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. 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. 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. 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.

中文翻译：

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了解影响加拿大安大略省卫生系统助产士角色的条件：一项嵌入式单例研究

尽管跨省和地区卫生系统在助产士的角色和整合方面存在很大差异，但是关于是否，如何以及在何种条件下将助产士分配到加拿大并纳入加拿大卫生系统的学术研究有限。我们使用Yin（2014）的嵌入式单案例研究设计，该研究设计可以进行深入的研究，以定性评估自1994年助产士的法规以来，安大略省卫生系统如何将助产士的角色分配和集成为服务提供者。金登（Kingdon）的议程设置和3i + E理论框架用于分析最近的两个关键政策方向（决定资助由助产士主导的独立式出生中心和“患者优先”初级保健改革的决定），这为将助产士融入卫生系统提供了机会。数据来自关键线人访谈和文件。进行了19次主要的知情人访谈，并在访谈期间记录了现场笔记，并审查了50份文件。我们的研究结果表明，助产士于1994年创建为一个自律职业，但卫生系统改革计划限制了该职业与安大略省卫生系统的融合。关于过去的决定如何影响今天可能做出的决定的政策遗留物具有最大的解释力，可以理解为什么助产士对职业间产妇保健的融合有限。从分析中得出的最重要的政策遗产与支付机制有关。在医疗模式中，付款机制优先考虑医师提供的和医院提供的服务，而助产模型中的支付机制却对该专业在跨专业环境中实践的能力施加了意想不到的限制。这是第一项解释为何助产士尚未完全融入安大略省卫生系统的研究，以及对助产士的作用和实践范围的限制。这项研究还建立了对医疗专业在医疗系统中的整合过程以及政策遗产如何影响服务提供选择的理论理解。