Understanding the conditions that influence the roles of midwives in Ontario, Canada’s health system: an embedded single-case study

Abstract: Background: 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. Methods: 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. Results: 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. Conclusions: 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

A critical interpretive synthesis of the roles of midwives in health systems

Abstract: Please refer to full text to view abstract

Women’s subsistence strategies predict fertility across cultures, but context matters

While it is commonly assumed that farmers have higher, and foragers lower, fertility compared to populations practicing other forms of subsistence, robust supportive evidence is lacking. We tested whether subsistence activities—incorporating market integration—are associated with fertility in 10,250 women from 27 small-scale societies and found considerable variation in fertility. This variation did not align with group-level subsistence typologies. Societies labeled as “farmers” did not have higher fertility than others, while “foragers” did not have lower fertility. However, at the individual level, we found strong evidence that fertility was positively associated with farming and moderate evidence of a negative relationship between foraging and fertility. Markers of market integration were strongly negatively correlated with fertility. Despite strong cross-cultural evidence, these relationships were not consistent in all populations, highlighting the importance of the socioecological context, which likely influences the diverse mechanisms driving the relationship between fertility and subsistence

Women's subsistence strategies predict fertility across cultures, but context matters.

While it is commonly assumed that farmers have higher, and foragers lower, fertility compared to populations practicing other forms of subsistence, robust supportive evidence is lacking. We tested whether subsistence activities-incorporating market integration-are associated with fertility in 10,250 women from 27 small-scale societies and found considerable variation in fertility. This variation did not align with group-level subsistence typologies. Societies labeled as "farmers" did not have higher fertility than others, while "foragers" did not have lower fertility. However, at the individual level, we found strong evidence that fertility was positively associated with farming and moderate evidence of a negative relationship between foraging and fertility. Markers of market integration were strongly negatively correlated with fertility. Despite strong cross-cultural evidence, these relationships were not consistent in all populations, highlighting the importance of the socioecological context, which likely influences the diverse mechanisms driving the relationship between fertility and subsistence

Introducing Midwifery-led Birth Centres to Ontario

In Ontario, maternal health systems are changing, with an increasing variety of childbirth options being offered to low-risk pregnant women. Midwifery became a regulated profession in the province in 1994: providing primary care throughout pregnancy, labour and for up to six weeks postpartum. Currently there are three midwifery-led birth centres operating in Ontario, two of which opened in early 2014. The Ministry of Health and Long-Term Care (MoHLTC) has launched these new birth centres in order to offer women more choice in health care provider and birth setting. This shift is representative of the MoHLTC’s push to move services out of hospitals and into community-based settings. While the birth centre initiative is in its early stages and a formal program evaluation is needed, it has the potential, if scaled up, to decrease the need for hospital beds as well as reduce health care costs through more appropriate care for low-risk pregnancies, leading to fewer interventions

Introducing Midwifery-led Birth Centres to Ontario

In Ontario, maternal health systems are changing, with an increasing variety of childbirth options being offered to low-risk pregnant women. Midwifery became a regulated profession in the province in 1994: providing primary care throughout pregnancy, labour and for up to six weeks postpartum. Currently there are three midwifery-led birth centres operating in Ontario, two of which opened in early 2014. The Ministry of Health and Long-Term Care (MoHLTC) has launched these new birth centres in order to offer women more choice in health care provider and birth setting. This shift is representative of the MoHLTC’s push to move services out of hospitals and into community-based settings. While the birth centre initiative is in its early stages and a formal program evaluation is needed, it has the potential, if scaled up, to decrease the need for hospital beds as well as reduce health care costs through more appropriate care for low-risk pregnancies, leading to fewer interventions. L'accroissement de l'éventail des choix pour l'accouchement offerts aux grossesses à bas risque est en train de faire évoluer les systèmes de santé maternelle en Ontario. La profession de sage-femme est régulée en Ontario depuis 1994. Les sages-femmes fournissent les soins primaires pendant la grossesse, l’accouchement et dans les six semaines post-partum. Il existe aujourd'hui trois centres de naissance dirigés par des sages-femmes en Ontario, dont deux ont ouvert au début de 2014. Le Ministère de la santé et des soins de longue durée (MSSLD) a créé ces centres de naissance afin d'offrir aux femmes un plus grand choix de types d'accouchement (personnels et lieux). Ce changement est représentatif d’un virage ambulatoire du MSSLD. Bien que l'initiative des centres de naissance n'en soit qu'à ses débuts et qu'une évaluation officielle du programme soit encore à venir, elle est susceptible, si généralisée à l'ensemble de la population, de diminuer la demande pesant sur les lits d'hôpitaux et de réduire les coûts des soins en fournissant des soins appropriés aux grossesses à bas risque nécessistant moins d'interventions

Women's subsistence strategies predict fertility across cultures, but context matters.

Peer reviewed: TruePublication status: PublishedWhile it is commonly assumed that farmers have higher, and foragers lower, fertility compared to populations practicing other forms of subsistence, robust supportive evidence is lacking. We tested whether subsistence activities-incorporating market integration-are associated with fertility in 10,250 women from 27 small-scale societies and found considerable variation in fertility. This variation did not align with group-level subsistence typologies. Societies labeled as "farmers" did not have higher fertility than others, while "foragers" did not have lower fertility. However, at the individual level, we found strong evidence that fertility was positively associated with farming and moderate evidence of a negative relationship between foraging and fertility. Markers of market integration were strongly negatively correlated with fertility. Despite strong cross-cultural evidence, these relationships were not consistent in all populations, highlighting the importance of the socioecological context, which likely influences the diverse mechanisms driving the relationship between fertility and subsistence

Women’s Subsistence Strategies Predict Fertility Across Cultures, but Context Matters

While it is commonly assumed that farmers have higher, and foragers lower, fertility compared to populations practicing other forms of subsistence, robust supportive evidence is lacking. We tested whether subsistence activities—incorporating market integration—are associated with fertility in 10,250 women from 27 small-scale societies and found considerable variation in fertility. This variation did not align with group-level subsistence typologies. Societies labeled as “farmers” did not have higher fertility than others, while “foragers” did not have lower fertility. However, at the individual level, we found strong evidence that fertility was positively associated with farming and moderate evidence of a negative relationship between foraging and fertility. Markers of market integration were strongly negatively correlated with fertility. Despite strong cross-cultural evidence, these relationships were not consistent in all populations, highlighting the importance of the socioecological context, which likely influences the diverse mechanisms driving the relationship between fertility and subsistence

Reproductive inequality in humans and other mammals

To address claims of human exceptionalism, we determine where humans fit within the greater mammalian distribution of reproductive inequality. We show that humans exhibit lower reproductive skew (i.e., inequality in the number of surviving offspring) among males and smaller sex differences in reproductive skew than most other mammals, while nevertheless falling within the mammalian range. Additionally, female reproductive skew is higher in polygynous human populations than in polygynous nonhumans mammals on average. This patterning of skew can be attributed in part to the prevalence of monogamy in humans compared to the predominance of polygyny in nonhuman mammals, to the limited degree of polygyny in the human societies that practice it, and to the importance of unequally held rival resources to women's fitness. The muted reproductive inequality observed in humans appears to be linked to several unusual characteristics of our species-including high levels of cooperation among males, high dependence on unequally held rival resources, complementarities between maternal and paternal investment, as well as social and legal institutions that enforce monogamous norms