create sustainable models of care over the next five years. “In rural regions especially, you need a team approach to care,” says Lalonde.

The plan would cost Health Canada $43.5 million, but Lalonde says the consequences of not rethinking maternity care in this country are very real. Already our maternity safety record is slipping. In 1990, according to the SOGC, Canada was ranked one of the safest places in the world to give birth. In 2006, data released by the Organisation for Economic Co-operation and Development showed that Canada’s rank had slipped to 21st with regard to infant mortality (compared to sixth in 1990), 14th in perinatal mortality rates (down from 12th), and 11th in maternal morbidity (down from second).

At the same time, there are more high-risk pregnancies than ever. “We have a lot more complex medical conditions,” says Lalonde. “Women are older having their babies. There’s more obesity. Multiple births are on the rise—some of which is related to IVF.” A 2006 study found that a stunning 75 per cent of all births in Canada involve some form of medical intervention—ranging from epidurals to induction to C-sections—contravening healthy standards set by the World Health Organization.

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.”