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.
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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.
