Maintaining Primary Care for Clients who Access Induction, Augmentation and Epidural

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The Association of Ontario Midwives supports midwives in maintaining primary care for clients who access induction, augmentation or epidural. As primary care providers who are key to the provision of maternity care in this province, midwives should be enabled to work to the scope of practice outlined in the Midwifery Act and by the College of Midwives of Ontario (CMO).[1] This includes retaining primary care for the administration of oxytocin for induction and augmentation, the monitoring and maintaining of epidural analgesia, and the administration of cervical ripening methods, including prostaglandin gel and Foley catheters. Enabling midwives to maintain care in these situations simply means enabling midwives to practice within the current regulatory framework.  

Midwives are primary care providers. As such, the Association does not see it as appropriate to shift primary care to another caregiver when the ability to provide that care lies wholly within the scope of midwifery.  Enabling midwives to maintain primary care in instances that are clinically indicated provides the following benefits:   

• Keeps birth normal. Midwives who manage interventions help keep birth as normal as possible. By remaining the primary care provider of a client who has an epidural, induction or augmentation, a midwife may reduce what has been referred to as a “cascade of interventions” from taking place.[2]
  
  
• Enhances continuity of care. Maintaining primary care means maximizing continuity of care. Research shows that continuity of care provider can enhance client safety and quality of care.[3],[4],[5],[6] Thus midwives can contribute to enhanced quality of care if they are able to maintain primary care in those clinical situations that they are trained to manage. Continuity of care is one of the main reasons why pregnant women choose midwives as their care providers.
  
  
• Minimizes medically unnecessary transfers of care. Although the management or administration of epidurals, augmentations and inductions are well within midwives scope of regulated practice, many hospitals in Ontario continue to require a transfer of care for these procedures. Yet there is no clinical evidence suggesting that a transfer of care is needed in these instances. Medically unnecessary transfers of care negatively affect clients, interprofessional relationships and hospital budgets.                                                                                    
  
  
• Ensures client safety. When care is transferred without a medically necessary reason, the likelihood of harm increases. Studies have shown that information accompanying clients is frequently lost when their care is transferred from one health care provider to another, sometimes leading to communication breakdowns.[7] Different providers may also perceive risk tolerance differently leading to an increase possibility of unnecessary tests and interventions, resulting in a higher chance of adverse health outcomes.[8]    
  
  
• Maximizes efficient use of health care resources. When midwives maintain primary care for their clients where clinically indicated, unnecessary transfers of care are avoided, and costs are contained. Unnecessarily involving and compensating two providers is prevented, benefiting the system as a whole and thus enhancing the cost benefit analysis for midwifery care within the Ontario health care system. Research from Ontario midwives reveals that maintaining care when clinically indicated may also lower the costly c-section rate.    
  
  
• Fosters interprofessional relationships and respect. Midwives who maintain primary care for clients accessing induction, augmentation and epidural have more opportunities to foster healthy interprofessional relationships. Trust is fostered among providers and communication and collaboration is enhanced. Improving health providers’ familiarity, understanding and comfort with colleagues’ respective scopes of practice contributes to quality assurance and the reduction of risk.    
  
  
• Assists compliance with the Excellent Care For All Act (ECFAA). Maintaining primary care helps fulfill the mandate of ECFAA, which requires that hospitals establish quality committees entrusted to monitor and report on quality issues. Enabling midwives to optimize scope enhances the quality of maternity care in a hospital.[9] For hospitals that may need to develop annual performance improvement targets around their high c-section rates, allowing midwives to maintain primary care will help to meet those targets.     

Conclusion 

The Association of Ontario Midwives encourages and supports midwives in maintaining primary care for clients accessing induction, augmentation and epidural. Transfers of care should only occur when medically necessary and in accordance with the CMO’s Indications for Mandatory Discussion, Consultation and Transfer of Care document.[10] Ending any unnecessary transfers of care from midwives to physicians would benefit women, care providers and the health care system. To this end, the Association supports members in their efforts to maintain primary care where clinically indicated in Ontario’s hospitals. 


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[1] College of Midwives of Ontario. Regulation Made Under the Midwifery Act, 1991. Available from: URL:www.cmo.on.ca/downloads/F3-Designated_Drugs_Sep04.pdf
[2] Hatem M, Sandall J, Devane D, Soltani H, Gates S. Midwife-led versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2008;4:CD004667.
[3] Public Health Agency of Canada. Family Centred Maternity Care Guidelines. 2000. Available from: URL:http://www.phac-aspc.gc.ca/dca-dea/publications/fcmc00-eng.php
[4] Homer CS, Davis GK, Cooke M, Barclay LM. Women's experiences of continuity of midwifery care in a randomised controlled trial in Australia. Midwifery 2002 Jun;18(2):102-112.
[5] Benjamin Y, Walsh D, Taub N. A comparison of partnership caseload midwifery care with conventional team midwifery care: labour and birth outcomes. Midwifery 2001 Sep;17(3):234-240.
[6] Hodnett ED. Continuity of caregivers during pregnancy and childbirth. [Online]. Available from: Cochrane Database of Systematic Reviews 2000; 2: CD000062.
[7] Greenberg CC, Studdert DM, Lipsitz ST, Rogers SO, Zinner MJ, Gawande AA. Patterns of communication breakdowns resulting in injury to surgical patients. J Am Coll Surg 2007;1(10):533-40; Patterson ES, Roth EM, Woods DD, et al. Handoff strategies in settings with high consequences for failure: lessons for health care operations. Int J Qual Health Care 2004;16:125-132.
[8] Glauser J. Handoffs, Sign-outs, and disasters. Emergency Medical News 2007; Feb 29(2): 10,12; Meisel ZF, Pollack C. Patient safety in emergency care transitions. (Case study). Emerg Med Specialty Reports 2006;S06178:1.
[9] Sharpe, M, van Wagner, Vicki. “Perinatal Outcomes, Four Practices: 2003-2007.” Unpublished presentation, August 26, 2010. Hatem M, Sandall J, Devane D, Soltani H, Gates S. Midwife-led versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2008;4:CD004667.
[10] College of Midwives of Ontario. Indications for Mandatory Discussion, Consultation and Transfer of  Care. Available from: URL: http://www.cmo.on.ca/downloads/communications/standards/G04Indications%20for%20Mandatory%20Discussion%20Consultation%20and%20Transfer%20Jun00.pdf