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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

 

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

Why cultural safety matters in maternity care

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

Learning culturally safe practice

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

Why emotion impacts learning cultural safety

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

Measuring emotion

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

Where to from here

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

References

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

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

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

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

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

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

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

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

Making continuity of care experiences work for midwifery students

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

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

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

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

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

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

References

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

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

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.

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.