Maintaining Primary Care for Clients Accessing Induction, Augmentation & Epidural

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 Midwifery Act and by the College of Midwives of Ontario (CMO).

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 AOM 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.

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. 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 clients 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. 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.

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. 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.

The AOM 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. Ending any unnecessary transfers of care from midwives to physicians would benefit clients, care providers and the health care system. To this end, the AOM supports members in their efforts to maintain primary care where clinically indicated in Ontario’s hospitals.