Making Space for Midwifery in a Hospital: Exploring the Built Birth Environment of Canada's First Alongside Midwifery Unit.

BACKGROUND: Canada's first alongside midwifery unit (AMU) was intentionally informed by evidence-based birth environment design principals, building on the growing evidence that the built environment can shape experiences, satisfaction, and birth outcomes. OBJECTIVES: To assess the impact of the built environment of the AMU for both service users and midwives. This study aimed to explore the meanings that individuals attribute to the built environment and how the built environment impacted people's experiences. METHODS: We conducted a mixed-methods study using a grounded theory methodology for data collection and analysis. Our research question and data collection tools were underpinned by a sociospatial conceptual approach. All midwives and all those who received midwifery care at the unit were eligible to participate. Data were collected through a structured online survey, interviews, and focus group. RESULTS: Fifty-nine participants completed the survey, and interviews or focus group were completed with 28 service users and 14 midwives. Our findings demonstrate high levels of satisfaction with the birth environment. We developed a theoretical model, where "making space" for midwifery in the hospital contributed to positive birth experiences and overall satisfaction with the built environment. The core elements of this model include creating domestic space in an institutional setting, shifting the technological approach, and shared ownership of the unit. CONCLUSIONS: Our model for creating, shifting, and sharing as a way to make space for midwifery can serve as a template for how intentional design can be used to promote favorable outcomes and user satisfaction.

Leveling up evidence syntheses: filling conceptual gaps of the role of midwifery in health systems through a network analysis.

OBJECTIVE: In the research note, our main objective is to explore the value of combining an evidence synthesis with a network analysis. The discussion is based on a critical interpretive synthesis, which combines systematic review methodology with qualitive inquiry, and 'research concept' network analysis focused on understanding the roles of midwives in health systems. The interpretative analytic approach of a critical interpretive synthesis has a high explanatory value by allowing for the review of a diverse body of literature and is well-suited to delving into areas that are not well understood, such as midwifery. RESULTS: Network analyses use graphs to represent relationships between concepts and brought to light important additional insights into the literature that were not present in the evidence synthesis alone. Given the lack of theoretical development in the area of midwifery in health systems, the critical interpretive synthesis allowed for the generation of concepts used to inform a theoretical framework, while the novel application of an exploratory network analysis deepened understanding of conceptual areas of saturation within the field, as well as identifying critical gaps in the literature.

Promoting safety and role clarity among health professionals on Canada's First Alongside Midwifery Unit (AMU): A mixed-methods evaluation.

OBJECTIVE: Globally, midwife-led units are associated with improved clinical outcomes and childbirth satisfaction, but little is known about the impact of the model on health professionals themselves and interprofessional collaboration. The aim of this research was to describe the experiences of health professionals providing care in Canada's first Alongside Midwifery Unit. DESIGN: A mixed-methods evaluation exploring healthcare provider's experiences using an online survey and qualitative semi-structured interviews and focus groups. SETTING: Canada's first Alongside Midwifery Unit, opened at X in 2018. In the Ontario context, the model reorganizes the way in which midwifery services are integrated in the hospital. PARTICIPANTS: Midwives, obstetricians, nurses, pediatricians, anesthetists, and other healthcare providers participated. MEASUREMENTS & FINDINGS: 82 online surveys, 17 semi-structured interviews and one focus group were completed. Providers agreed that they perceived the Alongside Midwifery Unit was a success (89%) and perceived satisfaction among those receiving care on the unit(93%). The majority of providers were satisfied working on the unit (82%) and reported greater role clarity in the new model (85%) compared to the traditional model of midwifery services. Four main themes emerged from the health professionals' perspectives regarding how the unit impacted care: promoting safety, clarifying roles, facilitating collaboration, and managing change. IMPLICATIONS FOR PRACTICE: Overall, healthcare professionals had positive experiences working on the AMU, including improved role clarity and interprofessional relationships, and they perceived high levels of satisfaction among those giving birth on the unit. Our findings indicate the Alongside Midwifery Unit model can be beneficial for health professionals, women and birthing people.

Lessons learned from the implementation of Canada's first alongside midwifery unit: A qualitative explanatory study.

BACKGROUND: In July 2018, Canada's first midwife-led alongside midwifery unit (AMU) opened at Markham Stouffville Hospital (MSH) in Markham, Ontario. Our objectives were to examine how the conditions at MSH made it possible for the hospital to create the first AMU in Canada and to identify lessons to inform spread by examining how characteristics of the intervention, the inner and outer settings, the individuals involved, and the processes used influenced the MSH-AMU implementation process. METHODS: We conducted key informant interviews and document analysis using Yin's research methods. We used the Consolidated Framework for Implementation Research to conceptualize the study and develop semi-structured interview guides. We recruited key informants, including midwives and other health professionals, hospital leaders, leaders of midwifery organizations, and consumers, by email using both purposive and respondent driven sampling. Interviews were digitally recorded and professionally transcribed. We identified documents through key informants and searches of Nexis Uni, Hansard, and Google databases. We analyzed the data using a coding framework based on Greenhalgh et al.'s evidence-informed theory of the diffusion of innovations. RESULTS: Between November 2018 and February 2019, we conducted fifteen key informant interviews. We identified thirteen relevant documentary sources of evidence, including news media coverage, website content, Ontario parliamentary records, and hospital documents. Conditions that influenced implementation of the AMU fell within the following domains from Greenhalgh's diffusion of innovations theory: the innovation, the outer context, the inner context - system antecedents for innovation and system readiness for innovation, communication and influence, linkage - design phase and implementation stage, and the implementation process. While several unique features of MSH supported innovation, factors that could be adopted elsewhere include organizational investment in the development of midwifery leadership skills, intentional use of change management theory, broad stakeholder involvement in the design and implementation processes, and frequent, open communication. CONCLUSIONS: The example of the MSH-AMU illustrates the value of utilizing best practices with respect to change management and system transformation and demonstrates the potential value of using implementation theory to drive the successful implementation of AMUs. Lessons learned from the MSH-AMU can inform successful spread of this innovative service model.

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

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.

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

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.

Enhancing Equitable Access to Assistive Technologies in Canada: Insights from Citizens and Stakeholders.

Les besoins en technologies d'assistance augmentent au Canada, mais l'accès à ces technologies est inégal et fragmentaire, ce qui ferait en sorte que des besoins demeureraient non comblés. Cette étude visait à identifier les valeurs et préférences des citoyens concernant les moyens à utiliser pour favoriser un accès équitable aux technologies d'assistance. Elle visait également à impliquer les décideurs politiques, les parties prenantes et les chercheurs dans des discussions afin d'élaborer des actions dans ce domaine. Au printemps 2017, nous avons organisé trois panels de citoyens et un dialogue avec les parties prenantes. Les principales conclusions des panels ont été incluses dans une synthèse qui a été partagée avec les participants du dialogue. Trente-sept citoyens ont participé aux panels et ont souligné l'importance de l'accès à de l'information fiable, d'un accès équitable aux technologies d'assistance (et ce, quelle que soit la capacité de payer), et de la collaboration. Les vingt-deux participants au dialogue ont fait valoir la nécessité d'un cadre d'orientation pour appuyer l'évolution des pratiques dans l'ensemble au pays. Le cadre d'orientation proposé combinerait des politiques et programmes simplifiés incluant la collecte et l'évaluation de données robustes pour appuyer l'innovation et l'imputabilité à travers le pays.The need for assistive technologies in Canada is increasing, but access is inconsistent and fragmented which can result in unmet needs. We aimed to identify citizens' values and preferences for how to enhance equitable access to assistive technologies and to engage policymakers, stakeholders, and researchers in deliberations to spark action. In spring 2017, we convened three citizen panels and a stakeholder dialogue. Key panel findings were included in an evidence brief that informed dialogue participants. Thirty-seven citizens participated in panels and emphasized the need for access to reliable information, equitable access to assistive technologies regardless of ability to pay, and the need for collaboration. Twenty-two dialogue participants focused on the need for a guiding framework that supports fundamental change across the country. The proposed policy framework can enhance access to assistive technologies through enabling simplified policies and programs, along with fostering robust data collection and evaluation to support countrywide innovation and accountability.

Enhancing the efficiency and effectiveness of non-urgent transportation models

What are the features of different non-urgent transportation models and what approaches may improve use of non-urgent transportation in Ontario?

Economic Analyses of policies to reduce cervical cancer

The Canadian Partnership Against Cancer (hereafter referred to as the Partnership) completed an environmental scan in 2018 of cervical cancer screening in Canada.(6) The scan found that organized cervical cancer screening programs are available in most provinces, with the exception of Quebec.(6) Organized cervical cancer screening programs are also not available in the three territories (Yukon, Northwest Territories and Nunavut).(6) Recommendations for screening varies by jurisdiction and includes commencement from the ages 21 to 25, with administration every two-to-three years, until the age of 61 to 70.

Determining the features of managed alcohol programs

There are growing concerns globally of the health and social harms caused by alcohol.(1) The harmful use of alcohol resulted in approximately three million deaths worldwide in 2016 (5.3% of all deaths globally).(1) Increases in the global burden of disease attributable to alcohol highlight the importance of policies, programs and services aimed at reducing the harmful use of alcohol.

Creating rapid-learning health systems in Canada / Créer des systèmes de santé apprenant rapidement au Canada

The 14 jurisdictions include one federal/national/panCanadian jurisdiction, 10 provincial jurisdictions, and three territorial jurisdictions. The first of these jurisdictions includes both areas of federal government responsibility for providing healthcare ­ most notably for Indigenous peoples, military personnel and veterans, and prisoners in federal correctional facilities ­ and areas where national or panCanadian initiatives have been developed to support provincial and territorial health systems.

Les 14 juridictions incluent la juridiction fédérale/nationale/pancanadienne, les dix juridictions provinciales et les trois juridictions territoriales. La première juridiction englobe tant la responsabilité fédérale de fournir des soins de santé ­ particulièrement aux Autochtones, aux militaires et aux anciens combattants, ainsi qu'aux personnes détenues dans les établissements fédéraux ­ que les domaines où des initiatives nationales ou pancanadiennes ont été instaurées pour soutenir les systèmes de santé provinciaux et territoriaux.

Enhancing health promotion and disease prevention in networked primary care

Health systems are moving away from traditional primary care (e.g., by increasingly shifting to group practice and interprofessional teams rather than solo practice primary-care providers), which is often siloed and results in barriers to timely access to care.(1) The Ministry of Health of British Columbia, which requested this rapid synthesis, is undergoing system transformation to better coordinate and potentially integrate primary care with some and community care and public-health services.(2) The transformation presents an important opportunity to improve primary care and preventive care services through improved management of clinical conditions coupled with health promotion and diseaseprevention services.

Examining the impacts of educational interventions for families affected by opioid use

Opioid addiction has emerged as a pressing publichealth challenge in recent years. From January 2016 to March 2018 more than 8,000 opioid-related deaths were recorded.(1) In 2018, the number of apparent opioidrelated deaths continues to rise, with more than 1,000 deaths in the first three months of the year.

Enhancing health system integration of nurse practitioners in Ontario

Nurses have a long tradition of informally working in expanded roles in rural and remote communities in Canada (e.g., outpost nurses).(1; 2) The formalization of the nurse practitioner role in Canada began in the mid1960s as a response to four interrelated factors: 1) introduction of publicly funded healthcare; 2) perceived physician shortage; 3) increased attention on primary care; and 4) increased medical specialization.(1) In the 1970s there were a number of initiatives led by provincial nursing groups to legitimize expanded nursing roles, which led to the development of educational programs.(1) The ways in which the nurse practitioner role has been formally introduced to health systems has varied across provinces and territories in Canada, and has resulted in jurisdictional variability in terms of the scope of practice (e.g., prescribing and referrals to specialists), remuneration and employment settings.

Identifying effective approaches to support parents and caregivers of children with fetal alcohol spectrum disorder

Fetal Alcohol Spectrum Disorder (FASD) is used "to describe a broader spectrum of presentations and disabilities resulting from alcohol exposure in utero."(1) FASD affects fetal and brain development and may result in limitations to any of an individual's: memory; sensory integration; social communication; language processing; emotional regulation; adaptive functioning; and other executive functions that may make conforming to social, behavioural and cognitive expectations difficult.(2; 3) These effects may mean that individuals affected by FASD are unable to live independently, have difficulty securing employment, and experience behavioural challenges that increase their risk of being in conflict with the law.

Midwifery and obstetrics: Factors influencing mothers' satisfaction with the birth experience.

BACKGROUND: Satisfaction is a key component of the care experience and part of the health system "triple aim," along with improving population health and reducing per capita health care costs, the other two parts of the "triple aim." The objectives of the study were to examine birth-experience satisfaction among women in Ontario, Canada, who received care from midwives, family physicians, and obstetricians. METHODS: We used Statistics Canada's 2006 national Maternity Experiences Survey. The sample includes 1900 Ontario women and is, with appropriate weighting, representative of an estimated population of 29 700 women who gave birth in Ontario to a singleton baby during the study period. Information was collected on respondents' satisfaction with their health care providers, demographic characteristics, and a range of pregnancy, labor, birth, and postpartum experiences. We used logistic regression analysis to assess differences in patient/client satisfaction by type of health care provider. RESULTS: Women cared for by midwives were three times more likely to be satisfied with their care (OR 3.32 [95% CI 2.26-4.86]) when compared with obstetrician-led care. Depression symptoms, having to travel outside the respondents' community to give birth, and being born in an East Asian country were associated with lower levels of satisfaction. CONCLUSION: Given recent health system reforms emphasizing the importance of shifting from expensive acute hospital-based care to community-based care, our findings support empirically the importance of supporting women's access to midwifery services within their communities. Findings of ethnocultural differences in satisfaction with care can inform policy makers as health systems move to provide culturally appropriate care to increasingly diverse populations.

Identifying performance measures, indicators and targets to monitor and evaluate dementia strategies

Dementia is a complex condition and refers to "progressive brain syndromes which affect memory, thinking, behavior and emotion."(1) While the experience of dementia is different for each person, it eventually progresses to an individual not being able to care for themselves and requiring assistance with all aspects of their daily life.(1) Accounting for approximately 50% to 60% of all cases of dementia, Alzheimer's disease is the most common of the more than 100 known forms of dementia. Common symptoms of all forms of dementia include memory loss (e.g., inability to recall details of recent events or conversations, not recognizing or knowing family members' names), frequent difficulty in finding words (e.g., with pauses or substitutions when finding words) or understanding what others are saying, not being to perform routine tasks, and changes in personality or mood

Fostering K-12 students' global competencies

The environment in which children are growing up today is very different than that of previous generations. There has been tremendous innovation in how society operates, with the rapid expansion of technology, globalization of businesses, new careers and opportunities, and increasingly diverse communities. Students graduating from high school have tremendous opportunities to be personally successful, economically productive, and actively engaged. To capitalize on these opportunities however, it is critical that our education systems support students in acquiring the right competencies to navigate increasingly complex societies.

Supporting professional learning approaches to foster global competencies in K-12 education

Education is key to equipping individuals with the necessary skills to meaningfully contribute to society.(1) Rapid developments in technology, workforce changes and the effects of globalization mean that societies are evolving at a faster than ever pace. Responsive education systems are needed to properly prepare students with the required skill sets to meet these changing demands

identifying tax benefits or incentives to reduce poverty among older adults

Poverty reduction measures are an important approach to improving health and well-being.(2) A recent survey found that poverty among older adults was lower in 20 out of 35 OECD countries when compared to the population as a whole.(3) In Canada, while the prevalence of low income among older adults has declined since 1976, older adults are more likely to be towards the bottom of the income distribution.(2; 4) Living in poverty is of particular concern among older adult populations given the additional challenges that are often associated with aging (e.g., multimorbidity, reduced mobility and independence, and loss of community and social supports).