Eye Prophylaxis Position Statement
The Association of Ontario Midwives supports the provision of informed choice by midwives in all aspects of care, including the administration of neonatal eye prophylaxis. Parents should have the right to decline neonatal eye prophylaxis for their newborns.
Neonatal eye prophylaxis was introduced in the 1800s prior to the development of screening and treatment for gonorrhea and chlamydia. At the time, the practice of putting silver nitrate drops in the eyes of newborns greatly reduced the incidence of blindness as a complication of ophthalmia neonatorum caused by the transmission of gonorrhea and/or chlamydia to the baby at birth. Current practice in Ontario is for the mandatory administration of erythromycin ointment as a prophylactic agent into the eyes of all newborns to reduce the risk of blindness.
Midwives are committed to providing evidence-based care to their clients. With the advent of laboratory testing and antibiotics to treat chlamydia and gonorrhea, the risk of these infections being transmitted to child at the time of birth is very low. Over the course of prenatal care, midwives offer testing and arrange treatment for infectious diseases such as gonorrhea and chlamydia. Midwives also provide frequent follow-up care to newborns in the postpartum period until six weeks of age. The risk of complications leading to blindness should a newborn develop ophthalmia neonatorum are also very low when there is adequate postpartum follow-up and access to care. Contrary to current public health policy, research evidence does not support mandatory neonatal eye prophylaxis since the agents used for eye prophylaxis show high rates of ineffectiveness. For this reason, along with low rates of maternal chlamydial and gonorrheal infection, a number of countries around the world and provinces within Canada have abandoned mandatory eye prophylaxis.
Respect for autonomy is a fundamental principle in health care ethics. In Ontario, the Health Care Consent Act aims to foster informed consent and protects the decision-making authority of patients and their substitute decision-maker. In contrast to this broadly accepted approach to autonomous decision-making, the requirement for the mandatory administration of a prophylactic agent into the eyes of all newborns is enshrined in the Health Protection and Promotion Act. This act requires all health care professionals in Ontario attending a birth to ensure that eye prophylaxis is administered. This law thus requires midwives to administer eye prophylaxis to all newborns in their care.
The Health Protection and Promotion Act specifies that the Health Care Consent Act does not apply to the prevention or treatment of communicable diseases of the eyes of the newborn. This exemption means that parents do not have the right to consent to or refuse the administration of neonatal eye prophylaxis as they do all other procedures or treatments for their child, despite the limited evidence of the effectiveness of treatment. The Ontario model of midwifery practice is grounded in the provision of informed choice, which is inherent in the ethical principle of respect for autonomy. In all aspects of care, midwives aim to empower clients to make the best decisions for themselves and their families with regards to their care. The Health Care Consent Act supports the principle of autonomy by recognizing parents as the most appropriate substitute decision-makers for their child and entrusts parents to make significant decisions in their child’s best interests. State intervention in parental decision-making authority is only warranted in cases where it is clear that the parent’s choice places the child at significant risk of serious harm. Excluding neonatal eye prophylaxis from the provisions enshrined in the Health Care Consent Act is a disproportionate response and interferes with the exercise of parent’s autonomy vis-à-vis decision-making in the best interests of their child.
Lack of a clear and legal process for opting out of neonatal eye prophylaxis affects both midwifery clients and midwives when parents refuse eye prophylaxis for their baby. Some parents who have refused eye prophylaxis for their newborns have been subject to the scrutiny of public health and child protection agencies. This is not only traumatic for new parents, it is also an inappropriate and unwarranted use of resources. This situation also negatively impacts midwives’ interprofessional relations and creates unnecessary tension between midwives and the law and the College of Midwives of Ontario. Legislated neonatal eye prophylaxis may also impact the ability of hospitals to provide evidence-based care and patient-centred care and thus impede their compliance with the Excellent Care for All Act.
Based on the current clinical context and the ethical principle of respect for autonomy and recognizing that parents make decisions in the best interests of their children, the AOM does not believe that there is reasonable evidence for the administration of eye prophylaxis to be exempt from the Health Care Consent Act. Changes to the legislation are warranted to enable midwives to provide evidence-based care and informed choice in this matter, and to enable parents to exercise their autonomy by allowing them the right to decline eye prophylaxis for their newborn if they choose to do so. The AOM will continue to advocate for every person’s rights to reproductive health care everywhere, including access to legal and safe abortion care.
This statement was passed by the AOM board November 2012 and updated June 2017 for gender inclusive language and current statistics.