where are all the midwives?

i can't even fathom what my children's births would have been like if i
hadn't had my midwives. they are truly PRICELESS.

From The Toronto Star

The hands in demand
Midwives are wanted more than ever as OB doctors retire, writes Andrea Gordon
May 25, 2007 Andrea Gordon

Dori Skye Engel has a tiny foot wedged high beneath her ribcage. It's been a long time since she could see her own neatly polished toes. And these days it requires a Herculean effort to hoist her toddler.

But still, Skye Engel's blue eyes sparkle. One month before her due date, she radiates that unmistakeable glow.

Pregnancy hasn't always been this serene, though. Two years ago, when just five weeks along with her first child, Skye Engel, 32, was frantic to find a midwife.

"I was on six wait lists in my catchment area, I called all of them every week," recalls the Toronto mom. "That was a pretty big shocker for me."

This is no surprise to midwives who are distressed at the number of women they are forced to turn away. According to the Association of Ontario Midwives, 40 per cent of women seeking midwifery care can't get it. Those in the profession say clients will lie about their due dates, addresses, and use different names to get on wait lists more than once.

"It's really heartbreaking," says Manavi Handa, Skye Engel's midwife at Kensington Midwives in downtown Toronto. "That's how desperate women are."

When she was five months pregnant, Skye Engel got the call she'd been waiting for from Kensington. She and her husband were elated. Four months later, Noah was born at home, all nine pounds, 13 ounces of him.

Now Skye Engel is back at Kensington, listening to the rhythmic swoosh of her second baby's heartbeat on the fetal Doppler, grinning as Handa gently prods the little being that responds with heels and elbows.

Midwifery has come a long way since joining the Ontario health care system 13 years ago.

Midwives have gone from having no hospital privileges to delivering eight per cent of the babies in Ontario says Handa, 35, who has been a midwife for seven years. It has meant more choice for women and families, a boom in midwifery services and a more collaborative and responsive maternity care system.

But the mismatch of supply and demand – which reflects a trend among all maternity care providers, including obstetricians and family physicians – is worrisome.

Kensington's eight midwives, who deliver about 320 babies a year and have privileges at St. Joseph's Health Centre, are among the many who can't meet the demand for their services. Similar tales prevail at practices throughout the GTA.

"You have to call the midwife and get on that list the minute you pee on the stick," says Stephanie Alouche, of Ajax, who had a home birth two years ago, thanks to Sages-Femmes Rouge Valley Midwives, which serves Scarborough and Durham.

The shortage of midwives also creates a conundrum for the profession, adds Elizabeth Brandeis of the Toronto Midwives Collective, a group of 10 who deliver a total of 300 babies a year – two-thirds at Mount Sinai Hospital, the rest at home.

"We're hesitant to promote our services because there isn't the access, but that's exactly what we need to do ... In order to really be providing choice to the women of Ontario, it's important they have access to midwifery."

The Society of Obstetricians and Gynaecologists of Canada, which over the years has become a big supporter of accredited midwives, has been warning for several years now that a crisis is looming in obstetrical care. Nearly one in three OBs is expected to retire from full-time practice over the next five years. Among family physicians, 13 per cent delivered babies in 2004, down from 36 per cent in 1990. And 36 per cent report they do not provide any maternity or newborn care in their practice.

Midwives would like to fill the gap and cite three areas that need to be addressed:

A raised cap on the number of midwives licensed to work in each hospital. Busy collectives can't hire more midwives unless they can promise them hospital privileges. Otherwise, those entering the field can't practise.

Adding spots at the province's three education programs at Ryerson University in Toronto, McMaster University in Hamilton and Laurentian University in Sudbury, which graduate a total 40 to 60 new midwives each year. As well, expand the accelerated program for midwives trained in other countries.

Create birthing centres that would take the pressure off hospitals.

Handa stresses that greater reliance on midwives is cost-efficient. Ten midwives might bring in a caseload equal to that of two obstetricians. But their patient-centred personal care, including 45-minute appointments and continuous emotional support, also means clients tend to leave hospital more quickly, require fewer medical interventions, and receive attentive prenatal and postnatal care. All of which translate to lower costs for the health care system. They are also the only regulated professionals to accommodate home births.

Many midwives are concerned about mounting C-section rates – currently about 25 per cent of all deliveries – and the medicalization of childbirth by specialists whose training focuses on high-risk situations and intervention. The price is fear and apprehension that translates even to women in low-risk labour and delivery. "When does a woman ever get told your body knows what to do?" says Handa.

Adds Brandeis: "A midwife's perspective is that addressing fear with information is probably a healthier place to start."

Personal care was one of the main reasons Lisa Marie Fletcher, of Whitby, wanted to have her babies with a midwife. Now 24 weeks pregnant with her third child, she has received her maternity care from Carole Cameron of Midwifery Services of Durham. Her eldest, 3-year-old William, arrived after a smooth four-hour labour. With her second, a little over a year ago, Fletcher had an hour of contractions, called her midwife and then promptly gave birth to Samuel on the floor of her front hall. Her husband delivered.

"This time around we are hoping for a different kind of home birth," she laughs.

To Fletcher, the most important element of midwifery has been the post-partum care. The midwives were there when Samuel turned blue at two days old and was rushed to intensive care with apnea. They sat with her in the hospital, helped her pump breast milk through the week she couldn't nurse him and helped with the transition when they were finally able to bring the baby home.

Cameron, the first midwife in Ontario to deliver a baby unassisted by a physician just after the legislation passed in 1994, remembers when women had to pay for services and also had to be under a physician's prenatal, labour and delivery care for hospital births.

Since joining the system, midwives can now stand up in hospital rounds, they teach nurses, and work collaboratively with obstetricians

Like many midwives, Cameron joined the profession following the birth of her own children, the first with a physician and the next two with midwives.

"For me, it was about control. I felt as if I gave it all up with my first child." She doesn't blame the people, just the system. "I had to fit."

As midwives, "it's our job to fit the client and what they need."

That's an approach that was hugely important to Alouche as she prepared for the birth of her fourth child. Alouche, 33, had delivered one baby with the OB on call, who wasn't her own; she had one baby induced so her own OB could be there; her third started with midwives and ended up a Caesarean after the baby turned to breech position, which she describes as "the most horrendous experience of my God-given life."

Fourth time round she knew what she wanted: to at least try for a natural vaginal birth at home. She found a midwife who was willing to try. "When I talked, I felt I was being heard. When I said no, she said okay." Alouche delivered Meaghan Rae at home in a joyous bathtub birth two years ago.

For Handa, it's a privilege to be with a woman during the transformative process of birth and motherhood.

"It's the continuity of care that really makes me care. That's what gets me out of my bed at three in the morning."Skye Engel says the trusting relationship with her midwives was what got her through the toughest parts of a home birth.

"People will say to me `I'm not a hero like you.' And I don't understand that. I'm no hero."
Handa doesn't miss a beat on that comment: "As a midwife, I say you are a hero, it doesn't matter how you do it."