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A Case Study of the Implementation of Regulated Midwifery in Manitoba

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A Case Study of the Implementation of Regulated Midwifery in Manitoba A Case Study of the Implementation of Regulated Midwifery in Manitoba By Kellie Thiessen A Thesis submitted to the Faculty of Graduate Studies of The University of Manitoba in partial fulfillment of the requirement for the degree of DOCTOR OF PHILOSOPHY Department of Applied Health Sciences University of Manitoba Winnipeg, Manitoba, Canada Copyright © 2014 Kellie Thiessen MIDWIFERY IN MANITOBA i Abstract In 2000, midwifery was regulated in the Canadian province of Manitoba. Since the inception of the midwifery program, little formal research has analyzed the utilization of regulated midwifery services. Currently, many women are denied access to midwifery care due to the shortage of midwives in Manitoba. The specific objectives of this mixed- methods case study were to describe the utilization of midwifery health care services in Manitoba from 2001/02 to 2009/10 and to explore factors influencing the implementation and utilization of regulated midwifery services in Manitoba. The study was guided by the Behavioral Model of Health Services Use (Andersen, 1995). Data collection and analysis were an iterative process between documents, interviews, and administrative data. The quantitative analysis used the population-based administrative data housed at the Manitoba Centre for Health Policy to study the utilization of midwifery care. There was modest growth in the overall rate of midwifery-attended births, as well as in the number of midwives over the 10-year time period. Twenty-four key informants were purposefully selected to participate in semi-structured interviews for the qualitative component. Interviews were audio-taped, transcribed verbatim and analyzed using content analysis. Three main topic areas were identified: barriers, facilitators, and future strategies/recommendations. Themes arising under barriers included conflict and power; lack of an educational program; perceptions of the profession, and a precarious profession. Issues of gender underpinned some of these barriers. Constituent influence was a prominent facilitator of the profession. Future strategies for sustaining the midwifery profession focused on ensuring avenues for registration and education, improving management strategies and accountability frameworks, enhancing the work MIDWIFERY IN MANITOBA ii environment, and evaluating the model of practice and employment. Results of the document analysis supported the themes arising from the interviews. In spite of scientific evidence that supports the midwifery model of care, there remains an inherent struggle to justify the profession and ensure its widespread implementation in Manitoba. The findings have implications for maternal child health professionals working on collaborative efforts to facilitate access to midwifery services for women. This study adds to the growing body of literature related to midwifery in Canada. Key words: midwifery, implementation, policy, Behavioral Model of Health Services Use, feminism, Manitoba, Canada MIDWIFERY IN MANITOBA iii Acknowledgements I would like to gratefully acknowledge my advisor, Dr. Maureen Heaman, who has provided a tremendous amount of support to me throughout the past five years. Dr. Heaman has always been readily available for feedback. She has also facilitated the advancement of my career in research through her continuous support of my attendance and participation in various research conferences throughout my years under her guidance. Thank you, Dr. Heaman, for the outstanding ways you support your students. I would like to thank my committee members: Dr. Javier Mignone, Dr. Patricia Martens, and Mrs. Kris Robinson, who have provided unconditional support for this project. Each member brings expertise and a diverse perspective that has created a platform for rich discussions and has challenged my thought processes. Thank you, Javier, for encouraging me to stay angry. Thank you, Pat, for your kind words of encouragement yet critical feedback. Thank you, Kris, for your expert advice and constant support in completing this research project. Your insight has been critically important throughout this process. I would like to thank the Manitoba Centre for Health Policy (MCHP) for all the support they have provided to me as a graduate student. Specifically, I am grateful for Charles Burchill’s kind demeanor and great teaching abilities in guiding me through problem-solving issues with SAS and the quantitative data. I am grateful to the College of Midwives of Manitoba (CMM), who made information accessible and provided insight into historical events in response to my numerous inquiries over the years. Thank you to the participants who graciously gave their time to be interviewed for this important project. I am also grateful to many others MIDWIFERY IN MANITOBA iv who have provided important insights regarding the historical events of Manitoba midwifery, which contributed to this study. This research project has been enriched by all those who have contributed in big and small ways. I would like to acknowledge with gratitude my funders for this research project: the Manitoba Health Research Council PhD Dissertation Award, the Manitoba Centre for Nursing and Health Research Award, the Evelyn Shapiro Award for Health Services Research, and the Kansas Hospital Education and Research Foundation Scholarship. Finally, the most important people that need to be acknowledged are my husband, Michael, and my children, Dora and Ana. Without their unwavering support, my work would have been not only impossible but meaningless. Words will never express how grateful I am to each of you for how you have inspired and motivated me to continue this important work. I dedicate this research project to midwives all over the world, in particular in Manitoba, where the details of the long arduous hours go unrecognized, yet their exemplary work is one of the reasons midwifery exists in the Manitoba and the fight for women’s choice is still alive. MIDWIFERY IN MANITOBA v Disclaimer The authors acknowledge the Manitoba Centre for Health Policy for use of data contained in the Population Health Research Data Repository under project #2012-032 (HIPC# 2012/2013-02). The results and conclusions are those of the authors and no official endorsement by the Manitoba Centre for Health Policy, Manitoba Health, or other data providers is intended or should be inferred. Data used in this study are from the Population Health Research Data Repository housed at the Manitoba Centre for Health Policy, University of Manitoba and were derived from data provided by Manitoba Health and the College of Midwives of Manitoba (CMM). MIDWIFERY IN MANITOBA vi Table of Contents Abstract .......................................................................................................................... i Acknowledgements ........................................................................................................ iii Disclaimer………………………………………………………………………………v List of Tables .................................................................................................................. xii List of Figures…………………………………………………………………………xiv List of Copyrighted Material for which Permission was Obtained ................................ xv Chapter I: Introduction .................................................................................................... 1 Background ......................................................................................................... 1 Description of Setting ......................................................................................... 3 Statement of the Problem .................................................................................... 4 Purpose of Study ................................................................................................. 8 Research Questions ............................................................................................. 8 Definition of Terms............................................................................................. 10 Barriers and facilitators ........................................................................... 10 Utilization ............................................................................................... 10 Implementation ....................................................................................... 11 Regulation ............................................................................................... 11 Constituent .............................................................................................. 11 Consumer ................................................................................................ 12 Significance of Study .......................................................................................... 12 Chapter II: Conceptual Framework ................................................................................ 15 Framework for the Study of Utilization .............................................................. 15 MIDWIFERY IN MANITOBA vii Feminist Framework ........................................................................................... 20 Chapter III: Literature Review ........................................................................................ 23 Historical Context of the Medicalization of Birth: Paradigms of Health Care ... 23 Historical Account of Obstetrics and Midwifery ................................................ 25 Global Midwifery...............................................................................................
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