Welcome to November’s Musings! This month I am going to introduce what I hope will become a regular feature of Midwifery Musings: an interview with a midwife. It is my intent to provide readers with an in-depth look at each midwife’s practice, an overview of the legal and professional aspects of midwifery in their location, and a discussion about the contributions they are making in the provision of maternity care.
Welcome to November’s Musings! This month I am going to introduce what I hope will become a regular feature of Midwifery Musings: an interview with a midwife. It is my intent to provide readers with an in-depth look at each midwife’s practice, an overview of the legal and professional aspects of midwifery in their location, and a discussion about the contributions they are making in the provision of maternity care. I have ‘met’ many midwives from all over the world via the Internet and I am inspired to share these wonderful individuals' stories with all our readers. We have so much to learn from those that may practice in very different situations with sometimes remarkably different models of care.
Let me introduce Kathi Wilson , my first interviewee. Ms. Wilson is a professional midwife from Ontario, Canada.
DEBORAH "Kathi, tell us about yourself and your practice. I would like to know what directed you into midwifery and what your educational path consisted of."
KATHI "I am an Ontario Registered Midwife, currently practicing in a group practice in London, Ontario, a city of approximately 360,000. The four of us in practice serve both the city and the surrounding rural tri-county area in Southwestern Ontario. As a practice, we attend approximately 160 births per year. I live with my partner and three children just outside of London, in a small bedroom community called Ilderton. London is the only large urban centre in Southwestern Ontario, and is a major medical centre. The University of Western Ontario is located here. Although it has a reputation of being a white, middle-class insurance town, we, in fact, serve a culturally and economically diverse population of women, from Amish to newly arrived immigrants to university students and professors to rural farm wives.
My interest in midwifery began with the births of my own three children during the 1970s and 80s, the last of which was attended by midwives. I taught childbirth education classes, facilitated a breastfeeding mothers support group and attended births as a labour support person for several years prior to becoming a midwife. When midwifery became legislated in Ontario, I applied to and was accepted into the first class of the Ontario Midwifery Education Programme at McMaster University in Hamilton, Ontario. I was one of seven students chosen from an applicant pool of 250. I graduated in 1996 with a Bachelors of Health Sciences (Midwifery), a 4-year baccalaureate degree. Over 50% of this programme is clinical training, and graduates must achieve the minimum standard for births conducted in order to be registered with the College of Midwives, our regulatory body.
In accordance with the Ontario model of midwifery care, we provide primary care to women and their babies during pregnancy, labour and birth and the first six weeks postpartum. We offer a choice of birthplace, both at home and in the hospital. Our practice is currently credentialled in three local hospitals, ranging from a level I rural hospital to the level III centre in London. Midwifery care in Ontario is funded by the Ministry of Health, and is free to all residents of the province."
DEBORAH "What is the overall environment for midwifery in Canada?"
KATHI "Until the Midwifery Act was passed in Ontario in 1994, Canada was the only industrialized nation in the world without a formal system of midwifery. Midwives until then practiced either alegally, or illegally, depending on the province. The only exception to this were midwives who served women in the Far North.
As one might expect, the transition and integration of midwifery into the health care system has not always been smooth. However, on the whole, we have found that there has been far more acceptance that we might have anticipated in 1994, and that we are regarded as part of the health care system providing perinatal care."
DEBORAH "Are there geographic differences in legal aspects?"
KATHI "Health care in under the jurisdiction of the provinces, rather than nationally. Ontario was the first province to legislate midwifery, in 1994. British Columbia and Alberta have also recently passed legislation to regulate midwifery. Quebec is also currently in the process of finalizing its legislative process. The other provinces are still undergoing the process, probably because the numbers of midwives in them is small, as is the population. However, we hope to soon see legislated midwifery across the Country."
DEBORAH "What are some of the most current legislative issues that you are familiar with Kathi?"
KATHI "Nationally, one of the issues which will need to be resolved is reciprocity. Currently, Ontario is the only province which has a university-level midwifery education programme, and there will tend to be variation across the provinces with respect to basic registration requirements.
Within Ontario, we are currently struggling with payment models, as well as trying to ensure that physicians with whom we consult are adequately compensated for their interactions with us."
DEBORAH "Here in the United States, health care providers are now struggling to adapt and survive within a managed care system. Canada is often referred to as an example for us to learn from. This is not always meant in a favorable manner. Would you comment on this?"
KATHI "Certainly, health-care in Canada is in an enormous state of change at present. However, I would say that the biggest philosophical difference between our nations is that Canadians in general highly value their system of public health insurance (and are sometimes bemused at how it is demonized south of the border). It's under a lot of pressure right now, and there are fears that there will be a push to privatize certain parts of our system.
That being said, I believe there are far bigger issues underlying the differences in our health care systems than just the means by which they are funded (or not). There is certainly a move here to streamline and more economically manage health care, but, at present, I would be very surprised to see our system become the purvue of private corporations."
DEBORAH "Has the presence of legislated midwifery in Canada since 1994 affected perinatal outcomes? Can you cite any data?"
KATHI "Canada already has a relatively low perinatal mortality rate, at less than 9/1,000, I believe. Our numbers of midwives are so small at present that, even if our outcomes were different, we would probably, from a statistical point of view, not have an impact. We are currently only in the beginning stages of collecting data on midwifery care in Ontario.
Similarly, with respect to outcomes like Caesarean section, our rates have not approached the levels in the US. The level III hospital where I am credentialled has a C/S rate of about 16% currently, and the level II hospital in our city runs about 10%. So, midwifery might have only a minimal impact on reducing the Caesarean rates.
Where I might safely say we should see a difference is in the rate of hospital readmissions for newborns. Like the US, Canada has moved to extremely short postpartum stays, 48 hours or less, and there has been considerable concern about issues around dehydration of breastfeeding newborns. Because we do a great deal of postpartum home care in the first week, and help get breastfeeding off to a good start, our babies rarely ever get into trouble from that perspective."
DEBORAH "What in your view is the single greatest thing that Canadian midwifery can teach the rest of us?"
KATHI "Back in the 1980's, when supporters of midwifery and midwives were lobbying the Ontario government to legislate midwifery, we were very clear that we did not wish to create a system which did not protect choice of birthplace for women. That, we felt, would drive homebirth underground and create, anew, illegal midwives. We feel very proud that choice of birthplace has been enshrined within our model of care.
In a sense, when Ontario was developing the legislation and regulations for midwifery in this province, the eyes of the world (at least from a midwifery perspective) were on us. We had an opportunity to create our system from the ground up and to do it "right" from the start. By and large, we were successful. We have an education programme that has been rated by external review to be one of the best in the world. We have based our model on those things which we strongly feel that women value: informed choice, choice of birthplace, and continuity of care. And the women and babies we are caring for are, of course, what it's all about.
It's not perfect, by any means, and we're constantly refining it. But I'm proud to have been a part of the movement that instituted midwifery in Ontario (and Canada), and happy to be a practicing midwife here."
You can visit Kathi and learn more about her, her colleagues and their practice at :
Thames Valley Midwives
346 Platts Lane,
London, Ontario, Canada