Nurturing Preference: Why Many Women Prefer Midwifery Care
When I told my mother that I would be using a midwife as my prenatal care provider for the birth of my first child her immediate response was, “Oh that’s nice, dear, and who will your obstetrician be?” After explaining to her that I would be using a midwife instead of an obstetrician, I was met with silence. Then came the question: “But what kind of training does a midwife have?” with disdainful emphasis on the word midwife. I assured her that midwives were medical professionals with lots of training and experience. I am now in my eighth month of pregnancy and I still think my mother is a little apprehensive about my choice for prenatal care. It dawned on me that it wasn’t only my mother who was a little sceptical about midwives. Many women I have chatted with in line at the grocery store, friends and colleagues have had various questions on the topic as well. Luckily, midwifery is a well-organized and regulated profession and there is ample information available.
While not all provinces and territories have regulated midwifery services, overall, there are approximately 1,030 registered midwives in Canada, with over 600 practising in Ontario, says the Canadian Association of Midwives (CAM). Midwives receive formal training in a four year program offered at seven universities throughout Canada. In Ontario, midwifery has been regulated since 1991 and was integrated into the government funded health care system by 1994. Anne Fortin, who has been a registered midwife for ten years and is a senior midwife at Midwife Alliance in Toronto says, “It is still a relatively small profession.” Despite interests from the Ontario Ministry of Health and the Ontario Ministry of Education to, “grow the profession,” says Fortin, “there still are not enough midwives for the demand.” That coupled with the fact that midwives are “capped” at a certain number of births per year makes for a situation where midwives are only available to a certain number of women.
Elizabeth Brandeis, the Association of Ontario Midwives’ (AOM) Vice President, notes that provision of midwifery care is very much tied to the feminist movement of the 1970s and 1980s that was calling for safer and legal abortions and also for a more woman-centred approach to providing care and support for pregnant women. Because there are many different ideas, cultural beliefs and values that women may have, midwifery strives to be as inclusive as possible of the many different needs and wants of women. This inclusivity and attention to women’s needs has resulted in fewer C-sections, fewer episiotomies, and better overall outcomes for mothers and their babies.
The CAM defines registered midwives as “health professionals who provide primary care to women and their babies during pregnancy, labour and the postpartum period.” Midwives have hospital privileges which allow them to attend births at a hospital as the primary caregiver for a pregnant woman and her baby. A woman may also opt to have her birth at home while under the care of a midwife. Whether the woman chooses to give birth at home or at the hospital, a midwife is qualified and skilled in providing all the necessary prenatal, labour, delivery and postnatal care to a woman and her baby until six weeks after the delivery for normal, low risk briths. This
includes the initial pregnancy testing and requests for any lab tests, genetic tests, or ultrasounds as needed. Routine urine testing is done on site at midwifery clinics as are some blood tests. In addition, midwives are available to their clients 24 hours a day, seven days a week via pager. If a woman is unsure about something or has a question, she can page her midwife at any time and the midwife will call her back. This ensures that the woman will not have to wait until her next appointment or go to a hospital emergency room if she is unsure about something she is experiencing.
Many women are interested in finding a midwife for their prenatal care, but are unsure as to the process for obtaining one. For example, my friend Carla, who is pregnant and looking for a midwife, asked me, “How much do midwives charge?” In Ontario midwifery services are covered by the Ontario Ministry of Health and Long Term Care, and so are free to pregnant women, whether they have OHIP or not. That does not include hospital or lab fees for tests, however, and the option to have a home birth is something that can be very cost effective for women who do not have OHIP. The only prerequisite to accessing midwifery care in Ontario is that the pregnant woman be an Ontario resident.
A midwife is trained to assist at normal births, which are those considered low-risk and will usually result in vaginal delivery. For all other situations, an OB/GYN would be the caregiver to use. A midwife does not conduct C-sections, but that does not mean midwives are unskilled in what they do. In fact, midwives support normal births through the midwifery model of care which aims to offer more instances of informed choice, provide continuity of care that ensures the labouring woman will have met the person who is providing her labour and delivery care (which is often not the case with OB/GYNs) and by offering a choice of either having a home birth or a hospital birth. In addition, midwives see birth as a natural part of a woman’s life, rather than viewing it as a sickness that needs medical
interventions. All of these options allow for a better overall birth experience and outcome for mother and baby. For example, 28% of births in Canada result in a Csection, but in Ontario, the rate for midwife assisted births is almost half of that at 15% of births, which is in line with the World Health Organization’s recommendations.
Anne Fortin says that the “key points” as to why many women prefer a midwife over an OB/GYN are, “The continuity of care, so… knowing that the person they’ve (pregnant women) been seeing is the person who will no doubt be at their birth. Caring for them in their home. And it’s the informed choice, especially for a first time mom, I find. They’re given a lot more information, a lot more time than OBs are allotted. That was the way the midwifery model was funded and designed.”
Of course, if there is an emergency, or if there are high risks in the pregnancy, medical interventions are warranted and available through a transfer of care to an OB/GYN. But for a normal, low risk birth, midwives offer a more holistic approach. This includes a more individualized management of the birth, rather than doing things based on routine or, in some cases, on what is convenient for the hospital. For instance, some hospitals will routinely induce a woman at 40 weeks, but it has often been shown that at 41 or even 42 weeks, a woman may go into natural labour and thereby reduce the need for Csections that happen after a woman is artificially induced but does not go into labour. Midwives are not bound by hospital routine in cases like this and so can offer individualized management to a woman who goes over-term in her pregnancy.
The midwifery model of care (continuity of care, informed choice and choice of birthplace) is becoming more popular and desirable among pregnant women in Ontario, especially in Toronto. Sometimes, however, mothers aren’t completely clear about what a midwife does. Kim Green, who has just had her second child, asked me, “How is a midwife different from a doula?” The answer is fairly simple. A doula is an expert in helping the labouring woman cope with labour and she is there to support the mother through the experiences of labour. She does not work with delivering the baby. She is support, both emotional and physical, to the labouring woman. A midwife is also supportive and can offer many wonderful suggestions to help the progression and experience of labour, but she is very much focused on the delivery of the baby, so can’t be massaging the mother’s back while the mother is pushing because she is focused on the safe delivery of the baby.
When asked what she thinks women may not know about midwifery, Anne Fortin says, “Midwives take evidence based and research based care very seriously. I think that there’s a misunderstanding that midwives just sit around and talk, but midwives are very evidence and research based and try to give their clients choice based on good evidence. So I think that that’s the thing that people probably don’t think of when they think of a midwife.”
This comes back to the misnomer that my mother had of midwives as being essentially labour coaches with no medical training. As the history of midwifery in Ontario has shown, especially since its regulation and integration, midwifery is a highly skilled profession that serves women from a woman-centred model that results in better birth experiences for mother and baby. These better experiences include both the emotional and the physical aspects that are included in providing care to the whole woman. This is a big reason why midwifery is growing in popularity. Its basis in evidence and researched based care as well as consideration of women’s wants, needs
and feelings is a winning combination.
There is a joke going around the prenatal community of caregivers in Toronto that goes something like this: If you think you’re pregnant, first, pee on a stick. Then call your midwife. Then tell your partner. The reason for this is that it is hard to find a midwife, even though the profession is gaining more exposure as women come to understand its benefits and how to access midwifery care.
The AOM states that there is quite an increasing want for midwives in Ontario and it is important to call a midwifery clinic as soon as a woman thinks she might be pregnant. Women do not need a referral to see a midwife. They can even see a midwife to confirm their pregnancy, rather than waiting for confirmation from their doctor. Often, if they do that, it will be too late.
When asked for the best advice to offer women who want a midwife, Anne Fortin says, “Call early!” There are other factors involved, though, as Fortin notes, “Midwives are funded based on geography and the number of births we can have, so a lot of it is first come, first serve. Most midwifery practices do save a few spots for repeat clients to come back in, but otherwise, it’s really just first come, first serve.”
So indeed, calling early would be one of the steps a woman can take in ensuring she finds a midwife. But where should she call? As Anne Fortin says, funding is based on geography which is the catchment area of a particular clinic. Helpful information regarding clinic locations, contact information and catchment areas can be found on the Association of Ontario Midwives’ website, www.ontariomidwives.ca. They can also be reached at 416-425-9974 or toll free at 1-866-418-3773.
Steps to Finding a Midwife:
1. Call a midwife early! Midwives can do the same testing as doctors do to confirm pregnancy. Even if you think you might be pregnant, call the nearest midwifery clinic to you right away. Don’t wait for confirmation from your doctor. If you do, it might be too late.
2. You do not need a referral to see a midwife, so you may call to make an appointment for yourself, which can be just enough of a timesaver to help you find a midwife.
3. If you get put on a waiting list, don’t despair. Sometimes spaces open up due to women being referred on to an OB/GYN due to complications, or due to early deliveries.
4. Check the Association of Ontario Midwives’ website: www.ontariomidwives.ca to find the midwifery clinic that serves your neighbourhood.
5. If you are outside of Ontario, check the Canadian Association of Midwives’ website for information on midwifery in your province or territory: www.canadianmidwives.org
Adrienne Kitchin is a Humanities Professor at Humber College in Toronto, Ontario and a freelance writer. She is currently expecting her first child and is passionate about maternal and infant health and well-being. www.adriennekitchin.com