What Can Ontario Midwives Tell Us About Policy Processes?
During the 1980s, midwives in Ontario, Canada underwent a dramatic transformation in which they went from being considered incompetent ‘quacks’ associated with a ‘lunatic fringe’ to authoritative professionals associated with the educated choices of white, middle class women. By the early 1990s, and despite persistent objections by physicians, the provincial government proclaimed the first act legislating midwifery in Canada, resulting in what is arguably one of the most progressive midwifery acts in the world. Indeed, the Midwifery Act established midwifery as a direct-entry, self-regulated profession, enabling midwives to ‘catch’ babies in homes, hospitals and birthing centres. Moreover, midwifery was integrated into the provincial health insurance programme, making the service free for pregnant and parturient women.
How might we explain this interesting turn of events? After considering alternative explanations, we argue that the policy process itself enabled this transformation. In particular, we suggest that commissions of inquiries (COI) fostered a reconsideration of previously held social constructions by providing the fora where social constructions of midwives shifted from ‘deviants’ to ‘experts’, eventually resulting in the adoption of policy favouring midwives. Thus, key to policy change was not just midwifery advocacy, but how midwives transformed themselves from ‘quacks’ to ‘professional’ health care providers.
With the ascendance of modern bio-medicine at the end of the 19th century, Canadian midwifery was nearly decimated. As medical historians have demonstrated, key to gaining a monopoly in obstetric care among physicians was maligning midwives as incompetent and unsafe. As this image took hold, and with physicians’ promises of effective pain management, midwives were removed from birth practices throughout much of the country. State sanctioned bio-medicine secured this monopoly by prohibiting by law the practice of medicine without a licence. Thus, by the mid-20th century, nearly all babies were born in hospitals attended by bio-medical professionals.
A number of factors, such as the natural birth and women’s health movements, led to the re-emergence of midwifery in Canada. In Ontario, both community midwives and nurse midwives operated clandestinely to serve a growing population of women seeking more humane birthing experiences. At the same time, by the early 1980s, the Ontario government was proactively seeking alternatives to a perceived crisis in health care, particularly in obstetric care. Although midwifery in various forms had been discussed as a potential alternative to rising costs of healthcare since the 1970s, its position in public debate was by no means certain. Indeed, midwives were much maligned in public discourse, despite their re-emergence among middle-class, educated women and despite increasing efforts to professionalize. Moveover, physicians vehemently rejected any proposals for midwifery, referencing concerns about safety and competence, and conservative politicians were unwilling to support the practice outright.
When the deaths of two infants in 1982 and 1984 brought widespread public attention to the issue, midwifery could no longer be ignored. In Ontario, infant deaths necessitate coroner’s inquests. These two inquests, followed by a provincial task force on administrative reform in healthcare and, subsequently, a task force specifically to assess options for midwifery, we argue, enabled a discursive shift within the arena of health care, by opening space for new actors and counter-narratives to gain legitimacy. These commissions of inquiry provided fora in which to explore new ways of thinking about midwives. Specifically, COI offered a context in which moral and political entrepreneurs could exchange ideas and advocate for a change in policy design, which led to the introduction of self-regulated midwifery in Ontario. Indeed, a number of well-positioned supporters, all of whom were male renowned physicians, spoke to the benefits of midwifery for mothers and babies, through better health outcomes, and for governments, through more cost effective service.
As this process unfolded, the social construction of midwives changed drastically. By the time the task force was commissioned, midwives were granted considerable professional legitimacy and authority by key political entrepreneurs, including senior bureaucrats and elected and appointed officials. This newfound legitimacy made it possible to conceive a new policy infrastructure where midwives would coexist with other professions within the health care system. To be sure, political entrepreneurs came to recommend that midwives themselves determine and govern the conditions and scope of practice, and also that Ontario women have access to their services as they desired. The professionalisation and mainstreaming of midwifery within the health care system represents a substantial policy change from previous arrangements where midwives operated mostly in obscurity.
The Ontario case demonstrates the importance of social constructions in facilitating changes in power relations between social groups vis-à-vis the state. The legalisation of midwifery in Ontario offers an example of the potential for marginalised groups to challenge dominant power relationships by shifting their social constructions. Shifting perceptions of midwives in Ontario, from being marginalised, deviant actors to legitimate health practitioners, significantly contributed to the ability of midwives to re-negotiate traditional power relations with physicians’ groups. In particular, this case demonstrates the importance of moral and political entrepreneurs in facilitating this social construction, and of COI in providing space for positive images to be communicated to policy-makers.
This is a significant finding given the international climate of midwifery. Despite continued support from the World Health Organization, midwifery services throughout the world are precarious, suggesting a possible negative shift in social constructions of midwives. For example, recent threats to independent midwives in the UK and the declining number of home births in the Netherlands suggest renewed scrutiny of midwives even in areas with longstanding commitments to midwifery services. In addition, midwives in the global south are under threat from the increasing use of biomedical science in the area of obstetric care. These conditions point to the importance of social constructions in policy design. Our goal in the paper is to continue dialogue on the potential role of shifting social constructions in policy change.