Midwifery Group Practice Research Articles

O79 - Moving Midwifery Group Practice Forward

O79 - Moving Midwifery Group Practice Forward

P25 - A rural town embracing Midwifery Group Practice

P25 - A rural town embracing Midwifery Group Practice

Everyone should have their own midwife: Women’s and staff experiences during the implementation of two midwifery continuity of care models in regional Australia

ProblemMidwifery Continuity of Care (MCoC) remains inaccessible for most Australian women; this is especially true in rural and regional areas. BackgroundStrong evidence demonstrates MCoC models improve experiences for women and their babies and are also shown to improve midwifery workforce wellbeing. However, implementation and upscale remains limited. AimTo explore the views and experiences of implementing MCoC for both staff and women, understanding their experiences, concerns and solutions in a regional context. MethodsQualitative data was collected via focus groups with women and healthcare staff, at six and twelve month post implementation. Data was thematically analysed using Braun and Clarke six step process. FindingsThe findings support that ‘women love it’ and midwives working in the new MCoC model ‘loved their job’. The major concern was that not all women could access the model and disconnected communication was problematic during implementation. ‘Sharing stories’ was a solution to overcoming these issues and promoting the positive impact of MCoC - in particular ways of working and adaption to an all-risk midwifery group practice. DiscussionThis study supports widespread evidence that MCoC is valued by both women and staff. In a regional context it is important to recognise challenges faced during implementation and identifying solutions that other maternity services could consider when implementing MCoC. ConclusionThe study offers strong recommendation for regional areas to consider MGP to maintain safe, quality local maternity services.

The sustainability of midwifery group practice: A cross-sectional study of midwives and managers

ProblemAlthough there is robust evidence for the benefits of midwifery group practice (MGP) caseload care, there are limited opportunities for women to access this model in Australia. There is also limited knowledge on how to sustain these services. BackgroundMGP can benefit childbearing women and babies and improve satisfaction for women and midwives. However, sustainability of the model is challenging. While MGPs are often supported and celebrated, in Australia some services have closed, while others struggle to adequately staff MGPs. AimTo investigate midwives and managers opinions on the management, culture, and sustainability of MGP. MethodsA national survey of MGP midwives and managers was distributed (2021 and 2022). Quantitative data were analysed using descriptive statistics, and qualitative data were analysed using content analysis. ResultsA total of 579 midwives and 90 managers completed the survey. The findings suggest that many MGPs do not support new graduates and students to work in MGP. Over half (59.8%) the participants (midwives and managers) reported that the women and families were the best aspect about working in MGP, while 44.3% said the effects on midwives’ lifestyle and families were the worst aspect. DiscussionThe relationship with women remains the major motivator for providing MGP care. However, work-life imbalance is a deterrent, exacerbated by staffing shortages. Staffing might be improved by adequate renumeration, strengthening orientation, and attracting new graduates and students through experience in MGP. ConclusionsThere is a need to attract midwives to MGP and improve work-life balance and sustainability.

Sustainability of rural Victorian maternity services: ‘We can work together’

BackgroundRural maternity service closures and service level reductions are continually increasing across Victoria. There is limited understanding of how rural board members and executives make decisions about their maternity service’s operations and sustainability. AimTo examine perspectives of rural Victorian board members and executives on the sustainability of rural maternity services. MethodsThis was a qualitative study. Interviews were conducted via Zoom™ with 16 rural Victorian hospital board members and executives. Data were thematically analysed. FindingsSevere shortages in the rural maternity workforce, primarily midwives, have contributed to service sustainability decisions. Challenges in offering midwifery workforce incentives cause difficulty in overcoming workforce shortages. A rural maternity workforce strategy harnessing connection with regional services was called for. Innovative models of maternity care were often actioned at the point of service suspension or closure. Participants requested a government policy position and funding for innovative, safe, and sustainable models of care in rural settings. DiscussionThere is an opportunity for workforce planning to occur between regional and rural services to ensure the development of sustainable maternity models such as midwifery group practice and incentivise the workforce to address current deficits and sustain service provision. ConclusionModels of care developed with rural communities, in collaboration with regional services, have the potential to strengthen the delivery of safe, sustainable maternity services. Workforce modelling and centralised government policies aimed at arresting workforce deficits are suggested to provide rural health service leaders with strategic and operational directions to support the delivery of safe, sustainable maternity services.

“It’s all about cultural understanding”: A reflexive thematic analysis of women’s experiences at a dedicated refugee midwifery group practice service

BackgroundInequitable maternity care provision in high-income countries contributes to ongoing poor outcomes for women of refugee backgrounds. To address barriers to quality maternity care and improve health equity, a co-designed maternity service incorporating community-based group antenatal care, onsite social worker and interpreters, continuity of midwifery carer through a caseload design with 24/7 phone access was implemented for women of refugee background. ObjectiveTo explore and describe women’s experiences and perceptions of care from a dedicated Refugee Midwifery Group Practice service. DesignQualitative exploratory descriptive study using focus group discussions and interpreters. SettingThe study was conducted at a community-based Refugee Midwifery Group Practice service in a tertiary maternity hospital in Brisbane, Australia. MethodsWe conducted three focus group discussions (June - December 2020) with 16 women, born in six different countries, in three language groups: Sudanese Arabic, Somali, and English. We used reflexive thematic analysis to interpret women’s perspectives and generate informed meanings of experiences of care. ResultsWe generated four themes 1) accessibility of care, 2) women feeling accepted, 3) value of relationality, and 4), service expansion and promotion. Results demonstrate positive experiences and acceptability due to easy access, strong woman-midwife relationships, and culturally safe care. ConclusionThe service addressed concerns raised in an early evaluation and provides evidence that redesigning maternity services to meet the needs of women with a refugee background speaking multiple languages from many countries is possible and promotes access, use, and satisfaction with care, contributing to improved health equity and perinatal outcomes.

A content analysis of women’s experiences of different models of maternity care: the Birth Experience Study (BESt)

BackgroundPregnancy, birth, and early parenthood are significant life experiences impacting women and their families. Growing evidence suggests models of maternity care impact clinical outcomes and birth experiences. The aim of this study was to explore the strengths and limitations of different maternity models of care accessed by women in Australia who had given birth in the past 5 years.MethodsThe data analysed and presented in this paper is from the Australian Birth Experience Study (BESt), an online national survey of 133 questions that received 8,804 completed responses. There were 2,909 open-ended comments in response to the question on health care provider/s. The data was analysed using content analysis and descriptive statistics.ResultsIn models of fragmented care, including standard public hospital care (SC), high-risk care (HRC), and GP Shared care (GPS), women reported feelings of frustration in being unknown and unheard by their health care providers (HCP) that included themes of exhaustion in having to repeat personal history and the difficulty in navigating conflicting medical advice. Women in continuity of care (CoC) models, including Midwifery Group Practice (MGP), Private Obstetric (POB), and Privately Practising Midwifery (PPM), reported positive experiences of healing past birth trauma and care extending for multiple births. Compared across models of care in private and public settings, comments in HRC contained the lowest percentage of strengths (11.94%) and the highest percentage of limitations (88.06%) while comments in PPM revealed the highest percentage of strengths (95.93%) and the lowest percentage of limitations (4.07%).ConclusionsWomen across models of care in public and private settings desire relational maternity care founded on their unique needs, wishes, and values. The strengths of continuity of care, specifically private midwifery, should be recognised and the limitations for women in high risk maternity care investigated and prioritised by policy makers and managers in health services.Trial registrationThe study is part of a larger project that has been retrospectively registered with OSF Registries Registration DOI https://doi.org/10.17605/OSF.IO/4KQXP.

Dietary supplements, guideline alignment and biochemical nutrient status in pregnancy: Findings from the Queensland Family Cohort pilot study.

In high-income nations, multiple micronutrient (MMN) supplementation during pregnancy is a common practice. We aimed to describe maternal characteristics associated with supplement use and daily dose of supplemental nutrients consumed in pregnancy, and whether guideline alignment and nutrient status are related to supplement use. The Queensland Family Cohort is a prospective, Australian observational longitudinal study. Maternal characteristics, nutrient intake from food and supplements, and biochemical nutrient status were assessed in the second trimester (n = 127). Supplement use was reported by 89% of participants, of whom 91% reported taking an MMN supplement. Participants who received private obstetric care, had private health insurance and had greater alignment to meat/vegetarian alternatives recommendations were more likely to report MMN supplement use. Private obstetric care and general practitioner shared care were associated with higher daily dose of supplemental nutrients consumed compared with midwifery group practice. There was high reliance on supplements to meet nutrient reference values for folate, iodine and iron, but only plasma folate concentrations were higher in MMN supplement versus nonsupplement users. Exceeding the upper level of intake for folic acid and iron was more likely among combined MMN and individual supplement/s users, and associated with higher plasma concentrations of the respective nutrients. Given the low alignment with food group recommendations and potential risks associated with high MMN supplement use, whole food diets should be emphasized. This study confirms the need to define effective strategies for optimizing nutrient intake in pregnancy, especially among those most vulnerable where MMN supplement use may be appropriate.

Outcomes and perspectives of woman-newborn dyads following discharge from a quaternary maternity service in Australia: A cross-sectional survey

BackgroundThe average postnatal stay for most Australian mothers is two days. Postnatal length of stay is dependent on various factors, such as maternal preferences, mode of birth or complications following birth. However, little is known about the relationship between these elements. AimTo prospectively explore maternal and neonatal postnatal outcomes within the context of length of stay, model of care and personal expectations and experiences within the first 3–5 weeks following birth. MethodsA cross-sectional study within an urban quaternary Australian hospital was conducted between January 2021 to April 2021. A mixed methods convergent approach was taken. FindingsOf the 1066 questionnaires distributed, 216(20.2%) responses were usable for analysis. Most mothers (82%) were satisfied with their postnatal stay length (range 6–78 h). Models of care (such as GP shared care, midwifery group practice) were not associated with mothers’ satisfaction with their postnatal stay length. Mothers following cesarean section felt less supported, had lower breastfeeding rates and more difficulty accessing postnatal services. Neonatal readmissions (n = 11, 5%) in the first week of life were most often for jaundice, poor feeding or both (n = 7, 64%). Three key themes were generated from the qualitative data and categorised into themes labeled ‘Environmental and healthcare delivery constraints’, ‘Ready or not for discharge’ and ‘Home now, but support missing’. ConclusionParticipants identified that improvements in postnatal care require more than extending in-hospital length of stay. Rather a more individualised woman-centred focus, in-home supported options, with flexibility in timing needed, especially for those following a complicated birth.

Midwifery group practice workforce in Australia: A cross-sectional survey of midwives and managers

BackgroundDespite robust evidence on the benefits of midwifery group practice (MGP), there remains difficulties with implementing and sustaining the model. However, contemporary data on the MGP workforce and how each model has been operationalised are limited. This constrains an understanding of the factors that help or hinder implementation and sustainability of MGP. AimTo describe the characteristics of Australian MGPs and the factors that help or hinder sustainability. MethodsA national cross-sectional survey was undertaken in Australia between March 2021 and July 2022, inclusive. Quantitative data were analysed using descriptive analysis while qualitative data were analysed using content analysis. FindingsOf 669 survey responses, 579 were midwives and 90 were managers. The mean years of experience for clinical midwives was eight years, and 47.8% (almost twice the national average) completed a Bachelor of Midwifery (BMid). Half (50.2%) the models provided care for women of all risk. Midwives resigned from MGP because of the MGP work conditions (30%) and how the service was managed or supported (12.7%). Managers resigned from MGP because of role changes, conflict with their manager, and limited support. Almost half (42.6%) of MGP managers also managed other areas, leading to heavy workloads, competing demands, and burnout. ConclusionThe BMid appears to be a common educational pathway for MGP midwives, and many MGP services are providing care to women with complexities. Flexible practice agreements, organisational support and appropriate workloads are vital for recruitment, retention, and sustainability of MGP.

P3 - Midwifery Group Practice – an essential change in practice for rural women

P3 - Midwifery Group Practice – an essential change in practice for rural women

O7 - Committing to the Change: Rolling out Midwifery Group Practice in Regional South Australia

O7 - Committing to the Change: Rolling out Midwifery Group Practice in Regional South Australia

P8 - Experience and perspective of Midwifery Group practice (MGP) midwives mentoring midwifery students on extended placement

P8 - Experience and perspective of Midwifery Group practice (MGP) midwives mentoring midwifery students on extended placement

O27 - Rural Midwifery Group Practice: Growing Communities and scope-filled graduates

O27 - Rural Midwifery Group Practice: Growing Communities and scope-filled graduates

O31 - Effect of an Australian community-based caseload midwifery group practice service on maternal and neonatal outcomes for women from a refugee background

O31 - Effect of an Australian community-based caseload midwifery group practice service on maternal and neonatal outcomes for women from a refugee background

Creating change with families: Reflections and recommendations for the care of gender diverse and LGBTQIA+ individuals and their families throughout pregnancy and birth

ObjectiveTo derive a deeper understanding of transgender and non-binary people's experience of pregnancy and birth, and ways to modify practice to provide inclusive care. DesignCase study reports describe the experiences of two transgender and non-binary people who received pregnancy and birth care through a Midwifery Group Practice program. SettingA tertiary hospital in metropolitan South Australia with approximately 3800 births per annum. MethodsQualitative methodology, utilising open-ended, semi-structured, face-to-face interviews were undertaken postnatally. Interviews were audio recorded and transcribed verbatim to analyse and identify themes. FindingsBoth clients feared being misgendered within pregnancy care services. They appreciated the constancy of the Midwifery Group Practice midwife, which meant they did not have to repeat their history to multiple health care providers. They appreciated their pronouns being documented on case notes and welcomed staff attempts to use their preferred terms. Both felt the pregnancy care environment was focussed on cisgender females and found this alienating. They appreciated the midwife's suggestion that the cot card for their baby did not have to be pink or blue. They both suggested staff use more gender-neutral language, and resources, when providing pregnancy care. Key conclusionStaff attempted to support these parents, and this was appreciated by them, but the continuity provided by the Midwifery Group Practice model was highly valued by both, regardless of risk status. It was identified that further education for staff was required to facilitate provision of more inclusive care. Implications for practiceThe case studies identified a need for greater awareness and education for staff regarding care provision for transgender and non-binary people. Simple adjustments had a big impact. Further research is needed to identify how best to meet the needs of gender-diverse people and address the educational needs of staff.

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.

Effect of an Australian community-based caseload midwifery group practice service on maternal and neonatal outcomes for women from a refugee background

BackgroundWomen from a refugee background who resettle in high-income countries experience poorer perinatal outcomes in comparison to women from host countries. There is a paucity of research on how best to improve these outcomes. AimTo report on the effectiveness of an Australian Refugee Midwifery Group Practice service on perinatal outcomes. MethodsWe used inverse probability of treatment weighting to balance confounders and calculate treatment effect and compare maternal and neonatal outcomes for women from a refugee background who received Refugee Midwifery Group Practice care (n = 625), to those receiving standard care (n = 634) at a large tertiary hospital (1 January 2016–31 December 2019). Prespecified primary outcomes included: proportion of women attending ≥ 5 antenatal visits, preterm birth (<37 weeks), spontaneous onset of labour, epidural analgesia in the first stage of labour, normal birth (term, spontaneous onset, vertex, spontaneous vaginal birth, no epidural, no episiotomy), and exclusively breast-feeding at discharge. FindingsWomen who received Refugee Midwifery Group Practice care were more likely to have spontaneous onset of labour (adjusted odds ratio 2·20, 95% CI 1·71–2·82; p < 0·0001), normal birth (1·55, 1·23–1·95; p < 0·0001), and less likely to use epidural analgesia (0·67, 0·50–0·89; p = 0·0067) and have a preterm baby (0·60, 0·36–0·99; p = 0·047). There was no difference between groups in women attending ≥ 5 antenatal visits and exclusive breastfeeding at discharge from hospital. DiscussionA Refugee Midwifery Group Practice is feasible and clinically effective. ConclusionSimilar services could potentially improve outcomes for women from a refugee background who resettle in high-income countries.

Implementation barriers and enablers of midwifery group practice for vulnerable women: a qualitative study in a tertiary urban Australian health service

BackgroundMaternity services have limited formalised guidance on planning new services such as midwifery group practice for vulnerable women, for example women with a history of substance abuse (alcohol, tobacco and other drugs), mental health challenges, complex social issues or other vulnerability. Continuity of care through midwifery group practice is mostly restricted to women with low-risk pregnancies and is not universally available to vulnerable women, despite evidence supporting benefits of this model of care for all women. The perception that midwifery group practice for vulnerable women is a high-risk model of care lacking in evidence may have in the past, thwarted implementation planning studies that seek to improve care for these women. We therefore aimed to identify the barriers and enablers that might impact the implementation of a midwifery group practice for vulnerable women.MethodsA qualitative context analysis using the Consolidated Framework for Implementation Research was conducted at a single-site tertiary health facility in Queensland, Australia. An interdisciplinary group of stakeholders from a purposeful sample of 31 people participated in semi-structured interviews. Data were analysed using manual and then Leximancer computer assisted methods. Themes were compared and mapped to the Framework.ResultsThemes identified were the woman’s experience, midwifery workforce capabilities, identifying “gold standard care”, the interdisciplinary team and costs. Potential enablers of implementation included perceptions that the model facilitates a relationship of trust with vulnerable women, that clinical benefit outweighs cost and universal stakeholder acceptance. Potential barriers were: potential isolation of the interdisciplinary team, costs and the potential for vicarious trauma for midwives.ConclusionThere was recognition that the proposed model of care is supported by research and a view that clinical benefits will outweigh costs, however supervision and support is required for midwives to manage and limit vicarious trauma. An interdisciplinary team structure is also an essential component of the service design. Attention to these key themes, barriers and enablers will assist with identification of strategies to aid successful implementation. Australian maternity services can use our results to compare how the perceptions of local stakeholders might be similar or different to the results presented in this paper.

Midwifery continuity of care: A scoping review of where, how, by whom and for whom?

Systems of care that provide midwifery care and services through a continuity of care model have positive health outcomes for women and newborns. We conducted a scoping review to understand the global implementation of these models, asking the questions: where, how, by whom and for whom are midwifery continuity of care models implemented? Using a scoping review framework, we searched electronic and grey literature databases for reports in any language between January 2012 and January 2022, which described current and recent trials, implementation or scaling-up of midwifery continuity of care studies or initiatives in high-, middle- and low-income countries. After screening, 175 reports were included, the majority (157, 90%) from high-income countries (HICs) and fewer (18, 10%) from low- to middle-income countries (LMICs). There were 163 unique studies including eight (4.9%) randomised or quasi-randomised trials, 58 (38.5%) qualitative, 53 (32.7%) quantitative (cohort, cross sectional, descriptive, observational), 31 (19.0%) survey studies, and three (1.9%) health economics analyses. There were 10 practice-based accounts that did not include research. Midwives led almost all continuity of care models. In HICs, the most dominant model was where small groups of midwives provided care for designated women, across the antenatal, childbirth and postnatal care continuum. This was mostly known as caseload midwifery or midwifery group practice. There was more diversity of models in low- to middle-income countries. Of the 175 initiatives described, 31 (18%) were implemented for women, newborns and families from priority or vulnerable communities. With the exception of New Zealand, no countries have managed to scale-up continuity of midwifery care at a national level. Further implementation studies are needed to support countries planning to transition to midwifery continuity of care models in all countries to determine optimal model types and strategies to achieve sustainable scale-up at a national level.