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Public Consultation: Standards Review: Phase 2

About this consultation

We are seeking feedback about Phase 2 of our standards review that includes several recommendations, including the proposed rescinding of the Consultation and Transfer of Care Standard (CTCS) and the implementation of a guide on the midwifery scope of practice. Download the Consultation Paper here.

Background

In 2016, the College adopted a principles-based approach to the development of the standards of practice; an approach that relies on broad principles, rather than rigid rules that midwives must follow. Adopting a principles-based approach required a review of all of the College’s existing standards in order to revise or rescind those with prescriptive rules that limited midwives’ ability to exercise clinical and professional judgment in their midwifery practice. The first part of this review, completed in June 2018, resulted in rescinding a number of standards, such as External Cephalic Version and the Ontario Midwifery Model of Care. At this time, the Professional Standards for Midwives was implemented.  We are now completing Phase 2 of our standards review after spending the past two years working on the remaining recommendations from Council.

Our proposals

To complete Phase 2 of the standards review, we are requesting feedback from midwives, the public and stakeholders about our proposal to:

How to provide feedback

Please review our Consultation Paper which describes the College’s rationale for rescinding the standards and what will replace them as well as the proposed draft of the Scope of Practice Guide. Once you have reviewed the Consultation Paper and the guide, please return to this page to submit your comments.

If you are a midwife, please consider the following when providing comments:

  1. Any positive or negative effects rescinding the CTCS will have on clients and your practice
  2. The time you will need to adjust your practice before the CTCS is rescinded
  3. Areas of the midwifery scope you don’t understand
  4. Concerns you have about using the proposed Scope of Practice Guide in practice
  5. Concerns you have about rescinding the Delegation, Orders and Directives standard
  6. Concerns you have about rescinding When A Client Chooses Care Outside Midwifery Standards of Practice  

All comments are reviewed before being posted publicly to ensure they meet the Posting Guidelines. Your name and email will not be published with your feedback. Your feedback will identify you as a member of the public, a midwife or a stakeholder. Email addresses are required to ensure that each individual only provides feedback once. If you prefer to provide feedback via email, want to respond using a different format, or if you have any questions about the consultation, please email us at: cmo@cmo.on.ca.

This consultation will be open until October 10, 2020.

Feedback Form

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All Feedback

  1. Midwife

    Although I recognize the value of creating more flexibility and personal judgement within Midwifery care, I also believe that there should be a standard of what midwives are comfortable navigating no matter the point in their career they are in. Having clear guidelines on when a midwife needs to transfer can be restrictive, but more often than not it actually enables midwives to defend to OBs why they don’t need to transfer care. This new document places much of the consult and transfer decisions in the hands of hospital policies and protocols which are more often than not created by OBs and are restrictive of midwifery care. I believe that in places where relations are already unsteady, this document will further restrict midwives from advocating for the care they can provide by binding them into hospital policies and protocols which do not serve the midwife or the client and which are not evidence-based but financially motivated. Maintaining clear guidelines of when to transfer and consult holds midwives to a clinical standard that they should be meeting and defends areas of normal pregnancy, labour, birth and postpartum by not including them on the lists.

    • Are you a: Midwife
    • Organization: Laurentian MEP Student
    • On behalf of: Yourself
  2. Midwife

    I would like to make a comment about the proposed change under delegation. Specifically, section 31.5. which states that “delegating controlled acts only when you have an existing relationship with the client for whom the controlled act will be delegated”.

    I’m concerned about how this will play out in Expanded Midwifery Care Models where a midwife may have an expanded scope of practice and work under delegation with clients where there is no existing relationship. How would an existing relationship be defined?

    For example, I currently see many clients for breastfeeding support beyond 6 weeks. I sometimes will prescribe APNO or Domperidone under a medical directive. Sometimes this prescribing is done on our first encounter.

    Additionally, I am getting my training to be an IUC inserter. Again, I may be asked to insert an IUC in someone who I may have just met or only met/spoke to once before. Could you comment on this?

    I wanted to ensure these aspects are being taken into account in adding this to the Standards of Practice.

    • Are you a: Midwife
    • Organization: Delhi Family Health Team
    • On behalf of: Yourself
  3. Midwife

    Instrument “ii beyond the point in the nasal passages where they normally narrow.”

    In the proposal is not authorized, but inserting an NG tube in a newborn is a procedure in an extentive resuscitation and is a part of NRP. To relieve stomach air. The regulation
    read as similar to the intubation legislation that follows it. Authorized for the purpose of NRP on a newborn.

    • Are you a: Midwife
    • Organization: Blue Heron Midwives
    • On behalf of: Yourself
  4. Midwife

    I’m ok to keep all the Transfer of Care list but will like the Consult list changed To : Consult base on Midwife’s judgement.
    Thanks

    • Are you a: Midwife
    • Organization: Ottawa South Midwives
    • On behalf of: Yourself
  5. Midwife

    The rescinding of the Consultation and Transfer of Care standard is a welcome and long overdue intervention. As identified in the member consultations, this is a prescriptive and confining document that negates professional judgement. The Midwifery Act is meant to govern our scope of practice; despite the evolution of this document since legislation, it continues to be a tool that facilitates others’ (hospital committees, other health disciplines), ability to supersede the Act, and to define what Midwives can or cannot do. It created a hierarchy of care with other providers, and negated the goal of person-centered care by dictating who was to be involved in a client’s care.
    For the most part, the proposed Scope Practice Guide is an effective replacement. Some of the examples of scope (p.10), are somewhat simple/unrealistic (and Jaundice is misspelled), and perhaps could be reconsidered.
    Section 3.2 The Controlled Acts is generally well presented in terms of clarity, however the example (p.14) of a ‘not authorized’ act (midwives performing venipuncture on a newborn), does not seem to coincide with the Act, which states Midwives may take blood ‘from persons from veins or by skin pricking’; is a newborn not a person once they have drawn a breath?

    • Are you a: Midwife
    • Organization: Sudbury Community Midwives
    • On behalf of: Yourself
  6. Midwife

    “It is worrying that midwives, as primary care providers with numerous controlled acts, including prescribing drugs and ordering laboratory tests, must defend their scope of practice with colleagues in the health care system. It does suggest, however, that midwives need clear guidance about the midwifery scope of practice for themselves as
    well as for their clients and their colleagues, and a list of clinical indications cannot define the profession’s scope of practice.” While the CMO’s role is ultimately to define midwifery for midwives and to protect the public who receives midwifery care, part of the reality that defines our practice, even 25+ years into our existence is that colleagues in the health system can have a huge impact on how midwifery is practiced. And defining midwifery for midwives doesn’t change this. For this reason I think it’s essential to ensure that the guide to the scope of practice include clear role and responsibility guidelines for midwives AND more importantly for our interprofessional colleagues. While it’s true to say that the purpose of the document should be to create autonomy for midwives and reinforce our role as primary care givers, I think it is naive to assume that the impact of our interprofessional colleagues opinions and enforcement won’t have an impact on how we practice and what access to safe high quality midwifery care our clients receive. “Knowledge of roles and responsibilities of OTHER healthcare professionals” is an integral core principle of effective interdisciplinary collaborative care and it’s important that the CMO help us to define our role and responsibility in a way that clarifies what is expected when we interact with other disciplines. The CTCS is vague and non inclusive, but removing it without replacing it with a better tool, isn’t going to improve that.

    The new Guide that is part of the strategy to replace the CTCS provides a reasonable replacement but I do wonder about it being titled a guide whereas the CTCS was a standard. A standard implies that it must be adhered to. A guide suggests it’s more optional. From the standpoint of helping to establish what the expected scope of midwifery is and should be, there might be value in titling the document something other than a guide to make it easier for folks with overlapping scopes who are trying to collaborate in an interdisciplinary manner and yet trying to ensure that everyone is practicing to the fullest and most appropriate extent of their scope, to do so appropriately. Make it easy for everyone to do the right thing.

    Placenta previa, is listed as an example of a high risk out of scope indicator in this guide. I would argue that a known placenta previa with a planned elective c/s, who is asymptomatic would NOT be out of scope for a midwife to provide prenatal care to and would in fact likely receive faster access to an emergent c/s should one become necessary due to an APH, because the client will be able to access her midwife 24/7 to initiate plans for an emergent c/s. So I think in terms of the argument being presented to remove the CTCS and replace it with this guide, that the example of placenta previa, in particular is a poor one and I would remove it from the list.

    The controlled act of inserting a urethral catheter specifies into a woman’s urethra but not all pregnant folks identify as women. If this is legislative wording that is difficult to change, might I suggest a preamble in the guide to identify why “woman” was used and specify that it is actually meant to reflect all clients midwives might care for?

    Individual scope of practice. I think it is REALLY important to spell out that while individual practice context (i.e. a midwife working in a hospitalist role, a midwife working in a prenatal and postnatal EMCM clinic, a midwife who is newer or near retirement) may impact a midwives chosen scope of individual practice, as with other autonomous clinical providers, individual scope of practice should not be influenced by “market pressures”, the opinions of other providers with overlapping scopes of practice or institutional restrictions (other than where there might be resource or community need related rationale).

    External factors which may influence scope. I take strong issue with normalizing that institutions should be able to restrict scope without limitation. While it may be true that they have the authority to implement institutional policies
    that prevent a health care provider from practising to the full extent of their legislative scope despite legislative authority and the necessary competencies they may possess and while this is not unique to midwifery, the CMO can choose to take the position and normalize that this shouldn’t happen without valid rationale for doing so. Restriction of scope should not be arbitrary and in fact both the current PC MoH and the previous Liberal MOHLTC were committed to enabling health professions to use their education and training more effectively and practicing where possible and appropriate to the fullest extent of their scope of practice. I think it would be incredibly valuable and establish an important norm, to state that where restrictions are placed, they should be based on validated rationale, and the best interests of clients and the community. In addition to ensuring the best available care for clients, we have an obligation to utilize health care resources responsibly, and that includes not sustaining practices that create unnecessary duplication of services.

    No comments re the delegations, orders and directives change.

    No comments at this time on the proposed changes to when a client selects care below the Midwifery standard.

    • Are you a: Midwife
    • Organization: Midwives of Mississauga - Trillium Health Partners
    • On behalf of: Yourself
  7. Midwife

    I have been very concerned with the idea of rescinding the Consultation & Transfer document. It has been a helpful guide for all of us, new and old, to remind us of when clients actually should be getting care from OBs. There’s sometimes a feeling that with enough consultations, we can keep on clients because THEY want midwives. But Lupus or pre-existing diabetes or weird cardiac stuff should not be managed by us. And the standard made that clear.
    Yet in reading the proposed Scope of Practice Guide, I am impressed with the detailed explanations of what all these terms mean. I agree that the previous standard was not always the best guide to my practice. Some situations that were listed as requiring a consult didn’t really warrant it, where as others I transferred for despite them being listed under consultation. So using my judgement, experience, and knowing my physician team/ressources seem like a great way to go forward.
    My biggest worry is that this change feels a lot like we are putting the cart before the horse. The MEP is, in my opinion, not offering a training matches the level of judgement, expertise and responsibility required to work in the way you propose. If the College really wants to protect the public, it will need to look to the MEP to raise the bar.

    • Are you a: Midwife
    • On behalf of: Yourself