When Ellie Shortt found out she was pregnant in March, choosing to use the services of a midwife to help her through her pregnancy was a no-brainer. 

She already wanted to have a natural birth at home—and once the pandemic hit, she had no doubt that was the right call. 

“I think having the option of doing a home birth was really important to me,” she said. “I’m a big advocate for women feeling empowered and autonomous in the process.”

On Oct. 18, Shortt gave birth to a healthy baby boy, and though she ended up in the hospital due to the potential for complications, she said the midwives helped her have the birth she wanted.

The demand for midwives has shot up to an all-time high during the pandemic. Like Shortt, more and more mothers are opting to avoid increased-exposure places like hospitals and give birth at home, if their pregnancy allows. 

That increase in demand for midwifery services, coupled with the strain of a pandemic and long-simmering challenges has pushed the profession close to its breaking point. BC’s 300 midwives currently deliver about a quarter of the province’s babies, but a large majority of them are suffering from burnout. A recent report shows if action by the provincial government isn’t taken quickly, a big portion of these primary care workers could leave. 

Skyrocketing burnout

Alyson Jones, a Victoria-based midwife, has been practicing for 11 years. Since March, she says her workload and the demand for her services have “increased a ton.”

Midwives in BC are trained to help and care for women and their babies during pregnancy, labour, birth and up to six weeks postpartum.  

The majority of the extra workload for Jones has been cleaning, pandemic planning and transitioning to virtual appointments. But with their office assistant working from home, the routine tasks assistants would usually do in the clinic—like weighing babies and wiping down surfaces—have fallen on the midwives.

Making matters more complicated, new clients have been transferring into the clinic’s care, in order to give birth at home, later than usual. According to a recent survey conducted in November, 89% of BC midwives reported an increased interest in home births, with each midwife planning an average of two home births per month. Midwives typically care for up to five clients each month.

The increased workload and lack of support from the government is resulting in skyrocketing burnout rates among BC midwives. 

According to the recent survey, midwives experiencing work-related burnout increased from 45% in 2017 to 77% during COVID-19. 

The survey also shows two thirds of midwives in the province say they are working more because of COVID-19, with 61% reporting they worked at least 10 additional hours of unpaid work per month. 

“One of our biggest challenges has been keeping ourselves and our clients and colleagues safe while also wanting to uphold and support the birthing environment for people,” Jones said. 

The biggest part of keeping clients safe has been, of course, the use of personal protective equipment like gloves and masks. However, for the first eight months of the pandemic, the government only provided midwives with PPE for hospital births. More than 80% of the midwives in the province reported having to buy their own PPE to protect themselves and their clients during clinic and home visits–which make up the majority of their work. In November, PPE was finally made available to them for all uses. 

“During COVID, midwives have shown that we’re skilled, dedicated, and adaptive, but midwives have been carrying that cost,” said Lorna McRae, co-founder of Access Midwifery and Family Care in Victoria. 

“The Ministry of Health only funded all our PPE in November and we’ve been going on this pandemic for nine months now—that’s as much time as it takes to make a baby.”

While quarantine replacement income has been available to other primary care workers throughout the pandemic, midwives haven’t had access to this support. 

The majority of midwives in the province are paid on a fee-for-service model rather than salary, meaning that they are not paid for time off and administrative duties. So, if a midwife gets sick or has to self-isolate due to COVID-19, they lose out on that pay. 

“What we’re just finding is that midwives have been really unfairly left out of these important programs for all other health-care providers and all other central and frontline workers,” said Lehe Spiegelman, president of the Midwives Association of BC. 

Spiegelman added that with an increase in home births, midwives are actually helping reduce the pressure on hospitals during the pandemic as well as saving money and resources. 

In a September report from the Sustainable Midwifery Practice Taskforce, nearly half of BC midwives highlighted poor pay as a barrier to successfully managing their workload. Some also reported having to take on more clients to earn enough income, sometimes sacrificing the time it takes to build relationships with their clients or having a healthy work-life balance.

“We all love the work and find it very rewarding, however, there are constant underlying stresses,” McRae said. “There are many pieces of the system that don’t allow us to fully do our work and be compensated properly.”

BC midwives are paid the second-lowest in the country, when comparing fees paid for clinical care in the three provinces where midwives work as independent contractors: Alberta, BC and Ontario. Despite the higher living costs in BC, midwives in the province have to care for 60 clients to make the same amount as an Alberta midwife caring for 40 clients. 

Ontario currently has the lowest pay, but earlier this year, the Ontario Human Rights Tribunal found that the provincial government was liable for discriminatory compensation practices and ordered that the government retroactively boost midwives’ pay by 20% for work between 2011 and 2015. The government appealed the ruling this summer and lost. 

The tribunal also requested a pay equity analysis for 2015 onwards. Luba Butska, an assistant midwifery professor at UBC, said in an email that it’s expected that Ontario midwives will see a large pay increase.

“BC midwives will soon be not only the worst paid in the country but well behind other midwives, as no similar adjustment nor analysis is planned for BC midwives’ pay,” she said. 

When considering total compensation, including benefits and funding to run clinics, BC midwives are already the lowest paid in the country. 

The majority of BC midwives have no sick leave and no pension plan. Midwives starting their own families don’t even get paid parental leave. They also have no funding to help start and run their own clinics like BC nurse practitioners and physicians do. The overhead costs are entirely on them.

These burnout rates and problems with compensation are in turn leading to a higher percentage of midwives preparing to leave the profession. One in five midwives is actively taking steps to leave—twice as many as in 2017. One in three say they will leave in the next five years if nothing changes. 

“I myself have thought about [leaving] at different times,” McRae said. “In part because of the long-term like a lack of benefit plan, retirement plan, pretty basic stuff.”

McRae, who has been a midwife for 20 years, says she’s getting to the age where retirement is becoming a big consideration. But without a pension plan, McRae expects she’ll have to keep working longer than she had planned. 

She probably would have left years earlier, she says, but she just loves the work.

Midwifery care lacking in Indigenous communities

With more midwives planning on leaving, it is rural and Indigenous communities—the ones who most rely on the profession—who will be most heavily impacted. 

“Midwives are really focused on respecting the preferences and choices that people make, so this kind of model of care has been especially beneficial to people who have been historically marginalized and have had a loss of power,” said Kathrin Stoll, midwifery researcher at UBC. 

While midwives delivered a quarter of the province’s babies in 2017 and 2018, only 15% of First Nations babies were delivered by midwives, according to the recent In Plain Sight report. Indigenous access to obstetricians was also 13% lower than other residents and First Nations were also significantly less likely to have access to more than nine visits with a health-care professional during their pregnancy (the usual schedule in most Western countries).

A Statistics Canada report showed that from May 2004 to May 2006, infant mortality rates were more than twice as high for the Indigenous population in Canada, compared to non-Indigenous populations. 

In Haida Gwaii there is an average of 50 births per year but there are only two midwives currently on the islands. There is also no hospital with a cesarean section capacity, so mothers expecting to need the operation have to travel to Prince Rupert. Even for mothers who don’t need a C-section, travelling to the nearest hospital can be a journey. 

“That’s why it’s so important to keep midwives in rural communities because they enable more women to give birth in that community,” Stoll said. 

Not all mothers can have a home birth—they have to have a low-risk pregnancy—but a US study shows that low-risk pregnant people who receive care from midwives have fewer interventions and fewer C-sections compared to similar women who have non-midwife-assisted births.

The Sustainable Midwifery report shows that when funding for BC midwives has increased in the past, there has been an expansion of midwives to more rural areas of the province to support a more diverse clientele. However, these changes came with no additional compensation, disincentivizing midwives from staying in these areas. 

The problems midwives face across the province are often amplified in remote communities, Stoll said. Midwives working in remote communities are even more burnt out because they have to travel further to see clients and there are fewer other health-care providers to share the workload. 

Midwifery care in BC has also not been free of racism. The In Plain Sight report about discrimination in BC’s healthcare system referenced complaints against midwives, including patients being treated disrespectfully, being yelled at or being the subject of racist remarks. 

The percentage of Black, Indigenous and people of colour (BIPOC) midwives graduating from programs “continues to not be high enough,” Stoll said, and the November survey showed that while 20% of midwives in the province are planning on leaving, that number is even higher, 25%, among BIPOC midwives.

“If people are already stretched to the limit, and now you have BIPOC midwives who are also experiencing systemic discrimination and racism, that makes everything harder and worse,” Stoll said. “So, it’s not surprising that more BIPOC midwives are considering leaving.”

Spiegelman says since the report came out, the association has been working to identify and reveal the problems within the system, and all midwives are expected to do cultural safety training. She added the association is committed to removing barriers and increasing the numbers of BIPOC midwives.

More support needed

Every three years, midwives renegotiate their contract with the government but the most recent collective agreement offer last fall was rejected by two thirds of midwives due to missing benefits.

“We’ve been hearing very clearly that it’s time for midwives to have access to robust programming such as parental leave, such as benefits, such as retirement plans,” Spiegelman said. “And the contract offer in October of 2019 did not successfully reach our needs for achieving enough funding for these programs.”

Negotiations resumed and went well into the summer, but the Midwives Association of BC has now requested to move to arbitration. 

In a statement, the Ministry of Health said the Midwifery Advisory Committee was created in partnership with the Midwifery Association of BC and is working to address priority issues such as burnout, financial concerns and intentions to leave the profession. The ministry said it values midwives’ roles as essential health-care providers in the province and is committed to addressing the concerns voiced by those in the profession. 

Spiegelman is a practicing midwife as well and said that midwives love the work they do and want to keep doing it, but the profession urgently needs the government to stand behind them. 

“Actually doing the work, waking up at three in the morning and showing up at a birth is what keeps us in these jobs,” Spiegelman said. “Otherwise, I think we would have seen the midwifery profession collapse. It’s because of the love of the work that we do that midwives continue to wake up around the clock.”