A History
Although the midwifery profession has developed only recently in Canada, it is an established concept around the world. In most countries, a midwife is the primary source of care for the pregnant woman and it is estimated that 80% of all births are attended by a midwife rather than a doctor.
For most of history, babies were born with the aid of a midwife. Although she would be uneducated according to today's standards, tribal customs were used and based on magic, charms, and chants to keep demons away. From the 1st to the 15th century, midwives continued to care for women in childbirth, although their status varied from time to time.
Healing was an important part of the midwife's role. She would use her knowledge of herbs, gemstones, touch, energy, and nutrition within her work to cure disease. And this wisdom would be passed from mother to daughter over many generations.
Around the 14th century in Europe, many female healers and midwives were accused of being witches and burned at the stake. These successful healers were seen as a threat to the church, patriarchy, and the developing medical profession. Witch hunts continued for several centuries, although the remaining midwives continued to attend the majority of births with their special knowledge.
This situation continued until the invention of obstetrical forceps during 17th and 18th century. With this development, men began to dominate both medical schools and the field of childbirth. In addition, there was little competition left from women midwives as witch hunts had killed nine million women over four centuries. By the mid 18th century, the number of male midwives had increased and the remaining female midwives were resentful of their presence.
In 1886, midwifery became a compulsory part of medical training and such doctors were primarily used by upper class women. Midwives would attend births for other families but were paid very little, if anything at all.
It was not until 1902 that the Midwives Act was developed to establish rules regulating the training and employment of midwives in Britain. Scotland and Ireland soon followed with similar Acts to protect the midwifery title. Between 1902 and 1936, the majority of births were at home with either a midwife or a doctor in attendance. In 1935, it was advised that midwives should hold pregnancy clinics and advise women to see their doctor both early and late in pregnancy.
World War II increased the demand for birth to take place in the hospital, since there was little friend or family support in the home. From this time onward, the hospital was the primary place of birth and, in Britain, this is where the majority of midwives now work.
Medical technology continued to develop after WWII. Coupled with the implementation of the National Health Service in 1948, more doctors and consultants were brought into the hospital and the autonomy of the midwife was greatly reduced. In 1970 ,it was recommended that 100% of births be carried out in a hospital in attempt to reduce infant deaths.
It is now understood that the hospital is not necessarily the safest place to give birth and, in fact, many problems may arise that could have been avoided at home. A new awareness seems to be evolving and birth once again is becoming accepted in the home, with a midwife.
Midwifery in Canada
Much of Canada's midwifery history began with the Aboriginal people in the early and mid 1800's. Women were working as midwives in every community and attending the majority of births, although they may not have had any particular training or special knowledge. They were, on the other hand, available to help women in labour and usually had experienced childbirth themselves. There were some women, known as "granny" midwives, who had learned the art of midwifery through their mothers and grandmothers in a more formal way. In addition, trained midwives had come from the United Kingdom, Europe, and other parts of the world, bringing their ancient traditions of midwifery practice with them.
Most circa 1800 midwives received very little payment of any kind for their work but saw it as their calling and their place in the community. Travel would occasionally be made over long distances by horseback or even foot to reach a family or woman in labour. From the late 1800's, doctors began to dominate medical practices and this carried over into the world of midwifery. Attempts were made to eliminate midwives and replace them by doctors. In 1815, an Act was passed that protected the role of the midwife in Upper Canada to practice without a license. However, the Ontario Medical Act of 1865 changed this to prohibit any person from practicing midwifery without registration. Midwives were then charged and doctors took over the control of childbirth. As a result, midwifery in Canada declined.
Throughout the 1900's, midwifery continued to decline, apart from a few strong midwives who followed their hearts and helped with births among friends and neighbours. It was not until the 1960's and 1970's that midwifery made its appearance again. Birth had become a highly medicalized practice and 98% were attended by doctors in hospitals. Groups of nonconformist women began to oppose hospitalization for childbirth. They fought for years to gain control over their bodies and to bring the experience of birth back to women.
Midwives were in demand in order to help women achieve positive birthing experiences. Important issues such as the percentage of episiotomies, drugs, artificial onset of labour, forceps deliveries and caesarian sections were of concern to women who believed their bodies were capable of giving birth without intervention. In addition, hospitals followed practices such as separating the mother and baby after birth and little attention was given to the family's emotional or psychological needs. As a result, midwifery is now returning as an accepted, and possibly preferred, method of care in pregnancy and childbirth.
Midwifery in Ontario
During the late 1970's, a small number of women began to educate themselves to be midwives. There was an increasing demand for this type of care and a few radical physicians supported this move. As interested increased over the next ten years, an apprentice program was started which included travel to other countries to educate others.
In 1983, a group of midwives and other members of the community met to form the Midwifery Task Force of Ontario. Their role was to promote the recognition of midwifery. About the same time, the Association of Ontario Midwives was formed in attempt to include midwifery into the health care system. This work continued until 1991 when the Midwifery Act was passed and on the last day of 1993 it was proclaimed. This made Ontario the first province in Canada to have midwifery as a regulated profession in the health care system. There are several provinces that have now legalized midwifery since 1993, including British Columbia, Alberta, Manitoba and Quebec.
What Is A Midwife?
A midwife has been internationally defined as "...[having] acquired the requisite qualifications to be registered and/or legally licensed to practice midwifery. She must be able to give the necessary supervision, care and advice to women during pregnancy, labour and the postpartum period, to conduct deliveries on her own responsibility and to care for the newborn infant...She has an important task in health counseling and education, not only for the patients, but also within the family and community...She may practice in hospitals, clinics, health units, domiciliary conditions, or in any other service."
A midwife should be an expert on normal birth. She should it as a healthy event in your life and be there for support and advice. She will respect the significance that birth has within your family, understand that your needs are unique, and ensure that each decision is your own. Health care will be given throughout pregnancy and after birth, with focus on prevention and using technology appropriately, to the extent that makes you feel comfortable. In addition, it is very important for the midwife to understand psychology and its importance in the birthing process.
Continuous care is given by one midwife so that a relationship may form between you. In most cases, this midwife will be on call during the time surrounding your expected date of delivery, give you support during labour, and assist you in giving birth. There will be a second midwife attending in your final stages of labour as support for the primary midwife. Visits during your pregnancy will be done at your home or community setting and you will give birth in the setting of your choice.
It is the midwife's duty to educate you with the information you need to make decisions about your care. She will then respect your decision, allowing you to feel in control.
Specific Activities of the Midwife
- Carry out physical examinations to ensure a healthy pregnancy
- Advise on and arrange necessary examinations for more complicated situations
- Provide education and preparation for childbirth including health care advice
- Care for the mother during labour and monitor the condition of the unborn baby by appropriate means
- Support and assist the woman during a normal vaginal birth
- Recognize warning signs or abnormality during pregnancy or birth which would need referral to an obstetrician
- Be prepared to carry out emergency procedures in the absence of an obstetrician
- Administer certain medications or pain relief
- Examine and care for the newborn infant
- Care for the woman after the birth for a period of six weeks, advising her on infant care and family planning
Continuity of Care
Continuity of care means that during your pregnancy, labour, and up to six weeks after, you will be able to reach one of four midwives involved in your care, 24 hours a day. Ideally, you will see the same midwife the majority of the time so you may develop a trusting relationship. She will get to know your physical and emotional needs and the time surrounding the birth should feel safe.
During your labour, your midwife will visit you at home, giving you the necessary support and encouragement. She may come and go as needed and if your baby is to be born in the hospital, this move will be made at the appropriate time. Your midwife will stay with you during the later stages of labour, throughout the birth, and for a period of time after your baby has been born.
It is not necessary, in most circumstances, for a doctor to be present at the birth. Continuity of care appears to have a positive effect on the satisfaction and emotional well-being of women. The frustration of inconsistent advice is avoided, labour is not disrupted by new staff who are unaware of your family's needs, and a familiar atmosphere can help relax you so you may focus on the incredible event taking place.
Choice of Birth Place
Consistent with the belief that pregnancy is not an illness, the majority of care given to you will be outside the hospital. A community setting or your home itself will often be used to provide pregnancy care over the nine month period. After the birth of your baby, care will once again be given in your home.
The choice of where to give birth is one that requires special consideration and plenty of information before a decision is made. This will be discussed with your midwife at various times during your pregnancy and it is important that both you and your partner are comfortable with this decision. Each midwife in Ontario is capable of providing birth care in your home, a birthing centre, or the hospital. It may be advised, however, that some women give birth in the hospital as a result of health concerns for either herself or her baby. These is discussed in Points To Be Aware Of. On the other hand, some women may be much better off at home. Home birth is discussed further in What This Care May Mean To You.
Informed Choice
The idea behind informed choice is that you, the pregnant woman, is made to be the primary decision maker. Naturally, your family plays an important role in this process and it is the midwife's responsibility to provide the necessary information so that you may make an informed decision regarding your care.
Time is also an important factor in midwifery care. Adequate time must be spent with the woman in a relaxed atmosphere so that any relevant issues may be discussed. During your pregnancy and after the birth, most visits with your midwife will last forty-five minutes to one hour. Discussions may include a wide range of topics such as health concerns, family dynamics, birth plans, specific fears, or infant feeding. By spending periods of time with your midwife, it is hoped you will be able to talk about what you feel is important in an open and equal partnership.
What This Care May Mean To You
There are many reasons why you may choose to have a midwife during your pregnancy and birth, some of which are outlined below.
Familiarity and Continuity of Care
A sense of familiarity develops from the first meeting with your midwife. The initial visit will take at least one hour and this time allows for the establishment of an important relationship to develop. As a result of knowing you so well, your midwife will feel a genuine interest in the outcome of your labour and in helping you achieve your expectations.
Studies have shown that women receiving continuity of care were more likely to discuss their worries in pregnancy, feel well prepared for labour, feel in control during labour, use less pain killers, regard her midwife as supportive, and actually enjoy the birthing experience. There was also less need for infant resuscitation.
Communication continues to be important after the birth, particularly when discussing the events that took place during labour. Most women do not have the opportunity to speak to the professional after their baby's birth, leaving them with many unanswered questions. It may be days or weeks until the moment comes when it is important for you or your partner to review the events of the birth and understand why certain situations may have appeared. One woman describes her feelings as such: "I felt most of the time that the care I received was impersonal and rushed, especially in the hospital after the birth of my daughter. I needed to discuss the birth and medical details, but was never given the chance or invited to." With midwifery care, this situation should not arise as your midwife will visit you for six weeks following your baby's birth and give you many opportunities to discuss the events surrounding it.
Support in Labour
The provision of both physical and emotional support during labour is an important aspect of the midwife's role. Physically, this may involve hand-holding and massage in some situations or simply a subtle presence in others.
Emotionally, your midwife must be prepared to deal with any number of emotions that may arise while you are in labour. Encouragement, truthfulness and a calm manner all play a part in helping you throughout. Relevant explanations will be provided and your fears will be dealt with gently.
Research has shown that the presence of a support person throughout labour reduced the need for pain relief, reduced the number of doctor assisted deliveries and caesarian sections, improved the condition of the newborn, and slightly reduced labour time. In addition, these women found their birth experience to be more positive and labour was better than expected, with fewer feelings of tension.
Labour Positions
It still remains that most hospitals encourage women to give birth lying down on their backs. In some cases, particularly when an epidural is being used, this may be a reasonable position. On the other hand, if you have full use of your body, there are many other ways to give birth that assist in the process and create less stress for your baby.
The image of a woman giving birth on her back is one that has been firmly planted through television and probably was the experience of our mothers and grandmothers. Although this may be the most convenient way for the caregiver to "assess progress" and "help" the baby birth, it is not necessarily the easiest method for you.
First, lying flat results in a great deal of pressure from the baby against your back, causing a decrease in blood flow coming from your heart. This, in turn, sends less blood to your baby and reduces his or her available oxygen.
Second, contractions from your womb become less effective in this position, thus lengthening the amount of time you need to be in labour. Walking, standing, sitting, squatting, or even lying on your side may be alternative positions that not only use the force of gravity but also give you the freedom of movement that allows you to feel empowered and in control. Every midwife should be familiar with these positions during labour, encourage their use, and be capable of helping you deliver your baby in the position most comfortable to you.
Home Birth
One option, when choosing to have a midwife, is to have your baby at home. There are many reasons why you may choose this option, including issues of control, safety, intimacy, freedom and normalcy. Childbirth is a normal, healthy, life-changing event in a woman's life. For some women, the hospital represents illness and helplessness. Simply entering the building may strip away her confidence and feelings of control over what is happening to her body in labour. Emergency equipment in the hallway and delivery rooms is a constant reminder that she may not be capable of giving birth, while continuous checking of her "progress" puts her under pressure to perform quickly. On the other hand, these procedures may be very reassuring to other women and are necessary in certain circumstances.
It is important to feel comfortable and safe in the place you choose to give birth. If your home is not a positive environment, then giving birth at home may not be the best option for you. One valuable aspect of having a home birth is the freedom you receive. The midwife is considered a guest in your home; you set the atmosphere, eat food when you feel hungry, spend time in different rooms or outdoors, and no one may enter unless invited. The period of time after your birth is given to you, as a family, and should not be disrupted by unnecessary procedures.
Research has shown that women who experience both home and hospital deliveries have a strong preference for home birth. Home birth safety has been questioned over the years, but it is now understood that the home is as safe a place to give birth as the hospital, provided your pregnancy is healthy and a skilled midwife is in attendance. It has been shown that women receiving care in a home-like setting used less pain killers, had fewer problems with the unborn baby's heart rate, were more mobile, and were more satisfied with their care.
Your midwife will openly discuss any relevant issues with you to help you decide the best place to give birth. Nancy Stewart of the Association for Improvements in Maternity Services summarizes: "All of living involves some risk, and this applies to giving birth and being born, wherever the birth takes place...It is important to go beyond the statistics, to consider the real influences on safety for you and your baby...Where to give birth is not a matter of physical safety versus feelings. They are inextricably wrapped up together and you can trust the wisdom of your feelings in choosing where your baby is to be born."
Breast Feeding
One important aspect of having a midwife is the support you will receive at home after the birth of your baby. In Ontario, a woman who delivers her baby in the hospital with a doctor will then return home after a period of one to three days and be left to cope alone. It is very important to have good support 24 hours a day for the first few weeks, particularly if you choose to breast feed.
Some women may find it quite natural to feed their babies, especially if they have been around other women breast feeding. Unfortunately this is not the experience of many women, some who have never been in contact with a baby this young. Your midwife will be available day and night to speak to in difficult times. She will frequently come to your home during the first week and she will be in contact during the six-week period following. Any breast feeding difficulties can be prevented with the proper advice and support.
While your midwife will respect any decision you make regarding breast or bottle feeding, she will inform you of the advantages breast feeding gives both you and your baby. Breast feeding increases your metabolism helps you lose weight after the birth of your baby. The likelihood of many cancers are reduced, including breast and ovarian cancer, and urinary tract infections become less frequent. Furthermore, women speak of a great physical and/or emotional satisfaction from breast feeding and the creation of a very special bond between mother and child.
Nutritionally, breast milk contains all the vitamins and minerals your baby needs in the right proportions. Elements are found in breast milk that promote growth and brain development that are not present in cow's milk. Breast milk is more easily digested and its composition changes daily, in tune with your growing baby's needs. In addition, breast milk strengthens your baby's immune system and protects against infection and many forms of disease. Your midwife will be able to discuss the benefits of breast feeding and, if you decide to do so, she will be there to guide you through what is often a very fulfilling experience.
For more information, see the dedicated section on Breastfeeding (and Related Issues).
Points To Be Aware Of
When planning, it is important to be aware of potential obstacles that could change the way you envisioned your birthing process. Different hospitals follow different guidelines and what may be accepted in one setting may not be possible in another. In addition, you may choose to be cared for by a midwife but find at some point that you need to see the doctor. Several examples follow.
The Use of Water in Labour
Water has been found to be very useful in labour to ease pressure and discomfort. Babies may be born into the water if certain procedures are followed, such as keeping the temperature within a specific range. Your midwife may be comfortable with the use of water for labour or delivery and can provide you with more information. On the other hand, many hospitals may not have a birthing pool or it may already be occupied and it is important to be flexible in such situations. In addition, it is thought that labour should reach a certain point before you enter the pool and some hospitals list certain birthing circumstances in which the pool may not be used. It is possible to either build or hire a birthing pool for use in your own home. This can be discussed with your midwife locally.
Transfer of Care to a Doctor
Certain complications may arise during the course of your pregnancy that should be referred to another specialist. This may simply be for one appointment or could be for the remainder of your pregnancy. A midwife is responsible for normal pregnancies and deliveries only. If you need to have care continued by a doctor, your midwife may remain with you in a supportive role throughout pregnancy, labour, and the time following, but is no longer part of the decision-making process. Some examples include pre-eclampsia, diabetes, polyhydramnious (excessive fluid around the baby), intra-uterine growth restriction, bleeding, multiple pregnancies, or very early labour. This is by no means a complete list and each of these situations have different degrees of severity. In most cases, if you need medical attention, you would be advised to deliver your baby in the hospital under a doctor's care.
Transfer From Home to Hospital During Labour
If you are having a home birth, it is important to be aware of reasons why you may have to transfer to the hospital during labour. Often it is the woman who makes this decision after being in labour for what she feels is too long, sometimes a couple of days. It may be that she feels exhausted or needs pain relief, or it is possible that she was not given an accurate explanation of what to expect.
The midwife in your home needs to feel confident with the birthing process so that you will feel this energy and know that you are safe. Reassurance and a calm manner will greatly help you, the birthing woman, in fearful times. Both you and your partner should eat when you are hungry and sleep when you feel tired. In the early stages of birth, the excitement can be overwhelming and your basic needs forgotten, leading to exhaustion in the later stages. Other reasons why hospital transfer may be advised include heavy bleeding, excessive pain, fetal heart abnormalities, and, in rare cases, for a placenta that is stuck after the birth or for difficult stitches. Every midwife is skilled in providing emergency care and if a move to the hospital is required, she will stay with you and continue to care for you in the hospital.
Unwanted Interventions in the Hospital
Often women will arrive in labour with a well constructed birth plan stating which interventions they would like to avoid in labour. This may not be necessary if you are being cared for by a midwife, since she should be well aware of your particular needs before labour begins. However, the hospital you give birth in, with or without a midwife, may have "rules" regarding machines to monitor your baby's heart rate, breaking your waters, regular internal examinations, restriction of food and drink in labour, and induction of labour for being overdue. If you feel strongly about natural birth and avoiding intervention, it is a good idea to understand when these may be necessary and when they can be avoided.
The medicalization of childbirth has left women feeling they no longer have control over birthing procedures and do not know how to give birth without these tools. We need to once again follow our intuition and trust our bodies. Further reading on natural childbirth is provided in the For More Information section.
"Real Life"
The Story of "Sean: My Midwife Baby"
My first two births were joyous and sacred events, and yet this time, for my third baby, I longed to do things a little differently. Birth had never been a problem, but what I really wanted was support during my pregnancy. I wanted someone to comfort me if I was concerned, and answer the many questions I had, even as a third time mother.
My midwives thought I had a great attitude. When I asked them how I could slow my labour a little, they suggested I deliver lying on my side this time. (My birthing history seemed to suggest a squat was too fast for me.)
Once again, my first indication of birth was my water breaking. It was a warm Sunday afternoon, and I was just preparing a picnic to go to the beach, when my water broke. This time I was afraid I didn't have much time. Phil and I had decided on a hospital birth, assisted by only a midwife (no doctors or nurses unless absolutely necessary.) I was tense in the car because we got into a traffic jam. When we reached the hospital, I felt calm. Our midwife met us at the hospital and helped my children get ready for my third birth. I especially wanted my daughter to have the opportunity to see a positive birth experience. Though my son was quite young, he insisted on attending also. (Perhaps one day he will be a great support to his partner in labour...)
As hoped, the birth went smoothly again, and I was perfectly lucid. I was on my side during birth, and this did help slow things down. The midwife used a hot oil massage on my perineum to help avoid tears. She applied the oil at just the right moment and it felt soothing.
Sean slipped out quickly and easily, quick as lightening. I needed no stitches, and had no tears. Sean lay on my stomach for 15 minutes while the umbilical cord continued to pulse, then Phil cut it. Within 20 minutes, baby Sean was nursing, and continued for an entire hour.
After, the midwife ran a warm bath, and baby and I went in. She helped to clean me up and while baby Sean continued to nurse, she washed him to. Then we all dried off, got dressed, and walked off to our car to go home. In total, I was in the hospital 3 hours. No drugs, no stitches, no interventions.
So much of life can be imperfect; I am honored I had the experiences of three sacred births.
-- Karin Harris, Calgary, Alberta
For More Information
Organizations
Association of Ontario Midwives
562 Eglinton Avenue East, Suite 102
Toronto, Ontario
M4P 1B9
Tel.: 416.481.2811
Fax: 416.481.7547
Web: www.aom.on.ca
Email: admin@aom.on.ca
College of Midwives of Ontario
2195 Yonge Street, 4th Floor
Toronto, Ontario
M4S 2B2
Tel.: 416.327.0874
Fax: 416.327.8219
Email: admin@cmo.on.ca
Midwife Alliance
27 Roncesvalles Avenue, Suite 301
Toronto, Ontario
M6R 3B2
Tel.: 416.534.9161
Fax: 416.531.3981
Websites
Midwifery Training in Ontario
www.fhs.mcmaster.ca/midwifery
Looking for a Midwife?
www.aom.on.ca/links.htm
The Compleat Mother -- A magazine on pregnancy, birth, and breastfeeding
www.compleatmother.com
Birthing and Midwifery Issues
www.birthlove.com
The Midwifery Link -- Resource for midwives, birth professionals, and parents
www.themidwife.org
Midwifery Today -- A midwifery magazine.
www.midwiferytoday.com
Books & Magazines
Baldwin, Rahima Pregnant Feelings. Celestial Arts.
Burgess A. Fatherhood Reclaimed. Vermilion Books.
Chamberlain, David Babies Remember Birth. Ballantine Books.
Gaskin, Ina May. Spiritual Midwifery. The Book Publishing Company.
Heinowitz J. Pregnant Fathers. Parents as Partners Press.
Inch, Sally. Birth Rights. Green Print Merlin Press.
Margaret, Jowitt and Peter Wooller. Childbirth Unmasked.
Marnie, Eve. Lovestart: Pre-birth Bonding.
Odent, Michel. Babies, Breastfeeding and Bonding.
Odent, Michel. Birth Reborn.
Peterson, Gayle. Birthing Normally. Shadow and Light Publications.
Ray, Sondra and Bob Mandel. Birth and Relationships.
Renfrew, Mary, Fisher, Chloe and Suzanne Arms. Bestfeeding. Celestial Arts.
Weed, Susan. Herbal for the Childbearing Year. New York: Ash Tree Publishing.
The Compleat Mother -- The Magazine of Pregnancy, Birth and Breastfeeding.
RR#3, Clifford, Ontario, Canada, NOG 1MO 519.327.8785
See also
Breastfeeding (and Related Issues), Pregnancy (and Related Issues)
