Facilitators of and barriers to providing high-quality midwifery education in South-East Asia—An integrative review

BackgroundWith a diversity in midwifery education across the South-East Asia region, and with the knowledge about the lifesaving competency of the midwife profession, this study’s aim is to describe facilitators of and barriers to providing high-quality midwifery education in South-East Asia.MethodsInspired by Whittemore and Knafl, we conducted a systematic integrative literature review including the five key stages of problem identification, literature search, data evaluation, data analysis, and presentation of results. The literature searches were conducted in October 2020 in the databases CINAHL, PubMed, and Scopus. A deductive data analysis based on global standards was performed.ResultsThe search identified 1257 articles, 34 of which were included. Countries in South-East Asia did not fully comply with the ICM global standards. Midwifery education was not separated from that of nursing, and educators lacked formal qualifications in midwifery. Curriculum implementation in the clinical area was a key barrier to achieving learning outcomes. Higher academic education for midwifery educators and mentorship programs facilitated the pedagogic and assessment process, focusing on the abilities of critical thinking, reflection, and decision-making.ConclusionsCountries in South-East Asia still have a long way to go before they can provide high-quality midwifery education. The identified facilitators can lead to a difference in students’ academic achievement and confidence in their clinical work. Coordinated actions will enable the progress in achieving competent midwives matching national health priorities. The findings highlight a need for more research on midwifery education in both theory and practice across the region.     

Acknowledging the primacy of continuity of care experiences in midwifery education

BackgroundContinuity of midwifery care is the best maternity care model for women at any risk level, and there is a global imperative to improve access to midwifery-led care. However, diverse perspectives about how best to prepare graduates for working in midwifery continuity of care models persist. The continuity of care experience standard in Australia was anticipated to address this.AimTo challenge the dearth of published information about the structures and processes in midwifery education programs by identifying: the educational value and pedagogical intent of the continuity of care experience; issues with the implementation, completion and assessment of learning associated with continuity of care experience; and discuss curriculum models that facilitate optimal learning outcomes associated with this experience. We discuss the primacy of continuity of care experience in midwifery education programs in Australia.DiscussionThe inclusion of continuity of care experience in midwifery programs in Australia became mandatory in 2010 requiring 20, however this number was reduced to 10 in 2014. Research has shown the beneficial outcomes of continuity of care experience to both students and women. Continuity of care experience builds mutual support and nurturing between women and students, fosters clinical confidence, resilience, and influences career goals. We require curriculum coherence with both structural and conceptual elements focusing on continuity of care experience.Implications and recommendationsEducation standards that preference continuity of care experience as the optimal clinical education model with measurable learning outcomes, and alignment to a whole of program philosophy and program learning outcomes is required.     

Identifying the priorities for midwifery education across Australia and New Zealand: A Delphi study

ProblemIn countries where education programmes are assessed as meeting international standards there is limited knowledge about the challenges facing midwifery education.Background/aimThe positive impact of quality midwifery education on maternal and newborn health is acknowledged by the World Health Organisation. However, there is limited research identifying the issues faced in providing quality midwifery education. The aim of this study was to identify the challenges and determine priority projects to strengthen midwifery education across Australia and New Zealand.MethodsA two-round Delphi study with experts in midwifery education was undertaken.FindingsIn round one, 85 participants identified an initial 366 issues for midwifery education. Through thematic content analysis these were categorised into 89 statements reflecting five major themes: In round two, 105 midwifery experts from Australia n = 86 (79%) and New Zealand n = 23 (21%) rated the 89 statements in order of priority. Across the combined data (Australia and New Zealand) a total of 19 statements gained consensus of ≥80%.DiscussionFive priority themes were identified including; (1) enabling success of First Peoples/Māori midwifery students; (2) increasing the visibility and influence of midwifery within regulation, accreditation and university governance; (3) determining how best to deliver the clinical practicum component of programmes; (4) reviewing midwifery programmes to enhance design, content and delivery; and (5) ongoing education and support for the midwifery workforce.ConclusionIn Australia and New Zealand, it is imperative that collaborative work is undertaken to design and action identified projects addressing these priorities.     

The experiences of Aboriginal and Torres Strait Islander Bachelor of Midwifery students: An integrative literature review

IssueThere is an underrepresentation of Aboriginal and Torres Strait Islander midwives across Australia and an inadequate number of graduating midwives to redress this. A major pillar for the Birthing on Country Model is maternity care workforce development.AimThe purpose of this review is to examine the enablers and barriers that Aboriginal students experience while undertaking the Bachelor of Midwifery degree in Australia.MethodsA search of the literature was undertaken through electronic databases. When only three papers were found looking at the experiences of Aboriginal midwifery students the search was broadened to include Aboriginal undergraduate health students.FindingsThe literature review reported a strong need for cultural safety in both the clinical and education systems. Students with access to cultural supports, relationships with Aboriginal mentors and academics and Aboriginal clinical placements felt empowered and were able to navigate the ‘two worlds’ in a meaningful way.DiscussionThis review highlights a significant gap in the literature. Despite the expanded search terms to include Aboriginal health students, a relatively narrow range of papers were found. Interestingly, the combined search revealed similar themes: kinship, personal factors, and cultural issues.ConclusionEmpowering and supporting Aboriginal Peoples to become midwives is essential. While systems and societies aim for cultural safety, this review shows there is still a way to go. Further research is essential to decolonise higher education and health care systems, and provide strong, well supported pathways for Aboriginal midwifery students.     

Hospital accreditation: Driving best outcomes through continuity of midwifery care? A scoping review

ProblemContinuity of midwifery care models are the gold standard of maternity care. Despite being recommended by the Australian Health Ministers’ Advisory Council, few women in Australia have access to such models.BackgroundExtensive research shows that if all women had access to continuity of midwifery care, maternal and neonatal outcomes would improve. Hospital accreditation, the main national safety and quality system in Australia, aims to encourage and enable the translation of healthcare quality and safety standards into practice.AimThis paper explored the realities and possibilities of a health care accreditation system driving health service re-organisation towards the provision of continuity of midwifery care for childbearing women.MethodsA scoping review sought literature at the macro (policy) level. From 3036 records identified, the final number of sources included was 100:73 research articles and eight expert opinion pieces/editorials from journals, 15 government/accreditation documents, three government/accreditation websites, and one thesis.FindingsTwo narrative themes emerged: (1) Hospital accreditation: ‘Here to stay’ but no clear evidence and calls for change. (2) Measuring and implementing quality and safety in maternity care.DiscussionRegulatory frameworks drive hospitals’ priorities, potentially creating conditions for change. The case for reform in the hospital accreditation system is persuasive and, in maternity services, clear. Mechanisms to actualise the required changes in maternity care are less apparent, but clearly possible.ConclusionsStructural changes to Australia’s health accreditation system are needed to prioritise, and mandate, continuity of midwifery care.     

‘Continuity of Care Experiences’ within pre-registration midwifery education programs: A scoping review

BackgroundMidwifery is based on the philosophy of woman-centred care. The continuity of care experience in pre-registration education programs exemplifies this philosophy. Wide variation in how education providers implement ‘Continuity of Care Experiences’ into their programs of study can challenge this valuable learning opportunity.AimTo provide a comprehensive analysis of the governance and empirical evidence of knowledge, practice and enablers to support continuity of care experiences within pre-registration midwifery education.MethodA scoping review of research, policy and professional documents pertaining to the continuity of care experience in pre-registration education programs was conducted with 46 articles meeting the inclusion criteria.FindingsSeveral factors were identified that support the implementation, facilitation and evaluation of the continuity of care experience within pre-registration midwifery education. These include: a woman-centred model of maternity care; enabling midwifery students and women to develop ‘relational continuity’; tripartite support models; optimising the sequencing of these experiences within the program and, woman-led evaluations of student performance. There was little consensus regarding the pedagogical intent and, therefore, an inability to clearly define and measure the learning outcomes of the continuity of care experience.ConclusionIn countries where the predominant model of maternity care is fragmented and not woman-centred, further research is required to understand the pedagogical intent of the continuity of care experience.     

Shared learning on an international clinical placement: Promoting symbiotic midwifery practice knowledge

AimThe aim of this study was to explore the experiences of shared learning between Australian and Balinese midwifery students during a two-week clinical placement in Bali Indonesia.BackgroundCultural safety in midwifery is a key concept that is underpinned by the provision of holistic quality midwifery care to all women. Therefore, culturally safe midwifery care identifies, protects and promotes women’s individual cultures and is a key concept that is fostered in midwifery education. To educate culturally safe midwives, international placements to resource limited countries have become more common within midwifery education programs.MethodsThis study used a qualitative research design with a convenience sampling design. The participants were enrolled in midwifery courses in a University in the Northern Territory of Australia (n = 9), a Balinese private midwifery school (n = 4) and a Balinese public midwifery school (n = 4). Thematic analysis was used to analyse the data.FindingsThe findings were categorised into major themes under the headings of “Learning together despite differences”; “Cultural differences”, “Communication, Resources”, and “Recommendations for future placements”.ConclusionThis study provides a valuable insight into how shared learning increases students’ midwifery knowledge and is fundamental in understanding cultural differences that could be applied to students’ clinical midwifery practice.     

Midwifery-led care in South Australia: Looking back to move forward

BackgroundFrom the 1980s to the turn of the century, Australia saw an evolution of midwifery-led models of care, in part due to legislative reform and federal funding, but largely owing to the efforts of strong midwifery leaders and consumers who rallied for the implementation of alternative models of care. Through persistence and extensive collaboration, the first South Australian birth centres were established.AimTo better understand the evolution of midwifery-led care in South Australia and identify the drivers and impediments to inform the upscaling of midwifery models into the future.MethodsSemi-structured interviews were conducted with ten midwifery leaders and/or those instrumental in setting up birth centres and midwifery-led care in South Australia. Data was analysed using thematic analysis.FindingsThree overarching themes and several sub-themes were identified, these included: ‘Midwifery suffragettes’ which explored ‘activism’, ‘adversity’ and ‘advocacy’; ‘Building bridges’ captured the importance of ‘gathering midwives’, a ‘movement of women’ and ‘champions and influencers’; and ‘Recognising midwifery’ identified the strong ‘sense of identity’ needed to outface ‘ignorance and opposition’ and the importance of ‘role reformation’.ConclusionThese midwifery leaders provide insight into an era of change in the history of midwifery in South Australia and contribute valuable learnings. In order to move forward, midwives must continue to embrace the political nature of midwifery, enact authentic, transformational leadership and engage women across all levels of influence. It is critical that midwives pursue equity in professional recognition, work collaboratively to provide quality, woman-centred maternity care and expand midwifery continuity of care models.     

Exploring global recognition of quality midwifery education: Vision or fiction?

Background

Midwifery education is the foundation for preparing competent midwives to provide a high standard of safe, evidence-based care for women and their newborns. Global competencies and standards for midwifery education have been defined as benchmarks for establishing quality midwifery education and practice worldwide. However, wide variations in type and nature of midwifery education programs exist.

Midwifery in Middle Eastern and North African countries: A scoping review

BackgroundWhile midwives are positioned as critical providers for improving sexual, reproductive, maternal and newborn health outcomes in the Middle East and North African (MENA) countries, the standards of midwifery have not been explored systematically in this region.AimThe purpose of this scoping review was to provide an overview of existing literature on midwifery practice, education, and regulation in MENA countries in the context of ICM standards.MethodsA search was conducted inclusive of English and Persian written studies published between 2000 and 2019 in CINAHL plus; Ovid MEDLINE; PubMed; Scopus; and grey literature. Title and abstract and full-text review were performed in Covidence, and data extraction and synthesis performed using NVivo 12.ResultsThe initial search identified 7,994 articles. Overall, 139 studies were included in the review. Although, the primary concept of most included studies was “midwifery practice”, “midwifery regulation” was addressed in limited way. Approximately 90% were from Middle Eastern countries. Forty-two per cent of studies used cross-sectional designs, and most originated from Iran, Jordan, and Palestine. Diversity was found in midwifery education, practice and regulation across the MENA countries. Midwives from different nations had uneven levels of proficiency, scope of practice, and education. Midwifery curricula were aligned with ICM competencies in some countries. Most countries had midwifery associations and were members of ICM. Some countries had regulations recognising midwifery as an autonomous profession.ConclusionMidwifery practice, education and regulation in MENA countries were not always comparable with ICM standards, although some progress was evident.     

Subversive acts and everyday midwifery: Feminism in content and context

BackgroundMidwives are often at the forefront of political campaigns for women's empowerment, overtly advocating for women's rights and reproductive justice. However, midwives can also be found engaging in inadvertent activism on a daily basis within routine care. When casting a feminist lens over both the content and context of midwifery practice in Australia, subversive acts and opportunities for feminist reform can be found.AimTo interrogate the significance of feminism in midwifery practice, identifying feminist successes and further opportunities for implementation including: analysis of the Midwifery Standards for Practice; the primary tenets of woman-centred care; the content versus context of midwifery in Australia; and feminist opportunities for enhanced practice. This paper will discuss the importance of feminism in midwifery practice and its significance in informing optimal midwifery care.DiscussionIncorporating women's voice and respecting women's bodies and agency in the delivery of care is a fundamental component of midwifery practice. However, while the content of midwifery practice is innately feminist in its emphasis on woman-centred care, it will be argued that the context of birthing in Australia is not. The resultant effect is the emergence of victim blaming in maternity care and the construction of an archetypal ‘good birthing woman’.Implications and recommendationsMoving away from the myth of the ‘good birthing woman’ and the act of victim blaming, midwifery could instead direct its focus towards challenging the rigid systems and structures within which midwives implement care. By further embracing feminist principles midwives will ensure a truly woman-centred future.     

Any action? Reflections on the Australian Midwifery Action Project

Background

In 1997 a group of midwifery academics, researchers and practitioners met to discuss issues of concern related to the midwifery profession in Australia. It became clear from this discussion that midwifery in Australia was lagging behind similarly developed countries and that urgent action was required. From this meeting, a plan was developed to seek funding for a major national study into midwifery education and practice standards and as such, the Australian Midwifery Action Project (AMAP) was born.

Barriers and enablers for midwives using endorsement for scheduled medicines: A literature review

ProblemThere are currently 429 midwives in Australia who hold the Nursing and Midwifery Board of Australia’s Endorsement for scheduled medicines for midwives. Little is known about how midwives are using the endorsement and what factors impact on its use.ObjectiveTo critically examine the literature to discover what the barriers and enablers are for midwives to use the endorsement.MethodA search was undertaken examining literature published since 2004. Due to a lack of articles specific to midwifery, the search was widened to include literature related to similar non-medical health professions. The search was divided into two streams: accessing the Medicare Benefits Schedule and accessing the Pharmaceutical Benefits Scheme and prescribing. Twenty-six primary articles from 2009 onward met the review criteria.FindingsAlthough singular barriers and enablers to both streams were identified, many of the themes act as both enabler and barrier. Themes common to both the Medicare Benefits Schedule focus and the Pharmaceutical Benefits Scheme and prescribing focus are that of medical support, scope of practice, ongoing support from health care consumers and management, and endorsement processes. Barriers occur approximately three times more frequently than enablers.ConclusionBarriers and enablers occur for various reasons including legislative, regulatory, organisational, and the individual’s support for and attitude towards these roles. To overcome barriers and facilitate the success of emerging non-medical extended practice roles, significant buy-in and investment is needed across all levels of the health system. The review highlights a significant gap in knowledge about the endorsement’s use in midwifery.     

Midwifery continuity of care for women with complex pregnancies in Australia: An integrative review

BackgroundAll women require access to quality maternity care. Continuity of midwifery care can enhance women’s experiences of childbearing and is associated with positive outcomes for women and infants. Much research on these models has been conducted with women with uncomplicated pregnancies; less is known about outcomes for women with complexities.AimTo explore the outcomes and experiences for women with complex pregnancies receiving midwifery continuity of care in Australia.MethodsThis integrative review used Whittemore and Knafl’s approach. Authors searched five electronic databases (PubMed/MEDLINE, EMBASE, CINAHL, Scopus, and MAG Online) and assessed the quality of relevant studies using the Critical Appraisal Skills Programme (CASP) appraisal tools.FindingsFourteen studies including women with different levels of obstetric risk were identified. However, only three reported outcomes separately for women categorised as either moderate or high risk. Perinatal outcomes reported included mode of birth, intervention rates, blood loss, perineal trauma, preterm birth, admission to special care and breastfeeding rates. Findings were synthesised into three themes: ‘Contributing to safe processes and outcomes’, ‘Building relational trust’, and ‘Collaborating and communicating’. This review demonstrated that women with complexities in midwifery continuity of care models had positive experiences and outcomes, consistent with findings about low risk women.DiscussionThe nascency of the research on midwifery continuity of care for women with complex pregnancies in Australia is limited, reflecting the relative dearth of these models in practice.ConclusionDespite favourable findings, further research on outcomes for women of all risk is needed to support the expansion of midwifery continuity of care.     

Developing an instrument to measure satisfaction with continuity of midwifery care drawing on the Delphi technique

BackgroundMaternal satisfaction with maternity care is an important indicator of quality maternity services. Continuity of midwifery models of care are increasing in Australia and while several instruments have been developed to measure satisfaction with maternity care most of these have not been validated and there are none that are appropriate to continuity of midwifery maternity care models.AimTo develop a questionnaire to measure women’s satisfaction with maternity services provided in a continuity of midwifery care service model.MethodsA modified Delphi technique was used. A heterogenous panel of eight experts provided feedback over four rounds. The starting point for the questionnaire was informed by two systematic literature reviews focusing on available instruments for measuring maternal satisfaction with maternity care and what women value continuity of midwifery models of care.FindingsThe Continuity of Midwifery Care Satisfaction Survey (COMcareSS) was developed after four rounds of feedback with the expert panel. The survey comprises nine domains and fifty-nine questions. The domains include demographics, maternity care outcomes, facilities, the midwife/woman relationship, building capacity-empowerment, decision making and involvement, personalised care, advice care and support and general.ConclusionsConsumer satisfaction is an important indicator of quality care. This is the first instrument to be developed that is appropriate to continuity of midwifery models of care. The important next step is to pilot test the instrument to establish its validity and reliability.