A cross-sectional survey of the mental health of midwives in Ontario, Canada: Burnout, depression, anxiety, stress, and associated factors.

PROBLEM: Burnout and the psychological co-morbidities stress, anxiety and depression have a significant impact on healthcare providers, including midwives. These conditions impact the quality of care provided to women, and midwives' ability to remain in the profession. BACKGROUND: There is growing concern regarding the retention of maternity care providers in Canada, particularly midwives. Nationally, 33% of Canadian midwives are seriously considering leaving practice; impacts of the profession on work-life-balance and mental health being commonly cited reasons. Burnout has been shown to contribute to workplace attrition, but little is known concerning burnout among Canadian midwives. AIM: To assess levels of stress, anxiety, depression, and burnout among midwives in Ontario, Canada and potential factors associated with these conditions. METHODS: A cross-sectional survey of Ontario midwives incorporating a series of well-validated tools including the Copenhagen Burnout Inventory and the Depression, Anxiety and Stress Scale. FINDINGS: Between February 5, and April 14, 2021, 275 Ontario midwives completed the survey. More than 50% of respondents reported depression, anxiety, stress, and burnout. Factors associated with poor mental health outcomes included having less than 10-years practice experience, identifying as a midwife with a disability, the inability to work off-call, and having taken a prior mental health leave. DISCUSSION & CONCLUSION: A significant proportion of Ontario midwives are experiencing high levels of stress, anxiety, depression, and burnout, which should be a serious concern for the profession, its leaders, and regulators. Investment in strategies aimed at retaining midwives that address underlying factors leading to attrition should be prioritized.

Canadian midwives' perspectives on the clinical impacts of point of care ultrasound in obstetrical care: A concurrent mixed-methods study.

Introduction: Point of Care Ultrasound (POCUS) is used globally in obstetrics to conduct real time bedside ultrasound scans to answer a clinical question, and it may be conducted by a non-sonography healthcare practitioner. The College of Midwives of Ontario expanded the scope of practice in 2018 to allow registered midwives to perform POCUS during clinical assessments. In response, a POCUS training curriculum for practicing midwives was developed. This paper reports on the perceptions of learners about the impact of this training on their clinical practice. Methods: We conducted a mixed-methods study to understand learner perceptions. Data collection included surveys at four time points over a year, and semi-structured interviews. Quantitative data were analyzed through descriptive statistics, and qualitative analyses used a constructivist approach to grounded theory. Results: The frequency of POCUS use within antenatal care increased among learners, with common applications including assessment of fetal presentation and confirmation of viability. POCUS was seen to holistically aid practitioners care by providing additional skills and knowledge to improve care quality and access to care, particularly for remote areas where ultrasounds are not easily available. However, participants articulated a need for clearer regulatory guidelines outlining how this technology should be applied in midwifery. Equipment purchasing and maintaining costs were a barrier for many midwives. Conclusions: Participants who had access to a device are continuing to use sonography within their clinics to provide comprehensive midwifery care informed by real-time ultrasound assessments. POCUS scans were seen to offer many benefits to improve patient care.

A Social-Ecological Model Exploring Gestational Diabetes Mellitus Screening Practices Among Antenatal Health Care Providers.

Gestational diabetes mellitus (GDM) is associated with adverse health outcomes for the pregnant individual and their baby. Screening approaches for GDM have undergone several iterations, introducing variability in practice among healthcare providers. As such, our study aimed to explore the views of antenatal providers regarding their practices of, and counseling experiences on the topic of, GDM screening in Ontario. We conducted a qualitative, grounded theory study. The study population included antenatal providers (midwives, family physicians, and obstetricians) practicing in Hamilton, Ottawa, or Sudbury, Ontario. Semi-structured telephone interviews were conducted and transcribed verbatim. Transcripts were analyzed using inductive coding upon which codes, categories, and themes were developed to generate a theory grounded in the data. Twenty-two participants were interviewed. Using the social-ecological theory, we created a model outlining four contextual levels that shaped the experiences of GDM counseling and screening: Intrapersonal factors included beliefs, knowledge, and skills; interpersonal factors characterized the patient-provider interactions; organizational strengths and challenges shaped collaboration and health services infrastructure; and finally, guidelines and policies were identified as systemic barriers to health care access and delivery. A focus on patient-centered care was a guiding principle for all care providers and permeated all four levels of the model. Patient-centered care and close attention to barriers and facilitators across intrapersonal, interpersonal, organizational, and policy domains can minimize the impact of variations in GDM screening guidelines. Among care providers, there is a desire for additional skill development related to GDM counseling, and for national consensus on optimal screening guidelines.

Perinatal transmission of Lyme disease: A qualitative study investigating the research priorities of patients with Lyme disease in pregnancy.

INTRODUCTION: Lyme disease is one of the most prevalent vector-borne disease in North America, yet its implications during pregnancy are poorly understood. Our knowledge of perinatal transmission of Lyme disease is limited due to the lack of robust epidemiological studies and longitudinal follow-up. OBJECTIVES: This study aimed to understand the research priorities of people who have experienced Lyme disease in pregnancy and the feasibility of recruiting this population for future studies on perinatal transmission of Lyme disease. We also sought to understand the barriers and enablers to participating in research on perinatal transmission of Lyme disease. METHODS: We conducted a qualitative study using focus groups and interviews with people who had experienced Lyme disease during pregnancy. English speaking participants were recruited through an online survey. There was no geographic restriction on participation. The focus groups and the interview were recorded and transcribed. Data were analyzed using interpretive content analysis. RESULTS: Twenty people participated in four semi-structured focus groups and one semi-structured individual interview. The majority of participants were from North America. Participants' research priorities fell into five categories: transmission, testing, treatment, disease presentation, and education. All study participants expressed interest in future participation in research on Lyme disease in pregnancy and highlighted barriers and enablers to participation that could be addressed to facilitate future study recruitment. CONCLUSION: The research priorities identified in this research would be well addressed through prospective research. People who experience Lyme disease in pregnancy are invested in continued research into perinatal transmission of Lyme disease.

Community level youth-led interventions to improve maternal-neonatal outcomes in low- and middle-income countries: A systematic review of randomised trials.

Background: Evidence on the effectiveness of youth-led interventions for improving maternal-neonatal health and well-being of women and gender diverse childbearing people in low-income and middle-income countries (LMICs) is incomplete. We aimed to summarise the evidence on whether community level youth-led interventions can improve maternal and neonatal outcomes in LMICs. Methods: We included experimental studies of youth-led interventions versus no intervention, standard care, or another intervention. Participants were women and gender diverse childbearing people during antepartum, intrapartum, and postpartum periods. MEDLINE, Embase, CINAHL, Global Health, Web of Science, and Cochrane Library, and grey literature were searched to January 2023. All interventions addressing and targeting maternal-neonatal health and well-being that were youth-led and community level were included. Primary outcomes of interest were maternal death and neonatal death. We excluded based on population, intervention, comparison, and outcome (PICO) and design. Two reviewers independently extracted key information from each included study and assessed risk of bias. Random-effects meta-analysis was performed where there were sufficient data. The certainty of evidence was assessed using Grading of Recommendations, Assessment, Development and Evaluation (GRADE). A narrative synthesis was done for results that could not be pooled. Results: Of the 8054 records retrieved, four trials (21 813 enrolled participants) met the inclusion criteria. The Cooperative for Assistance and Relieve Everywhere, Inc. (CARE) Community Score Card intervention compared to standard reproductive health services control did not significantly improve Antenatal Care coverage (difference-in-differences estimate ß = 0.04; 95% confidence interval (CI) = -0.11, 0.18, P = 0.610; one study, low certainty of evidence). The multi-component social mobilisation interventions compared to standard of care had no effect on adolescent/youth pregnancy (adjusted odds ratio estimate = 1.08; 95% CI = 0.87, 1.33; three studies; low certainty of evidence). Conclusions: Youth-led interventions in LMICs did not show a significant improvement in maternal outcomes. More studies are required to make more precise conclusions. Registration: PROSPERO: CRD42021288798.

The impact of funding models on the integration of Ontario midwives: a qualitative study.

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.

A mixed-method study exploring barriers and facilitators to midwives' mental health in Ontario.

BACKGROUND: There is a paucity of information regarding the mental health of midwives working in Ontario, Canada. Many studies have investigated midwives' mental health around the world, but little is known about how the model of midwifery care in Ontario contributes to or negatively impacts midwives' mental health. The aim of the study was to gain a deeper understanding of factors that contribute to and negatively impact Ontario midwives' mental health. METHODS: We employed a mixed-methods, sequential, exploratory design, which utilized focus groups and individual interviews, followed by an online survey. All midwives in Ontario who had actively practiced within the previous 15 months were eligible to participate. FINDINGS: We conducted 6 focus groups and 3 individual interviews, with 24 midwives, and 275 midwives subsequently completed the online survey. We identified four broad factors that impacted midwives' mental health: (1) the nature of midwifery work, (2) the remuneration model, (3) the culture of the profession, and (4) external factors. DISCUSSION: Based on our findings and the existing literature, we have five broad recommendations for improving Ontario midwives' mental health: (1) provide a variety of work options for midwives; (2) address the impacts of trauma on midwives; (3) make mental health services tailored for midwives accessible; (4) support healthy midwife-to-midwife relationships; and (5) support improved respect and understanding of midwifery. CONCLUSION: As one of the first comprehensive investigations into midwives' mental health in Ontario, this study highlights factors that contribute negatively to midwives' mental health and offers recommendations for how midwives' mental health can be improved systemically.

Exploring patients' perspectives of gestational diabetes mellitus screening and counselling in Ontario: A grounded theory study.

INTRODUCTION: Gestational diabetes mellitus (GDM) is associated with adverse perinatal outcomes. Approaches to screening for GDM continue to evolve, introducing potential variability of care. This study explored the impact of these variations on GDM counselling and screening from the perspectives of pregnant individuals. METHODS: Following a Corbin and Strauss approach to qualitative, grounded theory we recruited 28 individuals from three cities in Ontario, Canada who had a singleton pregnancy under the care of either a midwife, family physician or obstetrician. Convenience and purposive sampling techniques were used. Semi-structured telephone interviews were conducted and transcribed verbatim between March and December 2020. Transcripts were analysed inductively resulting in codes, categories and themes. RESULTS: Three themes were derived from the data about GDM screening and counselling: 'informing oneself', 'deciding' and 'screening'. All participants, regardless of geographical region, or antenatal care provider, moved through these three steps during the GDM counselling and screening process. Differences in counselling approaches between pregnancy care providers were noted throughout the 'informing' and 'deciding' stages of care. Factors influencing these differences included communication, healthcare autonomy and patient motivation to engage with health services. No differences were noted within care provider groups across the three geographic regions. Participant experiences of GDM screening were influenced by logistical challenges and personal preferences towards testing. CONCLUSION: Informing oneself about GDM may be a crucial step for facilitating decision-making and screening uptake, with an emphasis on information provision to facilitate patient autonomy and motivation. PATIENT OR PUBLIC CONTRIBUTION: Participants of our study included patients and service users. Participants were actively involved in the study design due to the qualitative, patient-centred nature of the research methods employed. Analysis of results was structured according to the emergent themes of the data which were grounded in patient perspectives and experiences.

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.

Lyme borreliosis in pregnancy and associations with parent and offspring health outcomes: An international cross-sectional survey.

Background: Lyme disease (LD) is a complex tick-borne pathology caused by Borrelia burgdorferi sensu lato bacteria. Currently, there are limited data regarding the health outcomes of people infected during pregnancy, the potential for perinatal transmission to their fetus, and the long-term effects on these children. Therefore, the primary objective of this survey study was to investigate the impact of LD in pregnancy on both the parent and their offspring. Methods: A seven-section survey was developed and administered in REDCap. Although recruitment was primarily through LD-focused organizations, participation was open to anyone over the age of 18 who had been pregnant. Participant health/symptoms were compared across those with "Diagnosed LD," "Suspected LD," or "No LD" at any time in their lives. The timing of LD events in the participants' histories (tick bite, diagnosis, treatment start, etc.) were then utilized to classify the participants' pregnancies into one of five groups: "Probable Treated LD," "Probable Untreated LD," "Possible Untreated LD," "No Evidence of LD," and "Unclear." Results: A total of 691 eligible people participated in the survey, of whom 65% had Diagnosed LD, 6% had Suspected LD, and 29% had No LD ever. Both the Diagnosed LD and Suspected LD groups indicated a high symptom burden (p < 0.01). Unfortunately, direct testing of fetal/newborn tissues for Borrelia burgdorferi only occurred following 3% of pregnancies at risk of transmission; positive/equivocal results were obtained in 14% of these cases. Pregnancies with No Evidence of LD experienced the fewest complications (p < 0.01) and were most likely to result in a live birth (p = 0.01) and limited short- and long-term offspring pathologies (p < 0.01). Within the LD-affected pregnancy groups, obtaining treatment did not decrease complications for the parent themselves but did ameliorate neonatal health status, with reduced rates of rashes, hypotonia, and respiratory distress (all p < 0.01). The impact of parent LD treatment on longer-term child outcomes was less clear. Conclusion: Overall, this pioneering survey represents significant progress toward understanding the effects of LD on pregnancy and child health. A large prospective study of pregnant people with LD, combining consistent diagnostic testing, exhaustive assessment of fetal/newborn samples, and long-term offspring follow-up, is warranted.

A framework for understanding how midwives perceive and provide care management for pregnancies complicated by gestational diabetes or hypertensive disorders of pregnancy.

BACKGROUND: Both gestational diabetes mellitus (GDM) and hypertensive disorders of pregnancy (HDP) are common, and each are associated with adverse maternal and perinatal outcomes. Midwives may be the first point of care when these conditions arise. This study evaluated the experiences of midwives when providing care to women and people with pregnancies complicated by GDM or HDP. METHODS: A mixed methods study was completed in Ontario, Canada, using a sequential, explanatory approach. A total of 144 online surveys were completed by midwives, followed by 20 semi-structured interviews that were audio recorded and transcribed verbatim. Survey data were analysed using descriptive statistics. Thematic analysis was used to generate codes from the interview data, which were mapped to the Theoretical Domains Framework (TDF), to elucidate factors that might influence management. RESULTS: Most of the midwives' clinical behaviours relating to GDM or HDP were in keeping with guidelines and regulatory standards set by existing provincial standards. Six theoretical domains from the TDF appeared to influence midwives'care pathway: "Internal influences" included knowledge, skills and beliefs about capabilities; while "external influences" included social/professional role and identity, environmental context, and social influences. Interprofessional collaboration emerged as a significant factor on both the internal and external levels of influence. CONCLUSIONS: We identified barriers and facilitators that may improve the experiences of midwives and clients when GDM or HDP newly arises in a pregnancy, necessitating further consultation or management by another health care provider.

Abortion services and providers in Canada in 2019: results of a national survey.

BACKGROUND: Since 2016, abortion care has undergone several important changes, particularly related to the provision of medical abortion using mifepristone. We aimed to document characteristics of the abortion care workforce in Canada after the update of clinical practice guidelines of mifepristone use for medical abortion. METHODS: We conducted a national, web-based, anonymized, bilingual (English/French) survey. We collected demographics and clinical care characteristics of physicians and nurse practitioners who provided abortion care in 2019. Between July and December 2020, we distributed the survey through professional organizations, including The College of Family Physicians of Canada and The Society of Obstetricians and Gynaecologists of Canada. We present descriptive statistics. RESULTS: Overall, 465 respondents representing all 10 provinces and 3 territories in Canada completed the survey. Of these, 388 (83.4%), including 30 nurse practitioners, provided first-trimester medical abortion, of which 350 (99.4%) used mifepristone. Two hundred and nineteen (47.1%) respondents provided first-trimester surgical abortion, 109 (23.4%) provided second-trimester surgical abortion and 115 (24.7%) provided second- or third-trimester medical abortion. Half of respondents reported fewer than 5 years of experience with any abortion care. Respondents reported providing a total of 48 509 abortions in 2019, including 32 345 (66.7%) first-trimester surgical abortions and 13 429 (27.7%) first-trimester medical abortions. In Quebec, only 1918 (12.5%) of reported abortions were first-trimester medical abortions. Primary care providers provided 34 540 (71.2%) of the total abortions. First-trimester medical abortions represented 44.4% (n = 2334) of all abortions in rural areas, as opposed to 25.6% (n = 11 067) in urban areas. INTERPRETATION: The increased availability of medical abortion facilitates abortion access, especially in primary care and rural settings, and where surgical abortion is not available. Rejuvenation of the workforce is a critical contributor to equitable access to abortion services.

Community Level Youth-Led Interventions to Improve Maternal-Neonatal Outcomes in Low- and Middle-Income Countries: Protocol for a Systematic Review.

Introduction: On a global scale, women and childbearing people and neonates continue to die from preventable causes related to pregnancy or childbirth. Sustained and accelerated efforts are critical to improve maternal and neonatal health and well-being. Globally, youth are a growing population and have strength in their numbers. Youth are critical, key drivers of change in their communities. Young people hold the potential to affect positive change, and their meaningful engagement is important to improving maternal health and well-being in low- and middle-income countries. Objectives: To assess the effects of community level youth-led interventions for improving maternal-neonatal health and well-being compared with no interventions or another intervention. Methods: We will undertake a literature search that is comprehensive, complete, and exhaustive. This will include databases such as MEDLINE, EMBASE, and the Cochrane Library, as well as a grey literature search. In our systematic review, we will include experimental studies evaluating maternal-neonatal health and well-being associated with or because of the implementation of community level youth-led interventions. Participants will include women and childbearing people (of any age) during antepartum, intrapartum, and postpartum periods (up to 42 days postpartum). We will examine all interventions addressing and targeting maternal-neonatal health and well-being that are youth-led and community-based and aimed at the members of the community. Our comparators will be no intervention or another intervention. Our primary outcomes are maternal deaths and neonatal deaths. Our review will include only studies in low- and middle-income countries conducted in urban or rural areas. Ethics and Dissemination. Ethics approval is not required as we will use secondary data that is publicly available. There are no active participants in our study. We will involve key stakeholders and experts in maternal-neonatal health regarding dissemination and knowledge mobilization strategies. Our findings will be disseminated as an open access publication, be presented publicly, and defended as part of a doctoral thesis. This trial is registered with CRD42021288798.

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.

A more accurate approach to define abortion cohorts using linked administrative data: an application to Ontario, Canada.

Background: The shifting landscape of abortion care from a hospital-only to a distributed service including primary care has implications for how to identify abortion cohorts for research and surveillance. The objectives of this study were to 1) create an improved approach to define abortion cohorts using linked administrative data sets and 2) evaluate the performance of this approach for abortion surveillance compared with standard approaches. Methods: We applied four principles to identify induced abortion cohorts when some services are delivered beyond hospital settings; 1) exclude early pregnancy losses and postpartum procedures; 2) use multiple data sources; 3) define episodes of care; 4) apply a hierarchical algorithm to determine abortion date to a population-based cohort of all abortion events in Ontario (Canada) from January 1, 2018-March 15, 2020. We calculated risk differences (RD, with 95% confidence intervals) comparing the proportion of medication vs. surgical, first vs. second trimester, and complication incidence applying these principles vs. standard approaches. Results: Hospital-only data (versus multiple data sources) underestimated the frequency of medication abortion (16.1% vs. 31.4%; RD -15.3% [-14.3, -16.3]) and first-trimester abortion (82.1% vs. 94.5%; RD -12.8 [-11.4, 13.4]) and overestimated incidence of abortion complication (2.9% vs. 0.69%; RD 2.2% [1.8, 2.7]). An unlinked (versus linked) approach underestimated the frequency of abortion complications (0.19% vs 0.69%, -RD 0.50% [-0.44--0.56]). Including (versus excluding) abortions following early pregnancy loss or delivery events increased the estimated incidence of abortion complications (1.29% vs. 0.69%, RD 0.60% [0.51-0.69]. Conclusion: New methods are required to accurately identify abortion cohorts for surveillance or research. When legal or regulatory approaches to medication abortion evolve to enable abortion in primary care or office-based settings, hospital-based surveillance systems will become incomplete and biased; to continue valid and complete abortion surveillance, methods must be adjusted to ensure complete capture of procedures across all settings.

Midwives perceptions of managing pregnancies complicated by obesity: A mixed methods study.

OBJECTIVE: The growing prevalence of obesity is a concern for midwives. In Canada, the absence of regulatory standards, varying protocols and consultant preferences shape clinical decision making for the midwife and may lead to inconsistent practice. Our aim was to understand the barriers, enablers, and knowledge gaps that influenced experiences of midwives in Ontario, Canada when providing care to clients impacted by obesity. METHODS: Mixed methods design using a sequential, explanatory approach. Surveys conducted with midwives were administered using an online platform, followed by semi-structured interviews to understand the perspectives elicited in the survey in greater detail. Interviews were audio recorded and transcribed verbatim. Survey data were analyzed using descriptive statistics, and thematic analysis was used for generating codes, categories and themes from the interview data. RESULTS: 144 midwives completed the survey and 20 participated in an interview. The participants described their clinical management when caring for those with obesity which included considerations regarding additional tests/investigations, consultation and transfer of care, and place of birth. Up to 93% of surveyed midwives believed that clients with obesity were appropriate for midwifery-led care however there was less certainty about suitability as BMI increased to higher ranges such as > 45). The care management was influenced by beliefs and attitudes, knowledge, and system-level factors. Midwives experienced barriers such as inconsistent practices and role confusion, and felt ill equipped to care for pregnancies affected by obesity due to unclear guidelines. CONCLUSIONS: Overall, midwives believe clients with obesity are suitable for midwifery-led care due to its individualized, non-judgmental approach to care. Additional training for midwives and other obstetric care providers would be beneficial to help overcome barriers in providing effective care to pregnancies affected by obesity.

Abortion Safety and Use with Normally Prescribed Mifepristone in Canada.

BACKGROUND: In the United States, mifepristone is available for medical abortion (for use with misoprostol) only with Risk Evaluation and Mitigation Strategy (REMS) restrictions, despite an absence of evidence to support such restrictions. Mifepristone has been available in Canada with a normal prescription since November 2017. METHODS: Using population-based administrative data from Ontario, Canada, we examined abortion use, safety, and effectiveness using an interrupted time-series analysis comparing trends in incidence before mifepristone was available (January 2012 through December 2016) with trends after its availability without restrictions (November 7, 2017, through March 15, 2020). RESULTS: A total of 195,183 abortions were performed before mifepristone was available and 84,032 after its availability without restrictions. After the availability of mifepristone with a normal prescription, the abortion rate continued to decline, although more slowly than was expected on the basis of trends before mifepristone had been available (adjusted risk difference in time-series analysis, 1.2 per 1000 female residents between 15 and 49 years of age; 95% confidence interval [CI], 1.1 to 1.4), whereas the percentage of abortions provided as medical procedures increased from 2.2% to 31.4% (adjusted risk difference, 28.8 percentage points; 95% CI, 28.0 to 29.7). There were no material changes between the period before mifepristone was available and the nonrestricted period in the incidence of severe adverse events (0.03% vs. 0.04%; adjusted risk difference, 0.01 percentage points; 95% CI, -0.06 to 0.03), complications (0.74% vs. 0.69%; adjusted risk difference, 0.06 percentage points; 95% CI, -0.07 to 0.18), or ectopic pregnancy detected after abortion (0.15% vs. 0.22%; adjusted risk difference, -0.03 percentage points; 95% CI, -0.19 to 0.09). There was a small increase in ongoing intrauterine pregnancy continuing to delivery (adjusted risk difference, 0.08 percentage points; 95% CI, 0.04 to 0.10). CONCLUSIONS: After mifepristone became available as a normal prescription, the abortion rate remained relatively stable, the proportion of abortions provided by medication increased rapidly, and adverse events and complications remained stable, as compared with the period when mifepristone was unavailable. (Funded by the Canadian Institutes of Health Research and the Women's Health Research Institute.).

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.

The effect of a new maternity unit on maternal outcomes in rural Haiti: an interrupted time series study.

BACKGROUND: In Haiti where there are high rates of maternal and neonatal mortality, efforts to reduce mortality and improve maternal newborn child health (MNCH) must be tracked and monitored to measure their success. At a rural Haitian hospital, local surveillance efforts allowed for the capture of MNCH indicators. In March 2018, a new stand-alone maternity unit was opened, with increased staff, personnel, and physical space. We aimed to determine if the new maternity unit brought about improvements in maternal and neonatal outcomes. METHODS: We conducted an interrupted time series analysis using data collected between July 2016 and October 2019 including 20 months before the opening of the maternity unit and 20 months after. We examined maternal-neonatal outcomes such as physiological (vaginal) births, caesarean birth, postpartum hemorrhage (PPH), maternal deaths, stillbirths and undesirable outcomes (eclampsia, PPH, perineal laceration, postpartum infection, maternal death or stillbirth). RESULTS: Immediately after the opening of the new maternity, the number of physiological births decreased by 7.0% (ß = - 0.070; 95% CI: - 0.110 to - 0.029; p = 0.001) and there was an increase of 6.7% in caesarean births (ß = 0.067; 95% CI: 0.026 to 0.107; p = 0.002). For all undesirable outcomes, preintervention there was an increasing trend of 1.8% (ß = 0.018; 95% CI: 0.013 to 0.024; p < 0.001), an immediate 14.4% decrease after the intervention (ß = - 0.144; 95% CI: - 0.255 to - 0.033; p = 0.012), and a decreasing trend of 1.8% through the postintervention period (ß = - 0.018; 95% CI: - 0.026 to - 0.009; p < 0.001). No other significant level or trend changes were noted. CONCLUSIONS: The new maternity unit led to an upward trend in caesarean births yet an overall reduction in all undesirable maternal and neonatal outcomes. The new maternity unit at this rural Haitian hospital positively impacted and improved maternal and neonatal outcomes.

"It's a Little Bit Tricky": Results from the POLYamorous Childbearing and Birth Experiences Study (POLYBABES).

The number of polyamorous people in Canada is growing steadily, and many polyamorous people are of childbearing age and report living with children. Experiences of polyamorous families, particularly those related to pregnancy and childbirth, have thus far been underrepresented in the literature. The POLYamorous Childbearing and Birth Experiences Study (POLYBABES) sought to explore the pregnancy and birth experiences of polyamorous people. Having previously reported findings relating to experiences with the health system and healthcare providers, this article specifically focuses on the social aspects of polyamorous families' experiences. We explored the impact of polyamory on one's self identity, relationship structures, and experiences navigating the social world. Anyone who self-identified as polyamorous during pregnancy and birth, gave birth in Canada within 5 years, and received some prenatal care was eligible to participate in this study. Participants were recruited through social media and interviewed online or in person. Twenty-four participants were interviewed (11 birthing people and 13 of their partners). Thematic analysis was used to explore the data, and four primary themes were identified: deliberately planning families, more is more, presenting polyamory, and living in a mononormative world. Each theme was further broken down into a number of sub-themes. We also collaborated with research participants to create a glossary of terms. By exploring the pregnancy and birth experiences of polyamorous families and focusing on participant voices, this research adds to the limited research on polyamorous families and contributes to the process of breaking down stigma associated with alternative family structures. Further, by creating an accessible glossary of terms, researchers and lay persons alike have been given access to a meaningful resource.