Crisp and unmarked behind its framed glass, the new registration certificate on Gisela Becker's office wall already has historic status.
The document, awarded earlier this year, makes Ms. Becker Newfoundland and Labrador's first registered midwife. She is also currently the province's only midwife.
Her job, though, will not involve catching any babies.
The province has hired Ms. Becker to help bring midwifery back to Newfoundland and Labrador, from which, despite a rich historical presence, midwives have been absent for more than half a century. The same is true for much of Atlantic Canada. Until early 2017, only Nova Scotia offered midwifery care to expectant mothers, although services are limited and overstretched, with a total of nine midwives working at capacity in just three areas of the province. New Brunswick's first midwife-delivered baby arrived in November. Three midwives now offer their services out of Fredericton (recruitment efforts are under way for a fourth).
Newfoundland and Labrador is one of the last jurisdictions in Canada to legalize midwifery, which involves providing prenatal, postnatal and primary care during low-risk births at home and in hospitals. Prince Edward Island and Yukon are the only remaining governments in Canada that do not allow it.
In the provinces where midwifery is well established – some have been funding it for more than 20 years – the profession has made great strides. In British Columbia, nearly a quarter of the babies born in 2015-2016 were delivered by a midwife; in Ontario, more than 20,000 babies, or 15 per cent of newborns, were caught by midwives during the same time period. In all, midwives delivered 10 per cent of the babies born in Canada in 2015-2016, according to statistics collected by the Canadian Association of Midwives.
Katrina Kilroy, president of the Canadian Association of Midwives, said national and international data increasingly support the provision of midwifery in small and rural places, which can realize health-care cost savings and better patient outcomes. "In the provinces and territories where midwifery has been supported and spread to rural and remote areas … the outcomes have been excellent," Ms. Kilroy said. "And it may turn out that it's easier to keep a midwife in a small community than it is a doctor."
Midwives are trained to provide complete care during pregnancy, and can order diagnostic tests and conduct routine blood work, and are often available 24 hours a day. While they oversee some low-risk births in private homes, most have hospital privileges and do deliveries there as well, including for mothers who elect to have epidurals (although midwives do not administer them). Midwives consult with obstetricians and pediatric specialists when required; in busy health-care systems, their case load of low-risk births allows obstetricians, who are trained surgical specialists, to focus more on high-risk and complicated cases. It is common for midwives to care for mothers and their babies up to six weeks after delivery.
In Newfoundland and Labrador, it will be months before midwives are seeing patients. The reason for this is the big gap between regulating midwifery and putting actual midwives on the ground, said Ms. Becker, who has held several professional leadership positions, including a term as president of the Canadian Association of Midwives. She trained in Germany and has worked and taught across Canada, including in Alberta, Nunavut, Quebec and the Northwest Territories.
It is Ms. Becker's job to figure out how to get the system up and running by the fall of 2018, which the government has set as its soft target.
"What do we need to do? Yes, hire a bunch of midwives and get going," she said, adding it is crucial to lay the groundwork for a receptive climate and a health-care system designed to include midwives. That includes educating other practitioners, including nurses and doctors, about the care midwives are qualified to provide, which ranges from helping women make informed choices about how they want to give birth to delivering primary care for mothers and babies until six weeks postpartum.
"When people have a good sense of what midwives do, they often start feeling more comfortable," Ms. Becker said. "In working relationships, it's about building trust. This is just all very much at the beginning."
Midwifery's roots in the province run as deep as the 1890s, according to a chronology published by the College of Midwives of Newfoundland and Labrador. A licensing regime was established in the 1920s, but when the province joined Canada in 1949, the landscape of health care began to shift; midwifery services were not offered in the rest of Canada. When hospital visits – and delivering babies there – became free under health insurance, interest in hiring midwives dwindled.
By the 1980s, a group of dedicated organizers was lobbying for the return of regulated midwifery, said Ann Noseworthy, president of the Association of Midwives of Newfoundland and Labrador.
"Newfoundland, being socially conservative … it takes a little while for us to take on new ideas," said Ms. Noseworthy, who teaches in the School of Nursing at Memorial University in St. John's. "But of course, midwifery is not a new idea here."
The exception to this is a pair of remote communities in northern Newfoundland and Labrador: St. Anthony and Goose Bay. Until last year, the health authority there allowed a small number of nurses with midwifery training, many of whom immigrated from Britain, to double as midwives when required.
"We had to wear two hats – you might be working on the pediatric floor as a nurse, but if someone came in in labour, you'd hand your duties as an RN to someone else and go do your midwifery bit," said Sylvia Patey, who arrived from Britain in 1994 to work in St. Anthony and stayed on.
Ms. Patey retired from clinical practice in 2006, but has continued to advocate for fully regulated midwifery. Her colleagues in the community practised right up until last year, when the new legislation was passed that recognized midwifery as a regulated health profession. Midwives must have a certificate of registration from the province. The northern nurse-midwives, now technically unregistered, were unintended casualties of the fledgling system.
"One day you'd be at work as a midwife, and tomorrow when you came in you weren't able to do it," Ms. Patey said. "You could attend a woman in labour as a nurse, but you couldn't deliver the baby or make decisions based on your training as a midwife."
While Ms. Becker and the province's health officials figure out how to lay the groundwork for the province-wide system, the northern nurse-midwives will remain in limbo, which Ms. Patey said her friends find demoralizing. "Your profession is a passion," she said. "It was taken away overnight: here today, gone tomorrow."
Health officials have not yet decided how to handle the northern nurse-midwives' situation.
Across Canada, midwives have been hoping their trade would one day make its way back to Newfoundland and Labrador and perhaps bring them with it. Inquiries from midwives who want to practice there have been arriving on Ms. Becker's desk in a steady stream, including from those who grew up in the province and were forced to choose between staying or pursuing their passion.
A few years ago, Stephanie Simon chose her passion. When she left to go to midwifery school in Sudbury, Ont., she knew her move was likely permanent. "Stepping into a career of midwifery meant I was taking a chance of not coming back home after I finished my degree," she said.
Ms. Simon, whose father was delivered by a midwife, graduated a year and a half ago and joined a rural practice in Halliburton, Ont. But her dream is to practice midwifery at home. "I was very hopeful that midwifery would eventually return to Newfoundland, and there would be options for working, teaching or being somehow involved," she said.
"Because there are no midwives in Newfoundland right now, people don't know there is a different approach out there."