YFFM Midwifery Regulation Consultation Response

Midwifery Regulation Consultation Response
on behalf of
Yukoners for Funded Midwifery
May 2010

Yukoners for Funded Midwifery does not think regulations are necessary for public safety for the following reasons. First, the midwifery model places high value on the informed choice of the woman and shared responsibility for decision making. This differs from the medical model, upon which most other health professions are based. Midwives place high value on disclosure to their clients, and foster an approach that invites the woman to ask questions about individual midwives’ qualifications and credentials. Ultimately, the burden of responsibility and choice for her maternity care rests with each individual woman.

Secondly, the Yukon is a unique jurisdiction, as the population is quite small and concentrated in Whitehorse. Because of the small population, word of mouth and reputation are important in establishing and maintaining a profession. Unlike large provinces such as Ontario or British Columbia, it is possible to personally know every midwife who would be practicing in the Yukon, as the population could only support four to eight midwives, assuming that about half to three quarters of the births in the territory would be attended by midwives if midwifery were funded. There are currently only two midwives practicing in the territory, both of whom are well known in the community and competent in their profession. Neither of the midwives currently practicing in the Yukon pose any public safety concerns, and we anticipate that if new midwives were to begin practicing in the Yukon their qualifications would very quickly become known and assessed in and by the community.

Third, the midwifery model of care is inherently less risky than the medical model of care, as the midwifery model recognizes pregnancy and birth as normal life processes that for ninety percent of women require no intervention. The main principle behind midwifery is ‘First, do not interfere.’ The midwifery model encourages midwives to intervene only when it is absolutely necessary, and to engage the woman in decision making for any interventions that might be considered medically necessary. The midwifery model also protects the environments in which women give birth most easily, particularly the home birth setting, reducing risk of problems in birth that are caused by the release of stress hormones due to unfamiliar environments with unfamiliar people. The midwifery model by its very nature provides supportive, continuous care by a trained labour support person, a measure that has been shown to be extremely effective in reducing stress, fear, and pain in birthing women, which in turn makes birth easier and the birth process most effective, reducing the need for interventions.1 Midwifery is not about treating pathology but about optimizing physiological, normal birth and recognizing pathology when it arises, in order to collaborate on care with medically trained professionals. Midwives obtain their education either through an apprenticeship or through a university education program, and either of these routes teach them how to recognize and respond to emergency situations, in order to protect the mother and the baby.

We recognize the possible advantages of regulating midwifery. We would like to see midwives have status as primary health care providers in the health care system of the Yukon. We would like midwives to be able to order diagnostic tests and prescriptions when indicated for women and babies, and to have hospital privileges. We would like there to be more collaborative care between midwives and other health care professionals, when it is in the best interest of the mother and baby. We would like midwifery to be funded, to make midwifery accessible to all mothers in the territory. We would like to see a free standing, government funded birth center, with living/birthing suites for families from the communities, staffed entirely by midwives. We would like mothers in the communities to have access to publicly funded midwifery services and the option of birthing in their own homes. We would like to see the choices for women expanded, so that every mother receives optimal, evidence-based prenatal, birth, and postpartum care that emphasizes informed choice and puts birth where it belongs—in the hands of the mother.

We are concerned that regulations could limit the choices currently available to mothers. Right now, pregnant women have no restrictions on their informed choices. If the midwife feels comfortable providing care for a woman, whatever her circumstances, and the woman has been informed of the risks and benefits and desires care, the woman and the midwife enter into an agreement of care. Historically, some jurisdictions have limited the choices available to women by limiting midwives in what they are allowed to do and to whom they are allowed to provide care. This has led to harms for women, one example being the case of breech births in Ontario, where midwives were required to consult with an obstetrician. Because of regulatory guidelines, women were restricted to a hospital birth with a breech baby, and because of the climate due to regulations, if a woman had a breech baby she was forced into a cesarean section, even if the midwife had the skills to assist in delivering a breech baby vaginally and the mother preferred that option.2, 3 Vaginal breech birth has been shown to be as safe as birth by cesarean section.4 Cesarean sections carry high risks for both mothers and babies, and when the benefits of performing them do not outweigh the risks, harm is done. There are restrictions in other jurisdictions for other circumstances a mother might encounter, such as twin births, that limit choice for women. The reason the woman’s choice ends up being limited is because midwives who go against guidelines set out by regulation are often concerned about being disciplined by their regulatory body and having their license revoked as a result of remaining with a woman who chooses a form of care that the midwife is not supposed to provide.

We do not want to see women’s choices limited, and are concerned that regulations could end up causing more harm than good, acting in opposition to public safety. While midwives and consumers would be part of drafting regulations and would create regulations that provide the most choice for women, our concern is that the doctors would also be involved in drafting the regulations. Because the majority of doctors in the Yukon are not familiar with the midwifery model of care and instead approach pregnancy and birth from a medical model of care, we are concerned that they would want to put in place restrictive regulations, based on their own experiences rather than on the evidence-based practice of midwifery. We are aware that the doctors have a strong voice and are very important to the government, and that the government has a strong interest in accommodating the Yukon Medical Association and individual doctors, as indicated in our meeting on January 26, 2007 with the former Minister of Health Brad Cathers. We feel that the tension between providing women choice and the doctors’ belief of what is best for women, with the government favouring doctors, could lead to regulations that are unfavourable and not what women want or in the best interest of women. We do not want our voices to be overpowered by perceived medical authority.

We are also concerned that regulations would limit choice for women by restricting who is allowed to provide maternity care to women, as has happened in other jurisdictions. If midwifery were regulated, we would want women to be able to choose from a registered, publicly funded midwife or a non-registered, private-fee-for-service midwife, if one was practicing in the Yukon. We would want the term ‘midwife’ to be usable by both registered and non-registered midwives alike, with the exclusive use of ‘registered midwife’ reserved for those midwives who are registered and whose practice is governed by regulations.

An alternate solution to regulation would be for the government to reimburse women who use the services of midwives who have passed a midwifery competency exam administered by the Canadian Midwifery Regulators Consortium. This would make midwifery services accessible to all women in the territory, expanding their choices.

The vision of Yukoners for Funded Midwifery is that in order to enable informed choice for all women in the Yukon regarding their pregnancy, birth, and post-partum care, we envision women retaining all the choices that midwifery services in the Yukon currently offer, and the extension of those choices through government funding.

If a guarantee could be put in place to give midwives and consumers the authority in what regulations are finalized, with the opinions of doctors, other health professionals, and government being given due consideration but not final determination, then under these conditions Yukoners for Funded Midwifery would be supportive of regulating midwifery.

1. DONA International. Research Shows Doulas Make a Difference. http://www.dona.org/resources/research.php (April 2010)
2. Coalition for Breech Birth. Miriam Hannah’s Birth Story. http://www.breechbirth.ca/Birth%20Stories/Birth%20Story%20Miriam%20Hannah.html (April 2010)
3. Coalition for Breech Birth. I Have Carried Two Breech Babies. http://www.breechbirth.ca/Birth%20Stories/Birth%20Story%20Jen.html (April 2010)
4. Society of Obstetricians and Gynecologists. SOGC Clinical Practice Guideline: Vaginal Delivery of Breech Presentaion, No. 226, June 2009. http://www.sogc.org/guidelines/documents/gui226CPG0906.pdf (April 2010)