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.

Conceptualising characteristics of resources withdrawal from medical services: a systematic qualitative synthesis.

BACKGROUND: Terms used to describe government-led resource withdrawal from ineffective and unsafe medical services, including 'rationing' and 'disinvestment', have tended to be used interchangeably, despite having distinct characteristics. This lack of descriptive precision for arguably distinct terms contributes to the obscurity that hinders effective communication and the achievement of evidence-based decision-making. The objectives of this study are to (1) identify the various terms used to describe resource withdrawal and (2) propose definitions for the key or foundational terms, which includes a clear description of the unique characteristics of each. METHODS: This is a systematic qualitative synthesis of characteristics and terms found through a search of the academic and grey literature. This approach involved identifying commonly used resource withdrawal terms, extracting data about resource withdrawal characteristics associated with each term and conducting a comparative analysis by categorising elements as antecedents, attributes or outcomes. RESULTS: Findings from an analysis of 106 documents demonstrated that terms used to describe resource withdrawal are inconsistently defined and applied. The characteristics associated with these terms, mainly antecedents and attributes, are used interchangeably by many authors but are differentiated by others. Our analysis resulted in the development of a framework that organises these characteristics to demonstrate the unique attributes associated with each term. To enhance precision, these terms were classified as either policy options or patient health outcomes and refined definitions for rationing and disinvestment were developed. Rationing was defined as resource withdrawal that denies, on average, patient health benefits. Disinvestment was defined as resource withdrawal that results in, on average, improved or no change in health benefits. CONCLUSION: Agreement on the definition of various resource withdrawal terms and their key characteristics is required for transparent government decision-making regarding medical service withdrawal. This systematic qualitative synthesis presents the proposed definitions of resource withdrawal terms that will promote consistency, benefit public policy dialogue and enhance the policy-making process for health systems.

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.

Research Methodology and Community Participation: A Decade of Indigenous Social Science Research in Canada.

Those engaged in community-based participatory research often comment on tensions between social scientific and community values, yet little systematic evidence exists about the relationship between social science research methodologies and community participation. We analyze nearly 500 peer-reviewed articles published between 2005 and 2015 on Indigenous issues in Canada, where policies encourage participatory research methods with disempowered groups. We find that research that includes Indigenous participation is more likely to include Indigenous epistemologies and participatory evidence sources and analysis methods. We also find that peer-reviewed research involving Indigenous participants often fails to go beyond minimum levels of consultation required by policies.

Les personnes qui prennent part à la recherche participative communautaire (RPC) font souvent des commentaires sur les tensions entre les valeurs sociales scientifiques et communautaires, bien qu'il y ait fort peu d'évidence systémique au sujet des relations entre les méthodologies de recherche en sciences sociales et la participation de la collectivité. Nous analysons près de 500 articles revus par des pairs publiés entre 2005 et 2015 sur des questions autochtones au Canada, lorsque les politiques ont favorisé les méthodes de recherche participative auprès de groupes privés de pouvoir. Nous avons découvert que la recherche qui avait recours à la participation autochtone tend davantage à inclure les épistémologies autochtones, les sources de preuve participative et les méthodes d'analyse. Nous avons également constaté que souvent, la recherche revue par les pairs faisant intervenir des participants autochtones n'allait pas au-delà des degrés minimaux de consultation qu'exigent les politiques.

Cultural continuity and Inuit health in Arctic Canada.

BACKGROUND: Previous research association increased levels of cultural continuity and decreased rates of youth suicide in First Nations communities. We investigate the relationship between cultural continuity and self-rated health looking specifically at Inuit living in the Canadian Arctic. METHODS: The Arctic Supplements of the Aboriginal Peoples Survey from years 2001 and 2006 were appended to explore the relationship between various measures of cultural continuity and self-rated health. These measures include access to government services in an Aboriginal language, Inuit cultural variables, community involvement and governance. Literature related to Inuit social determinants of health and health-related behaviours were used to build the models. RESULTS: All measures of cultural continuity were shown to have a positive association with self-rated health for Inuit participants. Background and other control variables influenced the strength of the association but not the direction of the association. Access to services in an Aboriginal language, harvesting activities and government satisfaction were all significantly related to the odds of better health outcomes. Finally, the study contributes a baseline from a known data horizon against which future studies can assess changes and understand future impacts of changes. CONCLUSION: The Canadian government and other agencies should address health inequalities between Inuit and non-Inuit people through programmes designed to foster cultural continuity at a community level. Providing access to services in an Aboriginal language is a superficial way of promoting cultural alignment of these services; however, more inclusion of Inuit traditional knowledge is needed to have a positive influence on health.

Transnational wealth-related health inequality measurement.

The study of international differences in wealth-related health inequalities has traditionally consisted of country-by-country comparisons using own-country relative measures of socioeconomic status, which effectively ignores absolute differences in both wealth and health that can differ between and within countries. To address these limitations, we propose an alternative approach: that of constructing a transnational measure of wealth-related health inequality. To illustrate the limitations of the country-by-country approach, we simulate the impact of changes in wealth and health inequalities both between and within countries on cross-country measures of health inequality and find at least five errors that may arise using country-by-country methods. We then empirically demonstrate the transnational approach to wealth-related health inequalities between and within Haiti and the Dominican Republic, the two constituent countries of the island of Hispaniola, using data from their respective Demographic and Health Surveys. Transnational socioeconomic rankings reveal a large and increasing divergence in wealth between the two countries, which would be ignored using the county-by-country approach. We find that wealth-related inequalities in long-term children's health outcomes are larger than inequalities in short-term health outcomes, and decompositions of the influence of place-based variables on these inequalities reveal country of residence to be the most important factor for long-term outcomes, while urban/rural residence and subnational regions are more important for short-term health outcomes. The significance of this novel methodological approach in relation to conventional health inequality research, including hidden dimensions of wealth-related health inequalities, for example the urbanized "middle class" distribution of HIV and a hidden unequal burden of wasting among children uncovered by the transnational approach are discussed, and errors in gauging changes in inequality over time using a country-by-country approach are highlighted. Using the transnational approach can help to measure important trends in wealth-related health inequalities across countries that more commonly used methods traditionally overlook.

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.