Understanding the conditions that influence the roles of midwives in Ontario, Canada’s health system: an embedded single-case study

Abstract

Background: Despite the significant variability in the role and integration of midwifery across provincial and territorial health systems, there has been limited scholarly inquiry into whether, how and under what conditions midwifery has been assigned roles and integrated into Canada's health systems. Methods: We use Yin's (2014) embedded single-case study design, which allows for an in-depth exploration to qualitatively assess how, since the regulation of midwives in 1994, the Ontario health system has assigned roles to and integrated midwives as a service delivery option. Kingdon's agenda setting and 3i + E theoretical frameworks are used to analyze two recent key policy directions (decision to fund freestanding midwifery-led birth centres and the Patients First primary care reform) that presented opportunities for the integration of midwives into the health system. Data were collected from key informant interviews and documents. Results: Nineteen key informant interviews were conducted, and 50 documents were reviewed in addition to field notes taken during the interviews. Our findings suggest that while midwifery was created as a self-regulated profession in 1994, health-system transformation initiatives have restricted the profession's integration into Ontario's health system. The policy legacies of how past decisions influence the decisions possible today have the most explanatory power to understand why midwives have had limited integration into interprofessional maternity care. The most important policy legacies to emerge from the analyses were related to payment mechanisms. In the medical model, payment mechanisms privilege physician-provided and hospital-based services, while payment mechanisms in the midwifery model have imposed unintended restrictions on the profession's ability to practice in interprofessional environments. Conclusions: This is the first study to explain why midwives have not been fully integrated into the Ontario health system, as well as the limitations placed on their roles and scope of practice. The study also builds a theoretical understanding of the integration process of healthcare professions within health systems and how policy legacies shape service delivery options.

A critical interpretive synthesis of the roles of midwives in health systems

“…Globally, there was a general lack of knowledge regarding the International Confederation of Midwives' Global Standards for Midwifery Education, which was a barrier to the provision of quality midwifery education [53,66,87,107,108]. Within financial arrangements, the literature focused primarily on how systems are financed, on the inclusion of midwifery services within financing systems and on the remuneration of • Lack of legislation to support regulatory activities [34,43,48,58,71,82,87,93,94] limited recognition and scope [38,87] [48], burn out [43,118] and lack of support to practice autonomously [75,104] leads to disempowerment [43] • Lack of equipment in schools and facilities can create gaps in teaching quality and practice [119] • Medical model prioritised physician-led care in hospitals and created friction between midwives and physicians [38,50,52] and also minimised the roles of midwives in primary care [99] • midwives that is reflective of scope of practice [1, 2, 6, 10, 13, 35, 38, 39, 43, 50, 55-59, 61, 69, 73, 74, 76, 80, 84, 95, 101, 104, 109, 115]. Lastly, the main themes relating to delivery arrangements focused on (1) accessing midwifery care ranging from availability and timely access to workforce supply, distribution and retention; (2) by whom care is provided (e.g.…”

“…midwives collecting or sharing data) [ 43 , 65 , 90 ] • Midwives were unable to practice to full scope because of inconsistent standards of education and professional regulation [ 78 , 91 , 106 ] • Globally, there was a general lack of knowledge regarding the International Confederation of Midwives’ Global Standards for Midwifery Education, which was a barrier to the provision of quality midwifery education [ 53 , 66 , 87 , 107 , 108 ] • Midwives were not practicing to their legislated full scope of practice (Canada), barriers included (1) hospitals — scope restrictions; (2) capping of the number of midwives granted hospital privileges; (3) capping the number of births attended by midwives; and (4) inconsistent midwifery policies across hospitals [ 52 , 77 ] • Healthcare reforms increased the centralisation of decision-making, which created barriers to change (Australia) [ 95 ] • Combination of regulatory processes and health systems that promoted birth as a natural process; favoured professional midwifery care (Nordic countries) [ 8 , 62 , 86 , 91 , 99 ] • Accreditation mechanisms supported midwifery education programmes and institutional capacities [ 63 , 70 , 93 , 107 ] • Environments that allowed midwives to practice autonomously and to full scope of practice [ 74 ] • Expanded scope from providing skilled delivery care to include SRHR ranging from abortion, family planning, screening (diabetes and several forms of cancer), immunisations, palliative care, and public health and promotion [ 10 – 13 , 55 , 74 , 94 , 109 – 113 ] • Increased contraceptive prevalence rate (Nigeria) by engaging midwives in provision of family planning services [ 114 ] • Engagement of midwives within broader humanitarian emergency contexts (e.g. conflict, epidemics, and natural disasters) [ 46 ] •...…”

“…task-shifting, interprofessional teams); and (3) where care is provided (e.g. hospital based, integration of services and continuity of care) • Delivery arrangements link with ‘institutions’, ‘interests’ and ‘ideas’ in that they influence the delivery of healthcare services • Unmet need for SRHR services in sub-Saharan Africa due to health workforce supply and demographic trends [ 117 ] • Re-emergence of traditional midwives as a result of limited skilled birth attendant workforce [ 46 ] • Midwives experienced role strain due to increasing workloads [ 48 ], burn out [ 43 , 118 ] and lack of support to practice autonomously [ 75 , 104 ] leads to disempowerment [ 43 ] • Lack of equipment in schools and facilities can create gaps in teaching quality and practice [ 119 ] • Medical model prioritised physician-led care in hospitals and created friction between midwives and physicians [ 38 , 50 , 52 ] and also minimised the roles of midwives in primary care [ 99 ] • When compared with eight HICs, midwifery in Canada played a relatively minor role in the provision of SRHR [ 6 ] • Rising caesarean rates in Latin America and medically induced labours [ 84 ] • Collaborative care involved interprofessional groups (e.g. midwives working with physicians and nurses) [ 10 , 34 , 55 , 74 , 75 , 100 , 116 ] • Based on statistical modelling, the projected effect of scaling-up midwifery will deliver the most impact on maternal, newborn and child health [ 2 , 73 ] • Task-sharing of HIV, tuberculosis [ 96 ], abortion-related (medication abortion and vacuum aspiration abortions) services to midwives [ 12 , 110 , 111 , 120 ] • Midwifery (led by Indigenous midwives) is returning culturally safe and appropriate SRHR to Inuit communities (Canada) [ 34 – 36 , 54 ] • Midwives increased access t...…”

“…• Midwives were not practicing to their legislated full scope of practice (Canada), barriers included (1) hospitals — scope restrictions; (2) capping of the number of midwives granted hospital privileges; (3) capping the number of births attended by midwives; and (4) inconsistent midwifery policies across hospitals [ 52 , 77 ]…”

“…• Medical model prioritised physician-led care in hospitals and created friction between midwives and physicians [ 38 , 50 , 52 ] and also minimised the roles of midwives in primary care [ 99 ]…”