Secretario de Salud, Mexico City Dr Jan Christilaw MD, OB-GYN, MHSc President BC Women’s Hospital

Professional Midwifery:Professional Midwifery:International Models and International Models and

ApplicationsApplicationsLessons from Canada and around Lessons from Canada and around

the worldthe world

Secretario de Salud, Mexico CitySecretario de Salud, Mexico City

Dr Jan ChristilawDr Jan ChristilawMD, OB-GYN, MHScMD, OB-GYN, MHSc

President BC Women’s HospitalPresident BC Women’s HospitalVancouver, BC, CanadaVancouver, BC, Canada

June 17, 2010June 17, 2010

The perfect time:The perfect time:““Women DeliverWomen Deliver” Conference:” Conference:Midwives are a large part of the Midwives are a large part of the solution to meeting the MDGssolution to meeting the MDGs

Questions we need to answerQuestions we need to answer

How do we best serve the obstetrical How do we best serve the obstetrical needs of the women in our respective needs of the women in our respective countries?countries?

How do we integrate midwifery care How do we integrate midwifery care into a highly scientific medical into a highly scientific medical system?system?

How do we assure safety, quality and How do we assure safety, quality and professional standards?professional standards?

How do we best serve our indigenous How do we best serve our indigenous and underserviced populations?and underserviced populations?

An Overview of this talkAn Overview of this talk

1) Historical perspectives: international, 1) Historical perspectives: international, national and localnational and local

2) Canadian midwifery: regulation and 2) Canadian midwifery: regulation and educationeducation

3) Obstetricians role (SOGC Policy)3) Obstetricians role (SOGC Policy) 4) Midwifery in BC: policy and outcomes4) Midwifery in BC: policy and outcomes 5) Applications to indigenous, 5) Applications to indigenous,

underserved and remote populationsunderserved and remote populations 6) Summary and lessons learned6) Summary and lessons learned

Midwifery around the worldMidwifery around the world

Since the dawn of Since the dawn of time…time…

Midwifery has been Midwifery has been the meeting point the meeting point for traditional for traditional knowledge and knowledge and modern caremodern care

Supplanted by the Supplanted by the medical model in medical model in some places much some places much more than othersmore than others

Midwifery around the worldMidwifery around the world

Decline of Decline of midwifery as an midwifery as an autonomous autonomous profession in the profession in the 1800-early 1900 1800-early 1900 corresponded to corresponded to the rise of the the rise of the medical professionmedical profession

Wide variations Wide variations around the worldaround the world

Midwifery around the worldMidwifery around the world

In indigenous In indigenous societies and societies and underserved areas, underserved areas, midwives remained midwives remained the primary providers the primary providers of perinatal careof perinatal care

Largely unregulated Largely unregulated and unsupported by and unsupported by mainstream medical mainstream medical systems until systems until recentlyrecently

Midwifery in CanadaMidwifery in Canada

In Canada, aboriginal midwifery has existed for In Canada, aboriginal midwifery has existed for 10,000 years10,000 years

Largely invisible, and undervalued until Largely invisible, and undervalued until recentlyrecently

Now, we as Obstetricians have embraced and Now, we as Obstetricians have embraced and welcomed midwives as our colleagues, and welcomed midwives as our colleagues, and strive to learn from them and they from usstrive to learn from them and they from us

Canadian Association of Midwives is a highly Canadian Association of Midwives is a highly respected national organization that works respected national organization that works closely with other providers of obstetrical careclosely with other providers of obstetrical care

Canadian Association of Canadian Association of MidwivesMidwives

CAM is the national professional CAM is the national professional organizationorganization

Currently 938 members; more than 800 Currently 938 members; more than 800 registered midwivesregistered midwives

Approximately 100 new registrants each Approximately 100 new registrants each yearyear

Midwifery regulated and funded in almost Midwifery regulated and funded in almost all Canadian jurisdictions, all Canadian jurisdictions, starting in starting in 19941994, covering over 95% of the Canadian , covering over 95% of the Canadian populationpopulation

Regulation of Midwifery In CanadaRegulation of Midwifery In CanadaProvince/TerritoryProvince/Territory ImplementationImplementation Public FundingPublic Funding

AlbertaAlberta Yes - 1998Yes - 1998 YesYes

British ColumbiaBritish Columbia Yes - 1998Yes - 1998 YesYes

ManitobaManitoba Yes - 2000Yes - 2000 YesYes

New BrunswickNew Brunswick Anticipated for 2010Anticipated for 2010 Likely yesLikely yes

Newfoundland & Newfoundland & LabradorLabrador Under reviewUnder review ??

North West North West TerritoriesTerritories Yes - 2005Yes - 2005 YesYes

Nova ScotiaNova Scotia Yes - 2009Yes - 2009 YesYes

NunavutNunavut Yes - 2008Yes - 2008 YesYes

OntarioOntario Yes - 1994Yes - 1994 YesYes

Prince Edward Prince Edward IslandIsland Under reviewUnder review ??

QuebecQuebec Yes – 1999Yes – 1999 YesYes

SaskatchewanSaskatchewan Yes – 2008Yes – 2008 YesYes

YukonYukon Under reviewUnder review ??

Professional MidwiferyProfessional Midwifery

Requires a robust infrastructure Requires a robust infrastructure than includesthan includes::

Funding and support from governmentFunding and support from government Support from other professional bodiesSupport from other professional bodies Quality assurance Quality assurance High quality educationHigh quality education Ongoing evaluation and assessmentOngoing evaluation and assessment

Midwifery Education in CanadaMidwifery Education in Canada

Education Education programprogram

Seats per Seats per yearyear

Current Current enrollmentenrollment

Total Total graduatesgraduates

Graduates Graduates in 2009in 2009

McMasterMcMaster 3030 9494 148148 1515LaurentianLaurentian 3030 9393 103103 1111RyersonRyerson 3030 108108 139139 2424UBCUBC 1010 4242 4141 99UQTRUQTR 2424 7474 5252 1616UCN/KOBPUCN/KOBP 55 44 NANA 11TOTALTOTAL 129129 415415 483483 7676

Professional PerspectivesProfessional Perspectives

SOGC (Society of Obstetrician-SOGC (Society of Obstetrician-Gynecologists of Canada) Policy Gynecologists of Canada) Policy Statement on MidwiferyStatement on Midwifery

EducationEducation Practice SettingPractice Setting Integration of Midwifery into Health Integration of Midwifery into Health

Care Service TeamsCare Service Teams

SOGC Policy StatementSOGC Policy Statement

Education:Education: SOGC supports midwifery education SOGC supports midwifery education

leading to a degree or diploma leading to a degree or diploma

SOGC extends membership to SOGC extends membership to registered midwives and midwifery registered midwives and midwifery students and offers them access to students and offers them access to ongoing educationongoing education

SOGC Policy StatementSOGC Policy Statement

Practice SettingPractice Setting SOGC recognizes the importance of SOGC recognizes the importance of

choice for women and their families, choice for women and their families, including setting of birthincluding setting of birth

All women should receive information All women should receive information about the risks and benefitsabout the risks and benefits

SOGC Policy StatementSOGC Policy Statement

Integration of Midwifery into Integration of Midwifery into Health Services TeamsHealth Services Teams

Midwives need access to resources Midwives need access to resources and facilities such as laboratory and facilities such as laboratory testing, ultrasound, etctesting, ultrasound, etc

Seamless integration with others Seamless integration with others professionals professionals

Appropriate remunerationAppropriate remuneration Continuous reviewContinuous review

SOGC Policy: IntegrationSOGC Policy: Integration

Inclusion in committees concerned Inclusion in committees concerned with maternal and newborn issueswith maternal and newborn issues

Development of policies concerned Development of policies concerned with complaintswith complaints

Harmonization of obstetrical standardsHarmonization of obstetrical standards Provision of appropriate malpractice Provision of appropriate malpractice

insuranceinsurance Support for achieving credentials and Support for achieving credentials and

hospital privilegeshospital privileges

SOGC summary statementSOGC summary statement

““We are confident that the We are confident that the integration of midwifery is fostering integration of midwifery is fostering excellence in maternity care for excellence in maternity care for women living in Canada and their women living in Canada and their families, which is the goal of our families, which is the goal of our organization”organization”

Scope of Practice of Canadian Scope of Practice of Canadian MidwivesMidwives

““Registered midwives are health Registered midwives are health professionals who provide primary professionals who provide primary care to women and their babies care to women and their babies during pregnancy, labour, birth and during pregnancy, labour, birth and the postpartum period. the postpartum period.

They are fully responsible for clinical They are fully responsible for clinical decisions and the management of decisions and the management of care within their scope of practice”.care within their scope of practice”.

CAMCAM

Midwives Scope of PracticeMidwives Scope of Practice

Provide the Provide the completecomplete course of low-risk course of low-risk prenatal, intrapartum and postnatal care, prenatal, intrapartum and postnatal care, including physical examinations, screening including physical examinations, screening and diagnostic tests, the assessment of and diagnostic tests, the assessment of risk and abnormal conditions, and the risk and abnormal conditions, and the conduct of normal vaginal deliveries. conduct of normal vaginal deliveries.

Work in collaboration with other health Work in collaboration with other health professionals and consult with or refer to professionals and consult with or refer to medical specialists as appropriate.medical specialists as appropriate.

Regulated by provincial collegesRegulated by provincial colleges

Midwifery at BC Women’s HospitalMidwifery at BC Women’s Hospital

7500 births per year at BC Women’s 7500 births per year at BC Women’s HospitalHospital

At the vast majority of births, fathers At the vast majority of births, fathers are presentare present

It is the high risk centre for the It is the high risk centre for the province which has 45,000 births per province which has 45,000 births per yearyear

50 midwives are on staff at BCW 50 midwives are on staff at BCW 166 midwives are registered in the 166 midwives are registered in the

province of British Columbiaprovince of British Columbia

Number of Number of DeliveriesDeliveries

2007/20082007/2008 2008/20092008/2009

TotalTotal %% TotalTotal %%

1. BCWH1. BCWH 609609 62.5%62.5% 761761 59.2%59.2%

2. SPH2. SPH 167167 17.1%17.1% 273273 21.2%21.2%

3. Home3. Home 198198 20.3%20.3% 251251 19.5%19.5%

TotalTotal 974974 100.0%100.0% 12851285 100.0%100.0%

Mode of Mode of DeliveryDelivery

2007/20082007/2008 2008/20092008/2009 BC TotalBC Total

TotalTotal %% TotalTotal %% TotalTotal% of Prov% of Prov

SVDSVD    709709 72.8%72.8% 940940 73.2%73.2% 2611426114 59.4%59.4%SVD- SVD- BreechBreech

% of all % of all SVDSVD 11 0.1%0.1% 66 0.6%0.6% 109109 0.4%0.4%

VacuumVacuum    3030 3.1%3.1% 4747 3.7%3.7% 30103010 6.8%6.8%

ForcepsForceps    6969 7.1%7.1% 7676 5.9%5.9% 15091509 3.4%3.4%

CesareanCesarean    166166 17.0%17.0% 222222 17.3%17.3% 1333713337 30.3%30.3%

TotalTotal    974974 100.0%100.0% 12851285 100.0%100.0% 4397043970 100.0%100.0%

Dept of MW 2007/2008and2008/2009

Midwifery at BC Women’s HospitalMidwifery at BC Women’s Hospital

Reasons for Success:Reasons for Success: Fully integrated into hospital structures Fully integrated into hospital structures On all relevant committees as full On all relevant committees as full

members of medical staffmembers of medical staff Immediate support available from Immediate support available from

obstetrics, anesthesia and pediatricsobstetrics, anesthesia and pediatrics Excellent communication with midwives Excellent communication with midwives

doing home births, so that if transport is doing home births, so that if transport is necessary, it is not delayednecessary, it is not delayed

National Aboriginal Council of National Aboriginal Council of MidwivesMidwives

As in Mexico, Canada has many As in Mexico, Canada has many indigenous peoples, many living in indigenous peoples, many living in remote underserviced areasremote underserviced areas

NACM established in 2008 under NACM established in 2008 under umbrella of CAMumbrella of CAM

The council provides opportunities for The council provides opportunities for networking and support for Aboriginal networking and support for Aboriginal midwifery in Canadamidwifery in Canada

Giving birth away from home Giving birth away from home Women in many Aboriginal, remote and Women in many Aboriginal, remote and

northern communities have to leave their northern communities have to leave their home communities to give birth to their babieshome communities to give birth to their babies

Separation from family, friends and community Separation from family, friends and community Increased financial burden on familiesIncreased financial burden on families Loss of traditional birthing practicesLoss of traditional birthing practices Birth has disappeared from communityBirth has disappeared from community Inconsistent with community wishesInconsistent with community wishes

Giving birth away from home…

Returning birth to the Returning birth to the communitiescommunities

1980s: women voiced 1980s: women voiced dissatisfaction with dissatisfaction with existing evacuation existing evacuation policypolicy

Women began Women began organizing to bring organizing to bring birth back to their birth back to their communitiescommunities

A number of A number of communities received communities received a maternity care a maternity care programs with programs with midwivesmidwives

Midwifery-led maternity programs in Midwifery-led maternity programs in

Aboriginal and remote settingsAboriginal and remote settings

Puvirnituq (Nunavik)Puvirnituq (Nunavik) Salluit (Nunavik)Salluit (Nunavik) Inukjuak (Nunavik)Inukjuak (Nunavik) Rankin Inlet (Nunavut)Rankin Inlet (Nunavut) Fort Smith (NWT)Fort Smith (NWT) The Pas and Norway The Pas and Norway

House (Manitoba)House (Manitoba) Six Nations of the Six Nations of the

Grand River (Ontario)Grand River (Ontario)

Hudson Bay CoastHudson Bay Coast

5500 Inuit people in 7 5500 Inuit people in 7 villagesvillages

200 births/ year200 births/ year 10 Inuit midwives and 10 Inuit midwives and

7 Inuit students7 Inuit students Births in Births in MaternitiesMaternities

in Puvirnituk, Inukjuak in Puvirnituk, Inukjuak or Salluit or Salluit

Transfers to MontrealTransfers to Montreal

Hudson’s Bay Coast MidwiferyHudson’s Bay Coast Midwifery

Education of Inuit Education of Inuit women locally has women locally has made program made program long-term long-term sustainablesustainable

Women receive Women receive maternity care maternity care close to home in a close to home in a culturally safe wayculturally safe way

Inuulitsivik Health Centre Inuulitsivik Health Centre (Puvirnituq/Hudson’s Bay Coast)(Puvirnituq/Hudson’s Bay Coast)

Local women trained Local women trained on the jobon the job using using traditional learning pathways traditional learning pathways

Mentor midwives provide support for Mentor midwives provide support for learning and formal traininglearning and formal training

Training takes as long as needed – Training takes as long as needed – usually 4 yearsusually 4 years

Community midwives employed by Community midwives employed by provincial government. Credentials provincial government. Credentials recently formally recognizedrecently formally recognized

Health Centre in InukjuakHealth Centre in Inukjuak

ResultsResults 1182 (85%) birthed in Nunavik1182 (85%) birthed in Nunavik

792 in Puvirnituk792 in Puvirnituk

254 in Inukjuak254 in Inukjuak

114 in Salluit114 in Salluit

14 in nursing stations14 in nursing stations

684 (58%) in their own village684 (58%) in their own village 206 (15%) transferred out of Nunavik206 (15%) transferred out of Nunavik

195 to Montreal195 to Montreal

5 to Iqaluit5 to Iqaluit

Results: Labour and BirthResults: Labour and Birth 89.6% of women gave birth between 89.6% of women gave birth between

37-42 weeks37-42 weeks28 births 28-33 weeks28 births 28-33 weeks4 births 23-27 weeks4 births 23-27 weeks101 births 34-36 weeks101 births 34-36 weeks

97.6% Spontaneous97.6% Spontaneous 0.8% Vacuum0.8% Vacuum 1.6% Cesarean Section 1.6% Cesarean Section

Rankin Inlet Birthing ProgramRankin Inlet Birthing Program Program was established in Program was established in

19931993 Initially set up as a ‘nurse – Initially set up as a ‘nurse –

midwifery’ program but was midwifery’ program but was not viable not viable

Introduction of 3 year Introduction of 3 year community midwife diploma community midwife diploma program through Arctic program through Arctic College in Nunavut with hands College in Nunavut with hands on training at the birthing on training at the birthing centre became successfulcentre became successful

Maternal and Child Centre Maternal and Child Centre Six Nations of the Grand RiverSix Nations of the Grand River

Successful midwifery-led maternity Successful midwifery-led maternity care program on reserve since 1996care program on reserve since 1996

Training site for Six Nations women Training site for Six Nations women to become midwivesto become midwives

Incorporates traditional and modern Incorporates traditional and modern teachingsteachings

Common features of existing Common features of existing programsprograms

Midwifery care is the normMidwifery care is the norm Community based midwifery Community based midwifery

education programs education programs Response to community demandResponse to community demand Maternity care review committeeMaternity care review committee Collaborative careCollaborative care Regional risk management systemRegional risk management system

Summing upSumming up

2 Different Cultures2 Different Cultures Midwives are taught to respect the Midwives are taught to respect the

natural process of birthnatural process of birth Obstetricians are taught to look for Obstetricians are taught to look for

problems that require interventionproblems that require intervention Our common ground is the best Our common ground is the best

interest of our patientsinterest of our patients This is lots of work to do, we are not This is lots of work to do, we are not

in competititionin competitition

Summing upSumming up

Midwifery will continue to grow in its Midwifery will continue to grow in its importanceimportance

Midwifery is part of the solution to Midwifery is part of the solution to assuring that physiologic birth is assuring that physiologic birth is understood and respectedunderstood and respected

Midwifery is part of the solution to Midwifery is part of the solution to serving our indigenous, underserved serving our indigenous, underserved and remote populations, whether and remote populations, whether they be in Canada or Mexicothey be in Canada or Mexico

Midwifery, properly supported by Midwifery, properly supported by policypolicy, , regulationregulation and and educationeducation, , is a large part of the solution to is a large part of the solution to maternity services that are:maternity services that are:

SustainableSustainable Women-centered and respectful of Women-centered and respectful of

cultureculture Excellent and safeExcellent and safe UniversalUniversal

Restore the wonder!Restore the wonder!Support birth in all its glorySupport birth in all its glory

Gracias!!!Gracias!!!