Status of Women Committee on May 10th, 2021

[The Chair, Conservative, Marilyn Gladu]

I call this meeting to order. Good evening and welcome to meeting number 33 of the House of Commons Standing Committee on the Status of Women. Today's meeting is taking place in a hybrid format pursuant to the House order of January 25, and the proceedings will be made available via the House of Commons website.

I would like to make a few comments for the benefit of the witnesses. Today our committee is continuing its study of midwifery services across Canada. If you're speaking, you're going to click on the microphone icon to activate it. I remind you that all comments should be addressed through the chair, and if you need interpretation, at the bottom of your screen you can choose English, French or the floor. When speaking, please speak slowly and clearly so that the interpreters can hear and interpret. When you're not speaking, your microphone should be on mute.

I'd like to welcome our witnesses. Each of you will have five minutes for your opening remarks, and then we'll go into our rounds of questions. We have Dr. Susan James with us tonight, and from the Association of Ontario Midwives, Jasmin Tecson, the president. From McMaster University, we have Kirsty Bourret, adjunct scientist at the McMaster Midwifery Research Centre.

Dr. James, we'll begin with you. You have five minutes.

[Dr. Susan James, As an Individual]

Thank you, Madam Chair and members of the committee.

I have been the director of the school of midwifery at Laurentian University for 20 years, and now, after a total of 22 years, the insolvency situation has caused me to be retired. I would like to focus on the role that the midwifery program has played in capacity building and then make some recommendations for going forward.

The first area is health human resources. The majority of current midwifery practices in northern Ontario did not exist before the midwifery program began. As noted in the first session, 60% of the midwives practising in these areas are graduates of the Laurentian program. Many students enter the program with the goal of joining existing northern practices or setting up new ones. For example, Mélanie Guérin entered the program in 1999, and in response to a question about setting up a practice in her home community of Hearst, a southern site director answered her, "There will never be practices in small communities like Hearst." This motivated Mélanie to spend every visit home networking with community members, and in 2005, she set up her practice.

Many northern communities still have no midwifery and, indeed, no maternity services. There are many professional provincial and federal actions that will be needed to realize the dream that every pregnant person should be able to birth close to home. These include new funding models, transportation issues, clean water and the improvement of Internet connections. A school of midwifery in a northern university is a very useful strategy for informing the population about midwifery and about choices that can be made related to childbirth, childbearing and other health situations.

One example of something that we created is a pelvic teaching program developed in 2002 to train midwifery, medical and nurse practitioner students, and hospital sexual assault nurses in sensitive, respectful and informative pelvic examinations, including pap smears. This program may be lost with the closure of the school, to the detriment of northern residents.

My next area is accessibility to education. Many of the northern students and graduates of the Laurentian program tell us that they would not a have done a degree in midwifery if they could not have remained in the north. Attention to the demographics of our applicant pool has lead us to accept direct from high school applicants every year, which helps to retain students.

The CNFS has assisted us with some resources for recruitment and scholarships for the program. The CNFS model is one that might be used for other aspects of a northern site for midwifery education.

My final area of capacity building is scholarship and research. Social science and humanities research about midwifery is common. There is a beginning collection of research by midwives to inform practice, but for the most part, this is not northern oriented. Midwifery is a nearly invisible research profession, not included in lists of professions within granting agencies or calls for proposals and research teams. Federal funding for midwives to conduct research in low income countries is available through the Canadian Association of Midwives, but similar opportunities for research in Canada's north are far less accessible.

My recommendations are, first, include health services in the responsibilities of FedNor. This may provide support for communities that can grow their economic picture when health services needed by residents of childbearing age are available locally. Second, build on the CNFS model to create federally supported but locally driven programs to address the needs of northern, indigenous, francophone, anglophone and racialized students. Third, support the development of a northern midwifery research institute. Possibly, this could be in conjunction with the Centre for Rural and Northern Health Research at Laurentian and Lakehead Universities.

Fourth, support the reintroduction of a school of midwifery in northern Ontario. This continues to need to support the educational and practice needs of northern, indigenous, racialized, francophone and anglophone populations. Fifth, and perhaps for the federal government most important, establish an office of midwifery within the federal government to coordinate and liaise with other departments and professions on questions related to the profession and health issues related to reproductive and sexual health.

Thank you very much, Madam Chair.

[The Chair, Conservative, Marilyn Gladu]

Thank you.

Now we'll go to Ms. Tecson for five minutes.

[Jasmin Tecson, President, Association of Ontario Midwives]

Good evening, Madam Chair, and committee members.

My name is Jasmin Tecson. I'm a registered midwife, and I speak to you today as the president of the Association of Ontario Midwives, the largest regional association of midwives in Canada.

We are proud to be a part of a profession that is deeply valued by families, one that we believe is essential to improving health outcomes for pregnant people and their babies. Currently, there are approximately a thousand midwives in Ontario delivering about 18% of the babies in the province. We are autonomous primary care providers. Our midwifery education program, the first of its kind in Canada and respected internationally, confers a bachelor of health science in midwifery. Our comprehensive, rigorous training includes tests; commonly prescribed medications; care management of healthy, low-risk pregnancy and birth and postpartum; as well as emergency skills and assessment, and clinical care for healthy newborns.

Our model of care has proven to be a highly successful method for delivering perinatal care with strong clinical outcomes, exemplary client experiences and efficiency in the delivery of evidence-based care. Our model incorporates the development of a working relationship as well as a trust relationship. The support for informed choice that comes from this leads to levels of client satisfaction that are outstanding for a profession, from 97% to 100%. High levels of client confidence and support combined with continuity of care lead to lower rates of interventions and shorter hospital stays.

In 2019, the c-section rate for midwifery clients was 20%. In contrast, the provincial average was 29%. For midwifery clients who planned home births, the rate was an impressive 7%. By offering safe, skilled birth attendance at home or at birth centres, and follow up care postpartum in the community, Ontario midwives effectively reduce hospital admissions, further reducing health care costs and saving hospital resources for those who need it most.

These facts clearly make the case that midwifery is worth investing in. Yet, there is a price for midwives' dedication. Even without the additional stress of frontline work during a global pandemic, our profession suffers from the underfunding of our education programs, discriminatory pay and demanding work conditions that contribute to increasing burnout and the loss of skilled, dedicated professionals from attrition and disability.

The closure of the midwifery education program at Laurentian is devastating to Canadian midwifery. One third of the student midwives in Ontario were enrolled in the program. Its graduates have gone on to become leaders in regional midwifery associations across the country and in the National Aboriginal Council of Midwives. Closing the program ends bilingual midwifery education in Canada and essentially closes the door to Franco-Ontarians seeking midwifery education in their first language. The program made education accessible to a host of indigenous and northern students who otherwise would not have become midwives. The loss of this access point is a loss that will significantly impact the health of indigenous and northern communities.

Now, we have the risk of a reduced cohort of midwifery graduates who will care for tens of thousands of families in Ontario. The demand for midwifery across the province is great. Fewer graduates will mean that families who choose midwifery care will be unable to access it, far more so in the north.

In a 2015 analysis and report, the AOM made several recommendations for strengthening care in rural, remote and northern communities. The Laurentian program prepared midwives to work in such areas across Canada. Among the recommendations included are that women should have access to high-quality maternity care as close to home as possible. Local perspectives and needs should be taken into account in health care planning. The right to self-determination and culturally safe care must be upheld in indigenous communities. Training opportunities for new and experienced health providers need to be offered within these communities. Rural and remote midwifery funding frameworks must reflect the realities of practising in these areas.

With its integrated, person-centred approach throughout the provision of excellent perinatal care, midwifery is uniquely positioned to address social determinants of health such as gender, culture, race and access to health services. Midwifery in Canada is growing, but it needs coordinated efforts in policy and funding from provincial and federal levels for sustainability.

Thank you for your attention.

[The Chair, Conservative, Marilyn Gladu]

Excellent.

Now we will go to Ms. Bourret for five minutes.

[Kirsty Bourret, Adjunct Scientist, McMaster Midwifery Research Centre, McMaster University]

Good afternoon, Madam Chair and honourable committee members.

I am here to talk about the concerns of francophone communities outside Quebec that feel aggrieved by the closure of the Laurentian University Midwifery Education Program. I thank everyone who has contributed to my testimony today.

I am a francophone midwife who grew up in northern Ontario, and I graduated from the Laurentian University Midwifery Education Program, where I have been a professor since 2007. I am one of the only francophone midwives outside Quebec to have earned a post-graduate degree.

Here is our main message: to enhance the education of francophone, indigenous and northern midwives, including midwives who identify as black or racialized, we must strengthen the integration of this profession at all levels of the public sector, across policies and health care systems.

The current closure of the midwifery education program has to do with the lack of understanding of midwifery by government and academic decision–makers. That underscores our recommendations at the federal level to increase the profession's impact across the country.

We want the committee to recommend to the province that: a midwifery education program be reinstated in northern Ontario; that it contain a francophone option; and that an indigenous midwifery education program be created in northern Ontario.

As for the federal government, we recommend that it create a position of chief administrator for midwives within the Public Health Agency of Canada and that midwives be included in decision–making wherever physicians and nurses are invited. We recommend investing in programs or creating programs at the federal level, such as the Consortium national de formation en santé, or CNFS, which improves the midwifery education capacity for northern and francophone communities. We recommend that those programs prioritize the education of indigenous and racialized midwives. Finally, we recommend supporting midwives' ability to complete their post–graduate studies, which enables them to be educators and researchers, in order to generate data for the profession and to increase the sustainability and impact of that profession over time.

The midwifery education program at Laurentian University has more than fulfilled its mandate to increase community services [technical difficulties] to monitor or increase our efforts. Those positive impacts will be cancelled out. Midwifery services in those communities, which are already difficult to obtain, will become inaccessible, and our families will suffer the consequences.

According to Mélanie Guérin, a midwife who graduated from Laurentian University, the communities of Hearst and Kapuskasing, which she has been serving for 15 years, are 95% francophone. Midwives who settle in small northern communities are rare, unless they come from there or from a similar community.

Pascale Alexandre, a student attending the Laurentian University Midwifery Education Program is a black francophone woman. She said she decided to become a midwife to help people in her community give birth in a context of cultural safety. According to her, eliminating the midwifery program's francophone component is an attack on black francophone minority groups and on people giving birth. She adds that, in a context where it is proven that racial discrimination has a negative impact on the provision of health care, reducing access for racialized and linguistic minority groups maintains that disparity, at best, and exacerbates it, at worst.

Carine Chalut, a client of the East Ottawa Midwives—a clinic that is almost completely francophone and whose midwives are Laurentian University graduates—says that she had francophone midwives for her three pregnancies and that having access to health services in her language was not only an advantage, it was a necessity. She adds that, when a woman is in a situation as vulnerable as that of giving birth, she cannot be expected to interact in a language that is not her mother tongue, as that puts her in a precarious, even dangerous, situation. She thinks it is important for francophone women to continue having access to that care in the language of their choice, as that is not only a matter of rights, but also of quality of care.

Although university education is a provincial responsibility, we feel that the federal government has a role to play in strengthening the impact of our profession. There are current examples of the federal government funding programs to improve the health staff through education and research programs. For instance, Health Canada has an official languages health program that funds the Consortium de formation en santé, the CNFS. Such programs can be implemented to improve the midwifery education capacity, especially in francophone, indigenous, black and northern communities, as well as in communities of colour.

In summary, the federal government has an opportunity to innovate and create structures that show an investment in midwifery through leadership, initial education and research in the field. That would increase our profession's capacity and impact.

Thank you.

[The Chair, Conservative, Marilyn Gladu]

Thank you very much.

We will start with our first round of questions.

Ms. Sahota, you have six minutes.

[Jag Sahota, Conservative, Calgary Skyview, AB]

Thank you, Madam Chair.

Thank you to the witnesses for being here today and for your testimony.

Ms. Tecson, you spoke about the number of midwives who are registered in Ontario and the percentage of births through midwives in Ontario. Do you know of any regional differences across Canada? What are some of the factors that lead to these differences?

[Jasmin Tecson]

Unfortunately, the Association of Ontario Midwives doesn't collect data specifically for regions. What we do have through our managed program with the Ontario Ministry of Health are registrations with the college and funding via transfer payment agencies and registered practices.

In terms of regional considerations, we do know that it's challenging to have midwives set up practices in rural, remote and northern areas. Part of it is the concentration of midwives in urban centres in the southern parts of the province and the facilities and accessibility, quite frankly. It is a driving concern to consciously monitor and maintain the registration and practising of midwives in those areas.

[Jag Sahota, Conservative, Calgary Skyview, AB]

Ms. James or Ms. Bourret, do you have anything to add to that?

[Dr. Susan James]

I can add a little bit to what Jasmin just said about the challenges of establishing practices in the north. This is a concern for students right from the time they begin the program throughout their placements and when they graduate.

Partially it's the funding model. It has added some wonderful improvements, but the funding model is basically fee-for-service. If you cannot generate enough clients for the midwife to make what would be an equivalent full-time salary or earnings in a southern placement or location, then it's quite possible that the midwife may not be able to stay there, particularly if she is the sole breadwinner for a family. Plus, she wouldn't necessarily have the ability to add in a second midwife to the practice to cover time off so that they can take vacations or take time off when they're ill. There is a locum program that can assist with that, but it isn't always possible to assist at the last minute and have somebody cover if they need that weekend off.

A funding model where we would expect...like in schools in the north, where you have small classrooms but the teachers are paid the same as teachers in a large urban centre with large classrooms. In fact they sometimes even get extra money for distance. Could it not be possible to develop funding models for supplements to funding models? If the Ontario government funding model is not sufficient, is this a place where something like FedNor might be able to help out to assist with the economic components of having midwifery right across the province?

[Jag Sahota, Conservative, Calgary Skyview, AB]

Ms. James, you spoke about a midwife not being able to have or to retain enough clients, perhaps even having to move to another part of the country. Is mobility an issue? Is it fairly easy in terms of the rules around how you move? Are there different criteria in different regions of the country?

[Dr. Susan James]

The basis of registration from one province to the next is that there is an agreement that each province accept the same registration exam, which is done at a national level. The competencies for midwives have been developed at a national level. There are some small additions that various jurisdictions have added to the requirement to get registered, but usually something can be accomplished in writing a small examination or attending a workshop to add in the additional either competencies or knowledge of how the registration or regulations work in that particular area.

It is possible to move from one province to another. They can do that right from graduation, but particularly once a midwife has one year of experience, then cross-province or into territories is not that difficult.

[Jasmin Tecson]

If I may, I will add to the member's question. While there are fewer barriers around education for midwives to take their education credentials across the country, there are structural framework issues that need to be considered that can help or hinder a midwife's ability to set up shop. It's not simply a matter of moving to a location and hanging up a shingle.

Depending on where a midwife would like to practice, there are issues such as how midwifery is located. They're not always autonomous primary care providers working independently in a self-employed model similar to Ontario. In other regions, they are employees who are part of a health service or a health centre.

There are also issues in terms of where—

[The Chair, Conservative, Marilyn Gladu]

I'm sorry, that's your time on this question.

We'll have to go now to Mrs. Zahid for six minutes.

[Salma Zahid, Liberal, Scarborough Centre, ON]

Thank you, Madam Chair. Thanks to all the witnesses for appearing before the committee today. Thank you for your time.

My first question is for Dr. James.

Do you think there are any opportunities for collaboration between the provincial and the federal governments that could potentially help your profession?

[Dr. Susan James]

I certainly have wonderful expectations and aspirations that there can be opportunities for collaboration. I have sat in on federal meetings in the last few weeks since we lost our program, as well as in provincial meetings. I have heard from representatives of every party, I think.

I think everybody is talking about the same thing. It's a matter of making sure there are ways that those collaborations can fit together. I think the reason both Kirsty and I have mentioned the CNFS as perhaps a model is that we have seen it work well.

When it first came to Laurentian, it mainly was interested in nursing, social work and maybe phys. ed., but over time we have also captured their interest. We created a proposal a few years ago where our francophone program would offer seats to students from other provinces where the other provinces would pay the grant part and maybe the student would pay the tuition part. They would be extra to our cohort of 30. We had provincial buy-in, we had federal buy-in and we had the individual potential student buy-in. Unfortunately, there was a change in the government at the time. Although the committee itself had found that we scored very highly on their priority list and we thought we may be going ahead with that, the funding to CNFS that year got cut and the program never actually happened.

I think that's an example of how the CNFS doesn't tread on provincial toes. It supplements provincial toes. I think we may be able to look at other possibilities for indigenous students, racialized students and for the north that would have the same kind of structure that's a partnership between a post-secondary institution and the federal government, but always with the co-operation of the provinces to make it work.

[Salma Zahid, Liberal, Scarborough Centre, ON]

Thank you, Dr. James.

I have one more question for you. As autonomous and primary health care providers, midwives are essential to the health care services.

How do the midwifery programs and the role of the midwives shape the health care system in Canada?

[Dr. Susan James]

That's a big question.

I think one of the first things that happened with midwives, as well as nurse practitioners—and I'll refer mostly to midwives because that's what I know best—is that this was the first time that some professionals in these two professions could work within the health care system as primary care providers, as autonomous, with hospital-admitting privileges in many provinces, an ability to prescribe medications and to order investigations without having to necessarily have permission from any other profession. It was a challenge within the health care system. We aren't doctors and we don't have to have doctors for certain situations where the client fits within the scope of practice of the midwife. The midwife then can carry on care without having to have permission that this client is able to come to a midwife—is able to stay with a midwife.

The scope of practice for the midwife is to know when things are coming outside of his or her scope and to move that client potentially into medical care. It may also be into care of a social services provider. We have created a partnership with physicians. We need them; they need us. It was a fairly significant challenge to the health care system to see health care providers who had that scope of practice, that level of responsibility, who weren't MDs.

[Salma Zahid, Liberal, Scarborough Centre, ON]

Thank you.

I think my time is up, or do I have some time?

I have one quick question for Ms. Tecson.

Can you tell us a bit about equity and access to midwifery?

[Jasmin Tecson]

I'm sorry, but I didn't hear the last part of your question.

[Salma Zahid, Liberal, Scarborough Centre, ON]

Can you tell us a bit about equity and access to midwifery?

[Jasmin Tecson]

The Association of Ontario Midwives has prioritized as one of its strategic goals addressing equity within the profession, with an awareness of racism, issues of a lack of diversity, and equity in the bigger health care system. Within the midwifery education program, that is also an area of specific focus.

Within how we work with our clients, especially in our “informed choice” model, we are able to spend more time with clients; an average of 30 minutes as opposed to the usual five minutes, which is the norm for a prenatal appointment. We are able to get to know a client to find out what is important to them culturally, individually, to provide the care that is most appropriate for their experience.

[The Chair, Conservative, Marilyn Gladu]

Thank you.

Ms. Larouche, go ahead for six minutes.

[Andréanne Larouche, Bloc, Shefford, QC]

Thank you, Madam Chair.

I would like to begin by thanking the three witnesses. Ms. James, Ms. Tecson on and Ms. Bourret, your testimony is very precious. Thank you for being here today to talk about both the importance of the midwifery service and the importance of Laurentian University.

That is why, as a Quebecker, I would like to, on behalf of the Bloc Québécois, express our solidarity with Franco-Ontarians in terms of their growing struggle for their language's survival. I am thinking of young people and members of the northeastern Ontario francophone community, who deserve quality services without having to move to Ottawa or to Quebec.

For a number of years, we have been seeing an erosion of French-language education. Laurentian University was providing services by and for francophones. For us, that is crucial. In your opening remarks, you mentioned the importance of being able to receive services in your language at a stage as critical as giving birth.

Without further ado, I will ask my first question, but I want to remind you that I am also trying, as a Bloc Québécois member, to untangle all this because the university, education, health and midwives are the jurisdiction, as you mentioned—