The Birth Centre is a midwife-led, out-of-hospital facility for normal births in Winnipeg, Manitoba. Exploring women’s experiences of choosing the Birth Centre was the primary objective for this thesis. Through a feminist perspective and using interpretative phenomenological analysis (IPA), each participant’s idiographic description of the decision-making experience was analysed. A sample of seventeen women participated in in-depth interviews. Six themes emerged through the qualitative analysis: Exercising personal agency; Making the decision in the context of relationships; An expression of one’s ideology; Really thinking it through; Fitting into the eligibility criteria; and The psychology of the space. The findings suggest that a woman’s sense of safety is related to these themes. The women had a normal birth influence in their lives from personal relationships, past experiences, or personal values and beliefs. The study highlighted the importance of access to midwifery services in order to increase awareness and access to the Birth Centre.

Free-standing birth centres (FSBCs) were formed in Ontario in 2014 and operate with the support of birth centre aides (BCAs), a novel birth worker role. As a recent introduction to the Ontario maternity care system, there have been no academic inquiries into BCAs and only a hand full of investigations on birth centres (Mattison, 2015; Mattison et al., 2020; Murray-Davis et al., 2014; Sprague et al., 2018). From a feminist perspective, an analysis of the BCA role offers a unique opportunity to conduct a feminist analysis of work in healthcare between largely women care providers (i.e., midwives and BCAs), leadership, and reproductive justice activism. My dissertation consists of three standalone papers based on empirical data gathered through in-depth semi-structured interviews and document analysis at the Ottawa Birth and Wellness Centre (OBWC). For my first paper, “Mapping the Development of Birth Centre Aides at the Ottawa Birth and Wellness Centre”, I applied a feminist sociology of professions framework (Davies, 1996; Witz, 1992) and employed an institutional ethnographic methodology (Smith, 1990) to understand how the BCA role was developed and operationalized in the OBWC. I mapped the development of the BCA role at the OBWC descriptively and visually using the documentary and interview data with key stakeholders from the OBWC (n=16), including BCAs, administrators, and midwives. In the second paper, “Feminist Leadership in Healthcare: The Case of Birth Centre Aides and the Ottawa Birth and Wellness Centre,” I integrated Tronto’s (1993) ethic of care with Dickson and Tholl’s (2014) LEADS in a Caring Environment leadership framework in an instrumental case study (Stake, 2005) to understand how BCAs lead from their position within the OBWC and how they experience feminist leadership practices in the OBWC. Finally, in my third paper, “Birth Work as Reproductive Activism: The Case of Birth Centre Aides at the Ottawa Birth and Wellness Centre,” I applied a reproductive justice theoretical framework (Ross, 2017; SisterSong, 2015) through an instrumental case study (Stake, 2005) to understand how BCAs undertake quiet reproductive activism at the OBWC. Taken together, my dissertation offers new knowledge on the role and development of BCAs in the OBWC and contributes to advancing feminist scholarship on healthcare leadership and reproductive justice activism.

Background Midwifery units (MUs) provide midwife-led care for women at low risk of complications. They may be located on the same site as an obstetric unit (OU), in a hospital without obstetric services or separate from any hospital. In MUs, if unforeseen complications arise, transfer to an OU may be necessary. Aim To provide evidence to contribute to the improvement of the transfer process, help make transfer safer and less distressing for women, thereby improving the care and experience of women planning to give birth in MUs. Methods A structured literature review of existing evidence was followed by three integrated component studies using different methods. The content and quality of local NHS transfer guidelines were evaluated. Data from the Birthplace national prospective cohort study were analysed to estimate transfer rates, describe the transfer process and identify factors associated with transfer. The experiences of women transferred were explored in qualitative interviews. Findings Transfer is a common event, affecting around 25% of women planning birth in MUs, although rates in different units vary. Primiparous women are more likely to be transferred than women having a second or subsequent baby. The risk of transfer for primiparous women increases with increasing age; around 50% of women having their first baby aged 40 years or over are transferred. Local NHS transfer guidelines are generally of poor quality and pay little attention to women’s experience. Women interviewed after transfer report feeling unprepared for transfer. Sensitive care and clear communication from midwives during labour facilitate feelings of control in women and help women accept transfer as the right decision and not a 'negative' event. Transfer that is perceived by women as “too late” can have potentially serious and long-lasting negative effects. Women’s experience of the transfer journey could be improved by the offer of choice in a number of areas which would help women feel 'cared for' rather than 'transported'. Having the MU midwife continue to care for the woman after transfer should be considered 'best practice'; where this is not possible a good handover is essential. Women who have experienced transfer should be offered the opportunity to talk to a midwife about their experience.