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August 11, 2009

Midwifery in Nova Scotia

The Halifax Media Co-op's next paid feature will examine the current state of midwifery in Nova Scotia.  Currently, full midwifery services (eg homebirth) are not available for all women in this province.

We want your input!

  • Should all women in Nova Scotia have access to fully funded midwifery services?  Why or why not?
  • What are important issues/angles/communities that are being left out of mainstream media coverage on this issue?
  • Do you have a personal experience or anecdote you'd like to share?
  • Who are the people and communities being left out of this debate?   

Please note: The journalist will take this discussion into consideration when writing the article and may contact you for further information or an interview.  If you would prefer not to be contacted, please indicate this on your post. 

Comments

Thank you

Dear Readers,

As you are probably aware, the story on Midwifery in NS has been posted to the Halifax Media Co-op website.

I want to thank you all for your sharing your insights and experiences, and for asking the hard questions that needed to be asked.

Unfortunately, I was unable to address some of the more specific questions in this piece. If you want to have a chat about those specifics, or just want keep the conversation going, please feel free contact me anytime.

Thanks again for being vocal and for sharing your stories.

Warmly,

Erin Hemmens

nsdoula@gmail.com

422-6429

 I had a wonderful home birth

 I had a wonderful home birth in Halifax in the 90's. Was active with Midwifery Coalition but bowed out as the focus became legislation and not women - i could see that today's outcomes were inevitable and couldnt put my energy into it any more. how much better off we were before the govt started meddling with birth regulation! sad that my daughter may not have a home birth option here. home increasingly is safer than hospital when you consider MRSA, the truth about Caesareans, interventions, etc. 

Personal Experience: Midwifery Care Comparison (BC vs. NS)

I have had two homebirths. My first in Vancouver, my second in Dartmouth. Both with midwives, both excellent care and both easy deliveries.
In BC, midwifery care is covered through the medical plan. Midwives have privileges in hospitals and can order tests like blood work and ultrasounds. We chose a homebirth because we wanted to be in comfortable, familiar surroundings.
Baby #2 was born in November of 2007, midwifery care was not yet covered by the NS provincial medical plan, yet midwives were able to practice homebirths. However they were not able to order tests. What I found frustrating was that I still had to see an MD. We moved here more than halfway through my pregnancy, and had to adjust to seeing an MD as well as a midwife. I found it more difficult to find an MD that was willing to see me knowing that I was planning a homebirth with a midwife. In the end, I was referred to an excellent doctor at the IWK who worked with midwives and was very open minded. Our appointments tended to be very brief since I felt that her time was better spent tending to her other patients than to me who was seeing a midwife every two weeks.
Baby #2 was born at home as planned with the care of a midwife.
I feel very lucky to be healthy and have had the option to choose midwifery care and a homebirth setting. I think its very unfortunate and unfair that other women in Nova Scotia do not have the same choices now because of government bureaucracy. Homebirths have been occurring since the beginning of time. Other provinces have homebirth policies, why must Nova Scotia drag their feet and deny women their rights' to choose where they want to deliver.

Feeling shut out!

I've just come to the full realization today as to the fact that as a pregnant woman in NS - I have little to no options for the delivery of my baby. I am expected to drive over one hour to drs appointments and when the time comes to deliver, and only with whatever dr I am told will see me. If I lived within HRM I would have the wonderful option of a midwife assisted delivery (which is what I wanted). But sadly since I am outside the "centre of NS" I am told there are no options for me. If this was an issue more directed at men, do you think we would be treated like this? I truely hope this is a snag in the progress of this province, and we will get to the day very shortly when the richness of knowledge and care from a midwife will be something our tax dollars will make equally available, in a variety of levels of care dependant only upon the woman's personal choice. For now, being rural is being a second class person. How sad.

As a doula practicing in

As a doula practicing in Halifax, I think that legislation is - or rather could be - a positive step in the birthing culture of Nova Scotia. However, we need WAY more midwives working out of a wide variety of offices and resource centres. Right now, I do wonder who is and is not accessing these highly sought after care-givers. Also the whole idea of not having the option to birth at home in Halifax is utterly rediculous, and I've seen it cause undue stress to expecting mothers who would rather birth at home, both in the planning of their birth and in the time of transfer.

That being said, midwives attending normal births in the hospital is pretty great (though ideally this would be because the mother had made that choice, not due to policy...) because more maternity nurses at the IWK are getting the experience of working with midwives. I've supported two mothers who birthed beautifully with the support of a midwife in the hospital since this legislation went through. Both were the first unmedicated births either of the attending nurses had witnessed. Crazy. And it makes me wonder how much training nurses generally receive with unmedicated birth... how to provide effective support, or even what it looks and sounds like.

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... yet here we are so tangled up in beaurocracy and old school (hospital??)policy that the potential benefits of legislation are not being seen by the people it is meant to serve.

Nova Scotia has such an opportunity to be a leader in accessible midwivery care - whats it gonna take for us to trust the research (and the families) and step up???

We should all be asking questions

I'm not here to say one way or the other if we've done the right thing here. Call me a fence sitter if you will, but I believe the focus is in the wrong place. We are so determined to point fingers and make accusations. I don't think any one place has the perfect solution. HRM is a very unique place. While certainly this decision to legislate midwifery care has affected families all over our province, just based on numbers, HRM is probably most affected. The thing is, why should women who are Caucasian, have money, and live on the Peninsula not have as equal access as those who are "marginalized?" I'm tired of everyone being labelled and put in corners. People are people, and if a woman wants a midwife and a birth that takes place at home, she should be able to have it and do it safely so that she does not put herself or her family at risk. It shouldn't matter if her home is a 5 bedroom house in the South End of Halifax, or a shack in the backwoods of Cape Breton. Women are women, people are people. Let's start asking the right questions, working together and stop making assumptions about what is best for people we don't even know.

How rare is natural childbirth?

I was shocked to read in Lindsay's post that there are nurses who have never witnessed a natural childbirth.  I knew childbrith had become medicalized, but I didn't realize to what extent.  Since then, a friend told me that the cessarian rate at the hospital in Truro is almost 40%.  Is this true?!!  This seems crazy and surely something we should be talking about more. 

from a student midwife's perspective

 

As a student midwife training in Switzerland and an eye on practicing back in her home province of Nova Scotia, it seems as if there is a lot of placating going on and very little progress or interest in actually providing a community based midwifery service to the women of Nova Scotia.  As a foreign trained midwife who will be registered and educated abroad, I will have to undergo ridiculous retraining either in Ontario or BC.  I can understand having your education evaluated and sitting for a licensing exam, or even being monitored for a provisionary period, but retraining?!  The programs are cost prohibitive, unfeasible for anyone with a family due to their length, and completely unnecessary.  How do they ever expect to provide midwifery services when there is not even a way of gaining a midwifery education in NS?  SO, let me get this straight they will either poach midwives from other provinces that DO provide educational opportunities or they must rely on foreign trained midwives, but they will retrain them at their own expense.  Sorry guys, but not many are going to buy that.  Australia and New Zealand provide far better opportunities and even bonuses for immigrating to provide midwifery services.  It's is only a few with either familial ties, like myself ,or other rare individuals who love their work and Nova Scotia who will be willing to jump through the hoops in order to practice.  I know of several British midwives living in NS who WILL NOT practice due to the licensing requirements and the lack of professional support from the medical community.

Honestly it sounds like a lot of talk and no action.  Hospital based midwifery is one thing... community midwifery is an entirely different animal.  Without the initiation of a community (ie. out of hospital) midwifery service, well, there really isn't any point.  The heart of a midwifery service is to offer women choices.  That choice must include home birth as a valid option and be supported by the health service.  Midwives AND doctors.  Midwives cannot work and provide women the best care with out the support of doctors and hospital staff as well.  A midwife must be able to activate emergency services and refer high risk patients to a doctor that works with the midwife and supports her professionally.  So far, I've seen little professional support.

Just my personal opinion.

 

Midwifery in N.S.

Midwifery should be legal, funded and available using the traditional model of proctice - that is the woman is given advice by the midwife about her risks, then, mother selects the place of birth, including home, unless her risk is too great. (twins, breech etc) Same with every other possible intervention - it is the woman's choice. In Ontario you must complete university level women's studies in order to be registered as a midwife! It is important to understand and respect women to be in the profession. Otherwise - what's the point?!

Both of my children were born at home with unregulated, privately funded midwives who gave me a year to pay. That was in 80 and 84. Later, I was the Implementation Coordinator for midwifery for the province of Ontario - the College of midwiives made up the protocols and practice standards for midwives not third parties like hospitals - I hear runours that the hospitals are writing the protocols instead of the midwives. I have also heard rumours that the identification of/ selecting women for/risk assessment of women appropriate for home births may also be set by hospitals. . . although for me these are just rumours. I know for sure that the transition team has members of other proferssions, like Doctors and Nurses that may not have the same approach to birth as midwives. Obstetricians insist that a birth can only be "normal in retrospect", whereas midwifery practice assumes that every birth is "normal" until the something happens to identify an increased risk. In Ontario, midwives refer women at increased risk to obsterciains and depending on when this happens stay involved or give up the case. . . No idea what is happening in this area in N.S. but getting permission to refer or consult from another profession to physicians is always difficult - its an isue for nurse practitioners as well.

In every study, home birth is as safe or safer than hospital births. It is not for everyone and women should have their babies where THEY feel safe and secure - whether that is home or hospital. Promoting midwifery has been a big part of my life - but not yet in N.S. It is actually hard to get information about the current state of it! I knew that they had hired only 5 midwives in hospitals as employees and that they were working as employees. Since there were midwives practicing in other parts of the province - those women now do not have access to legal care - this tends to drive provision of service - underground and makes it less safe.

So questions I have about midwifery in NS include:
Where (and when) is the Regulatory College?
How will admitting women to hospital work? - will it be the midwives who admit or someone else (like a physician)?
Are the midwives in charge of writing their own protocols and standards of practice or are they being imposed by institutions (hospitals) and other professions (Doctors).
When is this model that they have put into place which appears to be temporary, going to be expanded?
When will home births be possible with a legal funded midwife, when will the program be expanded?
Can midives prescribe drugs and if so has that Act been amended? Who is deciding what drugs they can prescribe?
Can midives direct ambulances and instruct ambulance attendants and para-medics (since they will be better educated than the paramedics about birth)
Which lab tests can they order and how is that done - under their own auspices or do they have to be signed off by physicians?
Are they providing pre-natal and post partum care only in the hosopital in this trial program?
The fact that the midwives are hospital employees likely means that they will be union members (and that's a good thing) but are unions and the employer ready to negotiate over a scope of practice that y\could put you on the job 24+ not allow for stat holidays etc. - I don;t want to see a stranger becuase my midwife has amassed too much overtime! I am sure that the unions will wortk with the midweives to ask for what they want - it just seems odd to me since BC and ONtario have the midwives funded as independent professionals - more like physicians - but in other provinces they are employees.

I have as you can tell more questions than answers but I do know how it was set up in detail in Ontario and BC - where I think, so far, they have the best systems. (But I am ten years out of date) Alberta does not pay for services (I don't think) although it is regulated, and Manitoba is s till "messing about" as I understand it - with small numbers and trial programs.

One last thing - someone mentioned in a post that it is "cheaper" to use midwifery services - and although that is true, as the outcomes are better, and shotial use is less and midweives make less than physicians, it does not save the heatlh care system any money. If a phsycian is not doing a boirth s/he does something else they can bill for - the billings do not go down. Same with hospitals, women who have midives ususally leave hsopital faster and if they have a home birth do not occupy a bed at all - but that does not mean that the bed lies empty - again it is filled with someone else - so it is extremely hard to realize actual savings to put into midwifery. There were a couple of studies in Ontario indicating the reduced costs per person of midwifery attended births complared to 100% physician/nurse/hospital births but it is not compelling for health system funders as they cannot realize the savings.

legislation of midwifery

should midwifery be legislated in nova scotia? absolutely. should midwives be able to do home births? yes of course! the province has gone ahead with this decision without a plan to make midwifery sustainable and accessible. there is no plan for expansion. this is so unfortunate.

i have just recently had my first baby delivered by a midwife at the iwk. i had an incredible experience, both throughout my pregnancy and at the hospital (hospital staff were also amazing). it saddens me that not all women will have the choices that i had (though home birth was not an option when i delivered in may due to legislation, it was certainly something i would have liked to have considered.)

home birthing is a safe and ideal option for many women. home births account for a large portion of births in other countries. the netherlands in particular has amazing home birth statistics.

nova scotia should really get with it and start respecting midwifery as it so deserves.

p.s. to the politicians: midwifery and home birthing save money!

Who has access?

I think it's really unfortunate that the new legislation is making homebirths impossible for some women in NS.  However, it does seem important that midwifery services are available to women regardless of income, and I'm wondering if the new legislation is resulting in more low income women using midwives.  Also curious about Aboriginal women and other women of colour. Who uses these servies?  How can they be made more accessible to all women, regardless of class and race? 

Re: Who has access?

I contacted the midwives VERY early in my pregnancy (probably six weeks) last fall, and was weeded out because I was not of low income or minority ethnicity.  This is completely unfair treatment... who has ever heard of "healthcare equity"?  This is just as bad as existing employment equity policies... COMPLETE DISCRIMINATION.  I would not recommend the IWK midwives because of this unfairness, spots should be distributed on a first come first serve basis.

no midwifery in the Vally

I am a Valley mama with one child and plan on having more. Before March of this year midwives were available here. Now that choice- that right- has been taking away from hundreds of women who have used and plan on using this service. To have a midwife at your birth is gold and can add so much to your experience. They are very valuable and really important and I would rather pay than to not have this kind of care at all. There is a long history of midwifery in the Valley and- poof- gone. For a midwife now to practice privately means she has to pay for mal-practice insurance that costs the amount she makes in a year. No choice for her, no choice for us.  

A fully funded midwifery program is a great idea with the conditions that 1) all women who wish to have a midwife could have one, 2) that they can choose the location of their birth (home, birth centre or hospital) and 3) that the program for the province is developed with genuine input of midwives and the families who support it. I also think that each region has different needs and these have to be considered. For example, rural women have a greater need for midwives to practice in their homes. It would not work to have midwives only practicing in hospitals here, it defeats the purpose. 

The previous government did not understand the essential service that midwives provided and my hope for the very near future is that the NDP's and the regional DHA's communicate quickly to establish - something - that allows women the access to midwives. Derrell Dexter made a promise on paper to move forward with this, thus we need to pursue this and hold him accountable.

If we are going to have a true midwifery program, make it available to everyone by hiring way more than 1-3 midwives per region and don't create unneccesary resistrictions on where they can practice and what they can do. Otherwise let it be private, don't let it hang somewhere in middle like forgotten laundry on the line. We know it works, so let's move it- move it.   

Why did we want legislation in the first place?

I received an email recently with the subject line "One step forward, two steps back" - and that is a perfect description of the so-called progess that has been made in making midwifery available to women in Nova Scotia.

Two years ago, pregnant with my first baby, I was receiving care from a midwife here in Nova Scotia. The care I received was extraordinary and worth much more than the price. It wasn't the ideal situation of course, since midwifery was not legislated so my midwife did not have admitting privileges for the hospital, nor could she order any of the tests that I wanted. But it was great in a number of ways: 1) when I got pregnant, I knew I would have access to midwifery care (provided that I could afford it, which I could); 2) I knew I would receive care based on the Canadian model of midwifery including my choice of birthplace (which was home).

This can't be said for midwifery in Nova Scotia today, despite the notion that we have made 'progress' by legislating the profession. Although I would like to be having a second child, I am using birth control (more diligently than ever before!) because I know that there is a good chance that if I were to become pregnant at this time, I would not have access to midwifery at all (for several reasons including the high demand for the service and the fact that I live a few kilometres outside the imaginary boundaries that have been imposed). And even if I was able to get midwifery care, it would not meet the standards of the Canadian model of midwifery, since homebirth in my region is currently not allowed.

Why did the Province bother to legislate a service that they apparently can't provide? Why is it taking so long to make this service available to ALL women who want it? And have they thought about the repercussions of this situation? I'm sure I'm not the only one in this province who would fly to another province or have an unassisted home birth before going to the IWK (again).

I think that ideally all

I think that ideally all women in Nova Scotia should have access to fully funded midwifery services because not offering them is tantamount to treating those without access as second class citizens. Childbirth is a beautiful, messy and life changing process, every woman should have a right to experience this in a way that is comfortable to them and their loved ones.

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