Midwifery integration


Sixteen years after midwifery was regulated in Ontario, there are more than 500 registered midwives managing approximately 10 per cent of births in the province. About 75 per cent of midwifery clients choose to have hospital births.
Yet despite midwifery’s history and success in Ontario, some challenges to fully integrating midwives into hospital settings persist. While midwives are well integrated into many hospitals, some hospitals do not optimize midwifery competencies.
A key component to ensuring excellent integration is furthering interprofessional collaboration between health professionals, which is vital to quality patient care and ensuring women and newborns have the best possible outcomes.
In an effort to provide hospitals with resources and tools to support integration and collaboration, the Ontario Hospital Association (OHA), in partnership with the Association of Ontario Midwives (AOM) and the College of Midwives of Ontario, has developed a new midwifery integration resource manual entitled Resource Manual for Sustaining Quality Midwifery Services in Hospitals.
“Mothers and their newborns will definitely benefit from having more, and better, interprofessional collaboration among their care givers. That’s why the OHA supports integrating midwives into Ontario’s hospitals, and believes that midwives are an important part of the maternity care system, alongside their physician and nurse colleagues. This manual can help maternity care teams improve and sustain positive working relationships, which will promote safer, high-quality care,” said Tom Closson, President and CEO, OHA.
Launched this September, the manual is designed for both hospital leaders looking to integrate midwives for the first time, as well as those who already have midwifery at their institution, and provides examples of existing integration models, protocols and lessons learned. For those seeking to integrate midwives for the first time, the manual provides seven clear steps for integration, including updating hospital bylaws, developing departmental or division policies and developing a depart ment orientation for new maternity staff.
The Trillium Health Centre in Mississauga has welcomed midwives since the profession was regulated in 1994 and serves as an example of how positive collaboration can support integration.
Kimberly Moore, manager of birthing services at the Trillium, says support from the leadership team was an essential component to successfully integrating midwives.
“Between the head midwife, myself and the chief OB, we have a close, tight team. We talk, come up with an action plan the same way we do with any departments. I do think it’s that we’re willing to talk and take accountability,” she says.
Trillium’s head midwife, Remi Ejiwunmi, RM, believes having the support of OBs and nurses was a key component ensuring successful integration. She notes, however, that perceptions and fear from other departments were major challenges that had to be initially overcome.
“Other departments had more questions, misinformation and didn’t understand midwives as primary care providers,” Ejiwunmi says.
The key to dealing with this issue both then and now, she says, is communication.
“Whenever misinformation was presented, it was corrected. Information sessions and information sheets went out to inform people of what impact, if any, the integration of midwifery would have for them. Interdisciplinary meetings were struck with one member from each department to brainstorm on what impact there would be,” she says.
Interprofessional collaboration is one of the many topics addressed in the OHA manual. A whole chapter is dedicated to addressing how midwifery care may affect different team members – including nurses, family physicians, paediatricians and paramedics – and how hospitals can overcome any potential challenges in this arena.
Dr. Douglas Bell, associate executive director and managing director of risk management services at the Canadian Medical Protective Agency agrees that communication is key.
“If a hospital is interested in integrating midwives into their program and the physicians are nervous, the hospital should have the doctors sit down and discuss what the issues are and address those concerns,” he says.
Though physicians may claim they fear liability issues with midwifery integration, that fear is unwarranted, Dr. Bell says.
Hospitals and physicians can consult the OHA manual chapter that deals with liability to find information on issues such as liability insurance for midwives.
Ejiwunmi recommends that anyone working through the integration process be upfront and clear during the planning process about how midwives will be practicing within the hospital.
Oftentimes there is a desire to place limitations on how midwives will provide care without definitive plans for addressing those limitations in the future. For example, hospitals may say that midwives should consult for components of care that is within their regulated scope of practice, or that a midwifery department will be set up at some undetermined time in the future.
Ejiwunmi cautions that it can be challenging to continue to move integration forward without concrete deadlines or plans.
Moore echoes the sentiment that laying the groundwork ahead of time helped ensure a smooth integration process at Trillium.
“I think what truly set the foundation here was the willingness to spend the time beforehand,” Moore says.
Bell says it is especially important for hospitals to set out clear policies and procedures for situations doctors may not be familiar with.
“The hospital administration (should) look at similarly sized hospitals with midwives to see how they’ve done it and what policies and procedures they have in place so that they don’t have to reinvent the wheel,” he says.
The OHA manual has been distributed to every OHA member hospital, and is available for free.

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