title: Barriers and facilitators related to implementation of regulated midwifery in Manitoba: a case study.
abstract: BACKGROUND
  In 2000, midwifery was regulated in the Canadian Province of Manitoba. Since the establishment of the midwifery program, little formal research has analyzed the utilization of regulated midwifery services. In Manitoba, the demand for midwifery services has exceeded the number of midwives in practice. The specific objective of this study was to explore factors influencing the implementation and utilization of regulated midwifery services in Manitoba.
  
  
  METHODS
  The case study design incorporated qualitative exploratory descriptive methods, using data derived from two sources: interviews and public documents. Twenty-four key informants were purposefully selected to participate in semi-structured in-depth interviews. All documents analyzed were in the public domain. Content analysis was employed to analyze the documents and transcripts of the interviews.
  
  
  RESULTS
  The results of the study were informed by the Behavioral Model of Health Services Use. Three main topic areas were explored: facilitators, barriers, and future strategies and recommendations. The most common themes arising under facilitators were funding of midwifery services and strategies to integrate the profession. Power and conflict, and lack of a productive education program emerged as the most prominent themes under barriers. Finally, future strategies for sustaining the midwifery profession focused on ensuring avenues for registration and education, improving management strategies and accountability frameworks within the employment model, enhancing the work environment, and evaluating both the practice and employment models. Results of the document analysis supported the themes arising from the interviews.
  
  
  CONCLUSIONS
  These findings on factors that influenced the implementation and integration of midwifery in Manitoba may provide useful information to key stakeholders in Manitoba, as well as other provinces as they work toward successful implementation of regulated midwifery practice. Funding for new positions and programs was consistently noted as a successful strategy. While barriers such as structures of power within Regional Health Authorities and inter and intra-professional conflict were identified, the lack of a productive midwifery education program emerged as the most prominent barrier. This new knowledge highlights issues that impact the ongoing growth and capacity of the midwifery profession and suggests directions for ensuring its sustainability.
authors.affiliation: College of Nursing, Faculty of Health Sciences, University of Manitoba, 89 Curry Place, Winnipeg, MB, R3T 2N2, Canada. Kellie.Thiessen@umanitoba.ca.
authors.forename: Kellie
authors.initials: K
authors.lastname: Thiessen
authors.affiliation: College of Nursing, Faculty of Health Sciences, University of Manitoba, 89 Curry Place, Winnipeg, MB, R3T 2N2, Canada.
authors.forename: Maureen
authors.initials: M
authors.lastname: Heaman
authors.affiliation: Department of Community Health Sciences, Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, R3T 2N2, Canada.
authors.forename: Javier
authors.initials: J
authors.lastname: Mignone
authors.affiliation: Department of Community Health Sciences, College of Medicine, Faculty of Health Sciences, University of Manitoba, 408-727 McDermot Avenue, Winnipeg, MB, R3E 3P5, Canada.
authors.forename: Patricia
authors.initials: P
authors.lastname: Martens
authors.affiliation: Winnipeg Regional Health Authority, Clinical Nurse Specialist St. Boniface General Hospital, 409 Tache Avenue, Winnipeg, MB, R2H 2A6, Canada.
authors.forename: Kristine
authors.initials: K
authors.lastname: Robinson
mesh_terms: D004059:Diffusion of Innovation; D005260:Female; D033161:Government Regulation; D006291:Health Policy; D006801:Humans; D007407:Interviews as Topic; D008350:Manitoba; D008880:Midwifery / Q000331:legislation & jurisprudence* / Q000592:standards*; D019982:Organizational Case Studies; D011247:Pregnancy; D036301:Qualitative Research
keywords: Barriers; Canada; Case study; Facilitators; Implementation; Manitoba; Midwifery; Utilization