Women-centred care models emerged because the Canadian health care system has not responded adequately to women’s needs. In order to meet women’s needs, numerous health centres and programs have developed to deliver services at the community level and within regional health authorities. Women-centred care, a concept with strong roots in the prairie provinces, is formalized in models and clearly labeled frameworks identified as women-centred or gender-sensitive. These include the Women’s Health Clinic in Winnipeg, the framework for the regulation of midwives in Manitoba, and services specifically for women who have experienced violence and abuse in both provinces.

This research looked at women-centred care within Saskatchewan and Manitoba and compared findings with other women-centred models. We have not provided a specific definition of women-centred care because there is not yet agreement on meanings. Rather, we found many examples of practices that deepen our understanding of women-centred. Additionally, we gained insight into the philosophies and values that need to be present for women-centred care to flourish. The lack of a common understanding is, in part, because women-centred care is a newer concept for many people. In order to reach a better understanding, we tried to look at health care in practice, rather than theoretical statements from those familiar with women-centred language. Women-centred care is about how we do our business, about processes, and whether or not we look at the particular needs of women differently than men.

BACKGROUND ON MODELS OF WOMEN-CENTRED CARE
Pathfinders for this research were the Invisible Women: Gender and Health Planning in Manitoba and Saskatchewan and Models for Progress evaluation framework used to determine the gender-sensitivity of health planning documents in Manitoba and Saskatchewan (Horne, et al., 1999) and the Vancouver/Richmond Health Board’s Framework for Women-Centred Health (VRHB, 2001). The preparation of both these two models involved scans of the literature and international models. Many of the same models were reviewed for both those projects and they are both still quite up to date. Both frameworks are consistent with and incorporate elements from several other models of women-centred policy, programming, and gender-based analysis tools, such as the Glasgow women’s health project in Scotland (Women’s Health Working Group 1996a) and the Pan American Health Organization’s gender analysis handbook (Hartigan, et al. 1997). Detailed descriptions of these and other models can be found in the Invisible Women report and references in both documents will lead readers to other models and research. The limited resources for this project and the belief that these models are current meant that a full literature scan was not completed for this project.

No one health care service will incorporate everything described in women-centred models because of varying contexts, size of organizations, mandates and resources. However, looking at a wide range of options can assist us in understanding women-centred care. It is our hope that readers can apply what is meaningful to their situations and enhance or develop new services for women.

It is important to note that integrating the concepts and practices of women-centred care may entail changes that go beyond what individuals can accomplish. Training is essential for professionals and staff across the health system. Successful women-centred models may require support in the form of funding and structural changes. Hence, numerous policy issues emanate from this research. Interview participants often describe advocating for policy changes to improve the lives of the women they work with or to expand the type of services they provide. Policies that promote these women-centred approaches need to be put in place.

METHODOLOGY
Integrated Framework for Women-Centred Care
To develop an initial framework to guide the interview process, we integrated the components of the Vancouver/Richmond Health Board’s Framework for Women-Centred Health with an adaptation of the framework from the Invisible Women report. This resulted in 9 elements:

1. The need for respect and safety
2. The importance of empowering women
3. A holistic view of women’s health, including a comprehensive range of services and women’s patterns or preferences in obtaining health care and health information
4. Involvement and participation of women
5. Women’s forms of communication, interaction and decision-making
6. A gender-inclusive approach to data gathering and using of this data in gendered research and evaluation
7. Social justice concerns
8. Gender-sensitive training
9. A team approach in the workplace

Interviews and analysis
Semi-structured interview questions were developed using the above elements.
The guide we created from the list above is a working tool, and was not intended to serve as a template. We spoke to 22 people, including medical practitioners (e.g., doctor, nurse, nurse practitioner, midwife), counsellors, social workers, program managers and executive directors, front line workers, community health promotion workers, managers of volunteers, and the director of a regional health authority.

We used the constant comparative method common in qualitative research, where earlier category codes are revised to fit with new information as it arises (Glaser and Strauss, 1967). The thematic categories that emerged from the data were sorted and compared as we proceeded through the analysis. Links from categories to broader themes were discussed among the researchers until we reached consensus. Overall themes and related categories are reported with generous numbers of quotes to illustrate what these meant to women in their own words and to show the extent of the issues.

WHAT WE LEARNED
This section offers an overview of some of the major social and demographic patterns in women’s lives in Manitoba and Saskatchewan. We then move into the details of our findings.

We noted that many participants did not use language such as ‘women-centred’, ‘gender’ or ‘social determinants’. However, because someone does not use the term ‘women-centred’ does not necessarily mean that they are not women-centred in their practice. It is important to look at the concepts participants used to understand how they incorporate elements of women-centred care in their practice. Themes of women-centred care emerged and participants described the efforts, successes, and challenges they face. Themes revolved around how to address the realities of women’s lives, as perceived and described by the service providers we interviewed.

This section begins with a discussion of the social and economic context of women’s lives. Participants highlighted:

• Women’s roles and responsibilities
• Low income and poverty issues
• Racism and colonialism
• Gender differences
• Abuse and violence against women
• Rural and northern issues

Next we present the broader philosophies, both explicit and implicit, that guided interview participants’ responses to women’s lives. These formed the following themes: holistic, spiritual, feminist, and First Nations’ rights. We describe the “cornerstones” of women-centred care. These are the conditions under which women-centred care is possible. Themes about delivering comprehensive services to women reflect the interview participants’ understanding of women’s patterns and preferences for care and acknowledge women’s ways of communication and interaction.

The discussion about knowledge development touches on evaluation and research; it considers research needs and capabilities to carry it out. Workplace environment is also important and participants provided ample discussion about what conditions are important for workers to be able to deliver women-centred care. Finally, a section about social justice links back to where we began, with women’s lives. All of the themes are interconnected. While it is not a component of women-centred care per se, adequate funding is important to facilitating and delivering women-centred care.

CONCLUSIONS
This overview of women-centred care in Manitoba and Saskatchewan parallels the Vancouver/Richmond Framework and the framework from Invisible Women. These frameworks flow from other models of women-centred planning and service provision such as the Women’s Health Working Group, Glasgow, Healthy City Project in Scotland. Our work provides validation of these working frameworks, and adds to them by fleshing out specific elements of women-centred care.

Some of the elements we found such as empowerment, respect, and safety are also present in the models underlying our working framework. Others such as Aboriginal spirituality and self-determination, integrated service delivery, a common women-centred philosophy in the workplace, staff mental health and safety arose here for the first time. Our working guide is particularly enhanced, and our understanding deepened, by evidence of how the workplace supports women-centred care. This is done by including Aboriginal perspectives, and utilizing the cornerstones of women-centred care found below. We can surmise that it is not enough to provide certain types of services that are merely "directed to women".

Our research demonstrates that all-encompassing women-centred care is comprised of the elements listed below.

The "cornerstones" of women-centred care are:

• A focus on women
• Involvement and participation of women
• Empowerment
• Respect and safety

Comprehensive services that reflect women's patterns and preferences for care and acknowledge women's ways of communication and interaction:

• Address the complexities of women's lives
• Are inclusive of diversity
• Have integrated service delivery
• Respond to women's forms of communication and interaction
• Provide information and education

Gender-sensitive knowledge development requires:

• Evaluation
• Research

A women-centred workplace must have:

• A collaborative work environment
• A women-centred philosophy shared in common
• Service providers as consultants with expertise in women's health
• Good communication and concern for staff mental health and safety
• Gender and inclusiveness training

Women can use this integrated guide to validate their own experiences and requests for changes in service delivery. Ongoing public and organizational processes can also engage in scrutiny of this document to develop tools and methods to implement women-centred care in their sites.

In the course of conducting our research it became evident that public policy in health governance and government needs
to catch up with what practitioners are doing. Gender-sensitive approaches should be embedded within policies. Policy makers could indeed expand policy parameters so practitioners implement their visions of women-centred care thereby allowing them to reach and benefit more women. Women-centred health policy is supported by what the participants told us: that they have better outcomes in meeting women’s needs because women were part of the process.

Finally, many participants articulated a need to base women-centred practice by conducting more research and having more evidence. However, they told us that funding has often been lacking, particularly for expansion of programs to further meet women's needs based on research. Evaluation of women-centred care practices is critical for policy makers so that future policies can be built upon what has been learned. Research that takes a gendered approach and uses data to describe the context of women's lives, rather than solely counting the number of clients, is crucial for all concerned. Currently practitioners are working with resources that are stretched to the limits. Adequate resources are required to enable service providers to provide care based in women’s lives that responds to women’s realities.

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