At some point in a kid’s life, the question will come up: where do babies come from? While the details of pregnancy and delivery are a mystery to most children – and even to some adults – that wasn’t the case for Samihah Patel. Ms. Patel grew up hearing stories of home births because her mother worked as a doula and kept in touch with the midwives who helped bring her own children into the world. When she started thinking about her own career path in high school, Ms. Patel decided on midwifery.

“I was just really drawn to the [profession’s] core values of informed choice and client-centred care … to the belief that people should be the primary decision-makers in their own health care, and their babies’ [health],” Ms. Patel, now a fourth-year student in the undergraduate midwifery program at Laurentian University, says.

Although Ms. Patel entered the midwifery program armed with this background, her first experience assisting with a birth while on a work placement in 2019 was still memorable. “It’s one of those moments,” she says, “where you really get to connect with the clients that you serve and bear witness to something really beautiful.”

But like many of her peers and future colleagues, Ms. Patel knows that special moment doesn’t come for everyone who wants it. Midwifery “is quite a difficult service to access for a lot of people,” she says. Ask a midwife, midwifery instructor or student why there never seems to be enough midwives to meet demand, and their responses vary: it’s a relatively young profession that’s still growing, it’s a health-care service that governments undervalue, it’s an unsustainable and challenging profession that leads to stress and burnout. The solution might seem simple: train more midwives. Although the profession is indeed advocating for more education and training opportunities, reaching that goal is a complicated process.

Professional regulation, jurisdiction and training

In Canada, a midwife can act as the primary health-care provider throughout a low-risk pregnancy, during birth and for postnatal care six weeks after birth. Midwifery services are regulated and funded by the provinces and territories (except in Yukon and Prince Edward Island) and these vary with each jurisdiction. According to Statistics Canada data from 2019, there are 1,909 practicing midwives in Canada, with most in Ontario (972), British Columbia (394) and Quebec (230). Although the profession has been around as long as anyone can remember, it has only officially been regulated in Canada for about 25 years. Ontario and Alberta were the first provinces to regulate midwifery care in 1994. Ontario also hosted the first class of undergraduate midwifery students in the country in 1993.

Currently, six universities in Canada offer four-year undergraduate programs in midwifery that train students to meet the requirements of their provincial or territorial midwifery regulatory bodies: the University of British Columbia; Alberta’s Mount Royal University; Laurentian, McMaster University and Ryerson University, all in Ontario; and Université du Québec à Trois-Rivières. It’s a small number of institutions with a fairly small number of students. In the 2017-2018 school year, there were a total of 555 seats for midwifery students at the six institutions. And these programs are very hands-on, with students spending a significant amount of their time working and learning in placements, which poses one of the biggest challenges to expansion.

“Since the number of midwives available is limited, we are always limited. It’s like the [paradox of] the chicken or the egg … and this is a problem in every province in Canada.”

“The capacity [for the profession] to grow has been limited all along by the number of midwives who are out there in clinical practice and can supervise students,” says Liz Darling, director of the midwifery education program at McMaster. “We don’t just bring them into a classroom and do simulated training. Students spend a lot of time in the clinical realm and developing a broad skill set.”

And these programs are competitive, turning away many potential students every year. “We have at least three times the number [of applicants] compared to the number of spaces,” says Caroline Paquet, director of midwifery at UQTR. “Since the number of midwives available is limited, we are always limited. It’s like the [paradox of] the chicken or the egg … and this is a problem in every province in Canada.”

A new program in Manitoba

It’s safe to say the past few years have been challenging for the field of midwifery in Manitoba. In 2016, the province ended funding for a short-lived midwifery program at University College of the North, located in The Pas, leaving about a dozen students in limbo, unable to complete their degrees. Within a few weeks, U of Manitoba had developed a memorandum of understanding with McMaster, which saw U of Manitoba deliver McMaster’s curriculum in collaboration with the Ontario university. All the while, U of Manitoba was in negotiations with the provincial government to establish its own midwifery program.

Five years later, the program, based out of the university’s college of nursing, will welcome its first cohort of six students this September. But that’s only six students, who won’t graduate for at least four years. And with only 69 working midwives, the province needs more, says Kellie Thiessen, director of the new midwifery program. The past year was particularly difficult for the profession in Manitoba after two young midwives died. The loss has had a huge impact on an already strained workforce.

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Before the new program had been approved, the provincial government had been looking to fund seats in midwifery programs in other provinces to help fill Manitoba’s service gaps. Dr. Thiessen and her colleagues had to make the case that even if the program at U of Manitoba started small, the province would be better off in the long term with a local option.

“If we bought seats in Ontario, we’d be paying [Ontario universities] to do what they already did, because on average, McMaster and other universities across the country [already] take in Manitoba students for midwifery,” she says. A midwifery program in Manitoba will help to keep Manitobans in their home province, she adds. “If you train local people, you can retain them because they have a reason to stay, they have family, friends, they have roots.”

Plus, it allows midwifery educators to tailor the program to the province’s needs. For example, all midwives practicing in Manitoba will learn about the province’s significant Indigenous populations and how to give Indigenous clients the care they need. “We want to train health professionals that [Indigenous peoples] want,” Dr. Thiessen says.

To help make this a reality, Darlene Birch, a Métis elder and midwife, was brought in to incorporate Indigenous practices into the new program’s curriculum. Ms. Birch analyzed each course’s learning outcomes through the lens of Indigenous midwifery, using a competencies framework set out by the National Aboriginal Council of Midwives. “Where [an Indigenous perspective] augments the curriculum is not so much in adding a certain way of doing something clinical … but really, it has much more to do with identities,” Ms. Birch says. “It’s an acknowledgement of that person’s spirit and an acknowledgement of their history.”

Despite the progress U of Manitoba has made for midwifery care in the province and the increase in demand for midwives across the country, Ms. Birch admits “there may be some people who still don’t know what modern midwifery is about, and we could probably do more public education and promotion.”

Confronting stereotypes and misconceptions

Kathrin Stoll, a lead investigator and associate researcher at UBC’s Birthplace Lab, knows all too well about midwifery’s need for public education and promotion. “When I talk to people outside of work, I’m always amazed at how little they know and understand about midwives even 20 years into regulation,” she says.

In 2013, Dr. Stoll was part of a research team investigating the attitudes toward birth among university students that examined some factors leading to a fear of birth and to preferences for obstetric interventions, such as caesarean section, labour induction and the use of epidurals. The researchers found that students who were more fearful of birth preferred epidural anaesthesia and birth by caesarean section, and that those who responded with the highest fear of labour and delivery also reported that their attitudes toward pregnancy and birth were shaped by the media.

“We’ve had an increasingly medicalized health-care system in general, but especially in the pregnancy and birth arena,” Dr. Stoll says. For many, childbirth appears to be a scary, painful experience that requires a doctor and the resources of a hospital. To counter that perception, Dr. Stoll suggests more public education about midwives, but also about the value of a “normal” or “physiological” birth – a birth that’s more or less free of interventions in a healthy pregnancy.

Midwives must also contend with health care’s professional hierarchies, which are dominated by physicians – a dynamic that researchers call “medical hegemony.” “Midwives have been actively fighting against that for a long time, which sometimes makes them unpopular with their colleagues,” Dr. Stoll says. There can be a lot of tension between maternal-health professionals, Dr. Thiessen admits. Midwives, she says, are often stereotyped both by the public and in health systems as hippies or “backwoods tree-huggers” who are assertive and sometimes abrasive when advocating for their clients. This is another reason, she adds, why a midwifery program is needed in Manitoba. Midwives are “foreigners in the health-care system,” she says; having a stronger presence in the province “breaks down the stereotypes.”

One of Dr. Stoll’s doctoral students at UBC is aiming to change perceptions of midwives with a midwife-led project that teaches kids about pregnancy through play-based education. The project “fulfills a dual goal of teaching kids about pregnancy and birth, which they don’t know much about and don’t get much exposure to, and introducing them to the role of the midwife,” Dr. Stoll explains. However, the student, a midwife named Michelle Turner, hasn’t been able to secure funding for a pilot. “This kind of thing is very hard to get funded. Most people don’t get why it’s important,” Dr. Stoll says. “To us, it’s obvious.”

Ms. Turner’s struggle to find funding is a perennial problem for midwives, whether in the academic world or outside of it. McMaster’s Liz Darling points out that governments have limited budgets and in the chorus of demands for funding, midwives rarely stand out. “Governments are always making decisions about what [they prioritize] … [and] it’s hard at a time where the governments just had to spend lots of money on a pandemic for them to prioritize something that’s often small and easy to ignore,” she says.

Stress and burnout

Dr. Stoll, who conducts research on workforce issues in midwifery, recently published a report on how to make midwifery more sustainable as a career. “There are points in the midwife’s career when that midwife is more vulnerable to burnout,” she says. These include early career, when a midwife is paying off student loan debt while settling into the practice; early parenthood; after experiencing a difficult “critical incident” at work; aging and/or during personal health crises. “When you have a burnt-out workforce, like we do in B.C., and students learn from preceptors … who are burnt out, that kind of reproduces itself,” she says. Indeed Ms. Patel says she has watched classmates leave the midwifery program at Laurentian due to stressful student-preceptor relationships.

Dr. Stoll heard from midwives about the need for better compensation and benefits – midwives in B.C. do not receive sick leave or pension benefits – and stronger mental-health supports. To illustrate her point, she notes that midwives in B.C. haven’t been extended pandemic-related pay increases offered to other health-care professionals. According to the Midwives Association of British Columbia, midwives are the only primary health-care providers in the province not given pandemic pay or pandemic support like PPE. A survey conducted and published by the association in late 2020 found that 90 percent of midwives in the province saw an increase in demand for home births during the pandemic, 79 percent reported their mental health has worsened and 18 percent said they are taking steps to leave the profession.

“We’re now seeing options for midwives to fill in the gaps in the health system that really meet their skills and knowledge, and make good use of them, but don’t necessarily have them … [working] on call.”

A glimmer of hope

The continuity of care model, where midwives provide care during pregnancy, at birth and six weeks after birth, means that the job is unpredictable and exhausting, but Dr. Darling sees some hope in new alternative models for midwifery care in Ontario. “We’re now seeing options for midwives to fill in the gaps in the health system that really meet their skills and knowledge, and make good use of them, but don’t necessarily have them … [working] on call,” she explains. “This is really important in terms of both making good use of the skills and what midwives have to offer to the health system, but also in terms of providing some options that might help to improve retention in the profession.”

An example of this is the Markham Stouffville Hospital’s Alongside Midwifery Unit, which opened its doors in 2018. The unit is the first of its kind in Canada, with birthing rooms and an array of equipment to support low-risk births. It’s also located beside the hospital’s obstetrical unit, with access to operating rooms and a neo-natal intensive care unit. The unit is staffed by hospital midwives who work alongside midwives employed in community-based practices. “It’s a really interesting model,” says Laurentian’s Ms. Patel, who’s completing a placement there. “I feel like if it were adopted more widely, that could be a really great way to help reduce burnout.”

Ms. Patel feels lucky that she’s young – she entered the Laurentian program right out of high school – doesn’t have kids and has help from her family. “There were definitely times where I’ve been up for over 24 hours, with multiple births in a row sometimes. And you don’t even have the energy to feed yourself. It’s kind of like you’re choosing between ‘do I want to shower, sleep or eat,’ it’s one of the three,” she says. “I don’t think you can really get through this program without family support.”

Burnt-out preceptors as well as the demands of midwifery programs and placements create significant stress for students that can lead them to drop out. But some program administrators believe students need to be prepared for a challenging career. “We try to provide very realistic information [to students] about what the profession’s like and what the work is like,” Dr. Darling, from McMaster, says. “We have paid a fair bit of attention within the program … trying to build the skills that midwives need in order to have a good work-life balance and maintain their own health.” For some midwives, that may mean they need to work part-time or take on a partial workload for most of their professional lives, Dr. Darling adds.

Those educators also agree that there’s a great need to make the profession more sustainable, to retain midwives and ensure students make it through their programs because the demand for midwifery care isn’t going away. “In Montreal, there are birthing centres that open almost every year and have waiting lists,” says Ms. Paquet, from UQTR. “Women [and pregnant people] want less and less of a paternalistic approach. It’s not just a trend … to want to be able to determine what is best for us.”

With a file from Pascale Castonguay.