News & Events

Tag Archives: Continuity of care

The transformative power of birth

Induction of labour, epidural analgesia, and caesarean section are now common themes in many women’s birth stories. Women are often fearful of childbirth which may drive them to seek out medical intervention without a medical reason (Nilsson et al., 2018). Indeed, fragmented hospital maternity care supports the view that pregnancy and birth are inherently dangerous and require management and control. From this perspective, labour pain is viewed as needing ‘relief’ and the use of epidural analgesia is seen as normal practice (Newnham, McKellar, & Pincombe, 2016). The community generally lack knowledge about normal birth and in particular, the benefits of physiological birth (Wong, He, Shorey, & Koh, 2017). However, having a vaginal birth with minimal interference has considerable benefits for women and their babies in both the short and long term.

Birth is a process best supported by a known and trusted midwife

Birth is a normal and deeply significant psychological and social event in a woman’s life – and in most instances does not require medical rescue or relief. Further, there is considerable evidence that birth is best supported by a known midwife who provides reassurance, nurturing and comfort (Walsh, 2006), so that a woman can work with pain rather than resist it (Leap, Sandall, Buckland, & Huber, 2010), and feel safe enough to ‘let go’ (Anderson, 2000). When women are supported in this way, birth has the potential to be positively transformative, producing a sense of inner strength, triumph, and bliss. These transformative experiences have a lasting impact on the woman’s sense of self (Schwartz et al 2015), confidence as a new mother (Fenwick et al 2015), and relationship with her newborn (Toohill et al 2014).

New theory explains the positive potential of birth-giving

While the subject of birth trauma is gaining traction, women’s potential to positively transform through birth is not well understood. New research has addressed this gap and developed new language that can facilitate women’s conversations about their experiences. PhD candidate Ella Kurz applied feminist theory to childbirth to develop a theory that explains the transformative power of giving birth (Kurz, Davis & Browne, 2021).

The new theory, Parturescence, describes the process of women ‘becoming’ through childbirth (Kurz et al., 2021). Positive transformation results in better psycho-social well-being after birth. Whereas negative transformation includes birth trauma and psychological injury following birth. Parturescence theory refers to lines of descent (activities that bring predictability and control in birth) and lines of ascent (activities which open new ways of thinking and being). Importantly, the challenging and destabilising parts of labour and birth – and how these are mediated by maternity care – are key to women’s positive or negative transformation (Kurz et al., 2021). Midwife-woman interactions can facilitate negative or positive transformation through birth (Kurz et al., 2021). Midwives need to have the motivation and capacity to support women to feel safe, loved, relaxed and unafraid during birth – but not all midwives behave this way (Allen, Kildea, Hartz, Tracy, & Tracy, 2017). Recent research has demonstrated the importance of midwives’ social and emotional competence to establish and maintain positive relationships (Hastie & Barclay, 2021).

What does this mean for women and maternity services?

Birth has intrinsic value for women and their babies – and this should be reflected in how maternity care is organised and provided. Women and the wider community should know that women benefit from the continuous supportive presence of a known and trusted midwife who can hold the space while they transform triumphant into motherhood. Importantly, when women are treated with respect and compassion, regardless of mode of birth, there is potential for positive transformation.

Highlighted research

Kurz, E., Davis, D., & Browne, J. (2021). Parturescence: A theorisation of women’s transformation through childbirth. Women and Birth. https://doi.org/10.1016/j.wombi.2021.03.009

References

Allen, J., Kildea, S., Hartz, D. L., Tracy, M., & Tracy, S. (2017). The motivation and capacity to go ‘above and beyond’: Qualitative analysis of free-text survey responses in the M@NGO randomised controlled trial of caseload midwifery. Midwifery, 50, 148-156. https://doi.org/10.1016/j.midw.2017.03.012

Anderson, T. (2000). Feeling safe enough to let go: the relationship between a woman and her midwife during the second stage of labour. In M. Kirkham (Ed.), The Midwife–Mother Relationship. Macmillan Press.

Fenwick J, Toohill J, Gamble J, Creedy DK, Buist A, Turkstra E, Sneddon A, Scuffham PA, & Ryding EL. (2015). Effects of a midwife psycho-education intervention to reduce childbirth fear on women’s birth outcomes and psychological well-being. BMC Pregnancy & Childbirth, 15, 284. https://doi.org/10.1186/s12884-015-0721-y

Hastie, C. R., & Barclay, L. (2021). Early career midwives’ perception of their teamwork skills following a specifically designed, whole-of-degree educational strategy utilising groupwork assessments. Midwifery. https://doi.org/10.1016/j.midw.2021.102997

Kurz, E., Davis, D., & Browne, J. (2021). Parturescence: A theorisation of women’s transformation through childbirth. Women and Birth. https://doi.org/10.1016/j.wombi.2021.03.009

Leap, N., Sandall, J., Buckland, S., & Huber, U. (2010). Journey to Confidence: Women’s Experiences of Pain in Labour and Relational Continuity of Care. Journal of Midwifery & Women’s Health, 55(3), 234-242. https://doi.org/10.1016/j.jmwh.2010.02.001

Newnham E., McKellar L., & Pincombe, J. (2016). A critical literature review of epidural analgesia. Evid Based Midwifery, 14(1), 22-28.

Nilsson, C., Hessman, E., Sjöblom, H., Dencker, A., Jangsten, E., Mollberg, M., . . . Begley, C. (2018). Definitions, measurements and prevalence of fear of childbirth: a systematic review. BMC Pregnancy Childbirth, 18(1), 28. https://doi.org/10.1186/s12884-018-1659-7

Schwartz L, Toohill J, Creedy DK, Baird K, Gamble G & Fenwick J. (2015) Factors associated with childbirth self-efficacy in childbearing women. BMC Pregnancy and Childbirth, 15:29.

Wong, C. Y. W., He, H. G., Shorey, S., & Koh, S. S. L. (2017). An integrative literature review on midwives’ perceptions on the facilitators and barriers of physiological birth. International Journal of Nursing Practice, 23(6). https://doi.org/10.1111/ijn.12602

How can we best prepare graduates to provide midwifery continuity of carer?

Less than 10% of Australian women can access midwifery continuity of carer. This model provides women with a known and trusted midwife, who is on-call to provide care throughout pregnancy, birth and the first six weeks afterwards. However, most women receive fragmented care from midwives on rostered shifts. For women this usually means a different midwife for each visit – and an unfamiliar midwife with them during labour and birth.

Benefits of midwifery continuity

Midwifery continuity of carer for women of any risk has outcomes that are similar or better than fragmented care – and it is cheaper to provide (Tracy et al., 2013). Women perceive care from known midwives as higher quality (Allen et al., 2019) and are more likely to feel satisfied with their care (Forster et al., 2016). Midwives working in these relationship-based models are less likely to experience burnout and more likely to feel empowered and autonomous in their roles (Fenwick et al., 2018). Despite these benefits, one barrier to expansion of midwifery continuity of carer is having enough midwives prepared and motivated to work in this way.

Learning midwifery through continuity of carer

Australian midwifery programs that lead to registration as a midwife require students to complete at least 10 Continuity of Care Experiences (CoCEs). Through CoCEs, students follow women through their pregnancy, birth, and postpartum experience – either in a fragemented or continuity model. In countries where the majority of women access midwifery continuity of carer, students are prepared with a higher number of midwifery continuity experiences. For example, New Zealand standards require students complete 25 CoCEs (New Zealand College of Midwives). While in Canada, students spend 50% of their clinical placement with community-based midwives who provide continuity of carer with hospital or homebirth options (Butler et al., 2016). There is considerable debate in Australia about the optimum number of CoCEs student need to facilitate learning and to prepare them to work in continuity models (Gamble et al., 2020).

Midwifery student experiences of continuity

Master of Primary Maternity Care student Joanne Carter was supervised by Transforming Maternity Care Collaborative’s Deputy Director, Associate Professor Mary Sidebotham, and Dr Elaine Dietsch. Together they investigated completing students’ motivation and preparedness to provide midwifery continuity of care after completing 20 CoCEs (Carter, Sidebotham & Dietsch, 2021). Survey data were collected using the Midwifery Student Evaluation of Practice (MidSTEP) tool which measures students’ experiences of clinical learning during placement (Griffiths et al., 2020), as well as free text response items. Over 120 students from one Australian university responded to the survey during 2017-2019.

Being prepared to provide midwifery continuity

Approximately 80%  of students indicated they felt well-prepared to work within a midwifery continuity of carer model on graduation (Carter, Sidebotham & Dietsch, 2021). Students explained, in their own words, that providing midwifery continuity of care had consolidated their clinical knowledge. Students described witnessing  how beneficial the model was to the women they followed. They also perceived that midwives were able to practice autonomously and in alignment with midwifery philosophy.

Being motivated to provide midwifery continuity

Approximately 50% of respondents indicated they would prefer to work in midwifery continuity of care on graduation. These students felt motivated to work to their “full scope of practice” and saw midwifery continuity of care as their “dream job”. Students who did not feel ready to graduate and move directly into a midwifery continuity models cited reasons such as wanting more skill or experience, although they did not identify which specific skills. Whilst students referred to other barriers (such as balancing on-call with family commitments), the majority indicated a preference to work in midwifery continuity of care in the future.

Over 90% of respondents who had been embedded in a midwifery continuity model and had a dedicated mentor, felt well-prepared and motivated to work this way.  This finding is consistent with international research that highlights the value of midwifery mentors within these models.

Recommendations from the research

A workforce prepared and motivated to work in this way is crucial to the expansion and sustainability of midwifery continuity of carer models. To achieve this, Carter et al. (2021) recommend:

  1. Increasing midwifery students’ access to continuity of care within clinical placement and CoCE.

  2. Co-designing placements with services and midwifery mentors who provide continuity of care.

  3. Offering flexible modes of learning to enable students to attend appointments and births.

  4. Reviewing midwifery accreditation standards so that all midwifery education programs prioritise midwifery continuity of care in program design.

You can currently access the free full-text article here

References

Allen, J., Kildea, S., Tracy, M. B., Hartz, D. L., Welsh, A. W., & Tracy, S. K. (2019). The impact of caseload midwifery, compared with standard care, on women’s perceptions of antenatal care quality: Survey results from the M@NGO randomized controlled trial for women of any risk. 46(3), 439-449. https://doi.org/10.1111/birt.12436

Butler, M. M., Hutton, E. K., & McNiven, P. S. (2016). Midwifery education in Canada. Midwifery, 33, 28-30. https://doi.org/10.1016/j.midw.2015.11.019

Carter, J., Sidebotham, M., & Dietsch, E. (2021). Prepared and motivated to work in midwifery continuity of care? A descriptive analysis of midwifery students’ perspectives. Women and Birth. https://doi.org/10.1016/j.wombi.2021.03.013

Fenwick, J., Sidebotham, M., Gamble, J., & Creedy, D. K. (2018). The emotional and professional wellbeing of Australian midwives: A comparison between those providing continuity of midwifery care and those not providing continuity. Women Birth, 31(1), 38-43. https://doi.org/10.1016/j.wombi.2017.06.013

Forster, D. A., McLachlan, H. L., Davey, M. A., Biro, M. A., Farrell, T., Gold, L., . . . Waldenstrom, 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 Childbirth, 16, 28. https://doi.org/10.1186/s12884-016-0798-y

Gamble, J., Sidebotham, M., Gilkison, A., Davis, D., & Sweet, L. (2020). Acknowledging the primacy of continuity of care experiences in midwifery education. Women Birth, 33(2), 111-118. https://doi.org10.1016/j.wombi.2019.09.002

Griffiths, M., Fenwick, J., Gamble, J., & Creedy, D. K. (2020). Midwifery Student Evaluation of Practice: The MidSTEP tool — Perceptions of clinical learning experiences. Women and Birth, 33(5), 440-447. https://doi.org/10.1016/j.wombi.2019.09.010

New Zealand College of Midwives. Undergraduate midwifery education. Retrieved from https://www.midwife.org.nz/midwives/education/undergraduate-midwifery-education/

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. https://doi.org/10.1016/S0140-6736(13)61406-3

 

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

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.

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

How well does midwifery education prepare graduates to work in continuity of care models?

Access to continuity of midwifery care (CoMC) models in Australia is increasing but the capacity of the emerging midwifery workforce to provide this care remains largely unknown. Continuity of midwifery care has been a required component of Australian midwifery education programs since 2009 (ANMAC, 2009). This has been primarily achieved through the concept of the ‘Continuity of Care Experience’ (COCE), where midwifery students follow a woman on her journey through the pregnancy, birth, and postnatal period (ANMAC, 2014). COCE are undertaken within all models of maternity care and the requirements surrounding these experiences vary widely by educational institution (Gamble et al., 2020). Midwifery education programs are required to contain equal parts theoretical and clinical hours and those clinical hours not achieved through COCE are undertaken via clinical placements, most often within standard (or fragmented) maternity care models (ANMAC, 2014; Gamble et al., 2020).

Researchers from the Transforming Maternity Care Collaborative recently published an integrative literature review which set out to discover how well pre-registration midwifery education prepares and motivates Australian midwifery students to work in continuity of midwifery care models when they enter practice (Carter et al., 2020). The findings reveal that access and exposure to CoMC is a crucial component of midwifery education. The full text of the paper is available free via this link for a short time.

Midwifery students consistently expressed that their COCE  equipped them with increased knowledge, skills, and confidence in midwifery practice (Browne et al., 2014; Dawson et al., 2015; Fenwick et al., 2016; McKellar et al., 2014; Sidebotham et al., 2015). Their COCE enabled them to build trusting relationships with women, enabling them to recognise and provide woman-centred midwifery care (Browne et al., 2014; Dawson et al., 2015; Fenwick et al., 2016; McKellar et al., 2014; Sidebotham et al., 2015). These factors improved work satisfaction amongst midwifery students and motivated them to provide CoMC upon entry to practice (Brown et al., 2014; Evans et al., 2020; McLachlan et al., 2013; Sidebotham et al., 2015; Sidebotham & Fenwick 2019). Midwifery support played an important role in influencing students learning and future career aspirations (Carter et al., 2015; Sidebotham & Fenwick 2019). Continuity of mentorship from a midwife, who worked in, and whose midwifery philosophy aligns with continuity of care, improved students’ understanding of the role, providing opportunity for them to gain insight into what working in these models really ‘looks like’ (Carter et al., 2015; Sidebotham & Fenwick, 2019).

Some midwifery students reported challenges in the achievement of their COCE. The most common concern was that of the impact on their work/ life balance and, to some extent, their finances (Brown et al., 2014, Carter et al., 2015; Dawson et al., 2015; Fenwick et al., 2016; McLachlan et al., 2013; Sidebotham & Fenwick 2019). It was evident from this research that existing methods of education program delivery and institutional structures often presented students with challenges, detracting from the value of their learning experiences. This was not the case however, when students’ clinical experiences took place within an established CoMC model (Sidebotham & Fenwick, 2019). When academic institutions actively support CoMC by prioritising and embedding it within program delivery, the challenges associated with CoMC are minimised (Sidebotham & Fenwick, 2019). These findings are in alignment with work by Gamble et al. (2020), who suggest that CoMC should become the core principle around which midwifery education programs are designed and delivered.

This integrative review found that while most midwifery students wished to work in continuity of midwifery care, not all felt able or capable to do so upon completion of their education. With motivation high, it is important to identify, expand, and promote factors that increase new midwives’ preparedness to work in CoMC. With little evidence as to how well theoretical and non-CoMC clinical learning prepares students to work in CoMC, further research is required to identify educational factors that enable and inhibit midwives from working this way upon entry to practice. Such research could be used to inform and implement a consistent approach to midwifery education internationally.

References

ANMAC (2009). Midwife accreditation standards 2009. 

ANMAC. (2014). Midwife accreditation standards 2014. 

Browne, J., Haora, P. J., Taylor, J., & Davis, D. L. (2014). “Continuity of care” experiences in midwifery education: Perspectives from diverse stakeholders. Nurse Education in Practice, 14, 573-578.

Carter, J., Dietsch, E., & Sidebotham, M. (2020). The impact of pre-registration education on the motivation and preparation of midwifery students to work in continuity of midwifery care: An integrative review. Nurse Education in Practice, 48, 102859.

Dawson, K., Newton, M., Forster, D., & McLachlan, H. (2015). Exploring midwifery students׳ views and experiences of caseload midwifery: A cross-sectional survey conducted in Victoria, Australia. Midwifery, 31, e7-e15. doi:10.1016/j.midw.2014.09.007

Evans, J., Taylor, J., Browne, J., Ferguson, S., Atchan, M., Maher, P., Homer, C. & Davis, D. (2020). The future in their hands: Graduating student midwives’ plans, job satisfaction and the desire to work in midwifery continuity of care. Women and Birth, 33(1), e59-e66.

Fenwick, J., Gamble, J. & Sidebotham, M. (2016). Being a young midwifery student: A qualitative exploration. Midwifery, 39, 27-34.

Gamble, J., Sidebotham, M., Gilkison, A., Davis, D., & Sweet, L. (2020). Acknowledging the primacy of continuity of care experiences in midwifery education. Women and Birth, 33(2), 111-118.

McKellar, L., Charlick, S., Warland, J. & Birbeck, D. (2014). Access, boundaries and confidence: The ABC of facilitating continuity of care experience in midwifery education. Women and Birth, 27(4), e61-e66.

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.

Sidebotham, M., Fenwick, J., Carter, A. & Gamble, J. (2015). Using the five senses of success framework to understand the experiences of midwifery students enrolled in an undergraduate degree program. Midwifery, 31(1), 201-207.

Sidebotham, M. &Fenwick, J. (2019). Midwifery students’ experiences of working within a midwifery caseload model. Midwifery, 74, 21-28.

Building birthing on country for the Yuin community

First Nations women of Australia have given birth on their country and within their cultural practices for most of their history. The colonisation of Australia by Europeans disrupted this, and it is now challenging for Aboriginal and Torres Strait Islander women to access maternity care that is local to them, and which honours their culture. Midwifery continuity of care delivered in models designed by and for Aboriginal and Torres Strait Islander women, by clinicians who are answerable to their local community can build the strength and vitality of communities.

The IBUS study (Hickey, et al., 2018) has been examining the outcomes of providing birthing on country services within a midwifery continuity of care model. Preliminary findings have shown a significant reduction in preterm birth rates (Kildea, et al., 2019). Preterm birth rates are higher for children born to indigenous women compared to non-indigenous women, and these children are at a life-long disadvantage. Few interventions designed to prevent preterm birth have been as effective as these structural changes to the way care is provided. Despite this, midwifery continuity of care models remain limited around Australia and access to such care is particularly lacking for Aboriginal and Torres Strait Islander women living in regional areas.

Waminda, the South Coast Women’s Health and Welfare Aboriginal Corporation – located on Yuin land in Nowra, NSW – is poised to solve this access issue for their local community. Extensive consultation within the community occurred in 2017 in the form of the Building on Our Strengths (BOOSt) project (Roe, Kildea, & Briggs, 2017). Participants identified that they wanted maternity systems based on Aboriginal ways of knowing and doing, that provide holistic care, and that were committed to giving their children the best start in life.

Waminda have designed a Birthing on Country program that puts the needs of the community first and is underpinned by sound research. A central part of this program is to build a Birthing and Community Hub which will enable the provision of maternity services, including birthing services. The major obstacle in their way at the present time is funding. To overcome this, Waminda are seeking public funding for the project. You can help make this happen by making a donation to support this work.  More information is available on the Waminda Birthing on Country website.

 

References
Hickey S, Roe Y, Gao Y, Nelson C, Carson A, Currie J, et al. The Indigenous Birthing in an Urban Setting study: the IBUS study: A prospective birth cohort study comparing different models of care for women having Aboriginal and Torres Strait Islander babies at two major maternity hospitals in urban South East Queensland, Australia. BMC Pregnancy Childbirth. 2018;18(1):431.

Kildea, S., Gao, Y., Hickey, S., Kruske, S., Nelson, C., Blackman, R., Tracy, S., Hurst, C., Williamson, D., & Roe, Y. (2019, Jul). Reducing preterm birth amongst Aboriginal and Torres Strait Islander babies: A prospective cohort study, Brisbane, Australia. EClinicalMedicine, 12, 43-51. https://doi.org/10.1016/j.eclinm.2019.06.001

Roe, Y., Kildea S. and Briggs, M. (2017). Birthing on Country, Best Start to Life, Illawarra Shoalhaven, 2017. Birthing on Country Working Group, Midwifery Research Unit, University of Queensland.

Access to midwifery continuity of care for childbearing women in the Australian health system

Equitable access to high quality maternity care is a critical priority for all health systems (Koblinsky et al. 2016; United Nations 2019). Strong evidence show that continuity of care delivered by a known midwife is safe, confers significant health benefits for women and babies, and results in higher reported satisfaction with care (Forster et al. 2016; Sandall et al. 2016). Not only is continuity of midwifery care linked to improved outcomes in general populations of childbearing women and those with social risk factors, studies also demonstrate the model meets the triple aims of health system improvement – improved satisfaction, better health care, and cost effectiveness (APPGGH 2016; Berwick 2008).

Despite this evidence, only a small proportion of women have access to continuity of midwifery care.  Scaling up access for women in vulnerable groups presents additional challenges (Renfrew et al. 2019). It’s important to know where families have or do not have access to high quality maternity care across birth settings, so that solutions can be found. A team of researchers from the Transforming Maternity Care Collaborative, led by Dr Rosalyn Donnellan-Fernandez have recently used modelling to provide a snapshot of the progress that is being made in Queensland towards providing universal access to publicly funded models of care (Donnellan-Fernandez et al., 2020).

2017 data for Queensland health services provided information about the number of services offering a midwifery continuity of carer model and the number of full-time equivalent midwives employed in such models. Assuming that each full-time equivalent midwife provided care to 35 women annually formed the basis of the model.

Almost 40,000 births occurred in public hospitals (excluding the Mater) in 2017. Overall, 18% of Queensland women who gave birth that year would have had access to a midwifery continuity of care model. When comparing hospitals by the number of births, geographical location, and whether they operated as a tertiary referral service, significant variations were present. Hospitals with a birth rate of 500 – 2000 births had the lowest estimated access to midwifery continuity of care at 11%. 11,830 women gave birth in these hospitals, almost 30% of the births in 2017.

Three large tertiary hospitals were the site of another 30% of the births. 17% of women giving birth in these facilities were estimated to have access to midwifery continuity of care. Five remote hospitals (providing birth care for 2%) had the highest rate of access at 77%, however this rate was noted to not reflect the full picture for these services. High rates of both planned and emergent antenatal and intrapartum transfer (from 30 to 90%) have been reported for these services. The estimated rates of access to midwifery continuity of carer include women who received antenatal and / or postnatal care in these five hospitals, but who gave birth elsewhere, therefore providing an artificially high estimate.

The authors concluded:

“scaling-up continuity of midwifery care models remains an important public health strategy to address equitable service access and disparate maternal and infant health outcomes.”

References
All Party Parliamentary Group on Global Health (APPGGH). (2016). Triple Impact Report. How developing nursing will improve health, promote gender equality and support economic growth. 

Berwick, D.M., Nolan, T.W., & Whittington, J. (2008). The triple aim: Care, health, And cost. Health Affairs, 27(3), 759-769.

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, in press. https://doi.org/10.1071/AH19264

Forster D.A., McLachlan, H.L., Davey, M.A., et al. (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 Childbirth, 28, 2016.

Koblinsky, M., Moyer, C., Calvert, C., Campbell, J., Campbell, O., Feigl, A., Graham, W., Hatt, L. Hodgins, S., Matthews, Z., McDougall, L., Moran, A., Nandakumar, A., Langer, A. (2016). Quality maternity care for every woman everywhere: a call to action. Lancet, 388, 2307-2320.

Renfrew, M., Ateva, E., Dennis-Antwi, J., Davis, D., Dixon, L., Johnson, P., Powell Kennedy, H., Knutsson, A., Lincetto, O., McConville, F., McFadden, A., Taniguchi, H., Ten Hoope Bender, B., Zeck, W. (2019). Midwifery is a vital solution—What is holding back global progress? Birth, 46, 396-399.

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, CD004667.

United Nations. (2019). The Sustainable Development Goals Report 2019. Department of Economic and Social Affairs: UN. New York.

Transforming maternity care requires the full contribution of the midwifery profession

Adjunct Professor Jocelyn Toohill PhD

Midwives play a critical role in healthcare. Unfortunately, most health leaders, and many health professionals have little understanding of what midwives can do. As a consequence, we have a significantly under-recognised and underutilized midwifery workforce relative to their scope of practice. For communities to have access to the highest standard of maternity care, and for health services to deliver world-class care we must have a midwifery workforce who are supported to work to full scope of practice.

Why is this important?

The “State of the World’s Midwifery” report is the 3rd international report to be published with a global focus to improving availability, accessibility, acceptability, and quality midwifery care. Importantly the report will demonstrate that “Power Comes from the Womb” and will be published by the United Nations Population Fund in 2021. This report will outline the 60-fold benefit that will come from investing in midwifery and highlight the impact midwifery can achieve through adopting a lifetime approach to care. Eighty-seven percent of all essential sexual, reproductive, maternal and newborn healthcare can be provided by midwives. Fifty-six maternal and neonatal outcomes are improved through midwifery practice alone. If we want a first-class health system, we must begin by acknowledging the value of midwives in saving lives and preventing lifetime morbidity, and midwives must be ready to meet this welcome but long overdue recognition.

Acknowledge

To make use of the all the opportunities quality midwifery care might provide for Queensland communities, we need to begin by knowing our existing midwifery workforce. Midwifery is relatively invisible within workforce systems, and is confused within a career structure not designed for the profession . We need to develop and articulate more clearly midwifery position description and generic level statements, that describe what it is that midwives do, when they do it, and where they do it.

Midwives are regulated to provide woman-centred care, and to promote normal physiology for women, both with and without complexities. When a woman has physical, medical, or psycho-social challenges her care does and will include members of the multidisciplinary team and will be guided by the Australian College of Midwives National Consultation and Referral Guidelines. Often health professionals have little understanding of the education preparation or lifesaving skills and knowledge midwives have and this lack of understanding of the scope of a midwife contributes to fragmented care for the woman and disrupts away from providing relationship based care within midwifery continuity. As such the professional role of the midwife must be articulated and embedded in human resource management systems, so that workforce numbers and workforce planning are focused to achieve best practice models where every woman has access to her own midwife. To promote and progress this, midwives must be included in all discussions to have a voice with executive health staff relating to the importance of midwives and of midwifery care.

Innovate

To innovate maternity care, midwifery continuity of carer models need to be scaled up. Despite overwhelming evidence of benefit, few women have access to this model of midwifery care. By tapping into the benefits to women and their families of consistent professional support from midwives during the first 1,000 days of life, we can provide a continuum of connected care and a professional career pathway for midwives that is integrated with child health. We recognise that a consistent and trusted carer means that psychosocial health needs, such as postnatal depression and domestic and family violence, are more likely to be identified earlier and addressed.

Home birth

Queensland is one of only two Australian jurisdictions without publicly funded homebirth. Homebirth is safe and provides improved outcomes in the right population of women. Queensland has strong consumer interest for home birth. During COVID-19 private midwives have reported a 35% increase in homebirths, and higher levels of demand than they can meet. There are concerning reports suggesting that women are giving birth without a midwife or doctor because they cannot afford a private midwife and are fearful of birthing in a hospital. Public health messaging of the safety of birth in hospital has not diminished the numbers of women continuing to seek out this choice. Equity of access to maternity and birth care that is physically and psychologically safe is important. Identifying opportunities for how homebirth could be facilitated remains a significant gap, with ‘hospital in the home’ arrangements perhaps an option.

Birthing on Country

Actioning and embedding culturally appropriate care and acknowledging the importance of birthing on country to Aboriginal and Torres Strait Island women is paramount in providing a world class health system and achieving sustainable development goals. Scaling up midwifery continuity of care with Aboriginal and Torres Strait Island women is vital. A major contributor to poor outcomes for Aboriginal and Torres Strait Island women is preterm birth, and we know that this is reduced by 50% where mothers receive midwifery continuity of care. Through implementing recommendations of the Queensland Rural Taskforce Report, maternity care can be provided closer to home and build continuity models. Technology will be a major conduit for midwives to connect women living rurally with specialist services.

Transform

Transforming maternity care will only come from the realisation of the full capacity of the midwifery profession. Currently, there are few midwives who have graduated in the past 12 years from a Bachelor of Midwifery program holding leadership roles. In 2018 surveys showed that contemporary midwifery education and practice remain poorly understood, with significant numbers of midwives indicating they were restricted from working to their full scope of practice. For those in leadership roles, a clear understanding of the differences between nursing and midwifery is necessary to grow and show the benefits of the midwifery workforce. Upon graduation midwives should be articulated directly to continuity models rather than restricted to and deskilled in historical and fragmented graduate programs. Ensuring culturally appropriate support is in place to attract and retain Aboriginal and Torres Strait Islander midwives is also key to building an equitable and inclusive workforce.

Additionally, through ensuring all women have access to a midwife – and specifically within a relationship-based continuity model where they are working to full scope – will assist in addressing the one in three women who have trauma symptoms from a poor birth experience or from feelings of having been treated disrespectfully. The protective factor for women is having a known midwife who understands her needs. Trust builds over time through cumulative education, information sharing, and decision-making, where the woman can feel confident in her midwife’s advocacy of her needs. Through this support – and regardless of birth or maternity outcome – the woman’s feelings of safety and control are likely to result in improved perinatal mental health, adaption to early parenting and greater capacity to meet the developmental needs of her child. Women who receive midwifery care are more likely to feel empowered, experience shared decision making and be more satisfied with their care.

Summary

For ongoing improvements in maternity care to be achieved we need to make the best use of our existing workforce by expanding opportunities for midwives to provide continuity of care. We need to be ready for the recommendations coming from the State of the World’s Midwifery report.

All midwives – regardless of the model they choose to work – in are vital to promoting the profession and to achieving a world class maternity system. Midwives are potent, and we must ensure that how midwives are educated and regulated to work is supported, translated to practice, and for women to have increased access. It has been said previously, that if midwifery were a pill, everyone would be prescribed it. I commend all midwives to primarily advocate for women, but fundamentally understand that universal access to best practice midwifery continuity is dependent on us all.

While our profession is predominantly women, all midwives, regardless of gender must safeguard gender equality. We must call out poor care or inequity. To be effective we must continue to strengthen our profession and stand united so women know, our communities know, and our governments know who we are, what we do and why midwifery is so fundamentality important to women, to strong communities and to generational health. Without this commitment the usefulness of the 2021 State of the World’s Midwifery report to our profession may be lost.