Bringing Midwifery Education Back to the Community
Midwife Rachel Dennis Couchie weighs a baby at a home visit. Midwives are primary care providers who work with families throughout pregnancy, during labor and delivery, and for six weeks after birth. (Photo courtesy: K'Tigaaning Midwives)
Every year thousands of pregnant Ontarians are unable to access midwifery care because there are not enough providers to meet demand. The problem is worse in the north, where many communities struggle to hire and retain midwives. Susan James fears these disparities will worsen now that the north’s only midwifery degree-granting program has closed. From 1999 to 2019, James was director of Laurentian University’s midwifery program, which was cut last April along with dozens of other programs as part of the university’s financial restructuring.
The loss of local programs such as Laurentian’s can have cascading social and economic effects for communities. With the loss of health care services like midwifery, it becomes harder to attract young families to the region, James explains, referring to research on rural health. “And then, maybe you don’t have enough kids for a school . . . or enough small families to have two grocery stores.”
Investment in local initiatives has the potential to not only increase the number of midwives practicing in the province but also ensure that midwifery services reflect the makeup of the country.
Before the closure, Ontario’s midwifery education program operated as a consortium of three schools that each admitted 30 students per year—Laurentian University, in the north, and McMaster University and Ryerson Universities, in the south.
Data from this year show that Laurentian graduates make up about 60 percent of all midwives practicing in the north, including 60 percent of the National Aboriginal Council of Midwives (NACM), and over 90 percent of francophone midwives. The latter statistic reflects the fact that Laurentian was the only option for Ontarians wanting to study midwifery in French. With the program closed, current students will learn remotely through McMaster or Ryerson and complete their placements in the north. French students will receive tutoring to make up for the lack of French instructors at these schools.
James and colleagues worked on a project that came close to getting federal funding in 2011 through the Consortium national de formation en santé, a program that provides grants for French-language health care provider education outside of Quebec. The idea involved offering other provinces that had a French university but no midwifery program, such as Alberta or Manitoba, the ability to buy seats at Laurentian. Students would complete much of their first-year coursework (e.g., women’s studies, anatomy and physiology) and electives at their home institution and/or by teleconference at Laurentian, attend Laurentian for one term of hands-on instruction, and, wherever possible, complete their placement at home. According to James, this project had the potential to increase the number of bilingual midwives (and future instructors) in Canada and was ready to go had the funding come through.
The province has committed to re-establishing a bilingual program in the north, but when reached for details on a potential timeline, the Office of the Minister of Colleges and Universities provided a statement indicating that it is focused on “identifying immediate pathways for students impacted through the only two other universities that offer midwifery programs.”
Carol Couchie grieves the loss of the bilingual program, noting its closure will affect a huge community. Couchie is Nishnawbe Kwe and was one of the first Indigenous midwives registered in Canada. Couchie says that Aboriginal midwifery education is thriving in Ontario. Now retired from practice, Couchie remains involved in the educational initiatives of NACM, an organization she helped found.
Under the Ontario Midwifery Act, Indigenous midwives may provide traditional midwifery care in their community without being certified by the midwifery regulator in their province or territory, though many choose to be registered. The NACM model of education is community based, with midwives chosen by the community and mentored by experienced midwives. The model also envisions an expanded scope of practice for midwives in smaller communities to include providing sexual health care and education to girls and women of childbearing age. NACM has recently received some provincial funding and Couchie is hopeful that more will be forthcoming as more Canadians become sensitized to anti-Indigenous racism and how it can be reduced by the presence of trusted Indigenous health care providers in a community. Here Couchie references the experience of Joyce Echaquan, an Atikamekw woman who live-streamed herself being verbally abused by staff and health care providers at a hospital in Joliette, Quebec, in the hours before her death in September 2020.
Federal funding, Couchie says, could make Aboriginal midwifery training accessible to communities that need it across the country. She adds that COVID-19 restrictions have proven that physical barriers can be overcome.
What made Laurentian’s program unique, according to James, was its focus on community building. Becoming a northern midwife requires sacrifice, James explains. Most students move at least once, and some move up to three times to complete the practice requirements for their program. To James it was important to build a network of support that could bridge distance because many graduates end up working in remote communities where they may be the only midwife.
James explains that programs that incentivized medical students studying at southern universities to work in the north failed because the new doctors often left. James says that “when they put the medical school [the Northern Ontario School of Medicine] in Sudbury and Thunder Bay, we started to see the solution to physicians in the north. Since the new school, which opened in 2005, started graduating students, “it’s not impossible to get a family doctor anymore.”
Given the difficulty of recruiting health care providers to work in rural and remote communities, Couchie says system change is needed, with education centered on an apprenticeship or a “grow your own midwife” model. In the Nunavik region of northern Quebec, the long-running Innulitsivik midwifery service provides what Couchie calls the “gold standard” for this model of education. This group of Inuit midwife-led birth centers was established to end the routine “evacuation” of local women in the final weeks of pregnancy to large southern hospitals not equipped to provide culturally competent care. The centers are connected to hospitals in the region and a tertiary center 1000 miles south in Montreal. The need for transfer during pregnancy is regularly assessed by all providers.
Recent data show that over 85 percent of Nunavik women delivered in the region and with similar outcomes to women in the rest of the country; only about 2 percent of babies were delivered by cesarean. “The story of Nunavik is 35 years old, but it needs to be told over and over again and needs to be replicated,” says Couchie.
The birth centers also provide hands-on midwifery training, with graduates eligible for registration with the midwifery regulator in Quebec. Couchie explains that Nunavik has a laddering program that students can complete on their own time. “They can leave for a maternity [leave] or two,” she says. “There’s no failure. You just keep working at it, and if you decide it’s not for you, you can leave.” Couchie cites the Six Nations Aboriginal Midwifery Training Program in Ohsweken, Ontario, as an example of a successful program closer to home, and they are just now getting funding to support students.
On the role of the federal government in improving access to midwifery care, Couchie says, “We have a lot of strength here [in Ontario] and a lot of abilities . . . We just need people to listen to us.”
