We all know about, and are very grateful for the role that Obstetricians/Gynocologists play in prenatal care, labour and delivery, especially when those dreaded horror stories come true and there is life saving surgical procedures that need to be performed for the sake of both mom and baby. For sure, without them, a lot of babies and mothers would die. However, in recent years, more and more research has surfaced that has suggested that a highly medicalized approach to birth may actually be causing more problems than first thought. And so, the rebirth (pun absolutely intended) of the midwifery care movement began and spread like wildfire. But so did a lot of old, outdated assumptions about exactly how midwives work, and what their skill level is when the really bad stuff happens.
What’s the difference, REALLY, between a midwife and an obstetrician/gynecologist caring for you here in Ontario, Canada? I mean, besides the obvious, that a midwife will clearly be able to help you still give birth in a barn full of animals, Jesus style, and will also help you if a field with deer is more to your liking….(yes, this is sarcasm for those who haven’t caught on yet). What makes having a midwife something more women in this province and country should consider if they (gasp) want to just do things the way it’s always been done, good ol’fashioned hospital style, complete with all the meds to help one forget that labour is what their body is experiencing, and of course access to an operating theatre should they need it for any reason?
First of all, I’m not here to convince you that you should have a home birth over a hospital birth. Despite studies that have now clearly shown that home birth in Ontario is just as safe, if not incrementally safer, at home with a registered midwife team, than it is in the hospital. And let’s be completely upfront here. Two out of my three birth experiences so far have been in the hospital, only one was at home. Despite my strongest desires to have another home birth with my 3rd baby, circumstances well out of my control dictated that the safest option for me and baby would be to give birth in the hospital scenario, and I was more than willing to accept that. I had an absolutely amazing birth there, with my amazing midwives there to monitor everything and allow me to deliver my baby exactly how I saw fit, even if we were surrounded by machines and meds and doctors and nurses and tools, and crappy lighting, and spotlights, and so much more. I had my husband, my doula, my best friend and another close friend and her daughter there in the room as we welcomed my third baby, and our first son, into this world. It was relaxed, perfect, complication free, hands down the easiest birth I’ve had to date. So I am absolutely the last person on earth who will try to convince anyone that having a home birth is always so much easier than a hospital birth. No, that’s not why I wanted to bring up the differences between care with midwives and care with ob/gyn’s. But there are a list of key differences that I felt it was really important that more parents-to-be out there knew about, and frankly these were differences that hundreds of other parents we asked also felt were really important to pass on to the next wave of parents about to give birth.
Although there were a LOT of differences, we narrowed our list down to just the top 5 differences between midwifery care and obstetric care. We love running our free monthly ‘Prenatal Healthcare Options’ workshop at Mums & Tums Canada because we get to fully expand on these 5 differences a lot more, and include everything else that we haven’t included here. If you want more information on how to sign up for a free workshop coming up next, visit our website at www.mumsandtumscanada.com/classes-workshops and also don’t forget to check out our calendar page to find out when the next scheduled one is.
Now on to the list!
Midwives do not provide the same amount of time to their clients as Obstetricians do.
One of the main points of feedback we got about this was the vast difference in the amount of time an expectant parent received from an OB versus a midwife. And this may surprise you to learn, if you didn’t know this to be the case.
The average amount of time that people reported waiting in their OB’s waiting room to even get in to see their doctor for their appointment was between 1 to 2 hours. In large part, this is due to the fact that 90% of the birthing population each year seek their prenatal care from an OB, and so each OB practice’s office is usually overwhelmed with other expectant parents in their care, and because they are specialists in high risk pregnancies and births, they usually do their best to save their time for their high risk clients who need more of their time than the average client does. This is also the main factor contributing to the fact that the average amount of time that people reported spending with their actual OB once they got into their offices for any given appointment, was between 10-15 minutes maximum, provided nothing was out of the ordinary or becoming high risk in some way, obviously needing further discussion. With so many in the waiting rooms, OB’s often need to keep appointments very short unless there is a specific reason to spend more time on something. Which means if you have anxieties about birth, or what might be coming up in future visits, ultrasounds, etc., unfortunately more often than not, those are not questions OB’s typically are able to have time to answer in any depth. There are the minority of OB’s who do take all the time they need to answer their client’s questions, however this is not the norm, unfortunately. Many of these same expectant parents report feeling like a ‘number’ or just another walking uterus with a baby in it.
Midwives, on the other hand, have a completely reversed system here in Ontario. The average time people reported waiting in the waiting rooms to see their midwives for their appointment was between 5-20 minutes. Again, part of this is because midwives across the country, see a total of 10-12% of the birthing population each year currently. So their offices are not typically filled to the brim with people. But the other factor to consider is that midwives have a much different model of care they follow with their clients, than OB’s typically do, and it’s one that centers around not just the physical experience of the birthing individual, but also the emotional experience of that person as well. Extra long wait times in care providers’ offices can add more stress and anxiety to a person, than shorter wait times do. The other part to this to know is that the average time that people reported spending in front of their midwife during any given appointment was between 45-60 minutes! This was a huge difference we found when we looked at the two approaches to prenatal care. The people who reported that they experienced one approach with one birth, and the other approach with another birth, all reported that with the midwifery model of care, they felt vastly more positive about their upcoming births, just from this factor alone. They were able to ask all of their questions, air all of their deep concerns, be fully and completely informed by their midwives of all their options and what each one entailed. In other words, they never felt like they were just another ‘number’ in the pile of expectant parents in the practice. They reported feeling special, validated and safe.
Obstetricians are trained surgeons. Midwives are not.
It’s true, that if there is a surgical procedure that needs to take place, such as a vacuum, forceps or caesarean delivery, that obstetricians are the sole healthcare provider that can offer this. Midwives, while trained in all the same obstetric emergency procedures as Ob’s are, are not trained as actual surgeons, and cannot perform a surgical birth if one is needed.
One thing to note about this, however, is that the assumption is that if you have midwifery care taking care of you for your pregnancy, and while you’re in labour, something happens which puts you and baby into a high risk situation, that you are essentially, S.O.L., and risk both you and baby dying from complications that could have been avoided if an OB had had you under their care. Here in Ontario, this could not be further from the truth.
Midwives here in Ontario have what are called ‘hospital privileges’ by their local hospital and OB teams. In fact, by law here, no midwife is able to establish a practice that accepts any clients at all, unless they first have been granted these privileges by their local hospital team. There is some controversy over whether this is fair to midwives who are wanting to improve access to their care in remote places that don’t offer midwifery care as yet, however there is a big perk to this being the case for those who are expecting babies who are especially concerned that they have access to an OB’s skills if needed. This stipulation ensures that the relationships between midwives and hospital staff/OB’s are such that they provide seamless and timely care to all midwifery clients who might need it during pregnancy and labour. In other words, making even MORE sure that lives are saved and optimal outcomes occur than already do.
What that means for anyone in midwifery care, to be more specific, is that if they are in labour in the hospital and their midwives are attending them, helping them to navigate and give birth safely, and something should happen that turns things into a high risk situation, that there would be absolutely no need for the client to worry about how fast the OB or other specialists would be able to respond, because the midwives would simply page them into the room, they would come in right away, and either assist in consulting with the midwife and client on what should happen, or if it’s an emergency situation, they would seamlessly take over the procedures, with the midwife moving into a supportive role to both the OB and the client. Whatever was needed to be done would be done immediately. Once everything was deemed to be safe for the birthing person, their care would then be turned back over to the midwives to continue on with their care, just as seamlessly as it was transferred to the OB before that. If baby needs more attention by specialists, or if baby needs to be moved into the NICU, then hospital staff would continue to care for the baby, with the birthing parent’s knowledge and full involvement as usual. However, if baby is also cleared of all complications at the same time as the birthing client is, then both the baby and the birthing client’s care is turned back over to the midwives to continue tests, checks and care with.
There is no need to worry, in other words, that just because an OB is the only one who can save your baby in an emergency, that you won’t have full, easy and anxiety-free access to their care if and when you need (or want) it.
Postpartum care is very different with each provider.
When you are with an OB, and you give birth, and all is considered normal and well with both you and baby, typically you are only kept in hospital for 24-48 hours and then both you and baby are discharged with instructions to come by 6 weeks later to see the OB so they can formally discharge you from their care. If there is no major issues happening in that 6 week period, there are no other appointments scheduled within that time to help support the postpartum client and their baby through the navigation of such things as discomfort after birth, breastfeeding issues, etc. Usually because of how busy OB practices are, they tell clients that if they run into any issues between then and their 6 week appointment, that they should instead go into their local doctor’s office, or they go into their local hospital’s ER to get more urgent attention and treatment.
If you are under care with a midwife, after birth, there is a very different form of postpartum care that is given. Your midwife would typically spend a few hours with you immediately post birth, to make sure everything is okay with you and baby before heading out. Once they do head out, within 24 hours, they come back to wherever you are. Which means, if all is well after birth and you’ve chosen to be discharged by them to your home, then they come to your home. If you decided to, or needed to stay in the hospital, they would come to the hospital again to continue their care with you. They would then come to see you in person again one or two days later, and once again, a couple of days after that. So within the first two weeks of your postpartum journey, you’ve had your midwife come to see you and baby 3 times, not requiring you to pack up baby and take them into an office anywhere to see them until baby is a bit older. After that, if you are having a tough time getting in to the office, they will continue to come see you at your home. If you are comfortable and able to go into their practice office to continue with scheduled visits, they then see you at their offices like they did for you prenatally. They continue this attentive and supportive care throughout the entire 6 week period. They help you arrange to get hearing tests done on baby, they make sure baby is constantly gaining weight each week properly and they offer support on all things postpartum, no matter what the concern is. If you need any extra resources, they do their best to refer you to other resources they know of, or specialists, should anything worrisome pop up.
This is another massive difference between the two approaches to care that most expectant parents might not realize, and is absolutely worth considering when thinking about who would be the best provider of care for your pregnancy and birth.
Obstetricians are experts in high-risk pregnancies and births. Midwives are experts in low-risk and normal pregnancies and births.
It’s estimated by the World Health Organization that 80-90% of people who give birth each year are considered by medical standards to be either low-risk or normal. Which means, according to their calculations, only 10-20% of birthing people would be considered to be truly medically high-risk during their pregnancies/deliveries. And even still, 50% of that high-risk group will still give birth normally, with no complications or risks that occur. Therefore, (follow me here) they have deemed that a national caesarean section rate of any higher than 10% per year, is not only problematic, but it gravely endangers the mortality of both birthing person and newborn baby. Canada currently reports a 30% national caesarean section rate, as of 2016. That’s 3 times higher than what the maximum national rate should be, according to the WHO.
One of the proposed reasons for this is that hospitals and medical staff have a number of birthing protocols and policies in place for those who give birth in their hospitals, that tend to lean more towards favoring the introductions of what’s called “interventions” in order to “augment” (translate: speed the heck up) labours and deliveries so that beds and facilities can be available for all birthing individuals who come in at any given time. Interventions can be as simple as continuous fetal monitoring, to insisting that a person dilate one centimeter per hour, and that if that’s not occurring, that induction medications must be given to speed things up. Other interventions are more obvious such as inducing a woman who isn’t in labour at all, to the administration of pain medications such as morphine or an epidural, or the need for an episiotomy (yes, all women round the world recoil in agony at the thought of this one), vacuum or forceps used, and of course a caesarean section.
There is research published that now points to interventions being introduced too early in either pregnancy or labour, as being linked to what’s called “a cascade of interventions” that ultimately result in the baby or birthing person going into medical distress, and obviously then needing an emergency c-section. Therefore, the theory goes that if those early interventions were introduced without a valid medical reason for it, that in fact we could be causing more unnecessary caesareans to be happening, than if those interventions that were not needed, were not introduced at all.
Midwives are the only healthcare provider in Ontario allowed to help you give birth IN hospital or OUT of hospital. And no, they are not only going to help you give birth if you want a medication/intervention-free birth.
What does this even mean? Remember when I started out by telling you that midwives will happily help you give birth in a barn or in a field, if you so choose to? Well, all sarcasm aside, there’s a very real point to be made when it comes to the privileges that midwives are licensed by the government and provincial regulatory body to practice with. One of those privileges is that they are the only healthcare provider currently in Ontario that is allowed to attend someone’s birth IN a hospital setting, or OUT of a hospital setting (i.e. a home birth, or a birth center birth).
A quick example of how they differ, from say, paramedics, in this regard is that if you were to be caught either at home, or on the road to the hospital, and baby was obviously coming much faster than anticipated, if you called 911 for a paramedic, they would obviously immediately respond to the call. If when they got there, it was either deemed too late or unsafe to move mom because baby was on its way out already, or baby had already been born by the time they got there, by Ontario law they would do initial assessments to make sure baby and mom were safe to move, and then they would be required to take both mom and baby into the hospital, regardless of whether mom and baby are both doing well and may not need or want to go into the hospital. The only loophole in this regard, would be if you outright refused medical care for both you and baby. This would, of course, come with quite a fight, due to the fact that paramedics would not be simply allowed to just let you stay at home, or escort you home safely to continue monitoring mom and baby there. This would also mean that if you refused medical care, you would be left to get home on your own or be at home alone, with no one being there for a while to make sure both mom and baby are continuing to do well. So should something change suddenly and one of you need further attention medically, no one will be there to catch these signs before it may be too late.
In contrast, however, if you were under midwifery care and you found yourself in the same circumstance as above, the midwife would first make sure that baby was safely delivered and both you and baby were safe and medically ok. Once that had been established, the midwife would then be able to give you the choice of whether or not to accompany you to the nearest hospital, or if you would prefer to go home, they would then accompany you home and continue their assessments and monitoring of you and baby for a few hours after birth to ensure that all is continuing to go well. And, once again, midwives will return to your home or hospital within 24 hours to do another round of assessments and support for you. To be clear, however, if you and/or baby were not doing well right after birth, midwives would be strongly encouraging or insisting that you transfer into the hospital immediately in order to get the medical care that may be necessary. So while they are able to give you this choice in most cases, there are times when that choice is not able to be offered by midwives, for obvious reasons.
One more point to consider on this topic, is the big misconception that midwives only care for those who want “all natural”, medication-free, intervention-free births. In other words, if you don’t want a home birth, or a birth with no medication involved whatsoever, then they are not willing to take you on as a client. This could not be further from the truth. Midwives encourage the safe use of medications and interventions as needed, and if a client feels it necessary to have pain relief during their labour and delivery, so long as the anesthesiologist deems it to be safe to do according to how far along she is progressed and other medical risk factors, pain relief is immediately ordered for that client, just as if they had an OB and nurses caring for them. If the client had planned a home birth, but decides halfway through it that they would prefer to transfer into the hospital to receive an epidural, then midwives would simply assist the family in easily travelling into the hospital, no paperwork needed since each client is already registered at that hospital, and they would immediately get settled in while the midwife helped prepare them for the anesthesiologist’s visit.
Midwives also receive extensive and thorough training on all obstetric emergency procedures, all except for surgical obstetric procedures, that is. However, it’s vital they are always up to date on these procedures because should they need to use them in order to help the client and their baby stay safe either while transferring into the hospital, or while the paramedics arrive to help transfer into the hospital, it’s pretty obvious why they would need to be very quick and easy on their feet in these types of circumstances.
So there it is. The top 5 things you probably didn’t know about midwives versus obstetricians here in Ontario. If you are part of the 80-90% of women experiencing a normal to low-risk pregnancy (and let’s face it, the chance is high that you are), then you should definitely consider contacting you local midwifery practice office for a no-obligation interview! Did somebody say personalized, safe and effective care that puts you back in the driver’s seat of your pregnancy and birth? Where do I sign up??? Oh wait….I’m not pregnant anymore. Okay….well….if I ever am again….
(A very big thank-you to all the amazing moms who contributed to the forming of this blog by giving us your invaluable feedback! And thank you for allowing us to share it with our community)