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Health Care Reform Serving Diversity Unpaid Caregiving Midwifery
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Challenges of Integration: Perspectives on the Regulation of Midwifery in British Columbia Jude Kornelsen, Visiting Scholar, University of British Columbia, School of Nursing and Elaine Carty, University of British Columbia, School of Nursing
After a long and arduous struggle stretching back more than two decades, midwifery in British Columbia began its tenure as a legalized and publicly-funded profession on January 1, 1998. This was a cause for celebration for the midwives and consumer groups who had worked for legalization, and for the birthing women in British Columbia who could now enjoy a pluralistic birthing environment. However, as with any social change, there have also been unanticipated consequences. To evaluate these, researchers at the British Columbia Centre of Excellence for Women’s Health are examining some of the effects of the legalization of midwifery. The program of research, which considers the integration of midwifery from various perspectives—consumers, midwives, other maternity health care providers—endeavours to lay the foundation for continued research within the province as well as for interprovincial and international comparative research. Three papers have been completed in the Perspectives on Midwifery series. The first, "Reality, Opinion and Uncertainty: Views on Midwifery in BC’s Health Care System," considers the way information was provided to practitioners and administrators—and their response to it—prior to the registration of midwives through the provincial Home Birth Demonstration Project Tour. The tour, undertaken by the Ministry of Health and the Ministry Responsible for Seniors, presented information about midwifery and home birth to hospitals around the province. A researcher accompanied the tour to most of its destinations in order to observe how information was disseminated and how the practitioners and administrators who attended responded to the committee. A clear sense of the underlying concerns with midwifery was evident in the questions that were posed and in the response to the committee. This study, which includes recommendations regarding the presentation of midwifery to other professions, provides part of the context for understanding interprofessional relationships when a new profession is introduced into the health care system. The second paper in the series, "In Transition: Nurses Respond to Midwifery Integration," explores perinatal and community health nurses’ knowledge, attitudes and beliefs about midwifery practice in British Columbia as midwifery was being introduced into the health care system. Specifically, it investigates the level of knowledge obstetrical nurses had about midwifery licensure qualifications and scope of practice as mandated by the College of Midwives. We also explored the beliefs of obstetrical nurses regarding the impact of midwifery practice on the quality of care, health care costs, nursing practice and interdisciplinary relationships. Quantitative and qualitative data showed nurses’ attitudes towards midwives ranged from supportive to hostile. Strongly negative reactions were correlated with misinformation about midwives’ skills, training requirements and scope of practice. Recommendations for in-services and other educational forms are made based on the findings of this study. Phase Two of the project involved re-administering the survey to measure changes in knowledge, attitudes and beliefs that occurred during the eighteen-month period after regulation. This second paper will be available early in 2001. A policy paper, "Pushing for Change: Challenges of Integrating Midwifery into the Health Care System," rounds off this first series by summarizing the immediate inter-professional challenges faced by midwives as newcomers to British Columbia’s health care system. Working from a historical context to understand current inter-professional relationships, the findings of the Home Birth Demonstration Project Tour and of the study of registered nurses’ attitudes and beliefs are used to suggest reasons why some nurses and physicians object to midwifery. The implications of these relationships for patient care and the profession of midwifery are explored, and recommendations are made to a variety of health authorities and professional organizations for ways to improve relations. Our second series of studies, "Structural Influences and the Regulation of Midwifery," considers how policy and legal parameters have affected the practice of midwifery in a regulated environment. The first paper, "Experiences of Registering to be a Midwife in BC," is an applied ethnographic study that investigates the experiences of the first group of women who applied to register. In the paper we report on the participants’ experiences of each step of the process and their comments about the more global aspects of their experiences of assessment. We found that the nature of the experience for each applicant depended primarily on five factors:
These recommendations work towards establishing a more equitable process for registration that would increase both the number and diversity of midwives in the province. The second paper in this series is titled "Life as a Registered Midwife," and documents how registration has had an effect on midwives’ professional and personal lives. In-depth interviews were done with 35 midwives from across the province to see whether there have been changes in their scope of practice as defined both by the regulations of the College of Midwives and the state of inter-professional relationships with general practitioners, obstetricians and perinatal nurses. We also examined the process of applying for and receiving, or not receiving, admitting privileges to hospitals and changes in the nature of clientele compared to pre-regulated practice. This paper will be available January 2001. Several other studies are still under way, including a study of family physicians’ attitudes towards midwives in BC (forthcoming) and a study of women’s satisfaction with their birth experiences that compares the care given by midwives and physicians in hospital. Taken together, all current and forthcoming studies within the program of research provide a glimpse into the changes that have been brought to the maternity health care environment in BC by the profession of midwifery. They also provide a foundation for further investigations that will be taken up by the Midwifery Research Group. The MRG is a joint undertaking between the BCCEWH, St. Paul’s and BC Women’s Hospital’s Department of Midwifery, and the University of British Columbia, made up of individuals with a commitment to on-going midwifery-related research. Its mandate is to gain funding and support for the development of a strategic program of research for clinical and non-clinical midwifery-related topics. The groups’ interest in midwifery is not limited to the British Columbia experience: we are also looking at comparing the experience in British Columbia to that of other provinces and to international data. For a full copy of the report contact: |
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