Sunday, August 15, 2010

Midwife prescribing in New Zealand

One thing I did not mention in my last post about the Midwifery council forum was the debate about midwife prescribing.

In New Zealand midwives are able to prescribe within the scope of midwifery practice. There is no list of drugs that midwives can prescribe however the midwives scope of practice is quite clearly defined. It is this definition which enables us to identify when we can and when we cannot prescribe. For example we can prescribe to a woman who has a urinary tract infection during pregnancy as this is often associated with a normal uncomplicated pregnancy and needs to be treated early to prevent complications such as preterm labour. Prescribing is a last resort of treatment in most circumstances. Midwives offer advice to try to reduce the chances of infection or to elliminate infection before it gets to the point where antibiotics are required. Midwives cannot however prescribe for a woman who has a chest infection as this is not directly related to pregnancy and requires a medical consultation, usually with the woman's General Practitioner.

The dilemma discussed at the Midwifery Council Forum was the issue of midwives prescribing to other members of the woman's family, in circumstances where this is of direct benefit to the woman and the progress of her pregnancy. The particular situations where this dilemma arises is with Nicotine Replacement Therapy (NRT) and antibiotics for Chlamydia.

Midwives are taking part in education about smoke change in pregnancy. Midwives are encouraged to discuss smokechange with women and the benefits of Nicotine Replacement Therapy. Midwives can prescribe NRT to women and this is seen as being within the midwives scope of practice. The issue we were discussing at the forum was whether midwives should be able to prescribe to partners or family members of the woman. Research suggests that a partner who smokes adversely affects a woman's ability to quite or remain smoke free. Smoking during pregnancy has a negative impact on the infant both during pregnancy and for the newborn infant. We know women are likely to be more successful in quitting smoking during pregnancy if their partner is also smokefree . The question then is should midwives be able to prescribe NRT to partners or close family members of the woman? If so what would this mean for the midwives scope of practice. We had a lively debate but did not reach a clear conclusion. What do you think? Should midwives be able to prescribe NRT to the partner of women? If so should this only be to assist the woman to stop smoking? What if the woman does not smoke but the partner wishes to quit?
Clearly their are benefits for the baby if the family are smokefree, but is this part of the midwives role?

Antibiotics for Chlamydia.

Once again there was a lively debate with no clear conclusion on this issue.
Midwives can and do treat women for chlamydia infection in pregnancy. Chlamydia is the most common STI in New Zealand, particularly in those under 25 years of age. It is important to identify and treat partners of women who are diagnosed with Chlamydia infection and this is important to avoid reinfection and serious consequences for the newborn, particularly serious eye infections. The question debated was should midwives prescribe antibiotics for the woman's partner? What about if there is no sexual health clinic nearby and the partner will not visit the GP? What are your thoughts about this and once again what does this mean in relation to the midwives scope of practice? Does the scope need to change to accommodate this type of prescribing?

Midwifery Council will continue to debate these issues and ultimately will make a decision on whether or not midwives can prescribe in these circumstances. I welcome your thoughts and feedback on these issues.


Anonymous said...

great post Carolyn.
I am not in favour of this extension to the midwifery scope of practice. I believe it looks simplistic on the face of it - but in reality exceeds the boundaries of the midwifery specialty.

It would involve full health assessments for wider members of the public - and I believe this work is beyond our scope and more importantly encroaches on the crucial role of the midwife in working specifically with women and pregnancy. What aspects of the midwifery role would need to be neglected to pick up these additional assessments and follow up prescriptions? I think we need to value the full and valuable role of the midwife and protect it from becoming a dumping ground for all public health issues. There needs to be a boundary here.

I do agree that we have an important role in health education around these issues - and a vital role in assessment/screening and if necessary follow up prescribing for pregnant women - and part of our role with the woman is to provide preventative counselling, education and advice which may include providing education to wider family - or equipping the woman to do so - but not to take a direct clinical role in the ongoing health care of all and sundry - this is where I believe we should refer. We can maximise the health relationship we have with with the woman and family - by providing education - but leave the full health assessment to those who are not pregnant is the domain of another health professionnal - its collaboration and I believe adequate systems are in place for this.

Within the debate there seemed to be concern that partners would not access health services unless the midwife provided them. I don't agree with this assumption. Is there evidence? With appropriate knowledge and education many likely will and this is where I believe our efforts are best focussed. There will always be people who do not take responsibility for tyheir health - and I don't see midwives braodening their scope as the best solution to this - frankly that approach is a bottomless pit.

I also sense an air of paternalism in the debate - or an assumption that women cannot be trusted to manage their health effectively by involving their wider circle ( ie informing partners of the need to be tested and treated) - and i am wary of that approach to health as well. of course some women will live in circumstances where they are disempowered - but braodening our scope is unlikely to provide an adequate band aide for that anyway.

look forward to watcghing the debate.

Anonymous said...

apologies for all the typo's

Anonymous said...

Thanks Carolyn for discussing this issue.

I was at the forum and it was certainly a very lively debate. I think for me the key points are:

~ We are the woman's health professional, her midwife not her partner's doctor.
~ Prescribing drugs requires us to have a health history of allergies and other medications used as well as general health etc. To do this with a partner takes time and is not part of our visits with women specifically.
~ We would have to monitor the health of the partner once prescribed, as a GP would and we do with women. Is this our job?
~ I agree with Rae, whilst it can be a very real issue in regards to health and well being of babies as well as a mother's, as some point we have to stand back and allow women and their families to make their own health decisions. We can make health education about certain relevent issues to pregnancy apart of our discussions and recommendations with women and their partners but ultimately we work with the women first and foremost.
~ How do we know where the chlamydia infection origionated...?
~ Most people have a phone of somesort, smoking partners of non-smoking women can call quit line, as can smoking partners of women who smoke.
~ Are midwives expanding their scope of practice, their 'job descriptions' to encorporate too many health issues? as Rae points out we could become a dumping ground for all good health causes.

Howver, I do sympathise with our rural collegues with their unique set of working issues and constraints and see how the ability to provide a woman and her partner NRT or antibiotics for chlamydia would ensure that access to these drugs is ensured.

~ for me though it still boils down to who is the client we sign on and book at the begining of the pregnancy, regardless of who her chosen support network and family is? it is the woman with her midwife.
Tracy W.

Carolyn said...

Thanks for your comments Rae and Tracy. As a midwife working in rural practice I know that there are particular issues around accessing services that are more readily available to urban women and do know the temptation to prescribe. However prescribing is a huge responsibility and involves much more than just writing a prescription. We then have to take responsibility for our prescribing. I have a good understanding of the health status of women in my care but not necessarily for their partners and prescribing for these others is too onerous a responsibility for me.

transit said...


Sarah Stewart said...

Hi Carolyn, intersting post - I missed the forum so really appreciate this sumamry.

I would never consider prescribing things for people other than the woman in my care. but what about meds that are available already over the counter?

BTW, I see your spam detection hasn't stopped spammers!

Carolyn said...

Thanks for the comment Sarah. I agree, I would not prescribe for those not in my care. If it is available over the counter I might suggest it if required but would not prescribe.

Can you tell me more about blocking spam?? Hope you are having fun :)
Thanks Carolyn

Sarah Stewart said...

I was just interested to note that although you have a spam tool thats supposed to stop spam, you are still getting it...I reason I commented is that I have played with the idea of enacting the spam 'thing' (gosh, can't remember what those wiggly words are called) but haven't...& I was interested to see your experience :)

Anonymous said...

Regarding chlamydia it is common practice if one partner is diagnosed to treat the other also as a precuation in an effort to stop the reinfection of chlamydia. Treating will only have positive implications for the woman and baby, and it makes little sense to treat the woman, then leave her open to the probability of reinfection from her partner. I am in favour of treating both, in the interest of the health of the woman and her baby. To not do that is leaving them open to infection again. I do not believe it needs to become complicated by requesting the partner see a doctor. Many wouldn't go, thats not in anyones interests. Midwives are there for the woman and baby, but there is a level where you are involved with the family. This is a wider issue than the woman and her baby, and not acknowledging that does both a disservice.

Carolyn said...

Thanks for this comment to the last annonymous person. It is interesting to get this perspeoctive which I think is the way many midwivesfeel, wanting to be able to treat the woman's partner for Chlamydia too thereby ensuring the treatment of the woman is more effective. I wonder if you would conduct a health assessment of the woman's partner prior to prescribing. Would you screen him for other medical conditions and allergies which may pose a health risk for him in relation to treatment? How do you screen him to ensure that the treatment has been effective and he is now clear of the infection? It is a tricky and complex situation.

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Anonymous said...

what Carolyn is saying is true, and it makes sense. we have to see the woman and her surroundings, otherwise you have not help her.
consider her environment, and her backgrounds. what is the use of cleaning yourself when you are on a ques of reinfection? she can tell the husband but men are very biz and most of men never bother to visit the GP. Other countries use to prescribe both to prevent re-infection. nothing wrong to consider to change the scope of practice. if you treat the mother alone you just misuse the medication .

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