On Monday morning, there is a rally planned to try and save the South Shore Community Midwives, one of Nova Scotia’s rural midwifery programs. The program has been suspended for three weeks and its long term survival is in question. The current crisis presents an opportunity to rethink the program's design, which has left many rural families in Nova Scotia without access at all.
In 2017, we began a study titled Pregnancy, birth, and parenting supports as sites of rural resilience. As well as focusing on maternity health care, the study worked from the premise that community and family resilience depends on high quality, culturally appropriate services that connect mothers to each other, to health services, and to other community supports. Our research design was to examine rural midwifery care needs since the program ‘roll out’ by comparing two rural areas — one with a provincially funded model midwifery site, Lunenburg, and the other, the Annapolis Valley, which — despite having a long history of lay midwifery pre-legislation — was not selected. While we set out to explore the opportunities and challenges to extend the midwifery care model to unserved areas, it quickly became clear that there was a crisis of sustainability within the existing model sites, which was overshadowing possible conversations on program enhancement to meet the needs of all rural women and families.
While the number of model midwifery sites in the province was, at just three, insufficient from the jump, the crux of the current crisis is a staffing strategy at the two rural sites best described as “built to fail.” Proposing to serve rural communities with teams of just two midwives created an unrealistic expectation for midwives, particularly around on-call requirements. Two-midwife teams leave no room for illness, vacation, or other absences. While at times health care policies can bring unintended consequences that are difficult to foresee, in this case, the potential for overwork, burnout and inability to meet client needs was inherent in the ‘roll out’ from the onset. Kelly Chisholm, president of the Association of Nova Scotia Midwives got to the heart of the problem when she said that "someone having the burden of being on call 24/7 is not sustainable over a long period of time. And teams of two are just not big enough." While this is presented as a temporary suspension while they hire a second midwife, simply getting back to two would represent a failure to address the problem.
Regulated midwifery in Nova Scotia arrived as a response to the long-held demands of birthing women and stakeholders in the province, who had called for a primary care option that met pregnant women’s health needs as well as desire to have choice in provider type and birth location. Yet the IWK program in Halifax is the only midwifery program not under immediate threat. The collapse of the rural model sites is evidence of the profound urban/rural divide that characterizes health care access in the province. Rural women in Nova Scotia have only had marginal access to midwifery from the beginning of the program. The recent state of affairs is close to total exclusion of the needs of rural women -- in violation of the Canadian Health Act’s principle of universality: that all insured residents are entitled to the same level of health care. Women we have interviewed in the Annapolis Valley spoke nostalgically of the days of lay midwifery. A decade into the regulation of professional midwifery, such nostalgia is a condemnation of a process that continues to offer too little, too late.
In the meantime, rural pregnant women are left bearing the burden created by the lack of health system investment. A clear first step for the Nova Scotia Health Authority is to provide more midwives at the rural sites, so that they are able to sustainably support each other and their pregnant clients. But, as the Annapolis Valley women we have heard from made clear, there must be real commitment to ‘build success’ for universal access to midwifery.
It is well past time for government investment in midwifery; simply deferring to the Nova Scotia Health Authority’s reported response that they are working on it, but constrained by fiscal responsibility is indeed shirking of its responsibilities. The roadmap set out in 2011 by an independent expert panel called for 20 midwives to be hired by 2017 (bringing the rural sites to 4 midwives). It is time to implement this recommendation in order to avoid losing the service entirely and all that has been invested in regulating publicly funded midwifery in Nova Scotia. That loss would indeed be fiscally irresponsible.
Dr. Sarah Rudrum, Sociology, Acadia University
Dr. Lesley Frank (@franklyless), Sociology, Acadia University, and Research Associate with CCPA-NS