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Navigating Midwifery Care in Ontario


A midwife supports a pregnant person

Positionality Statement 


I am a Black cisgender woman living on the traditional territories of the Anishinaabe Peoples and of the Haudenosaunee Peoples in what is now known as Markham, Ontario. The purpose of this article is to answer some of the frequently asked questions I hear as a perinatal health advocate and researcher. I would like to acknowledge my personal bias in favour of midwifery care as I had wonderful experiences using their services with two of my three births. I am also a person who has experienced medical racism within the Ontario healthcare system related to obstetric and gynecological care. I approach this topic from a lens of wanting to limit harm done to others and facilitating an informed choice discussion. It is important to mention that I am not a medical professional and this information is a summary of the Association of Ontario Midwives website. 


A note about language used in this piece:


Gender-neutral language - Not all people who are pregnant and/or become pregnant refer to themselves as women or mothers. Gender neutral language will be used throughout for inclusivity. 


Deliver vs. Attend - You will notice throughout this piece the term “attend” is used in place of “deliver”, the most commonly used term for the medical professional who catches a baby at birth. Midwives use the term “attend” when referring to being at a birth. The term deliver implies that the provider is doing the work when it is actually the person giving birth. Attending implies that the midwife is a secondary actor at the birth and not the star of the show. Simple language changes can give power to the person bringing new life into the world. There is a great book that discusses this issue and other power imbalances within perinatal health care called “Babies Are Not Pizzas: They’re Born Not Delivered” by Dr. Rebecca Dekker. 


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Introduction


When it comes to pregnancy and childbirth, there's no one-size-fits-all approach. There are so many choices that need to be made during pregnancy and childbirth, one of them being, who you want to be your medical care provider. While the majority of people choose an obstetrician-gynecologist (OBGYN), midwives attend an important percentage of births (about 15% in Ontario) (1). Like OBGYNs, midwifery care is covered by OHIP. Ontario residents who do not have OHIP coverage may qualify for free midwifery care as well (2). You can find out more about uninsured clients on the Association of Ontario Midwives website. https://www.ontariomidwives.ca/uninsured-clients


While midwifery care has been practiced on this land for as long as there have been pregnant people, midwifery care has only been a part of the Ontario healthcare system for less than 30 years, prior to that time, they were not publicly funded (3). People often have questions about what a midwife does, how to get one and how their care is different from that of an OBGYN. This article will answer all of these questions as well as some other frequently asked questions about midwifery care in Ontario. 


Let’s start at the beginning: What Does a Midwife Do?


Midwives are trained healthcare professionals who specialize in providing care throughout pregnancy, labor, and postpartum journeys. Unlike OBGYNs, midwives can only provide medical care to those experiencing a low-risk pregnancy without medical complications (1). Each practice has its own definition of low risk. The best way to find out if you personally qualify for midwifery care is to speak with your nearest midwifery practice directly. 


Midwives don’t attend medical school like OBGYNs. They attend a 4-year midwifery education program, an intensive program that includes coursework as well as extensive hands-on working experience (1). Midwives often operate in catchment areas, meaning they only service clients who live near their clinic. You do not need a referral to see a midwife, you can contact them directly (usually by phone or through a form on their website) when you find out you are pregnant and they will help you with the next steps. You can visit the Association of Ontario Midwives website to find a midwife near you. 


This is what midwifery care generally looks like throughout the childbearing year: 


Prenatal Care:

Midwives monitor your health and the development of your baby, order tests, labs and ultrasounds the same way an OBGYN would. They can also write prescriptions for certain medications such as anti-nausea medication or antibiotics for a urinary tract infection (4).

Midwives also operate in groups or teams of 2 or 3 midwives which allows them to offer continuity of care. Having a team of midwives helps to ensure a continuity of care, where the pregnant person has close familiarity with multiple midwives, one of whom will attend the birth. (5)



Labour and Delivery:

Midwives are skilled in assisting with a vaginal birth, including home births or vaginal deliveries in a hospital or birth centre. Midwives cannot provide C-sections as this is a surgical procedure. Clients can choose to deliver in a hospital, at home or at a birth centre. The birth location is a choice that is unique to each birthing person and their circumstances. Midwives need special permissions in order to attend births at a hospital but many hospitals across Ontario allow midwives to practice on their premises. The Association of Ontario Midwives website will let you know at which hospital the midwives at your nearest midwifery clinic are able to attend births. 


Ontario has two birth centres located in Toronto and Ottawa where midwives are able to attend births if the client lives close enough to the birth centre. (5) A birth centre is different from a hospital setting and is more similar to your home. There are birth pools and beds that are more like the ones you have at home rather than a hospital bed. You can view pictures of the rooms at a birth centre here. Midwives can administer nitrous oxide gas for pain relief during labour and can call for an anesthesiologist to administer an epidural for clients delivering in a hospital setting (5). 


Midwives can only provide care for low-risk births. This means that if you have any medical complications that may require more specialized care, you may not qualify for midwifery care. Care of the client may be transferred to an OBGYN if such a medical need arises. If you are at home or a birth centre when you need to transfer your care to an OBGYN, this will also mean travelling to a hospital to receive that care. It is important to talk with your midwifery team about what such a transfer of care might look like. You are only able to have one primary care provider at a time so you cannot have both a midwife and an OBGYN at the same time. Midwives may still be able to care for the client postpartum depending on the circumstances (5). 

   

Postpartum Care:

Midwives continue to care for you and your newborn for 6 weeks after birth. The first few appointments will be in your home so you do not have to travel to the clinic for checkups (5). Because midwives are able to visit clients in their homes, most midwifery clients who have an uncomplicated delivery in the hospital are discharged within 3-6 hours after giving birth if they choose to go home early. Additionally, midwives continue to be on call 24/7 for any concerns regarding the parent or baby. 


Benefits of Midwifery Care


Continuity of Care: The team practice approach to midwifery allows clients to enjoy having the same care providers for the full childbearing year. Having a midwife care for both client and baby for an extra 6 weeks postpartum allows for an extended care period rather than needing to visit a family doctor or pediatrician in the community. It can be helpful to have the person who supported you throughout your pregnancy and birth also support you through postpartum rather than having to transfer that information and experience to another provider. Midwives are also able to administer pap smears (6) and discuss family planning options with their clients before they close out care. Your midwife may discuss the type of birth you had and, based on that experience, give recommendations for how long you should wait to have another pregnancy and talk about potential methods of birth control. 


Lower Medical Intervention: Many pregnant people would like to have a vaginal birth if possible and midwifery care is well-suited to these preferences. Based on data collected in 2020 and 2021, in Ontario, the average C-section rate sits at around 32%. For midwifery clients, it is only 21%. For clients who plan a homebirth, it is significantly lower at only 1% (7). Please note that a vaginal birth may not be possible in all circumstances, especially higher-risk pregnancies. C-sections can only be performed in the hospital by an OBGYN. If you choose to have a home birth with a midwife, it is important to make arrangements in case an emergency C-section is needed. 


OHIP Coverage: Midwifery care is covered by the Ontario Health Insurance Plan (OHIP). If someone is a resident of Ontario but does not have OHIP coverage, they still can access midwifery care (this does not apply to hospital fees, only to the medical care from midwives) (2). This means that if you are someone who does not currently have OHIP, you are able to attend appointments with a midwife and have them attend your birth. There will be no financial cost for these services but you will have to pay for any fees related to a hospital stay. Home birth and birth centre births are also free to people who do not have OHIP coverage. You do still need to qualify for a midwife, be medically cleared to have a homebirth or birth centre birth, and live within the catchment area to give birth at the birth centre. 


Choice of Birthplace: Midwives are able to offer the choice of home or hospital birth to most clients. If the client lives near the Toronto or Ottawa birth centres, they may have the choice to deliver there as well. The Association of Ontario Midwives reported that 82% of babies born to midwifery clients are delivered in a hospital, 14% at home and 2% at a birth centre (7).


Traditional Practices: As of 2022, there are 12 Indigenous midwifery practices and 60 Indigenous midwives practicing culturally appropriate care in Indigenous communities. Some of the midwives are registered midwives while some are community-governed Indigenous midwives (8). You can find a list of practices and Indigenous midwives here. 


Limitations of Midwifery Care


Risk Factors: Not all pregnancies are suitable for midwifery care. Pregnant people with certain medical conditions or high-risk pregnancies may require specialized medical attention. While midwives and OBGYNs can consult with each other, pregnant people can only have one primary care provider at a time for the duration of their pregnancy (1). 


Limited Availability: Midwives may not be available in all areas of Ontario, which can limit your choice of care providers. If you live in a larger city like Toronto, you may have the choice of several clinics nearby, however, if you live in a more rural area, you may not have access to a midwife at all. Even if there is a midwifery clinic in your area, they tend to fill up very quickly. The Association of Ontario Midwives advises those wanting to have midwifery care to contact their local clinic as soon as they find out they are pregnant. You do not need a referral to access a midwife (1). 


Transfer of Care: If complications arise during pregnancy, labour, or birth, your care may need to be transferred to another care provider that is able to handle more high-risk situations. This may be emotionally distressing to some. In some cases, the transfer of care is only temporary, for example in the case of a C-section. Other times it is a permanent change in care provider when the complication is out of the scope of midwifery care (9). Your midwifery team will be sure to explain exactly what the next steps are. Sometimes midwives are still able to provide postpartum care if there is a reason to transfer your care for the birth only.



Conclusion


Choosing a care provider for pregnancy is a decision that requires careful consideration of your personal needs and preferences. Midwives offer a holistic and personalized approach to perinatal care, emphasizing vaginal childbirth and a strong patient-provider relationship. Understanding what your needs, wants, and desires for your pregnancy and birth experience can help you determine if midwifery care is right for you. Oftentimes, the best way to decide which provider is best for you is to determine what kind of birth you would like to have. Making a birth plan is a great way to think about some of the decisions you will need to make during your pregnancy birth and postpartum. Once you know what is important to you, you are better able to advocate for yourself during your birth experience. To read more about midwifery care in Ontario check out the Association of Ontario Midwives website. 


References

1. Ontario midwives: AOM [Internet]. [cited 2023 Sept 6]. Available from: https://www.ontariomidwives.ca/ 

2. Ontario midwives: AOM [Internet]. [cited 2023 Sept 6]. Available from: https://www.ontariomidwives.ca/uninsured-clients

3. Government of Ontario, Ministry of Health and Long-Term Care.  [Internet]. Government of Ontario, Ministry of Health and Long-Term Care; [cited 2023 Sept 6]. Available from: https://www.health.gov.on.ca/en/public/programs/midwife/ 

4. College of Ontario Midwives: PDF [Internet]. [cited 2023 Sept 6]. Available from: https://www.cmo.on.ca/wp-content/uploads/2019/10/Archived-16.Prescribing-and-Administering-Drugs.pdf

5.Ontario midwives: AOM [Internet]. [cited 2023 Sept 6]. Available from: https://www.ontariomidwives.ca/what-midwife

6.Cancer Care Ontario:  [Internet]. [cited 2023 Sept 6]. Available from: https://www.cancercareontario.ca/en/types-of-cancer/cervical/screening

7.Ontario midwives: AOM [Internet]. [cited 2023 Sept 6]. Available from: https://www.ontariomidwives.ca/midwifery-numbers

8.Ontario midwives: AOM [Internet]. [cited 2023 Sept 6]. Available from: https://www.ontariomidwives.ca/indigenous-midwifery

9.Ontario midwives: AOM [Internet]. [cited 2023 Sept 6]. Available from: https://www.ontariomidwives.ca/consultations-transfers-care-born


Additional Resources 


More information about midwives: 


How to find a midwife


The Toronto Birth Centre 


The Ottawa Birth Centre 


Birth Plans 



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