Implementing Midwife Led Models of Maternity Care in the North Coast Area Health Service: Recognizing The Challenges

Elizabeth McCall RN, RM, BHSc (Nursing), MHSc, IBCLC.

It is well documented that midwives are the appropriate health practitioners to provide maternity services for low risk women. The NSW Health Department (26/8/05) acknowledges this and is encouraging NSW Health Services to progress the implementation of midwife led models of maternity care. Additionally, recent Australian research asserts that small local birthing services of < 100 births per year are the safest place for low risk women to give birth and have post natal care (Tracy 2005). Therefore, it is imperative that all maternity care providers understand the education and skills of midwives and the midwife led maternity care models currently being implemented in other parts of Australia, so that both issues are demystified and these models of care are able to be implemented effectively in the North Coast Area Health Service (NCAHS).

Setting the Scene

The north coast of New South Wales (NSW) has developed a reputation for cultural diversity over the last 20 to 30 years. During the 1960s once predominantly farming and fishing communities changed slowly as the region acquired new populations of residents. The changing population created a subtle stratification of society overlaying the more conservative rural communities to the extent that today, the region is renowned for its diversities in society, and concomitantly in education and health care. This diversity has not been transformed the maternity services to reflect contemporary recommendations and evidence. In my experience, these services remain stagnant and do not meet the needs of women and their families.

Many government & professional reports since 1989 have asserted that change is required in the way maternity services are delivered in Australia  (ACMI 1989; NSW Health Department 1989; NHMRC 1996; NSW Health Department 1996; NHMRC 1998; ASRC 1999) and agree that a midwife is educated to provide supervision, care and advice to women during pregnancy, labour and the post partum period, to conduct deliveries on her own responsibility and to care for the newborn and infant. These reports all advocated that maternity care be shared between midwives and medical practitioners and that free standing birth centres and midwife led models of maternity care be increased. Additionally, they suggest that within the setting of public maternity services, increasing the responsibility of midwives … 'should contribute to the productivity of medical practitioners enabling them to devote more time to complicated cases and emergencies. It should also improve the overall continuity of car for women with uncomplicated pregnancies' (NHMRC 1998, p.34).

The long awaited Maternity Services Framework (New South Wales Health Department 2000, pp.1-2) reiterated the preceding recommendations, highlighting the need for availability and accessibility of services, particularly for rural and remote communities, improving the level and flexibility of available resources and responding to consumer expectations. These recommendations were then incorporated into the Northern Rivers Area Health Service (NRAHS) Maternity Services Plan (NRAHS 2001) following a review of maternity services on the far north coast (NRAHS 2000).

The Current Situation

To date there are no midwife led models of maternity care further north than Newcastle. The president of the New South Wales Midwives Association (NSWMA), Pat Brodie, maintains that the system (of maternity care) is broken (Brodie 2005 p.5). So, the question is, how do we move forward? The NSW Health Department (2003; 2005), NSWMA (2005), Council of Remote Area Nurses of Australia (CRANA) (2004 pp.24-26) and the Maternity Coalition (2002) have all given total support for expediting change. The Royal Australian & New Zealand College of Obstetricians & Gynaecologists (RANZCOG) has provided tacit acknowledgement of these new initiatives (RANZCOG 23/7/05). 

Given such support, what forces are preventing us developing appropriate models of maternity care in the NCAHS? There are several factors worthy of consideration that I have identified during a SWOT analysis, that may hinder implementation of midwife led models of maternity care.

The funding dichotomy

Budgetary constraints on the public health care system play a significant part in constraining women centred maternity care. The government recommendations discussed previously cannot be progressed within a milieu of economic rationalism. The fragmentation of funding Australian health care inadvertently supports medical control of maternity care (Barrett 1998, p.90; Australian Senate References Committee 1999). Implementation of the midwife led models of care endorsed by the NSW Health Department (2000) and the NRAHS (2000) will require recurrent funding. In an age of economic rationalism it could be speculated that maternity care provided by medical practitioners is a cost- effective option and may be supported by health facilities influenced more by financial constraints than best practice. Issues surrounding the anomalies of recurrent funding could also encroach on the provision of women centred maternity care (Smith 1998, pp.8-9; Rogers-Clark 1998, p.9) as annual, rather than recurrent funding, leads to service vulnerability (Broom 1991, p.107; Rogers-Clark 1998, p.13; Barrett 1998, p.90) where long term goals cannot be set or attained. Any midwife led model of care without recurrent funding could then be ceased as a financial expediency, if the need arose.

These models of care are not available unrestrictedly in the NCAHS, leading to issues of equity and access. There is no choice for women in the NCAHS and this inequitable situation prevails throughout most of rural NSW (Hastie 2000, p.28; Carnell et al 2001, p.27). Any woman desiring anything other than the medical paradigm of maternity care finds it necessary to contract with a midwife and/or medical practitioner to facilitate a home birth. Inequities arise here, as midwives do not have access to Medicare provider numbers and no payment may be claimed from the government or most private health insurance companies (Rogers-Clark 1998, p.76).

Therefore, to achieve the recent NSW Health Department recommendations (NSW DOH 2003; 2005) the NCAHS will need to affirm its commitment to the philosophy of women centred care, by ensuring adequate recurrent funding. Commonwealth Government policy also needs to be discerning and encompass vision as 'vision is about what we might become' (Mackay 2001, p.16). Extrapolation to the micro policies of the NCAHS maternity services could mean that this may be an opportunity to guarantee that the service ensures a better society and does not just cater for the needs of service providers or budgets.

The media – is it for or against?

It is also important to acknowledge the power of the media and to understand that the media is as influenced by powerful lobby groups as politicians. Lobby groups, who have power and the financial resources to influence policy formation, sway policy makers (Tew 1995, p.18; Declerq 2000, p.350; Sandall 2000, p.354). Indeed, according to Clara Zawawi's doctoral research on print media (Cadzow 2001, pp.20-21, 24), public relations people employed by lobby groups and businesses are 'the source of 60 per cent of stories in the front news sections and 80 per cent in the business news sections'.

The media supports invariably the dominant ideology of maternity care (Tew 1995, p.18). It is arguable that this support has arisen from the fact that the dominant ideology has been accepted as the societal norm (Fairclough 1985, p.754; Suter 2002). The recent media debates regarding the establishment of midwife led maternity services in Sydney and Newcastle in the Sydney Morning Herald (3/9/ 2005, p.8,   22/9/2005, p.11) support certainly this contention, despite some optimistic reports that this is beginning to change (Dahlen 2005, p.25). It could be argued that popular media coverage increases the angst of vulnerable pregnant and birthing women, who have been led to believe that the only acceptable (safe) maternity care is that provided by a medical practitioner (Osfield 2000, pp.65-70; Page 2001, p.1).

Therefore, it is important to develop relationships with key media links, to promote the advantages of women centred models of care. Midwives need to inform consumers of their education and ability to practice 'on their own responsibility' i.e. autonomously (ACMI 1989; Burrows 2000, p.373). With collegial support and the mutual recognition of skills and expertise, midwives and medical practitioners could change the face of maternity care in the NRAHS. To achieve change, all stakeholders will need to form a coalition that has the clout to influence policy (Declerq 2000, p.348).

The Interface Between Evidence-based Practice, Clinical Governance and Ethics

There is a continued aversion to providing maternity care in a way supported by sound research (Barclay 1996, p.130). Much of maternity care continues to be guided by individual opinion, life experiences and time constraints, rather than best practice (Dahlen 1999, p.15; West & Topping 2000, p.36-40). The National Health and Medical Research Council (1999, pp.13-20) is adamant that practice can no longer be guided by expert opinion. Their belief is that practice needs to be based on the highest level of evidence, where possible.  Midwife researchers believe that the key to providing the best possible care to women and their families is to transform evidence into practice (Shorten & Wallace 1996; Shorten & Wallace 1997; McKay 1998; Homer 1998; Page 1998). 

Evidence based practice is demanding intellectually and sometimes uncomfortable. It requires the highest art of practice; balancing and interpreting a number of sources of information, communicating and counseling, and working with the woman and her family to decide what is best for them. It is not enough to theorise intellectually – the essence of midwifery is to transform theory into practice, grounded by research, and truly 'get inside the skin' of what women want (Page 1998). 

The juxtaposition between evidence-based practice and clinical governance cannot be underestimated. Clinical governance has been defined as 'a framework through which health organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence of clinical care will flourish'  ( Robinson 2001). Further, clinical governance encompasses the routine application of evidence-based practice and would ensure that health professionals providing maternity care practice, with due regard for contemporary professional competencies (Royal College of Midwives 1998). Clinical governance goes beyond the outmoded concepts of quality assurance, as it ensures and values the participation of clinicians (Johnston 2001). Therefore, clinical governance could prove to be a strategy that will ensure that all maternity care providers develop ways to work together collegially, valuing each other's complementary skills.

If clinical governance is accepted as a methodology to ensure best practice, it follows surely that that practice will be evidence based. Therefore, extrapolating from this assumption, if the NCAHS accepts clinical governance as the heart of its core business, then the goals of women centred maternity care will be progressed smoothly, as those goals are based on the best available evidence.

The third string to this challenging bow is the ethical considerations involved in the provision of maternity care. 'Truth telling and honesty are two principal ethical values in maternity care' (Flint 1995, p.85) and may be compromised by pressures internal and/or external to the organisation. What ethical stance is employed when maternity care is driven by socio/cultural, political, historical and economic determinants? Where does best practice fit when maternity care providers bases their care on hidebound tradition or acquiesces for fear of reprisals?

All stakeholders in maternity care need to provide that care with a philosophy of cooperation between professions (Hart et al 1995, p.400). There is an obligation in maternity services to be open to other ways of knowing, acknowledging concomitantly the blurred roles and individual areas of expertise (Carnevali & Durand 1993, 144). All practitioners need to stay open possibilities for growth and change and recognise that their practice is a dynamic entity

The Burnout Debate

Issues of stress and potential burnout have been discussed briefly in the previous sections defining models of care. Within the literature, there is quite diverse opinion on the causative factors contributing to burnout. On the one hand, it has been asserted that caseload practice produces a restrictive, demanding lifestyle incompatible with most midwives' lives (Fenwick et al 1998, p.432; Banks 2001, p.6). Other authors support caseload practice as a viable, workable option (Leap 1997). Certainly, the research has indicated that caseload practice could be more sustainable in terms of burnout reduction than team models, because of increased occupational autonomy, social support and the ability to develop meaningful relationships with women (Bakker et al 1996;  Sandall 1997). It would seem that control and continuity of care are just as important for midwives in their professional lives as to pregnant and birthing women.

Analysis of Bakker et al's (1996) data indicated that it is not necessarily the model of care that leads to burnout. Rather, it is the inextricable mix of factors from within the individual's personal life and longer working hours than those midwives working within health facility birthing units. The longer hours are an integral part of continuity of care models and these may be unsustainable for those midwives, who have other life responsibilities and commitments, even though the hours may be evened out as accrued extra leave entitlement. It may well be a case of immediate versus accrued time off (Sandall 1998, pp.213-232).

At the end of the day, it is obvious that any model of care will have its positive and negative factors for women, midwives and medical practitioners. It would, therefore, be sensible to utilize pilot models in various health facilities to trial all the options as what may work at one site and for one group of midwives and/or medical practitioners may be unsustainable in another. The research previously cited (Hobbs 1993, p.147; Bakker et al 1996; Sandall 1998; Tyson 2001, p.5) has proposed that, overall, the main factors in preventing burnout are optimizing the organisational structure and midwives' personal resources. Midwives need to acknowledge that they have parallel rights in terms of their professional and personal needs. This, of course, implies that clinical midwives will have the support of effective, empathic managers as lack of support could lead to burnout s a result (Kirkham & Stapleton 2001, p.158). Transformative change at the individual level may well be stifled by lack of support from those who have delineated responsibility to approve policy and procedure changes, yet do not do so, because of collusion with or acquiescence to inappropriate practices (McCall, 1996). If managers are given the power to act in the best interests of women, provision of service and morale will improve as midwives are assured that they are supported in their practice. Kirkham & Stapleton (2001, p.160) have warned, however, that there is a fine line between support and 'nannying'. Midwives need to be empowered to personally challenge inappropriate practice in the knowledge that they will be supported.

Midwife Led Models of Maternity Care

It is important to realize that midwife led models of maternity care will only be utilised if the community knows that they are a viable and available option. Recent United Kingdom research asserted that unless women and their families know what is possible, they will not seek innovative, sensitive services that are responsive to their needs (Hundley & Ryan 2004 pp359 – 341).

Ground breaking Australian research in 1985 concluded that 'continuity of care provided by a small team of midwives resulted in a more satisfying birth experience at less cost than routine care and fewer adverse maternal and neonatal outcomes' (Rowley et al 1995, p.289). The study also recognised that a much larger study would be needed to detect 'rare outcomes' while noting that 'continuity of care by a midwife team was as safe as routine care'. This has been supported more recently by conclusive Australian research (Tracy et al 2005) that, for low risk prenatal care, births and post natal care, small birthing units close to home provide the best outcomes for both women and babies.

There are many midwife led maternity care models available in Australia, albeit predominantly in urban areas and large regional centres (FNCM 1997; Hynd 1999; Brodie et al 2001). These models of care are predicated on the assumption that the women choosing this model of care will not experience any complication during their pregnancies, births and post partum periods. If complications did occur, specialist obstetric consultation would be sought. Women centred care is predicated on the philosophy of primary health care that has an ethos of health promotion, equity and sensitivity to client needs. It has been suggested that the primary health care philosophy is well suited to midwifery and that midwives' unique skills would be utilize holistically and based on need and equity (Everett 1998, p.426).

Birth Centres

Birth centres have been in existence in Australia for many years, some predating the Shearman Report recommendations (NSW Health Department 1989). Most birth centres are free standing within the grounds of health facilities. The ethos of a birth centre is to provide a safe homelike environment, with midwife led care and access to higher levels of care on a needs basis. At this point in time most birth centres find that demand greatly exceeds accommodation capacity and allocation to a birth centre may be balloted with a waiting list (Dent 2001, p.225).

Midwives provide antenatal care and preparation for parenthood classes in a flexible manner, to ensure that partners and other family members are able to be included. Intra partum care is provided at the birth centre with minimum intervention and maximum support, adjunct therapies such as showers, baths and massage being actively encouraged. Postnatally, women may choose to return home within hours of the birth or stay at the birth centre for 24-36 hours of post natal care. When discharged, the midwife then follows up with home visits and follow up calls (Hynd 1999; Marshall 1999; Stapleton, Duereden & Kirkham 2000, pp.151-152). It is worthy to note at this point that a meta analysis of 'Home like versus conventional institutional settings for birth' (Hodnett 2000) acknowledged that it is not enough to provide structural changes to the birthing environment. Any structural changes need to be accompanied by a transformation in practice complimenting, supporting and affirming the environment. Therefore, it is not enough to provide a birth centre per se. It needs to be assured that the midwives practicing in such centres value and espouse the governing philosophy (Stapleton, Duereden & Kirkham 2000, pp151-152). Such recent centres have been established at both Ryde and Belmont health facilities with resounding success (NSWMA 2004, pp.6-7; Lamers 2005, pp.12-13; NSWNA 2005, pp.30-31; NSW Health Department 10/6/05 26/8/05).

Caseload

Caseload practice is defined as one where 'midwives provided care for a specific group of women throughout most of the maternity period … one named midwife would provide most of the care with support as necessary from a partner midwife (Pope et al 1998, p.89). An example of a successful caseload practice is cited in London, where the midwives were on call for their own caseload 24 hours a day and had 3 months holiday a year (Leap 1997). This practice worked well for both women and midwives, with cost effective, best practice outcomes.

Midwives have a duty of care to their clients that may override ensuring continuity of carer, however (Dimond 1999, pp141-143). Therefore, if the hours of work and subsequent exhaustion preclude the provision of safe care, the midwife must ensure that the appropriate supervisor is notified and alternative care arrangements are made. It is not enough for midwives to place themselves in a situation where safe care is not assured just to provide continuity of carer. This must, of course, include time for efficient record keeping.

Team Midwifery

The team approach to maternity care has evolved from the difficulties in sustaining caseload practice. Essentially, the team midwifery model functions in the same way as caseload practice. The major difference is that women meet a number of midwives, who will provide their care. This 'minimises the negative effects of on-call work and the impact on midwives' lives' (Fenwick et al 1998, p.433) while assuring continuity of care and carer.

However, some team models have been implemented for the 'benefit of the professionals and not the clients' (Hobbs 1993, p.147). Continuity of care could be predicated on the number of midwives in the team, and that sometimes continuity of carer could not be assured (Pope et al 1998, p.90). In order to ensure that team models are based on the philosophy of choice, control and continuity of care. Women need to know two to three midwives, who will provide evidence based information to enable her to make the best decisions for her and her baby, and to ensure continuity of care (Hobbs 1993, p.147; Tyson 2001, p.4).

Community Midwife Programs

This care model espouses the same philosophy as the preceding models described. However, it differs in the way that care is provided. Community midwife programs (CMP), such as those already operational in Fremantle and Adelaide and soon to be piloted at St. George Hospital (NSW Health Department 10/6/05), operate from a primary health care philosophy and as such are provided in the community. Primary health care centres and women's homes are used for antenatal visits. The midwives are accredited to provide intrapartum care in affiliated hospitals or as home births. Depending on the desires of the woman, post partum care is provided by the CMP at home, or, if the woman needs, or wishes to have a longer hospital stay, the CMP will negotiate with the hospital midwives to organise care delivery (Teate 2000, p.13). The midwives' work is organised in a caseload or team model, depending on the requirements of the midwives.

This model has the obvious advantages of being women centred and family-focused, recognising pregnancy and childbirth as a part of the life continuum. As with the previously cited models, if any complications are detected consultant is sought with specialist obstetrician at the affiliated hospitals.

Shared Care

This model involves maternity care being shared by midwives and general medical practitioners for uncomplicated pregnancies, although there are shared care models operating between midwives and specialist obstetricians for complicated pregnancies and births (Hynd 1999). A pilot project utilizing this model is set to commence at Mullumbimby Hospital in November 2005.

Shared care could be a way of ensuring continuity of care and partially of care giver where general medical practitioners do not wish to find themselves in the position of potential deskilling, as midwives do (NHMRC 1996). In this model, an initial antenatal assessment is conducted with the general practitioner where preliminary tests are ordered as necessary. Subsequent antenatal visits are shared between the general practitioner and the midwives, the midwives' clinic being based at the Primary Health Care centre or hospital.

Salary Structures for Models

I will only mention briefly the differences in salary structure in all the models described, apart from shared care. Annualised salary structures are ratified in consultation between the Area Health Service and the NSWNA using an Enterprise Bargaining Agreement framework. As there are already many different models of care operational in NSW, the NCAHS will be able to utilise those structures without recourse to reinventing the wheel.

Independent Practicing Midwives

Independent practicing midwives (IPMs) are certified midwives, who offer a range of prenatal, birthing and post partum services, as private practitioners. Some IPMs have accreditation to health facilities, allowing them to utilise health facility maternity units and birth centres for those women, who choose an IPM as their lead maternity carer, but who wish to birth at a health care facility, rather than at home. While there are inequities in service provision related to independent practice, IPMs have a valid role in 'pushing forward the boundaries of midwifery possibility' (Hunter 1998 PAGE NUMBER FOR DIRECT QUOTE) and indeed, are the only available alternative to hospital based maternity care in the NCAHS. However, at this point in time in Australia, IPMs are fast becoming a rare breed as professional indemnity insurance is not available, despite the best efforts of the ACMI. 

The Way Forward

I have had discussions with both Kathy Baker – Chief Nursing & Midwifery Officer, NSW Health Department (2005) and Pat Brodie, President, NSWMA (2005), regarding the difficulties inherent in implementing midwifery models of maternity care in rural NSW. Both women recommended that it would be necessary, in this climate of economic rationalism, to submit strong business cases to the NCAHS, based on efficiency and effectiveness. In those submissions the foci would need to be increased cost effectiveness, participation and involvement of midwives and subsequent positive working environments and decreased stress, attrition of midwives associated to professional burn out and use of sick leave to gain some 'time out'.

To achieve the goal of women centred models of maternity care, I propose that a re-examination of the proscribed gender roles of society, let alone in the micro culture of maternity care is needed. Acceptance of a partnership, rather than a dominator paradigm of culture, could assure a necessary transformation for the future of maternity services and ultimately families and society (Eisler 1990 p.xv ii: CRANA 2004, p.26; Brodie 2005, p.5). To achieve a partnership model for societal evolution there must be recognition of blurred roles and individual skills, not based necessarily on gender, or indeed, profession. It must be recognized, however, that the way will not be easy and transformation may well be a process of two steps forward, one step back. It is necessary for those who seek transformation in their own and others' practice to realize this to prevent disillusionment and burnout. (Eisler 1990, p.188 – 189).

Conclusion

All stakeholders need to engage in discussion to reach consensus on the suitability of maternity care models for individual health facilities. The process of negotiation will obviously require the commitment of midwives, medical practitioners and consumers, to realise the goals of women centred care. It would certainly not be appropriate for one stakeholder group to make unilateral decisions. All stakeholders will obviously need to be mindful of the cost effectiveness and safety of the models proposed and to ensure that the decisions reached are informed by the best available evidence and not just individual opinions and vested interests.

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