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.
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.
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
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.
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.class=Section3>
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.
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.
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. Thereclass=Section5>
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.
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 openingclass=Section6>
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:
Cameron, H. L. (2005, May). Modern midwifery in Ontario: An effective
model of health care. "University of Toronto Medical Journal", 82(3),
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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