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Why isn’t there a system of integrated maternity care in Ontario?


Midwives provide high quality care for normal, low risk pregnancy and child birth, but provide this care to relatively few women in Ontario. The demand for midwifery services is outstripping capacity. 

The philosophy and actual practice of care provided by midwives and obstetricians is different. Obstetricians deliver many more babies, but obstetrician-led care is more likely to result in costly interventions. Obstetricians also don’t spend as much time with mothers before and after birth as midwives. 

Although there are models in other countries of successful interprofessional care models where midwives and obstetricians work together, this is not widespread in Ontario.  

Christine Brown, a Toronto mother of two, chose to deliver her first child at home with a midwife. She says that “to have the opportunity to give birth in a non-medical environment was incredibly peaceful and unobtrusive.” Brown says that the “partnership and relationship established with my midwife” provided her with “the confidence to labour freely and safely at home.

Despite the growing number of midwives in Ontario, about 40% of women who seek midwife-care are turned away due a lack of capacity. There is controversy about how access to midwives can be expanded in Ontario and integrated with obstetrical care.

This story is one in a series that healthydebate.ca is writing regarding the role of various health professionals in Ontario, and how they do and do not work effectively together.

Different providers, different models of care

Midwives are trained to assess and monitor normal pregnancy and birth, as well as provide care after labour to mothers and their newborn babies. Midwives can deliver babies at home or in hospital, but only about 20% of midwifery clients choose to give birth at home. Obstetricians are doctors trained in women’s reproductive health. In addition to being trained to manage normal pregnancy and birth, they manage high risk pregnancies and also can perform surgical procedures such as cesarean sections.  Family doctors generally do not perform surgical procedures for labour and delivery, and manage low risk pregnancies and deliver babies in a hospital setting.

Obstetricians deliver between 75 and 80% of babies in Ontario, with midwives and family physicians sharing the remainder. The number of babies delivered by midwives in Ontario is increasing, while the number of babies delivered by family doctors has decreased over the last couple of decades.

Practice style and outcomes for childbirth

Midwives and obstetricians have very different styles of practicing prenatal, labour and postnatal care. Midwives spend much more time with pregnant mothers before and after delivery. In Ontario, the standard is 48 hours over the course of a woman’s pregnancy. Midwives are on call 24/7, which means that the vast majority of pregnant women are attended in labour by a known midwife. Katrina Kilroy, president of the Association of Ontario Midwives describes the midwifery model as an “intensive continuity of care model”-  that is they spend more direct time with expectant mothers prior to, an following, delivery than obstetricians.

Obstetricians provide care throughout pregnancy and delivery, but are usually not present throughout a woman’s labour, and the obstetrician who delivers the baby is often not the obstetrician who has provided prenatal care.

The average midwife in Ontario delivers many fewer babies per year than the average obstetrician. A full time midwifery practice can deliver up to 40 babies per year and attends an additional 40 births as an assistant. The average obstetrician in Ontario delivers 220 babies per year. Both midwives and obstetricians have good outcomes in terms of delivering healthy babies for low risk pregnancies.  In Ontario, women whose babies were delivered by midwives are less likely to use medical interventions such as epidurals, are less likely to undergo cesarean section, have shorter lengths of hospital stay and are more likely to breast feed their babies after delivery. However, many of these differences may be due to the differences between women who choose midwifery and women who choose obstetricians. An international review of studies where women were randomly assigned to either midwifery or other models of care found less dramatic differences between the two types of care, including no difference in the frequency of cesarean section, but still found fewer medical interventions, a shorter stay in hospital and higher rates of breast feeding.

The cost of pregnancy and child birth

The Ontario government pays midwives approximately $2500 for each woman they care for, which includes administrative overhead and supervision of midwifery trainees. In contrast,obstetricians are paid approximately $1500 for routine prenatal care and a normal delivery.

However, from the health care system point of view, other costs also need to be considered. Surprisingly, we were unable to find a study that incorporated all the relevant costs to determine the true costs of midwife versus obstetrician-led care in Ontario.

How to satisfy both patient wishes and health system priorities?

From the point of view of the pregnant mother and her baby, the ideal system would give her the choice of the type of care she wants, with a practitioner who would follow her throughout her pregnancy and birth, and provide high quality care with excellent clinical outcomes and a positive, patient-centred experience. Women need to be assured that should there be complications related to pregnancy, labour or delivery, the needed expertise to deal with unexpected complications is available immediately and seamlessly. From the point of view of the Ontario Ministry of Health and Long-Term Care, the pregnant mothers should be cared for by the practitioner whose skill set best meets her needs, such as access to surgical care for high risk pregnancies, yet is as cost-effective as possible and the least expensive and medically aggressive for low risk pregnancies.

The wishes of both patients and the health care system could be met with a better integrated model of care in which midwives, obstetricians, obstetrical nurses and family physicians all look after patients together, each using their special skills when needed. However, currently in Ontario there are two largely independent systems, midwife and obstetrician led that appear to co-exist with each other warily, and this fragmentation is likely not resulting in the most patient-centered, cost effective and efficient care possible.

In theory, women in Ontario can have their baby delivered by a midwife, a family doctor or an obstetrician. However, women must decide early in their pregnancy who they would like to mange their pregnancy and delivery, and changing health practitioners is difficult unless medical complications ensue. Guylaine Lefebvre, an obstetrician at St Michael’s Hospital in Toronto says that “in theory the assumption is that we are giving [women] choice” but in practice “we are limiting choice by forcing them to choose exclusively.

Integrating the best of midwifery and obstetrics – the example of the United Kingdom

In the United Kingdom, midwives have been the main providers of labour and delivery care since the formation of the National Health Service in the 1940s. Cathy Warwick, general secretary of the Royal College of Midwives says that in the UK “there has never been a battleground between midwives and doctors in terms of who leads that care” and that “there is no competition for labour and delivery because it has been a salaried service.” In the UK, both midwives and obstetricians are paid by salary, rather than for the number of procedures they undertake or the number of patients they care for. Obstetricians provide backup when midwives need help dealing with complications or when a C-section is required. Andre Lalonde, Vice-President of the Society of Obstetricians and Gynecologists says that this kind of a model is “cost effective and produce[s] better care.

Is a culture of collaboration possible in Ontario?

The number of midwives practicing in Ontario is likely to grow from around 540 currently to about 1000 in the next five years. Robin Kilpatrick, the deputy registrar of the College of Midwives of Ontario, says that “the integration issues are critical” to solve as more midwives enter the system.

One Ontario decision-maker said that midwives must ask themselves, “If you say that you want a bigger piece of the pie, are you willing to change your model of care, which is expensive and low volume, to work differently?” Similarly, obstetricians would need to work differently within an integrated model.  Kilroy says that given the increased demand for midwifery care, obstetricians need to consider “what their appropriate role is in low risk births” and how they can “support and facilitate choice” for patients.

Lefebvre says that while integrated models of care may be an improvement on the current fragmented system, there are concerns around how “both providers will retain scope of practice in this model” as “midwives want professional autonomy and obstetricians don’t want to give up normal deliveries.

However, many observers note an absence of trust between providers. Kilpatrick says that there is a “myth of liability” for doctors and that there have been efforts by regulatory bodies in Canada and the United States to debunk this myth. Kilpatrick adds that “there is a need for doctors to know that they are not in jeopardy by working with midwives.” But these attitudes may be changing. Lalonde, of the Society of Obstetricians and Gynecologists notes that in a recent survey of obstetricians, 40-50% said they would like to work more closely with midwives. Just 10 years ago, only 10% of obstetricians were willing to do so.

But Janice Willett, an obstetrician and gynecologist based in Sault Ste. Marie is not optimistic about improved integration of providers. Willett served as president of the Ontario Medical Association in 2007-08, and notes that a myriad of policy issues, such as funding, hospital privileges, and provider education all need to be considered to help “align all the incentives to ensure that there is good, patient-centred care.” Willett suggests that “years of saying ‘integrated care should happen isn’t working” and that better integration between midwives and obstetricians is not “a priority on decision maker horizons.”

Which model do you think would work best for delivering babies in Ontario?

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This article has been closed to comments. 4 comments

  1. Jeremy Petch

    Interesting piece, but I wonder why family doctors providing primary care obstetrics get so little attention. They are mentioned briefly, but then dropped, presumably because the number of deliveries by family doctors has decreased. But why the decrease? Are they being pushed out by obstetricians? Are we training fewer family doctors to do obstetrics? Is the fee schedule designed to discourage them? Do family docs just not want to do obstetrics anymore? And, perhaps most importantly, is this decrease good or bad?

    If continuity of care is of primary importance here, increasing the role of family docs might be the best option, since they can provide prenatal, postnatal, and pediatric care. They are also tend to cost less than obstetricians, while seeing a higher volume of patients than midwives. We are provided with some information about the outcomes of midwife care vs. care by obstetricians, but none about how these compare to care provided by family doctors. This may be of particular import for those living in rural settings, where one’s choice is often between a midwife and a family doctor, rather than between a midwife and an obstetrician.

    • Jeremy Petch

      The invisibility of family docs in this article is partly attributable to a bit of Ontario-centrism. While all provinces have seen a decrease in family doctors who provide primary care obstetrical services, Ontario far outstrips all other provinces in the proportion of obstetrical services provided by obstetricians/gynecologists. A look at CIHI’s report on the costs of pregnancy (http://secure.cihi.ca/cihiweb/products/Costs_Report_06_Eng.pdf) shows a very high proportion of family docs providing obstetrical care in the western provinces. While it’s very useful to hear about the UK system’s approach to marrying midwifery and OB, it would just as useful to hear about another province where family doctors are delivering the majority of babies.

      While I realize the authors of Healthy Debate are residents of Ontario, it will be hard for the website to encourage national debate if all of the issues are approached from a purely Ontario-centric perspective. In my opinion, one of the most insightful articles on this site included a discussion of Nova Scotia’s innovative approach to physician education about pharmaceuticals. We need more of this! Given how much all of the provincial systems have to learn from each other, this site should strive to present a more consistently diverse, national perspective on these issues.

      That issue aside, I continue to enjoy the excellent articles. Keep up the good work!

  2. Association of Ontario Midwives

    Just to be clear, the lump sum payment midwives get is for the entire course of care that they provide each woman, from conception to 6 weeks post-partum. You are correct that this funding also pays for overhead costs and supervising midwifery students. Because midwives do not work on a fee for service basis, it’s difficult to compare the income of midwives and that of physicians.

  3. Pat Campbell, Echo: Improving Women's Health in Ontario

    Ontario women need and deserve integrated care delivery systems that provide reliable and high quality care and there is room for improvement in maternity care in Ontario. This article suggests that interprofessional care models might help with improving the system of care and Echo: Improving Women’s Health in Ontario would agree. Most importantly, we need to take the focus off the providers and focus on care delivery systems that meet the needs of the people using them – in this case, mothers and babies. Service planning must put patients first and consider the unique needs of different groups of women, particularly those who are marginalized by poverty, racial or cultural factors, and those who face geographic barriers, if we want to achieve better health outcomes and improved equity for women and their families.

    Increased centralization of care has removed birthing services from some communities in Ontario, and family physicians are also playing less of a role in maternity care. However, there is international evidence which demonstrates that birth outcomes are better when care is provided locally, regardless of the type of care. Pregnant women should be able to access the majority of their pregnancy care locally even if travel to larger centres to give birth is required. Developing new models of care, and removing barriers to collaborative practice need to emerge particularly for women with complex needs. Collaborative care models can be supported by the adoption of practice standards and sharing of information across sites of care to enable seamless care delivery and reduce risks for women and providers.

    Currently there is a wide variation in who provides care to women and allowing women choice of provider is a strength; however, the wide variation in outcomes in this province is concerning. The caesarean section rate varies widely by Local Health Integration Network (LHIN)(among women with full-term (37 or more weeks gestation), single baby, non- breech births): , from 17 % of deliveries in the South West LHIN to 26 %t of deliveries in the North Simcoe Muskoka LHIN (POWER Study Reproductive and Gynaecological Health Chapter, http://www.powerstudy.ca). The 2010 report from BORN Ontario showed that 33% of higher risk babies (born at less than 32 weeks gestation or less than 1500 grams) were not born in an appropriate hospital to meet their needs. Ensuring patient- centred care delivery will require integrated, standards based, community appropriate models that are evaluated. The perspectives of the users, the providers and the funders need to be taken into account and outcomes need to be assessed for different groups of women to ensure excellent care for all. For more information on improving women’s health please reference the Ontario Women’s Health Framework (www.echo-ontario.ca).

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