Skip to main content
College of Midwives Ontario logo
'

Closed Public Consultation: Second Birth Attendant Standard

About this consultation

The College’s commitment to risk-based regulation requires a rigorous approach to policy development. This means revisions to the College’s policies and standards must be based on numerous factors including an evaluation of risks of harm, research evidence, and an analysis of options and impacts. This process ensures that our regulatory tools are not adopted as the default solution but are introduced to mitigate risk when other non-regulatory options are unable to deliver the desired results.

Consultation with midwives, midwifery and regulatory organizations, and the public is an essential part of our policy development process, and in keeping with our guiding principles of accountability and transparency.

Background

The Professional Standards for Midwives requires that all births must be attended by a midwife and a second birth attendant defined as an individual, other than a midwife registered with the College of Midwives of Ontario, who works with a midwife to provide care during labour, birth and the immediate postpartum, not in a subsequent postpartum visit.  The Second Birth Attendant Standard sets out the minimum requirements for midwives working with second birth attendants and requires, among other things, that second birth attendants h0ld certificates of completion in neonatal resuscitation (NRP), cardiopulmonary resuscitation (CPR) and obstetric emergency skills (ES). 

College standards should be achievable by all midwives and this standard is not achievable by midwives practising in some rural practices that are unable to reliably find second birth attendants who can certify in NRP.  The reason they are unable to find second birth attendants with NRP certification is because only a small number of licensed or regulated health professions are eligible to participate in NRP courses and these care providers are difficult to recruit and retain in areas with shortages in health human resources.

Key Revisions

This standard was revised so it is achievable by all midwives by requiring midwives work with second birth attendants who are competent in NRP rather than certified in NRP.

Addition – A line has been added to the definition of second birth attendant to specify that second birth attendants may be care providers who are regulated or who are not regulated. This means that midwives will be permitted to work with second attendants who are not licensed or regulated health professions or students of a licensed or regulated health profession.

Revision – The requirement that midwives must work with second birth attendants who are certified in NRP has been replaced with the requirement that midwives must work with second birth attendants who are competent to assist in the provision of care to clients during neonatal resuscitation

Consultation request

The proposed Second Birth Attendant Standard 

Consider: 

  1. Are the proposed requirements clear?  
  2. Are risks of harm to the public addressed?   
  3. Is the standard achievable for all midwives? 
  4. Is there anything missing? 

How to Provide Feedback

You may submit your comments using this page.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, however, you will be identified as a member of the public, a midwife, or a stakeholder. Email addresses are required to ensure that individuals provide feedback only once. If you prefer to provide feedback using a different format, including email, or if you have any questions about the consultation, please contact us as qac@cmo.on.ca

This consultation is open until May 11, 2022

All Feedback

  1. Midwife

    This is definitely a move in the right direction and I support the changes.

    Are the proposed requirements clear? – I feel they are. I am particularly pleased as these amendments allow for more and better access to care for our rural clients, and more help for our rural colleagues in providing care within their communities.

    Are risks of harm to the public addressed? -No. I don’t feel that this is addressed adequately. What are the risks to the client by using a SA vs. a MW? Does that risk change if the SA is registered or not in their field? How does a MW have an ICD to “ensure clients understand the role the second birth attendant will play during the client’s care” without biasing the client against an SA who may not be registered?

    Is the standard achievable for all midwives? – I’m not sure. For instance, how would a midwife be able to “ensure the midwives’ professional liability insurance extends to cover the care provided by the second birth attendants” ? Especially if the MW is working with a variety of SA’s. Perhaps this piece needs to be outlined a little more

    Is there anything missing? While I am happy to see this change come to light because it is greatly needed, I think some assistance, tools, or information should be available to MW’s to ensure that (a) the SAs they are working with are covered by insurance; and (b) that they have met competency requirements.

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

    These changes are positive and I agree. As a small rural practice we rely on our second attendants who are not registered health care providers. We have attempted to hire RNs, who would qualify to receive a NRP certificate, but there are no RNs with availability to be on call at the current rate of pay, and with the nursing shortage there is no pool of applicants. We have managed with non-registered health care providers as our second attendants for years now. They are able to take the NRP exam and course, but unable to receive a certificate due to a restriction of the CPS not giving out certificates to non-registered health care providers. They have the same training and competency, but simply lack a piece of paper. As a practice group we also have other methods of ensuring competency such as regular skills drills, a skills checklist and feedback from practice. SAs take ESW and CPR and are not any less skilled than a regulated health care provider. This change in standard allows us to continue with our skilled SAs without the additional burden of applying for a waiver on an annual basis, which wastes the practice group’s and CMO’s time with unnecessary administrative tasks. This is a change that enhances the safe access to home births in our rural setting.

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

    The second birth attendant I see must be proficient in OBs emerg skills and CPR, but not NRP this is a little concerning as in the event of a neonatal resus in the community this is where I would most want expertise in.

    • Are you a: Midwife
    • Organization: Maternity Care Midwives-Thunder Bay
    • On behalf of: Yourself
  4. Midwife

    I agree with this change, since it has become more difficult to get NRP certified if you do not belong to a health care profession. I would suggest the same wording for Emergency Skills and certainly not be required intubation training. During the 18 years that I practised solely with Second Attendants, it was enough of a challenge to find anyone willing to work and be on call for such a small amount of money, let alone have ESW certification.

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

    I appreciate the second birth attendant standard being looked at. Our practice has used one since the very beginning and we couldn’t imagine life without her (she attended 108 of our births last year). That being said, she is an RPN and our other one is an RN so they are both able to continue certifying in NRP. NRP is the biggest responsibility the second has and our rural/remote setting where backup services are far away our midwives are comfortable with our second attendants because they know their NRP is as competent as the midwives. I understand the desire to change this to competency base, but without certifying it will be harder for a practice starting off with a second attendant to ensure that they do have the skills required to have that competency without formal tracking. Our nurses acting as second attendants also have been crucial in PPH by being competent in IV insertion and medication administration, and I am not sure you would get the competence in those skills if you also weren’t required to be one of the regulated professions that can certify in NRP. It would be nice if midwifery students who have those skills could be second attendants before they graduate, so I would support that as an option if not regulated health care provider. I just wouldn’t want a practice to hire a second attendant on who then proves to be not competent and a poor outcome occurs, and then investigation into the use of seconds in general. We have had unplanned emergencies at home and it is the exceptional skills of our second attendants that have supported good outcomes. Straight forward normal births anyone could do, but you never know what you are walking into and second attendants need to be highly skilled. My best solution in supporting more skilled second attendants that are so crucial for rural midwifery and work-life balance of midwives, is to push for NRP to certify participants the same way CPR does regardless of health care status. If unregulated second attendants are going to practice and do NRP training, they should be able to be certified for the skills they obtain and I think this is part of the root cause for this change.

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

    I am a partner in a practice that has relied heavily on second attendants. When the Second Birth Attendant Standard was initially changed, we had to apply for a waiver to have our long-standing second attendant get approved. We are happy to see this obstacle removed. In our practice we have always insisted that our second attendants participate in NRP and ESW training, and we do not intend to change this. However we are also glad that the College is taking our input into consideration to emphasize the importance of midwives making their own assessment of readiness and competence for second birth attendants.

    • Are you a: Midwife
    • Organization: K'Tigaaning Midwives
    • On behalf of: Yourself
  7. Midwife

    I am part of a practice that has relied heavily on second attendants. When the CMO initially changed the requirements, we had to apply for a waiver to have our long-standing second attendants get approved. We are delighted to see this obstacle removed. We have always insisted that our second attendants participate in NRP and ESW training, and we do not intend to change this, but we are glad that the College trusts us to make our own assessment of readiness and competence for our birth attendants.

    • Are you a: Midwife
    • Organization: K'Tigaaning Midwives
    • On behalf of: Yourself
  8. Midwife

    No suggested edits. Good work

    • Are you a: Midwife
    • Organization: Sages-Femmes Rouge Valley Midwives
    • On behalf of: Yourself
  9. Midwife

    I support the changes to allow Second Attendants, who are not regulated health professionals, to act as Second Attendants in out of hospital and homebirth situations.
    As previously mentioned in the comments, the word “competent” should probably be changed as even completion of the NRP course does not determine “competence”. In my informed choice discussions regarding use of second attendants at home births I use “trained”.
    Back in 2000, I addressed the issue of the prerequisites for the NRP course with the College of Midwives of Ontario and the Heart and Stroke Foundation of Ontario. I was able to receive an exemption to allow my Second Attendant to participate in NRP training, including the on line exam and the hands on component.
    I feel comfortable working with my Second Attendant, and the NRP training, reviews and practise that we do on an ongoing basis. However, I think it would be beneficial for the College of Midwives to approach the Canadian Pediatric Society to enable Second Attendants, who are uanble to meet the prerequisite of being a Regulated Health Professional, to be allowed to complete this course.

    • Are you a: Midwife
    • Organization: MIDWIVES*SAGES-FEMMES of NORTH BAY
    • On behalf of: Organization
  10. Member of the public

    Agree with second attendant in urban and remote areas.

    • Are you a: Member of the public
    • Organization: WEST END MIDWIVES
    • On behalf of: Yourself
  11. Midwife

    the proposed requirements are clear and will help women in rural and remote areas to have access to homebirth with a midwife.
    may be the public will continue to be protected but I wonder what will be the mecanisms of CMO to evaluate and verify the second birth attendant, not a member of the College? any validation of “competencies’? is the midwife responsible accountable for the actions of the second attendant? any insurances required? I am thinking about a difficult event, a complaint or even a trial…. I wonder about the reputation of the CMO…
    who is accepting the second attendant? the individual midwife? the CMO? having to be accepted? any experience?

    you have to help midwifery practice in different places, helping the population to have access to services and also to quality….balancing rigor and confidence

    • Are you a: Midwife
    • Organization: Université du Québec à Trois-Rivières
    • On behalf of: Yourself
  12. Midwife

    If safety to the public is a real concern then even midwives on a leave from Active Practice should be eligible to offer themselves as Second Attendants. I was once in a small community, Inactive for a couple years, (I returned to Active Practice). While on leave, a neighbouring Community, desperate for a Second Attendant, approached me to be a Second Attendant and the CMO would not allow it. I suspect if you asked birthing families who they would feel more confident in at their births they might chose an Inactive Registered Midwife with lots of experience over someone else with less expertise. Personally, if someone were attending my birth with the responsibility to assist in the potential resuscitation of my newborn I would want them to annually have to do the NRP course. I could see that in a rural area doing the in-person part of the training may be challenging and so perhaps only the written portion as well as the VIRTUAL SIMULATION could be required.

    • Are you a: Midwife
    • Organization: Registered Midwife
    • On behalf of: Yourself
  13. Midwife

    Changes is good but there should be training for second attendants in order to provide care as expected.

    • Are you a: Midwife
    • On behalf of: Yourself
  14. Member of the public

    I agree

    • Are you a: Member of the public
    • Organization: Home
    • On behalf of: Organization
  15. Midwife

    Standards are clear and should allow second birth attendants to be able to support midwives in remote communities where number of midwives is low.

    • Are you a: Midwife
    • Organization: Midwifery Care NDRV
    • On behalf of: Yourself
  16. Midwife

    I fully support these changes and am happy to see their development.

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

    I agree

    • Are you a: Midwife
    • Organization: CMOH
    • On behalf of: Yourself
  18. Midwife

    I strongly support these changes. This will support access to home birth in rural and remote communities, and support safety, work/life balance for midwives in smaller practice groups. Staffing during waves of the pandemic has been extremely challenging – and strides to help ensure second attendants are able to work is a huge benefit in these times.
    This change is essential to midwifery care in rural and remote Ontario and will increase client safety.

    • Are you a: Midwife
    • Organization: Countryside Midwifery Services
    • On behalf of: Yourself
  19. Midwife

    Are the proposed requirements clear? The wording is.

    Are risks of harm to the public addressed? Not clearly.

    Is the standard achievable for all midwives? No, see below

    Is there anything missing? Yes
    – what does unregulated professional mean? Who does it include? Who is exempt?
    – second attendant requirements: how do THEY prove to the midwife they are qualified, in order for the midwife to confirm/satisfy the midwife’s responsibility?
    What is their responsibility?

    My opinion is that if the midwife is accepting liability for a unregulated professional/second attendant, the onus should be on the SA to provide proof to the midwife so that person can follow up and reference if needed.

    • Are you a: Midwife
    • Organization: N/A
    • On behalf of: Yourself
  20. Member of the public

    Good development,

    • Are you a: Member of the public
    • On behalf of: Organization
  21. Midwife

    Yes! I know women eager and competent to be second attendants but not regulated by a college. This would be a wonderful option. How would this work with insurance or coverage though?

    • Are you a: Midwife
    • Organization: Member of AAM and with Wild Sage Midwives practice
    • On behalf of: Yourself
  22. Midwife

    Agree with proposed changes.

    One area is not clear in the way it is worded. The document is explicit about midwives being responsible for care provided by unregulated providers. There is less clarity about regulated providers which just seems like an odd oversight? If a regulated provider is doing something that is in scope for them, I’m assuming they would be accountable for their own care. But if a regulated provider is doing something that has been delegated by the midwife, wouldn’t the midwife be accountable for that action as with any delegation? I don’t work with Second Attendants but the fact that this isn’t clear to me, suggests the document could be clearer in it’s wording/phrasing.

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

    The real issue here is that practices are not provided with adequate funding to hire appropriately trained second attendants. People living in rural and remote communities should have the same access to care as people living in urban locations. There should be two well-trained care providers at every birth, regardless of location. It is not realistic to expect that practices will find well-trained and experienced second attendants who are going to be willing to be on-call, pay for childcare and a vehicle, undergo regular training, and be responsible for assisting in emergencies and resuscitating babies, unless they pay them well. Are physicians in hospitals expected to attend births with inadequately trained staff? Why are rural and remote midwives, who are already working in more challenging conditions, with longer transfer times to hospital, and often poorer working conditions themselves (inadequate offcall/vacation time for example), expected to put so much time and effort into finding and training second attendants? Why isn’t there an education program designed to train second attendants? Yes it will help practices, especially small practices, if the CMO removes the condition that second attendants need to have a certificate showing that they completed an NRP course, but the issue here is a lack of political will to provide funding and resources to practices who need these second attendants.

    • Are you a: Midwife
    • On behalf of: Yourself
  24. Member of the public

    Second Attendants are an extremely important part of Midwifery care, especially in rural areas. Being a “registered health provider” does not mean that they are a better fit for the job. I personally have been a Second Attendant for close to 9 years. I have taken my ESW, NRP and CPR faithfully the entire time. I am PSW with additional medical science courses. I have taken lactation consultant courses and currently an a Certified HypnoBirthing Therapist. I also with an extensive background in healthcare working for many Physicians. I have attended over 100 births. Experience and knowledge need to count for something!!

    • Are you a: Member of the public
    • On behalf of: Yourself
  25. Midwife

    The Canadian Paediatric Society Neonatal resuscitation program/course does not ‘certify in NRP’ as stated above. The blended program delivery offers assessment of knowledge via the online exam, in addition to the opportunity to practice, demonstrate, and consolidate hands-on skills in a simulated resuscitation environment.

    It is problematic that participation in the in-person part of the course is currently limited, I would suggest, however, that evidence of successful completion of the cognitive assessment (online exam), continues to be required, even if attendance at a course is not. Users are allowed multiple attempts to complete the online exam. Requiring completion of the exam would provide objective evidence to satisfy the portion of the standard which includes ‘Midwives working with second attendants must: …ensure the second birth attendants are competent to assist in the provision of care to clients during neonatal resuscitation’. In addition, just as midwives are required to maintain a record of the dates that the hands-on portion of the NRP course is completed, it would seem prudent to continue to require evidence of Midwife-second attendant simulations/practice dates as proof of skill maintenance.

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

    We fully support these changes/revisions. Working in a small rural Northern Ontario practice, we have used 2nd birth attendants often. We have nurses and other skilled attendants who we ensure work to the highest and up to date practices. These revisions will allow greater access to home births for clients in our area since we have struggled since the beginning of the pandemic to maintain the nurses as second attendants given the shortage of nurses in our local hospital. The Association on Ontario Midwives has a component of NRP in their Emergency Skills Workshop as well which assists us in ensuring our Second Birth Attendants maintain up to date competencies.

    • Are you a: Midwife
    • Organization: Sages-femmes Temiskaming Midwives
    • On behalf of: Organization
  27. Midwife

    I work with a number of highly skilled second birth attendants, some of whom are members of a regulated health profession and some who are not. We perform our NRP and Emergency skills training as a group, together with the nurses and physicians at our privileging hospital. Being a member of a regulated health profession does not make a person more proficient at NRP. Practice, training, and experience are the keys to proficiency.

    Second birth attendants are vital to our ability to offer home birth. As a solo midwife in an area with significant health human resource shortages, particularly physicians and nurses, it would not be possible to maintain adequate second birth attendant call coverage to reliably offer home birth with NRP certification as a requirement. Ensuring competence adequately addresses safety while also ensuring midwives can maintain the midwifery tenet of choice of birthplace despite health human resource shortages often exacerbated by geography.

    • Are you a: Midwife
    • Organization: North Channel Midwifery
    • On behalf of: Organization
  28. Midwife

    I support these changes and believe that they will improve the ability of midwives to provide safe care in rural communities. I am very happy to see the College make these changes.

    I would like to see an addition stating that, in a hospital, nurses can act as second attendants. While this happens informally in many communities, it can sometimes be hard to “convince” nurses to do this (many nurses believe they cannot take orders from midwives, which is not true). I would like to see this formalized within this standard.

    I also feel that a New Registrant should be allowed to attend a birth with a second attendant provided it takes place in a hospital. Some second attendants have hospital privileges, and as mentioned above some communities use nurses in lieu of a second midwife at hospital births. My community has had several instances of having to transfer care to physicians because NRs couldn’t attend a birth without another midwife present. Unnecessary transfers create confusion and can decrease safety.

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

    I think that second attendants should be certified and competent in NRP.

    • Are you a: Midwife
    • Organization: The Midwives' Clinic of EYDM
    • On behalf of: Organization
  30. Midwife

    I can’t say enough how much I support the changes to this guideline. I am a midwife who works in a rural setting and uses second attendants who are not midwives or nurses. We tried to hire nurses…advertised and tried recruiting at our local hospital. None were available. Then our local hospital closed due to a nursing shortage. Our already high home birth rate has increased even further now that clients to travel a far distance to access hospital care with a midwife. If we weren’t able to continue to use our current second attendants, I’m not confident that our practice would be able to continue providing safe, accessible care to our clients. Our second attendants are very competent and undergo regular training (even out side of ES, NRP and CPR) and provide our clinic and our clients with an invaluable service.

    • Are you a: Midwife
    • On behalf of: Organization
  31. Midwife

    This change is very good. It contributes to the much needed Human Resources, especially in rural and remote areas. Second attendants are key to small rural and remote practices being able to offer choice and autonomy that we should strive to make available to all birthing individuals. In fact, it is much safer to have second attendants available to assist, when needed, for small practices then not.

    • Are you a: Midwife
    • Organization: Midwives of East Erie
    • On behalf of: Yourself
  32. Midwife

    I support these changes

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

    I just need to point out that the use of “certified” is avoided and discouraged by the NRP program for all participants. As an NRP instructor we remind everyone that takes the training that they are not certified. One demonstrates competency by completing the course only and are not “certified”. I think “demonstrating competency” should probably be defined further for second attendants. I absolutely agree that this is a restrictive barrier that must be rectified for midwives so that there is more access to second attendant support. Please refer to the NRP manual for further clarification.

    • Are you a: Midwife
    • Organization: Midwifery Services of Haliburton-Bancroft
    • On behalf of: Yourself
  34. Midwife

    This is a GrEAT change! Thanks.

    • Are you a: Midwife
    • Organization: CMOH
    • On behalf of: Yourself
  35. Member of the public

    I support the changes.

    • Are you a: Member of the public
    • On behalf of: Yourself

Comments are closed.