Table 2 Factors influencing the likelihood of the decision to fund freestanding midwifery-led birth centres

Institutions

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Policy legacies

Payment systems in the medical model privilege physician-provided and hospital-based services, restricting the options for growth of midwifery services

• Hospital barriers to midwifery practice include: capping the number of midwives who have hospital privileges, number of births attended by midwives and restrictions to scope of practice (e.g., transfer of care criteria to an obstetrician for inductions and epidurals)

• Birth centres allow midwives to circumvent barriers in hospital setting by providing an alternate practice setting

KIs [38];

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Midwifery model of care is inflexible, acting as a barrier to integration and birth centres emerged as a response to these limitations (other key informants presented an alternative interpretation, which is captured below)

• Midwives had to fight hard for regulation but as time has passed, the model (two midwives attending births) has become a barrier to integration in hospital settings as nurses cannot be seconds, which segregates midwives from other healthcare professionals

• While autonomy is central to the model, it can limit interprofessional collaboration

KIs [1];

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The midwifery model of care facilitates integration into the health system as midwives hold hospital privileges, which strengthens interprofessional collaboration through the visibility of midwives in hospital settings

KIs [39];

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The 2008/09 increases to the number of midwifery education seats (90 total) mean that there are more new registrants looking hospital privileges and birth centres alleviate some of the pressure created by hospital barriers (e.g., capping of privileges) by offering an alternate practice setting

KIs [52];

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For birth centres to be created they had to fit under existing legislation (Independent Health Facilities Act, 1990), as a result they are the only Independent Health Facilities that are not physician-led and birth centres are not named under the legislation or defined, which may restrict their visibility and potential for growth

KIs [53, 54];

Interests

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Interest groups

• The Association for Ontario Midwives is a strong interest group and was key to lobbying for the creation of birth centres

KIs [21, 46];

Ideas

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Knowledge about ‘what is’

Increasing evidence on the quality and outcomes of midwifery-led birth centres

• The National Institute for Health and Care Excellence released guidelines encouraging women in the United Kingdom to give birth in midwifery-led units

KIs [55, 56];

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Birth centres offer one possible approach to improved care for childbearing clients and there are other settings being considered by the Ministry of Health and Long-Term Care for the delivery of midwifery services

• Midwifery-led care within the hospital and facilitates transfer of care when necessary (e.g., along-side birth unit in Markham-Stouffville Hospital)

KIs

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Values about ‘what ought to be’

Many women value a less medicalized approach to maternity care, as reflected by the demand for midwifery services

• Many practices have wait lists for midwifery services

• Not all women want to deliver at the hospital and also do not feel comfortable delivering at home, birth centres provide an alternate setting/in-between option

• Many women have positive experiences midwifery care or know someone that has

KIs [21, 46, 51, 57,58,59,60];

External factors

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Professional groups finding little success within the healthcare sector have increasingly gone outside in hopes of better remuneration

• In 2013 the Association of Ontario Midwives filed an application with the Human Rights Tribunal of Ontario against the Government of Ontario, citing that midwives experience a gender penalty in their remuneration (31.5%)

• In early 2016 settlement talks with the Ministry of Health and Long-Term care ended without resolution and the association continues to present their case to the tribunal

KIs [61,62,63];