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.