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The work of midwives has been chronically undervalued and underpaid because it’s a female-dominated profession and that needs to be corrected, the Human Rights Tribunal of Ontario (HRTO) has ruled.

The groundbreaking pay equity ruling released late Monday says the province needs to correct the pay gap between midwifery and comparable professions, make retroactive payments back to 2005, and create a mechanism for future contract talks that takes gender into consideration.

But instead of imposing specific penalties, Leslie Reaume, the vice-chair of the HRTO, ordered the two parties – the Association of Ontario Midwives (AOM) and the Ministry of Health and Long-Term Care – to negotiate a settlement. If they are unable to do so, the tribunal will set remedies.

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The decision is obviously a victory for the province’s 900 midwives.

It is also another warning to governments to take pay equity issues more seriously – something the Supreme Court did forcefully with two decisions it issued in May.

And it is yet another reminder that the way that health care workers are paid, and their contracts are negotiated, need some fundamental rethinking.

Midwifery became a regulated profession in Ontario in 1994. The AOM and the Ministry of Health worked well together, reaching an initial contract that was “gender sensitive and inclusive.”

Among other things, they negotiated a pay scale that situated midwives between senior community health nurses and community health physicians, with salaries ranging from $55,000 to $77,000, along with benefits. (Like physicians, midwives are independent contractors; they work in practice groups and negotiate a master contract centrally through their association or union.)

That first deal was followed by 11 years of salary freeze.

Interestingly, the tribunal ruled that there was no discrimination in that period. Midwives continued to receive roughly two-thirds of the salary of community health doctors.

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In 2005, however, the provincial government stopped using physicians working at Community Health Centres as a comparable.

It is at this point the discrimination began, the tribunal ruled, because the province failed to proactively monitor, identify and redress sex-based discrimination.

In subsequent years, the salaries of community care physicians, a male-dominated profession, rose twice as fast as those of midwives, a female-dominated profession. (Ontario has a single male midwife.)

The province argued that the difference in pay scales was a result of “occupational status,” not sex.

But the tribunal rejected that argument, saying that while the Ministry of Health did not appear to discriminate deliberately, the pay gap reflects deeply ingrained attitudes that women’s work is of lesser value.

The AOM eloquently described midwifery as a “gender trifecta of services provided by women, for women, in relation to women’s reproductive health.”

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Currently, Ontario midwives – who already deliver one in every six babies in the province, and can’t keep up with demand – earn between $69,020 and $105,760, plus benefits and overhead. Salaried Ontario doctors earn more than twice that much.

The broader issue here is relativity. Stated bluntly: How much is a midwife worth compared to a doctor? Or compared to a nurse?

These are not easy questions to answer. But in trying to answer them, we at least have to be conscious of our biases.

There is no question that, in medicine, the letters after your name matter. Medical doctor is above nurse-practitioner, which is (maybe) above midwife, which is above registered nurse – at least in the unofficial hierarchy.

“Doing stuff” – surgery, MRIs, tests, prescribing, etc – is more valued than “caring.” The highest-paid health practitioners do procedures. The lowest paid do tasks.

It is no secret that men get paid more than women. While medicine is being “feminized,” male doctors still earn more than female doctors. Female-dominated professions, notably nursing and midwifery, earn significantly less.

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We have to challenge the assumptions that resulted in those realities.

This is not to suggest everyone should be paid the same. Years of education matter, complexity and hours of work matter, and what patients and the public value matters. Compensation should reflect what we value, as well as our values.

People should be paid equitably, and this tribunal ruling reminds us once again that we are a long way from gender equity in health care.

Finally, this case underscores how overwhelmingly complicated and bureaucratic contract negotiations have become. It takes years to settle seemingly simple issues.

In the 50 days of expert testimony, the vice-chair reminds us, can be found a “rich source of guidance on how the MOH could reform its compensation practices.”

That broader reform is well overdue. Hopefully, pay equity will be the impetus.

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