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Public Consultation: Designated Drugs Regulation

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

    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
  2. 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
  3. 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
  4. 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
  5. 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
  6. 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
  7. 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
  8. 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
  9. 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
  10. 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
  11. 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
  12. 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
  13. 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
  14. 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
  15. 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
  16. 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
  17. 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
  18. 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
  19. 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
  20. 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
  21. 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
  22. 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
  23. Midwife

    Ranitidine for Neonatal GERD

    • Are you a: Midwife
    • Organization: Kitchener Waterloo Midwifery Associates
    • On behalf of: Yourself
  24. 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