What led to changes in maternity care?

Former College President Dr Pat Brodie discusses the key issue that led to changes in maternity care

Second wave feminism had an impact on midwifery and birth in Australia. By the mid-1970s consumer and political pressure for birthing alternatives began to mount in Australia. Homebirth continued to be strenuously opposed by the medical profession. Until the 1990s the only non-medicalised option for women in Australia was a homebirth with a privately practicing midwife [PPM].

Unfortunately, this option was not available for a lot of women as cost, access and availability of PPMs were prohibitive factors.

Birth centres were another option. The centres are usually attached to hospitals, thus enabling quick access to the ‘safety’ of the hospital and the supervision of the doctors. Between 1989 – 1999, The Alternative Birthing Services Program [ABSP] was a Commonwealth government initiative that aimed to provide funding to develop alternative birth choices for women including birth centres and homebirth. It is generally agreed that ABSP funding was used across Australia to develop safe havens in which midwifery could flourish.

Many planned programs across Australia were not implemented, and some that were implemented did not continue once the ABSP funding ran out.

Women enjoy this type of care because of freedom of choice of carer, control of the situation, personalised care and choice of the place to give birth.

Women choosing this type of care are found to be less anxious at the time of delivery, use much less analgesia, experience less intervention an perineal trauma. The majority of women continue breastfeeding longer than three months.

The drawback with this mode of care is the cost, because although research shows it to be both safe and cost effective, there remains no Medicare refund for either the use of the birth centre or the midwives fees. Hence the service can only be accessed by those able to pay.

This has not always been the case. There was funding from the Commonwealth Government for four years, from July 1992 to September 1996, through the Alternative Birthing Services Program. However, when the Commonwealth Government gave the money to the States to distribute, the rules changed and the funding for the Launceston Birth Centre ceased.

Elaine Smallbane, RN, RM, BAppSci (Health), FACM

(1998). Launceston Birth Centre, Australian Nursing Journal, 5(11): 34.

However, many of the programs that were funded did survive – mostly in the form of birth centres and a few continuity of care programs. Launceston Birth Centre had survived before the ABSP funding, and continued after it ended. In WA, two alternative birth services were implemented, the Family Birth Centre (FBC) and the Community Midwives Program (CMP). The FBC opened in 1992 and was the first government funded birth centre in WA. The Community Midwives Program (CMP) was the result of many years of lobbying by midwives providing homebirth services to women privately and was the first government funded homebirth program in Australia. (Dr Carol Thorogood provides an in-depth review of the ABSP in her doctoral thesis Politics and the Professions: Homebirth in Western Australia.)

Alternative Birthing Services Program [ABSP] funded programs

Launceston Birth Centre [LBC] was Australia’s first free standing birth centre. Founded in 1983, it continues to be run by a consumer committee and serviced by a team of private midwives.

During Phase One of the Alternative Birthing Services Program [ABSP], only three projects in Australia received grants to provide services that specifically included home births. One of these was LBC.

LBC received $43,770 of Phase One ABSP funding ‘to increase its accessibility to all women, including those previously excluded by financial constraints and to upgrade the physical environment and equipment at the centre’ (Smallbane, 1994).

What led to changes in the education and regulation of midwifery?

It may seem surprising to know that not all midwives were nurses in the early years of midwifery education in Australia. King Edward Memorial Hospital, Perth, opened on 4 July 1916 as the first women’s hospital in WA. Students paid a fee of ten pounds to study midwifery, which was 6 months for qualified nurses and 12 months those without a nursing qualification. The last original direct entry hospital-based midwifery students graduated from Crown Street Hospital in Sydney in 1970.

Midwifery became a post registration nursing qualification, based in hospitals using an apprenticeship model. The major focus of practice remained with the biomedical model that reflects an illness approach to care. Midwifery education gradually moved away from hospital-based courses to the tertiary sector as either graduate diplomas or master’s degrees continuing as a post-nursing qualification.

In 1986 Lesley Barclay provided a comprehensive historical analysis of midwifery education in Australia (see below). She identified a lack of definition of the role of the midwife or standards of education in most states. Regulation was inconsistent and often rendered invisible by nursing leaders who made decisions on behalf of midwifery. She found that for a midwife to be promoted there was often a pre-requisite to be a qualified nurse. Midwifery skills were not fully utilised and there were few opportunities for midwives to practice autonomously. Lesley recommended that ‘direct entry’ be re-examined in the light of international developments and the inefficient current system of midwifery education.

Barclay. L. (1986). One right way: the midwifes’ dilemma. An examination of the influences that have shaped Australian midwifery and the effects of these on the training and practice of midwives. (Masters Thesis). Canberra College of Advanced Education.

CONTENTS

Introduction

1. How do we see midwifery today and why?

2. What are the origins of the regulations, training and practice of midwifery in Australia?

3. How is the midwife’s training and practice defined within regulations and policies?

4. How does the midwife define her own role?

5. How is the midwife educated for her role?

6. “The pattern which connects”

7. Where do we go from here?

 

A copy of this thesis is available to borrow through the University of Canberra library

In her article Midwifery: Women, History and Politics (linked below) Carolyn Hastie suggested that the issues confronting women and those confronting midwives were on a ‘parallel course’. Midwifery has struggled by being subsumed into nursing as well as being seen as a subordinate profession by medicine. An example of the control of midwifery by nursing was evidenced by the review of the NSW Nurses Act in 1991 when midwifery lost its’ own separate register. It took until 2004 for the Nurses’ and Midwives’ Registration Board in NSW to be legislated.

ABSTRACT

Much has ben made of evidence-based practice in health care and in particulate, in maternity  care. Numerous studies have indicated that small maternity units plus midwifery, as a primary health care practice, is best for the physical and emotional health of the majority of childbearing women and their babies. However, despite various State and Federal Government reports recommending midwifery led care, and a flurry of alternative birthing services pilot programs in the early 1990s, Australian governments and health care organisations have not generally shifted from a medically dominated approach to a social health model for maternity care provision. History suggests that t odd so conflicts with  the professional and economic interest of medicine. This paper explores the history, the politics, and women’s place in society within a midwifery context, so that midwives have a wider perspective on contemporary issues associated with midwifery practice. Such broad view will enable newer members of the midwifery profession to recognise that the current negativity from some medical colleagues about moves to increase midwifery-led options for childbearing women and the associated midwifery autonomy have long standing historical and political roots. Such an understanding will help make sense of the current political and practice landscape.

Bachelor of Midwifery National Taskforce & AMAP: Australian Midwifery Action Project

An international move towards a model that recognised the definition of a midwife and a philosophy of practice that was ‘with woman’ resulted in renewed interest in educating midwives without the need for a nursing qualification. In 1999, Flinders University and the University of South Australia were considering starting a 3-year Bachelor of Midwifery course however believed that it was best to wait until other universities could commence courses at the same time to maximise support for this option. This led to the creation of the ACMI Bachelor of Midwifery National Taskforce with a commitment to develop national Standards for the Accreditation of a Bachelor of Midwifery that could be used as a framework for use across Australia.

The Australian Midwifery Action Project (AMAP) commenced in 2001 (read the reports below). The two main aims of the research project were to investigate the service delivery, educational, policy and regulatory environments affecting midwifery in Australia; and to analyse and facilitate collaboration, planning and communication across these sectors.

This project, funded by the Australian Research Council in association with industry partners, supported the work of the ACMI Taskforce and recommended that national research should investigate, monitor and evaluate the introduction of the Bachelor of Midwifery, and compare and standardise outcomes with a strengthened and improved national approach and standards for the midwifery education of nurses. In promoting national standards for the introduction of BMid programs in Australia, the (successful) argument was then made that these standards should apply to ALL midwifery education programs, not just the BMid.

It was not until 2002 that ‘new’ direct entry programs recommenced in South Australia and Victoria, and New South Wales in 2005.

It is now over 20 years since the first Bachelor of Midwifery (BMid) programs began in Australia. The Bachelor of Midwifery (or BMid) was one of the most significant developments in the history of midwifery education in Australia.

How and why did this enormous change happen?

 

READ MORE ABOUT THE INTRODUCTION OF THE BACHELOR OF MIDWIFERY IN AUSTRALIA

Resources

Maternity Choices Australia

Maternity Choices Australia (formerly Maternity Coalition) is a national consumer advocacy organisation committed to the advancement of best-practice maternity care for all Australian women and their families, bringing together groups and individuals for effective lobbying, information sharing, networking and support.

Midwifery: ‘At the edge of history’

SUMMARY

The paper focuses on possible future pathways in maternity care for midwives and nations to consider. The paper blends personal and professional experiences to outline priority areas facing midwives in the future. It begins by examining maternal mortality and morbidity in the developing world and considering the potential of the ten high priority action messages (1997) in helping to improve the plight of women and children in the future. The paper then examines major issues facing midwives in the developed world including: the way birth is viewed; the medical-midwifery divide; marketing midwifery; and finally the challenge of dealing with fear around birth. The third part of the paper examines a part of society where the two worlds meet and there are issues from both the developed and developing world to consider. The paper focuses on women from culturally and linguistically diverse communities, Aboriginal and Torres Strait Islander women and women birthing in remote and rural areas. By looking at these three worlds separately the paper examines different concerns facing midwives in the future but also draws on common issues that face us all as citizens of this planet and particularly as predominantly women. The paper challenges midwives to be politically active and dare to change the world.

The invisibility of midwifery: will professional capital make a difference?

ABSTRACT

Serious questions need to be asked about the current status of midwifery in Australia. This doctorate examines the lack of recognition of midwifery as an autonomous profession and its consequential invisibility in Australian maternity care.

Despite the significant amount of evidence that continues to accumulate to support the expansion of midwifery models of care, such changes have not been widespread in Australia. An examination of international, national and local health policy and strategic direction in maternity services, together with a critique of contemporary Australian midwifery and the role of the midwife within the public health system, provide the rationale and context for the study. The ‘case’ for introducing improved systems and models of maternity care is developed with regard to the evidence for increasing the utilisation of midwifery. The doctorate argues for greater visibility and recognition of midwifery in Australia with a focus on the role of midwifery leadership and its potential to improve collaboration.

A number of case studies report experiences and insights of leadership and collaboration across different contexts: clinical practice, organisation of health services and health policy leadership in maternity services. The result is a comprehensive understanding of the reasons for the lack of visibility of midwifery and the potential costs of such a situation continuing. The exploration of this situation highlights the barriers to recognising and acknowledging midwifery itself.

Attention is drawn to the continuing lack of voice and visible leadership in Australian midwifery, with midwives being absent from decision-making in situations where others, predominantly nurses and doctors, speak ‘for’ them.

This work examines the barriers to midwives forming alliances and working to influence government agendas at the social, organisational and political level. Exploration of the power structures and hierarchical constraints that exist reveals particular barriers and highlights what is needed to address the impending decline of the profession in Australia.

The enhanced capacity that midwives would experience if their work were to be understood, recognised and valued in the provision of maternity services in Australia, is postulated through the development of a construct called ‘professional capital’. Drawing on several theoretical perspectives, it is argued that the notion of ‘professional capital’ is dependent on a strategy of focused and deliberate leadership and collaboration within maternity services and the creation of positive social networks and affiliations amongst midwives.

Professional capital would enable greater visibility and recognition of midwifery and a more effective midwifery contribution to maternity services. It is suggested that improved professional and societal recognition will ultimately enhance the professional performance and self image of midwives. Such developments will enable new and effective ways of supporting and strengthening inter-professional relationships and systems of care that will, in the long term, improve the outcomes and experiences of women who access maternity services.

Pat’s PhD thesis is available electronically via the UTS OPUS portal

Contemporary issues in Australian midwifery regulation

ABSTRACT

This paper reports on research that examined the Nurses’ Acts, regulations and current policies of each state and territory in Australia, in order to determine their adequacy in regulating the education and practice of midwifery. This is part of a three-year study (Australian Midwifery Action Project) set up to identify and investigate barriers to midwifery within the provision of mainstream maternity services in Australia. Through an in-depth examination and comparison of key factors in the various statutes, the paper identifies their effect on contemporary midwifery roles and practices.

The work assessed whether the current regulatory system that subsumes midwifery into nursing is adequate in protecting the public appropriately and ensuring that minimum professional standards are met. This is of particular importance in Australia, where many maternity health care services are seeking to maximise midwives’ contributions through the development of new models of care that increase midwives’ autonomy and level of accountability.

A lack of consistency and evidence of discrepancies in the standards of midwifery education and practice regulation nationally are identified. When these are considered alongside the planned development of a three-year Bachelor of Midwifery, due to be introduced into Australia in mid-2002, there exists an urgent need for regulatory change. The need is also identified for appropriate national midwifery competency standards that meet consumer, employer and practitioner expectations, which can be used to guide state and territory regulations.

We argue the importance of a need for change in the view and legal positioning of the Australian Nursing Council and all Nurses Boards regarding the identification of midwifery as distinct from nursing, and substantiate it with a rationale for a national and consistent approach to midwifery regulation.

Addressing the barriers to midwifery – Australian midwives speaking out

ABSTRACT

This research gives a voice to midwives in identifying the barriers and current problems in the organisation of maternity care in Australia. Using a critical feminist research approach, data was collected from a cross section of midwives nationally. Through standard qualitative research methods, themes were identified that enabled analysis of significant issues affecting the current status of midwifery.

The system of maternity care was identified as being dominated by medicine, not evidence based and restricting of women’s choices, with midwifery autonomy not recognised or supported. The invisibility of midwifery within the community was identified as a significant barrier which, in conjunction with the occupational imperialism of obstetrics, ensures ongoing strategic control of maternity services and a denial of the rights of consumers to access midwifery care.

AMAP: Australian Midwifery Action Project

Results of AMAP

AMAP: Australian Midwifery Action Project

All the AMAP reference papers are produced in full in part 2 of the AMAP report.

Paper 1. Identifying the midwifery practice component of the Australian Midwifery Education Programs

Leap, N. (2002). Identifying the midwifery practice component of the Australian Midwifery Education Programs. Results of the Australian Midwifery Action Project (AMAP) Education Survey. Paper 1. Australian Midwifery, 15(3), pp 15-23. https://doi.org/10.1016/S1031-170X(02)80004-6
ABSTRACT
This paper is the first in a series of papers reporting on the findings of the AMAP Education Survey of the 27 universities providing a program for initial authorisation to practise midwifery. It concentrates on issues related to the practice component of courses. Subsequent papers will present findings related to workforce issues and the barriers to effective midwifery education as identified by the midwifery course coordinators.
Serious concerns are raised about the standards of Australian midwifery education, particularly when international comparisons are made, in terms of the length of courses, clinical practice requirements and the opportunities for students to engage with contemporary midwifery practice across community and acute settings.

Paper 2. Barriers to effective midwifery education as identified by midwifery course coordinators

Leap, N., Barclay, L., & Sheehan, A. (2003). Results of the Australian Midwifery Action Project Education Survey. Paper 2: Barriers to effective midwifery education as identified by midwifery course coordinators. Australian Midwifery, 16(3), pp6-11. https://doi.org/10.1016/S1448-8272(03)80010-X
ABSTRACT
This paper is the second in a series of three, reporting on the findings of the Australian Midwifery Action Project (AMAP) Education Survey. It concentrates on the barriers to effective midwifery education as identified by the midwifery course coordinators from the 27 Australian universities providing a midwifery program for initial authorisation to practise as a midwife.
In line with the major research questions of the AMAP, the midwifery course coordinators were asked to identify what they saw as the barriers to providing quality midwifery education and strategies to overcome these barriers. Their main concerns centred on the difficulties in providing appropriate clinical practice placements, financial pressures for students and barriers to effective teaching and learning.
Mostly the strategies were a reversal of the identified barriers. These findings highlight the need for major reform in the way midwifery education is organised and funded in Australia.

Paper 3. Workforce Issues

Leap, N., Barclay, & Sheehan (2003). Results of the Australian Midwifery Action Project Education Survey. Paper 3: Workforce Issues. Australian Midwifery,16(3), pp. 12-17. https://doi.org/10.1016/S1448-8272(03)80011-1
ABSTRACT
This paper is the third in a series reporting on thefindings of the AMAP Education Survey of the 27 Australian universities providing a program for initial authorisation to practise as a midwife. Workforce issues were identified by this research, such as the potential number of places in courses, attrition rates, and the number of graduates from midwifery education programs who seek and obtain employment in midwifery. The findings pose serious challenges to the development and sustainability of the Australian midwifery workforce.

Reflections on AMAP

Any action? Reflections on the Australian Midwifery Action Project

ABSTRACT

Background: In 1997 a group of midwifery academics, researchers and practitioners met to discuss issues of concern related to the midwifery profession in Australia. It became clear from this discussion that midwifery in Australia was lagging behind similarly developed countries and that urgent action was required. From this meeting, a plan was developed to seek funding for a major national study into midwifery education and practice standards and as such, the Australian Midwifery Action Project (AMAP) was born.

Discussion: This discussion paper presents an overview of a number of midwifery education and regulation changes within the framework of the recommendations from the Australian Midwifery Action Project. A key question arising from this discussion is whether our current midwifery education and regulation standards provide a fit-for-purpose workforce that ensures all women and their families receive best practice midwifery care. Over the past 20 years the Midwifery profession in Australia has undergone significant changes and developments and these changes have had, and continue to have, significant impact on midwifery education and therefore on the quality of midwifery practice in Australia.

Conclusion: Many changes have been implemented in the nearly 20 years since AMAP was first conceived. However, many of the issues that provided the impetus for a project such as AMAP remain and are still to be resolved. The midwifery profession continues to be subsumed with nursing, it is not possible to gain accurate midwifery workforce data and, despite the development of national standards for midwifery education, wide variations in courses still exist across Australia.

Collective action for the development of national standards for midwifery education in Australia

ABSTRACT

This article describes a sequence of events that led to the development of national standards for the accreditation of Australian midwifery education programmes for initial registration. This process occurred within a climate of polarised opinions about the value of the introduction of three-year degree programmes for midwives who are not nurses (known as the BMid in Australia) and concerns about the invisibility of midwifery within nursing regulation, education, policy and nomenclature.

Concerted efforts to develop standards to inform the introduction of BMid programmes through a process of collective action are described. This involved arguing successfully for the positioning of midwifery as a separate profession from nursing, with a need for its own discreet regulation.

AMAP- The End of a Beginning

On the 1st of April 2002 The Australian Midwifery Action Project (AMAP) will draw to a close after three busy years of intense action research and information gathering…

The overall aim of the study was to provide evidence on which to base strategic planning, workforce review, educational reform, and policy direction. The project was conceptualized within two main ‘strands’.

STRAND 1 consisted of interrelated studies investigating state and territory differences in service provision, education, policy and regulation associated with midwifery care within maternity services.

STRAND 2 aimed to develop and test strategies for improving midwives’ contribution to maternity care through facilitating and supporting institutional and systems reform.

The research team was led by Professor Lesley Barclay and consisted of two full time research midwives, Pat Brodie and Sally Tracy and four associate researchers, Nicky Leap and Linda Saunders (Flinders University, Adelaide), and two well known sociologists, Karen Lane (Deakin University) and Kerreen Reiger (La Trobe University). A final report will consist of papers that were prepared and submitted separately for publication during the three years.

After AMAP: The development of competency standards

The development of national competency standards for the midwife in Australia

ABSTRACT

Objective: To develop and validate national competency standards for midwives in Australia. This study was part of a commissioned national research project to articulate the scope of practice of Australian midwives and to develop national competency standards to assist midwives to deliver safe and competent midwifery care.

Design: A multi-method, staged approach collected data through a literature review, workshop consultations, interviews, surveys and written submissions in order to develop national competency standards for Australian midwives. Subsequently, direct observation of practice in a range of settings ensured validation of the competencies.

Setting: Maternity care settings in each state and territory in Australia.

Participants: Midwives, other health professionals and consumers of midwifery care.

Findings: The National Competency Standards for the Midwife were developed through research and consultation prior to being validated in practice.

Key conclusions: The national competency standards are currently being implemented into education, regulation and practice in Australia. These will be minimum competency standards required of all midwives who seek authority to practise as a midwife in Australia. It is expected that all midwives will demonstrate that they are able to meet the competency standards relevant to the position they hold.

Implications for practice: The competency standards establish a national standard for midwives and reinforce responsibility and accountability in the provision of quality midwifery care through safe and effective practice. In addition, individual midwives may use the competency standards as the basis of their ongoing professional development plans.

The role of the midwife in Australia: views of women and midwives

ABSTRACT

Objective: to research the role of midwives in Australia from the perspectives of women and midwives. This study was part of a commissioned national research project to articulate the scope of practice of Australian midwives and to develop national competency standards to assist midwives to deliver safe and competent midwifery care.

Design: a multi-method approach with qualitative data collected from surveys with women and interviews with midwives.

Setting: participants represented each state and territory in Australia. Participants: midwives who were randomly selected by the regulatory authorities across the country and women who were consumers of midwifery care and involved in maternity activism.

Key conclusions: midwives and women identified a series of key elements that were required of a midwife. These included: being woman centred; providing safe and supportive care; and working in collaboration with others when necessary. These findings were consistent with much of the international literature. Implications for practice: a number of barriers to achieving the full role of the midwife were identified. These included a lack of opportunity to practice across the full spectrum of maternity care, the invisibility of midwifery in regulation and practice, the domination of medicine, workforce shortages, the institutional system of maternity care, and the lack of a clear image of what midwifery is within the wider community. These barriers must be addressed if midwives in Australia are to be able to function according to the full potential of their role.