Why Can’t Midwives Provide Abortion?

I sat in the waiting room of a busy reproductive health-care clinic with averted eyes, glancing every so often at the people around me. I was pregnant and sitting in a clinic that provides medical abortions in a large urban Canadian centre. The space felt tense — or maybe my own tension was reading the room as I felt it. Some had coloured sheets of paper on their lap as I did. I suspected they were here for the same reasons I was. As a midwife, I also sat uncharacteristically as a patient — on the receiving end of the health care I was used to providing.

As a registered midwife in British Columbia, I along with colleague midwives, family physicians and nurse practitioners, are reproductive primary care providers. It’s not uncommon to think of midwives as people who deliver babies — which of course we do at increasing rates across this country.

What’s often overlooked is that, for the period of pregnancy, birth and up to three months postpartum, we also manage pregnancy loss, prescribe contraception, test and treat certain sexually transmitted infections, support perinatal mental health, discuss pregnancy planning and sexuality and do Pap tests to screen for cervical cancer.

For many of my clients, pregnancy is the first time they interact with the health-care system for a sustained period of time. Family doctor and nurse practitioner shortages mean that many patients arrive into my care without having ever had a physical exam to assess for breast cancer, for example. Many have never been screened for thyroid disorders despite being symptomatic. Many have not had an opportunity to discuss their mental health with a care provider. So as midwives, much like other primary care providers, we screen for medical concerns, treat those within our skillset and then refer to specialists when it moves outside our scope.

While abortion care is not currently considered within the midwife’s scope of practice in B.C., it’s closely connected to what we already do as clinicians.

I already manage and counsel folks on what to expect when a pregnancy doesn’t progress in the form of a miscarriage. I already provide anticipatory guidance and care for those who elect to not be pregnant, even though I don’t prescribe the medications or manage the surgical procedure itself.

Sometimes, a miscarriage demands the very same medical treatment as an abortion. Depending on gestational age and preference, a client with a missed miscarriage — one where the fetus has stopped growing but the tissue hasn’t yet passed — will typically elect either a surgical procedure or a combination of misoprostol and mifepristone medications.

I can’t prescribe those medications even though midwives already use misoprostol to medically manage postpartum hemorrhages on our own authority.

Later this month, in fact, I will take the same course that teaches the management of medical abortions to family physicians and nurse practitioners. I just will not be allowed to use these skills, unlike in other jurisdictions including Quebec and South Africa.

In the reproductive health-care clinic, I was actually, in some ways, pretending I was there to have what is often called a therapeutic abortion. I told the family physicians and counsellors that I was certain of my plans, as I knew that’s what they needed to hear.

But in truth, I wasn’t sure just yet. As a midwife I was well aware of the long wait times and tight gestational age deadlines for abortion appointments, and I wanted to be prepared in case that was the direction I decided on. But at the same time, I also reached out to midwives for pregnancy care — I was preparing for that potentiality as well. I was privileged. Being a midwife gave me intimate knowledge of how to navigate the reproductive health-care system so that I had time to consider both options. I also lived in a large urban centre where both these options were readily accessible.

Canada is one of a few countries in the world without laws restricting abortion. One in four pregnancies end in elective pregnancy termination. However, the biggest limitation to abortion care in Canada is access. Those living in rural and remote areas, underserved communities, as well as those who are uninsured are particularly vulnerable.

Since 2009, the World Health Organization has recommended that midwives be trained to provide abortion care. The International Confederation of Midwives includes abortion care for up to 12 completed weeks of pregnancy in their list of competencies for midwifery practice. And the Canadian Association of Midwives has a provision statement that affirms abortion care as part of a midwife’s professional role.

International research demonstrates that adding abortion to the midwifery scope of practice results in safe outcomes and improved access. Some argue that midwives are, in fact, ideal health-care providers to offer abortions given that our medical model centres informed decision-making, continuity of care and around-the-clock on-call health-care provision at home, clinics and hospitals.

Additionally, in some communities, a midwife is already the most skilled clinician when it comes to reproductive health care. Indigenous midwives are already experts in the provision of culturally safe reproductive health. Including midwives within provincial and territorial plans to safeguard abortion care is one important way that access and safe care can be improved.

In my case, I left the clinic as a pregnant patient with medications in hand. I could take the pills at home as prescribed, including medications for pain relief. I was given instructions on who to call if I needed medical help. I then met up with a midwife to manage the continued pregnancy.

Using the resources of multiple care providers allowed me to sit with both decisions simultaneously. But in truth, I just needed one provider: one who saw my decision as complex, personal and not political. I needed a health-care provider that would allow me to receive good medical care for a pregnancy knowing that, as is the case with all pregnancies, it may not work out in the end. In my case, I just needed a midwife.

So, what would need to happen for midwifery expertise to be brought into the provision of safe abortion care?

Health Canada already permits health professionals to provide abortions, including midwives. However, what a midwife is or is not allowed to do or prescribe is regulated at the provincial and territorial level. There are significant legal and regulatory differences across jurisdictions, and the legislation addressing midwifery in B.C. is known for being particularly restrictive when it comes to scope expansion.

As such, despite our intimate knowledge of reproductive primary care and despite interprofessional consultation and advocacy, bringing midwives into the fold in B.C. requires the impetus of the Ministry of Health, a change to the Midwives Regulation in the Health Professions Act, followed by the support of our provincial regulatory body.

In other words, access to abortion really does remain a matter of political will.