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.

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.

Taking up the challenge of trans and non-binary inclusion in midwifery education: Reflections from educators in Aotearoa and Ontario Canada.

Perinatal services are being challenged to acknowledge that not all pregnant and birthing people are women and to ensure the design and delivery of services that are inclusive of, and deliver equitable outcomes for, trans, non-binary, and other gender diverse people. This is posing unique challenges for midwifery with its women-centred philosophy and professional frameworks. This paper presents the critical reflections of midwifery educators located in two midwifery programmes in Aotearoa1 and Ontario Canada, who are engaged in taking up the challenge of trans and non-binary inclusion in their local contexts. The need to progress trans and non-binary inclusion in midwifery education to secure the human rights of gender diverse people to safe midwifery care and equitable perinatal outcomes is affirmed. We respond to an existing lack of research or guidance on how to progress trans and non-binary inclusion in midwifery education. We offer our insights and reflections organised as four themes located within the frameworks of cultural humility and safety. These themes address midwifery leadership for inclusion, inclusive language, a broader holistic approach, and the importance of positioning this work intersectionally. We conclude by affirming the critical role of midwifery education/educators in taking up the challenge of trans and non-binary inclusion to ensure a future midwifery workforce skilled and supported in the provision of care to the growing gender diverse population.

The COVID-19 Mask: Toward an Understanding of Social Meanings and Responses.

The COVID-19 pandemic has imposed unprecedented restrictions on everyday life. Unlike lockdown or shelter-in-place measures, the facemask has emerged as an empowering response to the public spread of the virus, permitting some degree of return to prepandemic life-such as school or work-by disrupting transmission that would otherwise occur. And yet, this utilitarian tool has attracted considerable controversy and polarized opinions. This article uses Blumer's adaptation of symbolic interactionism as a theoretical roadmap to examine the various meanings ascribed to the facemask and its usage. We discuss how it is socially perceived and consider implications for health care providers within the Canadian social context.

Overview of literature on RMC and applications to Tanzania.

Respectful maternity care research in Tanzania continues to increase. This is an overview of the literature summarizing research based on the domains which comprise this quality of care indicator, ranging from exploratory and descriptive to quantitative measurements of birth perinatal outcomes when respectful interventions are made. The domains of respectful care are reflected in the seven Universal Rights of Childbearing Women but go further to implicate facility administrators and policy makers to provide supportive infrastructure to allay disrespect and abuse.The research methodologies continue to be problematic and several ethical cautions restrict how much control is possible. Similarly, the barriers to collecting accurate accounts in qualitative studies of disrespect require astute interviewing and observation techniques. The participatory community-based and the critical sociology and human rights frameworks appear to provide a good basis for both researcher and participants to identify problems and determine possible solutions to the multiple factors that contribute to disrespect and abuse. The work-life conditions of midwives in the Global South are plagued with poor infrastructure and significantly low resources which deters respectful care while decreasing retention of workers. Researchers and policy-makers have addressed disrespectful care by building human resource capacity, by strengthening professional organizations and by educating midwives in low-resource countries. Furthermore, researchers encourage midwives not only to acquire attitudinal change and to adopt respectful maternity care skills, but also to emerge as leaders and change agents.Safe methods for conducting care while addressing low resources, skilled management of conflict and creative innovations to engage the community are all interventions that are being considered for quality improvement research. Tanzania is poised to evaluate the outcomes of education workshops that address all seven domains of respectful care.

Teaching respectful maternity care using an intellectual partnership model in Tanzania.

OBJECTIVE: to develop and deliver a two-day Respectful Maternity Care workshop for midwives using Intellectual Partnership Model principles SETTING: rural Tanzania BACKGROUND: respectful Maternity Care is an objective, measurable indicator of quality maternal newborn care INTERVENTIONS: using the Intellectual Partnership Model, educators facilitated cocreation of solutions alongside learners for complex ethical and logistic problems in the workplace FINDINGS: the mean scores on a 10-item multiple choice test increased by 20% on average following completion of the interventions; however 2-year certificate learners were less prepared for critical thinking work and social innovations than those midwives who had 3 or 4 year formal training KEY CONCLUSIONS: the implementation of the Intellectual Partnership Model revealed that midwife learners were creative, innovative, context specific in their social innovation creations related to Respectful Maternity Care when supported by respectful facilitators. IMPLICATIONS FOR PRACTICE: the Intellectual Partnership Model should be considered along with problem-based learning in the Global South, for pre and post-service education.

Diversifying the Midwifery Workforce: Inclusivity, Culturally Sensitive Bridging, and Innovation.

Midwifery educators and regulators in Canada have begun to address diversity, equity, and inclusion in admission processes and program curricula. Populations served by midwives value internationally educated midwives from their countries of origin. The International Midwifery Pre-Registration Program at Ryerson University in Toronto, Ontario, provides assessment, midwifery workplace orientation, and accelerated education for internationally educated midwives on behalf of the regulatory College of Midwives of Ontario. Between 2003 and 2015, midwives from 41 countries participated in the bridging program, and 214 (80%) successfully completed the program and qualified for licensure. Of these 214 graduates, 100% passed the Canadian Midwifery Registration Examination and 193 (90%) were employed full time as midwives within 4 months of graduation. The program curriculum enables the integration of these midwives into health care workplaces utilizing innovative approaches to assessment and competency enhancement. Critical to the bridging process are simulation-based practices to develop effective psychomotor learning, virtual and real primary care community placements, and coaching in empathetic, client-centered communication. Cultural sensitivity is embedded into the multiple assessment and learning modalities, and addresses relevant barriers faced by immigrant midwives in the workplace. Findings from the 13 years of the program may be applicable to increase diversity in other North American midwifery settings. This article describes the process, content, outcomes, and findings of the program. Midwifery educators and regulators may consider the utility of these approaches for their settings.

Infusing Diversity and Equity Into Clinical Teaching: Training the Trainers.

Clinical instructors in health care disciplines are charged with engaging students in experiential learning wherein respect and cultural sensitivity is applied. This article reports on the results of 3 diversity workshops conducted for clinical preceptors and field instructors from various disciplines. The workshops were developed in response to students' growing concerns that their academic learning experiences were negatively affected by dissatisfying management of differences between students, faculty, and preceptors with respect to ethno-racial group membership, socioeconomic level, and degree of privilege and power. The workshops included a didactic session that presented basic principles of social and health equity followed by small-group reflection about various ethical and moral dilemmas that were presented in clinical education scenarios. Examples of discrimination on a variety of levels were addressed in these workshops, including race, ethnicity, immigration status, sexual orientation, religion, body size and appearance, ability, age, socioeconomic class, religious faith, and gender. The group exercises and discussion from these sessions provided valuable insight and approaches to difficult but common areas of discomfiture encountered in the clinical teaching setting. This article presents the findings from participants of these diversity workshops in order to encourage the application of equity principles into clinical teaching in midwifery and other health care education contexts.

Taking action on violence through research, policy, and practice.

BACKGROUND: Violence is a critical public health problem associated with compromised health and social suffering that are preventable. The Centre for Global Health and Health Equity organized a forum in 2014 to identify: (1) priority issues related to violence affecting different population groups in Canada, and (2) strategies to take action on priority issues to reduce violence-related health inequities in Canada. In this paper, we present findings from the roundtable discussions held at the Forum, offer insights on the socio-political implications of these findings, and provide recommendations for action to reduce violence through research, policy and practice. METHODS: Over 60 academic researchers, health and social service agency staff, community advocates and graduate students attended the daylong Forum, which included presentations on structural violence, community violence, gender-based violence, and violence against marginalized groups. Detailed notes taken at the roundtables were analyzed by the first author using a thematic analysis technique. FINDINGS: The thematic analysis identified four thematic areas: 1) structural violence perpetuates interpersonal violence - the historical, social, political and economic marginalization that contributes to personal and community violence. 2) social norms of gender-based violence-the role of dominant social norms in perpetuating the practice of violence, especially towards women, children and older adults; 3) violence prevention and mitigation programs-the need for policy and programming to address violence at the individual/interpersonal, community, and societal levels; and 4) research gaps-the need for comprehensive research evidence made up of systematic reviews, community-based intervention and evaluation of implementation research to identify effective programming to address violence. CONCLUSIONS: The proceedings from the Global Health and Health Equity Forum underscored the importance of recognizing violence as a public health issue that requires immediate and meaningful communal and structural investment to break its historic cycles. Based on our thematic analysis and literature review, four recommendations are offered: (1) Support and adopt policies to prevent or reduce structural violence; (2) Adopt multi-pronged strategies to transform dominant social norms associated with violence; (3) Establish standards and ensure adequate funding for violence prevention programs and services; and (4) Fund higher level ecological research on violence prevention and mitigation.

Postpartum depression in refugee and asylum-seeking women in Canada: A critical health psychology perspective.

Canada has one of the world's largest refugee resettlement programs in the world. Just over 48 percent of Canadian refugees are women, with many of them of childbearing age and pregnant. Refugee and asylum-seeking women in Canada face a five times greater risk of developing postpartum depression than Canadian-born women. Mainstream psychological approaches to postpartum depression emphasize individual-level risk factors (e.g. hormones, thoughts, emotions) and individualized treatments (e.g. psychotherapy, medication). This conceptualization is problematic when applied to refugee and asylum-seeking women because it fails to acknowledge the migrant experience and the unique set of circumstances from which these women have come. The present theoretical article explores some of the consequences of applying this psychiatric label to the distress experienced by refugee and asylum-seeking women and presents an alternative way of conceptualizing and alleviating this distress.

Psychological health and life experiences of pregnant adolescent mothers in Jamaica.

A recent Jamaican school-based survey revealed that 23.1% of 13-15 year-olds, had attempted suicide one or more times during the last 12 months. Research that links adolescent pregnancy and suicidal behaviour is lacking in Jamaica. Psychological distress and suicidal behaviours amongst pregnant adolescents elsewhere in the Americas has been documented at prevalence of between 13.3%-20%. The purpose of the study was to explore the experiences and the impact of pregnancy on pregnant adolescent psychological health. Individual interviews and focus groups were conducted with adolescents in two Jamaican antenatal clinics. One clinic was designed as a 'Teen Pregnancy Clinic' and the other used the standard antenatal clinic design. The following themes were identified: decision-making, resilience, social support, community support system, distress, and perceptions of service. Participants reported positively on the specific interventions tailored to their needs at the Teen Clinic. Although motherhood is valued, none of the pregnancies in this study were planned by the mother. Of the 30 adolescents interviewed, seven cases were referred for counseling due to their need for emotional and psychological support. One of the adolescents reported recent sexual violence and another reported having experienced childhood sexual abuse. Historically, Jamaican adolescent mothers faced barriers to education, self determination, and family planning. Empowering, adolescent-centred healthcare and comprehensive reproductive health education may mitigate psychosocial distress.

Increasing access to prenatal care: disease prevention and sound business practice.

Following our study of birth outcomes for uninsured new immigrant and refugee women in Toronto, we discovered clinically significant numbers of women with hypertension and diabetes. As this population ages and prevalence increases, the expense of treating uncontrolled chronic illness increases. Prudent health policy change, a reduction in treatment delays, and equitable access to care will decrease clinical risk and limit the financial burden on the health care system. This unanticipated finding supports the argument for establishing government-funded maternity care insurance for all women. Such policies could prevent perinatal complications and decrease the rate of uncontrolled chronic illness later in life.

Perinatal outcomes of uninsured immigrant, refugee and migrant mothers and newborns living in Toronto, Canada.

Canadian healthcare insurance is not universal for all newcomer populations. New immigrant, refugee claimant, and migrant women face various barriers to healthcare due to the lack of public health insurance coverage. This retrospective study explored the relationships between insurance status and various perinatal outcomes. Researchers examined and compared perinatal outcomes for 453 uninsured and provincially insured women who delivered at two general hospitals in the Greater Toronto Area between 2007 and 2010. Data on key perinatal health indicators were collected via chart review of hospital medical records. Comparisons were made with regional statistics and professional guidelines where available. Four-in-five uninsured pregnant women received less-than-adequate prenatal care. More than half of them received clearly inadequate prenatal care, and 6.5% received no prenatal care at all. Insurance status was also related to the type of health care provider, reason for caesarean section, neonatal resuscitation rates, and maternal length of hospital stay. Uninsured mothers experienced a higher percentage of caesarian sections due to abnormal fetal heart rates and required more neonatal resuscitations. No significant difference was found for low birth weight, preterm birth, NCIU admissions, postpartum hemorrhage, breast feeding, or intrapartum care provided.