When governments make funding cuts, they are doing more than removing financial support; they are signalling that they are prioritizing or, more accurately, deprioritizing certain interests.
On November 8, 2018, the Ontario Ministry of Health and Long-Term Care notified the College of Midwives of Ontario that it would no longer receive operational grants, reducing the capacity of the College to provide oversight of midwives in their provision of care to expectant mothers and their families. The move seems to run counter to the government’s stated aims in health care. If strengthening Ontario’s system is its objective, funding for midwifery should be restored and expanded, not slashed.
The College, which has been receiving less than $1 million yearly from the ministry (about one-third of its operating budget), uses that funding to ensure a high level of practitioner standards in order to protect the public and to adhere to the profession’s guiding legislation. It ensures that midwives have oversight in their practice and that the public has an active body to which it can report problems with their care if needed. The funding cut, which eerily coincided with the College’s 25th year of regulating midwifery in the province, had two observable effects.
First, it immediately curtailed the College’s ability to operate at its current capacity. The government didn’t just phase out funding and give the College time to prepare a sustainable operational plan without the grant; it made the cut retroactive to April 1, 2018, forcing the College to make swift decisions that would impact the livelihood of midwives. Such a cut appears punitive, not measured. The College reported that, in order to maintain its current level of services, it would require increases to the $2,200 per year in members’ annual dues. On an average salary of $60,000 to $80,000, additional fees are not easy to swallow. Yet the College cannot reduce its oversight of midwives, as this role is mandated by Ontario law, so the funding must come from elsewhere.
Second, it muddies the public’s understanding of the Ford government’s framework for health care renewal. When it is widely understood that Ontario’s health care costs are escalating and the resources available are insufficient to meet current needs, cutting resources to professionals who play an important parallel role to physicians in maternity and neonatal care is short-sighted.
When Ontarians reflect on the problems associated with their health care system, most point to the obvious factors: long wait times for certain procedures such as MRIs, the lack of hospital beds, not enough primary care physicians. All are valid concerns that must be addressed. However, more thorough analyses also point to Ontario’s threadbare framework for parallel health services: non-emergency, community-centred care, including at-home visits for seniors, home care for individuals with chronic illness and midwifery care.
Midwives perform a vital service. They take 17 percent of births out of the hands of Ontario’s obstetricians and primary care physicians, whose services are urgently required elsewhere in our system. They provide an extraordinarily high level of pre- and post-natal care, offering the same diagnostics and monitoring women would receive from a physician for labour and delivery. In providing home visits after birth, they also reduce the need for new parents to haul their infants into doctors’ waiting rooms full of sick patients. This type of care is of particular importance in rural and remote areas, where expectant and new mothers are even farther away from (already limited) pre- and post-natal care. The effects of midwifery care on patients are clear: mothers who have been in their care overwhelmingly report a high level of satisfaction and tend to return to midwifery care for later pregnancies. Further, mothers who have received midwifery care tend to require less medical intervention and spend far less time (if any) in hospital. In other words, the midwifery model of care saves money.
The goal of the provincial government should be not to limit the College’s ability to maintain high standards of midwifery service, but to enhance midwives’ capacity and in so doing provide greater relief for our overextended primary health care system. The demand is certainly there. According to the Association of Ontario Midwives, the province’s more than 900 midwives have to turn away roughly 25 to 40 percent of mothers who want to be in their care. Indeed, pervasive problems such as wait times and the lack of available care are seen in midwifery, too.
The government should consider a number of initiatives. First, it should strengthen the College of Midwives of Ontario and provide a high level of resources to these health care professionals. Second, it should increase midwives’ compensation, as the Human Rights Tribunal of Ontario directed in a September 2018 decision on pay equity. Health care professionals must receive a competitive wage for their services if they are to remain in this province. Finally, the government should look at midwives as part of a network of health care professionals that already reduces the strain on Ontario’s traditional health care services; it should recognize that midwives, if given the opportunity, could greatly improve health services and outcomes for low-risk pregnant women, as well as for those in higher-risk groups who prefer midwifery care for traditional, cultural or gender-related reasons.
One way for midwives to do more is through expanding the number and type of diagnostic services and treatments that midwives – university-educated medical specialists – can provide. This could include allowing midwives to perform ultrasounds (reducing wait times in overburdened imaging clinics), increasing midwives’ hospital privileges so that they do not have to call in obstetricians for routine matters, and expanding the list of medications that midwives can prescribe (partially done in 2017).
Reducing spending is a declared priority of this small-c conservative government. However, it had previously announced a $90-million infusion into health care, part of which was geared specifically toward long-term care in the province. Why would a government that recognizes a need to take the burden off hospitals engage in such a frivolous cost-cutting exercise as stripping operating funds from a profession that shares this goal and, indeed, already takes on some of this burden? The dollars are a small line item in the government’s budget, but essential to the profession and the public whom they serve. At best, this decision appears intended to trim administrative costs (without any improvement in services). At worst, it could be construed as a way for the government to prevent the College from advocating for the pay equity supported by the HRTO.
Public outcry against the funding cut appears to have resulted in a temporary hold. But the larger issue remains: we ignore the role of specialized services in Ontario’s health care system at our own peril. This episode is an unwelcome distraction from an essential conversation about the role of health care services outside of hospitals. Academic research in Ontario and elsewhere shows better health outcomes, higher rates of patient satisfaction and lower costs when health care is delivered at home or in clinics. Furthermore, we need only look at health care statistics south of the border to be reminded that emergency care is the most expensive care option.
Childbirth is the number one reason for hospitalization in Canada. Midwifery services are a part of this network of health care professionals who can bring our health care costs down, while improving patient experience. Moreover, as one of the most established professions in parallel health care in the province, midwifery could serve as a model of health care delivery for other sectors seeking to expand out-of-hospital health care. Ontario has the opportunity to lead with smart, transformative change. This should include the restoration of funding to the College of Midwives.
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