A SUMMARY OF THE HISTORY OF MIDWIFERY IN
Although midwives have been
practising in Canada ever since people first lived here, and then immigrants
brought midwives with them to the new country, it is only recently that midwifery
legislation has started to be introduced. For a long time Canada was one of
nine countries which did not recognize midwifery, and still there are several
jurisdictions in Canada where midwifery
is not regulated. In Canada, as in most countries, the term “midwife” is used
without any prefix. This is in keeping with the WHO/FIGO/ICM International Definition of a Midwife.
(The USA deviated and prefixed words such as “nurse”). The following is only
intended as a summary of the history of midwifery, but the author would be
pleased to hear of any important events which should be included.
Some Historical International
Happenings of Interest
1861 - Kings
College Hospital School for Midwives opened by Florence Nightingale but closed
after two years by circumstances beyond her control.
1893 - First
civilian hospital outside of St. John’s opened in Battle Harbour, Labrador, by
Dr. Wilfred Grenfell. Staffed by nurses with midwifery skills brought from
Britain. British midwives who were nurses continued to staff other hospitals
and nursing stations as they were built.
1902 - Midwifery
legislation implemented in England and Wales.
1916 - Midwifery
legislation implemented in Scotland.
1918 - Midwifery
legislation implemented in Northern Ireland.
1920 - Midwives
Act implemented in the colony of Newfoundland. A Government appointed Board
issued licenses until 1963. Lay midwives provided with upgrade education
through the Maternity Club, midwives who were nurses and health visitors
(public health nurses) brought from Britain to work in the Outports. From 1924
to 1934 direct-entry midwifery and paediatric training started at the Grace
Maternity Hospital in St. John’s. In 1934 the health care reforms changed the
way midwifery was administered and midwifery training ceased.
1925 - Kentucky
Committee for Mothers and Babies commenced by Mary Breckenridge (in 1928
renamed Kentucky Frontier Nursing Service) midwifery services provided based on
the British model. Primary providers continue to be nurse-midwives and family
nurse practitioners, and physician consultants.
1932 - Maternity
Center clinic and school for midwives who were nurses commenced in New York.
(Had been providing prenatal classes since 1918).
1949 - Newfoundland
and Labrador joined Canada, a country where midwifery was not recognized.
1976 - Representatives
from various agencies, including the International Council of Nurses (ICN),
World Health Organization (WHO), International Confederation of Midwives (ICM)
agreed that midwifery “was a discipline in its own right,” and responsible for
its own practice.
Some Old Canadian History
1691 - The
Government in what is now Quebec, established three autonomous branches of
medicine: physicians, surgeons, midwives.
1755 - British
government paid the wages of midwives from England who settled in Nova Scotia.
to
1764
1843 - Midwives
working at the University Lying-in-Hospital in Montreal.
Midwives given licenses by local governments in
Montreal, Quebec City, and the local churches in rural areas.
1872 - Compulsory
certification for midwives introduced in Nova Scotia, New Brunswick, and
Quebec.
to 1881
1912 - Medical
Council of Canada formed and midwifery practice eliminated in most locations.
1939 - During
the war years Public Health Nurses provided midwifery care in rural Alberta
under legislation contained in the Medical Profession Act.
1944 - Midwifery
certificates repealed in Quebec.
1946 - Canadian
Nurses Association (CNA) approved the practice of registered nurses as midwives
in outlying areas where there were no physicians.
More Recent History
Midwives Associations
1973 - Western
Nurse Midwives Association started (included midwives in the western provinces
and in the Yukon and Northwest Territories). Disbanded in 1988 as the midwives
were becoming very involved with the
provincial midwives associations.
1973 - Ontario
Nurse Midwives Association started. A nurse-midwifery statement was accepted by
the Registered Nurses Association of Ontario.
1974 - Atlantic
Nurse Midwifery Association started (included midwives in the Maritime
provinces and in Newfoundland and Labrador).
197? - Quebec
Nurse Midwives Association commenced.
1983 - Newfoundland
and Labrador Midwives Association formed as the Maritime members of the
Atlantic Nurse Midwifery Association had decreased. Now renamed the Association
of Midwives of Newfoundland and Labrador.
1987 - Canadian
Confederation of Midwives (CCM) formed to facilitate communication between the
various provincial midwives associations. A confederation of midwives associations,
not individuals.
1988 - Saskatchewan
Association of Midwives formed. The Saskatchewan Association of Safe
Alternatives in Childbirth was disbanded and consumers formed the Friends of
the Midwives group.
1991 - March
- the CCM adopted the ICM definition of midwifery, and “nurse-midwife”
unacceptable.
2001 - The
CCM became the Canadian Association of Midwives (CAM). The progress of
midwifery legislation in the country resulted in more work, and the need for a
national Association.
2001 - The
Midwifery Mutual Recognition Agreement on
Labour Mobility in Canada was completed, signed and accepted under the
Agreement on Internal Trade.
Midwifery Education
1943 - The
University of Alberta commenced an Advanced Practical Obstetrics course, which
lengthened as more knowledge and skills became available for midwives.
In 1982 it was evaluated and recognized as being
equivalent to Part 1 of the British State Certified Midwife qualification.
In 1987 the undergraduate program was discontinued and
a midwifery certificate was offered in conjunction with the Master’s in Nursing
degree. This program was discontinued when midwifery legislation was
implemented in Alberta.
1962 - Laval
University in collaboration with St. Sacrement Hospital, provided a 9-month midwifery
course for missionary nurses. This was discontinued in 1972.
1967 - Dalhousie
University School of Nursing commenced a two-year Outpost Nursing Program which
included an academic year of nurse-midwifery.
In 1979 this Outpost Nursing Program was revised to a
15-month program, and emphasis was shifted away from labour and delivery as
mothers were now having their babies in a hospital setting.
1978 - Memorial
University of Newfoundland School of Nursing commenced a two-year Outpost
Nursing Program which included a 10-month nurse-midwifery program in the second
year. The first students were admitted in 1979, and rotation during a 6-month
clinical experience included hospitals in western Newfoundland, Grenfell
Regional Health Services (GRHS), and Scotland. University credits were obtained
towards a bachelor of nursing degree. The GRHS requested such an Outpost
Nursing Program at the 1977 Conference on Northern Medicine and Health
following Dalhousie University’s decision to shorten their program.
In 1981 it was evaluated by Miss Annie Grant, of the
Scottish National Board, and it was considered to be the equivalent of Part 1
of the State Certified Midwifery program in Britain (prior to the revision of
the program and removal of the Part 1 and Part 2).
In 1981 the program was revised so that each of the
two years could be taken independently of each other. The last students
graduated in 1986 as a result of university cut-backs and the need for large
classes, which would have made it impossible to provide clinical experiences
for all students.
1984 - Fraser
Valley School of Midwifery, a branch of Seattle Midwifery School, was
established to give a three-year program to direct-entry midwives. As part of
the Seattle Midwifery School was included in the accreditation from the State
of Washington. Two classes of students graduated from the program before the
School had to close because of a fire.
1986 - Innuulitsivik
Hospital in Povungnituk, Quebec, commenced a midwifery program to prepare Inuit
women to be “community midwives”, in no less than three years.
1993 - In
Ontario, the first undergraduate students entered the midwifery degree program.
This collaborative program is offered by a consortium of three universities:
Laurentian, McMaster, and Ryerson.
Inukjuak, Quebec, midwifery program started, similar
to the Povungnituk program,.
2000 - The
first students accepted at Université de Quebec a Trois Rivières for the
four-year undergraduate midwifery degree program, which is similar to the
Ontario program.
2000 - First
students accepted into the midwifery program at Tsi Non:we Ionnakeratstha
Ona:grahsta on the Six Nations Territory in Ohsweken, Ontario. This is a
three-year program, each year 10 months long, of academic and clinical
practice. Students must be of native ancestry. In Ontario aboriginal midwives
practice on reserves and are not regulated by the College of Midwives of
Ontario.
2002 - The
four-year undergraduate midwifery degree program commenced at the University of
British Columbia.
Midwifery
Projects
1981 - September,
“The Hands-on Clinic for Nursing Instructors” started at the Vancouver General
Hospital and
to transferred
to the Grace Hospital when the hospitals amalgamated the maternity care units.
When the program
1984 was
evaluated the 61 families gave positive reports. They had received continuity
of care, which was more adequate and comprehensive than physician care.
Midwifery care was then instituted at the Grace Hospital, as a service and not
a project.
1985 - Midwifery
care to low risk women at a tertiary care hospital in Hamilton, Ontario. After
2 years the care provided to 79 women was evaluated and compared to physician
care. Difficulties encountered as interventions were usual in this setting, but
gradually the physicians were willing for midwives, who were nurses employed by
the hospital, to have complete control of the management of their patients.
199? - The
Misericordia Hospital, Edmonton, had a project with nurses at the hospital who
were also midwives, working as a team, but it lasted less than a year and no
evaluation was published.
1990 - In
Quebec, Bill 4, Bill on the Practice of
Midwives in the Pilot Projects was sanctioned. Eight pilot projects were to
be funded, for a maximum of 5 years, to evaluate the effects of midwifery on
premature births. The projects were to be in birthing centres but no priority
given for the regions selected. In 1992 it was decided to evaluate all midwives
with a rigorous simulated practical examination. In December 1997 the
evaluation was released and the majority of the recommendations accepted by the
Quebec Ministry of Health. The law for the pilot projects was extended until
midwifery legislation was passed and implemented.
1991- Foothills
Hospital, Calgary, project commenced with midwives who were nurses employed by
the hospital, and
to when
funding for this ceased the consumer demand resulted in midwifery services
being allowed to continue.
1994
1991 - Plans
were made to submit a proposal for a project at the Grace Maternity Hospital,
Halifax, but the project never
materialized.
1992 - The
NWT Dept. of Health financed a community birthing pilot project in Rankin
Inlet, involving both midwives who were nurses and those who were direct-entry.
1998 - The
Home Birth Demonstration Project commenced in BC when midwives were licensed to
practice. This was evaluated a year later, recommendations made, and home
births accepted as a choice for women.
Registered Nurses Associations
regarding Midwives
1974 - June
- the Canadian National Committee of Nurse-Midwives was organized at the
Canadian Nurses Association (CNA) convention in Winnipeg, but soon disbanded as
midwives were involved with other Midwives Associations. The CNA issued a
statement on nurse-midwifery recommending recognition of the nurse-midwife.
Registered
Nurses Association of British Columbia (RNABC)
1979 - RNABC
approved the Report of the Task Committee
on the Future of Nurse Midwifery in BC.
1988 - RNABC
published a paper stating that it did not support the concept of midwifery as
an autonomous and separately regulated discipline. Midwifery was considered not
to include health promotion or advocacy, or that midwives had successfully
completed a recognized midwifery program. Statements which are included in the
WHO/FIGO/ICM International Definition of
a Midwife.
Association of Registered Nurses (AARN)
1981 College
of Physicians and Surgeons of stated
that they would impose a $1,000.00 fine or revoke the licence of physicians who
attended a home birth. Twenty years later this policy was revoked.
1987 - AARN
wrote that they supported nurse-midwives practicing in the recognized health
care system.
1991 - AARN
published a Position Paper on Birthing
Alternatives in which they supported home births if a highly prepared
professional was present and emergency services available.
Saskatchewan
Registered Nurses Association (SRNA)
1988 - SRNA
published Position Statement on Midwifery
supporting nurse midwives, and omitted the presentation from consumers for
autonomous midwifery and home births.
1991 - Annie
Johnson, aboriginal midwife, received the Order of Saskatchewan for help given
to her community.
Manitoba
Association of Registered Nurses (MARN)
1991 - A
joint statement by the College of Physicians and Surgeons of Manitoba and MARN
entitled, Report on the Future Role of
Midwifery in Manitoba, stated that nurse-midwives be regulated by both of
these bodies. There
were questions about lack of public input
and so the government appointed a Working Group on Midwifery.
Ordre
des Infirmiers et Infirmiers du Quebec
(nursing professional association)
1985 - The
Ordre des Infirmieres et Infirmiers du Quebec published Position Paper on the Nurse-Midwife, and also a Support Document for the Position Paper of
the Ordre on the Nurse-Midwife. It recommended that the Quebec Legislature
modify both the Medical Act and the Nurses Act to allow nurse-midwives to
practice wherever the parents wished their baby to be born.
1988 - The
Federation des Infirmieres et Infirmiers (Union for Nurses) published Ad Hoc Committee on Midwives and the
following year Memoire for the Midwives
Paper, supporting autonomous midwifery, both nurse and direct entry
midwives.
The
Nurses Association of New Brunswick (NANB)
1990 - NANB
wrote in a draft Discussion Paper that
it did not recognize midwifery as being a separate discipline, but could
recognize nurse-midwifery as a valid area of nursing practice working in tandem
with physicians in institutions and community settings, but not at home births.
The
Registered Nurses’ Association of Nova Scotia (RNANS)
1985 - RNANS
published Childbirth in Nova Scotia,
and that nurse-midwives had a role which should be recognized by nurses,
medical profession and the public. At the RNANS annual meeting in 1991 is was
unanimously passed that the RNANS promote the role of nurse-midwife, and that a
nurse-midwifery education program be developed.
Association
of Registered Nurses of Newfoundland and Labrador (ARNNL)
1978 - ARNNL
Home Birth Policy - which was revised
in 1994 and is still in effect.
1997 - Advanced Practice Nurse Position Statement
- definition of a nurse-midwife and roles.
2002 - Advanced Nursing and Medical Nursing Shared
Skills Booklet Revised -
“Delivery of Infants (when delivery is imminent and the physician is not readily
available). In certain geographical areas and circumstances, delivery of an
infant by the registered nurse may be accepted practice. Episiotomy (When
appropriate in the absence of a physician where delivery is imminent)”.
Other position statements regarding nurse-midwives
have been rescinded.
Northwest
Territories Registered Nurses Association (NWTRNA)
1991 - NWTRNA
circulated a Discussion Paper.
Recommendations were that the NWTRNA develop a position paper on midwifery, and
to work jointly with government and consumer groups to plan and develop
strategies for implementation of proposed changes.
Midwifery Legislation
In
the Spring of 1981, the British Columbia
Midwifery Task Force and the Midwives Association of British Columbia organized
an international conference, Midwifery is a Labour of Love. In 1981
the first Canadian midwife was charged with practising medicine without a
license. At the 1993 International Confederation of Midwives Congress in
Vancouver the BC Minister of Health announced that midwifery was to be
legalised. The Midwives Regulation
was proclaimed in March 1995, and the government appointed the first Board of
Directors to the College of Midwives. The first midwives were registered to
practice in BC on January 1, 1998,
under the Health Professions Act [RSBC
1996], Chapter 183, which had come into force on April 21, 1997. Midwifery
is an autonomous and funded profession. There were 29 registered midwives when
legislation was implemented and now there are 88 registered midwives, actively
practising and 15 non-practicing.
In
1989 the Alberta Association of
Midwives applied for designation of midwives under the Health Disciplines Act.
The hearings were held in January 1991. In June 1991 the Health Disciplines
Board recommended the regulation of midwifery. In June 1991 the provincial
court judge found a midwife not guilty of illegally practising medicine. The Midwifery
Regulation (AR 328/94), Health Disciplines Act/(Ch H-3.5) came into force
on August 1, 1995. The opening
of
the register for midwifery licensure occurred in July 1998. As there were too few midwives to form a College
these functions were undertaken by the Health and Wellness, Health Workforce
Planning Branch, of the Government of Alberta. Midwifery is not funded and so
midwives practice privately. There were 24 registered midwives when legislation
was implemented but now the number has decreased to 18 midwives
practicing.
In
August 1994 the Saskatchewan
government announced the formation of a Midwifery Advisory Committee and their
findings, which included autonomous midwifery, were submitted to the government
in May 1996. The Chapter M-14.1 An Act
respecting Midwives, was passed May 6, 1999 but has not come into effect,
partly because there is no guarantee that midwifery will be a funded
profession. There are two midwives practising without
regulations.
In
1992 a Working Group on Midwifery was convened in Manitoba. In 1994 the Government appointed a Midwifery
Implementation Council. Following three readings of Bill 7 The Midwifery and Consequential Amendments Act the Royal
Assent was given June 28, 1997. The Midwifery
Act (C.C.S.M. c. M125) Midwifery Regulation 68/2000 was registered June
2000 and midwifery legislation came into effect on June 12, 2000, for an autonomous, funded profession. At
implementation there were 11 registered midwives and now there are 28
registered midwives.
In
Ontario, following the death of a
baby delivered at home by midwives, there was a court case and the jury made 15
recommendations regarding the practice of midwifery. In 1986 the Government
announced that it intended to establish midwifery as a recognized part of the
Ontario health care system, and that midwifery would become a regulated health
profession. In 1987 the Government published the Report of the Task Force on the Implementation of Midwifery in Ontario.
In 1989 the Government of Ontario created the Interim Regulatory Council on
Midwifery. Bill 56 (Chapter 31 Statutes
of Ontario, 1991) An Act respecting the regulation of the Profession of Midwifery
had three readings in 1991 and Royal Assent was given on November 25, 1991, and
came into effect on January 1, 1994,
for funded, autonomous midwifery. At implementation there were 62 registered
midwives and now there are more than 300 registered midwives.
In
Quebec, in 1990 Bill 4 was passed to allow midwives assessed as being qualified,
but not licensed, to practise at recognized sites for a limited time. The
objective was to evaluate the effects of midwifery on premature births. The
project, which commenced at seven sites in 1993 (Innuulitsivik Hospital in
Povungnituk had commenced in 1986), was evaluated and the final report of the Conseil d’Evaluation des Projects-Pilots
Sages-Femmes was released in December 1997. The Quebec Ministry of Health
accepted the majority of the recommendations. The law for the pilot projects
was extended until midwifery legislation was passed and implemented. The new
law, Bill 28 (1999, Chapter 24) Midwives
Act, received three readings in 1999 and was adopted by the National
Assembly on June 19, 1999, and came into effect on September 24, 1999. There are 84 registered midwives
practicing in birthing centres, of which two are now located in northern
Quebec.
In
New Brunswick there is no law
prohibiting the practice of midwifery, and no Midwives Act. Midwives practice privately, and as there are
no hospital privileges they attend home births. The Midwives Association of NB
is working with a lawyer to submit proposed legislation to the provincial government.
In
Prince Edward Island there is no
midwifery legislation. There is one practicing midwife who practices privately,
and backup support is by an Ontario midwife, who visits for home births.
Without legislation there are no hospital privileges.
In
Nova Scotia the Interdisciplinary Working
Group on Midwifery Regulation submitted its report, Recommendations for the Regulation and Implementation of Midwifery in
Nova Scotia, in June 1999. The Government took no action and midwifery is
still unregulated. There are four actively practicing midwives and a
growing number of mothers who are looking for midwifery care. The Primary Health Care Renewal report mentions midwives and has some
suggestions for the profession with only a small number, such as regulation
under a program of a department of government.
In
1996 the Northwest Territories government agreed to policies and regulations
regarding the practice of midwifery in that territory. A birthing centre,
opened in Rankin Inlet in 1992, was evaluated as satisfactory. Rankin Inlet is
now located in Nunavut, and the
birthing centre is for the Kivaliq region. A midwife consultant is being hired
to help with
the
development of midwifery services in Nunavut and plans for additional birth
centres in Pond Inlet, Arviat and Cambridge Bay.
In
2003 the NWT government hired an
advisory consulting team, which submitted its report, and the Midwifery Profession Act (Bill 24)
received two readings in June 2003 and the third in October 2003.The Act
was implemente in 2005. Midwives are required to be registered to
practice in a province where there is regulated midwifery (as is usual for a
new profession commencing in the NWT). Midwives are providing community
services in the Fort Smith area.
Midwifery
remains unregulated in the Yukon
Territory.
Midwifery
remains unregulated in Newfoundland and
Labrador despite the 1994 Final
Report of the Provincial Advisory Committee for Midwifery and the work from
1999 to 2001 of the Midwifery Implementation Committee.
See
A Brief History of Midwifery in
Newfoundland and Labrador for further information.
Midwives
provide safe care, which is cost efficient and enhances women's overall
satisfaction with care throughout pregnancy, birth and postpartum:
MacDorman,
M. F., & Singh, G. K. (1998). Midwifery care, social and medical risk
factors and birth outcomes in the USA. "Journal of Epidemiology and
Community Health", 52(5), 310-317.
Turnbull
et al. (1996). Randomised, controlled trial of efficacy of midwife-managed
care. "Lancet", 148, 213-218.
In
Ontario, where midwifery is regulated, for the 3740 women attended by midwives
in 1996: there were fewer episiotomies, 8% compared with 50% of physician
attended births; 5% of women used epidural anaesthesia for pain relief compared
with 30% of physician attended births; 95% of the mothers were successfully
breastfeeding at 6 weeks; 40% of midwife-assisted births took place at home
representing the lowest cost option for healthy births (Association of Ontario
Midwives. (1997). "Fact Sheet. Cost Effectiveness of Midwifery
Care").
In
Quebec where midwifery is regulated, in 1997 there was a saving of
approximately $780 per mother who received pregnancy, labour and birth, and
postpartum care from midwives, when compared with the cost of similar care
received from physicians at hospitals. (Evaluation des projets-pilotes de la
pratique des sages- femmes au Quebec. Rapportfinal. 1997). "The reduction
of interventions, maternal morbidity and length of hospital [when using
midwives] has the potential to reduce the cost of maternity care to women,
their infants and the health care system".
Harvey
et al. (1996). Randomized controlled trial of nurse- midwifery care [in
Calgary, AB]. "Birth", 23(3), 128-135. Planned home birth for women
classified as having no problems has been found to be safe.
Anderson,
R. E., & Anderson, D. A. (1999). The cost-effectiveness of home birth.
"Journal of Nurse-Midwifery", 44(1), 30-35.
Campbell,
R., & Macfarlane, A. (1994). Where to be born? The debate and the evidence
(2nd ed.). Oxford: National Perinatal Epidemiology Unit. Olson, O. (1997). Meta
analysis of the safety of home births. "Birth", 24(1), 4-13.
Rooks,
J. P. (1997). Safety in out-of-hospital
births in the United States. In Midwifery and childbirth in America (pp.
345-384). Philadelphia: Temple University Press.
Tew,
M. (1998). Safer childbirth? A critical history of maternity care (3rd ed.).
Published by Free Association Books, 57 Warren Street, London W1P 5PA, England.
ISBN 1-85343-426-4
For
information on the requirements to become licensed in a province/territory see
the page containing addresses for Information Regarding Midwifery Licensure.
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