Designated Drugs Regulation

Feedback

1. Midwife on November 22, 2019

   I appreciate all the work that has gone into the proposed new drug regulation and the thoughtful and comprehensive consideration by so many people, midwives and stakeholders alike. I understand why midwives are feeling frustrated by the lack of movement on the HRTO decision. However, this change to categories of drugs is decades overdue, and has led to intolerably slow changes such as GBS prophylaxis and undue burdens on our clients in terms of time delays for medications which are accepted standards in maternity care. I am writing from the perspective of working in a small midwifery practice in a small rural community.

   There is significant poverty in rural Ontario, with no public transit, and some families having no access to a car except by a taxi or when their partner is home from work. The nearest obstetrician or paediatrician or RT is 1 hour and 20 minutes away, in good weather. Criticall can take hours to get a transport team to our local hospital in spite of having a helipad and a small airport 20 minutes away. Weather can make anything other than land ambulance not an option. We regularly consult with the OB on call in the Level 2 centre, but if they give an order for a medication or a treatment, I can only give it because I have medical directives for those substances, because that physician doesn’t have privileges at my hospital. I agree with all the comments about the desperate need to expand our Lab tests to enable us to order the lab tests that are required to provide comprehensive information to the OB or Paediatrician with whom we are consulting. Yes, medical directives can achieve that, but I think it is very appropriate and time -saving to be able to have that information before I am consulting.

   I agree that not all midwives may want or need to utilize all the medications that might be included in the categories. I don’t see it so much as expanded scope, but supporting optimum care in your practice setting. Being able to contribute to timely and appropriate care for midwifery clients and members of the community (offering medical termination or contraception prescribing when there aren’t accessible options available for example). Mag Sulph is a drug worth having in a Level 1 hospital as I may be the one on-call if a pregnant woman comes in and starts seizing. That is not the time I want to be calling around for a family doc.

   I agree with most of the drugs that have been suggested to be added, with the exception of SSRIs. I think that family physicians and nurse practitioners have a longer ongoing relationship with those clients that allows for more appropriate long-term follow-up than our childbearing year.

   I would also add Surfactant, though I have no idea what category it would fit in. It is very important when a preterm birth happens in a small centre given the lengthy time it can take for the transport team to arrive.

   I hope that midwives will see that the challenges of working without on-site or even local OBs and Paeds is that extra delay is incurred in complex situations where the clients can’t get out in a timely manner and midwives can’t order appropriate medications on our own responsibility. We are not trying to take on sole management of complex pregnancy, intrapartum or postpartum situations. We are trying to provide appropriate and necessary care without delay. As was mentioned by a number of respondents, even in large centres there can be significant delays in getting an OB to see our client if it’s not an emergent situation.

2. Midwife on November 22, 2019

   I would like to have the legislation include tranexamic acid for preventing traumatic blood loss. It could be valuable for midwives managing PPH, hemorrhaging miscarriage or an abortion that has become abnormal. This would be particularly valuable in remote communities.
   This drug is “up and coming” in trauma management and in abortion care and it would be a shame to exclude it due to lack of fore though.

   The drug class = antifribrinolytic

3. Midwifery Education Program Consortium on November 22, 2019

   Thank- you to the CMO for the work that has gone into the research and negotiations with government in terms of the new drug regulation.

   The MEP consortium strongly supports revisions to drug regulation that can allow midwives to work in more flexible models, reduce inappropriate consultations and delay in consultation and support better care in rural and remote settings. We strongly support access to medications that allow midwives to work fully in the area of sexual and reproductive health, consistent with the International Definition of a Midwife. The dialogue this consultation has inspired points to the need to clarify the underlying principles of changing the drug regulation, and how scope of practice will be defined in this new context. A clear articulation of how moving away from specific drugs can support sustainability and flexibility of the profession is needed. Broader categories allow the inclusion of new drugs and new uses of existing drugs as practice evolves. Our understanding was that the CMO’s goal was to move to the broadest possible categories of drugs, but that the MoHLTC will not support that and that the AFHS system is a compromise.

   It is our assumption that not all midwives will be required or expected to use all of the drugs it is possible to access under the new regulation. Under an expanded drug regulation, we envision that depending on their model of care and local resources midwives will establish protocols for when and how to integrate new medications into their practice. It would be helpful for the CMO and AOM to clarify their vision of how midwives will use this expanded list. The MEP recommends that certain new drugs become part of routine or emergency care for all midwives, while others would be considered relevant in certain settings and others in certain models. The entry level midwife with good access to consultation would be expected to be confident in routine and emergency drugs, which would be covered in detail the MEP curriculum. Other drugs in the scope would involve on the job or continuing education for example for rural and remote practice, or for sexual and reproductive health care beyond what is covered in the MEP.

   We assume for example that not all midwives will choose to provide sexual and reproductive health services such as medical abortion but that some will integrate this as part of their midwifery care and while others will develop alternate models of care that focus on this.

   We understand midwives concerns about workload and scope but are hopeful that access to a less restrictive list of drugs will actually reduce work and stress for midwives. Our understanding of the College’s communication is that having an expanded group of drugs allowed by the regulation does not change the scope of practice of midwifery or the ability of midwives to consult or transfer care when they feel that is necessary. Consultation would continue to be guided by both our scope as a profession and individual competence/training.

   For example, we would expect most urban midwives with ready access to consultation would not change their current practice for clients with hypertension. However, using the example of hypertension, more open access to drugs could allow the development of models of care where midwives could work in an interprofessional clinic serving clients with hypertension or with diabetes. It could also allow a more straightforward and medico-legally appropriate approach to emergency protocols in rural and remote settings where midwives begin emergency treatment according to protocol as they are arranging consultation and transfer. This could also be important in an urban setting if access to consultation or primary care is limited/delayed, allowing midwives for example to give antenatal steroids in a timely way or to continue anti-hypertensives postpartum which is a common gap after clients leave hospital. 

   It would be helpful for the CMO, AOM and MEP to work together to describe and give the community of midwives a picture of how an expanded drug regulation can support best care and reassure midwives about how this fits into our current scope and workload.

   On reviewing the new system it is not readily transparent what all of the drugs that would be included are, or what the rationale is for the categories that are included or not included: for example it would appear that nifedipine which is widely used as a tocolytic and anti-hypertensive drug is not included, whereas other antihypertensives such as labetolol and methyldopa are included. It would be helpful to know what system/ review process was used for the determination of the drugs included and not included and the rationale for inclusions and exclusions.

   We recommend that the CMO (in collaboration with the AOM and the MEP) ensure that all drugs currently recommended as best practice are included. This should be in keeping with SOGC or AOM guidelines, the ALARM and MOREob courses, and appropriate newborn guidelines, and ensure that drugs included in the regulations in other provinces and territories and appropriate countries have been considered. It might also be useful to get some expert input from family medicine and extended role nurses to ensure that common practice for those who currently have access to broader prescribing is taken into account. Similarly, a consultation with and midwives working in an extended role in remote communities would be valuable. It would be unfortunate to leave out any important categories as it may be years before additional changes are possible. We know from past experience, inappropriate limitations to the drug regulation can impact not only client care but also undermine positive interprofessional relationships and the reputation of the CMO and the profession. Midwifery organizations should work together to provide guidance so midwives can support removing barriers to timely and appropriate care and work confidently appropriately in their scope, but also not taking on things they are not trained appropriately to do AND not being barred from consultations or transfers of care where necessary. 

   We know the CMO is aware that these changes go hand in hand with the need to modernize regulations around laboratory testing. Some of the proposed medications require management through laboratory testing that midwives cannot currently order on their own authority. We support the CMO’s work towards changes to this regulation.

   The “how to” of the AHFS classification system is not transparent or easy to understand. Access to up to date information appears to be behind a pay wall. This may have limited the quality of the input midwives have been able to provide. If this system is retained we will have to address issues of transparency and access. Our input below may be limited given that we did not have full access to the AHFS classification system.

   Some additional changes/drugs we think are important to be included are:
   -naloxone is an opiate antagonist not agonist – this may be a typo
   -nitroglyerine for use as spray, patch or IV for emergency use to promote uterine relaxation – this is recommended by ESW ALARM and is in the Quebec drug regulation AHFS category: Vasodilating agents (please clarify if this would be covered by Direct vasodilators)
   -betamethasone and dexamethasone for preterm labour to promote lung maturity – key especially in rural and remote communities -part of a preterm labour protocol
   -iron preparations – IM or IV iron can prevent unnecessary transfer in a rural or remote community and can be part of a routine anemia protocol AHFS category 1. Blood Formation and Coagulation 2. Iron Preparations
   – nifedipine as noted above re tocolysis or emergency care of hypertension
   -indomethacin for tocolysis
   -ursodeoxycholic acid for cholestasis (with access to appropriate labs)
   -if the goal is to open up potential extended role models midwives in many countries work in diabetes clinics we may want to consider drugs related to diabetes care (insulin, metformin) for extended role practice model and or collaborative care model (AHFS classification: Adrenals)
   -consideration should be given to levothyroxine if that is not already included under one of the existing tiers

   Thank-you for this opportunity to provide input on behalf of the MEP.

   Lisa Morgan, Director, Laurentian University
   Elizabeth Darling, McMaster University
   Karline Wilson Mitchell, Ryerson University

   Thanks to the MEP faculty subcommittee who worked on this issue: Elizabeth Cates, Vicki Van Wagner and Kathi Wilson.

4. Member of the public on November 22, 2019

   I glad that midwives are expanding their drug prescription authority. This will decrease unnecessary obstetrical consultations and save money for the system. It will add value to the profession and decrease unnecessary waiting time for their clients when they have to wait for the consultant for a prescription.

5. Midwife on November 22, 2019

   I am excited to see changes within the drug regulation to increase midwives’ ability to practice more autonomously, meet needs of our clients, and reduce strain on the healthcare system through needless consultations. There is good evidence to support midwives in administering certain medications in other Canadian jurisdictions, and internationally. I think a category approach will allow for flexibility in prescribing without changing the regulation everytime new gold standards in practice arise. I’m wondering if there is a Canadian model of drug categories that was considered?

   I am in favour of midwives remaining primary care providers for low-risk clients and being able to respond appropriately and urgently to emergent situations. I am less comfortable with prescribing and maintaining care for high risk clients (ie. hypertension).

   I agree with other comments in this chain that have highlighted that with these proposed changes come other challenges that will need to be addressed:
   1) our ability to order complimentary lab tests and screens will be essential
   2) training and education will need to include the use of the new medications beyond narcotics – I think we need to be learning in a standardized way that is accessible for midwives in rural, remote and on-call – I don’t think we should make any assumptions about midwives coming to these medications with the same comfort, confidence, competency and skill currently. MEP training should be consistent between sites.
   3) early pregnancy care (spontaneous and incomplete abortion and therapeutic abortion) as well as well-woman care (contraceptives, sexual health, etc) will need new ways to address compensation beyond EMCM and Schedule Q for more midwives to be able to offer these services if they want to
   4) our policy teams will need to take a systems approach to understanding the implications beyond the benefits to clients and midwives for prescribing changes (how does this shape our relationships with physicians?) and be prepared to address these emerging challenges

   I also really hear what midwives are saying about wanting to provide more complete and responsive care to their clients BUT not at the expense of midwife health (burnout) or by a downloading of responsibility without proper compensation, integration and respect within the healthcare system. I am also curious about the idea of different prescribing classes among midwives – has this been considered or evaluated from other professions?

   This may be a silly question, but the regulation changes above were specific to injection, inhalation, prescription and per rectum, but I want to insure I can offer oral and administer vaginal medications – is that a given in the blanket word “prescription’?

   Thanks again to the CMO for working on this. I hope the comments here are also shared with the AOM as many of the issues raised are ones they are working on.

6. Midwife on November 22, 2019

   I support the changes to categories as well as some of the suggested expansions (contraceptives, mifegymiso). However, I echo the other comments in my concern that midwives will be expected to manage things that have been out of our scope and should, in my opinion, remain out of our about. Hypertension is the most obvious example, as others have mentioned. Regarding abortion, I would love for that to be part of our scope, but not without a way to be compensated!

   I am also concerned about the additional (unpaid, as always) conditioning education needed to receive training, as well as the increased workload, which will also not be compensated. For example, opiates in early labour are usually a transfer of care at my hospital, but with these changes, it will likely be expected that we retain care of those clients. Physicians have the help of nurses to manage those clients, we do not. This will add hours of work and lead to even more inadequate compensation.

7. Mothers of Change of the National Capital Region on November 22, 2019

   I support all of the drugs/categories listed above, in order to maintain continuity of care for those with a midwife. Would you consider adding drugs to treat diabetes/gestational diabetes, in order to maintain care for these people (for example, to include insulin under the category “hormones”). I understand some midwives have a variance to do this in certain circumstances. This change would allow those to benefit from midwifery care (continuity of care, good outcomes with fewer interventions) without midwives needing to seek a practice variance.

8. Midwife on November 21, 2019

   I appreciate the move to categories of drugs and substances yet feel cautious. This regulatory change further supports midwives as self regulating professionals. It reduces the need for constant change in a drug list as new medications within our scope are adopted/removed in obstetrical practice in Ontario. Categories of drugs allows for a broader pharmacopoeia for midwives.
   I would like to be assured the CMO will allow adequate time for the necessary educational opportunities and that the cost not be a financial burden..
   These changes will expand the prescribing scope and as such midwives will do more work in an already poorly compensated environment. However we will be serving a broader community, and moving away from low risk midwifery, and expanding into well woman care in the reproductive years. How can this all be supported when equal pay for equal work does not exist in the midwifery profession?
   I agree with other midwives that these changes will improve client care and reduce the number of practitioners a client might see in her pregnancy or reproductive years.
   Comments reflecting the implementation challenges in our respective obstetrical communities are also very valid.

9. Midwifery Care ~ North Don River Valley on November 21, 2019

   Thank you the CMO for all the work that has gone into negotiating new drug legislation on behalf of Ontario midwives, and to all other stakeholders for adding to this discussion.

   As a practice, we echo the comments made around guidance from the CMO on how this affects the ability of midwives to work within their scope of practice. We assume, and are hopeful that this new legislation opens up possibility for midwives to provide care appropriate to their setting; removing barriers both for our clients, and for us as midwives by removing inappropriate consultations. We would request some clarity however, such that barriers are not created in taking away from our ability to consult or transfer care as our training and comfort dictate. We assume that this new list opens up possibilities, but is not prescriptive – that these are medications that we CAN use as appropriate, but not that we MUST use in all cases.

   We raised questions in the following areas:
   Insurance – with increased responsibility will this impact our insurance with HIROC and the cost to said insurance?
   Hospital Integration – Even with our current, constrained, drug legislation, midwives experience barriers to their practice at the hospital level. Is there a plan in place for increased advocacy to assist midwives in increasing assess to these medications in their communities?
   Continuing Education – How will midwives be supported in training for these new medications? Will there be continuing education courses?

   It is unclear to us based on the documentation provided which drugs will now be included in each category, or how we would discern this information going forward. Greater transparency around what has been included/excluded and why would be helpful, as well as how much flexibility exists for additions in the future. That being said, there are a few medications that would be useful in our context that we didn’t see listed that lead to unnecessary consultations are:
   – ursodeoxycholic acid (for management of cholestasis) [This also requires much needed changes to the laboratory testing regulations]
   – nifedipine
   – CELESTONE (for fetal lung maturation; it appears only topical betamethasone is currently listed?)
   – all dinoprostone preparations for cervical ripening
   – progesterone for antepartum use
   – misoprostol for induction of labour, not just PPH – does the current listing remove all restrictions?
   – estrogel for postpartum
   – Iron preparations
   – nitroglycerine preparations for uterine relaxation, in line with emergency skills

   The points made from other stakeholders RE: changes and increased responsibility/workload in the context of compensation are well-taken. It is true that midwives remain undervalued and under-compensated for the work that we do. That being said, there are many ways in which the proposed changes will reduce our overall workload, or save us time spent waiting for consultations that could be avoided. In addition, we are hopeful these changes will remove stress by improving interprofessional collaboration within the broader medical community. The prior restrictions on our ability to use certain medications on our own authority raised questions RE: the competence of midwives that, at times, undermined relationships.

   Thank you again for pursuing these expansions, and we look forward to hearing more.

10. Midwife on November 21, 2019

    Like many midwives, I appreciate the effort to move to broader classes of drugs as this is a sensible approach that will allow drug regulation to adapt to changes in drug availability, changing research, guidelines, drug resistance etc. I understand this approach, and am in support of moving to drug classes, however, I do have significant concerns with the proposed drug regulation as it is presented here.

    The broadness of the drug classes as presented is so general and non-specific that it is confusing to me as a midwife when reading this document, which drugs I might be expected to use, for which indications and in which scenarios. As the scope of midwifery in Ontario has become broader over the years, I am concerned that different midwives may interpret their scope and the drug regulation differently resulting in such nebulous and non-specific use of these medications that there would be no standardized practice across the province. I feel strongly that the document as presented with drug classes would require, at minimum, a companion document that outlines typical indications, scenarios and specific drug dosages to further clarify and define for midwives what the expectation might be. Additional training, educational and reference documents for several of the drug classes would also need to be created to guide safe and consistent practice.

    Additionally I have concerns with some of the drug classes listed. For example the inclusion of B-adrenergic blockers, anti-convulsants and central nervous system agents gives the impression that midwives will be managing hypertension, pre-eclampsia and/or seizures. We cannot simultaneously define midwifery as the provision of care during normal pregnancy, labour and post-partum period, while also seeking to manage high-risk pregnancies and deliveries. These two narratives are in direct contradiction with each other. I understand for midwives working in under-serviced areas that it may be helpful for them to access a broader scope of medications as there may not be other health care providers who could manage a high-risk pregnancy. For the vast majority of us however, there is access to safe, skilled health care providers for referrals who can manage these high risk conditions. We do not need to do it all. Other solutions could be sought via standing orders, telemedicine consultant etc to ensure that those in remote communities can access medications needed for clients experiencing high-risk scenarios without expanding all midwives’ scope of practice to include these drugs.

    The inclusion of opiates and benzodiazpines is also troubling to me. I of course see the role of these medications in the occasional delivery, but feel these would be so seldom used that accepting the risks to midwives, clients and society of easier access to these medications and potential for mis-use and over-use far outweighs the utility of these. I have been happily practicing midwifery in Ontario for over a decade without ever feeling these medications are missing from my scope. To be clear, I am not in favour of the inclusion of opiates in midwifery scope, and if the CMO was to proceed with including these drugs I would want to see significant education and monitoring to protect midwives/clients and society from the harm these drugs pose,

    Lastly I would like to state that I feel a lack of support from the CMO, AOM and the profession in general for those of us that do not chose to enthusiastically pursue “full scope” midwifery (the definition of which seems to change month to month). Each community has unique needs and resources, and midwives should be empowered to define their practice within their own context without pressure or devaluation for not continually leaping to secure an ever-growing scope of practice. I am quite content to practice and preserve my midwifery skills and work as part of an appropriate team when obstetric-scope skills are required to ensure the best outcomes for clients. I do not need to perform procedures or prescribe drugs appropriate for an obstetrician or physician in order to provide midwifery care. If the proposed drug regulation moves forward, I would like to see support for midwives who would choose not to prescribe some of the drugs listed when care falls outside of “normal low-risk” scenarios and a move for the profession to start re-affirming midwifery care as care for healthy, normal low-risk scenarios.

    Thank you for your careful consideration of our feedback.

11. Midwife on November 21, 2019

    Until we are fairly compensated for the work we do, I am not interested in expanding the scope in which I practice which is essentially what the proposed regulation change will do. I also believe that midwives are specialists in low-risk pregnancies, and as such should only be able to prescribe medications required in low-risk pregnancies. Managing a higher risk pregnancy involves more than just the prescription of medicines. It should be managed by those who are trained in managing higher-risk pregnancies.

12. Midwife on November 21, 2019

    I echo the many statements here that are not supportive of an increase in training and workload without a change in compensation. I am similarly concerned about the Inclusion of anti-hypertensives and anti-convulsants. Why? Midwives are trained to care for low risk pregnancies.

13. Midwife on November 20, 2019

    I believe this proposed amendment would allow midwives to provide better quality healthcare to their clients. Having a larger scope when it comes to medications prevents clients from seeing multiple care providers for common conditions arising in pregnancy, and therefore, using less healthcare resources, staff and time. Also, it allows for better continuity of care and direct follow-up.. Furthermore, in small rural centres, it would allow for clients to receive the care they need in their own community (rather than traveling elsewhere to consult other healthcare providers). Not only would this amendment benefit midwifery clients, I think it would save time for midwives. Being able to prescribe a wider range of medications helps remove the “middle man” and saves midwives from consulting other healthcare providers for common remedies. At the same time, I am interested in having more information about the courses that would be required in order to have the appropriate certifications, including the costs and time commitment. Would future midwives receive this extra education in the MEP?

14. Midwife on November 20, 2019

    Currently seen as being potentially harmful to neonates.

    https://www.aappublications.org/news/2017/05/04/PASAntacids050417

15. Midwife on November 19, 2019

    The expansion of midwifery prescribing practices to categories rather than individual medications will allow clients to receive the best client centred care – and ultimately save tax payer dollars by avoiding unnecessary consultations simply for a prescription not covered in our current list.
    ***not sure if I just missed it – but I don’t recall seeing progesterone. Being able to prescribe this for preterm labour prevention would be nice!!

16. Midwife on November 19, 2019

    I am opposed to the changed in drug regulations. I do not feel that we/midwives have the education – even with the specified training to be done, or time to add more work to our plate. We are not trained to treat the conditions these drugs are for (e.g.,Labetalol, benzodiazapine and others). Also it seems to be another way for us to have more liability, responsibility and work without fair compensation. We have been trained for low-rise/healthy pregnancy and I would like to keep a clientele that is healthy and low-risk.

17. Midwife on November 18, 2019

    Thank you to the CMO for your work to make appropriate changes to the drug regulations for midwives. I support the change to use of categories of drugs and also categories of testing so midwives can be current wit ordering new drugs and or tests that are most appropriate for a given situation.
    There are cases where midwives could help avoid unnecessary visits to a GP, such as, if midwives can order hemoglobin electrophoresis testing, the full thyroid panel of testing and oral contraceptives. So in these cases I think the changes would be positive for midwifery clients as well as cost saving for the health care system.
    I do not however feel qualified to prescribe and care for women using B-adrenergic blockers.
    If this is passed and there will be mandatory training for all midwives is there any increase in compensation for the increased responsibility and workload?

18. Niagara Midwives on November 18, 2019

    I would prefer not to include haemostatics in our scope. I do not feel that a woman on blood thinners is someone I want to be providing care to. My main concern is actually around our training in this area; will the midwives be paying for training in all these new drugs? If the list moves forward, we are being asked to care for more complex people, with no increase in pay and then potentially a pay out of pocket for the knowledge.

19. Midwife on November 18, 2019

    I do see that to some extent autonomy in cases may be helpful. However, I do not support this proposed draft for further training and responsibility of expanding our designated drug regulation without further details. Also, I am not interested in further training or taking on increased responsibility and liability without fair compensation and insurance to reflect this increase in scope.

20. Midwife on November 15, 2019

    ** Related to comment received as Member of the public November 15, 2019 6:24 pm

    Sorry not a member of the public. I am a midwife.

21. Member of the public on November 15, 2019

    Happy to see these changes.
    It seems many members are rightly concerned about more work in an already under-compensated undervalued profession. I feel I’m already taking care of women who need many of these drugs and the proposed changes will lighten the load as I won’t have to always navigate an onerous and inefficient consultation process for things I’m capable of managing myself. It goes without saying that I will continue to transfer care appropriately whenever a situation arises that is beyond my capacity/capabilities/competency. If we view these proposed changes in conjunction with the Professional Standards it is very clear I’m responsible to decide what I can and cannot manage and what I am being held accountable for as a primary care provider . A positive move toward true autonomy.
    Two thumbs up CMO!

22. Midwife on November 15, 2019

    Thank you for your ongoing work at the College.
    I have worked full time for 9 years. I am grateful for some of these changes and hope to work in a scope that evolves as standards of care evolve (for example it would have been nice having NIPT in our scope when it became available). I understand that to be the goal of the CMO.
    I appreciate having more options for prescribing antibiotics (amoxicillin for both UTI and mastitis), appropriate anti-fungals for mothers and babies, contraceptives for midwives who wish to work in well women care.
    When I worked in BC, certain midwives with a need in their community could choose to take a specific training to prescribe contraceptives for example. Exploring choice for midwives to expand their scope and choice of having additional training would be in my opinion safer for clients and midwives.
    I do also like the idea of expansion of scope for drugs for PPH and IOL. However, midwives have this expectation of being the sole care provider for the entire duration of labour and I would like for the expectation to change so that we are present for the duration of active labour. Due to our expanding scope and less need to consult, midwives at my hospital are being offered less nursing support making it more likely for midwives to work more than 24h-36h for one client. Midwives need a better integration system where we can use nurses for all in-patient early labour inductions especially with an expanding scope. Exploring the possibility of having a midwife be on the floor for consults, triage assessments and early labour inductions would be beneficial for our profession and integration.
    Prescribing drugs for high risk clients like anti epileptic drugs would be best done as a team based approach. I understand that midwives in rural communities may be the most experienced care providers for these clients but in my urban community, for client safety, it would be much safer for obstetricians to take over care. A midwife in a very rural area could call the receiving physician to help manage her pre-eclampsia/eclampsia as a team. I would also like to state that as a midwife I am competent in pregnancy, birth and common postpartum ailments, however I am no expert in illness and I do not intend to be unless my client population changes drastically.
    How safe is it for midwives to prescribe and administer magnesium sulfate if in over 9 yrs of practice only 1 of my clients has needed it?
    My main point here is for midwives to have choice in their scope and choice in what additional training they want/need based on their community’s needs.
    I thank you for seeking our input on the possible changes to our scope.

23. Midwife on November 14, 2019

    Labetalol and the benzodiazapines stand out to me, as I would think if a client is requiring these prescriptions that is outside of the healthy low risk normal a midwife would be managing. I do not feel comfortable prescribing labetalol, there is a reason we consult for high blood pressure, I do not feel it’s in my scope to prescribe that or then manage a pregnancy on that.

24. Midwife on November 13, 2019

    I have already made a comment but have (many) further thoughts on the matter, the most salient of which are these:
    1. How does the ministry expect to roll out these changes when many many midwives across the province already don’t work to our full scope?
    2. Even in full scope settings like mine, I do not expect OB buy-in on some of these proposed changes such as anti-hypertensives. And it’s delusional to think that collegial relationships can be maintained without OB buy-in. Let’s get ALL Ontario midwives running oxytocin and epidurals first before we jump the gun on higher risk care.
    3. The proposed prescription legislation can change- that doesn’t mean anyone needs to actually implement it. No once can force me to provide care I’m not comfortable with and quite frankly unless the ministry compensates me fairly I have very little interest beyond adding contraceptives for well woman care.

25. Midwife on November 12, 2019

    Thank you for providing the information regarding the proposed drug regulations amendments. There are several positive changes that I would like to highlight:
    1) move towards umbrella terminology
    2) inclusion of contraceptives
    3) antibacterials

    I was wondering if we can include the following to the list (as these are the most common reasons I send clients to see their GP/consult with OB). Apologies if this is already covered in the proposed amendments.
    1) Thyroid testing (TSH, T3, T4)
    2) Hb electrophoresis
    3) vitamin B 12 testing
    4) anti-acid prescription
    5) feto-fibronectin
    6) liver enzymes

    I should note that although the proposed changes to the drug regulations is generally positive, I am a bit concerned about the fact that:
    1) many of these medications are outside our current scope of practice and would require significant training
    2) increased responsibility without reciprocal increase in pay (midwives need to be paid equitably for their work).

    I would also like to note that there was little information presented regarding the rationale behind the inclusion of some drug categories: e.g benzodiazepines. I think it would be beneficial to understand why the CMO has proposed certain drugs to be included.

26. Midwife on November 12, 2019

    I think that it is disgusting of the Ministry to task the CMO with undertaking such a project in the same budget year as our funding was cut and we have had to scale back.

    I think this change will benefit clients in terms of convenience, access, streamlining treatment and continuity of care. It will validate midwives in that we are currently undermined every time we need to consult for a drug which really falls within our scope. The health system will save money and physician time will be freed up. It will also save midwives time when they are able to access treatments for their clients on the wards when needed instead of waiting (often for hours) until the doctors are available.

    This change will however mean increased responsibility and work load for midwives in a climate where we have already proven in court that we are not compensated adequately and the government is actively fighting against making things right. Yet again, the government is asking midwives to subsidize health care provision and I for one am sick of it. I would ask the CMO to make a statement within the proposal that they urge the Ministry to collaborate with the AOM to ensure equitable compensation for this expanded scope.

    I am especially happy with the prospect of prescribing for early miscarriages and pregnancy terminations as well as contraception.

    I am whole heartedly against the inclusion of cardiovascular and anticonvulsant drugs in our pharmacopia. I simply cannot reconcile hypertension management with healthy/low-risk. Midwives working in low resource or remote areas would be best served with medical directives for initiating therapy in emergent situations until a physician can be consulted. I believe that having these drugs in our purview infers that hypertension is normal and within our scope and I don’t believe that it is.

    As an aside, as others have mentioned, it is time to reexamine the list of approved lab tests. There are so many “every day” investigations that our clients cannot access without the inconvenience and cost to the system of seeing a physician.

27. Midwife on November 12, 2019

    Thank you for the insightful comment. I agree with you completely with regards to the government getting lots and lots of cost savings at the expense of our time and energy. Until we see the major pay equity adjustment that we are waiting for, we should not be entertaining taking on increased responsibility. As you say, the CMO deals with regulation and not compensation but these issues really can not be addressed independently.

    I have to disagree with you though on the suggestion to add insulin, metformin, thyroxin and antidepressants to our pharmacopia. I feel that these are quite out of scope and if people require these medications, they should be under the care of a physician for their issues. There is also the matter of there not being a funding mechanism for providing pre-conception care at present.

28. Midwife on November 11, 2019

    My thoughts echo what most have already mentioned but I will state them so that our thoughts are heard:
    -A substantial increase in pay is needed if we will be required to prescribe and administer these drugs. We will be spending more time in training and administering drugs (eg. inserting cervadils and monitoring for two hours after administration will take a great deal of time) and we will presumably pay higher insurance rates with this expanded pharmacopoeia.

    -I would like to see valacyclovir added to our scope for HSV prophylaxis. I also hope that the antibiotics such as penicillin will be drugs we can prescribe at any point in pregnancy, labour and postpartum.

    -I do not want antihypertensives, anticonvulsant, or hemostatics added to our scope. Women who require these drugs are high risk and not within a midwife’s scope of practice. I included hemostatics in my list because tranexamic acid has currently only been proven to be effective in reducing blood loss in clients having a C-section. It does not make a significant difference in vaginal births so I don’t see why we would need to prescribe this.

29. Midwife on November 10, 2019

    I would definitely like to see some additions to the the list including antivirals for HSV prophylaxis and progesterone for miscarriage & preterm labour prophylaxis.

    While not a part of this regulation full access to lab testing e.g. TSH would be very beneficial, ordering Zika testing.
    I look forward to seeing the appropriate training provided to midwives and the expansion of compensation to include the increase in responsibility.

30. Midwife on November 7, 2019

    I definitely agree this is a step in the right direction, it is poor use of the training of midwives when there is so much restriction with specifying certain drugs from a broad class. The amendments are not changing the scopes of practice under the Midwifery Act 1991. Unless midwives get into specialised training for higher risk pregnancies, I don’t believe we should be prescribing cardiovascular drugs , anticonvulsants MgSo4 which is used in preeclampsia, or electrolyte meds Calcium Gluconate / Carbonate.
    These changes are good for our clients especially if have no access to GPS or NPs .
    if midwives are deciding they want to prescribe contraceptives there should be a certification training.
    Please add silver nitrite sticks to the list useful in treating granulomas after cord separation.
    As far as training programs re pharmaceuticals let us not reinvent the wheel , other provincial Jurisdictions have online resources and guidelines in place.

31. Lincoln Community Midwives on November 6, 2019

    I support the drug expansion. It will reduce barriers to care experienced by clients and will avoid delays in receiving care due to the inefficiencies of having to arrange a consult for something that I feel should be within my scope (e.g. order a narcotic for patient who is in early labour, order a tDap booster, order birth control).

    I do believe that we would receive compensation for work that is part of this expanded scope and this is the duty of our professional organisation to lobby for this.

    I predict that by expanding our scope this also will allow me to work in a capacity that is beyond the traditional model of midwifery care — and this is something I welcome into our profession. I would like to see the ability for a midwife to use her skills in other areas of the healthcare system. This is also where appropriate payment and billing mechanism need to be created and supported.

32. Midwife on November 4, 2019

    I think that the list you provide is extensive and complete. I would, however, recommend cross referencing with other Midwifery Colleges across the country. I trust that the CMO has already done this, but in the event that it has not, here are the links to the Standards, Limits and Conditions for Prescribing in BC:

    https://www.cmbc.bc.ca/wp-content/uploads/2019/10/Standards-Limits-and-Conditions-for-Prescribing-Ordering-and-Administering-Therapeutics.pdf

    https://www.cmbc.bc.ca/wp-content/uploads/2019/10/Standards-Limits-and-Conditions-for-Prescribing-Ordering-and-Administering-Therapeutics.pdf

    https://www.cmbc.bc.ca/wp-content/uploads/2019/10/Standards-Limits-and-Conditions-for-Prescribing-Ordering-and-Administering-Drugs-for-STIs.pdf

    https://www.cmbc.bc.ca/wp-content/uploads/2019/03/Standards-Limits-and-Conditions-for-PrescribingOrdering-and-Administering-Contraceptives.pdf

    Thanks so much for soliciting member input!

33. Kenora Midwives on November 2, 2019

    Antiviral agents should be included (Acyclovir, Valcyclovir etc.)

34. Midwife on November 2, 2019

    This seems an excellent adjustment that may help us provide more streamlined client care and also may help pave the way to a very valuable expansion of scope.

35. Midwife on November 1, 2019

    Until the model is fixed, burnout is addressed and the gov starts compensating us fairly, I want absolutely no part of this.

36. Midwife on November 1, 2019

    I echo the concern about midwives already not receiving appropriate compensation for the work we do, so to take on more responsibility is unimaginable. Besides the extra work for midwives, and the stress on individual midwives who are already struggling in an unsustainable work load, the ministry needs to take into account the cost of providing the means of providing expanded care. For example, it’s all well and good to give midwives the opportunity to prescribe vaccines but unless the capital investment is provided for vaccine refrigerators, we will not provide the service in our clinic.

37. Midwife on November 1, 2019

    I would like to see a template for how the College plans to educate its members on this extensive change. What kind of time line are we talking, how many hours of education and is this an appropriate amount of time to truly allow for the skill, knowledge and judgement required to prescribe such an extensive list of medications?

    As well, I understand there are reasons for the change such as keeping up with the standard followed by other prescribing bodies… but to be frank, I find it infuriating that the provincial government is requiring such a change from us while simultaneously ignoring and denying the validity of the HRTO’s decision. I know the College is in place to protect the public but these issues are intertwined and I cannot comment on the proposed changes without referring to this.

38. Midwife on November 1, 2019

    I am thrilled about these proposed changes, as it will remove significant barriers for our clients in accessing vital health care services such as contraception. I’m happy to see that Ontario will finally catch up to other provinces/regions in the world where midwives have an expanded scope such as BC. I’m particularly excited about the ability to provide sexual health services, including medical abortion, IUD insertion (I already have the training, but cannot prescribe), STI treatment, and contraception. For clients with limited resources, these additional midwifery services will be especially beneficial. I’m quite tired of having to tell folks that, for example, the tDap vaccine is recommended, but sorry, we can’t provide it for you, you’ll have to make another appointment with another provider. This is costly for both the system and our clients. And I’ll be more than happy to never have to wait a few hours when the floor is busy for a consult for narcotics in early labour again. In this way, I see some of these changes as actually reducing our workload.

    I completely understand the concerns raised by others, and feel that midwives should be able to choose whether they wish to seek out the training to expand their scope in this way, as they do in BC. And also feel that it will be essential for us to be able to bill for these additional services.

39. Midwife on November 1, 2019

    I echo the same excitement and concerns of many of the postings.
    I am excited to be able to offer more comprehensive care where simple barriers make annoying workload issues (ex sending notes with clients to GPS to get abx prescriptions) or using oxytocin independently after 10 years of experience with it. However I have concerns with workload and the time and money it’s going to take to maintain competency. I don’t think midwifery will be very sustainable for me within the next 10 years. As an example, can’t imagine running full inductions from prostaglandins to birth without serious implications for my midwife team. How much more on call can we work and how can we preserve mw/client relationships!

40. Midwife on November 1, 2019

    I am not interested in expanding my scope / responsibilities / liability in any way until we start to receive adequate compensation.

41. Midwife on November 1, 2019

    I appreciate the comments that have been shared so far.

    I am in agreement with worries about expanding responsibilities and workload without also increasing compensation.

    Perhaps
    It would make sense to offer the expanded pharmacopeia as a special certificate (as they do in BC), so that individual rmS can choose whether they would like the expanded authority or not.

    I am also interested in expanded ordering authority to include drug screens, tsh, PIH
    Labs, hep c RNA, etc.

    I would like to be able to prescribe OATs just as Nurse Practitioners do (very happy to do the same training they do). At this time I am sometimes more knowledgeable about this than the on call OB, which means an awkward situation where the physician is asking me what to do. This can make people feel uncomfortable.

42. Midwife on November 1, 2019

    I agree with those that recognise that these expansions will increase our workload, training, responsibility, and liability with no foreseeable compensation.
    Midwives would be saving the ministry MILLIONS in consultation fees without any reciprocity.
    I worked in BC when the pharmacopoeia was expanded to include morphine and benzodiazepines and MIDWIVES had to pay $400 out of their pockets for the training. Absolutely ridiculous.
    Yes, I want the access for my clients; but at whose expense? My own?
    The last email I just read was about how our short and long term leaves have so significantly increased over the past year. Are we crippling ourselves? Are we burning ourselves out?
    Yes.
    and unfortunately its because we are working ever harder and harder and harder for our clients without the proper support, compensation or recognition.

43. Midwife on November 1, 2019

    I believe the public will be much better served with midwives able to prescribe well within their scope of practice. The proposed changes will mean much less money spent on unnecessary consults for medications a midwife can easily prescribe (i.e. for UTIs unresponsive to first-line antibacterial agents, for acyclovir prophylaxis, for IUD insertion at 6 weeks postpartum, etc.).

    Along with these proposed changes, I would also propose a way for midwives to charge for performing at an increased scope. For example, performing ultrasound and inserting IUDs. Expanding the scope of practice in a profession that is already underpaid just compounds the issue.

44. Midwife on October 30, 2019

    The section on contraceptives seeming does not include combined hormonal non-oral contraceptives, specifically the patch and the vaginal ring.
    Vitamins B6 and K should be included, however, I would assume vitamins to include any vitamin.

45. Midwife on October 29, 2019

    I agree with some of expansion and not others. Some of these medications will expand the scope beyond normal and low risk to more complex clients. As pointed out training would be necessary to expand the scope of my role. I do not wish to have mifepristone and mifegymiso for medical abortion either. This is a role not desired as I became a midwife to deliver babies and would only use these in the case of incomplete miscarriage/abortion and this access would be most helpful along with training in u/s to confirm findings of same.

46. Midwives Grey Bruce on October 28, 2019

    I echo the previous comments regarding concerns of training and compensation. In this current political climate, I urge us to carefully consider the work we are signing ourselves up for. This proposed drug list is a dramatic expansion from our previous list. It will require a lot of education and time (likely uncompensated) from our membership. Would it be prudent to take smaller steps to an expanded drug list? Could we select areas of highest need and proceed there? Ie. considering starting with some groups before others. In my opinion, contraception and vaccinations would important remove barriers to care. In my experience clients may not access contraception or vaccinations if they are not available in our office, even though they are otherwise interested. However, someone with hypertension would have ready access to labetalol through another health care provider with an urgent consult.

    I also urge us to carefully consider the direction we are taking. I see treating hypertension with labetalol as a step towards an entirely different direction of midwifery in Ontario. I believe there should be more extensive polling and opportunity for discussion amongst our membership before proposing such a drastic shift.

    Lastly, it is unclear to me if restrictions will be listed on when these drugs can be prescribed. For example, would Pen G be able to be prescribed for a prenatal UTI as well as for IAP in labour?

47. Midwife on October 25, 2019

    I will take on this pharmacopeia ONLY if we have pay increase, sustainable work hours or some other incentives. More respect interprofessionally, more midwives, more support.

    I DON’T want beta blockers, seizure medication… I rather have pharmacists take on that role.
    I’m amendable to narcotics intrapartum, abx for sti/gbs bacterurea, Abx post partum, iron infusion, contraception, and stronger pain meds besides naproxen and diclofanac.

    More than meds, I rather have the scope to order such things as NIPT, pediatric ultrasounds, consult with endocrinology, psychiatry.

    Before rolling this out, let’s survey all the active mws who want this extra work for free.

48. Midwife on October 25, 2019

    As a midwife of 12 years, I am excited about some of the proposed changes but I am also disappointed that the College of Midwives would consider expanding our scope of practice to include such medications to manage hypertensive disorders and seizures! I am not interested in increasing my work load, attending more mandatory learning for pharmaceuticals, that will require me to maintain competency, while there is absolutely no discussion on how our scope is no longer low risk and yet we are not compensated appropriately for the expanding scope of higher risk care being provided.

    In my opinion, this is another example of how we are not being compensated for the work we already do and now we are being required to do more (simply because we are women).
    Midwives pride ourselves on low risk obstetrical care. Our pharmacopoeia should reflect that. While some of the changes proposed is excellent, I feel the need to draw the line at beta blockers and anti seizure medications!

49. Midwife on October 24, 2019

    While some of these changes are very welcome (eg. contraceptives and treatments for STI) in the sense that they reduce barriers to care by eliminating the need for consultation to GPs, there are also other classes in this proposed regulation change that are absolutely beyond the scope of HEALTHY and LOW RISK. This is both a philosophical issue as well as one of appropriate training and appropriate compensation. If we are to now be expected to care for higher risk clients, we should expect to be renumerated as such. If I wanted to care for hypertensive clients as their MRP, I would have become an obstetrician with 3 times the income and 1/7th the on call time. I find these proposed changes very concerning and generally largely unwelcome.

50. Midwife on October 24, 2019

    I think this is a good step moving forward in benefiting our clients. Although I am seeing our scope, workload and responsibility increasing without increasing compensation for midwives. Midwifery is quickly becoming unsustainable as a profession if this continues. The increasing scope is beneficial to clients but not to midwives. In a profession that requires significant sacrifice on a personal and professional level, things need to change. by change, I do not mean increasing our scope to include more work without equal compensation. The college should bring this back to the ministry saying midwives will only expand their scope when we get paid more! I can’t imagine trying to arrange for off call time, and pay for another course that I need to maintain my license as a midwife, let alone the college and AOM fees.

51. Midwife on October 16, 2019

    As a new midwife, I am not interested in expanding my scope to include categories of drugs and substances that we as midwives are able to prescribe. This entails more responsibility and liability for us as midwives and without an increase in our wages, I feel this is adding extra work to already tired midwives. I do not recommend this change unless we see a change in our compensation to reflect the added responsibility this change will include.

52. Midwife on October 15, 2019

    I think this expanded list is exciting and overwhelming. It has the potential to remove all kinds of barriers to access to care and seemingly unnecessary referrals to NP/GP/OB (contraception, vaccines, antivirals, GBSuria, Tdap, narcotics in labour). But I am concerned about the use of labetol (also antiseizure meds) the stretch of “low risk” and the slippery slope of expanded scope without appropriate compensation.

    Would there be room for phasing in some of these drugs?

53. Midwife on October 10, 2019

    I am in full support of the proposed changes to existing drug regulation.

54. Midwife on October 10, 2019

    Hello- I am greatly in support of these changes. I have taken the SOGC course on IUD insertion and also the medicalized abortion training and am very interested in using both of these trainings in my practice. However, I need to have the prescribing rights. As midwives are able to expand their scope in the future and also with new alternate practice arrangements underway in communities across Ontario, it is absolutely essential that we are able to prescribe and and administer a wider pharmacopoeia. Also essential to this is further training to ensure competency and ways to bill so that we are able to be compensated appropriately.

55. Midwife on October 4, 2019

    Although I think the classification system is a necessary step, some of these categories extend beyond normal, low-risk care that Ontario Midwives provide. For example, management of hypertension in pregnancy. Why would I be able to prescribe medications to treat, but not order lab tests to monitor? This extends well beyond our appropriate scope. However, I am happy to see the addition of contraceptions and STI treatments. If this regulation passes, the College must ensure that proper education is available to all Midwives, and must establish clear guidelines regarding scope. Also, I believe it is extremely important that the College support any and every Midwife who does not feel she/he/they have the appropriate skill, knowledge or judgement to prescribe/administer these additional medications, though they may be within our scope. As reflected in many of the previous comments, I am also very concerned about the expansion of scope/pharmacopeia/knowledge/training/etc. without fair compensation, including in the case of use of abortifacients, where care provided is < 12 weeks – surely it is not unreasonable to expect compensation for this. I sincerely hope that the College of Midwives will advocate for their members while pursuing this extended pharmacopeia.

56. Member of the public on October 3, 2019

    I am happy to see sexual health being added to the scope of midwifery care in the form of abortifacients, IUDs and STI treatments.

57. Midwife on October 2, 2019

    There are medications in which the condition they would be used for requires an OB consultation and potential management under current CMO consultation and transfer of care standards (e.g. labetalol and magnesium sulfate for gestational hypertension). Using this specific example, I feel that the need to utilize medication to in order to manage hypertension is moving beyond the realm of low-risk obstetrical practice, therefore having the ability to prescribe these medications is moot and not appropriate for the current Ontario midwifery scope.

    I would appreciate the wider range of antibiotics that would be available – particularly for UTIs (e.g oral penicillin for the purpose of treating GBS bacteriuria) as it eliminates the need to refer back to the client’s GP/NP. Including tdap and influenza vaccines is important to include in our pharmacopoeia as it reflects current immunization recommendations and also promotes continuity of care(r) as clients would not have to be referred back to their GP/NP for these immunizations.

    I think it would be great to be able to prescribe birth control, however, if we are to prescribe IUDs, then we also require standardized training to insert them…as well as amend our scope to order non-obstetrical ultrasound to assess correct placement of said IUDs.

    Overall, I am excited to see this change occurring as it promotes midwifery autonomy, however with an expansion of the pharmacopoeia, I like many others, have concerns about the increase to our already heavy work load in relation to our compensation.

    Further education to be completed for the new pharmacopoeia should include not only responsible use for narcotics but also all new medications which become available to midwives. This training should be provided to midwives at no cost until it is well incorporated into MEP/IMPP curriculums, and should be delivered in a manner which has the lowest impact to the midwifery workload (e.g. asynchronous online training modules).

58. Midwife on October 1, 2019

    I believe the new proposed regulation is an important step towards patient-centred, efficient care for clients and their families. Although I am in agreement with broadening midwifery scope and autonomy, I believe the following must also be considered:
    1) Clear statements or guidelines on the scope of midwifery care
    2) Further education/refreshers on all of the new drugs used in pregnancy that we will now be able to prescribe, not only narcotics
    3) Ability to order the associated tests to be able to diagnose and monitor the conditions that these drugs are used for
    4) A concerted look at alternative compensations models for ancillary services.

    Although I am a big proponent of the current model of care, there is a need within Ontario’s health care system to streamline, integrate services and work together. Midwives need to be a fully functional participant in OHTs. They need to have the ability to fill in the gaps in the system, and to do that, we need to be able to order tests and treat pregnant people and their babies when next-to-normal complications arise. I think it is an integral step to garnishing more respect and consideration from our health provider peers, which will improve care for the familes/babies we serve, as we advocate for normal birth.
    I would love to be able to move beyond saying
    “I know exactly what needs to be done but I just can’t do that” when other providers who may have less experience with labour, birth and babies can.”

59. Midwife on September 30, 2019

    I have a question regarding the drug amendments. Since some of the medication categories that will be included include medications for the management of hypertension, will the labs required to assess hypertension also be amended such that midwives can order them? Otherwise midwives will still need to consult for the lab work required to determine the appropriate plan of care and won’t be able to proceed with management until we secure a physician to order the labs, still delaying care and treatment. Thanks!

60. Midwife on September 29, 2019

    The proposed amendments to the Designated Drugs Regulation are necessary. It is ridiculous that midwives are bound in their prescribing authority by clinical condition; if a midwife is versed in the pharmacokinetics and pharmacodynamics of a drug, then they should be able to appropriately prescribe that drug regardless of if it’s for GBS bacteriuria or mastitis.

    Additional education will be required to ensure clinical competency in the ordering of narcotics. However, this has already been accomplished for midwives in British Columbia and Nova Scotia, thus accessing this education should not be arduous.

61. Midwife on September 26, 2019

    While I am excited to see some much needed improvements to pharmacopea (antivirals. Antibiotics. OCPs etc) I am unclear as to why midwives would ever need to prescribe some of the meds used in management of the high risk patient. (antihypertensives, Mag sulph. Etc). I can’t order liver or renal function tests but I can treat hypertension?
    I feel this will further compromise relationships between midwives and physicians, confuse clients as to our role as low risk car providers and burn out midwives who are already taking on more than we ought to for minimal compensation.

62. Midwife on September 26, 2019

    If these proposed changes come into effect there is an increased level of responsibility, new education requirements and added stress/work load. Will we be compensated fairly for all of this increased work? While some drugs on this list would be helpful in streamlining healthcare i.e. contraceptives, antibiotics, prostaglandins. The rest would require extensive education in order to be fully prepared to integrate them into my practice. Will the time set aside for education be compensated for? With a 40 BCC case load in primary care?

63. Midwife on September 25, 2019

    Changing the Designated Drug Regularion is a great idea! Categories of drugs allows Midwives to prescribe the best option and not tax the health care system for silly referrals. Additionally allowing us to prescribe with MD:NP authority is also very helpful! Medication categories should include care from preconception to 1 year post partum, including methods to terminate a pregnancy and deal with STIs.
    Very excited to see these changes implemented!

64. Midwife on September 25, 2019

    I am writing as a registered midwife to support this change to amend the Midwifery Drug regulations to include the AHFS categories. This will result in more timely and appropriate care for patients as midwives will be able to prescribe and administer the most appropriate, evidence based medications rather than being restricted to providing only a specific list of medications that can change from time to time, resulting in midwives having to administer outdated medications or make additional unnecessary referrals. This will mean fewer transitions in care as patients will only need to be seen by their primary caregiver (midwife) and won’t need to involved additional providers simply for the purpose of accessing medications. This will result in safer care for patients. There is good evidence that allowing providers to practice to the fullest extent of their scope, while ensuring competence and confidence results in safer, more efficient, effective, patient centred, accessible care at a better value.

    I would encourage colleagues who have questions to ensure they have read the drop down sections that have the bolded questions above as they list some additional details.

65. Midwife on September 25, 2019

    I am writing to say that I am very excited about this proposed new legislation and the opportunities it holds for improving access to comprehensive prenatal, intrapartum, and postpartum care in Ontario. In particular the addition of contraceptives, antivirals, and abortifacients are essential aspects of reproductive healthcare that will dovetail nicely with the care that midwives are already providing. That said, my concerns (which appear to be echoed amongst many of my colleages) are twofold:
    1) How will the College and the province account for knowledge gaps around safe prescribing of added medications? Will this be up to our College (who was recently with a major funding cut from the same government seeking to expand our scope of practice) and Association, or will there be additional government funding for comprehensive continuing education around these topics? By comprehensive I mean available in a variety of formats including in-person sessions, free, accessible throughout the province, and designed with midwifery workload/on call care providers in mind. The medications I am particularly concerned about include opioids, antihypertensives, benzodiazepines and the expanded list of antibiotics. Comprehensive contraceptive prescribing resources already exist from the SOGC but continuing education on this topic will also be beneficial.

    2) The addition of medications for termination of pregnancy (including medical management of miscarriage) is an important move in my opinion, however it carries the necessary question of reimbursement when usage of these medications implies that a midwife will not be able to bill for a complete 12 week course of care. Will billing codes be added for termination of pregnancy or will midwives be expected to provide this service for free? I believe that providing midwives with a financial incentive to provide out-of-hospital management of miscarriage and therapeutic abortion is in the province’s interest, in terms of reducing healthcare costs and the province’s stated goal of ending “hallway medicine” (ie. overcrowding of hospitals and particularly emergency rooms), in addition to expanding access to these services. Early access also facilitates cost savings, as medical management out of hospital can be carried out in early pregnancy, but delays to accessing care necessitate surgical management and hospital admission. Well-compensated midwives can provide this care out of hospital when appropriate, but not receiving compensation for this service will certainly mean that many midwives (who I remind the Ministry, are underpaid and overworked) will not take on the extra workload and will send clients to the ER anyway.

66. Midwife on September 25, 2019

    I think this needs work but am very pleased with the direction this is going!

67. Family midwifery care on September 25, 2019

    I am not seeing the category which would allow us to prescribe rhogam, epinephrine, cervical ripening agents (cervidil and prostaglandin gel)

68. Midwife on September 25, 2019

    Would like to see
    Antivirals for prophylaxis treatment of herpes
    Range of antibiotics for gbs and bladder infections

69. Midwife on September 25, 2019

    This is an exciting change, but also daunting! With more power comes more responsibility! Will be interesting to see how these changes are received by our OB colleagues!

70. Midwife on September 25, 2019

    I think this is a very positive move forward. It will provide clients with quicker treatments, especially those who are less mobile, of lower socioeconomic status, and without health insurance. In my experience, treatments of STIs have been significantly delayed due to midwives inability to prescribe the drugs necessary. This move forward removes an unnecessary barrier to those with the least access.

71. Midwife on September 24, 2019

    Updating the current Designated Drug Regulations is overdue and I’m glad this is happening. As a practicing midwife there are several medications that I routinely need to refer my patients back to their family physican or to an obstrician , often to significant inconvenience of the patient and resulting in delayed treatment. This can be confusing for the family physician if they are not overly familiar with midwives and our limited pharmacopoeia. I need to be able to prescribe penicillin and amoxicillin for the treatment of UTI in pregnancy and postpartum. I also need to be able to prescribe antivirals such as acyclovir, for the prophylactic treatment of genital herpes. I often have a significant delay in appropriate pain management for my partients who are experiencing very painful early labour and require morphine for therapeutic rest. I need to consult with the OB on call and then they often need to do their own assessment that may take several hours as the patient is not medically a priority. I am also hesitant to consult my on call OB at my level 2 hospital during the night for therapeutic rest as it is not an obstetric emergency. They often do not appreciate being woken in the middle of the night for this consult. It negatively affects my professional relationship with my consultants. It makes midwives as a profession look foolish and unorganized. It undermines us. Thank you for your time.

72. Midwife on September 24, 2019

    I have 2 very contradictory points of view about this proposed drug reg change.
    First, in the face of ongoing pay inequity, I see this list of medications under a midwife’s prescription pervue and think, we don’t need more work. There is the work of initial and ongoing education and familiarity with using the drugs, the extra work of now managing clients we would have transferred care for or shared care for, and this likely meaning caseloads will have to decrease in order to provide all the care we will be aloud to provide.
    Given the lack of proper compensation, it is on the backs of midwives, again, that the government is decreasing costs for care. I understand that the college is not a body representing the midwives in advocacy or collective bargaining, that it’s responsibility is to protecting the public interest. It is still hard to see the continued growth of responsibility in the face of stagnating and already inadequate compensation.
    That said, I also applaud the work done by the College to get to this point. Great job!
    I would add thyroid replacement hormone (we may evolve to prescribe for pregnant people with borderline low thyroid function), biguanides (metformin) as it can be used preconception in the face of difficulty conceiving with PCOS, Nitrates (for use of nitoglycering as tocolitic), insulin as some hospital protocols require even diet controlled GDM clients be put on a sliding scale insulin during labour, SSRI’s as depression and anxiety are sooo prevalent in our client populations.
    I will assume that the CMO will source out and approve education for on boarding midwives once the new reg is in place.
    This is all I can think to add to the list at this time. I will consider this and may bring more feedback to the October council meeting.
    Thank you for the opportunity to give feedback.

73. Midwife on September 24, 2019

    I am curious what the purpose of having some of these items under midwifery scope such as mag sulphate, labetelol, and lorazepam…..if a client was in need of these medications they would require involvement of an OB anyway I would expect and therefore it seems like adding extra responsibility when midwives would not be managing these conditions.

    I would like to additionally see progesterone added for prevention of preterm labour. In my area, it is widely prescribed for women with a history of preterm labour and requires a consult. often the OB continues to see the woman and it results in two care providers providing care.

74. Midwife on September 24, 2019

    I do not see Midwives as obstetrical care givers to feel comfortable to use these medications . I do not see Midwives to use these additional drugs frequent enough to keep up with knowledge required.

75. Midwife on September 24, 2019

    Moving to categories is the only reasonable approach to allow for appropriate and responsive care for midwifery clients. Standards and recommended practice changes constantly and there is no way a limited list of specific drugs for specific indications can allow for midwives to prescribe appropriately and to keep up with changing evidence.

76. Midwife on September 24, 2019

    Ranitidine for Neonatal GERD

77. Countryside Midwives on September 24, 2019

    since the ability to administer medications not in our pharmacopoeia is being repealed, what replaces this?
    There are times that medications outside of our scope are prescribed, such as progesterone injections, (to prevent PTL) and can we still administer this? (at least it looks like that will be outside of our pharmacopoeia)
    And if new medications come to being that are not currently in a class we have authority to use, how will this be handled.

    Will we now be able to prescribe oxytocin and prostaglandins for cervical ripening and induction on our own authority under our own college guidelines, and only consult regarding unit ability to manage said inductions?

    Thanks