Category Archives: Recent research

Midwives are leaving the profession – could group clinical supervision help?

The world needs midwives

Maternal and infant health are a global priority. Midwives are pivotal to the wellbeing of women and their babies. Indeed, there is an urgent call to upscale midwifery to stem the rates of women and babies who are injured or die in childbirth. However, in Australia, like many other high-income countries, there is another type of crisis occurring that we can no longer ignore – midwives in significant numbers are leaving the profession.

Why midwives leave

Midwives are feeling demoralised, disempowered, and overwhelmed. Some of the reasons for this are medicalisation of birth, a lack of autonomy and under-staffing. These factors are leaving midwives emotionally fragile and feeling unsupported by their managers (Catling & Rossiter, 2020; Hunter et al, 2018; Pezaro et al. 2016).

There are heartbreaking accounts of midwives responding to this blog discussing the results of the Work, Health and Emotional Lives of Midwives (WHELM) study (Hunter et al, 2018). The WHELM study surveyed the wellbeing of nearly 2000 midwives in the UK and found significant levels of emotional distress, burnout, stress, anxiety, and depression. Two thirds of participants stated that they had thought about leaving their profession in the last six months, and alarmingly, early career midwives were over-represented in those leaving (Harvie et al, 2019).

Australian research echoes findings about midwives who have left the profession (Matthews, 2021), along with similar findings about work-related distress (Creedy et al., 2017; Catling & Rossiter, 2020). A Royal College of Midwives document Why midwives leave – revisited (2016) reported that 88% of midwives who had left the profession might consider returning if there were appropriate staffing levels. Eighty percent of midwives said they would return if their workplace culture was changed for the better, although this report did not outline what a positive workplace culture was.

Positive workplace culture

We suggest the following list (although not exhaustive) highlights some important things that midwives want from maternity services:

  • fully staffed ward/unit with adequate resources for staff to do their jobs;
  • visible managers who provide support to their staff to excel and flourish
  • support to engage in educational opportunities, support to attend conferences / seminars / complete higher degrees
  • emotional support following adverse events
  • timely feedback and assistance with relationships in the workplace including zero tolerance for bullying behaviour
  • autonomy in practice with multi-disciplinary assistance when indicated
  • opportunity to work in midwifery continuity of care

In essence, a positive workplace culture would have trust in, and collegiality with, work colleagues and knowledge that your work with women was high-quality and valuable.

How best to support midwives?

Clinical supervision is a well-known supportive strategy that has been used in many health disciplines to help promote staff professional development and health and wellbeing. Transforming Maternity Care Collaborative’s Director of Workforce, Associate Professor Christine Catling, gained a National Health and Medical Research Council investigator grant over the next 5 years to investigate whether group clinical supervision makes a difference to Australian midwives and the midwifery workplace culture.

The trial of group clinical supervision

The cluster randomised controlled trial (for maternity units in Greater Sydney) will involve 12 maternity sites (the ‘clusters’). Each cluster will be randomised to either receive the intervention (group clinical supervision) or not.

The trial will measure midwifery burnout rates (using the Copenhagen Burnout Inventory), the perceptions of their workplace culture (using the Australian Midwifery Workplace Culture tool), and intentions to leave the profession. For the intervention sites, the efficacy of the clinical supervision will be measured through using the Clinical Supervision Evaluation Questionnaire (Horton, 2008).

The results of this 5-year study are forthcoming. This year the research team will conduct a review of all available research evidence (both qualitative and quantitative) on group clinical supervision. Pending the study results, midwives and managers of maternity units could think about their workplace culture. Specifically, what they can do to build an environment where staff want to work, feel supported and feel safe.

References

Catling, C. & Rossiter, C. (2020). Midwifery workplace culture in Australia: A national survey of midwives. Women and Birth, 33(5), 464-472.

Creedy, DK., Sidebotham, M., Gamble, J., Pallant, J. & Fenwick, J. (2017). Prevalence of burnout, depression, anxiety and stress in Australian midwives: a cross-sectional survey. BMC Pregnancy and Childbirth, 17(1), 1-8.

Harvie K., Sidebotham, M. & Fenwick. J. (2019) Australian midwives’ intentions to leave the profession and the reasons why. Women and Birth, 32(6), e584-e593.

Horton S, de Lourdes Drachler M, Fuller A, de Carvalho Leite JC. (2008). Development and preliminary validation of a measure for assessing staff perspectives on the quality of clinical group supervision. International Journal of Language and Communication Disorders, 43, 126–34.

Hunter B, Henley J, Fenwick J et al. (2018). Work, Health and Emotional Lives of Midwives in the United Kingdom: The UK WHELM study. School of Healthcare Sciences, Cardiff University.

Matthews, R. (2021). Impact of stage of career on burnout and experience of work for midwives and neonatal nurses working in a tertiary service. Paper presented at the PSANZ Digital Congress.

Pezaro, S., Clyne, W., Turner, A., Fulton, E. & Gerada, C. (2016). ‘Midwives Overboard!’ Inside their hearts are breaking, their makeup may be flaking but their smile still stays on, Women and Birth, 29(3), e59-e66.

Royal College of Midwives. (2016). Why midwives leave – revisited. RCM, London.

Home-visiting in early labour may reduce fear and better meet women’s needs

Key issues in early labour

Early labour at home is a significant component of women’s birth experience. Women commonly feel fear and uncertainty in early labour and seek reassurance (Barnett, Hundley, Cheyne, & Kane, 2008), yet midwifery support is often limited. Fear, stress, and anxiety during childbearing inhibit labour progress (Buckley, 2015) and increase their perception of pain (Floris & Irion, 2015). If women are admitted in early labour, clinicians are more likely to intervene too soon by augmenting labour and offering epidural analgesia (Davey, McLachlan, Forster, & Flood, 2013; Neal et al., 2014) – even if labour progress is within normal limits (Zhang, 2010).

Regardless of model of care, telephone triage is routinely used for early labour assessment (Kobayashi et al., 2017). When women experience signs of labour, they usually contact either their own midwife (caseload midwifery) or the midwife on shift in the hospital assessment unit (standard care). When midwives assess  that women are in early labour, they advise them to stay at home, rest, eat, hydrate, mobilise and consider comfort strategies (Queensland Health Guidelines, 2018). However, research has shown that women are largely dissatisfied with telephone assessment in early labour. Participants describe unclear advice, unmet needs, unaddressed anxieties, and negative midwife manner (Green, Spiby, Hucknall, & Richardson Foster, 2012).

The M@NGO trial 6-week survey

A study from a large RCT of caseload midwifery, called the M@NGO trial, was the first to look at Australian women’s experience of early labour care (Allen et al., 2020). Participants were allocated to either caseload midwifery or standard fragmented care. Neither group were provided with midwife home visits during early labour. About 1,000 women (58% of M@NGO trial participants) completed a survey 6-weeks after birth. The 6-week survey included five questions that invited free-text answers. The free text data were analysed to determine categories – early labour care was one of them.

Analysis of women’s survey responses

The joint first authors searched the free text data to identify relevant phrases (such as ‘early’, ‘went to hospital’, ‘telephone’, ‘sent home’, ‘return’). They determined which comments were about early labour and analysed them to develop three themes to capture what women said. The researchers selected quotes to illustrate and validate the themes. Finally, the researchers used a critical lens to synthesise and explain the findings. To do this, they focussed on larger social forces and structures that impact how labour and birth is constructed (as something frightening and needing medical attention) and how maternity care is provided (institutionalised vs. individualised care).

Women’s experiences

The data included unique responses from 84 women: 44 in caseload care and 40 in standard care. Women’s views about early labour care were:

  1. they needed permission to come to hospital;
  2. they felt like if they came to hospital in early labour, they had done the “wrong” thing;
  3. midwives dismissed their experiences in early labour.

Critical analysis of the data generated two further themes to explain women’s experiences: women seeking and midwives shielding. Women in early labour sought care because they wanted to be close to those who knew what was going on. Medicine sends the message that birth is dangerous outside of hospital (Roome, Hartz, Tracy, & Welsh, 2015) – so this is understandable behaviour. Whereas by delaying presentation to hospital or sending women home, midwives were effectively shielding the hospital (and in caseload midwifery, their time) to protect resources. Midwives may also have been shielding women from the cascade of intervention.

Limitations of this study

This study did not collect data from midwives about early labour care. For the women who answered the survey, having their own midwife in caseload midwifery did not protect women against having negative experiences of early labour care. However, it remains possible that women who had positive experiences did not report on them in the survey.

Strategies to improve early labour care

Three strategies have been trialled to improve maternal and neonatal outcomes include: 1) early labour assessment vs. immediate admission;  2) home visits vs. telephone triage, and 3) one-to-one structure care vs. usual care) (Kobayashi et al., 2017). Of these three strategies, only early labour assessment made a difference to outcomes – shorter labour duration (average 5 hours), less epidural analgesia (13% less likely), and much less oxytocin augmentation (43% less likely) (Kobayashi et al., 2017). While early labour home visits do not appear to impact outcomes, they are  known to increase women’s satisfaction with care (Janssen & Desmarais, 2013). Another strategy is a dedicated early labour area for women who prefer to stay in hospital rather than return home. A comparison of intervention rates and birth outcomes before, and after, this area was introduced in a large Australian maternity hospital, found it made no difference to outcomes (Williams et al., 2020).

How can health services respond to women’s needs in early labour?

Women require support in early labour, not just assessment (Allen et al, 2020).  Midwives need to understand that emotional support is a valid and important part of their role (O’Connell & Downe, 2009). Health service managers should recognise that early labour is important to women and adjust the service model accordingly. To do this, services could evaluate women’s current satisfaction with early labour care (in all models of care) and then codesign a strategy to promote positive experiences. For caseload midwifery models in particular, evaluation of early labour home-visiting may be a feasible and valuable option.

References

Allen, J., Jenkinson, B., Tracy, S. K., Hartz, D. L., Tracy, M., & Kildea, S. (2020). Women’s unmet needs in early labour: Qualitative analysis of free-text survey responses in the M@NGO trial of caseload midwifery. Midwifery, 88, 102751. https://doi.org/10.1016/j.midw.2020.102751

Barnett, C., Hundley, V., Cheyne, H., & Kane, F. (2008). ‘Not in labour’: impact of sending women home in the latent phase. British Journal of Midwifery, 16(3), 144-153. https://doi.org/10.12968/bjom.2008.16.3.28692

Buckley, S. J. (2015). Executive Summary of Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies, and Maternity Care. Journal of Perinat al Education, 24(3), 145-153. https://doi.org/10.1891/1058-1243.24.3.145

Davey, M., McLachlan, H., Forster, D., & Flood, M. (2013). Influence of timing of admission in labour and management of labour on method of birth: Results from a randomised controlled trial of caseload midwifery (COSMOS trial). Midwifery, 29(12), 1297 – 1302.  https://doi.org/10.1016/j.midw.2013.05.014

Floris, L., & Irion, O. (2015). Association between anxiety and pain in the latent phase of labour upon admission to the maternity hospital: a prospective, descriptive study. J ournal of Health Psychology, 20(4), 446-455. https://doi.org/10.1177/1359105313502695

Green, J. M., Spiby, H., Hucknall, C., & Richardson Foster, H. (2012). Converting policy into care: women’s satisfaction with the early labour telephone component of the All Wales Clinical Pathway for Normal Labour. J ournal of Adv anced Nursing, 68(10), 2218-2228. https://doi.org/10.1111/j.1365-2648.2011.05906.x

Janssen, P., & Desmarais, S. L. (2013). Women’s experience with early labour management at home vs. in hospital: a randomised controlled trial. Midwifery, 29(3), 190-194. https://doi.org/10.1016/j.midw.2012.05.011

Kobayashi, S., Hanada, N., Matsuzaki, M., Takehara, K., Ota, E., Sasaki, H., . . . Mori, R. (2017). Assessment and support during early labour for improving birth outcomes. Cochrane Database of Systematic Reviews, 4(4), Cd011516. https://doi.org/10.1002/14651858.CD011516.pub2

Neal, J. L., Lamp, J. M., Buck, J. S., Lowe, N. K., Gillespie, S. L., & Ryna, S. L. (2014). Outcomes of nulliparous women with spontaneous labor onset admitted to hospitals in preactive versus active labor. Journal of Midwifery & Women’s Health, 59(1), 28-34. https://doi.org/10.1111/jmwh.12160

O’Connell, R., & Downe, S. (2009). A metasynthesis of midwives’ experience of hospital practice in publicly funded settings: compliance, resistance and authenticity. Health, 13(6), 589-609. https://doi.org/10.1177/1363459308341439

Queensland Clinical Guidelines. (2018). Queensland Maternity and Neonatal Clinical Guideline: Normal birth. (MN17.25-V3-R22). Brisbane: Queensland Health Retrieved from https://www.health.qld.gov.au/qcg/documents/g_normbirth.pdf

Williams, L., Jenkinson, B., Lee, N., Gao, Y., Allen, J., Morrow, J., & Kildea, S. (2020). Does introducing a dedicated early labour area improve birth outcomes? A pre-post intervention study. Women and Birth, 33(3), 259-264. https://doi.org/10.1016/j.wombi.2019.05.001

Zhang, J., Landy, H. J., Branch, D. W., Burkman, R., Haberman, S., Gregory, K. D., . . . Reddy, U. M. (2010). Contemporary Patterns of Spontaneous Labor With Normal Neonatal Outcomes. Obstetrics and Gynecology, 116(6), 1281-1287. https://doi.org/10.1097/AOG.0b013e3181fdef6e

Understanding and measuring emotion could be key to cultural safety in maternity care

Why cultural safety matters in maternity care

In Australia, the chance of dying or being unwell around the time of birth is higher for Aboriginal and Torres Strait Islander mothers and babies than non-Indigenous peoples (Australian Institute of Health and Welfare, 2020). Health professionals need to understand that racism fundamentally determines these health outcomes (Paradies et al., 2015). Institutionalised racism occurs when racism is hidden in the governance, policies, and practices of the organisation – in ways that work best for some groups and worse for others. One of the reasons Aboriginal and Torres Strait Islander families may avoid maternity care is that they do not feel safe or respected (Sivertsen et al., 2020). In part, this is because the western, biomedical approach to healthcare is at odds with Aboriginal and Torres Strait Islander holistic approaches to birth and birthing practices. These holistic approaches recognise the intricate relationships mothers and babies have to Country. There is a national drive for Birthing on Country, to provide Aboriginal and Torres Strait Islander families with a holistic, integrated and culturally safe model of care that supports the best start in life (Molly Wardaguga Research Centre, 2019).

Learning culturally safe practice

Recognising that institutional racism underpins Australian healthcare, has sparked new ways of teaching and learning to promote health equity and social justice. Indeed, midwives must learn to practice in culturally safe ways when working with Aboriginal and Torres Strait Islander families and communities. This requirement has been mandated by Aboriginal and Torres Strait Islander leaders and peak professional bodies (Australian Nursing and Midwifery Council (ANMAC), 2017; Australian Health Professional Regulation Agency (AHPRA), 2018). But learning cultural safety learning is not just about understanding Aboriginal and Torres Strait Islander culture, outcomes and social determinants of health. Primarily, it is about how non-Indigenous health students grapple with institutional racism within the healthcare system and critically reflect on their role within it.

Why emotion impacts learning cultural safety

Students react in different ways when learning cultural safety content. Some may begin to adopt anti-oppressive practice quickly, while others can become defiant, or experience significant emotional adversity. Non-Indigenous students may lack knowledge of the effects of settler colonialism and/or feel that their social identity is being challenged. This may lead to emotional reactions that are complex, and often semi-conscious. As students work through these emotional experiences, protective mechanisms (such as outward displays of anger) may arise. Alternatively, students may become caught in feelings of guilt and shame (Mills and Creedy, 2019). Becoming ‘stuck’ in these emotions reinforces inertia and preserves the status quo. Staying stuck makes institutional racism difficult to address in any meaningful way. Despite the complexity of teaching and learning in cultural safety, research about students’ complex emotional reactions has been rare.

Measuring emotion

Our research team developed and tested a survey tool to understand non-Indigenous student emotional learning experiences in cultural safety education (Mills, Creedy, Sunderland & Allen, 2021). The tool, named the Student Emotional Learning in Cultural Safety Instrument (SELCSI), is First Peoples-led with two scales of measurement: witnessing and comfort. The SELCSI was tested with 109 nursing and midwifery students after finishing a semester-long cultural safety course. Our results showed that the SELCSI is a valid and reliable measure of emotion in cultural safety education. In addition, the comfort scale can be used to support students to reflect on their level of comfort with cultural safety content. For educators, the scale can be used to see how students are sitting with the content to enable them to adapt to students’ needs.

Where to from here

Understanding and measuring non-Indigenous students’ emotions when learning cultural safety will support student reflection and learning. At the same time, it will promote responsive and innovative approaches to cultural safety education. Significantly, measuring emotion using the SELCSI may be fundamental to culturally safe health practice. Cultural safety is required to achieve health equity for Aboriginal and Torres Strait Islander peoples.

References

Australian Health Practitioner Regulation Agency (AHPRA). (2018). Aboriginal and Torres Strait Islander Health Strategy – Statement of Intent. https://www.ahpra.gov.au/About-AHPRA/Aboriginal-and-Torres-Strait-Islander-Health-Strategy/Statement-of-intent.aspx

Australian Institute of Health and Welfare. (2020). Australia’s Mothers and Babies 2018 – In Brief. Canberra: AIHW.

Australian Nursing and Midwifery Accreditation Council (ANMAC). (2017). Enrolled Nurse Accreditation Standards 2017. https://www.anmac.org.au/sites/default/files/documents/ANMAC_EN_Standards_web.pdf

Mills, K., & Creedy, D. (2019). The ‘Pedagogy of discomfort’: A qualitative exploration of non-indigenous student learning in a First Peoples health course. The Australian Journal of Indigenous Education, 1-9. https://doi.org/10.1017/jie.2019.16

Mills, K., Creedy, D. K., Sunderland, N., & Allen, J. (2021). Examining the transformative potential of emotion in education: A new measure of nursing and midwifery students’ emotional learning in first peoples’ cultural safety. Nurse Education Today, 104854. https://doi.org/10.1016/j.nedt.2021.104854

Molly Wardaguga Research Centre. (2019). Birthing on Country. Retrieved from www.birthingoncountry.com

Paradies, Y., Ben, J., Denson, N., Elias, A., Priest, N., Pieterse, A., Gee, G., 2015. Racism as a determinant of health: a systematic review and meta-analysis. PLoS One 10 (9), e0138511.

Sivertsen, N., Anikeeva, O., Deverix, J., & Grant, J. (2020). Aboriginal and Torres Strait Islander family access to continuity of health care services in the first 1000 days of life: a systematic review of the literature. BMC Health Serv Res, 20(1), 829. https://doi.org/10.1186/s12913-020-05673-w

The two most common reasons women have a first caesarean section

 

Research in context

In Australia and many high-income countries, the rate of caesarean section (CS) is increasing. There is no evidence that higher rates of CS improve health outcomes, which raises concerns about overuse of the surgical procedure (ACOG et al., 2014).

In 2000, 1 in 5 Australian women had a caesarean section. That rate is now more than 1 in 3 (AIHW, 2018). For women having their first baby in Australia the risk of CS is 37% (AIHW, 2020). Once a woman has experienced a CS, future vaginal birth is much less likely. In Australia, 7 out of 8 women will have a repeat CS for their next baby (AIHW, 2020). Therefore, preventing the first caesarean section (called a “primary CS”) is paramount wherever safely possible (ACOG et al., 2014).

Some have attributed the significant rise in CS rates to the increase in older and more obese pregnant women (RANZCOGAIHW releases data on caesarean section in Australia). Indeed, age ≥35 years and obesity can increase the chances of health issues including high blood pressure, diabetes, and multiple pregnancies. Nevertheless, this change alone is unlikely to explain the magnitude of the rise in CS rates, nor the differences in CS rates in different settings (WHO, 2018).

What the research did 

New research led by PhD candidate Haylee Fox, supervised by TMCC Deputy-Director, Associate Professor Emily Callander, aimed to build our knowledge in this area: https://onlinelibrary.wiley.com/doi/full/10.1111/birt.12530

Fox et al. (2021) used routinely collected hospital data to analyse the main reasons recorded by clinicians for primary CS in Queensland Health hospitals. Nearly 100,000 women either having their first baby or having a subsequent baby after previous vaginal birth were included in the study. Women who had experienced a previous CS were excluded.

What the research found

The top two reasons women in Queensland public hospitals had a primary CS were: ‘abnormal fetal heart rate’ (23%) and ’primary inadequate contractions’ (23%). Medical interventions including artificial rupture of membranes (ARM), oxytocin augmentation or induction of labour, and epidural analgesia predicted CS for fetal heart rate concerns (as did obstructed labour). Where a primary CS was performed due to “inadequate” contractions, epidural analgesia, ARM, fetal stress, and oxytocin augmentation or induction were predictive factors.

So what does this mean?

Induction of labour and epidural analgesia predict the two most common reasons for primary CS.  Accurate, evidence-based information about the potential consequences of induction of labour or epidural should be provided to all women (Fox et al, 2021). Indeed, these results warrant professional reflection on the use of induction of labour and epidural analgesia, alongside critical review of relevant policies, given the clear link with primary CS.

An Australian study including 1.25 million reported women who accessed birth centre or homebirth had lower rates of oxytocin augmentation and epidural use. Maternal and perinatal outcomes by planned place of birth in Australia 2000 – 2012: a linked population data study | BMJ Open. The Cochrane systematic review found women receiving midwife-led care in a hospital setting were less likely to receive an epidural, although it appeared to make no difference to rates of induction of labour or oxytocin augmentation. Midwife-led continuity models of care compared with other models of care for women during pregnancy, birth and early parenting | Cochrane

Midwifery continuity of care models and out-of-hospital birth protect against overuse of medical interventions including CS. Universal access to continuity of midwifery care should be a national policy priority.

References

American College of Obstetricians and Gynecologists (College); Society for Maternal-Fetal Medicine, Caughey AB, Cahill AG, Guise JM, Rouse DJ. (2014). Safe prevention of the primary cesarean delivery. American Journal of Obstetrics and Gynecology, 210(3), 179-93. https://doi.10.1016/j.ajog.2014.01.026

Australian Institute of Health and Welfare. (2020). Australia’s Mothers and Babies 2018 – In Brief. AIHW.

Fox, H., Topp, S. M., Lindsay, D., & Callander, E. (2021). A cascade of interventions: A classification tree analysis of the determinants of primary cesareans in Australian public hospitals. Birth: Issues in Perinatal Care, 00, 1-12. https://doi.org/10.1111/birt.12530

Homer, C.S.E., Cheah, S.L., Rossiter, C. et al. (2019). Maternal and perinatal outcomes by planned place of birth in Australia 2000 – 2012: a linked population data study. BMJ Open, 9, e029192. https://doi.10.1136/bmjopen-2019-029192

Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2016). Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD004667. https://doi.10.1002/14651858.CD004667.pub5

World Health Organization. (2018). WHO Recommendations Non-Clinical Interventions to Reduce Unnecessary Caesarean Sections. WHO.

Preterm birth and the cost to women

When a baby is born preterm, they are more likely to face significant health challenges. As a consequence, the care they receive is more expensive than a baby born around term. Some of this cost is met by government funding, but not all. Women who give birth to preterm babies provide the bulk of the care for preterm babies during their first years of life, and therefore incur most of these cost shortfalls. Just how much this amounts to is a question that has recently been addressed (Fox & Callander, 2021).

Ms Haylee Fox from James Cook University and Associate Professor Emily Callander, a Transforming Maternity Care Collaborative member, set out to determine both the out-of-pocket health care costs women who have recently given birth face, and the loss of income incurred as a consequence of a delayed return to employment. They did this for women who gave birth at term, and those who gave birth preterm so any differences could be measured. Data from the Longitudinal Study of Australian Children and the Maternity 1000 dataset were used to provide answers.

Women who gave birth preterm took longer to return to employment (2.8 years) than women who gave at term (1.9 years). Mothers of preterm babies were more likely to not return to paid employment at all, while those who did had a lower income than women who gave birth at term. Out of pocket healthcare expenses were $1059 for women who gave birth at term, $1298 for women who gave birth between 32 and 36 weeks, and $2491 for those who gave birth at less than 32 weeks.

It has long been recognised that being born preterm does not provide the optimum start to life. Fox and Callander’s research suggests that financial hardship is likely to compound the health challenges preterm children face during early childhood. They have demonstrated that preterm birth limits women’s capacity to participate in the workforce. While ensuring adequate government income support for new mothers is an important step in rectifying the financial shortfall, interventions to prevent preterm birth are likely to be far more cost effective and assist women to re-enter the workforce in a timely manner.

Midwifery led continuity of care is backed by sound evidence demonstrating both a reduction in preterm birth and lower mortality rates related to this (Medley et al., 2018). Implementation of continuity models has been found to be cost neutral, however the research to date has not considered the potential impact of changes to downstream costs from a reduction in preterm birth (Sandall et al., 2016). Access to continuity of midwifery care models remains below demand for such services (Donnellan-Fernandez et al., 2020). Addressing barriers to accessing such models should be a priority focus for policy makers.

References

Donnellan-Fernandez, R. E., Creedy, D. K., Callander, E. J., Gamble, J., & Toohill, J. (2020, Aug 28). Differential access to continuity of midwifery care in Queensland, Australia. Australian Health Review, 45(1), 28-35. https://doi.org/10.1071/AH19264

Fox, H., & Callander, E. (2021, Jan 10). Cost of preterm birth to Australian mothers: Assessing the financial impact of a birth outcome with an increasing prevalence. Journal of Paediatrics and Child Health, in press. https://doi.org/10.1111/jpc.15278

Medley, N., Vogel, J. P., Care, A., & Alfirevic, Z. (2018, Nov 14). Interventions during pregnancy to prevent preterm birth: an overview of Cochrane systematic reviews. Cochrane Database of Systematic Reviews, 11, CD012505. https://doi.org/10.1002/14651858.CD012505.pub2

Sandall, J., Coxon, K., Mackintosh, N., Rayment-Jones, H., Locock, L., & Page, L. A. (2016). Relationships: the pathway to safe, high-quality maternity care.

Making continuity of care experiences work for midwifery students

There has been an expansion in research focussed on how best to prepare midwifery students for practice over recent years. In Australia and many other high-income countries, a key component of pre-registration education is the completion of continuity of care experiences. During these continuity experiences, midwifery students participate in the care of an individual woman across multiple antenatal visits, during her labour, and through the postpartum period. This requires students to recruit women and remain on-call for them over an extended period, which is challenging for many. It is therefore important to ensure that continuity of care experiences provide valuable learning experiences for students.

Moncrieff et al. (2021) recently reviewed the published literature, asking what the evidence says about how to optimise students’ learning during continuity experiences. The research team identified twelve studies which helped to address this question, all but one of which was undertaken in Australia. The value of continuity experiences as an educational tool was clear. Three main themes were described:

1. Relationships.
Relationships with women, midwifery mentors, and other clinicians were central to students learning. Ensuring that attending appointments with women was a priority and structuring the curriculum around this in ways that supported sustainable study practices for students facilitated the development of relationships with women. Having continuity of placement site and mentor also enhanced relationship-based learning.

2. Conflict or coherence.
Providing continuity within a fragmented model of care was challenging, with better quality learning occurring when students were placed in continuity of care models.

3. Setting the standards.
Unclear communication with students regarding the purpose, numbers, management, and documentation of continuity experiences generated confusion for students. When clear guidance, flexible program delivery, and appropriate assessment were provided, students were enabled to develop confidence and competence.

In completing this literature review, the authors highlighted the absence of a solid evidence base to underpin the intent and design of continuity experiences for midwifery students. Since their review was completed, further evidence to support the benefits of placing students in continuity models has been published (Baird et al., 2021). There remain many opportunities to pursue further research that seeks to ensure that midwifery students graduate with the confidence and competence required to take up a productive role in a midwifery continuity of care program.

References

Baird, K., Hastie, C. R., Stanton, P., & Gamble, J. (2021). Learning to be a midwife: Midwifery students’ experiences of an extended placement within a midwifery group practice. Women and Birth, in press. https://doi.org/10.1016/j.wombi.2021.01.002

Moncrieff, G., MacVicar, S., Norris, G., & Hollins Martin, C. J. (2021, Feb). Optimising the continuity experiences of student midwives: an integrative review. Women Birth, 34(1), 77-86. https://doi.org/10.1016/j.wombi.2020.01.007

Bundles for perineal care: the impact on midwifery practice

When attempting to solve difficult problems in healthcare, professional organisations are increasingly making use of bundled approaches to care. A care bundle consists of collection of interventions which are believed to work interactively to address the issue in question. Using several interventions at once, at a whole of population level, is considered to be a more effective approach than the application of single interventions. There is however little evidence to support this assumption (Lavallee et al., 2017).

In maternity care, severe perineal trauma (sometimes called obstetric anal sphincter injury or OASI) is an issue that has received attention in both the United Kingdom and Australia. Tearing of the tissues at the opening of the vagina is common at birth. Typically, these tears are small and heal well without impacting on the function of the pelvic floor. Less often, tearing can be more extensive and extend to include the muscles around the anus (categorised as a third-degree tear) or into the anal passage (categorised as a fourth-degree tear). Trauma involving the anal sphincter muscles and / or anal passage can result in long term problems controlling the passage of wind and bowel movements. Recognising the extent of the trauma is important, as appropriate surgical repair and physiotherapy enhances the likelihood of restoring the normal function of the muscles.

Concerns have been raised that severe perineal trauma has become more common in recent years, though some argue that it is simply that clinicians have become better at recognising when it has occurred (Thornton & Dahlen, 2020). A bundle designed to prevent and identify severe perineal trauma was introduced in the United Kingdom in 2016 (Gurol-Urganci et al., 2021) in the hope that the rate of severe perineal trauma might be reduced. Another perineal care bundle was introduced in Australia in 2018 (Women’s Healthcare Australasia, 2019), with slight differences to the interventions included. In Australia the bundle consisted of:

  • Applying warm compresses to the perineum during birth
  • Applying manual pressure to the fetal head and the woman’s perineum during birth
  • Performing an episiotomy (a cut made at the opening of the vagina) for all women giving birth for the first time when instrumental birth is being conducted (vacuum extraction or forceps assisted birth), and when an episiotomy is done, ensuring that the angle of incision is at least 60 degrees from the vertical
  • All women having two people assess their perineum after vaginal birth, and
  • This assessment included a digital rectal examination, even when the perineum appeared intact.

High quality research evidence is only available for the first of these practices (Aasheim et al., 2017). Outcomes from the United Kingdom perineal bundle were reported after the Australian bundle was rolled out (Gurol-Urganci et al., 2021), finding a small but statistically significant reduction in the incidence of severe perineal trauma, occurring in 3 less women per 1000 following the introduction of the bundle. What is not known is how the bundle impacts on midwifery practice nor has there been research to understand the bundle from the perspective of birthing women.

Recently published research from Transforming Maternity Care Collaborative researchers Dr Jyai Allen, Dr Kirsten Small, and Dr Nigel Lee of the University of Queensland set out to examine the impact that the Australia perineal bundle had on midwifery practice (Allen et al., 2021).

Midwives working in Queensland hospitals where the bundle had been introduced were recruited, with twelve midwives from five hospitals being interviewed. Midwives were asked about the approaches to perineal care they used prior to the introduction of the bundle and how this had changed with the introduction of the bundle. The findings were presented relating to three themes:

  1. Design and implementation of the bundle,
  2. Changes to midwifery practice, and
  3. Obstetric domination and midwifery submission.

Participants expressed confusion about whether the bundle was a research project or a quality improvement measure. Emotive appeals rather than the presentation of sound evidence for the elements of the bundle was used in education sessions supporting the introduction of the bundle. Some midwives readily accepted all the changes to practice that occurred with the introduction of the bundle, with others used a variety of approaches to “get around” aspects of the bundle they considered inappropriate. When midwives did comply with all elements of the bundle there was a sense that this was done from a position of relative powerlessness to provide alternative approaches to practice.

Midwives described concerns about the standardising effects of the bundle, which prevented them from being able to provide individualised care. The practices outlined in the bundle were considered easiest to apply when women had an epidural and were confined to bed for birth. Meeting the bundle requirements (particularly maintaining manual perineal support) was not always possible when approaches such as waterbirth or upright, forward leaning postures where used. Midwives were concerned that the bundle therefore favoured forms of care (such as restricting women to the bed for birth) which made it easier to comply with the bundle requirements.

Overall, the bundle appeared to reflect and reinforce technocratic obstetric ways of knowing and acting. Midwives were therefore placed in a position where they were required to frame their practices in relation to an obstetric view of the ideal approach to preventing severe perineal trauma. Providing care consistent with midwifery philosophy, such as individualised care that supports physiological processes would be seen as non-compliant behaviour. To avoid this, future bundle development should include consultation and collaboration with women and midwives, and routine evaluation of the bundle should include research to examine the impact of the bundle on midwifery practice and women’s experiences of their births.

References

Aasheim, V., Nilsen, A. B. V., Reinar, L. M., & Lukasse, M. (2017). Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database of Systematic Reviews, 6, CD006672. https://doi.org/10.1002/14651858.CD006672.pub3

Allen, J., Small, K., & Lee, N. (2021, Jan 20). How a perineal care bundle impacts midwifery practice in Australian maternity hospitals: A critical, reflexive thematic analysis. Women and Birth, in press. https://doi.org/10.1016/j.wombi.2021.01.012

Gurol-Urganci, I., Bidwell, P., Sevdalis, N., Silverton, L., Novis, V., Freeman, R., Hellyer, A., van der Meulen, J., & Thakar, R. (2021). Impact of a quality improvement project to reduce the rate of obstetric anal sphincter injury: a multicentre study with a stepped-wedge design. British Journal of Obstetrics and Gynaecology, 128(3), 584-592. https://doi.org/10.1111/1471-0528.16396

Lavallee, J. F., Gray, T. A., Dumville, J., Russell, W., & Cullum, N. (2017). The effects of care bundles on patient outcomes: a systematic review and meta-analysis. Implementation Science, 12(1), 142. https://doi.org/10.1186/s13012-017-0670-0

Thornton, J. G., & Dahlen, H. G. (2020). The UK Obstetric Anal Sphincter Injury (OASI) Care Bundle: A critical review. Midwifery, 90, 102801. https://doi.org/10.1016/j.midw.2020.102801

Women’s Healthcare Australasia. (2019). The how to guide: WHA CEC perineal protection bundle. https://women.wcha.asn.au/sites/default/files/docs/wha_national_collaborative_how_to_guide_21.1.20.pdf

 

Preparing students to provide continuity of care

Continuity of midwifery care provides superior maternal and neonatal outcomes (Sandall et al., 2016). Access to continuity of care models is limited, both for women and for midwifery students who have the opportunity to gain direct experience of such models. There is also concern that placing students in a continuity of care model rather than a standard hospital model of care may reduce their learning.

New research from Professor Kathleen Baird, Ms Carolyn Hastie, Ms Paula Stanton and Emeritus Professor Jenny Gamble of the Transforming Maternity Care Collaborative focussed on the learning experiences of students who complete an extended placement in a midwifery group practice providing continuity of care at Griffith University (Baird et al., 2021). Final year midwifery students were able to elect to take part in a six-month placement in a midwifery group practice team. The research team conducted focus group interviews to explore the experiences of fifteen students who had taken part in the placement.

Students reported that their placement in the midwifery group practice was the highlight of their degree and was not as demanding as they had anticipated. Being able to develop skills in providing relationship-based care was highly valued by students and was enabled and supported by the midwives they were working with. The culture of the midwifery group practice in which students were placed provided a supportive environment were students learned to take care of themselves and their team members, and to collaborate with other members of the team. Students felt that they were valued members of the team. Returning back to the hospital shift-based system was challenging for most students. They were aware of a loss of autonomy and a faster pace of care. Some were supported well in this transition, while others were criticised for their choice to spend time in the midwifery group practice.

This research enables midwifery educators to be confident that prolonged immersive student placements in midwifery continuity of care models provides positive learning experiences. The students described feeling and acting like a “real midwife” during their placement, with six being adamant that they would apply for a position in a midwifery group practice immediately after graduation. Increased access to midwifery continuity of care models for women would provide more opportunities for midwifery students to gain experience of working in this model.

References

Baird, K., Hastie, C. R., Stanton, P., & Gamble, J. (2021). Learning to be a midwife: Midwifery students’ experiences of an extended placement within a midwifery group practice. Women and Birth, in press.

Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2016, Apr 28). Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews, 4(11), CD004667.

Midwifery students and birthing women: a valuable relationship

Women value midwifery students and midwifery students value women. One Australian university has begun to collect routine, ongoing, web-based feedback from all women who complete a continuity of care experience (CCE) with a midwifery student. Analysis of the first 12 months of data found that women value CCE with student midwives and midwifery students are providing above and beyond the minimum requirements for care. Continuity of midwifery care (CMC) has long been recognised as the cornerstone of quality midwifery care but how does this manifest in pre-registration midwifery programs?

CCE was introduced to Australian pre-registration midwifery programs as a way to provide students “experience in woman-centred care” (ANMAC, 2015, p. 24). Currently Australian midwifery students must support a minimum of 10 women within a CCE including a minimum of four antenatal visits, attendance at the majority of women’s labour and births as well as a minimum of two postnatal visits (ANMAC, 2015). The number of CCE students are required to undertake has been reviewed periodically by accreditation board ANMAC since 2010 and has reduced from a total of 30 in 2010 to the current 10 (Teirney et al., 2018). Some midwifery students and accredited midwifery education providers have previously argued that they have found complexities when managing clinical placements, CCE experiences, assessment, course requirements, employment and family responsibilities (Gray et al., 2013; McLaughlan et al., 2013). It was thought that reducing the number of total CCE would provide a higher quality of CCE experiences for students and women (ANMAC, 2014).

Although minimum requirements of a Bachelor of Midwifery (BMid) program at one Australian university are double the number (20) of minimum CCE and a minimum of five antenatal visits, all labour and births, and three postnatal visits (to six weeks postpartum), a recent study has shown that midwifery students at this university provide women even more support than this (Tickle et al., 2020). Students in this program completed a mean average of 5.83 antenatal visits, attended 92.6 percent of women’s labour and births and a provided a mean average of six postnatal contacts. The authors state that the midwifery program in this study is flexible in its design to privilege the CCE (Tickle et al., 2020). This may have allowed students to prioritise women’s care where necessary.

From previous statements made regarding the reduction of CCE requirements with intention to increase the quality of a CCE, you may be mistaken for believing that although student attendance in this study was high, the quality of the experience for women was lacking, however this is untrue. The study, where 57 percent of women provided feedback, found that the majority of women were satisfied with the student in the antenatal period (86.6 percent), labour and birth (86.4 percent) and postnatally (79 percent) (Tickle et al., 2020). Women were more satisfied when their CCE student attended their labour and birth (Tickle et al., 2020). Additionally, there was a positive correlation between a woman’s level of satisfaction and respect (measured on standardised scales) and the number of antenatal visits and postnatal contacts midwifery students had with women (Tickle et al., 2020). Nearly all women would recommend a midwifery student (97.6 percent) (Tickle et al., 2020). It could be argued that in order for the original purpose of the introduction of CCE by ANMAC (to provide experience in woman-centred care) to be fully realised, women should remain at the centre of a CCE. Women clearly value their midwifery student providing CCE and therefore the authors recommend midwifery standards be revised to increase both the total number and minimum requirements of CCE  for pre-registration midwifery students (Tickle et al., 2020).

Providing all women the opportunity to feedback their experiences gives women a voice and exemplifies respectful, woman-centred, professional practice. Feedback from women affords students and faculty a unique perspective for reflection, practice and program review and revision to help ensure women remain at the centre of learning and teaching in midwifery.

For women to receive continuity of midwifery care the midwifery workforce requires midwives to work within continuity models (Gamble et al., 2020). Midwifery students placed in CMC models are more likely to want to work in these models after graduation (Carter et al, 2015; Cummins et al., 2017). Over one third (34.7 percent) of women in the Tickle et al. (2020) study received a midwifery continuity primary model of care meaning that many students are being exposed to CMC models which may contribute to a growing CMC workforce.

CCE is important for women, students and the future midwifery workforce. Increasing pre-registration midwifery program standards to include a larger number of CCE, increased minimum requirements, routine feedback from women and maintaining quality is both feasible and optimal. In the same way women’s satisfaction with a midwifery student providing CCE echoes current research with midwives providing CMC (Sandall et al., 2016), it is possible clinical outcomes for women receiving a CCE will follow the same trajectory.

References

Australian Nursing and Midwifery Accreditation Council. (2014). Midwife accreditation standards. ANMAC. https://www.anmac.org.au/sites/default/files/documents/ANMAC_Midwife_Accreditation_Standards_2014.pdf

Carter, A., Wilkes, E., Gamble, J., Sidebotham, & Creedy, D.K. (2015). Midwifery students׳ experiences of an innovative clinical placement model embedded within midwifery continuity of care in Australia, Midwifery, 31(8), 765. https://doi.org/10.1016/j.midw.2015.04.006

Cummins, A.M., Denney-Wilson, E., & Homer, C.S.E. (2017). The mentoring experiences of new graduate midwives working within midwifery continuity of care models in Australia. Nurse Education in Practice, 24, 106-111. https://doi.org/10.1016/j.nepr.2016.01.003

Gamble, J., Sidebotham, M., Gilkison, A., David, D. & Sweet, L. (2020). Acknowledging the primacy of continuity of care experiences in midwifery education. Women and Birth, 33(2), 111-118. https://doi.org/10.1016/j.wombi.2019.09.002

Gray, J., Leap, N., Sheehy, A. & Homer, C.S. (2013). Students’ perceptions of the follow-through experience in 3 year bachelor of midwifery programmes in Australia. Midwifery, 29(4), 400-406. https://doi.org/10.1016/j.midw.2012.07.015

McLachlan, H.L., Newton, M., Nightingale, H., Morrow, J., Kruger, G. (2013). Exploring the ‘follow-through experience’: a statewide survey of midwifery students and academics conducted in Victoria, Australia. Midwifery, 29(9), 1064-1072. https://doi.org/10.1016/j.midw.2012.12.017

Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2016). Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews, 4. https://doi.org/ 10.1002/14651858.CD004667.pub5

Tickle N., Gamble J. & Creedy DK. (2020) Women’s reports of satisfaction and respect with continuity of midwifery care experiences by students: Findings from a routine, online survey. Women & Birth, in press. doi.org/10.1016/j.wombi.2020.11.004

Tierney, O., Sweet, L., Houston, D. & Ebert, L. (2018). A historical account of the governance of midwifery education Australia and the evolution of the continuity of care experience. Women and Birth, 31(210-215). https://doi.org/10.1016/j.wombi.2017.09.009

Midwives’ mental health during the COVID19 pandemic

Identifying as a midwife is a source of joy and purpose for most midwives, but many midwives describe their midwifery work as challenging. Researchers from the Transforming Maternity Care Collaborative have been co-ordinating the Work, Health, and Emotional Lives of Midwives (WHELM) project. The project has identified high levels of burnout, depression, anxiety, and stress in Australian midwives (Creedy, et al., 2017) and also internationally (Cull, et al., 2020; Dixon, et al., 2017, Pezaro, et al., 2016, Stoll & Gallagher, 2019). Many midwives with high levels of burnout planned to leave midwifery practice, creating the potential for a significant shortfall in the number of qualified midwives available to provide safe maternity care.

This research was conducted prior to the arrival of the novel coronavirus pandemic that has transformed the maternity care workplace. Concerns have been raised regarding the potential for the pandemic to have a significant impact on the mental wellbeing of health professionals (Pfefferbaum & North, 2020). Recent research has shown high levels of anxiety among doctors, midwives, and nurses working in maternity services (Uzun, et al., 2020). Rapid and significant changes to the workplace have been required, particularly in places with large numbers of cases. Whether there will be further waves of infection is unpredictable. It is therefore highly likely that midwives’ emotional coping resources are under pressure.

It is important that we continue to measure the emotional health of midwives. To do that we need tools which are fit for purpose and have been used previously so there is a secure baseline to measure against. The WHELM team have developed, tested, and deployed such tools for a number of years (Pallant, et al., 2015; 2016), and are therefore well placed to provide advice this area.

Previous research from the WHELM consortium has demonstrated that a key protector of midwives’ mental wellbeing is working in a midwifery continuity of carer model (Sidhu, et al., 2020). Prioritising a shift away from traditional, fragmented models of maternity care to midwifery continuity of care is likely to enhance the sustainability of maternity care services through this and any future significant external challenges.

You can access the most recent paper from the WHELM consortium for free for a limited time – here.

References

Creedy, D. K., Sidebotham, M., Gamble, J., Pallant, J., & Fenwick, J. (2017). Prevalence of burnout, depression, anxiety and stress in Australian midwives: a cross-sectional survey. BMC Pregnancy and Childbirth, 17, 13.

Cull, Hunter, Henley, Fenwick, Sidebotham. (2020). “Overwhelmed and out of my depth”: Responses from early career midwives in the United Kingdom to the Work, Health and Emotional Lives of Midwives study. Women and Birth, 33(6), e549-557.

Dixon,L., Guilliland,K., Pallant,J., Gilkison,A., Sidebotham,M., Fenwick,J.,McAra-Couper,J. (2017).The emotional wellbeing of New Zealand midwives: comparing responses between employed, self-employed (case loading) and midwives who do both. New Zealand College of Midwives Journal, 53, 5-14

Pallant, J. F., Dixon, L., Sidebotham, M., & Fenwick, J. (2015). Further validation of the Perceptions of Empowerment in Midwifery Scale. Midwifery, 31(10), 941– 945.

Pallant, J. F., Dixon, L., Sidebotham, M., & Fenwick, J. (2016). Adaptation and psychometric testing of the Practice Environment Scale for use with midwives. Women and Birth, 29(1), 24– 29.

Pezaro, S., Clyne, W., Turner, A., Fulton, E. A., & Gerada, C. (2016). ‘Midwives Overboard!’ Inside their hearts are breaking, their makeup may be flaking but their smile still stays on. Women and Birth, 29(3), e59– 66.

Pfefferbaum, B., & North, C.S. (2020). Mental health and the Covid-19 pandemic. New England Journal of Medicine, in press. https://doi.org/10.1056/NEJMp2008017

Sidhu R, Su B, Shapiro K & Stoll K. (2020). Exploring prevalence of and factors associated with Burnout in Midwifery: A Scoping Review. European Journal of Midwifery, 4(February), 4.

Stoll K & Gallagher J. (2019). A survey of burnout and intentions to leave the profession among Western Canadian midwives. Women and Birth, 32(4): e441-e449.

Uzun, N, Teki̇n, M, Sertel, E, Tuncar, A. (2020). Psychological and social effects of COVID-19 pandemic on obstetrics and gynecology employees. Journal of Surgery and Medicine, 4(5), 355-358. DOI: 10.28982/josam.735384