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.”