Introduction The College of Midwives of Ontario (CMO), as the regulatory body for the profession of midwifery in Ontario, is committed to working collaboratively to improve maternity care to women and infants and address barriers to interprofessional collaboration. The CMO appreciates the opportunity to respond to the Ontario Medical Association s (OMA) letter regarding the proposed amendments to midwives scope of practice. As a preface to this response, it is important to note that the OMA is a professional association whose mission is to represent and serve Ontario physicians, provide leadership for an accessible, quality health-care system, and advocate for the health of Ontarians. The CMO does not believe that it is the OMA s role to develop policies regarding midwifery, or any other health profession. That being said, the CMO understands that there may be areas of the proposal that require further clarification and is pleased to provide this. Midwives are specialists in the provision of quality primary maternal health care to women with low-risk pregnancies and their infants. It is our belief that the current scope of midwifery is unnecessarily limiting and that midwives, as a very useful human resource (pg. 1 of OMA submission), are not being granted the authority to work to their full potential in the service of Ontario s women and infants. Updating and expanding the scope of practice of midwifery will eliminate the disparities between the practice and self regulation of midwifery in Ontario and that of the other regulated provinces in this country; acknowledge and incorporate the changes to best practice in maternity care that have taken place since the profession was regulated 15 years ago; allow for increased access to safe and comprehensive primary maternity care for more women; and provide the flexibility for midwives to respond to the needs of diverse communities across the province. Before addressing the specific concerns expressed in the OMA s response to the CMO submission, it is necessary to note that many of the objections raised by the OMA seem to ignore the context in which the submission was framed. For example, the full submission goes into detail regarding how the proposed amendments to midwives scope of practice are connected to the maternity care crisis in Ontario; the Ministry s appropriate focus on and support for interprofessional collaboration; the provision of care in remote and underserviced areas; timely access to care across the province; and the CMO s position on standard emergency obstetrical procedures (i.e. that all primary maternity care providers need to be prepared to act in an emergency situation). Many of the OMA s concerns are framed as though the CMO expects that midwives across the province will immediately be authorized to perform an expanded scope of practice, with no time for training and education, or the establishment of the necessary regulatory mechanisms. Rather, the CMO proposes a future for maternity and midwifery care, as well as the establishment of interprofessional care relationships, which will be integrated safely and thoughtfully over time. The CMO recognizes that an implementation plan is required, and much of the groundwork for this has already begun among midwifery stakeholders. Midwives are primary maternity care providers for women with low-risk pregnancies, and in order to ensure safe and effective care, the delivery of that care must be equivalent among care providers. It is the CMO s position that midwives should be authorized to provide the same 1
scope of care that other primary maternity professionals caring for women with low-risk pregnancies provide to their clients. For example, there are well-established guidelines for the treatment of common pregnancy-related infections (e.g. urinary tract infections, mastitis, and group B strep) that midwives are trained to screen for and identify, yet they are currently not authorized to diagnose or treat them. The proposed amendments to midwives scope of practice will help to ensure the timely delivery of an appropriate level of care according to the most recent guidelines and standards, without unnecessary consultations. Finally, the Multidisciplinary Collaborative Primary Maternity Care Project (MCP 2 ), a multidisciplinary project funded by Health Canada in 2006, looked in-depth at the development of interdisciplinary teams for the delivery of maternity care. One of the key deliverables from this project was a comprehensive toolkit intended to support the establishment of interdisciplinary maternity care teams. Throughout this toolkit, the project committee stressed that a critical component to an effective interdisciplinary team is the interchangeability of all primary care providers, as well as a shared set of competencies. The OMA had a representative appointed to the MCP 2 working group and so, ostensibly, was an active participant in reaching the conclusions and developing the recommendations included in the project report. The CMO s proposed amendments to the midwifery scope of practice reflect these conclusions and recommendations. Response to the OMA s Concerns The overriding concern expressed by the OMA in response to the CMO s submission is safety. They assert that many of the proposed amendments to midwives scope of practice would result in care to women and infants that is not as safe as the care provided by a physician. The role of the CMO is to regulate the profession of midwifery in the interest of public safety, and the CMO believes that it has fulfilled that role for the past fifteen years, as well as in the scope of practice submission to HPRAC. As demonstrated in the submission, the statistics from the Midwifery Outcomes Report (MOR) database (which collects data on every midwife attended birth in the province), as well as other research studies (see bibliography in the full report), support midwifery as a safe and reliable option for women with low-risk pregnancies. Further, midwifery clients consistently experience fewer technological and/or medical interventions during pregnancy and birth than those women whose primary care provider is not a midwife. For example, and as stated in the submission: The Canadian Institute for Health Information (CIHI) released a report in 2004 entitled Giving Birth in Canada: A Regional Profile, which provides statistics regarding medical interventions that occur during labour and delivery per province/territory. In Ontario, the report cites an overall epidural rate of 45%, whereas the clients of Ontario midwives have a 21.5% epidural rate. 1 Similarly, Ontario has a 24% episiotomy rate overall, 2 while the rate for midwifery clients is 6.5%. Cesarean sections are at an all-time high of 28% across the province 3 while only 15.3% of midwifery clients require this surgical intervention (the World Health Organization states that no region in the world is justified in having a cesarean rate greater than 10 to 15 percent). It has been argued that midwives have low intervention rates because they provide care to low-risk women who are less 2
likely to encounter complications throughout pregnancy and birth; however, there is strong evidence to support the case that the midwifery model of care results in fewer interventions when compared to low-risk women whose maternity care is provided by a physician. 4 (pg. 5) Current vs. Expanded Scope of Practice for Midwives The OMA states that Rather than fully exploring ways to optimize their current scope of practice, the CMO seeks to step outside of its intended role into the field that should be managed by physicians and medical teams in response to the acuity of care required. (pg. 1) This suggests that the OMA would prefer that the CMO focus on flexibility within the existing scope of practice for midwives. However, the scope of practice was developed over 15 years ago, and no longer reflects the reality of the primary maternity care system. Ontario is facing a maternity care crisis that can be partially alleviated through safe and careful expansion to midwives scope of practice, which is the intention of the submission to HPRAC. There are two ways that the above OMA statement could be interpreted: 1. The OMA is suggesting that the CMO is proposing that midwives go beyond their current scope of providing primary maternity care to women with low-risk pregnancies. Rather, the CMO is proposing that some midwives receive specialized training to provide enhanced care to women and infants in regions of the province where there are serious human resource shortages, and where a midwife may be the most accessible skilled care provider. The CMO is also proposing that all of Ontario s midwives, as specialists in the provision of primary maternity care to women with low-risk pregnancies, be authorized to provide all of the services involved in the routine provision of that care. These services comprise the scope of practice of midwives in other provinces and territories, and are supported by the evidence as best practice. The focus on non-interventionist care, informed choice, as well as the woman as the primary decision-maker, will remain central to the philosophy of midwifery in all cases. These proposed areas of practice are detailed extensively in the full submission. As stated in the full submission the creation of flexibility within the current scope and responsiveness to community needs is not solely up to the CMO. It is important to note that there is inconsistency among hospitals and physicians regarding authorizing midwives to practice to their current full scope. For example, many midwives are not permitted to monitor inductions, augmentations, and epidurals for their clients, despite these tasks being within the boundaries of the current scope of practice. This is a costly and unnecessary restriction on practice. 2. The OMA suggests that the CMO has stepped outside of its role as the regulator of midwifery, into the field that should be managed by physicians and medical teams. It is the role of the regulatory body of every health profession to ensure that the scope of practice for the profession is in the public s interest. The CMO submission to HPRAC was informed by 15 years of experience by practicing midwives, a thorough jurisdictional review to ascertain where Ontario s scope is lagging in comparison to other regulated 3
provinces, a review of published and grey literature, and analysis of current midwifery outcome statistics. The CMO would not have presumed to submit a report on the state of the midwifery scope of practice without such research and consultation. The CMO believes that midwives comprise a significant part of the medical teams the OMA would have managing scope of practice issues. Further, the CMO recognizes that there are a number of scope of practice issues that can be dealt with at the CMO level, rather than through a regulatory amendment process. As stated in the submission: In our planning for expanding the scope of midwifery practice, building the capacity of the profession to respond to emerging health care needs, and the province s plans for the provision of maternity care, the CMO has identified standards and policies that will need to be reviewed, revised or rescinded. These policies will be examined within the framework of our guiding principles of informed choice, choice of birthplace, and continuity of care to continue to support the philosophy of birth as a normal physiologic process. This review also considers the current context of health care (i.e. the appropriate and increasing emphasis on interprofessional collaboration, continued and growing economical constraints on the system, the shifting demographics of the province s population, etc.) Specifically, the CMO will be reviewing: The requirement that there be 2 midwives at every birth; the current active practice requirements; the continuity of care requirements; the guidelines for certification to work outside the primary scope of practice; and the CMO standard Indications for Mandatory Discussion, Consultation, and Transfer of Care (IMDCTC). (pg. 24) (Please see appendix C of the full CMO submission to HPRAC for the IMDCTC document) Academic & Technical Training and Practice Experience The OMA states that they are concerned that the changes to midwives scope of practice proposed by the CMO do not fully consider the academic and technical training as well as the practice experience that dictate the legitimate boundaries of midwives scope of practice. (pg. 1) Every regulatory body has a duty and obligation to fully consider the academic and technical training, as well as the practice experience to determine the legitimate boundaries, of the health professions practice. This is precisely what the CMO did in preparation of the submission. Pages 55-58 of the CMO submission to HPRAC outline the educational component of the proposed amendments. They include a detailed explanation from the midwifery education program (MEP) regarding the plan for integrating the proposed changes into the MEP. Similarly, the CMO is working with the education programs, as well as the AOM, in the development of a plan to address the learning needs for those midwives currently in practice, with respect to the proposed changes to the scope of practice. 4
Midwives Providing an Appropriate Level of Care The OMA notes that the number of births handled by midwives in Ontario is relatively low compared with the number of deliveries performed by obstetricians In 2003 over 80% of women were attended by an obstetrician; 11% by a GP; 3.5% by a midwife in hospital, and the balance by a midwife at home or by other providers. (pg. 1) Midwives who practice full time attend 40 births per year as the primary caregiver, and 40 births as the secondary caregiver. It is the type of care provided by midwives, not necessarily the total number of births attended by all midwives, that is important to this discussion. Midwives provide continuous care to their clients throughout pregnancy, birth and postpartum, and are available as a team 24 hours/day, 7 days/week. Prenatal appointments with a midwife typically last between 30 to 45 minutes, and are scheduled at frequent intervals. Furthermore, midwifery care is founded upon the principle of informed choice, which means that women are the primary decision-makers regarding their pregnancies and births, and midwives are responsible for ensuring that their clients receive enough information to make informed decisions. This model of care is incongruent with the medical model that employs a system of informed consent, which is largely a physician liability issue, rather than a client-centred model of care. In terms of the statistics referred to by the OMA it is important to note that the balance of midwives attending clients at home and other providers amounts to 5.5% of all births in this scenario. Given that statistics show that the number of births attended by other providers is very low, 5.5 % added to the 3.5% of births by midwives in hospital actually results in midwives attending approximately 9% of all births. This number will only continue to rise, as the Ministry of Health and Long-Term Care has committed funding to increase the number of midwives graduating from the MEP. And as stated in the submission: As the only practitioners whose sole responsibility is primary maternity care, midwives, particularly with access to full current or expanded scope, are a consistent and predictable resource that should be better utilised in health human resource planning to meet the gaps in services for women and families in Ontario (pg. 34). Midwifery is a relatively new self-regulated profession when compared to obstetrics and family practice, yet the number of women choosing midwifery care is growing at an exponential rate. As noted by the AOM in their June 2008 Position Paper on Interprofessional Care: Consumer demand for midwifery far outpaces the supply. In 2005-06 for example, 16,409 women requested midwifery care but only 10,403 were able to access care. 5 This number does not include those women who enquire about midwifery care but choose not to be waitlisted because of the relative unlikelihood that they will be able to receive care from a midwife. The OMA goes on to state that These statistics indicate that midwives handle few complex cases this is owing to their practice philosophy and scope of practice. This scenario results in midwives having limited ongoing exposure to higher-risk pregnancies and an inability to ensure skills maintenance in this area. (pg. 2) The CMO believes that this line of reasoning is misleading. Midwives, as primary maternity care providers for women with low-risk pregnancies, handle the same proportion of complex cases as 5
any practitioner caring for women who present as low-risk. Their exposure to higher-risk pregnancies is no different than family physicians. Midwives have highly developed skills in screening, detecting and appropriately referring high-risk cases. The CMO s submission to HPRAC in no way expresses a desire for midwives to attend high-risk deliveries as a routine practice. Rather, it proposes changes to the current scope of practice that would allow midwives to provide the level of care that is appropriate for a primary maternity care provider, to the same low-risk clients (e.g. antibiotic treatment for routine pregnancy infections), as well as the appropriate level of emergency skills should they ever be necessary (e.g. intubation of the newborn), and the appropriate level of extended scope tasks for midwives practicing in regions of the province where there are human resource shortages and the possession of the skills would allow for increased access to health care and decrease the burden on the existing system (e.g. vacuum extraction). By appropriate level the CMO means those skills that are already within the skill set of a practicing midwife, or could be upgraded over a reasonable period of time. Midwives will still be required to adhere to the CMO s Indications for Mandatory Discussion, Consultation and Transfer of Care document, which details the clinical scenarios wherein they are required to consult with or transfer care to a physician. In terms of maintaining competency for emergency cases, the CMO believes that this is something every health care professional must address as a part of their professional development. Midwives are regulated health professionals and as such are responsible for maintaining competence in those areas where there is not a lot of opportunity to gain clinical experience. Further, the CMO requires that midwives maintain continuing competency in a number of specific areas. These skills are presumed to be required in emergency situations where the midwife is the most skilled professional available to conduct the task. For instance, in the very rare event that manual removal of the placenta is indicated as the safest, possibly life-saving option in a setting where more skilled help is not immediately available (i.e. community hospital where a surgeon or OB is called in, home birth, etc.), the midwife needs to be able to provide that service to her client. In all instances where a more experienced professional is present (or transfer or waiting is safe) it is understood that the intervention will be carried out by that professional. Further, the focus on volume of cases in terms of maintaining competency has been regarded as insufficient by other professionals in the maternity care community. The SOGC joint policy statement on Number of Births to Maintain Competence states: The belief that attending a specific number of births can imply a competence threshold for all providers fails to take into account several important variables. These include: the stage of a provider s career (early, middle, or approaching retirement), and hence the value of accumulated experience; the shared experience of the members of a practice group; well-developed collegial relationships among family physicians, specialists, and sub-specialists; the practice setting and organization; and the use of risk management and/or quality assurance programs. Although the literature clearly supports volume thresholds for complex surgical and some rare medical conditions, there is no evidence to support the extrapolation of these volume concepts to normal pregnancy and newborn 6
care. Rather, findings demonstrate good outcomes in low-volume settings when access to specialist consultation and timely transfer is available and used appropriately. 6 Midwives Participating In Interprofessional Collaboration The OMA strongly believes that the most useful approach to improving interprofessional collaboration is to assist midwives (and all health professionals) in fulfilling their current scope of practice to the fullest extent. (pg.2) Given the advancements that have been made in health care, particularly those specific to maternity care, it is unrealistic to assume that the scopes of practice of all regulated health professions, regardless of when and in what context they were developed, remain adequate to address the changing needs of Ontario s citizens. The current scope of practice of midwifery was written over 15 years ago, and no longer reflects evidence-based best practice in primary maternity care, nor does it meet the standard of the scope of midwifery across the country. While the CMO agrees that there are areas of the current scope of practice of midwifery that require attention (e.g. midwives are currently authorized to manage epidurals, inductions and augmentations but are often limited by their hospital rules and regulations or by individual physicians), addressing these issues alone will not be sufficient to allow midwives to fully participate in meeting the needs of Ontario s women and families. The CMO believes that many of the existing barriers to midwives practicing to their current full scope of practice can be found in the resistance to midwifery among health systems and policies, as well as a select few practitioners. For example, hospital policies that place caps on the number of midwives granted privileges or the number of births attended by midwives; medical advisory committees that do not facilitate midwifery membership; or hospital/physician policies that prevent midwives from practicing to their current full scope of care, i.e. physicians who enforce mandatory transfers of care when a simple consult is required. The OMA states that Certain pregnancies demand physician attention and management of these complex cases should not be undermined because of practitioners unwillingness to share care or refer. (pg. 3) The CMO agrees that certain pregnancies require the attention of a physician and in no way does it sanction midwives managing complex cases as a routine part of scope of practice. The proposed changes to the scope of practice are made with the intention of complementing current practice; allowing for the proactive identification of potential or existing problems in order to facilitate appropriate treatment and referral when needed; and to permit access to best practices, as well as the most current and appropriate diagnostics and technology. As mentioned, midwives are mandated to consult with a physician through the college s Indications for Mandatory Discussion, Consultation and Transfer of Care document (IMDCTC). Midwives regularly report situations wherein they are required by a hospital or physician to 7
transfer the care of a client for a clinical scenario for which the IMDCTC only requires a consultation. This is despite the recommendation from the Ontario Hospital Association and further support from the Ontario Maternity Care Expert Panel that the IMDCTC be adopted across the province as an effective tool for everyone involved in the maternity care system where midwives work. The CMO is aware of a number of barriers to physicians working with midwives; these are detailed and addressed in the full submission. Of particular concern is the fact that some physicians continue to suggest that their liability risk may be increased when working with midwives. This is despite the Canadian Medical Protective Association (CMPA) and the Healthcare Insurance Reciprocal of Canada s (HIROC) Joint Statement on Liability Protection for Midwives and Physicians, which states that: Hospitals that offer privileges to midwives scrutinize their professional liability coverage to ensure that coverage is sufficient from the point of view of the hospital. 7 Further, in a recent article printed in the Ontario Medical Review (which is a publication of the OMA), in regard to liability coverage for allied health professionals, the author states that there is no need for physicians to be concerned about those professionals (including midwives) who are covered by HIROC. HIROC offers claims-based coverage that incorporates many features that would normally be found in occurrence-based coverage. The CMPA has indicated that it is satisfied with the coverage provided by HIROC, indicating that HIROC provides adequate protection. The CMPA is comfortable with HIROC s liability limits, expecting that professionals who cease working for a hospital and/or organization covered under a HIROC policy will not need to purchase tail coverage. 8 The CMO also recognizes that payment issues may constitute a barrier for some care providers. These issues will need to be considered as part of the discussion of the sustainability of the province s health care system and in relation to the ongoing work required to facilitate effective interprofessional maternity care. The OMA contends that the level of training required for many of the expanded and additional controlled acts mentioned by the CMO is tantamount to that required by physicians practicing obstetrics. (pg. 2) The level of training required for the proposed additions to the midwifery scope of practice is equivalent to that of any primary caregiver attending births. The education that is required is appropriate to this role and to equipping midwives to deal with emergencies that can occur during the course of a normal delivery. While they are not frequent, midwives - as with any other care provider - must be prepared to manage any emergencies that may occur during the normal course of pregnancy and birth. The scope of practice needs to authorize midwives to perform these emergency procedures. The OMA also believes that the CMO proposal fails to address the two key issues that the OMA believes undermine collaboration. (pg. 4) 1. The fact that shared care is not permitted except under special approval by the CMO. 8
The midwifery model of care, which has resulted in excellent clinical outcomes as well as very high satisfaction rates among clients, is based upon the tenets of continuity of care, informed choice, and choice of birthplace. Shared care, in that regard, has not been considered an ideal arrangement for midwifery clients because the model of midwifery care is not congruent with the medical model of care. In most cases and communities there is neither the demand nor the necessity for midwifery clients to be seen routinely by a physician. That being said, shared care is a possibility between physician and midwives. The CMO has worked to allow flexibility within the model, while protecting the primary tenets listed above. Further, the college has always recognized that the ideal model will not perfectly serve all communities, and provides standards on second birth attendants who are not midwives or regulated health professionals, as well as for temporary alternate practice arrangements (TAPA) for those practices that require more flexibility. Currently, just over half of all midwifery practices have a temporary alternate practice arrangement, though not all practices use it regularly. The TAPA standard states that In order to provide continuity of care and choice of birth place in a midwifery practice, primary care is normally shared by a small group of midwives with two of these midwives present at each birth. The College of Midwives recognizes that alternate practice arrangements may be needed in some circumstances where this is not possible Applications will be considered according to individual circumstances, based on the following criteria: 1) Demonstrated need for temporary alternate practice arrangements. For example: a) insufficient number of midwives to provide on call coverage for clients; b) geographically remote locations; c) practice covers large geographic area; d) serving communities with special needs; e) recently established midwifery practice. 2) Evidence that the temporary alternate practice arrangements are consistent with he model of midwifery practice in Ontario. 3) Demonstrated support from the community. While it is true that shared care requires permission from the college, the intent of this regulatory mechanism has been to protect the midwifery model of care and maintain a high standard of care among midwives, in the interest of the diverse needs of midwifery clients. The CMO does not believe that this system undermines collaboration. Rather, it has worked to support collaboration in those regions where the needs of the midwifery practice and community require it. 2. That the midwifery payment model penalizes midwives who refer care to physicians midcourse. The CMO believes that this is a misunderstanding on the part of the OMA of how the midwifery payment model and referral system works. Midwives who transfer care to a physician for a clinical indication remain involved in that woman s care in a supportive care role. They receive the same payment that they would have received if they had not transferred care, provided that the transfer occurs after twelve weeks of midwifery care provisions. Further, the CMO 9
guidelines specify when a physician consult is required, thereby providing a clear incentive for midwives to consult and transfer appropriately, as a disciplinary action can be taken by the CMO. The midwifery payment model was informed by the World Health Organization s guidelines and standards regarding the optimal course of care and was developed in consultation with the CMO in order to ensure that it supports the midwifery model of care. The CMO believes that it does this. Moreover, the safety outcomes and workload statistics for midwifery care do not bear out the OMA s conclusion that the payment model is a disincentive for midwives to refer women to a physician midcourse. That is, there is nothing to indicate that midwives are maintaining the primary care role for women inappropriately in order to secure payment for a course of care. The issue of payment as a real or perceived barrier to IPC is one that should be addressed through the course of work on interprofessional care and the CMO believes that it should not be a consideration in determining the appropriate scope of practice for midwives. Midwives are Specialists in Low-Risk Primary Maternity Care The OMA further states that a lack of physicians in rural areas should not result in patients receiving care from physicians whose training/experience is not suitable for the acuity of the care required. (pg. 4) The CMO is not proposing that women and infants receive care from physicians whose training and/or experience is not suitable. What the submission does propose is that midwives, who are highly trained and experienced specialists in normal pregnancy and newborn care, be authorized to extend their scope of practice to help meet the particular needs of a community. The tasks included in the extended scope of practice will be regulated by the college to ensure proper education, as well as the necessary quality assurance requirements. These program components are already under development and/or being planned by the college and other stakeholders. Well-woman and Well-baby Care The OMA states that pediatricians have seen a significant number of missed diagnoses such as heart murmurs, genetic syndromes, and physical abnormalities in midwife referral cases. While the CMO understands the value of anecdotal reports, it would be useful to be made aware of any statistical information or clinical studies related to midwives and missed diagnoses, particularly how the rates compare to those of family physicians. The CMO s preliminary searches revealed no such data. If this is a concern to the OMA, the CMO would suggest that it would be imperative to undertake an interprofessional collaboration at the organizational level to identify and address any deficiencies or issues. Well-baby and well-woman care beyond the current scope of six weeks are components of the specialized extended scope of practice area that are being proposed for midwives whose communities may benefit from care in these areas. Again, this proposed amendment is in line with standards of care across the country (for example, midwives in the Northwest Territories routinely provide well-baby care to their clients for up to one year). They will be implemented, 10
as with the other proposed amendments, with the appropriate level of training and rigorous quality assurance. Non-spontaneous Normal Vaginal Deliveries The OMA state a number of times in their response that midwives scope of practice should stay within the confines of caring for women with normal pregnancies and natural births. The philosophy of midwifery care espouses a view of pregnancy and birth as normal physiological life events. The CMO proposal to remove the word spontaneous from the scope of practice statement and controlled act is intended to allow more flexibility in providing care to clients whose births are induced or augmented, or who receive an epidural for pain relief. While some midwifery clients with normal low-risk pregnancies have intervention-free births, others require an augmentation, induction, or want pain relief during labour. Midwives, in the interest of continuity of care, are already authorized to manage epidurals, inductions, and augmentations and the scope of practice statement and controlled act should reflect that. Emergency Procedures - manual removal of the placenta, intubation of the newborn, and umbilical vein catheterization There are a number of emergency procedures that the OMA feels midwives should not be authorized to perform. They include manual removal of the placenta, intubation of the newborn, and umbilical vein catheterization. Midwives, as primary maternity care providers, already have the competency to perform these skills in an emergency situation, and the legislated scope of practice needs to reflect that. It is in the interest of public safety that these emergency skills have been proposed as additions to the scope of practice for midwives. In each instance the most skilled care provider available will manage the task. Vacuum assisted birth The OMA note that when used properly, the risks of vacuum-assisted vaginal deliveries are far fewer that the risks of c-section or prolonged fetal distress. The intention of authorizing midwives to conduct vacuum deliveries as an extended scope of practice skill is to allow more flexibility for those midwives working in communities where possessing this skill will be of benefit to women and infants, as well as the broader health care system. Again, this amendment is proposed in the interest of public safety. And as noted in the full submission: Midwives are committed to a non-interventionist approach to maternity care, and while they are eager to have the tools available to them to provide a broader scope of maternity care to their clients, midwifery philosophy dictates an appropriate use of technology. 9 Further, the Organization for Economic Co-operation and Development (OECD) Issue Paper on Supporting Midwifery recognizes that the tasks that a qualified midwife may perform vary greatly. One could say that midwives work more independently the more peripherally they are located. When there is no doctor available to perform a certain procedure, the midwife is often the natural choice. Practical experience gathered in this way has gradually resulted in wise and knowledgeable midwives in many parts of the world, and such midwives prove not only that 11
certain doctors only procedures - such as vacuum extraction - can be performed by other staff, but also that new qualities of care may develop. 10 Expansion of current authorized acts The OMA expresses concern over the expansion of current authorized acts, specifically, going beyond the dermis for scalp Ph and taking blood from fathers/donors. The intention of the expansion of the controlled act is to ensure timely access to care potentially through referral to an obstetrician or other specialist, at the initial point of care. Underlying this proposed change is also the fact that it better positions midwives to act most effectively within an interdisciplinary team. The CMO s IMDCTC document will continue to be referred to as the framework for when referrals should be made to a physician. Repair of 3 rd and 4 th degree tears This expansion was included in the submission using the same framework that was developed by the MCP 2 project. That is, to consider the skills required in a maternity care team and to ensure that at least one member of the team is capable of contributing each of these skills. Within this framework, the repair of 3 rd and 4 th degree tears are presented together, hence its inclusion in the submission in this way. The CMO recognizes that 4 th degree tear repair is a surgical intervention. A midwife practicing in a community that does not have consistent or immediate access to a physician able to perform this repair would need to have sufficient knowledge to care for a woman with such an injury, i.e. to prepare her for transport and assist with repairs. The midwife must possess the same degree of skill and knowledge as a family physician providing obstetrical care. Medications & Vaccinations The OMA states that Drugs such as oxytocics, narcotics and antibiotics should be prescribed by a physician. The risks associated with over-prescribing, adverse drug reactions and drug side-effects are all reasons why prescribing drugs is beyond midwifery training. (pg. 9) Midwives currently have a regulated list of drugs that they are authorized to prescribe and administer, and therefore midwifery training has already been assessed to include the skills required for prescribing. The proposed amendments to the drugs that midwives are authorized to prescribe and administer are in line with current best-practices in primary maternity care, as well as the standard of midwifery care across the nation. The OMA goes on to say that they believe that vaccines should be handled by family physicians to ensure continuity of care. Granting midwives the authority to administer vaccines to their clients does ensure continuity of care since they are typically required during the time a woman would be in care with and have developed a relationship of trust with a midwife. 12
Laboratory Tests The OMA states that this expansion in scope (PIH testing) is acceptable if it is qualified with a requirement that such an order necessitates immediate referral to a specialist. While the CMO agrees that the results of a PIH test could warrant referral to a physician, the ordering of the test should not dictate referral. As primary maternity caregivers, midwives should be granted the authority to an expanded list of laboratory tests in an effort to increase safe and efficient access to the necessary diagnostics and care, and to reduce unnecessary referrals. All regulatory amendments undergo a rigorous review process, and client safety is the primary concern of the CMO, as well as the government-appointed reviewing agency. Again, midwives will be required to adhere to the requirements of the Indications for Mandatory Discussion, Consultation and Transfer of Care document. Ambulance Act The OMA has concerns with respect to amending the provisions in the Ambulance Act that would allow midwives to direct ambulances to hospitals where privileges are held It is absolutely inappropriate to place a practitioner s wishes above the medical needs of the patient. (pg. 10) The CMO has the responsibility of regulating the profession of midwifery in the interest of public safety, and therefore, would not suggest that a midwife s wishes should be placed above those of a client. The CMO believes that this concern is being taken out of the context in which it was provided in the full submission to HPRAC. It states that: According to changes made to the Ambulance Act, midwives, as primary maternity care providers, currently do not have the authority to provide care to women and infants during an ambulance transport; to direct the ambulance to a particular facility where the midwife holds privileges; or be able to give orders to ambulance personnel regarding the care of a woman or infant. The CMO was neither consulted prior to these changes being made, nor notified of the changes once they took place. This did not provide an opportunity for education of our members and led to confusion in a number of situations. As a result of these amendments to the Ambulance Act, clarification regarding decisionmaking with respect to hospital transfer is required. The College worked with Ministry representatives in 1994 to prepare a document entitled Midwives at the Scene that set out the roles and responsibilities of midwives and ambulance personnel. This document states: A midwife, in relation to their patient, has the same status as a physician and will be afforded the same actions as for a physician. Where a midwife or physician remains in attendance with the patient throughout transport, the midwife or physician will have overall responsibility for the care of the patient. 13
When arriving upon a scene with a midwife in attendance to a patient who is their client and for whom the midwife is acting as a midwife, the ambulance crew will accept the advice and direction of the midwife as it relates to the care of the patient(s). The CMO recognizes that every ambulance transport is urgent, but not necessarily an emergency. It is our position that midwives, as highly skilled professionals in the provision of out of hospital birth care and who have hospital privileges, should have a role to play in the decisions respecting the most appropriate hospital for transport. (pg. 30) The midwife is the most qualified and knowledgeable person on site to make a decision about the facility where the woman will receive the most appropriate care. Midwives are fully qualified to triage labouring women and are trained to provide care during ambulance transport. This is the practice in most ambulance transport situations, and the legislation needs to reflect this. Midwifery: A Distinct Primary Care Profession The OMA states that some requests appear to position midwives as physician substitutes without full recognition of the extensive and comprehensive training that family physicians and obstetricians undertake. The CMO recognizes that midwives are not physicians but feels that the existing scope of midwifery practice is outdated and does not reflect the current best-practices in maternity care for low-risk clients, nor does it maximize midwifery s potential to contribute to alleviating Ontario s maternity care crisis. The OMA s response suggests that that they do not recognize or appreciate the high level and variety of skills that midwives in Ontario possess, along with the intensive education and training they go through to become registered, as well as to maintain registration. The CMO recognizes that the areas where the OMA feels that midwives are being positioned as physician substitutes are those where an extended scope of practice that goes beyond the routine provision of maternity care for low-risk clients is being proposed. In that regard, midwives will most assuredly be doing more tasks that a physician might also do; however, they will be performing the tasks in an effort to meet the needs of communities where other practitioners are not available. In urban centres, where there are a sufficient number of adequately staffed maternity care teams that include midwives, nurses, respiratory therapists, anesthesiologists, family doctors, obstetricians and surgeons, the extended scope skills will likely not be necessary. Finally, it is important to note that individuals entering the midwifery profession are currently the only consistent, predictable, and reliable source of the maternity care workforce and are therefore a significant part of the health human resource crisis solution. 14
1 Ontario Midwifery Program Reporting System, MOHLTC 2 Provincial Dataset, Ontario Perinatal Surveillance System 3 Ibid. 4 For example, see: Janssen et al. Outcomes of Planned Hospital Birth Attended by Midwives Compared with Physicians in British Columbia. Birth, (2007) 34:2. Rosenblatt et al. Interspecialty differences in the obstetric care of low-risk women. American Journal Public Health; (1997) 87(3): 344 351. Tucker et al. Should Obstetricians see women with normal pregnancies? A multicentre, randomized, controlled trial of routine antenatal care by general practitioners and midwives compared with shared care led by obstetricians. British Medical Journal; (1996) 312: 554. 5 Association of Ontario Midwives Position Paper on Interprofessional Care, June 2008. Available online at http://www.aom.on.ca/files/pdf/communications/ipc_position_paper_final.pdf 6 SOGC Joint Policy Statement: Number of Births to Maintain Competence (2002). Available online at http://www.sogc.org/guidelines/public/113e-jps-april2002.pdf 7 Canadian Medical Protective Association and the Healthcare Insurance Reciprocal of Canada s Joint Statement on Liability Protection for Midwives and Physicians. Available online at http://www.canadianmidwives.org/pdf/2007_hiroc_eng.pdf 8 Legal Update: liability protection coverage among allied health professionals key issues for MDs. Available online at http://www.oma.org/pcomm/omr/mar/08maintoc.htm 9 For example, see: Alexander, J., Anderson, T., Cunningham, S. An evaluation by focus group and survey of a course for Midwifery Ventouse Practitioners. Midwifery, Vol. 18 (2002), 165-172. 10 Organization for Economic Co-operation and Development (OECD) Issue Paper on Supporting Midwifery. Available online at http://www.oecd.org/dataoecd/28/51/35225108.pdf p. 6 15