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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.

New research from the Transforming Maternity Care Collaborative Team

Collectively, the Transforming Maternity Care Collaborative generate a large volume of high quality, impactful research. This week has seen the publication of five new papers from our team members in the Women and Birth journal. You can access the full text of each of these via the links below. Settle in with a cuppa and enjoy getting up to date.

Intrapartum CTG monitoring does not improve perinatal outcomes.

Authors: Dr Kirsten Small, Associate Professor Mary Sidebotham, Professor Jennifer Fenwick, Professor Jenny Gamble.

This systematic literature review identified all randomised controlled trials and non-experimental evidence which has examined whether the use of CTG monitoring during labour rather than intermittent auscultation reduces perinatal mortality or cerebral palsy rates in babies born to women considered to be at high risk. No improvement in mortality was found, while an increase in the cerebral palsy rate was noted when CTG monitoring was used during preterm labour.

“High-quality research is urgently required to identify which women, if any, obtain a perinatal benefit from intrapartum CTG monitoring.”

Access this paper here.

Measuring midwifery students’ experiences of learning in clinical practice environments.

Authors: Ms Marnie Griffiths, Professor Jennifer Fenwick, Professor Jenny Gamble, Professor Debra Creedy.

Learning in a clinical environment is a key component of a comprehensive midwifery education program. Being able to measure how well specific learning environments support midwifery students as they develop the knowledge and skills required for professional practice is important. This paper reports on the development and testing of the MidSTEP tool which offers a robust way to capture students’ perceptions of the clinical practice component of their degree. Students indicated high level support for the statements that the clinical environment supported their learning, enabled them to work across the full scope of practice, and fostered a self-directed approach to learning.

Access this paper here.

Placing students in the driver’s seat.

Authors: Ms Valerie Hamilton, Professor Kathleen Baird, Professor Jennifer Fenwick

This research reports on students’ experiences of learning to provide midwifery care in a student-led midwifery clinic providing antenatal and postnatal care. Students who were on-call for individual women were supported to provide antenatal and postnatal care under the supervision and guidance of their university practice lecturer. “Being in the driver’s seat” was the major theme of the findings, with students reporting a sense of being in control and feeling like “a real midwife”. Students described growing in confidence over time and feeling competent to step into practice.

Access this paper here.

Stepping from student to employment through simulated employment interviews.