With a resurging demand for midwifery services by the public and community organizations, the government of PEI responded with a commitment in 2019 to introduce regulated midwifery services. This paper compares the process used in Canada’s smallest province, Prince Edward Island, to launch midwifery services using the International Confederation of Midwives (ICM) Midwifery Services Framework (MSF).
Étant donné la demande croissante de services sage-femme par la population et les organismes communautaires, le gouvernement de l’Île-du-Prince-Édouard a répondu en 2019 en s’engageant à instaurer de telles prestations réglementées. Le présent article vise à comparer le processus adopté pour le lancement des services sage-femme par la plus petite province canadienne, l’Île-du-Prince-Édouard, qui s’est servie du cadre élaboré par la Confédération internationale des sages-femmes.
Key words: Midwifery Services, Midwife, Framework, Midwifery Implementation
All articles published in DPG Open Access journals
This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International (CC BY-NC 4.0)(https://creativecommons.org/licenses/by-nc/4.0/).
Midwifery care has been offered on Prince Edward Island (PEI) first by the Mi’kmaq and then by women who shared their self-taught skills between generations and communities. The Prince Edward Island Midwifery Association (PEIMA) can trace the names of women who offered midwifery care as far back as the mid-1850s.1 With the help of horse-drawn carriages, these early midwives raced through farms and snowstorms to support and care for women and newborns. Despite this rich history, the demand for midwives decreased dramatically in the mid-1900s partly due to the medicalization of birth and because of the requirements associated with legalizing midwifery.2 Fast forward to the modern era, midwifery care is at the height of a resurgence in both demand and government support. By 2021, midwifery had become a regulated profession in every province and territory (P/T) in Canada except for PEI.3 According to the Canadian Midwives Association (CAM) in 2021 there were 1,892 regulated midwives in Canada, and approximately 13% of all births in Canada were led by a midwife.4 In fact, the “Canadian Model” of midwifery care has become renowned for its seamless integration between hospital and community care.5 Aside from providing high levels of client satisfaction (close to 99%6), midwifery-led births have less “instrument interventions, lower C-section rates, and reduced hospital stays.7
Public demand for regulated midwifery services in PEI has been ongoing for decades, with the most recent peak in 2016, with public demonstrations and petitions. In response, the PEI government committed to “integrating midwives into the healthcare system” and developing regulatory processes to approve midwives’ credentials.8
Since this time, several landmark documents have demonstrated the PEI government’s interest and investment in maternal and child health, including the First 100 Days Initiative, the formation of Maternal Newborn Quality Teams and the Health Strategy for Women and Islanders who are Gender Diverse. Support from various clinical stakeholder groups within PEI, including obstetrics, neonatology, pediatrics, and the Department of Health and Wellness, has also been garnered recently. All of these have informed the pursuit of regulated midwifery care in PEI. In 2019, the Cabinet provided direction and budget approval to begin planning for Midwifery Services.
The International Confederation of Midwives (ICM) created the Midwifery Services Framework (MSF) (Figure 1) in 2015 as a tool for countries to use when launching or strengthening midwifery service.9 This seven-step process facilitates implementation to align with “sexual, reproductive, maternal and newborn health services to an international standard (SRMNH).”9 This paper aims to compare ICM’s Midwifery Services Framework (ICMMSF), and the process used by PEI to launch midwifery services.
Figure 1. ICM Midwifery Services Framework. Reprinted from Nove, Andrea et al., an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
The ICM MSF describes a step by step process to strengthen and support the roll-out and provision of midwifery care around the world.
Midwives in PEI can practice as autonomous primary health care providers who deliver comprehensive care during pregnancy, labour, postpartum, and the newborn period. The following list of legislative and regulatory documents was identified as needing to change or be amended to support midwifery services.
Regulated Health Professions Act
Drug Information System
Creation of Midwives Regulations
Health Information Regulations
Ambulance Services Act, RSPEI 1988, c A-10.01
Domestic Violence, Intimate Partner Violence and Sexual Violence Leave Regulations, PEI Reg EC188/19
Health Information Regulations, PEI Reg EC359/17
Health Services Act, RSPEI 1988, c H-1.6
Hospitals Act, RSPEI 1988, c H-10.1
Hospital and Diagnostic Services Insurance Act Regulations, PEI Reg EC539/63
Hospital Management Regulations, PEI Reg EC574/76
Immunization Regulations, PEI Reg EC529/14
Notifiable Diseases and Conditions and Communicable Diseases Regulations, PEI Reg EC560/13
Public Health Act, RSPEI 1988, c P-30.1
The amount of detailed work, peer-to-peer education, and lobbying by senior government leadership champions cannot be underestimated in getting legislation, regulations, and supporting documents changed and required permissions in place. Throughout this process, senior leadership in the health authority and the Ministry of Health were committed to laying a foundation of best practices and evidence. This required time, multidisciplinary dialogue, and a commitment to midwifery service to reach a consensus and achieve the buy-in needed to make such decisions. The hope was that this bureaucratic investment would create program and system-wide readiness to ensure PEI’s success in launching this important healthcare service.
Lessons from our peers indicated that the successful implementation of midwifery services would require extensive engagement and change management activities among a wide range of stakeholders. Therefore, planning for and envisioning midwifery care on PEI began with forming the Midwifery Steering Committee (MSC) in 2020 (Figure 2). This multidisciplinary and inter-governmental committee brought together several key stakeholders who would be directly affected by and involved with midwifery care.
Figure 2. Midwifery Steering Committee Structure. This figure depicts the governance structure of the Midwifery Services Steering Committee. The work of MSC was supported and guided by several, multidisciplinary subcommittees. The project management team executed task level work and along with subcommittees provided evidence and recommendations to the overarching Steering Committee. A Framework for Midwifery Services in Prince Edward Island. Prince Edward Island; 2021 Internal Government Document available from author upon request.
Members of the MSC includes:
Society of Obstetrics and Gynecology Canada/Obstetrician Representative
Executive Director and Program Development Lead - Community Specialist Services
Assistant Deputy Minister, Director, Special Projects Officer - Department of Health & Wellness
PEI Midwives Association and PEI rep of Canadian Association of Midwives
2 Primary Care and Chronic Disease Practitioners
2 Family Physicians
Nurse Practitioner Association Representative
Mi’kmaq Confederacy of PEI Representative
2 Patient Advisors
2 Hospital representative/Obstetrics Nursing
Public Health and Children’s Developmental Services Representative
Provincial Perinatal Health Program Coordinator
Senior Midwifery Advisor
Clinical Midwifery Consultant
Communication representative
Administrative Support
Primary Care Network Medical Director
College of RNs Representative
Chief Nursing and Professional Practice
Quality & Risk, Community Specialist Services
While the ICMMSF suggests using technical support teams, PEI chose task-specific subcommittees to guide service planning, creating a governance structure that followed the ICMMSF and reflected local objectives.
Critical to the MSC was a core project team. These are the individuals who executed specific tasks identified by the subcommittees. For example, they drafted policies, wrote briefs, provided presentations, and worked with human resources to write job descriptions. For most of the time, the core team included two midwifery consultants and a project coordinator. The assistant deputy minister first led the team from the ministry, followed by a director from the health authority. Given the impact decisions related to midwifery care will have on other elements of healthcare service delivery, senior management level participation on the project team was a critical element of success to ensure senior leaders were kept informed and decisions could be made promptly.
A preparatory step recommended by ICMMSF is the articulation of guiding principles (Figure 3) that would influence the launch of Midwifery Services. The following principles were adopted in March of 2021 by the PEI MSC and ensured engagement and decision-making remained focused on adopting and integrating the Canadian Model of Midwifery Care.
Figure 3. PEI guiding principles for midwifery services. This figure identifies the principles and values that guided the MSC and the subcommittees as they planned for and launched midwifery services in PEI. These principles were reached by consensus though a facilitated conversation. A Framework for Midwifery Services in Prince Edward Island. Prince Edward Island; 2021 Internal Government Document available from author upon request.
Registered midwives in PEI will:
be primary care providers,
be fully integrated into the provincial healthcare system,
work in collaboration with other members of the maternity care team, and
provide cultural safe care within the Canadian Model of Midwifery Care.
The College of Registered Nurses in PEI (CRNPEI) was confirmed by the government to be the regulating body for PEI Midwives. The impact this had on CRNPEI was felt in every corner of their organization and required at least 18 months of dedicated effort on their part. In addition to creating, cross-referencing, and approving at least 15 midwifery policies, the CRNPEI had to create relevant and appropriate governance and review processes, launch an online application portal, change their website, and re-brand their organization.
One goal of the MSC was to make recommendations to Health PEI and the Department of Health and Wellness on the model of care for midwifery service in PEI. This led to the generation of its own Midwifery Services Care framework that provided program model recommendations and collected data to inform program planning.10
Results from that research confirmed that midwifery services in PEI could be a provincial program, with midwives providing care across the prenatal, intrapartum, and postpartum patient journey with midwifery-led births in both hospitals that provide labour and birthing services and community. It is estimated that nine full-time-equivalent (FTE) midwives can cover midwifery services in PEI, where one FTE assumes a lead administrative role. This is based on several factors. The number of anticipated midwifery-led pregnancies/births is approximately one hundred and forty per year; the need to create teams that could crossover and cover each other to provide 24/7 service, without risk of burnout; and to provide appropriate clinical coverage for the urban, rural and remote nature of PEI.
Relying heavily on jurisdictional scans from Canada and elsewhere, and in conjunction with the CRNPEI, the MSC created a scope of practice that would empower midwives to practice to their full scope. The government of PEI committed early on to following the Canadian model of midwifery as outlined in a position statement by the Canadian Association of Midwives.11 Initially prepared by our senior midwifery advisor and clinical midwifery consultant, the scope of practice was defined and circulated to the MSC for review. From there, senior leadership within the health authority and ministry sought approval. The resulting scope of practice formed the basis of midwifery regulations and was added to the Regulated Health Professions Act.12 Essentially, this means that in PEI, midwives can be the most responsible care provider for low-risk, healthy pregnancies and childbirth. To summarize, midwives in PEI can:
admit, transfer & discharge from hospital,
order medications, labs, diagnostic imaging, testing and procedures,
manage births including epidural and augmentation,
provide supportive care for the client and direct newborn care during C-sections,
provide care spanning preconception through to 8 weeks postpartum,
accept and receive appointments in a variety of settings including self-referrals,
offer the choice of birthplace in either a hospital or a home/community setting,
document and enter orders within existing clinical information systems,
request consults and provide consultations including letters in follow up, and
complete reports such as discharge summaries and provide to primary care providers.
The amount of professional insight and wisdom offered by the senior midwifery advisors and the clinical practice consultant cannot be underestimated in this step. Having decades of experience in midwifery service provision and experts in health services planning at the table guided the MSC. PEI Midwives will be health authority employees and are regulated to admit, transfer and discharge from hospitals. Furthermore, midwives will be represented by a collective bargaining unit to ensure equitable employment conditions and to pre-empt the known level of burnout that midwives’ experience in other models of employment.13 Professional liability insurance was secured through the Health Insurance Reciprocal of Canada (HIROC). Within the PEI employment model, midwives will practice in community and hospital settings, offering seamless care integration regardless of birthplace choice.
The ICMMSF divides this step into two tasks: (1) Recruiting midwives needed to meet the current and future client demands, and (2) Creating a workspace suitable for midwives to see clients.
Given the increasing difficulty of filling mid-- wifery positions across Canada, one MSC subcommittee focused solely on recruiting midwives.14 Members on this subcommittee had the challenging task of creating job descriptions that followed the brand new legislation and regulations yet aligned with existing healthcare providers (HCP), were comparable in scope and salary to other jurisdictions in Canada, and reflected both the employment model and the collective agreement of the targeted union. As in other jurisdictions, PEI decided to have midwives report directly to a Midwifery Lead/administrator instead of another HCP. The recruiting subcommittee then had to create and get approval for the clinical/administrative lead and the clinical midwife positions. While midwives will report directly to their clinical/administrative lead midwife, midwifery services will have a dual reporting mandate as an overarching, provincial program. The Director of Community Specialty Services will have administrative and supervisory oversight for the operation of services while, clinical oversight falls to the Chief of Nursing, Professional Practice, and Quality Officer.
The PEI government further demonstrated its commitment to integrating midwives by providing dedicated midwifery space. Midwives will have office space near the labour and birthing units despite hospital office space being in high demand. Along with the support of a brand new, custom-built, community clinic that is fully furnished/equipped, and large enough to have a designated exam room, two consultation rooms, and separate education and meeting spaces. The clinic is in a building that is accessible, on a public bus route, and is co-located with other clinics that offer other sexual, reproductive, maternal, and newborn health services, enabling collaborative opportunities within the work environment for midwives and ease of access for clients to access other services in one location.
The government of PEI ensured evaluation planning was part of the MSC from the beginning. The evaluation subcommittee, led by an evaluation consultant, worked to define measures of success based on time-bound milestones and indicators based on easily accessible data points. The multi-phased evaluation plan, which included the generation of a midwifery program logic model and the creation of several satisfaction surveys, had the following objectives:
review implementation and uptake of midwifery services,
assess the integration of midwifery into the PEI health system,
examine the impact of midwifery services on preconception, prenatal, birth and postpartum care, including client satisfaction,
evaluate the extent to which anticipated outcomes have been achieved to date, and
identify key barriers and enablers for the achievement of anticipated outcomes and sustainability.
PEI is well positioned to monitor success as midwives enter their data into existing clinical information systems to facilitate cyclical monitoring and reporting of midwifery outcomes.
ICM suggests it could take 3–5 years to complete the steps it outlined in the MSF. A look at PEI’s Gantt chart confirms this timeframe. It is important to note that the tasks listed in Table 1 comprise several smaller, yet equally important tasks that depend entirely on the health system responsiveness, recruitment success, and the senior leadership champions that must weigh competing healthcare priorities. For example, creating and adopting midwifery practice policies took almost eighteen months. The core team completed research and drafted the policies, which required several rounds of consultation among related healthcare providers, multiple versions of subsequent formatting and editing with a policy analyst, presentation to medical advisory committees across the province, and finally to senior leadership for approval. The ability of clinical and administrative personnel to schedule time to review and provide feedback drove the timeline to craft practice policies. Likewise, getting on the agendas of senior leadership groups to approve said policies was triaged by more urgent matters, including staffing shortages, critical incidents, and, at separate times, a fire and a flood.
Table 1. Health PEI Midwifery Services Planning Time Frame
2019 | 2020 | 2021 | 2022 | 2023 | 2024 | |
---|---|---|---|---|---|---|
Cabinet Approval and Budget | ||||||
Legislations | ||||||
Regulations | ||||||
Licensing | ||||||
Practice Policies | ||||||
Clinic Space (Construction, Equipment and Supplies) | ||||||
Recruitment | → |
ICMMSF suggests establishing and strengthening the local midwifery association as an ongoing activity. Unfortunately, this has not been easy to execute. The PEI Midwifery Association (PEIMA) is critical to launching midwifery services due to its role in registration and licensing and as part of a tripartite agreement to provide insurance. However, until the hiring of the lead midwife, PEIMA did not have any regulated midwives among their members. It is difficult to strengthen an association whose volunteer executive and membership have largely been based on champions and advocates of the midwifery profession from outside the jurisdiction, as opposed to local registered midwives. The size of the population of PEI (<200,000) naturally influences the size of an association such as PEIMA. Every effort is underway to strengthen PEIMA further.
The MSC maintained stakeholder engagement with support from a dedicated communication subcommittee. The subcommittee engaged with stakeholders and partners through a variety of means. It informed these groups through monthly submission updates to a province-wide clinical newsletter. It hosted virtual group meetings with over 25 healthcare provider groups, many of whom intersect a midwifery client’s journey. Additionally, the Steering Committee hosted a Midwifery Engagement Day, where over 90 participants engaged in large and small group discussions on how, when, and where midwifery care pathways will intersect with existing health services. Including providers like public health nurses, obstetricians, pediatricians, nurse practitioners, social workers, and pharmacists opened the dialogue on how midwifery clients can move through and receive care within the existing healthcare system and created a work plan to facilitate successful integration.
Being Canada’s last province/territory to launch midwifery services provided an invaluable opportunity to learn what worked and what didn’t work in other provinces and territories. We learned that policy alignment between the health authority/ministry and the regulatory body is critical to success. We learned that an employment model versus a fee-for-service contract model offers midwives additional work-life balance opportunities if they can work in sufficiently large teams. However, the employment model requires advanced communications with human resource, legal, and clinical departments to get buy-in and processes in place. We learned that framing policy/procedures (i.e., consult indication list) similar to what works elsewhere does not guarantee it will be accepted locally. We also learned that having clinical, administrative, or political champions can impact timelines. Being the last province/territory to implement also comes with political, professional, and public scrutiny to do it well and quickly. The ICMMSF provided an objective and respected planning framework against which PEI could compare their progress. Access to the front-line expertise offered by the senior midwifery advisor and clinical midwifery consultant allowed PEI to successfully adopt the ICMMSF to guide our roll-out and ensure that our steady progress towards launch was on track. PEI has now moved from the planning phase to implementation and operations. With the legislative, regulative, and licensing pieces in place, clinic spaces identified and developed, and a midwifery lead was hired and her way to being the first licensed and insured midwife on PEI, the MSC decided to sunset. The focus will now shift to the day-to-day operations and integration of midwives into the existing health system in PEI.
The authors would like to thank each member of the Midwifery Steering Committee for their support and commitment to bringing Midwifery Services to Prince Edward Island. The authors appreciate the time and energy members of the Health PEI Senior Leadership team provided, especially Andrew MacDougall and Marion Dowling. The authors acknowledge the commitment and collaboration with the Department of Health especially Debra Bradley, Kelley Rayner and Mary Acorn. For their professional insights and expertise, the authors would like to thank Gisela Becker, Melissa Roberts, and Dr. Krista Cassell.
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2. McCracken K. A Patchwork of Care: Midwifery in Canada. Active History, 2015. Available from: https://activehistory.ca/blog/2015/01/12/a-patchwork-of-care-midwifery-in-canada/.
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Cora Cole is an Epidemiologist by training, and has been working in community health her whole career. Cora is delighted to bring her committment to evidence informed practice, knowledge mobilzation, and program planning and evaluation to Health PEI as they launch Midiwifery Services.
Eileen Larkin Eileen Larkin completed an Undergraduate Degree in Nursing at UNB Nursing and a Masters of Leadership in Health at Royal Roads University. With a lifetime career in health, she is currently the Director Community Specialty Services at Health PEI. In this role she brings a passionate leadership approach to setting the Midwifery team up for success and sustainability and to provide a new choice for birthing families in Prince Edward Island.