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Public Consultation: Designated Drugs Regulation

On May 30, 2019, the College of Midwives of Ontario (College) received a letter from the Health Minister Christine Elliott requesting that the College amend its Designated Drugs Regulation made under the Midwifery Act, 1991 to include categories of drugs and substances.

The College’s current Designated Drugs Regulation includes lists of individual drugs and substances that can be prescribed or administered by injection or inhalation on midwife’s own authority.

The College was requested to undertake this work immediately with a view that the formal submission to the Ministry should be made no later than December 31, 2019.

What will change?

The College is proposing the following amendments to the Designated Drugs Regulation:

  1. Rescind lists of drugs and substances in the current Designated Drugs Regulation and include categories of drugs and substances in accordance with the American Hospital Formulary Services (AHFS) pharmacologic-therapeutic classification categories.
  2. Make it a condition of registration that all members and midwifery applicants must successfully complete, within a time period specified by Council, a mandatory training approved by Council relating to the safe, effective, and ethical prescription and administration of controlled substances.
  3. Enable midwives, in the course of engaging in the practice of midwifery, to prescribe any drug and administer any substance by injection or inhalation on the order of a physician and a nurse practitioner.

The College’s Council has reviewed the proposed draft of the Designated Drugs Regulation at its September 20, 2019, meeting and made a decision to circulate the draft for a 60-day consultation.

Click here to access the proposed draft of the Designated Drugs Regulation.


What are the AHFS pharmacologic-therapeutic classification categories?

The Ministry requested that the College propose categories using the AHFS pharmacologic-therapeutic classification. The AHFS is a system of organizing drugs developed and maintained by the American Society of Health-System Pharmacists (ASHP) and has been used for organizing drugs in institutional, governmental, and other settings since 1959. The classification system is based on a hierarchical numeric structure and the drugs are classified together with other drugs with similar pharmacologic, therapeutic, and/or chemical characteristics in a 4-tier hierarchy. The hierarchy begins with Tier 1 as the broadest category whereas Tier 4 consists of specific categories that fall under Tiers 1 to 3. There are 31 classifications in the first tier, 200 in the second tier, 285 in the third tier, and 112 in the fourth tier.

What AHFS categories does the College propose to include in the amended regulation?

The Ministry requested that the College propose categories at a Tier 3 level citing both flexibility and specificity that can be achieved at this level. For instance, in the below example, Cephalosporins is a Tier 3 category of anti-infective agents.

In some categories, the College has requested Tier 1 or Tier 2 rather than Tier 3. This was done either because there were no Tier 3 categories (e.g. there are no Tier 3 categories in Electrolytic, Caloric and Water Balance but only Tier 1 and Tier 2) or because many of the drugs or categories in Tier 1 or Tier 2 a midwife requires access to (e.g. Anti-infective agents).

The below table provides the categories of drugs and substances that the College proposes to include in the amended regulation. We have also included, for your reference, individual drugs and substances to show what individual drugs and substances fit into the AHFS categories.

Note that the regulation itself will only contain the categories listed in the category column (in light blue). The regulation WILL NOT CONTAIN the Tier Requested (column 2) or individual drugs and substances (column 3). The information in columns 2 and 3 has been included for your reference only.

When will the regulation be approved?

Once the consultation closes, the results will be brought back to Council in December for its final review and approval. If approved, the regulation will be formally submitted to the Ministry at the end of December, as requested by the Minister. Based on our preliminary discussion with the Ministry, it is expected that the regulation will be approved in the winter of 2020.

What happened to the College’s previous submission requesting broad prescribing and administering?

In January 2018, the College made a submission to the Ministry requesting that the list of drugs and substances in the current Designated Drugs Regulation be rescinded to instead allow midwives access to any drug or substance approved by Health Canada, within the scope of midwifery practice.  At this stage, however, the Ministry is not willing to move from lists to broad prescribing and will only consider including categories of drugs and substances in the drug regulation.

While the College still believes that the public will be best served by midwifery care when clients receive the treatments that are in their midwives’ scope of practice, we acknowledge that rescinding the current list in the Designated Drugs regulation and moving to the category approach will bring positive change as midwives and their clients will have more access to up-to-date treatments than they currently have.


We invite midwives, stakeholders, and members of the public to comment on the proposed changes to the Designated Drugs Regulation below.

You are welcome to share any comments you might have. It will be helpful if in addition to your general comments, you could also address the following question:

After reviewing the proposed categories (and individual drugs and substances that fall under these categories), what additional drugs or substances should be included and what will they be used to treat?


Our consultation is open until Friday, November 22, 2019, and all members of the public, stakeholders, and midwives are invited to share their thoughts below.

Thank you for taking the time to read and provide your comments. We will carefully consider your feedback. We greatly appreciate your participation and contribution to this initiative.

Please note that all comments are reviewed before being posted publicly to ensure they meet the Posting Guidelines. If you prefer to provide feedback via email, please email cmo@cmo.on.ca with “Proposed Amendments to the Designated Drugs Regulation” in the subject line.


Consultation Documents

Proposed Draft of the Designated Drugs Regulation

Feedback Form

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All Feedback

  1. Midwife

    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.

    • Are you a: Midwife
    • On behalf of: Yourself
  2. Midwife

    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.

    • Are you a: Midwife
    • On behalf of: Yourself
  3. Midwife

    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.

    • Are you a: Midwife
    • Organization: Midwifery Practice
    • On behalf of: Yourself
  4. Midwife

    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.

    • Are you a: Midwife
    • On behalf of: Yourself
  5. Midwife

    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.

    • Are you a: Midwife
    • Organization: Thunder Bay Regional Health Sciences Centre
    • On behalf of: Yourself
  6. Midwife

    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.

    • Are you a: Midwife
    • Organization: Lincoln Community Midwives
    • On behalf of: Organization
  7. Midwife

    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!

    • Are you a: Midwife
    • On behalf of: Yourself
  8. Midwife

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

    • Are you a: Midwife
    • Organization: Kenora Midwives
    • On behalf of: Organization
  9. Midwife

    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.

    • Are you a: Midwife
    • On behalf of: Yourself
  10. Midwife

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

    • Are you a: Midwife
    • On behalf of: Yourself
  11. Midwife

    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.

    • Are you a: Midwife
    • Organization: Stratford Midwives
    • On behalf of: Yourself
  12. Midwife

    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.

    • Are you a: Midwife
    • Organization: Midwife
    • On behalf of: Yourself
  13. Midwife

    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.

    • Are you a: Midwife
    • Organization: 1985
    • On behalf of: Yourself
  14. Midwife

    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!

    • Are you a: Midwife
    • Organization: mississauga
    • On behalf of: Yourself
  15. Midwife

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

    • Are you a: Midwife
    • On behalf of: Yourself
  16. Midwife

    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.

    • Are you a: Midwife
    • Organization: Midwife
    • On behalf of: Organization
  17. Midwife

    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.

    • Are you a: Midwife
    • Organization: countryside midwifery services
    • On behalf of: Yourself
  18. Midwife

    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.

    • Are you a: Midwife
    • On behalf of: Yourself
  19. Midwife

    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.

    • Are you a: Midwife
    • Organization: Community Midwives of Hamilton and Crown Point
    • On behalf of: Yourself
  20. Midwife

    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.

    • Are you a: Midwife
    • Organization: Ontario member
    • On behalf of: Yourself
  21. Midwife

    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?

    • Are you a: Midwife
    • Organization: Midwives Grey Bruce
    • On behalf of: Organization
  22. Midwife

    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.

    • Are you a: Midwife
    • On behalf of: Yourself
  23. Midwife

    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!

    • Are you a: Midwife
    • Organization: Mountain Midwifery Care
    • On behalf of: Yourself
  24. Midwife

    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.

    • Are you a: Midwife
    • Organization: midwifery practice
    • On behalf of: Yourself
  25. Midwife

    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.

    • Are you a: Midwife
    • On behalf of: Yourself
  26. Midwife

    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.

    • Are you a: Midwife
    • On behalf of: Organization
  27. Midwife

    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?

    • Are you a: Midwife
    • Organization: Midwives Grey Bruce
    • On behalf of: Yourself
  28. Midwife

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

    • Are you a: Midwife
    • Organization: West End Midwives
    • On behalf of: Yourself
  29. Midwife

    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.

    • Are you a: Midwife
    • Organization: Midwife
    • On behalf of: Yourself
  30. Midwife

    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.

    • Are you a: Midwife
    • On behalf of: Yourself
  31. Member of the public

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

    • Are you a: Member of the public
    • Organization: Midwifery Student
    • On behalf of: Yourself
  32. Midwife

    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).

    • Are you a: Midwife
    • Organization: Born Midwives
    • On behalf of: Yourself
  33. Midwife

    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.”

    • Are you a: Midwife
    • Organization: Midwives of Mississauga
    • On behalf of: Yourself
  34. Midwife

    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!

    • Are you a: Midwife
    • Organization: Midwives of Mississauga
    • On behalf of: Yourself
  35. Midwife

    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.

    • Are you a: Midwife
    • Organization: Sudbury Community Midwives
    • On behalf of: Yourself
  36. Midwife

    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?

    • Are you a: Midwife
    • On behalf of: Yourself
  37. Midwife

    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!

    • Are you a: Midwife
    • Organization: Diversity Midwives
    • On behalf of: Yourself
  38. Midwife

    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.

    • Are you a: Midwife
    • Organization: Midwives of Mississauga
    • On behalf of: Yourself
  39. Midwife

    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.

    • Are you a: Midwife
    • Organization: Community Midwives of Hamilton
    • On behalf of: Yourself
  40. Midwife

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

    • Are you a: Midwife
    • Organization: Genesis Midwife
    • On behalf of: Yourself
  41. Midwife

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

    • Are you a: Midwife
    • Organization: Family midwifery care
    • On behalf of: Organization
  42. Midwife

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

    • Are you a: Midwife
    • Organization: Markham Stouffville hospital
    • On behalf of: Yourself
  43. Midwife

    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!

    • Are you a: Midwife
    • Organization: Midwives of Chatham-Kent
    • On behalf of: Yourself
  44. Midwife

    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.

    • Are you a: Midwife
    • On behalf of: Yourself
  45. Midwife

    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.

    • Are you a: Midwife
    • Organization: Talbot Creek Midwives
    • On behalf of: Yourself
  46. Midwife

    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.

    • Are you a: Midwife
    • On behalf of: Yourself
    1. Midwife

      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.

      • Are you a: Midwife
      • Organization: Ontario Member
      • On behalf of: Yourself
  47. Midwife

    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.

    • Are you a: Midwife
    • On behalf of: Yourself
  48. Midwife

    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.

    • Are you a: Midwife
    • Organization: Family care Midwives
    • On behalf of: Yourself
    1. Midwife

      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.

      • Are you a: Midwife
      • On behalf of: Yourself
  49. Midwife

    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.

    • Are you a: Midwife
    • Organization: MATCH Program -South Riverdale CHC
    • On behalf of: Yourself
  50. Midwife

    Ranitidine for Neonatal GERD

    • Are you a: Midwife
    • Organization: Kitchener Waterloo Midwifery Associates
    • On behalf of: Yourself
  51. Midwife

    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

    • Are you a: Midwife
    • Organization: Countryside Midwives
    • On behalf of: Organization