Status of Women Committee on May 25th, 2021

[Claire Dion Fletcher, Indigenous Registered Midwife, Co-Chair, National Aboriginal Council of Midwives]

Thank you, Madam Chair and members of the committee.

Greetings from the many communities of indigenous midwives that make up and contribute to the National Aboriginal Council of Midwives.

I would like to start by acknowledging the land we gather upon today. It is the land that brings us health, wisdom and opportunity for renewal.

My name is Claire Dion Fletcher, and I am a Lenape-Potawatomi and mixed settler midwife.

Indigenous midwives have been the backbone of our communities from time immemorial. Colonization, including the medicalization of birth, sought to erase our pivotal role in our communities, our indigenous knowledges and our governance systems, drastically contributing to the poor health outcomes we see today.

Anti-indigenous racism is a problem in this country. It exists in all of our systems: judicial, health, education and beyond. Indigenous midwives provide a protective force against racism—not only in our role as indigenous health care providers, not only in our role as advocates for our clients and not only in being a witness to how our people are treated, but also by providing care in a way that promotes the sovereignty of indigenous people, so that our babies, from the moment of birth, are surrounded by indigenous knowledge and teachings and grow up with us as a part of their community to help them understand their bodies and their rights.

Indigenous midwives are culturally safe care for our communities. We are not the same as mainstream midwives. Yes, there are many similarities, but there is no replacement for indigenous midwives in our communities. Growing and sustaining indigenous midwifery is a direct commitment to addressing anti-indigenous racism and gender inequality that all levels of government can make today.

The following are our three recommendations.

Recommendation one is a reinvestment in indigenous midwifery by the federal government. We must acknowledge that substantive equity starts at birth. The Government of Canada made a historic first five-year investment in indigenous midwifery in 2017. We urge the federal government to renew and substantially increase this funding in 2022 and beyond.

We have numerous reports that highlight the inequities in health outcomes for indigenous people. How many more reports do we need before we take real action? The health of indigenous women, girls and gender-diverse people is an indicator of the health and wellness of the entire nation, and we are failing. The recently released report on the state of the world's midwifery indicates that investing in midwives directly improves health outcomes. A substantial and long-term commitment to indigenous-led midwifery increases equitable access to sexual and reproductive health, works toward addressing gender-based violence and promotes the empowerment of all members of our communities, particularly women, girls and gender-diverse people.

Recommendation two is the addition of midwifery to the job classification system of the Treasury Board of Canada. At present, there is no federal recognition for the profession of midwifery, which creates barriers for communities wanting to hire midwives. Midwives are essential primary health care providers. The lack of recognition by Treasury Board is a key barrier to establishing and sustaining midwifery services for indigenous communities. The cost of non-indigenous-led primary health care to the health system and to indigenous communities is unjustifiable.

Recommendation three is an investment in indigenous-led midwifery education. As indigenous midwives, we know that education programs need to be close to home. We need to train and retain more students within our communities. The closure of the Laurentian midwifery education program is devastating for rural, northern, francophone and indigenous midwifery.

However, we need to also be clear about the limitations of the current university-based education program for indigenous midwifery students. These programs have rigid structures that do not acknowledge the family and community roles of indigenous students and are based in colonial systems that fail to recognize the importance of indigenous knowledge and ways of being. The recognition of indigenous knowledge is a skill in midwifery, and it is crucial for meeting the health needs of our communities.

Our current system is failing prospective indigenous midwives and urgently needs to be reimagined. Indigenous midwives in communities across the country are working to diversify pathways to education for indigenous midwifery students. It's time for the government and the university system to catch up and invest seriously in indigenous-led midwifery education. This is a commitment the government can make as part of its work in addressing anti-indigenous racism.

Anti-indigenous racism is the root of inequity in Canada. Our colonial legacy has been uniquely borne out by indigenous women, girls and gender-diverse peoples, which affects all of our families. Indigenous midwives return to indigenous communities the respect, autonomy and reverence for all of our life-givers.

Anushiik. Thank you.

[The Chair, Conservative, Marilyn Gladu]

Thank you very much.

We're going to briefly pause while we do sound checks for our two other witnesses who are here now.

Ms. Giroux, you have the floor for five minutes.

[Josyane Giroux, President, Midwife, Regroupement Les Sages-femmes du Québec]

Good afternoon.

I hear music. I don't know if I'm the only one, but it's going to be hard to do my presentation.

[The Chair, Conservative, Marilyn Gladu]

Clerk, could you check why she's still hearing music?

[The Clerk]

I don't know why you are hearing music. It's not coming from us.

[Josyane Giroux]

Okay, it stopped.

[The Chair, Conservative, Marilyn Gladu]

You may begin your presentation, Ms. Giroux. You have the floor for five minutes.

[Josyane Giroux]

Good afternoon, everyone.

Madam Chair, I thank you for having me here today.

My name is Josyane Giroux. I am a midwife and president of the Regroupement Les Sages-femmes du Québec. In Quebec—

I'm sorry, but there's an audio lag. I can still hear myself speaking.

[The Clerk]

Madam Chair, please suspend.

[The Chair, Conservative, Marilyn Gladu]

We'll suspend while we address the technical issue.

[The Chair, Conservative, Marilyn Gladu]

Ms. Giroux, you have the floor again for five minutes.

[Josyane Giroux]

Thank you, Madam Chair.

Good afternoon, everyone.

I thank the committee for having me here today.

I am Josyane Giroux, a midwife and president of the Regroupement les Sages-femmes du Québec, or RSFQ.

The RSFQ is the professional association that represents more than 240 midwives working in the profession throughout the province. It works to develop the profession and its specificity within Quebec's health care system. In collaboration with the authorities and citizen groups, the RSFQ is committed to supporting access to midwifery services that meet the needs of the population.

The RSFQ also defends the free choice birthplace for women or people who give birth, in accordance with the standards of practice of the profession, as well as its philosophy of practice. The RSFQ is recognized by Quebec's department of health and social services as a spokesperson for midwives, and it negotiates their working conditions.

In Quebec, midwifery has been legally recognized since 1999. At the time, there were already six birth centres where 50 midwives worked. In 2008, the Quebec government published its perinatal policy, in which it pledged that, by 2018, midwifery services would be available in all regions of Quebec, that 10% of women and birth attendants could access services and that there would be a total of 20 birthing centres across the province.

According to 2019-20 data, only 4% of maternity follow-ups are carried out by midwives. Many regions still don't have access to services, and all the birthing centres have very long waiting lists, sometimes representing 30% of the number of annual follow-ups that can be offered by the teams.

We think there are three main reasons for this slow-motion development. First, the lack of recognition of the profession in general and its crucial role in reproductive and sexual health is a major issue. The midwifery model of practice, based on relational continuity, confidence in autonomy and respect for the physiological process of pregnancy and childbirth, is not recognized and valued.

In Quebec, the lack of knowledge of the profession heightens tensions and still leads to refusals of collaboration by medical teams. Ultimately, this remains an obstacle in the development of interdisciplinary services or projects that meet the needs of communities. The government has failed in its crucial role of demystifying and valuing the midwifery profession and its importance to the health system. On a day-to-day basis, it is midwives and families who are experiencing this pressure and are still fighting against misperceptions about their practice by clinical teams and the public.

The second major deficiency is the lack of workforce planning and workforce monitoring consistent with the objectives presented. Despite numerous representations in this regard by the RSFQ and other organizations, the warnings were not heard by the Quebec department of health social services. Midwives and families are the main victims of this lack of political leadership, as labour shortages are now affecting all midwives and forcing them to reduce services to the population. At this very moment, more than 20 contracts are unfilled in the province, and the opening of at least two birthing homes has been delayed.

In Quebec, the Université du Québec à Trois-Rivières is the only educational institution for the midwifery profession. It has a capacity of 24 students per year since the program opened in 1999, but is struggling to fill these places due to the lack of midwives to accompany trainees. It is essential that national consultation work involving the groups and community-based organizations directly involved, including citizen groups, be undertaken in order to find solutions and establish a clear plan.

The third very important element to consider in the analysis of the development of midwifery services and its slowness is the gender discrimination that midwives experience. The midwifery model, developed to meet the needs of women and pregnant persons and whose services are mainly aimed at women, is the source of indecent working conditions. Quebec midwives, at the end of their careers, earn 20% less than their comparable pay equity jobs. In Quebec, in 2019-20, the government paid only a total of $23,561,343 for midwifery services, including all operating costs. These working conditions, in addition to the context described above, lead to many early departures from the profession, exacerbating the shortage of human resources.

At the same time, the RSFQ operates solely based on membership dues, as the government does not recognize the importance of a strong professional association for supporting the development of the profession. Our association therefore struggles to meet all the needs, both those of its members in a global way and the support in the strategic work more than necessary.

Finally, it is with humility that I would like to add that the elements I've described are an exacerbated reality for women, pregnant people, and midwives from indigenous communities.

To date, there is no clear plan to provide families in these communities with access to midwifery services. Collaboration is at its starting point between governmental and legal organizations, communities, universities, and associations.

Our NACM colleagues and indigenous midwives will certainly be able to explain the issues in detail, but we believe it is crucial that the committee look at these matters.

In short, the RSFQ asks the provincial, territorial and federal governments to set up a campaign to demystify, promote and recognize the midwifery profession; invest in the establishment of a working committee for workforce and development planning in line with community needs; provide funding to professional midwifery associations, essential in supporting practice at all levels; recognize gender discrimination faced by midwives and adjust working conditions to end it; and prioritize work for the training, accessibility and development of midwifery services in indigenous communities.

Thank you, committee members, for your attention.

I will be happy to answer any questions you may have.

[The Chair, Conservative, Marilyn Gladu]

Thank you very much.

We're going to pause for a moment now to do a sound check for Brenda Epoo.

Now we will go to Ms. Claire Dion Fletcher, who will read Brenda's remarks. Thanks so much.

[Claire Dion Fletcher]

Thank you, Madam Chair and members of the committee, for allowing me to speak on behalf of Brenda. It's unfortunate that she's not able to connect, as she brings a very unique perspective to this committee.

I'm now going to read her statement for you, as follows.

My name is Brenda Epoo and I'm an Inuk midwife from Inukjuak, a small village in the remote Arctic region of Nunavik, Quebec. I am part of a team of indigenous midwives that serves seven villages on the Hudson coast, using modern and traditional Inuit midwifery skills.

The month of May celebrates midwives and nurses globally. To acknowledge this, the World Health Organization and partners launched “The State of the World's Midwifery 2021” report, which tells the story of the COVID-19 pandemic and how midwives serve their communities in a time of crisis.

A key finding of the report is that during the crisis there has been an increase in violence and reduced access to essential reproductive and sexual health services, and that, critically, midwives play a crucial role in providing support and guidance and access to these important health services.

Across the world, including here in Canada, women and gender-diverse pregnant people are struggling, which has led to increases in maternal mortality, unintended pregnancies, unsafe abortions and infant mortality. While Canada has an established public health care system, it is highly inequitable.

At home in the Arctic, midwives are the leaders of the maternity. We protect our communities and help lessen the impacts of COVID-19 on families. Our Inuit-led model of midwifery is culturally appropriate, with excellent clinical outcomes, including 86% of births taking place in Nunavik between 2000 and 2015. Our model leads the world in linking traditional and medical ways of knowing, and yet we remain largely unrecognized and unseen.

The significant contributions we make day in and day out are not known to most Canadians and policy-makers. Systemic racism is rampant in the health care system, especially against indigenous people. We need a more compassionate and thoughtful system that recognizes the important role that indigenous medical professionals play as clinicians, educators and mentors.

The National Aboriginal Council of Midwives believes that investments in indigenous-led community-based education strategies are critically needed. This investment will create meaningful opportunities for indigenous training, apprenticeships and, ultimately, increased culturally relevant service capacity.

NACM has already developed a sophisticated indigenous midwifery core competency framework that allows communities to customize opportunities to maximize local benefit. We are ready to partner on expanding this initiative to create a more inclusive, responsive and equitable health care system, especially for indigenous people living in rural and remote communities.

Here in the north, we do more than catch babies and do postpartum care. We provide an opportunity for children to be born on our land, in our communities, with a sense of place and pride. It's all about our families, communities and creating future generations of healthy people.

Thank you.

[The Chair, Conservative, Marilyn Gladu]

Thank you very much.

I apologize for all of the technical difficulties. It looks like we will get in one round of questions.

We will begin with Ms. Wong for six minutes.

[Alice Wong, Conservative, Richmond Centre, BC]

Thank you, Madam Chair.

Thank you to all the witnesses from different parts of our nation. I have had the privilege of visiting many of your communities. I was especially impressed that we have somebody from B.C., because my riding is in Richmond Centre. Welcome, Louise, as one of our witnesses.

I understand that the professional recognition of midwives is so important, because then it leads to status, pay equity and a lot of those related issues. Can either Tracy or Louise comment further on how important it is for the regulators to make sure the quality's out there and that the midwives get the training and recognition, especially in pay equity and all the other areas?

[Louise Aerts]

Thank you for the question.

I think it's really important that midwives are regulated health professionals, that we are able to provide the safety that comes with being part of a regulated college. It speaks to the registration requirements, those education requirements. It speaks to the quality assurance programs that we put in place, and in particular the ability to respond to any complaints and address any conduct or competence issues that might exist. That has definitely impacted the professionalism of midwifery.

However, a lot of the issues that the other witnesses have spoken to remain. There are areas that still block midwives and there are lots of turf wars between different providers and such. Definitely in terms of where we've gone in professionalizing this and through regulation, I think we've gone a long way. Wherever midwifery can be recognized as a primary care service benefits midwives across the country.

[Alice Wong, Conservative, Richmond Centre, BC]

Thank you.

My other question is about foreign credential recognition. I think this is also a very important element to meeting the growing demand for midwives across the nation. This is a federal committee, so I want you to comment further on that, please.

[Louise Aerts]

At the moment, there are two bridging programs for internationally educated midwives in Canada, one in Ontario and one in B.C. The method for getting registered in Canada as an internationally educated midwife is to take one of the bridging programs in order to bridge to the Canadian model of midwifery. As I say, at present, there are just the two programs that are bringing in internationally educated midwives.

[Alice Wong, Conservative, Richmond Centre, BC]

Thank you.

My next question is directed to Madame Fletcher.

You did mention a lot about inequity and also the recognition that we just mentioned for the professional status of indigenous people. You also mentioned in some of your reports that access to health care services is challenging in many indigenous communities, which may force indigenous people to seek care outside their communities, and then they report experiences of racism and violence. I'm really alarmed by what the council has reported. Madame Fletcher, can you comment further on that, please?

[Claire Dion Fletcher]

Yes. Thank you for this question.

As I mentioned in my remarks, we have a number of reports that have been put out at both the national and provincial levels. There's the “In Plain Sight” report from B.C., the “First Peoples, Second Class Treatment” report, and the recommendations from the Truth and Reconciliation Commission, the study on missing and murdered indigenous women and girls. We have numerous reports that speak to the racism that indigenous people face in the health care system, and this is happening to us on a daily basis and really affects access to care.

One of the ways to combat it is by having indigenous health care providers. The closer to the community and the closer to our ways of knowing and being that those providers are, the better it will be for our health outcomes.

[Alice Wong, Conservative, Richmond Centre, BC]

Thank you.

In my past experience visiting indigenous families and seniors especially, I have heard them mention that language has always been a challenge when they go outside their communities for health care services. Can you comment further on that point, please?

[Claire Dion Fletcher]

Yes, that is a crucial aspect, and thank you for bringing it up.

Not being able to access health care in your own language makes it extremely difficult. We can see this in many areas of health care, but as one of the earlier witnesses said, imagine being in labour and trying to deliver your baby and not being able to speak in the language of the health care providers who are providing your care. Imagine the difficulty that presents at such an important time in being able to understand what is happening to your body, what health care providers are doing and what is going on in the room.

It's an extremely isolating experience, and then to be in the situation that a number of indigenous women are when giving birth far from home.... You don't have family members around. You don't have the support of your extended family or your community. It's very isolating and it does not improve health outcomes.

[The Chair, Conservative, Marilyn Gladu]

That's very good. Now we'll go to Ms. Hutchings for six minutes.

[Gudie Hutchings, Liberal, Long Range Mountains, NL]

Thank you, Madam Chair; and to all the witnesses, thank you for your passion. This has certainly been an education process for us on the committee and a topic that has been so interesting.

I live in a very rural riding, and there are many similarities with indigenous people for people in rural ridings.

Louise, I have a question for you. How has the COVID-19 pandemic impacted the practices of midwives all across the country, but especially in rural areas? Do you have a comment or two on that?