MAI Submission to NMBI
Consultation on the 2019 NMBI Draft Standards & Requirements for Education Programmes for Nurses & Midwives with Prescriptive Authority
The document mentions the ‘discipline’ of midwifery. Midwifery is not a discipline or branch of Nursing, rather it is a ‘profession’ separate to nursing as confirmed by the Nurses and Midwives Act (2011) which recognises the distinct nature of midwifery.
- NMBI have taken the view (we believe rightly) that SI 201 of 2007 applies equally to midwives as to nurses. The Medicinal Products (Prescription and Control of Supply) (Amendment) Regulations, 2007 (Statutory Instruments, (S.I.) No. 201 of 2007) and the Misuse of Drugs Regulations 2017 (S.I. No. 173 of 2017) (this revokes the 2007 Misuse of Drugs (Amendment) Regulations) specify the legislative requirements/conditions for prescribing of medicinal products by registered nurses. The MAI request the words “and midwives” are added.
- In order to fulfil the ‘supported’ care pathway of the Irish Maternity Strategy 2016 -2026, the MAI recommend that there is a national midwife medication formulary that permits the limited prescription of medications that support women being cared for on the supported care or assisted care pathway by a midwife. ‘Supported Care’ This care pathway is intended for normal-risk mothers and babies, with midwives leading and delivering care within a multidisciplinary framework. ‘Assisted Care’ This care pathway is intended for mothers and babies considered to be at medium risk, and for normal risk women who choose an obstetric service. Care will be led by a named obstetrician and delivered by obstetricians and midwives, as part of a multidisciplinary team.
- This proposed national midwife medication formularly should be part of the Midwife Registration Programme Standards and Requirements (2016) so that at the point of registration or within a within a specific agreed length of practice time midwives will be able to use this limited authority to prescribe and administer medications.
- As set out in the 2007 NMBI medication administration guidance in order to safely administer medication the midwife or nurse must adhere to the ‘ five rights’ (being updated currently) therefore must know a significant amount of information about the medication to check and administer it.
Suggested but not limited to medications for management of normal risk pregnancy
Paracetamol, Diclofenac Sodium, Entonox, Lidocaine, Syntometrine, Syntocinon for 3rd stage
? Medication for haemorrhoids e.g. Scheriproct
The programme set out in the draft standards may be more suitable for advanced midwifery practice where prescribing is for women with complex medical needs and are on the ‘Specialised Care’ pathway. This care pathway is intended for high-risk mothers and babies and will be led by a named obstetrician, and will be delivered by obstetricians and midwives, as part of a multidisciplinary team.
- Section 3: Standards and Requirements for Nurse/Midwife Education Programme for Prescriptive Authority
3.1 Minimum Entry Requirements
a. ‘Only registered nurses and midwives can be admitted to the programme for education and training in prescriptive authority.’ ‘They must have at least one year of full-time or the equivalent post-registration clinical experience in their specific area of practice within the previous two years’. The MAI notes that this excludes Self Employed Community Midwives (SECMs) at point of signing HSE MOU/agreement. The MAI recommends therefore that it should be mandatory for all HSE Domiciliary Officers (DMO’s) who co-ordinate and oversee the HSE Home Birth services to be become Registered Midwife Prescribers (RMP).
b. ‘They must be employed by a health service provider in a hospital, nursing home, clinic or other health service setting (including any case where the health service is provided in a private home)’ The MAI believe this does not take into account the definition in Section 5 a (3) SI 201 of 2007 which states In this Regulation, “health service provider” means the Health Service Executive, a hospital, a nursing home, a clinic or other person whose sole or principal activity or business is the provision of health services, or a class of health services, to the public or a class of the public.
c. Having this requirement excludes SECMs and so limits the SECM in the provision of a safe and effective service whilst at the same time insurance issues with GPs and lack of access to maternity hospitals, particularly in the voluntary sector is greatly reducing access to prescriptions for women who plan to have a home birth even under the HSE scheme. Being a self-employed community midwife should not be a discriminatory factor in access to education and progression. The above provisions exclude SECMs as ‘contractors’ but DMOs as employees and supporters of the service would be eligible. This exclusion of one cadre of registered midwife practitioners is a significant safety and public protection issue that needs to be considered by the NMBI as the regulatory body for SECMs. NMBI need to protect public safety and protect the midwife’s ability to practice in all settings as laid out in EU directive. Any diminishing of the ability of midwives to practice (including to prescribe) in all (but particularly independent self-employed home birth) settings would be detrimental for the midwifery profession and would be hazardous for women during pregnancy, labour and the puerperium.
- 3.3.2 Competencies for a Midwife Prescriber
3.5 Theoretical and Clinical Instruction for Nurse/Midwife Prescriptive Authority
Whereby an eligible SECM wishes to do this course s/he is excluded by lack of access to clinical instruction. This excludes a cohort of midwives working in practice who meet the eligibility criteria to achieve prescriptive authority, registered with NMBI, but by choosing to provide the HSE homebirth service as their means of livelihood are unable to undertake this course to enhance their practice and provide women centred maternity care. This too conflicts with the EU directive on Midwifery. The MAI recommend that this provision be adjusted to enable and promote SECMS to undertake the required education/ assessments and so achieve registration as Registered Midwife Practitioners.
- 5.2 Programme Design and Development
“The curriculum model chosen should be dynamic and flexible to allow for changes in nursing/midwifery practice and health care delivery”. The MAI note that excluding SECMs in a variety of ways does not reflect NMBI aspirations to be ‘dynamic and flexible’ and recommend that this anomaly be rectified.
- 5.3 Clinical Practice Experience
“Clinical placements are based in health care institutions that are audited/approved by the education programme team and satisfy NMBI requirements and standards.” The MAI note that increasingly in Ireland, care will need to be provided ‘in hospitals without walls’ , i.e., in the community, in people’s own home etc. The MAI note therefore, that this wording does not reflect the changes and ongoing recommended evolution of maternity services to the community in line with the National Maternity Strategy and the ethos of Government policy, Sláintecare and respectfully request that consideration be given to this.
- “Confirmation is needed from the health service provider that the nurse/midwife is working in the area where the clinical practicum will occur and that there is an expressed service need for the nurse/midwife to prescribe as part of their individual role”. The MAI advise that there is an urgent and immediate clinical need for equitable access to safe and effective prescribing services for all women irrespective of chosen location of birth (home or hospital) therefore the draft document requires significant rethinking and rewording otherwise this gap in service will remain unachievable by the midwife working in this specific clinical area.
Note: This submission has been prepared and approved by a working group of midwife members of the MAI representing midwifery practice in both hospital and community locations. The MAI is open and willing to provide additional information/advice on the above matters should this be required.
From: Midwives Association of Ireland
Date: 11th December 2019