Multiplying Alternatives: ASAC and the Development of Midwifery in Alberta 1979-2009.

By Cherilyn Michaels

A historical article about the origins of ASAC and the birth of Birth Issues Previously published in Birth Issues, Summer 2009 

The Association for Safe Alternatives in Childbirth has been an important voice for birth choices in Alberta for the last thirty years.  Although ASAC has never had more than a few hundred members, it has had a large impact out on childbirth options in Alberta. Two of ASAC’s goals, I believe, best represent the organization’s position:

1. To encourage families to take an active role and assume responsibility for decisions regarding their care

2. To assist families to achieve the birth experience they desire in the setting of their choice (hospital, home or birthing centre)

Although a major focus of ASAC has always been to promote the legalization and funding of midwifery care, ASAC’s underlying position has always been one of respect for families’ choices regarding their care, whatever form it takes.

ASAC has played a critical, if sometimes indirect, role in the development of birth alternatives such as legal midwifery care in Alberta. The value of simply providing information to families about topics such as home birth cannot be underestimated.  It is impossible to say for certain how ASAC’s persistent lobbying efforts in the end affected the timing of the legalization and funding of midwifery in Alberta, but there is no doubt that they helped keep the issues in public view, and helped maintain political pressure to make real birth choices available to Alberta women.  Perhaps most importantly, the ASAC community itself has been a unique source of support to families seeking information and support for their birth related decisions.

The founding of ASAC

The beginning of ASAC’s story is inseparable from that of Dr. Ben Toane, who spearheaded its creation thirty years ago at a meeting attended by close to one hundred people.  As a young physician, Dr. Toane was the only Edmonton doctor willing to attend home births, and one of only two in Alberta.

Starting in 1978, Dr. Toane worked with midwives Noreen Walker and Sandy Pullin, both of whom were just starting out in their chosen profession, to provide an avenue for women seeking an alternative to hospital birth.  Despite keeping a low profile, he immediately attracted the attention and censure of the Alberta College of Physicians and Surgeons (ACOPS). Before long, the college revoked Dr. Toane’s admitting privileges at the Sturgeon General Hospital because of his involvement in home births. This action was followed up in December 1980 by the ACOPS ruling that no Alberta doctor was permitted to attend home births without obstetrical admitting privileges. This one-two punch effectively eliminated the possibility of physician attended home birth as an option for all Alberta families, as by this time Dr. Toane was the only Alberta doctor still attending them.

This was the context in which the newly formed Association for Safe Alternatives in Childbirth was defining itself as an organization. The editorial in the ASAC newsletter of January 1981 conveys the desperate situation among those planning home births at that time:

The [ACOPS] ruling also left a lot of couples in a very uncomfortable and disappointing position. What can you do when for 9 months you have been planning and preparing for a homebirth and all of a sudden ‘those doctors who are here to protect us’ tell you it is too bad and you are just being selfish anyway! The ability to have a medically attended homebirth in Alberta means finding a doctor to be there that also has admitting privileges. Good luck.1

Some insight into the attitude of the college is perhaps given by that of the college registrar, Dr. Roy le Riche, who reportedly commented,”… isn’t it silly that some ladies are fussing about whether to have their babies at home or in hospital?”Ironically, this ban on physician attended home birth may have actually benefited the development of midwifery in Alberta comments Dr. Toane, “… really we can credit Dr. LeRiche with the establishment of midwifery as a profession in this province, because he single-handedly convinced physicians to prohibit their colleagues from attending home births in this province, thereby leaving the door open for the venerable profession of midwifery to find its rightful place.”3

Sandy Pullin and Noreen Walker, the midwives who had been working with Dr. Toane, decided to continue practicing on their own, attending 43 home births in 1981, and over one hundred in 1982.  Any hope that Dr. Toane or any other doctor might return to attending home births was dashed by the 1981 ACOPS ruling prohibiting all Alberta doctors from attending home births, whether they had admitting privileges or not.

Midwifery not a legally recognized profession

Initially, ASAC’s focus was to attempt to reinstate physician attended home births. “If ASAC is to succeed in persuading ACOPS to change its recent position, ASAC members must mount a massive campaign to educate and gain the support of the public, physicians, nurses, and politicians.”4

In 1981, as now, a major purpose of the ASAC was to educate families regarding childbirth alternatives.  However, the mode was a little different.  Because the ASAC newsletter was a member’s only publication, as opposed to being widely available to the public, the strategy was to train ASAC members to debate and argue the case for home birth so that they could convince others.  There were actually study questions in the newsletter, along with photocopied articles in which relevant information could be found.  The questions in the April 1981 issue of the newsletter were as follows:

– Dr. Mehl has researched homebirths versus hospital births and found that in many ways hospital births are actually more dangerous than homebirths.  Can you summarize his findings?

– What hospital procedures were found to lead to a higher incidence of hospital birth complications?

– What percentage of women require hospital intervention?

– Describe the role of screening in a homebirth program?

– The American College of Gynecologists and Local Physicians have stated that homebirths are two to five times more risky than hospital births.  What information are they basing this statement on and why is it invalid?5

In the ongoing societal debate about the safety of home birth, it does not seem like the types of misconceptions that exist about the safety of home birth, nor the arguments that are leveled against them, have changed much in thirty years.

In 1981, ASAC’s stated goals were as follows:

– To promote education about the principles of natural childbirth.

– To act as a forum facilitating communication and cooperation among parents, medical professionals, and childbirth educators.

– To encourage and aid in the implementation of family centered maternity care in hospitals.

– To assist in the establishment of maternity and childbearing centres.

– To help establish safe home birth programs.

– To provide educational opportunities to parents and parents-to-be that will enable them to assume more personal responsibility for pregnancy, childbirth, infant care, and childrearing.

Although these goals are certainly shared by the ASAC of today, it is interesting that they make no reference to midwifery. There were of course practicing midwives in 1981, but they were working in a legal gray area. Without legal recognition, all midwives were open to lawsuits, charges of practicing medicine without a license, and the like. The following reminder in the July 1982 ASAC News brings home this situation: “Please note that the legal position of our midwives is tenuous at best.  Out of respect for the personal and professional service these individuals provide for us, please do not give their names to the media or use them in birth announcements without their individual and prior approval.”6

The first attempt in Alberta to legally recognize midwifery was unsuccessful, but did bring the issue into public view.  This attempt was an application by the Alberta association of home birth midwives (the Alberta Council and Register of Domiciliary Midwives Association) to be licensed under the Health Occupations Board.  The underlying tension with respect to licensing was whether midwifery was to be viewed as a specialized form of nursing, integrated into the regular hospital childbirth system, and managed by doctors, or whether it was to enter legal existence as a fully independent profession, able to practice according to the “midwifery model of care” which includes such tenets as choice of birth location (including, of course, home birth).

After this first unsuccessful attempt, the home birth midwives joined forces with the Western Nurse Midwives Association to form the current organization, the Alberta Association of Midwives. This allowed the issue of birth location to become somewhat decoupled from the question of the legalization of midwifery care in general.7 It was important because it set the stage for midwifery to exist as an independent profession, as opposed to a specialty of hospital-based nursing.

The roots of other ASAC programs and activities

The first few years of ASAC’s existence saw the beginnings of most of the programs and activities still around in one form or another today.

Initially meetings were held at the homes of members.  There were family dances for fundraising right from the start, and ASAC members sold raffle tickets and held garage sales. Soon ASAC had locked onto the mother-lode of funding for non-profits in Alberta.  ASAC volunteers worked their first casino in October 1983, and jubilantly proclaimed it, “our most profitable fundraising event to date. And how profitable you ask? How does $10,000 sound to you? That’s an awful lot of cookies to bake!”8

Then, as now, the funds were used to support ASAC programs such as bringing well-known speakers to Edmonton. Early on, ASAC brought in Dr. Robert Mendelsohn (December, 1981), Sheila Kitzinger (October, 1982), and Ina May Gaskin (March, 1983) all of whom delivered public lectures to ASAC members and many others. The cumulative effect of these sorts of events, plus ASAC’s ongoing letter writing campaigns and media interactions, was to raise the profile of childbirth related issues among the general public and the medical profession.

The ASAC library was established at the librarian’s house in late 1983, and reprints of articles from ASAC publications were made available at cost for $0.50.  The first ASAC-organized Maternal Health Fair was held in November, 1984.

The birth of Birth Issues

By June 1981, the original ASAC newsletter had evolved into the ASAC News, still a members only newsletter, but with a strong educational component. Issues in the early years contained informational articles on topics such as breastfeeding, episiotomies, vaginal deliveries after caesareans, comparisons of obstetric care at home and in hospital, immunizations, circumcision, midwifery care, post-partum sexuality, ultrasound, and birth control: on the whole content that would be entirely at home in Birth Issues today.   It’s easy to forget, though, how much more difficult it was to obtain good information on many of these topics at that time, before the advent of the internet, and thus what an important role ASAC publications played in disseminating information to the membership, and later on to many others.

In the summer of 1983, ASAC began to publish ASAC News bi-monthly in a newsprint format, in order to attract advertisers and reach a larger audience. The distribution was increased from 250 to 1000, representing the first time ASAC had attempted to produce a publication primarily for the general public. Birth stories were included in ASAC News for the first time: the first two stories, contributed by Wendy Antoniuk and Heather Brown, reported a positive hospital birth experience and a positive home birth experience, starting a tradition of depiction of a variety of safe choices in childbirth that continues to this day.

Later that year, ASAC and it sister organization, the Calgary Association of Parents and Professionals for Safe Alternatives in Childbirth (CAPSAC) merged their publications to form Birth Issues, and the province-wide circulation increased to 3000 by 1984.

One aspect of Birth Issues content that was very much in evidence in the early years was the presence of statistics on home birth outcomes reported by local midwives. For example, the “Domiciliary Midwifery Report” published the July 1984 issue of Birth Issues includes a complete report on all 245 births attended by Sandy Pullin and Noreen Walker from 1980 to 1983.  It supplied detailed information about outcomes, such as length of gestation, apgars, transfers, presence of meconium, episiotomies, cord wrap, and much more. This kind of information was an excellent resource for evaluating the safety of midwife attended home birth.

In the following years, Birth Issues underwent several other transformations: back to a newsletter format, complete with fancy Mac fonts (remember those?) and later to its current newsprint magazine format. A little over ten years ago, ASAC and CAPSAC decided to once again run independent publications.  ASAC kept Birth Issues, and CAPSAC started publishing Birthing. By 1997, Birth Issues had a circulation of 5000, which was doubled to 10,000 in 1998, and is presently somewhat more.

The recognition of midwifery

The increased visibility of the midwifery and home birth debate helped lead in 1984 to the creation of a new hospital based study project to evaluate the use of midwives in a hospital setting. The designer of the study, Dr. Fawzy Morcos, chief of obstetrics at the Misericordia hospital, stated that the “experiment grew out of concerns about possible dangers surrounding home births,” coupled with “empathy for women’s desire for attentive, constant care in home-like surroundings.”9 In this study, foreign trained midwives worked with obstetricians as part of the “birthing team”.

This pilot project was well received, and in 1988, the hospital proposed “bringing midwives into the delivery room”, a prospect that would require that they be licensed. The next year, the Alberta Association of Midwives applied to be recognized under the Health Disciplines Act.  Before a decision was reached, midwife Noreen Walker faced criminal charges for practicing medicine without a license, at a birth that had proceeded without incident, and with which the parents had no complaint.10 In the end she was acquitted.  The case probably helped the cause of licensed midwifery in that it increased public sympathy and revealed medical harassment of working midwives.11 Noreen Walker commented, “It consolidated the whole issue.  We had 100 per cent public support.”12

In July of 1992, legislation was finally passed that legalized the profession of midwifery in Alberta. Another two years later, a detailed proposal for the regulation of midwifery had been worked out. The government promised that funding was imminent:”Billing details have yet to worked out, but Alberta Health communications officer Gordon Turtle says midwifery will become an insured service.” Susan James, at the time head of the Alberta Association of Midwives, added, “For women it will be just like seeing a physician — they won’t have to pay up front.”13 However, it would be another fifteen years before funding of midwifery in Alberta actually occurred. What happened?

Regulation without funding

In 1994, health care administration in Alberta was splintered into seventeen regional health authorities, each of which was supposed to make independent decisions about midwifery funding. Midwifery regulations came into effect in 1996, after which local midwives had to be assessed, and then register if they wished to practice as recognized professional midwives. By 1998, the midwives had registered.

Ironically, this period was a low point for ASAC. An organization like ASAC thrives when it has an urgent purpose, and after the regulation of midwifery, it appeared to many that the battle had been won. Directly or indirectly, this resulted in a very large turnover in ASAC’s volunteers, including the entire executive in 1998, the year I became a member.

In fact, the regional health authority situation had virtually guaranteed that there would be no progress on funding midwifery care. ASAC representatives spoke out whenever possible about funding, but little changed.

It was quickly apparent that from a consumer’s point of view, regulation without funding was in many ways worse than nothing. Saddled with registration related costs and large insurance premiums, the midwives were forced to raise their rates steeply. The cost of hiring a midwife privately more than tripled between 1994 and 2009. Many midwives stopped practicing. Some chose not to register and reportedly attended births as ‘attendants’. Some moved to provinces such as Ontario and British Columbia where midwife attended births were fully funded as part of the provincial health care. There were not enough practicing midwives to meet the demand from parents.

ASAC regrouped around the twin goals of achieving funding for midwifery, and of providing information about childbirth alternatives to as wide an audience as possible. ASAC focused particularly on providing information via Birth Issues, and in growing a supportive community of parents. Playgroups were started, the library was expanded.

Sadly, the actual options available to women in Alberta continued to deteriorate, as more and more midwives were unable to continue to practice. By 2003, when fully half of the practicing midwives in Edmonton chose not to continue, the situation was becoming dire.

Funding at last

Given the total lack of progress on midwifery funding for fifteen years, it was more than a little astonishing when on the International Day of the Midwife, May 5, 2008, Minister of Health Ron Liepert stated in question period:

“I believe that midwifery does play an important role in the delivery of the health system. We included midwives as part of our health workforce action plan, and we will be delivering on that plan over the course of the year.”14

This time, the promise of funding was not a mirage. In October 2008, two months after recombining the regional health’s authorities, the Alberta government announced that starting in April 2009, midwife attended births, at home or in hospital, would be fully funded by Alberta Health.

The road ahead

Now that midwifery is to be integrated into the mainstream health care system, much remains for ASAC to accomplish. It will be essential for ASAC to act as a watchdog with respect to the implementation of midwifery within the healthcare system. ASAC will maintain its role as a critical resource for families seeking to take responsibility for their childbirth choices, and will provide a voice for those concerned with these issues. ASAC will also continue its role as a unique and supportive community of those who are passionately committed to making the best possible birthing and parenting choices for their families.

Cherilyn Michaels has an M. Sc. in Computer Engineering and works as a software developer.  She has two children, Jacob (14) and Madeleine (11), both born at home with wonderful midwives.  She was ASAC president in 2002-2003, and has served in various other roles with ASAC since she first got involved in 1998.  She is currently the ASAC webmaster.

Note from Editor in Chief: Since the publication of this article, Alberta has a College which regulates the midwifery profession (Jan 1, 2013) and Alberta doctors can again attend home births, if they have a sanctioned 2nd attendant (such as a nurse, doctor or midwife).