Evaluation of a regional midwifery caseload model of care integrated across five birthing sites in South Australia: Women’s experiences and birth outcomes

IntroductionThe ongoing closure of regional maternity services in Australia has significant consequences for women and communities. In South Australia, a regional midwifery model of care servicing five birthing sites was piloted with the aim of bringing sustainable birthing services to the area. An independent evaluation was undertaken. This paper reports on women’s experiences and birth outcomes.AimTo evaluate the effectiveness, acceptability, continuity of care and birth outcomes of women utilising the new midwifery model of care.MethodAn anonymous questionnaire incorporating validated surveys and key questions from the Quality Maternal and Newborn Care (QMNC) Framework was used to assess care across the antenatal, intrapartum and postnatal period. Selected key labour and birth outcome indicators as reported by the sites to government perinatal data collections were included.FindingsThe response rate was 52.6% (205/390). Women were overwhelmingly positive about the care they received during pregnancy, birth and the postnatal period. About half of women had caseload midwives as their main antenatal care provider; the other half experienced shared care with local general practitioners and caseload midwives. Most women (81.4%) had a known midwife at their birth. Women averaged 4 post-natal home visits with their midwife and 77.5% were breastfeeding at 6–8 weeks. Ninety-five percent of women would seek this model again and recommend it to a friend. Maternity indicators demonstrated a lower induction rate compared to state averages, a high primiparous normal birth rate (73.8%) and good clinical outcomes.ConclusionThis innovative model of care was embraced by women in regional SA and labour and birth outcomes were good as compared with state-wide indicators

‘There is no other option’: Exploring health care providers' experiences implementing regional multisite midwifery model of care in South Australia

IntroductionIn the past 30 years, 60% of South Australia’s rural maternity units have closed. Evidence demonstrates midwifery models of care offer regional Australia sustainable birthing services. Five birthing sites within the York and Northern Region of South Australia, designed in collaboration with key stakeholders, offered a new all-risk midwifery continuity of care model (MMoC). All pregnant women in the region were allocated to a known midwife once pregnancy was confirmed. In July 2019, the pilot program was implemented and an evaluation undertaken.ObjectiveThe study aimed to evaluate the effectiveness, acceptability, and sustainability of the new midwifery model of care from the perspective of health care providers.DesignThe evaluation utilised a mixed methods design using focus groups and surveys to explore experiences of health care providers impacted by the implementation of the MMoC. This paper reports on midwives, doctors and nurses experiences at different time points, to gain insight into the model of care from the care providers impacted by the change to services.FindingsThe first round of focus groups included 14 midwives, 6 hospital nurses/midwives and 5 doctors with the overarching theme that the ‘MMoC was working well.’ The second round of focus groups were undertaken across the five sites with 10 midwives, 9 hospital nurses/midwives and 5 doctors. The overarching theme captured all participants commitment to the MMoC, with agreement that ‘there is no other option - it has to work’.DiscussionAll participants reported positive outcomes and a strong commitment to navigate the changes required to implement the new model of care. Collaboration and communication was expressed as key elements for success. Specific challenges and complexities were evident including a need to clarify expectations and the workload for midwives, and for nurses who were accustomed to having midwives 24 hours a day in hospitals.ConclusionThis innovative model responds to challenges in providing rural maternity care and offers a sustainable model for maternity services and workforce. There is an overwhelming commitment and consensus that there is ‘no other option–it has to work’

Measuring organizational readiness for implementing change (ORIC) in a new midwifery model of care in rural South Australia

BackgroundThe sustainability of Australian rural maternity services is under threat due to current workforce shortages. In July 2019, a new midwifery caseload model of care was implemented in rural South Australia to provide midwifery continuity of care and promote a sustainable workforce in the area. The model is unique as it brings together five birthing sites connecting midwives, doctors, nurses and community teams. A critical precursor to successful implementation requires those working in the model be ready to adopt to the change. We surveyed clinicians at the five sites transitioning to the new model of care in order to assess their organizational readiness to implement change.MethodsA descriptive study assessing readiness for change was measured using the Organizational Readiness for Implementing Change scale (ORIC). The 12 item Likert scale measures a participant’s commitment to change and change efficacy. All clinicians working within the model of care (midwives, nurses and doctors) were invited to complete an e-survey.ResultsOverall, 55% (56/102) of clinicians participating in the model responded. The mean ORIC score was 41.5 (range 12–60) suggesting collectively, midwives, nurses and doctors began the new model of care with a sense of readiness for change. Participants were most likely to agree on the change efficacy statements, “People who work here feel confident that the organization can get people invested in implementing this change and the change commitment statements “People who work here are determined to implement this change”, “People who work here want to implement this change”, and “People who work here are committed to implementing this change.ConclusionResults of the ORIC survey indicate that clinicians transitioning to the new model of care were willing to embrace change and commit to the new model. The process of organizational change in health care settings is challenging and a continuous process. If readiness for change is high, organizational members invest more in the change effort and exhibit greater persistence to overcome barriers and setbacks. This is the first reported use of the instrument amongst midwives and nurses in Australia and should be considered for use in other national and international clinical implementation studies

Examining the transformation of midwifery education in Australia to inform future directions: an integrative review

BackgroundIntegral to quality midwifery practice is the education of midwives. Like other countries, Australia faces ongoing challenges in delivering midwifery education programs. Reasons include escalating program costs, challenges in securing meaningful clinical experiences, subsumption of midwifery with nursing, and associated loss of identity in some institutions.AimTo critically examine the literature exploring the historical and current drivers, supports and impediments for entry-to-practice midwifery programs to identify strategies to strengthen midwifery education in Australia.MethodsA structured integrative literature review using Whittemore and Knafl’s five-stage framework was undertaken; 1) problem identification, 2) literature search, 3) data evaluation, 4) data analysis, and 5) presentation of results.FindingsThe literature search identified 50 articles for inclusion. The thematic analysis identified four key themes: i. a commitment to educational reform, ii. building a midwifery workforce, iii. quality maternity care through midwifery education, and iv. progressing excellence in midwifery education.DiscussionExtensive literature describes the evolution of midwifery education in Australia over the last 30 years. Through collaboration and amidst opposition, quality midwifery education has been established in Australia. Identification of midwifery as a distinct profession and transformative leadership have been integral to this evolution and must be grown and sustained to prevent a decline in standards or quality.ConclusionThere is a need to address priorities in midwifery education and for the evaluation of midwifery programs and pedagogy. The provision and maintenance of quality education and practice require shared responsibility between education providers and health care services

Long-distance migratory shorebirds travel faster towards their breeding grounds, but fly faster post-breeding

Long-distance migrants are assumed to be more time-limited during the pre-breeding season compared to the post-breeding season. Although breeding-related time constraints may be absent post-breeding, additional factors such as predation risk could lead to time constraints that were previously underestimated. By using an automated radio telemetry system, we compared pre- and post-breeding movements of long-distance migrant shorebirds on a continent-wide scale. From 2014 to 2016, we deployed radio transmitters on 1,937 individuals of 4 shorebird species at 13 sites distributed across North America. Following theoretical predictions, all species migrated faster during the pre-breeding season, compared to the post-breeding season. These differences in migration speed between seasons were attributable primarily to longer stopover durations in the post-breeding season. In contrast, and counter to our expectations, all species had higher airspeeds during the post-breeding season, even after accounting for seasonal differences in wind. Arriving at the breeding grounds in good body condition is beneficial for survival and reproductive success and this energetic constraint might explain why airspeeds are not maximised in the pre-breeding season. We show that the higher airspeeds in the post-breeding season precede a wave of avian predators, which could suggest that migrant shorebirds show predation-minimizing behaviour during the post-breeding season. Our results reaffirm the important role of time constraints during northward migration and suggest that both energy and predation-risk constrain migratory behaviour during the post-breeding season

It’s more than just luck: A qualitative exploration of breastfeeding in rural Australia

ProblemDespite significant public health benefits, breastfeeding for six months continues to be challenging for women.BackgroundIn the Mid North of South Australia, healthcare professionals were concerned that breastfeeding rates were lower than the national average and that a collaborative approach was needed to promote breastfeeding.AimTo explore the experiences of women and health professional in the Mid North, to inform interventions to improve breastfeeding longevity.MethodTwo focus groups were conducted to examine breastfeeding experience in the region. Focus group one included nine mothers who had breastfed more than six months and focus group two consisted of ten health professionals from the Mid North. Thematic analysis was used to analyse the data.FindingsTwo overarching themes were identified; ‘breastfeeding: It’s more than just luck’ represented the voices of the mothers and ‘breastfeeding: It’s everybody’s business’ captured the discussion between the health professionals. Women described themselves as lucky while acknowledging that their own persistence, as well as positive support was vital. Health professionals identified education and support as key foci, and a need for a holistic approach to improve breastfeeding rates.DiscussionBreastfeeding should be understood as a relationship, in which broadly applied solutions do not necessarily influence longevity, particularly in rural communities. Strategies should also reflect a realistic picture of breastfeeding and safeguard against idealistic expectation of the experience.ConclusionA holistic approach to improve breastfeeding rates is imperative. One of the most promising antidotes to the breastfeeding dilemma is the provision of midwifery continuity of care

Moral distress in midwifery practice: A concept analysis

Research suggests that the incidence of moral distress experienced by health professionals is significant and increasing, yet the concept lacks clarity and remains largely misunderstood. Currently, there is limited understanding of moral distress in the context of midwifery practice. The term moral distress was first used to label the psychological distress experienced following complex ethical decision-making and moral constraint in nursing. The term is now used across multiple health professions including midwifery, nursing, pharmacy and medicine, yet is used cautiously due to confusion regarding its theoretical and contextual basis. The aim of this study is to understand the concept of moral distress in the context of midwifery practice, describing the attributes, antecedents and consequences. This concept analysis uses Rodgers’ evolutionary framework and is the first stage of a sequential mixed-methods study. A literature search was conducted using multiple databases resulting in eight articles for review. Data were analysed using NVivo12©. Three core attributes were identified: moral actions and inactions, conflicting needs and negative feelings/emotions. The antecedents of clinical situations, moral awareness, uncertainty and constraint were identified. Consequences of moral distress include adverse personal professional and organisational outcomes. A model case depicting these aspects is presented. A midwifery focused definition of moral distress is offered as ‘a psychological suffering following clinical situations of moral uncertainty and/or constraint, which result in an experience of personal powerlessness where the midwife perceives an inability to preserve all competing moral commitments’. This concept analysis affirms the presence of moral distress in midwifery practice and provides evidence to move towards a consistent definition of moral distress

Simulation in midwifery education: A descriptive explorative study exploring students’ knowledge, confidence and skills in the care of the preterm neonate

Undergraduate midwifery programs across Australia have embedded simulation into their curriculum although there is limited but emerging evidence to support the use of simulation as an effective teaching strategy. The purpose of this study was to evaluate the impact that a simulated learning activity (insertion and management of a neonatal nasogastric tube), had on midwifery students' knowledge, confidence and skills post-simulation, and on completion of a clinical placement. A descriptive explorative study was undertaken in two phases. Phase 1: Midwifery students (n = 60) completed a purpose-designed questionnaire to assess their knowledge, confidence and skills, pre and post simulation. Phase 2: Students (n = 46) repeated the questionnaire to reassess their knowledge, confidence and skills after the completion of a neonatal nursery placement. The findings demonstrate that simulation is an effective learning strategy in an undergraduate midwifery program. Students' knowledge, confidence and skills increased significantly post-simulation activity (p0.001). A further increase in these areas was noted post-placement. Key aspects that contributed to student learning included; the demonstrators’ level of knowledge, expertise and currency of practice, as well as the role the student assumes in the simulation activity

Midwifery-led care in South Australia: Looking back to move forward

BackgroundFrom the 1980s to the turn of the century, Australia saw an evolution of midwifery-led models of care, in part due to legislative reform and federal funding, but largely owing to the efforts of strong midwifery leaders and consumers who rallied for the implementation of alternative models of care. Through persistence and extensive collaboration, the first South Australian birth centres were established.AimTo better understand the evolution of midwifery-led care in South Australia and identify the drivers and impediments to inform the upscaling of midwifery models into the future.MethodsSemi-structured interviews were conducted with ten midwifery leaders and/or those instrumental in setting up birth centres and midwifery-led care in South Australia. Data was analysed using thematic analysis.FindingsThree overarching themes and several sub-themes were identified, these included: ‘Midwifery suffragettes’ which explored ‘activism’, ‘adversity’ and ‘advocacy’; ‘Building bridges’ captured the importance of ‘gathering midwives’, a ‘movement of women’ and ‘champions and influencers’; and ‘Recognising midwifery’ identified the strong ‘sense of identity’ needed to outface ‘ignorance and opposition’ and the importance of ‘role reformation’.ConclusionThese midwifery leaders provide insight into an era of change in the history of midwifery in South Australia and contribute valuable learnings. In order to move forward, midwives must continue to embrace the political nature of midwifery, enact authentic, transformational leadership and engage women across all levels of influence. It is critical that midwives pursue equity in professional recognition, work collaboratively to provide quality, woman-centred maternity care and expand midwifery continuity of care models

Exploring moral distress in Australian midwifery practice

ProblemAustralian midwives are considering leaving the profession. Moral distress may be a contributing factor, yet there is limited research regarding the influence of moral distress on midwifery practice.BackgroundMoral distress was first used to describe the psychological harm incurred following actions or inactions that oppose an individuals’ moral values. Current research concerning moral distress in midwifery is varied and often focuses only on one aspect of practice.AimTo explore Australian midwives experience and consequences of moral distress.MethodsSemi-structured interviews were used to understand the experiences of moral distress of 14 Australian midwives. Interviews were recorded and transcribed verbatim. Data were analysed using thematic analysis and NVIVO12©.FindingsThree key themes were identified: experiencing moral compromise; experiencing moral constraints, dilemmas and uncertainties; and professional and personal consequences. Describing hierarchical and oppressive health services, midwives indicated they were unable to adequately advocate for themselves, their profession, and the women in their care.DiscussionIt is evident that some midwives experience significant and often ongoing moral compromise as a catalyst to moral distress. A difference in outcomes between early career midwives and those with more than five years experiences suggests the cumulative nature of moral distress is a significant concern. A possible trajectory across moral frustration, moral distress, and moral injury with repeated exposure to morally compromising situations could explain this finding.ConclusionThis study affirms the presence of moral distress in Australian midwives and identified the cumulative effect of moral compromise on the degree of moral distress experienced