Translating Priorities Into Practice: Midwifery Care for Uninsured Migrant Populations Across Canada

ABSTRACT

Background

Immigrants and newcomers are identified by many provincial midwifery associations as “priority populations.” Recently, newcomer populations have shifted considerably, with more people coming to Canada with precarious immigration status who are increasingly ineligible for public healthcare insurance and facing barriers to accessing care. Our aims were to: (1) gain an understanding of the policies related to equitable access to midwifery care and how they may apply to migrant groups without public healthcare insurance and (2) identify existing policy themes, gaps, and regulatory barriers that limit access for this vulnerable population in Canada.

Methods

We conducted a high‐level document content analysis using a health equity framework. We aimed to identify language related to equitable access in midwifery services, with particular emphasis on uninsured populations. A total of 64 documents were analyzed, including legislation and publicly available statements from midwifery regulatory bodies and associations.

Results

Midwifery regulatory authorities and associations across Canada are consistent in establishing an expectation that midwives will provide accessible care to diverse clientele. However, how these commitments are put into practice varies considerably between jurisdictions. We compared the cases of Manitoba and Ontario to illustrate the disconnect between commitments to priority populations and implementation.

Discussion

While there is a clearly demonstrated intention to provide equitable access to midwifery care to all people, including “priority populations” like migrants and newcomers, in practice, these commitments have not been fully realized. Equity is encumbered by broader structural issues, such as the growth in the number of newcomers without access to public health insurance. Moves toward equity within midwifery and healthcare more broadly need to meaningfully engage with other policy sectors, such as immigration, to be able to adapt to emerging issues affecting reproductive care, such as the growing precarity of newcomer populations in Canada.

Equity commitments centering migrant pregnant people are present in many Canadian midwifery policies, but how they translate into practice is unequal across jurisdictions. Ultimately, meaningful engagement with communities and with cross‐policy sectors is needed to meet the perinatal health care needs of migrants experiencing pregnancy while uninsured in Canada.

1. Background

Within Canada, taxpayer‐funded healthcare insurance is available to all citizens, permanent residents, and some temporary residents. This includes full coverage for medical costs associated with labor and delivery, as well as prenatal and postpartum care. Public health insurance is administered at the provincial or territorial level and is federally mandated to be comprehensive, publicly administered, portable, and accessible across the country. Formal regulation and provision of funding via public insurance for midwifery services at the provincial level began in the early 1990s, with all of Canada's ten provinces and three territories now implementing state‐regulated midwifery care within their public health systems. Many provinces adopted midwifery with the explicit goal of addressing gaps in maternity care for marginalized groups, collectively described as “priority populations”—a definition that includes Indigenous, adolescent, newcomer/immigrant, LGBTQ+, single, socially isolated, and low socioeconomic status (SES) groups [1, 2, 3, 4, 5].

The Canadian midwifery model promotes a holistic biopsychosocial approach to health care that addresses the diverse medical, emotional, and social needs of pregnant, laboring, and postpartum clientele, grounded in social justice and reproductive rights [6, 7]. This model is considered to offer more supportive perinatal care to marginalized groups compared to other obstetric care providers [8]. Midwives provide care in a variety of settings, which allows them to offer creative solutions to access challenges. Such solutions may include providing care exclusively in the client's home, facilitating home birth, connecting clients to community resources, and/or navigating the socioeconomic barriers within the healthcare system [9, 10]. That said, equitable access to midwifery care for marginalized priority populations has been difficult to achieve [1, 8, 11, 12, 13, 14].

One such barrier is immigration status and trajectory for newcomer and migrant clients. Immigration policies that structure the conditions of residency and of healthcare access for migrant populations have shifted considerably since the early 2000s from a model under which the majority of newcomers arrived with permanent residency and full eligibility for provincial healthcare insurance to one where the majority of newcomers are first granted temporary residency status and are increasingly ineligible for public healthcare insurance [15, 16] (see Figure 1). This growing migrant population includes people arriving in Canada with student and work visas, as well as asylum seekers, family sponsorship applicants and other temporary resident permits, and those who have lost their immigrant status temporarily or altogether. Many of these migrant groups are ineligible for public health insurance and therefore rely on private insurance (which often does not cover perinatal care) or pay directly out of pocket. Visitors and people without formal status are not eligible for any form of public insurance. For others, it largely depends on individual provincial regulations—for example, international students in certain provinces do not have access to public insurance plans, and temporary residents with work permits may also be excluded based on the length of their permit.

FIGURE 1.

Temporary status migration by the year visa became effective. Source: Immigration, Refugees, and Citizenship Canada [17, 18, 19, 20].

Medically uninsured migrants who are pregnant experience an array of intersecting vulnerabilities. The precarious nature of immigration status, service eligibility, and securing residency are compounded by racism, social prejudice, language barriers, financial barriers, and navigating new systems [15]. As a result, people living in Canada without access to government‐funded health care are less likely to receive adequate prenatal care and less likely to seek midwifery care [8, 11]. Patient data from two major hospitals in Toronto over 3 years found that 80% of uninsured pregnant patients received inadequate prenatal care compared to their insured counterparts, and 6.5% received no care at all [21]. In Montreal, patient data from one hospital and two community health clinics over 2 years also reflect a substandard level of prenatal care, with 73% of uninsured pregnant patients having no blood tests done and 77% having no ultrasounds [22]. Inadequate prenatal care, generally defined as less than six prenatal appointments, is a major leading cause of perinatal morbidity and mortality, with potential complications including preterm delivery, low birth weight, and caesarean delivery [21, 23, 24, 25]. These preventable outcomes can be addressed by improving access to prenatal care for this population [9, 26, 27, 28].

Ontario is currently the only province to offer funded perinatal care for uninsured midwifery clients. This includes midwifery prenatal care, out‐of‐hospital intrapartum care, routine lab work, and diagnostic investigations, although hospital fees are still billed to anyone without insurance [29, 30]. Although Ontario midwives perceive themselves to be well‐suited to care for low SES clients, including uninsured pregnant people [31], systemic barriers continue to prevent the implementation of truly equitable access across all provinces. Concerns have been raised that midwifery's radical potential has been limited by its incorporation into the state‐regulated health system [32]. Additionally, midwifery funding models are identified as having a significant impact on accessibility [13]. The limited midwifery workforce and inadequate compensation, the designation of midwives as only low‐risk care providers, strained interprofessional relationships, geographical availability of services, lack of education about midwifery scope and care, poor integration of midwifery into local health systems, and an overall lack of regulatory and funding policies that adapt an equity lens aimed at improving the accessibility of midwifery care have been identified as barriers impacting the equitable implementation of midwifery services across Canada [11, 12, 13, 14].

Our aims are to gain an understanding of commitments related to equitable access to midwifery care and how they may apply to migrant groups without public healthcare insurance and to identify existing policy themes, gaps, and regulatory barriers that limit access for this vulnerable population in Canada. We examined midwifery legislation, regulator policies, and other guiding documentation from professional regulatory and association bodies across Canada. In analyzing these documents, we asked: What kinds of claims/commitments are being made regarding access? What acknowledgement is there of the diverse and unique needs of different migrant groups in the context of an increasingly precarious immigration landscape? What evidence is there of how care for this group is navigated in practice? Our objective was not only to identify systemic barriers but also reflect on the role of midwifery in creating and dismantling these barriers. We approached this work with a reproductive justice and health equity lens, in the acknowledgment that issues of accessibility are inherently intertwined with a myriad of social and political institutions grounded in colonial, racist, and heteropatriarchal logics.

2. Methods

We conducted a nation‐wide, high‐level, web‐based thematic analysis of all publicly available documents from all midwifery governing bodies and professional organizations that made equity commitments regarding access to midwifery services for newcomer and uninsured populations in Canada.

We first identified all provincial/territorial and national midwifery organizations, including regulatory bodies and professional associations across Canada. The national midwifery organizations, the Canadian Association of Midwives and the Canadian Midwifery Regulators Council, and most provincial and territorial midwifery regulatory bodies and professional associations had publicly accessible websites or web‐based platforms containing professional regulatory and scope‐related documentation. In some jurisdictions, midwifery was not yet well‐established or large enough to sustain an independent regulatory body, and regulation was obtained through the jurisdictional acting regulator. In some smaller jurisdictions, an independent professional association was either not yet established or still informally organized with limited documents or policies publicly available. Documents and web domains containing one of the following keywords (or their variations) were identified as relevant for analysis, including “equitable access,” “accessibility,” “immigrants,” “newcomers,” “refugees,” and “uninsured.” Midwifery organizations and documents specific to other marginalized priority groups, such as Indigenous populations, were considered beyond the scope of this review and not included. Documents from francophone jurisdictions were included if they were able to be translated with browser translation. Two documents of interest that were not translated were omitted. In total, 64 documents and resources were included in the analysis (see Supporting Information S1). Each regulated jurisdiction was represented, with a range of three to eight resources identified as being of interest from each. We determined these documents provided appropriate data for our inquiry because, collectively, they represent the guiding values that inform the overall provision of midwifery care and represent a formal commitment to which leadership can be held accountable. We excluded documents aimed specifically at providing clinical guidance, such as clinical guidelines, protocols, and standards.

Our thematic analysis was grounded in the health equity framework developed by Peterson et al., which defines health equity as “having the personal agency and fair access to resources and opportunities needed to achieve the best possible physical, emotional, and social well‐being.” [33] Focusing on the “Systems of Power” arm of the health equity framework, documents were analyzed for (1) commitments to equitable access for newcomer and migrant populations, which surfaced both as themes of inclusivity featuring language like “for all,” as well as themes of equity and addressing marginalization specific to “immigrants,” (2) who was making these commitments and with what authority, and (3) directions or measures taken toward the implementation of commitments, ranging from present, somewhat present, to not present. Two provinces, Ontario and Manitoba, were selected as case studies that allowed for a deeper dive into the extent to which commitments were translated into practice.

3. Findings

3.1. Legislation and Regulations

Government legislation that institutionalizes the legitimacy, structures of governance, and, for some, the scope of midwifery practice within their jurisdiction was not found to contain language regarding the accessibility of midwifery to diverse clientele [34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46]. This is notable as several provinces, such as Manitoba, Saskatchewan, Ontario, and Nova Scotia, implemented midwifery services with a stated goal of improving access for “priority populations”; however, this is not legally mandated [1, 2, 3, 4, 5].

The overarching regulatory authority on midwifery in Canada is the Canadian Midwifery Regulatory Council (CMRC). The CMRC is a network of regulatory representatives from the provinces and territories, and their roles, collectively and individually, are to set the national standards for midwifery practice and to protect the interests and safety of midwifery clientele. The CMRC sets forth the national entry‐level competencies expected of a registered midwife in Canada, which include several statements addressing human rights and accessibility of care. The responsibilities of a midwife explicitly include advocating for health equity for clients, especially from marginalized groups:

Midwives understand the unique health needs of childbearing and reproductive care clients and the issues that may impact their access to care. All midwives play an important role in protecting and strengthening human rights. Midwives uphold these rights and are committed to anti‐discriminatory, anti‐racist and inclusive practice [47].

Expanding on this commitment, the CMRC also offers a “Statement on Equity, Diversity, and Inclusion” that recognizes the diversity of midwifery clients in Canada and sets the expectation of both midwifery regulators and individual midwives to actively remove systemic barriers for marginalized midwifery clients [48].

At the provincial and territorial level, regulatory body documents that spoke to this commitment included by‐laws, policies, standards, and position statements. Significant variation in language and volume of documents were discovered between jurisdictions. Most provinces and territories have a “Code of Ethics” or similarly intended document that instructs registered midwives to provide care for diverse clientele without discrimination [49, 50, 51, 52, 53, 54, 55]. Most of these Codes include a statement with the following intent:

Midwives actively promote equitable access to health care and services that meet the needs of childbearing clients and families [53].

Most regulatory bodies also have separate position statements or policies addressing equity and accessibility of midwifery within their jurisdiction [56, 57, 58, 59, 60, 61, 62, 63, 64]. These statements, often titled “Accessibility of Midwifery Care,” are not explicit to migrant or uninsured populations but use language such as:

…ensure equitable access for all clients regardless of their circumstances, [64]

Mechanisms should be in place to ensure equitable access to midwifery care for all individuals regardless of place of residence or circumstance, [56, 61] and

Midwifery care must be accessible to all women [56].

Although not institutionalized within the legislation, many midwifery regulatory bodies within Canada provide statements that make commitments to equitable access to midwifery services for all people and make no distinction between people with different citizenship and immigration or health insurance statuses.

3.2. Professional Associations

Professional associations do not govern a profession in the way regulatory authorities do; instead, associations represent the members of the profession and can offer support and resources to their members and the public. Associations also advocate for the profession with employers and policymakers. Midwifery associations vary widely across Canada in their size and capacity in this regard. The Canadian Association of Midwives (CAM) is the parent body of midwifery associations across Canada and has stated their “desired ultimate impact [is] equitable access to excellent sexual, reproductive and newborn midwifery services for everyone” [65].

Several provincial midwifery associations address access to midwifery care for migrants or the uninsured. The Association of Ontario Midwives (AOM) is notable for offering significant resources to its membership and the public in this regard. Among these resources is substantial information on the AOM's approach to addressing racism, equity, and human rights within the midwifery and healthcare systems. To support its strong commitment to racial justice and equity, the AOM has developed a Racial Equity Committee, a Health‐Care Equity, Quality and Human Rights (HEQHR) Department, a Racial Justice Statement, and a Diversity, Equity and Inclusion position statement, along with Strategic Plan commitments aimed at racial injustice [7, 66, 67, 68, 69]. These are unique features not offered by any other Canadian midwifery association. The AOM also publishes information for midwives and clients about care for uninsured clients [29, 30]. The associations in British Columbia and Alberta also offer some resources concerning newcomers, immigrants, and refugees. These resources include links on their websites to the Interim Federal Health Program (used primarily by asylum claimants), how to get a provincial health card, and to programs supporting these populations, and some midwifery specific resources are offered in a variety of languages [70, 71, 72]. The Association of Nova Scotia Midwives (ANSM) website mentions refugees and recent immigrants as priorities for acceptance into midwifery care [5]. The ANSM website states:

Our vision and goal is to make midwifery care available and accessible to all families in the province, especially those who are most vulnerable [73].

All other Canadian midwifery association websites did not address access to midwifery care for migrants or uninsured populations [74, 75, 76, 77, 78, 79, 80].

Although several provincial midwifery associations provide information and resources that demonstrate awareness of how immigration status can shape access to midwifery care, this varies considerably across provinces. Furthermore, aside from in Ontario, how this awareness impacts access for the most vulnerable migrant groups (e.g., undocumented and medically uninsured clients) in practice is less clear.

3.3. Practice Implications: Comparing Ontario and Manitoba

Nearly all provinces and territories have a documented commitment to ensuring equitable access to midwifery services, but there is considerable variation as to how these commitments are demonstrated in practice. To further illustrate how this plays out, we provide a comparison between midwifery services in the provinces of Ontario and Manitoba.

Midwifery in Ontario has been regulated since 1991 and is publicly funded [38]. In 2021, there were 1031 Registered Midwives in Ontario, who supported 20% of births in the province [81]. Ontario midwives are employed as independent contractors and are compensated on a course‐of‐care funding model [3]. Most midwives in Ontario work in local private practice groups to arrange their contract and compensation [82]. Midwifery practice groups function autonomously and have the ability to set their own priorities in who they offer care to. As such, some practice groups specialize in caring for uninsured or other marginalized clientele. The College of Midwives of Ontario (CMO) was one of few Canadian midwifery regulatory bodies found to contain no reference to client accessibility and equity language in their publicly available documentation on their website, which also did not contain any reference to uninsured clientele at the time of data review [83].

At the same time, Ontario is the only province in Canada to currently offer a program of funded midwifery care to uninsured clients [29] and therefore, arguably, offers the best access to midwifery care for uninsured populations in the country. Although the CMO does not publicly publish any statements on the issue, the AOM is a robust organization with a clear antidiscrimination mandate and policies to support this position. Furthermore, the AOM offers the public and its membership resources regarding the uninsured care program [29, 30]. As the only province to offer funded midwifery care to uninsured populations, Canadian research in this area is predominantly Ontario‐focused.

Midwifery in Manitoba has been regulated since 1999 and is publicly funded [34]. In 2021, there were 69 Registered Midwives in Manitoba, who supported 8.8% of births in this province [81]. Midwives are employed by Regional Health Authorities under a salaried employment model in this province. As employees, midwives are governed by their employers' policies regarding the provision of care to those without insurance. When Manitoba regulated midwifery, the profession was mandated to provide 50% of their care to “priority populations.” [1, 3, 4] To this end, the College of Midwives of Manitoba (CMM) has produced several documents that address the accessibility and equity of midwifery in the province [56, 57, 58]. The CMM is the only Canadian regulatory body to produce a policy explicitly addressing equity and accessibility, the “Policy on Equity and Accessibility in the College of Midwives,” and this was the only regulatory document found in our review to explicitly reference ensuring midwifery access for immigrants and newcomers [57]. The CMM was also the only regulatory body to explicitly state its own responsibility “for monitoring who is served by midwifery and advocating for those who have not had access to midwifery care” [58].

Despite these commitments, Manitoba does not offer funded midwifery care for the uninsured, as seen in Ontario. Uninsured clients who can afford to pay for midwifery care may have the opportunity to do so in some Regional Health Authorities, but access is inconsistent across the province. Currently, the Winnipeg Regional Health Authority (the largest health authority in Manitoba per capita and employer of approximately half of midwives in the province) does not offer any pathway to midwifery care for the medically uninsured (including private insurance or directly paying fees). The Midwives Association of Manitoba (MAM) website offered no additional supportive documentation advocating for equitable access for uninsured or other vulnerable populations in Manitoba [74].

In comparing these two provinces, there are stark differences noted in both policy and implementation pertaining to equitable access. Although Ontario's regulatory body does not comment on the profession's commitment to serving diverse populations or striving toward equitable access for all, the professional association makes up for this in strides and represents the profession's antidiscrimination, antiracist stance. As the first province to implement regulated midwifery in Canada, Ontario is looked to as a leader and example of Canadian midwifery. The model of employment for midwives in Ontario is one of contracted, self‐employment where midwives are reimbursed by the provincial government for completed courses of care, allowing for significant flexibility for midwives to decide who and how they provide care and spend funds. This model is found, with slight variations, in Ontario, Alberta, and British Columbia. Manitoba, on the other hand, and all remaining provinces and territories have implemented midwifery under a salaried employment model where midwives are hired as staff by hospitals or health authorities. Although this model offers employment securities and benefits not found in self‐employment, it comes with a loss of autonomy for the midwives. As seen in the case of Manitoba, midwives are not able to offer care to the medically uninsured unless the Regional Health Authority permits it, despite regulatory policies that explicitly support it.

4. Discussion

Overall, while there is a clearly demonstrated intention to provide equitable access to midwifery care to all people, including “priority populations” like migrants and newcomers (with no articulated limitations related to citizenship, immigration, or health insurance status), these commitments have not been fully realized. In practice, equity commitments are encumbered by broader structural dynamics, such as employment structures affecting midwife autonomy and a lack of affordable perinatal healthcare pathways for the uninsured. For example, despite the robust accessibility policies found in Manitoba, most people with temporary immigration status do not benefit from such policies. Our analysis aligns with concerns raised in other studies [2, 13, 32] that structures of power, regulation of the profession, and restrictive funding arrangements can have the effect of disempowering and depoliticizing midwifery practice. Midwives themselves have reported that flexibility in their practice has an influence on equitable access [11]. With increases in precarious migration status and the shifting needs and challenges faced by migrant communities, midwives will face increasing demand to provide care to uninsured clients nationwide. Research consistently indicates that financial barriers are one of the biggest obstacles for uninsured migrant populations needing to access reproductive care. Therefore, reducing out‐of‐pocket fees by expanding access to public health insurance and/or allowing midwives to work unobstructed with migrant communities would have a positive impact on prenatal care options and their health outcomes [11]. The unique provincial funding program offering midwifery care to the uninsured in Ontario demonstrates this [21, 23].

Migrant communities have a rich advocacy history but remain politically marginalized, especially when they have precarious immigration status. For this work to be most effective, allied care providers need to be active in advocacy for greater health equity for priority populations and commitments to equity by care providers must include interventions at the policy level. One example of this type of work was the open letter drafted by two Ontario midwives, supported and distributed by the AOM, in response to provincial funding cuts to health care for uninsured persons in Ontario during the Covid‐19 pandemic [84]. In recognizing that not all jurisdictions have the capacity for effective advocacy work, it is incumbent on CAM to prioritize supporting the improvement to access to midwifery care for “priority populations.” We contend that moves toward equity within midwifery, and healthcare systems more broadly, need to meaningfully engage with other policy sectors, such as immigration, to be able to adapt to emerging needs such as the growing precarity of newcomer populations in Canada. For example, we see a role for midwives in ongoing campaigns to pressure the governments to follow through on their promises of immigration status regularization at the federal level and, at the local level, re‐establishing public health insurance to international students in Manitoba. Furthermore, attention must be paid to the ways in which systemic and institutional constraints shape how midwifery can fulfill its commitments to health equity and social justice.

The strengths of this study lie in the comprehensive pan‐Canadian survey of regulatory and professional association policies and documents that were reviewed. All publicly available legislation, regulatory, and professional association documentation from each Canadian province and territory were included in our policy review. A limitation is that documents not accessible to the public were not included—for example, any documents that may be only accessible to college or association membership. Further exploration is needed into the relationship between Canadian midwifery employment models and regulatory policies and whether employment models facilitate or preclude equitable access to midwifery care for vulnerable populations. It is our perspective that instead of prescribing solutions to improving access for marginalized groups, midwives, researchers, and policymakers should dismantle systemic barriers by using evidence informed by the population they seek to serve.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Data S1.

Data Availability Statement

The data that supports the findings of this study are available in the Supporting Information of this article.