There are two main paths to integration for ITMs. In Ontario, there is an International Midwifery Pre-Registration Program (IMPP) which is a one-year bridging program offered at Ryerson University in Toronto. It is designed to offer assessment and upgrading of 20 to 25 ITMs per year, to ensure that they meet the required standards of practice for Ontario. The content of the nine to 12 month program includes a midwifery language proficiency test, two ESL courses, and workshops which orient the ITMs to midwifery in Ontario. Once they have completed the program, graduates are registered in the 'Supervised Class' to provide them with sufficient experience to meet the number of clinical births required by the College. Supervision will typically last anywhere from six to 12 months (IMPP, 2005).

The second path is through one of the Prior Learning Assessment (PLA) or Prior Learning and Experience Assessment (PLEA) processes available in the provinces of Quebec, British Columbia and Manitoba. The PLEA processes are labour intensive and typically include: the submission and review of a portfolio to determine if the ITM is eligible to sit for written and clinical exams. If successful, the ITM then follows a module which introduces the specific provincial practice contexts. The PLEA program in Manitoba has had a very small intake of three ITMs per year. Unlike the IMPP, most of the applicants to the PLEA program are Canadians who have sought midwifery training elsewhere.

Recognizing the capacity limitations of low enrolment in each province's midwifery integration programs, and an equally low availability of preceptors to supervise new ITMs, the Canadian Midwifery Regulators Consortium (CMRC) undertook a National Midwifery Assessment Strategy (NAS) from 2003 to 2006. The aims of this strategy were to: increase ITM access to the profession; build on the high degree of similarity in professional requirements and standards across the country to create an effective inter-jurisdictional process; honour the unique aspects of midwifery in each province and territory; and support each regulator in carrying out its legislated responsibility to protect the public.

One of the outcomes of this process is the recently established Multi-Jurisdictional Midwifery Bridging Project – a collaboration with the University of British Columbia, Mount Royal College and l'Université du Québec à Trois-Rivières - which started its piloting phase in 2009. Accepting applicants wishing to practice in British Columbia, Alberta, the Northwest Territories, Nunavut, Manitoba, Saskatchewan, and Quebec, the program offers a general stream and an accelerated option for qualified candidates. The program is designed as a seven-month project (for regular enrolment) during which the midwives attend online education classes and courses available in their community (i.e., English classes available in their hometown). In addition, one to three-week midwifery intensive courses are offered through the University of British Columbia. The ITMs are also required to undertake a three-month placement. Table 3.5 outlines the intended number of ITMs to follow these programs in 2010.

Table 3.5: Assessment and Bridging Programs for ITMs (April 2010)

Source: CAM (2010). Midwifery Education in Canada 2010. http://www.canadianmidwives.org/DATA/DOCUMENT/FACT_SHEET_Education_updatedApril2010.pdf

In sum, although there are alternatives to the typical entry to practice processes outlined here, these are few and far between. We now turn to the barriers experienced by the IEHPs we interviewed, along with what they felt facilitated their integration process. We end with a section on recommendations for further action.