Birth Models That Work

3. The Ontario Midwifery Model of Care

89 Chapter 3 The Ontario Midwifery Model of Care Margaret E. MacDonald and Ivy Lynn Bourgeault As a profession, Canadian midwifery is a latecomer of sorts, only having been officially integrated into several provincial health care systems beginning as recently as 1994. Prior to this time, Canada had no formally recognized profession of midwifery. Midwives in most Canadian provinces are now autonomous professionals who provide primary, continuous care at home and in the hospital. Midwifery is legally accessible to women in these provinces experiencing normal, uncomplicated pregnancy and birth, and in all but one province where services are provided, it is publicly funded. Drawing on ethnographic, historical, and sociological data, in this chapter we describe the integration of midwifery in the province of Ontario from its days as a grassroots social movement to its present status as a full profession.1 We begin by outlining the history of midwifery in Canada and the ways in which it has influenced the profession’s contemporary form. We then go on to detail the structural aspects of midwifery in Ontario that make it unique, including midwives’ autonomous, professional status; their model of care, including home birth and public funding; and their direct-entry education program. We show how these aspects of the Ontario midwifery profession work to support women to “give birth safely with power and with dignity” (College of Midwives of Ontario 1994: 1) in their choice of birth setting. In building a case for Ontario midwifery as a birth model that works, we also include data on client satisfaction and clinical outcomes. Finally, we reflect on several challenges and questions still facing midwifery in Ontario and Canada as it continues to grow. 90 m. e. macdonald and i. l. bourgeault HISTORICAL FORCES SHAPING CANADIAN MIDWIFERY: A PIONEERING SPIRIT AND A HISTORY OF ERASURE Canadian midwifery’s contemporary philosophy and form has been shaped significantly by its unique history, including the pioneering spirit of traditional midwives in the 18th and 19th centuries, and the history of their subsequent denigration and erasure. In the 20th century, the most significant shaping forces included the central values and goals of midwifery as a social movement as it emerged in the 1970s and 1980s, the role of the state, and the influences of professional midwifery in other jurisdictions. Historically, the nature of midwifery practice varied across Canada. Neighbor networks, in which women were assisted in childbirth by local women respected for their expertise, were common in Ontario and in some western provinces, while established midwifery professions existed in Nova Scotia, Quebec, Newfoundland, and in certain ethnic and aboriginal communities (Benoit 1991; Biggs 1983; Kaufert and O’Neil 1993; Laforce 1990; Mason 1988; Mitchenson 2002). Historical accounts of midwifery in Canada tend to represent it largely as a set of social practices embedded in women’s domestic culture in which continuity of care was central: midwives stayed with the mother throughout the labor; guided and comforted her; offered gifts of food, clothing, and housework; and ensured a postpartum rest period. As in many places in the world, such forms of traditional midwifery either were stamped out or faded away. Starting in the mid-19th century , physicians in Canada, concerned with establishing their authority and obtaining a reliable clientele, engaged in a successful campaign to discredit traditional midwives as incompetent, unclean, and outdated (Ehrenreich and English 1973; Mason 1988; Mitchenson 1991). At the same time, childbirth was being redefined as a medical event for which women were considered essentially unsuited as attendants and too frail to attempt unaided by male experts. Thus, prevailing gender ideals—especially among the middle and upper classes—also contributed to the demise of midwifery (James-Chetalet 1989). Hospital-based, physician-attended childbirth grew steadily through the late 19th and early 20th centuries in Canada, and by the 1940s, traditional forms of midwifery virtually had ceased to exist.2 In the United Kingdom and the United States, the maternity care gap opened up by the elimination of traditional forms of midwifery was to some extent filled by the introduction of professional nurse-midwifery, but this was not the case in Canada. Consequently, Canada had the dubious distinction of being one of the only industrialized nations without a midwifery profession for more than a century. This social and legal void was significant in that it left open a space for midwifery to emerge as a social movement because “midwife” was not a protected title in Canada. The...