Organized medicine is a uniquely powerful political force in Canada, with physician colleges and associations exerting extensive influence over healthcare provision. Their influence has contributed to what social scientists describe as medical dominance, or the exceptional power of the medical profession within the healthcare system and wider society. However, Canadian medical organizations do not consistently defend this dominance; rather, they have occasionally lent support to policy changes that, on their face, would appear incompatible with traditional conceptions of medical power and authority. Typically, these instances are explained as a simple matter of strategic retreat: medicine conceding defeat on a particular issue in an effort to save face or conserve resources, without any change in underlying beliefs. This dissertation questions that assumption, asking if at times organized medicine’s support for threats to medical dominance is instead a function of more fundamental shifts in core policy beliefs. Through a series of interviews exploring how organized medicine responded to the re-emergence of midwifery and expansions of pharmacy scope in four provinces (Alberta, Ontario, Quebec and Nova Scotia), the analysis determines that, while medicine only supported expanded pharmacy scope out of strategic retreat, there are signs of more substantive shifts in belief with respect to midwifery. This suggests that the relationship between organized medicine and traditional medical dominance is more flexible and dynamic than has been assumed.

Philosophiae Doctor - PhD / Although TB is a curable communicable disease, poor adherence to TB treatment is a major barrier to TB control in South Africa as it increases the risks of morbidity, mortality and drug resistance at individual and community level. As a result, multi-drug-resistant TB (MDR-TB) has become a serious public health issue. Underpinning this study was the assumption that a client-centred approach to treatment of MDR-TB clients, with a hospital programme which adopts an integrated multidisciplinary approach that is client-centred and is not purely biomedically driven, would improve treatment outcomes of MDR-TB clients.

The role of midwife has been an integral part of the culture of childbirth in Queensland throughout its history, but it is a role that has been modified and reshaped over time. This thesis explores the factors that underpinned a crucial aspect of that modification and reshaping. Specifically, the thesis examines the factors that contributed to the statutory regulation of midwives that began in 1912 and argues that it was that event that etched the development of midwifery practice for the remainder of the twentieth century. In 1859, when Queensland seceded from New South Wales, childbirth was very much a private event that took place predominantly in the home attended by a woman who acted as midwife. In the fifty-threeyears that followed, childbirth became a medical event that was the subject of scrutiny by the medical profession and the state. The thesis argues that, the year 1912 marks the point at which the practice of midwifery by midwives in Queensland began a transition from lay practice in the home to qualified status in the hospital. In 1912, through the combined efforts of the medical profession, senior nurses and the state, midwives in Queensland were brought under the jurisdiction of the Nurses' Registration Board as "midwifery nurses". The Nurses' Registration Board was established as part of the Health Act Amendment Act of 1911. The inclusion of midwives within a regulatory authority for nurses represented the beginning of the end of midwifery practice as a discrete occupational role and marked its redefinition as a nursing specialty. It was a redefinition that suited the three major stakeholders. The medical profession perceived lay midwives to be a disjointed and uncoordinated body of women whose practice contributed to needless loss of life in childbirth. Further, lay midwives inhibited the generalist medical practitioners' access to family practice. Trained nurses looked upon midwifery as an extension of nursing and one which offered them an area in which they might specialise in order to enhance their occupational status and career prospects. The state was keen to improve birth rates and to reduce infant mortality. It was prepared to accept that the regulation of midwives under the auspices of nursing was a reasonable and proper strategy and one that might assist it to meet its objectives. It was these separate, but complementary, agendas that prompted the medical profession and the state to debate the culture of childbirth, to examine the role of midwives within it, and to support the amalgamation of nursing and midwifery practice. This thesis argues that the medical profession was the most active and persistent protagonist in the moves to limit the scope of midwives and to claim midwifery practice as a medical specialty. Through a campaign to defame midwives and to reduce their credibility as birth attendants, the medical profession enlisted the help of senior nurses and the state in order to redefine midwifery practice as a nursing role and to cultivate the notion of the midwife as a subordinate to the medical practitioner. While this thesis contests the intervention of the medical profession in the reproductive lives of women and the occupational territory of midwives, it concedes that there was a need to initiate change. Drawing on evidence submitted at Inquests into deaths associated with childbirth, the thesis illuminates a childbirth culture that was characterised by anguish and suffering and it depicts the lay midwife as a further peril to an already hazardous event that helps to explain medical intervention in childbirth and, in part, to excuse it. The strategies developed by the medical profession and the state to bring about the occupational transition of midwives from lay to qualified were based upon a conceptual unity between the work of midwives and nurses. That conceptualisation was reinforced by a practical training schedule that deployed midwives within the institution of the lying-in hospital in order to receive the formal instruction that underpinned their entitlement to inclusion on the Register of Midwifery Nurses held by the Nurses' Registration Board. The structure that was put in place in Queensland in 1912 to control and monitor the practice of midwives was consistent with the policies of other Australian states at that time. It was an arrangement that gained acceptance and strength over time so that by the end of the twentieth century, throughout Australia, the practice of midwifery by midwives was, generally, consequent upon prior qualification as a Registered Nurse. In Queensland, in the opening years of the twenty-first century, the role of midwife remains tied to that of the nurse but the balance of power has shifted from the medical profession to the nursing profession. At this time, with the exception of a small number of midwives who have acquired their qualification in midwifery from an overseas country that recognises midwifery practice as a discipline independent of nursing, the vast majority of midwives practising in Queensland do so on the basis of their registration as a nurse. Methodology This thesis explores the factors that influenced the decision to regulate midwifery practice in Queensland in 1912 and the means by which that regulation was achieved. The historical approach underpins this research. The historical approach is an inductive process that is an appropriate method to employ for several reasons. First, it assists in identifying the origins of midwifery as a social role performed by women. Second, it presents a systematic way of analysing the evidence concerning the development of the midwifery role and the status of the midwife in society. Third, it highlights the political, social and economic influences which have impacted on midwifery in the past and which have had a bearing on subsequent midwifery practice in Queensland. Fourth, the historical approach exposes important chronological elements pertaining to the research question. Finally, it assists the exposure of themes in the sources that demonstrate the behaviour of key individuals and governing authorities and their connection to the transition of midwifery from lay to qualified. Consequently, through analysing the sources and collating the emerging evidence, a cogent account of interpretations of midwifery history in Queensland may be constructed. Data collection and analysis The data collection began with secondary source material in the formative stages of the research and this provided direction for the primary sources that were later accessed. The primary source material that is employed includes testimonies submitted at Inquests into maternal and neonatal deaths; parliamentary records; legislation, government gazettes, and medical journals. The data has been analysed through an inductive process and its presentation has combined exploration and narration to produce an accurate and plausible account. The story that unfolds is complex and confusing. Its primary focus lies in ascertaining why and how midwifery practice was regulated in Queensland. The thesis therefore explores the factors that influenced the decision to regulate midwifery practice in Queensland in 1912 and the means by which that regulation was achieved. Limitations of the study The limitations of the study relate to the documentary evidence and to the cultural group that form the basis of the study. It is acknowledged that historical accounts rely upon the integrity of the historian to select and interpret the data in a fair and plausible manner. In the case of this thesis, one of its limitations is that midwives did not speak for themselves but were, instead, spoken for by medical practitioners and parliamentarians. As a consequence, the coronial and magisterial testimonies that are employed constitute a limitation in that while they reveal the ways in which lay midwifery occurred, they relate only to those childbirth events that resulted in death. Thus, they may be said to represent the minority of cases involving the lay midwife rather than to offer a broader and perhaps more balanced picture. A second limitation is that the accounts are recorded by an official such as a member of the police or of the Coroner's Office and are sanctioned by the witness with a signature or, more often, a cross. It is therefore possible that the recorder has guided these accounts and that they are not the spontaneous evidence of the witness. Those witnesses and the culture they represent are drawn predominantly from non- Indigenous working class. Thus, a third limitation is that the principal ethnic group featured in this thesis has been women of European descent who were born in Queensland or other parts of Australia. This focus has originated from the data itself and has not been contrived. However, it does impose a restriction to the scope of the study.