Midwifery prescribing in Australia

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.

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.

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

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. 

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

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. 

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.). 

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