Status of Women Committee on May 10th, 2021

[Marc Serré, Liberal, Nickel Belt, ON]

Okay.

Right now, Laurentian blew up the program. No francophones are getting services in September. Aboriginals are not going to get much service in September. Rural is blown up. It's dead; it's gone.

I'm trying to figure out.... I know we're talking about the federal government's role. I know we have the tri-council here that was submitting proposals to the provincial government.

Madam James, you talked about the CNFS. They do marvellous work, but they haven't proposed anything back to the federal government.

I dealt with

the Fédération des communautés francophones et acadienne, the Association des collèges et universités de la francophonie canadienne, and the Société Santé en français.

These are all organizations.

My question for Ms. Tecson is this: How do we try to coordinate a plan? Right now the provincial government has zero plans for midwifery other than just giving it to McMaster and Ryerson.

How do we try to coordinate our efforts? I thank Lindsay Mathyssen for bringing this motion forward here. How do we try to coordinate efforts to get a plan, so that we could have the federal government at the table with proposals?

Right now there have been no proposals submitted. I wanted to see if you could help to try to steer us in the right direction here with some recommendations to the federal government.

[Jasmin Tecson]

I would say as a starting point it would be valuable to reach out to the Ministry of Health, which manages the Ontario midwifery program, and to the Ministry of Colleges and Universities in Ontario. Work with them to develop a cohesive plan that looks long term.

At the federal level, it helps to have midwifery recognized even just as a job category because it's not. If the federal government starts with a clear position on midwifery with goals and targets for how they would see midwifery positioned to support birthing people across Canada, that vision can translate down as an expectation to provincial governments for setting their policies and programs.

[Marc Serré, Liberal, Nickel Belt, ON]

Dr. James, you mentioned earlier that you were at the table with the CNFS. You were at the table with the provincial government—the Wynne government prior. They were making some movement. Now it's gone.

I'm trying to get a handle here on understanding how we get together, if we don't have a willing provincial partner at the table. We have to get the provincial government to outline that there's an issue. I know it's difficult right now with the court situation at Laurentian. The court has made it a worst-case scenario. How do we get to sitting down with the provincial government?

[The Chair, Conservative, Marilyn Gladu]

I'm sorry. That's the end of your time.

[Marc Serré, Liberal, Nickel Belt, ON]

Oh, that went so fast.

[The Chair, Conservative, Marilyn Gladu]

I hate to interrupt before the answer.

Ms. Larouche, you have the floor for two and a half minutes.

[Andréanne Larouche, Bloc, Shefford, QC]

Thank you very much, Madam Chair.

Once again, I thank the three witnesses. I will try to be quick.

Ms. Bourret, I would like to come back to the program's closure. Correct me if I am wrong, but there were only 30 spots for 300 applications last fall. If that is not the reason the program is closed, why do you think it is?

[Kirsty Bourret]

I think the discussion is the same on the provincial side, and I think the answer is the same when it comes to what can be done on the federal side. I think it is just a matter of a lack of awareness and understanding of the role midwives play in Canada and in the provinces. With proper understanding of the potential contribution of midwives at Laurentian University, it would be difficult to justify abolishing a program. Gender equality is also involved. We have discussed this already with a minister. I generally think that we are given less importance because we are involved in a female occupation.

I want to come back to Mr. Serré's question. At the federal level, it's a matter of not only helping provinces better recognize the role midwives play, but as Ms. Tecson said, the role of midwives should also be better recognized by the federal government. I work on Global Affairs Canada's programs that strengthen midwifery on a global scale. The first thing we do is raise awareness at the federal level in order to integrate midwifery at the administrative level. That is why Ms. James and I asked that a position of federal chief administrator for midwives be created, to have an office that manages anything to do with midwifery.

Global Affairs Canada funds all sorts of innovations abroad, and it could not have that same innovation here, in Canada. That makes no sense. We must work together to innovate well on the federal side to integrate midwifery, which will also strengthen its integration at the provincial level afterwards.

[The Chair, Conservative, Marilyn Gladu]

Very good.

We'll go to Ms. Mathyssen for two and a half minutes.

[Lindsay Mathyssen, NDP, London—Fanshawe, ON]

Thank you.

One of the things the Canadian government has a responsibility for doing is to enforce the Canada Health Act. Within that, of course, is reproductive services being available to women across Canada equally and fairly. Certainly the role of midwives has the ability to expand. For example, in Hamilton, Ontario, they are working with other doctors, ensuring that they have medications available so that women who need access to reproductive services can get them.

Can one of you, or all of you, quickly talk about expanding that role of midwives to ensure that women have that equal access under the Canada Health Act to reproductive services and health services?

[Kirsty Bourret]

I have to jump in and speak here, because this is an area of interest of mine.

It's important to point out that it actually isn't an expansion of our role. In Ontario it is, but when you look at our global definition of midwifery, we have it within our scope to provide all sexual and reproductive health care, which includes contraception, which includes access to abortion. This is something that's well known and that we are trained to do.

Again, around the world, I am working with Global Affairs Canada to ensure that midwives have the capacity to do this within their scope, which means increasing access to sexual and reproductive health care, especially in very, very remote and rural areas. We've been arguing for that for a really long time. While in Ontario it might look like an expanded scope, really the vision of midwifery at the national level is to be able to provide these services across Canada.

You know, this will have a huge impact on our ability to impact this issue around our overall lack of access to contraceptive and reproductive health care, especially with indigenous and other populations that are at a disadvantage. I think there is an opportunity here to have this discussion and to raise awareness of midwives' capacity to function in that way.

[The Chair, Conservative, Marilyn Gladu]

Very good. I think we'll leave it there.

To our witnesses, thank you for your excellent testimony and helping us with our study.

We will briefly suspend while we do sound checks for our next panel.

[The Chair, Conservative, Marilyn Gladu]

I want to welcome our witnesses for our second panel of our study on midwifery services across Canada.

From the Canadian Association for Midwifery Education, we have Kim Campbell, the chair—not the former prime minister, but an expert in her field—and from the Canadian Association of Midwives, Alixandra Bacon, the president.

Each of you will have five minutes to make your remarks.

We'll start with Ms. Campbell.

[Kim Campbell, Chair, Canadian Association for Midwifery Education]

Thank you very much.

Madam Chair, thank you for the opportunity today to provide evidence, through an education lens, regarding midwifery and the impact of the Laurentian University program closure.

I'm representing the Canadian Association for Midwifery Education, as we said, which is a not-for-profit organization of midwifery educators. Our mission is to promote excellence in midwifery education. We do this through setting and maintaining standards for curricula—

[Andréanne Larouche, Bloc, Shefford, QC]

Madam Chair, I have a point of order.

I apologize, Ms. Campbell, but I cannot hear what you are saying, as there is no interpretation.

[The Chair, Conservative, Marilyn Gladu]

Yes.

[The Clerk of the Committee, Ms. Stephanie Bond]

You don't actually have to hold it so close to your mouth, Ms. Campbell. We'll do another sound check.

[Kim Campbell]

Okay.

Testing. Can you hear me okay?

[The Clerk]

I would just leave it there and not push it close, because it distorts the audio.

We'll try the best we can and we'll let you know if we have to interrupt. Please resume.

[The Chair, Conservative, Marilyn Gladu]

Go ahead.

[Kim Campbell]

I'm going ahead here.

I wanted to tell you that we are the accrediting agency for midwifery education, and one of our goals is to maintain the standards of curriculum and scholarship as well as supporting continuing development of midwifery faculty and programs. Currently, we are also exploring the ways in which we can support the indigenous midwifery education programs that currently exist and are being developed.

Before Laurentian’s closure last month, Canada had seven baccalaureate midwifery education programs in five provinces. Combined, they admitted just over 150 individuals into a highly competitive stream each year, where approximately 10% of all applicants are given an offer of admission. Upon graduation, these new midwives will have spent over 2,500 hours in supervised clinical practice and exit the education program ready to provide primary care, meeting the sexual and reproductive health care needs of women, trans and non-binary people.

Midwifery is the international standard supported by the World Health Organization for primary maternity care. Professional midwifery is the most cost-effective primary maternity care for health care payers, and 85% of pregnant people can complete their pregnancy and birth safely with only midwifery care. We have an obstetrical primary care provider crisis in many communities across Canada, and midwives see themselves well prepared to fill this need.

As you may know, I think you probably heard that midwives attend about 20% of births in Ontario per year and 26% of births in British Columbia. Those are the two largest midwifery-represented provinces. The loss of a program threatens the production of enough midwives to replace midwifery retirement or those promoted into leadership work. Ontario also educates midwives for the provinces and territories without sufficient midwives in practice to have their own educational programs such as Atlantic Canada and the far north. That need, combined with educating midwives for Ontario, cannot be managed by two midwifery programs in the south.

We must also highlight that we lack sufficient midwifery providers who represent the diversity of our communities across the country. Birth is a psychosocial health event that proceeds most normally when the culture of the primary provider matches that of the birthing family. Therefore, diverse provider backgrounds, including indigenous and French-speaking midwives, are essential to culturally safe care.

Students should be able to study midwifery close to their home communities. Having students move south to large urban centres for midwifery education places an unnecessary burden on families when they plan to live and work in the north. Students may learn and perform less well when separated from their community supports, and program attrition is linked to such barriers and stressors.

As a collective, the midwifery education program has recognized the urgent need to address inequities and facilitate diversity within our programs to support a safe and inclusive environment for indigenous, Black and people of colour within the student cohorts. We also know that the populations that suffer Canada’s highest perinatal morbidity and mortality are found in our northern, indigenous and racialized communities.

When there are insufficient maternity community obstetrical services, the birthing units close. Pregnant people must travel, sometime significant distances, to receive care. This intersects with multiple social determinants of health. Researchers from the University of British Columbia have reported the negative impact on birth outcomes when obstetrical services close and people must travel from their communities to give birth. Several universities are instituting processes to remove barriers for indigenous applicants and others to join midwifery education programs.

Education programs that reduce barriers to enable inclusivity of folk, who, due to racism and colonization, have experienced systemic trauma, violence and oppression, is essential to support equity underserved populations. Closing Laurentian University's midwifery program, a program that helped meet those gaps, imperils those communities.

I also need to stress that midwives continue to struggle for recognition, and it is exhausting to continue to have to do so. At the federal level, there are barriers to midwives. Notwithstanding the long indigenous and settler history of midwives' roles in Canadian history, the first new midwifery wasn't regulated in Ontario until 1994. Now, 27 years later, midwifery is regulated or is in the process of being regulated in all provinces and territories in Canada.

In the current health care climate, there is a pressing need to support capacity building. Midwives should have pathways in leadership and service at the federal level. Unfortunately, there's lack of access to research awards and representation at the table where policy is forged.

Many midwives will graduate from a four-year degree with a debt burden of $90,000 to $100,000. However, if they work in rural and remote communities, they do not benefit from the federal education loan forgiveness programs that their colleagues in nursing and medicine enjoy.

Midwifery is a gendered profession, and we serve a gendered population. Laurentian provided education to future midwives who serve indigenous, francophone and northern and remote communities.

It has been said by others that you can assess the health of a nation by how it treats its indigenous peoples. Limiting the education of health professionals who can ably serve these communities does not reflect very well on us.

Thank you very much for the time to allow me to speak to you today.

[The Chair, Conservative, Marilyn Gladu]

That's very good. Thank you so much.

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

[Alixandra Bacon, President, Canadian Association of Midwives]

Thank you, Madam Chair.

The Canadian Association of Midwives and the National Aboriginal Council of Midwives are the organizations representing midwifery in Canada. Our vision is equitable access to excellent sexual, reproductive and newborn midwifery services for everyone. Our focus to achieve this is on advocacy, midwifery association strengthening in Canada and abroad, and promoting excellence in clinical care.

Midwives are involved in 11% of births in Canada and play a vital role in the provision of equitable, accessible, culturally safe and high-quality health care, when and where people need it the most. Evidence shows that midwives working in the continuity of care model decrease pre-term birth, stillbirth, epidural use and instrumental birth. Canadian midwives also decrease rates of cesarean birth, hospital admission and readmission, and shorten hospital stays. All of this saves the system money.

For birthers of low socio-economic status, midwifery has been shown to reduce the prevalence of small for gestational age and pre-term birth when compared with physician care. Similarly, Canadian evidence shows birthers who are substance using or who have mental illness also experience improved outcomes when cared for by midwives, but access to midwifery care is constrained by a lack of awareness.

We know, as Kim has mentioned, that there's an inverse relationship between perinatal outcomes and distance travelled to care. Canadian midwives, however, have a long history of providing care closer to home, particularly in Inuit, indigenous and remote communities.

The UNFPA's state of the world's midwifery report was released on May 5, the International Day of the Midwife. For the first time, it includes a Canadian report showing that our workforce of 2,000 midwives amounts to only 0.5 midwives per 10,000 individuals. This is an inverted ratio of midwives to physicians compared to most high-income countries, and indeed, most other countries in the world.

Our sexual, reproductive, maternal and newborn child health workforce theoretically may exceed need; however, in reality, many communities do not have their needs met due to inequitable distribution of providers, as well as scope of practice restrictions.

The report also points to a potentially inefficient skill mix within the workforce, which may contribute to overmedicalization of childbirth or too much too soon in urban areas, and too little too late in rural areas, each contributing to higher cost to the system and poorer outcomes for Canadians. Given the improved outcomes and cost savings, the case for increasing the proportion of midwives involved in births is sound. However, if Canada wanted to adopt a midwife-led perinatal care system, we would need to increase the number of midwives to 9,000 by 2030.

What the state of the world's midwifery report doesn't take into consideration are the factors that threaten the future of the midwifery workforce in Canada. These include, as have been mentioned by previous witnesses, a shortage of midwives to meet the demands of Canadian birthers; a failure to address the needs of indigenous midwifery and fulfill the TRC call to action number 23; gender discrimination manifesting as a scarcity of midwifery leadership in administration and governance; inequitable pay,; lack of provincial or territorial funding; and a stagnation of growth in some jurisdictions due to health system arrangements and/or a lack of professional autonomy. These factors culminate to ultimately result in significant levels of burnout for the midwifery profession.

The closure of the Laurentian University MEP, Canada's only bilingual and tri-cultural MEP, further threatens the stability, diversity and equity of our workforce.

We call upon the federal government to co-operate with provincial and territorial governments to support the relocation of the Laurentian program to a northern university that can support its bilingual and tri-cultural mandate; expand investment in indigenous midwifery and focus on creating diverse pathways to education, including community-based education for indigenous students; extend federal student loan forgiveness to midwives working in underserved, rural and remote communities; add midwifery as a primary health care provider as defined by the Treasury Board of Canada, to facilitate midwives eligibility to work in federal service jurisdictions; create senior midwifery leadership positions, including a chief midwifery officer within Health Canada; and invest in CAM's capacity-building work with Canadian midwifery associations and invest in midwifery research and advanced education and leadership training for midwives.

Thank you.

[The Chair, Conservative, Marilyn Gladu]

Excellent.

Now we're going to start our rounds of questioning with Ms. Shin for six minutes.

[Nelly Shin, Conservative, Port Moody—Coquitlam, BC]

Thank you. I'd like to thank the witnesses on this panel for sharing their information and giving us more insight and understanding of midwifery in Canada.

Alix, you mentioned that 11% of births in Canada involve midwives. I like the terms, just to quote you, “culturally safe” health care and “improved outcomes”. I'd love to hear testimony from both witnesses on any situations or scenarios you were directly involved in or that you're aware of where culturally safe health care in the context of the work of midwives really did improve the outcome. Could you give us an example in the indigenous community and another example in a racialized community?