Midwifery in Nova Scotia Report

8/6/2019 Midwifery in Nova Scotia Report

1/23

MidwiferyinNovaScotiaReportoftheexternalassessmentteam

July12,2011


2/23

Honoura

MinisterDepartm

4thfloor,JosephH1690HollHalifax,NB3J2R8

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Acknowledgements

Weextendourthankstothemanyindividualswhogenerouslygaveoftheirtimetomeetwith

us. Thehospitality,friendlyreception,candiddiscussionandreadinesstosupportmidwifery

pervaded

all

our

meetings.

Staff

members

within

Primary

Health

Care,

Department

of

Health

andWellnessgenerouslyprovidedsupportandinformation. WeespeciallythankRebecca

AttenboroughandMarilynMuisefromtheReproductiveCareProgramforoutstandinglogistic

support. Ourtaskwasmadeeasierasaresultoftheeffortsofothers. Oursincerehopeisthat

actionsresultingfromourrecommendationswillstrengthenmidwiferyinNovaScotiaforthe

benefitofmothersandtheirinfants.


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TableofContents

Purposeoftheexternalassessment 4

Membersoftheexternalreviewteam

Conductoftheassessment 5

Findingsoftheassessment 5

MidwiferyinNovaScotia

Descriptionofmodelsites

IdentificationandanalysisofIssues 10

Sustainability

Clinicalleadership

Employmentmodel

Qualityassurance

Prioritypopulations

RecommendationstoDHW 13

Stabilizeandstrengthentheexistingmidwiferyservices

Announce

a

plan

for

growth

of

midwifery

services

in

Nova

Scotia

Formalizeaccountabilityformidwivestoserveprioritypopulations

Strengthenmaternitycareteamfunctioningandqualityimprovementprocesses

Recommendationsspecifictothethreemodelsites 19

Conclusion 20

Endnotes 21


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PurposeoftheexternalassessmentAnexternalassessmentwasrequestedbytheDepartmentofHealthandWellness(DHW)toprovide

adviceaboutNovaScotiasmidwiferyprogramingeneralaswellassitespecificrecommendations. In

doingsotheteamwastoprovideanindependentassessmentofthekeyrecommendationsdeveloped

bytheMIENSCommitteebasedonthemidwiferyimplementationevaluationsubmittedinDecember

2010. Theteamwasaskedtoexaminethestrengthsandchallengesateachofthemodelsitesand

provideadviceaboutrebuildingthemidwiferyserviceattheIWK,tomakerecommendationsabout

qualityimprovementandriskmanagement,andreachingprioritypopulations.

MembersofexternalreviewteamAfourpersonteamwithexpertiseinprimarymaternitycareincludingmidwiferywasinvitedtocarryout

theexternalassessment.

KarynKaufman,DrPH (TeamLeader)ProfessorEmerita,McMasterUniversity,HamiltonOntario

(Former)AssistantDean,FacultyofHealthSciencesandDirector,MidwiferyEducationProgram.

(Former)practicingmidwife,Hamilton,Ontario.

(Former)MidwiferyImplementationCoordinator,OntarioMinistryofHealthandLongTerm

Care.

KrisRobinson,RM,MScClinicalMidwiferySpecialist

WinnipegRegionalHealthAuthority

ChairpersonCanadianMidwiferyRegulatorsConsortium(CMRCNS)

ClinicalNurseSpecialist

St.BonifaceGeneralHospital

Winnipeg,Manitoba

KarenBuhlerMD,CCFP,FRCPHead,DepartmentofFamilyPractice,BCWomensHospital

ClinicalAssociateProfessor,DepartmentofFamilyPractice,UBC

(Former)Member,MidwiferyImplementationCommitteeofBC

(Former)Member,RegistrationCommitteeandAppealsCommittee,CollegeofMidwivesofBC

Extensiveleadershipinqualityimprovementprogramsandinitiatives,BCWomensHospital

Vancouver,BC

GailHazlit,RN, RDMSManager of Patient Care, Womens Hospital, Family Birthplace and Perinatal Assessment Unit,

Health Sciences Centre

Winnipeg, Manitoba

Founding Board member of Canadian Association of Perinatal and Womens Health Nurses


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ConductoftheassessmentTherecruitmentofteammemberswasfinalizedinApril2011. Materialsrelevanttotheimplementation

ofmidwiferyinNovaScotiawereprovidedtoallmembers. TheTeamLeadervisitedthethreemodel

sitesinApril(1820)togatherpreliminaryinformation,meetprincipalsateachsiteandplantheteam

visitwhichtookplaceMay1721,2011. ThescheduleofvisitsisincludedinAnnex1. Weheldteam

meetingstodiscussourobservationsandformulatetentativerecommendations. Follow upquestions

weremanagedbyemailandphoneasneeded. Draftsofthereportwerecirculatedtoteammembers

forcorrectionsandadditions. Teammembersendorsedallfinalrecommendations.

FindingsoftheassessmentThefollowingsectionprovidesanoverviewoftheestablishmentofmidwiferyinNovaScotiafollowedby

asummaryofmidwiferyineachmodelsite. Thesummaryfindingswereinformedbybackground

documentsandthenumerousinterviewsheldduringtheteamvisit.

MidwiferyinNovaScotiaMidwiferyregulationwasachievedin2009andwastheculminationofworkthatbeganinthelate

1990s. AchievingthismilestonewasverysignificantforNovaScotiamidwivesandsupportive

consumers. TheMidwiferyRegulatoryCouncilofNovaScotia(MRCNS)becameofficialwhenmidwifery

legislationwasproclaimed. TheCouncilhasamultidisciplinarymembershipwithamidwifechairperson.

Aparttimeregistrarisitsonlystaffperson.

Aonetimeassessmentofindividualsholdingmidwiferyqualificationstookplaceinearly2009justprior

toproclamation. Onthebasisoftheassessment,theCouncildeterminedeligibilityforregistration.

Someinitialregistrantshadprovisionallicensesthatnecessitatedsupervisionbyapersonapprovedby

theCouncil,usuallyamidwifeholdingalicensewithoutconditionsorrestrictions.

The

MRCNS

is

still

in

a

developmental

phase;

for

example

a

mandatory

peer

review

and

quality

assuranceprogramarenotyetinplace,noraretheresufficientregistrantstocarryoutthesefunctions.

HealthDistrictswereinvitedtosubmitproposalsforimplementingamidwiferyservice;threewere

receivedandthreewereaccepted. Aninitialbudgetaccommodated7fulltimemidwiferypositionswith

3allocatedtoIWKand2eachtoSouthShoreDistrictHealthAuthority(SSDHA)andGuysborough

AntigonishStraitHealthAuthority(GASHA). Nootherdistrictshavesubmittedorbeeninvitedtosubmit

aproposal. Nonewpositionshavebeenaddedsincetheinitialhiring.


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MidwivesareemployedbytheDistrictHealthAuthority(IWKinHalifax),receiveasalary,benefitsand

coverageofprofessionalliabilityinsurance. Theyreporttoaunit/programmanagerwho,atthetimeof

theexternalreview,wasanurseinallsites.

TheDHWestablishedastakeholdercommittee(MIENS)tomonitorimplementation. Partoftheirtask

wassecuringanassessmentofintegrationoneyearafterserviceswereestablished. TheDHWwas

concernedsufficientlybytheimplementationevaluationandthesuspensionoftheIWKserviceinlate

2010torequestthisexternalassessment.

Descriptionofmodelsites

IzaakWaltonKillam(IWK)HealthCentreNomidwiferyserviceshavebeenofferedsinceDecember2010. Initially4midwiveswerehiredtofill

the3FTEpositions. Threeofthe4midwiveshadexistingcaseloadswhenregulationcameintoeffect;

theirexperienceinNovaScotiawaslargelybasedinprovidinghomebirthinthepreregulationperiod.

OnemidwifehadpreviousexperienceinregulatedmidwiferyinCanada. Ofthefirsthires,onefulltime

personremainsbutisonleaveofabsenceforanuncertainperiod.

Weheardmanyperspectivesabouttheintegrationdifficulties. Someproblemsappearedattributableto

ashortleadintimetohavemidwiferyestablished,sometocreatingafitbetweenamodelofmidwifery

practiceandthelargematernitycareservicethatisknownforexcellenceinperinatalhighriskcare,and

otherstotheawkwardfitofahospitalemploymentmodelwhenmidwivesareautonomousprimary

maternitycareproviderswhoconductalargeportionoftheirworkoutsidethehospital.

Interprofessionalandinterpersonalconflictswerebothcauseandeffectforawidespreadlossoftrust

andconfidenceamongallparties. Wediscernedsadness,disappointmentandregretacrossallsectors

atthepresentcircumstancecoupledwithadesiretoreestablishmidwiferyatIWK.

Strengths:

CommitmenttorebuildamidwiferyteamtoprovidecaretowomeninHalifax;supportand

interestfrommanyindividualstoseemidwiferysucceed

StrongprograminprimarymaternitycarewithinFamilyMedicine

Interestfromobstetricsandadministrationinbringingamorefocusedapproachtolowrisk

(normal)birth

StronginterestfromwomeninHalifaxtohavemidwiferyreestablished

Challenges:

Overcomingprevioushistoryandrebuildingpositiveworkingrelationships

RecruitingmidwivestoworkinHalifaxinviewofpreviousdifficulties


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Clarifyingandmanagingoperationalaccountabilitiesandprofessionalpracticeaccountabilities

Developingacultureofrespectandsupportfornormalbirthwhenthedominantethosisthat

ofhighriskcareandpreventinguntowardevents

GuysboroughAntigonishStraitHealthAuthority(GASHA)TwofulltimemidwivesarebasedatStMarthasRegionalHospitalinAntigonish;onebeganinAugust

2009,thesecondwashiredinAugust2010. Nomidwiferyserviceexistedintheareapriortoregulation.

ThemidwivesareemployeesoftheHealthAuthorityandresponsibletotheManager,Childrenand

WomensHealthUnit. Theyworkwithtwoobstetricians(a3rdrecentlyretired)whohavebeenlong

establishedinthecommunity. Ahospitalclinicwasestablishedwhenthemidwivesarrived. Together

theobstetriciansandmidwivesprovideprimaryandsecondarymaternitycaretoapproximately400

womenperyear. Themidwivesidentifylowriskwomenforantepartumvisits,attendthelabourand

birthoflowriskwomenandprovidepostpartumandinfantvisits. Theintrapartumoncallcoverageis

shared;midwivescoverweekdays,severalweeknightsandalternateweekends. Theobstetricians

haveacontractforalternatefundingfortheirmaternitycareworkthatremovesapotentiallysignificant

barriertosharedinterprofessionalpractice. Weheardfromthemidwivesandothersthatcriticisms

havebeendirectedatthemforworkingwithintheinterprofessionalmodelofserviceprovision,butwe

alsolearnedthatwomensresponsestoroutinehospitalsurveysabouttheircarehavebeenvery

positive.

Familydoctorshaveastrongpresenceinantepartumcare,butmostrefertothematernityclinicforlate

pregnancycareandbirth. Uncertaintyandtensionaboutmidwivesinvolvementinnewborncareare

beingcapablyaddressed. Familydoctorsarenotparticipantsinthematernityclinicwhichhasresulted

inthemidwivesbeingcloselyalignedwithobstetriciansratherthanfamilyphysicians.

BeginningeffortsarebeingmadetoextendantenatalservicestositesoutsideAntigonishwiththegoal

ofattractingwomenintocareearlierinpregnancy. ThereisaspecialinterestinoutreachtotheFirst

Nationscommunitiesinthedistrict. Out ofhospitalbirthisnotavailablesinceattendancebyboth

midwivesatbirthsoutsidethehospitalwouldleavethehospitalwithoutamidwifeandprovidenooff

calltimeforthemidwivesthemselves.

Strengths:

Highlevelofsupportformidwivesinadistrictwithoutpreviousexperienceofmidwiferycare.

ThePerinatalClinicteamisenthusedandhappywiththeirwork. Thereisahighdegreeof

interpersonalcordiality.

Theinvolvementofmidwiveshasdevelopedgradually;anorientationperiodwasbuiltintothe

beginningstages;midwivesareundertakingmorecommunityoutreach.


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Midwiveshavesetrealisticlimitsontheirpresentavailabilityforoutofhospitalbirthsandare

committedtointegratingoutofhospitalbirthintotheirservicesinthefuture.

ExternalfundswerereceivedtoparticipateinMOREOB(ManagingObstetricalRiskEfficiently;a

professionaldevelopmentprogramthatfostersteamwork,teamcommunication,knowledge

andskillstomanageobstetricalemergencies. Seehttp://moreob.com). Theobstetricians,

midwivesandafamilyphysicianareparticipating.

Challenges:

Dominanceofobstetriciansinprimarymaternitycareandalignmentofmidwiveswith

specialists.

Achievingcontinuityofcareanddevelopingrelationshipsbetweenwomenandmidwivesis

moredifficultwithinthesharedcaremodel.

Ensuringlongtermstabilityofasuitablealternativetofeeforservicefundingforphysicianswho

provideprimarymaternitycare.

Establishingcloserrelationshipsbetweenmidwivesandfamilydoctors.

SouthShoreDistrictHealthAuthority(SSDHA)

TwofulltimemidwivesareemployedbySSDHA. OnepracticedinNovaScotiapriortoregulationand

theotherinOntarioandNovaScotia. TheyformedanewpracticebasedinBridgewaterattheonsetof

regulation. Theircaseloadhassteadilygrownandisatfullcapacitycurrently. Theyhaveclinicspacein

asmallhomelikebuildinginBridgewaterandplantoofferprenatalvisitsintheadjacentcounty.

Practicedatashowthattodate45%oftheirclientshavehadhomebirthsandasimilarpercentageis

definedtobefromdiversepopulations. TheirpracticeisbeingaffectedbythesuspensionoftheIWK

midwiferyservicewithagrowingnumberofrequestsforcarefromwomenwholiveoutsidetheDistrict

butarewillingtotraveltoSouthShoretoaccessmidwiferyservices.

UntilrecentlythemidwivesreportedtothePrimaryCareManagerwhereasnowtheyreporttothe

ManagerofMaternalChildHealth,partofacutecareservices. Thisresultedfromreorganizationof

responsibilitieswithinthehealthdistrictandajudgementthatissuescouldbebetterresolvedwithinthe

clinicalsectorwherebirthsoccurred.

Approximately400birthsperyeartakeplaceattheSouthShoreRegionalHospital,themajorityunder

thecareofateamoffamilydoctorswhoprovidearoundtheclockcoverage. Theteamrecently

negotiatedafundingcontractforanalternativetofeeforserviceformaternitycareprovision. They

provideprenatalcareinanoutpatientareaofthehospital. Fourobstetricians(3FTEpositions)provide

referralspecialistcareunderanalternatepaymentplan. Midwivesareabletoconsultwiththeoncall

familydoctororthespecialistdependingontheclientsituation. Themidwivesmeetwithobstetricians

todiscussplannedmanagementandsometimestoreviewcasesthatraisedconcerns. Theyalsoattend


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meetingsofthefamilydoctorswherecasesarediscussed. Recently,discussionshavebeenorganized

withthenursingstafftoaddressemergingissues.

Strengths:

Experiencedmidwiveswhoarehighlycommittedtotheirmodeofpractice;servicesare

providedacrosstheDistrictandmanyreferralscomefromclients

Midwivesareresponsivetoissuesandengagewithindividualsandgroupstosolveproblems

Stronghistoryofprimarycarepractitionersprovidingmaternityservices

Congenialworkingrelationshipsamongmaternitycareproviders

Challenges:

ThefullcaseloadandhighproportionofhomebirthsspreadovermanypartsoftheDistrict

increasetheprobabilityofclustersofbirthsthatallowlittleresttimeformidwives

Therearenofundstosupporta(nonmidwife)secondattendant;thereforebothmidwivesmust

attendhomebirths,asituationthatcanleadtoexcessfatigueandbecomeunsustainableover

time.

AcceptingrequestsforservicefromwomenwhoresideoutsidetheDistrictiscontentious

amongadministratorsandsomeproviders

Themidwivesarenotorganizationallyalignedwithfamilydoctorswhoprovideprimary

maternitycare. Therearefewsharedvenuesforqualityassuranceactivities,skillstraining,and

othercontinuingeducationdiscussions

Ensuring

long

term

stability

of

an

alternative

to

fee

for

service

for

physicians

providing

primary

maternitycare

Theindependentpracticeofthemidwivesandthestronglyheldviewsofclientsabouttheir

carehaveunderlineddifferingphilosophicperspectivesabouttheinterfacebetweenmedical

adviceandclientautonomy


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IdentificationandanalysisofissuesWehaveformulatedthefollowingcategoriesofissuesbasedontheinformationgatheredduringour

visits. Thecategoriesaredistilledfrommanyconversationsandreflectrecurringthemesfromacross

thethreesites.

SustainabilityThereisnoannouncedplanaboutthefutureofmidwiferyinNovaScotia. Morethanoncewewere

askedifthepurposeoftheexternalreviewwastorecommendclosureoftheexistingtwosites. With

onlyfourmidwivesinpractice,thepresentsituationismarkedbyanxiety,uncertaintyandalossof

publicconfidenceingovernmentscommitmenttomidwifery.

InourviewmidwiferyinNScannotlongsurviveinitspresentstate. Ifnothingisdone,theprofession

willcollapseandthebenefitsofregulationwillnotberealized. Therearetoofewmemberstomeet

increasingrequestsformidwiferycare,provideservicessafelyandeffectively,andattendtothe

complexityofregulatoryandprofessionalassociationactivitiesthatarerequiredofanewlyregulated

profession.

Theinvestmenttodateinsettinguptheregulatorystructureandprovidingpubliclyfundedservicesis

considerableandmayappearhighinrelationtothenumberofpractitioners,butisanecessarypartof

launchinganewprofession. DHWisattemptingtobuildacostbenefitmodeltoassessmidwiferythat

iscauseforconcernatthisearlystage,giventheverysmallnumberofmidwiferybirthstodate,the

initial

investments,

ongoing

integration

costs,

and

different

models

of

care

provision.

As

well,

the

qualitativebenefitstowomenofmidwiferycarearenoteasilymeasuredanddonotconvertreadilyto

dollarsineconomicanalyses. Womendescribesuchbenefitsasbeingwellinformed,involvedin

decisionmakingandgaininggreaterselfconfidenceforparenthood.

ClinicalleadershipSomeoftheinterprofessionaltensionsweobservedresultfromintroducingmidwivesintoahealthcare

systemthatmaturedwithoutmidwives. Theirrolesasprovidersofprimarymaternitycarearenew,not

wellunderstoodandcausestrainwithinsystems. Anexperiencedmidwiferyclinicalleaderatthe

provinciallevelwouldbeaninterprofessionalliaison,bringingperspectiveandpracticalinformationto

preventorresolvemanyintegrationissues. Shewouldoverseethestandardofclinicalpracticeof

midwives,conductpeerreviewsandpracticeauditsforqualityimprovement,andassistwithrebuilding

servicesattheIWK.


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EmploymentmodelMidwivesintheNovaScotiaemploymentmodelareaccountabletomanagers(allhavebeennurses)for

professionalpracticeaswellasforlogistic/operationalarrangements. Themixingofoperationaland

practiceaccountabilitieswasevidentindescriptionsofvariousgroupmeetingsaboutmidwifery.

Forumsdevelopedformandatorydiscussionofclientmanagement(anMRCNSrequirement)sometimes

hadinconsistentmembershipandagendas,oftenoverlappingwithsolvingsystemsissuesand/orde

briefingaboutanadverseevent. Managersnotedalargeworkloadrelatedtointegrationissuesthat

reflectthedualaccountabilities.

Theemploymentmodelsucceedsinotherlocationswherethereisclearseparationofthe

operational/administrativecomponentofmidwiferyfromtheoversightofprofessionalpractice. This

separationisessentialforensuringthatemployersdonotplacerestrictionsonpracticethatare

inconsistentwithprofessionalstandardsoftheregulatorybody. Practiceoversightistheresponsibility

ofamidwiferyleaderwithinanorganizationalcontextwheremidwivesareformallyalignedwithother

primarymaternitycareproviders. Suchanalignmenthelpsstrengthenapproachesandpoliciestoward

normalbirth.

Wedonotendorseatthisjunctureintroducingselfemployedcontractingofservicesasasecondmodel

ofmidwiferyorganization. Thismodelwouldrequireaddedadministrativepoliciesandareporting

structurefornoobviousgain. Withmodifications,theemploymentmodelnowinplacecanworkwell.

QualityassurancequalityimprovementriskmanagementDifferingperceptionsaboutrisksandriskmanagementwereseeninresponsetowomenschoicesfor

homebirthanddesirestoavoidinterventions. Whenwomenspreferencesconflictwithusualmedical

practicemanyprofessionalsareconcernedaboutethicalandliabilityquestions. Institutional

policies/practicesdesignedtominimizeriskexposurethatareinconsistentwithawomansrightto

makechoicesabouthercarecanprecipitatecontroversyandsometimesconflictabouthowtoprovide

careunderthosecircumstances. Proactiveriskmanagementstrategiesthatanticipatecontroversies

andcreateappropriateprotocolscanhelpavoidconflictsarisinginthemidstofclinicalcare.

Overall,wenotedalackofplanned,regularlyscheduled,multidisciplinaryqualityassurance/quality

improvementactivitiesthatcenteronprimarymaternitycare,whereresearchfindings,bestpractices

andcareprotocolsarereviewed. Mostoftenitappearedthatmidwiferycarewasdiscussedwhenthere

wasaneedformultidisciplinaryinputintoplanningawomanscareorwhencontroversiesaroseabout

clientsituations. Thesediscussionsarelargelyadhocandoutsideanoverallqualityframework.


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TheGASHAsitehasreceivedexternalfundingforundertakingMOREOB,amultidisciplinarycontinuing

educationriskmanagementprogramwidelyusedinCanada. Itsprohibitivecosthasbeenabarrierto

morewidespreaduseinNS. Theexperienceinotherprovincesshowsthatsmallercentersbenefitfrom

wellstructuredprogramssuchasMOREOBsincetheyoftenlackonsiteresourcestoprepareand

monitorclinicaleducationprograms.

PrioritypopulationsAnexpectedcompetencyofmidwivesisprovisionofculturallyappropriate/competentcareacrossa

rangeofpopulations;midwiferypracticesshouldreflectthiscompetenceintheiractivitiesandclientele.

Becausesofewmidwivesareinpractice,theircaseloadshavebeenquicklyfilledandrequestsforcare

arelargelymetonafirstcomefirstservedbasis. Theirclinicalactivitiesaretimeconsumingandleave

littletimeforengaginginoutreachactivities,suchasmeetingwithwomenorcommunitygroupswho

maynothaveanunderstandingofmidwiferycare. InGASHAandSouthShore,themidwivesare

beginningtoextendprenatalservicesintosmallercommunitiesasameansofreachingmorewomen.

Themidwivesarerequiredtoreporttheirprogressinservingprioritycommunities/populationsand

theircaseloadsshowevidenceofreachingadiverseclientele. Therequestsformidwiferycarearelikely

toquicklyexceedtheavailablecapacity,whichindicatesaneedforensuringthatoutreachanddiversity

areprioritized.


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Actasaconsultanttomidwivesandothersaboutpracticeissuesandthescopeand

standardsofmidwiferypractice

Participateinplanningexpansionofmidwifery;providedirectionandassistthe

integrationofmidwivesintoanewdistrict

Werecommendanappointment,ideally,for5years. Analternativemaybesecondmentof

anexternalleaderfornolessthanoneyearwhilerecruitingforalongertermappointee. An

assessmentoftheneedforandscopeofresponsibilityshouldbeconductedattheendof

fiveyears. Aspectsoftherolemayintimebetakenoverbytheprofessionalassociationor

regulatorycouncil. Alargereducationalrolecouldevolveinconjunctionwithaparttime

attachmenttotheReproductiveCareProgram.

3. Workwith DHAsandIWK,SSRH,StMarthasRegionalHospitaltoimplementorganizationalchangesformidwivesWerecommendthatmidwivesbecredentialedbyhospitalsinaprocessanalogousto

physiciansasthemeansofobtainingprivilegesconsistentwiththeirscopeofpractice.

Ourrationaleforrecommendingacredentialingprocessformidwivesistorecognizeand

supporttheirresponsibilitiesasprimarymaternitycareprovidersandassistinestablishing

collegialrelationshipswithmedicalstaff. Thereisnoinherentcontradictionbetweenan

employmentmodelandobtainingprivilegesthroughacredentialingprocesswitha

Departmentalappointment.ThisarrangementhasbeeninplacesuccessfullyinManitobafor

overadecade.OperationalandemployeestandardsbelongwiththeDHAandstandardsof

professionalpracticewiththeDepartmentHead. Werecommendtheaccountabilitybe

sharedbetweentheDepartmentHeadandthemidwiferypracticespecialist.

Themidwiveswouldbeappointedtoahospitaldepartmentsuchasprimarycare/family

medicineuntiltherearesufficientmidwivesinadistricttosupportamidwiferydepartment,

oradivisionofmidwiferywithinfamilymedicine.

Halifax: accomplishingorganizationalchange

UndertakeexploringwithCapitalDistrictHealthAuthority(CDHA)the

feasibilityofassumingtheadministrative/employerresponsibilityfor

midwiferyservices. Thisistheclearestwaytoseparateadministrativeand

professionalpracticeaccountabilities.Themidwivesshouldbelocatedina

settingwithothercommunitybasedprimarycareservices,preferablyina

locationthatprovidesaccessforprioritypopulations. Onesitementioned

touswastheNorthEndCommunityHealthCentrebecauseofitslocation

andthepresenceofotherprimarycareproviders. Potentially,theCenter


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couldcontractwithCDHAformidwivesserviceswithCDHAasthe

employer.

IfemploymentwithCDHAprovesnottobefeasible,thendiscussionswillbe

requiredwithinIWKtocontinueastheemployerbutwithdifferent

arrangementsthatseparateadministrativeandprofessionalpractice

accountabilities.

Ineithercircumstance,werecommendthatDHWdirectachangeto

hospitalbylawsthatwouldpermitmidwivestobecredentialedwithinthe

FamilyMedicineDepartmentofIWK.

SSDHAandGASHA: accomplishingorganizationalchange

WerecommendthatDHWdirectchangestothehospitalbylawsatSt

MarthasRegionalHospitalandSouthShoreRegionalHospitalthatwould

permitmidwivestobecredentialedwithinanappropriatedepartmentof

themedicalstaff.

WerecommendthattheDHW:II.AnnounceaplanforgrowthofmidwiferyinNovaScotia

1. ArticulatealongtermgoalfortheprovincetohavemidwivesineachDistrictasanessentialpartofwomenshealthcareservices. Forthenearfuture,establishatargetofhaving20FTEfundedmidwiferypositionsintotalbytheendoffiscal2017.Newpositionsshouldbeintroducedinstagesaccordingtothefollowingtimetable:

Animmediatenewpositionforamidwiferypracticespecialist

Increaseof1FTEpositiontoSSDHAwithin612months

Increaseof1FTEtoGASHAinwithin1218months

Increaseof5FTEpositionstoHalifaxbytheendof5yearsenablingtheformationof

2practicegroupsof4midwiveseach(totalof8positionsinHalifax)

Increaseof1FTEtoSSDHAandIFTEtoGASHAbythethirdyeartobringeachgroup

to 4FTE

2FTEtoanewdistrictin23yearsincreasingto3FTEafter2furtheryears,with

provisionforsecondattendants


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Inadditiontothe20FTEpositions,theMRCNSwillrequireaddedadministrative

supporttocarryoutessentialfunctions

2. IntroducemidwiferytoanewdistrictWerecommendtheDHWinitiateaprocesstointroducemidwiferywithinthenext23years

intoaDistrictwithoutmidwives. BothAnnapolisValleyHealthandCapeBretonHealth

Authorityweresuggestedtobesuitable. ThereisexpressedconsumerinterestinAnnapolis

Valley. TheremaybeopportunitieswithinprimarymaternitycareinCapeBretontowork

withFirstNationscommunities. ThepaperwereceivedauthoredbyMariahBattisteabout

midwiferyinFirstNationscommunitiesinCapeBretonprovidesthoughtfulideasfor

midwiferyinvolvement.

Animplementationcommitteeshouldassistwithandmonitoranexplicityearlong

integrationprocessofmidwivesintoanewdistrict. Theplanshouldincludeteambuilding

within

the

maternity

service.

Midwives

should

be

informally

mentored

by

existing

primary

healthcareproviderstogainanunderstandingofusualpatternsofpractice. Conversely,

midwivesneedtoorientexistingproviderstotheirprofessionalstandardsandphilosophic

principles.

Theorganizationalmodelofanewpracticeshouldbeappropriatetothesetting,the

preferencesofmidwivesandwomen,andmeetstandardsoftheMRCNS. Inanynewsite

midwivesmustbeintegratedasprimarymaternitycareproviders

3. SupportoverallprimarymaternitycareinparallelwithexpandingmidwiferyWerecommendthatattentionbepaidtostabilizingphysicianswhoprovideprimary

maternitycarewhenmidwiferyisintroducedinanewdistrict,particularlywherebirth

volumesaresmaller.

Fundingstrategiesthatretainfamilyphysicianand/orobstetricianinvolvementinprimary

maternitycareareimportantforpromotingcollaborativearrangements. Midwivesand

familydoctorscanexplorearangeofoptionsforworkingtogether,e.g. sharedcare,cross

coverageforbackupwhenneeded,separatepracticeswithsharedqualityimprovement

andcontinuingeducationsessions.

WeareawareofaninnovativefundingmodelintheSouthCommunityBirthProgramin

Vancouver,BC(www.scbp.ca)wheremidwivesandfamilydoctorsworkinpartnership.

Incomeisderivedfromtwofundingstreams,butpartnerspoolfundsandestablishindividual

compensation.


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4. ExplorepartnershipswithotherAtlanticProvincestodevelopeducationalopportunitiesWesuggestthatNovaScotiataketheleadinformingpartnershipswithotherAtlantic

Provincesindevelopingabridgingprogramfortheregion.Inordertoincreasethenumber

ofmidwiveswhoqualifyforNSregistration,abridgingprogramisneededthatprovides

assessment,teachingandskillsdevelopmentonanindividualbasisformidwiveseducatedin

otherjurisdictionswhosecompetenciesdifferfromCanadiannorms.

Secondly,wesuggestthatNSexploreoptionsforprovidinguniversitypreparationin

midwiferyforthosewhoaspiretoacareerinmidwifery. AnAtlanticconsortiumofdegree

grantinginstitutionsisoneoptionthatwouldcapitalizeonkeepingstudentsclosetotheir

homeprovince. Asecondoptionisexploringinterprovincialcooperationtoholdseatsfor

Atlanticstudentsinoneormoreofthecurrentlyexisting7programsinCanada.

WerecommendthattheDHW:III.Formalizeaccountabilityformidwivestoserveprioritypopulations

WerecommendtheDHW/HealthAuthoritiesrequirethatmidwiferypracticesreserve50%of

midwiferycaseloadsforwomenfromprioritypopulationsandthatmidwivesbeexpectedto

takepartincommunityoutreachactivitiesaspartofpaidemployment.

Womenandinfantsareoftenthemostdisadvantagedmembersofmarginalizedgroups.

Midwiferycareoffersopportunitiesforrelationshipbuilding,healtheducationandparticipatory

decisionmakingthatcanbuildconfidenceandtrustwithprofessionsandhealthcaresystems.

Activitiessuchasthefollowingcancontributetoservingdiversepopulations

Worktogetherwithstakeholderswithinthedistricttodeveloptheprofileof

prioritypopulations.

Buildrelationshipsandseekopportunitiestoincludewomenincarewhomay

haveminimalunderstandingofmidwifery.

Stimulateandassistinprogramstotraindoulas(womenwhoprovidelabour

supportandcoaching)whoalsocanprovidelinkstocommunity

groups/agencies,knowledgeofculturalpracticesandmayshareacommon

languagewithclients.

Implementnewerapproachestoprenatalcare,suchasgroupvisitsthatarepart

ofcenteringpregnancy,anewerformofcarethatsupportscommunity

relationships. [SeeEndnote1]


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Establishsatellitesitesforantenatalandpostnatalvisitsineasilyaccessed

facilities(communitycentres/halls,churches,localhealthclinics).

WeencouragetheMidwiferyCoalitionofNovaScotiatopartnerwithmidwivestodevelop

communityoutreachprogramsthatincreaseawarenessandknowledgeaboutmidwiferycare.

WerecommendthattheDHW:IV.Strengthenmaternitycareteamfunctioningandqualityimprovementprocesses

WerecommendthatDHWrequestRCPundertakeworkingwithdistrictswithmidwiferyservices

toplanacomprehensiveprogramofqualityimprovement. RCPhascredibilitywithhealthcare

professionalsandalreadyleadsseveralqualityimprovementactivities.

Wefurtherrecommendthataspartofthequalityimprovementprogram,DHWprovidesupport

toDistrictsthatpresentlyhavemidwiferyservices(andtoanynewdistrictsthatestablish

midwifery)toimplementMOREOBorCareTeamOB,anewprogramthatblendscontentfrom

theALSOprogramwithteamtraining. [SeeEndnote2]Theimportantprincipleistheinclusion

ofallthecareprovidersinthesettingtopromoteincreasedknowledge,teamfunctionandclear

communicationandactionplansforemergency/lifesavingskills.

Acomprehensiveprogramshouldincorporatearangeofqualityimprovementactivitiesin

additiontotheabove. Activitiessuchasthefollowingneedtobemultidisciplinary,coordinated

andregularlyscheduled:

mandatorycasereviewsofnearmisses,

significantmorbidityandmortalityarisingfromlowriskmaternitycare;followupof

adverseevents

randomchartauditsbypeerstoassessqualityofrecordkeeping

systematicreviewofthefrequencyofspecificpracticese.g.electiveinductionof

labour,frequencyofepisiotomy,postpartumhemorrhage

reviewofsituationswhereclientorproviderdecisionmakinghasbeencontroversial

principlesandconductofconsultations

preventingandresolvingworkplaceconflicts

providingculturallycompetentandsafecareforsociallydiversepopulations

educationaldiscussionsoftopicsofinterestandrecentresearchconcerninglowrisk

maternitycare


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Recommendationsspecifictothethreemodelsites

I. WerecommendthefollowingtotheleadershipatIWK ParticipatewithDHWinrecruitingtheseniormidwifepracticespecialistand

provideasuitableclinicalappointmentatIWKtofacilitateaspectsoftherole.

TakestepstocredentialmidwivestotheDepartmentofFamilyMedicineatthe

IWKwithprivilegesconsistentwiththeirscopeofpractice.

Undertakedevelopmentofaprogram/centreofexcellencefocusedonnormal

birth,engagingmidwives,publicmembers,familydoctors,nursesand

obstetriciansinplanning. Orientpolicies,practicesandthephysicalsettingto

promote

and

support

care

practices

that

apply

to

the

large

percentage

of

womenwhoarenotreferredforhighriskconditions.

Amendthepresenthomebirthpolicysuchthatconflictingobligationsto

womenschoicesandemployerpoliciesareremoved,(e.g.antibioticswhen

GBS+,inabilitytousetubs). Restrictivepoliciesthatcreatedifficultethical

dilemmasformidwivescouldresultinwomenresortingtounattendedhome

births.

II. WerecommendthefollowingtomidwivesandotherswithinGASHA Createmoremultidisciplinaryopportunitiesforcasereviews,quality

improvementdiscussions(currenttopicsandpractices)inwhichobstetricians,

familydoctorsandmidwivesareparticipants.

Themidwivescreateaplanforattendanceatoutofhospitalbirths

incorporatingsecondattendantstoincreaseservicecoverage.

ThehealthauthorityexplorewithDHWfundingmethodstofacilitate

participationofinterestedfamilyphysiciansinthemultidisciplinarymaternity

clinicatStMarthasRegionalHospital. Itshouldbepossibletoevolvethe

obstetricalservicetoalargerconsultativeroleformidwivesandfamilydoctors

whoprovideprimarymaternitycare.


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MidwivesdiscusswithStFrancisXaviernursingfacultywhoareworkingto

increaseparticipationofFirstNationspeopleinhealthprofessionsthe

possibilityofadoulatrainingprogram.

III. WerecommendthefollowingtomidwivesandotherswithinSSDHA Createmoremultidisciplinaryopportunitiesforcasereviews,quality

improvementdiscussions(currenttopicsandpractices)inwhich

obstetricians,familydoctorsandmidwivesareparticipants.

Midwivesandpublichealthpersonnelincreasetheircollaborationto

facilitatetimelyreferralofantenatalandpostnatalclientsto

community/socialservices.

Midwiveskeepothersfullyinformedaboutpossibleandactualbookingof

clients

who

reside

outside

the

district

and

discuss

best

approaches

for

their

care. ClientsfromwithintheDistrictmusthavepriorityinbookings.

ConclusionWethinkmidwiferyinNovaScotiahasgoodpotentialandthatinvestmentinitsfutureisfully

warranted. Theprecedingrecommendationsforchangereflectlocalcircumstancesbutalsomuchlarger

issues. Manyofthechallengesthatarisewhenmidwivesareintroducedintoahealthsystemarenot

uniquetoonelocationortomidwiferyitself. Maternityunitsacrossthiscountryandelsewherestruggle

withsimilarissuesinforgingproductivecollaborativeenvironments. Theimplementationofmidwifery

createschangeinallpartsofthematernitycaresystem. Itthereforeprovidesaperfectopportunityto

strengthentheentiresystemofcareforchildbearingwomen. Wehopetherecommendationsinthis

reportwillassistthateffort.


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