Monday marked a groundbreaking victory for Ontario midwives. In 2013, the Association of Ontario Midwives (AOM) filed a complaint calling for back pay and a raise to redress over two decades of gender-based pay discrimination. Five years later, the Human Rights Tribunal of Ontario ruled that the Ministry of Health and Long-Term Care’s failure to proactively monitor and regularly negotiate midwives’ compensation rates indeed constitutes discrimination.
Midwifery has historically been, and remains today, a women-dominated profession, providing primary care to women, non-binary, and trans patients, and in response to a reproductive health issue. When midwifery was first recognized as a regulated profession in 1994, the Ministry and midwives’ professional association, the AOM, came up with a comparative process to ensure that midwifery was not subject to discriminatory pay practices.
Noting the Ministry’s repeated disregard for both the AOM’s and independent expert’s calls for equitable pay increases based on this initial collaborative process, tribunal chair Leslie Raume’s decision agrees that “midwives experienced adverse treatment and that gender is more likely than not a factor in that treatment.” While the tribunal has not yet prescribed specific remedies, it has determined liability and called for the AOM and Ministry to meet and negotiate “appropriate and fair compensation levels for midwives now and into the future.”
“We knew that there was a lack of process to maintain fair and equitable pay, and now the government’s been ordered to do just that. It feels like a real victory,” said AOM president Elizabeth Brandeis.
The win for midwives is historic, with potentially far-reaching implications. In this particular political moment in Ontario, the decision is a beacon of light for many. And while the tribunal’s decision acknowledges gender pay discrimination between 2005 and 2013, the devaluation of and struggle for midwifery started much earlier.
Midwifery was once the dominant form of maternal care in Canada, performed by Indigenous midwives prior to colonization, and accepted as an integral part of early settler colonial health care. Starting in the late 18th century, however, male medical practitioners in what would become Ontario successfully lobbied the government to deny midwives, along with homeopathic and non-allopathic practitioners, professional licenses. Home births became stigmatized, and hospital births increased in a transition that helped to legitimize physicians’ and specialists’ social and economic dominance in health care, which they still enjoy today. This medicalization of childbirth has had many health impacts for women, including the requirement that those living in rural communities and the North leave their communities in order to give birth in hospitals. As Indigenous midwives have noted, this trend continues to contribute to particularly negative health outcomes among Indigenous women.
In the late 70s and 80s, when the demand for comprehensive, client-led midwifery care was growing significantly, there was a growing shortage of physicians offering maternal care (in general, family physicians can make more money doing less complex and time consuming procedures under their fee-for-service compensation model). Still the medical community perceived the growing popularity of midwives as a competitive threat to their monopoly over health care, and led legal actions against midwives on the grounds of criminal negligence causing death or harm as well as practicing without a license. This backlash prompted midwives to formalize their practice and take political action, with a strong contingent eventually calling for integration into the healthcare system through the regulation of midwifery as a profession. The Liberal government at this time was responsive to midwives’ demands, seeing regulation of the profession as an opportunity to address the chronic shortage of physicians delivering babies and save public money in the process (To lean more about the history of midwifery and its regulation, read Ivy Lynn Bourgeault Push! The Struggle for Midwifery).
Midwives were officially regulated in 1994, and integrated into Ontario’s health care system as independent practitioners with a self-regulatory college, a university-based education program, and public funding for hospital and outside of hospital births. This professionalization process initially resulted in a significant pay increase for registered midwives, who at the time were making an average of about $20,000 a year. Compensation rates were set through a rough pay equity analysis; while complex and technical, this approach essentially compares midwives to Community Health Care physicians, a profession dominated by men at the time. Accounting for differences and similarities skills, efforts, responsibilities, and working conditions, the Ministry, the AOM, and pay equity experts determined together that midwives should receive approximately 90% of CHC physicians’ starting rate of compensation.
Though this process successfully ensured midwives’ initial pay scale was not discriminatory, any commitment on behalf of the Ministry to ensuring equitable pay for midwives has since been abandoned; midwives’ pay was frozen from 1993 until 2005, when the Ministry reluctantly agreed to increase compensation rates after mounting pressure from the midwifery community. From 2005 to 2013, irregular negotiations and inadequate wage increases ensured that midwives’ compensation was incommensurate to that of their comparators. In 2010, the AOM collaborated with the Liberal provincial government to commission a independent compensation study that found midwives required a 20% equity adjustment in pay, which the Ministry ignored. By 2013, independent reports prepared for the AOM found a 48% gap in pay, or a difference of $94,800 a year when comparing midwives and CHC physicians.
Frustrated by this discriminatory treatment, the AOM filed a Human Rights complaint on behalf of their membership against the Ministry. “It really did feel like a last resort…but we couldn’t keep going back to the table and be told “no” for a variety of reasons, said Brandies. “We had to do something else.”
The Human Rights Tribunal of Ontario has now found that gender was very likely a contributing factor in the persistent pay gap between CHC physicians and midwives, and that the Ministry has expanded midwifery in this way to “take advantage of their remarkable skill set and to respond to changing health care priorities, under-serviced communities and vulnerable patient populations.”
The decision also notes that, though CHC physicians are no longer a male dominant group, the initial process for determining pay still stands. Raume aptly points out, the Ministry has accepted and promoted midwives as alternatives to physicians for those seeking maternal and intrapartum care—in other words, it’s time for the Ministry to put its money where its mouth is.
“The work is not finished,” said Brandeis. “But it’s a very different context sitting down with government now that we have established liability—they are liable to redress discrimination.”
The AOM’s negotiation process will take place in a political climate where the provincial government is promising massive cuts to public spending, and the privatization of public health care is a very real threat. While midwives were hoping that the tribunal would adopt the remedies they put forward, Brandeis said that AOM is optimistic that “involving government in the resolution of it will lead to lasting impacts and an enduring process going forward.” How this all plays out, Brandeis noted, of course remains to be seen.
In this sense, while the case is a huge victory, it’s also one step in a long fight that has required a huge amount of organizing efforts and financial resources. “One of the reasons that pay inequity exists, is that groups of women workers don’t have the resources to fight this kind of fight,” said Brandeis.
Midwives have been deemed less valuable than physicians because their holistic approach is seen as less scientific, their low intervention perspective: inefficient. This case is exciting because it challenges such normative understandings of what’s valuable and recognizes that midwives’ required knowledge and skills overlaps with a wide variety of health professionals, ranging from obstetricians to social workers. Still, important questions remain: what does this case mean for gendered health care workers who don’t have a well paid comparator or the resources to pursue legal action? What does this case mean for health practitioners who are not registered by the state, such as Indigenous midwives, but are instead recognized as health practitioners by their community?
The AOM’s case reveals the systemic nature of pay inequity, while demonstrating how the exploitative and oppressive relations that have been accepted as status quo are in fact dynamic, and they can shift. Such transformations will take much more than policy reform and legal action, but the AOM is hopeful that this decision will contribute to the broader movement for more equitable employment practices within the sector and beyond.