Midwifery in Canada - Quebec

Report submitted September 2007 by the Regroupement les sages-femmes du Quebec

A prevalent theme for Quebec midwives and women’s support groups this year has centered around how to develop midwifery and make services more accessible, while maintaining the essence of “with woman” care.

Midwifery has served as a self-regulating profession legislated under the Quebec Ministry of Health and Social Services (MSSS) since 1999. Over the years, numerous formal links with community groups have assured that midwifery practice in Quebec continues to be informed by women and families. This year much concern over midwifery’s future directions, and how to best conserve a community model of care has been expressed in the wake of the Ministry’s expansion plan proposed in their 2006 Politique en perinatalité. In late spring 2006 a document entitled “Les Enjeux de l`intégration des sages-femmes : s`intégrer sans se désinégrer, Actes du Colloque”, voiced some of these initial concerns in the form of recommendations for further development and integration of midwifery in Quebec. (Both documents are available from the RSFQ office.) Over a year later, while demand for midwifery services increases (birth centre waiting lists range from 80 to 800), the final version of the Ministry’s Policy document has yet to be released, creating a striking disconnect between government policy, funding, and the efforts of the university midwifery program to strengthen the profession. Nonetheless, the freeze is predicted to thaw by winter, and it is expected that some of the concerns expressed over the last two years will be addressed. In any case, a sizable representation of women and midwives are ready to respond.

Legislation and regulation:
The evaluation of a 5 year pilot project funded by the MSSS involving midwifery practice in out-of-hospital birth centers gave rise to the 1999 Quebec Midwifery Act which prescribes the regulation of midwifery through the Ordre des Sages Femmes du Québec (OSFQ), the professional organization which serves to protect the public. The Regroupement des Sages Femmes du Québec (RSFQ) is the main provincial association working on behalf of the professional interests of midwives while striving to develop the profession according to its model and philosophy of care.

Midwifery Model of Care:
Midwives offer comprehensive primary maternity care in home, birth centers and hospital settings. The model is founded on 4 guiding precepts which are intimately connected and contribute to fundamental concepts of responsibility and safety:

• Confidence and respect for the physiological process of pregnancy and birth
• Confidence and respect for the competency, autonomy and personal choices of childbearing women
• Continuity of care and the care relationship
• Development and fostering of personal and egalitarian relationships with women

These principles assume a subtle shift away from a paradigm where an expert provides care, advise and education to the beneficiary, to one that values accompaniment and exploration within the context of a relationship developed over time. The objective of this relationship is not to change or fix the individuals involved. Rather, it encourages the possibility of mutual trust and empowerment by focusing on the whole person through dialogue and deep listening. The midwifery model is inclusive of a biomedical approach, but extends and complements the biomedical model of maternity care through its regard for each woman’s unique expression of what is normal to the birth process.

Funding and remuneration:
Midwifery services in Quebec are fully funded by the MSSS. Women have access to services covered by provincial health care insurance. The RSFQ signed a preliminary agreement regarding working conditions with the Health Ministry in December 2004. Negotiations continue, however, with the intension of better aligning remuneration and working conditions with the reality of midwifery practice and perspective.

Requirements for registration:
The OSFQ registers midwives who have either passed through the 4 year Midwifery Baccalaureate Program at the Université du Quebec à Trois Rivières (UQTR), or otherwise demonstrated competency and safety to practice according to requirements set out in their bylaws .The Midwifery Program at UQTR graduated nine midwives this year. The program has seen 47 graduates since it opened in 1998. The OSFQ is presently developing a formal Prior Learning and Education Assessment tool, which is to contain an orientation component for midwives educated or experienced in jurisdictions outside the Quebec system.

Implementation and development:
Midwives are considered primary care workers and so are employed through regional community health centers (CSSS), which serve as umbrella organizations for the 11 maternity centres throughout southern and northern Quebec. An additional maternity centre in the Laurentian region of Quebec opened its doors this year, and budgeting has been approved for two more centers each in the Montreal and Quebec City regions. These services are intended to target, in part, certain “vulnerable populations”. Care and follow-up is primarily provided out of these maternity centers. Women have the choice to give birth at home, in the maternity center or in hospital. To date, however, despite political and financial pressure for hospital based midwifery care, given the option, most women followed by midwives in Quebec still choose to give birth in their homes or in birth centres.

In response to results of its 2005 survey of women’s maternity care preferences, the MSSS proposed within the context of its 2006 Politique en perinatalité to increase the projected number of Quebec women having access to midwifery services by 10% within the next 10 years.

Statistics:
The number of births attended by the 93 practicing midwives in Quebec and recorded by the maternity centers this year was slightly over 2% of the approximated 70,000 births per year in Quebec. This represents a rise of almost 200% since 1994. Two years ago the Health Ministry took initial steps to standardize data collection for all the maternity centers. However, implementation of these programs is now indefinitely on hold. A promotional package prepared by the RSFQ is available from their office. It outlines in more detail some of the statistical findings related to midwifery care in Quebec, including results from studies comparing women followed by midwives with a similar population of women followed by doctors.

Additional RSFQ initiatives:
The work of the RSFQ board has been particularly preoccupied with the issue of development this year. The Association has taken the lead and spent many hours educating policy makers on the needs and benefits of our profession. Recommendations have focused on supporting the Ministry’s initiatives, while calling for ongoing dialogue among all implicated partners in order to honor the essential principles of midwifery and articulate its role as “guardian of normal birth” to colleagues in the field.

In collaboration with the OSFQ and the Group Maman, the RSFQ produced a working definition of the “Maison Naissance” (Maternity Centre). This initiative was intended to permit the RSFQ to take an official position on the subject, and to serve as a means to preserve the philosophy of care applied in these community based locations.

Somewhat in the spirit of “small is beautiful” (and so is intimacy, confidence in normal birth, and all the rest….) and that care is strengthened through relationship and continuity, the following definition emerged from the June 2007 AGM:

Maison de naissance

« Une maison de naissance est un espace d’accueil pour les femmes enceintes et leur famille. C’est une maison au cœur d’une communauté, un lieu physique distinct du domicile et du centre hospitalier, mais faisant partie du réseau public de la santé. C’est une petite installation où est basée la pratique sage-femme et qui accueille environ 300 naissances par année, afin de garder son caractère familial et humain.

En maison de naissance se donnent uniquement des services de première ligne. Les sages-femmes qui y travaillent, offrent aux femmes et à leur famille, un accompagnement global de la naissance, comprenant entre autres ; le suivi de grossesse, l’accouchement, le postnatal de la mère et de l’enfant jusqu’à 6 semaines. Son environnement et la philosophie des sages-femmes qui y pratiquent favorisent l’accouchement naturel. C’est l’endroit privilégié du développement de la pratique sage-femme, de la formation et de la recherche.

Une maison de naissance répond aux besoins de la communauté dans laquelle elle est installée. On y développe une vision sociale et citoyenne de la naissance. Ceci implique un partenariat avec les familles et les citoyenNEs à toutes les étapes de la vie de la maison de naissance. Des activités communautaires en lien avec la parentalité et la santé peuvent s’y tenir et créer aussi de nouvelles solidarities.”

The RSFQ continues to produce its newsletter, Mes Sages. This publication encourages the sharing of narrative, and promotes the importance of the tradition of storytelling in making visible the diverse events which occur around birth and, consequently, in generating midwifery knowledge.

Northern midwifery:
Nunavik’s Inuulitsivik midwifery service and education program celebrated its 20th anniversary last October. There are 3 maternity centers on the Hudson Bay Coast (serving 7 villages). Midwives follow 100% of pregnant women from that region, accounting for about 200 births per year. They also provide well-woman and baby care within the three village communities.

The Quebec Midwifery Act recognized 5 of the local midwives practicing in Nunavik in 1999 by granting them regional licenses. However, the Act did not provide for the ongoing education of future midwives in this region, and consequently, the 4 community midwives who have since graduated from the apprentice based Inuulitsivik Midwifery Program have no legal status. They continue to provide comprehensive care in Inutitut to women and families in their communities, nonetheless, along with 11 students and a number of part time midwives serving as mentors and preceptors from different regions of southern Canada.

The scope of practice for northern midwives is broader in the areas of emergency care and community health due to the remote nature of the region. 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 8-11%.

Inuulitsivik Health Centre, with the help of the Ontario Health Ministry and Ryerson Midwifery Program received a Health Canada grant to conduct a 20 year retroactive study of childbirth related outcomes for the coast. This is being seen as a major step towards gaining long awaited recognition for the Inuulitsivik Midwifery Program, as well as a way to validate bringing birth closer to remote communities.

Inuulitsivik midwives and students joined Inuit from across the north, health professionals, and government representatives in Iqaluit for the first Nunavuut Inuit Nunaat Midwifery Gathering to share experiences, concerns, elder wisdom, and politics.. Some positive discussion about solutions regarding recognition and regulation of Nunavik midwives took place between the Department of Aboriginal Affairs and Northern Regions, the Quebec Department of Health representative, Jeannine Auger and Nunavik midwives. The potential for a Nunavik or Arctic Assessment Process that could be accepted by the OSFQ and/or by a Pan-Arctic Body was also seriously discussed. While there seemed to be general support for a Pan Arctic Midwifery Association network board, there was also recognition that the unique and diverse needs existing among the Arctic Inuit Communities would have to be addressed differently by such an organization.

Meanwhile, Tulatavik Hospital in Kuujjuak has posted a positions for 3 midwives to help set up midwifery services for the Ungava Coast. These communities have expressed a desire to have services based on the Inuulitsivik model.

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 a registered midwife to start the process of developing midwifery services beginning with the villages of Mistissini and Chisassibi. Funding for a birth center in Mistissini was approved last spring.

Representatives from both the James Bay and Nunavik regions have joined a core group of aboriginal midwives from across Canada to organize a second Aboriginal Midwifery Gathering to be held in conjunction with the CAM Vancouver Conference. This group will also be exploring, over the next year, the possibility of creating a National Aboriginal Midwifery Council.

Looking back on this year of reflection and movement, one perspective on Quebec Midwifery that still rings true resonates from the words of a mother from a remote community in James Bay: “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.”

Contact information:

RSFQ
Céline Lemay, President
6555 Côtes-des-Neiges, bureau 442
Montréal, QC H3S 2A6
514-738-8090 819-254-0172
Email: sages.femmes.qc@bellnet.ca
Website: under construction

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