LETTER

“Shame on Us!”

To the Editor,

In response to Beverley Chalmers’s guest editorial in

Birth (2011;38[4]:279–281), the College of Midwives

of Ontario would like to provide an important

clarification. The editorial implies that it is a Canadian

standard in the midwifery profession for regulatory

bodies to support their members in terminating the

care of clients who do not follow the midwife’s

clinical recommendations. This is not the case—to

suggest it is paints a false and negative picture of

regulated midwifery across the country.

Chalmers’s editorial discusses a case described in a

previous article by Andrew Kotaska (“Routine

Cesarean Section for Breech: The Unmeasured

Cost,” Birth 2011:38[2]:162–164), wherein a British

Columbia midwife, with the support of her College,

terminated the care of a woman who refused to

follow her (and two obstetricians’) recommendation to

undergo a cesarean section for a breech baby. The

mother chose to labor at home unattended, and

unfortunately the baby died shortly after birth.

Chalmers makes the following statement about this

tragic incident (p 279):

Had this birth occurred in the United Kingdom and not in

Canada, the midwife would have been advised by the Royal

College of Midwives to continue to give the best care

possible, even if the woman refused the advice given to her.

Is it not possible to find a reasonable compromise that,

although not approving risky birthing settings, also allows for

skilled care at birth and protection of the caregiver from

adverse legal consequences? Such a compromise is possible

in the United Kingdom but not in Canada. Why?

In actuality, such a compromise is not only possible

but promoted in most, if not all, Canadian jurisdictions

where midwifery is regulated. Although the details of

this case are not discussed, it is an isolated incident

that does not warrant blanket statements like that by

Chalmers. Her comments are problematic because they

assume that all Canadian midwifery regulators would

have managed the situation the same way, which is

inaccurate.

The College of Midwives of Ontario has a standard

entitled “When a Client Chooses Care Outside

Midwifery Standards of Practice” that outlines a step-

by-step process to assist midwives “to support a

woman’s decision after an informed choice discussion

has taken place” and—ideally—to reach a mutually

agreed upon decision. However, if this process is not

successful, the standard clearly states that the midwife

must attend the client in labor: “In the course of

labour or urgent situations, the midwife may not refuse

to attend the client. When the steps for discontinuing

care of the client have not been undertaken or

completed prior to the onset of labour, the midwife

must attend the woman.”

Other provinces and territories have similar

processes for managing cases where the client’s

informed choice does not follow the recommendation

of the midwife. Abandoning the care of a client is not

standard practice anywhere in Canadian midwifery.

Deborah Adams MA, MHSc, CHERegistrar and CEO

College of Midwives of Ontario55 St. Clair Avenue West

Suite 812, Box 27Toronto, Ontario M4V 2Y7

Canada

Reply:

I welcome the College of Midwives of Ontario

clarification that it is not standard practice in Canada

for the midwifery regulatory bodies to support their

members in terminating the care of clients who do not

follow the midwife’s clinical recommendation.

According to Andrew Kotaska’s article in Birth(1, p 163), “The College of Midwifery guidelines in

the province of British Columbia clearly state that

breech birth is outside the midwifery scope of practice

and advise withdrawal of care rather than attendance

in labor.” This statement appears to be in contradiction

to Deborah Adams’s letter that states “such a

compromise [that allows for skilled care at birth in

risky circumstances such as these] is not only possible

but is promoted in most, if not all, Canadian

jurisdictions where midwifery is regulated.” Both

Kotaska (1) and I (2) note that British Columbia is the

jurisdiction in question. Adams’s letter does not

specifically state that British Columbia is in agreement

with her generalization to “most, if not all, Canadian

172 BIRTH 39:2 June 2012