On February 6, the College of Midwives of Ontario reported that its funding from the Ministry of Health and Long-Term Care was “under review” and that it was not sure whether it would be receiving government support this year or in the future. (Previously, it had told the media that its funding had been cut; neither the ministry nor the college commented on the discrepancy when asked for clarification by TVO.org.) The CMO has been the only medical college to receive provincial funding, an equity measure introduced because the number of practising midwives is relatively small — the province’s $800,000 grant makes up about a third of the CMO’s annual budget.
The CMO, like the regulatory medical colleges for physicians, nurses, and pharmacists, is responsible for licensing practitioners in the province, setting practice standards, and processing complaints. “Despite our difference in membership size, we all have similar programs, and they’re all mandated under [health care] legislation,” says Kelly Dobbin, CEO and registrar of the CMO. “Whether you have one registered member or 150,000, you have to deliver on the same programs, whether it’s registration, quality assurance, or professional conduct.”
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The funding review comes at an important juncture for midwifery in Ontario, which in 2019 reached its 25-year milestone as a regulated profession in the province. In 1994, there were 71 registered midwives; today, more than 950 oversee about 17 per cent of births in Ontario. The births they facilitate, whether at homes or at one of Ontario’s three birth-centre facilities, cost the province less than hospital-attended ones, and studies show that midwife-attended pregnancies tend to result in fewer C-sections and higher breastfeeding rates.
But a number of structural roadblocks prevent the field from growing at a rate that can meet the demand for its services, building a well-supported workforce, and expanding the number of health-care services midwives can provide. As Association of Ontario Midwives president Elizabeth Brandeis puts it, “I think that our biggest challenge comes down to the valuing of the actual work of midwives.”
In September 2018, the Ontario Human Rights Tribunal ruled in AOM’s favour in a four-year case that it had brought against the province in which it argued that a gendered pay gap (nearly all of registered and practising midwives in Ontario are women) had developed since 2005 — the last time the province had applied a pay-equity lens to midwife-salary increases. (In 1994, at the time of regulation, midwife salaries were set at 65 per cent of a community-health-care physician’s; since then, the salary of a community-health-care physician has increased by 76 per cent, while midwife salaries have increased by 33 per cent.)
“The concept was that we were slotted at a level between a salaried family doctor and a salaried nurse practitioner,” says Vicki Van Wagner, a founding director of Ryerson University’s midwifery program who participated in pay-scale construction for the profession in its early regulated years. The tribunal ordered the provincial government and the AOM to negotiate a settlement, but the AOM has requested official terms of remedy, which would include directions for such a settlement.
Ivy Bourgeault, the Canadian Institutes of Health Research chair in gender, work, and health human resources at the University of Ottawa, says, “We burn out midwives at a much faster pace than other professions” through both the work itself and the training programs required for accreditation. Currently, there are only three four-year midwifery programs in the province. “It’s successive governments over 25 years that have not shown support for expanding midwifery,” says Bourgeault. “Why don’t we have a training program at the University of Ottawa? Why not at U of T?”
Eileen Hutton, who recently retired as the assistant dean of McMaster University’s midwifery program, says that existing training programs and the research they generate would benefit from better institutional support. “We haven’t seen a change in funding for 15 years. Salaries have increased, and tuition has gone up. So bringing new people on board is challenging.”
“There’s also been no Canadian research chairs in midwifery, and this is an area one could get an edge in,” she adds. “The majority of births in Canada are low-risk. Having a research agenda that addresses the needs of low-risk-birthing women would seem to be to be an excellent investment for the CIHR.”
So how can the profession grow from here? Midwives and industry advocates suggest that it needs more integration with hospitals. While many seek out midwifery care with the intention of giving birth at home or in a birth centre, 83 per cent of midwife-attended births take place in hospitals, which set caps on the number of midwives who can deliver babies there. Van Wagner, for example, has hospital privileges at Mount Sinai, in Toronto. “The demand for that particular hospital outstrips the number of beds available. Obstetricians, family doctors, and midwives all end up having to turn people away. But the context for us that’s challenging is that, with continued growth, if these quotas don’t expand, it becomes a territorial thing,” she says.
Another option would be to expand the scope of practice — in 2017, for example, the AOM noted a growing interest among midwives in being allowed to perform abortions — and the scenarios in which a midwife can carry out perinatal care. Hutton points to a 2018 pilot project, run by McMaster’s program in conjunction with a family-physician group in Hamilton, that saw midwives provide reproductive-health services, such as IUD insertions. Last June, Markham Stouffville Hospital launched an in-hospital midwifery unit that runs independently but can access physicians if medical complications arise during labour. “It’s reproducible in other settings and allows women to access care in a setting that they have become familiar with,” says Hutton. “I think it’s really an excellent prototype.”
Dobbin says that the CMO will have to consider raising the registration fees for licensed midwives in order to make up for any potential funding shortfall — a process that will need to start in March. “It is unfortunate that our numbers are so low,” says Dobbin. “It does mean that the work that we have to do gets spread out over fewer members, which increases the cost per member.”
For her part, Van Wagner emphasizes that, despite such challenges, the 25th anniversary is a major milestone. “When I worked pre-regulation, we charged people money for the most basic of health services. A significant portion of the people who went to midwives were willing to pay for care they could have gotten for free. People should never have to pay for reproductive health care and pregnancy and birth care. It’s just so important to have achieved that.”