In this study, we investigated the characteristics of women receiving prenatal care from midwives on a national scale in Canada. Our results show that receiving midwife-led care during pregnancy was influenced most notably by higher levels of education, aboriginal status, and self-reported alcohol use during pregnancy. Moreover, the prevalence of midwife-led prenatal care varies greatly by province, being highest in British Columbia at 9.8% and lowest in all of: Nova Scotia, Prince Edward Island, Newfoundland and Labrador, New Brunswick, Saskatchewan, and Yukon (combined prevalence: 0.32%). This study is one of the first to describe the fundamental characteristics of women in Canada who receive prenatal care from a midwife and highlights the importance of gaining more up-to-date statistics of midwifery utilization.
Based on the findings of the present study, the three provinces with the highest uptake of midwife-led prenatal care were British Columbia (9.8%), followed by Manitoba (9.4%) and Ontario (9.2%). However, in general there has been an increase in the uptake of midwife-led prenatal care; nationally increasing from 6.1% in 2005/2006  to 9.8% in 2015/2016 . As of 2016 the three provinces with the highest uptake of midwife-led prenatal care was as follows: British Columbia (21%), Nunavut (15.4%) and Ontario (15.2%), while Manitoba’s uptake has now dropped to 6.5% . Midwifery in Manitoba has been regulated and publicly funded since the year 2000 , however, there have been some setbacks in recent years where the newly elected provincial government opted to cancel the existing joint educational program . This could have contributed to the decline in midwife-led prenatal care in Manitoba from 2005/2006 to 2015/2016. On the other hand, the rise in midwife-led prenatal care in Nunavut during that period can be explained by the later regulation of midwifery as a profession in that region, having only been regulated since 2011 . In addition to Nunavut, the following provinces have become regulated since the MES data collection, potentially contributing to the observed increase in the national uptake of midwife-led prenatal care: Saskatchewan, Nova Scotia, Newfoundland and Labrador, and New Brunswick . Midwifery in Prince Edward Island and Yukon Territory currently lacks a regulating body . Moreover, it seems that with regulation comes funding, and midwifery is now covered by provincial/territorial health care plans in most regions of Canada, potentially increasing accessibility to this service . On the other hand, midwifery is not covered by the health care plan in Prince Edward Island . Unfortunately, no information about midwifery coverage was found for New Brunswick, Newfoundland and Labrador, and Yukon territory.
In terms of demographic characteristics, having aboriginal status was associated with increased likelihood of choosing a midwife. Aboriginal individuals are less likely to seek medical attention through government-run health care systems in Canada, due to factors such as social inequality, decreased specialist referrals, lowered access to higher-tier medical therapies, and decreased standards of medical care (both perceived and actual) . Aboriginal communities are also more likely to look for alternative therapies, perhaps as a result of disintegration throughout the non-aboriginal Canadian community, or as a complement to the increased importance placed on spiritual practices; however, data on the use of this population is under-represented .
In terms of socioeconomic factors, higher levels of education, was associated with increased use of midwives. Looking solely at education, previous literature has shown that university-educated women are more likely to feel in charge of their own health, perhaps due to increased education leading to a more keen interest in their own health status [22, 23]. Midwifery programs focusing solely on a more highly-educated demographic may choose to incorporate health literacy as a core component, which may serve to keep their patient demographic involved in their own care and emotionally engaged about the process throughout .
In terms of health factors, this study found that alcohol use during pregnancy is associated with higher odds of receiving prenatal care from a midwife. For the purposes of this study, this variable was dichotomoized which may mask the effects of heavy drinking versus light drinking during pregnancy. If this association does exist, however, it may be because alcohol users prefer to avoid using physicians and the national healthcare system for fear of being judged by the physicians, nurses and staff. Alternatively, women receiving care from a midwife may feel more comfortable disclosing their habits (alcohol or otherwise) to one individual. Moreover, alcohol users may not be able to uphold a doctor-patient relationship and may prefer the flexibility of a midwife. Future studies can further investigate the association between alcohol use during pregnancy and receiving prenatal care from a midwife.
The main limitation of this study is that the data used is 10 years old. However, up to the authors’ knowledge, the MES is the most recent database that provides information about the characteristics of midwife-led prenatal care on a national scale in Canada. Another limitation is the cross-sectional design of the survey, which may introduce reverse causality. In addition, with self-reported data, the possibility of information bias should be considered, especially for alcohol use and smoking during pregnancy where respondents may not feel encouraged to provide accurate answers that may present themselves unfavourably. Other contributors to information bias include lack of recall and closed-ended questions, which have a lower validity rate than other question types and the answer options could lead to unclear data due to differences in interpretation by different respondents (for example, the answer option “somewhat agree” may elicit different responses). Last but not least, this study did not control for all of the confounding variables that could have contributed to the associations we found. These include midwife-led care in previous pregnancies and ethnicity. Regardless of these limitations, this study used a large dataset which studied a large amount of predictors and was weighted to represent the Canadian population of pregnant women. This survey also had a high response rate of 78%. As far as the authors are aware, this is the first study that aims to describe the characteristics of women choosing midwife-led prenatal care in Canada on a national scale.