BACKGROUND

Postgraduate education is a challenge for many people. Graduate school can be particularly challenging when students must balance their studies with additional work and family demands.¹ In Ontario, midwives who pursue postgraduate education are often faced with multiple demands for their time because of their academic, clinical, and family roles.

Currently, there is only one midwifery graduate education program in Canada. In the fall of 2022, McMaster University introduced the first postgraduate program for midwives in Canada.² The program was created recognizing the unique needs and experiences of midwives in the workforce and aims to provide advanced education while accommodating their professional commitments.³ The program is primarily delivered asynchronously, allowing students to complete their graduate degree full-time or part-time while continuing to work and without having to relocate.³ After completion of the program, midwives graduate with the degree of Master of Science in Midwifery. There are currently no doctoral midwifery education programs in Ontario or in the rest of Canada.

While midwives in Ontario are fortunate to have a midwifery postgraduate program in their province, the yearly intake does not yet match the demand for the program. The midwifery program has been created by and for midwives, to build an educational pathway that supports career progression for midwives.² However, anecdotally we know that because of limited postgraduate midwifery education programs, many midwives who wish to pursue postgraduate education in Canada enroll in programs in different disciplines such as psychology, business, nursing, and education. These various enrollments mean that most midwives who pursue postgraduate education do so within programs that were not developed for midwives. These anecdotes are consistent with research about midwives’ enrollment in various nonmidwifery-specific programs such as nursing, sociology, and psychology for doctoral education in Germany, Switzerland, Austria, and The Netherlands in 2013.⁴

The aims of this study were (1) to explore midwives’ experiences of postgraduate education in Eastern Ontario, Canada and (2) to examine how social and historical discourses and gender may influence midwives’ experiences of postgraduate education. Our research question was, what are midwives’ experiences of postgraduate education?

POSITIONALITY AND REFLEXIVITY

All research team members identify as women and work in nursing and midwifery. At the time of data collection and analysis, three team members were enrolled in graduate studies and one team member was enrolled in undergraduate studies. Three team members were faculty members, two of them were in leadership positions, and one was an early career researcher and educator. The breadth of our experiences strengthened our engagement with the data and our analysis. Most of the team was or is currently enrolled in graduate education, which provided a familiarity of understanding about graduate experiences generally, and gendered experiences of graduate education specifically. Our shared gender identity and positions within health care professions dominated by people who predominantly identify as women shaped our understandings of gendered discourses as they related to work, education, and family responsibilities. We encouraged each other to be curious throughout data collection and analysis and focused on data. We maintained field notes to document decision-making throughout the study and engaged in reflexivity throughout the analysis (see below). Disagreements were resolved through discussion. The PI and research assistant who conducted the interviews debriefed during data collection and analysis, and the whole team debriefed during the study.

METHODOLOGY

We used feminist poststructuralism (FPS),⁵ a qualitative methodology, because it brings together ideas and concepts from feminism and poststructuralism. Feminism provides understandings of gender, intersectionality, power, and challenging the status quo.^5–7 Poststructuralism offers ways to understand relations of power, discourses, subject positions, and the use and study of language and texts.^7,8 As a critical methodology, FPS can be used to critique discourses and how relations of power are expressed.⁵ In this study, we examined gender, power relations, subject positions, and discourses^5,8,9 within the context of midwives’ experiences of postgraduate education.

SETTING

The study setting was Eastern Ontario, Canada. Ontario was the first province to regulate midwifery in 1994.¹⁰ We defined Eastern Ontario as the Eastern Ontario Health Region.¹¹ In the Eastern Ontario Health Region, there are approximately 28,000 births per year in urban and rural communities.¹² Ottawa, the nation’s capital, is the largest urban community in the Eastern Ontario Health Region.

RECRUITMENT, DATA COLLECTION, AND ANALYSIS

We received ethical approval from the Queen’s University Health Sciences Research Ethics Board (#6036299) before recruitment and data collection. We used social media posts, word of mouth, and sent emails to 21 midwifery practices located in the Eastern Ontario Health Region to recruit potential participants. We purposively aimed to recruit four to six participants; however, only four participants were recruited for the study. This was a smaller number of participants than we had hoped. However, given the geographical boundaries of a specific region of Ontario, and the fact that not all midwives are enrolled in postgraduate education, this sample size was appropriate. Please see another paper we published¹⁶ about this study for additional recruitment details. We were guided by information power¹³ to determine if the sample was sufficient for the purpose of this study. Specifically, we reflected about the aim of the study, study specificity, use of theory, the quality of the dialogue, and our analysis strategy¹³ to ensure that the sample aligned with information power.

Participants were eligible if they (a) had enrolled in a nonclinical postgraduate education program (master’s or PhD) within the last 7 years, (b) were in progress, completed, or not completed the postgraduate program, (c) held current registration with the College of Midwives of Ontario, and (d) lived and worked in Eastern Ontario. Participants were aged between 24 and 59, all identified as women, all were working clinically as midwives while being enrolled in postgraduate education programs and had less than 1 year left of their programs. See our other publication about this study¹⁶ for additional demographic details.

In-depth individual interviews occurred virtually or via telephone between October and December 2022 and lasted up to 60 minutes. Interviews were audio recorded using zoom and transcribed using Otter.ai©. To protect anonymity, pseudonyms, identified by participants, have been used.

We used feminist poststructuralist discourse analysis^14,15 to analyze the transcripts. All members of the team were involved in reviewing and analyzing transcripts. We examined and deconstructed the text, identifying important issues related to our research question, and explored the beliefs, values, and practices in the corresponding text for each issue,¹⁴ and considered how socially constructed concepts of power relations, gender, subject positions, and discourses were illustrated.¹⁵ DM and RK grouped similar issues into subthemes and similar subthemes into themes.¹⁵ Subthemes and themes were then shared with the larger team for feedback. We documented reflections and ideas throughout the analysis and openly discussed how our positionalities impacted how we understood the data and constructed the findings.

FINDINGS

We constructed 4 main themes and 16 subthemes. One main theme and its corresponding subthemes have been published.¹⁶ To ensure that the richness of the data and depth of analysis used to create the themes was honoured in the dissemination of the findings, we have chosen to publish the second theme in a separate paper. In this paper, we will describe the main theme Juggling multiple priorities—Keeping all the balls in the air—and present the four corresponding subthemes: (1) Approaches to integrating midwifery and school—taking one step at a time, (2) Tensions between midwifery and school demands—babies don’t care that you have a paper due, (3) Competing priorities—Keeping all the balls in the air, and (4) Navigating sacrifices—it is a challenge, sometimes it’s a sacrifice.

APPROACHES TO INTEGRATING MIDWIFERY AND SCHOOL—TAKING ONE STEP AT A TIME

One midwife shared that how she integrated midwifery and academic demands was an important aspect of postgraduate education experience. She described the organization that was required to maintain all her commitments.

Victoria believed that she needed to be organized to ensure that she fulfilled all her work and academic responsibilities. She valued organization as a tool to minimize being overwhelmed with all her commitments, which included running the midwifery practice. Her organizational practices included breaking down activities into tasks and she reflected that at times things were a blur. To cope she took each day as it came.

Victoria reiterated her approach to taking one day at a time. She described how she did not look too far into the future. She believed that if she considered what she needed to do too far in advance that it became overwhelming,

Victoria valued completion of activities and tasks and not creating too much stress. She compartmentalized her tasks and activities, and this meant she could focus on what was immediately needed, before proceeding to the next task or activity.

Victoria’s experiences were influenced by a discourse of flexibility to accommodate both her work and educational demands. A flexibility discourse is omnipresent within the midwifery profession, because midwives must be flexible to accommodate the needs of women, birthing people, and families before, during, and after birth. For Victoria, this flexibility discourse, which was required for her clinical work as a midwife, extended to the demands of her education.

TENSIONS BETWEEN MIDWIFERY AND SCHOOL DEMANDS—BABIES DON’T CARE THAT YOU HAVE A PAPER DUE

Most of the midwives interviewed for this study talked about the tensions between the clinical demands of midwifery and the academic demands of their education programs. Midwifery work, and its need to be prioritized, challenged graduate students as they realized the reality of the demands of their respective education programs. The nonmidwifery programs were inflexible when it came to accommodating demands outside of academia.

The tensions between these demands were clear for participants who described how the design of postgraduate education programs was not responsive to the needs of students who were also working midwives. Samantha believed that postgraduate education, in its current design, did not work for midwives,

Samantha valued education programs that could facilitate education for midwives who worked clinically. The demands of midwifery are not typical demands of students enrolled in postgraduate education, and Samantha advocated for changes to postgraduate education programs that could accommodate midwives.

Natalie also talked about the challenges of postgraduate education that was not designed for midwives. Natalie shared how she imagined a nonmidwifery postgraduate education program would be when it came to group work. She believed that a nonmidwifery program would expect group work where students would have to arrange a time to meet,

Natalie valued being a good academic partner in relation to other students, and she believed that co-students who were not midwives would not understand her inability to meet. For Natalie, being a good academic partner meant that she needed to be present and making contributions to the group. Without time to meet, she could not be present or contribute and she imagined how this would create negative experiences for everyone. Natalie’s notion of a lack of understanding of midwifery and the grace needed for midwives to engage in existing nonmidwifery programs illustrated the continued impact of patriarchal discourses that influence educational institutions, models, and expectations.

The midwives also talked about the tensions of meeting deadlines for coursework while attending to midwifery demands, such as being on call and the unpredictable nature of birth. Victoria described her strategy to try to mitigate the submission of late assignments,

Victoria believed that preparing assignments early helped her meet deadlines. She valued completing her assignments and submitting them in advance of their deadlines. However, in practice, she found that while she worked hard to submit assignments early, sometimes births and the demands of her clinical midwifery work meant that this strategy did not always work. To address the tension between her academic and clinical demands, she used her agency to work on assignments so that they could be submitted early.

There was a shared experience amongst the participants about the incongruences between postgraduate education and midwifery practice. Participants positioned themselves as both midwives and students. Midwifery is a gendered profession which was incongruent with academic programs that were not designed to include and support midwives as students. Samantha described being unable to conceptualize a postgraduate education program that would work for midwives without creating a whole new program. Natalie talked about how group work was challenging for midwives in a postgraduate program because of the unpredictability of birth work. Victoria talked about handing in assignments early to mitigate lateness. In spite of this incongruence discourse, the participants in this study still pursued postgraduate education, and as a result experienced tensions between professional and education demands.

COMPETING PRIORITIES—KEEPING ALL THE BALLS IN THE AIR

For midwives in this study, the challenge of managing various priorities was likened to juggling where they attempted to keep all the balls in motion. Midwives described the various strategies they used to respond to their priorities of midwifery clinical work, school, and family life. While some excelled at time management, others described how managing these priorities came at a cost to their sleep and self-care.

Nora shared how time management was the key to her ability to manage all her work, school, and family priorities. She believed that time management was the only way to juggle her multiple commitments and responsibilities,

Nora believed that when times were particularly hectic, her family got the leftovers of her time and attention. She valued family time and recognized that prioritizing work and school demands over time with her family was not good. She experienced tensions between her multiple roles. Nora believed that she was good at time management but that some periods of time were worse in terms of work and school demands. When work and school were less busy, she prioritized her family by setting time aside to be with them,

For Nora, time management meant understanding that the demands in each area of her life had ebbs and flows, and she adapted how she spent her time in response to those changes. This contrasted with Samantha who described how her capacity to manage multiple priorities meant that she often prioritized work and school during time typically allotted for sleep, self-care, rest, and family,

Samantha believed that school and work were not optional commitments. The choice to prioritize work and school came at an expense that meant that she prioritized them over her time spent doing other things, particularly things for her own restoration and health. She valued getting things done, as they related to her work and school priorities, and this was more important for her than sleep. Using her agency, she chose to use her time to attend to work and school commitments rather than to engage in restorative activities.

In this subtheme, participants’ experiences were influenced by a discourse of prioritizing others before self. For both Nora and Samantha, the main priorities were work and education. Nora described that this meant her time with family was often compromised. For Samantha, prioritizing education and work meant that her own sleep, self-care, and time with family were impacted. The midwives’ positions as family member, midwife, and student created tensions during times of increased demands. The discourse of prioritizing others before self has often been a gendered discourse, where women have historically ensured that their families’ needs were met before their own.¹⁷ In midwifery, a profession predominantly involving women, this discourse often accompanies a discourse of care which places a client’s needs before a health care provider’s needs.

NAVIGATING SACRIFICES—IT IS A CHALLENGE SOMETIMES IT’S A SACRIFICE

Most of the midwives described how being enrolled in postgraduate education programs meant that they had to navigate challenges and sacrifices. Challenges involved having to manage feelings of guilt, and how those feelings were manifested. Sacrifices involved dealing with financial challenges and time constraints, where decisions about finances and the use of time meant there was less to be used in other areas of life.

Samantha described her experiences of navigating feelings of guilt when she needed accommodations,

Samantha believed that no one had ever made her feel guilty. She valued that others had not played a role in making her feel guilty. She connected her feelings of guilt to her identity as a woman, her concept of self, and to her profession. She described that working in midwifery meant that she experienced low levels of guilt related to asking for accommodations. She articulated her gratitude for others having not played a role in her feelings of guilt.

While Samantha faced the challenge of navigating guilt, Natalie described the financial and time sacrifices she faced as a midwife enrolled in postgraduate education,

Natalie believed it was a challenge to finance her education and to use her personal time to attend to her education. She valued postgraduate education and believed that this investment in her education would ensure a stable future. Using her agency, she budgeted carefully to address the financial burden of postgraduate education and articulated that this was possible because of her attention to detail and her income. She described her use of personal time to engage in postgraduate education as a sacrifice and navigated this by managing her time.

A discourse of sacrifice was present in this subtheme. For Samantha, the sacrifices she made and asked others to make to accommodate her education needs were accompanied with a feeling of guilt. She linked her guilt feelings to her gender. Natalie described the financial sacrifices she made, as well as the sacrifice of her personal time for her graduate education. Sacrifice as a discourse has often been linked to women’s experiences pursuing education at later stages of their lives,¹⁸ particularly when completing additional education during life stages that require commitments to family and career. Some life stages during educational pursuits make family, time, and financial sacrifices unavoidable.

DISCUSSION

Midwives who participated in this study described their experiences of “juggling” the multiple demands for their time, primarily their professional midwifery responsibilities and their postgraduate educational responsibilities. Participants described how they integrated and met different demands in spite of the tensions. School, midwifery, and family responsibilities were competing priorities for their time, and they made sacrifices to meet various expectations. Structural barriers such as a lack of academic and clinical infrastructure to support midwives’ pursuit of postgraduate education limit the advancement of midwifery in Canada. Structural barriers such as a lack of midwifery-specific postgraduate education programs, demands of on call, and limited funding to support midwives pursuing postgraduate education must be addressed to ensure the growth and sustainability of the midwifery profession in Canada.

Postgraduate education demands

In our study, midwives described the challenges of meeting the clinical demands of their profession in addition to the stresses of attending to financial strain and attempting to maintain work–life balance. This is consistent with an exploratory descriptive observational study about European midwives’ experiences of doctoral education, where participants described challenges such as emotional and financial strain, inability to engage with family, and balancing numerous demands.¹⁹ Similarly, in a phenomenological study, nursing faculty described the need for balance, as they juggled competing academic, work, and family responsibilities during their experiences as postgraduate students in Canada.¹ For midwives in this study, the ongoing (re)prioritization of academic, personal, and clinical/work demands required careful planning and time management, created tensions, and introduced additional sacrifices to midwives’ lives.

Gender and juggling multiple priorities

The embedded and often invisible influence of gender throughout the participants’ experiences illustrated how midwives navigate dual historically patriarchal systems of academia and health care. The intersections of hegemonic and historically gendered expectations of women’s professional, career, home, and family roles were clear in the experiences of the participants. Neiterman and Lobb²⁰ identified how these gendered obstacles, specific to Canadian midwifery education and service model, places an unsustainable burden on midwives because of the hours, on-call model, and the high level of acuity and responsibility of providing care for clients. Neiterman and Lobb²⁰ argued that a structural reorganization of midwifery service delivery is necessary to improve recruitment and retention of midwifery students in undergraduate programs. We echo Neiterman and Lobb’s recommendation for a reorganization of midwifery work²⁰ to ensure that the pursuit of postgraduate education for midwives is sustainable.

RECOMMENDATIONS

The findings of this study highlighted the inequities and sacrifices that midwives endure in their pursuit of postgraduate education for knowledge and career advancement. To address these inequities, we recommend the following:

1. Explore how the current Canadian undergraduate midwifery education programs may enable entry into postgraduate education.

2. Explore alternatives to current practice and care models in Ontario to enable midwives’ pursuit of postgraduate education.

3. Expand or redefine regulatory and active practice requirements to maintain optimal safety and care for clients and support midwives pursuing postgraduate education.

Study Strengths and Limitations

We recognize that our sample size was small for this study. However, it aligns with both FPS⁵ and our use of FPSDA¹⁴ given their emphasis on a depth of analysis and deconstruction. In addition, this smaller regional study was intended to inform a larger study, starting by understanding current experiences in our region. We have provided rich descriptions of participants’ experiences. However, within this context, we recognize that transferability of these study findings may be limited. In addition, the demographic data we collected focused on aspects of gender, career, and education. Our decision to not collect and disclose identity-specific data about participants was ethical, to ensure that the identities of participants remain confidential. However, this was a limitation, and future, larger studies should include the collection and analysis of broader demographic data, as they relate to intersecting identities.

The aim of this study was not to produce generalizable findings, and we believe that the data presented in this paper offer important insights to begin further exploration and planning for midwifery career trajectories and advancement in Canada. More research by and with Canadian midwives who have completed postgraduate education should be conducted to provide additional insights into future directions.

CONCLUSIONS

Midwives must use their professional and academic agency to advocate and lead structural changes to the profession and to academic pathways in midwifery that can support the career trajectories of midwives individually and collectively as a profession in Canada. A strong vision for the advancement of midwifery in scholarship, policy, and practice must be informed by midwives who see growth beyond clinical practice as essential for the sustainability of midwifery in Canada in the long term. A midwife-led and informed vision for advanced midwifery roles has the potential to redress the inequities of inherited inequitable systems of learning and care to position midwives as stewards and leaders in health care practice, scholarship, and policy.