Ontario ponders expanded prescribing by midwives
Ontario midwives may soon be able to prescribe an expanded list of drugs, but doctors are warning against the change.
The College of Midwives of Ontario is proposing sweeping changes to the list of drugs members can prescribe, adding opiate painkillers, the abortion pill, blood pressure medications, treatments for sexually transmitted infections and oral contraceptives. The idea has drawn criticism from the Ontario Medical Association (OMA), which says the change could put patients at risk.
Currently, Ontario midwives may only administer or prescribe medications from a list of 48 drugs for specific indications. Drugs not included on the list require a physician’s order or prescription. The midwives’ proposal would expand the approved list to hundreds of drugs under 17 broad categories, including anti-infective agents, oxytocics, and hormones.
Last year, Ontario Health Minister Christine Elliott asked the College to propose amendments to drug regulations as part of a plan to expand midwifery services and scope of practice. According to the ministry, “the proposal will allow midwives to prescribe and administer treatment for conditions they are already managing and to respond to changes in best practices without the need for continually updating a regulation.” The government is considering the proposed amendments and will post them on the province’s regulatory registry for public comment.
Current prescribing rules pose many frustrations for midwives, according to Aynsley Donohue, a midwife based in Toronto. For example, under the existing regulations, a woman diagnosed with chlamydia by her midwife requires a separate appointment with her family doctor to receive treatment.
In some cases, “patients are left in precarious situations if midwives are unable to immediately respond to obstetrical emergencies until the patients can be transferred to appropriate obstetrical care,” said Donohue.
The proposed prescribing rules reflect the reality of modern midwifery, she added. “Midwives are primary health care providers and have the knowledge, skill and judgement to educate, assess, and treat their patients in a fulsome fashion without disjointed or fragmented care.”
However, some doctors beg to differ. In a written response to the midwives’ proposal, Dr. James Wright of the OMA noted that midwives are trained to provide care during a normal, low-risk pregnancy and for the six weeks post-partum. “As such, midwives do not need to prescribe medications for chronic medical conditions, as these medications are for women who have high-risk pregnancies,” he said.
In his letter, Wright also warned that midwives do not have training in pharmacology that would enable them to anticipate adverse effects, complications or potential for addiction for the classes of medications included in the proposal. Some of the substances on the list, such as anti-infectives, carry the risk of immediate life-threatening reactions, he explained. “In these instances, the risk to patients far outweighs the benefit of easy access to care.”
OMA President Dr. Sohail Gandhi said a balance between timeliness and appropriateness of care is needed. “This change is driven by some concern that patients are not given timely care,” he said in an interview. “My concern is about safe and appropriate health care. You must ensure the knowledge and training is there to ensure the expanded scope of practice is appropriate.”
Ontario is not alone in seeking to expand the role of midwives in a bid to contain costs and expand access to maternity care. Expanded midwifery prescribing is well-established in New Zealand and the United Kingdom. Both jurisdictions require midwives to complete accredited courses before they can apply for authority to prescribe.
According to Liz Darling, director of midwifery education at McMaster University, the proposed changes in Ontario would enable midwives to use their full knowledge and skills without unnecessary barriers. “The more flexibility we have in how midwives work, the more easily they are able to work in communities that are under-served or with populations that have poor access to care,” she said.
As for the concerns raised by doctors, she noted that “like physicians, midwives have the responsibility to ensure that anything they are doing within the scope of practice is something that they are adequately prepared to do.”
Beyond introducing mandatory training for prescribing opiates and benzodiazepines, it’s not yet clear how the College of Midwives of Ontario will ensure midwives are adequately prepared to implement the proposed changes. However, in a prepared statement, the College said it “intends to provide a formal response to feedback received during the consultation.”
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