What should midwives do regarding mask policies now that the provincial mask mandate in health care spaces has been lifted?

COVID-19 is still circulating in our communities and the effectiveness of masking to reduce transmission has not changed. Effective June 11, 2022, the Ministry of Health (MOH) revoked the directive concerning most of the remaining mask mandates, effectively returning responsibility for maintaining policies that reduce the risk of transmission in health care to health care organizations and providers. The Chief Medical Officer of Health has stated that organizations may implement their own policies and individuals should continue to wear masks if it feels right to them. Unfortunately, MOH communication on this issue may contribute to public perception that prevention and control interventions for COVID-19 are no longer necessary.

Health care settings such as midwifery clinics, birth centres, hospitals, community labs and diagnostic imaging facilities are responsible for deciding whether to maintain current masking policies or amend them. Public Health Ontario cautions that “due to changes in the Ministry of Health’s updated guidance on testing and case, contact and outbreak management, counts are an underestimate of the true number of cases and outbreaks with COVID-19 in Ontario”. Decisions about maintaining masking policies will be influenced by transmission risks in different communities, risks of severe COVID-19 illness in the population served, and the toll already taken and on health human resources which may be further impacted by a relaxing of IPAC measures.

The diversity of policies which will result from the revoking of the MOH Directive has the potential to create confusion, tension and even conflict amongst health care professionals, health care organizations, clients, and the general public. To reduce the risk that midwives and midwifery clients will be negatively impacted by the confusion, consider the following strategies:

• Everyone in the workplace, including owners, partners, associates, new registrants, locums, student midwives and staff should be engaged in the discussion and have input into the decision about maintaining or amending masking policies.
• Ensure that policy decisions address all locations of work including clients’ homes.
• Midwives should check if hospitals and birth centres where they have privileges and community labs and diagnostic imaging facilities used by clients have maintained or amended their policies.
• Consider the benefits of making midwifery workplace masking policies align with hospital policies. Clients and the public may be better able to understand and more likely to comply with a community standard for health care organizations.
• Communicate the policies of the clinic, the hospital and community facilities attended by clients on the clinic’s website, on social media, when appointments are booked and with office signage.
• If the midwifery group decides to continue to require clients and support people to mask in the clinic and at visits in the community, provide a rationale based on:

1. Public Health data that shows that the virus is still circulating.
2. A reminder that pregnancy is a risk factor for more severe disease requiring hospitalization and midwives need to promote policies to keep all clients safe.
3. Midwives need to be protected from infection risk so that they can continue to work and provide safe care to clients.
4. Evidence that face mask use results in a large reduction in risk of infection, with greater protection associated with N95 or similar respirators compared with disposable surgical masks or similar (e.g., reusable 12–16-layer cotton). Infographics can be shared on social media or posted in the clinic to explain how various IPAC measures reduce transmission and more specifically the significance of masking in reducing transmission.

• Providing a rationale for continuing masking requirements may help to reduce resistance from clients.

Midwives should continue to perform a point-of-care risk assessment (PCRA) for every clinical encounter and use their knowledge, skill, and judgement to recommend higher levels of infection prevention and control measures in higher risk situations.

MPGs can still access PPE from the Ministry of Health. The original ordering form is now defunct, and practice groups must create an account to access the new ordering portal. Please reach out to sco.supplies@ontario.ca and they will assist you with account creation.

[April 17, 2023] 
 

Should clients wear masks or face coverings for their appointments with their midwives or during labour?

Ontario's Chief Medical Officer of Health announced that "Ontario will remove the mandatory masking requirement for most settings on March 21st, with the exception of select settings such as public transit, health care settings, long-term care homes and congregate care settings." Clients may be confused and question having to wear a mask for their midwifery care and midwives may need to explain how there are different measures for higher risk settings like health care.

Please see the AOM's COVID-19 Bulletin: Issue #149 - April 14, 2023 (PDF, 162 KB) for guidance and considerations regarding masks in clinic spaces.

Many hospitals still require masks in all areas for patients and support people, including in labour (as tolerated). The recommendation from the Provincial Council for Maternal and Child Health (PCMCH) (PDF, 399 KB) is that "pregnant patients who screen positive for signs/symptoms of COVID-19 should be treated as suspected for COVID-19, and should be given a surgical/procedure mask for all stages of labour (if tolerated), and that support people and care providers wear PPE for all labours. PCMCH has not recommended that clients who have not tested positive and have no symptoms wear masks in labour.

The Public Health Agency of Canada (PHAC) released Infection prevention and control for COVID-19: Interim guidance for outpatient and ambulatory care settings and recommend that "Medical masks are recommended to be worn by all patients (where tolerated)". 

[March 22nd 2022]

What if clients refuse to wear a mask?

Midwives may encounter clients (or their support person) who refuse to wear a mask. These are very complex issues, midwives can call the AOM On Call to access advice and support regarding their particular situation.

Before considering how and if to provide care to such a client, explore the client’s rationale. It may be based on past trauma, a health condition, or a perception of health risk from wearing a mask. Personal circumstances warrant special consideration, and misunderstandings of risk can be addressed by reviewing the evidence.

Violence and harassment around mask refusal should not be tolerated. Under the Occupational Health and Safety Act, midwifery practice groups are required to have an Anti-Harassment and Anti-Violence policy; the AOM has produced a template (under "Midwives Safety"). 

In January 2022, the Criminal Code of Canada was amended to enhance protections for healthcare workers. The newly enacted section 423.2 makes it an offence to intimidate a health professional or a person who assists a health professional, in order to impede them in the performance of their duties. Midwives should not hesitate to contact hospital security or the police with any threat of violence

The College of Physicians and Surgeons of Ontario provides advice on balancing the care needs of the individual declining to wear a mask and the need to protect other clients, the care provider, and staff of the clinic:

If you encounter a situation where a patient declines to wear a mask, sensitively explain the expectation that they wear a mask and the importance of protecting public health by following the recommendations of public health organizations. Depending on your patient’s needs, your ability to safely isolate them from other patients, and your ability to safely provide care, you may need to defer or reschedule their appointment or redirect them to a setting that can safely provide care. Be aware that some patients have health conditions that make it difficult or uncomfortable to wear a mask, so plan ahead to help accommodate their needs and find ways to help them access care safely (e.g. providing as much care virtually, scheduling appointments during specific times, etc.).

Clients should be informed that they may be required to self isolate (PDF, 714 KB) if they are exposed to COVID-19 through their midwifery care and were not wearing a mask, even if the midwives were wearing masks.

Similarly, midwives need to carefully consider their professional and ethical obligations to this client, to themselves and to other clients and staff. Consider:

• Having a practice protocol/policy about masking that is shared with all clients on intake
• A client's decisions and understanding may change over time; a client that refuses to wear a mask at one appointment may choose to wear a mask in the future or wear one in certain circumstances (i.e. only when the midwives are within 2 metres distance)
• The safety of midwives (e.g. can the midwives wear full PPE during visits with the unmasked client, just as health-care providers caring for patients with COVID-19 do, including gowns and face shields/goggles?)
• The safety of other clients, virtual care and visit scheduling to avoid contact with other clients
• The occupational health and safety of clinic staff, avoiding or reducing contact
• Thinking ahead to birth plans: 
  • if the client is symptomatic for COVID-19 and refusing to mask, in areas of high community spread, or in other higher risk situations, consider the use of N95 respirator upon completion of a point-of-care risk assessment
  • consider creating a policy for rapid covid testing (RATs) at the beginning of a home birth for the client and support person(s)
• What can be done to enhance the safety of the space for home visits or home births, such as ventilation, designating a separate disinfected bathroom for the midwives, etc. (see the AOM's guidance on home birth during COVID-19 [PDF, 768 KB] for further suggestions)
• Making a decision about whether to continue to provide care before the client is term, to ensure adequate time to transfer care if needed
• Documenting all discussions and the plan of care thoroughly

There may be circumstances where interactions about this issue contribute to a breakdown in the trust relationship between client and midwife. If this occurs, the midwife should consult CMO standards and guidance documents about loss of trust and ending the client/midwife relationship and contact  AOM On Call. 

[March 22nd 2022]