"Miracle in My Life": Clients' Perspectives of Reproductive Healthcare Received through Expanded Midwifery Models in Ontario

Background and Purpose: In Ontario, recent policies have funded “expanded midwifery care models” (EMCMs) to improve choice, access, and sustainability of midwifery care; to support inter-professional collaboration and coordination; and to encourage greater integration of midwifery services into the broader health system. This funding also supports a wider range of services than what midwives previously offered (e.g., reproductive healthcare outside of the perinatal period; prenatal and postpartum care with enhanced system-navigation to patients receiving interpartum care from a physician; surgical first assist at caesarean births, family planning), and provided in a broader range of healthcare settings (e.g., family health teams, community health centres, hospitals). However, the implications of this shift in policy and funding are not yet well-understood, especially regarding experiences and outcomes among under-served populations accessing midwifery care. This study thus sought to understand, among a diverse sample of midwifery clients, how they became engaged with midwifery care, what services were accessed through midwifery care, and what about their experiences may have been uniquely facilitated by expanded midwifery approaches. Clients’ perspectives and experiences were also considered in relationship to Levesque’s Patient-centred Access to Care framework, which theoretically guided this study.

Methods: Qualitative data were collected through semi-structured individual interviews with 16 clients who accessed midwifery care in the year prior. Clients were recruited through purposive sampling via midwives practicing in EMCMs across the province. Using deductive thematic analysis, interview transcripts were examined for codes related to tenets of Levesque’s framework (e.g., acceptability, affordability, approachability, appropriateness, availability and accommodation), and for any emergent “open” codes.

Results: Our research incorporated perspectives across genders, sexual orientations, races, disabilities, countries of birth, and household incomes. For numerous individuals, pregnancy presented a challenge while new to Canada, without insurance, and navigating an unfamiliar healthcare system. Many clients spoke about feeling fearful until they were connected to midwives. Some mentioned first trying to access OB-GYN services, but encountered long wait-lists or found that the care provided was not an ideal fit for their needs or cultural preferences. Clients discussed how the care made possible by EMCMs, including access to contraception, abortion, and supports regarding surrogacy, reflected a more customized and comfortable experience for their respective circumstances and wishes. Clients appreciated that midwives “seemed like family”, were fierce advocates for their clients, were always available, and met clients where they were, in terms of cultural humility as well as physical location (e.g., home-visits, services provided in shelters and community-based settings). Results truly reflected each tenet of Levesque’s framework, and most notably with regard to appropriateness and affordability.

Conclusion and Implications: Results showed that clients were highly satisfied with the care they received through midwifery, and that they were able to access a much wider range of reproductive services and supports due to policy shifts toward EMCMs. Results also suggest a need for increased awareness-raising so that more people, and especially among equity-seeking populations, have more knowledge of the many options for reproductive healthcare that exist through midwifery’s expanded scope of practice.