Midwifery in Canada - Quebec

Report submitted September 2008 by the Regroupement les sages-femmes du Quebec

Legislation and regulation
In Québec, legalization took place after a five year evaluation of midwifery within pilot projects. These pilot projects took the shape of birth centers which were affiliated with community health centers (CLSC). Most of the pilot projects began in 1994. The legalization of midwifery practice and the implementation of a midwifery education program at the University of Quebec in Trois-Rivières took place in 1999. So, this year we are celebrating 10 years of midwifery implementation and midwifery education in Quebec, as well as 15 years of birth centers. In 2006, there were 1279 births attended by midwives, representing 1.6 % of births in Quebec.

The Ordre des Sages Femmes du Québec (OSFQ) is the professional order whose mandate it is to protect the public. As of the 31st of March 2007, there were 101 midwives registered with the OSFQ. Quebec’s association of Midwives is called the Regroupement Les Sages Femmes du Québec (RSFQ); it is the main provincial association working to protect the professional interests of midwives. The RSFQ also works towards the development of midwifery practice in accordance with its professional standards of practice as well as its philosophy of care.

Model of Midwifery practice
Midwives offer comprehensive primary maternity care in home, birth centers and hospital settings. The model is founded on 4 guiding precepts:

• Confidence in and respect for pregnancy and childbirth as normal physiological processes
• Confidence and respect for the competency, autonomy and personal choices of childbearing women
• Providing Continuity of care and building trusting relationships with women
• Development and fostering of personal and egalitarian relationships with women

Funding and remuneration
Midwifery services in Quebec are fully funded by province’s Ministry of Health and Social Services, the MSSS. Women have access to free services because these are covered by the provincial health care insurance.

The RSFQ signed an agreement regarding the working conditions for midwives with the Ministry of Health in December 2004. However, negotiations are on-going and are focused on making certain that compensation and working conditions better reflect the reality of midwifery practice. Midwives in Québec are hired under contract with the Health and Social Service Centres the CSSS (formerly the Community Health Centers CLSC). Midwives are not self-employed and as employees they benefit from certain advantages such as offices, a secretary, equipment paid for by the CSSS as well as certain holidays.

Furthermore, midwives in Quebec do not have hospital privileges. When there exists an agreement between a hospital and the CSSS, the midwives will use the hospital premises and equipment when they are accompanying a women who has chosen a hospital birth.

Midwifery Education
Midwives in Quebec are presently trained at the University of Quebec in Trois-Rivières; it is a 4 year bachelor’s degree. This program focuses on practical instruction. Aside from the theoretical classes, students must complete several training courses where they are paired up with a practicing midwife under a preceptorship model. At the moment there are 76 students admitted in the four year program. This fall, around twenty internationally-educated midwives, who have passed an assessment by the Quebec order of Midwives (OSFQ), will be starting a midwifery bridging program at the UQTR which will enable them to practice midwifery in Quebec.

Perinatal Policy
The government of Quebec has put forth a new perinatal policy for 2008-2018. In this new policy, it foresees that midwives will be responsible for 10% of the prenatal care and births. The government also plans to set up 13 new birth centers and to promote midwifery services to women living in vulnerability contexts.
At the moment there are 11 midwifery practices in Quebec, 2 new practices came into being this year, one in Limoilou in Quebec city and one in Montreal’s Plateau Mont-Royal burough. The government’s new policy is therefore very good news for us, enabling us to double the number of midwifery practices in Quebec.

Northern midwifery
Nunavik’s Inuulitsivik midwifery service and education program have been providing complete perinatal services in Inuktitut to the communities of the Hudson Bay region since October 1986. Three maternity centers serve the seven villages along on the Hudson Bay Coast. Midwives follow 100% of pregnant women from this region, accounting for about 200 births per year. They also provide well-woman and baby care within the three village communities where the maternities are located.

Due to the remote nature of the region, the scope of practice for northern midwives is broader in the fields of emergency care and community health. Statistics are comparable to those for midwives practicing in southern Quebec, although intervention rates tend to be slightly lower and the C-section rate has ranged between 1.7 and 2.4 since the practice began. The transfer rate ranges from 8-14%.

Five local midwives practicing in Nunavik were granted recognition and received regional licenses under the 1999 Quebec Midwifery Act. However, the Act did not provide for the ongoing education of future midwives in Nunavik. Consequently, the community midwives who graduated from the apprentice based Inuulitsivik Midwifery Program after 1999 held no legal status. Despite this lack of official endorsement, they continued to provide comprehensive care in their communities, together with local midwifery students and several part time midwives from southern regions of Canada who serve as mentors and preceptors.

But this year witnessed change and movement for northern midwives and their communities.

During the spring and summer of 2008, representatives from the Quebec Health Ministry, together with executive members of the OSFQ, made several visits to the Maternities on the Hudson Coast to observe the services and to discuss the education process. Their newly developed prior learning assessment tool allowed the OSFQ to evaluate the program, and particularly the work and education of two community midwives from Inukjuak. On September 24 2008, Brenda Epoo and Aileen Moorhouse were granted full licensure by the OSFQ along with the new university graduates in Quebec City. Brenda and Aileen took their oath in Inuktitut, and were honored by family, community representatives, OSFQ membership and government officials alike. The Puvirnituq midwives who currently hold restricted licenses now also have the opportunity to change their status to “full” licensure.

This bold step marks, perhaps for the first time, the recognition and value of traditional pathways to learning midwifery alongside the prescribed and dominant routes to practice. It sets a precedent, not only for Nunavik, but for Northern and aboriginal communities across Canada, and perhaps the world, who wish to bring birth back to their regions. This was truly a moment for celebration.

A retrospective study which analyzed childbirth related outcomes from 2000-2007, was completed this fall with the support of Ryerson University Midwifery Program and funds from First Nations Inuit Health Branch of Health Canada. The findings, consistent with previous research done in Nunavik, uphold the premise that safe care can be provided in remote communities and in communities without cesarean section capacity. The success of the midwifery service was attributed to the knowledge and skills of the Inuit midwives and the support of an inter-professional team. The research also supports recommendations for integration of midwifery care in remote communities and for the recognition and education of aboriginal midwives. (Van Wagner et al. 2008. Remote Midwifery in Nunavik: Outcomes of Perinatal Care 2000-2007 for the Inuulitsivik Health Centre, awaiting publication).

The communities of the Ungava Coast may soon have access to similar maternity care. Tulatavik Hospital in Kuujjuak has hired a midwife to help set up midwifery services based on adapting the Inuulitsivik model to the needs of their region. The James Bay Cree, under the auspices of the Cree Health Board and the Awash Healthy Children Program, continue to move forward on establishing midwifery services and a local midwifery education program for their region. The Cree Board has hired two registered midwives to develop midwifery services in the villages of Misticini and Chisassibi. Funding for a birth center in Misticini was approved in the spring of 2007..

Inuulitsivik midwives and students joined with other aboriginal voices this year around several national and international initiatives. They have taken an active role in the Nunaani Midwifery Working Group led by Pauktuutit, the National Association for Inuit Women of Canada and funded by First Nations Inuit Health Branch (FNIHB). This group was formed to promote, support and strengthen Inuit midwifery for all Inuit communities by developing an action plan for northern midwifery certification standards. Representatives from Hudson Bay were also invited to present at meeting of Aboriginal midwivies and policy makers from the United States and Canada in Washington DC in May 2008.
Representatives from both the James Bay and Nunavik regions have worked together with a core group of aboriginal midwives from diverse communities across Canada in creating a National Aboriginal Council of Midwives. This Council, which will initially be under the umbrella of CAM, is to serve as a forum for aboriginal midwives to discuss ways of bringing birth back to their communities, to share stories, experiences and policies, and to begin dialogue with other Canadian and International midwives. The Council will be having its first annual meeting in conjunction with the CAM annual Conference in Quebec City in November of this year.

Both the Cree Health Board and Inuulitsivik Health Centre have produced DVD,s honoring the wisdom of their elder midwives. These films are available through the National Aboriginal Health Organization (NAHO): www.naho.ca.

Two years ago, a mother from a remote community in James Bay commented during a focus group meeting: “We hope that by sharing our stories and deepening bonds of communication and reflection among women, midwives, and other health care workers, we can bring to light the memory of what is essential to maternity care as it evolves across regions and cultures.” For communities in the northern regions of Quebec, this has been a year in which the story of midwifery has evolved in many essential ways. May dialogue and diversity continue to be honored.

Le Regroupement les sages-femmes du Québec

• Présidente : Céline Lemay
• Vice President : Christiane Léonard
• Treasurer : Katryne Doré Théroux
• Secretary : Mounia Amine
• Administrator : Arianne Morrissette
• Administrator : Caroline Savard
• Consumer representative : Mirabelle Lavoie

Contact information:

RSFQ
Céline Lemay, President
6555 Côtes-des-Neiges, bureau 442
Montréal, QC H3S 2A6
514-738-8090
Email: sages.femmes.qc@bellnet.ca
Website: www.rsfq.qc.ca

Nunavik Midwifery Association
Brenda Epoo, President
Inukjuak Maternity
Inukjuak, Nunavik, QC J0M 1G0
Email: brenda.epoo@ssss.gouv.qc.ca

OSFQ
ordresagesfemmes@osfq.org
www.osfq.org

UQTR
www.uqtr.org

Regroupement Naissance Renaissance
www.cam/org~rnr

Groupe Maman
www.groupemaman.org