the modern midwife: challenging convention and putting patients first
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cj blennerhassett, left, is a midwife in nova scotia helping women make informed choices in pregnancy, postpartum and overall sexual health.
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“midwives sometimes get a kind of cowboy reputation. the joke is that we’ll support somebody to give birth in the woods, under the full moon,” says cj blennerhassett, a midwife for a decade in nova scotia. she’s a strong advocate for the profession and president of the canadian association of midwives.
“what’s important is that the patient is giving birth in the location of their choice, the time, the place and that they have all the information they need.” for her, midwifery is about empowering women so they can participate in their care and share in decision-making at some of life’s most vulnerable moments, like childbirth, whether it’s at home, a birthing centre or hospital.
midwives, like doctors and nurses, are regulated, primary health-care providers. their most recognized role is delivering holistic, person-centred care from pregnancy through six weeks postpartum—typically an overwhelming time for women when their body is under incredible stress. in postpartum, new moms are sleep-deprived and often lonely, trying to keep up with feeding and caring for their newborn.
what many people may not realize is that midwives, who have been registered in canada since 1994 and are publicly funded, are also trained to provide reproductive and sexual health care throughout a person’s life stages.
blennerhassett lists more of the wide-ranging midwifery skills of screening and treatment for sexually transmitted infections, cervical cancer screening, infant feeding care, like supporting breastfeeding, abortion care, gender affirming care, perimenopause and menopause care. given wait times to see a gynecologist can be up to a year or more, these midwife services go a long way to support the system for women’s health.
“we can do most of the things that women need in that area from cradle to grave,” she says. “we work so closely with our nursing colleagues, with obstetricians, gynecologists, with family physicians. and so if somebody has an abnormal pap smear result, then they might need a colposcopy or more treatment, we refer to our colleagues. that kind of follow-up that’s more complicated or high risk, which is true during birth and just general sexual reproductive health care, we work closely with our colleagues.”
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the growing demand for midwives in canada
canada is seeing a growing demand for midwives, reflecting a desire for low-intervention births and increasing comfort with birth outside the hospital setting. low-intervention means the expectant mom may not want an epidural for pain relief during delivery, oxytocin to augment their labour contractions, or their water breaks and they don’t want to be induced. “maybe they’re two weeks past their due date and they don’t want to be induced. or they want a vaginal breach birth where that’s not offered,” blennerhassett says, adding the midwife is expected to make recommendations and outline the risks to women—and respect their wishes.
“so sometimes these things can be seen as kind of cowboy or rogue,” she adds, although high-risk cases are planned for and transferred to hospital well in advance.
“it’s not always easy, but ultimately we don’t get to have feelings that override the client’s own definition of risk.”
cj blennerhassett had never heard of a midwife when she was deciding on a career. now, she’s on the front lines of prenatal and postpartum care.
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most pregnancies fall into the category of natural “physiologic” birth without medications or surgical interventions, which midwives are highly trained to support.
blennerhassett also has a carload of equipment for home births as well as a good working relationship with the ambulance service for the unexpected. with any birth, of course, something can go wrong. she has hospital privileges to work in the hospital, so patients are not just transferred and dropped at the door. “most transfers from home to hospital are actually for non-emergent reasons, so things like pain relief or lack of progress. our goal is if we see that things are moving in a direction where we may need to be in a hospital environment, we want to be there before we need to be there.”
not surprisingly, demand for midwives soared during the pandemic when no one wanted to be in hospital to avoid exposure to the virus, and the proportion of non-hospital births in 2020 (2.1 per cent) was the highest it had been in more than a decade, according to statistics canada. that trend continues and right now in alberta, for example, the desire for midwife care far outpaces availability, with 40 per cent of people on the waitlist of the alberta association of midwives never paired with a midwife or team of midwives.
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yet there’s still a lot of misconception about what midwives provide and how they support health care for women as well as the health-care system itself. blennerhassett had never heard of a midwife when she was deciding on a career, but she had a baby when she was young and remembers her own lack of knowledge at the time. “i had known nothing about pregnancy until i became pregnant and then really only knew what i was told,” she recalls. her daughter is turning 20 this year.
“i had great care providers but the baseline for information sharing and educating was so low. you know, most of the time i didn’t really know what was happening. i didn’t really know why. so i came out of that experience and in my brain was just this fascination with birth and understanding that it is something we all have in common, being born, and yet it’s so mysterious in so many ways.”
when she started reading about midwifery, it clicked. “the part that drew me the most is our foundational principle of informed choice. and that’s what i was missing when i was young and giving birth, that focus. i don’t mean this to say other providers don’t understand, but this is just deeply held to us, that the client is the expert in their own body. so it’s my job to provide them with information, with resources, distill the research, talk about what does a standard of care even mean? and then it’s really the client’s job to make their own decisions for themselves. and that to me is what we’re missing not only in pregnancy, but in all health care.”
midwives are part of the health-care team
one of the hallmarks of canadian midwifery is the integration with the health-care system. when people become pregnant in an area where there are midwives, they can choose to either have a midwife, family physician doing obstetrics or an obstetrician. these are the three models for perinatal care available. midwives can offer birthing in hospital or in a non-hospital setting and provide seamless care if someone is transferred to hospital.
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dr. heather scott, obstetrician-gynecologist, maternal fetal medicine specialist and former chief of obstetrics at the iwk health centre in halifax, n.s., has long been an advocate for midwifery.
“i’m actually a midwife at heart. so to me it’s amazing,” she says. “what they model is shared decision-making and the patient at the centre of all of this. so while we may be critical, you know the more traditional healthcare providers may be more critical of decisions that people make: ‘oh, you’re overdue. you need to be induced. don’t you know that you’re putting your baby at risk?’ that kind of stuff. what they [midwives] model is that idea that you need to give them accurate information, but that in the end the client is at the core of the decision … it’s really empowering.”
when policymakers were looking at maternal newborn care in nova scotia about 30 years ago, dr. scott supported key conversations that brought midwives to three communities in the province, including the first hospitalist midwife to iwk where she practices.
“we’ve got midwives out in the community. they offer the range of choice in terms of where you deliver and all of that. they are excellent in that they’ve worked really hard to establish a rapport with other care providers in the province,” she says, adding having midwives stationed at iwk has been a great step forward.
“more and more, it’s not just physicians, specifically obstetricians, but also family doctors reaching out to them and nursing as well. so i think it’s really helped to enhance that collaboration amongst care providers.”
“there are several different ways that you can get prenatal care and midwifery provides them with an option,” dr. heather scott says.
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the reality is that increasing demand for midwives means there aren’t enough to go around and many women have chosen an obstetrician by default, she says.
dr. scott also says that midwifery exemplifies the quality of care framework set out by the world health organization to guide health-care around the globe. “at the centre of this framework is patient experience. and we have sort of forgotten or we’re just gradually learning how important that is to the care that we provide, that the way patients experience it, it’s not just a fluffy thing.”
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research is revealing the long-term effects for people who experience trauma with childbirth, yet practitioners say the experience is peripheral; it’s not central to the care provided. “we want a baby to come out with good apgar scores, you know, breathing on its own, all of these things, forgetting that maybe in the route that we took to get there, it was quite traumatic.”
she points to the most recent parental survey by the public health agency of canada that included questions around the birth experience and whether or not people felt traumatized by the birth—which had never been on the radar screen to ask in previous surveys. attitudes and awareness of patient-focused care are shifting for the better.
“there are several different ways that you can get prenatal care and midwifery provides them with an option,” dr. scott says. “it’s addressing our need to be responsive to the desires of women and how they see their pregnancy and the birth experience.”
improving prenatal and postpartum care
midwife remi ejiwunmi is vice president of the shah family hospital for women and children now in development by trillium health partners (thp) in mississauga, ont. the facility will be designed to transform care for women, children and families. she joined thp in 1996 and became head midwife in 2001, cementing the role of midwives as integrated and integral to hospital site services.
“about 60 to 70 per cent of all pregnancies are considered low risk and uncomplicated and midwives are the primary care providers for low risk,” ejiwunmi says of the current landscape. in ontario, the first province to legislate and publicly fund midwives, about 20 per cent of all pregnancies are cared for by midwives.
she explains that midwifery offers a system of care that reflects the vision for the new hospital.
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“it’s not just a building. we want to follow the patient where they go, whether they’re in or out of the hospital,” she says. “we want to have good connections to the rest of the health system and partners who can provide services to them when we’ve reached the limit of what we can do and we want to make it seamless and low barrier for patients so that they don’t have to figure out how to navigate.”
for example, she might bring a lactation consultant to help the new mom with breastfeeding. when a patient gets discharged home from the hospital, she’s going to follow them into the community for home visits for care for mom and baby.
later, she discharges them back to their family doctor, “until they get pregnant the next time when they come back to me again. so that seamless journey through pregnancy, postpartum and the team members really wrapping around the patient is midwifery.”
providing midwifery goes beyond thinking about just the clinical picture, she adds: “what are their values? what are their goals, expectations, culture? what’s their socioeconomic background? it’s using all of that to inform the care that they receive.”
thp has about 25 midwives on staff who are part of the credentialed team. a newer prenatal care program also leverages the skills and expertise of a separate team of midwives who care for patients identified by the hospital as particularly vulnerable, needing postpartum support.
the midwives focus on clinical assessments for the mom and their newborn, including mental health check-ins and support for breastfeeding and family adjustments. many of these patients don’t have family doctors, so the midwives connect them to social services if needed and help them find a primary care practitioner, again offering pathways of support.
this leads to another distinction of midwifery as closing a critical care gap in women’s health. convention follows that women have their postpartum check-up with an obstetrician or family doctor in about six weeks. midwives, however, are on call around the clock and visit moms several times over those first six weeks. they provide that inclusive and accessible care that women need, as blennerhassett says.
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“so at the time of birth, midwives become the care provider for the baby as well. we look after the parent and the baby for six weeks,” she notes. “we try our best to provide as much contact as possible. one thing that’s important to know about continuity of care models for midwifery care in canada, is we are on call for our patients 24/7. so if they need us at any time. it’s not easy, but it’s essential and it helps people stay out of hospitals.”
canada has work to do to meet postpartum care standards
without the services of a midwife, canada’s current system doesn’t meet the world health organization standard for postpartum care for parents for 24 hours after birth and a minimum of three additional checkups in the first six weeks postpartum.
“it’s hard to see that,” blennerhassett says of women struggling. “most people who get discharged from hospital, let’s say they had an ob for their care provider, there is one visit they have scheduled when that person who gave birth is at six weeks, one visit, and that is not up to snuff.”
she holds a bachelor of health sciences in midwifery from mcmaster university in hamilton, ont., giving her four years of focus on pregnancy, birth, sex and reproductive health care.
mcmaster and toronto metropolitan university are the two schools that offer the midwifery program in ontario. four other universities in canada offer similar four-year programs: the university of british columbia, mount royal university in calgary, the university of manitoba and université du québec à trois-rivières in quebec.
“because we’re regulated health-care providers, we have all of the abilities to do routine care in pregnancy. so things like prescriptions—i can order an ultrasound; if you need an epidural, i can order it; if you need oxytocin, i can order it. if you need your perineum to be sutured after you have the baby, i’m going to do it. so we provide all of that clinical care.”
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blennerhassett also spent a month on a training placement in the netherlands, opening her eyes to the scope of practice and recognition of midwifery in that country, which is shared in other nations, including the united kingdom.
“midwives provide the vast majority of care in pregnancy around the world,” she says, explaining that new moms in the netherlands even have an additional trained maternity professional called a kraamzorg come to their home for about eight days, guiding baby care, recovery and alerting the midwife or family doctor to any concerns. the service is part of the basic health insurance package that all residents must have.
“when i was there, i had a patient who had a cesarean section and they had 10 or 14 days of care from this person. so you have somebody there supporting you every day,” she adds.
by contrast, family doctors and obstetrician-gynecologists overseeing pregnancy and postpartum care don’t have the same bandwidth for the extensive care midwifery offers, blennerhassett says. canada does “a really terrible job of supporting people in (postpartum), and not because providers suck at it. our systems are not set up to support it.”
how midwives bring calm to trials of delivery
for siddhatri seth, a financial planner with td bank in mississauga, now on maternity leave with her daughter, the services of a midwife team were invaluable.
she’d been on the rollercoaster of fertility treatment for a year, coping with commuting to work, clinic visits and trying to manage her home life. getting pregnant years after trying naturally, and finally going through fertility treatment with success, meant her baby was even more precious. and when a pregnant work colleague told her she’d chosen a midwife, she did some research and decided on midwife care. she had a team of three as well as a student midwife.
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“they give you time. whenever you call them, they’re available. and that’s not the case with obgyns because you have to wait maybe a month to get an appointment and discuss whatever your concern is,” seth says. “until then, you know you’ll always be in fear because you know something might happen,” seth says of her team of four midwives.
she chose to have her baby in the hospital, just as an extra precaution. “i knew them all. i had met them all. i talked to them and i had my confidence in all of them. so whoever was free would be with me during the delivery, unlike the obgyn, where whoever is on duty would come.”
siddhatri seth says she “felt so loved,” by the midwives that helped her through the birth of her child. “i felt informed and cared for. i was calm because i knew everything and it was all because of the midwives and i’m really, really thankful for them.”
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her baby was due on january 10 of this year, but she was born by c-section on january 15. seth wasn’t getting pains or dilated, and the midwife went through procedures and gave her oxytocin, but no progress was made. a doctor had to be called for the c-section, outside the scope of midwifery.
she says the midwives made the experience far less stressful because they told her all the medication and steps involved. it was the day of a snowstorm, adding some drama that seth was also able to take in stride. she knew the midwives would be visiting her at home after being discharged and helping her with the transition.
“i’m having a snow baby and you know they’re coming home to help me. that was excellent. i felt so loved. i felt informed and cared for. i was calm because i knew everything and it was all because of the midwives and i’m really, really thankful for them.”
blennerhassett is hopeful about leaving women more confident in speaking up. “we often go to the doctor because we want them to tell us what to do. that hierarchical relationship is one that has existed for a long time in western medicine, and it’s one that isn’t serving us very well,” she says. “i can support (women) in changing their relationship with the health system and their relationships with their own bodies. i mean, that’s like a big statement.”
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but those big statements are needed for change, and reflect her commitment to the profession and all that it offers.
“once they understand the way that we deliver care, which is really focused on supplying them with whatever information and context they need to make a decision for themselves, then moving forward in their life, they can ask that of the health system.”
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