Title: A Mixed-Method study exploring barriers and facilitators to midwives’ mental health in
Ontario
Version: 1 Date: 25 Feb 2023
Reviewer's report:
Thank you for the opportunity to review this important work. Overall, I am pleased with
manuscript, but have offered some comments on the manuscript for consideration which are
listed below the general comments. I do think that the data analysis could be strengthened
and the use of a theoretic framework could improve the impact of the  discussion which is
currently a reiteration of the results. I believe that the data (which is strong) would benefit
from either a gender-based analysis or an intersectional analysis to better understand how these
themes, especially power in its various forms, impacts the working conditions  of midwives and
subsequently their mental health. As it stands, Figure 1 does not offer much for the reader (see
comments on how authors generated themes), and the reader would benefit from understanding
how each theme intersects with one another (as I believe they do) and how attention to one
theme (in the form of recommendations or policy change) has the capacity to  impact change
in the other themes.
pg 2 line 60: APA, period comes after the reference.
pg.4 line 103:did you seek diversity by geography as well? Perhaps be more explicit about
whom you reached out to? Indigenous midwives? Midwives from the BIPOC community?In
Table 1 you note those identifying as racialized. Is this consistent with representation within the
midwifery profession in Ontario?
pg. 5, line 134:How did you decide on final themes? A sentence about this would be helpful.
pg. 5 line 135:This could be more explicit. Did you member check with groups of midwives
who participated in either a focus group or interview?
pg. 6, lines 139-144:All of this should be in the methods section.
pg. 6, lines 158:The themes seem fine, however the way they are presented infers that they are
mutually dependent of one another, which I suspect is not accurate. How do the various themes
intersect and influence on another? If a change in one, will this have an effect on another theme?
Also, I believe APA requires Figure headings to have a descriptive title and be located below
the figure.
pg. 7, line 187: are the words situations and work reversed?
pg. 11, line 265: Is EMCM correct? It doesn't seem to quite fit the wording expanded models
of midwifery care (EMMC)?
pg. 12, line 291:The quotes are super and very powerful…however, there is no way for the reader
to know if these are different speakers within the FG. Want to see multiple participants saying
the same things for dependable findings.
pg. 15, line 384:Interesting…this statement does not really fit with what follows below. Perhaps
state it that way, While many reported…this finding was inconsistent with focus group and
survey responses regarding the extent of bullying experienced within the profession…
pg. 16, line 417:Again, you have dedicated quite a bit of space for something that it is not
representative? Maybe you didn’t ask the right questions? Bullying seems pervasive and may
be more a reflection of the culture of midwifery and gender based issues than individual factors.
Just a thought.
pg. 17, line 421: do you have a percentage of how many experienced discrimination from your
survey? If so, include here.
pg. 18, line 463:are they distinct sub themes? How so are they different? How did you decide
this breakdown?
pg. 19, line 495:Is this not related to the model of care and how midwives in Ontario are not
supported by nursing staff in L&D wards?
pg. 20, line 514:How much of this might be related to power/gender?
pg. 21, line 540:APA: cannot start a sentence with numbers. Use word form: Forty-four percent.
pg. 23, line 594:should this not be a header: Strengths and Limitations?
pg. 23, line 595:Just a small point: This is an exploratory sequential design, so not using  the term
explanations would be helpful. Instead, use descriptions as you have identified several areas to
target for improving the conditions within which midwifery is situated in Ontario.
pg. 24, line 609:Again, it might be worthwhile to comment on the representation here. Usually,
folks experiencing discrimination of any form are more comfortable to express this in an
anonymous survey…so?
pg. 24, line 609-610: I am unsure that you can claim this..perhaps of a representative sample
of Ontario midwives?
pg 25, line 631: formatting error.
pg 25, line 643-44: repetitive sentence. Does not add.
pg. 25, line 644-46: conclude with your aim…mental health, which may impact retention and
overall well-being.