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Maternal Health Care: Midwives in Canada and Laos

This is the first piece in a series exploring the profession of a midwife and their value at birth.

“Here comes another one.” The fetal monitor spiked as another contraction began. I paced the floor, trying to block out the beeping machines and freezing operating room. After three home births, this was no doubt unchartered territory. But the high-risk nature of delivering twins dictated that even a natural birth should take place here.

Our babies arrived healthy and without complication. Working to make this happen was a medical team consisting of an obstetrician, nurses, and an anesthesiologist standing by in case of emergency. At the core of this group were two midwives whose support remain invaluable to this day.

Midwifery is an anomaly to many in the modern world. The term often conjures images of home births with basic medical supplies. This is a snapshot of prenatal care in much of the developing world. In rural Lao PDR, midwives are stationed at the front lines of maternal and newborn health. A single clinic serves several villages, and the homes situated beyond them. While these resources are sparse and understaffed, they are the only option for many living in remote areas. In North America, the landscape of midwifery takes an entirely different shape.

Here in Ontario, Canada, the profession has roots as an underground service. The ’70s and ’80s saw women quietly birth at home, paying out-of-pocket or bartering for care. Regulation in 1994 ushered in professional standards and an official governing body. A rigorous 4-year training program took shape, consisting of course work and clinical placement. Under the provincial health-care system, midwifery became accessible through OHIP (Ontario Health Insurance Plan  — each province and territory in Canada provides free health services for permanent residents).

More than 20 years after regulation, about 15% of pregnant women in Ontario are choosing midwifery care. It may seem like a small percentage, but the increasing demand is worth noting. The province currently has more than 800 registered midwives. This number has surpassed the family doctors and obstetricians who are delivering babies today. The field is making gains in Lao PDR, too. A 2012 initiative to improve maternal health has led to intensive training and the disbursement of care to the country’s most vulnerable. At the moment, there are about 1,700 midwives practising in remote regions. The results of this work has been dramatic: in 2015, the maternal mortality ratio decreased from 357/100,000 live births to 206/100,000.

North American families who’ve experienced both midwifery and obstetric care will attest to the stark difference between the two. Both models follow the same schedule of prenatal checkups and routine testing. But hour-long appointments and individualized attention are valued beyond measure. Discussing personal history and incorporating informed choice foster an intimate sense of support among client and care provider.

Of the two options, midwifery is the only to offer postpartum care. Six weeks of home and clinical visits are reminiscent of the community support my mother knew in her childbearing years. Previous generations of Lao women advocate a month of lying in with baby to rest and heal after childbirth. But such a long pause on household (and in some cases, career) responsibilities is a luxury many North American women can’t afford. In its place, ongoing consultations are crucial to establishing breastfeeding and managing the transitional period for new mothers.

Lao women in the past traditionally delivered at home with an experienced attendant. In recent years, birth has steadily moved into hospitals and clinics across the country, some even to neighboring Thailand. But for many living in rural areas, a medical environment is out of reach. Unfavorable roads and dangerous travel keep laboring women at home. The fortunate ones are attended by a midwife who makes the difficult journey to them.

Across the world, Ontario midwifery allows a woman to birth where she chooses. Over 75% opt for a hospital delivery, while the rest remain at home. Modern home births are equipped with an abundance of medical equipment and a backup plan for hospital transfer. For a low-risk pregnancy, both settings are equally safe. Recent years have offered a third option, bridging the two environments. In 2012, the province launched pilot birthing centers in Toronto and Ottawa. Aimed at reducing the cost of birth, these community spaces offer a comfortable clinical setting without medical intervention.

Midwifery is still in its infancy in both the modern and developing world. Fuelling its evolution is a focus on improving maternal and infant health universally. In Canada, this involves regulation across the country, and reaching groups who lack access to care, like Aboriginals or newcomers.

The Ministry of Health in the Lao PDR continues to work towards reducing maternal and newborn mortality. Adequate training is crucial to reaching this goal. Recent initiatives have seen Lao midwifery utilize technology and connect to a global community of health care providers. The inclusion of a Lao representative at the International Confederation of Midwives Triennial Congress in Toronto this past summer is a sure sign of the immense progress being made on both sides of the globe.

Share with us below–the options you were given, and what you chose!

Donna Luangmany, dluangmany@gmail.com

 

1 Comment

  1. Nice article but some small mistakes. Thank you for raising awareness on the role of midwives, especially for Laos.
    At UNFPA Laos, we support MOH on this, let us know if you want to do a follow up article. We definitely would like to raise the profile of the Lao Midwife Association, which you mentioned in the article about the representative being at the ICM congress.

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