Emily Jarrett fell unconscious on the operating table before her C-section. Her blood pressure had dropped significantly after being given spinal anaesthesia, and everything went black.
When she regained consciousness, her midwife’s face was the first that she saw.
“She was the one who held me and laid me down on the table […] I don’t know what that would have been like, without that kind of presence in the room,” she told The Pigeon. “It was enormous for me.”
Jarrett gave birth to her son, Thomas, on Nov. 28, 2019. She knows her pregnancy and labour would not have been the same without the help of her registered midwife.
When she found out she was pregnant, Jarrett researched a variety of primary care options before deciding to use a midwife. She said that her friends’ positive experiences with B.C. midwives, and the level of care that they provide after birth, made her confident she was making the right choice.
In Canada, health care is regulated provincially, meaning that primary care providers—physicians and other professionals who connect directly with patients—practice medicine through provincial mandates. For pregnant folks in B.C., provincial health insurance covers the use of either a family physician, obstetrician, or midwife for pregnancy care.
The province’s registered midwives—who attend four years of post-secondary instruction and pass a provincially-regulated exam—are health care providers who specialize in pregnancies. They work with healthy, low-risk patients from conception up until six weeks after birth.
Higher-risk patients, including those with pre-existing medical conditions, infections, or genetic disorders, may be encouraged to consult an obstetrician instead.
While midwifery is arguably one of the world’s oldest professions, its modern practice is not yet normalized in mainstream conversations surrounding birth. In B.C., the practice wasn’t officially regulated until 1998.
Midwifery patients in B.C. have the option of delivering at home or in the hospital under the care of their midwife.
While Jarrett anticipated giving birth in a hospital, her C-section was unplanned, necessitated by her baby’s breech position before birth. Instead of facing down towards the birthing canal, the baby’s head was up behind her ribs, and could make a vaginal delivery very difficult.
B.C. midwives do not perform C-sections and must send their patients to the hospital for surgical deliveries, but their involvement doesn’t stop at the operating room doors. Midwives are able to attend C-sections alongside their patients and provide emotional support.
Jarrett found her midwife’s presence in the operating room incredibly comforting. She said that, while her partner was not allowed to be in the room for the administering of anaesthesia or the suturing of incisions, her midwife was a constant presence.
“[After the surgery], my partner went to wait for me in the recovery room, and my midwife stayed with me,” Jarrett said. “She held the handles [of my hospital bed] as they wheeled me out of the surgical suite and into the recovery room. And then [she was there] to help my husband place our son back on me so that he could breastfeed.”
After her surgery, Jarrett’s midwife began post-natal visits with her at home and in the clinic, during a six-week period where midwives check in on the baby and parent, perform tests, and answer questions.
“I knew already that midwives come to you in that first week or two weeks postpartum,” Jarrett said. “Knowing what that postpartum period can be like for some people, that was really important to me. As someone who ended up having a C-section […] I can’t express how grateful I am that I made that decision.”
Jarrett added that her midwife even continued to provide support after the typical six weeks of post-natal care, booking additional appointments to help Jarrett with lactation problems. These visits continued despite the B.C. midwives’ pay schedule only compensating them for the initial six-week post-natal period.
“Because of ongoing issues with breastfeeding, [my midwife] kept me an extra four weeks before formally releasing me [from her care],” Jarrett said. “[This] did not increase her pay, [but] she kept me because I needed the support.”
Finding out that midwives have to take on the burden of paying for their own supplies was especially concerning to Jarrett, who works in health care.
Now, almost eight months after giving birth to her son, Jarrett continues to advocate for midwives.
“I’ve never met a midwife […] who went into the field because they wanted to be a small business owner,” she added. “Their skill set is clinical, and it is compassionate.”
“C-sections are terrifying. Recovery is terrible. I will tell you that now. But both myself and my partner were supported through it all by the compassion of a midwife.”
B.C. midwives attend the highest percentage of births compared to their counterparts in other provinces and territories. Their presence at hospital births is directly correlated to a reduced rates of obstetric interventions, and patients under the care of midwives have a 42 per cent lower C-section rate than those being cared for by physicians.
Despite this, midwives continue to be compensated less than other members of B.C.’s provincial health care system.
Most B.C. care providers, like physicians, are mainly compensated on a fee-per-service basis as patients require care, but midwives’ payment schedule divides care into five distinct phases—the first, second, and third trimesters, labour and delivery, and a six-week post-partum period.
This schedule was intentionally segmented to ensure that midwifery patients can access as much or as little care as they need throughout their pregnancies. However, 22 years after midwifery was first regulated in B.C., midwives’ compensation rates have not adapted to significantly reflect the growing cost and burden of midwifery as a profession.
Lehe Spiegelman, interim president of the Midwives Association of BC (MABC), believes that investing in the wellbeing of the province’s midwives will benefit both patients and the midwives who care for them.
“We don’t have a benefits plan, we don’t have parental leave, we don’t have any kind of contributory retirement saving plan,” Spiegelman said. “That has really damaged the sustainability of our profession over the years.”
The MABC hopes to see a concrete commitment to midwives’ wellbeing from the provincial government.
“The government is going to have to reckon with the fact that we’ve fallen so far behind our [physician] colleagues in terms of infrastructure, and we need to catch up,” Spiegelman said.
In Oct. 2019, the B.C. provincial government presented midwives with a new contract. This type of contract, called the Midwife Master Agreement, is an agreement between the provincial government and midwives. Renewed every five years, it outlines the compensation, programming, and research the government will provide to midwives within its time frame.
The new contract, which was similar to its 2014 predecessor, did not address new findings about the level of personal and professional stress B.C. midwives report experiencing in recent years.
Kathrin Stoll, a researcher with the University of British Columbia (UBC) Faculty of Medicine-based Birth Place Lab, conducted a study in 2019 that detailed the level of burnout among Western Canadian midwives.
Most notably, the study—which asked 158 practicing midwives to participate in a WHELM (work, health, and emotional lives of midwives) survey—found that 34.7 per cent of those surveyed had considered leaving the profession due to burnout.
This term is commonly used to refer to the physical and emotional distress “care” professionals, especially those in the health care field, experience after overexerting themselves in the workplace.
Spiegelman said the survey’s results were a wake-up call for B.C. midwives.
“[The survey] was a real reckoning [for us] to recognize that in the last five years, midwives have been working more and more and more, and that sustainability is at a critical juncture right now for midwives.”
After voting against the proposed contract, B.C. midwives returned to the bargaining table on June 22, 2020, demanding significant changes to their current compensation model. The call for a renewed commitment to midwives’ wellbeing was spurred on by these findings about how B.C. midwives are handling the profession’s pressures.
“The message that the government really needs to make more clear [in the new contract] is that they’re invested in our profession,” Spiegelman said. “By investing in midwifery, they’re really showing an investment in families.”
Burnout comes from the long hours that midwives work, especially during on-call shifts when a patient could go into labour, causing a midwife’s pager to buzz in the middle of the night.
Spiegelman believes that while this type of work is expected, there is little compensation for it.
“[The pressure has] accumulated over the years in terms of how midwives have continued to work more and more for less and less.”
Additionally, for midwives, not having access to benefits like paid parental leave or sick days means continually having to be overworked. Spiegelman, who is also a practicing midwife, recalls sacrificing her own post-natal care to go back to work sooner after her pregnancy. Asking patients to take time off that she couldn’t give herself felt insincere.
“I had three children without [paid] parental leave,” she said. “It was a struggle to see that dissonance between my own capacity to take time off work and [me encouraging] families in my care to have time to nourish that early postpartum period.”
“There’s that ring of irony that midwives don’t have access to parental leave.”
Lindsey Ririe, who gave birth to her daughter, Rowan, on October 21, 2019, felt incredibly supported by the staff at her local midwifery practice.
Reflecting on the care she’d received from both doctors and midwives during her pregnancy, Ririe explained that she felt a deeper connection with the midwives who assisted her.
“[At] an appointment with your doctor, you’re rushed through, you’re just a number. It’s not personal,” she said. “Then you go to a midwife appointment […] and it [lasts] four times as long. They’re asking you questions or asking if you have questions. It just [feels] so much more supportive.”
The current negotiations are happening between B.C. midwives and a provincial government run by the New Democratic Party (NDP). Ririe said she expected better from a party known for its progressive policies.
“There was an expectation going into negotiations that things would be better than [with] the Liberal government, because [the NDP] is a government that cares for people,” Ririe said. “There’s more that could be done.”
Ririe hopes the provincial government considers how burnout impacts care providers, who continue to work throughout the pandemic to ensure their patients are safe.
“[It’s so important] when we’re caring for other people to take care of yourself,” she said. “It’s inevitable that you’re going to burn out. You can’t pour from an empty cup.”
In B.C., midwifery instruction is provided at the University of British Columbia (UBC) through the Faculty of Medicine’s midwifery program. The program accepts around 20 applicants per year and is intended to fully prepare students for a career as a midwife.
Allison Campbell, who heads UBC’s undergraduate program, says resilience is a foundational topic of midwifery instruction.
“We start with resilience education and training [in first year],” she said. “[We get] people to be self-reflective and think about their emotional well-being from the very start.”
Campbell says that, while students are also prepared for the often burdensome nature of being a care provider, it’s difficult to know how each midwife will react to stress.
“Unfortunately, to some degree, there’s only so much that we can prepare people for,” she said. “[Burnout] really has so much to do with how each individual manages stress.”
For Campbell, who is a practicing midwife as well as an instructor, burnout often means being too tired to advocate for oneself.
“To be honest, once you get out in the workforce, you just feel busy all the time and [being on call] is exhausting,” she said. “Once you […] turn that pager off you don’t want to look at your phone again for the next three days.”
Alongside struggles with burnout, the ongoing negotiations between the B.C. government and the province’s midwives are happening against the backdrop of a global pandemic. While COVID-19 has presented significant challenges within every facet of health care, the province’s midwives are finding it especially difficult to cope with less government support.
Spiegelman cited the pandemic as an example of the contrast between midwives and other primary care providers. For example, B.C. midwives struggled to find enough Personal Protective Equipment (PPE) in the early weeks of the health crisis, causing a significant amount of stress for midwives, who continued to provide care to patients throughout the pandemic.
While some midwives were able to connect with hospitals or health authorities in their area to find PPE, others—especially those in rural areas—struggled to purchase PPE directly from medical supply companies that were experiencing shortages.
This funding gap shows how B.C. midwives are less of a priority as medical professionals providing the same type of care. Spiegelman said midwives had to depend on regional authorities to access PPE.
“There wasn’t a clear pathway for midwives in B.C. to receive appropriate PPE […] It depended on, not necessarily the relationships with the midwives in their communities, but [on] the different health authorities and how they were providing PPE to their care providers,” she said.
“[Midwives were] buying [PPE] out of pocket, spending a great deal of personal funds to ensure that they were safe for their patients, and also for themselves and their families,” Spiegelman said.
To Spiegelman, COVID-19 and the challenges midwives have faced because of it are emblematic of the B.C. government’s treatment of those in the profession.
“That’s one of the issues where midwifery integration in the overall system is confusing. On a systems level, where do we put midwives?”
For Hilary Agro, whose daughter, Ella, was born on Sept. 20, 2018, choosing a midwife went hand-in-hand with her hopes for a natural birth. Unfortunately, several medical complications leading up to her due date made medical interventions necessary.
Agro developed gestational diabetes, a condition where a pregnant person develops high blood sugar levels. Prenatal depression and a baby resting in the breech position increased her stress.
When asked about her pregnancy, Agro detailed a litany of things that went wrong.
“So, baby’s breech. I’ve got diabetes. I can’t eat any cake […] I can’t drink. I can’t do anything,” Agro recalled, “And then one day in the middle of the night, I wake my partner up, unintentionally, because I’m scratching my shins so loudly […] My hands and feet [feel like they’re] on fire.”
After her midwife ordered some more tests, Agro was diagnosed with obstetric cholestasis, a liver disorder which causes a build-up of bile acids and increases the risk of stillbirth, fetal distress, and maternal hemorrhage.
When Agro returned for more tests the next day and her condition hadn’t improved, she was booked for an emergency C-section. Agro remembered feeling completely unprepared.
“I didn’t have my partner there. I didn’t have my stuff with me,” she said. “I [was] on the phone with [my midwife], sobbing.”
Agro’s partner was able to make it to the hospital in time, but her midwife wasn’t. Suddenly, her original birth plan went out the window.
“I think a lot of people go with midwives because of their more tangential relationship to the medical system […] they don’t want birth to be medicalized. With that being my guiding ethos […] all of a sudden I had no control.”
Even though Agro’s midwife was unable to attend her C-section, her post-natal care, both emotional and medical, was a source of incredible support.
“I remember telling her about how the birth went and seeing the look in her eyes of how happy she was for me,” Agro said. “[She told me], ‘I have just been rooting for you for the last nine months. And I’m so happy that everything turned out fine.’”
“it was so beautiful to have that connection with somebody who I knew was deeply invested in the health of my baby and of myself.”
Seeing the current negotiations between B.C. midwives and the provincial government has been frustrating for Agro. She noted that the significant contribution B.C. midwives make to the province’s pregnancy care demonstrates the level of compensation they deserve.
“[It shows] how we organize our society in terms of the value that we place on different kinds of work,” Agro said. “If you’re a midwife who’s helping babies be born, it’s [considered] fine for you to be overworked. F—ck that.”
“Give them paid leave, give them [parental] leave […] give them anything that they’re asking for. All workers deserve all of these things. It’s unfortunate that we have to [fight for them].”