Scope of Practice

The scope of practice statement is found in each profession-specific Act, and it defines, in broad terms, the outer parameters of what that particular profession can do. For example, the midwifery scope of practice is set out in the Midwifery Act, 1991, which is the profession-specific Act for midwives. Profession-specific Acts of other health care professionals include the Medicine Act, 1991 for physicians, the Nursing Act, 1991 for nurses, and the Pharmacy Act,1991 for pharmacists.

Controlled acts are set out in the RHPA and are procedures, tests, and treatments that are considered to pose a risk of harm when performed by someone who is not qualified to perform them. Because there is implicit risk of harm in the performance of controlled acts, they can be performed only by the regulated health professionals who are authorized by their profession-specific Acts (e.g. the Midwifery Act, 1991) to perform them. There are 14 controlled acts listed in the RHPA¹RHPA at s. 27(2)12.. Some professions do not have any controlled acts. Other professions, like midwifery, are authorized to perform many controlled acts. No profession is authorized to perform all controlled acts.

Controlled acts can be authorized to professions either in their entirety or only partially depending on what is considered appropriate for that profession’s scope of practice. For example, the controlled act of managing labour or conducting the delivery of a baby² Medicine Act, S.O. 1991, c. 30 at s. 4.11. is authorized to physicians in its entirety but is authorized to midwives only partially. This means that physicians can perform all of the controlled act of managing labour or conducting the delivery of a baby without limitations; whereas for midwives this controlled act is limited, and they can only manage labour and conduct spontaneous normal vaginal deliveries.³Midwifery Act at s. 4.2.

2.2.1 Delegation of Controlled Acts

Delegation is a formal process by which a regulated health professional, who is authorized to perform a controlled act, delegates the performance of that controlled act to another person who is otherwise not authorized to perform it. This other person may be a member of another profession regulated under the RHPA, a member of an unregulated profession, or a member of the public.

For example, a midwife may be delegated the controlled act of placing an instrument, hand or finger into an artificial opening into the body⁴RHPA at s. 27(2)6vii. by a physician allowing the midwife to assist during a caesarean birth. Similarly, a midwife might delegate the act of managing labour and conducting spontaneous normal vaginal deliveries⁵Supra note 5. to a registered nurse.

The delegation must be in accordance with any regulations or standards of practice. For example, it is a College standard that midwives are prohibited from delegating the controlled act of prescribing.⁶College of Midwives of Ontario, Standard on Prescribing and Administrating Drugs (January 2014). It is also a standard of practice that midwives must only accept delegated acts that they are competent to perform.⁷ College of Midwives of Ontario, Professional Standards for Midwives (June 2018).

2.2.2. Exceptions to Controlled Acts under the RHPA

Section 29 of the RHPA permits the performance of controlled acts by people who do not have the authority to perform a controlled act. This person may be a member of another profession regulated under the RHPA, a member of an unregulated profession, or a member of the public. These exceptions differ from delegation because no handover of responsibility is required; however, the person must possess the knowledge, skills, and judgment required to perform the controlled act.

One of the exceptions is rendering first aid or temporary assistance in an emergency.⁸RHPA at s. 29(1)(a). Whether or not a situation constitutes an “emergency” will depend on a number of factors, including the immediate harm to the client and the availability of other resources. What may be an emergency in a remote location may not be an emergency in an urban setting where other care providers, more experienced in managing such an emergency, may be readily available. This exception permits midwives to perform the controlled act of putting an instrument, hand, or finger beyond the point in the nasal passages where they normally narrow during the performance of neonatal resuscitation.

Another exception is granted to students or trainees who are authorized to perform controlled acts within the scope of their future profession if those acts are done under the direction and supervision of a member of the profession.⁹Ibid at s. 29(1)(b). This exception permits midwifery students to insert a urinary catheter into a pregnant client under the supervision of a midwife registered with the College.¹⁰For a complete list of exceptions to controlled acts, see s. 29(1) of the RHPA.

The Laboratory and Specimen Collection Centre Licensing Act, 1990 regulates Ontario’s hospitals and private medical laboratories, including these laboratories’ specimen-collection centres. General Regulation 45/22 of the Laboratory and Specimen Collection Centre Licensing Act, 1990 authorizes midwives to collect specimens and order laboratory tests in accordance with a specific list outlined in Schedule 2.¹¹ Laboratory and Specimen Collection Centre Licensing Act, 1990 S.O. 1990. This means that while midwives are authorized to order laboratory tests and collect specimens, this authority extends only to those tests and specimens that are listed in Schedule 2.

While the RHPA limits the performance of controlled acts to health professionals who are authorized by their profession-specific Act to perform them, many components of health care are not controlled acts because they do not pose risk of harm. This means that these components of care are not prohibited by the controlled acts in the RHPA and can be done by anyone, not only by regulated health professionals. This care is sometimes referred to as being in the public domain. For example, taking a blood pressure is in the public domain (i.e., is not a controlled act), which means that unregulated professionals and members of the public can do it. But diagnosing someone with a disease or disorder based on the reading of that blood pressure (e.g., diagnosing a pregnant client with gestational hypertension based on their blood pressure) is a controlled act. This is because there is not a great risk of harm in taking the blood pressure, but there may be a risk of harm when making a diagnosis based on that blood pressure.

The midwifery scope of practice statement is set out in the Midwifery Act:

The practice of midwifery is the assessment and monitoring of women during pregnancy, labour, and the post-partum period and of their newborn babies, the provision of care during normal pregnancy, labour, and post-partum period and the conducting of spontaneous normal vaginal deliveries.¹²Midwifery Act at s. 3.

The scope of practice statement uses several terms including postpartum, newborn, spontaneous, and normal that have no universal definition. In order to understand the scope, these terms need to be defined. The following are definitions of these terms for the purpose of interpreting the scope of practice statement in the Midwifery Act, 1991.

Newborn means a baby from the moment of birth up to eight weeks after birth. Note: Midwives are authorized to perform the controlled act of communicating a diagnosis only up to six weeks after birth. More on the controlled act of communicating a diagnosis is described in Table 1.

Normal means a clinical picture that is considered healthy or uncomplicated. Normal applies to the overall health status of the individual and does not necessarily rule out the presence of a specific condition or indicate the complete absence of abnormal. Normal can include infections, conditions, or clinical presentations requiring monitoring or treatment when the overall health status of the client or newborn is considered healthy or uncomplicated. Determining if a clinical situation is normal requires clinical judgment and may also require diagnostic tests or consultations with other care providers.

Postpartum means the period of time beginning with the birth of a baby and ending eight weeks after the birth when the effects of pregnancy on many systems have largely returned to the unpregnant state. Note: Midwives are authorized to perform the controlled act of communicating a diagnosis only up to six weeks after birth. More on the controlled act of communicating a diagnosis is described in Table 1.

Spontaneous means a birth that occurs with maternal effort only and is not assisted by any means. A birth requiring forceps or vacuum is not spontaneous. Spontaneous refers only to the birth of the newborn and does not refer to the onset of labour and can therefore include induction and augmentation.

Woman means an individual who is pregnant, labouring, giving birth, or postpartum. In this document, the terms “client” and “individual” will be used in place of woman unless woman exists in the language of the legislation.

Using the definitions provided above, the midwifery scope of practice involves providing care to individuals during normal pregnancy, labour, spontaneous vaginal birth, and for up to eight weeks postpartum for both clients and newborns. Any person who falls outside of this time frame is not considered in the scope of practice, and midwives cannot provide care to them on their own authority. This means midwives are not permitted to provide midwifery care to anyone who is not pregnant or postpartum or who are not in labour or having a spontaneous vaginal birth. Midwives also cannot provide midwifery care to babies over eight weeks of age.

Midwives are authorized to perform a number of controlled acts. Controlled acts are only authorized to midwives while engaging in the practice of midwifery. All of the controlled acts authorized to midwives are authorized only partially, which means midwives do not have the authority to perform any of the controlled acts in their entirety. The details of the controlled acts are described below in Table 1. Column 1 sets out the controlled acts authorized to midwives as set out in the Midwifery Act and the Controlled Acts Regulation. Column 2 describes what the authorized act permits midwives to do and column 3 describes what midwives are not permitted to do related to the authorized act.

Table 1: Controlled acts authorized to midwives and their interpretation

Practising to the full legislative scope, also known as full scope midwifery, means providing all aspects of midwifery care scope including labour, birth, postpartum and newborn care, including all of the authorized acts.

The ability to work to the full midwifery scope is influenced by intrinsic and extrinsic factors. Intrinsic factors are personal factors, such as being a new midwife who has not been exposed to all of the procedures required to work to full scope or a midwife who has an injury that limits their ability to provide all aspects of midwifery care. Midwives cannot, however, limit their scope of practice in contravention of provincial or national laws. For example, a midwife cannot use discretion over their own scope of practice to exclude individuals from care based on one of the protected grounds in the Ontario Human Rights Code.

Extrinsic factors are those such as practice setting or client needs. For example, a midwife may be practising in a hospital that does not provide epidural analgaesia so would not have access to this part of the scope. While extrinsic factors should be based on resources and the best interest of clients, there are situations where this is not the case. This occurs when midwifery practices choose not to work to the full scope even when their privileging hospital supports it. This also occurs when institutions, such as hospitals, limit midwives from providing full scope midwifery care despite evidence showing that optimizing the midwifery scope of practice is in the best interest of the public. The scope of practice of every health professional should enable them to contribute optimally to providing high quality patient-centred care without compromising patient safety and that … the health care system should enable them to practise to the fullest extent of this scope.¹³Canadian Medical Association, “Best Practices and Federal Barriers: Practice and Training Healthcare Professionals” (Submission to the House of Commons Standing Committee on Health: 2015) at 3.
When client care is not central to the decision-making about scope limitations then midwives, midwifery practices, and advocacy organizations should work with these institutions to develop policies and protocols that reflect the legislative scope of midwifery practice.

Practising to the full legislative scope requires that midwives have the necessary competencies to do so. As primary care providers and regulated healthcare providers, midwives are responsible for determining the limits of their own competence. A midwife’s competence can change throughout their career. Midwives can gain new competencies by engaging in professional development activities, such as participating in trainings, taking courses, and providing elements of care they had not previously provided. At the same time, a midwife may lose competencies if they have not provided certain elements of care for an extended period of time. In all situations midwives must be competent in all aspects of care they are providing or they must consult with, or transfer the care of the client to, another care provider.

A transfer of care is the transfer of primary clinical responsibility to another care provider and is required when a client’s condition is outside the legislative scope of practice. For example, a pregnant client with a breech presentation choosing a caesarean section must be transferred to a physician for the birth because only births that are spontaneous and vaginal are in the midwifery scope of practice and a caesarean birth is not spontaneous and vaginal. If this same client were to choose a vaginal birth, then a transfer of care would not be required if the midwife is competent to provide this care because a spontaneous vaginal birth is not outside the legislative scope of practice.

Transfers can be temporary, such as in this case of a planned caesarean section for a breech presentation, because only the intrapartum period is outside of the scope of practice. Transfers can also be permanent, for example, when a client gives birth at 24 weeks gestation, and the newborn requires months of hospitalization and treatments. When a transfer of care is required, clients should understand the need to transfer and that they will be under the care of a physician so their plan of care may change. After a transfer of care has taken place, a midwife should continue providing care in collaboration with the most responsible provider and in the best interest of the client and their newborn. In this situation, all controlled acts must be performed under delegation.

Delegation allows midwives to provide care outside the scope of practice as long as a regulated health professional with the authority to perform the controlled act grants this authority to the midwife. This provides midwives with the legal authority to perform a controlled act that is otherwise not authorized to the profession. For example, in the case of the 24-week preterm infant transferred to physician care, a midwife can participate in the care of this newborn as long as any controlled acts, such as inserting an intravenous catheter, are provided under delegation. Midwives must also work under delegation when performing controlled acts on individuals who are not pregnant, in labour, postpartum or newborn. A decision-making tool for working under delegation can be found in Appendix A.