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.     

‘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.     

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.     

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.     

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.     

Embracing the continuity of care experience: A new Australian graduate entry master of midwifery course with a student caseload of 15 women per year

BackgroundWomen receiving continuity of midwifery care have increased satisfaction and improved outcomes. Preparation of midwifery students to work in continuity models from the point of graduation may provide an ongoing midwifery workforce that meets rising demand from women for access to such care.Aim of the paperThe aim of this paper is to describe an innovative midwifery course based on a continuity model, where students acquire more than 50 % of clinical hours through continuity of care experiences. Additional educational strategies incorporated in the course to enhance the CCE experience within the philosophy of midwifery care, include a virtual maternity centre, case-based learning and the Resources Activities Support Evaluation (RASE) pedagogical model of learning.DiscussionAustralian accredited midwifery courses vary in structure, format and philosophy; this new course provides students with an alternative option of study for those who have a particular interest in continuity of midwifery care.ConclusionA midwifery course which provides the majority of clinical hours through continuity of care may prepare graduates for employment within midwifery group practice models by demonstrating the benefits of relationship building, improved outcomes and the reality of an on-call lifestyle.     

Midwife experiences of providing continuity of carer: A qualitative systematic review

ProblemContinuity of carer models present positives and challenges for midwives working in them, and are difficult to sustain.BackgroundResearch shows midwifery continuity of carer improves perinatal outcomes and experiences, and is considered the optimal model of care.AimTo synthesise existing research on midwives’ experiences of providing continuity of carer and generate further understanding of what sustains them in practice.MethodsProtocol for the review was developed using PRISMA guidelines and registered with PROSPERO. 22 studies were included with original themes and findings extracted using JBI tools and synthesised using meta-ethnographic techniques. GRADE CERQual assessment of review findings showed high confidence.FindingsMidwives identified working in continuity of carer models as both fulfilling and challenging. Professional autonomy and ability to develop meaningful relationships were the most commonly cited positives, while lack of work life balance and conflict with the wider maternity team were the main challenges. 15 studies identified strategies employed by midwives which sustained them in practice.DiscussionMidwife experiences of providing continuity are impacted by personal and professional factors. Of paramount importance to sustainability of the model is the support of the wider organisation, and their alignment with principles of person-centred, relational care.ConclusionRelational models of care are desired by midwives, service users and are recommended in policy. Relational models of care must be responsive to midwives needs as well as birthing people, and therefore need to be designed and managed by those working in them and supported by the whole organisation to be sustainable.     

Enabling new graduate midwives to work in midwifery continuity of care models: A conceptual model for implementation

Background

High-level evidence demonstrates midwifery continuity of care is beneficial for women and babies. Women have limited access to midwifery continuity of care models in Australia. One of the factors limiting women’s access is recruiting enough midwives to work in continuity. Our research found that newly graduated midwives felt well prepared to work in midwifery led continuity of care models, were well supported to work in the models and the main driver to employing them was a need to staff the models. However limited opportunities exist for new graduate midwives to work in midwifery continuity of care.

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.     

A comparison of midwife-led care versus obstetrician-led care for low-risk women in Japan

BackgroundContinuity of midwife-led care is recommended in maternity care because of its various positive outcomes. In Japan, midwife-led care is receiving broad attention as well. In order to popularise midwifery care within the entire system of perinatal care in Japan, there is a need to show evidence that continuity of midwife care for women will bring about positive outcomes.AimThe objectives of this study were to compare the health outcomes of women and infants who received midwife-led care with obstetrician-led care in Japan.MethodsThis was an observational study using non-random purposive sampling with a survey questionnaire. Settings where midwife-led care and obstetrician-led care were chosen by purposive samples. Participants were low-risk women who received antenatal care and delivered a term-singleton-infant at the participating settings during the research period. Measurements were: Women-centred care pregnancy questionnaire, Stein's maternity blues questionnaire, and Edinburgh Postnatal Depression Scale.FindingsMidwife-led care was perceived by women to be beneficial and had no adverse outcomes compared to obstetrician-led care. Main findings are: (1) Perception of Women-centred care was higher; (2) Less premature rupture of membranes, and the Apgar scores of the infants were similar; (3) Exclusively breast-feeding during hospitalisation and at one-month postpartum; (4) Stein's maternity blues scale scores was lower in women who received midwife-led care than those who received obstetrician-led care.ConclusionsContinuity of midwife-led care was perceived by women to be beneficial and had no adverse outcomes. Therefore, midwife-led care in low-risk pregnancy could be applicable and recommended.     

Exploring the qualities of midwifery-led continuity of care in Australia (MiLCCA) using the quality maternal and newborn care framework

ProblemMidwifery-led continuity of care has well documented evidence of benefits for mothers and babies, however uptake of these models by Australian maternity services has been slow.BackgroundIt is estimated that only 10% of women have access to midwifery-led continuity of care in Australia. The Quality Maternal Newborn Care (QMNC) Framework has been developed as a way to implement and upscale health systems that meet the needs of childbearing women and their infants. The Framework can be used to explore the qualities of existing maternity services.AimWe aimed to use the QMNC Framework to explore the qualities of midwifery-led continuity of care in two distinct settings in Australia with recommendations for replication of the model in similar settings.MethodsData were collected from services users and service providers via focus groups. Thematic analysis was used to develop initial findings that were then mapped back to the QMNC Framework.FindingsGood quality care was facilitated by Fostering connection, Providing flexibility for women and midwives and Having a sense of choice and control. Barriers to the provision of quality care were: Contested care and Needing more preparation for unexpected outcomes.DiscussionMidwifery-led continuity of carer models shift the power dynamic from a hierarchical one, to one of equality between women and midwives facilitating informed decision making. There are ongoing issues with collaboration between general practice, obstetrics and midwifery. Organisations have a responsibility to address the challenges of contested care and to prepare women for all possible outcomes to ensure women experience the best quality care as described in the framework.ConclusionThe QMNC Framework is a useful tool for exploring the facilitators and barriers to the widespread provision of midwifery-led continuity of care.     

Women’s reports of satisfaction and respect with continuity of care experiences by students: Findings from a routine,online survey

BackgroundPre-registration midwifery students in Australia undertake a minimum of ten continuity of care experiences with childbearing women. However, women are rarely asked to formally evaluate this care by students.AimTo evaluate data from a routine, web-based survey of women about having a midwifery student provide a continuity of care experience.MethodsAll women (n = 886) recruited by a midwifery student for a continuity of care experience during a 12 month period received an email inviting them to complete an online survey. The survey included personal details, experiences of care, and two scales on Respect and Satisfaction.ResultsA response rate of 57% (n = 501) was achieved. On average students attended six antenatal visits (mean = 5.83) and had six postnatal contacts with women. Most students attended labour and birth (92.6% n = 464). Most women rated overall satisfaction with care by their student as ‘better than they had hoped’. Positive correlations were found between number of antenatal visits and postnatal contact with students on both levels of satisfaction and respect felt by women. Women felt more satisfied when their midwifery student attended labour and birth.ConclusionsThe online survey was feasible and provided valid and reliable feedback from women about their student during a continuity of care experience. Women valued having an ongoing relationship with a student during pregnancy, labour and birth, and postpartum. Pre-registration midwifery education programs should continue to privilege relationship-based care and national standards should support the effective integration of continuity of care experiences.     

Where do low risk women live relative to maternity services across Victoria? Expanding access to public homebirth models across Victoria

ProblemCurrently <1% of Australian women give birth at home.BackgroundIn Australia there are very few options for women to access public funded homebirth.AimWe aimed to use geo-mapping to identify the number of women eligible for homebirth in Victoria, based on the criteria of uncomplicated pregnancies and residing within 15–25 kms of suitable maternity services, to plan future maternity care options.MethodsRetrospective study of births between 2015 and 2017 in Victoria, Australia. All women who were identified as having a low risk pregnancy at the beginning of pregnancy were included. The number of women within 15 and 25 km of a suitable Victorian public maternity hospital and catchment boundaries around each hospital were determined.FindingsBetween 2015 and 2017, 126,830 low risk women gave birth in Victoria, of whom half live within 25 km of seven Victorian hospitals. Currently, 2% of suitable women who live close to the current public homebirth models accessed them.DiscussionWe present a method to inform the expansion of maternity service options using Victoria as an example. On the basis of the maximum number of low risk women living close by, we have also identified the Victorian maternity services that would be most suitable for creation of public homebirth or low risk continuity of midwifery models.ConclusionThis approach could can be used to plan other maternity care services.