Episode 12: Standing on the Shoulders of Giants with Elizabeth Brandeis, President, Association of Ontario Midwives

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Elizabeth looks back at the past 25 years since the regulation of midwifery in Ontario and reflects on some of the challenges still to face on road ahead.

Today, your host Ellen Gardner, Communications and Marketing at HIROC, speaks with Elizabeth Brandeis, President of the Board of the Association of Ontario Midwives (AOM).

For Elizabeth, the road to becoming a midwife started with her own personal experience with midwifery care, during the birth of her daughter 25 years ago. Now, on the 25th anniversary of regulated midwifery in Ontario, she looks back on where we’ve been and where we are headed.

Elizabeth speaks to the long history of midwifery in Ontario. As President of the Board of the AOM, she shares her view on the critical role the AOM has played in developing a model of care that promotes partnership and informed choice.

Transcript

Imagine you could step inside the minds of Canada's healthcare leaders, glimpse their greatest fears, strongest drivers, and what makes them tick. Welcome to Healthcare Change Makers, a podcast where we talk to those leaders about the joys and challenges of driving change in our complex and demanding healthcare organizations.

Ellen Gardner: Good afternoon, I'm Ellen Gardner. I work in communications and marketing at HIROC and today we're fortunate to be talking with Elizabeth Brandeis, President of the Board of the Association of Ontario Midwives. And we're coping with a bit of outside noise, construction going down. You can tell we're in the heart of downtown Toronto, but also Elizabeth herself might get called away to an impending birth. So we have just a really close view to the kinds of challenges you cope with every day. Maybe I can start by asking you, what makes AOM such a unique organization?

Elizabeth Brandeis: There are many things that make the AOM unique. We're a member organization of the nearly 1,000 midwives who work in Ontario. The AOM has a very long history of organizing midwives and being the advocacy body for midwives in Ontario and Ontario has a very unique history in terms of regulated midwifery. We were the first province in Canada to have regulated midwifery and we have grown tremendously since we became regulated 25 years ago in 1994.

We're unique because we fill many, many different roles for the profession. As I mentioned, we're the advocacy organization, so that means we're very involved in advocacy to government for things like funding and program enhancements. We provide space for midwives to communicate with one another and connect around issues that are important to them in the profession. We also have a department of clinical practice guidelines. So we support the clinical excellence and development of clinical practice of midwives around the province. We also have a very unique relationship with our insurer, with HIROC, and that provides incredible benefits to our membership in terms of being able to engage in risk management activities. And very excitingly more recently, we have a department of Indigenous midwifery, and that's a department that has supported the growth of the resurgence of Indigenous midwifery in Ontario. And that means that midwives who work outside of the regulated midwifery protection under the exception for Aboriginal midwives that existed in 1994 have become funded to practice in their communities and bring Indigenous midwifery back to their communities.

So really the AOM is engaged in a whole number of different activities. Another thing I didn't mention is continuing professional development, exciting events like our upcoming Ontario Midwifery Conference, and opportunities for midwives to learn and to grow together.

Ellen Gardner: Were Indigenous midwives not funded before? They may have been practicing, but they were not funded to practice?

Elizabeth Brandeis: Exactly. One of the things that we were able to negotiate with government in our 2017 three-year contract was funding for those midwives who had previously been working in their communities without public funding, to begin to develop their own practices. There has been, for over 20 years, a birth center in the Six Nations Reserve, but that was funding that had been secured outside of the Ontario midwifery program. And so as an equity measure, we really advocated to the government to be able to grow that program and provide access to Indigenous midwives on par with the kind of access registered midwives have to actually have practice groups and community responsive care.

Ellen Gardner: What drew you to the profession?

Elizabeth Brandeis: It's an excellent question and I would say the short answer is my own experience in midwifery care was kind of the inciting element that really got me engaged with midwifery. I had my own pregnancy and midwifery experience in 1994, which was the year that midwifery became regulated in Ontario. And at the time I was living in Guelph and there was one midwife who practiced in Guelph. And she really exposed me to not just the incredible model of care and quality of care of midwifery, which for me was so different from any other healthcare experience I had had at that point, but also because it was a new, burgeoning profession she also exposed me to all sorts of other complex issues that the newly regulated profession was facing.
And I remember as a client at that time thinking "This is a fascinating profession." This is a group of women organizing around women's healthcare and really trying to integrate into a system that isn't necessarily hospitable all the time to these new members of the profession and things like hospital integration where something was an issue that my midwife at the time talked about when we were talking about the choices that I had around birthplace. I had come into care thinking a birth center would be a great place for me to give birth in, having had a sister who had that option for her in the United States. And when I was told that's not an option here, I thought "Oh, there's a lot of work to do in really growing this new system, but there's so much here to work with." And so it was quite early on in my exposure as a client that I became quite politicized around the issues that midwives were facing. And unfortunately, many of those issues are quite similar to what we're still facing 25 years later, issues of integrating into the system, securing hospital privileges, having our scope of practice respected within hospitals, those things that were being faced by midwives 25 years ago, unfortunately, have come a long way but still have a lot to work on.

Ellen Gardner: Well, how do you maintain your passion for advocacy when there's always these bumps in the road that make it difficult?

Elizabeth Brandeis: Absolutely. I think a real belief in the kind of care that midwives provide is what motivates my advocacy and activism around midwifery. I think midwifery is such a valuable model, not just for pregnancy and birth, but as a model that can be looked at for all sorts of other aspects of the healthcare system, including things like palliative care, senior care, other elements of acute care where patients can be followed in the home in a really personalized way. I really believe in the model. And so I think as we face these perennial challenges and as governments come and go and funding continues to be an issue that we really need to advocate for, it's that belief in the model and that knowledge that the benefit our clients receive from the model is something that can't be disputed. Our client base really is what motivates us as well because we know we need more midwifery, we know that there's still not the supply that's needed for the demand that's out there. So it's really on behalf of those families who are relying on and demanding and benefiting from midwifery care that keeps us doing this work.

Ellen Gardner: If there was something you could say, "You know what? I'm really proud of this, that we've made huge strides in making this happen," and maybe this could be something you personally feel like "I played a role in this," would there be something that comes to mind?

Elizabeth Brandeis: I would say the funding for Indigenous midwifery. That's a fairly new gain in the system. It's something that I certainly can't take any personal credit for, but I feel very proud for the small part that I've played in that growth, in that recognition that the restoration and renewal of Indigenous midwifery is something that's desperately needed. As we move towards reconciliation with Indigenous communities in Canada, it's a key piece in really bringing back midwifery to those communities is a way to see birth in places where previously loss and death have been so much a part of the experience. It's quite profound. So I would say that's one of the areas that I feel very proud to have been a part of, even in a very small way.

The other thing that I feel very proud of, and again I can humbly acknowledge my very small role, is the advocacy around pay equity that midwives have championed. And this is a fight that has come out of years of frustration, of governments not taking midwives' demands for fair and better pay seriously, and taking that all the way to the Human Rights Tribunal and actually winning a favorable decision at the Human Rights Tribunal is something that I think will not just impact midwives for generations to come, but really sets a precedent in gender equity legislation that I know many community groups and lawyers and others have looked to as a very important laying the groundwork for important future equity measures for female-dominated work.

So those are two things off the top of my head. In 2014, we were able to secure funding for birth centers in Toronto and Ottawa and those, I think, on a very personal level, being able to work at the Toronto Birth Center as a practicing midwife has been a tremendous development in my career and something that my clients really benefit from. So I'm quite proud, again, in a small way that I've been a part of that development and I hope that we have the opportunity in the future to have more birth centers grow in Ontario.

Ellen Gardner: You've held a real diversity of roles since entering the profession. You've been very active in AOM, obviously. Now you're president of the board. You're a senior partner of the Midwives Collective of Toronto. You teach at Ryerson. And you've also been on joint committees with the Ministry of Health and Long-Term Care. I mean, any one of those is a very challenging role. Why is leadership involvement so important to you?

Elizabeth Brandeis: I think the answer to that question links back to the passion I feel for the model of care. But on a very selfish level, it's been incredible to have the opportunities for professional development that I have in these various roles. I never imagined when I became a midwife that one of the things I'd be learning in this career path would be government relations, labor negotiations. These kinds of things that really I feel so grateful for the opportunity to have been able to learn in those roles and who knows where that might lead in the future in terms of how I can put those skills to use once my term as president is finished. But I feel very grateful for the diversity of experiences I've been able to have in this role.

Ellen Gardner: Has becoming a more politicized midwife been a bit of a revelation to you?

Elizabeth Brandeis: I would say that has been a through line even from those early days when I was a client in 1994. I had the opportunity to be on the board of what was then called the Ontario Midwifery Consumer Network, which was an advocacy body for consumers to be making noise to government about the importance of midwifery. I did student government work and was the student liaison between faculty and students at Ryerson. So that has really been a through line. I think the surprise has been that opportunity for skill development and also to be a part of so many exciting, historical moments in midwifery. And I think in reflecting on that a lot in this 25 year anniversary of midwifery, I'm reflecting on it because I have one year left in the role as president and thinking about what kinds of things that I'm eager and interested to do in that last year, and also what I feel I want to be able to move forward with future leaders in the AOM. So I think the opportunities that have presented themselves to me have been what have been surprising, but the fire in my own belly about doing this work has kind of always been there.

Ellen Gardner: So what is the most difficult part about managing all your different roles? Because you do juggle a lot. So is it just second nature for you now, doing all these things?

Elizabeth Brandeis: To some degree, yes. But I always say to midwives as they're coming into this profession that the unpredictability never gets easier to manage. I think we rely on surrounding ourselves with people who understand the importance of our work. And so being unreliable, meaning we might miss events because we're at a birth, or I'd have to run away from this interview because I have to go to a birth, this is something that level of unpredictability is always challenging. Lack of sleep is always challenging. It doesn't get easier over time.

Ellen Gardner: We know that, based on the things that you've just said, there's a lot of things we can feel proud of in terms of the Canadian system and even within Ontario. What are some of the things, when you've traveled around and seen in other jurisdictions, maybe in the United States, things that maybe impact the way midwifery is practiced and those things having an influence on safety?

Elizabeth Brandeis: I've had the incredible opportunity to travel both a lot within Canada and fairly recently had the opportunity to spend some time teaching a group of midwifery educators in Ethiopia and also attending an international confederation of midwives, America's meeting in Paraguay, just this last Fall. And I would say there are elements of midwifery in every system that I learned about around the world that can be learned from. But really, the big lesson in seeing that is how our model in Canada and maybe even more specifically in Ontario blends many of the beneficial elements of midwifery that I see in jurisdictions across the world. So the fact that we're community-based practices and that we're not based solely in the hospital is something that's actually quite unique to midwifery. Many models have community-based care and hospital-based care quite separated. And that might even be different midwifery workforces working in the community and working in the hospital. So I think our model in Ontario blends those two systems quite beautifully.

One of the major differences between our system and say, for example, the US system is the way that Ontario midwifery and generally Canadian midwifery really creates a seamless continuity between community-based care and hospital care. So we know, for example, one of the things that really improves the safety of out of hospital birth, and we see that borne out in the outcomes and statistics around out of hospital birth in Canada versus the United States, is that ability for midwives to provide that seamless continuity. So we may be at a planned home birth or a planned birth at a birth center, and have an indication or a need to move into hospital, and we have no hesitation to do that because we know we're welcomed in the hospital, we're part of the staff there, we can maintain primary care in most situations of our clients, and that really does optimize safety for our clients. One of the other things that I would say is really quite unique is our relationship with our insurer, with HIROC, and the fact that HIROC really partners with us and we with HIROC to create mechanisms for safety and support for out of hospital birth, knowing that that continuity that our clients receive is safe care and excellent care that can be supported through a great relationship with our insurer.

Ellen Gardner: So you are talking about the future, thinking about the future and you've got one year left in your term, but if you were going to think about a vision, in other words, what would be something that AOM would really like to see happen in the next five years or 10 years... I'm sure it's something you've thought about.

Elizabeth Brandeis:  Absolutely. One of the things I think we still face, as a profession, is a lot of misconception of what we do and who we are, and I think a vision of the association between pregnancy and midwifery being automatic for Ontarians is something we're still a ways away from. I think we're becoming more known in the public, that it's less common that people say "Wait a second, midwives? That's publicly funded?" But still people don't necessarily know. Still people don't necessarily know that midwives work in hospitals, that midwives work as primary healthcare providers, that it's funded by the government and that people don't have to pay out of pocket, or that it isn't considered sort of a perk but a choice that people have who are having healthy pregnancies. So I think that automatic association is something that we would really love to see in the future in many places around the world, when somebody's pregnant they say "I need to find a midwife." And it's been really only in the last 100 years in Canada that that association has been severed between the obviousness of midwifery as the care that people would receive through their pregnancy and birth. So I hope we can shift that in the next short-term.

Ellen Gardner: So if I was going to give you this sentence, I want you to finish it for me. Midwives make a difference because ...

Elizabeth Brandeis: I would say midwives make a difference because we create true partnership with our clients. The client-centeredness in midwifery care is not just language that we use. It really is about a true alliance that we build with our clients, the principle of really meeting our clients where they're at, honoring their informed choices, bringing our skills and best knowledge to supporting those choices in the best way we can, guiding those choices in the best way we can, truly does individualize our care. We believe strongly that there isn't a one size fits all approach for healthcare in general, but you know, specifically in the arena of pregnancy, labor and birth, it's such a personal experience, and that can be informed by people's experiences in their lives with healthcare before that, in terms of trauma they may have experienced in their lives, cultural and religious beliefs that may impact the kind of care that they need. And midwives really make a difference because we're situated to be able to respond to those needs. So I think that's really the transformative quality of midwifery care and why it feels so different when somebody experiences midwifery care as a very different model than other kinds of healthcare they've received in the past. We have the time to develop those partnerships with our clients and really meet them where they're at.

Ellen Gardner: So where do you turn for inspiration?

Elizabeth Brandeis: I'm very fortunate to have incredible mentors in midwifery. I've been incredibly influenced by the midwives who have come before me. I really feel like I am on the shoulders of giants. The work of bringing regulated midwifery to Ontario was a herculean feat, really an uphill battle that midwives fought together in an incredibly unified and powerful way, really relying on their clients. Just the history of midwifery keeps me inspired and those mentors who I'm lucky enough to know the people who brought us to this point and they inspire me. I'm very fortunate to have developed incredible community in my own practice. I'm still best friends with people I went to midwifery school with and it's so crucial in the kind of intense work that we do to have one another to bounce the ideas off of, the stresses and the challenges of the work, so I'm inspired by my peers as well, and really by my clients. Like at the end of the day, the work is so inspiring, seeing somebody give birth, overcoming the adversities that people do in their lives but also in their labors is incredibly inspiring. There's really nothing more inspiring than seeing somebody get through the challenge of the labor and all the different ways that can look like and so really I'm fortunate enough to sort of be a witness to that power on a regular basis. So that keeps me inspired as well.

Ellen Gardner: Just thinking about those giants whose shoulders you're standing on, are there any in particular that you want to mention or any advice that they've given you that has really stood you well?

Elizabeth Brandeis: Oh my goodness. Well, yes, I think of how fortunate I've been to learn from incredible, skilled clinical preceptors. So as a student, my primary mentors were Jay MacGillivray who has really woven in social justice to her practice of midwifery and is still very much a leader in that way. Elizabeth Allemang is the other primary clinical preceptor who embedded in me a really deep belief in primary care management and the responsibility of midwives as primary caregivers, especially within a system that often can feel undermining to that kind of core of being a primary caregiver. So I feel like Elizabeth is with me often when I'm in a situation where I'm needed to advocate for perhaps a different style of management for a client that is reasonable and safe, but may not be conventional medical model and that she really instilled in me that we are skilled primary care providers who can work that way and have the right and in fact the obligation to do so. Katrina Kilroy, who is a past president of the AOM and past president of the Canadian Association of Midwives, is a practice partner of mine and an enduring mentor, somebody who I look to on a regular basis for guidance around all the hats that I wear.

And one of my other practice partners, Vicki Van Wagner who was right there at the center of the fight for regulated midwifery and really putting herself on the line in very intense ways to fight for a regulated midwifery system. It's a small handful of people who inspire me. And I would say on a kind of contemporary basis right now, the group that inspires me the most is NACM, and NACM is doing incredible work locally and federally to bring Indigenous midwifery back to Indigenous communities and I definitely feel inspired every day by the work that they're doing and by the change that they're making.

Ellen Gardner: Thinking about what we can look forward to from AOM, is there anything coming up soon that we can look forward to hearing more about.

Elizabeth Brandeis: Well, we do have a very big conference to mark our 25th anniversary. So that's always a great event to celebrate our gains and to envision our future direction. So that's a very immediate something to look forward to. I think our advocacy for growth and particularly growth for our populations who have been underserved by midwives, thinking of Indigenous midwifery in particular is something that I really hope we can continue to move forward with. That's definitely something that I'm hoping to continue to look forward to. And I think the issue of hospital integration is something that I can say very hopefully that we'll make improvements in that way and that midwives will be able to hopefully gain more leadership and decision-making roles within the hospital system and really be looked to as leaders who can assist in a really positive healthcare transformation. I would love to envision a future where midwives are seen as heads of departments, heads of facilities, to be able to move the ideas that we have into more widely adopted practice.

Ellen Gardner: And I wanted to ask one last question about music. Well, we were wondering if there's a song that inspires you, or that maybe you use in your practice, or something that you're listening to now that you really like?

Elizabeth Brandeis: My practice as a team-building exercise recently went to a Beyoncé choreography class and the song that we danced to was Who Runs the World (Girls), so I would say that's a good motivating song doing this work.

Ellen Gardner: I'd love to see a video of that.

Elizabeth Brandeis: I don't think one was taken.

Ellen Gardner: Why does that song motivate you?

Elizabeth Brandeis: It's a great song, but I think also just as a feminist profession and as a profession that's working hard to make a difference in terms of the disparities that women and girls face in society, in particular around pay discrimination, it's sort of a rallying cry to remind us that even though we have far to go to achieve gender-equity, really it is girls who run the world.

Ellen Gardner: That's great. Well, I really want to thank you, Elizabeth. You've got, yes, a lot of hats on, but a lot of exciting projects underway and we're excited at the fact that we've reached the 25 year mark and just want to say great work and we really will be watching as things unfold.

Elizabeth Brandeis: Thank you so much, Ellen.