SUMMARY

Suitably qualified Australian midwives may prescribe drugs. By June 2016, 250 midwives were endorsed to prescribe.

The range of drugs that midwives may prescribe is determined by state and territory legislation. There are therefore significant variations across the country in what can be prescribed.

Midwives must undertake additional training to become competent to prescribe. Clear guidelines for consultation and referral also underpin safe prescribing.

Introduction 

Prescribing rights are being granted to a range of non-medical health professionals. Some midwives can now prescribe as a result of an expansion in their role.1 

As part of the Australian Government’s maternity service reform agenda,2 national legislation was amended in 2010 to enable midwives to become ‘Medicare eligible’.3 Women who consult midwives with this notation on their registration can access Medicare rebates for midwifery services. These midwives can also request Medicare-funded pathology and radiology services. 

After completing a program of education approved by the Nursing and Midwifery Board of Australia, eligible midwives can also prescribe drugs within their scope of midwifery practice. The aim of this part of the national maternity reform agenda was to enhance women’s choice and increase access to timely and appropriate health care.

Who can become a midwifery prescriber? 

Only midwives who are Medicare eligible are able to become prescribers. The Box lists the prerequisites for Medicare eligibility. The Australian Health Practitioners Regulatory Agency is responsible for processing applications for Medicare eligibility. Midwives granted this notation on their registration may obtain a Medicare provider number and provide Medicare rebatable maternity services. They must be working in private practice, have professional indemnity insurance and have collaborative arrangements in place with a specified medical practitioner or healthcare service.4

Box - Prerequisites for Medicare eligibility

Midwives must meet the following criteria:

  1. Current general registration as a midwife in Australia with no restrictions on practice
  2. Midwifery experience that constitutes the equivalent of three years full-time post initial registration as a midwife
  3. Current competence to provide pregnancy, labour, birth and postnatal care to women and their infants
  4. Successful completion of an approved professional practice review program for midwives working across the continuum of midwifery care
  5. 20 additional hours per year of continuing professional development relating to the continuum of midwifery care
  6. Successful completion of:

a)     an accredited and approved program of study determined by the Nursing and Midwifery Board of Australia to develop midwives’ knowledge and skills in prescribing, or

b)    a program that is substantially equivalent to such an approved program of study, as determined by the Board.

      Source: Reference 4

Education

Entry to practice education for midwives can be delivered at undergraduate level, or registered nurses can complete a postgraduate entry to practice program. All entry to practice programs include physiology, pharmacology and communication so that on graduation midwives are able to appropriately advise women on the correct use of medicines, and to safely administer drugs that have been prescribed by a doctor. National competency standards state that midwives have ‘the ability to initiate, supply and administer relevant pharmacological substances in a safe and effective manner within relevant state or territory legislation’.5 Unlike some other professions such as medical practitioners and dentists, midwives do not gain authority to prescribe on graduation from an entry to practice program. 

To obtain the authority to prescribe, midwives must successfully complete an additional accredited program of education.6 These programs are postgraduate courses of at least one semester’s duration and meet the standards and criteria for accreditation approved by the Nursing and Midwifery Board of Australia.

The curriculum requirements include the diagnostic process, pharmacology, legal and regulatory frameworks, and how to generate inpatient and outpatient prescriptions. The courses address the importance of working collaboratively with other healthcare providers involved in the care of the woman and baby. A variety of assessment methods are used to ensure that midwives demonstrate mastery of the knowledge and skills required for safe prescribing.6 

Successful completion of an accredited course enables the midwife to apply to the Australian Health Practitioner Regulatory Agency for endorsement of their registration to include the authority to prescribe. Once endorsed, the midwife may apply to the Pharmaceutical Benefits Scheme (PBS) for a prescriber number and to obtain PBS stationery for prescriptions. 

There was a significant delay between the introduction of legislative changes and the availability of an accredited educational course.7 One university commenced enrolling students in the first accredited course in July 2012. Four universities now offer accredited courses and it is anticipated that other education providers will offer courses in response to an increasing demand. 

Competency and responsibility 

NPS MedicineWise outlines the responsibilities of all Australian prescribers to select drugs that are clinically effective, safe, cost-effective and are acceptable to the patients.8 The Australian College of Midwives’ National Midwifery Guidelines for Consultation and Referral9 outline the conditions for which consultation with, or referral to, a medical practitioner is recommended. These frameworks serve to create a safe environment for midwifery prescribing.

Protocols to guide midwifery prescribing in Australia have not been developed, however prescribing occurs within a defined scope of practice and with clear guidelines for professional accountability and responsibility.5 This scope of practice includes prescribing for the woman and her infant, up to the end of the sixth postnatal week. No formal process is in place for supervision or monitoring of midwifery prescribing. While there is no regulatory requirement for midwives to notify the woman’s medical practitioner that a prescription has been generated, good communication with members of the woman’s care team is included in the guidelines for professional practice, so this would be expected to occur.

Midwifery prescribing is well established in New Zealand and the United Kingdom within a similar professional framework. Research undertaken to date has found no evidence to suggest poor outcomes arising from the introduction of non-medical prescribing in those countries.10

What can midwives prescribe? 

The Nursing and Midwifery Board of Australia has developed a formulary to help midwives select appropriate drugs.11 This lists drugs, the indication for their use and the duration of their use. It includes drugs such as antibiotics, opioids and uterotonics. 

The formulary arose from a collaborative process involving midwives and obstetricians. It offers no rationale for the choice to include or exclude certain drugs from the list and it gives no evidence to support the indications. The formulary has not been reviewed since its inception, and there appears to be no program for review. 

Each Australian state and territory has its own drug regulations, and the governance of midwifery prescribing varies from one jurisdiction to another. Western Australian legislation requires midwives to only prescribe drugs according to the formulary.12 Victoria and Tasmania have generated a list of approved drugs, and place no restrictions on the indications for prescribing each drug or the duration of treatment.13,14 Queensland does not permit the prescribing of Schedule 8 drugs, but Schedule 4 drugs that are used in midwifery may legally be prescribed.15 New South Wales, South Australia and the Northern Territory have placed no limitations on midwifery prescribing, and provide full access to all the drugs used within the scope of midwifery care. 

Some of the drugs available through the PBS, such as antibiotics, attract subsidies when prescribed by midwives. Midwives in the Australian Capital Territory are restricted to only prescribe the drugs on the PBS list for midwives.16 The absence of a PBS listing does not prevent midwives in all other states from being able to legally prescribe these drugs as a private prescription. 

How many midwives are prescribing? 

The first midwife obtained the authority to prescribe in Australia in June 2012,17 by receiving retrospective recognition of a non-accredited course. It was not until completion of the first accredited course late in 2012 that additional midwives were endorsed. The numbers of prescribers have increased significantly since that time with 250 midwives having been endorsed by June 2016 (see Fig.). 

Fig. Number of midwives with endorsement to prescribe

Source: Reference 17

The future of midwifery prescribing

As increasing numbers of midwives complete accredited programs of education and commence prescribing, it is important to confirm that their prescribing is safe, appropriate and addresses the needs of women and their babies. No published research has yet addressed midwifery prescribing, as distinct from other forms of non-medical prescribing. We do not currently know what proportion of endorsed midwives actually prescribe, which drugs are used and the reasons they are prescribed. 

It is important that a body of research evidence is developed concerning midwifery prescribing and its outcomes, in order to inform the ongoing development of midwifery education. Non-medical prescribers require ongoing support from doctors, pharmacists and other non-medical prescribers in order to integrate prescribing into their practices.18 Widespread acceptance of midwifery prescribing in Australia will enable midwives to access the support they need to become effective prescribers. As momentum grows there will be a need to identify ongoing professional development requirements and to establish a framework that ensures such education is available and accessible.

It is likely that Australia will see an expansion of midwifery and non-medical prescribing in line with international experience.19 There is a growing call to move from a postgraduate prescribing qualification to include prescribing in the undergraduate curriculum. Good evidence will be required to justify such a transition.

Conclusion

Midwifery prescribing in Australia continues to grow but there is significant variation in the range of drugs that can be prescribed. Further research is required to ensure that midwifery prescribing is achieving the aims of the maternity reform process in offering enhanced access to appropriate health care, with more choice of care provider.

Conflict of interest: none declared

References

  1. Nissen L, Kyle G. Non-medical prescribing in Australia. Aust Prescr 2010;33:166-7.
  2. Department of Health. Improving maternity services in Australia: the report of the maternity services review. Canberra: Australian Government Department of Health; 2009. [cited 2016 Nov 1]
  3. Health Legislation Amendment (Midwives and Nurse Practitioners) Act 2010 - C2010A00029. [cited 2016 Nov 1]
  4. Nursing and Midwifery Board of Australia. Registration standard for endorsement for scheduled medicines for midwives. Melbourne: Nursing and Midwifery Board of Australia; 2010. [cited 2016 Nov 1]
  5. Nursing and Midwifery Board of Australia. Professional standards. National competency standards for the midwife. Melbourne: Nursing and Midwifery Board of Australia; 2006. [cited 2016 Nov 1]
  6. Australian Nursing and Midwifery Accreditation Council. Programs leading to endorsement for scheduled medicines for midwives: accreditation standards 2015. Canberra: ANMAC; 2015. [cited 2016 Nov 1]
  7. Cresswell A. Midwives still await PBS script training. The Australian. 2012 Aug 20. [cited 2016 Nov 1]
  8. NPS MedicineWise. Prescribing competencies framework. Competencies required to prescribe medicines: putting quality use of medicines into practice. Sydney: National Prescribing Service Limited; 2012. [cited 2016 Nov 1]
  9. Australian College of Midwives. National Midwifery Guidelines for Consultation and Referral. 3rd edition, issue 2. Canberra: Australian College of Midwives; 2014.
  10. Gielen SC, Dekker J, Francke AL, Mistiaen P, Kroezen M. The effects of nurse prescribing: a systematic review. Int J Nurs Stud 2014;51:1048-61.
  11. Nursing and Midwifery Board of Australia. Prescribing formulary for eligible midwives with a scheduled medicines endorsement. Melbourne: Nursing and Midwifery Board of Australia; 2011. [cited 2016 Nov 1]
  12. Government of Western Australia. Poisons Regulations 1965. Part 2A, Division 2. 2012. [cited 2016 Nov 1]
  13. State of Victoria. Victoria Government Gazette. No. S 410. Drugs, Poisons and Controlled Substances Act 1981, Section 14A(1). 2012. [cited 2016 Nov 1]
  14. State of Tasmania. Tasmanian numbered regulations. Poisons (Midwifery Substances) Order 2011 (S.R. 2011, No. 1). [cited 2016 Nov 1]
  15. State of Queensland. Health (Drugs and Poisons) Regulation 1996. Chapter 3, Part 2, Division 3, Section 167A. [cited 2016 Nov 1]
  16. Australian Capital Territory. Current acts. Medicines, Poisons and Therapeutic Goods Act 2008. [cited 2016 Nov 1]
  17. Nursing and Midwifery Board of Australia. Statistics. Nurse and Midwife Registration Data, March 2012 – June 2016. Melbourne: Nursing and Midwifery Board of Australia; 2016. [cited 2016 Nov 1]
  18. Bowskill D, Timmons S, James V. How do nurse prescribers integrate prescribing in practice: case studies in primary and secondary care. J Clin Nurs 2013;22:2077-86.
  19. Kroezen M, Francke AL, Groenewegen PP, van Dijk L. Nurse prescribing of medicines in Western European and Anglo-Saxon countries: a survey on forces, conditions and jurisdictional control. Int J Nurs Stud 2012;49:1002-12.