Professional Midwifery:
International Models and
Applications
Lessons from Canada and around
the world
Secretario de Salud, Mexico City
Dr Jan Christilaw
MD, OB-GYN, MHSc
President BC Women’s Hospital
Vancouver, BC, Canada
June 17, 2010
The perfect time:
“Women Deliver” Conference:
Midwives are a large part of the
solution to meeting the MDGs
Questions we need to answer
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How do we best serve the obstetrical
needs of the women in our respective
countries?
How do we integrate midwifery care into a
highly scientific medical system?
How do we assure safety, quality and
professional standards?
How do we best serve our indigenous and
underserviced populations?
An Overview of this talk
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1) Historical perspectives: international,
national and local
2) Canadian midwifery: regulation and
education
3) Obstetricians role (SOGC Policy)
4) Midwifery in BC: policy and outcomes
5) Applications to indigenous, underserved
and remote populations
6) Summary and lessons learned
Midwifery around the world
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Since the dawn of
time…
Midwifery has been
the meeting point for
traditional knowledge
and modern care
Supplanted by the
medical model in
some places much
more than others
Midwifery around the world

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Decline of midwifery
as an autonomous
profession in the
1800-early 1900
corresponded to the
rise of the medical
profession
Wide variations
around the world
Midwifery around the world
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In indigenous
societies and
underserved areas,
midwives remained
the primary providers
of perinatal care
Largely unregulated
and unsupported by
mainstream medical
systems until recently
Midwifery in Canada
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In Canada, aboriginal midwifery has existed for
10,000 years
Largely invisible, and undervalued until recently
Now, we as Obstetricians have embraced and
welcomed midwives as our colleagues, and
strive to learn from them and they from us
Canadian Association of Midwives is a highly
respected national organization that works
closely with other providers of obstetrical care
Canadian Association of
Midwives
CAM is the national professional organization
 Currently 938 members; more than 800
registered midwives
 Approximately 100 new registrants each year
 Midwifery regulated and funded in almost all
Canadian jurisdictions, starting in 1994,
covering over 95% of the Canadian population

Regulation of Midwifery In Canada
Province/Territory
Implementation
Public Funding
Alberta
Yes - 1998
Yes
British Columbia
Yes - 1998
Yes
Manitoba
Yes - 2000
Yes
New Brunswick
Anticipated for 2010
Likely yes
Newfoundland &
Labrador
Under review
?
North West
Territories
Yes - 2005
Yes
Nova Scotia
Yes - 2009
Yes
Nunavut
Yes - 2008
Yes
Ontario
Yes - 1994
Yes
Prince Edward Island
Under review
?
Quebec
Yes – 1999
Yes
Saskatchewan
Yes – 2008
Yes
Yukon
Under review
?
Professional Midwifery
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Requires a robust infrastructure than
includes:
Funding and support from government
Support from other professional bodies
Quality assurance
High quality education
Ongoing evaluation and assessment
Midwifery Education in Canada
Education
program
Seats per
year
Current
enrollment
Total
graduates
Graduates in
2009
McMaster
30
94
148
15
Laurentian
30
93
103
11
Ryerson
30
108
139
24
UBC
10
42
41
9
UQTR
24
74
52
16
UCN/KOBP
5
4
NA
1
TOTAL
129
415
483
76
Professional Perspectives
SOGC (Society of ObstetricianGynecologists of Canada) Policy
Statement on Midwifery
 Education
 Practice Setting
 Integration of Midwifery into Health Care
Service Teams
SOGC Policy Statement
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Education:
SOGC supports midwifery education
leading to a degree or diploma
SOGC extends membership to registered
midwives and midwifery students and
offers them access to ongoing education
SOGC Policy Statement
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Practice Setting
SOGC recognizes the importance of choice
for women and their families, including
setting of birth
All women should receive information
about the risks and benefits
SOGC Policy Statement
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Integration of Midwifery into Health
Services Teams
Midwives need access to resources and
facilities such as laboratory testing,
ultrasound, etc
Seamless integration with others
professionals
Appropriate remuneration
Continuous review
SOGC Policy: Integration
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Inclusion in committees concerned with
maternal and newborn issues
Development of policies concerned with
complaints
Harmonization of obstetrical standards
Provision of appropriate malpractice
insurance
Support for achieving credentials and
hospital privileges
SOGC summary statement
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“We are confident that the integration of
midwifery is fostering excellence in
maternity care for women living in Canada
and their families, which is the goal of our
organization”
Scope of Practice of Canadian
Midwives
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“Registered midwives are health
professionals who provide primary care to
women and their babies during pregnancy,
labour, birth and the postpartum period.
They are fully responsible for clinical
decisions and the management of care
within their scope of practice”.
CAM
Midwives Scope of Practice
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Provide the complete course of low-risk
prenatal, intrapartum and postnatal care,
including physical examinations, screening and
diagnostic tests, the assessment of risk and
abnormal conditions, and the conduct of normal
vaginal deliveries.
Work in collaboration with other health
professionals and consult with or refer to
medical specialists as appropriate.
Regulated by provincial colleges
Midwifery at BC Women’s Hospital
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7500 births per year at BC Women’s
Hospital
At the vast majority of births, fathers are
present
It is the high risk centre for the province
which has 45,000 births per year
50 midwives are on staff at BCW
166 midwives are registered in the
province of British Columbia
2007/2008
Total
Number of
Deliveries
2008/2009
%
Total
%
1. BCWH
609
62.5%
761
59.2%
2. SPH
167
17.1%
273
21.2%
3. Home
198
20.3%
251
19.5%
974
100.0% 1285 100.0%
Total
19.5%
21.2%
59.2%
2007/2008
Mode of
Delivery
2008/2009
BC Total
Total
%
Total
%
709
72.8%
940
73.2%
26114
59.4%
1
0.1%
6
0.6%
109
0.4%
Vacuum
30
3.1%
47
3.7%
3010
6.8%
Forceps
69
7.1%
76
5.9%
1509
3.4%
166
17.0%
222
17.3%
13337
30.3%
SVD
SVDBreech
% of all
SVD
Cesarean
Total
974 100.0%
1285 100.0%
Total% of Prov
43970 100.0%
1000
Dept of MW
2007/2008
and
2008/2009
900
800
700
SVD
600
SVD- Breech
500
Vacuum
400
Forceps
300
Cesarean
200
100
0
1
2
3
4
5
Midwifery at BC Women’s Hospital
Reasons for Success:
 Fully integrated into hospital structures
 On all relevant committees as full
members of medical staff
 Immediate support available from
obstetrics, anesthesia and pediatrics
 Excellent communication with midwives
doing home births, so that if transport is
necessary, it is not delayed
National Aboriginal Council of
Midwives
 As
in Mexico, Canada has many
indigenous peoples, many living in
remote underserviced areas
 NACM established in 2008 under umbrella
of CAM
 The council provides opportunities for
networking and support for Aboriginal
midwifery in Canada
Giving birth away from home
Women in many Aboriginal, remote and
northern communities have to leave their home
communities to give birth to their babies
 Separation from family, friends and community
 Increased financial burden on families
 Loss of traditional birthing practices
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 Birth
has disappeared from community
 Inconsistent with community wishes
Giving birth away
from home…
Returning birth to the
communities
1980s: women voiced
dissatisfaction with
existing evacuation
policy
 Women began organizing
to bring birth back to
their communities
 A number of communities
received a maternity
care programs with
midwives
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Midwifery-led maternity programs in
Aboriginal and remote settings
Puvirnituq (Nunavik)
 Salluit (Nunavik)
 Inukjuak (Nunavik)
 Rankin Inlet (Nunavut)
 Fort Smith (NWT)
 The Pas and Norway
House (Manitoba)
 Six Nations of the Grand
River (Ontario)
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Hudson Bay Coast
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5500 Inuit people in 7
villages
200 births/ year
10 Inuit midwives and 7
Inuit students
Births in Maternities in
Puvirnituk, Inukjuak or
Salluit
Transfers to Montreal
Hudson’s Bay Coast Midwifery
 Education
of Inuit
women locally has
made program
long-term
sustainable
 Women receive
maternity care
close to home in a
culturally safe way
Inuulitsivik Health Centre
(Puvirnituq/Hudson’s Bay Coast)
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Local women trained on the job using
traditional learning pathways
Mentor midwives provide support for
learning and formal training
Training takes as long as needed – usually
4 years
Community midwives employed by
provincial government. Credentials
recently formally recognized
Health Centre in Inukjuak
Results
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1182 (85%) birthed in Nunavik
792 in Puvirnituk
254 in Inukjuak
114 in Salluit
14 in nursing stations
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684 (58%) in their own village
206 (15%) transferred out of Nunavik
195 to Montreal
5 to Iqaluit
Results: Labour and Birth
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89.6% of women gave birth between 3742 weeks
28 births 28-33 weeks
4 births 23-27 weeks
101 births 34-36 weeks
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97.6% Spontaneous
0.8% Vacuum
1.6% Cesarean Section
Rankin Inlet Birthing Program
Program was established in
1993
 Initially set up as a ‘nurse –
midwifery’ program but was
not viable
 Introduction of 3 year
community midwife diploma
program through Arctic College
in Nunavut with hands on
training at the birthing centre
became successful
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Maternal and Child Centre
Six Nations of the Grand River
 Successful
midwifery-led maternity care
program on reserve since 1996
 Training site for Six Nations women to
become midwives
 Incorporates traditional and modern
teachings
Common features of existing
programs
 Midwifery
care is the norm
 Community based midwifery education
programs
 Response to community demand
 Maternity care review committee
 Collaborative care
 Regional risk management system
Summing up
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2 Different Cultures
Midwives are taught to respect the natural
process of birth
Obstetricians are taught to look for
problems that require intervention
Our common ground is the best interest of
our patients
This is lots of work to do, we are not in
competitition
Summing up
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Midwifery will continue to grow in its
importance
Midwifery is part of the solution to
assuring that physiologic birth is
understood and respected
Midwifery is part of the solution to serving
our indigenous, underserved and remote
populations, whether they be in Canada or
Mexico
Midwifery, properly supported by
policy, regulation and education, is a
large part of the solution to
maternity services that are:
 Sustainable
 Women-centered and respectful of culture
 Excellent and safe
 Universal
Restore the wonder!
Support birth in all its glory
Gracias!!!