In 2000, midwifery was regulated in the Canadian province of Manitoba. Since the inception of the midwifery program, little formal research has analyzed the utilization of regulated midwifery services. Currently, many women are denied access to midwifery care due to the shortage of midwives in Manitoba. The specific objectives of this mixed-methods case study were to describe the utilization of midwifery health care services in Manitoba from 2001/02 to 2009/10 and to explore factors influencing the implementation and utilization of regulated midwifery services in Manitoba. The study was guided by the Behavioral Model of Health Services Use (Andersen, 1995). Data collection and analysis were an iterative process between documents, interviews, and administrative data. The quantitative analysis used the population-based administrative data housed at the Manitoba Centre for Health Policy to study the utilization of midwifery care. There was modest growth in the overall rate of midwifery-attended births, as well as in the number of midwives over the 10-year time period. Twenty-four key informants were purposefully selected to participate in semi-structured interviews for the qualitative component. Interviews were audio-taped, transcribed verbatim and analyzed using content analysis. Three main topic areas were identified: barriers, facilitators, and future strategies/recommendations. Themes arising under barriers included conflict and power; lack of an educational program; perceptions of the profession, and a precarious profession. Issues of gender underpinned some of these barriers. Constituent influence was a prominent facilitator of the profession. Future strategies for sustaining the midwifery profession focused on ensuring avenues for registration and education, improving management strategies and accountability frameworks, enhancing the work environment, and evaluating the model of practice and employment. Results of the document analysis supported the themes arising from the interviews. In spite of scientific evidence that supports the midwifery model of care, there remains an inherent struggle to justify the profession and ensure its widespread implementation in Manitoba. The findings have implications for maternal child health professionals working on collaborative efforts to facilitate access to midwifery services for women. This study adds to the growing body of literature related to midwifery in Canada.

Introduction Transition care clinics (TCCs) have proven to be effective in meeting the time-sensitive needs of patients in the post-discharge period and ensuring smooth transitions of patients from hospital to home. These clinics have led to lower readmissions, lower emergency department visits, cost savings, and lower rates of other adverse events following discharge. However, TCCs, including the East Tennessee State University Family Medicine (ETSU-FM) TCC have been facing high rates of patient no-shows. Aim The aim of this dissertation is to identify the different components and outcomes of TCC based on the literature. We further aim to analyze the TCC implementation process at the ETSU-FM clinic, identify gaps, and provide recommendations to address those gaps. Methods A scoping review was conducted using three databases (PubMed, Web of Science, and PsycINFO) searches while following the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews Checklist to identify different components of TCCs and the associated outcomes. Additionally, a mixed-methods study was conducted using patients and providers from the ETSU-FM clinic to identify different factors associated with patients’ no-shows to scheduled TCC appointments. Results Eighteen studies were analyzed and TCC components and patients’ outcomes were assessed. Predischarge communication with patients and caregivers, early post-discharge contacts, etc. were identified as some of the effective components of TCC. Our review also highlighted that TCC resulted in lower readmissions, lower ED visits, and cost-effectiveness. For the mixed-methods study, we included 520 patients in our quantitative analysis and interviewed 10 providers for the qualitative analysis. Several patient-level and system-level factors were found to be associated with TCC no-shows. A few of the factors that were deemed modifiable by the clinic have been identified and recommendations provided accordingly. Conclusion TCCs play a vital role in ensuring smooth care transitions of patients following discharge. It is crucial to conduct context-level studies to identify factors that are associated with TCC no-shows and design interventions accordingly. Doing so could lead to pursuit of the triple aim of healthcare: improving patients’ experience of care, improving the health of populations, and reducing the per capita cost of health care.