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One Step Forward and Two Steps Back?

New midwifery legislation is causing some women to delay pregnancy in Nova Scotia

by Erin Hemmens

The lack of availability of homebirth in the HRM has caused Marlo Shinyei and her partner to delay having a second child.  Marlo says she felt "utterly disempowered" after the hosptial birth of her first child (pictured here).  photo: Erin Hemmens
The lack of availability of homebirth in the HRM has caused Marlo Shinyei and her partner to delay having a second child. Marlo says she felt "utterly disempowered" after the hosptial birth of her first child (pictured here). photo: Erin Hemmens

In March of this year, Nova Scotia became the first Atlantic province to legislate and regulate the profession of midwifery. While this move was celebrated by many as a step forward for women and families, activists with close ties to the midwifery movement feel their work is far from complete.

“All birthing women need a choice of where they birth and who their caregiver is - I think good midwife and family-led legislation could provide that," remarks Halifax doula, Lindsay Miller.  "Yet here we are so tangled up in bureaucracy and old school policy that the potential benefits of legislation are not being seen by the people it is meant to serve.”

For many women in Nova Scotia, access to care based on the Canadian midwifery model - a model based on tenets of continuity of care and choice of birth place – has become more difficult since the introduction of legislation, rather than less.

Early in 2008, three District Health Authorities – the IWK Health Centre, Guysborough/Antigonish/Strait (GASHA) and the south shore - were chosen as model sites into which midwifery services would be integrated into the existing health system, and midwives, or a midwife in the case of GASHA, were hired to work in each.

As promising as this milestone seemed, it was quickly overshadowed by some glaring flaws in the process of midwifery integration that leave many women questioning whether we are indeed any further ahead in terms of maternity care in this province.

At the IWK model site, homebirth, or its lack of availability, has garnered most of the attention.

Under the care of a midwife in the Canadian model of midwifery, women are given the option of birthplace based on the principles of informed consent. Women choose to give birth at home for a variety of reasons, including the comfort of being in familiar surroundings, fewer pressures to proceed at a predetermined pace and having family members – including children – present and involved.

Having a maternity care provider who respects this choice and offers this service is a high priority for Marlo Shinyei, a mother living within HRM. She states that the lack of availability of homebirth, coupled with a number of other issues with the IWK program, is affecting her and her partner’s decision to have more children in the near future. “The hospital - a great big institution with a lot of policies and power - is not the place for me to be. I was utterly disempowered by my previous experience; it left me feeling violated and ashamed. Two years later I continue to grieve over that experience. And that is why I would rather raise an only child than have a baby without a midwife. "

Kelley Morrisey of the IWK speaks to the delay in the approval of the homebirth policy, stating that “it is imperative that proper policies and procedures are developed to ensure the safety and well-being of our patients and families.”

Christine Saulnier, co-chair of the Midwifery Coalition of Nova Scotia (MCNS), responds to this by pointing out that the safety of homebirth has been proven in numerous research contexts: as recently as late August, a large-scale research project out of the University of British Columbia found homebirth with a regulated midwife to be as safe as a hospital birth.

In Guysborough/Antigonish/Straight District Health Authority women are facing an entirely different set of challenges. The one midwife that has been hired by GASHA is currently working in a shared care model, meaning that she shares her professional responsibilities with other health care professionals on a rotational basis. For pregnant women, this means that they won’t know who will be attending them in labour as that will be based solely on who is on shift. For those who know midwifery, they know that this model of care is not it.

According to the midwifery model, a woman under the care of a midwife will have developed a trusting relationship with her based on a mutual understanding of the birthing woman’s wishes. In a health system characterized by minimal interaction between patients and primary caregivers, high rates of medical intervention and little knowledge of normal physiological birth, the midwifery model offers and delivers something unique and empowering to expectant mothers.

Outside of the three midwifery model sites many women and families are facing perhaps an even more painful situation as they deal with the total loss of midwifery services in their communities.  Without the financial backing of the Department of Health, those DHAs that were not chosen as model sites are unable to hire midwives. Technically, midwives are allowed to register privately; however, the costs of malpractice insurance and the burden of individually negotiating hospital privileges make the option of private practice unrealistic. Remaining in the old system, in which midwives practiced without insurance and held no hospital privileges, is not an option for midwives outside of the model sites either as new regulations governing the practice of midwifery demand that midwives meet these criteria, or not practice midwifery.

For women in the Annapolis Valley, a region of Nova Scotia with a long-standing tradition of midwifery, the loss of services is a particularly difficult pill to swallow. Dawn Hare, a mother of two children birthed under the care of a midwife, and member of Valley Families for Midwifery, a group dedicated to reinstating midwifery services in the Valley, states that she is “extremely disappointed that midwifery services are no longer available to me based solely on where I live in the province”. The repercussions of this are vast for Dawn and her family as it forces her and her partner into the vulnerable position of re-evaluating their decision to have more children. As part of her work with Valley Families for Midwifery, Dawn is in touch with several women who are currently pregnant in the Valley and says that she “feels deeply for them, for those who have lost their right to safely choose how and where they want to birth their babies.”

Despite the glaring flaws in how regulated and funded midwifery is being introduced and provided in Nova Scotia, there are still highlights that should be considered and celebrated for what they offer to birthing women. Women on the south shore have access to full midwifery services, including homebirth. Women in the three model sites who qualify and are accepted into midwifery care don’t have to pay a dime: their care is fully funded by the health system. The IWK Community Midwives are able to reserve a couple of spaces each month in their practice for African Nova Scotians, Aboriginal women and teen moms. And lastly, people are talking about midwifery. They may be talking about the problems, but in doing so, midwifery is moving out of the fringes and into the mainstream.

When asked if midwifery care in Nova Scotia has gone one step forward and two steps back, Jan Catano, co-founder of MCNS, remains hopeful. The midwifery model is an integrated part of 7 Canadian provincial and one territory’s health systems, and Catano believes that the better outcomes associated with midwifery care in the rest of Canada can be reproduced here.  However, Catano cautions that the issues emerging in Nova Scotia stem from “an essential misunderstanding of the nature of midwifery care” – a misunderstanding that risks the future of the profession in the province. In order to see the same positive outcomes associated with midwifery in the rest of the country, women and communities must advocate for midwifery that is in line with the Canadian model, one that respects continuity of care and choice of birth place as the rights of all women, she says. 

As for the women of Nova Scotia and whether they think we have gone one step forward and two steps back? Well, that will probably depend on who you ask and where they live.

Officials in the Department of Health, the department overseeing midwifery implementation in the province, were not available for comment for this story, despite several requests for an interview. 

Erin Hemmens is a mom, a writer and an activist in the women’s health movement.  She is currently volunteer co-chair of the Midwifery Coalition of Nova Scotia. 


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Topics: GenderHealth
Tags: Halifax
1367 words


A point I didn't see

A point I didn't see mentioned is that within the IWK model site, many of us still do not have access to midwifery care. The midwifery program is only available to those of us who live within a 30 minute drive of the IWK. It seems irrelevant that the 45 minute or hour long drive to the IWK is acceptable if we're using a doctor with IWK privledges. The IWK is the only place many of us can deliver babies yet all of it's services are not available to all of it's clients.

hospital births

I'm glad that midwifery in NS is getting a lot of attention latetly, there are definitely positive and negative aspects to the early beginings of Regulated Midwifery. It could be worse, we could live in NB where midwifery is still illegal for everyone.

I wanted to voice my opinion on hospital births. I gave birth to my daughter at the Valley Regional Hospital in Kentville in 2008 and had a WONDERFUL birthing experience. No pressure to use drugs, intimate (only my partner, my delivery doctor (whom I knew and had a good relationship with) and a delivery nurse were in the room).

I thought about it for a long time, but in the end didn't feel comfortable trying a homebirth for my first child even though I was low risk, was planning a natural birth and no complications were expected. In the
end I had my natural birth in the hospital but had post-birth complications that had nothing to do with being in the hospital (i.e. would of happened even if I was at home) and they almost lost me. I was happy that I was already at the hospital and was able to get immediate emergency care which wouldn't of been available at home (would of been ambulanced and may have died etc etc). My post-delivery experiences don't make me high risk now, but because of them, I wouldn't feel comfortable birthing at home in case it happened again. I feel that in all the midwifery talks and articles, hospital births get a bad wrap and I don't think that's fair.

It's a personal choice where to give birth, and I do hope that Valley/NS women will be able to attract a midwife to their area to be able to home birth again soon.

I also think that it makes sense for a midwife to have malpractice insurance, but perhaps the problem lies in the actual insurance type or cost. I've heard that they pay the same as general practitioners for their insurance, which is not a realistic cost when you consider how little a midwife gets paid compared to a GP... has anyone done research on this?

It's also too bad that someone would choose not to have more children simply because they'd need to birth at the hospital. Yes, your birth experience will be different, but that's only 1 day and at the end your child will be just as healthy and happy and loved!


One Step Forward and Two Steps Back?

I feel for Marlo, though I don't think her experience is common for women who have competent health care providers at the IWK.

These road blocks need to be opened up so that women like her can have a homebirth if they choose. It's a shame that she would have to feel unsure about having another baby!!!



It's about where the power lies...

Marlo here - feeling like I have to explain a few things. First, please be careful not to make assumptions when you hear (or read) about someone's birth experience. In fact, I had extraordinarily competent care providers at the IWK. The physician who cared for me was phenomenal (though I had never met her before). The nurses were both caring people and competent professionals. And my midwife and her student also provided excellent care despite the legal circumstances at the time which prevented them from being my primary care providers.
Despite having received extraordinary care from indivudual people, I was "utterly disempowered" by the institutionalized nature of my care. I was presented with a lot of information about "hospital policies" - some of which were not founded in research evidence, and some of which in fact contradicted research evidence. I was "violated" because I had no control - strangers could come and go from my room as they pleased - while I was deep in the throes of such a personal experience!!! And I "grieve" over the experience because it didn't have to be like that. It could have been so different if the instiution had less control, and if I had more control.
The Canadian midwifery model of care puts control in the hands of pregnant and birthing women - where it belongs. Of course, there are some "policies" that are a part of that model too - but they're all based in research evidence!
The nature of one-to-one midwifery care allows a midwife to adapt to the changing needs of her clients. But institutionalized care requires that women adapt to the needs of the institution.
I absolutely respect every woman's choice to birth where she chooses. For those women who choose to give birth in a hospital, I hope that the introuction of midwifery will help to change some of those policies that are currently not woman-centred. For those women who choose home birth... I just hope that they can access the care they need to make that choice!

Ahh, got it. I did make an

Ahh, got it. I did make an assumption about your care.
Keep up the fight...


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