Ontario Midwife: Why No One Is Checking on Mom and the Postpartum Care Gap

Most birthing people have one six-week postpartum appointment focused on contraception and whether they want another baby. No one screens their mental health. No one asks how they're feeding. No one checks on them at all. In this episode, Ontario midwife Ola Levitin (15 years in practice) talks about the postpartum care gap that midwifery is designed to fill, the three care provider options most people don't know they have, and why the way we talk about birth shapes how we experience it. If you've had a baby and felt invisible after, or if you're pregnant and wondering who's actually going to look out for you, this is the episode for you.

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Transcript

Speaker 3 0:00

Another very paternalistic idea that if you don't give somebody access to a midwife, that means you're not giving them access to a home birth. Therefore, they will make the wrong choice.

Speaker 0:11

Today we're chatting with Ola Levitin, a registered midwife here in Ottawa with 15 years of experience. In this episode, we unpack common misconceptions about midwifery care, an often underutilized option for families.

Speaker 1 0:27

If you're curious about your care provider choices during pregnancy and birth, this conversation is for you.

Speaker 0:33

Thank you for agreeing to chat with us today, especially since you're taking time out of your holiday. We are so excited to have this conversation and really, really wanting to highlight that there is multiple care providers available for people who are starting to plan a family or have already become pregnant and are looking for their care provider. So I think there's um some myths and uh miscommunication and uh misunderstandings about who families can go to for their care during their pregnancy and postpartum period. And we thought, who better to speak to than a care provider who is one of those people for the community? So, Ola, maybe start off by letting listeners know how long have you um been a registered midwife and how did you come into this profession?

Speaker 3 1:34

Such a loaded question. Um, I've been practicing for 15 years. I had a whole different profession and life before. And um really after my own births and pregnancies, realized that choice in birth is really important. My life's log logo is peace on earth begins with birth. Um, and I truly believe that. Uh, when we uh have an opportunity to birth our babies in a safe uh place where we're where we're heard and understood and respected, um, that sets us up for a life that's empowered. And I think it's strength that we draw on later on as as um as we grow, like for the rest of our lives. So I think that is a really, really important part um life. And and that's you know, a lot of people will um I did an interview for midwifery um applicants at Ryerson a long time ago, and some people said, I want to be a midwife because I love babies. And I remember thinking, huh, I didn't even thought of it. Babies part of it. Your job really, like I really wanted to be uh a midwife for for women uh to provide that choice, you know, like uh what's a good birth? Um a good birth is one where someone feels heard, understood, in control of their decision making, right? And so then no matter what happens, whether you have a you know a vaginal birth by your fireplace uh at home uh or you have an emergency caesarean, um, once you process it, um, you will feel uh still empowered by it and still feel that you had control over that experience, um, which I think is really, really, uh, really important. Um, but now that I've been practicing for 15 years, I love the babies. They're like they're like the cherry on top. Once uh once everything else has been uh uh done kind of thing. So so that was my motivation for for being a midwife. I worked in Toronto for a couple of years uh and then um moved to Ottawa in uh in 2013 and have worked at a number of practices in uh in the Ottawa area, but always with um have privileges at the civic hospital. So that's where I attend uh the hospital-based births when people choose, and then the birth and wellness center, and of course at home.

Speaker 4:00

Which I I feel is pretty fantastic that within a care provider there is more choice. But if a family is not able to connect and get a midwife, the other two options are obstetrician and uh family doctors who deliver. Is that how you kind of language is powerful?

Speaker 3 4:25

Okay, uh, so I'm gonna get on my soapbox uh and uh say pizza gets delivered, not babies. Uh birth their babies, uh, and that comes from uh from a place of of active participation and power. And and some people will say, well, if you say a woman delivered her baby, that is also an active term. Um, but if you look historically of of what the word delivery meant, it comes um through a lot of paternalistic lenses where it came from. So I do think that um the language is really powerful. And um always fall into that term myself because it's still so widely used, but really try to consciously use the word uh birth, whether somebody birthed their baby or birthed their placenta or I catch their baby or at their birth uh versus use the the word delivery.

Speaker 5:18

Delivery. It's so funny. My very, very first birth as a brand new spank and doula, it was a home birth, and I arrived and the midwife was already there, and her license plate said I delivered. And I was like, huh, interesting. But I too agree with you that nobody delivers the baby but the birthing person.

Speaker 3 5:38

Yeah. And um, but uh, it's funny. I said to um a friend actually, I said, Oh, I'm a midwife, and uh I have caught about 537 babies and been to over a thousand births, and she said, Oh my god, did you drop the rest of them?

Speaker 1 5:59

You're like that. The term caught makes it sound like they're shooting out of it. And it's interesting too, but oh my god, did you drop the rest of them?

Speaker 3 6:12

Your hands were actively there.

Speaker 1 6:14

Is that what you're describing?

Speaker 3 6:15

Exactly. But you're absolutely right, Christine. Uh, and and every province has uh, you know, different regulations for who can attend birth. And in Ontario, particularly, you're right. We have three options. So a registered midwife, um, an obstetrician, um, or a family doctor who does OB. Right.

Speaker 6:37

So the born stats just came out and I had it written down. Do you remember? So they had the division of percentage of the amount of families that accessed obstetrical care, uh, family OBs, and midwives. Does anyone remember? Do you remember?

Speaker 3 6:54

I just have to percentage. I think it was about 19%. Um, yeah. Well, over the last 12 years, but in the last couple of years have got we've gone up to about 19% of uh, but I do remember it went from 12% to 19%.

Speaker 7:12

And then the family OBs, whatever their percentage was, it went down. And then obstetrical was in the 80s.

Speaker 1 7:21

And does that mean that's there's a weakness, right? So that means we're not meeting the demands. Exactly.

Speaker 3 7:26

And a lot of people don't even know that there is a thing called family OB. Um, and they do a wonderful job of of attending births. Um, I feel like their philosophy can't speak for them, but it it appears to me that their philosophy is a little bit between midwifery and um and obstetrics, um, where many of them will um have be smaller groups, they'll have more of the continuity of care piece, you know. Um so they'll actually still come for their births. Um, you know, they still have nursing involved, um, you know, monitoring the labors, but um, you have a bit of more of a continuity of care with the family dogs, and then they'll follow the um the mums and the babies for the six weeks uh postpartum, just just like midwives do.

Speaker 8:10

Just like midwives do, yeah. And with obstetrical care, it has the biggest percentage. And in can you speak to why the the biggest percentage is more for um families using OBs versus um the family OBs or midwives? Of course.

Speaker 3 8:31

So, you know, in in the past, um uh it was uh midwives that uh delivered or caught all all the babies, right? And um, and uh it was uh obviously um a female-led profession. And in the beginning of the 1900s, patriarchy came in um and pretty much took over uh birth, um, control over women's bodies, um, and midwifery was pushed to the wayside, it became illegal in many places, and so and still is today. It still is, right? Um, but uh, you know, if you look at countries like Holland, uh their system is that by default, when you are pregnant, you get a midwife. And then if your pregnancy becomes uh more complicated higher risk, you are uh, you know, to an obese. So so in a system where, and as you know, most births are uh normal or they start out as as normal pregnancies, you know, uh low risk is best followed by midwife-free, both for uh for the women, but also for um for a healthcare system, right? As far as costs. And so it in reality, um, we should have a lot more midwives than we have OBs. Yes. Right.

Speaker 1 9:45

But that's they're trained surgeons, right? Like that is ultimately what they are. Yeah. Yeah. Exactly.

Speaker 9:52

And thank goodness we have that for the times that that is needed. But not just Holland, I would also think other parts of the world have a bigger midwifery presence than obstacle, like the UK and other places in Europe. Is that 100%?

Speaker 3 10:10

Um, but if you look at and if you look at maternal and neonatal mortality and morbidity, the countries that do have a midwifery as a very integrated profession, uh, not just for births or pregnancy or postpartum, but for primary care, because there's a whole spectrum, right, of women's health throughout their whole uh life that can be really supported well by midwifery. Um and so in countries where that's really well integrated, we do have better, better outcomes.

Speaker 1 10:41

Yeah. Yeah. So what does midwifery care if someone's new to it? What does it look like from your perspective and the philosophy behind midwifery? I guess we're speaking obviously to Ontario at this point because it's different in other places and countries and provinces. Right.

Speaker 3 10:57

Um, and it's a really good question. Like, what's the difference, right? Like if I when I'm pregnant, what would my care look like differently if I had any one of those uh three care providers in Ontario? And so um midwives, uh family OB, and obstetricians will follow the same protocols we have in Ontario. We'll offer all the same blood work, all the same uh ultrasound, um, yep, all the same ultrasounds. Um that's an accepted um, you know, protocols in Ontario for following pregnancy, a minimum number of prenatal visits. So we will attend people's births wherever they choose, whether it's hospital, home, or um the birth center. We can chat about the birth center later, what it means. Um and then um the differences kind of end a little bit at this point, in the sense that yes, family OB will continue to take care of mom and baby for those six weeks. People will go to their um clinics uh for weight checks for for well mom or baby checks, or people will go see their own family doctor at that point or uh a pediatrician if that's what they choose to have uh for their baby. And with midwifery, uh we will follow that mom and baby diet for six weeks. Um the first week we will see people at home, uh usually on days two, four, and six, kind of every other day for the first week. Uh, and then in two weeks, four weeks, and six weeks, people will uh come to our clinic uh for those well women checks and baby checks, uh, support with breastfeeding or whatever kind of feeding uh somebody chooses to um, you know, to do. So lots of support. I always say those are kind of the bare bones visits. Um if if somebody has struggles breastfeeding, their baby's not gaining weight, um, we will come back every other day. Um and there there's a lot of value in in supporting people in their own home, right? Because I can see what their pillows look like, right? Uh I can see that they're hanging over the edge of the bed when, you know, and I'm like, no, no, like this is the pillow. This is, you know, this is where your partner needs to to help you. Um and there's help you, yeah.

Speaker 1 13:11

Yeah. I those for me, like I had midway free care, and those for me were life-saving. Also, just like not leaving the house, not like this. I think the stress of leaving the house also contributed to a contributes to a lot of anxiety, and maybe yeah, the feeding goes differently than it does, right, when you're out versus at home. And so yeah, you being able to see the real deal. And I think there's a so maybe a better mental health assessment, like how does the house generally look? Like mess is perfect. Fine, fine. We love seeing mess. We don't love seeing perfect 15 houses, right? But is it functioning well in there too, right? Like, is there enough kind of uh food and force that way? And there's a couple of other things.

Speaker 3 13:51

If if somebody has other children, um uh putting their baby in uh, you know, in the car and going to see a care provider, may feel, you know what, um, I've breastfed three other kids, they they've all done well. Um, so really, do I really need to go? I'll go maybe once. Um, but sometimes those are the babies that that actually aren't doing well, right? So sometimes you only get the care because the midwife shows up and follows closely. The other piece I feel really, really sad is that there is no check on the mom, right? So if you have an OB, um, you have that six-week appointment. But in those six weeks, um, I remember a family friend called me on on day three. They didn't have midwifery um and said, Hey, we're really worried about our baby. And can you come in? Can you weigh them? And and I came in and did all this stuff. And then I asked her, I said, and how are you doing? And she started to cry. No one had asked her, you know. So she's she'd been to see the pediatrician. Everyone's all about the baby, but no A B, right? No one had taken her blood pressure, no one had checked her fundus, no one had asked her, How are you feeling? Bleeping. Do you have an appetite?

Speaker 1 15:00

Yeah, or yeah, what are you crying a lot? Like those, yeah, those early indicators of there could be some anxiety or just what's normal versus kind of what's milk and tears come together, right?

Speaker 3 15:10

There's a huge progesterone crash, right? Unless somebody explains it to you, uh, we read so much about postpartum depression that when your milk comes in and you're bawling because your body's not feeling the same as it did, you're like, oh my gosh, is this postpartum depression? Where am I at with all this? So having that midwife come into your home and reassure you, like you said, and you know, tell you what's normal is just as valuable as catching something really abnormal. Right? Absolutely.

Speaker 15:39

Yeah for sure. And midwifery only became legal in Ontario in 1995.

Speaker 2 15:48

Wow.

Speaker 1 15:49

Oh my goodness. Yeah. Like 70, no, 95. It's not that it became legal.

Speaker 15:55

So it was it wasn't illegal. It was regulated. It was more regulated. Exactly.

Speaker 3 16:00

So so before 1995, we did have midwives um who were trained in other countries uh who were paid privately uh by people who wanted a home birth. Uh so mid, you know, there were no midwives in hospitals, there was no regulation about it, but it wasn't illegal. Um and then in 1995 it became a regulated profession. All the midwives that were already practicing in Ontario got grandfathered in by a credentialing program. And then we had the uh Midwifer Education Program that was established in in Ontario at three sites, right? We had Laurentian University, McMaster, uh, and um it was called Ryerson at the time in Toronto. Now it's called, you know, TMU. Um, unfortunately, Laurentian closed um a few years ago, which was devastating for um for rural populations, for indigenous populations, and for the francophone populations, especially. Um there is uh a big ask right now happening in hopes to open a francophone midrid for education in Ottawa. So fingers crossed. You see any petitions coming across your desk, please sign them.

Speaker 17:10

We have absolutely yeah, yeah, for sure.

Speaker 1 17:14

One of the things I valued too, like so the postpartum, like we can go back to postpartum, but the prenatal. So I had an OB for the first, I can't remember how many weeks. It was quite, quite far in. I would say 28, maybe, and that's usually I think when people risk out of midwifery care. So I was able to get one, but in the meantime, I'd been seeing an OB, and my appointments were literally go pee on the thing. I come in, they're like on the floor, and like they're late always. And it was just like this kind of everything's good. Yeah, everything's good. Okay, great by like the normal pregnancy is the normal pregnancy. And then when I switched to midwifery care, they made me sit there for like an hour. I was like, um, really? I can just sit here and talk about all of these things, all of them. Oh yeah, maybe did you would you mind walking us through kind of that that that model of care is so different?

Speaker 3 18:00

And and and it's not that OBs don't care more, it's just that their volume it's volume, right? So um, you know, if you look at the 4,600 births that happened at the Ottawa Hospital, you know, last year, um, and the number of births that were done by OBs versus the number of births that midwives, like I think we're did like 700 births in all the you know, the true practices. Um, so very few. And so every midwife in uh in Ontario takes, let's say, an average of 36 to 40 uh clients per year. Per year. Um, and so that is why we have such long waiting lists. Um, but also that's what allows us to provide uh we call it Cadillac care.

Speaker 1 18:48

Wet care? Sorry, the cat the Cadillac care? Cadillac care.

unknown 18:52

Yeah.

Speaker 3 18:52

So so so you're absolutely right. Your appointments are 30-minute long appointments. I I'm still late though on a lot of my appointments. Oh, yeah, that's okay. But uh 30-minute appointments for sure. That's why we can do home visits. Um, if you think about it, home visits, like some days I might only have, you know, four home visits, which is actually a lot. It doesn't sound like very much. But when they are anywhere from Stittsville to Russell, and each appointment takes a good 45 minutes or sometimes an hour and a half if somebody's really struggling with breastfeeding. Um, that is a full day. I'll be lucky if I'm home home for dinner, right? Right. And in that day, I might get called to um to do a labor assessment, right? Like when we're doing that, we we are on call. Um obs um have a lot more clients that they're taking care of, so they have a a much faster turn in their day. Part of the midwifery uh program actually is to do a month of following an obstetrician. And so I remember when I did my placement with an amazing doctor in in Toronto, um, he just let me do my thing. And he would see three people and I would see one. I just like I couldn't not say all the things. Like, how could I not say all the things?

Speaker 20:09

That's it. Well, and I also had midwives for my care providers with my children, and I brought up the regulation in the year because I gave birth for the first time in 2000. And when I was telling people that I was gonna have a midwife in my care, they were like, Are you are you gonna have the baby in like the jungle? Or like, are you having a home birth? What what shouldn't you have a doctor? I'm like, no. No, but anyway, so going to the appointments, of course, my partner, my husband would come with me. And at one of the appointments, uh, my midwife had me lay on the exam table and palpate my belly. And she's like, Oh yeah, there's there's your baby's head, and did the like thing. And she looked at at my husband and said, Wanna feel your baby's head? And he was like, What? So she put his hands and then rocked his hand back and forth, and she said, That's your baby's head. And we left the office, and he looked at me and he said, Why would anybody want anything other than the care of a person like that? Like for her to involve him and like just he felt so included, he felt so part of the experience, and it made all the difference to him.

Speaker 1 21:33

Yeah, you know, yeah, and having the partner at those like prenatal visits too was so invaluable as well.

Speaker 3 21:39

And not just the partner, I think my favorite part is when I have repeat clients that come back and now they're having their second or their third baby, and those and that first child who I was at their birth, I now get to teach them how to feel where the head is on their and I can teach them to push the buttons. Include them. Um and Uh, you know, have that picture of them listening to the heart rate of their sibling. It's really special. It is truly a family-centered experience from you're right, from the pregnancy to birth, where we're actually offering um the partners to have their hands on the baby if that's what they uh want to do, or or have children present uh at the birth if if that's appropriate for this family um to involve in postpartum. I have lovely pictures of siblings with my stethoscope and listening.

Speaker 22:32

Listening. That's a baby. There's so many pieces that midwifery care is different. And I feel like we really also want to touch on a little bit of the misconceptions and differences between midwives and doulas, as Erin and I came from our careers as birth and postpartum doulas. We really want to address that. There's still so many misconceptions that, you know, I say, well, I uh I'm gonna have uh a doula at my birth, I don't need a midwife, or equating them to be the same thing, which they clearly are not. So could you walk our listeners through what your education and what it takes for you to become a registered midwife? My earbuds keep falling out because my ears are very small. If I smile too much, my ears push them out. And then Erin and I will, of course, then let people know what education and training looks like for doulas. And so let's let's teach people the differences between the two.

Speaker 3 23:37

I I love that you asked that question because there are, even though midwifery has been regulated since 95, there are so many misconceptions, not just in the public, but actually in the healthcare system itself. Um, I have had people um who have come from um, you know, having just their regular family dog that did their first initial pregnancy tests and now they're trying to decide which care provider to have. And the conversation goes something like, Well, uh, if you want a hospital birth with an epidural, you need to have an obstetrician. And if you want to have a home birth, then you can have a midwife. And it's like, no, no, no, no, no. Um, but that's coming from a health care provider. Um, and then the same, um, like you said, I've hear that a lot. Well, I have a midwife, why do I need a or why would I consider having a doula? Or the opposite. Um, I'm just gonna have a doula, why do I need a midwife? So lots of misconceptions, and I love that you asked. So for midwifery, um, it is a so we have a bachelor of health sciences uh degree. Um, if you're doing it full time, it's a year and a half of of coursework and two and a half years of clinical placements. Uh, part of those placements, like I said, you're uh doing a month with um an LD nurse, uh, a month with an obstetrician, um, people do a month in various other interprofessional settings, like I did mine with NICU and then uh a lactation consultant. Um, some people will do that interprofessional placement overseas to learn what uh mid looks like elsewhere to add to the richness of their experience. And then the rest of the time, um so it's an apprenticeship program in the two and a half years where you're hands-on, you are in a midwifery clinic, you're following midwives, uh, you're making those relationships with uh pregnant people going to their births and postpartum, really learning hands-on in the community what it means to be a midwife. So then we graduate uh and we receive the it's an official name, midwife. Uh, so nobody else can use the term midwife because it is actually a legal profession. Uh so there are certain restricted acts in our healthcare system uh that nobody can just do. So, for example, uh putting in an IV, so puncturing somebody's skin, your fingers and somebody's vagina, those are protected acts and can only be done by registered professions. So I keep my registration active uh every year. Uh when I retire, I am no longer allowed to call myself a midwife. I might still be. Um, so it it's a it's it is a profession, uh, just like uh uh a doctor is, uh just like a physiotherapist, like a uh chiropractor, you know, name it. Uh we have a college, uh College of Ontario of Midwives, who regulates what our scope is, what we're allowed to do, what we're not. Uh the college protects the public, making sure that all the midwives are educated appropriately, registered, um, continuing education. Education. Absolutely. So every year when we register, we have to show proof that we are up to date on emergency skills, on neonatal resuscitation. Um, and only then are we then granted our registration. And so that's how the public is protected. So if anyone has any complaints, so just like the uh the College of Physicians um of Ontario, we have a college of midwives in the same way. Um so uh, and then do las for me are very, very valuable as a profession as well. Um, so not a regulated profession, as as you'll see, but provides incredible um physical and emotional uh support to for me, the whole family in that birthing experience, right? So you have your midwife who's providing clinical care, right? Um monitoring blood pressure, making sure the baby is head down, right? In the labor, listening to baby's heartbeat, uh putting in an IV, setting up an epidural, right? Like depending what this vaginal exams. And then the doula is there uh for the birthing person, hands-on, hundred percent, you know, focused on that person, advocacy, uh, like I said, physical emotional support, which is really important. I have um people say to me, um, so I always bring up doulas in prenatal appointments. Um, and so I have people say to me, well, we decided we don't need a doula because we have you, we have a midwife. And I really have to explain that the clinical care that I provide, the documentation that I provide, the discussions or the communication with hospital staff, like that all takes me away from being with you every single contraction. And as you know, right, labor can be really intense and you need someone there every single contraction. And so I think doulas are invaluable in in helping people have an amazing experience. Um, so I encourage doulas for for all my clients if they have the resources to to have one. Where there are volunteer doors organizations in Ottawa as well that support different populations that uh that are really valuable.

Speaker 1 28:53

Yeah, so you're not providing that kind of hip squeeze, you might hear there, but you you've got paperwork, right? You're mentioning all the other there's you're so busy, and we want your obviously you need to be there for that clinical aspect. So as doula as you know, being there for the that continuity piece and the physical, like you mentioned and the emotional piece, so that you can also do your job properly, right? And being able to focus on the things you need to. So yeah, I love working with midwives as a doula. I know Christine did as well. Like that, there was a lot of partnership and yeah, um, the same connection of care, right?

Speaker 29:26

Well, I also remember being at a birth at the birth center, and Ola, I think you came in as the second, or you were just like even a temporary, and my client was in the in the tub, and I was leaning over the tub and and squeezing her hips. And then as I was doing that, you were rubbing my back. And I was like, This is so nice. It's a new profession, the doula for the doula. Okay. Yeah, but I have a question, and I know what the answer is, but I would just like to bring to light. I'm pretty sure that when obstetricians go through their education, do they have to do that kind of rotation like you do? Do they spend a month with midwives?

Speaker 3 30:09

Not not in Ontario. Um, I think in other countries they do, and I've I've read some books where um um, you know, people have done that, but but not not in Ontario.

Speaker 30:21

Yeah, that's unfortunate. I remember I I think for nurses as well, labor and delivery nurses, if they haven't had the chance to attend, because if you have a midwife, you don't get a nurse at the hospital. You're you don't get a combined care. So they don't always get exposure to how um the philosophy of midwifery care can be. My client was having a pretty precipitous last stage of her labor, which moved into second stage very quickly. And we um, the midwife called in a nurse off the floor, and uh the baby was born before the second midwife could get there, essentially. And once the birth had happened, I had stepped back and the nurse was there, and she came back and she stood against the wall, and she went, I had no idea a birth could be like that. Because the birthing person was kind of in this half squat, and the midwife was behind her and caught the baby, quite literally, and then passed the baby through her legs, and then mom claimed her baby, and then we all just kind of stopped and took a breath. And the she was so bewildered and so rocked, but in such a positive way, that I feel like that peace on earth starts with birth really should encompass this greater knowledge of the different levels of care. I think I'm speaking to the choir here, I know about it.

Speaker 3 31:59

You know, it's what you see, it's what you're you're trained. So, yeah, absolutely. I mean, I will catch a baby in in any position, really, because it's it's you learn from um from being a student uh this ability to pivot, right? And meet the birthing person where they're at, um, and have a lot of confidence in your skills for protecting the perineum, to you know, try to avoid a tear, uh, being able to do maneuvers in case the baby is is stuck in any way, right? Um, so part of the reasons so many births are on their back with obstetrics in the hospital, because that is that is what you're taught, right? Um, and so if you're not taught how to even do a vaginal exam when someone's on their hands and knees, um, everything is a little bit upside down, right? So if you're only ever taught certain maneuvers, that's what your safety zone is, right? And you're feeling you're keeping the patients as as they call them, right? The birthday mums on their back. That's the safest thing you can do for them because that's how you know how to deliver their babies. Um, right. Versus when you've been taught to catch a baby in the bathtub or in the shower, um, you are able to pivot, right? You know that if the baby is stuck, you can move the mom. And so it's wonderful that that we can do that, that that we have that training.

Speaker 1 33:24

It is, it really is. Upside down checks.

Speaker 3 33:29

Exactly.

Speaker 33:30

Following. Well, and and maybe we can go back to now you said that your education was a year and a half that the learning in the classes, and then two. So that's four years of of university. And maybe Erin can speak to the difference between what our training was.

Speaker 1 33:51

Our training was a four-day in person. We did in person, I know there's a lot more virtual now, especially since COVID. So ours was four days, and then we had a certain amount of uh births we had to attend and readings and a few papers and shadowing that we had to do. And then pretty much, I mean, you know, after that, then it's up to the doula. They don't even have to get officially certified. Once they've done the training, they can call themselves a doula and start practicing. So a lot of people don't even get quote unquote certified, they just kind of do a bit of the homework and then off they go. So our training is um a lot shorter. And and I we always say like midwifery is like from the waist down, and doulas are waist up kind of thing, right? So we have nothing to do with any of that clinical pieces. We have an understanding of it, and we've studied um birth, but not the way you have, right? Really from that emotional information and physical components. So I don't know if I missed anything, Christine.

Speaker 34:49

No, it sounds perfect, yeah. Yeah, for sure. The difference is four days and four years. So how you could possibly put us put those two professions on the same plane is, and it is due to the lack of education sometimes, and it's the lack of the information sharing. There is a time where I bravely asked my family doctor um who uh was she's female, and I said, when someone comes to you and says, you know, and then you do the pre the test and you confirm pregnancy, what is what is your information that you she says, well, I I refer them to an obstetrician. And I said, Oh, well, you don't tell them about the other options in care provider. And her response was, we feed our own. Interesting. So I was surprised, and I I think it it it wasn't for her lack of knowing what the options were. So that was maybe her preference, maybe her bias, maybe her, but family doc OBs are her own. And yes, there's less of them, but it should still be offered as an option, you know. I just I was very surprised by her response. And that was like eight years ago, nine years ago. It wasn't like 20 years ago, right? And it just it still baffles me that there's still so much uh confusion around the options for families.

Speaker 3 36:20

You know what? I think there's a uh also a sense that um home birth or out of hospital birth is unsafe. And unfortunately, another very paternalistic idea that if you don't give somebody access to a midwife, that means you're not giving them access to a home birth, therefore they will make the wrong choice, right? Um, just like we know with if you don't have access to abortion, that doesn't mean women don't get abortion. It just means they get unsafe abortions, right? So and that is the the reason why midwifery became regulated in Ontario, right? Um, I always tell the story that in 1985, before we were regulated, there was a birth on um Toronto Island where a baby was born at home, uh, and unfortunately the baby um died. Uh, and there was an inquest uh as to what the heck was going on, who were these midwives that were attending this home birth, and our government had to make a decision. Do we make midwifery illegal uh and therefore stop women from even choosing an out-of-hospital birth? Uh or to be regulated and making it safe. And thankfully, just like with abortion, um, there was enough wisdom to say that no, the best thing to do is to make it safe, right? Because women will make the choices that they will make. And if you force something to go underground, you are not it will go underground. It will go underground, and then you will have untrained care providers. So it felt that women will choose to birth their babies wherever it is, whether it's under a tree at a birth center, at home, or at the hospital. And the best thing we can do is have care providers who are trained in all of those places so that it's a safe choice. And so I wonder with the response that you received, um, because there is still bias against women birthing not in hospital, uh, there's this very misguided sense of protecting their patient of not offering them uh, you know, the choice. An unsafe choice in their eyes. Exactly. In their eyes. Versus we know that um uh an out-of-hospital birth uh for uh women who have a healthy pregnancy, have a baby that's that's head down, who are being attended by a care provider trained in and out-of-hospital birth. I always say this in my info sessions. Uh, an obstetrician is amazing at surgery, but you do not want them to have at the at your home birth because they're not trained to do that. And so you want to have a midwife who is trained, who has equipment. Um, our tax dollars pay for every midwife when we graduate. We get $8,000 in equipment that we buy. We have a level one hospital in our car at all times. I often joke, there's no room in my car for my children because you know, we bring sterile instruments, um, you know, oxygen for mom, oxygen for baby, uh, everything. Uh, a level one hospital means everything that you need for a low risk birth. There's no obstetrician on site, so that if we have a complication, we are um moving to to hospital for for that extra help. And so you have to have all that. I would not want to be a midwife in the US, in the states where midwifery is not integrated. The equipment, um, I tried to buy resuscitation equipment in the US because I thought it would be cheaper when I first graduated. I was not allowed to purchase it. Yeah. I had to have a prescription from a doctor. And I said, but but I am the the doctor. Like I'm writing my own prescription. I'm I know I'm allowed to use a Doppler. I could not buy it over there, right? Um, so when you're doing a home birth at a home without the equipment you need, without, you know, life-saving drugs, um, without resuscitation for baby, that is not safe. I a hundred percent agree. That is not a safe place. Um, but in Ontario where you have two trained midwives at every birth, whether it's home birth center or hospital, um, an out of hospital birth is a very, very reasonable option for people.

Speaker 1 40:41

Yeah, and I think for a low risk, of course. The other misconception, right, is the epid like the hospital and the epidural option, right, with a midwife. And I think that's something hopefully people will learn today is that you have those options. Here in Ontario, at least. Again, not in an Oswald specifically, not everywhere, but yeah, that can stop people, I think, right? If they're like, but what if I want an epidural? Yes. Support as well. When do you when is it the moment though that you have to transfer care? So either in the pregnancy or during a birth, for example, when would that moment kind of come?

Speaker 3 41:16

So um usually only people without pre-existing significant conditions are accepted into mid-wiffery care, right? So you don't have diabetes, um, you don't have high blood pressure, um, you're expected to have a um a low risk pregnancy, a low risk birth. And as we know, in pregnancy, lots of things can come up. So what happens when that happens? As a midwife, I would um consult with an obstetrician. Usually there are obstetricians uh in my hospital who I know and love and trust. I will send them a referral, they will see my client in person. Um, and depending on what's going on, different things may happen. Um, it may be that they provide advice on how to monitor the pregnancy going forward. Uh, it might be that it is a transfer of care. For example, if somebody develops diabetes uh with insulin, you know, they require insulin to keep their blood sugars normal for the rest of their pregnancy, that is out of midwifery scope. Um, they will be transferred to an obstetrician. But as I say to everyone on their first visit, it's very difficult to get a midwife, it's very difficult to lose a midwife once you get one. Because once we have that spot and we have given you that spot, we do not kick people out of care if they are transferred to an OB. So if my client is transferred to an OB as the most responsible care provider because they need insulin, for example, for diabetes or high blood pressure medication, I still stay in their care. I am still part of their circle of care. They will still come to see me, not as often because that's just too many appointments. Um, but they will come to see me. We will still chat about what their labor might look like, what are their birth wishes. Um and uh I help them understand what that uh induction might look like, right? What their labor might look like with an obstetrician at the civic hospital. They might still page me in early labor and get advice. Um, so very much still remain in that person's care if they're transferred to obstetrics, uh, and then will attend their birth in what we call supportive care. Um usually will come at the time uh of pushing, at the time of the birth. And once the baby is born, we're there, try to be there for the birth as much as we can. Once the baby is born, usually babies are admitted in hospital under midwifery. So under me, mom might remain under the obstetrician, let's say if her blood pressure is still high. Um, but if there was some another reason, for example, if you have a very, very tiny baby on ultrasound and the birth is Happening under OB and the baby is born, and the baby, lo and behold, is seven and a half pounds. Uh, and all was well, and mom is well. Then the OB says, Congratulations, Ola, she's all yours, and and off they go. Uh, and both mom and baby are admitted under under midwifery uh in hospital. And then regardless of what happens with the birth, we will still follow people for that full six weeks postpartum. So they still have our 24 by seven availability to pager uh pre or postpartum, like I said, will still come to their birth. So still very much involved in their care.

Speaker 1 44:38

Yeah.

Speaker 44:38

Is that the case for every midwifery collective in Ottawa? Well, so if if their transfer of care happens, but they still are in your care, how do those other spots is it open up kind of spontaneously? Is it babies that deliver early or you know, that kind of thing? Like how do those magical spots open up sometimes?

Speaker 3 45:02

So sometimes people will move away. That's like the number one way that magical last-minute spots will uh will show up. Um, so one thing that midwifery can do, so the way midwives get paid, uh, we are paid by our healthcare system. A lot of times people say, Here are all these things that we do and go, and how much will this cost me? And they go, No, it's free. It's still part of our healthcare system, right? Um, but um, we do get paid from a different pocket of money from the Ministry of Health, not through OHIP, right? So physicians, right? Some midwifery is paid um by the same pocket of money that Page Community Health Centers. And so we are able to take care of uninsured people, right? So newcomers to uh to Ontario or to Ottawa who are waiting for their permanent residence statuses to be established, their residents of Ontario, uh, but they have not received their OHIP status yet, um, or their students who have uh lost their university insurance because pregnancy um isn't covered, uh, find themselves in this uninsured state and have to pay for care. There's a whole reason, uh there's a whole population of people that are uninsured. Uh, we're not talking about visitors that just come to Canada to uh give birth.

Speaker 46:26

Have therapy.

Speaker 3 46:27

Uh there's a lot of misconceptions about that. That's what that means to be uninsured. It actually is not. And so midwives are in a unique place where I get paid the exact same salary, uh, whether I take care of someone who doesn't have OHIP or whether someone that does. And as you can imagine, newcomers who don't understand our system, who um don't have the resources to pay tons of money for obcetrics, are really well served by midwifery, right? On a level, uh, on a clinical level. And so we try to leave some spots. I know in our clinic we do. Personally, I do. I try to leave some spots um in my practice for what we call late-intercare clients, right? I have had people walk off a plane at 35 weeks pregnant, um, and the immigration uh worker calls me and says, This Ukrainian woman just just came. Uh, can you please take her? And because I leave those last minute spots, I I'm able to support people. And so sometimes those late-interes don't come at the last minute, right? So then I reach out to the community and go, but I do have a spot, happy to take whoever wants it.

Speaker 2 47:37

Oh wow.

Speaker 47:38

Yeah. I had a client switch care at like 37 weeks once, just because the the midwifery model is was something she really wanted. And I think people do have misconceptions that it can still happen. Just because it if you tried to get a midwife early in your pregnancy and you were put on the wait list, don't give up hope. It could still happen.

Speaker 3 47:59

Yep, exactly. And if you are on the waiting list um and you're getting to that third trimester, it's still worth emailing the practice and saying, Hey, you know what? I know I'm just a couple of months from giving birth, but I would still like to switch to a midwife because when we do have those little spots that are have been kept and now we're trying to fill, we might reach out, but having somebody reach out and say, I'm still interested, is is really helpful.

Speaker 48:31

Well, maybe we wrap up with a hot button question. How would you like to see the future of midwifery? What would be the most important change for you in the next decade?

Speaker 3 48:47

Midwives everywhere. Um, I really think the way the system is, you know, too many details to go into uh in this forum. Um, but we really should have midwives at every point of um women's lives because we're really well positioned. As you know, we have a primary care crisis, we don't have enough family doctors. Um, it's not just about uh catching babies. Um, midwifery is really suited to be serving um our population and families in so many, many different ways. Um, and that and that is my hope that um that we can have postpartum clinics where a midwife runs those wall baby checks and those childhood vaccinations, right? And also checks on mom in those six weeks, right? For all those people that don't have a midwife in their pregnancy and birth should be able to at least for the postpartum. Postpartum um pop tests, right? Um, it doesn't even have to be in that in that six weeks, you know, um birth and six weeks piece uh of their lives, right? Like you can have midwives everywhere. We have excellent clinical skills that are completely being um underused uh in our healthcare. I agree. I agree.

Speaker 50:08

All right, well, we'll build we'll build the postpartum house for you to come and take care of all the postpartum. I love it.

Speaker 1 50:16

That's perfect.

Speaker 50:19

Thank you so much, Ola. I think we're we're gonna have like part C, part D. We're gonna have to chat with you again and explore some some other pieces.

Speaker 3 50:29

Yeah. So much I look forward to it.