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Educating midwives of the future: Do professional standards reflect what students need?

In Australia, the standards for education programs leading to registration as a midwife are set by the Australian Nursing and Midwifery Accreditation Council (ANMAC). These are periodically updated to reflect the needs of the community for a flexible, responsive and sustainable midwifery workforce. Last updated in 2014, the Midwife Accreditation Standards are currently under review.

Education for prescribing practice

One of the significant changes under consideration relates to the inclusion of education on prescribing. At present midwives who intend to prescribe medications in their clinical practice must have a minimum of three years of post-registration experience and complete a postgraduate course in prescribing in order to be endorsed with AHPRA as a prescriber. In the new standard, ANMAC is considering shifting education for prescribing into the primary, pre-registration midwifery qualification. While further changes to legislation would be required to facilitate midwives commencing prescribing immediately on registration, the proposed change represents an important necessary first step. If introduced, this would mean that midwives would not need to return to university study at a later date to satisfy this part of the requirement for endorsement.

In other high-income countries such as New Zealand, prescribing education is successfully provided within the primary midwifery degree and immediately on registration midwives have the authority to prescribe medications. This avoids placing a number of significant barriers in the way of midwives being able to include prescribing in their scope of practice. It also provides the advantage that midwives new to prescribing are better supported in healthcare systems that recognise that them as new to practice. This is not the case for midwives new to prescribing in Australia who may be left to “sink or swim” in their prescribing practice with little support. The New Zealand example demonstrates that it is possible to include prescribing education within the primary degree without compromising the quality of midwifery education or undermining the safe care provided by midwives with this educational exposure.

Preparing midwives for a full scope of practice in midwifery continuity of care models

A team from the Trans-Tasman Midwifery Education Consortium recently conducted research which identified future priorities for midwifery education in both Australia and New Zealand (Sidebotham et al., 2020). Among the priorities considered essential for the preparation of the future midwifery workforce was the provision of clinical practice experience within a continuity of midwifery care model. Given clear evidence of the superiority of continuity of midwifery care models, it is imperative that midwifery education prepare students to experience, and develop confidence and competence in providing care in continuity models (Gamble, Sidebotham, Gilkison, Davis, & Sweet, 2020).

In 2010 ANMAC introduced a requirement requiring students to experience continuity of care for twenty women, and in 2014 reduced this to only ten. It is important that ANMAC standards continue to support and promote the expectation that students will develop competence in providing quality care in continuity models.
Also of note is the proposal to remove an existing ANMAC recommendation that all students be provided the opportunity to develop competence in essential, but less often used skills in midwifery practice such as vaginal breech birth, perineal infiltration, episiotomy and repair, through the use of simulation. In order for midwives to provide autonomous care with the scope for practice it is important that midwifery students are taught to assess the perineum following birth and develop skills to suture the perineum. This recommendation should therefore be retained.

How to contribute

Have your say about the future standards governing midwifery education in Australia by submitting a response to ANMAC. Information about the standards and how to submit your response can be found on their website .
Submissions for the current round of consultation close on 13 August, 2020.

References

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. doi:10.1016/j.wombi.2019.09.002
Sidebotham, M., McKellar, L., Walters, C., Gilkison, A., Davis, D., & Gamble, J. (2020). Identifying the priorities for midwifery education across Australia and New Zealand: A Delphi study. Women & Birth, in press. doi:10.1016/j.wombi.2020.05.011

Preventing stillbirth: What works best?

Preventing stillbirth has been, and continues to be, a major focus in both practice and research in maternity care. Reducing rates of stillbirth in high-income countries has proven challenging, with little significant change over the past two decades. One of the current approaches to tackle stillbirth has been to routinely and regularly encourage women to focus on the movement pattern of their fetus and report any changes to their maternity care provider. Is this the best approach, or might midwifery continuity of care be more effective?

Earlier this year Bellussi et al. (2020) published a systematic review of literature which addressed the question of whether heightened awareness of fetal  movement patterns reduces stillbirth. On the basis of the research available at that time, the answer was no – increasing awareness of fetal movements didn’t reduce the rate of stillbirth. Several large trials remained unreported at the time they conducted their analysis, and one of these has just been published.

The latest addition to the pool of evidence is the Mindfetalness study (Akselsson et al., 2020). Conducted in 67 maternity services in Sweden, individual clinics were randomly selected to provide either routine care, or to provide women written and verbal information about an approach they called Mindfetalness. Starting from 28 weeks of gestation, women were asked to spend 15 mins at rest daily, during a period of fetal activity, being mindful of the pattern of movements. Women were encouraged to “trust their intuition” and seek care if they were worried about the movement pattern.

A cluster-randomisation process was used to ensure that socio-economic status and the number of births conducted at the clinic didn’t influence the outcome. In total, 19,639 women were registered for care at clinics where Mindfetalness was used, and 20,226 in the control clinics. Stillbirth is a (fortunately) rare outcome, so astonishingly large studies are needed to examine any change in the outcome. Because of this, the more common occurrence of low Apgar scores (under seven at five minutes of age) was chosen as the outcome of interest, and the size of the study was planned to be big enough to confidently find an improvement of 4 fewer babies in every 1000 births having better Apgar scores, if this effect was present. Data were collected from women who gave birth after 32 weeks of gestation.

The rate of babies born with low Apgar scores was the same regardless of whether Mindfetalness was recommended or not (11 in every 1000 births). While the primary aim of the trial was not to look at deaths, they did collect this information. There was a slightly higher rate of stillbirth (2 in 1000) in the Mindfetalness group, than the control group (1.4 in 1000). No statistical measure was offered to judge whether this was a chance finding or not. Neonatal death was extremely low in both groups (1 and 2 in 10,000 respectively – not statistically different).

The abstract of the article highlights two benefits of the Mindfetalness approach. There was a statistically significant reduction in the caesarean section rate, from 20% to 19%. This is far from being a clinically significant difference, and it is far less than has been seen in other interventions proven to be effective for reducing the rate (for example introducing midwives into obstetric only maternity care models reduced the rate by 7% – Chen et al., 2018). The other benefit was a reduction in the rate of babies born under the tenth centile. This fell from 107 per 1000 to 102 per 1000. However, there was no difference in the more clinically relevant measure of the rate of babies born under the fifth centile.

The authors argue that “increasing women’s awareness of fetal movements is not harmful” (p.835). While this is true within the context of their research findings, widespread adoption of programs focusing on fetal movement as a means to reduce the stillbirth rate comes with an opportunity cost. Maternity systems have finite resources in terms of money, people, and time. Focussing efforts towards an ineffective but not harmful approach to care directs effort and people away from other approaches to care which are already known to be effective.

Much attention has focussed on reducing stillbirth close to the end of pregnancy. The relationship between gestational age and stillbirth is a ‘U’ shaped curve (Ibiebele et al., 2016). The rate rises beyond 36 weeks of pregnancy, but we often forget that it also is high prior to 24 weeks of gestation. Fetal movement monitoring will be entirely ineffective for this population of fetuses, as it presumes that achieving the birth of the baby will prevent death. This is not true in the time prior to viability.

We already have sound research evidence that the rate of deaths prior to and after birth before 24 weeks of gestation can be reduced – a 19% reduction from 32 deaths per 1000 births to 23 – which is both statistically and clinically significant. This can be achieved through midwife-led continuity of care (Sandall et al., 2016). In other words, by ensuring that each pregnant woman has her own midwife. It’s time we did something about making this the universal standard of care with the same level of enthusiasm that clinicians describe for fetal movement monitoring programs.

Dr Kirsten Small

Meet Associate Professor Kathleen Baird – TMCC collaborator and researcher

Kathleen Baird
Associate Professor Kathleen Baird – Board Member of Queensland Domestic Violence Implementation Council 2015-2019

“Midwives have an important role to play in addressing domestic and family violence.”

I wear a range of hats that inform my perspective on Queensland’s domestic and family violence reform program. I have been a midwife for over two decades, and most days, you will find me working as an academic in the field of midwifery at Griffith University or as the Director of Midwifery and Nursing Education, for the Women Newborn & Children’s Services at the Gold Coast University Hospital. As a member of the Council and Deputy Chair of Queensland’s Domestic and Family Violence Death Review and Advisory Board, I have been particularly interested in reforms directed at comprehensive and integrated services with a special interest in the role of midwives and the health services to identify, empower and effectively support those experiencing domestic and family violence to escape violence and safely rebuild their lives.

These reforms include the integrated service response trials in Beenleigh, Mount Isa and Cherbourg that aim to ensure the safety of victims and manage the risk posed by perpetrators through a collaborative multiagency process. Fundamentally, this approach is about breaking down the silos which have so often been identified as a barrier to protecting victims of domestic violence. But identifying those experiencing domestic and family violence is the first critical step in engaging the service responses necessary to help them to safety. As a midwife, I have long been passionate about improving the health response to domestic and family violence and advocated for routine screening by midwives. The trusting relationship women form with their midwives throughout pregnancy, labour and after her child is born makes midwives ideally placed to enquire about the nature of a woman’s relationship, her sense of safety and available support and to provide appropriate support and referrals if domestic violence is disclosed.

Hospitals are often the first point contact for those experiencing domestic and family violence and are uniquely placed to identify victims and survivors and then offer appropriate support and referrals. In October this year, I was incredibly proud that the Council had the opportunity to see firsthand the response we have developed at the Gold Coast University Hospital. We have worked hard to embed a culture that domestic and family violence is everyone’s business and all hospital staff have a role in identifying and supporting victims and perpetrators of domestic and family violence whether they are pregnant women, patients, children or fellow staff members. Gold Coast Health was the first public health service in Queensland to appoint a specialist and dedicated Domestic and Family Violence Coordinator. The Coordinator ensures that all hospital staff understand their roles, and that our frontline health workers are well trained and supported to sensitively ask the right questions to identify potential domestic and family violence victims, and then to open pathways towards assistance for them.

Experienced social workers work across the health services’ emergency and maternity departments and with the Homeless Health Outreach Team. The Emergency Department is supported by an in-house forensic unit, an active elder abuse support worker, improved platforms for information sharing and a multidisciplinary team to support patients affected by domestic and family violence. Midwives are trained to not only ask the right questions, but to look out for particular signs of domestic and family violence, and to respond and refer accordingly. A partnership with the Women’s Legal Service Queensland has made free and confidential onsite legal services available for women experiencing domestic and family violence who present to the hospital.

It took a great deal of hard work by many dedicated people, supported by strong commitment from our health service executive and managers and a broader integrated service network across the Gold Coast, to deliver a responsive, compassionate and integrated support system for patients and staff affected by domestic and family violence. The hospital continues to refine its systems and processes, but I hope that our experience will encourage and support other health services to develop integrated services that focus on the safety of those experiencing domestic and family violence.

Access the November 2019 Full Council Report here

Maternity continuity of care model changing lives

Our workforce studies show working in continuity of care is better for midwives and women and helps retain this very important workforce. Our collaborator and Lead Author of the study Mary Sidebotham was interviewed for this Channel 7 News story that demonstrates the benefits of a Continuity of Maternity Care model for midwives and women.

Watch the full news story here.