Table 1 Key findings regarding Ontario funding arrangements for antepartum, intrapartum, and postpartum care by healthcare provider

Impacts of own funding arrangements on ability to work with other maternity care providers

Shared care is possible between OBs and FPs, depending on the care providers' comfort

RNs don't feel there are large impacts of their funding on MWs’ ability to work with other providers

OBs mostly work with FPs and MWs, not other OBs

Typical ways MWs work (e.g., consultations to physicians) are supported by the existing funding model, but there is desire for more collaborative models which doesn't work with current funding

May be potential for lost income if care transferred from FP to OB but not a big concern

RNs don't always understand scope of practice of MWs; this can cause tensions after transfers of care (TOCs)

Easier to work with FPs than MWs because financial incentives are structured different

When a client moves or their care is transferred, there are differences in payment to MWs depending which type of providers a client sees

In rural settings (particularly contexts where there are no Obs available), challenges arise when FPs doing maternity care bill OHIP for patients from a different family health team (FHT) as the other FHT gets negated for that visit, even if they do not provide that type of primary care

Differences in education and provider philosophy on provision of maternity care are seen as biggest challenge to interprofessional interaction

When OBs collaborate with MWs it can be challenging for collaboration with RNs; people unsure who should be doing what

Funding model is a barrier to collaboration with other health professionals

Funding between OBs and FPs separate, so few impacts other than transfers of care, FP not always staying involved

Funding model is okay for being able to see patients and for consultations, but not collaboration

There is the potential for increased collaboration or role-sharing of MWs and physicians, but funding doesn't allow for it

When OBs work with FPs both can bill for delivery; no penalization

Currently, lots of free labour happens; there is a need to not devalue work of MWs through this

FPs quicker to transfer care to OBs than MWs because they can still bill for delivery; Obs perceive need for TOC to impact MWs more

Funding model is a barrier to creativity to address health system needs

Impacts of midwifery funding arrangements on your ability to work with them (or for midwives, impacts of physician funding arrangements)

Increasingly low-risk pregnant people are choosing midwifery care, so FPs seeing decreased volume of low-risk obstetrics to the point of potentially affecting feasibility and viability of providing care

When MWs are struggling with volume demands, hospitals are unable to implement novel approaches to address these challenges because of siloed funding arrangements

MWs as surgical assistants are beneficial and support continuity of care, but it may not be cost effective to have a midwife on standby for that task only

MWs pay is less than physicians; this hinders sense of equity between the professions

Not possible to do shared care with midwifery because of differences in funding—not possible to divide up course of care without losing funding; "no one wants to work for free"

MWs' budgets and funding arrangements are not public information; lack of transparency is an issue

OBs still have to be available to the labour ward while MWs attend births; perception of babysitting

Some MWs have restrictions imposed by Obs on how much they can consult before a TOC is required; this impedes professional autonomy of MWs, interprofessional collegiality, and respect

When there are examples of collaboration (for example in some FHTs), midwifery insurance costs present a barrier

Some RNs feel there are no impacts of funding arrangements

Some OBs perceive medicolegal concerns to be a bigger challenge than funding arrangements

Midwifery specific guidelines help legitimize the way MWs practice and supports them with evidence

Ultimately collaboration very challenging because even with options for billing for consultations, FPs don't feel they are properly remunerated, or billing differences just present too much of a barrier

Frustration about multiple consults without a transfer of care because of the unremunerated work involved

Funding arrangements for MWs and physicians are a major barrier to multidisciplinary or inter-professional care

Physicians and MWs work in parallel, not really possible to collaborate

Many MWs consult with OBs, not cost-effective

Funding differences means MWs are often not included in funding conversations in hospitals, which makes them be seen as second tier

With FHTs, even if client is seeing a midwife who then consults with FP, FP doesn't get paid if client is originally theirs—only paid if they attend delivery

Feeling of being taken advantage by MWs because they are already at the hospital; MWs may not see patient before asking for a consult

No impacts with MFM

Lack of understanding of midwifery funding arrangements

Unintended consequences of funding arrangements

Lower volumes of low-risk OB clients; declining volumes for family medicine means financial sustainability of providing this care challenging

System performance bench marking can affect funding allocation

Birth tourism places billing onus on provider; need for government regulation

Lack of flexibility of the midwifery model or ability to combine it with other models of care

Funding arrangements haven't kept up with necessary changes to prenatal care that require more time

Health Based Allocation Model weighted cases are not always accurate, so intrapartum hospital care is not always appropriately funded; other factors should be considered in hospital funding allocations

Decreasing volume of deliveries per on-call shift over the last 15 years impacts income

For AMU, being funded separately means there is protection over MWs’ space and finances

Funding of midwifery impedes ability to collaborate, innovative programs, integration of MWs into healthcare system

Increased funding for midwifery services may take away clients from OBs

Gender bias impacts funding of women's health

Presence of AMU means some MWs have never had experience working in other systems, find those systems very onerous

Extra challenges with billing in rural areas as not all family doctors provide OB care, those that do end up taking funds away from the pregnant person’s primary FP

Reluctance to consult; discrepancies between providers about how many times to consult before TOC

Fee schedule doesn't necessarily reflect time or skill required for a procedure

Siloed funding means MWs are left out of many administrative conversations at hospitals

C-sections and vaginal deliveries receive very similar payments, but sometimes C-sections are extra challenging or time-intensive, and physicians feel a bit frustrated that they are not adequately compensated for that

Nurse pushback to TOC because it increases their workload

Fee for service not helpful if not busy

In some settings, OBs/hospitals require MWs to transfer care under some circumstances where care remains within MWs’ scope; this leads to multiple billings for the same patient

Lack of transparency about funding for MWs creates barriers and misperceptions

OBs don't personally know MWs at their hospital as well as they used to because of expanding practice and high turnover; no longer helping friends, helping strangers leads to tension

Need for MWs to consult with an FP or OB to arrange referral to some specialists increases cost to healthcare system and creates burden to pregnant person

Billing arrangements present extra challenges for TOCs and when they should happen

OBs seen as a safety net for midwifery patients in hospital

Lack of strategic planning for the sector and not enough focus on money and who controls it, how, where; limited MWs integration into hospitals

Clients and MWs experience disappointment when TOCs need to happen because it impedes involvement of midwifery

Some believe that expanding scope of practice of MWs erodes the work of OBs

Independent contractor model dictated much of current funding and working arrangements; this approach was originally preferred because of legal implications related to employment standards and on-call midwifery work

Frustration because MWs get paid to care for uninsured patients, but OBs do not

Independent contractor model allowed for different places of birth

Funding impacts satisfaction, but not delivery of services

There may be unintended consequences from shifting costs for surgical assistants between different funding sources (i.e., physician vs. midwife funding pools)

Funded for sick care, not wellness; no funding for prevention and keeping people healthy because fee for service provides incentives to have visits with patients

Little incentive for OBs to support expanded scope of care for midwifery because "easier" things which MWs could do are easy for OBs to do and therefore easy money

Solutions: Types of funding arrangements that would create the optimal delivery of maternity care in Ontario

Funding arrangement that would allow for shared care and shared income between FPs and MWs; collaborative funding model

Hospital funding based on percentage of maternity visits

Having MWs as surgical assistants would help with collaboration

Physician funding better suited to a salary model; some believe midwifery funding okay, but should be more options for consultations

Hospitalist MWs would help reduce consults and assist new MWs

Salaried models facilitate interprofessional collaboration

Creating quality-based procedures around maternity services

OBs need to be compensated for all consults, without limit and also compensated if present as a backup

More AMUs as they allow for autonomy but also integration within the system and allow for MWs to work in different, more flexible way

Salary for MWs to work within family practices and provide maternity care

Funding for length of care provided and based on risk categories for people who are pregnant vs. billing based on volume of care and per conversation

Salary model; this would help avoid unnecessary TOCs and pay OBs even when they are not conducting births

Hybrid model with course of care as the core, but equitable FFS payments similar to physicians for other services above scope (but still within ability and competency)

In rural settings, fee for service is okay, with additional maternity care things being "out of the basket"; need to avoid penalizing other providers for FPs who provide OB care caring for their clients however

MWs funded for all low-risk patients, can only see OB if high risk otherwise pregnant person has to pay

Truly coordinated care where multiple providers are available to pregnant people

Need for a hybrid model that is similar for both MWs and physicians; MWs should be allowed to bill some things FFS, or provide episodic care at times

Blended models are ideal to avoid incentivizing volume or disincentivizing quality and care

Model where low-risk patients see midwifery, and higher risk-patients have a shared care model with Obs; model of collaboration vs. competition

A model which promotes interprofessional collaboration is ideal

Salaried models for OBs and physicians

Financial incentives for hospitals to promote intra-professional collaboration

A model which remunerates antenatal care as much as deliveries

Need for a longer-term budget for maternity care; annualization doesn't work

A combination model of fee-for-service and salaried positions

Need to ensure funding arrangements incentive working unusual ('unsociable') hours

Pooled billings between OBs to even out differences in volume

Regionalization and funding relatively to hospital populations

A capitation or roster model where you are paid for a certain number of patients—promotes health and prevention, instead of fee-for-service which pays for sickness or disease

Family doctors and MWs should provide all low-risk care, OBs just for high-risk or when a transfer is necessary because of risk

Hospital On-Call Coverage funding could be really beneficial, especially in rural communities

Need to restructure funding for MWs so it is not so complicated