Looking back moving forward: The history of midwifery in Western Australia

ProblemTo date there is has been very little research into midwifery in Western Australia (WA), therefore this paper addresses a significant gap in the literature. The aim of this paper was to gain insight into the history of midwifery in WA.BackgroundSince the beginning of recorded history midwives have assisted women in childbirth. Midwifery is recognised as one of the oldest professions; midwives are mentioned in ancient Hindu texts, featured on Egyptian papyrus and in The Bible. Up until the seventeenth century childbirth was the responsibility of midwives, but the gradual emergence of barber-surgeons, then man-midwives and obstetricians heralded a shift from women-led and community-supported birth to a patriarchal and medical model. Throughout the twentieth century childbirth practices in the Western World have continued to change, leading to a move from midwifery-led care at home to doctor-led care in the hospital.DiscussionThe first non-Indigenous Australian midwives were not formally trained; they came on ships bringing convicts to Australia and are described as ‘accidental’ midwives, as assistance in childbirth came from whoever was available at the time. This period was followed by what was called the ‘Aunt Rubina’ period where older married women helped younger women in childbirth. Throughout the early 1800s untrained or ‘lay’ midwifery care continued alongside the more formally trained midwives who had arrived with the colonists.From the early 20th century, when birth moved into the hospital, midwives in WA have been incorporated into the hierarchy of the professions with obstetrics as the lead profession and midwifery considered a speciality of nursing. The role of the midwife has been subordinated, initially controlled by medicine and then incorporated into the institutions and nursing. The increase in legislative and training requirements for midwives throughout Australia and the move from home to the hospital, gradually led to the decrease in autonomous midwives working within the community, impacting women’s choice of birth attendant and place of birth.ConclusionThe historical suppression of midwifery in Australia has impacted the understanding of the role of the midwife in the contemporary setting. Understanding the development and evolution of the midwifery profession in Australia can help future directions of the profession.     

Collective action for the development of national standards for midwifery education in Australia

This article describes a sequence of events that led to the development of national standards for the accreditation of Australian midwifery education programmes for initial registration. This process occurred within a climate of polarised opinions about the value of the introduction of three-year degree programmes for midwives who are not nurses (known as the BMid in Australia) and concerns about the invisibility of midwifery within nursing regulation, education, policy and nomenclature.Concerted efforts to develop standards to inform the introduction of BMid programmes through a process of collective action are described. This involved arguing successfully for the positioning of midwifery as a separate profession from nursing, with a need for its own discreet regulation.     

A feminist history of Australian midwifery from colonisation until the 1980s

This paper uses a feminist interpretation and secondary sources to describe the history of Australian midwifery from colonisation until the 1980s. There have been too few midwife scholars who have had access to or used primary data collections to describe the role and place of midwives in the colonising community. I draw on a range of biography, medical literature and work by sociologists and economic historians to produce a limited picture of the history of professional midwifery. This helps to explain the position of midwives today and the problematic relationship we often have with medicine.     

A historical narrative of the development of midwifery education in Indonesia

AimTo describe the history of midwifery education, present the current education programmes and explore the ways that have been undertaken to advance the midwifery profession in Indonesia.MethodsHistorical and contemporary government documents were reviewed.FindingsThe history of midwifery education in Indonesia shows a complex picture during and since colonisation with government, education institutes and association proposing different ways in which midwives were to be educated. Advocacy from the midwifery profession in Indonesia meant increasingly it is midwives who are determining how midwifery education is provided. Recent initiatives have resulted in a diploma, advanced diploma, bachelor’s degree, and a master’s degree in midwifery. The work of the midwifery profession advocating for midwifery education culminated in the Midwifery Act 2019. These changes in this Act will ensure that midwifery education meets the needs of women and their families but also lead to competent midwives who have the knowledge and skills to provide midwifery services at all levels of health provision. The history of midwifery in Indonesia illustrates the importance of the ICM pillars of association, regulation, and education.ConclusionThe history of midwifery education in Indonesia shows that for too long midwifery education was decided, determined and even regulated by authorities and disciplines other than midwifery. However, when the midwifery association and regulation inform and regulate midwifery education then there is an opportunity to provide care that will make a difference in outcomes for women and their families. The historical analysis of the story of Indonesia midwifery gives insight into what is required for quality education.     

An Australian history of the subordination of midwifery

This paper analyses the history of the subordination of midwifery to medicine and nursing. With the important exception of Evan Willis’ work on medical dominance and Annette Summers’ work on the takeover of midwifery by nursing, other histories of Australian midwifery have taken a neutral approach to issue of power and control. The aim of analysing this period is to identify the strategies of power that were used to subordinate midwifery. With increased consciousness of how power has operated in the past, midwives and woman of today can be more empowered when seeking to promote normal birth and midwifery models of care.Concepts of ‘power’, ‘the state’ and midwife are defined and discussed. A summary of the decline of midwifery and the rise of obstetrics in Europe and the United Kingdom (UK) gives a background against which to understand the Australian experience. The historical account given here draws to a climax by focussing on the period 1886–1928. It was during this time that medicine forged an alliance with nursing and achieved both legal and disciplinary control of midwifery. Knowing how this was done is important because it helps us to recognise the power strategies that are currently being used by medicine. This is helpful when planning how these strategies might be matched or countered by contemporary woman and midwives when seeking to promote normal birth and midwifery models of care.     

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.     

Pregnant in prison: An integrative literature review

BackgroundPregnant women in prisons are recognised as a marginalised group. However, there is a limited understanding of the women’s unique maternity needs and how correctional institutions and maternity service providers respond to these needs.AimThe aims of the review are threefold.

• 1.Identify pregnant women’s needs during the antenatal, birthing and postnatal periods in prison.
• 2.Examine how the pregnant incarcerated women’s needs are met by the correctional institutions.
• 3.Explore what maternity services are available and how these services are provided.

MethodAn integrative literature review was undertaken. A comprehensive search strategy using seven electronic databases resulted in the retrieval of 363 articles. Of them, 32 peer-reviewed studies met the final selection criteria and were included in this review which utilised the Critical Appraisal Skills Program tools and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart. Thematic analysis identified universal themes.FindingsThree dominant themes emerged related to the experience of pregnant women in prison: (1) risks and vulnerability factors; (2) prison enablers and supports; and (3) prison barriers. Extant research on risks and vulnerability factors is disproportionate to research examining how prisons can enable or obstruct responding to the women’s perinatal needs. Limited research on the midwifery support available to the women in prison is available. Significantly, only two out of 32 reviewed papers include research directly conducted with the pregnant women in prison.ConclusionPregnant women in prisons have complex needs. More research is required to understand how prisons can enhance the pregnancy experience by engaging pregnant women in prisons as research participants.     

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.     

Validation of the Australian Midwifery Standards Assessment Tool (AMSAT): A tool to assess midwifery competence

Background

There is no current validated clinical assessment tool to measure the attainment of midwifery student competence in the midwifery practice setting. The lack of a valid assessment tool has led to a proliferation of tools and inconsistency in assessment of, and feedback on student learning.

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.     

A historical account of the governance of midwifery education in Australia and the evolution of the Continuity of Care Experience

Background

Midwifery programs leading to registration as a midwife in Australia have undergone significant change over the last 20 years. During this time accreditation and governance around midwifery education has been reviewed and refined, moving from state to national jurisdiction. A major change has been the mandated inclusion of Continuity of Care Experiences as a clinical practice-based learning component.

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.     

Optimising the continuity experiences of student midwives: an integrative review

BackgroundIn several countries, midwifery students undertake continuity of care experiences as part of their pre-registration education. This is thought to enable the development of a woman-centred approach, as well as providing students with the skills to work in continuity models. A comprehensive overview of factors that may promote optimal learning within continuity experiences is lacking.AimTo identify barriers and facilitators to optimal learning within continuity experiences, in order to provide a holistic overview of factors that may impact on, modify and determine learning within this educational model.MethodsAn integrative literature review was undertaken using a five-step framework which established the search strategy, screening and eligibility assessment, and data evaluation processes. Quality of included literature was critically appraised and extracted data were analysed thematically.FindingsThree key themes were identified. A central theme was relationships, which are instrumental in learning within continuity experiences. Conflict or coherence represents the different models of care in which the continuity experience is situated, which may conflict with or cohere to the intentions of this educational model. The final theme is setting the standards, which emerged from the lack of evidence and guidance to inform the implementation of student placements within continuity experiences.ConclusionThe learning from continuity experiences must be optimised to prepare students to be confident, competent and enthusiastic to work in continuity models, ultimately at the point of graduation. This will require an evidence-based approach to inform clear guidance around the intent, implementation, documentation and assessment of continuity experiences.     

Implementing midwifery continuity of care models in regional Australia: A constructivist grounded theory study

Problem/backgroundStrong international evidence demonstrates significantly improved outcomes for women and their babies when supported by midwifery continuity of care models. Despite this, widespread implementation has not been achieved, especially in regional settings.AimTo develop a theoretical understanding of the factors that facilitate or inhibit the implementation of midwifery continuity models within regional settings.MethodsA Constructivist Grounded Theory approach was used to collect and analyse data from 34 interviews with regional public hospital key informants.ResultsThree concepts of theory emerged: ‘engaging the gatekeepers’, ‘midwives lacking confidence’ and ‘women rallying together’. The concepts of theory and sub-categories generated a substantive theory: A partnership between midwives and women is required to build confidence and enable the promotion of current evidence; this is essential for engaging key hospital stakeholders to invest in the implementation of midwifery continuity of care models.DiscussionThe findings from this research suggest that midwives and women can significantly influence the implementation of midwifery continuity models within their local maternity services, particularly in regional settings. Midwives’ reluctance to transition is based on a lack of confidence and knowledge of what it is really like to work in midwifery continuity models. Similarly, women require education to increase awareness of continuity of care benefits, and a partnership between women and midwives can be a strong political force to overcome many of the barriers.ConclusionImplementation of midwifery continuity of care needs a coordinated ground up approach in which midwives partner with women and promote widespread dissemination of evidence for this model, directed towards consumers, midwives, and hospital management to increase awareness of the benefits.     

Supporting the midwifery workforce: An evaluation of an undergraduate midwifery student employment model at a large tertiary maternity service in Victoria,Australia

BackgroundIn 2020, in response to major maternity workforce challenges exacerbated by the COVID-19 pandemic, the Victorian Department of Health implemented a number of workforce maximisation strategies, one of which was employment of undergraduate midwifery students called ‘Registered Undergraduate Student Of Midwifery’ (RUSOM).AimTo evaluate the RUSOM model implemented in a tertiary maternity service in Melbourne, Australia.MethodsA cross-sectional online survey was distributed to all RUSOMs and midwives at the study site in August 2021.FindingsTwenty of 26 RUSOMs (77%) and 110 of 338 permanent midwives (33%) responded. Both groups considered the model to be a positive workforce strategy that contributed to work readiness of students, and increased confidence and competence to practise. RUSOMS and midwives reported positives for the organisation including improving workload for midwives on the postnatal ward, enhancing quality of care and outcomes for women and babies, and the value of RUSOMs as team members. RUSOMs felt well supported, supervised and clinically and theoretically prepared. Both groups considered RUSOMs were underutilised, and that they could undertake additional duties, and both thought that the RUSOM model should continue.ConclusionThe model was highly valued by both RUSOMs and midwives. There was strong agreement that the model should continue and that the list of duties could be expanded. Given these findings, further research should explore the expansion and sustainability of RUSOMs in the maternity workforce.     

Addressing the midwifery workforce crisis: evaluating an employment model for undergraduate midwifery students at a tertiary maternity hospital in Melbourne, Australia

Background and aims

In Victoria, maternity services are under significant strain due to increased numbers of women giving birth and critical workforce shortages. Hospitals have experienced challenges in adequately staffing maternity units, particularly on postnatal wards. In 2008, a tertiary maternity hospital in Melbourne introduced a model where undergraduate midwifery students were employed as Division 2 nurses (SMW_Div2) (enrolled nurses), to work in the postnatal area only. This study explored the pilot employment model from the perspective of the SMW_Div2 and hospital midwives.

Methods

A web-based survey was administered to hospital midwives and the SMW_Div2s in the employment model in January 2010. The survey explored the views of midwives and SMW_Div2s regarding the perceived impact of the model on workforce readiness, recruitment and retention, and clinical competence and confidence.

Findings

Forty-seven of 158 midwives (30%) and five of nine SMW_Div2s employed in the model responded to the survey. Both groups considered the model to have benefits for the organisation, including increased: student workforce readiness; clinical confidence and competence; and organisational loyalty. Both groups also considered that the model would facilitate: workforce recruitment; a teaching and learning culture within the organisation; and enhanced partnerships between students, hospitals and universities. Caution was expressed regarding workload and the need for ongoing support for SMW_Div2s working in the model.

Discussion and conclusion

SMW_Div2s and midwives were positive about the introduction of the paid employment model at the Women's. The findings are consistent with evaluations of similar programs in the nursing setting. The employment model has potential short and long term individual and organisational advantages, which is important in the context of increasing births and workforce shortages. Progression of such models will be contingent on the collaboration and cooperation of the various stakeholders involved in maternity workforce and education.     

Responding to catastrophe: A case study of learning from perinatal death in midwifery practice

Problem/BackgroundPerinatal death has far reaching emotional effects for all involved in this devastating event. The opportunity for learning as a result of this catastrophe, however, remains unexplored.AimTo explore midwives’ experiences of caring through, and learning from, perinatal death, to better inform the effective planning and delivery of education that optimises both midwifery and self-care.MethodsA naturalistic interpretive multiple case study design. Seventeen midwives, located in Australia, participated in an online group activity hosted as a blog, followed by telephonic focus groups and in-depth email interviews.FindingsThematic data analysis revealed seven major themes: Grappling with the reality of perinatal death; Struggling with personal and professional heartache; Seeking the space to grieve as a professional; Being with the woman and her family; Finding a new purpose; Strengthened through support; and Developing the courage to care.DiscussionThe initial turmoil and impact of loss reflected the catastrophic nature of perinatal death. Midwives uncovered a journey to acceptance and learning, realising a determination to enhance expertise and discovering value in experiential knowledge. Insecurity regarding competence and confidence to manage perinatal death and bereavement care was highlighted. However, sharing their stories revealed professional fulfilment, personal strength, and solidarity amongst midwives who have endured similar experiences.ConclusionA coordinated approach to support and the dissemination of experiential knowledge and learning could be developed within an online model of narrative sharing and discussion. Debriefing, support and sharing of expertise in this way may foster engagement within and beyond the workplace.