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.     

How a perineal care bundle impacts midwifery practice in Australian maternity hospitals: A critical,reflexive thematic analysis

BackgroundA care bundle to reduce severe perineal trauma (the bundle) was introduced in 28 Australian maternity hospitals in 2018. The bundle includes five components of which only one – warm perineal compresses – has highest level evidence. There is scant published research about the impact of implementation of perineal bundles.QuestionHow does a perineal care bundle impact midwifery practice in Australian maternity hospitals?MethodsPurposively sampled midwives who worked in hospitals where the bundle had been implemented. Interested midwives were recruited to participate in one-to-one, semi-structured interviews. The researchers conducted critical, reflexive thematic analysis informed by Foucauldian concepts of power.FindingsWe interviewed 12 midwives from five hospitals in one state of Australia. Participants varied by age, clinical role, experience, and education. Three themes were generated: 1) bundle design and implementation 2) changing midwifery practice: obedience, subversion, and compliance; and 3) obstetric dominance and midwifery submission.DiscussionThe bundle exemplifies tensions between obstetric and midwifery constructs of safety in normal birth. Participants’ responses appear consistent with oppressed group behaviour previously reported in nurses and midwives. Women expect midwives to facilitate maternal autonomy yet decision-making in maternity care is commonly geared towards obtaining consent. In our study midwives encouraged women to consent or decline depending on their personal preferences.ConclusionThe introduction of the perineal bundle acts as an exemplar of obstetric dominance in Australian maternity care. We recommend midwives advocate autonomy – women’s and their own – by using clinical judgement, evidence, and woman-centred care.     

The feasibility of caseload midwifery in rural Australia: A literature review

BackgroundCaseload midwifery is a continuity of care(r) model being implemented in an increasing number of Australian maternity settings. Question for review: is caseload midwifery a feasible model for introducing into the rural Australian context?MethodIntegrative literature review.FindingsFour main categories were identified and these include the evidence for caseload midwifery; applicability to the rural context; experiences of registered and student midwives and implementation of caseload midwifery models.ConclusionThere is evidence to support caseload midwifery and its implementation in the rural setting. However, literature to date is limited by small participant size and possible selection bias. Further research, including rural midwives’ expectations and experience of caseload midwifery may lead to improved sustainability of midwifery care for rural Australian women.     

The future in their hands: Graduating student midwives’ plans,job satisfaction and the desire to work in midwifery continuity of care

BackgroundMidwife-led continuity of care models benefit women and the midwives who work in them. Australian graduate midwives are familiar with, and educated to provide, continuity of care to women although the opportunity to work exclusively in positions providing continuity of care on graduation is uncommon.AimTo explore the immediate and aspirational employment plans and workforce choices, reasons for staying in midwifery and perceptions around factors likely to influence job satisfaction of midwives about to graduate from one Australian university during the years 2012–2016.MethodsThis longitudinal study draws on survey responses from five cohorts of midwifery students in their final year of study.FindingsNinety five out of 137 midwifery students responded to the survey. Almost nine out of ten respondents either aspired to work in a continuity of care model or recognised that they would gain job satisfaction by providing continuity of care to women. Factors leading to job satisfaction identified included making a difference to the women for whom they care, working in models of care which enabled them to provide women with ‘the care I want to give’, and having the ability to make autonomous midwifery decisions.ConclusionAligning early graduate work experiences with continuity of care models may have a positive impact on the confidence and professional development of graduate midwives, which in turn may lead to greater satisfaction and retention among a workforce already committed to supporting the maternity healthcare reform agenda.     

Midwives’ experiences of providing maternity care to women and families during the COVID-19 pandemic in Northern Italy

ProblemThe COVID-19 pandemic has significantly challenged maternity provision internationally. Rapid and radical changes were implemented, with midwives facing anxiety and moral distress if not able to provide optimal and woman-centred care in line with professional values.BackgroundHealthcare professionals’ stress and burnout are commonly reported during other global emergencies, which may eventually contribute to reduced quality of care. There is lack of evidence of the challenges faced by midwives in Italy during the COVID-19 pandemic.AimTo explore midwives’ experiences of providing care to women and families during the COVID-19 pandemic.MethodsQualitative interpretive phenomenological approach, using semi-structured interviews and thematic analysis. The sample included 15 midwives. Ethical approval was obtained.FindingsFour themes were identified: 1) adjusting to the ever-evolving organisation of care; 2) physical, psychological and relational challenges; 3) support network; 4) deferred sense of awareness.DiscussionMidwives faced professional and personal challenges during the pandemic, displaying feelings of fear, anxiety, uncertainty, discomfort, lack of support and knowledge with potential long-term effects. Adjusting to the continuous, rapid and drastic re-organisation of maternity services was particularly challenging. Factors facilitating a safe, supportive and empowering workplace included support from colleagues and managers, access to appropriate PPE, reliable guidelines, good communication and emotional support. Positive aspects of personal and professional development included communication skills, establishment of trusting relationships, sense of empowerment and teamwork.ConclusionIn the context of a pandemic, optimisation of midwives’ physical, emotional and psychological wellbeing should be considered. Timely and comprehensive guidelines and appropriate resources should be provided to assist midwives in facilitating family-centred respectful maternity care and preserving childbirth as a bio-psychosocial event.     

The future of the Australian midwifery workforce – impacts of ageing and workforce exit on the number of registered midwives

ProblemEnsuring an adequate supply of the midwife workforce will be essential to meet the future demands for maternity care within Australia.BackgroundAim: To project the overall number of midwives registered with the Nursing and Midwifery Board of Australia and the timing of their retirement to 2043 based upon the ageing of the population.Methods: Using data on the number of registered midwives released by the Nursing and Midwifery Board of Australia we calculated the five-year cumulative attrition rate of each five-year age group. This attrition rate was then utilized to estimate the number of midwives registered in each five-year time period from 2018 to 2043. We then estimated the number of midwives that would be registered after also accounting for stated retirement intentions.FindingsBetween 2018 and 2023 the overall number of registered midwives will decline from 28,087 to 26,642. After this time there is expected to be growth in the total number, reaching 28,392 in 2028 and 55,747 in 2043. If midwives did relinquish their registration at a rate indicated in previous workforce satisfaction surveys, the overall number of registered midwives would decline to 19,422 in 2023, and remain below 2018 levels until 2038.DiscussionDue to the age distribution of the current registered midwifery workforce the imminent retirement of a large proportion of the workforce will see a decline in the number of registered midwives in the coming years. Additional retirement due to workforce dis-satisfaction may exacerbate this shortfall.     

Midwives’ experiences of using the Mindfetalness method when talking with pregnant women about fetal movements

BackgroundInformation given to pregnant women about fetal movements is important in maternity care and decreased fetal movements is associated with fetal growth restriction and stillbirth. The fetal movement pattern is different for every fetus and women perceive different types of movements. Mindfetalness is a self-assessment method for a woman to use to become familiar with her unborn baby’s fetal movement pattern.AimWe aimed to explore midwives’ perceptions about informing pregnant women about fetal movements and their experiences of working with Mindfetalness in their daily work.MethodsA web-questionnaire was distributed to midwives who participated in a randomized controlled trial evaluating Mindfetalness, a method for the observation of fetal movements. In total, 67 maternity clinics in Stockholm, Sweden, were randomized to Mindfetalness or routine care. Of the 144 midwives working in maternity clinics randomized to Mindfetalness, 80% answered the questionnaire.FindingsThe midwives thought that the leaflet about Mindfetalness was supportive in their work when informing women about fetal movements and the majority wanted to continue to distribute the leaflet when the trial ended. The midwives also expressed that the study increased their own knowledge about fetal movements. Women embraced the information about Mindfetalness positively and appreciated the written material. The midwives thought that talking about fetal movements in maternity care is an important but challenging task.ConclusionMindfetalness is a useful tool to use in maternity clinics when informing pregnant women about fetal movements. The written information was appreciated by both pregnant women and midwives.     

Factors associated with midwives’ job satisfaction and experience of work: a cross-sectional survey of midwives in a tertiary maternity hospital in Melbourne,Australia

BackgroundSignificant factors affecting the Australian maternity care context include an ageing, predominantly part-time midwifery workforce, increasingly medicalised maternity care, and women with more complex health/social needs. This results in challenges for the maternity care system. There is a lack of understanding of midwives’ experiences and job satisfaction in this context.AimTo explore factors affecting Australian midwives’ job satisfaction and experience of work.MethodsIn 2017 an online cross-sectional questionnaire was used to survey midwives employed in a tertiary hospital. Data collected included characteristics, work roles, hours, midwives’ views and experiences of their job. The Midwifery Process Questionnaire was used to measure midwives’ satisfaction in four domains: Professional Satisfaction, Professional Support, Client Interaction and Professional Development. Data were analysed as a whole, then univariate and multivariate logistic regression analyses conducted to explore any associations between each domain, participant characteristics and other relevant factors.FindingsThe overall survey response rate was 73% (302/411), with 96% (255/266) of permanently employed midwives responding. About half (53%) had a negative attitude about their Professional Support and Client Interaction (49%), and 21% felt negatively about Professional Development. The majority felt positively regarding Professional Satisfaction (85%). The main factors that impacted midwives’ satisfaction was inadequate acknowledgment from the organisation and needing more support to fulfil their current role.ConclusionFocus on leadership and mentorship around appropriate acknowledgement and support may impact positively on midwives’ satisfaction and experiences of work. A larger study could explore how widespread these findings are in the Australian maternity care setting.     

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.     

Intentions to leave and actual turnover of community midwives in the Netherlands: A mixed method study exploring the reasons why

BackgroundIn the Netherlands, the turnover of midwives of relatively young age is high. This is concerning since a lack of midwifery experience can negatively affect the quality of maternity care.AimTo study the rate and the reasons for intending to leave, and to explore the reasons for leaving midwifery jobs in the Netherlands.MethodsWe used a mixed-methods design including a quantitative survey (N = 726) followed by qualitative interviews (N = 17) with community midwives.FindingsAlmost one third of the respondents considered leaving the profession. The decision to actually leave the job was the result of a process in which midwives first tried to adapt to their working conditions, followed by feelings of frustration and finally feelings of decreased engagement with the work. The reasons for leaving midwifery practice are an accumulation of job demands, lack of social resources and family responsibilities.DiscussionCompared to international figures, we found a lower rate of midwives who considered leaving the profession. This could be explained by the differences in the organisation of midwifery care and the relatively high job autonomy of midwives in the Netherlands. Nevertheless, changes must be made in terms of decreasing the demands of the job and creating more job resources.ConclusionInnovations in the organisational structure that focus on continuity of care for pregnant individuals, job satisfaction for midwives and building a sustainable workforce may result in an increase in the retention of midwives. These innovations would ensure that women and their babies receive the best care possible.     

Health professionals’ perceptions of a midwifery model of woman-centred care implemented on a hospital labour ward

BackgroundTheoretical models as a basis for midwives’ care have been developed over recent decades. Although there are similarities between these models, their usefulness in practice needs to be researched in specific cultural contexts.AimTo explore whether, when adopted by midwives on labour wards, a midwifery model of woman-centred care (MiMo) was useful in practice from the viewpoint of a variety of health professionals.MethodsData were collected from a variety of health professionals before and after an intervention of implementating MiMo at a hospital-based labour ward in Sweden, using nine focus group interviews with a total of 43 participants: midwives (n = 16), obstetricians (n = 8), assistant nurses (n = 11) and managers (n = 8). The text from interviews was analysed using content analysis.FindingsFrom expressing no explicit need of a midwifery model of woman-centred care before the intervention, there was a shift in midwives, obstetricians and managers perceptions towards identifying advantages of using the MiMo as it gives words to woman-centred midwifery care. Such shift in perception was not found among the assistant nurses.DiscussionClarification of the various roles of health professionals is needed to develop the model. Heavy workloads and stress were barriers to implementing the model. Thus, more support is needed from organisational management.ConclusionsThe model was useful for all professional groups, except for assistant nurses. Further studies are needed in order to clarify the various professional roles and interdisciplinary collaborations in making the MiMo more useful in daily maternity care.     

Midwives’ views of caseload midwifery – comparing the caseload and non-caseload midwives’ opinions. A cross-sectional survey of Australian midwives.

BackgroundMidwife-led continuity of care has substantial benefits for women and infants and positive outcomes for midwives, yet access to these models remains limited. Caseload midwifery is associated with professional satisfaction and lower burnout, but also impacts on work-life boundaries. Few studies have explored caseload midwifery from the perspective of midwives working in caseload models compared to those in standard care models, understanding this is critical to sustainability and upscaling.AimTo compare views of caseload midwifery – those working in caseload models and those in standard care models in hospitals with and without caseload.MethodsA national cross-sectional survey of midwives working in Australian public hospitals providing birthing services.FindingsResponses were received from 542/3850 (14%) midwives from 111 hospitals – 20% worked in caseload, 39% worked in hospitals with caseload but did not work in the model, and 41% worked in hospitals without caseload. Regardless of exposure, midwives expressed support for caseload models, and for increased access to all women regardless of risk. Fifty percent of midwives not working in caseload expressed willingness to work in the model in the future. Flexibility, autonomy and building relationships were positive influencing factors, with on-call work the most common reason midwives did not want to work in caseload.ConclusionsThere was widespread support for and willingness to work in caseload. The findings suggest that the workforce could support increasing access to caseload models at existing and new caseload sites. Exposure to the model provides insight into understanding how the model works, which can positively or negatively influence midwives’ views.