Prescribing Medications New to Midwives

Are midwives required to offer all of medications in the Designated Drugs and Substances Regulation?

Many new medications were added to the legal midwifery scope of practice in 2024, and the College of Midwives of Ontario (CMO) is recommending further expansion to the Ministry of Health. Midwives are not required to prescribe or administer every drug listed in the regulation. This is explained in Section 3.3 of the CMO’s Scope of Practice document.

Before administering any drug or substance authorized to midwives in legislation, each midwife must ensure that they have the knowledge, skill and judgment to do so safely.

See Designated Drugs and Substances Regulation

[July 2024]

What does the CMO require before midwives can add new drugs to their scope of practice?

The CMO provides resources describing the drug regulation and what is required of midwives. The CMO does not specify the training required, with the exception of the regulatory training required for controlled substances (opioids). On their resources page, the CMO states:

Midwives must be competent in all areas of their practice including prescribing and administering drugs and substances.

As such, prior to initiating any drug therapy, midwives must have sufficient knowledge, skill, and judgment to use the drug or substance safely and effectively.  Anything less may constitute professional misconduct. Midwives are expected to seek out the resources, courses, and training they need to be competent at prescribing or administering drugs and substances.

The CMO recognizes that midwives have different educational backgrounds and experience and different learning needs.

[July 2024]

What should midwives read before prescribing every medication new to their scope of practice?

•           The Health Canada Drug Product Data Base online query provides approved product monograms for health care providers. Drugs with lengthy market histories and established safety profiles may not have a product monograph in the data base. If this is the case, read the package labels and inserts, which are also approved by Health Canada.
•      The AOM RM RX pharmacology app is a convenient and curated educational guide. It provides prescribing information and links to trusted sources for further information.
•           Clinical Practice Guidelines and recommendations from sources like the AOM, the Society of Obstetricians and Gynecologists of Canada (SOGC), local/provincial/national Public Health organizations, the Provincial Council for Maternal and Child Health (PCMCH) and the National Advisory Committee on Immunizations (NACI) should be consulted for information about protocols and best practices for using specific medications and vaccines.
• .        Institutional policies and protocols should be reviewed for medications used in hospitals or birth centres.

These four sources may provide enough information for a midwife to begin prescribing or administering some medications. The midwife may already have considerable knowledge and experience managing a specific condition and the new drug is an additional option in a clinical treatment algorithm. For example, if the midwife has experience diagnosing and treating urinary tract infections (UTIs) in pregnancy and a new antibiotic is added to the list that can treat UTIs, the midwife may be able to easily incorporate the new drug into care management by reading product monographs and consulting guidelines and protocols.

[July 2024]

When is a more extensive learning plan recommended?

Offering new types of care or using classes of drugs that are unfamiliar may require more comprehensive learning plans. Before midwives start prescribing contraceptives, or inserting IUDs, or administering narcotics or any other new care process made possible by the changes to the regulations, they must ensure that they have the necessary knowledge and skill.

Midwives should consider taking courses (in person or on-line), attending webinars or conference sessions, and/or receive mentorship or instruction from an experienced practitioner. For examples of courses to consider, see the Education section on the Safe Medication Practice web page.

[July 2024]

Is specific training required to administer or prescribe opioids (controlled substances)?

The Controlled Drugs and Substances Education and Training or Course Requirement policy explains CMO requirements. For midwives who have not yet met the requirements, the CMO offers a free on-line training webinar. Some hospitals may also have required training for administering opioids.

It is important to note that the CMO training focuses on laws, regulations and standards midwives must follow. It also provides information about the opioid crisis. The training does not provide the clinical knowledge required to add the medications to the midwife’s scope of practice.

[July 2024]

Should midwives keep a record of their learning activities?

Keeping a record of learning activities may be helpful if the midwife’s competency to provide the care is ever questioned in a legal, regulatory or hospital proceeding. This is particularly important if the necessary skills and knowledge are new to the midwife’s scope of practice and if the training required is more than reading monograms and clinical practice guidelines. The record can be kept in any format, in a personal file. The record may also be a helpful reference when the midwife is required to submit a Professional Development Portfolio to the CMO.

[July 2024]

Should midwives attend sessions provided by pharmaceutical companies?

Pharmaceutical companies sometimes invite midwives to training sessions or “discussion groups” about their products. Choose wisely how to use drug company training. Where special skills or knowledge are needed for administration, it may make sense to attend a product demonstration or training session hosted by the manufacturer. This may be one of the PD opportunities midwives undertake to ensure they are ready to provide the new care.

Midwives should be aware that, despite Canadian laws prohibiting advertising or promotion of prescription drugs and devices, some sessions provided by pharmaceutical companies may include incomplete, inaccurate and biased information to promote their products. Health Canada provides guidance on the difference between promotion or advertising of drugs and dissemination of non-promotional information.

[July 2024]

Are approvals required before midwives can administer new drugs in hospital?

Unless hospital policies impose restrictions, midwives can prescribe and administer drugs that are new to the midwifery scope of practice when they have the knowledge, skill, and judgement to do so safely. Midwives should ensure that they are knowledgeable about hospital policies and protocols concerning administration of the drugs in their pharmacopeia. Failure to follow hospital polices and protocols while working in hospital can be a risk to maintaining hospital privileges.

The CMO does not support hospitals placing arbitrary restrictions on midwives’ scope of practice. This is explained in section 3.3 of the CMO Midwifery Scope of Practice document. Some hospitals restrict midwives’ scope of practice in ways that are not in the best interests of clients, and the CMO recommends advocating to end these restrictions.

The AOM offers resources to support midwives working to change hospital policies, and midwives can get direct support for strategies to resolve conflicts through AOM ON CALL.

[October 2024]

What is the role of Head Midwives in introducing changes to the drug regulation?

The CMO has informed all hospitals of the 2024 drug regulation changes, but additional work may be required from Head Midwives. The CMO FAQ on the Designated Drugs and Substances Regulation recommends that Head Midwives make sure to inform their hospital’s leadership of the changes and work collaboratively with hospital leaders to make changes to existing hospital policies, procedure lists, and protocols as needed.

Some hospitals may be concerned that midwives do not have the knowledge, skill, and judgement to prescribe and administer the new drugs. It may be reasonable for hospitals to set some requirements to ensure that midwives are familiar with hospital-specific policies (e.g. requiring double sign off for opioids or adopting standard treatment protocols). Training requirements should be respectful of the value of midwives’ time and should acknowledge that all midwives may not require the same training. For example, a midwife who has considerable experience administering opioids in the hospital under a directive or physician orders will not have the same learning needs as a midwife who has little or no experience working with opioids. Midwives may already have training and experience from other settings or other jurisdictions.

The job descriptions of some Head Midwives include responsibility for oversight and/or evaluation of the standard of care provided by each midwife. If the Head Midwife is called upon by hospital management to answer concerns about midwives’ preparation to administer new drugs safely, the Head Midwife can address this through discussion with the midwives about their knowledge, skill, and judgement and reaching agreement about group and individual learning plans. This may be a more effective method of quality control than a rigid training requirement for all midwives.

[October 2024]

What are the benefits of midwives in hospitals working together on policies and education?

Head Midwives should be proactive in bringing all midwives at the hospital together to discuss any policy changes required and any concerns about training needs. Head Midwives should call upon other midwives to volunteer time to share the workload. Taking control of the issues as a group may preempt the imposition of unreasonable and ineffective requirements or restrictions by physicians or managers at the hospital.

The plan should detail the expectations for all midwives, which would include knowledge of hospital protocols and policies adapted as necessary to be inclusive of midwives, compliance with CMO requirements, and may also include internal and external resources for midwives who identify that they need to acquire or refresh knowledge and skills.

As a group, midwives may decide that they want to organize in-hospital learning opportunities. An experienced midwife, obstetrician or anesthetist could be recruited to present rounds to midwives on drugs they are newly authorized to administer or prescribe. A midwife with experience could volunteer to provide mentorship to others who have learning needs. Midwives can share or review together at meetings product monograms, clinical practice guidelines, research articles, webinars and other resources.

Head Midwives and other midwives who contribute time to organizing hospital integration activities should track the hours spent on this work to claim caseload variables.

[October 2024]