Benefits of Midwifery to the Health Care System

Midwives are already providing the kind of care the government is seeking to achieve through transformation, with a cost-effective, client-centred approach that moves care from the hospital to the community. In August 2004, Minister Smitherman said, “Midwifery is a living example of the health principles we are aspiring to. They can help show us the way forward.”

Enabling midwives to play their full potential role requires addressing the sustainability of the profession, including responding to under-compensation and an ongoing commitment to fund the ongoing growth of midwifery. At the same time, the sharp decline in doctors practicing obstetrics makes the growth and sustainability of the midwifery profession essential.

Supporting the Transformation Agenda

The midwifery model of care directly supports the Ministry vision for major changes in the approach to delivering health care in Ontario.

· Limiting the growth of hospital funding. The growth of midwifery can significantly reduce the demand for hospital services because most of the care that midwives provide is in the community. Midwifery-assisted deliveries in hospitals have now been demonstrated to use fewer resources than deliveries by other maternity care providers for reasons including lower intervention rates and earlier discharges. Midwives free up hospitals and obstetricians to focus on care to women with high-risk pregnancies and emergency care.

· A culture of accountability. As a managed program, midwives are already working within one of the most rigorous accountability frameworks of any health care provider. Midwives support the principle of accountability, but also caution that the effort midwives put into supporting accountability measures should not reduce the time and capacity to care for clients.

· Creating strong community health care services. The needs of the mother and her baby are already at the centre of the midwifery model of care. Midwives are able to support births at home, achieve a significantly higher rate of early hospital discharge and lower rate of readmission, reduced ER visits and a lower rate of obstetrical intervention, creating significant savings for the health care system.

· A new emphasis on health promotion. Midwives build a trust relationship with their clients and are available on-call 24/7. This makes them effective in promoting healthy living including nutrition and smoking cessation, a higher breastfeeding rate which research shows is associated with lower rates of juvenile diabetes, obesity, asthma and allergies, and a unique ability to address complex issues like domestic violence. This approach makes prevention and health promotion an integral part of midwifery care.

Investing in the growth and sustainability of midwifery directly supports the Ministry’s transformation agenda.

Cost-Effective Care

In 2003, the Ministry completed a program evaluation of midwifery. Program evaluation showed that midwifery is very cost effective compared to the care provided by obstetricians and family physicians.

According to Ministry estimates, the cost to the health care system of a midwife-attended birth in a hospital is about $800 less than with a family physician. If a midwifery client gives birth at home, the cost is about $1,800 less. (Savings are due to a c-section rate for midwifery clients that are 30% lower than for family doctors, an episiotomy rate that is less than half, a re-admission rate to hospital that is 65% lower than other providers, and shorter hospital stays including over double the rate of early discharge of low-risk patients.)

There are broader savings to the health care system resulting from midwifery care not captured in the savings shown above, including reduced nursing staff time, reduced emergency room visits, and reduced use of walk-in clinics. As well, the focus of midwives on health promotion can yield other long-term savings.

Midwifery produces direct savings for hospitals. According to a report in The Ottawa Citizen, the Ottawa Hospital estimates that a midwife-assisted birth costs the hospital about $450 while a physician-assisted birth costs $1,400. Home births increase savings for the health care sector by an even greater amount.

Maternity Care Crisis

There is a continuing sharp decline in doctors providing maternity care, and the Ministry has determined that most of the province is underserved for maternity care. This makes investing in midwifery the best and most practical way to ensure that expectant mothers and their babies get the care they need in their communities.

A generation ago, about half of family doctors still delivered babies. Today, that figure has dropped to less than 10%, according to the Ministry. In recent years, more than 300 family doctors have left the practice of obstetrics. Family doctors now deliver about 20% of babies.

The number of obstetricians doing deliveries is declining slightly, but those who remain are doing an increasing number of births each. In 2001/02, 466 obstetricians were delivering babies, 15 fewer than 3 years before according to a study by the Institute for Clinical Evaluative Services. In the absence of other obstetrical care providers, these doctors were doing on average 221 births per year, 7% more than 3 years before. At the same time, the percentage of births by c-section increased by 17.5%, which results in increased costs to the health care system.

Responding to the maternity care crisis depends on addressing the sustainability of midwifery. Midwifery is the only obstetrical care profession that is growing, particularly in areas that are underserved for maternity care. There are currently approxmately 366 midwives practicing in Ontario, and the number of women they have cared for has increased by almost 80% over the past five years. Midwives look after healthy women with normal pregnancies in their communities, thereby freeing up obstetricians and other specialists to handle more complicated pregnancies.

However, many of the same pressures pushing doctors out of obstetrical care are also impacting midwives, including job-related stress resulting from long and irregular hours, and substantial amounts of time on call. As a result, action is needed by the province to support both the growth and the sustainability of midwifery.

May 2007