Managing Change In Midwifery Practice

by Pat Brodie This paper will describe the process of improving maternity care through an innovative program, based at St George Hospital, that enabled the introduction of a community based ‘continuity of midwifery care’ model incorporating collaboration between midwives and obstetricians. This model of care was initially based on evidence and experiences gained elsewhere, such as that from the team midwifery models at John Hunter Hospital, Newcastle NSW and Westmead Hospital in Sydney. Importantly, the St George model took an additional step in moving the public hospital antenatal services into two community-based clinics. A small team of midwives and an obstetrician or registrar staffs these. A high level of inter-disciplinary collaboration and negotiation was required in order to achieve the move of the regular clinics into the community. This involved midwives, obstetricians, community health staff, hospital managers, staff from non-government agencies, researchers, bilingual health workers and others. The outcome has been the successful relocation of what, in urban Australia, is traditionally a hospital-focused service, to a community based setting. What has emerged is a model of care with the capacity to improve perinatal health outcomes, increase the utilisation of midwives skills and promote effective collaboration. Some experiences will be shared, in order that they may assist others in the development of more women centred, community oriented maternity care. The session will also invite participants to contribute their experiences and ideas around the development of midwifery services and new models of care in their local area. Barriers and resistance to introducing changes will be explored and these will contribute to a project that is of vital concern to all involved in maternity care across Australia — the Australian Midwifery Action Project.

Background

It could be said that Australian maternity care is in a state of crisis. The spiralling costs of health care, pressure on reducing length of stay, efforts designed to ensure only the very ill are inpatients in acute care and numerous governments reports recommending widespread reform in the way services are organised, all herald a state of massive change. Within this context, new models of care are emerging, some developed within a research base, others as part of health service directives. Some of these new models are flourishing and demonstrating improved outcomes and greater efficiency whilst others, equally efficient and effective, are being closed. With a greater emphasis on consumer choice and accessibility to a range of options in care, many of these new models also raise the profile and status of midwifery care. It is therefore important to explore the issues, constraints and opportunities that this presents. An understanding of the occupational and professional relationships that are necessary to ensure that changes are positive and sustainable, are but one of the many challenges that we will face as we strive to improve the experiences and outcomes of maternity care for Australian women.

The Australian Midwifery Action Project (AMAP)

This project is a three year study, funded jointly by Commonwealth Government and five industry partners, which include two state governments, an area health service, the consortium of teaching hospital leaders known as “Women’s Hospitals Australia” and the Australian College of Midwives. Commenced in April 1999, the project is set up as a collaborative venture between industry and research sectors who are concerned with the role of midwifery within the maternity services in Australia. At present, health services across Australia are having difficulty maintaining high quality maternity services because of shortfalls in the number of midwives, especially in rural and remote areas. Additionally, there are concerns over the standard and quality of midwifery that is provided in some areas. The AMAP project addresses these concerns, in the light of national policies which increasingly are seeking to promote midwifery care within maternity services. This research will investigate the barriers identified by industry to improve midwifery care within a climate of extensive policy change in maternity services. Problems to be investigated through the course of the project are:

• Increasing shortfalls in numbers of midwives
• Problems and inadequacies of educational preparation.
• Limitations of regulation and standards and their comparability at a national level.

The project will enable a collaboration of industry partners and researchers in order to produce:

• An analysis of service delivery, models of care and organisation of services.
• A strategy for future education of midwives.
• Recommendations for policy and the regulation of midwives.

The study will also develop processes through action research to:

• Improve communication across sectors.
• Promote organisational links and cohesive leadership.
• Improve inter-sectoral collaboration in the long-term.

Other important research participants will include: health services and agencies who provide maternity care; consumer groups; professional organisations; statutory authorities and industrial relations organisations.

Context

Several Australian government reports have recommended changes and reorientation of maternity services to ensure increased continuity of care, greater utilisation of midwifery skills and redirection of maternity services towards the community (NSW Department of Health, 1989; Health Department of Victoria, 1990; South Australian Health Commission, 1995). Of significance is the work of two NH&MRC committees that have confirmed the safety and benefits of midwife led care for healthy women (NHMRC 1996; 1998). All public health services across Australia are needing to reconceptualise maternity services and how they are provided. This ‘rethink’ of the systems and organisation of health care delivery needs to:

• Address priorities for care and safety.
• Meet the needs of consumers.
• Be guided by evidence and demonstrate cost effectiveness.
• Be mindful of the need to maintain and develop a skilled health workforce.

The changes that are recommended, and indeed already implemented in many places around Australia are consistent with moves internationally where increased costs, women’s declining satisfaction with maternity services and increasing morbidity attached to intervention rates, are forcing many to reconsider medically dominated systems of birthing. Based on evidence provided by the Cochrane Collaboration Database of Systematic Reviews (Hodnett, 1997) and the World Health Organisation (WHO, 1996), it is becoming increasingly recognised that health services need to develop maternity models of care that are woman centred and based on sound evidence. The process requires service providers to actively incorporate consumer’s needs rather than work from a basis of professional or provider’s preference. Put simply, these developments should occur within a framework of three basic principles: choice, control and continuity (Department of Health UK, 1993). In Australia, we must also respond to the need to move to community based services and improve our skills in collaboration, in order to change systems. The AMAP project will provide information that will assist health departments, regional health services, universities and regulatory bodies to co-ordinate planning and improve the implementation of maternity care. Importantly, the profession of midwifery will be examined, analysed and better understood. This will enable the attainment of new knowledge and greater understanding that will assist in the expansion of Australian midwifery that sees it develop up to international standards of practice.

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This paper was presented at the Enriching Midwifery Conference, Australia, March 2000.