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Alternate Practice Arrangements

July 18, 2018

Note: This article was originally posted in our  July 2018 newsletter, and has not been updated.

The College’s Alternate Practice Arrangement (APA) program is no longer in place. See below for information on what has replaced our APA Type 1 and Type 2 programs.

APA Type 1

In 2014, the College created the Alternate Practice Arrangement (APA) Type 1 program (Modified Primary Care) to support interprofessional care models and to respond to requests from midwives for flexibility in the delivery of midwifery care. The APA Type 1 program gave midwives alternate ways to practice, subject to approval from the Registrar, in the public interest.

In June 2018, the need for the majority of the current APAs was eliminated when the new Professional Standards for Midwives (Professional Standards) came into effect. The Professional Standards are principles-based, not prescriptive like the standards of practice they replaced, so midwives are not restricted by rules about the numbers and types of care providers they can practice with. The Professional Standards also addresses midwives’ ability to both accept and receive delegation reinforcing the fact that midwives are not required to enter into an APA to work under delegation.

Delegation of controlled acts is authorized under the Regulated Health Professions Act, 1991 (RHPA) and can be made by a health care provider to another health care provider or to an unregulated person.  For example, a physician can delegate a controlled act of placing an instrument, hand, or finger into an artificial opening into the body to a midwife who does not have this controlled act and is allowed to accept a delegation from the physician if they have the knowledge, skills, and judgment to perform the procedure competently and safely. The College’s expectations for midwives who accept delegations are set out in the Professional Standards (see standard #31) and the Delegation, Orders and Directives standard.

Continuity of Care and Interprofessional Collaboration

With the implementation of the Professional Standards, the College’s expectations around continuity of care and collaborative care have changed. Previously, midwives were required to work in “a small group of no more than four midwives” so required an APA to be able to work with physicians in their communities. Standards #17 and #25 of the Professional Standards set the College’s new expectations for continuity of care and interprofessional collaboration. All midwives are able to work interprofessionally with other health care providers without the College’s approval as long as they are able to meet these standards.

Practice Environment and Choice of Birthplace

All midwives working in midwifery practice groups must provide choice of birthplace at all times (standard #18). However, midwives providing care in physician-led practice environments where home birth is not provided (e.g. work only in a hospital or provide prenatal or postpartum care to physician clients) do not fall below standard #18 when they do not offer choice of birthplace. The standard is interpreted this way because hospital birth is implicit in these practice environments, and so clients are considered to have already made a birthplace choice. Take an example of a midwife who joins a collaborative care team of physicians. In this role, the midwife provides care to clients during the prenatal, intrapartum, and postpartum period. All clients of the physcian group give birth at the local hospital. The midwife does not fall below standard #18 because of the practice environment. If the midwife changes practice environments and joins a midwifery practice group, they are expected to meet standard #18.

Active Practice Requirements and Quality Assurance Program Reporting

The elimination of the APA program also means that exemptions from the active practice requirements and the quality assurance program requirements will no longer be addressed in individual APA agreements and will be dealt with through the College’s registration and quality assurance committees.

The current Active Practice Reporting Policy outlines a consistent process when members have a shortfall in active practice numbers. If you have a shortfall, the College will request a response from you explaining the reasons for the shortfall. A panel of the Registration Committee may convene to determine an appropriate shortfall plan, if needed.

Similarly, in accordance with the College’s General Regulation, members can be granted exemptions from any or all of the requirements of the Quality Assurance Program (QAP) because of illness or any other circumstance the Quality Assurance Committee (QAC) considers appropriate. If you are requesting an exemption from some or all of the QAP requirements, you must provide the QAC with a completed exemption request form to be reviewed by a QAC panel. For more information on QAP exemptions please click here.

Application for a Waiver of Standards

Under the newly approved Waiver Policy College standards can be waived if midwives can demonstrate that there are exceptional circumstances related to their practice that warrant a departure from the current standards of practice. “Exceptional circumstances” is defined as conditions beyond one’s control that justify waiving College standards. A midwife applying for a waiver will need to show that the circumstances of the application are both in the public interest and are sufficiently exceptional to justify a departure from the relevant standards. It is for the applicant to demonstrate that exceptional circumstances exist. For more information, please click here.

Ask a Question

Please feel free to contact the College to find out more about the College’s new approach and how it will affect your practice:

If you currently have an APA or if your question is about the standards of practice and the new waiver policy, please contact the Professional Practice Advisor by phone: 416.640.2252 ext. 230 or by email:

If you anticipate a shortfall in active practice numbers, please contact our Registration Department by phone 416.640.2252 ext. 208 or by email:

If you need an exemption from all or some of the Quality Assurance Program requirements, please contact our Quality Assurance Department by phone 416.640.2252 ext. 227 or by email:

APA Type 2

The new Professional Standards require midwives to “ensure that every birth you attend as the most responsible provider is also attended by a second midwife or another individual competent to perform the role of second attendant.” With this new standard, we have eliminated the need for midwives to work in APA 2s, as of June 1st, 2018.

You can click here to read more about how the  new Professional Standards affect midwives working with a second birth attendant, and find out about the College’s revised Second Birth Attendant Standard, which will come into effect on October 1st, 2018.

As mentioned on page 4 of this newsletter, there has been some feedback from members on the Second Birth Attendant Standard. Click here to read more.

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