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McNeil D, Elliott SA, Wong A, Kromm S, Bialy L, Montesanti S, Purificati-Fuñe A, Juul S, Roach P, Bromely J, Tailfeathers E, Amyotte M, Oster RT. Indigenous maternal and infant outcomes and women's experiences of midwifery care: A mixed-methods systematic review. Birth 2024. [PMID: 38898696 DOI: 10.1111/birt.12841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 01/16/2024] [Accepted: 05/02/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND The impact of midwifery, and especially Indigenous midwifery, care for Indigenous women and communities has not been comprehensively reviewed. To address this knowledge gap, we conducted a mixed-methods systematic review to understand Indigenous maternal and infant outcomes and women's' experiences with midwifery care. METHODS We searched nine databases to identify primary studies reporting on midwifery and Indigenous maternal and infant birth outcomes and experiences, published in English since 2000. We synthesized quantitative and qualitative outcome data using a convergent segregated mixed-methods approach and used a mixed-methods appraisal tool (MMAT) to assess the methodological quality of included studies. The Aboriginal and Torres Strait Islander Quality Appraisal Tool (ATSI QAT) was used to appraise the inclusion of Indigenous perspectives in the evidence. RESULTS Out of 3044 records, we included 35 individual studies with 55% (19 studies) reporting on maternal and infant health outcomes. Comparative studies (n = 13) showed no significant differences in mortality rates but identified reduced preterm births, earlier prenatal care, and an increased number of prenatal visits for Indigenous women receiving midwifery care. Quality of care studies indicated a preference for midwifery care among Indigenous women. Sixteen qualitative studies highlighted three key findings - culturally safe care, holistic care, and improved access to care. The majority of studies were of high methodological quality (91% met ≥80% criteria), while only 14% of studies were considered to have appropriately included Indigenous perspectives. CONCLUSION This review demonstrates the value of midwifery care for Indigenous women, providing evidence to support policy recommendations promoting midwifery care as a physically and culturally safe model for Indigenous women and families.
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Affiliation(s)
- Deborah McNeil
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Maternal Newborn Child & Youth Strategic Clinical Network™, Alberta Health Services, Edmonton, Alberta, Canada
- Faculty of Nursing, University of Calgary, Calgary, Alberta, Canada
| | - Sarah A Elliott
- Alberta Research Centre for Health Evidence, Department of Pediatrics, Faculty of Medicine & Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Angie Wong
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Indigenous Wellness Core, Alberta Health Services, Edmonton, Alberta, Canada
| | - Seija Kromm
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Maternal Newborn Child & Youth Strategic Clinical Network™, Alberta Health Services, Edmonton, Alberta, Canada
| | - Liza Bialy
- Alberta Research Centre for Health Evidence, Department of Pediatrics, Faculty of Medicine & Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Stephanie Montesanti
- School of Public Health, College of Health Sciences, Edmonton, Alberta, Canada
- Centre for Healthy Communities, School of Public Health, College of Health Sciences, Edmonton, Alberta, Canada
| | - Adam Purificati-Fuñe
- Department of Agricultural, Food & Nutritional Sciences, Faculty of Agricultural, Life & Environmental Sciences, College of Natural & Applied Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Sonje Juul
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Pamela Roach
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Family Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jackie Bromely
- Awo Taan Healing Lodge Society, Calgary, Alberta, Canada
| | | | - Maddie Amyotte
- ihkapaskwa Indigenous Wellness Collective, Fort McMurray, Alberta, Canada
| | - Richard T Oster
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Indigenous Wellness Core, Alberta Health Services, Edmonton, Alberta, Canada
- School of Public Health, College of Health Sciences, Edmonton, Alberta, Canada
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Kim K, Kim Y, Park J. A comparison of the perceived importance and performance of midwives' roles between midwives and nurses in Korea: a cross-sectional study. KOREAN JOURNAL OF WOMEN HEALTH NURSING 2023; 29:263-273. [PMID: 38204387 PMCID: PMC10788394 DOI: 10.4069/kjwhn.2023.11.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/01/2023] [Accepted: 11/13/2023] [Indexed: 01/12/2024] Open
Abstract
PURPOSE This study aimed to identify the perceptions, importance, and performance of midwives' roles among midwives and nurses in Korea. METHODS A descriptive correlational design was employed. Data were collected from 164 nurses and 79 midwives from April 1 to June 25, 2021. Midwives enrolled in the Korean Midwifery Association and nurses and midwives from two hospitals each Daegu and Gyeonggi Province in Korea were invited to participate. The independent t-test, chi-square test, the Welch-Aspin test, and Pearson correlation coefficient were used for analysis. RESULTS The midwives' role perception score (3.47±1.46) was lower than that of nurses (3.95±0.85), and the midwives' role performance score (2.98±0.83) was also lower than that of nurses (3.34±0.89). Significant differences were observed between midwives and nurses in their perception and performance of roles related to prenatal management, childbirth management, management of psychological changes, postpartum management, and newborn care. Higher role perception and performance among midwives were linked to the management of psychological changes and women's health, indicating potential areas for future development. CONCLUSION The study results suggest directions for developing new roles for midwives. It is necessary to find a way to expand the field of midwives in public health by benchmarking the roles of midwives in various countries.
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Affiliation(s)
- Kyungwon Kim
- Department of Nursing, Daegu Haany University, Daegu, Korea
| | - Yunmi Kim
- College of Nursing, Gachon University, Incheon, Korea
| | - Jummi Park
- Department of Nursing, Namseoul University, Cheonan, Korea
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Darling EK, Lemay SB, Ejiwunmi 'R, Miller KJ, Sprague AE, D'Souza R. The impact of funding models on the integration of Ontario midwives: a qualitative study. BMC Health Serv Res 2023; 23:1087. [PMID: 37821937 PMCID: PMC10568882 DOI: 10.1186/s12913-023-10104-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 10/03/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND Nearly 30 years post legalisation and introduction, midwifery is still not optimally integrated within the health system of Canada's largest province, Ontario. Funding models have been identified as one of the main barriers. METHODS Using a constructivist perspective, we conducted a qualitative descriptive study to examine how antepartum, intrapartum, and postpartum funding arrangements in Ontario impact midwifery integration. We conceptualized optimal 'integration' as circumstances in which midwives' knowledge, skills, and model of care are broadly respected and fully utilized, interprofessional collaboration and referral support the best possible care for patients, and midwives feel a sense of belonging within hospitals and the greater health system. We collected data through semi-structured telephone interviews with midwives, obstetricians, family physicians, and nurses. The data was examined using thematic analysis. RESULTS We interviewed 20 participants, including 5 obstetricians, 5 family physicians, 5 midwives, 4 nurses, and 1 policy expert. We found that while course-of-care-based midwifery funding is perceived to support high levels of midwifery client satisfaction and excellent clinical outcomes, it lacks flexibility. This limits opportunities for interprofessional collaboration and for midwives to use their knowledge and skills to respond to health system gaps. The physician fee-for-service funding model creates competition for births, has unintended consequences that limit midwives' scope and access to hospital privileges, and fails to appropriately compensate physician consultants, particularly as midwifery volumes grow. Siloing of midwifery funding from hospital funding further restricts innovative contributions from midwives to respond to community healthcare needs. CONCLUSIONS Significant policy changes, such as adequate remuneration for consultants, possibly including salary-based physician funding; flexibility to compensate midwives for care beyond the existing course of care model; and a clearly articulated health human resource plan for sexual and reproductive care are needed to improve midwifery integration.
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Affiliation(s)
- Elizabeth K Darling
- McMaster Midwifery Research Centre, McMaster University, 1280 Main St. West, HSC-4H26, Hamilton, ON, L8S 4K1, Canada.
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, ON, Canada.
| | - Sylvie B Lemay
- McMaster Midwifery Research Centre, McMaster University, 1280 Main St. West, HSC-4H26, Hamilton, ON, L8S 4K1, Canada
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, ON, Canada
| | - 'Remi Ejiwunmi
- McMaster Midwifery Research Centre, McMaster University, 1280 Main St. West, HSC-4H26, Hamilton, ON, L8S 4K1, Canada
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Katherine J Miller
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Ann E Sprague
- Better Outcomes Registry and Network (BORN) Ontario, Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Rohan D'Souza
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, ON, Canada
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Watkins V, Nagle C, Yates K, McAuliffe M, Brown L, Byrne M, Waters A. The role and scope of contemporary midwifery practice in Australia: A scoping review of the literature. Women Birth 2023:S1871-5192(22)00361-4. [PMID: 36631386 DOI: 10.1016/j.wombi.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 11/02/2022] [Accepted: 12/01/2022] [Indexed: 01/11/2023]
Abstract
PROBLEM Little is known about the breadth of midwifery scope within Australia, and few midwives work to their full scope of practice. BACKGROUND Midwives in Australia are educated and professionally accountable to work in partnership with childbearing women and their families, yet they are currently hindered from practicing within their full scope of practice by contextual influences. AIMS To perform a scoping review of the literature to map out the role and scope of contemporary midwifery practice in Australia To identify any key issues that impact upon working within the full scope of midwifery practice in the Australian context METHODS: A scoping review of the literature guided by the Arksey and O'Malley's five-stage methodological framework, and the 'best fit' framework synthesis using the Nursing and Midwifery Board of Australia's Midwifery Standards for Practice. FINDINGS Key themes that emerged from the review included Partnership with women; The professional role of the midwife; and Contextual influences upon midwifery practice.Discussion Tensions were identified between the midwifery scope of practice associated with optimal outcomes for women and babies supported by current evidence and the actual role and scope of most midwives employed in models of care in the current Australian public healthcare system. CONCLUSIONS There is a mismatch between the operational parameters for midwifery practice in Australia and the evidence-based models of continuity of midwifery carer that are associated with optimal outcomes for childbearing women and babies and the midwives themselves.
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Affiliation(s)
- Vanessa Watkins
- Centre for Nursing and Midwifery Research, James Cook University, Queensland 4814, Australia
| | - Cate Nagle
- Centre for Nursing and Midwifery Research, James Cook University, Queensland 4814, Australia; Townsville Institute of Health Research and Innovation, Townsville Hospital and Health Service, 100 Angus Smith Drive, Douglas, Queensland 4814, Australia.
| | - Karen Yates
- Centre for Nursing and Midwifery Research, James Cook University, Queensland 4814, Australia
| | - Marie McAuliffe
- Centre for Nursing and Midwifery Research, James Cook University, Queensland 4814, Australia
| | - Lesley Brown
- Centre for Nursing and Midwifery Research, James Cook University, Queensland 4814, Australia
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Zeytinoglu IU, Sayin FK, Neiterman E, HakemZadeh F, Geraci J, Plenderleith J, Lobb D. Hours of work and on-call weeks preferences of Canadian midwives: relationships with intention to stay in the profession. BMC Health Serv Res 2022; 22:950. [PMID: 35883071 PMCID: PMC9316842 DOI: 10.1186/s12913-022-08287-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 06/30/2022] [Indexed: 11/10/2022] Open
Abstract
Background Midwives have long workdays and work many weeks on call. There is a concern that these extended work schedules can negatively affect their intention to stay in the profession. Purpose This study provides evidence on Canadian midwives’ preferences for and experiences with policies and guidelines which limit the hours of work and weeks per year preferred to be on call, and examines the relationship between preferences and midwives’ intention to stay in the profession. Methods Data come from our 2018 pan-Canadian survey of midwives. Descriptive statistics of 720 midwives’ preferences and experiences are provided. In the correlations followed by the OLS regressions, 596 midwives’ data are used to test the associations between preferences and intention to stay in the profession. STATA (version 15) is used. A thematic analysis of 274 midwives’ responses to the open-ended survey question is conducted to give voice to midwives on what can be done for retention. Results Three quarters of the 720 respondents prefer policies and guidelines to limit hours of work in a 24-hour period, though less than half have policies and guidelines on hours of work. More than half prefer to have fewer on-call weeks or never to be on call, less than a third prefer same number of on-call weeks, and only 2% prefer more weeks to be on call. Midwives are currently working on average 33 weeks per year on call. OLS regression analysis shows that ‘met preference’ for hours of work and on-call weeks are positively associated with intention to stay. In responding to the open-ended survey question, midwives recommend limiting the consecutive hours of work and on-call weeks to manageable hours and weeks to retain them in the profession. Conclusion Midwives whose preferences are met are the ones intending to stay in the profession. There is, however, a large number of midwives with ‘unmet needs’ preferring to have policies and guidelines to limit the hours but do not have that currently, and would like to work fewer weeks on call than currently. These are the midwives who are not intending to stay in the profession. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08287-6.
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Affiliation(s)
- Isik U Zeytinoglu
- DeGroote School of Business, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4M4, Canada.
| | - Firat K Sayin
- Sobey School of Business, Saint Mary's University, 923 Robie Street, Halifax, Nova Scotia, B3H 3C3, Canada
| | - Elena Neiterman
- School of Public Health Sciences, University of Waterloo, 200 University Avenue West, Waterloo, Ontario, N2L 3G1, Canada
| | - Farimah HakemZadeh
- School of Human Resource Management, Faculty of Liberal Arts and Professional Studies, York University, 4700 Keele Street, Toronto, Ontario, M3J 1P3, Canada
| | - Johanna Geraci
- College of Midwives of Ontario, 21 St Clair Ave E #303, Toronto, Ontario, M4T 1L9, Canada
| | - Jennifer Plenderleith
- DeGroote School of Business, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4M4, Canada
| | - Derek Lobb
- Faculty of Health Sciences, McMaster University, 1280 Main St W, Hamilton, Ontario, L8S 4K1, Canada
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HakemZadeh F, Sayin FK, Neiterman E, Zeytinoglu IU, Geraci J, Plenderleith J, Lobb D. Does an alignment of employment policies and individual preferences affect intention to stay in the profession? Evidence from Canadian Midwives. Health Policy 2021; 125:450-458. [PMID: 33551204 DOI: 10.1016/j.healthpol.2021.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 11/20/2020] [Accepted: 01/20/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND This study examines whether alignment of actual and preferred employment policies, including compensation method, employment status, and work schedule, affect midwives' intention to stay in the profession. The study further investigates the moderating effect of financial-rewards satisfaction and compares midwives' policy preferences in urban/rural practices. METHODS Cross-sectional survey data from 549 midwives across Canada were analysed through descriptive statistics, bivariate correlations, and hierarchical linear regressions. Further regression analysis separated data for urban/rural practicing midwives. RESULTS Three-quarters of the respondents are paid through a billable-course-of-care, while only one-third prefer this model. Another one-third prefer a combination of salary and billable-course-of-care. More than three-quarters of the respondents are independent contractors, but half prefer other forms of employee status. Lastly, half prefer a part-time work schedule, while others prefer full-time. Alignment of actual and preferred employment policies significantly explains midwives' intention to stay in the profession. Intentions to stay in the profession for urban midwives is significantly affected by the alignment of actual and preferred compensation methods, but not for rural ones. Both urban and rural midwives report similar preferences for employment status and work schedule policies. Furthermore, satisfaction with financial rewards is significantly associated with their intention to stay. CONCLUSION Policymakers can positively influence midwives' intention to stay in the profession by facilitating alignment of their actual and preferred employment policies.
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Affiliation(s)
- Farimah HakemZadeh
- School of Human Resource Management, Faculty of Liberal Arts and Professional Studies, York University, 4700 Keele Street, Toronto, Ontario, M3J 1P3, Canada.
| | - Firat K Sayin
- Sobey School of Business, Saint Mary's University, 923 Robie Street, Halifax, Nova Scotia, B3H 3C3, Canada.
| | - Elena Neiterman
- School of Public Health and Health Systems, University of Waterloo, 200 University Avenue West, Waterloo, Ontario, N2L 3G1, Canada.
| | - Isik Urla Zeytinoglu
- DeGroote School of Business, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4M4, Canada.
| | - Johanna Geraci
- College of Midwives of Ontario, 21 St Clair Ave E #303, Toronto, Ontario, M4T 1L9, Canada.
| | - Jennifer Plenderleith
- DeGroote School of Business, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4M4, Canada.
| | - Derek Lobb
- Faculty of Health Sciences, McMaster University, 1280 Main St W, Hamilton, Ontario, L8S 4L8, Canada.
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Kruger P, Abdool Karim S, Tugendhaft A, Goldstein S. An Analysis of the Adoption and Implementation of A Sugar-Sweetened Beverage Tax in South Africa: A Multiple Streams Approach. Health Syst Reform 2021; 7:e1969721. [PMID: 34606415 DOI: 10.1080/23288604.2021.1969721] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
This paper describes a case study of the adoption and implementation of the sugar-sweetened beverage tax in South Africa, termed the Health Promotion Levy. Qualitative data extraction and analysis of institutional documents, such as policy proposals and parliamentary debate records, stakeholder submissions to Parliament and media reports, were guided by the Kingdon Multiple Streams Theory as adapted to study agenda setting, policy adoption, and implementation. We present the following key findings: First, consistent messaging from policy entrepreneurs, consisting of advocacy groups, health organizations, and research entities, was key to ensuring that a tax policy solution was proposed and passed. Second, the continuity of certain key policymakers contributed to the relatively expedient passage of the tax policy. Third, the use of an excise tax was, amongst others, an appealing policy solution because of its revenue-raising potential; however, uncertainty regarding the purpose of the tax negatively impacted public attitudes toward it. Fourth, industry arguments, relating to unemployment, were effective in restructuring the tax in favor of industry actors. Finally, regulatory action by sectors outside of finance and health impacted stakeholder perceptions of the tax and possibly obstructed regular annual adjustments for inflation.
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Affiliation(s)
- Petronell Kruger
- SAMRC/WITS Centre for Health Economics and Decision Science, PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Safura Abdool Karim
- SAMRC/WITS Centre for Health Economics and Decision Science, PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Aviva Tugendhaft
- SAMRC/WITS Centre for Health Economics and Decision Science, PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Susan Goldstein
- SAMRC/WITS Centre for Health Economics and Decision Science, PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Mattison CA, Lavis JN, Wilson MG, Hutton EK, Dion ML. A critical interpretive synthesis of the roles of midwives in health systems. Health Res Policy Syst 2020; 18:77. [PMID: 32641053 PMCID: PMC7346500 DOI: 10.1186/s12961-020-00590-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 06/14/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Midwives' roles in sexual and reproductive health and rights continues to evolve. Understanding the profession's role and how midwives can be integrated into health systems is essential in creating evidence-informed policies. Our objective was to develop a theoretical framework of how political system factors and health systems arrangements influence the roles of midwives within the health system. METHODS A critical interpretive synthesis was used to develop the theoretical framework. A range of electronic bibliographic databases (CINAHL, EMBASE, Global Health database, HealthSTAR, Health Systems Evidence, MEDLINE and Web of Science) was searched through to 14 May 2020 as were policy and health systems-related and midwifery organisation websites. A coding structure was created to guide the data extraction. RESULTS A total of 4533 unique documents were retrieved through electronic searches, of which 4132 were excluded using explicit criteria, leaving 401 potentially relevant records, in addition to the 29 records that were purposively sampled through grey literature. A total of 100 documents were included in the critical interpretive synthesis. The resulting theoretical framework identified the range of political and health system components that can work together to facilitate the integration of midwifery into health systems or act as barriers that restrict the roles of the profession. CONCLUSIONS Any changes to the roles of midwives in health systems need to take into account the political system where decisions about their integration will be made as well as the nature of the health system in which they are being integrated. The theoretical framework, which can be thought of as a heuristic, identifies the core contextual factors that governments can use to best leverage their position when working to improve sexual and reproductive health and rights.
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Affiliation(s)
- Cristina A Mattison
- Department of Obstetrics and Gynecology, McMaster Midwifery Research Centre, 1280 Main St. West, HSC-4H26, Hamilton, ON, L8S 4K1, Canada.
| | - John N Lavis
- McMaster Health Forum, 1280 Main St West, MML-417, Hamilton, ON, L8S 4L6, Canada
| | - Michael G Wilson
- McMaster Health Forum, 1280 Main St West, MML-417, Hamilton, ON, L8S 4L6, Canada
| | - Eileen K Hutton
- Department of Obstetrics and Gynecology, McMaster Midwifery Research Centre, 1280 Main St. West, HSC-4H26, Hamilton, ON, L8S 4K1, Canada
| | - Michelle L Dion
- Department of Political Science, McMaster University, 1280 Main St. West, KTH-533, Hamilton, ON, L8S 4M4, Canada
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