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Midwives, Doctors & Doulas

by Skylar Hill-Jackson & Karen Weinthal
published in Woman Newsmagazine, 1996.

When Susan and Dan were expecting their first baby they decided to have a hospital delivery attended by a midwife instead of a doctor. They both felt birthing a baby was a natural process and not a medical procedure.

Susan’s first prenatal visit had been with an obstetrician where, with 30 other pregnant women, she waited for 40 minutes for a seven-minute appointment. Wanting an alternative Susan, with some difficulty, found a midwife team who would do her prenatal care, and her hospital delivery.

At the first appointment she waited for five minutes for a one-hour visit. “I was in a relaxed environment in a waiting room where there was water to drink, toys for older siblings and photographs of the midwives’ babies. It was obvious with every visit that the midwives enjoyed their work,” she says. Susan also found the midwives had an extensive resource library of books, articles, magazines and videos for clients to borrow.

Susan’s partner, Dan, was encouraged to attend every hour- long check-up and visit, and to be as involved in the pregnancy, labour and birth as he wanted. When Susan went into labour, “I was able to assist her but also to stand back and let Susan’s labour unfold, trusting in the midwife, the surroundings and the process”, he says.

After a fairly quick, easy, and unmedicated birth, Susan and Dan left the hospital 12 hours later with their new baby daughter, Bianka. They both felt confident with the knowledge that the midwife would do three home visit follow-ups to ensure they were all doing well. And, there would be unlimited 24-hour telephone consultation. At the six-week check-up the midwife sent all pregnancy and birth information onto Susan’s family doctor.

On January 1, 1994, Ontario became the first province to end the monopoly doctors held so long of caring for pregnant women and delivering babies, by allowing registered midwives hospital delivery privileges. Today a pregnant woman in Ontario can consider which option suits her pregnancy and hospital birth vision: an obstetrician, a family doctor, or a midwife. The costs involved in any of these three options is totally covered by the Ontario Health Insurance Plan (OHIP).

Obstetricians on call
An obstetrician is a medical specialist in high risk pregnancies and births. This includes pregnancies involving multiples, prematurity, breech and other maternal or fetal problems. There is always an obstetrician available (‘on call’) in the hospital to consult or intervene when birth complications arise even when a family doctor or midwife is the primary caregiver.

Obstetricians are often viewed as the best prenatal and delivery care available because of their virtual monopoly on obstetrical care and their training and experience in medical intervention. Pregnant women flock to them. The question is, do high risk doctors provide the most appropriate care to low risk clients? Perhaps not.

Women with uncomplicated pregnancies can be treated by high risk methods which may increase unnecessary intervention. One intervention increases the risk of further interventions. For example, in Toronto there is a 33% induction rate, and inductions increase the use of Cesarean section. With obstetricians delivering 75% of babies in Ontario this means many low risk pregnant women do not have the births they had hoped for.

Obstetricians do not guarantee they will attend a patient’s birth because they work nine-to-five and often only one weekend a month. Women labouring during the nighttime hours will have their baby delivered by the obstetrician ‘on call’.

On their own
With early discharge from hospitals new parents are finding themselves ‘on their own’ with their baby. Public Health nurses no longer visit new mothers routinely. With little postpartum follow-up many new mothers are experiencing a variety of medical and non-medical concerns and often find themselves with their babies back in hospital or at a clinic for help.

A family doctor who includes prenatal care and delivering babies as part of his/her practice will carry a smaller case load of low risk pregnant women. The doctor has more time to spend with a client during check-up visits, and he/she often guarantees to attend the birth. The clients meet other doctors in a shared practice in case back-up is necessary. Family doctors often view childbearing as a natural process and use fewer interventions. These doctors, and some obstetricians, are also willing to work with a birth attendant, as well as the client’s partner, during labour and delivery.

Continuity of care
More and more women are taking additional birth attendants, called ‘doulas’, into the hospital delivery room. A doula (from the Greek word meaning ‘servant’ or ‘server’) is a woman trained and experienced in childbirth, who provides the labouring woman and her partner with continuity of care, emotional support, physical comfort measures, an objective viewpoint, and information so the couple can make informed decisions. A doula also records the birth story for the new parents. And, a doula includes postpartum follow-ups. A doulas’ service is not covered by OHIP and fees range from $300 to $500, or less depending on income.

Tired of the stresses of long, unpredictable working hours, the growing risk of legal liability, and the high cost of malpractice insurance, many family doctors are opting out of the baby-delivery business. This often leaves pregnant couples with only two options, an obstetrician or a midwife.

Women attended women
Midwifery is a lost and found art. Until the 16th century births were attended by midwives who employed personal experience and skills handed down through generations. Women attended women. Loss of control of birth by midwives is often attributed to the French King Louis 14th who preferred his mistresses give birth not only flat on their backs (replacing the popular squat position) so he could watch the event, but that they be attended by his personal male physicians.

It became a status symbol to have male physicians attend births and midwives were relegated to the poorer classes only to be eventually denounced altogether. Midwives and women healers were sometimes murdered having been condemned as witches. But women practitioners did not give up and eventually many European communities began to include midwives in the scientific and medical management of birth. This practice has now become routine where pregnancies are considered to be ‘normal’ and ‘uncomplicated’.

In North America, midwifery has been slower to regain acceptance. In the early 20th century the value placed on science and technology, the growing respect for doctors, and general prejudice against professional women, almost eliminated midwifery. In spite of studies proving the safety of midwifery, and often superior birth outcomes, it has been a long and bitter fight for midwives to regain their traditional role.

Midwives provide care that involves the whole woman and are concerned with the emotional as well as the physical aspects of pregnancy, labour and birth. Midwives are trained and experienced in uncomplicated birth and will refer clients to physicians if complications arise. In Ontario, midwives can now attend women in a hospital, birthing centre or home birth setting. Midwives provide comprehensive prenatal care including routine examinations, ordering blood tests and ultrasound, and they can also prescribe a small range of drugs.

But the real benefit of midwifery care is on a personal level. “They gave me the confidence and support to trust my body’s ability to birth a baby, and not be fearful of ‘labour pain’, and to view the birth as a natural process,” says Susan. Today women who choose to use a midwife may never see a doctor as a midwife provides constant care throughout the pregnancy, labour, delivery and the first six weeks following birth. Then family physicians and pediatricians take over.

Midwives in demand
At present, the demand for midwives far exceeds the supply. Today there are 71 registered midwives in Ontario. Three Ontario universities have begun midwifery training programs and by the end of l996 there will be approximately 30 to 40 new midwives. But calling early in the pregnancy is advisable. The Association of Ontario Midwives (494-4819) directs individuals to the closest midwife group practice.

For parents-to-be who choose an obstetrician or a family doctor, accessing the services of a doula may reduce length of labour, the use of induction, pain medication, epidural, and the chance of Cesarean birth. Doulas are listed with the Labour Support Association and Registry (905) 842-3385 or (905) 844-0503. Some doulas offer postpartum support separate from labour support.

New mothers may also contact Visiting Homemakers Association (489-2500) which provides postpartum care including help with the new baby, looking after siblings, light housekeeping, laundry, and shopping, etc.

There is a continuum of risk, complication and intervention involved in birth. The obstetrician’s training and experience provide care for the most medically demanding population; those requiring aggressive management of pregnancy and medical control of the birth process.

The family physician holds the middle ground, providing medical intervention as needed while philosophically viewing birth as natural and normal.

The midwife, as the guardian of normal birth, participates as a non-interventionist practitioner allowing women to continue giving birth on their own, providing support and knowledge, but not interfering.

Childbearing women today are entitled to choose for themselves the best possible care for the best possible labour and birth experience, as well as choosing appropriate postpartum support during the challenging early weeks with their new baby.