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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.
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Professional Midwifery:International Models and ApplicationsLessons 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 • 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 • 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 • 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 • 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 • 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 • 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
Professional Midwifery • 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
Professional Perspectives SOGC (Society of Obstetrician-Gynecologists of Canada) Policy Statement on Midwifery • Education • Practice Setting • Integration of Midwifery into Health Care Service Teams
SOGC Policy Statement • 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 • 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 • 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 • 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
“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” SOGC summary statement
Scope of Practice of Canadian Midwives • “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 • 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 • 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
Service Delivery & CoordinationStatistics Dept of MW 2007/2008 and 2008/2009
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 Birth has disappeared from community Inconsistent with community wishes
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
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)
Hudson Bay Coast 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) 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
Results 1182 (85%) birthed in Nunavik 792 in Puvirnituk 254 in Inukjuak 114 in Salluit 14 in nursing stations 684 (58%) in their own village 206 (15%) transferred out of Nunavik 195 to Montreal 5 to Iqaluit
Results: Labour and Birth 89.6% of women gave birth between 37-42 weeks 28 births 28-33 weeks 4 births 23-27 weeks 101 births 34-36 weeks 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
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 • 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 • 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
