Hello and welcome back to so you got a lifestyle degree We're your hosts Frieda and Lisa to lifestyle undergrad students trying to navigate for future careers. This is Episode 22. And we're talking to Dr. Liz darling about midwifery. How are you doing today, Lisa? I'm doing okay. I've been having a series of days of very bad sleep.
But I did also recently have a birthday which was fun.
July 8, so if you didn't get me anything as your chance No, just kidding.
Yeah, it was actually really sweet birthday I had a bunch of people give me like little small things basically didn't have to pay for any food for myself the entire day. I plan to like, buy myself sushi and then buy myself a birthday cake. But my friends came through and like 10 seconds before I was going to click the order sushi button. I get a message from my friend. That's like, I hope you have an ordered dinner. It turned out that she had sent me like the exact same thing I was about to order which is funny. Cute. Yeah, but the one of the main components, I guess if my birthday was going to build a bear with my girlfriend. Oh. I know. So yeah. So like growing up, I was always super into stuff toys. Like I didn't care about anything else. Like I wasn't into cars or Lego that much or even like Barbies, or I was just all about the stuff toys. Yeah. And so little Lisa always dreamed of going to build a bear, but never really, you know, like I knew it was like expensive and it was like a fancy thing. And I was like No, no, no, no, it's too bad. But you know, now I've got Yeah, slashed my girlfriend's income for my birthday present. Yeah, I feel like there's so many things as a child I wanted and now as an adult, I'm like, wow, I can just do. Okay, okay. But here's, here's the thing, we're going to build a very unit. All right, we're okay. So in front of you, the customer in front of you was like this little girl. She's seven or eight with her mom, which I was like, okay, like, this is what I get for the bilderbergers. And but the two customers after us were also like couples and like their early 20s, which which did better, but like going through the whole build process, like listen, like the employees that work there, they have a speech, they have a series of things they're supposed to ask you and like, these questions and phrases are calibrated for an average age of nine. Possibly younger, and so I remember at one point, she had just stuffed my bear for me. Yeah. And she handed me like this, this tiny kind of paper or like whatever heart and she gave it to me. She was like, This is his bar. And I was like, Uh huh. Okay. And then, and then she said, You got to rub it all over him and give him the lovers. I was like, Oh, God, okay. Like awkwardly did that. And then she asked me to do like a couple other things. It was like progressively getting more and more like, I want to say weird, but really just childish. And her final request. I just like, looked at her. And I was like, I'm sorry. I can't. I'm sorry. I'm 20. I'm 22. Yeah. And I was just like, yeah, yeah. So what's your review? Is it still worth it as an adult? I think it was a nice experience. I named my bear stuffy. He has a birth certificate is very cute. It does slightly bother me that they they put the heart in the back of the bear. I feel like that's not teaching children proper anatomy. Right ask me. What do you mean? It has to be not in the back. Like I don't care. The left right positioning is not like behind your spinal cord. But I guess that's really stuff that I mentioned that to the employee and she was like, Okay.
Anyways, so yeah, that was my little birthday outing. How have you been cute? I've been pretty good. Oh, yeah. I don't think I mentioned on the podcast before, but I ended up getting that job that I was interviewing so much for which I told you a while ago. Yeah. So we've been having like these orientation sessions. And one of them because everything is online, and there's no HR directly to handled all the hiring documents was just like, here's what your hiring package is. And then also, we had like a meet and greet with all the other it insurance, which was very fun. Everyone is so legit. I'm like, I don't really know what I'm doing. Yeah, but it was fun. And in the hiring documents session, they spent like a solid 20 minutes trying to convince us that we should really sign up for their pension plan. And I was like, I'm pretty sure everyone was gonna sign up anyway. But the longer you talk, the more exactly like I'm getting. Yeah, sign up for our quote, pension. Yeah, it was absurd, because the entire session was like 40 minutes and a half of it was about the pension plan. That is kind of weird. Yeah. And also, it's only optional for the fixed term employees and not the full time employees. So the entire presentation was only for the interns like they made this whole pitch just for the interview. It was really weird. Yeah, yeah. But besides that I'm very excited. And yeah, we started a discord with the other interns. So we've been messaging on there. It's been fun look at you going into the workforce to our economy. So proud. Thanks. So Lisa, what's the squirrel of the week? I'm very excited about the squirrel the week which is roof squirrel. So the squirrel goes away is back to the time when I was still living in my quaint little house in Mississauga. And so if you click on this link that I have put in the document, you will see a series of photos of roof squirrel. So basically, I was in my in my bedroom one day and this was in Mississauga, and I look across like through the window to the house across the street from us. Yeah. And there's a squirrel kind of sitting in there with weather vane formation, like like, you know, farm houses have like a weather vane at the peak of the squirrel is a function. Yeah, this looks like a rooster on a farm. Yeah, much quieter, though. But yeah, he was just kind of like scampering about and I was that was the first time I've ever seen one on a roof. And I was very surprised by that. I've seen them sometimes on the gutters. I didn't know that they would exit the gutter. So yeah, it's this pointy edge, really the most comfortable place. I mean, it's a gutter, the most comfortable place. You play cosy. You can stay there for very long. I was lucky with the photo. Very cute. I like the squirrel that week. Thanks. Alright. Are you ready for an interview with Liz very excited. You know, side note. Sometimes when I'm scrolling through Canva, which is our graphics app, I just, I see a graphic that I think could work for future episodes. I kind of just save it. And I've had like this perfect graphic from midwifery save half of the duration of our podcast like months ago. I was like, Oh, this could work. We did a bit of a free episode. The real reason you wanted to do the midwifery episode was a little bit I kind of pushed her. Anyways, I'm ready to interview Dr. Liz darling sounds good. This episode is sponsored by resume word. Resume word is an AI powered online career platform that gives you instant tailored feedback on your resume and LinkedIn profile. They offer three main tools score my resume, which uses AI technology to instantly score your resume according to what recruiters are looking for. Targeted resume which analyses job descriptions to identify important keywords and skills missing from your resume and LinkedIn review which identifies gaps in your profile to increase your visibility. Each of these features provide specific feedback to help you get past automated resume filtering and land interviews. They both offer free tools and optional paid features. I've been using resume worded myself for the past few months and I'm finding it really improves my job applications. I'm consistently surprised by how many weaknesses it is able to identify and the helpfulness of the step by step feedback. I'm also subscribed to the email newsletter. I normally hate email newsletters, but this one genuinely provides the synced and helpful advice that I would have never thought of otherwise. To check them out visit resume wordid calm.
This week's guest is Dr. Elizabeth darling. Dr. Darling is a registered midwife and the assistant dean of midwifery at McMaster University, as well as an associate professor in the Department of Obstetrics and Gynaecology. She practised midwifery in Ottawa and was a part time faculty member with the midwifery education programme at Laurentian University. Prior to joining McMaster in 2017. She has received multiple awards for her research, including the CIA, HR early career Investigator Award and maternal reproductive Child and Youth health in 2019. For her work on the impact of funding expanded midwifery care models in Ontario, her qualifications include an honours Bachelor of Arts and Science, a Bachelor of health science in midwifery, and a Master of Science in health research methodology offer McMaster as well as a PhD in Population Health from the University of Ottawa. Thank you so much for joining us today. Dr. Daly. Thank you. It's nice to be here. All right. So the first question I have for you is what is a midwife?
What is a midwife? So a midwife is a health care provider who provides care during pregnancy, birth and the postpartum period, both to the birthing person and to their newborn during the postpartum period. And they are an independent primary health care provider who's capable of providing probably about 87% of the health care that the population in general needs during that period of time. And in some settings, midwives also provide care outside of the childbearing years providing health care that relates to family planning, and other sexual and reproductive health care and later life stages as well.
All right, great, thanks for that summary. Do you think you can maybe highlight for us some more specific responsibilities a midwife would have in each of those three stages. So pregnancy, labour and postpartum? Yeah, sure. So
during the premium
It'll period midwives would provide all of the prenatal care that somebody would need if they're having a normal pregnancy. So that typically involves prenatal visits once a month in the first part of pregnancy. And as you get further on in the pregnancy, to the third trimester, those visits increase in frequency first moving up to every couple of weeks, and then to every week, in the last month or so of pregnancy. And during those visits, midwives are providing clinical assessments to make sure that the person that they're caring for is healthy, and that the pregnancy is developing. Normally, they provide information and education to inform people about some of the options for care during pregnancy and during birth, and they would order lab tests or ultrasounds that might be needed also to provide information that's valuable for managing the care during the pregnancy, a lot of the time in the prenatal visits is really spent providing information to people and one of the core elements of midwifery care is the idea of informed choice. So midwives really take a lot of time to make sure that people understand the things that are routine interventions that most people would opt to have as part of their care, making sure that people understand why those things are offered and what benefits and or risks they provide to people. And so that's that's a big part of the time that's involved in each of the visits that somebody would have with their midwife in the prenatal period, then during the the intrapartum period, or the during labour and birth midwives would provide, again, all of the care that somebody would need if the labour and birth progress normally. And so that would include providing monitoring the labour to make sure that things are progressing normally. And that includes monitoring the foetus to make sure that the baby is coping Okay, with labour providing support to help people cope with labour and then conducting the birth sort of assisting when the person is giving birth gives birth to their baby afterwards, if there's a need, they would potentially be involved in providing sutures to repair a parent, they would provide monitoring again in that immediate period right after the birth of both the birthing person and the baby and provide assistance with breast or chest feeding. And so that would sort of be the you know, the main responsibilities during that period of time. And then in the postpartum period, they would be monitoring both the birthing person and the newborn and monitoring the recovery of the person who's given birth. And with the newborn, assessing growth and supporting feeding, making sure that the that the baby is growing and developing normally, so there'd be both clinical assessments that the midwife would do during that period of time. And also, again, a fair bit of provision of information and education to support that transition to parenthood. Yeah, great. Thank you for that. And just to clarify, how long is that period of postpartum surveillance? So most midwives in Canada would provide care for about six weeks following the birth. Okay, got it. And so another question I have, which I think is a question that often comes up is, what is the difference between a midwife an obstetrician and a doula? And why might someone who's giving birth choose one of those professions to assist them throughout that process? Okay, great, good questions. So one of the big differences, if you think about those three groups is that two of those groups are healthcare providers. So midwives and obstetricians are healthcare providers, and doulas provide a service but they're not trained as health professionals. So they have a full skill set as doulas that's really valuable, but they wouldn't provide any of the health care that I've just described in sort of my list of responsibilities of what a midwife would do. If you look at what an obstetrician would do, they would provide all of the sort of clinical assessments and monitoring and access to tests that a midwife would do, but in the provision of care from an obstetrician in labour in particular, there often would be a nurse also supporting and providing some of the care that a midwife would provide. So if you think about a labour often when somebody goes into the hospital, I have to give birth with an obstetrician. The obstetrician is meant like sort of the person who is most responsible and managing and making decisions in consultation with the person who's giving birth, obviously, about how the care unfolds. But there's also a large part of the care and the monitoring and the assessment that would be conducted by a nurse in if you can compare that to a midwife and midwife would be providing the complete package of both of those pieces in a normal birth. But there are limits to the scope of a midwife. So if there are complications that arise, then a midwife would involve an obstetrician to take advantage of their additional expertise in complications related to pregnancy and childbirth. So that might happen in the prenatal period if somebody develops some kind of medical complication in their pregnancy, or it might happen during the birth and the most common reasons during a birth would be any of the kinds of reasons that might require somebody to need us as arion section or an assist.
To like an operative vaginal birth, which are things that midwives in most settings wouldn't provide. So midwives nowhere in Canada did midwives provide conductances arion sections, they don't also usually provide care for forceps delivery. So those are both specialised skills that obstetricians have. And so an obstetrician will become involved if either of those are necessary in a small number of settings, particularly where midwives are working in more remote settings, there are some midwives who would have additional training to be able to provide care with the with a vacuum assisted delivery in emergencies. But that's a that's a special skill set that not every midwife was would have as part of their their core set. So and a doula then, is somebody who focuses on providing support. And so they often might provide support to somebody at an earlier time point in labour, like an early labour before somebody would have any clinical care either from a midwife or an obstetrician or a nurse. And sometimes doulas will also provide support outside of the Labour and birth period as well. So there's some doulas who focus on providing support in the postpartum period. But really, that support is primarily sort of emotional and psychosocial support, rather than health care that involves monitoring and assessment.
Alright, thanks for that explanation. And just in terms of how you would go about accessing these forms of care, I myself have never had a child. So I'm not very familiar with the process, you know, so like, let's say you you become pregnant, and you need to plan out a care provider for your pregnancy. What does that look like? Do people apply? I know that's the right word, like apply for a midwife? Do you have a midwife and an obstetrician? Or is it one or the other? Things like that?
Yep. Great questions. So in most in under most circumstances, people would just have one person who is the primary health care provider providing their care for their pregnancy. So there's actually another group two of people who provide prenatal and birth care as primary care providers in Canada, and that's family physicians, many family physicians don't provide that care. But there are lots that do. So if somebody is looking for care in their pregnancy, for lots of people actually going to see their family doctor is the first step in finding a care provider. So many people start off that way. And they might follow the recommendation of their health care provider of their family doctor and just go with whoever they recommend. So if their family doctor provides care in pregnancy, they might be the one to provide them with that care. Lots of family physicians who don't provide prenatal care, we'll do some of the prenatal care in the first half of pregnancy and then refer people on and so they might then organise for them to be referred to a specific obstetrician. But then there are also many people who actually ended up finding their final care provider for their birth on their own. In most cases, midwives in Canada operate in terms of like sort of a cell on a self referral basis. So people who are interested in midwifery care can just contact a midwife or a practice group where a midwife is working and request care. And then with obstetricians, there are some obstetricians who will primarily just worked through referral. But in some cases, the family physician might provide sort of a blanket referral, and the pregnant person is the one who has to kind of actually figure out which obstetrician they can get care from in terms of applying, there isn't a formal application for receiving midwifery care. But midwives do usually do a little bit of screening just to make sure that somebody is appropriate for midwifery care, because our scope does have some limitations on it. So we would usually ask people a small number of questions just to make sure that there aren't things about their situation that would make it ideal for them to have care from an obstetrician. And then the other. The other thing that sometimes affects finding a care provider is that in many places in Canada, the demand for midwifery services is higher than the supply. So sometimes what'll happen is people will call a midwifery practice and get put on a waitlist. And then the practice group will sort of assess all the calls that they've gotten for, you know, charactering, a certain month or a certain time period, and figure out how many of the people who are interested they can actually take into care. So sometimes there is a bit of a waiting period after you've made your initial contact to get care from the midwife.
Do you know how long that waiting period typically is? I mean, I mean, Pregnancy itself is Yeah, months, which is like a long time. But do you help people who have to call ahead before they even become pregnant?
Well, practices don't won't usually create a waiting list before somebody is pregnant. So you need to be pregnant before you would contact a practice to try and seek care. And midwives are usually trying to provide care throughout all of pregnancy. So most often, they would want to be trying to get people into care in the first trimester so that they can provide them with the care that normally would be provided in the early part of pregnancy. But some people will sometimes be on a waiting list for a little bit longer than that, because part of what can sometimes happen is that the practice might be full and somebody says that they're still interested and they might sit on the waiting list and then there might be somebody else who unfortunately might have a miscarriage or who might end up with a complication where they need to be referred to obstetrical care. And if that does happen and a spot opens up, then the midwives might be able to take an additional person into care. So sometimes people might be waiting a little bit longer. And in those cases, usually they would be encouraged to still be seeking care from from their family physician if they have a family physician who can provide that care to them.
Yeah, that makes sense. And sort of On a related note, you've kind of spoken about like being referred to places and I was wondering where sort of in terms of like location or employer do midwives work for like, Is it the government that pays them or another source?
Yeah. Oh, great questions. So in now, in all of the, in all the jurisdictions in Canada, where midwives are regulated, which is now Fortunately, most of them, there's public funding to cover midwifery services. So the funding does come from the government, the way in which that funding gets to midwives varies a bit from province to province in Ontario. What happens is that midwives work in group practices, and the funding flows to those group practices. So if you're a new midwife who's just graduated, can't just hang up your shingle and work anywhere, you need to find an existing practice and work with that practice. There are processes for people to start new practices, but that's not something you do as an as a new graduate. And so then the midwives in Ontario work on it what's called a course of care basis, not exactly like fee for service where your midwives aren't billing the government for every single thing that they do. But they bill basically, for each person that they provide a full course of care or package of care that includes the prenatal care care during the birth and the postpartum care for. And so they get paid sort of on the basis of how many people they're looking after each year, there are some other provinces where midwives work as employees, and so they're employed by a health centre, or some other organisation to provide care. And we now actually, since 2018, have a really small number of midwives in Ontario working under those alternative funding type arrangements where they're working as employees for community health centres or family health teams, and still providing similar care, but doing it in this under a slightly different funding model.
Alright. Yeah, seems complicated. Yeah. As funding always is, yeah, um, maybe switching gears a bit. I was wondering if you could tell us a bit. You know, having worked as a midwife, yourself for several years, sort of what the daily schedule of a working midwife looks like, because I can imagine that could be sort of busy, especially if there are times where you have to be on call. So yeah, just like, what times during the day do you see clients? Do you have a lunch break? How many days you work a week, that kind of thing? Yeah.
So that can really vary. It is possible as a midwife to not work full time some midwives carry a part time caseload and how busy you are will depend on how many clients you're looking after in a year. But if you're working as a full time midwife, one of the things that I would say as characteristic of midwifery care is that it's pretty rare to have two days that are exactly the same. So if you're, many midwives will work in models of care where they have about half of their time where they're on call. And that's because the model of midwifery care ensures that people who are being cared for by a midwife have 24, seven access to services from their midwife or from their team of midwives, who's looking after them. And so many midwives will work in a pair of two and a half, say, you know, one week, every every other week, where they're fully on call, and what they would be doing during that time is responding and going out whenever they're needed if somebody goes into labour, and they probably also be doing some of the visits that might occur in the client's homes in the postpartum period in the early early days after the baby's born. And so when a midwives on called, your schedule can be all over the place, you might get called in the middle of the night, and be going out to birth at two in the morning and getting home in the middle of the next day. And then sleeping part of the day, you could have a really busy stretch where you have a few days with multiple births in a row, or you might have a really quiet week really do very little, you maybe go out a couple of times to see some, you know, babies that were born recently and be be doing some home visits. And then during that other time when people aren't on call, they would typically be doing care that's based in the clinic for a lot of the time. So for most of the prenatal visits that midwifery clients have, they would come into the practice where the midwife works and have visits with which will often range from maybe half an hour to 45 minutes. They're fairly long because of the amount of time that midwives take to sort of answer people's questions and provide information. So a full day of seeing clients, you know, might include like seeing, you know, eight to 12 clients or something over the course of that day. And so you would probably have a few days of the week where you would need to be doing those visits in addition to that midwives because they're providing on call care to people also are available to answer other kinds of urgent things that might come up outside of actually going into labour. So if for example, somebody
isn't feeling their baby move and is worried about that, then the midwife might be going to the hospital and meeting them there and doing an assessment in the hospital. So there's quite a variety of different kinds of things that the midwife might be doing. And then there also are sort of administrative type pieces of work that might be done in terms of just running the practice and making sure that you're you've got things organised and well set up to take care of all of the infrastructure that is built around the clinical care. So you know, things like developing resources for your clients, or working on spending time with your colleagues, developing protocols for how you're going to do things being involved in meetings with the hospital to talk about how care works, and the integration of those the midwifery services within the hospital setting or contributing to other work at the hospital at the committee level and ongoing sort of professional education to keeping up to date on the most recent literature and those kinds of things. So there's a big variety of different activities that are part of your job as a midwife. And yeah, like I said, it's pretty rare to have two days that are exactly the same. Yeah. Sounds like going back a bit to something you mentioned earlier about how sometimes you have let's say, for example, a week where you might be on call, what does that really mean to be on call? I know that might be a bit of a naive question, does it literally actually, more or less mean that you can be called to work or help someone at like, any time during the day? And also as kind of like an associated question to that, I know that sometimes there can be someone who goes into labour and it can be 24 hours or like 36 hours. So would you be working that whole time straight? Yeah. So great questions. Yeah, being on call does mean that you could get called at any point back in the good old days,
used to carry pagers, oh, very many midwives who still carry pagers, most of us
still carry a pager No,
sort of, or use some kind of version of a pager or some kind of way of getting in touch with us on an app on our phone or something. Some midwives will just be accessible directly through their phone. But it does mean that if somebody has an urgent concern, if you're on call, as a midwife, you need to be available to answer that phone call or page or eye contact on pretty short notice, you know, usually you're calling somebody back within a few minutes. And you do need to be prepared to head off and go and do an assessment in their house or head into the hospital to meet them at any point in time. Sometimes labor's are long. So yeah, you definitely can sometimes be out for a long period of time. But I think one of the things that's happened I serve more broadly in healthcare is sort of attention and awareness to the impact of lack of sleep on the quality of health care. So we've been paying attention to that within midwifery to as much as possible. And so balancing out that desire to make sure that people have a known care provider with them and provide that continuity over the course of labour, we also try to figure out policies or protocols within our practice, to be able to have the group of midwives who are working together support each other to avoid people being too tired to actually provide safe care. So it varies a little bit from practice to practice how that works. But often, you know, if you've been up overnight, you would call for relief in the morning and somebody would come in and, and take over and you'd go off to sleep. Some practices also support each other a little bit like if somebody has been at a labour all day, somebody might come in and provide them with a little bit of relief before the evening. So they can go off and have a meal or something. But yeah, yeah, it does mean that you can have be working long stretches. And sometimes it is challenging to get meal breaks and those kinds of things.
Yeah, that seems really tough. How does that ever impact how you can schedule events? Like, obviously, you won't be able to go on vacation or anything, but let's say you wanted to make plans to go to dinner? Or to go to the movies, that kind of thing? Does How do you balance that with being on call?
Yeah, I think midwives do a lot of contingency planning. So it does mean that sometimes, like if you're going out somewhere with your family, you might end up taking an extra car, because you need to be able to leave on a moment's notice. Or it might mean that yeah, it might mean that you avoid doing some things that would take you too far away from where you need to be, or you just make plans with people. And they're aware of the fact that you might need to cancel at the last minute and reschedule I think, yeah, a lot of our you know, meetings that happen as midwives, we just sort of work on the assumption that if midwives are participating in a meeting, there's a chance that some of them might not be able to attend, because they might end up getting called to a birth or something. And we just worked with that.
Yeah. Have you ever had times where you've literally just had to run out of a restaurant or like a theatre or something like that?
I'm trying to think of whether I've, I don't think I've had to run out of a restaurant or a theatre, but that may be more a reflection of the fact that I would try and not schedule those things so much when I'm on call. And people have different thresholds. Yes, I mean, I think it's, um, it is definitely a skill that you need to develop in order to stay sane as a midwife is being able to live with that uncertainty, and people have different thresholds around what they'll feel comfortable doing. I've heard, you know, some people as new midwives feeling stressed about even just going to the grocery store and kind of one wondering about Yeah, I got a call the middle of the grocery store, and this was my card. And I think you do sort of develop a tolerance over time to some of those things. But I think, yeah, I mean, the thing that comes to mind is one of my memories of having to go really quickly was basically getting called to a birth and having to just pick my kids up, you know, we were all at home very quickly dropped them off at a friend's house and kind of rushed to the neighbours just because I had to get there clearer. Yeah, get get to the hospital quickly. For a birth, I feel
like that would be really difficult. For me, I recently found out about this term called, quote, waiting mode, which is when you're waiting to leave for a dentist appointment or for your podcast guest to come online. And yeah, 30 minutes before the event, you're just like, okay, I can't do anything else. This is I just have to sit here and wait for the next 30 minutes. And I feel like if I were to work as a midwife, the whole time I'm on call, I would just be in constant waiting mode. So yeah, I feel like that would be challenging for me probably is for anyone but yeah,
yeah, I mean, I think there are, you know, there certainly there probably are certain personalities that are find it, you find it easier than others. But I do think part of it is a it's partially a bit of a mindset that you can learn you'd but you have to be pretty intentional about it. Yeah,
yeah, definitely. Speaking of which, this, you know, maybe the scheduling is that, but I was wondering, what are some of the most challenging aspects of your work. Um,
I would say that, that probably, if you talked to many midwives, they would say that being on call is one of the most challenging pieces, it does mean that it creates demands on your family and your loved ones that are a little bit different than most jobs would require. And so I think some people find them more challenging than others, but I think many midwives, you know, feel a certain amount of guilt at times around having to leave leaving, especially if you have young children or you have you're responsible for parents who are ageing or unwell, I think it can create a lot of guilt, if you're not able to always be there and provide care for your own family members, and when you're leaving to go and provide care for your clients. So I would say that probably is, is a big challenge. One of the other things that I think also can be challenging is that the vast majority of the work that we do as midwives is really positive and rewarding and happy work that pregnancy and birth also do entail that sometimes we care for people who are experiencing loss. And so that can be challenging to supporting somebody through even early loss in pregnancy, but particularly losing a baby, later in pregnancy or during labour or after the baby's been born. That can be really difficult, difficult work to do, I think it can also be very rewarding work to do. Because I think the way in which our model of care is set up means that we do develop relationships with clients that allow us to provide really good support in those challenging times. But it does demand a lot of you as a midwife going through those those circumstances in addition to loss, sometimes there are also other events that can be can be traumatic when people have other you know, sudden bad outcomes. And those can be difficult for people to to process as a health care provider. That's it's obviously not what we want to experience when we go into healthcare. Anybody who enters enters a health profession genuinely is interested in trying to help people and support good outcomes. And when they don't happen, it can be it can be emotionally difficult to deal with.
Yeah, yeah, that definitely sounds challenging. I think on his On a similar note, what do you think are some key considerations then for someone to think about if they're trying to evaluate if midwifery would be a good profession for them to
pursue? Yeah, well, I think in terms of the demands, and sort of what would what might push you the most Those are probably those things that I've just described probably are some of the biggest challenges. So you know, being able to live with uncertainty and being able to live with pretty high percentage of your time that you need to be on call, even people who've kind of worked in creative arrangements, often still would be spending about 30 of their time on call. And we may still, we may yet have further developments in the profession and other kinds of job opportunities for people that have slightly lower on call demands, or maybe no on call demands. But at the moment, there are pretty limited opportunities for people who aren't able to do on call work. So that's that's definitely a consideration. I think another piece is just being willing to take on a role that does entail essentially life or death responsibility, right? Like you do need to be willing to commit the level of attention to like attention to detail and acquisition of knowledge and keeping up to date with your skills to know that you're really providing thorough and safe care to people because if you do miss something or make a wrong decision, much of the time It might not have serious consequences, but it can have very serious consequences. And so I think being willing to take on that role as a primary care provider who is making that final level of decision making and provision of advice is different than some other health care provider roles where you're not the last person in the chain of decision making. So I think that that definitely would be another responsibility or consideration. I think another thing too, is that I think if you're going to work as a midwife, you need to make sure that you love working with people like because that's a big part of the job, right? And so if you're just doing it, because you think babies are cute, and you're, like, so keen on interacting with adults, then that might not be a good choice. And I think,
yeah, those are the ones you got to talk to. Exactly. Yeah. And, yeah, I
mean, I think that's one of the things that I love about my work as a midwife is the fact that, you know, we really get to know our clients, well, we build a relationship over the course of an entire pregnancy, we get to be with our clients and their families, that what's going to be one of the most significant times in their lives. It's such a privilege to be there and be a part of that. Yeah, I think it's, you know, it's it's definitely one of the things that is most rewarding about our work. But if you're not really a people person, then you may find it hard.
Yeah, I would expect that the vast majority of your clients would definitely remember you as well, because it's not like people would have several midwives during their life. So yeah, it's definitely like an important role to play. Yeah, yeah, for sure. So you mentioned briefly how the profession is continuing to evolve, and it's growing. In fact, the demand is increasing. And so how do you think as a summary, the field of midwifery has changed in the past few decades? And how do you personally see it changing in the future?
That's an interesting question. So midwifery in Canada, at least. Yeah, I guess midwifery has an interesting history in Canada. So there are some parts of the world where midwives have been part of the health care system for forever. They never weren't part of the health care system. But we have this interesting history in Canada where you know, midwifery was part of the history of birth on this land. From the beginning of people being here, there are strong indigenous traditions of midwifery. And when settlers came to North America, midwives came with those settlers. And so midwives were among the original people attending births. But with the growth of the medical profession, in the sort of early 19 hundred's midwives really disappeared from the scene and physicians took over the provision of care during birth primarily. And so when I began in the profession in the early 1990s, it was just after the regulation of midwifery. And at that time, midwife, midwives had really been reintroduced through a huge amount of advocacy, both by midwives themselves, but also by the clients that they served. And I think the profession of midwifery, in Ontario, at least to us, I would say, has always had an element of it that is very committed to social justice, and to providing good health care for for women was sort of the initial the initial impetus, but providing good health care for a diverse range of women. But that said, in those early days, I think the people who were who had the most time and played the biggest role in terms of advocacy, often were middle class white women, primarily, not exclusively. And so I think our you know, our early origins of midwifery really were based around values that are reflective of sort of the women's movement at that time. So the idea of the focus on informed choice and autonomy over our bodies, which are still really strong and central tenants really are reflective of those origins. And I think one of the things that I see, changing in the profession over the last few decades is just a growing diversity of who is being served by midwifery and who is included in the profession, we still have lots of room for growth in both of those. And like I said, I think from the beginning of the, you know, the move to regulate midwifery in Ontario, and how that be reintegrated into the healthcare system, there has been a strong commitment to social justice and trying to make those services accessible to people. And that was part of the drive behind no thinking that midwifery services should be funded publicly was to make them accessible, but we still know that there are people who are of lower socioeconomic status are less likely to have made refree care than people who are of higher socio economic status. We still we also know that the diversity within the profession right now doesn't fully reflect the diversity of the province, although it's you know, it's it's increasing over time. So I think those kinds of changes in which we we see an increasing diversity and also changes in the in the profession that are then responsive to the more diverse things that the people who are seeking midwifery care want When we started in the early 1990s, it was, you know, maybe one or 2% of the population who was receiving midwifery care. And we're now you know, roughly one in five people who's pregnant in the province receives care from the midwife. And so that means there was a much, you know, a much greater portion of the population getting served. And people don't necessarily want exactly the same things, as people in those early days did. So one of the biggest examples would be that in the early days of midwifery overall, it was a higher portion of midwifery clients who would plan to get birth out of hospital and over time, while those numbers have you know, steadily grown, the number of home births in the provinces increasing the total number of clients is increasing at a higher rate. So as an individual midwife apart from some pockets of the province, where the home birth rates are really high, as a midwife in your day to day work, you're probably spending a bit more time attending births in the hospital than attending births at home, then you might have previously, that sort of as a, you know, another evolution that sort of a bit in contrast to that, we also now have a couple of large birth centres in the province, which weren't available before. And so that means that some midwives are also providing birth care in birthing centres as opposed to just in hospital or at home. Another change that we've seen is that a few years ago, we had the inauguration of the first hospital based midwife led unit. So it's called an alongside midwifery unit. And I think that holds a lot of promise for changes that we might see in the future in terms of how care within hospitals is organised and the level of leadership that midwives play in terms of the delivery of those services. And then I think the other change, too, that I I see as happening is that I think midwives have a broad skill set that really probably could be better used to address some of the gaps that we have an access to sexual reproductive health care even beyond just the childbearing period. And so some of the midwives that are working in the projects that were funded in Ontario, through the expanded funding models are actually filling some of those gaps and addressing some of those health care needs in the settings where they're working. And I think as we have those, you know, examples existing, I think that will, over time hopefully allow and support other midwives to expand the roles that they're playing to. So that's something that I would I hope happens as we move forward in the future, and in some ways, it also would could address some of the challenges that we have right now within the profession of the demand for everybody to have to do on call work. When we look at other examples of places like New Zealand, for example, where midwives worked in a very similar model, most midwives are working in community based practices and providing care now in a continuity kind of model like we do in Ontario. But there are some options for them to work in other ways. If that doesn't work well for them at a particular life stage. I think in those settings, we see better retention in the profession. And so in order for us to improve retention within the midwifery profession, I think we need more more options for ways in which midwives can make good use of their knowledge and skills, even during those times in their lives where they're not able to work in a model that demands them to be on call.
Yeah, like maybe if they have a young child. I'm so sorry. pending. So yeah, thank you for that. That was a really interesting answer. I feel like I learned a lot. And especially I didn't know that it was so new, like early 1990s. That's like 30 years. Yeah. So that's it hasn't been regulated for very long. And that's like, it was really interesting. It's definitely changing a lot. Yeah.
Yeah. So 94 is when mid where preucil was first became like 30 years ago, integrated and funded in Yeah, Ontario. And the the midwifery education programme that Mac took in its first students like in the fall of 1993. So they know they started. Yeah, just before regulation happened.
Yeah, that's really cool. And to finish this off, I was wondering if you would like to also maybe take a moment to tell us about your research, because you are a McMaster professor, and you do midwifery research. And so yeah, if you'd like just to give us a brief overview of what you work on, yeah, sure,
that would be great. So I do health services research. And I do mixed methods research, which means some of my research involves using a combination of both quantitative and qualitative methods, which I find really interesting. And some of the things that I've been looking at, you mentioned at the beginning this EHR award that I have, which is basically funding to support research, looking at what is the value of the policy in Ontario to provide these alternative funding mechanisms for midwifery care, which allows midwives basically to work in an employee type model. And it builds off of some of the research that I've done kind of leading up to it looking at Access to Care Access to midwifery care, and we looked at access based on socioeconomic status in Ontario and found that there really actually hasn't been much of an increase at least over the time period that we could look at in access to it. If we care for people of lower socioeconomic status, and what we see when we compare who's accessing midwifery care versus who's actually accessing care from physicians is that in most parts of the province, there's a discrepancy there. And people of lower SES are more likely to receive care from a physician than from a midwife. And there might be, you know, in some cases, good reasons why that might happen if there actually are medical reasons for people to be having care from an obstetrician instead of a midwife. But we suspect that that's not the only thing that's going on. We also did some qualitative research where we talked to people who are pregnant or have recently given birth and ask them about how they made those decisions. And we found that there actually are really big gaps in knowledge. Still, even though midwifery is now been regulated for over 25 years, there still are lots of people who really don't know what midwives are, they don't know what they do. They don't understand how we're educated, they don't know that midwives go to university for four years to become midwives. And all of those gaps in knowledge impact the choices that they make when when they're pregnant. There also are a lot of them surprisingly, don't get much information from their family physicians about midwifery. And part of that may be because of the limited supply. So sometimes physicians might not want to share information about midwifery care with people because they know that it will be difficult to get a midwife, especially if they're coming into care a little bit later. But we think in some cases, maybe we also need to be sharing more information with family physicians in order to encourage the spread of that information. And the other piece that we did also with that project was we talked to midwives about things that they do to try and improve access to midwifery care. And that was really interesting research, there are some midwives who do like incredibly creative things to try and improve the ways in which people can make it to their care, and also the ways in which the care that they deliver can be responsive to their needs. And so that includes being very flexible in terms of where they deliver care, there are midwives who do outreach to in various settings, midwives who have developed partnerships with community health centres that serve particular groups that are underserved. So there's lots of really great work going on. But we also heard a lot about some of the barriers to doing that work. So I mentioned earlier that midwives get paid on a course of care basis where they get paid, you know, the same amount for each client. And if you're a midwife who's trying to meet the needs of people who aren't well served by the healthcare system, that may mean that it takes a lot more time in order to provide good care to somebody who isn't typically as well served. And so there are some disincentives built into the funding model to stop midwives from providing care sometimes to underserved populations. And so one of the things that we really are interested in in this new study that's funded by ch er is trying to figure out what the impact is of funding a midwife to work in an employee model instead of in this course of care basis. And part of our research involves doing interviews, and we've completed all of those. And definitely, there seems to be some really big benefits to this model. Some of the really amazing examples of the services that have been created with this funding model have shown that for midwives working in employee model, it makes it much easier for them to take time during their work time to build networks and create linkages with other existing services. So that people who do have more complex social needs or other health care needs can have those met in services that really wrapped around them cohesively, and that support them to even find out about midwifery services in a more streamlined way, because they're really good linkages between some of the other services that they might be receiving the linkages between the midwives and other health care providers that they're working with as part of a team and linkages that the midwives have then made with other kinds of services that might be supportive for them during pregnancy. So it's really exciting, what we found, were pretty excited about the potential that it offers to really move midwives into again, sort of addressing gaps in the system for people who often are the least well served by the health care system. And I think midwives skills, that kind of being flexible and working with people in the community, there are sort of the underlying philosophy of being client centred. And the ability to build trusting relationships with people and spend a bit more time with people who might otherwise have previously had negative experiences with the healthcare system and be a little bit less comfortable, really present an opportunity for midwives to make some pretty valuable contributions. Yeah,
yeah. Well, thank you so much for your podcast. I think you were such a great guest, especially because you mentioned like you started working in this profession around the time it was regulated. And you've you've seen a lot of its changes and you do research on its future. So yeah, like, thank you so much. It was it was so nice to speak with you. And yeah, really appreciate the opportunity. Great. Thanks. So that was fun. If you would like to learn more about midwifery research at McMaster you can visit the link in the show notes. This has been another episode of so you got to lifestyle degree with Dr. Liz darling about midwifery. We want to give special thanks to our crew of lovely patrons including our little leaf patrons. nyeem The Neil should be an Mima and our fantastic foliage patrons Stephanie. If you like to become a supporter of this podcast, you can visit our patreon@patreon.com slash so you got to Lakeside degree. The music you're hearing is no regrets from audio hub.com Thanks for listening and see you next time.
