Safe, affordable midwives are in demand, but a lack of education and funding forces healthy mothers into hospitals. Creative Commons Photo by Dave Haygarth.

It wasn’t until the early 1900s that it became “normal” to have a baby under the watch of an obstetrician in a hospital. But over the last few decades, childbirth has become an increasingly complicated, medicalized affair, with more inductions, surgeries, and drugs than ever before. The advancements have saved many otherwise dangerous deliveries, but it can also traumatize healthy mothers who would otherwise be fine on their own. Cesarean sections are increasingly common, for instance: Canada’s current C-section rate is 28 percent. The World Health Organization says it should be closer to 15.

Modern hospital-based childbirth, says Tonia Occhionero, Executive Director of the Canadian Association of Midwives, could result in a “cascade of interventions.” Sometimes there’s a temptation to use every tool available, even if that’s not always the best option. An unnecessary induction of labour, for example, can produce a snowball effect, with medical interventions accumulating, quickly complicating low-risk births into higher-risk ones.

According to the Canadian Association of Midwives, 70 to 80 percent of women could deliver on their own without complications and would therefore benefit from midwife supervised delivery at home, in a special birthing centre (only in Quebec) or even at a hospital. But health-care providers have been slow on the uptake.

“There are a lot of misconceptions about what a midwife is,” says Occhionero. “But how can we expect the general public to understand when midwifery still manages to be left out of Health Canada’s literature?”

But even without promotion of midwifery, more women are rejecting the assembly-line hospital birth—demand for midwives far outruns supply. There are only 850 midwives across Canada, 435 of whom are in Ontario, the first province where the profession was regulated in 1994. Ten percent of Ontario births are attended by midwife—but 40 percent of women who request a midwife cannot get one. With only six university programs offering certification, the shortage persists.

Occhionero says that situation will continue this way until schools add midwife training, which despite its earth-mother reputation is a highly professionalized four-year baccalaureate degree.

“It’s very regulated,” says Occhionero. “Not just anybody goes around catching babies.”

Providing midwifery in a public health system presents challenges, but they're worth it. Creative Commons photo by Flickr user limaoscarjuliet.

In March 2009, Nova Scotia became the seventh province to incorporate midwifery into the public health care system. Instead of paying and arranging for the service privately, residents now have it covered and regulated by the provincial government.

Midwifery should be seen as the progressive (yet traditional) and cost-effective method of childbirth in Canada. But the upfront cost of creating a regulatory body for midwives, especially in smaller provinces with few practitioners, is offputting for governments. Still, this community-based model of birth, with its decreased hospital time (due to homebirths, shorter hospital stays for hospital births, and less frequent obstetrical interventions) and on-call services, creates significant long-term savings for the health care system.

Nova Scotia’s example offers important lessons to New Brunswick, Newfoundland and Labrador, the Yukon, and Nunavut, all of which will soon regulate midwifery. (New Brunswick will institute legislation and begin hiring midwives in just a few months.) Nova Scotia’s transition hasn’t come without kinks: there remains a shortage of midwives, a lack of public funds allocated to midwifery and the entire health care system faces geographical challenges—rural communities still have trouble accessing public services.

On the positive side, the change means that midwifery services will now be free in Nova Scotia, as they are from British Columbia to Quebec. “Just the very fact of covering midwifery in a provincial health plan and making that known will attract women of all different backgrounds,” explains Aimee Carbonneau, a Toronto midwife who has only ever worked in a public system. Ontario was the first province to regulate midwifery, in 1994. “If it is not supported and paid for by the government, you end up seeing a clientele that is mostly white, middle-class and up, with post-secondary education,” she says.

Maren Dietze, past president of the Association of Nova Scotia Midwives and a practicing midwife in Nova Scotia’s South Shore District, says regulation also gives midwives a new level of legitimacy: “Before we couldn’t deliver in hospital and we couldn’t order ultrasounds. Now we are accepted as part of the team.”

Midwife groups in Nova Scotia have struggled with successive governments since the early ’80s for public care, yet it remains available in only three of the province’s nine health districts. The other six District Health Authorities did not respond to the province’s call for model midwifery sites. According to Jan Catano, co-founder of the Midwifery Coalition of Nova Scotia, “The province didn’t want to roll out midwifery to the whole province at once because there were not enough midwives.”

Instead, a two-year budget for seven fulltime midwives was created. They work from sites in Halifax, Antigonish, and Bridgewater, leaving most of the province without access. Even if more midwives become available to Nova Scotia, from new graduates and a strong pool of internationally trained talent, the money isn’t yet budgeted to hire them.

Consequently, some midwives were essentially forced out of business in the transition.

To create universal access, Dietze says, “We would need more funding for midwives and we would need to be promoting midwifery to all the health districts,” so that local District Health Authorities demand the service and funding.

In the meantime, any Nova Scotian mother living outside the model districts in the centre of the province will lack access. And the situation is not unique to Nova Scotia. “I think for most of Canada, geography represents a big challenge,” Carbonneau says. “Many northern and especially Aboriginal northern communities are trying to bring birth back, but it’s quite tricky juggling the low numbers with the allocation of resources.” The Association of Ontario Midwives, for example, estimates its members serve only 60 percent of their demand.

Meanwhile, the three midwifery centres in Nova Scotia are swamped. And demand seems to be skyrocketing in some areas, such as Dietze’s South Shore District.

“A year ago we had five or six births here; now we have 40 on our books and we’ll have 70 or 80 people next year,” she says.

But, despite the increased demand regulation brings, midwifery is still not a financial priority in the province; compared to other health issues such as senior care or, more recently, H1N1.

The irony is that midwifery is less expensive than the medical model of childbirth, which treats pregnancy as an illness requiring costly medical interventions like drugs or surgeries. Further, midwives have a rich

Canadian history of catching babies in the most remote locations, especially when doctors weren’t available. In that traditional system, midwives went where doctors couldn’t or wouldn’t.

Now, as more provinces regulate midwifery, those remote areas are being left behind. Midwifery can’t properly be called “public” until access is universal.

To make that happen, more midwives are needed and that requires more Canadian midwifery graduates and greater integration of internationally trained midwives. Provincial governments need to make a special effort to promote midwifery to rural health districts and back up their words with trained midwives ready to live in and serve rural communities and First Nations reserves. And a culture change is needed in the medical institutions hosting midwives. To do their jobs properly, midwives need the freedom, flexibility, and mobility to provide homebirths and travel significant distances when necessary.

All of these changes require upfront investments, but collectively they will save taxpayer dollars currently being wasted on unnecessary birthing interventions and hospital stays that only hurt women and their families.