Enablers and barriers to the reform of maternity services
Study 1 – Power and technology
Research evidence does not support the widespread use of intrapartum CTG monitoring, yet it continues to be widely used. Central fetal monitoring systems are becoming more commonplace, again without evidence of benefit. Given the design of central monitoring systems they also provide a means for surveillance of maternity clinicians as they work with birthing women.
This Doctoral research used Institutional Ethnography to critically examine the textual environment in maternity care. The findings identified the dominance of patriarchal obstetric knowledge paradigms and provided specific examples of how birthing women were considered to be risky and largely irrelevant to decision-making, the fetus was portrayed as precious and constantly at risk, and midwives were considered to be poorly informed and in need of supervision.
The frequent use of intrapartum CTG monitoring in a central monitoring system, and the intrusive behaviour of senior staff in response to perceived CTG abnormalities became logical given these assumptions. Diverting midwives’ attention away from the birthing woman to attend to the CTG monitoring system had the potential to undermine the safe provision of maternity care.
Study 2 – Tools for scaling up Midwifery Continuity of Care
Policy makers, funders, health service managers, the midwifery profession, and maternity service users need tools to model the cost-benefit impact of midwifery continuity of care to enable the case for service re-design to be effective.
We have developed a Midwifery Model Estimator to help address this need. The Estimator is a custom-built interactive business-costing tool to enable scale-up of midwifery continuity of care models for use with health services in Australia.
It provides an analysis of the cost benefit achieved relative to the proportion of women provided with midwifery continuity of care. Local data is used to model potential cost savings for the health service using different scenarios.
Study 3 – Mapping access to Midwifery Continuity of Care for vulnerable mothers and babies
This study investigates using spatial mapping to develop a population health tool to measure access, outcomes and the impact of midwifery continuity of care for vulnerable and disadvantaged groups of mothers and babies compared with other maternity models.
Women from culturally and linguistically diverse backgrounds, Indigenous women, young women, women living in poverty, and women who reside in rural and remote locations are the focus of this study.
Study 4 – Health care accreditation and maternity services reform
Australia has a complex public and private maternity health system that provides care for childbearing women, their babies and families. We also have a well-established national health care accreditation system that is government funded, legislated, and mandated, with government action for unmet standards (Duckett, Jorm, Moran, et al., 2018). Hospital accreditation is the main national safety and quality system in Australia.
However, there is a disconnect between the health care accreditation and the implementation of widespread access to continuity of midwifery care.
This program of work has commenced with a scoping review of the literature investigating the issues related to hospital accreditation, in particular in the Australian healthcare system, and as it relates to driving health service re-organisation towards continuity of midwifery care.
Study 5 – Midwives and maternity reform
A motivated well educated midwifery workforce is a critical factor in the implementation of continuity of midwifery care models. This qualitative descriptive study explores the motivation, willingness and ability of midwives in Victoria to contribute to maternity services reform through working in and supporting continuity of midwifery practice models.
Study 6 – Obstetricians and trauma
Trauma during childbirth, such as maternal death or severe injury to a baby, impacts not only the family but maternity staff, and may contribute to a range of psychological responses, including post-traumatic stress (PTSD). Furthermore, for some medical practitioners, subsequent trauma may include stress related to being reported to the medical board. Trauma exposure and PTSD has consequences for the mental health of the individual (including possible suicide) or leaving the workforce. Doctors with burnout, or mental health conditions including PTSD, may be less able to provide appropriate patient care. Little is known about the impact of birth trauma on the mental health of obstetricians in Australia and New Zealand. Our recent feasibility study with 32 obstetricians found that nearly all (n=31, 96.9%) had been exposed to some type of birth trauma. Three quarters had current symptoms of traumatic stress, one quarter had symptoms of burnout associated with the workplace, but over 40 percent reported significant posttraumatic growth. Thematic analysis revealed perceptions that ‘obstetricians experience substantial trauma’, a ‘culture of blame in obstetrics’, and only ‘some workplaces were supportive and safe’.