ITMs in Canada identified two unique barriers to integration into the system: 1) the challenges of the relative newness of the profession, which results in both a low number of available preceptors to date, and a lack of availability of integration programs until most recently; and 2) the difficulties posed by the primary care model of Canadian midwifery and its requirement to offer midwifery services in home settings.

Newness of the profession

Because midwifery is a newly recognized profession in most of Canada, and is indeed yet to be recognized in some Canadian provinces and territories, integration processes for ITMs have only been established recently (see Section 3 above). In Quebec, for example, prior to 2003, ITMs were asked to take an equivalency exam established by the Université de Montréal – a university not linked to the OSFQ (Ordre des sages-femmes du Québec) or UQTR (Université du Québec à Trois-Rivières) where the training program for Canadian midwives is situated. There was no assistance provided to ITMs in preparation for this exam and, as a result, the vast majority of them failed. Between 2004 and 2008, there was no exam process whatsoever, effectively closing the doors completely to ITMs in Québec. Only most recently was the assessment process re-established.

The relative newness of the profession creates other barriers: the low availability of integration processes and the low number of available preceptors. This affects not only ITMs but also Canadian trained midwifery students:

Respondent: Donc on est dix-huit dans la promo actuellement. Donc la formation théorique jusqu'à fin janvier, ensuite selon les personnes, selon les personnes on a des prescriptions de stages, donc moi j'ai trois mois, c'est le minimum que j'ai eu droit et j'ai trois mois de stages en maison de naissance. Parce que le stage en maison de naissance c'est une sage-femme pour une étudiante sage-femme. Donc il y a des problèmes parce qu'il n'y a pas beaucoup de perceptrice.
Interviewer : Non, puis il y a le programme à l'UQTR aussi qui demande [des préceptrices].
Respondent : Exactement, donc on finit notre théorie en janvier, fin janvier, et on ne sait pas quand on va faire notre trois mois de stage. Ça peut prendre un an et demi.

[Respondent: There are eighteen of us in our current class. We have theoretical training until the end of January, then depending on the person, we have training requirements, I have three months, it's the minimum I could get, I have three months of training at a birthing centre. Because the training at a birthing centre is one midwife for one mid-wife student, there are problems because there are not many tutors.
Interviewer: No, and the UQTR program is also looking for [tutors].Respondent: Exactly, and so we finish our theoretical training in January, late January, and we don't know when our three months of training will start. It could take a year and a half.] [Québec, ITM #3, in progress].

The small numbers in the profession also limits access to integration programs; there are insufficient students to justify running the program more than once per year. Since the number of students attending the program is small, the stakeholders have had to find ways to fund the program initiative using external funding, which is sometimes difficult to arrange.

Primary care model

Canadian midwives can be the first point of contact with the maternity care system for those women who have access to, and choose, midwifery care. This – referred to as a primary care model – means that midwives are not supervised nor do midwifery clients need to see another maternity care provider unless complications arise in the ante- or intra-partum period. The Canadian midwifery model of practice further stipulates that midwives follow the womento her choice of birth place. Hence, midwives must be able to practice and often maintain competencies in both in hospital and home settings. Although some countries provide this as a training and practice option for midwifery practice, this is presently the only model in those Canadian provinces where midwifery is regulated.

The majority of our respondents came from countries where midwifery is a part of nursing. Midwives practiced only under the supervision of a physician and would rarely promote home birth. This model of practice is very different from the Canadian one, and many midwives found it difficult to adjust to this model without extensive preparation:

What I realize now is that in Belgium we really have the choice whether we wanted to do primary care or whether we wanted to be hospital staff and so that's the big down point I believe here, and that's why a lot of midwives that are midwives back in their countries work here as nurses, because they just can't do the primary care. Or, like primary care being on-call, right? So, that's why I think that not many midwives that are actually here are working as midwives [Ontario ITM #1, practicing].

While some ITMs feel uncomfortable practicing primary care midwifery, for others the problem of such a model of care lies not in the culture of Canadian midwifery per se, but in the difficulties reconciling family responsibilities with both the integration process and the model of practice.

A related barrier to the model of practice is the requirement of community based, or home birth practice:

My biggest thing would be that they need to be really thorough with the assessment before you write the exam to check that, and really insist that people have to have community experience cause having gone through that and having gone through the trauma of not getting through it [the assessment] twice, um, I wouldn't wish that on my worst enemy. ... So I would definitely say that they need to make sure that that's a stipulation before anybody pays a single dollar, invests any of their time in this process. You have to have community experience because the model here is community focused. If they had the hospital midwives that would be totally different, but here we are community focused. We're primary health care providers. [Manitoba ITM #1, practicing]

Thus, many ITMs can find it difficult to adjust to Canadian practices. They feel unprepared to practise within the primary care model. The programs for ITMs require time and money for individual ITMs because there are so few who are eligible. Some respondents felt that the time commitment involved in enrolment in such programs is extremely difficult to manage for women with families. At the same time, there is some flexibility of credentials required to attend these programs. Indeed, among our participants were other health professionals that became licensed as a midwife in Canada because of this flexibility.