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CLOSED 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 The time you will need to adjust your practice before the CTCS is rescinded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 17, 2020.

All Feedback

  1. Midwife

    We as a practice support AOM comments and agree with the proposed changes. We believe it will bring more autonomy in the way midwives practice and will help with collaborative model of care.

    • Are you a: Midwife
    • Organization: The Midwives Clinic Of East York- Don Mills
    • On behalf of: Organization
  2. Midwife

    I agree with rescinding old CTCS and with the new ones. I wish that new standards be distributed and discussed among Obstetricians and Labour and Delivery Nurses. There is lack of information an misunderstanding of consultation vs transfer of care and midwifery scope of practice. Also, incorporation of new skills within the midwifery scope such as surgical assist, inserting IUDs or preforming ultrasound without clearly specifying funding for these procedures needs to be further explored and clarified.

    • Are you a: Midwife
    • Organization: West End Midwives
    • On behalf of: Yourself
  3. Midwife

    I feel like there are a few aspects that put midwives in a position of liability due to lack of clarity or discrepancy with actual practice.
    Page 13, as others mentioned above, there are often times where care extends beyond 6 weeks due to the day of the week a discharge appointment is booked, or if the midwife is on holidays and waits until return to discharge.
    Page 14, Intraoseous access for administration of medications during NRP is likely to be encouraged with the next edition of NRP. Is there potential to add this quickly if it becomes expected practice so midwives can remain up to standard?
    Page 16, Nasogastric tube for NRP can be used for decompression of stomach contents and for ruling out choanal atresia during resuscitation of the newborn.
    Page 20, Is breech considered “normal” and twins? Some guidance here to ensure we can still work to our full scope and include these in our hospital protocols as a consult only, ensures unnecessary transfer of care to a MD.
    I have to admit, I like the idea of these becoming more open-ended instead of list based myself, although our hospital has created their protocols specifically based on the previous list, which actually helped to expand our very limited scope there. I hope this new document doesn’t impinge on our recent protocol development there.
    Thank you.

    • Are you a: Midwife
    • Organization: Norfolk Roots Midwives
    • On behalf of: Yourself
  4. Midwife

    – The area that needs the most clarity for me is the baseline expectations when a consultation occurs- a decision making tree for consultation is absolutely necessary if we are removing the indications. This would also help in deciding when the transfer of care should occur. The decision to transfer care often comes as a natural outflow of the plan made with a consultation, but the current CTCS have a number of criteria to consider consultation which is a useful prompt(ie: in taking medical or OB hx, during pregnancy) for a midwife to reference which can help to justify that a peer in the same situation would respond in the same way, without this it leaves midwives feeling as if the decision is totally in her discretion with the client but that there are no standards for the situation.I am concerned about lack of consistency within institutions or practice groups in the regard.
    In the same way that there are guidelines in fetal health surveillance for when to consider and when it is recommended to switch from IA to EFM, similar suggested guidelines are useful in triggering addition care plans for clients who may benefit from additional expertise.

    I agree with the AOM feedback:

    1. State in the introduction that the guide is intended to explain the midwifery scope of practice not only to midwives, but also to other health care professionals with overlapping scope, and to facilities that credential midwives;
    2. Clarify the definition of “normal”, avoid examples that do not explain the decision- making process, and avoid terms such as high risk and low risk;
    3. Describe the step-by-step process, starting with the legislative framework, that midwives should apply to determine if care is within their scope, including using examples that demonstrate how this step-by-step decision-making process is applied;
    4. Clarify “individual scope of practice” by explaining that midwives are primary care providers who use knowledge, skill, and judgement to make appropriate plans of care and to determine when to recommend a consultation or transfer of care;
    5. Explicitly state that the CMO does not condone scope restrictions unless they serve the public interest and remove reference to “external factors”.

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

    I am in complete support of rescinding the CTCS Standard for many of the reasons already listed:
    -diminishes the RM’s ability to consolidate their education, knowledge, skill and judgement when providing care
    -compromises sense of autonomy
    -demeans the RMs ability to be a Primary Care Provider (again, you do not see MDs resort to a list)
    -it is a crutch for new RMs and establishes an unbalanced hierarchy. It creates a lack of trust between MD and RM and even from Client to RM that the RM cannot practice without a list or being told what to do by the CMO
    -does not build confidence in one’s own skills and knowledge. Do not take ownership of own decision-making.
    -creates over-reliance and dependency
    – prescriptive and yet, not exhaustive.
    -Newer RMs should be mentored by experienced RMs and not be dependant on this Standard to navigate care and identify Scope.
    -embarrassing to have to consult for an issue that will not change the plan of management—so the consultant then asks what we from them….and the answer is “nothing -as we know the plan of management, however we are obligated to consult due to CMO Standards” . Often, it places the burden on the client to then decline the consult when they learn there will be no further information provided or no change in the plan of care.
    Solution- creating a GUIDE to allow RMs to practice in full-Scope utilizing their own autonomy, knowledge, skill and judgement within their own health care context.
    Perhaps without this Standard, RMs will put a heavier emphasis on reading, knowing and advocating for their Scope through the RHPA and the Midwifery Act.
    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
    Thank you to the CMO for continuing to regulate in the Public’s best interests and with safety at the forefront!.

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

    Page 8 was a typo where two words appeared as one
    Page 12 information written twice
    Page 16 seems to restrict inserting a small tube into nasal passages to ensure patency when indicated
    Page 18 discussing restrictions beyond the anal verge – seems like it would restrict an exam for tears/sutures

    Otherwise, the changes are likely beneficial. However, the information that was contained in the previous Consultation documentation was very clear, particularly for newer/less experienced midwives to have information and guidelines. It would be unfortunate to lose those guidelines completely.

    • Are you a: Midwife
    • Organization: Midwives of Middlesex & Area
    • On behalf of: Organization
  7. Midwife

    I agree with the changes proposed. I believe they will give us more autonomy and allow for changes is scope and collaborative models.

    • Are you a: Midwife
    • Organization: Cambridge Midwife
    • On behalf of: Yourself
  8. Midwife

    Overall I like these changes and will hopefully give us more autonomy.
    Do these changes apply to laboratory tests or medications or just consults that don’t require drugs and laboratory testing?
    This will further increase OBs to implement rules of 2 consults become a TOC and potential major differences in midwives who practice at the same hospital making which can lead to more internal complaints/conflict.
    Will there be a webinar for more information?
    Will there be relevant training for new laboratory testing or medications through the AOM for midwives who wish to expand their scope?
    Thank you

    • Are you a: Midwife
    • Organization: EOM
    • On behalf of: Yourself
  9. Midwife

    I agree with the aom comments. thank you for your hard work. I would find it helpful if there is a historical piece that refers to the discussion/consultation/transfer of care document and how examples were once used to help give a framework….. I worry that without it many places will have further erosion of scope and midwives will have an ambiguous document to stand on.

    Having a reference to the old document and stating that the goal is optimize midwives’ skill and scope would be helpful. The the new document (assuming the aom revisions)… would make me happy. Sincerely 1 out of 1000 midwives. Thank you for everything you do.

    • Are you a: Midwife
    • Organization: Burlington & Area Midwives
    • On behalf of: Yourself
  10. Midwife

    I support the idea of not having a list of conditions to transfer/consult.
    I do wonder therefore about the inclusion of a few conditions, namely HIV as a reason that is not in scope? A person living with HIV, on medication, could have a lovely home birth! I have spoken with HIV experts in our area who would work in partnership with us to ensure that the client is appropriate – but other than a pediatric consult within 72 hours after birth for HIV meds, would need no additional care. I don’t see why this is still excluded included.
    Additionally, I would encourage the CMO also to use pregnant person rather than woman in the document.

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

    I assume this is the place to do this, but, like others, I would really like an increase in scope (with adequate training, but NOT under delegation) for certain acts, including medication and surgical abortion, IUD and IUS insertion, and neonatal frenotomy.

    I also wish this document (though again – perhaps this isn’t the time or the place for this) would provide more support/weight for midwives to work to their full scope. For example, I work at a hospital where they do not allow us to do ECVs even though I feel comfortable and would like to do them. It would be nice to have more support from the CMO that this is within our scope of practice and that we should be able to do them should we feel it’s appropriate.

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

    Would like permission to insert IUD and IUS insertions mentioned as well as the scope expanded to provide reproductive healthcare services like birth control, abortion services.

    • Are you a: Midwife
    • Organization: New Life Midwives
    • On behalf of: Organization
  13. Midwife

    On page 10 of the Scope of Practice Guide, it shows that midwives can take care of women in the post-partum period and babies until 6-8 weeks post-partum. However, on page 13, it says that providing care to a person is not permitted after 6 weeks post-partum.

    I like this new standard. I foresee that it may make working in a team challenging as midwives will have various levels of comfort and knowledge and willingness to accept delegated acts and provide care for a same person. For example, on a team of three midwives, one midwife may be competent and knowledgeable taking care of a client planning a breech delivery, but the others don’t so when that client goes into labor, they won’t know if they will receive midwifery care or not. This issue already exists, but I can foresee that the disparity amongst the skills of all midwives will vary more and more.

    • Are you a: Midwife
    • Organization: Community Midwives of Thunder Bay
    • On behalf of: Yourself
  14. Midwife

    Overall, I find this document clear, informative, and useful. When the additional appendices are attached, it will be really helpful resource. I like how it balances providing some hard boundaries on scope while maintaining flexibility. I don’t find it necessary to list authorized acts that are very much not pregnancy-related (like references to dental work) but perhaps these things are useful to those coming from places with very broad scopes of practice.

    In the definitions section, the definition of a newborn would be clearer if it states: Newborn means a baby from the
    moment of birth up to 8 weeks after birth (remove ‘6 to’ ).

    Page 12 has the same information repeated twice.

    Page 13: I’m not clear on what this section is supposed to relay- “Midwives also may provide care to clients and newborns up to approximately 8 weeks after the birth providing the care does not involve the diagnosis of a
    disease or disorder providing they have not yet been discharged from midwifery care.”
    Wondering if this captures the point more clearly? (if this is actually what this is trying to say): Midwives may provide care to clients and newborns beyond 6 weeks to a maximum of 8 weeks following the birth provided the extended period of care does not involve diagnosing a disease or disorder and provided they have not yet been discharged from midwifery care”

    • Are you a: Midwife
    • Organization: Born Midwives
    • On behalf of: Yourself
  15. 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
  16. 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
    1. Midwife

      🙏👏👏👏
      Love the definitions and the explanations.
      I feel the document clarifies the intent behind what we do and how we work.
      After many years of working under the prescriptive nature of the indications doc I see this as a win. It doesn’t matter whether we have a document that defines every situation or not. There will always be care providers that will challenge other providers. In my experience these are the caregivers that don’t put patient safety and collaboration at the forefront. This document allows us the freedom to ensure that the best care provider for the clinical situation and setting is available to our clients. Whether that be ourselves based on our individual competencies or someone else we work with, it allows patient safety to be the primary motivator in each situation.
      Thank you for all your hard work and persistence and for always trying to elevate our profession to the next level.

      • Are you a: Midwife
      • On behalf of: Yourself
  17. 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
  18. 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
  19. 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
  20. 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
  21. 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
    1. Midwife

      I welcome these changes. They seem a natural evolution for Midwifery in Ontario. My comment is that I witnessed the MCTC documents being used practically verbatim at 5 hospitals i worked at as a student and new midwife 25 years ago. It formed the basis of their policies around consults and transfers on care within the hospital setting (inductions of labour, intrapartum, post partum. Midwives will need help and guidance in getting all these hospital policies to align with these changes

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

Comments are closed.