A Midwife Under Fire

March/03 SHARED VISION MAGAZINE., Vancouver

By Jennifer Wohl

Let's say you are a pregnant woman living in B.C. in 2003. If you want the costs of your birth covered by the Medical Services Plan of British Columbia, you can have your baby in hospital, attended by a doctor or a registered midwife, or deliver at home, attended by a registered midwife. Should you wish your home birth attended by a birth attendant, a doula, or anyone else "without a physician or midwife present" you're on your own. If you deliver in hospital in B.C., there's a 26 percent chance you'll have a Caesarean; if you are over 35 years of age, that risk increases to 34 percent (based on 2001 data). Although, according to the results of the Home Birth Demonstration Project carried out by the Ministry of Health, your chances of having a Caesarean are reduced if you are in the care of a registered midwife. The Caesarean section rate for women planning a home birth with a midwife is 6.4 percent, and 11.9 percent for those who planned a hospital birth with a midwife (December 2000).

Since 1998, when the newly formed College of Midwives began regulating the practice of midwifery in B.C., women in this province could elect to have a registered midwife attend their birth. If you were a practicing midwife, you could elect to be "registered" with the College, and have your services covered under the Medical Services Plan. To become registered, practicing midwives had to pass registration exams, apply for hospital privileges, and buy malpractice insurance. Once registered, a midwife can attend home births or hospital births, as their clients wish. A home birth is an option as long as the mother-to-be is deemed "low-risk."

If you decide to have your baby in the privacy of your own bedroom, don't expect Birth Attendant Gloria Lemay to be at your birth if you deliver before December 3 of this year. Found guilty of a criminal contempt of court charge in January 2001, Lemay is currently on probation after serving two months of a five-month prison sentence. Although currently allowed to teach prenatal and midwifery courses, and offer postpartum support for women, she is not permitted to attend births until either she wins her appeal or December 3 rolls around. After that, a B.C. Supreme Court permanent injunction will still prohibit her from practicing midwifery. In 2000, Lemay was served an injunction by the court for having practiced midwifery. Under the injunction, she was not allowed to perform certain restricted acts (for example, she could not perform a pelvic exam or "manage" a spontaneous vaginal delivery) unless there was an emergency. Nor could she call herself a midwife. She was allowed to attend births, and be paid for doing so. She was also allowed to teach midwifery. However, the court later clarified that by regularly attending births for a fee, without a qualified physician or midwife present, she could not use the emergency provisions of the health legislation to do reserved acts. In his reasons, the judge said that the emergency provisions in the legislation referred to in the injunction are intended to protect passers-by when they provide emergency aid, not to exempt people in business from regulations designed to protect the public.

According to Lemay, while she was still under the injunction, a private detective was present in one of her midwifery classes when she told the class about a pelvic exam she said she had conducted in an emergency situation. Lemay says, "The College's position was, ‘Look, she's going to births, she's doing pelvic exams, that wasn't an emergency, she's just telling the class it was.'" Lemay was found guilty. "I really am innocent of contempt of court," she maintains. "I had no reason to defy that [earlier] judge. Whenever I did an act, it was an emergency…my injunction was a civil injunction, but [the judge] found me guilty of criminal contempt. I didn't do anything publicly. I didn't do anything that my clients weren't completely happy with. I didn't do anything that happened outside someone's bedroom. I was very disciplined about speaking in a respectful way. There was no reason to make it criminal."

Although Lemay had been practicing midwifery for 17 years when the College began registering midwives, she elected not to become registered. "If someone like me applied to the College of Midwives to be registered," Lemay said recently in an interview with Shared Vision in her home, "they would say to me, ‘You have a lot of experience with home births, but you have no experience delivering babies in the hospital. So we want you to work alongside a nurse and a doctor for three months, do 25 hospital births and learn from them how to order IVs, how to chart, how to do all these things that come with working in the hospital.' I would have to apply for hospital privileges. Then the hospital committee would say to me, 'We'll give you privileges at our hospital, but you have to go by our rules. You will not allow any woman to go past 42 weeks of pregnancy. You will not be doing homebirths for women who have had previous Caesareans. So are you willing to obey our rules?' And this is what the midwives have had to do. The hospital privileges committee gets to regulate what they do. And they have had to buy malpractice insurance and the malpractice insurance corporation gets to tell them what to do. Again, ‘You will not do this, you will not do that, you will inject every baby with Vitamin K, you will give antibiotic eye drops to every baby. The parents have the right to refuse, but you better get it documented from here to China and it better not be your suggestion that they did something like that.'…If I could register as a midwife and be a midwife in a way that I know is good for people's health and in a way that I know serves people, I would do it in a minute. But the way it is set up, I would just have to be a lackey for a doctor."

You'll get a different perspective from Jane Kilthei, Registrar for the College of Midwives. In a recent phone interview, she said, "We are so strongly working towards supporting midwives who are out there in carrying on a long tradition of women-centred care. We fought long and hard to provide women with homebirths. The College requires that midwives support women in the birth location they choose. In fact, informed choice is a key principle of what our midwives offer women. We have guidelines to help midwives support women who have had previous caesarean sections to have home births if they want them. Midwives have to discuss the pros and cons of any suggested therapy and follow the mother's choice." Kilthei feels that birth attendants and doulas can provide valuable additional labour support to women. The problem, she says, is when these providers act as the primary service provider. "One of the difficulties for women choosing caregivers for their births," Kilthei says, "is that a good percentage of the time, regardless of what the attendant does, things will turn out fine, so a recommendation from a friend can't necessarily tell you about someone's skill in managing an emergency. The problem is when something goes wrong. Someone attending a birth needs to pick up on these things at the appropriate time and take action, otherwise the woman and baby are at risk." As for Gloria Lemay, Kilthei says, "The framework for registration is set up to assure that practitioners are appropriately trained, safe, and competent. Our perspective is that Gloria Lemay should either stop practicing or get the appropriate training and apply for registration."

Linda Knox became a registered midwife in 1998 when the College began registering midwives, but she has been practicing midwifery since 1980. She was well aware of the concern that midwifery would become overly medicalized and that midwives would become doctors' lackeys. "They call us ‘medwives,'" she says. "People said we would regret [establishing the College to register midwives], that we wouldn't be able to give women the service the way we wanted to. I had trust that women would still get what they needed because our model was based on informed choice and shared decision making. The key is how informed choice is presented - do you present your own bias or do you take the high road and give women the facts and the latest information and let them make their own choice?" She also felt that she was somewhat limited practicing as a community midwife before the College was established. "When I entered hospital with a woman, I had to surrender care and become a consumer advocate. Registration has changed my practice in terms of the services I can now provide women that I couldn't before. I can order diagnostic tests, do screening, work in all settings, and consult with others involved in a woman's care. I don't feel the weight of the College over my shoulders. Yes, there are regulations and protocols. Do I find them restrictive? Most of the time, no."

Having midwifery services covered by the Medical Services Plan also increased access to midwifery services to women who might not otherwise have access, says Knox. "Our main goal [in establishing the College] was that if women wanted midwifery care, they could get it. Before, it was mostly the affluent who used midwives."

Because midwives previously operated outside the medical system, word of mouth was usually their source of new business. The College set out to change this, Kilthei explains. "Women need information from an unbiased third party who can say, ‘Yes, this person has been assessed and is competent.' Women need someone, who has actually tested the midwife's skills, saying, ‘This person can handle postpartum haemorrhage or a breech birth.'"

Leilah McCracken found Gloria Lemay through word of mouth. In 1997, she was pregnant with her sixth child and wanted to have a home birth. Her first five children were born in hospital — one was a Caesarean and the other four were induced. She did not feel that her pregnancy could progress naturally in the alien environment of the hospital, and until that point, she thought she couldn't give birth without a C-section or induction. Her sixth child was born in the computer room in her home with Gloria attending. The pregnancy went to 44 weeks. McCracken says, "There was no paperwork, no nurse's fingers touching me, nobody's face up my crotch, no strangers at the birth. My confidence just soared after my 10-month pregnancy. My body knows what it's doing." She was very happy with Lemay's services. "She was like a shirpa guide, a gentle guiding force. She didn't run the birth. Gloria does what's best for me and my baby, not what's best for the registering body, or what's best for the obstetrician. This is not so for the College who has to answer to a lot of parties." McCracken is currently pregnant with her ninth child.

If you give birth in 2003, your baby will be one of approximately 40,000 babies born in B.C. this year (based on 2001 data). With approximately 780 midwives currently registered with the College of Midwives, each funded to attend 40 births a year, almost 93 percent of women having babies will not be attended by a registered midwife. If you are one of those women, you'll either have your baby in hospital with a doctor (most likely), or you'll give birth at home or elsewhere, with or without attendance. Currently there are 20 midwifery students enrolled in a four-year midwifery education program at UBC, with the first graduates expected in 2004. The College of Midwives also registers approximately 10 new midwives with education from outside of Canada each year through its Prior Learning and Experience Assessment process.

Gloria Lemay has attended over 1,000 births in her career. In 2002, she was awarded the Women's Voice Award, an award given every year by Choices — a non-profit group in Ontario —to the woman who has had the most impact on improving maternity services in Canada. In 2000, she was nominated for the YWCA Woman of Distinction Award in the field of Health and Wellness. She is a contributing editor with Midwifery Today magazine, and she sits on the Advisory Board of the International Caesarean Awareness Network. But unless she wins her appeal, she will not be attending your birth in 2003.

Jennifer Wohl is a freelance writer living in Vancouver. She can be contacted at jenwohl@shaw.ca.

The Way It Was

Imagine it's 1926 and you're a pregnant woman living in B.C. Chances are 50/50 that you'll have your baby in a hospital (the percentage of hospital births in 1926 in B.C. is significantly higher than in any other province — 26 percent for Quebec, 25 percent for Ontario, and only three percent for PEI, for example).

Things have changed over the past 25 years and doctors and hospitals have increasingly taken over the role of delivering babies. If you do have your baby in the hospital, your baby will likely be delivered by a male doctor, and you'll probably have some kind of obstetric intervention — anaesthesia, induction of labour, episiotomy (cutting several inches of the perineum to facilitate birth), forceps, or Caesarean section, for example. Indeed, obstetrics in the 1920s have been characterized by historians as "an orgy of interference."

You won't have any say about who will be in the delivery room; most likely you'll be surrounded by strangers. You might have your pubic area shaved, and receive enemas and various "washes." You'll probably deliver your baby lying on your back with your legs in stirrups — a position most convenient for the doctor, not so comfortable or effective for you and baby.

If you deliver at home, you'll probably have a midwife, neighbour, friend, or relative attend your birth. Midwives are available, but they are not formally trained in Canada or licensed (although they may have training from a European country), and their practice is opposed by the medical profession. Between 1925 and 1926, nine percent of births are attended by midwives.

Fifty years later in 1976, chances are even better that you'll have your baby in hospital. Natural childbirth is in vogue and in preparation for your birth, you may take a Lamaze class to learn breathing techniques or you may learn the Bradley method, also known as "husband-coached childbirth." If you are married and you have your baby in hospital, your husband will be allowed, and perhaps even encouraged, to be in the delivery room. Medication-free birth is not uncommon.

Midwifery Regulation in Canada

Ontario was the first province in Canada to regulate and legislate midwifery (in 1994). The profession is now regulated in Ontario, British Columbia, Alberta, Manitoba and Quebec.

There is no regulation or public funding of midwifery care in New Brunswick, PEI, or Nunavut.

Legislation and regulation of midwifery care are in the works in the Yukon, Saskatchewan, Newfoundland and Labrador, Northwest Territories, and Nova Scotia.

Resources

Gloria Lemay's web site: www.glorialemay.com

College of Midwives: www.cmbc.bc.ca Phone: 604-875-3580

Midwives Association of BC www.bcmidwives.com

Home Birth Association: www.homebirthbc.org Phone: 604-514-5029 Email: info@homebirthbc.org

BirthLove: www.birthlove.com

UBC Midwifery Program: www.midwifery.ubc.ca Phone: (604) 822-0352