CPGs vs Protocols

What are Clinical Practice Guidelines (CPGs)?

CPGs are “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.” (Palda, Davis & Goldman).

With the rise of evidence-based health care, the amount of research being generated far exceeds what an individual clinician can hope to review, appraise and apply to their daily practice. AOM CPGs examine research applicable to the midwifery management of a specified topic, including similar guidelines from allied professional organizations, and translate those varied sources into a coherent discussion and set of recommendations.

AOM CPGs are relevant to midwifery practice, contextualized within the midwifery model and philosophy of care, and designed to provide information for midwives engaged in complex clinical decision-making. While AOM CPGs provide recommendations related to care management, they are not prescriptive. The complexity of clinical care (with outcomes influenced by the interrelationships between the client, the setting, the attendant and local policies) may be challenging to capture and consider in a single document. In keeping with the midwifery model of care, AOM CPGs are not meant to trump or interrupt the informed choice process, but rather to support midwives and clients in informed decision-making.

Midwifery CPGs are meant to allow for clinician and/or client choice and discretion. AOM CPGs may differ from those of other organizations because they aim to ensure that, where possible, all reasonable options are presented and their evidence base considered. The expectation is that the midwife will use the content of the CPG to help clients contextualize and weigh risks and benefits in relation to their own preferences, values and particular clinical situation. Midwifery- specific CPGs do not seek to articulate one "right" way of approaching practice when multiple reasonable options exist. Even when research seems to point to one option being associated with the least risk, the midwifery model of care understands that different people will weigh risks and benefits differently and that midwives should facilitate access to all reasonable care options.

CPGs are systematically developed, providing transparency on how information is gathered (and included or discounted) and how recommendations are arrived at. A transparent development process is key in determining whether or not recommendations made in a CPG can be trusted by those for whom they are developed.

How do the AOM’s CPGs strengthen midwifery in Ontario?

  1. CPGs fulfill unmet needs.
    • They summarize research evidence relevant to the Ontario midwifery scope of practice and address clinical considerations such as providing care in an out-of-hospital setting.
    • They encourage care that supports normal birth whenever safe and possible and a minimal-intervention approach.
  2. CPGs improve the quality of health care.
    • They support both midwife and client decision-making based on high-quality clinical evidence.
    • They enable midwives to practice evidence-based care consistent with the midwifery model. They enhance inter-professional communication and understanding by clarifying the parameters of acceptable midwifery practice.
    • They have also been used to inform hospital policy and procedures, evidence reviews and resources developed by other organizations, and a textbook.
  3. CPGs encourage appropriate care.
    • They recognize a minimal intervention approach in support of normal birth and recommend appropriate interventions for specific clinical circumstances.
    • They articulate a professional standard of practice for midwifery and promote consistent practice.

What are Midwifery Practice Protocols?

Midwifery practice protocols “outline and guide midwifery practice groups’ shared approach to clinical practice, where applicable.” They should draw on the best available evidence and then propose a plan of action, taking into consideration client feedback, midwives’ preferences and shared approach to practice, local needs and limitations, providers and services. Practice protocols identify a clinical issue and describe the midwifery practice group’s approach to addressing the issue, within the context of informed choice. Practice protocols facilitate consistency among a particular group of midwives and help guide decision-making. Unlike institutional protocols that act within a hierarchy to “provide details of specific procedures to enable the implementation of particular policies,” midwifery practice protocols are intended to shape and define the clinical approach of a group of collaborative primary care providers sharing responsibility with one another.

What’s the Difference?

CPGs reflect broad statements of best practice with little operational detail, while protocols offer information that is adapted to local contexts and reflects the agreed-upon approach for a specific midwifery practice.

AOM CPGs Midwifery Practice Protocols Hospital Protocols
Reflect broad statements of best practice based on synthesis of best available evidence with an emphasis on support for normal birth and the midwifery model of care. Adapt evidence to respond to local contexts in accordance with the CMO guidelines; reflect agreed upon process for midwives (and students) working in a practice; may incorporate client feedback, local needs and/or limitations. Adapt evidence to meet institutional needs. Usually more directive/prescriptive.
Require interpretation and clinical judgment. Guide decision-making and management of care for a particular group of midwives. Direct care in a step-wise fashion; may allow for expanded non-MD provider scope.
Are non-prescriptive: uptake of recommendations depends on midwife and client choice. Carry an expectation that midwives will refer to them, and follow them as part of their clinical decision-making and documentation. Carry an expectation that they will be applied in all cases.
Serve as decision-making aids. Facilitate a consistent approach to care for a particular practice setting. Assists in management of institutional risk.