Nova Scotia midwifery services in jeopardy amid struggle to meet demand

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Eight months.

That is nearly the span of a full-term pregnancy, and exactly how long Nova Scotia midwife Leslie Niblett once spent on call without relief, delivering babies, breastfeeding support and figuring out whether mothers' middle-of-the-night pains were early labour contractions or Braxton Hicks.

But last October, Ms. Niblett's exhausted body began to protest. A medical crisis rendered her unable to walk, and she was forced to take a leave from her position as one of just two midwives serving the communities along the South Shore.

Her leave set off a domino effect that has resulted a second midwife taking a leave after she grew exhausted from trying to do the work of two. Now, midwifery services have been suspended across one of just three regions that offer the service in Nova Scotia. And a second region at the other end of the province is also in jeopardy: One of two midwives in Antigonish will take a leave of absence this year, but no one has been found to replace her. One midwife cannot carry a practice.

Nova Scotia has a fraught history with midwifery, which collapsed in Halifax shortly after the service was first set up in 2009 due to "interpersonal and interprofessional conflicts," according to a government-funded report. Midwives and other observers argue that the most recent problems have been brewing for years and are symptomatic of a broader sustainability crisis threatening the future of midwifery in the province at a time when services should be expanding to meet burgeoning demand.

Ms. Niblett said her South Shore practice was turning away as many as 10 women seeking care each month even though she and her partner took on as much as they could manage. That often meant being on call together for long stretches, because home births, which many of their clients request, require two attendants.

"We pushed ourselves beyond what a normal capacity would really be in order to make sure we could preserve the model of midwifery care that we were committed to and that the community wanted," Ms. Niblett said. "There's a limit to how long you can do that for. You need to be able to call in another midwife when you've been up for 36 hours and you need a rest."

But two of Nova Scotia's three practice areas have never had a third midwife to call. When regulated midwifery was established here in 2009, three "model" sites were chosen to host the new practices: Halifax, Bridgewater and Antigonish. The latter two would serve mostly rural communities in the south and east ends of the province. While three midwives were budgeted for Halifax, just two each would be hired for the rural practices.

Midwives at each site were under the impression their practices would see increased funding in the long term, Ms. Niblett said. "From the get-go, there was an implication that midwifery services would grow both within the model sites and to other parts of the province," she said.

Service in Halifax collapsed not long after it was introduced; health officials carefully rebuilt it to include five midwives. But at the rural sites with only two midwives, no positions were added.

Midwives attend births at hospitals and private homes; they provide prenatal care and postnatal home visits for mothers and babies up to six weeks after delivery that last about 45 minutes to an hour. The personalized service is a big draw for families who choose midwife care.

But the strains of delivering that care soon became apparent. The South Shore practice developed "a situation that can lead to excess fatigue and become unsustainable over time," according to a report from a panel of external experts hired by the Department of Health and Wellness in 2011 to examine how to strengthen midwifery services in Nova Scotia.

The experts warned that "midwifery in NS cannot long survive in its present state" given that the province had too few midwives to meet demand safely and effectively. "If nothing is done, the profession will collapse, …" they wrote.

Sarah Rudrum, an associate professor of sociology at Acadia University who studies rural resilience, recently began looking at why midwifery has not expanded to other areas that would like the service.

"It really seems dead in the water," she said. "We're 10 years into regulated midwifery but we're stuck." Women whom Ms. Rudrum has interviewed have said they felt they had better options for alternative care before midwifery was regulated.

"The fact that we're looking back to [unregulated] midwifery with nostalgia is a really bad sign," she said, adding: "But at least there was someone there to catch your baby."

Sally Loring, senior director for maternity and child health services for the Nova Scotia Health Authority, said she is doing "everything I can" to maintain the rural midwifery services. Recruitment efforts have been hampered by the fact that midwives are not trained in Nova Scotia and must come from out of province; the temporary positions on offer, Ms. Loring said, have not been attractive enough to persuade people to move from elsewhere.

But she said the outlook is grim for funding to grow the two-person teams, which are "not long-term sustainable," she said. "Ultimately, the government would have to support us with that. They have a lot of other health-related issues which are looking for funding."

The availability of midwifery was a big draw for Danielle Griffin, a mother of one who recently moved to the South Shore from Alberta with her husband and son. "We had a checklist. A midwifery program was high on it," she said.

"The area is just so ripe with young families who move here and are creative, innovative and entrepreneurial," Ms. Griffin said. She, too, has those skills and put them to use earlier this week by organizing a protest in which about 100 expectant mothers, midwives, doctors and community residents rallied for midwives.

One of them was Whitney Cruikshank. At 28 weeks pregnant with her third child, she and more than 20 other families had to find a new care provider when midwifery was suspended this month. Ms. Cruikshank works part time as a doula, assisting women during and after they give birth, and she said those who will be hit hardest by the loss of midwives are vulnerable populations such as teen mothers who cannot drive themselves to far-off doctors' appointments, refugees or immigrants, and others who require more time and support than family doctors can give.

"This is not just about hippies that want to have their babies at home," Ms. Cruikshank said, adding that she has found midwifery care, which aims to give women choices regarding their options, empowering. "Your self-confidence benefits at a really precarious time," she said.