Our Updates

What makes maternity care “worth it”?

Childbirth is the most common reason for hospitalisation and the most expensive. Many high-income countries have witnessed escalating obstetric intervention rates (“too much, too soon”) with either no improvement or worsening health outcomes for women and babies (Miller et al., 2016). Overuse, or misuse, of medical intervention is wasteful of resources – and perhaps more importantly, it harms mothers and babies (Miller et al., 2016) – with potential life course consequences (Peters et al., 2018).

Quality care maternity care has been referred to “right care” (Kennedy et al., 2018). Right care is woman-centred and individualised, informed by evidence, cost-effective, includes consideration of benefits and harms, strengthens equity and is available across the continuum (World Health Organization, 2016).

Value-based maternity care

Value-based healthcare means care that is not only safe and effective, but “worth it” for the people providing care, receiving care, and paying for care (Sudhof & Shah, 2019). Value, however, is hard to measure. When hospitals and clinicians that provide maternity care are reimbursed for the quantity of services, rather than the quality of services, there is no incentive to provide right care (Sudhof & Shah, 2019). The authors describe some of the barriers to providing high-value maternity care – time pressure, fear of malpractice, and misaligned financial incentives (Sudhof & Shah, 2019).

Sudhof & Shah (2019) recommend five strategies to deliver high-value maternity care:

  1. When treatments are equivalent, choose based on price. For example, birth centre care for women at low risk of complications.
  2. Critically evaluate and individualise emerging technologies. For example, consider the cost, risk, and benefit of specific screening tests rather than offering them to all pregnant women.
  3. Prioritise team-based approaches to care. For example, provide collaborative obstetric and midwifery care, and access to professional labour support.
  4. Integrate contraception and pregnancy counselling. For example, provide access to immediate postpartum long-acting reversible contraception.
  5. Expand ways of engaging women in maternity care. For example, consider home visits for women that are otherwise hard to reach or follow up.

Value-based performance programs

Many countries have implemented and evaluated value-based performance (VBP) programs to financially reward quality of care (Chee et al., 2017). For example, the US Hospital VBP program takes 2% of the participating hospitals’ diagnosis-related payments for the financial year to redistribute based on each hospital’s quality performance (U.S. Centers for Medicare & Medicaid Services, 2021). Quality performance is measured in four areas: 1) clinical outcomes; 2) patient-reported experience measure; 3) safety and 4) efficiency. A systematic review of VBP programs reports they are marginally effective in some settings, but some results are mixed, and some positive changes are not sustained (Chee et al., 2017). The review authors identified several opportunities to strengthen VBP programs. For example, getting better at measuring what ‘quality’ is and increasing the size and design of financial incentives (Chee et al., 2017).

Currently, in the US Hospital VBP program, women who have given birth in hospital are combined with all other hospital patients. Indeed, there is no specific VBP programs for maternity and/or obstetric care in any country. In addition, the patient-reported outcome and experience measures used in VBP programs are not specific to pregnancy and childbirth (Childbirth Connections, 2016).

Patient reported outcomes and experiences 

Kennedy et al. (2018) recommend research to determine which measures can be used to effectively see quantifiable improvements in clinical outcomes and women’s experiences during pregnancy and childbirth. A Patient Reported Outcome Measure (PROM) is used to get healthcare users views of “their symptoms, their functional status, and their health-related quality of life” (Black, 2013). Whereas a Patient Reported Experience Measure (PREM) refers to the person’s experiences of the healthcare services they received (Chen et al., 2021); specifically, what happened during their care encounter and how it happened (Bull et al., 2019). The International Consortium for Health Outcomes Measurement have developed a Pregnancy and Childbirth outcome set of 24 measures that are internationally appropriate and represent what matters to women and families (Nijagal et al., 2018). While research using these measures has been limited, routine collection would be valuable for health services (Chen et al., 2021).

Conclusion

Once the ICHOM pregnancy and childbirth outcome set has been validated across international settings, it could be used to benchmark and incentivise the improvement of maternity care (Nijagal et al., 2018). Potentially, this could be incorporated intoa  maternity-specific VBP program. Reducing unnecessary interventions and improving the quality of care during childbirth is not only critical to the outcomes and experiences of childbearing women and newborns – it would save the taxpayer money (Childbirth Connections, 2016).

Highlighted article

Sudhof, L. & Shah, N.T. (2019). In pursuit of value-based maternity care. Obstetrics & Gynecolology, 133, 541–551. https://doi.10.1097/AOG.0000000000003113

References

Black N. (2013). Patient reported outcome measures could help transform healthcare. British Medical Journal, 346(167). https://doi.org/10.1136/bmj.f167

Bull C, Byrnes J, Hettiarachchi R, Downes M. (2019). A systematic review of the validity and reliability of patient-reported experience measures. Health Services Research, 54(5), 1023-1035.

Chee, T. T., Ryan, A. M., Wasfy, J. H., & Borden, W. B. (2016). Current state of value-based purchasing programs. Circulation133(22), 2197–2205. https://doi.org/10.1161/CIRCULATIONAHA.115.010268

Chen, A., Väyrynen, K., Leskelä, R. L., Heinonen, S., Lillrank, P., Tekay, A., & Torkki, P. (2021). A qualitative study on professionals’ attitudes and views towards the introduction of patient reported measures into public maternity care pathway. BMC Health Services Research21(1), 645. https://doi.org/10.1186/s12913-021-06658-z

Childbirth Connections. (2016). The Quality Care for Moms and Babies Act: Improving Maternity Care for Women and Families. National Partnership for Women and Families.

Dickinson, F., McCauley, M., Smith, H., & van den Broek, N. (2019). Patient reported outcome measures for use in pregnancy and childbirth: a systematic review. BMC Pregnancy and Childbirth, 19(1).

Kennedy, HP, Cheyney, M, Dahlen, HG, et al. (2018). Asking different questions: A call to action for research to improve the quality of care for every woman, every child. Birth: Issues in Perinatal Care, 45, 222- 231. https://doi.org/10.1111/birt.12361

Miller, S., et al. (2016). Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide. The Lancet, 388(10056), 2176 – 2192.

Nijagal, M. A., Wissig, S., Stowell, C., Olson, E., Amer-Wahlin, I., Bonsel, G., Brooks, A., Coleman, M., Devi Karalasingam, S., Duffy, J., Flanagan, T., Gebhardt, S., Greene, M. E., Groenendaal, F., R Jeganathan, J. R., Kowaliw, T., Lamain-de-Ruiter, M., Main, E., Owens, M., Petersen, R., … Franx, A. (2018). Standardized outcome measures for pregnancy and childbirth, an ICHOM proposal. BMC Health Services Research18(1), 953. https://doi.org/10.1186/s12913-018-3732-3

Peters LL, Thornton C, de Jonge A, et al. (2018). The effect of medical and operative birth interventions on child health outcomes in the first 28 days and up to 5 years of age: a linked data populationbased cohort study. Birth: Issues in Perinatal Care, 1‐11.

Symon, A., Downe, S., Finlayson, K. W., Knapp, R., & Diggle, P. (2015). The feasibility and acceptability of using the Mother-Generated Index (MGI) as a patient reported outcome measure in a randomised controlled trial of maternity care. BMC Medical Research Methodology, 15(92).

U.S. Centers for Medicare & Medicaid Services. (2021). Hospital Value-Based Purchasing Program. Retrieved from: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/HVBP/Hospital-Value-Based-Purchasing.

World Health Organization. (2016). WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience. World Health Organization.

COVID-19 related maternity restrictions – more harm than good?

COVID-19 maternity care restrictions

During the global COVID-19 pandemic, maternity care guidelines have been produced rapidly and largely without evidence (Pavlidis et al., 2021). For example, US labour and birth guidelines encouraged providers to use artificial rupture of membranes; use higher doses of oxytocin to shorten length of labour; offer early epidurals; and lower the threshold for caesarean section (Stephens et al., 2020). Across the globe, women have experienced significant restrictions including prohibition of a birth companion in labour, limits around breastfeeding, and reduction in contact between mother and baby (Topalidou et al., 2020). While pregnant women commonly feel fear, stress, or concern about loss of agency during childbirth – COVID-19 has amplified these experiences by adding unknown factors about labour support and medical interventions (Almeida et al., 2020). Fears about restrictions include having to choose between a partner and a doula for labour support, or not having a labour support person at all, and fear of being separated from their baby after birth (Groschow & Floyd, 2021).

In the US, Gutschow & Davis-Floyd (2021) report recent lifting of non-evidence-based restrictions in terms of labour support, immediate skin-to-skin contact, breastfeeding and rooming-in. In Australia, however, there is community concern about increased maternity care restrictions on presence of partners at birth and on the postnatal ward, as reported by the ABC and Guardian. Researchers worldwide have raised concerns about the potential for restrictions to have long-term negative clinical and psychosocial consequences for mothers, families, and babies (Topalidou et al., 2020).

Women’s right to clinically and psychologically safe care

An article was recently published by a team who work across Europe “to ensure women’s rights to give birth in a clinically and psychologically safe environment including during the current COVID-19 pandemic” (Lalor et al., 2021). The commentary includes findings from a two-day virtual meeting of the network that included 88 clinicians and researchers from a variety of disciplines (e.g., midwifery, obstetrics, nursing, psychology) alongside lay advocacy groups from altogether 32 participating countries (Lalor et al., 2021). Information about variations in maternity care and COVID-19 related restrictions were discussed and summarised (Lalor et al., 2021).

Maternity care restrictions inconsistent and without evidence-base

The application of guidelines and restrictions was highly inconsistent between European countries (Lalor et al., 2021). Furthermore, local application of non-evidence-based restrictions significantly deviated from recommendations from the World Health Organization and professional bodies (Lalor et al., 2021). Similar international inconsistencies have been reported in intrapartum care practices outside Europe – including Australia and the United States. For example, use of nitrous oxide and water immersion during labour, birth companions, delayed cord clamping, and isolation of the newborn after birth (Pavlidis et al., 2020).

Lalor et al. (2021) raise concerns that women are being exposed to an environment where traumatic birth experiences are more likely – and where the continued implementation of harmful practices constitute a human rights violation (Lalor et al., 2021). The authors highlight that maternity care providers may be following guidelines that contradict with evidence, professional recommendations and/or deeply held values around woman-centred care – which in turn affects staff morale and productivity (Lalor et al., 2021). Indeed, a survey of key stakeholders in Australian maternity care reported that midwives and midwifery students are largely dissatisfied with restrictions that limit the quality of care they can provide (Bradfield et al., 2021).

Recommendations for maternity services and policymakers

Renfrew et al. (2020) provide key principles for services to sustain quality care during the pandemic. These include continuing to provide “evidence-informed, equitable, safe, respectful, and compassionate care for the physical and mental health of all women and newborn infants, wherever and whenever care takes place” (Renfrew et al., 2020). More specifically they recommend maintaining community-based continuity of care models, ensuring access to chosen birth support, facilitating mother-baby contact at birth, and promoting breastfeeding (Renfrew et al., 2020).

Any proposed change to maternity care practice must be considered within a quality framework, based on evidence, and evaluated for unintended effects (Lalor et al., 2021). Furthermore, women, families and staff should co-design proposed changes (Renfrew et al., 2020). Policies in response to COVID-19 have not been sensitive to maternal health – this could be addressed through the inclusion of maternal health experts in emergency planning – as well as rapid monitoring of barriers to maternity care (Takemoto et al., 2021).

Highlighted research

Lalor, J., Ayers, S., Celleja, J., Downe, S., Gouni, O., Hartmann, K., Nieuwenhuijze, M., Oosterman, M. Turner, J. D. (accepted in press, 2021). Balancing restrictions and access to maternity care for women and birthing partners during the COVID-19 pandemic: the psychosocial impact of suboptimal care. BJOG https://doi.org/10.1111/1471-0528.16844

References

Almeida M, Shrestha A. D., Stojanac B., Miller L J. (2020). The impact of the pandemic of women’s mental health. Archives Women’s Mental Health 23 (7), 741-748.  https://doi.org/10.1007/s00737-020-01092-2

Bradfield, Z., Wynter, K., Hauck, Y., Vasilevski, V., Kuliukas, L., Wilson, A. N., Szabo, R. A., Homer, C., & Sweet, L. (2021). Experiences of receiving and providing maternity care during the COVID-19 pandemic in Australia: A five-cohort cross-sectional comparison. PloS one16(3), e0248488. https://doi.org/10.1371/journal.pone.0248488

Gutschow, K., & Davis-Floyd, R. (2021). The Impacts of COVID-19 on US Maternity Care Practices: A Followup Study. Frontiers in Sociology6, 655401. https://doi.org/10.3389/fsoc.2021.655401

Pavlidis, P., Eddy, K., Phung, K., Farrington, E., Connolly, M., Lopes, R., Wilson, A.N., Homer, C.S.E., Vogel, P. (2020). Clinical guidelines for caring for women with COVID-19 during pregnancy, childbirth, and the immediate postpartum period. Women and Birth. https://doi.org/10.1016/j.wombi.2020.10.015

Renfrew, M. J., Cheyne, H., Craig, J., Duff, E., Dykes, F., Hunter, B., Lavender, T., Page, L., Ross-Davie, M., Spiby, H., & Downe, S. (2020). Sustaining quality midwifery care in a pandemic and beyond. Midwifery88, 102759. https://doi.org/10.1016/j.midw.2020.102759

Stephens A. J., Barton J. R., Bentum N.-A. A., Blackwell S. C., Sibai B. M. (2020). General Guidelines in the Management of an Obstetrical Patient on the Labor and Delivery Unit during the COVID-19 Pandemic. American Journal of Perinatolology, 37, 08, 829–836.

Topalidou, A., Thomson, G., Downe, S. (2020). COVID-19 and maternal and infant health: Are we getting the balance right? A rapid scoping review. The Practising Midwife, 23, 36- 45.

 

Decisions aids & staff training needed for shared decision making

Rising rates of induction and caesarean

In high-income countries, rates of induction of labour and caesarean section (CS) are rising at an alarming rate. In Australia, almost 1 in 2 women having their first baby will be induced (45%) (AIHW, 2020a) – while more than 1 in 3 will experience CS (37%) (AIHW, 2020b). While planned vaginal birth after caesarean (VBAC) is a safe choice for most women, the rate of successful VBAC in Australia remains low (12%) (AIHW, 2020b). The recent Australian Atlas on Variation in Healthcare reported that about half of CS performed at < 39 weeks’ gestation had no medical or obstetric indication for the surgical procedure (ACSQHC, 2021). The few studies on women’s experiences of decision-making about induction report women are not actively involved in the decision (Coates et al., 2021). The International Federation of Gynaecology and Obstetrics suggests that “properly informing” women about the risks and benefits of CS would effectively reduce CS (Visser et al., 2018).

Shared decision making

Shared decision making (SDM) is a process where clinicians facilitate people to reach “evidence-informed and value-congruent” decisions about their healthcare (Grad et al., 2017, p.682). In other words, a semi-structured conversation that includes explanation of the problem, the risks and benefits of different options, the woman’s desires and circumstances, and the provider’s recommendations (Legare et al., 2018). SDM is particularly important when the difference between risks and benefits of available options is marginal (Grad et al., 2017); as is often the case for induction of labour and planned CS (Coates et al, 2021, Coates et al., 2020).

Shared decision making and caesarean section

Researchers wanted to find out what is known about SDM and planned CS. Specifically, Coates et al. (2020) were interested in:

  • what women need to make informed decisions;
  • what women know about the risks and benefits of CS;
  • what interventions works to facilitate informed decision-making; and
  • what clinicians think about SDM.

The authors used key terms and a list of criteria to systematically search the literature. They included studies in their review that addressed the research aims and were either quantitative research (measurements and statistics) or qualitative research (participant accounts and experiences). The researchers then used an assessment tool to rate the quality of the studies included in the review.

Key findings

Coates et al. (2020) review included 34 studies. Most studies were about women’s experiences of decision-making (22 studies), many were about where women source information to make decisions (11 studies), some were about women’s knowledge of the risks and benefits of CS (7 studies) or interventions to assist women with decision-making (7 studies), and 6 studies were about clinicians’ perceptions of SDM.

There were two main findings from this review. First, women reported limited SDM in relation to CS, and many did not have the information required to make informed decisions (Coates et al., 2020). Second, while clinicians tended to agree with SDM they acknowledged it rarely occurs in practice (Coates et al., 2020).

Shared decision making and induction

The key findings about limited SDM when planning CS, are echoed in Coates et al. (2021) latest article about induction of labour. Here the researchers analysed women’s accounts (collected through telephone interviews). The findings were summarised as:

  • women told they needed an induction rather than being offered a choice;
  • women had little information and limited/no discussion about pros and cons;
  • women perceived they got conflicting information; and
  • women were not prepared for the process of induction.

Implementing shared decision making

Whether the decision is about CS or induction, most women want information so they can weigh up the pros and cons of available options before they make a decision. Many maternity care providers have not received training in SDM, or the high-level communication skills that underpin it (Coates & Clerke, 2020). Therefore, maternity services could provide obstetricians and midwives training in SDM so they have the skills required to help women make informed decisions.

Decision aids in pregnancy increase women’s knowledge and reduce decision-making conflict and anxiety (Vlemmix et al., 2013). Coates et al. (2021) support the development and testing of decision aids for induction because there are currently no high-quality decision aids available. Interestingly, advances in artificial intelligence, machine learning and risk prediction analytics have opened up the opportunity to use this data to predict the likely short- and long-term outcomes of decision-making. In maternity care, such approaches have been used to predict hypertensive disorders (Betts et al., 2019),  stillbirth (Koivu et al., 2020), and preterm birth (Moreira et al., 2018). But to date none have been incorporated into a decision aid to help women make evidence-informed decisions.

Highlighted research

Coates, D., Thirukumar, P., Henry, A. (2021). The experiences of shared decision-making of women who had an induction of labour. Patient Education and Counseling, 104(3), 489-495.

Coates, D., Thirukumar, P., Henry, A. (2020). Making shared decisions in relation to planned caesarean sections: What are we up to? Patient Education and Counseling, 103(6), 1176-1190.

References

Australian Institute of Health and Welfare. (1993). Caesarean births in Australia, 1985-1990. Canberra: AIHW.

Australian Institute of Health and Welfare (2020a). National Core Maternity Indicators 2018: summary report. Canberra: AIHW.

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

Australian Commission on Safety and Quality in Health Care, Australian Institute of Health and Welfare. The Fourth Australian Atlas of Healthcare Variation. Sydney: ACSQHC; 2021.

Betts K, Kisely S, Alati R. (2019). Predicting common maternal postpartum complications: leveraging health administrative data and machine learning. BJOG, 126, 702-709.

Coates D., & Clerke T. (2020). Training interventions to equip healthcare professionals with shared decision-making skills: a systematic scoping review. Journal of Continuing Education for Health Professionals, 40, 100-119.

Grad et al. (2017). Shared decision making in preventive health care: What it is, what it is not. Canadian Family Physician, 63(9), 682-684.

Koivu A, Sairanen M. (2020). Health information science and systems, 8, 1-12.

Legare, F, et al. (2018). Interventions for increasing the use of shared decision making by healthcare professionals. Cochrane Database of Systematic Reviews, 7. Cd006732

Moreira M, Rodrigues J, Marcondes G, Neto A, Kumar N, Diez I.  (2018). A preterm birth risk prediction system for mobile health applications based on the support vector machine algorithm.  International Conference on Communications (ICC), IEEE, 1-5.

Vlemmix, F, Warendorf, J, Rosman, A, Kok, M, Mol, B, Morris, J, Nassar, N. (2013). Aids to improve informed decision-making in pregnancy care: a systematic review. BJOG, 120, 257– 266

Visser GHA, Ayres-de-Campos D, Barnea ER, et al. (2018). FIGO position paper: how to stop the caesarean section epidemic. Lancet392(10155), 1286-7.

 

Midwifery centres – the what, the how, the why

Women across the globe (in low-, middle- and high-income countries) are concerned about misuse of medical intervention, and disrespectful or abusive treatment during labour and birth (World Health Organization, 2014). For example, in Mexico where the caesarean section rate is 50%, 30% of women report they have experienced ‘obstetric violence’ (Alonso et al., 2018). Whereas the poorest women in Sub Saharan Africa usually give birth at home either unattended (56%) or with a traditional birth attendant (41%), because they lack access to a skilled birth attendant, or do not think one is needed (Montagu et al., 2011). Midwifery centres – also known as birth centres – are sought by women who want to experience safe, respectful, and satisfying birth in a facility, while avoiding unnecessary intervention (Stevens & Alonso, 2020).

What is a midwifery centre?

A Midwifery Centre is a home-like healthcare facility that is guided by a midwifery philosophy of care, centred on the woman’s experience, specialising in physiological birth, with access to basic emergency care, and fully integrated within the healthcare system (Stevens & Alonso, 2020). Midwifery centres operate all over the world in over 56 countries – see map here. While midwifery centres could be key to achieving quality maternal and newborn care, there are negative perceptions about their capacity, limited understanding of what midwives do, and lack of access globally.

Midwifery centres in high-income countries

In high-income countries (e.g., Australia, Canada, United Kingdom, United States) highest-level evidence demonstrates women who plan to birth in a midwifery centre have a higher chance of normal birth, with a lower chance of obstetric intervention, and no difference in infant mortality (Scarf et al., 2018). Approximately 3% of women in Australia give birth in a midwifery centre. A study in one Australian state determined that 34% of women having their first baby, and 12% of women having a subsequent baby, were transferred from a midwifery centre and gave birth in hospital (Scarf et al., 2019). While there has been a near doubling of demand for midwifery centres in Australia over the past two decades, access has remained limited and birth numbers in midwifery centres have been static (Adelson et al., 2021).

Midwifery centres in low-income countries

In low- and middle- income countries, less is known about the outcomes associated with midwifery centre care. In these settings, there are challenges including lack of equipment, supplies, medication, blood, electricity and water; combined with difficulty transferring women to higher level care when needed either through lack of transport or women’s unwillingness to access hospital care (Munabi-Babigumira et al., 2017). Furthermore, midwifery centres in low- and middle- income countries tend to operate outside the healthcare system. Safe and respectful care, with seamless access to higher level services when required, is key to increasing access to skilled birth attendants in low- and middle-income countries; and therefore, addressing maternal and infant mortality in these settings.

How standards contribute to quality care

Without international standards, including a consensus definition of what a midwifery centre is (and is not), it is difficult to implement, monitor, evaluate and scale up.  Rigorously developed international standards guide funders, policy makers, managers and maternity advocates. It is important to be able to measure and compare outcomes between midwifery centres within and between countries, while accounting for variation in the population.

Development of international standards

Researchers Stevens & Alonso (2021) wanted to develop clear guidance through international standards to ensure the quality of care provided in midwifery centres. To do this, they initially gathered midwifery centre operation standards from the United States and Europe and compared these with international guidance on quality of maternal and newborn care, rights of childbearing women, and respectful maternity care (Stevens & Alonso, 2021). The research team analysed the documents to determine commonalities and to develop draft international standards. Next, international experts in low-, middle- and high-income settings provided feedback on the draft standards. The researchers then piloted 52 standards at 8 midwifery centres in 8 countries (Sierra Leone, Cambodia, Bangladesh, Mexico, Haiti, Peru, Uganda, and Trinidad) (Stevens & Alonso, 2021). Discussions with the pilot sites helped determine the final list.

Assessing how midwifery centres meet international standards

The Operational Standards for Midwifery Centers are freely available here. There are 43 process standards in three domains: Dignity, Quality, and Community-Facility (Stevens & Alonso, 2021). Each standard includes indicators which can be used to measure and assess whether, and how, the standard is met. Dignity includes 13 standards that are focussed on the woman. For example, Standard 10 Every mother is informed about the benefits of supporting physiological processes, includes indicators like policy, and woman’s health record. Quality includes 13 standards that are focussed on the maternity care providers. For example, Standard 24 At every birth, there are at least two staff currently trained for emergency management of common birth complications, can be assessed through staff education logs and birth documentation. Community-Facility includes 17 standards that are about administration. For example, Standard 31 The facility has functioning, reliable, safe, and sufficient systems for each of the following: clean water, dependable energy, facility sanitation, hand hygiene, general waste disposal, and medical waste disposal, can be assessed through availability of policies and procedures.

Primary midwifery care is the solution

Some argue that universal access to high-quality obstetric care and facility-based birth is the path to address maternal and infant mortality in low- and middle-income countries (Bohren et al., 2014). From this perspective, midwives are seen as an ‘add on’ to provide emotional support during obstetric-led birth (Austad et al., 2021). An alternative solution, that would address women’s expressed desires to birth close to home, with minimal intervention, and avoid disrespectful care, would be to rapidly scale up midwifery centres that meet international standards. Primary midwifery care should be the foundation of any maternity system. Midwives need to be supported in systems and health services to deliver care and outcomes for women and babies.

Scale-up of midwifery centres

Using the term ‘midwifery centre’ instead of ‘birth centre’ may help reorient thinking about how best to organise and provide quality maternal and newborn care. In high-income settings, a midwifery centre is not a room with an armchair and a birth pool within an obstetric-led unit. Midwifery centres are midwifery-led, woman-centred – designed to promote physiological birth and enable midwives to work to their full scope of practice. In low- and middle-income settings, a facility outside the hospital that offers birth care, but is not fully integrated to enable consultation, referral and transfer to higher level services, is also not a midwifery centre. The consensus definition and operational standards can be used in any global setting to establish, monitor and scale-up midwifery centres.

Highlighted research

Stevens, J. R., & Alonso, C. (2021). Developing operational standards for Midwifery Centers. Midwifery, 93, 102882. https://doi.org/10.1016/j.midw.2020.102882

References

Adelson, P., Fleet, J. A., McKellar, L., & Eckert, M. (2021). Two decades of Birth Centre and midwifery-led care in South Australia, 1998-2016. Women and Birth34(1), e84–e91. https://doi.org/10.1016/j.wombi.2020.05.005

Alonso, C., Storey, A. S., Fajardo, I., & Borboleta, H. S. (2021). Emergent change in a Mexican midwifery center organization amidst the COVID-19 crisis. Frontiers in Sociology6, 611321. https://doi.org/10.3389/fsoc.2021.611321

Austad, K., Juarez, M., Shryer, H. et al. (2021). Improving the experience of facility-based delivery for vulnerable women through obstetric care navigation: a qualitative evaluation. BMC Pregnancy and Childbirth, 21, 425. https://doi.org/10.1186/s12884-021-03842-1

Bohren, M.A., Hunter, E.C., Munthe-Kaas, H.M. et al. (2014). Facilitators and barriers to facility-based delivery in low- and middle-income countries: a qualitative evidence synthesis. Reproductive Health, 11, 71.

Montagu D, Yamey G, Visconti A, Harding A, Yoong J (2011) Where Do Poor Women in Developing Countries Give Birth? A Multi-Country Analysis of Demographic and Health Survey Data. PLOS ONE, 6(2): e17155. https://doi.org/10.1371/journal.pone.0017155

Munabi-Babigumira, S., Glenton, C., Lewin, S., Fretheim, A., & Nabudere, H. (2017). Factors that influence the provision of intrapartum and postnatal care by skilled birth attendants in low- and middle-income countries: a qualitative evidence synthesis. The Cochrane Database of Systematic Reviews11(11), CD011558. https://doi.org/10.1002/14651858.CD011558.pub2

Scarf, V. L., Viney, R., Yu, S., Foureur, M., Rossiter, C., Dahlen, H., Thornton, C., Cheah, S. L., & Homer, C. (2019). Mapping the trajectories for women and their babies from births planned at home, in a birth centre or in a hospital in New South Wales, Australia, between 2000 and 2012. BMC Pregnancy and Childbirth19(1), 513. https://doi.org/10.1186/s12884-019-2584-0

Scarf, V. L., Rossiter, C., Vedam, S., Dahlen, H. G., Ellwood, D., Forster, D., . . . Homer, C. S. E. (2018). Maternal and perinatal outcomes by planned place of birth among women with low-risk pregnancies in high-income countries: A systematic review and meta-analysis. Midwifery, 62, 240-255. https://doi.org/10.1016/j.midw.2018.03.024

Stevens, J. R., & Alonso, C. (2020). Commentary: Creating a definition for global midwifery centers. Midwifery, 85, 102684. https://doi.org/10.1016/j.midw.2020.102684

World Health Organization. (2014). Prevention and elimination of disrespect and abuse during childbirth. Retrieved from: https://www.who.int/reproductivehealth/topics/maternal_perinatal/statement-childbirth/en/

Strategies that work to increase vaginal birth rate after caesarean

Vaginal birth after caesarean around the world

VBAC is a vaginal birth after caesarean section. While planned VBAC is a safe choice for most women, rates of VBAC vary considerably. VBAC rates are high in countries like Finland, Sweden and Netherlands (approximately 50%), lower in Ireland, Scotland, Italy, Spain and Germany (approximately 30%), and lowest in countries like the US and Australia (approximately 12%) (Lundgren et al., 2020). Indeed, the rate of successful VBAC in Australia has remained stagnant over the past decade – 13.1% in 2007 to 12.1% in 2018 (Australian Institute of Health and Welfare, 2020).

Research finds that in settings where rates are low , VBAC is not considered the obvious first choice for most women (Lundgren et al., 2020). Furthermore, obstetricians tend to determine whether VBAC should be attempted in countries with low-rates rather than women themselves (Lundgren et al., 2020). In a recent US study, women described having to “fight hard” for a VBAC including navigating obstacles, finding a supportive care provider, and sometimes travelling long distances to access care (Basile Ibrahim et al. 2021). Wingert et al. (2018) conducted a systematic review of all studies that had looked at the impact of interventions (e.g., education) on planned and/or successful VBAC rates.

Strategies for maternity care providers

Education for healthcare providers about the benefits of VBAC was effective, particularly when it was provided by a respected obstetric opinion leader (Wingert et al., 2018). When doctors were required to seek a second opinion from an obstetrician – regarding first or subsequent caesarean section (CS) – the rates of planned and successful VBACs increased (Wingert et al., 2018). Furthermore, having a night float on-call system which uses doctors who were more rested, compared to doctors on a 24-hour on-call shift, increased VBAC success rates (Wingert et al., 2021). 

Strategies for pregnant and birthing women

The systematic review included several studies that assessed the usefulness of a decision aid, compared to no decision aid, for women choosing between VBAC and CS for their next birth. Every decision aid was associated with an increase in women’s knowledge and decrease in their anxiety about decision –  but none of the decision aids made a difference to planned VBAC rates (Wingert et al., 2018).

Health system strategies

Providing hospitals funding contingent on increasing VBAC rates was an effective strategy in one study (Wingert et al., 2018). Models of care – midwifery continuity of carer, midwifery antenatal continuity, and dedicated VBAC antenatal clinics – were associated with higher rates of planned and successful VBAC compared to standard care (Wingert et al., 2018).

Midwifery continuity of carer models

Women’s experiences of planned VBAC in midwifery continuity of carer models were more positive than standard care (Keedle et al., 2020). For example, women were more likely to feel in control of their decision making and feel their health care provider positively supported their decision to have a VBAC.  Furthermore, women with a known midwife were more likely to have been active in labour, labour in water, and use an upright birth position (Keedle et al., 2020).

A small randomised trial aimed to compare a midwifery continuity of carer model (antenatal, birth, postnatal), with a midwifery antenatal continuity model, on VBAC rates (Homer et al., 2021). In this study, there was no significant difference between midwifery continuity of carer or antenatal continuity for planned VBAC (67% vs 57%) or VBAC success (28% vs 33%)  (Homer et al., 2021). However, the likely reason was that both models were similar to each other (i.e. women saw a similar number of midwives antenatally and during labour and birth) (Homer et al., 2021). Therefore, a trial of midwifery continuity of carer – using a model where a genuine and trusting relationship can develop between midwife and woman – is still required (Homer et al., 2021).

Recommendations to support VBAC

Health services should increase access to models of care that include a significant role for midwives, and use evidence-based strategies that proactively encourage vaginal birth for women after previous CS (Davis et al., 2020).

Maternity care providers can facilitate women to plan a VBAC by providing information in a supportive way, viewing VBAC as the first alternative in the absence of complications, and helping women to ‘let go’ of their previous childbirth experience to prepare for their next birth (Nilsson et al., 2017). The discussion of risks and benefits for next birth after CS, should include information about recovery from surgical birth (Davis et al., 2020). During labour, midwives and obstetricians can help women achieve a VBAC by offering calm and confident support  (Nilsson et al., 2017).

A national mass media public health campaign about the benefits of VBAC has been an effective strategy in one country with low rates of planned VBAC. Women who viewed the campaign had increased self-reported knowledge, positive attitude towards VBAC and higher intention toward VBAC (Majilesi et al., 2020). A similar campaign could be considered in other countries with low rates of VBAC intention.

Highlighted research

Homer, C., Davis, D. L., Mollart, L., Turkmani, S., Smith, R. M., Bullard, M., Leiser, B., & Foureur, M. (2021). Midwifery continuity of care and vaginal birth after caesarean section: A randomised controlled trial. Women and Birth, S1871-5192(21)00089-5. Advance online publication. https://doi.org/10.1016/j.wombi.2021.05.010

References

Australian Institute of Health and Welfare. (2020). National Core Maternity Indicators 2018: summary report. Retrieved from Canberra: https://www.aihw.gov.au/reports/mothers-babies/national-core-maternity-indicators-summary-report

Basile Ibrahim, B., Knobf, M. T., Shorten, A., Vedam, S., Cheyney, M., Illuzzi, J., & Kennedy, H. P. (2021). “I had to fight for my VBAC”: A mixed methods exploration of women’s experiences of pregnancy and vaginal birth after cesarean in the United States. Birth (Berkeley, Calif.)48(2), 164–177. https://doi.org/10.1111/birt.12513

Davis, D., S Homer, C., Clack, D., Turkmani, S., & Foureur, M. (2020). Choosing vaginal birth after caesarean section: Motivating factors. Midwifery88, 102766. https://doi.org/10.1016/j.midw.2020.102766

Keedle, H., Peters, L., Schmied, V., Burns, E., Keedle, W., & Dahlen, H. G. (2020). Women’s experiences of planning a vaginal birth after caesarean in different models of maternity care in Australia. BMC Pregnancy and Childbirth20(1), 381. https://doi.org/10.1186/s12884-020-03075-8

Lundgren, I., Morano, S., Nilsson, C., Sinclair, M., & Begley, C. (2020). Cultural perspectives on vaginal birth after previous caesarean section in countries with high and low rates – A hermeneutic study. Women Birth, 33(4), e339-e347. https://doi.org/10.1016/j.wombi.2019.07.300

Majlesi, M., Montazeri, A., Rakhshani, F., Nouri-Khashe-Heiran, E., & Akbari, N. (2020). ‘No to unnecessary caesarean sections’: Evaluation of a mass-media campaign on women’s knowledge, attitude and intention for mode of delivery. PloS One15(8), e0235688. https://doi.org/10.1371/journal.pone.0235688

Nilsson, C., van Limbeek, E., Vehvilainen-Julkunen, K., & Lundgren, I. (2017). Vaginal birth after cesarean: Views of women from countries with high VBAC rates. Qualitative Health Research27(3), 325–340. https://doi.org/10.1177/1049732315612041

Wingert, A., Johnson, C., Featherstone, R., Sebastianski, M., Hartling, L., & Douglas Wilson, R. (2018). Adjunct clinical interventions that influence vaginal birth after cesarean rates: Systematic review. BMC Pregnancy and Childbirth18(1), 452. https://doi.org/10.1186/s12884-018-2065-x

Supporting new midwifery graduates transition to practice

Transition from midwifery student to graduate

After years of dedicated study and hours of supervised practice, the midwifery student finally steps into role of midwife. Much like becoming a mother -where the ideals of motherhood can quickly be challenged by the realities of wakeful nights, unexpected behaviours and an overwhelming sense of responsibility – so too the new graduate can find this transition challenging and stressful. Researchers have suggested that new midwives are surviving but not thriving (Fenwick et al., 2012). The experience of graduate midwives was described as similar to swimming in a pond –  sink or swim. Notably, a positive and supportive relationships with other midwives were described as a ‘life-raft’, whereby the new midwife could build her confidence and engage competently in practice (Fenwick et al., 2012).

Midwifery transition to practice is a key priority

Professor Mary Sidebotham, Deputy Director of Transforming Maternity Care Collaborative, and Associate Professor Lois McKellar, Program Lead – Education, recently coordinated a Delphi study to look at this issue. A Delphi study is a process used to gain reliable expert consensus on a topic (Barrett & Heale, 2020). Sidebotham et al. (2020) sought to identify priorities for midwifery education across Australia and New Zealand. Experts identified that one of the priorities was support for new graduate midwives in their transition to practice (Sidebotham et al. 2020).

Midwifery transition to practice programmes

Currently, in Australia, most graduate midwives are employed by health services into a formal hospital graduate program, with only a few transitioning directly into midwifery continuity models of care (Cummins & Gray, 2019). These graduate programs were largely developed based on the early model for nursing graduates. In this way, graduate programs aim to provide a structured approach to transition, rotating graduates through a variety of clinical areas, as well as providing additional educational support.

Anecdotally and drawing on limited research, there is a growing frustration with the lack of opportunity for graduates to transition directly into midwifery continuity of care models (Cummins et al., 2015). Furthermore, there are suggestions these programs foster institutional enculturation, with graduates feeling overwhelmed by organisational time pressures and policy driven agendas, which at times leaving them feeling isolated and unsupported (Clements et al., 2012). There is a need to understand the experience of the graduate midwife, and to explore how midwives can nurture the confidence and ongoing development of new graduates.

New graduates’ perceptions of transition programmes

Professor Virginia Stulz, Chair of the Trans-Tasman Midwifery Education Consortium, is currently leading a multisite study, collaborating with nine organisations across Australia. The study aims to explore midwifery graduates’ perceptions of existing graduate transition programs. Additionally, the study will explore the perspectives of the midwife engaged in supporting new graduates within these programs. The study hopes to  further unpack the larger organisational challenges to employing new graduate midwives in midwifery continuity of care models (Cummins et al., 2018).

Preliminary survey findings

While the study is still underway, there are preliminary findings from a survey with 218 midwives across all states of Australia in metropolitan/tertiary and rural/regional areas. This survey showed that 85% of midwives perceived they supported new midwifery graduates to work autonomously, with nearly three quarters stating that their health service was committed to fostering the importance of the midwife in facilitating positive birth experiences. Nevertheless, only 54% of the participants reported that the transition programme at their health service supported new midwifery graduates to advocate for women’s rights. Additionally, only 50% of the midwives surveyed felt that they had the resources to support a new midwifery graduate. The majority (96%) of respondents thought access to a mentor and/or preceptor was important for new midwifery graduates. Participants recognised that new graduates are likely to stay in the workforce if they feel a sense of belonging in their workplace. Indeed, midwives who provide caring and nurturing mentorship to midwifery students increase the likelihood that they will remain in the profession when they graduate (Stulz et al., 2021).

Survey now open

A survey is still open for midwives to respond and offer their experience of supporting new graduates. The project is also recruiting final year midwifery students to complete a survey  about their expectations, aspirations, and any anticipated concerns or fears. The survey will also seek feedback about their first year of practice and experience in graduate transition programs. The surveys can be accessed via the links below.

Midwife link: https://surveyswesternsydney.au1.qualtrics.com/jfe/form/SV_22Vgr7CZnzBiV5X

Midwifery student link:   https://surveyswesternsydney.au1.qualtrics.com/jfe/form/SV_6VDsShbDgWO2dLf

References

Barrett, D., & Heale, R. (2020). What are Delphi studies? Evidence-Based Nursing, 23, 68-69.

Clements, V., Fenwick, J., & Davis, D. (2012). Core elements of transition support programs: the experiences of newly qualified Australian midwives. Sex, Reproduction and Healthcare, 3(4). 155–162.

Cummins, A.M. & Gray, M. (2019). Birth of a Midwife: The transitional journey from student to practitioner. In M. Gray et al. (Eds.), Starting Life as a Midwife an International Review of Transition from Student to Practitioner (1st ed.), Springer International Publishing, Cham.

Cummins, A.M., Catling, C., Homer, C.S.E. (2018). Enabling new graduate midwives to work in midwifery continuity of care models: A conceptual model for implementation. Women and Birth, 31, 343–349.

Cummins, A.M., Denney-Wilson, E., Homer, C.S.E. (2015). The experiences of new graduate midwives working in midwifery continuity of care models in Australia. Midwifery, 31(4), 438–444.

Fenwick, J., Hammond, A., Raymond, J., Smith, R., Gray, J., Foureur, M., Homer, C., & Symon, A. (2012). Surviving, not thriving: a qualitative study of newly qualified midwives’ experience of their transition to practice. Journal of Clinical Nursing, 21, 2054–2063

Sidebotham, M, Davis, D., Gamble, J., McKellar, L., Gilkison., A. (2021). The priorities of midwifery education across Australia and New Zealand: a Delphi study. Women and Birth, 34,136–144.

Stulz, V., Francis, L., Pathrose, S., Sheehan, A., & Drayton, N. (2021). Appreciative inquiry as an intervention to improve nursing and midwifery students transitioning into becoming new graduates: An integrative review. Nurse Education Today, 98, 104727. doi:https://doi.org/10.1016/j.nedt.2020.104727

 

 

Equipping midwifery leaders to drive reform

Maternity services reform

The maternity reform agenda aims to re-orient maternity care to be primary health focussed, community-based and woman-centred.  Woman-centred care requires access to a known and trusted midwife, commonly provided through a Midwifery Group Practice (MGP). The evidence is clear that MGP is gold standard, but implementation of these models in Australia has been slow (Hewitt et al., 2021a), which has resulted in 90% of women without access (Dawson et al., 2015). Midwives in leadership roles are ideally placed to drive maternity services reform, including rollout of MGP models of care. Research has identified what makes an effective midwifery leader –  clinical experience and skill, good communication, emotional intelligence, innovation and desire to make a difference (Byrom & Downe, 2010). However, little is known about what midwifery leaders specifically need to re-orient maternity services.

Exploring midwifery leaders’ perspectives

Masters of Primary Maternity Care student, Joy Adcock, recently conducted a study under the supervision of Professors Emeritus Mary Sidebotham and Jenny Gamble. The qualitative study sought to answer the question: What do midwives in leadership positions need to be effective in contributing to the reform of maternity services in Australia? The first author interviewed 13 Australian midwifery leaders – midwifery consultants, midwifery unit managers, MGP managers, midwifery service directors, and state/national midwifery leaders. The research team analysed interview data to describe the views and perspectives of midwifery leaders.

What midwifery leaders need 

Resilience, bravery and confidence were crucial for midwifery leaders to manage resistance and barriers to implementation of MGP (Adcock et al., 2021). Midwifery leaders who demonstrated a strong motivation and commitment to implementing midwifery continuity of care, were more able to navigate set-backs and drive maternity reform (Adcock et al., 2021). This ability was underlined by a belief that MGP was ‘the answer’ to maternity care and a determination to use the evidence to improve care for mothers and babies (Adcock et al., 2021). With this foundation, effective leaders described influencing the midwifery culture of their organisation to embody woman-centred care (Adcock et al., 2021).

Participants described their need for support from their organisation and from respectful relationships with key stakeholders (Adcock et al., 2021). Indeed, trusting relationships across all organisational levels is critical for midwifery continuity of care to work (McInnes et al., 2021). To achieve positive relationships, leaders described learning to speak ‘executives’ language’, form strategic alliances with like-minded obstetricians, challenge medical views, and respond to the needs of midwives and consumers (Adcock et al., 2021). This fits with a study of  MGP managers that found that the ability to advocate for midwives and women was key to the role (Hewitt et al., 2019).

Midwifery leaders valued opportunities for professional development in the form of leadership training, mentoring and clinical supervision (Adcock et al., 2021). Indeed, previous research has emphasised the importance of leadership attributes and development opportunities for midwifery leaders (Byrom & Downe, 2010; Hewitt et al., 2018; Miskelly & Duncan, 2014).

Recommendations

Midwifery leaders need to be specifically equipped to drive maternity care reform. To facilitate midwifery leaders to reach their potential requires investment in their professional development through leadership training and mentoring programs (Adcock et al., 2021). To effectively lead the change, midwifery leaders require a strong personal commitment and confidence to push for expansion of MGP.  This commitment could be strengthened by developing a network of Australian midwifery leaders (Adcock et al., 2021) to share strategies, support and bolster resilience. Additionally, there must be a willingness and ability to develop and nurture strategic relationships.  Because midwifery is a profession separate from nursing, midwifery leaders should be included on executive leadership teams, rather than represented by nursing leaders (Adcock et al., 2021). The role of midwifery leaders is to ensure MGP is “prioritised, nurtured and embraced” (Hewitt et al., 2021b).

Highlighted research

Adcock, J. E., Sidebotham, M., & Gamble, J. (2021, 2021/04/28/). What do midwifery leaders need in order to be effective in contributing to the reform of maternity services? Women and Birth. https://doi.org/https://doi.org/10.1016/j.wombi.2021.04.008

References

Byrom, S., & Downe, S. (2010). ‘She sort of shines’: midwives’ accounts of ‘good’ midwifery and ‘good’ leadership. Midwifery, 26(1), 126-137. https://doi.org/10.1016/j.midw.2008.01.011

Dawson, K., Newton, M., Forster, D., & McLachlan, H. (2015, 2015/01/01/). Caseload midwifery in Australia: What access do women have? Women and Birth, 28, S12. https://doi.org/https://doi.org/10.1016/j.wombi.2015.07.048

Hewitt, L., Dahlen, H. G., Hartz, D. L., & Dadich, A. (2021a). Leadership and management in midwifery-led continuity of care models: A thematic and lexical analysis of a scoping review. Midwifery98, 102986. https://doi.org/10.1016/j.midw.2021.102986

Hewitt, L., Dadich, A., Hartz, D. L., & Dahlen, H. G. (2021b). Management and sustainability of midwifery group practice: Thematic and lexical analyses of midwife interviews. Women and Birth, S1871-5192(21)00081-0. Advance online publication. https://doi.org/10.1016/j.wombi.2021.05.002

Hewitt, L., Priddis, H., & Dahlen, H. G. (2018). What attributes do Australian midwifery leaders identify as essential to effectively manage a Midwifery Group Practice? Women and Birth. https://doi.org/https://doi.org/10.1016/j.wombi.2018.06.017

McInnes, R. J., Aitken-Arbuckle, A., Lake, S., Hollins Martin, C., & MacArthur, J. (2020). Implementing continuity of midwife carer – just a friendly face? A realist evaluation. BMC Health Services Research20(1), 304. https://doi.org/10.1186/s12913-020-05159-9

Central fetal monitoring – time to de-implement?

Investment in fetal monitoring technology

Maternity services in high-income countries have invested heavily in medical technologies. However, some technologies have been implemented without clear evidence of clinical benefit or safety. Cardiotocograph (CTG) is commonly used to monitor the fetal heart rate in labour. Professional position statements and clinical guidelines recommend the use of CTG, despite highest-level evidence that it does not improve perinatal outcomes, even for women with risk factors (Small et al., 2020). See more here does-intrapartum-ctg-monitoring-save-lives. Furthermore, one of the unintended consequences of CTG has been escalating rates of caesarean section (Small et al., 2020).

Impact of fetal monitoring technology

Central  monitoring systems (CMS) transmit data from the CTG to a central site where it can be interpreted outside the room. CMS are being rolled out as a valuable add-on to CTGs, yet there have been no randomised trials of CMS. Indeed, the only evidence available is from three small studies that demonstrated CMS do not impact perinatal outcomes (Small et al., 2021). Furthermore, two of the studies measured an increase rates of instrumental birth and caesarean section after CMS was introduced (Brown et al., 2016; Weiss et al., 1997). Additional concerns include that midwives spend less time in the room with labouring women when these are CMS (Brown et al., 2016).

New research with clinicians in a setting with CMS

Obstetrician Dr Kirsten Small (PhD), project lead with Transforming Maternity Care Collaborative, conducted doctoral research about how CMS organise the work of maternity clinicians. Her PhD was supervised by Emeritus Professors Mary Sidebotham and Jenny Gamble, and Professor Jennifer Fenwick. Their latest publication describes how CMS affect maternity care providers clinical behaviours (Small et al., 2021). The setting for this qualitative study was a maternity hospital where 90% of women had a CTG in labour (all connected to a CMS). Thirty-six midwives (including midwifery students), and 16 doctors (including obstetric residents, registrars, and consultants) participated in the study. Dr Small interviewed (individually and in groups) and/or observed (e.g., when interacting with the CMS) participants and then led analysis of the data.

Undermining midwifery autonomy and compromising maternity care

The study found that clinicians outside the room made clinical decisions without all the relevant information, which potentially compromises safety (Small et al., 2021). Informants described how decisions were made, before engaging with the birthing woman and her midwife. Team leaders were perceived to check-in less with individual midwives (i.e., to get updated about the woman’s labour), if they could see that the CTG was normal.

Some midwives felt professionally disrespected by obstetricians, who would see the CMS and enter a room without invitation or permission (Small et al., 2021). This behaviour required midwives to de-escalate concerns, sometimes in a context of forceful obstetric communication. Importantly, this is the opposite of the usual process where midwives escalate concerns based on the midwife’s professional judgement. Taken together, making decisions outside the room, and coming into the room to then bypass or contradict the midwife’s interpretation of the CTG, was perceived to undermine women’s confidence in their midwife (Small et al., 2021).

Midwives lamented they were spending more time documenting on the CMS rather than being with woman. To limit disruptions to the birth space, midwives described changing their practice. For example, midwives limited women’s positions to ensure good contact for a CTG and directed women’s pushing efforts to speed up second stage labour. Informants described obstetricians acting on normal second stage decelerations (seen on the CMS), by performing surgical/instrumental birth.

Time to pause and consider next steps

Maternity services who are considering installation of CMS should pause – further research that demonstrates clinical benefit is required. Maternity services that have installed CMS, should rigorously evaluate the risks and benefits of these systems. Next steps may include the decision to de-implement CMS. De-implementation is the “process of identifying and removing harmful, non-cost-effective, or ineffective practices” (Upvall & Bourgault, 2018, p.495). Unlike implementation research, however, little is known about the process of de-implementation (van Bodegom-Vos et al., 2017). Three criteria have been suggested to help services identify which interventions are appropriate for de-implementation (McKay et al., 2018):

1) not effective or harmful; or

2) not the most effective or efficient to provide; or

3) no longer necessary.

Managers and service leaders have a responsibility to disinvest from technologies that meet any of these criteria.

Highlighted research

Small, K. A., Sidebotham, M., Fenwick, J., & Gamble, J. (2021). “I’m not doing what I should be doing as a midwife”: An ethnographic exploration of central fetal monitoring and perceptions of clinical safety. Women and Birth. https://doi.org/10.1016/j.wombi.2021.05.006

References

Brown, J., McIntyre, A., Gasparotto, R., & McGee, T. M. (2016). Birth outcomes, intervention frequency, and the disappearing Midwife—Potential hazards of central fetal monitoring: A single center review. Birth43(2), 100-107.

Burton, C., Williams, L., Bucknall, T. et al. (2019). Understanding how and why de-implementation works in health and care: research protocol for a realist synthesis of evidence. Systematic Reviews, 8(194). https://doi.org/10.1186/s13643-019-1111-8

McKay, V. R., Morshed, A. B., Brownson, R. C., Proctor, E. K., & Prusaczyk, B. (2018). Letting Go: Conceptualizing Intervention De-implementation in Public Health and Social Service Settings. American Journal of Community Psychology62(1-2), 189–202. https://doi.org/10.1002/ajcp.12258

Small, K. A., Sidebotham, M., Fenwick, J., & Gamble, J. (2020). Intrapartum cardiotocograph monitoring and perinatal outcomes for women at risk: Literature review. Women and birth : journal of the Australian College of Midwives33(5), 411–418. https://doi.org/10.1016/j.wombi.2019.10.002

Upvall, M. J., & Bourgault, A. M. (2018). De-implementation: A concept analysis. Nursing forum, 10.1111/nuf.12256. Advance online publication. https://doi.org/10.1111/nuf.12256

van Bodegom-Vos L, Davidoff F, Marang-van de Mheen PJ. (2017). Implementation and de-implementation: two sides of the same coin? BMJ Quality & Safety, 26, 495-501.

Weiss, P. M., Balducci, J., Reed, J., Klasko, S. K., & Rust, O. A. (1997). Does centralized monitoring affect perinatal outcome?. The Journal of Maternal‐Fetal Medicine6(6), 317-319.

Withiam-Leitch, M., Shelton, J., & Fleming, E. (2007). Central fetal monitoring: Effect on perinatal outcomes and cesarean section rate. Obstetrical & gynecological survey62(4), 232-233.

Health services lack incentive to be cost-effective

Maternity service funding in Australia

Most maternity care funding is allocated to State and Territory health departments who then resource hospitals and health services. The funding given to health services is ‘activity-based’ which means the more episodes of care, and the more expensive types of care provided, the more funding the health services receive (COAG, 2014). Complex care (e.g., caesarean surgery, inpatient postnatal ward stay) costs more to provide, and therefore attracts more funding under this activity-based scheme, than normal birth with early discharge.  Therefore, health services may have no incentive to provide models of care that are cost-effective – even if they deliver better outcomes and experiences for women and babies.

Cost and benefits of maternity care up to 12-months after birth

Deputy Director of Transforming Maternity Care Collaborative, Associate Professor Emily Callander, is an expert in the health economics of maternity care. She recently led a study to determine the cost and benefit (in terms of quality of life) associated with public midwifery continuity of carer (Midwifery Group Practice – MGP)(Callander et al., 2021). MGP was compared with standard care, which included all other models of public maternity care, and excluded private obstetric/midwifery care.

The study collected data from 85 women who had continuity of carer and 72 women who had standard care, including data about their infants. The women in each group were similar in terms of parity, education, and insurance status. The two key measures were ‘health-related quality of life’ and ‘cost’. Quality of life years were calculated based on participant surveys using valid tools at study entry, 36-weeks of pregnancy – and then 6 weeks, 6 months, and 12 months post-partum. Cost was assessed including costs to Medicare, hospital funders and women through out-of-pocket expenses.

Public MGP was 22% cheaper than other models of care – it delivered a cost-saving of approximately $5,000 per woman to hospital funders. The researchers explained this cost-saving was largely because of shorter inpatient hospital stays. At the same time public MGP delivered similar outcomes (quality of life up to 12 months after birth) compared to standard care. Callander et al. (2021) results build on previous evidence of the cost-saving benefit of public MGP in Australian settings.

MGP delivers cost-savings for different groups

Women with low-risk status

Toohill et als., (2012) study of low-risk women who accessed either birth centre MGP, or standard care, calculated an approximate $1,000 cost-saving per woman with MGP. Women in MGP had a lower chance of induction of labour, fewer antenatal visits, and fewer neonatal admissions to nursery – which explained the cost-saving (Toohill et al., 2012).

Women with any-risk status

The M@NGO trial demonstrated that MGP  delivered an approximate cost-saving of $500 per woman compared to standard care (Tracy et al., 2013). This cost-saving was because women allocated to MGP had one fewer antenatal visit, were more likely go into labour spontaneously, use less pharmacological analgesia, have fewer postpartum haemorrhages, and have a shorter length of postnatal stay (Tracy et al., 2013).

Women with low-risk having their first baby

The cost of maternity care for first-time, low-risk women in 3 models – public MGP, public standard care, and private obstetric care –  was cheaper in public MGP  (approximate cost-saving $1500 per woman)(Tracy et al., 2014). This cost-saving was largely explained by lower rates of induction of labour and elective caesarean section, and lower rates of instrumental/surgical birth in public MGP (Tracy et al., 2014).

Aboriginal mothers

Gao et al. (2014) conducted a study of the cost consequences of MGP for Aboriginal mothers and infants compared to standard care. While Aboriginal mothers who accessed MGP had more antenatal care, including antenatal admissions, if their babies went to special care nursery they had a shorter length of stay, compared to babies born to Aboriginal mothers in standard care  (Gao et al., 2014). The study reported an approximate cost-saving $700 per woman associated with MGP.

Return on investment in safe quality care

The evidence is clear. Investing in expansion of public MGP is a more efficient use of health resources than the status quo. In the absence of financial incentives, however, the status quo in Australia – where <20% of women have access to MGP – is likely to persist. There is precedent to show that financial incentives and disincentives impact maternity care provision. For example, providing the same ‘delivery fees’ for vaginal birth and caesarean birth in both public and private, is an effective strategy to curb the overuse of caesarean section (V isser et al., 2018).

Alternative funding models, namely bundled funding, work in other countries that have high levels of access to MGP (e.g., New Zealand). In these models, services are provided a single payment for each birth, which covers all the care provided to the woman throughout pregnancy, intrapartum, and postnatally. Therefore, bundled funding directly rewards services who provide care most efficiently, rather than rewarding those who deliver the most episodes and highest-cost procedures.

There is need for whole-of-system redesign that recognises MGP not only improves health outcomes (Sandall et al., 2016) and women’s experiences (Forster et al., 2016) –  but also reduces the cost of providing maternity care.

Highlighted research

Callander, E. J., Slavin, V., Gamble, J., Creedy, D. K., & Brittain, H. (2021). Cost-effectiveness of public caseload midwifery compared to standard care in an Australian setting: a pragmatic analysis to inform service delivery. International Journal for Quality in Health Care, 33(2). https://doi.org/10.1093/intqhc/mzab084

References

Council of Australian Governments. (2014). National Health Reform Agreement. COAG.

Forster, D. A., McLachlan, H. L., Davey, M. A., Biro, M. A., Farrell, T., Gold, L., Flood, M., Shafiei, T., & Waldenström, U. (2016). Continuity of care by a primary midwife (caseload midwifery) increases women’s satisfaction with antenatal, intrapartum and postpartum care: results from the COSMOS randomised controlled trial. BMC Pregnancy and Childbirth16, 28. https://doi.org/10.1186/s12884-016-0798-y

Gao, Y., Gold, L., Josif, C., Bar-Zeev, S., Steenkamp, M., Barclay, L., Zhao, Y., Tracy, S., & Kildea, S. (2014). A cost-consequences analysis of a midwifery group practice for Aboriginal mothers and infants in the top end of the Northern Territory, Australia. Midwifery30(4), 447–455. https://doi.org/10.1016/j.midw.2013.04.004

Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2016). Midwife-led continuity models versus other models of care for childbearing women. The Cochrane Database of Systematic Reviews4, CD004667. https://doi.org/10.1002/14651858.CD004667.pub5

Toohill, J., Turkstra, E., Gamble, J., & Scuffham, P. A. (2012). A non-randomised trial investigating the cost-effectiveness of Midwifery Group Practice compared with standard maternity care arrangements in one Australian hospital. Midwifery28(6), e874–e879.

Tracy, S.K., Welsh, A., Hall, B. et al. (2014). Caseload midwifery compared to standard or private obstetric care for first time mothers in a public teaching hospital in Australia: a cross sectional study of cost and birth outcomes. BMC Pregnancy Childbirth 1446.

Tracy, S. K., Hartz, D. L., Tracy, M. B., Allen, J., Forti, A., Hall, B., . . . Kildea, S. (2013). Caseload midwifery care versus standard maternity care for women of any risk: M@NGO, a randomised controlled trial. The Lancet, 382(9906), 1723-1732.

Visser GHA, Ayres-de-Campos D, Barnea ER, et al. (2018). FIGO position paper: how to stop the caesarean section epidemic. The Lancet, 392(10155), 1286-1287.

The midwife’s public health role

Midwifery is a public health strategy

Public health is “the art and science of preventing disease, prolonging life and promoting health” (WHO, 1988). The Quality Maternal and Newborn Care Framework highlights the preventative and supportive care midwives provide – tailored to individual needs and focussed on strengthening capabilities (QMNC, 2021).  Midwives use strategies that prevent or minimise complications during pregnancy, birth, or early parenting – and promote health and well-being (QNMC, 2021). For example, brief-interventions about smoking, screening and support for perinatal mental health, and promotion of normal birth and breastfeeding. The World Health Organization (2020) underscores the importance of working to strengthen families to provide a nurturing environment for children to thrive.

Midwifery continuity provides ideal context for change

Midwives in continuity of carer models are best placed to form genuine caring relationships with women (Jepsen et al., 2016). The midwife-woman relationship provides the context for women to buy-in to maternity care. Women buy-in when they feel safe enough to disclose risks and concerns, and trust and accept the midwife’s recommendations for making positive health changes (Allen et al., 2016).  There is high level evidence for midwifery continuity of care in terms of clinical outcomes (Sandall et al., 2016) and cost-efficiency (Callander et al., 2021). However, the evidence of effective midwifery public health interventions is still growing.

Evidence on midwifery public health interventions

Definitive evidence of effective midwifery public health interventions comes from a systematic review of systematic reviews (McNeill et al., 2012). This study considered the level of evidence included in reviews, and assessed how well each review was conducted. McNeill et al. (2012) identified 36 good quality systematic reviews which reported on effective interventions during the antenatal period (20 reviews), labour and birth (5 reviews) and postpartum (11 reviews). The review included 8 interventions categorised as:

  1. screening
  2. supplementation
  3. support
  4. education
  5. mental health
  6. birthing environment
  7. clinical care in labour
  8. breast feeding

Effective antenatal public health interventions included screening for lower genital tract infection, use of decision-aids, and specific nutrient supplementation – i.e., iron and folic acid (McNeill et al., 2012). However, the review noted a need for further research on calcium supplementation to reduce risk of pre-eclampsia (McNeill et al., 2012). Interventions designed to help women stop smoking during pregnancy were particularly effective (McNeill et al., 2012). While emotional support interventions, including telephone support, showed a trend towards positive psycho-social outcomes – further research is needed (McNeill et al., 2012).

Effective intrapartum public health interventions included having a known midwife, which reduced the risk of intrapartum analgesia and caesarean section, and increased the chance of spontaneous vaginal birth and breastfeeding (McNeill et al., 2012). Other effective interventions included access to birth centres, continuous emotional support in labour, warm water immersion, and delayed cord clamping (McNeill et al., 2012).

Effective postpartum public health interventions, included intensive midwifery home visiting which reduced the incidence of postnatal depression by 33% (Dennis & Creedy, 2004). Indeed, any intervention design to provide psycho-social support (e.g., non-directive counselling, group support) reduced postnatal depression when compared to standard care (McNeill et al., 2012). Interestingly, all types of interventions tested to increase breastfeeding had a positive impact. Antenatal education increased breastfeeding initiation for low-income women, whereas only postnatal interventions had an impact on duration and exclusivity (McNeill et al., 2012). Teaching and enhancing parenting skills improved children’s neurodevelopment up to 3 years of age compared to standard care (McNeill et al., 2012).

COVID-19 and the public health role of midwives

The COVID-19 pandemic has shown the importance of investing in public health care to meet population health needs (Szabo et al., 2021). Dr Zoe Bradfield, Transforming Maternity Care Collaborative’s Health Promotion Program Co-Director, led a survey of midwives about providing maternity care during the pandemic (Bradfield et al., 2021). The results showed that having a known midwife was important particularly when woman had limited face-to-face midwifery contact during pregnancy and postpartum, and restrictions around social support in labour (Bradfield et al., 2021). Women’s experience of becoming mothers during the pandemic created additional needs for psycho-social support to manage isolation, anxiety, and stress; advocacy and access to reliable information; and reassurance (Sweet et al., 2021). Midwives are ideally placed to meet these needs through advocacy, education and support.

Midwifery investment improves public health

There is a lack of understanding about the impact and value of midwifery practice on public health outcomes. The 2021 State of the World’s Midwifery Report calls for significant investment in the education of midwives and expansion of midwifery-led models of care, to promote the health and well-being of mothers and babies (UNPF, WHO & ICM, 2021).  Midwives are essential providers of public health care contributing to improved outcomes, especially for women who may not experience equitable access to maternity care.

Highlighted research

McNeill J, Lynn F. & Alderdice F. (2012) Public health interventions in midwifery: A systematic review of systematic reviews. BMC Public Health, 12, 955. Retrieved from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-12-955

References

Allen, J., Kildea, S., & Stapleton, H. (2016). How optimal caseload midwifery can modify predictors for preterm birth in young women: integrated findings from a mixed methods study. Midwifery. https://doi.org/10.1016/j.midw.2016.07.012

Bradfield, Z., Hauck, Y., Kuliukas, L., Sweet, L., Homer, C. Wilson, A., Vasilevski, V., Wynter, K. & Szabo, R.(2021). Midwifery care during the CoVID-19 pandemic in Australia: A cross-sectional study. Women and Birth (In Press). https://doi.org/10.1016/j.wombi.2021.02.007

Callander, E. J., Slavin, V., Gamble, J., Creedy, D. K., & Brittain, H. (2021). Cost-effectiveness of public caseload midwifery compared to standard care in an Australian setting: a pragmatic analysis to inform service delivery. International Journal for Quality in Health Care, 33(2). https://doi.org/10.1093/intqhc/mzab084

Jepsen, I., Mark, E., Nohr, E. A., Foureur, M., & Sorensen, E. E. (2016). A qualitative study of how caseload midwifery is constituted and experienced by Danish midwives. Midwifery, 36, 61-69. https://doi.org/10.1016/j.midw.2016.03.002

Quality Maternal and Newborn Care. (2021). Framework for Quality Maternal and Newborn Care. Retrieved from: https://www.qmnc.org/qmnc-research-alliance/framework-for-quality-maternal-and-newborn-care/

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, Cd004667. https://doi.org/10.1002/14651858.CD004667.pub5

Sweet, L., Bradfield, Z., Vasilevski, V. Wynter, K.  Hauck, Y., Kuliukas, L., Homer, C., Szabo, R. & Wilson, A. (2021). Becoming a mother in the ‘new’ social world in Australia during the first wave of the COVID-19 pandemic. Midwifery. (In Press)https://doi.org/10.1016/j.midw.2021.102996

Szabo, R. Sweet, L., Homer, C., Wilson, A., Kuliukas, L., Hauck, Y., Vasilevski, V., Wynter, K. & Bradfield, Z. (2021). COVID-19 changes to maternity care: Experiences of Australian doctors. ANZJOGhttp://dx.doi.org/10.1111/ajo.13307

United Nations Population Fund (UNPF), World Health Organization (WHO), & International Confederation of Midwives (ICM).(2021). State of the world’s midwifery: delivering health, saving lives. United Nations Population Fund.

World Health Organization. (2020). Improving Early Childhood Development: WHO Guideline. WHO.

World Health Organization. (1988). Public Health Services. Retrieved from: https://www.euro.who.int/en/health-topics/Health-systems/public-health-services/public-health-services