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.     

Job satisfaction and sustainability of midwives working in caseload models of care: An integrative literature review

BackgroundDemand for caseload midwifery care continues to outstrip supply. We know little about what sustains midwives working in caseload models of care.AimThis review systematically identifies and synthesises research findings reporting on factors which contribute to job satisfaction, and therefore the sustainability of practice, of midwives working in caseload models of care.MethodsA comprehensive search strategy explored the electronic databases CINAHL Plus with Full Text, MEDLINE, PubMED, Cochrane Database of Systematic Reviews, and Scopus. Articles were assessed using the Crowe Critical Appraisal Tool. Data analysis and synthesis of these publications were conducted using a narrative synthesis approach.FindingsTwenty-two articles were reviewed. Factors which contribute to the job satisfaction and sustainability of practice of midwives working in caseload models are: the ability to build relationships with women; flexibility and control over own working arrangements; professional autonomy and identity; and, organisational and practice arrangements.ConclusionInsights into the factors which contribute to the job satisfaction and sustainability of practice of midwives in caseload models of care enables both midwives and healthcare administrators to more effectively implement and support midwifery-led caseload models of care which have been shown to improve outcomes for childbearing women.     

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.     

Making practice transparent through e-portfolio

BackgroundMidwives are required to maintain a professional portfolio as part of their statutory requirements. Some midwives are using open social networking tools and processes to develop an e-portfolio. However, confidentiality of patient and client data and professional reputation have to be taken into consideration when using online public spaces for reflection.QuestionThere is little evidence about how midwives use social networking tools for ongoing learning. It is uncertain how reflecting in an e-portfolio with an audience impacts on learning outcomes. This paper investigates ways in which reflective midwifery practice be carried out using e-portfolio in open, social networking platforms using collaborative processes.MethodsUsing an auto-ethnographic approach I explored my e-portfolio and selected posts that had attracted six or more comments. I used thematic analysis to identify themes within the textual conversations in the posts and responses posted by readers.FindingsThe analysis identified that my collaborative e-portfolio had four themes: to provide commentary and discuss issues; to reflect and process learning; to seek advice, brainstorm and process ideas for practice, projects and research, and provide evidence of professional development.ConclusionsE-portfolio using open social networking tools and processes is a viable option for midwives because it facilitates collaborative reflection and shared learning. However, my experience shows that concerns about what people think, and client confidentiality does impact on the nature of open reflection and learning outcomes. I conclude this paper with a framework for managing midwifery statutory obligations using online public spaces and social networking tools.     

Working in caseload midwifery care: The experience of midwives working in a birth centre in North Queensland

BackgroundPregnancy, birth and child rearing are significant life events for women and their families. The demand for services that are family friendly, women focused, safe and accessible is increasing. These demands and rights of women have led to increased government and consumer interest in continuity of care and the establishment in Australia of birth centres, and the introduction of caseload midwifery models of care.AimThe aim of this research project was to uncover how birth centre midwives working within a caseload model care constructed their midwifery role in order to maintain a positive work–life balance.MethodsA Grounded Theory study using semi-structured individual interviews was undertaken with seven midwives who work at a regional hospital birth centre to ascertain their views as to how they construct their midwifery role while working in a caseload model of care.FindingsThe results showed that caseload midwifery care enabled the midwives to practice autonomously within hospital policies and guidelines for birth centre midwifery practice and that they did not feel too restricted in regards to the eligibility of women who could give birth at the centre. Work relationships were found to be a key component in being able to construct their birth centre midwifery role. The midwives valued the flexibility that came with working in supportive partnerships with many feeling this enabled them to achieve a good work–life balance.ConclusionThe research contributes to the current body of knowledge surrounding working in a caseload model of care as it shows how the birth centre midwives construct their midwifery role. It provides information for development and improvement of these models of care to ensure that sustainability and quality of care is provided to women and their families.     

Conflicting contexts: Midwives’ interpretation of childbirth through photo elicitation

IntroductionThis study seeks to explore midwives’ perceptions about childbirth and in particular their beliefs about normality and risk. In the current climate of increasing interventions during labour, it is important to understand the thought processes that impact on midwifery care in order to examine whether these beliefs influence midwifery clinical decision-making.Method12 Midwives who worked in a variety of metropolitan hospitals in Sydney, Australia were interviewed about how they care for women during labour. The study utilised an inductive qualitative design using photo elicitation during the interview process.ResultsSix themes emerged from the data that clearly indicated midwives felt challenged by working in a system dominated by an obstetric model of care that undermined midwifery autonomy in maintaining normal birth. These themes were: desiring normal, scanning the environment, constructing the context, navigating the way, relinquishing desire and reflecting on reality. Most midwives felt they were unable to practice in the manner they were philosophically aligned to, that is, promoting normal birth, as the medical model restricted their practice.DiscussionThe polarised views of childbirth held by midwives and obstetricians do little to enhance normal birth outcomes. Midwives in this study expressed frustration that they were unable to practice midwifery in a way that reflected their belief in normal birth. This, they cite is a result of the oppressive obstetric model prevalent in maternity care facilities in Sydney and the over use of technological interventions during childbirth.     

Development of a tool to measure holistic reflection in midwifery students and midwives

BackgroundHolistic reflection encompasses reflection as a continuum, incorporating critical reflection, reflexivity, critical thinking and a whole-of-person approach. The development of holistic reflection in midwifery students and midwives is rarely measured in a standardised way.AimTo develop and test a tool to measure holistic reflection in midwifery students and midwives, for use in pre-registration and post-graduate education, and research.DesignThe eight-step approach to tool development by DeVellis was followed with psychometric testing of data from a cross-sectional survey.ParticipantsMidwifery students (pre-registration and postgraduate), and midwifery alumni of an Australian university.MethodsDraft items (n = 84) were generated from review of the literature, qualitative research, and a theoretical model. An expert panel (n = 19) reviewed draft items resulting in 39 items. The survey included demographic details, the draft Holistic Reflection Assessment Tool, emotional intelligence subscale, and a social desirability scale. Participants repeated the online survey at two weeks to confirm test-retest reliability.ResultsThe 187 responses were received. Exploratory factor analysis with varimax rotation revealed three factors accounting for 49% of variance. Internal consistency of the tool was high (α = .91) and test-retest reliability at two weeks (α = .93) demonstrated stability. There were low correlations between social desirability (r = .22, p < .001) and emotional intelligence (r = .21, p < .001) with the new holistic reflection scale.ConclusionsThe Holistic Reflection Assessment Tool is the first for midwifery. The tool was reliable, stable, and valid. Further research is warranted for criterion validity.     

Australian midwives and clinical investigation: Exploration of the personal and professional impact

BackgroundThe purpose of regulation of health professionals is public protection. Concerns regarding professional conduct or midwifery care can lead to clinical investigation. Midwifery literature reveals midwives feel ill-equipped and unprepared for clinical investigation and experience stress and abreaction.AimTo explore the lived experience of clinical investigation and identify the personal and professional impact on Australian midwives.MethodSemi-structured interviews of a purposive sample of Australian midwives. Data analysis was informed by a phenomenological conceptual framework derived from Husserl, Heidegger and Merleau-Ponty.FindingsTwelve midwives were interviewed, with seven under current investigation. Discussion involved personal and professional experiences of three or more investigations each, over a period of three to five years. Most investigations were instigated by hospitals with two complaints from women. Seven participants were alleged negligent following adverse neonatal outcomes and five had misconduct allegations. Midwives were employed or in private practice and half provided homebirth services. Themes included being safe, being connected, time and being, perception and well-being.DiscussionThe investigative process involves different health services, state and national bodies using varying powers and processes over protracted time periods. Participants discussed aspects such as disrespect, inequity, powerlessness, silence and ostracization. Midwives who successfully navigated clinical investigation developed resilience through reflection on clinical practice in a culture of safety.ConclusionThe process of regulating midwives, designed to protect the Australian public, may be harming investigated midwives. Understanding the personal and professional impact of clinical investigation needs to underpin midwifery education, clinical practice, inform policy and regulatory reform.     

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.     

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.     

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.