The Decibel - Maternity care and midwives in Canada’s health labour shortage

Episode Date: June 12, 2024

Hospitals across Canada have long been overwhelmed by patient demand and staff shortages. But another category of medical experts, specializing in childbirth and pregnancy care, has been growing to lift the weight – midwives. In 2021, midwives oversaw more than 48,000 live births. So why aren’t they recognized as other health professionals are?Carly Weeks, the Globe’s former health reporter joins the show to explain why midwives could be a vital answer to Canada’s health care labour shortage.Questions? Comments? Ideas? Email us at [e-mail]

The profession of midwifery is very old. It can be traced back thousands of years. But in Canada, less than a quarter of births are supported by midwives. And until recent decades, midwifery was separate from, and often had a tense relationship with the mainstream medical field. As the country faces a crisis in health care, many midwives are saying they can help alleviate some of that pressure in the system. Carly Weeks is The Globe's health reporter. Today, she explains the role midwives could play in Canada's health care and why many say they're not being fully utilized by our current system.

I'm Maina Karaman-Wilms, and this is The Decibel from The Globe and Mail. Carly, thank you so much for being here. Of course. I think we should really just start with basics here. What is a midwife? I mean, really, in essence, a midwife is a regulated health professional who oversees the period sort of before, during, and after pregnancy. So they're sort of like your primary care provider covering all things prenatal,

pregnancy, birth, and beyond. You know, in some ways we kind of think of midwives in some sense, and we hearken back to this era of, you know, sort of women helping other women give birth. We're really speaking about a very highly regulated, licensed health professional regulated in similar ways as nurses, even physicians. So midwives have to go to school. They have a lot of strict criteria they have to meet in order to be licensed to practice in Canada. And how common is midwifery in Canada? It's more common than people might think. So I looked up some stats from the Canadian Association of Midwives. And from 2021, which is the latest data available, it shows that there

were nearly 2000 midwives in Canada that assisted with nearly 50,000 births in that year, which is about 13% of the total. It varies from jurisdiction to jurisdiction. But I think it just goes to show that this is really becoming more and more of a mainstream option for people. Yeah. Yeah. I think the numbers from Ontario seems to be where most midwives are assisting with births. And that's like 18%. That was in 2022. But it decreases about, I think, 14% in Northwest Territories. But somewhere around those ranges is really what we're seeing across the country. Yeah, exactly. I think that the top were, you know, Ontario and BC at around 20, 25 percent. And then it kind of goes down from there.

But really, PEI, I should note, actually, I think has become the last province to have regulated midwives in 2022. And as of January, they have two midwives working on the island now. And what exactly does midwifery care look like? Like, how is it different from care with an obstetrician? Full disclosure, I had my two with an obstetrician. So these comments are from my expertise as a health journalist. When you look at the world of sort of midwifery care versus OB care, there has often been very much that emphasis on versus. Really, I think it's important to kind of separate out that these are two different sort of specialties doing two different things. So midwives, in addition to all the things

they can do, like, you know, blood work and diagnostic tests, often have a very big focus on sort of more of that personal support and that personal touch. So, you know, visiting people in their homes, supporting people with home births, kind of removing the clinical aspect from pregnancy and childbirth. Okay. And like, what can they not do, I guess, is the other question, right? So they can do all of these things that we just touched on, but what is different here? Yeah, that's a really important distinction. So midwives are real specialists in low risk pregnancies. So if someone is pregnant and everything looks very much stable, there's nothing detected that, you know, would put a person in a higher risk category. They can be followed along with a midwife.

So that means, you know, they can sort of have their monthly scans or tests or whatever they need to have done, their gestational diabetes tests. All of that is very much similar, but it's just not necessarily taking place in sort of, you know, a hospital or clinic setting like an OB would do. You know, other things that make it a little bit different if you're under the care of midwife, I mean, there's certainly medication options that you can have. There's, you know, tests that you can get, but midwives are not going to be, you know, caring for someone who, say, is in labor and there is a rapidly escalating situation. Say the fetus is in distress. At that point, the midwife will transfer care in most cases to an obstetrician. If a C-section needs to be done, the obstetrician will be doing that.

And in most cases, if a person wants an epidural, they will be transferred to the care of a physician who can provide that epidural for them. So it depends. There are some rules that will allow for midwives to kind of order an epidural, although they won't be administering it. But in a lot of cases, they would have to actually transfer care to a different care provider at that point in time. You touched on the fact that they can prescribe drugs and things, but some of this actually came out just recently this spring, right? Can we talk about what's changed here? Definitely, yeah. So Ontario, I think, has been really at the forefront.

And if you look at the numbers of midwives practicing and the number of births they're assisting at, they're certainly among the leaders in jurisdictions in Canada for midwifery care. And I think for that reason, we've seen the province kind of responding to some of the advocacy work that they've done. Yeah, it was actually at the beginning of May, the Ontario government made a big announcement about some changes to what midwives are able to do. And in fact, it's the biggest changes since 2010. So now in the province, midwives will be able to prescribe a whole host of new drugs, including routine vaccines. For a lot of people, it's really important to get that kind of care when you're trying to get pregnant or you are pregnant or in the period just after.

There are a lot of health vulnerabilities. Midwives in Ontario will also be able to prescribe new treatments for nausea and vomiting in pregnancy, pain relief for people who are in labor, as well as birth control, which is, of course, again, a really important part of that sort of whole spectrum of care around childbirth. Yeah. And so you talked about how it can be a less clinical feel with a midwife. There's more flexibility. You can have a home birth. But midwives can also deliver babies in hospitals, right? Can you explain how that works? Yeah, definitely. So of course, this will all depend on where you live. We know healthcare is very jurisdictional and patchwork in Canada,

so it may not be available where everyone lives. But for the most part, in a lot of cases, midwives can apply to have hospital privileges. So essentially, they can, you know, work in a hospital setting. You know, it has to be sort of set up and established beforehand, of course, they'll have a relationship with that hospital. And the midwife will basically be there to help someone, you know, through birth, through labor. And then at that point, where the patient is typically discharged, and then the midwife will be able to follow them at home. But I think it's a really important way for people that want to have the care of a midwife, but also want that comfort in case something goes wrong, that they will be immediately able to be

seen by an obstetrician if, say, if they need an emergency C-section or some sort of other intervention. It's a really important way for some patients to sort of feel like they're getting the best of both worlds. So they're able to have a midwife who's able to sort of connect with them and support them, but they're also able to be in that clinical setting should something go wrong. Midwives are part of the Canadian health care system now, but they weren't always, right? So can we just walk through some of the history of how that changed? Definitely. I mean, to look at the history of midwives, we're around, but I think for a long time there was a real reluctance and resistance sometimes coming from members of the medical community like obstetricians who were basically sort of suggesting at the time, decades ago, that midwives were not practicing a safe form of childbirth, of pregnancy support, that this is not something that should be regulated and brought into the system. Part of the evolution in making midwives a regulated health profession with its own regulatory college was also ensuring that

there's a layer of accountability built in as well. So there's a certain set of standards midwives have to meet. There's a college who's there who's going to sort of make sure that midwives are upholding those standards and stepping in if there are concerns. It took a really long time until sort of the mid to late 90s for provinces like Ontario and beyond to start regulating midwives the same way that they would regulate other health professionals, which would allow them to practice, to see patients, to basically you know, to basically have clients in their roster that they can treat. And I think there were, you know, meeting a demand that a lot of people wanted to have that midwife assisted birth and they weren't sort of permitted to or allowed to.

So it was a lot of slow change that started happening in and around the 90s. And that trajectory has continued since then. So it's, there's still, I would say, and the midwives and the associations I've spoken to would argue that there's still a long way to go to fully leverage midwives to their full capacity. here before? What was the shift that needed to happen in order to kind of bring midwives into this regulated medical space the same way that we see OBs? I mean, I've been reporting on this for, you know, more than a decade. And I think a lot of the controversy was really coming from a place of patient safety. And in some ways, you know, maybe certain groups, certain medical professions, like obstetricians or others, many years ago, saying that, you know, to be safe and to uphold the best standards of practice in medicine, this is the way things need to be done. You know, people are seen in our offices, they're in a hospital setting to give birth to maintain

the utmost safety standards for the person who's pregnant, their unborn child, and then, you know, their little baby. So I think there was a real worry and fear around patient safety that kind of, I think, grew and became something else entirely, which I think in some ways what we saw manifest was at times hostile relationship between obstetricians and midwives. And I remember the show, The Mindy Project, that was one of the really funny, the protagonist of the show is an obstetrician who's constantly dunking on the midwives before eventually realizing they actually have something to add, you know, in that bedside manner and all

of the other things that midwives can do. So there was a bit of that animosity. And, you know, one of the things that was underpinning all of that too was clinical evidence. So, you know, studies coming out showing that, you know, home births were unsafe, that, you know, there were worse outcomes in babies who were born at home or the higher risk of adverse events, which I think fueled a lot of the backlash against allowing midwives to practice and has continued to play a big role in that narrative. More research has since come out, and particularly in a Canadian setting, a Canadian context, which is really important. But as we've seen more research come out in this topic, it really shows that when the conditions are right and when

you're working with fully trained and licensed midwives who are focused on low-risk pregnancies, things like home births can be perfectly safe. Hospital births assisted with a midwife are safe. And, you know, a lot of people who are sort of in that room, you know, the people who are, you know, having that baby report really high levels of satisfaction. We'll be back in a minute. So midwives are part of Canada's health care system now, but there are lingering concerns when it comes to pay equity. So, Carly, how different is the pay between midwives and, I guess, similar health care professionals? This has been a huge contention point in the last couple of years, and I think it's most pronounced in Ontario. They've dominated a

lot of our discussion today, I think with good reason. So the Association of Ontario Midwives has waged a very long, arduous legal battle against the provincial government for pay equity. You know, there was a ruling and an appeal. So this decision was upheld in 2022, essentially awarding midwives pay equity. And so the decision noted that there's a 45% gap between midwives and other similar health professions. And midwives have long been arguing, now that they're regulated, they deserve to be compensated fairly and equitably. And because it is a workforce that is dominated by women, we know that there's a very large and longstanding pay gap between men and women. And midwives have kind of pointed out that there's a huge disparity going on here and this needs to be rectified. And this is something we also saw manifest with a very contentious bill in Ontario that held back pay for nurses. And again, the province has lost on that. So now nurses, teachers and other sort of female dominated professions, they're making up more of that gap. But according to the midwives and the experts in midwifery care that I've spoken to,

this kind of battle continues. There's still, despite winning this court battle in 2022, there's still huge, huge problems with pay equity in midwifery care across Canada that needs to be addressed. When we're talking about the pay gap here, Carly, I guess I just want to be clear, like, are we talking about the pay of midwives equal to the pay of an OB? Because, of course, an OB can do a lot more, right? Can perform surgery, C-section, epidurals, all those other things. So, I guess, what are we comparing here? So, when we're talking about, say, in the case of Ontario, this 45% wage gap between, you gap between similar health professions, I think that there's an argument or case that's made among some midwives about who that should be. And so should they be making, say, as much as an OB who's performing surgeries or billing at certain rates or seeing a certain number of patients?

I think it's often quite variable in the health care system, but I think certainly what they would say is that the pay that they are getting is nowhere near what it needs to be. And that if you look at other regulated health professions even, where we sort of are more readily able to have pay transparency. So say with registered nurses or nurse practitioners, we often can get better access to the data on exactly what they're getting compensated. Midwives are looking at even that and saying this is falling short of where we want to be. There's some concern among midwives that they're underutilized in our health care system. What exactly does this mean? What do midwives mean when they say that? The argument that midwives make is that they are now regulated health professionals licensed to provide essentially what is primary care for

people who are pregnant, people who are giving birth. The argument that midwives make is that they could be doing a lot more and that could then be alleviating strain and stress on the healthcare system, on overworked obstetricians. We know there's shortages of specialists, including OBs. We know that family doctors are already overloaded and overwhelmed. So a really strong argument to be made for midwives filling in some of those gaps there where the rest of the system is facing strain. They're saying we can leverage our skills to see more people, to work in more places, to help work with other members of the team to alleviate that strain. Can we look at this in detail here a little bit? Like how would having midwives help alleviate some of that strain, some of that pressure in the health care system? So in a couple of different ways. So let's just take the example of a very busy, stretched, overworked obstetrician.

I mean, we know that especially in, say, smaller cities or more rural and remote areas, obstetricians can be really hard to come by. Wait lists for appointments can stretch for months. And if you're someone who's like newly pregnant, you don't have a whole lot of time to wait. You need someone to provide you that care now. And so that might mean you're having to travel to see someone or you might be going without that care, which we know is the case for a lot of people who are more at risk, people who are vulnerable, people who are, say, working multiple jobs to make end meets. Maybe they're a newcomer. These are the people that need care the most. They may not be getting it.

So we know that we have these shortages in the system. And so midwives, if there were more of them regulated, more of them able to work, say, alongside obstetricians where they're setting up clinics and making it more of an established profession rather than a bit more of a niche one, the argument is that this would then make it easier for people to get access to care and also relieve some of that burden from OBs. And similar to family doctors, those family doctors who follow people who are pregnant until they're, you know, ready to give birth as well, the same argument applies that, you know, it just, it's one person with expertise in a certain area that can take

a patient off of the plate of a very busy family doctor or obstetrician. We talked before about midwives working in spaces in hospitals. And I want to ask you directly about a program that you actually wrote about in Markham Stouffville Hospital in Ontario, it's just north of Toronto, where they're doing something actually a little bit different. Can you tell me about that? Yeah, definitely. This hospital has launched what is essentially the first of its kind in Canada. And I believe since the launch a few years ago, there's been a couple of similar attempts at making programs like this.

But really what it is is a midwifery clinic unit that's embedded into the hospital. So it's not just that midwives have privileges and are able to attend births there. It's that midwives have their own dedicated space to see patients, to assist with births in a room that has a very sort of home-like environment. There's birthing stools and other kinds of therapeutic options. And I think there is a Murphy bed for when people do need to take a rest or when partners need to take a rest. But what they've done here at this program was and continues to be truly innovative because they're really embedding midwives in the fabric of the hospital as opposed to just sort of allowing midwives to come in. And, you know, I think what they've seen, I mean, is huge interest from the community. According to the people that are running the program there, there's been, you know, overwhelming interest for the limited number of beds that they have, for the limited resources that they have. Again, that argument for needing to scale that up and

do more because the demand is certainly there. And again, the advantage being that, you know, you have all of the comforts of sort of a birthing center where, you know, it's not a hospital room, it's really more of a home-like environment. But should something go wrong, you know that there's an obstetrician sort of, you know, right around the corner or right, you know, down a hallway who will be able to assist in an emergency. And according to the midwife who's running the program there, the midwives are actually also being called upon a lot to help out in the hospital itself. So, you know, say if we know that the, you know, the healthcare workforce is

struggling to, there's not enough nurses, there's shortages everywhere. And so in this case, they're actually allowing or seeing midwives going into, say, labor and delivery units when they're short of a pair of hands and assisting in that way. So it's really this truly collaborative kind of model. And I understand this program is also helping with the family doctor shortage as well. Can you explain that? That's right. Yeah. So during the pandemic, the hospital sort of created this add-on program where patients who were giving birth within this midwifery unit would then automatically be sort of followed or have primary care following them in that really vulnerable period after giving birth. So, you know, needing to go

and bring your newborn in for a weight check or, you know, to sort of have someone monitoring that really, really risky period right after the baby is born. So for a lot of people, we know there's a family doctor's crisis with millions of people without primary care. And this hospital has found a way to kind of leverage the talents of the people working there to ensure that any baby born and their family is going to be connected to that primary care, at least for a short time. And they thought that they would actually be able to end this program. It was sort of be a pandemic standalone measure, but it became so popular and it proved to be in such high demand that they were, you know, they basically had no choice but to keep it going to meet the needs of the community. Wow. We've been talking about how, you know,

how this could help the healthcare system, but how could midwives be better utilized across the country? What would actually help here? When you look at the scope of the challenges facing the healthcare system, I think, and really, we have to recognize that any innovative solution needs to be, you know, talked about and at the table. And so when you hear midwives make the argument that they have the skills, the knowledge, the expertise to be doing more, it makes sense to sort of we can start as a collective, as provinces, starting to promote it more as a very important, legitimate health profession to be pursuing, you know, to make sure that there are enough midwives to meet the growing demand, you know, more partnerships between hospitals, creating more of these midwifery units inside of hospitals or other standalone birthing centers for people who say don't want to have a home birth, but do want to have the attention and care of a midwife.

You know, if we talked about this 20 years ago, I think it would have sounded a bit more pie in the sky. But in the context of 2024, you know, every health care solution should be on the table to get us out of the mess that we're in. And I think the midwives have made a really strong case for why their profession can be a really important part of addressing that crisis. Carly, thank you so much for being here. Of course. And this is, of course, our last interview together because this is your last week at The Globe. But thank you. You've been such a steady guest on our show, and we're going to miss you.

I'm going to miss this place. It's hard to believe. And, yeah, I think in some ways we're breaking news here that I am wrapping up my 16 and a half year career as a health reporter at the Globe. You'll be very missed here. It's hard to leave. But I started my first day at the Globe and Mail. I ended it in tears. And so it's only fitting that I will cry my way out the door at the end of this week.

Well, you're on to some new adventures. So congratulations and we will miss you. Thank you. That's it for today. I'm Maina Karaman-Wellms. Our interns are Aja Sauter and Kelsey Arnett. Our producers are Madeline White, Cheryl Sutherland, and Rachel Levy-McLaughlin. David Crosby edits the show.

Adrienne Chung is our senior producer and Matt Frainer is our managing editor. Thanks so much for listening and I'll talk to you soon.