My focus in this post, however, rather than rambling about how I came to be a pharmacy student, is to clear the air regarding some myths about midwives (and there are a lot of them floating around out there). One of the frustrating things for me when I was still planning on attending midwifery school was the widespread lack of understanding about who a midwife is, what her qualifications are, what she does, etc. The average individual - including many health professionals - doesn't really have a full body of knowledge about midwifery. They only know the stereotypes associated with the profession, not the facts.
I recently had a conversation with someone about my midwifery/pharmacy dilemma during my first year and during that conversation they said to me: "Really, midwifery? That's a long way off from pharmacy. There's not much science in that." This came from an individual who has worked in the health professional realm for decades but still had no concept of midwifery as a health profession and clearly was thinking of it as its unfortunate stereotypes, probably including some variation on the image of a Birkenstock wearing, non-leg-shaving, home birth-only, Wicca-practicing woman with the nerve to call herself a "health professional." Certainly not as the respectable, evidence-based designation that it is. Time and time again, I have been disappointed in my conversations with others about midwifery, and so much of it stems from, quite simply, lack of awareness.
This being said, I feel it is beneficial for health professionals and the general public to be aware of the myths surrounding the profession of midwifery, such that they are in a position to better understand and advocate for their patients, or for themselves.
Since this is a Canadian blog, I will focus on answering these myths from a Canadian perspective. Before I begin, for clarification purposes, women have three options in Canada for whom they can choose as their care provider during pregnancy and labor: a family physician, an obstetrician, or a registered midwife. Obstetricians are specialists in the medical management of pregnancy and birth and have the training to perform surgical caesarean births. They have additional training for high-risk pregnancies that family physicians and midwives don't have and they require a referral from a family physician or midwife. They may also act in consultation with family physicians or midwives in caring for a pregnancy, rather than being the sole primary care provider. I will speak in more detail about these three options throughout the myths.
Here are six myths about midwives cleared up for you:
Myth #1: Midwives Aren't Properly Educated Or Trained
As of 2015, midwifery is a regulated profession in 10 Canadian Provinces and Territories, including: British Columbia, Alberta, Saskatchewan, Manitoba, Ontario, Quebec, Nova Scotia, New Brunswick, Northwest Territories, and Nunavut. This means that in these Provinces/Territories, those who have achieved an accredited midwifery education must register with the regulatory body where they wish to practice and only those individuals who are registered can legally use the title of midwife. They must also adhere to the professional standards as governed by their regulatory body. The major health professions are all regulated: doctors, pharmacists, nurses, dentists, etc.
There are seven universities in Canada which offer accredited four year baccalaureate programs in midwifery. Admission to these programs is very competitive. Most of the programs are direct entry programs (meaning you can apply straight out of high school), but it is not common for individuals to be granted admission as direct entry candidates. Many of the successful applicants have previous degrees and other life experiences, as assessed by admissions essays and multiple-mini-interviews. Some programs have required prerequisite courses, such as university level biology/physiology and English. The minimum GPA required for admission (whether based on high school grades or post secondary grades) is generally 70%, but the actual cut off is typically much higher. Since there are only a small number of seats in each program, the actual cut off is more like 80% and higher.
The four year curriculums vary slightly between programs, but generally they all include courses in physiology, biology, nutrition, lab sciences, pharmacotherapeutics, pathophysiology, and extensive clinical practice in maternity care. For example, the program I was accepted into included 3620 hours of clinical practice - the equivalent of 453 eight hour work days; other programs have similar requirements. Once a midwife graduates and becomes registered, she still has to work under the supervision of another registered practicing midwife who holds an unrestricted license, usually for a period of 6-12 months or 1000-2000 hours. This is similar in concept to a medical residency. After this point, the newly registered midwife is permitted to work under her own unrestricted license.
By contrast, most undergraduate medicine programs include a six week rotation in obstetrics and gynaecology; family practice doctors undergo a two year residency program during which they may deliver some babies, but the majority of their residency is not going to focus on maternal care. A 2008 survey conducted by the Maternity and Newborn Care Committee, as part of The College of Family Physicians of Canada, looked at the amount of maternity care education given in the family medicine residency programs across Canada. During the family medicine residency programs, most residents received an average of two months of maternity care training. Over the course of the two years, most residents attended 25-30 births and followed (e.g. provided primary care for) 6-8 pregnancies during the same time period. An update published by the MNCC in 2012 stated that little has changed since the 2008 publication. They have reported that there are barriers to family medicine residents receiving adequate training in maternity care, including but not limited to: a lack of specific maternity care training and educational programs, lack of exposure to maternity care, and lack of faculty role models for maternity care. They suggest that some areas of Canada should be using midwives as teachers of intrapartum care to family medicine residents, encouraging a collaborative approach to maternity care education.
Whereas a medical student may have attended a few births during their medical school clinical rotations and about 25-30 during their two-year residency program (at which they weren't necessarily the primary care provider), midwives have to attend a minimum of 60 births in order to register with their regulatory body, 40 of which they must have been the primary care provider, and will likely have attended another 40-60 in the following year before they can practice with an unrestricted license. All things considered, family doctors are very likely receiving significantly less clinical experience in maternity care and labor/delivery compared to midwives: approximately 25-40 births over the course of six years for doctors versus 100-120 births over the course of five years for midwives, not to mention that the entirety of the midwifery curriculum is dedicated to maternity care, versus only a subset of the medical school curriculum.
edit: It should be noted that 100-120 births attended by midwives by the time they can practice with an unrestricted license is the minimum, but in actuality, the numbers are likely much higher. One of our readers, a student midwife, indicated that as she just finished her final year of school, she has already attended well over 100 labours/births prior to becoming registered. For the family physician, 25-40 births is not the minimum, but rather the average number of births attended from medical school through residency, based on information provided by The College of Family Physicians of Canada.
Myth #2: Doctors Are More Qualified Than Midwives To Deliver Babies
No, they aren't. The same goes for the opposite statement - midwives aren't "more qualified" than doctors, either. The undergraduate curriculum for medical school is a rigorous one that educates future doctors in a multitude of areas over a period of four years. They are certainly qualified health professionals and there is nothing amiss with trusting your doctor to deliver your baby. However, I do want people to understand that midwives receive a rigorous four year education too, specific to maternal health, labor and delivery and infant care. They are experts in their field and they deserve to be recognized as such. Whereas doctors divide their clinical placements between a range of areas (surgery, obstetrics, paediatrics, psychiatry, etc.), midwives devote all their time to labor and birth. This is their area of specialization and they are competent at what they do.
Midwives are sometimes described as "normal birth" experts. This means that they are primarily trained to work with low-risk pregnancies, which the majority of pregnancies are. Examples of high-risk pregnancies may include pregnant women with cancer, kidney disease, HIV, very high blood pressure or epilepsy, or women who have had pregnancy complications in the past, such as three or more miscarriages, preterm labor, or having a baby with a genetic problem such as Down Syndrome. In these instances, a pregnancy may be considered high-risk and care may be transferred to an obstetrician.
To reiterate, obstetricians aren't the same as a regular family doctor. They are highly trained in areas specific to pregnancy complications, which is something that neither your regular family doctor nor midwife receives in their education/residency/clinical work. A family doctor will refer you to a specialist if complications occur, just as a midwife would. This isn't to say that family doctors and midwives don't receive any education about pregnancy complications, because of course they do, but they aren't the experts in this arena. Only an obstetrician is the expert in this arena. An obstetrician trained in high-risk pregnancy may be more qualified to deliver a high-risk baby, but in low-risk pregnancies, which are the majority of pregnancies, neither your family doctor or midwife is essentially more qualified to perform the delivery, though your midwife very likely has significantly more clinical experience in the area (see Myth #1).
Myth #3: If You Have A Midwife, You Have To Have A Home Birth
One of the foundations of midwifery practice is that the mother is the primary decision maker. In keeping with this, women are free to choose where they would like to give birth to their child, whether that be at home, in hospital or at a birth center. It's a common misconception that most midwife-attended births take place at home. In reality, about 75% of midwife attended births take place in hospitals. Midwives are granted what are called "privileges" at hospitals in their practicing area which means that they have an agreement with the hospital that they can use the facility and admit/discharge you from the hospital as your primary care provider. If a complication arises during labor and delivery, then your midwife will collaborate with other health professionals in the hospital to ensure the safety of you and your baby. If ever your care has to be transferred to an obstetrician while you are in hospital, that doesn't mean that you will "lose" your midwife, it means that they will work together to provide the safest outcome.
Myth #4: If You Have A Midwife, You Can't Have Drugs / An Epidural
In keeping with the idea that the mother is the primary decision maker in planning her birth experience, if a woman feels during her labor she would like an epidural, then she can very well have an epidural. However, having an epidural would require a hospital birth setting. Midwives and family physicians don't administer epidurals themselves, but rather they are administered by anesthesiologists. Your midwife can usually still act as your primary care provider even if you have received an epidural, but this depends on the policy of the hospital. In some hospitals, care must be transferred to an obstetrician, but this is not always the case. Even if your care is transferred, your midwife can still be in the delivery room as support during the birth process.
Midwives also have prescribing authority, which means they are able to prescribe for their patients as appropriate within their scope of practice. Having a midwife doesn't mean that you have to go 'all-natural' with your pregnancy and birth plan. Midwives can independently prescribe a wide range of pharmaceuticals and can administer some controlled substances in consultation with medical practitioners, if necessary (see here for a sample list of drugs that can be prescribed/administered by midwives in the province of British Columbia).
Myth #5: You'd Have To Pay For A Midwife Out Of Pocket
Currently, if you so choose to have a midwife as your primary care provider during your pregnancy, the cost is covered by your provincial health care in most of Canada, including British Columbia, Alberta, Saskatchewan, Manitoba, Ontario, Quebec, Nova Scotia (within three health districts: Guysborough Antigonish Straight Health Authority, South Shore Health and the IWK Health Center in Halifax), the Northwest Territories and Nunavut. This means that when you become pregnant, you can make an appointment with your local midwife and they will bill the province directly so that you don't have to pay for anything out of pocket.
Unfortunately, midwifery costs are not covered in New Brunswick, Prince Edward Island, the Yukon and Newfoundland and Labrador, so if you live in these areas, you would have to pay for midwifery services on your own.
The demand for midwives is very high across Canada, but government funding is a limiting factor in terms of how many women can actually receive midwifery care. The government limits the number of clients an individual midwife can take on because it has a limited budget for how much it is willing to pay all midwives in total across its province. For example, if the provincial government says it has a budget of one million dollars for midwives per year, and they pay a midwife $3000 per single course of care, that means only 333 women in that province can receive midwifery care before the budget dries up. These aren't the actual numbers, of course, but are used for illustrative purposes.
Various evaluations have been conducted across Canada to look at the savings that exist when women utilize midwifery care versus family physician care; per single course of care, the savings range between $800-$1200. Many of these cost reductions are associated with shorter hospital stays, fewer re-admissions to hospitals following birth, fewer obstetrical interventions, lower c-section rates, and fewer instrument-assisted births. Increasing government funding for midwifery would significantly reduce overall healthcare costs in Canada.
Myth #6: Midwifery Is a "Long Way Off" From Pharmacy/Medicine/Nursing Any Other Health Profession
Midwives undergo extensive training in order to become experts in low-risk pregnancy, labor and delivery. They are a regulated health profession in most locations, they adhere to a high standard of practice and code of ethics, they work collaboratively with other health professionals, their services are publicly funded in many parts of Canada, and studies have shown that their care leads to a number of positive health outcomes, such as lower numbers of preterm birth, fewer incidences of fetal loss before 24 weeks gestation, fewer instrument-assisted births, fewer incidences of induced-labor, and less use of analgesia/anesthesia during labour and delivery. I am fairly certain that midwives don't accomplish these outcomes by burning incense and dancing around their patients.
Of course, I am being facetious now, but I stand firmly behind the notion that is is our responsibility as health professionals to be aware of the evidence in support of our colleagues in other disciplines and to make recommendations based on that evidence, not on our own preconceived notions - which typically aren't accurate, anyway. Midwives use evidence-based practice to provide safe and effective health outcomes for pregnant women and their babies; a Cochrane Review, one of the highest standards for evidence-based medicine and evidence-based healthcare, supports this, having published that women who have low-risk pregnancies should be encouraged to seek midwifery care.
To conclude, here are some Bonus Facts About Midwives:
- Most people pronounce midwifery as 'mid-wife-ery', but it is actually pronounced 'mid-whiff-ery.'
- Midwife appointments are generally much longer than physician appointments (about 30 min - 1 hour), allowing you plenty of time to ask all the questions you desire.
- Midwives are on call 24/7. If at any time you have concerns during your pregnancy, you are free to contact your midwife for support.
- Midwives will follow up with you at your home following the birth of your child and can provide help and support with breastfeeding, postpartum depression, and anything to do with the care of your newborn. It is nice that they come directly to your home and save you the trouble of bringing your newborn to a crowded doctor's office. They provide this care for six weeks postpartum for both you and your baby.
- Midwives place a heavy emphasis on the autonomy of the mother throughout her pregnancy and support her right to making informed choices about how she wants to bring her baby into the world, including the location of the birth, whether or not drugs are used throughout the pregnancy or during labour, and which diagnostic tests are utilized throughout the pregnancy. To that end, we didn't mention this as a myth, but you should be aware that your midwife has the ability to order the exact same diagnostic tests as your physician.
- Midwives typically work in teams of 2-4 and you will get to know all of them throughout your appointments so that when the time comes to give birth, you will be familiar with who is delivering your baby. This is part of their promise for continuity of care.
- Midwives are different than doulas, who provide care and support for the mother during her labour and delivery, but do not provide medical care and are not involved in the actual delivery of the baby. Their service is more of an emotional support system for the mother.
Have you had a midwife-attended birth in Canada? What was the experience like for you? Are you a student or health professional who didn't know about the evidence behind midwifery until you read this post? We'd love to hear from you in the comments.