Midwifery: Legal and Policy Issues – Part II

Posted By William Stephenson

In Part I, I discussed the regulatory environment in which midwifery exists. Here, I turn to three more specific legal and policy challenges that midwives or aspiring midwives face.

Liability and Professional
As healthcare professionals with full responsibility for care before, during, and after birth, midwives are exposed to liability for any departure from their professional standards. When complications arise, midwives must transfer patients and ensure that they receive continuous care. Midwives must also give their patients sufficient information to make informed choices about their care. This places a significant burden of responsibility on midwives – a responsibility for which they rarely receive recognition.

In SS v SD, tests revealed that the patient had gestational diabetes that required insulin treatment. The midwives told the patient that this was beyond the scope of their practice and that she should seek care from a hospital that could offer the appropriate care. The midwives eventually terminated their care of the patient.

Based on an investigation, the Ontario Health Professions Appeal and Review Board found that the midwives had not provided the patient with adequate information to make an informed choice about her care. It also found that the midwives terminated their care “without reasonable cause and without adequate notice,” which resulted in a discontinuity of care.

This case illustrates the extent to which midwives are subject to liability – an inevitable fact of the profession. However, few professions are as heavily exposed to liability while at the same time being as undervalued as midwives.


A little more pay goes a long way
Considering midwives’ exposure to liability and the medical expertise required in their profession, one might expect that midwives’ salaries would be reflective of their level of responsibility. However, the average salary for a midwife in Canada is $65,000. Taking into account the responsibility, knowledge, and exposure to liability midwives face, $65,000 seems low, especially given that the average physician earns around $225,000 after taking into account overhead costs.

Speaking to the CBC, midwife Crystal Hall noted: “When we first started, we were funded to provide women in low risk normal settings, provide care from the beginning of the pregnancy right to the end … [n]ow, we’re prescribing more medications. We’re just doing way more than we were funded for.”

After years of lobbying the Ontario government for more pay, the Association of Ontario Midwives launched a Human Rights Tribunal complaint for greater pay equity. Their complaint is based on gender discrimination, given that the profession is female-dominated. It also relies on a report by Paul Durber, in which he found that the value of midwives’ services is about 91% of what family physicians are paid. Currently, their pay is about 52% of a family physician’s.

While the details of how much more midwives should be paid is debatable, they deserve to be paid much more than they currently receive. Cash-strapped provinces can make this work by emphasizing midwifery over obstetric care for normal pregnancies, since this would mean obstetricians would bill less. Midwives’ salaries, on the other hand, would still remain below physicians’ pay, resulting in net savings. Furthermore, the demand for midwifery services already exists – 40% of women who seek midwifery care are turned away because of the shortage of midwives.

Licensing & Education: Penury of Programs
Midwifery is not an accessible profession in Canada. This is especially true given the small number of midwifery programs in Canada, and their irregular locations. It would be hard to meet the demand for trained midwives if greater emphasis were to be placed on midwifery as an option for pregnant women. As it stands, the supply of midwives can barely keep up with the demand for their services.

There are seven midwifery programs in Canada, but five provinces do not have any midwifery programs at all. Three programs are in Ontario, while the other four are in British Columbia, Alberta, Manitoba, and Québec. A number of these programs are in less populated cities: Trois Rivières (the only program in Québec), Sudbury, and The Pas (the only program in Manitoba). Additional programs in larger urban centers would make it easier to pursue a career in midwifery.

It’s time we recognize the value of midwifery both to the women they care for and to the provincial healthcare systems they operate within. Midwifery is a policy win-win. It’s time our healthcare system embrace this reality.

Midwifery: a policy win-win – Part I

Posted By William Stephenson

When it comes to perinatal care, midwifery should be the norm, not the alternative. Not only do midwives provide extraordinary care, they do so at a fraction of the cost of obstetric care. Midwifery is a win-win for cash-strapped provinces: it’s good for the women under the care of midwives, and it’s good for the healthcare budget.

A personal perspective

My wife raves about the midwives who cared for her before, during and after our daughter’s birth. They were extremely knowledgeable, some of them drawing on their experience of having delivered over 800 babies, and they communicated this knowledge in a friendly, down-to-earth way. They were warm, empathetic and relaxed. Her visits took place in an inviting setting, dressed up with homestyle décor to avoid the cold, clinical feel. For post-birth visits, the midwives came to our home. Many of the midwives who cared for her had also had children themselves and could therefore directly relate to my wife’s concerns and offer her firsthand advice.

They managed to give this exceptional, very personal care despite the stressful dimensions of their work. Constantly on call, midwives have to try to avoid situations where due dates conflict. This can be difficult, since babies have a tendency not to arrive when expected.

More and more women seem drawn to seeking care from midwives. In our case, my wife was on a waiting list for a brief period of time before they confirmed that they could take her on as a patient.

Regulating midwifery in Canada

 This resurgence in interest in care by midwives comes after the profession relatively recently came out of a regulatory wilderness. While midwifery is a very old profession, it has often been viewed with traces of suspicion. From accusations of witchcraft in the middle ages to statements that midwives were unscientific and a “relic of barbarism” in the 20th Century, midwifery in Canada has been building its good name over the past 25 years.

Prior to the 1990s, midwifery was not recognized as a profession in Canada. Ontario was the first province to do so, in 1991, with amendments to the Regulated Health Professions Act and the passage of the Midwifery Act. Quebec began regulating the profession in 1999, while most other provinces introduced legislation in the 2000s. In provinces which regulate midwifery, a board or college of midwives oversees the profession.

However, the profession is still unrecognized in Prince Edward Island and the Yukon. And New Brunswick, which only established midwifery regulation in 2010, scrapped its program last year, claiming that it did “not seem prudent to introduce a new profession in the midst of systemic change.” Thus, the state of midwifery regulation in Canada is a patchwork at best.

In Ontario, on the other hand, midwives appear to have the government on their side. Ontario recently established two new birth centres, in Ottawa and Toronto, bringing its total to three, including the Tsi Non:we Ionnakeratstha Ona:grahsta’ Maternal and Child Centre located on the Six Nations territory.

Ontario is on the right track. Midwives, with their intensive four-year program, which involves a number of clinical placements, are well equipped to deal with non-complicated perinatal care. The profession’s culture of personal, nurturing care is aligned with the needs of the women they serve. And they provide this level of care at an incredible value. The average midwife in Ontario makes $65 000 per year. By contrast, the average total payments to an obstetrician/gynaecologist is well over $300,000. While the two are certainly not directly comparable, transferring more of the share of perinatal care to midwives would undoubtedly result in lower costs and happier mothers.


In part II, I will canvass some of the legal and policy issues that are currently facing midwives, and explore potential solutions.

For more information:

Overview of midwifery and the law in Canada

Summary of provincial midwifery laws and regulations