AOM Response to OMCEP Report

The Association of Ontario Midwives commends the Ontario Women’s Health Council for establishing the Ontario Maternity Care Expert Panel. Maternity Care in Ontario 2006: Emerging Crisis, Emerging Solutions is a timely and thorough report. OMCEP provides the province with a clear vision for improving the health of mothers and families across Ontario. The report provides clear guidance for the immediate action required to address this emerging crisis, and provides important recommendations for the efforts that will be required to ensure that women in Ontario will be able to access quality maternity care in a way that makes wise use of resources.

Adding to the timeliness of OMCEP’s call for action is the convergence of three other major initiatives examining the emerging maternity care crisis. The Multidisciplinary Collaborative Primary Care Project, the Integrated Maternity Care for Rural and Remote Communities, and Babies Can’t Wait: Primary Care Obstetrics in Crisis together identify serious challenges in maternity care, and provide an emerging consensus on the kinds of actions that are necessary. It is clear that OMCEP has strongly benefited from these related initiatives, and as a result has been able to provide a comprehensive set of recommendations that can be the basis for immediate action.

In our review of the OMCEP report, there were some areas where more detailed consideration is needed to achieve effective implementation. However, this should not delay the Ontario government in announcing their intention to move forward with developing clear plans for action. These plans should be built upon the excellent work of OMCEP. Making maternity care a priority area for funding is urgently needed to respond to this emerging crisis for women in Ontario.

Alignment with the Transformation Agenda

The direction OMCEP recommends is fully in keeping with the important efforts of the Ontario government to transform health care in Ontario.[i] These efforts include promoting primary health care and ensuring the ability of Ontarians to get the care they need, when they need it, by the appropriate health care professional, and as close to home as possible.

The provincial government’s Transformation Agenda has made important progress in promoting primary care in the health care system, but has not extended this approach to maternity care. For example, there is no current provincial strategy for ensuring that women are able to receive comprehensive prenatal and post-partum care.

While the Ontario government has been heavily engaged in their Transformation Agenda, the emerging crisis in maternity care that OMCEP has identified still has not yet been addressed in any substantive way.[ii] The AOM strongly believes that the Transformation Agenda will be strengthened by explicitly relating it to maternity care. There are immediate opportunities for the Ontario government to act, beginning with making a commitment that maternity care is a vital part of primary care and is to become one of Ontario’s priority areas for funding. The solutions presented in the OMCEP report provide an excellent opportunity for the Ontario government to reconsider their current approach to maternity care, and to bring it into alignment with the Transformation Agenda, particularly with regard to planning for maternity care human resources.

Midwives Ready to be Part of the Solution

OMCEP outlines an important role for midwives in responding to the emerging crisis in maternity care. Midwives are ready to work with the government and other stakeholders in developing effective solutions.

Ontario’s midwives will provide high-quality primary maternity care to approximately 10,700 women this year.[iii] In fact, midwives are already providing the kind of care that the Ontario government is seeking to achieve through their Transformation Agenda, with an accountable, cost-effective and client-centred approach that moves care from the hospital to the community and emphasizes health promotion.[iv]

Midwifery has a clear record of growth over a period when there has been an overall decline in the numbers of primary maternity care providers.[v] With the necessary support from the Ontario government, midwives have the capacity to continue to increase their role in providing critically needed maternity care to Ontario women.

Comprehensive Provincial Approach for Maternity Care

The AOM agrees with OMCEP that a comprehensive provincial approach that establishes strategic directions and priorities in maternity care strategy is needed if Ontario is to address the emerging crisis identified by OMCEP and others.[vi],[vii],[viii],[ix] The need for this strategy is underscored by OMCEP’s finding that maternity care is one of the leading reasons for hospital admissions.[x] A key part of this strategy must be to make maternity care a priority area for funding in order to ensure that there are the resources available to address this emerging crisis.

This provincial strategy must expand maternity care based on the needs and preferences of maternity care consumers, and must be developed through a process that brings all practitioners and consumers to the table.

OMCEP has noted the importance of more women having access to primary maternity care.[xi] A new provincial strategy is a timely opportunity to include maternity care in the province’s vision for transforming primary health care in Ontario. This strategy can provide critical support for transformation over the long term, including reducing reliance on emergency rooms, being more client centred, ensuring care is provided closer to home, and focussing more on health promotion for both the mother and her newborn baby.[xii]

OMCEP’s vision and principles for maternity care not only provide a strong foundation for a provincial strategy for primary maternity care, but also for LHINs to develop regional maternity care strategies, including the provision of low risk primary maternity care.

Woman-Centred Care

OMCEP is to be highly commended for the vision of a system that is driven by the needs of women including valuing birth as a normal and healthy event.[xiii] A woman-centred approach to maternity care places the mother and her baby at the centre of care. It plans and provides for the primary care that supports the preferences and needs of her and her family, and is based on the understanding of birth as a normal life event.[xiv] It involves women in making informed choices about their care, including how to manage the inherent risks in birth.

In designing a maternity care system, it is important to have a well-articulated vision for the underlying approach to birth that the system is trying to support. Without this vision, maternity care can become simply a series of health services that lack coordination, continuity and support for women, and may result in inappropriate use of scarce health care resources. Such a vision can also support a system that is responsive to diverse and vulnerable populations.

The AOM supports OMCEP’s approach that values all care providers and their contributions, while at the same time provides a basis for a continuing dialogue regarding both the factors that are contributing to current trends, and also the judicious and appropriate use of obstetrical interventions in Ontario. We are living in a world where technology has provided many benefits. With high and rising rates of interventions in Ontario, such as an induction rate that is twice the Canadian average,[xv],[xvi] it is essential that the use of interventions be guided by best evidence. That is why OMCEP’s guiding principle that birth is normal must remain as a cornerstone of the province’s approach to maternity care, and also provide guidance to LHINs in the development of regional strategies.

The development of a provincial maternity care strategy is an opportunity for the careful consideration of current evidence regarding obstetrical interventions. The goal should be to bring the rate of obstetrical interventions in line with the rest of Canada.[xvii] Support for the vision that birth is normal and providing women with evidence regarding the risks of interventions can affect the choices women make.

We appreciate that OMCEP recognizes the reality of home birth and the importance of choice of birthplace to women.[xviii] Home birth is an option that has proven to be safe and valued.[xix] For those women who choose home birth, skilled attendance must continue to be offered. Midwives recognize that choice of birthplace creates challenges, but has also become a valued choice for many women. As we explore collaboration, we are open to a continuing dialogue about how best to support choice of birthplace.

Addressing the Shortage of Maternity Care Providers

Almost all experts now agree that there is a serious shortage of maternity care providers in Ontario, and that this shortage is expected to worsen as a large proportion of physicians currently providing maternity care will retire in the next five years.[xx],[xxi],[xxii] Rural and remote areas are particularly affected by the practitioner shortage.[xxiii]

The AOM appreciates the efforts of OMCEP to establish a fuller understanding of the scope and urgency of this emerging crisis, and to provide clear guidance for woman-centred solutions that ensures that there is the right mix and distribution of providers. We acknowledge the most important conclusion that for the foreseeable future Ontario will require more maternity care providers of all types.[xxiv]

The province has begun laudable efforts to accelerate initiatives to ensure an adequate supply and appropriate mix of care providers for the health system as a whole. The province must extend its efforts by creating a special focus on maternity care, including making maternity care a priority area for funding. Enrolments have increased in medical, nursing and nurse practitioner programs, all of who provide essential primary care.[xxv]

However, it is important to note that none of these increases guarantees an increase in maternity care providers. Midwives are the only primary care providers with a single focus on maternity care. Therefore, it is of concern that the province to date has not moved forward on a 2004 proposal to expand the enrolment in midwifery education in Ontario. The AOM fully endorses OMCEP’s support for immediate expansion of the Midwifery Education Program[xxvi] as this is an essential element of addressing the shortage of maternity care providers.

Given the lack of a Ministry response to the 2004 proposal, the AOM has particular concern regarding the memo from the Health Human Resources Policy Branch, found in Appendix K of the OMCEP report, which does not support plans to increase the number of midwives. OMCEP concludes that the ministry projections are incorrect. The AOM agrees with their conclusion. Data on which the assumptions in this memo are based are not an accurate reflection of the true provider compliments because it does not attribute the birth to the primary care provider where there has been a transfer of care. Also, the Ministry memo assumes that if there is an increase in maternity care practitioners, all would chose to provide intrapartum care. More importantly, we question the basis for the memo’s analysis that concludes that there is no current or projected shortage of providers. On the contrary, last year, for example, midwives could not accommodate 39% of the women seeking midwifery care.[xxvii] Many other organizations have also identified that there is an emerging crisis.[xxviii],[xxix],[xxx], [xxxi] It is important for the Ministry to bring its work on health human resources into alignment with the Transformation Agenda. There is great need to promote primary care, including maternity care. The Ministry would also benefit from consulting with consumers about their preferences for maternity care when making plans for future provider targets.

OMCEP’s recommendations provide a thoroughly considered assessment of the current challenges in health human resources, and a foundation for developing a strategy that is in alignment with the province’s Transformation Agenda. As outlined above, provincial planning for maternity care health human resources must be updated to incorporate OMCEP recommendations.

Access to Maternity Care

OMCEP’s report underscores concerns that midwives have about the increasing difficulty that Ontario women face in accessing the maternity care that they need.[xxxii] OMCEP has identified the key factors contributing to current barriers, and is to be commended for their clear vision that “every woman in Ontario will have access to high quality, woman and family centred maternity care as close to home as possible.”[xxxiii] This vision is a solid foundation for the development of a provincial maternity care strategy.

The AOM is very concerned about the evidence presented by OMCEP that many women are not able to access early prenatal care, and that this is resulting in preventable complications in late pregnancy and birth that are “almost unheard of in systems with adequate prenatal care.”[xxxiv] Provincial and regional maternity care strategies must place a priority on ensuring that women have access to comprehensive prenatal, intrapartum and postpartum care as close to home as possible. This is in keeping with the vision of the Ontario Minister of Health, who said, “Our entire plan for health care is built on the understanding – one I think we all share – that the best health care is that which is delivered closer to home.” [xxxv]

While ensuring access presents many challenges, OMCEP has identified the essential elements of the necessary provincial response to ensure it. As discussed above, the province must address the serious shortage of maternity care providers in Ontario in a way that supports the Transformation Agenda. This includes emphasizing community based primary care providers like family physicians and midwives. Obstetricians are also an important part of the maternity care team, and can act as primary care providers for woman at low risk, but their high level of skills and training means they play an essential role in focussing on high-risk care and being available to consult with other practitioners.

The difficulty of obtaining hospital privileges can effectively prevent maternity care providers from being able to serve women in some communities, even where there is a clear shortage.[xxxvi],[xxxvii] OMCEP’s recommendations are helpful in encouraging hospitals and their existing departments to adjust policies to be more inclusive of all providers. However, the report does not direct these recommendations sufficiently to match the urgency of this issue.

In keeping with OMCEP’s vision of a woman-centred approach to maternity care, it is important that women have access to the maternity care provider of their choice. For example, Ontario women are currently facing a significant lack of access to midwifery care. Women seeking midwifery care often face waiting lists. Furthermore, with the demand for midwifery continuing to increase, midwives still cannot provide care for four in ten women seeking their care, indicating a need for urgent action.[xxxviii]

The value of OMCEP’s comprehensive approach to maternity care is evident in the value placed in the report on maintaining birth close to home, and corresponding concern about the consolidation of maternity services in larger centres. Midwives have watched with dismay as the number of hospitals providing maternity care has dwindled to the detriment of women, primarily in rural areas, who are put at enormous risk when maternity services are only available at a distance. The result is that women are having more difficulty identifying the care they need, and are being required to travel longer and potentially unsafe distances, in order to obtain that care.[xxxix]

The Ontario government can have a positive impact on access to maternity care by immediately acting on OMCEP’s recommendation of a moratorium on maternity care closures. There is also a need for the Ontario government to work with LHINs to establish regional plans that align with the province’s Transformation Agenda. Regional plans should incorporate OMCEP’s efforts to put a priority on supporting low risk births as close to home as possible, and work with hospitals to ensure that needed maternity care providers are able to obtain hospital privileges. These outcomes are more likely to be achieved by the province making maternity care a priority area for funding.

Removing Barriers to Collaboration

The AOM can strongly support OMCEP’s clear and positive approach to collaboration. The report presents a well-articulated and comprehensive vision for a systemic and collaborative approach to maternity care in Ontario. OMCEP is to be commended for acknowledging the important role that inter-professional respect plays in care provision and job satisfaction, and also for accepting that there are many different models for how practitioners can provide high quality care to women. However, developing effective, equitable and mutually respectful approaches to collaboration may present more challenges than fully recognized in the OMCEP report. Ultimately, innovative collaborative models must be based on the needs of women and their families.

OMCEP’s call for the harmonization of regulatory, liability and funding mechanisms is critical to the success and facilitation of collaborative models. We believe that midwives would welcome the proposed liability changes and appreciate the recognition that regulatory change is absurdly onerous and long overdue. Revising the Public Hospitals Act would further facilitate inter-professional participation in hospital governance, and better support collaboration.

OMCEP correctly identifies current maternity care provider funding models as significant barriers to effective collaboration.[xl] In particular, the report provides an important analysis of the negative impact that current funding models can have on collaborative care, such as insufficiently compensating obstetricians for their critical contributions as consultants for other maternity care providers.[xli] It is the view of the AOM that the current funding model has also posed a significant barrier to the establishment of innovative pilot projects that explore various collaborative models.

The report identifies important opportunities for creating diversity in the current midwifery model of care. These opportunities are intended to facilitate collaboration that will make the most effective use of all practitioners, and allow more access to woman-centred care.[xlii],[xliii] Midwifery is open to change, but there is a significant need for care to ensure the benefits of midwifery are preserved, including access to the current model as an option for women.

The province must play a leadership role in fostering collaboration, including establishing a process for practitioners to work together to identify current barriers to collaboration and the required solutions, as well as workable options for new funding models. It is imperative that new, non-competitive funding models are developed that support the provision of secondary care by physicians. This process should be part of the development of a provincial maternity care strategy.

There are many positive aspects to the recommendation about advanced entry for registered nurses to midwifery education and at the same time there will be challenges in successfully implementing this recommendation. The midwifery profession has no wish to decrease the supply of maternity care nurses. We recognize that some registered nurses want to acquire midwifery skills and knowledge, just as some midwives want to acquire the broad scope of nursing practice. Reciprocal educational opportunities should be strongly considered. The best place for registered nurses to obtain the knowledge, skills and philosophic principles of midwifery care is with other midwifery learners. The Midwifery Education Program can enact curriculum revisions that would accommodate advanced entry of nurses but only with appropriate enhancement of teaching resources. 
 

What Ontario Needs to Do

The following are actions that the Government of Ontario could undertake immediately in response to the OMCEP report and other current initiatives intended to have an immediate impact in addressing the emerging crisis in maternity care in Ontario:

1. Announce a provincial commitment to make maternity care a priority area for funding and to develop a maternity care strategy based on the work of OMCEP;

2. Communicate to LHINs that regional plans must include maternity care, with a priority on sustaining care close to home;

3. Announce the expansion of the MEP and equitable funding for preceptors;

4. Work with stakeholders to develop funding models that will remove current barriers to collaboration;

5. Make a provincial commitment to work with hospitals to address restrictions on providers obtaining privileges;

6. Establish a moratorium on maternity care closures; and

7. Support a campaign to promote the benefits of primary maternity care including birth as a normal life event.

[i] Ministry of Health and Long-Term Care. Minister speaking notes. 2004 Feb. Available from: http://www.health.gov.on.ca/english/media/speeches/archives/sp_04/sp_022404.html

[ii] Ontario Maternity Care Expert Panel. Maternity care in Ontario 2006: emerging crisis, emerging solutions. 2006.

[iii] Ministry of Health and Long-Term Care, Ontario Midwifery Program projection. 2006.

[iv] Association of Ontario Midwives. Benefits of midwifery to health care system. 2005 Oct.

[v] Lofsky S, Adamson M. Changing trends in obstetrical physician resources in Ontario 1992-2003. Report to “Babies Can’t Wait”. 2005 Mar.

[vi] Lalonde AB. Access to maternity care. JOGC. 2005 May; 27(5): 445-446.

[vii] Pellizzari R, Medves J. Ontario’s maternity crisis: a time for action. Ontario Women’s Health Council. 2002.

[viii] Kasperski JM. Babies can’t wait: Primary care in obstetrics crisis. A solution focused PHCTF research project. 2004.

[ix] Ontario Maternity Care Expert Panel, op cit (p. 16-17).

[x] Ontario Maternity Care Expert Panel, op cit (p. 9).

[xi] Ontario Maternity Care Expert Panel, op cit (p. 48).

[xii] Association of Ontario Midwives, op cit (p. 2).

[xiii] Ontario Maternity Care Expert Panel, op cit (p. 44).

[xiv] Public Health Agency of Canada. The family-centred maternity and newborn care: national guidelines, 4th edition. Chapter 1: introduction and philosophy. 2000.

[xv] Ontario Midwifery Program, Ministry of Health and Long-Term Care. Ontario midwifery program evaluation. 2003.

[xvi] Ontario Maternity Care Expert Panel, op cit (p. 35).

[xvii] Canadian Institute for Health Information. Giving birth in Canada: providers of maternity and infant care. 2004.

[xviii] Ontario Maternity Care Expert Panel, op cit (p. 46).

[xix] Johnson K, Daviss B. Public Health Agency of Canada. Outcomes of planned home births with certified professional midwives: large prospective study in North America. BMJ. 2005 Jun; 330:1416.

[xx] The Society of Obstetricians and Gynaecologists of Canada. Shortage of ob/gyns, Aboriginal health top SOGC president’s agenda. SOGC annual clinical meeting. 2006 Jun.

[xxi] Lofsky S et al. Ontario Medical Association. The Ontario physician shortage 2005: seeds of progress, but resource crisis deepening. 2005. Available from: http://www.oma.org/pcomm/OMR/nov/05physicianshortage.htm

[xxii] Pellizzari R, Medves J, op cit (p. ii).

[xxiii] Rogers J. Sustainability and collaboration in maternity care in Canada: dreams and obstacles. Canadian Journal of Rural Medicine. 2003; 8(3):193-8.

[xxiv] Ontario Maternity Care Expert Panel, op cit (p. 77).

[xxv] Ministry of Health and Long-Term Care. Laying the foundation for change: a progress report on Ontario’s health human resources initiatives. 2005. Available from: http://www.health.gov.on.ca/english/public/pub/ministry_reports/hhr_05/hhr_05.html

[xxvi] Ontario Maternity Care Expert Panel, op cit (p. 154).

[xxvii] Ontario Maternity Care Expert Panel, op cit (p. 28).

[xxviii] Lalonde AB, op cit (p. 445-446).

[xxix] Pellizzari R, Medves J, op cit (p.3).

[xxx] Kasperski JM, op cit.

[xxxi] Ontario Maternity Care Expert Panel, op cit (p. 16-17).

[xxxii] Ontario Maternity Care Expert Panel, op cit (p. 35-38).

[xxxiii] Ontario Maternity Care Expert Panel, op cit (p. 10).

[xxxiv] Ontario Maternity Care Expert Panel, op cit (p. 17).

[xxxv] Ministry of Health and Long-Term Care. Minister speech. 2005 Oct. Available from: http://www.health.gov.on.ca/english/media/speeches/archives/sp_05/sp_100605.html

[xxxvi] Ontario Maternity Care Expert Panel, op cit (p. 30).

[xxxvii] Association of Ontario Midwives, Midwifery practice group – hospital integration survey. 2004 May.

[xxxviii] Ontario Maternity Care Expert Panel, op cit (p. 28).

[xxxix] Ontario Maternity Care Expert Panel, op cit (p. 17-19).

[xl] Ontario Maternity Care Expert Panel, op cit (p. 123).

[xli] Ontario Maternity Care Expert Panel, op cit (p. 83).

[xlii] Ontario Maternity Care Expert Panel, op cit (p. 104-106).

[xliii] Multidisciplinary Collaborative Primary Maternity Care Project. Guidelines and implementation tools for multidisciplinary collaborative primary maternity care models. Ottawa; 2006 Apr.