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The Birth of a Dilemma

With more and more family doctors opting out of the delivery room, women are facing a polarized choice when having a baby -- midwife or medical intervention? MARGARET PHILP reports

By MARGARET PHILP

UPDATED AT 2:56 PM EDT Saturday, Oct 16, 2004

Angus Clive Breakspear McCormick slipped a few weeks ago, slick and bluish and squalling, into the gloved hands of a midwife crouched on the bed.

In the spare room of his parents' Ottawa house, there was no delivery table fixed with stirrups. No anesthetist on call. Just a cookie sheet on a table holding basic medical supplies, an electric heating pad warming a stack of flannel receiving blankets, and a portable oxygen tank.

Short of delivering in the backseat of a taxi cab, childbirth seldom gets more low-tech. But from the beginning of her pregnancy, Angus's mother, Julia McCormick, wanted it no other way.

Not for her were the medical miracles of the highly trained obstetrician skilled with scalpel and forceps and vacuum. In the aftermath of the SARS epidemic, even the specter of delivering her first-born in a hospital full of sick people was unthinkable.

"Hospitals are places you go when you're in a crisis and someone has to save you, and I didn't feel that way about birth," she says. "Birth is something that women do."

While pregnant friends were delivering their babies in hospitals with doctors and anesthetic, Ms. McCormick called a midwife, becoming one of the swelling ranks of Canadian women passing up modern medicine for a more old-fashioned birth.

Angus was born at a time when childbirth in Canada is growing more polarized. While more women are turning to midwives and home births, far more are delivering babies in hospital under the watch of obstetricians using medical interventions such as cesarean sections and chemical inductions. With family doctors abandoning the delivery of babies in alarming numbers, more and more normal, low-risk births are being handled by experts in complicated, high-risk deliveries, even as pregnant women flock to midwives whose stock-in-trade is natural childbirth.

Ms. McCormick is no granola-crunching hippie throwback. At 34, she is a modern Canadian woman with a university degree, working for a big Ottawa high-tech firm as a software developer and driving a Subaru Outback station wagon to work.

Over the past decade, midwifery has leaped from the fringe to the mainstream, from a service uncovered by provincial health insurance to one regulated and publicly funded in Ontario, British Columbia, Manitoba and Quebec. (They are regulated, but not funded, in Alberta, while midwifery legislation has been passed, but not proclaimed, in Saskatchewan and the Northwest Territories.)

The five Canadian universities graduating dozens of new midwives with bachelor of health science degrees each year are falling far short of the swelling demand, as telephones at midwifery practices around the country ring off the hook with women who, if not choosing a home birth, wanted to deliver their babies as naturally as possible.

Ontario midwives turned away nearly half of the women who knocked on their doors last year. When the province became the first to regulate midwives a decade ago, the fledgling profession delivered about 1.2 per cent of the province's newborns. Last year, the 7,948 babies brought into the world by midwives accounted for about 6.2 per cent of all those born in Ontario. While it's a drop in the bucket, midwives would have performed closer to 10 percent of Ontario's obstetrical work were there enough to go around.

And yet, while midwifery has come into fashion, medical intervention has more so, with growing numbers of expectant mothers requesting procedures such as C-sections when they are not medically necessary.

A recent report by the Canadian Institute of Health Information showed that the number of Canadian babies born after a C-section, an induced labor, or an epidural -- anesthetic injected into the mother's spine -- is on the rise. Epidurals were used in nearly half of vaginal births in the year ending March of 2002, while one in six first-time labors ended in a C-section. The rate of induced labor, meanwhile, swelled over the course of a decade from one in eight births to one in five.

"Yes, there are growing numbers of women having a very positive experience with midwives," says Vicky Van Wagner, a pioneering midwife who has practiced in Toronto for the past 25 years. "But the norm in society is still to give birth without midwives. And within that group, the norm is shifting to a strong growth in the normalization of intervention." It used to be that the expectant mothers calling on midwives were educated, middle-class women with a strong feminist bent. Nowadays, philosophical leanings have taken a backseat to more practical considerations and the expectant women walking through the door represent everyone from poor, new immigrants to stylish working women in heels.

The appeal of midwives is this: They are trained professionals on call around the clock for their clients, schedule long and usually unhurried prenatal appointments, remain at the woman's side for the latter stages of her labor and all of the birth no matter what time of the night or how long it takes, provide postnatal care for six weeks after the baby's birth, and hold to a philosophy that informed women should be supported in whatever choices they make -- even if opting for interventions such as an epidural.

"Before regulation and in the first few years after, the women we got were the typical suburban clients who were well-educated, fairly comfortable financially, well-informed, and looking for a type of care," says Remi Ejiwunmi, a midwife at a bustling practice in suburban Mississauga that turned away one woman for every expectant mother it accepted last year.

"Now, we're getting women from culturally diverse backgrounds, but also professional, upwardly mobile women who are not coming because of a strong philosophical attachment so much as they like the care that we provide."

It isn't just expectant mothers who like the care they provide. When Ontario Health Minister George Smitherman announced an increase in funding last month of $7-million to allow 55 more midwives to practice in the province, the minister, eager to curb health-care spending by admitting fewer people to hospital, said he wants midwives to "play a more prominent part in front-line primary care" in the province.

And little wonder. A government report released last year said that not only is it cheaper for midwives to deliver babies, with less medical intervention, earlier hospital discharges and fewer preadmissions of mothers and babies than when family physicians perform similarly low-risk births, but also that breast-feeding rates were higher (91 per cent of mothers were still nursing six weeks after their infants were born, as opposed to 71.5 per cent for those who used doctors or obstetricians) and mothers were almost unanimous -- to the tune of 98.7 per cent -- in reporting satisfaction with their care.

The report, which estimated that hospital births by midwives cost an average of $800 less than those performed by family physicians, concluded that mothers and their babies face no more danger giving birth at home than in the hospital, and that babies were no more at risk of death being delivered by a midwife rather than a family doctor.

But only 500 midwives are practicing across Canada. And the universities can graduate only a few dozen more each year, limited by the small number of experienced midwives who can work as professors and provide the on-the-job training that is half of the students' academic curriculum.

Midwives are hardly filling the breach left by family doctors leaving obstetrics by the hundreds, no longer willing to tolerate the wildly unpredictable lifestyle of being on call to women in labor, never mind rising malpractice awards in the courts. While about half of family doctors delivered babies two decades ago, fewer than 10 percent do so now.

And so, more and more expectant mothers are heading to the offices of obstetricians skilled in the technologies of the delivery room. Not that obstetricians alone are to blame for the rising use of medical interventions in birth. Women are older when giving birth and more are overweight before becoming pregnant. Add to the mix research findings published over the past decade that have prodded doctors to perform surgeries they were willing to avoid in the past. Where obstetricians not so long ago delivered breech babies vaginally as a routine, for example, current wisdom has shifted to recommend C-sections and few doctors are prepared to take a chance.

But pregnant women themselves are insisting on medical intervention in their births, and often long before their labors have begun. Some fret about the danger of a vaginal birth. For others -- a phenomenon known as "too posh to push" -- it's a matter of convenience.

In his first 15 years as an obstetrician in Nova Scotia, David Young can recall only one woman demanding a C-section. "But if you asked in the past year how often that's happened, I would say several times.

"I suspect that it will become a bigger number," says Dr. Young, the past president of the Society of Obstetricians and Gynecologists of Canada. "There are concerns related to what those patients consider as safe -- what they're prepared to endure in terms of pain relief and risks they're going to take. There are also issues of convenience."

If a healthy pregnant woman feels safer with a medical intervention that appears to be unnecessary, he says, her wishes should be respected.

"I think that what the mother wants, and all providers want, is the safest possible delivery and the best outcome for mother and baby. If that means, in order to achieve that, intervention rates go up and women and their families wish that, then that's fine."

For Ms. McCormick, a labor ending in surgery would not have been fine. "I knew the only way it would happen with the midwives is if it were a life-and-death situation," she says. "I don't trust the obstetrical system to go that route. I think there are too many C-sections done, and I didn't want to be put in the position where I was told it was a life-and-death situation when it really wasn't."

"I want people to understand that you don't have to be superhuman to have a baby at home or to have a midwife. Women have babies. Our bodies are made to have babies."

Margaret Philp is a Globe and Mail writer.


Did You Know?
Home births have been shown to be safer than hospital birth for healthy moms???
Read more!

We have a secret in our culture, and it's not that birth is painful... it's that women are strong.
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