• Longman Group UK Ltd 1992 ©
Midwifery
The rebirth of midwifery in Canada: an historical perspective M. Joyce Relyea
T h e history o f midwifery in Canada, beginning in the 17th century in New France, is characterised by periods o f suppression and rebirth. At present, the long standing dominance o f the medical establishment is giving way to the d e m a n d of women to assume greater control over the birthing process. Several provinces in Canada are in the process o f obtaining midwifery legislation designed to strengthen, support and legalise the practice of midwifery. Lack of supportive legislation has discouraged the practice of midwifery. T h o u g h midwifery care has not been readily accessible, w o m e n have persisted in their search for care by a midwife. In response, female friends with a variety of educational preparation have f o u n d ways to prepare themselves and respond to women's need for an expert in normal birth. From an historical analysis o f midwifery in Canada it would appear that a primary factor influencing midwifery's rebirth has been the power and determination o f women to demedicalise normal birth and r e t u r n it to the d o m a i n of women.
INTRODUCTION The purpose of this paper is to provide a historical account of midwifery in Canada from the 17th century to the present. A survey of the works of various authors has led to the identification of major trends in both the suppression and rebirth of midwifery education and practice over the last four centuries. Secondary sources have been used for the periods of the 17th to 19th centuries and original documents and personal interviews have been the principal source of information for the twentieth century. M. Joyce Relyea RN, MPH, CNM, Assistant Professor, Faculty of Nursing, University of Alberta, 400-11044 82nd Ave, Edmonton, Alberta, Canada T6G 2G3. Manuscript accepted 25 June 1992 (Requests for offprints to M JR)
Midwifery was practised amongst our indigenous peoples and European settlers long before Canada became a nation. This is not surprising as, 'The midwife's calling is so ancient that the medical and nursing professions, in even their earliest traditions, are parvenus beside it' (Breckinridge, 1927). Midwifery practice is recognised in the early Greek myth of Artemis who assists her mother in the birthing of Apollo, her twin brother. There are also several biblical references to midwives, such as the defiant Shiphrah and Puah who refused to kill the Israelite male babies they delivered (Exodus 1: 15-22). For many years Canada distinguished itself as the only industrialised nation which did not have legislation which supported midwifery practice (Burtch, 1987). In 1985 an examination of the legal status of midwifery in each of Canada's ten 159
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provinces revealed that midwifery practice was legal in only one province, Newfoundland, and alegal, that is, no existing regulations or licensing requirements in a second province, New Brunswick. In the remaining provinces and territories the legal status was debatable (Barrington, 1985). For example, in Alberta an unlicensed midwife may practise where there is no registered practitioner and nurses with or without midwifery preparation 'may assist' women in childbirth (Nursing Profession Act, 1985). Due to the lack of definitive legislation it is not surprising that the practice of midwifery has been severely constrained (Burtch, 1988). This lack o f clarity regarding midwifery's legal status in Canada is beginning to change. Midwifery legislation has become a reality in Ontario and is being proposed in Quebec, Alberta and British Columbia. It is therefore an appropriate time to examine the history of midwifery in Canada as an understanding of this history is germane to the development of a broad understanding of the present situation and has the potential to provide insights regarding the integration of midwifery into the Canadian health care system.
Not all women in New France who practised midwifery had formal preparation. It is recorded in 1703 that the women of a parish in the village of St. T h o m a s elected their midwife, who then pledged before the assembled women to do her duty (Laforce, 1985; Ward, 1984). This was not an isolated incident as records of the election of other midwives exist (Barrington, 1985). Ironically, the Church, the persecutor of midwives and women healers in Europe in the 15th and 16th centuries and now influential in the governing of the colony, was responsible for the activities of midwives. T h e midwife, irrespective of her training, practised u n d e r the code of ethics operative in France at the time. She had to be Roman Catholic and was responsible for baptising all babies born into her hands. She was also required to care for women at birth regardless of economic status, to do her duty virtuously, honestly and wisely, to remove her rings and wash her hands and to seek help of a surgeon should anything unnatural occur (Laforce, 1985). In an attempt to thwart abortions she was also required to report all such events (Burtch, 1987).
EFFECTS OF URBANISATION ON MIDWIFERY LEGISLATION MIDWIFERY IN NEW FRANCE In the 17th century Europeans in increasing numbers emigrated to New France. In the New World childbirth occurred in the h o m e with the support of a neighbour or midwife. T h e services of the midwife were well known to French settlers as midwifery in France was a regulated and respected craft. T h e new colony had a system of health care (Kerr & MacPhail, 1988) and midwives were considered an essential component. Requested by the surgeons of the colony, p r e p a r e d midwives from the H6tel Dieu in Paris came to work in New France. T h e y were salaried or financially subsidised by the King of France (Laforce, 1985; Ward, 1984). On December 20 1654, the cur~ of the Parish of Notre-Dame of Quebec mentions Marguerite Langloise as the first official midwife of Quebec (Laforce, 1985).
By 1788 Quebec was u n d e r British rule and midwives were required to have a certificate only if they practised in Montreal, Quebec City or suburbs. 'Thus, from the late eighteenth century onward, two forms of female midwifery coexisted in Quebec, one of licensed practitioners who often had formal training, the other of "wise women" whose tutor had been experience and whose licence to practise was their reputation' (Ward, 1984, p.8). T h e latter were women without formal midwifery training who practised midwifery wherever there was a need and did so on a part time basis (Mason, 1988). T h e y saw their work as a necessity, a caring for one another, a neighbourly deed which need not be reimbursed. This perception of their work supported their belief that childbirth belonged to the community and need not be a career (Task Force on the Implementation of Midwifery,
MtOW[VE~V 161 1987). It can be argued that this understanding of the work of assisting at childbirth contributed to the ease with which the neighbourly midwife was replaced by the growing n u m b e r of physicians. Physician monopoly of the practice of midwifery was supported by an 1865 statute of the Province of Canada (later n a m e d the provinces of Ontario and Quebec) which placed midwifery u n d e r the jurisdiction of licensed medical practitioners. However this statute did not appear to have any immediate effect on the practice of midwifery. T h e sparse numbers of physicians, particularly in rural areas, may well have rendered the 1865 statute non-enforceable. For whatever reasons, physicians continued to tolerate the practice of midwifery for several decades (Burtch, 1987). By the end of the 19th century the n u m b e r o f physicians had increased to the extent that it became difficult to earn a decent living and for this reason they began to view childbirth as an opportunity to a u g m e n t their personal incomes (Barrington, 1985). T h e y began to exercise both their power and influence to persuade women of the increased safety of birth with physician attendance, demeaning traditional childbirth as 'dirty and potentially dangerous' (Task Force on the Implementation of Midwifery, 1987). T h u s births became increasingly the realm of the ' m a n with the forceps' who would come to your home. Specific legislation for midwifery practice was introduced in Nova Scotia in 1872 and in Quebec in 1879 (Ward, 1984). Midwifery practice in these provinces remained legal until after the First World War (Task Force on the Implementation o f Midwifery, 1987). J o h n s (1925) reported that to be a qualified registered midwife in Quebec the individual was required to have a certificate stating that she had attended fifty lectures given by a professor in one of the Universities affiliated with a maternity hospital. T h e midwife must have had six months' service in residence in a maternity hospital, assisted at twenty-four cases, have p r o o f of good character and be able to read and write. In Nova Scotia the regulations were similar though registration was required only if the midwife was practising in the city of Halifax. It was clear that outside the city
'any competent female' could practise midwifery (Johns, 1925). T h u s women, licensed or not, were able to practise midwifery if there was no doctor available. This remains true to the present day; midwives practise by default should a doctor be unavailable. T h e y are rarely valued in their own right except by the women and families they serve.
PIONEERS MOVED WESTWARD In the 19th and early 20th century increasing numbers of settlers, primarily of British origin, moved westward. T h e y found themselves living in a sparsely-populated country, often many miles from both their closest neighbour and from a medical or health care facility. T h o u g h women sometimes found themselves alone in childbirth, generally they could rely on their husband, daughters, ~native midwives and neighbours for assistance at childbirth (Mason, 1988). ' T h e r e was a bond o f compassion a m o n g these pioneer settlers and they would willingly come to the aid o f a neighbour' (Stewart, 1979, p.17). Some neighbours may have had some midwifery preparation in their country of origin, others may have pursued self study, or learned about childbirth from their own personal birth experiences. Most women of this era had explicit midwifery manuals available as well as an allpurpose medical book, both considered essential references for a pioneer household. T h o u g h not widely publicised the Canadian G o v e r n m e n t provided a handbook on midwifery, containing specific instructions regarding how to assist at childbirth. It could be obtained on request by women who lived in remote areas and who had a letter of recommendation from a physician (Task Force on the Implementation of Midwifery, 1987). T h u s there is evidence of official recognition of the essential role women played in assiting each other at childbirth.
INITIAL ATTEMPTS TO ORGANISE MIDWIFERY EDUCATION T h e early recognition of the need for trained midwives in the sparsely populated areas of
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Canada resulted in several attempts to provide midwifery courses for women who were respected by their communities and assisting at births. One of the first educational endeavours was by the National Council of W o m e n of Canada in 1897. This group pressed for the formation of the Victorian O r d e r of H o m e Helpers. T h e H o m e Helpers were to be trained for a period of six months to a year in midwifery, first aid, sanitation and the running of a household, with emphasis on midwifery. T h e women of the National Council thought trained nurses were unsuitable assistants at childbirth because they were too bound by rules to be able to respond to the many needs of the pioneer household including, if need be, the cleaning of the barn. However, both nurses and doctors strongly opposed the organisation of this service and the National Council of W o m e n were forced to modify their proposal which led to the inception of the Victorian O r d e r of Nurses (VON) (Ward, 1984; Mason, 1988). From 1898 to 1920 the VON provided short midwifery courses for their staff in Training Homes for District Nurses. In spite of this preparation of their nursing staff, Cran (1910) observed that the VON and other health services in very rural areas of western Canada did not meet the needs of women for maternity care. She claimed that general nurses' training nearly always made a woman too superior for maternity work, ' . . . useless practically in the little prairie shacks where she would have to do all the domestic work as well as the nursing'. So concerned was this British trained maternity nurse that she lobbied government and the V O N for trained midwives, maternity specialists to be attached to the existing order of the VON. Regarding her meeting with the matron of the VON she writes, ' T h e pity of the whole position is this, that while the tully trained nurse is more than a trifle scornful of maternity work, she is violently antipathetic to the "half-baked" sister, the midwife who has taken only the short maternity training and is not qualified for all branches of nursing . . . T h e y oppose the idea of giving maternity nurses a definite status, and themselves leave the work undone'. It would appear that Charlotte Hanington,
superintendent of the V O N in 1920 may have recognised the shortcomings o f her staff. Echoing the vision of the National Council of W o m e n twenty-three years perviously, she suggested midwifery training be given to local women who were already assisting at births. Unfortunately, Mrs Hannington received no support and the VON was belittled in the eyes of the public by what appeared to many as the unprogessive ideas of their leader (Task Force on the Implementation of Midwifery, 1987). It was in Newfoundland that the need for midwifery preparation for women in isolated communities, who f r o m necessity assisted with childbirth, was recognised. Early in 1920 a nurse and social worker, Miss Haslem, hired by the Child Welfare Movement, organised a Midwives' Club for practising and aspiring midwives. T h e club sponsored three-month courses for lay midwives. These courses included both lectures and supervised practice and were taught by physicians, and nurses with midwifery preparation obtained abroad (Nevitt, 1978; P. H e r b e r t personal communication, J u n e 6, 1990). T h e women who completed the course were required to sit examinations set by the Midwives Board, an appointed body, in o r d e r to be certified under the Newfoundland Midwives Act of 1920 (Nevitt, 1978; P. H e r b e r t personal communication, J u n e 6, 1990). ' T h e r e was no opportunity in Newfoundland for trained nurses to become fully qualified midwives' (Nevitt, 1978, p.127) therefore the community's need for midwives was met by the e m p l o y m e n t of midwives from the UK or of women who had taken the Midwives' Club courses. T h e contribution of the graduates of the three m o n t h Midwives' Club course was described by a British trained midwife who arrived in the outport of Daniel's H a r b o u r in 1921. She found them 'to be very good to their patients. "They would stay in the home, cook and clean and wash. T h e y are the salt of the e a r t h " ' (Nevitt, 1978, p.133). However their practice was limited by their lack of skill and knowledge about asepsis and the importance of prenatal care. T h e r e f o r e in 1924 the Grace Maternity Hospital in St Johns, Newfoundland c o m m e n c e d an eighteen month prog r a m m e to train ten 'maternity nurses' per year.
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'This course was based on criteria established by the Central Midwives Board, London with the addition of special training in obstetric and children's diseases' (Nevitt, 1978). T o distinguish between those who graduated from the three-month Midwives' Club's course and those from the eighteen m o n t h maternity course it was decided to call the f o r m e r 'midwives' and those with more education 'maternity nurses'. This was one of the first indications that the designation 'nurse' would be used for those with formal preparation in maternity care and that these 'maternity nurses' would be recognised as having greater expertise with regard to normal childbearing than the person designated as 'midwife'. Those who completed the maternity nursing course, like those who graduated from the three-month course, were certified u n d e r the Newfoundland Midwives Act of 1920. I f the maternity nurses wished to become trained nurses they were required to complete two years of a new three-year general nursing p r o g r a m m e started at the Grace Hospital in 1925 (Nevitt, 1978).
THE MOVE TO HOSPITAL BIRTHS Following the closure of the last VON training centre in 1920, nurses without midwifery preparation were employed by the VON and the newly formed g o v e r n m e n t - f u n d e d public health nursing services to provide care to childbearing women in the community. Lacking specialised training in maternity care and with a strong need to gain recognition by the medical profession these nurses often pressed for medical management and hospital birth (Task Force on the Implementation o f Midwifery, 1987). For instance, Barrington (1985) notes that in the early 1920s public health nurses were known to provide free layettes as incentives to women to give birth in hospital. T h o u g h hospitals were convenient for the physician, they were not necessarily safer (Task Force on the Implementation of Midwifery, 1987). O p p e n h e i m e r (1983) reports on a major study by the Ontario D e p a r t m e n t of Health in 1933. ' T h e r e were 5.3 maternal deaths per 1000
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births in hospital as opposed to 2.3 maternal deaths per 1000 births in home births. It was found that deaths associated with sepsis and abortion had risen in the urban population, and that both were connected with hospitalisation'. T h e increased death rates in hospitals usually located in urban areas may have been related to the poverty and inferior health of the urban poor or the high caesarean section rates in hospitals, recorded at 18% (Oppenheimer, 1983). Nevertheless, it appears that women were being deceived into believing that hospital was best. By the 1940s the neighbourhood self help network, often r e f e r r e d to as the popular birth culture, was slowly disappearing. T h e Task Force on the Implementation of Midwifery (1987) suggested that industrialisation was a leading factor in the breakdown in the mutual aid birthing network. Also, changing views about female modesty seemed to he a factor ' T h e r e was a growing sense that decent people didn't have their babies in their small farm homes, where the children would know about it' (p.206). Middle class women in particular, intrigued with technology and innovation, and influenced by the public health crusade suggesting birth was dangerous without medical attendance, seemed to develop a lack o f confidence in their ability to give birth. T h e y gradually came to believe that women, the neighbourhood helpers, were dangerously unequipped to deal with childbirth.
RESOURCEFUL NURSES AND MATERNITY HOMES T h o u g h hospitals became popular as the place of birth in urban areas, in the rural parts of the country nurses who practised midwifery where physicians were scarce were innovative in the provision of maternity care. Small private maternity hospitals existed, and some were initiated by nurses. For instance in Lethbridge, Alberta, Mrs Grace Dainty, a nurse, owned and ran a maternity hospital f r o m the turn of the century to 1918 (Dainty Hospital, 1975). As late as 1940, Mrs Boyd, a nurse near Fawcett, Alberta, had a small birthing home. She and her husband built a
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'large lean-to on one side of their h o m e which has made into a four bed maternity ward with a small room at one end which served as the case r o o m ' (Lea, 1979). Mrs Boyd took maternity 'patients' for delivery and women often enjoyed ten days o f postpartum rest and care for the sum o f $10.00. T h e district nurse often went to Mrs Boyd's maternity home to deliver babies (Lea, 1979).
ALBERTA'S RESPONSE TO LACK OF MATERNITY CARE Maternity homes were few and far between. By the 1940s women had become d e p e n d e n t on physicians for maternity care. At the same time there were decreasing numbers of practising physicians due to many enlisting for military service in World War II. T h e Canadian government recognised that nurses did not have sufficient training in midwifery to provide safe care without the direction of a physician. T h e r e fore midwives trained in the UK were sought to provide maternity services in rural areas. However, as the need for midwives increased there was a decrease in their immigration due to the war. It was also impossible during the war for nurses to go to Britain for training (Madden, 1961). T h u s the Canadian g o v e r n m e n t was unable to meet the needs of the rural population for maternity services. This spurred interest in the preparation of midwives in Canada. It was fortuitous that Helen McArthur, a highly regarded nurse-educator, returned to Alberta after completing a Masters degree at the Columbia Teachers College, New York (Madden, 1961). Miss McArthur was instrumental in the development of a three-month course, later expanded to four months and later still to nine months, called 'Advanced Practical Obstetrics for District Nurses' at the University of Alberta. T h e course was designed to provide nurses with advanced preparation in care of the parturient woman in preparation for district nursing in isolated areas of Alberta (Madden, 1961). T h e p r o g r a m m e was not described as midwifery preparation because of the belief that the word midwife referred to an untrained woman (Eben,
1979). T h e course content was evaluated by Miss Mary Williams, past president of the Royal College of Midwives, Great Britain and j u d g e d to be 'equivalent of their First Certificate' (Madden, 1962) but could not be recognised at the second level due in part to a lack of opportunity for students to attend births outside a hospital (P.A. Field, personal communication, March 20 1991). T h e last student graduated f r o m this p r o g r a m m e in 1984. No f u r t h e r students were admitted because of a lack of applicants. Two factors seemed to be influential in the dearth of applicants; the opening of a direct entry midwifery p r o g r a m m e in the neighbouring province of British Columbia and the increasing n u m b e r of nurses pursuing a degree in nursing. It was believed that the latter provided greater career opportunities than the diploma route offered by the Advanced Practical Obstetrics programme. In the 1950s there was again an increased d e m a n d for midwives due to the federal government expansion o f health care services to Canada's Inuit and Native people. In response to this need Nova Scotia's Dalhousie University in 1967 and Newfoundland's Memorial University in 1978 instituted diploma courses in outpost nursing. T h e course at Memorial University provided considerably m o r e midwifery preparation than did the Dalhousie p r o g r a m m e (P. A. Field, personal communication, March 20, 1991). T h e Memorial outpost nursing prog r a m m e was evaluated by a m e m b e r of the Central Midwives Board for Scotland in much the same way as the University of Alberta programme. T h e appraiser r e c o m m e n d e d that the course be accepted as equivalent to Part One of the State Certified Midwife requirements. Due to a lack of p r e p a r e d teachers there have been no graduates of the midwifery course since 1985. (P. Herbert, personal communication, J u n e 6, 1990). In addition to the outpost nursing programme, Memorial University has provided the opportunity for registered nurses to specialise at the Baccalaureate level in public health and midwifery. This p r o g r a m m e is unavailable in 1991-'92 due to a lack of provincial funding (P. Herbert, personal communication, November 13, 1991).
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NURSE-MIDWIFERY ASSOCIATIONS By the 1970s there were two nurse-midwifery associations in Canada, the Western Nurse-Midwives Association, representing the four western provinces, and the Ontario Nurse-Midwives Association (Tobin, 1988). T h r o u g h these associations newsletters, midwifery update materials and continuing education were provided to the members. However, the membership rarely challenged the status quo and thus inadvertently, if not directly, supported the predominant illness model of maternity care. Members generally fulfilled nursing roles in hospitals and were denied the right to call themselves midwives. As a member o f the Western Nurse-Midwives Association this author was privy to the concerns of many members regarding their experience of loss o f confidence in their midwifery skills. They found that many decisions which were the prerogative o f the midwife in Great Britain were now the physician's responsibility. T h e nurse-midwives' apparent lack of opposition to the physician/illness dominated system o f care of the childbearing family may be understood by examining Roberts' (1983) analysis of oppressed group behaviour. She suggests that nurses work in a system which contributes to their lack of self esteem leading to the development o f a 'submissive-aggressive syndrome' (Roberts, 1983). Thus socialised in this system they seldom directly challenge the dominator group, the physicians. They internalise medical values, and begin to resemble the dominant culture in attitudes and beliefs. Thus one could speculate that nurse-midwives, entrenched in the hospital hierarchical system, found it impossible to hear the voices of women who by the early 1970s were, in increasing numbers, expressing dissatisfaction with the medical management of birth.
EMERGENCE OF NEW-AGE MIDWIVES Women, discontented with the medicalisation of the birth process and demanding control of their bodies, their births and choice of birth atten-
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dants (Rothman, 1984; Barrington, 1985) found it difficult to find a care provider who would encourage and support normal childbirth in a setting of the woman's choice. Institutionalised care did not provide the freedom nor the care many women were desiring. T h e r e f o r e they were compelled to seek care providers outside the established health care system (Barrington, 1985). Women, often friends and neighbours, began to assist one another at childbirth resulting in the rebirth o f the 'community midwife'. These women providing midwifery care in the community held courageously to the belief in a woman's ability to give birth. T h o u g h some o f these women were nurses, regardless of their educational background, few options were available for midwifery education. Some women sought opportunities to study in the USA or abroad, others took correspondence courses, or did self directed studies. Still others with no nursing background entered nursing programmes, with the belief that nursing education was a way to gain valuable knowledge regarding childbirth and the health care system. As more midwives began practising community apprenticeship models developed, providing another educational option for aspiring midwives. However, apprenticeship also had its limitations. T h e r e were no standards for apprenticeship courses, it took an inordinate amount of time to obtain the appropriate number of births to become proficient and it was difficult to know when one had completed training (James, 1990). Therefore, though midwives sought preparation for their practice in a number and variety of ways their education was often fragmented and incomplete. T h e lack of available education for midwives appeared to be related to the lack of political recognition and legislation for midwifery practice. Some midwives, both those with nursing training and empirically trained, believed that the enactment of legislation ensuring standards for midwifery practice and education would protect women from unskilled practitioners. Others resisted this idea, recognising the potential pitfalls o f legalisation (Gross, 1984; Devries, 1985; Mason, 1990). Based on the findings of his qualitative study of the effects of
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licensure on American midwives and their practices DeVries (1985) outlines some of these pitfalls. He found that state sanction to practise midwifery does not bring autonomy to midwives but rather formalises the dominance o f physicians over them. He cites Carson (1977) who suggests that this further results in a diminishing of accountability to the consumer in favour of accountability to the licensing body. Gross (1984) suggests that licensing systems do not necessarily protect the public but merely serve to increase the monopoly, career security and incomes of those who are licensed. In spite of the existence of opposing viewpoints regarding the value of legislation amongst practising community midwives, many, with the support of their clients, spearheaded the campaign for supportive legislation for midwifery practice. As previously noted, midwives employed as nurses in hospitals were not in the forefront of this campaign. In Alberta, it was the membership of the Alberta Council and Register o f Domiciliary Midwives Association which first applied to the Health Occupations Board, in 1982, for legal practice for midwives. They failed in their first attempt to secure legislation but in response to the Board's recommendations, the Association contacted the Western Nurse-Midwives Association in order to realise common goals. As in British Columbia and Ontario the nurse-midwives and the practising empirical midwives, after lengthy discussion and debate, agreed upon mutual goals and formed provincial midwifery associations. The membership included both hospital and community based midwives, with varied backgrounds in both education, training and experience. With consumer support these organisations have continued to dedicate themselves to lobby for legislation in support of autonomous midwifery.
DIRECT-ENTRY MIDWIFERY EDUCATION Political will lagged far behind both the needs and wishes of childbearing women and the commitment of midwives to meet their needs. Thus in 1984, when the first direct-entry mid-
wifery education programme, the British Columbia School of Midwifery was established, there was no legal practice for midwives in British Columbia. For this reason the school could not be recognised as a bonafide educational institution. Due to lack of legal recognition of midwives in British Columbia the school pursued and received accreditation from the United States by the Washington State Licensing Board for Higher Education. T h e school received no government funding and was supported by membership fees, tuition fees and donations. Clinical practice for students was obtained in various countries, such as Holland, Germany, and Jamaica, which recognised directentry midwifery. After graduating two classes, a total of twenty-two students from the three-year programme, the school ceased to admit students because of lack of economic and legal support (C. Herd, personal communication, October 10, 1990). In 1986 one of the most exciting and innovative midwifery education programmes was initiated in the very isolated community of Povungnituk, Quebec. Stonier (1990) reports that the programme developed in response to community recognition that the official policy to evacuate all pregnant women for childbirth had deterimental effects on women, families and the community. T h r e e Inuit midwife apprentices, nominated by their communities were selected by a committee for training. The midwives' education under the supervision of'Qualunaak', meaning white women midwives, has involved on-the-job training, with one and a half days per week devoted to theoretical learning, skill workshops and the development of public education programmes. T h e i r work, particularly in health education, has had an impact on the health of the women in the area (Stonier, 1990). It is expected that this three-year training programme will be followed by a one to two-year preceptorship.
RESPONSE OF NURSING AND THE ESTABLISHED HEALTH CARE SYSTEM By the mid 1980s nurses also began to see the
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need for a different kind of care for childbearing women. As happens when an idea whose time has come takes hold, new initiatives in midwifery preparation developed across the country. At the Grace Hospital in British Columbia, at both the Misericordia Hospital and Foothills Hospital in Alberta, and at the Chedoke-McMaster Health Sciences Centre in Ontario, part-time inservice midwifery education p r o g r a m m e s for selected nurses were initiated. These programmes propose to provide obstetric nurses employed within these hospitals with knowledge and training to work in extended roles, providing midwifery care to women and families throughout the antepartum and intrapartum period. Since 1987 the University o f Alberta Faculty of Nursing has offered a midwifery certificate prog r a m m e in conjunction with the Masters in Nursing degree. T h e goal o f the p r o g r a m m e is to prepare midwives who will offer leadership to the development of the profession. Up to September 1991 there have been six graduates.
STEPS TOWARDS ENACTMENT OF LEGISLATION When democratic process exists, consumer demand and lobbying can have significant effect on the provision of health care services in a government administered universal health care system. T h e fruits of such action are now evident in at least four of the provinces. In 1986 in response to consumer lobbying, the government of the province of Ontario established a Midwifery Task Force to examine midwifery practice and education. T h e Ontario Task Force, after surveying midwifery education in Denmark, the Netherlands, England, Scotland and Wales and the USA concluded that the public would be served best by an autonomous, independent midwifery profession, p r e p a r e d through a direct/multiple-route entry, Baccalaureate education p r o g r a m m e (Task Force on the Implementation of Midwifery, 1987). Following the acceptance by the government of Ontario of the Report of the Ontario Task Force on Midwifery a Curriculum Design Com-
mittee was appointed. Holliday Tyson, chairperson of this committee described their work at a conference in Calgary Alberta, Midwifery and the Community in September 1990. T h e purpose of the committee was to propose a curriculum in midwifery education which would enable graduates to meet standards of safe midwifery practice within the unique political, sociocultural and geographical e n v i r o n m e n t of Canada. Members of this committee were midwives, nurses, physicians, educators and consumers. Committee members agreed that their first task was to develop consensus regarding their beliefs about midwifery practice and the qualities they believed essential to a practising midwife. From the discussion o f their beliefs there developed the philosophical basis for the recommendations regarding the education o f midwives. T h e r e was a strong relationship between the philosophy espoused by m e m b e r s of the committee and their ensuing recommendations regarding midwifery education. For instance, the committee had a stated belief and trust in the normalcy o f birth and viewed the midwife as having unique and valued expertise related to this process. This resulted in the recommendation that the midwifery curriculum focus on normal childbearing and utilise a health model not a medical model. T h e belief that women have a right to make decisions regarding their bodies and can articulate their needs resulted in a recommendation that consumer input must be sought for the development of a curriculum which would prepare midwives to be responsive to consumer needs. T h e belief that quality care must value the relationship of a woman and her midwife resulted in the recommendation that the curriculum must provide students with the opportunity to provide continuity of care to women and their families. Building further on this strong philosophical base the Curriculum Design Committee advised that midwifery education consist of a four year Baccalaureate p r o g r a m m e taught by practising midwives; that fifty percent of the content be clinical; that the student's first exposure to childbirth be in the community where normal childbirth takes place. It also stressed the importance of accessibility of midwifery education to
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motivated, mature and experienced applicants regardless of their geographic location. This was to be assured through flexibile admission policies and through the utilisation of innovative, interactive, long distance learning methods.
PROFESSIONALISATION AND ELITISM Professionalisation has the potential for the development of an elitist occupational group (Gross, 1984; Benoit, ! 987). This author believes that elitism in midwifery may best be avoided by the development of a profession without walls, a profession which encourages and values the admittance of persons from a variety of backgrounds and educational preparation, whose primary motivation is to expand their ability to be 'with woman', continuing the ancient tradition of the calling and naming of midwife. Benoit (1987) concludes that the educational preparation of the midwife must recognise experience as a legitimate source o f knowledge, be committed to the education of women who are firmly based in their communities, and assure that the educational process does not alienate them from the clients they seek to serve. T h e new system must avoid preparing 'contemporary midwives' whom Benoit (1987) described as merely 'strangers to captive clients' (p. 85), midwives alienated from colleagues, clients and understandings of commitment. It appears that the struggle of the rebirth of the midwife in Canada and the development of midwifery legislation is a question of who controls birthing. This author believes that childbirth must and should belong to women. A truly feminist based autonomous midwifery profession will protect the rights of women giving birth. It will assure its members are proactive in providing information to women so that decisions regarding birth are the domain of the birthing mother. In this paper the history of midwifery in Canada, from the 17th century to the present, is traced. Midwives have existed t h r o u g h o u t Canada's history, as licensed practitioners, as unregulated empirically trained 'wise women' and as
nurses working within the recognised health care system. T h o u g h midwifery was valued when Canada was a country sparsely populated, with urbanisation and an increasing n u m b e r of physicians, midwives were displaced by doctors. Thus midwives have f o u n d it a struggle to maintain their skills, define their practice and develop standards with regards to midwifery education and practice. T h e r e is evidence that the determination of women to regain control of their bodies and their births has contributed to the recent enactment of legislation supportive of midwifery in the province of Ontario and to the progress which is being made towards enactment of midwifery legislation in several of Canada's other provinces.
STOP PRESS On July 8th, 1992 the Province of Alberta passed legislation designating midwifery as a profession.
References Barrington E 1985 Midwifery is Catching. N.C. Press Ltd, Toronto Benoit C M 1987 Midwives in Passage: A Case Study of Occupational Change, Unpublished PhD dissertation, University of Toronto Breckinridge M 1927 The Nurse-midwife: a Pioneer. In: LitoffJ. (ed) The American Midwife Debate. Greenwood Press, London Burtch B E 1987 Midwifery Practice and State Regulation a SociologicalPerspective (unpublished PhD dissertation). The University of British Columbia, Vancouver Burtch B E 1988 Promoting Midwifery, Frosecuting Midwives: the State and the Midwifery Movement in Canada. In: Singh B. S. & Dickinson H. D. (eds) Sociologyof Health Care in Canada. Harcourt Brace Jovanich, Toronto Cran M 1910 A Woman in Canada. In: Jackel S. (ed) (1982) A Flannel Shirt and Liberty: British Emigrant Gentlewomen in the Canadian West 1980-1914. University of British Columbia Press, Vancouver and London Dainty Hospital 1975,June 25. Lethbridge Herald. Gait Museum Hospital Archives. Lethbridge, Alberta. DeVries R G 1985 Regulating Birth Midwives, Medicine, & the Law. Temple University Press, Philadelphia Eben B 1979 Chapt. xviii Advanced Practical Obstetrics for District Nurses. In: Stewart I. (ed) These were our Yesterdays. D. W. Friesen & Sons Ltd., Altona, Manitoba
MIDWIFERY Gross S J 1984 O f Foxes and Hen Houses: Licensing and the Health Professions. Q u o r u m Books, London James S 1990 Education of Midwives: A Position Paper. Unpublished manuscript. University of Alberta, Edmonton, Alberta Johns E 1925 T h e Practice of Midwifery in Canada. T h e Canadian Nurse 21 (1): 10-32 Kerr J, MacPhail J (eds) 1988 Canadian Nursing Issues and Perspectives. McGraw - Hill Ryerson Limited, Toronto Lea E R 1979 Chapter xvi 1940. In: Stewart I. (ed) These were our Yesterdays. D. W. Friesen & Sons Ltd, Altona, Manitoba Laforce H 1985 Histoire de la Sage-femme dans la R~gion de Qu6bec. Collection No. 4. Institut Qu~b6cois de Recherche sur la Culture, Qu6bec Madden M M 1961 The Storks Fly On. T h e Canadian Nurse 57 (8): 762-763 Madden M M 1962 T h e Storks Fly Higher. T h e Canadian Nurse 58 (7) 626 Mason J 1988 Midwifery in Canada. In: Kitzinger S. (ed) T h e Midwife Challenge. Pandora Press, Unwin Hyman Limited, London Mason J 1990 T h e Trouble with Licensing Midwives. Canadian Research Institute for the Advancement of Women/Institut Canadien de Recherches sur les Femmes, Ottawa Ontario Nevitt J 1978 White Caps and Black Bands. Jesperson Printing Ltd, St. Johns, Newfoundland
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Nursing Profession Act, Province of Alberta. Statutes of Alberta 1983. Chapter N-14.5 with amendments in force as of J u n e 5, 1985. Consolidated Feb. 24 1987, Queen's printer, Alberta Oppenheimer J 1983 Childbirth in Ontario: The Transition from Home to Hospital in the Early Twentieth Century. Ontario History LXXV (1): 36-60 Roberts S J 1983 Oppressed Group Behaviour: Implications for Nursing. Advances in Nursing Science. 5 (4): 21-30 Rothman B K 1984 Giving Birth. Penguin Books, Markham, Ontario Stewart I (ed) 1979 These were our Yesterdays. D. W. Friesen & Sons Ltd, Altona, Manitoba Stonier J 1990 The Innulitsivik Maternity. In: O'NeilJ. D. & Gilbert P. (eds) Childbirth in the Canadian North: epidemiological, Clinical and Cultural Perspectives. Monograph series no. 2 Northern Health Research Unit, Winnipeg, Manitoba Task Force on the Implementation of Midwifery in Ontario 1987 Report of the Task Force on the Implementation of Midwifery in Ontario. Toronto, Ontario Tobin C M 1988 Midwifery in Canada: A Critical Review. Unpublished manuscript, University of Alberta, Edmonton, Alberta Ward P (ed) 1984 T h e Mysteries of Montreal: Memoirs of a Midwife by Charlotte Fuhrer. University of British Columbia Press, Vancouver
Midwifery
The rebirth of midwifery in Canada: an historical perspective M. Joyce Relyea
T h e history o f midwifery in Canada, beginning in the 17th century in New France, is characterised by periods o f suppression and rebirth. At present, the long standing dominance o f the medical establishment is giving way to the d e m a n d of women to assume greater control over the birthing process. Several provinces in Canada are in the process o f obtaining midwifery legislation designed to strengthen, support and legalise the practice of midwifery. Lack of supportive legislation has discouraged the practice of midwifery. T h o u g h midwifery care has not been readily accessible, w o m e n have persisted in their search for care by a midwife. In response, female friends with a variety of educational preparation have f o u n d ways to prepare themselves and respond to women's need for an expert in normal birth. From an historical analysis o f midwifery in Canada it would appear that a primary factor influencing midwifery's rebirth has been the power and determination o f women to demedicalise normal birth and r e t u r n it to the d o m a i n of women.
INTRODUCTION The purpose of this paper is to provide a historical account of midwifery in Canada from the 17th century to the present. A survey of the works of various authors has led to the identification of major trends in both the suppression and rebirth of midwifery education and practice over the last four centuries. Secondary sources have been used for the periods of the 17th to 19th centuries and original documents and personal interviews have been the principal source of information for the twentieth century. M. Joyce Relyea RN, MPH, CNM, Assistant Professor, Faculty of Nursing, University of Alberta, 400-11044 82nd Ave, Edmonton, Alberta, Canada T6G 2G3. Manuscript accepted 25 June 1992 (Requests for offprints to M JR)
Midwifery was practised amongst our indigenous peoples and European settlers long before Canada became a nation. This is not surprising as, 'The midwife's calling is so ancient that the medical and nursing professions, in even their earliest traditions, are parvenus beside it' (Breckinridge, 1927). Midwifery practice is recognised in the early Greek myth of Artemis who assists her mother in the birthing of Apollo, her twin brother. There are also several biblical references to midwives, such as the defiant Shiphrah and Puah who refused to kill the Israelite male babies they delivered (Exodus 1: 15-22). For many years Canada distinguished itself as the only industrialised nation which did not have legislation which supported midwifery practice (Burtch, 1987). In 1985 an examination of the legal status of midwifery in each of Canada's ten 159
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provinces revealed that midwifery practice was legal in only one province, Newfoundland, and alegal, that is, no existing regulations or licensing requirements in a second province, New Brunswick. In the remaining provinces and territories the legal status was debatable (Barrington, 1985). For example, in Alberta an unlicensed midwife may practise where there is no registered practitioner and nurses with or without midwifery preparation 'may assist' women in childbirth (Nursing Profession Act, 1985). Due to the lack of definitive legislation it is not surprising that the practice of midwifery has been severely constrained (Burtch, 1988). This lack o f clarity regarding midwifery's legal status in Canada is beginning to change. Midwifery legislation has become a reality in Ontario and is being proposed in Quebec, Alberta and British Columbia. It is therefore an appropriate time to examine the history of midwifery in Canada as an understanding of this history is germane to the development of a broad understanding of the present situation and has the potential to provide insights regarding the integration of midwifery into the Canadian health care system.
Not all women in New France who practised midwifery had formal preparation. It is recorded in 1703 that the women of a parish in the village of St. T h o m a s elected their midwife, who then pledged before the assembled women to do her duty (Laforce, 1985; Ward, 1984). This was not an isolated incident as records of the election of other midwives exist (Barrington, 1985). Ironically, the Church, the persecutor of midwives and women healers in Europe in the 15th and 16th centuries and now influential in the governing of the colony, was responsible for the activities of midwives. T h e midwife, irrespective of her training, practised u n d e r the code of ethics operative in France at the time. She had to be Roman Catholic and was responsible for baptising all babies born into her hands. She was also required to care for women at birth regardless of economic status, to do her duty virtuously, honestly and wisely, to remove her rings and wash her hands and to seek help of a surgeon should anything unnatural occur (Laforce, 1985). In an attempt to thwart abortions she was also required to report all such events (Burtch, 1987).
EFFECTS OF URBANISATION ON MIDWIFERY LEGISLATION MIDWIFERY IN NEW FRANCE In the 17th century Europeans in increasing numbers emigrated to New France. In the New World childbirth occurred in the h o m e with the support of a neighbour or midwife. T h e services of the midwife were well known to French settlers as midwifery in France was a regulated and respected craft. T h e new colony had a system of health care (Kerr & MacPhail, 1988) and midwives were considered an essential component. Requested by the surgeons of the colony, p r e p a r e d midwives from the H6tel Dieu in Paris came to work in New France. T h e y were salaried or financially subsidised by the King of France (Laforce, 1985; Ward, 1984). On December 20 1654, the cur~ of the Parish of Notre-Dame of Quebec mentions Marguerite Langloise as the first official midwife of Quebec (Laforce, 1985).
By 1788 Quebec was u n d e r British rule and midwives were required to have a certificate only if they practised in Montreal, Quebec City or suburbs. 'Thus, from the late eighteenth century onward, two forms of female midwifery coexisted in Quebec, one of licensed practitioners who often had formal training, the other of "wise women" whose tutor had been experience and whose licence to practise was their reputation' (Ward, 1984, p.8). T h e latter were women without formal midwifery training who practised midwifery wherever there was a need and did so on a part time basis (Mason, 1988). T h e y saw their work as a necessity, a caring for one another, a neighbourly deed which need not be reimbursed. This perception of their work supported their belief that childbirth belonged to the community and need not be a career (Task Force on the Implementation of Midwifery,
MtOW[VE~V 161 1987). It can be argued that this understanding of the work of assisting at childbirth contributed to the ease with which the neighbourly midwife was replaced by the growing n u m b e r of physicians. Physician monopoly of the practice of midwifery was supported by an 1865 statute of the Province of Canada (later n a m e d the provinces of Ontario and Quebec) which placed midwifery u n d e r the jurisdiction of licensed medical practitioners. However this statute did not appear to have any immediate effect on the practice of midwifery. T h e sparse numbers of physicians, particularly in rural areas, may well have rendered the 1865 statute non-enforceable. For whatever reasons, physicians continued to tolerate the practice of midwifery for several decades (Burtch, 1987). By the end of the 19th century the n u m b e r o f physicians had increased to the extent that it became difficult to earn a decent living and for this reason they began to view childbirth as an opportunity to a u g m e n t their personal incomes (Barrington, 1985). T h e y began to exercise both their power and influence to persuade women of the increased safety of birth with physician attendance, demeaning traditional childbirth as 'dirty and potentially dangerous' (Task Force on the Implementation of Midwifery, 1987). T h u s births became increasingly the realm of the ' m a n with the forceps' who would come to your home. Specific legislation for midwifery practice was introduced in Nova Scotia in 1872 and in Quebec in 1879 (Ward, 1984). Midwifery practice in these provinces remained legal until after the First World War (Task Force on the Implementation o f Midwifery, 1987). J o h n s (1925) reported that to be a qualified registered midwife in Quebec the individual was required to have a certificate stating that she had attended fifty lectures given by a professor in one of the Universities affiliated with a maternity hospital. T h e midwife must have had six months' service in residence in a maternity hospital, assisted at twenty-four cases, have p r o o f of good character and be able to read and write. In Nova Scotia the regulations were similar though registration was required only if the midwife was practising in the city of Halifax. It was clear that outside the city
'any competent female' could practise midwifery (Johns, 1925). T h u s women, licensed or not, were able to practise midwifery if there was no doctor available. This remains true to the present day; midwives practise by default should a doctor be unavailable. T h e y are rarely valued in their own right except by the women and families they serve.
PIONEERS MOVED WESTWARD In the 19th and early 20th century increasing numbers of settlers, primarily of British origin, moved westward. T h e y found themselves living in a sparsely-populated country, often many miles from both their closest neighbour and from a medical or health care facility. T h o u g h women sometimes found themselves alone in childbirth, generally they could rely on their husband, daughters, ~native midwives and neighbours for assistance at childbirth (Mason, 1988). ' T h e r e was a bond o f compassion a m o n g these pioneer settlers and they would willingly come to the aid o f a neighbour' (Stewart, 1979, p.17). Some neighbours may have had some midwifery preparation in their country of origin, others may have pursued self study, or learned about childbirth from their own personal birth experiences. Most women of this era had explicit midwifery manuals available as well as an allpurpose medical book, both considered essential references for a pioneer household. T h o u g h not widely publicised the Canadian G o v e r n m e n t provided a handbook on midwifery, containing specific instructions regarding how to assist at childbirth. It could be obtained on request by women who lived in remote areas and who had a letter of recommendation from a physician (Task Force on the Implementation of Midwifery, 1987). T h u s there is evidence of official recognition of the essential role women played in assiting each other at childbirth.
INITIAL ATTEMPTS TO ORGANISE MIDWIFERY EDUCATION T h e early recognition of the need for trained midwives in the sparsely populated areas of
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Canada resulted in several attempts to provide midwifery courses for women who were respected by their communities and assisting at births. One of the first educational endeavours was by the National Council of W o m e n of Canada in 1897. This group pressed for the formation of the Victorian O r d e r of H o m e Helpers. T h e H o m e Helpers were to be trained for a period of six months to a year in midwifery, first aid, sanitation and the running of a household, with emphasis on midwifery. T h e women of the National Council thought trained nurses were unsuitable assistants at childbirth because they were too bound by rules to be able to respond to the many needs of the pioneer household including, if need be, the cleaning of the barn. However, both nurses and doctors strongly opposed the organisation of this service and the National Council of W o m e n were forced to modify their proposal which led to the inception of the Victorian O r d e r of Nurses (VON) (Ward, 1984; Mason, 1988). From 1898 to 1920 the VON provided short midwifery courses for their staff in Training Homes for District Nurses. In spite of this preparation of their nursing staff, Cran (1910) observed that the VON and other health services in very rural areas of western Canada did not meet the needs of women for maternity care. She claimed that general nurses' training nearly always made a woman too superior for maternity work, ' . . . useless practically in the little prairie shacks where she would have to do all the domestic work as well as the nursing'. So concerned was this British trained maternity nurse that she lobbied government and the V O N for trained midwives, maternity specialists to be attached to the existing order of the VON. Regarding her meeting with the matron of the VON she writes, ' T h e pity of the whole position is this, that while the tully trained nurse is more than a trifle scornful of maternity work, she is violently antipathetic to the "half-baked" sister, the midwife who has taken only the short maternity training and is not qualified for all branches of nursing . . . T h e y oppose the idea of giving maternity nurses a definite status, and themselves leave the work undone'. It would appear that Charlotte Hanington,
superintendent of the V O N in 1920 may have recognised the shortcomings o f her staff. Echoing the vision of the National Council of W o m e n twenty-three years perviously, she suggested midwifery training be given to local women who were already assisting at births. Unfortunately, Mrs Hannington received no support and the VON was belittled in the eyes of the public by what appeared to many as the unprogessive ideas of their leader (Task Force on the Implementation of Midwifery, 1987). It was in Newfoundland that the need for midwifery preparation for women in isolated communities, who f r o m necessity assisted with childbirth, was recognised. Early in 1920 a nurse and social worker, Miss Haslem, hired by the Child Welfare Movement, organised a Midwives' Club for practising and aspiring midwives. T h e club sponsored three-month courses for lay midwives. These courses included both lectures and supervised practice and were taught by physicians, and nurses with midwifery preparation obtained abroad (Nevitt, 1978; P. H e r b e r t personal communication, J u n e 6, 1990). T h e women who completed the course were required to sit examinations set by the Midwives Board, an appointed body, in o r d e r to be certified under the Newfoundland Midwives Act of 1920 (Nevitt, 1978; P. H e r b e r t personal communication, J u n e 6, 1990). ' T h e r e was no opportunity in Newfoundland for trained nurses to become fully qualified midwives' (Nevitt, 1978, p.127) therefore the community's need for midwives was met by the e m p l o y m e n t of midwives from the UK or of women who had taken the Midwives' Club courses. T h e contribution of the graduates of the three m o n t h Midwives' Club course was described by a British trained midwife who arrived in the outport of Daniel's H a r b o u r in 1921. She found them 'to be very good to their patients. "They would stay in the home, cook and clean and wash. T h e y are the salt of the e a r t h " ' (Nevitt, 1978, p.133). However their practice was limited by their lack of skill and knowledge about asepsis and the importance of prenatal care. T h e r e f o r e in 1924 the Grace Maternity Hospital in St Johns, Newfoundland c o m m e n c e d an eighteen month prog r a m m e to train ten 'maternity nurses' per year.
MIDWIFERY
'This course was based on criteria established by the Central Midwives Board, London with the addition of special training in obstetric and children's diseases' (Nevitt, 1978). T o distinguish between those who graduated from the three-month Midwives' Club's course and those from the eighteen m o n t h maternity course it was decided to call the f o r m e r 'midwives' and those with more education 'maternity nurses'. This was one of the first indications that the designation 'nurse' would be used for those with formal preparation in maternity care and that these 'maternity nurses' would be recognised as having greater expertise with regard to normal childbearing than the person designated as 'midwife'. Those who completed the maternity nursing course, like those who graduated from the three-month course, were certified u n d e r the Newfoundland Midwives Act of 1920. I f the maternity nurses wished to become trained nurses they were required to complete two years of a new three-year general nursing p r o g r a m m e started at the Grace Hospital in 1925 (Nevitt, 1978).
THE MOVE TO HOSPITAL BIRTHS Following the closure of the last VON training centre in 1920, nurses without midwifery preparation were employed by the VON and the newly formed g o v e r n m e n t - f u n d e d public health nursing services to provide care to childbearing women in the community. Lacking specialised training in maternity care and with a strong need to gain recognition by the medical profession these nurses often pressed for medical management and hospital birth (Task Force on the Implementation o f Midwifery, 1987). For instance, Barrington (1985) notes that in the early 1920s public health nurses were known to provide free layettes as incentives to women to give birth in hospital. T h o u g h hospitals were convenient for the physician, they were not necessarily safer (Task Force on the Implementation of Midwifery, 1987). O p p e n h e i m e r (1983) reports on a major study by the Ontario D e p a r t m e n t of Health in 1933. ' T h e r e were 5.3 maternal deaths per 1000
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births in hospital as opposed to 2.3 maternal deaths per 1000 births in home births. It was found that deaths associated with sepsis and abortion had risen in the urban population, and that both were connected with hospitalisation'. T h e increased death rates in hospitals usually located in urban areas may have been related to the poverty and inferior health of the urban poor or the high caesarean section rates in hospitals, recorded at 18% (Oppenheimer, 1983). Nevertheless, it appears that women were being deceived into believing that hospital was best. By the 1940s the neighbourhood self help network, often r e f e r r e d to as the popular birth culture, was slowly disappearing. T h e Task Force on the Implementation of Midwifery (1987) suggested that industrialisation was a leading factor in the breakdown in the mutual aid birthing network. Also, changing views about female modesty seemed to he a factor ' T h e r e was a growing sense that decent people didn't have their babies in their small farm homes, where the children would know about it' (p.206). Middle class women in particular, intrigued with technology and innovation, and influenced by the public health crusade suggesting birth was dangerous without medical attendance, seemed to develop a lack o f confidence in their ability to give birth. T h e y gradually came to believe that women, the neighbourhood helpers, were dangerously unequipped to deal with childbirth.
RESOURCEFUL NURSES AND MATERNITY HOMES T h o u g h hospitals became popular as the place of birth in urban areas, in the rural parts of the country nurses who practised midwifery where physicians were scarce were innovative in the provision of maternity care. Small private maternity hospitals existed, and some were initiated by nurses. For instance in Lethbridge, Alberta, Mrs Grace Dainty, a nurse, owned and ran a maternity hospital f r o m the turn of the century to 1918 (Dainty Hospital, 1975). As late as 1940, Mrs Boyd, a nurse near Fawcett, Alberta, had a small birthing home. She and her husband built a
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'large lean-to on one side of their h o m e which has made into a four bed maternity ward with a small room at one end which served as the case r o o m ' (Lea, 1979). Mrs Boyd took maternity 'patients' for delivery and women often enjoyed ten days o f postpartum rest and care for the sum o f $10.00. T h e district nurse often went to Mrs Boyd's maternity home to deliver babies (Lea, 1979).
ALBERTA'S RESPONSE TO LACK OF MATERNITY CARE Maternity homes were few and far between. By the 1940s women had become d e p e n d e n t on physicians for maternity care. At the same time there were decreasing numbers of practising physicians due to many enlisting for military service in World War II. T h e Canadian government recognised that nurses did not have sufficient training in midwifery to provide safe care without the direction of a physician. T h e r e fore midwives trained in the UK were sought to provide maternity services in rural areas. However, as the need for midwives increased there was a decrease in their immigration due to the war. It was also impossible during the war for nurses to go to Britain for training (Madden, 1961). T h u s the Canadian g o v e r n m e n t was unable to meet the needs of the rural population for maternity services. This spurred interest in the preparation of midwives in Canada. It was fortuitous that Helen McArthur, a highly regarded nurse-educator, returned to Alberta after completing a Masters degree at the Columbia Teachers College, New York (Madden, 1961). Miss McArthur was instrumental in the development of a three-month course, later expanded to four months and later still to nine months, called 'Advanced Practical Obstetrics for District Nurses' at the University of Alberta. T h e course was designed to provide nurses with advanced preparation in care of the parturient woman in preparation for district nursing in isolated areas of Alberta (Madden, 1961). T h e p r o g r a m m e was not described as midwifery preparation because of the belief that the word midwife referred to an untrained woman (Eben,
1979). T h e course content was evaluated by Miss Mary Williams, past president of the Royal College of Midwives, Great Britain and j u d g e d to be 'equivalent of their First Certificate' (Madden, 1962) but could not be recognised at the second level due in part to a lack of opportunity for students to attend births outside a hospital (P.A. Field, personal communication, March 20 1991). T h e last student graduated f r o m this p r o g r a m m e in 1984. No f u r t h e r students were admitted because of a lack of applicants. Two factors seemed to be influential in the dearth of applicants; the opening of a direct entry midwifery p r o g r a m m e in the neighbouring province of British Columbia and the increasing n u m b e r of nurses pursuing a degree in nursing. It was believed that the latter provided greater career opportunities than the diploma route offered by the Advanced Practical Obstetrics programme. In the 1950s there was again an increased d e m a n d for midwives due to the federal government expansion o f health care services to Canada's Inuit and Native people. In response to this need Nova Scotia's Dalhousie University in 1967 and Newfoundland's Memorial University in 1978 instituted diploma courses in outpost nursing. T h e course at Memorial University provided considerably m o r e midwifery preparation than did the Dalhousie p r o g r a m m e (P. A. Field, personal communication, March 20, 1991). T h e Memorial outpost nursing prog r a m m e was evaluated by a m e m b e r of the Central Midwives Board for Scotland in much the same way as the University of Alberta programme. T h e appraiser r e c o m m e n d e d that the course be accepted as equivalent to Part One of the State Certified Midwife requirements. Due to a lack of p r e p a r e d teachers there have been no graduates of the midwifery course since 1985. (P. Herbert, personal communication, J u n e 6, 1990). In addition to the outpost nursing programme, Memorial University has provided the opportunity for registered nurses to specialise at the Baccalaureate level in public health and midwifery. This p r o g r a m m e is unavailable in 1991-'92 due to a lack of provincial funding (P. Herbert, personal communication, November 13, 1991).
MIDWIFERY
NURSE-MIDWIFERY ASSOCIATIONS By the 1970s there were two nurse-midwifery associations in Canada, the Western Nurse-Midwives Association, representing the four western provinces, and the Ontario Nurse-Midwives Association (Tobin, 1988). T h r o u g h these associations newsletters, midwifery update materials and continuing education were provided to the members. However, the membership rarely challenged the status quo and thus inadvertently, if not directly, supported the predominant illness model of maternity care. Members generally fulfilled nursing roles in hospitals and were denied the right to call themselves midwives. As a member o f the Western Nurse-Midwives Association this author was privy to the concerns of many members regarding their experience of loss o f confidence in their midwifery skills. They found that many decisions which were the prerogative o f the midwife in Great Britain were now the physician's responsibility. T h e nurse-midwives' apparent lack of opposition to the physician/illness dominated system o f care of the childbearing family may be understood by examining Roberts' (1983) analysis of oppressed group behaviour. She suggests that nurses work in a system which contributes to their lack of self esteem leading to the development o f a 'submissive-aggressive syndrome' (Roberts, 1983). Thus socialised in this system they seldom directly challenge the dominator group, the physicians. They internalise medical values, and begin to resemble the dominant culture in attitudes and beliefs. Thus one could speculate that nurse-midwives, entrenched in the hospital hierarchical system, found it impossible to hear the voices of women who by the early 1970s were, in increasing numbers, expressing dissatisfaction with the medical management of birth.
EMERGENCE OF NEW-AGE MIDWIVES Women, discontented with the medicalisation of the birth process and demanding control of their bodies, their births and choice of birth atten-
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dants (Rothman, 1984; Barrington, 1985) found it difficult to find a care provider who would encourage and support normal childbirth in a setting of the woman's choice. Institutionalised care did not provide the freedom nor the care many women were desiring. T h e r e f o r e they were compelled to seek care providers outside the established health care system (Barrington, 1985). Women, often friends and neighbours, began to assist one another at childbirth resulting in the rebirth o f the 'community midwife'. These women providing midwifery care in the community held courageously to the belief in a woman's ability to give birth. T h o u g h some o f these women were nurses, regardless of their educational background, few options were available for midwifery education. Some women sought opportunities to study in the USA or abroad, others took correspondence courses, or did self directed studies. Still others with no nursing background entered nursing programmes, with the belief that nursing education was a way to gain valuable knowledge regarding childbirth and the health care system. As more midwives began practising community apprenticeship models developed, providing another educational option for aspiring midwives. However, apprenticeship also had its limitations. T h e r e were no standards for apprenticeship courses, it took an inordinate amount of time to obtain the appropriate number of births to become proficient and it was difficult to know when one had completed training (James, 1990). Therefore, though midwives sought preparation for their practice in a number and variety of ways their education was often fragmented and incomplete. T h e lack of available education for midwives appeared to be related to the lack of political recognition and legislation for midwifery practice. Some midwives, both those with nursing training and empirically trained, believed that the enactment of legislation ensuring standards for midwifery practice and education would protect women from unskilled practitioners. Others resisted this idea, recognising the potential pitfalls o f legalisation (Gross, 1984; Devries, 1985; Mason, 1990). Based on the findings of his qualitative study of the effects of
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licensure on American midwives and their practices DeVries (1985) outlines some of these pitfalls. He found that state sanction to practise midwifery does not bring autonomy to midwives but rather formalises the dominance o f physicians over them. He cites Carson (1977) who suggests that this further results in a diminishing of accountability to the consumer in favour of accountability to the licensing body. Gross (1984) suggests that licensing systems do not necessarily protect the public but merely serve to increase the monopoly, career security and incomes of those who are licensed. In spite of the existence of opposing viewpoints regarding the value of legislation amongst practising community midwives, many, with the support of their clients, spearheaded the campaign for supportive legislation for midwifery practice. As previously noted, midwives employed as nurses in hospitals were not in the forefront of this campaign. In Alberta, it was the membership of the Alberta Council and Register o f Domiciliary Midwives Association which first applied to the Health Occupations Board, in 1982, for legal practice for midwives. They failed in their first attempt to secure legislation but in response to the Board's recommendations, the Association contacted the Western Nurse-Midwives Association in order to realise common goals. As in British Columbia and Ontario the nurse-midwives and the practising empirical midwives, after lengthy discussion and debate, agreed upon mutual goals and formed provincial midwifery associations. The membership included both hospital and community based midwives, with varied backgrounds in both education, training and experience. With consumer support these organisations have continued to dedicate themselves to lobby for legislation in support of autonomous midwifery.
DIRECT-ENTRY MIDWIFERY EDUCATION Political will lagged far behind both the needs and wishes of childbearing women and the commitment of midwives to meet their needs. Thus in 1984, when the first direct-entry mid-
wifery education programme, the British Columbia School of Midwifery was established, there was no legal practice for midwives in British Columbia. For this reason the school could not be recognised as a bonafide educational institution. Due to lack of legal recognition of midwives in British Columbia the school pursued and received accreditation from the United States by the Washington State Licensing Board for Higher Education. T h e school received no government funding and was supported by membership fees, tuition fees and donations. Clinical practice for students was obtained in various countries, such as Holland, Germany, and Jamaica, which recognised directentry midwifery. After graduating two classes, a total of twenty-two students from the three-year programme, the school ceased to admit students because of lack of economic and legal support (C. Herd, personal communication, October 10, 1990). In 1986 one of the most exciting and innovative midwifery education programmes was initiated in the very isolated community of Povungnituk, Quebec. Stonier (1990) reports that the programme developed in response to community recognition that the official policy to evacuate all pregnant women for childbirth had deterimental effects on women, families and the community. T h r e e Inuit midwife apprentices, nominated by their communities were selected by a committee for training. The midwives' education under the supervision of'Qualunaak', meaning white women midwives, has involved on-the-job training, with one and a half days per week devoted to theoretical learning, skill workshops and the development of public education programmes. T h e i r work, particularly in health education, has had an impact on the health of the women in the area (Stonier, 1990). It is expected that this three-year training programme will be followed by a one to two-year preceptorship.
RESPONSE OF NURSING AND THE ESTABLISHED HEALTH CARE SYSTEM By the mid 1980s nurses also began to see the
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need for a different kind of care for childbearing women. As happens when an idea whose time has come takes hold, new initiatives in midwifery preparation developed across the country. At the Grace Hospital in British Columbia, at both the Misericordia Hospital and Foothills Hospital in Alberta, and at the Chedoke-McMaster Health Sciences Centre in Ontario, part-time inservice midwifery education p r o g r a m m e s for selected nurses were initiated. These programmes propose to provide obstetric nurses employed within these hospitals with knowledge and training to work in extended roles, providing midwifery care to women and families throughout the antepartum and intrapartum period. Since 1987 the University o f Alberta Faculty of Nursing has offered a midwifery certificate prog r a m m e in conjunction with the Masters in Nursing degree. T h e goal o f the p r o g r a m m e is to prepare midwives who will offer leadership to the development of the profession. Up to September 1991 there have been six graduates.
STEPS TOWARDS ENACTMENT OF LEGISLATION When democratic process exists, consumer demand and lobbying can have significant effect on the provision of health care services in a government administered universal health care system. T h e fruits of such action are now evident in at least four of the provinces. In 1986 in response to consumer lobbying, the government of the province of Ontario established a Midwifery Task Force to examine midwifery practice and education. T h e Ontario Task Force, after surveying midwifery education in Denmark, the Netherlands, England, Scotland and Wales and the USA concluded that the public would be served best by an autonomous, independent midwifery profession, p r e p a r e d through a direct/multiple-route entry, Baccalaureate education p r o g r a m m e (Task Force on the Implementation of Midwifery, 1987). Following the acceptance by the government of Ontario of the Report of the Ontario Task Force on Midwifery a Curriculum Design Com-
mittee was appointed. Holliday Tyson, chairperson of this committee described their work at a conference in Calgary Alberta, Midwifery and the Community in September 1990. T h e purpose of the committee was to propose a curriculum in midwifery education which would enable graduates to meet standards of safe midwifery practice within the unique political, sociocultural and geographical e n v i r o n m e n t of Canada. Members of this committee were midwives, nurses, physicians, educators and consumers. Committee members agreed that their first task was to develop consensus regarding their beliefs about midwifery practice and the qualities they believed essential to a practising midwife. From the discussion o f their beliefs there developed the philosophical basis for the recommendations regarding the education o f midwives. T h e r e was a strong relationship between the philosophy espoused by m e m b e r s of the committee and their ensuing recommendations regarding midwifery education. For instance, the committee had a stated belief and trust in the normalcy o f birth and viewed the midwife as having unique and valued expertise related to this process. This resulted in the recommendation that the midwifery curriculum focus on normal childbearing and utilise a health model not a medical model. T h e belief that women have a right to make decisions regarding their bodies and can articulate their needs resulted in a recommendation that consumer input must be sought for the development of a curriculum which would prepare midwives to be responsive to consumer needs. T h e belief that quality care must value the relationship of a woman and her midwife resulted in the recommendation that the curriculum must provide students with the opportunity to provide continuity of care to women and their families. Building further on this strong philosophical base the Curriculum Design Committee advised that midwifery education consist of a four year Baccalaureate p r o g r a m m e taught by practising midwives; that fifty percent of the content be clinical; that the student's first exposure to childbirth be in the community where normal childbirth takes place. It also stressed the importance of accessibility of midwifery education to
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motivated, mature and experienced applicants regardless of their geographic location. This was to be assured through flexibile admission policies and through the utilisation of innovative, interactive, long distance learning methods.
PROFESSIONALISATION AND ELITISM Professionalisation has the potential for the development of an elitist occupational group (Gross, 1984; Benoit, ! 987). This author believes that elitism in midwifery may best be avoided by the development of a profession without walls, a profession which encourages and values the admittance of persons from a variety of backgrounds and educational preparation, whose primary motivation is to expand their ability to be 'with woman', continuing the ancient tradition of the calling and naming of midwife. Benoit (1987) concludes that the educational preparation of the midwife must recognise experience as a legitimate source o f knowledge, be committed to the education of women who are firmly based in their communities, and assure that the educational process does not alienate them from the clients they seek to serve. T h e new system must avoid preparing 'contemporary midwives' whom Benoit (1987) described as merely 'strangers to captive clients' (p. 85), midwives alienated from colleagues, clients and understandings of commitment. It appears that the struggle of the rebirth of the midwife in Canada and the development of midwifery legislation is a question of who controls birthing. This author believes that childbirth must and should belong to women. A truly feminist based autonomous midwifery profession will protect the rights of women giving birth. It will assure its members are proactive in providing information to women so that decisions regarding birth are the domain of the birthing mother. In this paper the history of midwifery in Canada, from the 17th century to the present, is traced. Midwives have existed t h r o u g h o u t Canada's history, as licensed practitioners, as unregulated empirically trained 'wise women' and as
nurses working within the recognised health care system. T h o u g h midwifery was valued when Canada was a country sparsely populated, with urbanisation and an increasing n u m b e r of physicians, midwives were displaced by doctors. Thus midwives have f o u n d it a struggle to maintain their skills, define their practice and develop standards with regards to midwifery education and practice. T h e r e is evidence that the determination of women to regain control of their bodies and their births has contributed to the recent enactment of legislation supportive of midwifery in the province of Ontario and to the progress which is being made towards enactment of midwifery legislation in several of Canada's other provinces.
STOP PRESS On July 8th, 1992 the Province of Alberta passed legislation designating midwifery as a profession.
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Nursing Profession Act, Province of Alberta. Statutes of Alberta 1983. Chapter N-14.5 with amendments in force as of J u n e 5, 1985. Consolidated Feb. 24 1987, Queen's printer, Alberta Oppenheimer J 1983 Childbirth in Ontario: The Transition from Home to Hospital in the Early Twentieth Century. Ontario History LXXV (1): 36-60 Roberts S J 1983 Oppressed Group Behaviour: Implications for Nursing. Advances in Nursing Science. 5 (4): 21-30 Rothman B K 1984 Giving Birth. Penguin Books, Markham, Ontario Stewart I (ed) 1979 These were our Yesterdays. D. W. Friesen & Sons Ltd, Altona, Manitoba Stonier J 1990 The Innulitsivik Maternity. In: O'NeilJ. D. & Gilbert P. (eds) Childbirth in the Canadian North: epidemiological, Clinical and Cultural Perspectives. Monograph series no. 2 Northern Health Research Unit, Winnipeg, Manitoba Task Force on the Implementation of Midwifery in Ontario 1987 Report of the Task Force on the Implementation of Midwifery in Ontario. Toronto, Ontario Tobin C M 1988 Midwifery in Canada: A Critical Review. Unpublished manuscript, University of Alberta, Edmonton, Alberta Ward P (ed) 1984 T h e Mysteries of Montreal: Memoirs of a Midwife by Charlotte Fuhrer. University of British Columbia Press, Vancouver
