Maternity care in rural Victoria: Midwives' perspectives

Abstract

This modified Grounded Theory study explored the experiences of midwives working in a rural Victorian setting during a period of maternity service redesign. Changes to the local maternity service under study were block funded by the Rural Maternity Initiative, Victoria, Australia (Edwards & Gale, 2007). The Rural Maternity Initiative, along with the release of the maternity service review report (Commonwealth of Australia, 2009), incorporated women’s requests for continuity of care provision, demedicalised care, choice in care, and accessibility of services across the pregnancy, birth and postnatal period. Midwifery workforce shortages and maternity unit closures in rural Australia have been identified by the government, maternity service users and other stakeholders as factors reducing options, and increasing travel requirements, and social and emotional costs for women (Hoang, Le, & Ogden, 2014). Australian state and territory governments encouraged the redesign of maternity services with continuity models of care, more often caseload care or team midwifery, in an effort to combat workforce deficits and rural inequities (Commonwealth of Australia, 2009). A review of literature was undertaken to frame key points associated with Australian health and maternity provision, recent policy developments, health workforce strategies, models of continuity care and rural maternity care accessibility. Significant gaps were noted, relating to the experience of the maternity service restructure in the rural setting, and the relationship between the health services undergoing maternity redesign and local communities. A modified Grounded Theory methodological approach was undertaken, using symbolic interactionalism as the theoretical perspective to frame the study. The work of seminal theorists Glaser and Strauss (1967) informed the design methods employed, particularly that of constant comparative analysis, coding and memoing. A modified approach was taken, however, influenced by constructivist concepts. Charmaz asserts that rather than ‘discovering’ theory, data is socially constructed by study participants with reference to their individual circumstances (Charmaz, 2006). Developmental work by Blumer (1986) significantly influenced the theoretical perspective of this study, as an inquiry based on the lived experiences of a small group of midwives who were affected by maternity service redesign in one locality. In line with symbolic interactionism, this study seeks to understand the meaning these midwives placed on changes and the social interactions they attributed to their work environment. The research setting was a small, rural maternity service, with a select sample population of fifteen. Participants were theoretically sampled and semi-structured interviews were the primary method of data collection. Constant comparative analysis was employed throughout the study, during which time the researcher became increasingly and thoroughly immersed in the data. Coding and categorisation was completed using OneNote Microsoft software to demonstrate thematic saturation and emerging theoretical concepts. It was during this rigorous analysis of data that a deep appreciation and understanding of Grounded Theory methodology was achieved. Constant comparative analysis enabled repeated interaction with data, comparative assessment of literature in conjunction with further data collection, and self-examination by the researcher. Themes that emerged from the midwives’ experiences of maternity service redesign in the rural Victorian context reflected known elements such as midwifery retention rates and burnout (Mollart, Skinner, Newing, & Foureur, 2013), and change planning, change leadership and interprofessional relationships associated with sustaining continuity models of maternity care (Monk, Tracy, Foureur, & Barclay, 2013). Two key themes related specifically to the rural context were communication of maternity service change, and change preparedness inclusive of women, families and interwoven rural communities.