When Jane Church was pregnant with her first child, her labour unexpectedly progressed so quickly she ended up giving birth at home.
But she was not worried. In fact, Church felt relief. Even though her plan to deliver at a Toronto birth centre had fallen through, she was safe and felt peaceful. She credits her sense of peace with having a midwife, who had taken the time to explain every birthing detail and scenario to Church.
“I felt very well prepared,” said Church, who works at an environmental non-profit in Toronto. “I never felt like there was anything I didn’t understand… I just felt competent in the whole process.”
In many countries, including Sweden and England, midwives are the primary health-care provider for pregnancy and births, resulting in lower health-care costs and more choices for their birth plan.
But this is not the case for midwifery in Canada.
Obstetricians and physicians specialized in obstetrics were the primary health care providers for 87 per cent of births in Canada in 2021, according to the Canadian Association of Midwives.
“It’s a uniquely North American phenomenon [in] Canada and the United States and a few select other places around the world where it’s physicians that are providing the majority of care,” said CJ Blennerhassett, president of the association.
The specialists who provide the care in Canada cost the system more than midwives do, even though their specialist skills are not needed in most cases, said Blennerhassett.
High-risk births that require surgery must be overseen by a physician. But most births do not require interventions, such as a cesarean section — surgical removal of the baby — or an induction — when a doctor or nurse starts labour instead of allowing it to begin on its own.
Fewer than 30 per cent of Canadian women had a cesarean section in 2019, according to a study published in the Journal of Obstetrics and Gynaecology Canada. The rest were vaginal deliveries.
Provinces that integrate midwifery into Canada’s health-care system could see savings that can add up to millions.
A 2016 Maternity Care in Alberta report found that a hospital birth with a midwife costs $540 less than with an obstetrician. British Columbia saved more than $4.6 million in perinatal health care costs in 2014 and 2015, according to the Midwives Association of British Columbia.
‘A hospital affair’
Before April 1993, midwifery was illegal in Canada. Ontario became the first province to regulate midwifery in Canada. In 2022, Prince Edward Island began regulating midwifery, the last province to do so.
Decades of restrictions on the midwife profession enforced the belief that pregnancy and birth must be managed by physicians, said Julie Pelletier, president of the Order of Midwives of Quebec.
“The culture that we have as families and women is that birth is still a hospital affair,” she said.
The fact that midwifery’s place in the health-care system was accepted so much later than physicians and obstetricians’ has impacted midwives’ numbers and role in perinatal care, said Pelletier. Obstetric colleges were inaugurated in Canada in the early 1800s, almost 200 years before midwives were regulated and allowed to legally practise.
The effects are still felt today as midwives deliver only 14 per cent of births in Canada, despite their numbers multiplying 30-fold since 1994 when 60 midwives were registered. Now nearly 1,900 midwives can deliver babies in Canada.
Midwives’ services are covered by Canada’s publicly funded health-care system. They can manage a patient’s birth in a hospital or, unlike physicians, deliver a baby outside the hospital at a patient’s home or at a birthing centre.
Midwifery-led births have resulted in some of the best outcomes for perinatal care, with lower rates of cesarean and hemorrhaging, according to multiple studies.
“Midwives have lower rates of inductions and lower rates of cesarean sections … that comes with lifelong, positive outcomes,” said Blennerhassett.
When necessary, midwives are trained to transfer high-risk patients or births to doctors, said Pelletier.
‘Not enough midwives’
In British Columbia, more than 320 practicing midwives delivered 25.3 per cent of births in the province in 2021. B.C. midwives “deliver proportionally more babies than other midwifery providers” in other provinces, said Cynthia Johansen, registrar and CEO of the British Columbia College of Midwives and Nurses, the province’s professional regulator.
But there are too few midwives to meet the growing demand for services. “There is not enough midwives for the demand by far,” said Blennerhassett.
Church said she had heard there was a shortage of midwives in Toronto. That prompted her to sign up for a midwife soon after she found out she was pregnant, and luckily was able to get an appointment. “They can only accommodate so many people in a month.”
The shortage of registered midwives has led to some families, perhaps unknowingly, working with an unregistered midwife. B.C. has seen a spike in unregistered midwives managing births, from four last year to 20, said Johansen.
“Unregulated providers is one consequence of a shortage of midwifery care,” said Blennerhassett.
The consequences have been severe. Some deliveries resulted in infant death; in others, the mother was harmed during birth, said Johansen.
The onus is on families to check if midwives are registered. Professional midwives are listed on a provincial midwifery regulatory database. Families in doubt can contact the regulatory body if they need help accessing a midwife.
Midwifery expansion
The two pillars of midwifery are providing continuity of care and helping patients make informed choices, said Blennerhassett. Midwives help families develop a birth plan and can continue to provide services post-birth.
Appointments with midwives tend to run 30 minutes to an hour, and Blennerhassett. During pregnancy, women generally have 10 to 12 prenatal visits with a midwife. Midwives are also present in the room during the duration of labour, unlike physicians who can be in and out of different patients’ rooms until their delivery.
“By the time people go into labour… they know that they have a care team behind them that they’ve really come to know.”
Church agrees.
“I like my family doctor but I don’t [feel like I have] this really familiar relationship [with them],” said Church. “I love my midwife… She was a wonderful woman and I will think of her fondly throughout the rest of my life.”
Midwives take the time to explain every aspect of the labour, delivery and care for the baby, she said. And they not only spend more time with patients during appointments, but also do follow-up appointments until six weeks after the delivery to help with post-birth care.
“They talk you through everything — they’re very focused on informed consent,” said Church.
Blennerhassett believes the midwifery in Canada would grow even faster if the health ministries had midwives on staff to advise on how to best integrate them into the system.
For example, in Nunavut, which has included midwives in its health-care system since 2011, a chief midwifery officer manages midwifery programs and provides health-care expertise to the government.
“We have a lot to offer… across health systems,” said Blennerhassett.
“A huge requirement of moving the profession forward is increased investment from governments to midwives.”
Church continues to tout midwifery care to friends who are expecting. “Having a midwife is the best thing ever.”
“I always highly recommend it to anybody who’s having a low-risk birth,” said Church.
Correction: A previous version of the story incorrectly said 520 BC midwives delivered 27 per cent of the births in the province.
