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In Ontario, supporting "a system of care that provides women and their families with equitable choice in birth environment and provider," (PCMCH & MOHLTC, 2017, p.33) has been identified as one of the central objectives of the Provincial Council for Maternal and Child Health's Low Risk Maternal Newborn Strategy. In theory, pregnant people in Ontario can choose to seek maternity care from a midwife, a family physician, or an obstetrician; however, in practice, pregnant people's choice of provider remains constrained. Extant literature suggests that in order to afford pregnant people the opportunity to exercise autonomous choice of provider, health systems must ensure that an acceptable range of provider options is available and accessible within the local organization of maternity care, that pregnant people are made aware of and knowledgeable about the available provider options, and that pregnant people have the ability and resources to navigate access to their provider of choice (Mackenzie, 2014; Sutherns, 2004). As a result, I designed this thesis to fill a gap in the evidence base to determine whether or not provincial policies had translated into the levels of access, awareness, and resourcing required to afford pregnant people the opportunity, ability and propensity to exercise autonomous choice of provider within the local maternity care system in Ontario's Champlain Region. I sought to elicit the structural conditions that would be necessary to equitably support pregnant people's access to and choice of a maternity care provider. In the pursuit of these objectives, I adopted an integrated knowledge translation approach (Bowen & Graham, 2013), using an explanatory sequential mixed methods design (Creswell, 2014), which encompassed two complementary stages: (1) quantitative geospatial mapping to assess pregnant people's access to the full range of maternity care providers across the Champlain Region; and (2) qualitative focus groups and individual interviews with parents, providers, and policy-makers to explore the individual, organizational, and system-level factors that are enabling or restricting access and autonomy. Using a systems approach to the investigation of this locally-identified issue, I demonstrate in this thesis that pregnant people within the Champlain Region have inequitable opportunities to exercise autonomous choice of maternity care provider due to (1) system and organizational-level factors that are creating imbalances in the supply, distribution and mix of maternity care provider options, and (2) pregnant people's differential access to the enabling information and resources required to exercise autonomous choice of provider and to navigate access to their services.

Additional file 1. Supplementary Data: Hours and clients per week before and during the COVID-19 pandemic by primary workforce roleand gender.

Additional file 2: Adapted (inductive) coding scheme for the policy dialogue.

Additional file 1: Initial (deductive) coding scheme for the policy dialogue based on main research study.