Table 4 Factors influencing the likelihood of inclusion of midwifery as a service delivery option in Patients First primary care reform
Factors affecting policy choice | Influence on policy choicea | Description of how the factors influenced likelihood of inclusion of midwifery as a service delivery option in Patients First primary care reform | Sources of evidence |
|---|---|---|---|
Institutions | ↓ | Policy legacies Midwifery payment mechanisms limit their ability to practice in interprofessional environments • During the 2005 primary care reforms for Family Health Teams, the call went out to midwives but they were unable to participate because they were not eligible for alternate funding arrangements | KIs |
↓ | Midwifery payment mechanisms act as barriers to new registrants entering the workforce, as midwives can only bill for a course of care once the client has been discharged | KIs | |
↓ | Midwifery model of care is inflexible and limits the ability to be integrated into primary care teams • How midwives were regulated constrains the practice options available to them and many levers (regulatory, funding and educational) are needed to further integrate midwives into primary care teams | KIs | |
↓ | Payment systems in the medical model privilege physician-provided and hospital-based services, making reform difficult and an underlying barrier to change | KIs | |
↓ | Healthcare has been traditionally gendered, with priority given to physicians, which was until recently a majority male profession • Midwifery is a small workforce, providing services for women by women, which has been traditionally overlooked by the health system | ||
↓ | Midwives are primary care providers and are a feasible option given the majority of family physicians are no longer providing maternity care due to lack flexible schedules and liability issues; however midwives are often overlooked by other regulated healthcare professionals as primary care providers in the health system | KIs | |
↔ | Policy networks • While tenuous at present, historically the Ontario Medical Association has had a seat at the decision-making table while the Association of Ontario Midwives has not | ||
Interests | ↑ | Interest groups • The Association of Ontario Midwives prepared a position statement in response to the discussion paper, Patients First: A proposal to strengthen patient-centred health care in Ontario encouraging the Ministry of Health and Long-Term to include maternity care services in primary care reforms | KIs [38]; |
↓ | • Advocacy groups for older adults are larger and more established but there is a lack of formal consumer groups advocating for maternity care and midwifery services | KIs [75]; | |
Ideas | ↑ | Knowledge about ‘what is’ • Increasing evidence on the quality and outcomes of midwifery care | |
↓ | • The health system is more focused on older adults and chronic disease than it is on maternity care | ||
↓ | Values about ‘what ought to be’ • There is a disconnect between who should receive midwifery care and who seeks it (e.g., midwives provide a range of supports that are particularly important to vulnerable and marginalized populations, yet many clients are middle-class) • Social norms act as barriers and privilege physicians over midwives in maternity care • Maternity care is not on the radar like the large numbers of people dealing with caring for older adults | ||
External factors | ↔ | 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 |