Ontario midwives say there's growing interest in letting them perform abortions

The association representing more than 800 midwives in Ontario says there is a "burgeoning interest" in allowing them to offer abortion services.

The idea was floated in recent months during discussions with the Ministry of the Attorney General and Health Ministry officials while the Association of Ontario Midwives was offering advice on the recently passed Safe Access to Abortion Services Act, which prohibits protests within 50 metres of abortion clinics.

Now the idea is "on their radar," Elizabeth Brandeis, president of the association, said in an interview.

"The Association of Ontario Midwives has a pro-choice position," said Brandeis. "We believe very strongly that reproductive rights, including a spectrum of choices around birthing, also encompass safe access to abortion care."

Midwives do not currently provide abortions anywhere in Canada. In other parts of the world, they play a role, including in France, where they are allowed to prescribe and perform medical abortions. In Sweden, midwives can administer abortion medications, and they counsel women through the process. They can also prescribe contraception.

In Canada, midwives are limited to providing care to women during pregnancy, labour and birth, as well as post-natal care for up to six weeks. There are more than 1,500 midwives working across the country. They go to school for four years to earn a degree in midwifery from one of seven schools offering it and then must meet the standards set by the college of midwives in their province or territory.

Brandeis said the continuity of care and a client-centred approach midwives already provide could easily translate into a model for the provision of abortions.

Abortion system 'fragile'

Midwives could support women as they are making a decision about pregnancy termination or if they have suffered a miscarriage and, as a result, need an abortion, she said. They could also support them through the procedure and provide post-abortion care.

Right now, the system of abortion providers operates in silos, said Brandeis, and that's not helpful for women.

The other main benefit to midwives providing abortions would be increased access to it, especially in rural and remote areas, she said.

"We know that the abortion system is fragile," she said. "There are decreasing numbers of providers offering abortion, and so midwives being able to fill gaps within the health care system is something we are very interested in looking at, not just in abortion provision but in many aspects of reproductive care."

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Abortion clinics exist mostly in urban centres, and women outside those areas largely rely on hospitals for the procedure. Fewer than one in five hospitals in Canada provide abortion, according to the Abortion Rights Coalition of Canada, and they can have long waiting lists or other restrictions, such as requiring a doctor's referral.

The coalition says there is a shortage of doctors able and willing to provide abortion.

Katrina Kilroy, a midwife in Toronto who heads the Canadian Association of Midwives, said there is interest among midwives across the country in providing abortion. "This is not a contentious issue in the midwifery community," she said. 

Kilroy said it's well within a midwife's knowledge base to provide medical abortions by prescribing a medication that terminates pregnancy, and they could be trained to do manual vacuum aspirations, a type of surgical abortion.

It would be a "shame" if governments didn't take the opportunity to allow midwives to provide abortion given the interest and the gaps in the system that need to be filled, she said.

"If there is an entire class of caregivers who could be offering that service, and they're not able to offer that service, that's a question for policymakers," said Kilroy.

Health minister rejects idea

Ontario Health Minister Eric Hoskins, who was a physician before he was a politician, told CBC that the government has already been working with the midwives association to expand their scope of practice, which is set out in the Midwifery Act and is regulated by the College of Midwives of Ontario. The expansion includes ordering laboratory tests and prescribing more drugs that fall under the Controlled Drugs and Substances Act.

"We are not currently considering expanding the scope to include abortion services," said Hoskins.

"This would require a significant amount of work, and although we are open to all discussions, it's not currently an activity that the ministry is undertaking."

The health minister said he's not ruling it out, but right now, it's not a priority.

Updating the Midwifery Act and creating any necessary training would be a "big undertaking" said Hoskins.

The NDP's health critic, France Gélinas, said removing barriers to abortion access would help women in rural and remote areas like her northern Ontario riding, Nickel Belt, and the government should take the midwives up on their offer to provide the service.

"It's a huge opportunity lost, and the big losers in this are women in northern and rural Ontario," she said.

"Why not pursue it? It's a good fit. It makes sense." 

If the government did follow through on the idea, there would no doubt be some opposition, the Ontario midwives association said.

"There are people opposed to abortion in general, so having another provider enter that space, we expect that there would be reaction and backlash from anti-choice advocates," said Brandeis.

Minister should 'entertain' idea

The idea is getting traction, however, with doctors and nurses at Planned Parenthood Toronto.

"Adding midwives to the roster of people providing abortion care is a smart way to go," said Sarah Hobbs Blyth, executive director of the clinic. "I think the minister should entertain it."

If the Health Ministry is already expanding the drugs that midwives can prescribe, it should consider allowing them to prescribe Mifegymiso for medical abortions, said Hobbs Blyth.

"The timing seems fortuitous," she said.

Doctors at the Planned Parenthood Toronto clinic will soon have Mifesymiso at their disposal.

Mifegymiso is a prescription drug used to terminate early pregnancies that was made available in Canada in January after a lengthy Health Canada approval process.

Ontario began covering the cost of it in August. The government said that would help increase access to abortion and provide a more affordable option for women.

Health Canada told CBC the decision whether or not to allow midwives to prescribe and administer Mifegymiso is up to the provinces. 

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Manavi Handa, an assistant professor at Ryerson University in its midwifery program who has been a midwife for 17 years, said it would be a personal decision for midwives to offer abortion services, but they should have the option.

Some countries have "physician-only" laws that prohibit anyone other than doctors from providing abortions, but Canada isn't one of them, said Handa, and that would make it easier for the provinces to proceed with incorporating abortions into midwives' scope of care.

In many other countries, midwives are thought of as specialists in reproductive health and not only providers of care during and after pregnancy, she said. She said she'd like to see that spectrum of knowledge more recognized in Canada, especially as access to abortion "continues to be an issue" in some parts of the country.