Introduction

Midwifery is a fast-growing perinatal care option in Canada, which has demonstrated improved health outcomes for birthing persons and their newborns.¹ The small-team, continuity-of-care midwifery model widely practiced by midwives in Canada has resulted in higher satisfaction for birthing people due to the meaningful relationships created between midwives and clients and from the person-centred ideology of midwifery.^2–4

Despite these successes, barriers to sustainable midwifery care and practice remain in Canada. The number of midwives with baccalaureate degrees in the workforce is limited given the relatively shorter history of midwifery being regulated in Canada and only six undergraduate midwifery programs.⁵ The demanding 24/7 on-call availability required of midwives and limited intake into competitive undergraduate programs make it difficult to recruit and retain midwives. Many midwives report overworking, feelings of burnout, and strains on personal relationships, which may push them to leave the profession.^3,5 Working in midwife continuity of care teams has been seen to mitigate feelings of stress and burnout, as midwives can rely on the team dynamic for support and time off, but a general lack of midwives still remains a concern.^3,6

Interprofessional challenges within hospital settings also present a barrier to midwife-led care. Differences in the approaches of doctors and midwives can lead to conflict between the two professions. When practicing in hospitals, midwives may face an undermining of their knowledge and skills and barriers to practicing person-centred care, which is a central tenet of midwifery in Canada.³

In Alberta, midwifery was regulated in 1994 and became publicly funded in 2009. Alberta Health Services (AHS) publicly funds midwifery care in Alberta. Midwives are independent contractors, not AHS employees, but their service reimbursement is negotiated through AHS.⁷ There are approximately 164 midwives in the province, who account for 10.6% of births.¹ The demand for midwives has been steadily increasing, but the availability of midwives does not match and has resulted in lengthy wait lists. Furthermore, many midwifery clinics are centralized in the major urban centers in Alberta (Calgary and Edmonton), making access difficult for rural residents.⁸

There is a gap in the literature surrounding the experiences of Alberta midwives from their perspective. Some studies have looked at burnout within Albertan midwives and found that despite similar caseloads, Albertan midwives experienced less burnout than other provinces, possibly due to their higher salaries.⁵ Interprofessional relationships have also been identified as an issue. Most Albertan midwives have hospital admitting privileges,⁹ but as one Calgary-based study found, there is still a general lack of communication and trust between midwives and doctors, which causes tensions within the hospital setting.^5,10

This study seeks to understand the successes, barriers, and challenges to practicing midwifery in Alberta. This research aims to achieve a “first-hand” account of midwifery. We seek to highlight the voices of midwives and produce knowledge about midwifery in Alberta that has implications for policy action to support midwives better and make midwife-led care a more accessible choice for Albertans.

Methods

Design

A feminist standpoint methodology was chosen for this study, using in-depth, semi-structured interviews. This feminist research approach prioritizes lived experience and recognizes that marginalized groups have a powerful standpoint to critique unjust social conditions.¹¹ A feminist methodology, which highlights the voices of midwives and their experiences, is a clear choice for this research project, given that midwifery in Alberta is a feminized and under-supported profession. The historical roots of midwifery are grounded in feminism with the goal of “de-medicalizing” birth and advocating for the reclamation of person-centered births.¹² A feminist methodological approach allows researchers to connect personal lived experiences to political and social contexts.¹³ Using qualitative interviews, rooted in the feminist understanding that personal experience must be the source of research and the production of knowledge,¹⁴ provides the means to gain these insights. Interviewing midwives in Alberta, Canada about their experiences and perspectives on their profession permits a deeper understanding of the opportunities and barriers to practicing midwifery in this context. The use of in-depth interviews was chosen to allow the midwives to share their experiences in their own words, producing rich and nuanced “insider” accounts.

A SWOT Analysis was used in this study to assess the strengths (S), weaknesses (W), opportunities (O), and threats (T) revealed through the midwives’ interviews. SWOT Analysis allows researchers to evaluate what is working and what needs to change in the future by analyzing present circumstances.¹⁵ The SWOT Analysis of the midwives’ interviews aimed to produce recommendations to address weaknesses and threats and further leverage existing strengths and opportunities.

Setting

The results presented here are part of a larger study examining the opportunities and barriers to providing midwifery care in Alberta, Canada. In this context, midwifery is relatively “new” and is not a perinatal care option for all (i.e., remote areas in Alberta). As mentioned above, midwifery in Alberta has only been a fully funded part of the publicly funded healthcare system since 2009, and accessibility to this fulsome care model is a serious issue as the demand is greater than the current resources available. Midwives in Alberta are autonomous, primary-care practitioners.¹⁶ There are just over 160 Registered Midwives (RMs) in Alberta, the primary care providers for roughly 10% of birthing people in the province.⁷

Ethical Approval

The research was approved by the Conjoint Health Research Ethics Board (CHREB) at the University of Calgary and the Health Research Ethics Board at Mount Royal University. All aspects of research participation were entirely voluntary, and identifying information was removed from the study documents. The participants completed consent forms before the interviews and permitted to have the interviews recorded. The participants were informed they could withdraw at any time; however, none chose to withdraw from the study.

Participants

RMs in the province of Alberta were invited to participate in the research. In-depth interviews were conducted with 16 midwives. Participants were recruited until theoretical saturation was achieved.¹⁷ The participants ranged in age from 24 to 69 (with a mean age of 41), and the majority of the midwives were actively practicing at the time of the interviews. Two of the sixteen midwives interviewed identified as racialized with the remaining fourteen identifying as Caucasian. All the participants identified as women. The participants had varying experiences working as midwives, ranging between two and 29 years. Most midwives (14) interviewed had a Bachelor’s Degree in Midwifery. The sample included midwives working in different locations throughout Alberta, including urban and rural areas. Questions regarding the participants’ cultural, spiritual, and religious identity were posed, and most participants stated they were Christian or not affiliated to a particular religion or spiritual background.

Data Collection

Midwives were invited to participate through a newsletter sent to all Alberta Association of Midwives members by emailing midwifery clinics and individual practitioners and through the first and second authors’ previous contacts and networks. Snowball sampling through referrals from other participants was also used to invite midwives to participate. Following informed consent, the participants and the first author arranged a place and time for the interviews. The first three interviews were done in-person before the COVID-19 pandemic, but most (13) were done online or over the phone due to COVID-19 restrictions and safety concerns. The first author conducted all of the interviews. The in-depth interviews lasted between one and three hours. A semi-structured interview guide was used to facilitate the interviews. The open-ended questions in the interview guide were designed to encourage the participants to talk candidly about their experiences. Participants’ perspectives and opinions on working as midwives in the province of Alberta were explored, including their insights into the barriers, challenges, and successes of practicing midwifery.

Data Analysis

All of the interviews were recorded to permit detailed transcription. The transcribed interviews were analyzed using a team approach and through the qualitative data analysis software, NVivo 12. Transcripts were analyzed first individually and then collectively by the team to identify strengths, weaknesses, opportunities, and threats to midwifery practice in Alberta. While this was predominately a deductive approach because we applied a SWOT analysis framework, we also used an inductive approach as we identified and coded additional themes that emerged from the data.¹⁸ Our coding approach was informed by Braun and Clarke’s guide to thematic analysis.¹⁹ The process included each team member individually uploading the de-identified transcripts into NVivo and then reading and reviewing all the transcripts to become immersed in the data and get an initial sense of common recurring themes. Each team member independently reviewed the transcripts, coding them using the SWOT analysis framework. We had regular team meetings during the coding process to deepen the analytical process. At these meetings all team members brought their coded transcripts prepared to engage in collective coding, where we compared notes, discussed codes, and reached a consensus if there was uncertainty or disagreement. Once all the interviews were coded, we collectively created a master list of the major themes identified across all the interviews. This list included quotations from the interviews that reflected the meaning of each of the major themes.

Results

Based on our analysis of the midwives’ interviews, the following major themes were identified: Strengths – strong connections to profession and clients; Weaknesses – barriers to work-life balance; Opportunities – strategies for sustainability; Threats – difficult working conditions and limited funding for midwifery.

Strengths – Strong connections to profession and clients

The two main strengths identified in the interviews were the midwives’ passion for the profession and the relationships they build in their work. The first strength was revealed in the interviews when the midwives discussed their journeys in pursuing midwifery as a career. When asked to describe what started them on the path to midwifery, many midwives explained that the journey began years before they even started training when they felt a strong calling to the profession rooted in their lived experiences. For some of the interviewees, being pregnant and giving birth sparked their desire to enter the profession:

Another midwife stated that “there was something about being pregnant that sort of woke me up to the realization that I needed to practice something to do with babies and birth” (Participant 8). Many midwives in this study also stated the impetus for becoming a midwife was the impactful care they received from their own midwife, and some made the decision to go into midwifery after witnessing family or friends giving birth. As one midwife explained, “my mother had a beautiful home birth and I just remember thinking I’m going to be a midwife” (Participant 3).

The participants’ passion for midwifery is further reflected by the great lengths taken to become a midwife in Alberta. One midwife compared her journey to midwifery to that of an Olympic athlete:

Summarizing her journey, the same midwife as above said: “It took me actually about 11 years in all of midwifery school. Oh my goodness. And there was a lot of crying” (Participant 5). Other midwives similarly described the often challenging and long road to becoming a trained midwife. For some participants, this included moving long distances away from their families and support networks to complete the necessary educational training to become RMs.

In addition to having a strong connection to the profession, the second major strength identified was the meaningful relationships the midwives develop with the clients and families they work with. Many of the midwives discussed how these relationships are the best part of their job. As one midwife said: “I definitely love the relationship piece” (Participant 6). This aspect of the job makes it all worthwhile: “You know, wherever you go, the women make it all worth it” (Participant 1). Another midwife similarly explained:

The interviews further reveal that the continuity of care model mainly practiced in Alberta facilitates the creation of strong bonds with clients and families. For example, one midwife said, “because of our model of care, we create more relationships with clients” (Participant 12). Another said, “one of the biggest benefits I think is the relationship that you build with [the clients]. You get to see them throughout…I really get to know them well (Participant 13). Echoing these sentiments, a midwife stated that, “birth is a moment in time and prenatal care and postpartum care is this long-term relationship building and helping people transition from one phase of life to the other (Participant 9).

Weaknesses – Barriers to work life balance

The major weaknesses identified in the interviews focused on work-life balance challenges as a midwife. These issues were mainly rooted in the demanding on-call schedule, limited time off, and the challenges of being self-employed. The midwives interviewed described how their work put a toll on their personal lives and relationships. They also raised serious concerns about how to continue working in the current system: “every week I think God, can I keep doing this? I don’t know if I want to keep doing this” (Participant 4). They discussed how these work-life balance barriers must be addressed to deal with stress and burnout. As one midwife stated, “I’m definitely on the path to quitting and have been for a while because burnout is real” (Participant 16).

Interestingly, the continuity of care model practiced by Alberta midwives was a clear strength (as discussed above) and a major contributing factor to the weaknesses revealed in the interviews. As two midwives explained:

This demanding work schedule was a common theme in all of the interviews, and as one midwife explained, this means that to practice midwifery in Alberta under the current model you must be “able-bodied” and willing to make substantial personal sacrifices:

Other midwives similarly spoke about having to make personal sacrifices to continue working and the toll this was having on them and their loved ones. As one midwife explained, “I think sometimes there’s not only a valorization, but there’s a bit of martyrdom that goes along with our model of care; and I think it supersedes everything else in your life” (Participant 4). Another midwife said, “We’re crazy. You have to be crazy to sign up and do this job the way we have been doing it” (Participant 11).

The interviews also revealed additional challenges tied to Alberta midwives being employed as independent practitioners. As contractors, midwives do not receive health and disability benefits, and must cover their clinic’s operational costs (e.g., space, reception, electronic medical record system, etc.). These costs are exacerbated by Albertan midwives only recently receiving a nominal pay raise after 11 years.⁷ One midwife explained that this status as self-employed meant that she does not have any health benefits for herself or her family and thus “taking our family of five to the dentist is terrifying. So we don’t go enough” (Participant 10). Being self-employed also means that midwives, ironically, do not receive paid parental leave, and this combined with the demanding on-call schedule, resulted in additional challenges for some of the midwives who were parents or were planning families. One participant stated, “it would be great to have a system where midwives don’t leave the profession because they want to have kids” (Participant 9).

Opportunities – Strategies for sustainability

Midwife participants provided strategies for sustainability as major opportunities for the profession. Suggestions involved alternative models for practice, increases in the number and diversity of midwives, enhanced skills, and expanding research and leadership dedicated to midwifery care in Alberta. Further suggestions involved using public support to help sustain the midwifery model.

The need for alternative models of practice was a major finding in this research, and the participants explained that alternative models would benefit midwives and clients. Summarizing this, one midwife explained:

As discussed above, a continuity model has limited options for part-time work for those phasing into retirement or with family care needs. This was further expressed by midwives who stated that:

Other midwives similarly advocated for having more opportunities to work outside of the continuity of care model, explaining that this would be especially beneficial for midwives who want less demanding schedules due to family responsibilities or as they get older or have health issues. As one midwife explained: “If there was a different model, I think midwives would stay longer. I think we’d have longer careers. I think it’d be sustainable through childbearing years” (Participant 14).

With the relatively few RMs in Alberta, increasing number and diversity could offset some of the challenges. The participants articulated that we need opportunities to increase sustainability by increasing the number of midwives practicing in the province; especially increasing the number of Indigenous and racialized midwives. Participants were also interested in building professional relationships and caring for diverse populations. One midwife explained that a priority should be “to make sure the clientele is diverse” and to “hold space for vulnerable populations” (Participant 9).

Participants also highlighted research and strong leadership as opportunities to promote sustainability. One participant said, “I think that midwifery, it’s such a young profession in Canada. We really need academic midwives, and we need midwifery-driven research and that’s really important” (Participant 4). Another explained, “I think we need strong leadership that is willing to stand up and fight for midwives in the hospitals and to say this is not okay, what you’re not allowing them to do or how you’re treating them” (Participant 3).

Lastly, the midwives interviewed described opportunities for drawing on public support to sustain the midwifery model. They explained that care recipients are often the greatest advocates for midwives. One midwife stated:

Similarly, other midwives spoke about the importance of public support: “this is coming from the public and this is the public stepping up and saying, we want a better standard of care. We want a better experience, and we are saying midwifery is offering that to us” (Participant 9). Another participant explained “And if people really know what midwives are and what they do and what they’re all about, I think that would make a huge difference because then they can rally the government for midwives in their area, for funding, for increased awareness” (Participant 3).

Threats – Difficult working conditions and limited funding

The main threats to midwifery in Alberta included difficult working conditions and lack of funding for midwifery.

While some participants described positive working relationships with hospital affiliates, many had the opposite experience. Some of the midwives described feeling powerless when trying to overcome barriers to providing person-centred care in hospital settings:

Another midwife (Participant 15) similarly explained that “stigmas that come with midwives” influence interprofessional relationships with obstetricians and nurses, making the hospital setting a very difficult place to work.

The lack of collaboration in the hospital environment was further magnified when other health providers had no knowledge of midwives’ education and training. As two of the participants explained:

In addition to interprofessional tensions and difficult working conditions, the other major threat revealed in the research is Alberta’s lack of funding for midwifery. Canadian Registered Midwives (RMs) provide care in and out of hospital settings. In Alberta, RMs have to pay for birth supplies for out of hospital settings. With a lack of funding for service increases and no benefits, this model of care is further threatened. Predominantly a woman-oriented profession, it is hard not to extrapolate that sexism plays a part in the lack of funding, but also as an under supported option for women. One midwife explained that Alberta is “not a midwifery friendly environment” (Participant 9). Another addressed sexism directly by saying, “And in all honesty, it’s a women’s profession serving women and children so it’s not seen as important, right?” The participants interviewed pointed to their stagnant wages as evidence of the devaluation of the profession. As one midwife said: “We haven’t had a pay increase in 11 years, 11 years (Participant 9). Similarly, Participant 11 said: “There’s nothing. We haven’t even had a pay raise in over 10 years, like not even a cost of living increase. Nothing.”

Discussion

Midwifery is an in-demand field in Alberta with only one undergraduate program in the province. Based on Albertan midwives’ perspectives, the findings from this study highlight how the current structure of midwifery in Alberta is largely unsustainable for midwives. Suggestions were made by the participants on how to better support and fund midwifery services, for example participants discussed an increasingly diversified workforce, alternative models for practice, more opportunities for research, and leadership and professional development. The SWOT analysis demonstrates the strong passion and patient-centered care midwives bring, but it also highlights the significant weaknesses and threats that signal a lack of sustainability for individual midwives, and their overall practice. Based on these findings we argue that it is essential for healthcare services in Alberta to prioritize support for midwifery services to make midwife-led care accessible to all birthing people in the province, and to ensure the midwives who provide this care are valued and supported.

The challenging midwifery education and training routes often described by participants highlighted the commitment to providing this comprehensive care model to individuals and families in Alberta. In our study, midwives spoke in depth about the value of creating trusting relationships with clients and families. Becoming a midwife was often described as a calling with the strong bonds developed with care recipients as the essential adhesive. The interconnectedness between the art and science of midwifery²⁰ and its relationship with clients is interpreted to be a major strength as demonstrated by positive outcomes for stakeholders.

The great benefits of working with midwifery clients did not necessarily balance the effects of barriers within the healthcare system, lack of work-life balance, and further inequities. In fact, the person-centred model contributes to challenges as continuity of care requires that one or a few midwives provide wrap-around care to clients. Participants felt that the requirements to practice midwifery were almost sacrificial. The midwives described high levels of work-related stress and burnout that were further compounded by the negative impact of their 24/7 on-call work schedules on their personal lives and the lack of benefits for midwives (i.e., no paid parental leave or extended health benefits). Other research on midwifery in western provinces confirms high burnout rates.⁵ Our findings contribute to this body of research by providing evidence to help address burnout and devaluation of midwives by outlining strengths to be leveraged and opportunities for sustainability.

Our study highlights that midwives can clearly articulate their status and offer strategies for improvement. Stakeholders have a very committed workforce for providing person-centered care; however, this pool of providers perceives a lack of financial and professional value challenging the profession’s sustainability. In the fall of 2022, RMs received a pay increase after 11 years of salary stagnation. However, the one percent increase (retroactive to April 2022) equates to less than $50 per each pregnancy course of care (AAM President, personal communication, August 30, 2023). Threats to professional sustainability will remain until midwives are considered essential collaborators within Alberta’s provincial healthcare system and in all rural and urban spaces. As healthcare continues to be redefined in Alberta, decision-makers must prioritize support for this highly skilled and committed profession.