There is a lack of conceptual clarity regarding the drivers of midwives’ roles within health systems, which has contributed to the significant variability both within and across countries in whether, to what extent and how midwives are integrated in these systems. This dissertation incorporated a mix of methodological approaches to address this gap. First, a critical interpretive synthesis was used to develop a theoretical framework that identifies the different types of policy levers that would be required to enhance to roles of midwives within any given health system, and an exploratory network analysis was used to analyze relationships among the ‘health system arrangements’ part of the framework and to identify gaps in the literature. Second, a logistic regression was used to examine the correlates of birth-experience satisfaction – as a patient experience component of the health system ‘triple aim’ – among women receiving care from midwives, family physicians and/or obstetricians in Ontario’s health system. Third, an embedded single-case study design and Kingdon’s agenda setting and the 3i+E theoretical frameworks were used to qualitatively assess how and under what conditions the Ontario health system has assigned roles to midwives. The research chapters build on each other and make substantive, methodological and theoretical contributions. Specifically, insights gained from the theoretical framework informed variable selection and definition for the quantitative analysis and were tested in the embedded single-case study. Substantively, the dissertation provides a rich understanding of the roles of midwives in health systems through a mix of qualitative and quantitative research evidence, adding to the evidence base that policymakers can draw from when making decisions regarding midwifery care.
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Methodologically, the dissertation introduces a novel combination of a critical interpretive synthesis and exploratory network analysis. Lastly, the dissertation advances the theoretical understanding of the roles of midwives within health systems through a new theoretical framework.
