The Challenges of Midwifery Practice in Australia

Summary
The midwifery profession in Australia is aimed at meeting the needs of women and ensuring that good standard of care and best practices are provided by its members.

A widespread expectation of a Physician-accoucheur, accentuated by a lack of recognition of midwives as parallel professionals, as we as the limited opportunities for professional development, are significant barriers.

It is important for midwives to develop their skills and take on more responsibilities in order to achieve the full role expected of them.

Background
Australia is a continent with an estimated size of 768,684km square and a population of just over 21.5 million people¹.

The country is made up of six states and two territories, these states and territories have their own health ministers, with a national health minister at the Federal level.

The states and territories are primarily responsible for the delivery and management of the public health services and the regulation of healthcare providers.

Introduction
The Australian Nursing and Midwifery council is a statutory body which regulates the practice of nursing and midwifery at the national level, with members from all the states and territories.

Apart from the Australian College of Midwives, there are other non-profit Midwifery organisations who continue to draw attention to the mother-baby-family friendly, safe, but neglected relevance of the profession and its members.

Places of employment ranges from the public sector, where a large number of midwives practice and a small number in the communities and the private sector.

Most of the midwives are located in the cities and bigger towns (working in the private and public sectors) with very few in the remote areas of the country.

This article will discuss the practice and challenges in the areas of team working, workload, remote community practice, midwifery training and continuous professional development.

Midwifery in the public sector
In recent years, the Australian maternity service has been under significant critical review, with policies recommending changes in model of care and in professional relationships^2,3.

In the public sector where midwives are expected to be the primary carers, Obstetricians continue to remain the main caregivers. This is so, even if they are low risk obstetric patients. Physicians are involved in the antenatal, intrapartum as well as the postnatal care – making one wonder what role the midwife has!

Australian midwives appear to recognise that fulfilling their roles in relation to the international definition of the Midwife may not always possible, as considerable barriers exist.

There are deeply-entrenched hierarchies which require modification with more modern work models of management. However, hospitals need to respond by implementing roles and restructuring jobs which would enhance the role played by midwives.

Reiger et al (2006) identifies this, especially with the idea of obstetricians managing low-risk intrapartum care².

The variation is remarkable, compared to some western countries where Midwives and Obstetricians work together as a team.

Midwifery autonomy is less recognised nor supported in Australia. Midwives are hardly given any opportunity to practice what they have learnt during their training. Many therefore lack the confidence to give the required care and practice to their full potential.

There are instances where doctors get very upset and unhappy with midwives when they are not called to be present for low risk deliveries in the public sector. In the same vein, many low risk women have wondered when the Obstetrician would come to review them or even demanding that doctors to be called in to take their delivery!

This overwhelming perception that an Obstetrician is a sine qua non of safe childbirth tends to trivialise the place of the Midwife -at least to a good number of the Australian public.

Creswell A. (2009) wrote:” Obstetricians have stepped up their counter attack against a push to give midwives a bigger role, claiming dire consequences will result if a federal review recommends midwives to practice with inadequate medical supervision…”

Creswell added that some doctors know that the midwife focused model of care would lead to less intervention, but are Australian Obstetricians prepared to accept this⁴?

Remote area midwifery
The vast nature of the Australian continent with large regions, small scattered communities and the remote and isolated areas makes practicing midwifery a challenge⁵.

Choices of midwifery care are limited due to the geographical location so that though midwives offer some form of care, this does little for women who want to access community care. Women who live in these remote places generally have very limited antenatal care, compared to those in the more accessible areas.

The invisibility of midwifery in the community was identified as a significant barrier which ensures ongoing strategic control of the maternity services, and a denial of the rights of consumers to access midwifery care⁶.

As much as midwives will like to give the best care to all women in their own communities, this is not always possible because, sometimes, these women have to travel long distance to access these services.

Working in remote areas is unique and challenging. Sometimes one has to work in dangerous or isolated environments to provide a diverse range of healthcare including midwifery services. These areas include the aboriginal communities, with their unique culture.

It is therefore necessary that midwives who work in these areas be informed about how to give culturally sensitive and acceptable care to the women.

The state governments have made provisions for women to access these health care facilities, but more incentives are needed to attract midwives to these areas.

In the aboriginal communities, midwives and obstetricians usually run antenatal clinics alternatively, but some of the women either do not turn up or do regularly miss clinics.

Women in remote areas are frequently advised to move to the larger towns with easy access to hospital care when they are 37 weeks pregnant, and beyond. This is to enable quick access to emergency care.

This usually poses problems with accommodation; especially, in the absence of family in these towns. Relations and husbands left at home are quite affected by this family disruption, as are the women, who feel lonely and isolated.

Workload and expectation
The workload and the code of practice in the maternity hospitals in Australia are not different from other developed countries. However, in some of the hospitals in Australia, midwives are also expected to look after gynecological, surgical and sometimes paediatric patients who are admitted to ‘maternity wards’ quite regularly, because of ‘bed crises’ .

One could say that since these midwives are also trained General Nurses, this should not be a difficult task. Although midwives are usually happy to manage such patients, no regular training sessions and updates exists for them about taking up such responsibilities.

There is a high expectation of achieving baby friendly units in the country yet it is difficult to educate and support women to establish breastfeeding because of the divided attention to non obstetric clients.

Shortage of midwives is a real problem. The few who are around, have to cope with a large workload, doing overtime and eventually taking sick off, putting additional strain and pressure on the already tired and available few staff.

Due to limited services available in the communities, certain roles like the newborn hearing test and the neonatal screening test which could be carried out in the communities are otherwise expected to be performed by the midwives in the hospital before discharge.

Challenges faced by student midwives
The challenges faced by students are different. It is fair to say there are some challenges that student’s face which is unavoidable. However, these problems are more accentuated in Australia because of the land area and the population variations.

One major challenge is the demand for student positions compared to the number of courses available. There are courses throughout Australia, however, the spaces are extremely limited and the areas of highest populations are much harder to get in to. Often, students will have to relocate in order to obtain a student position. Because of the distance between cities, this can mean moving to another state, or even the other side of the country.

Student midwives sometimes have to move over 1700km in order to be able to undertake their studies. To overcome this problem, many universities now offer a distance learning curriculum, to allow students work at hospitals where there are openings available.

This opens creates another difficulty in the learning process.

In order to have a successful distance program, there needs to be a strong Midwife Link Academic (MLA) from the university and a strong Midwife Student Coordinator (MSC) at the hospital in which the student is employed. The MLA’s job is to liaise with the student and the facility to negotiate clinical hours, clinical support, completion of clinical requirements, as well as ensuring that the student is working in a safe environment. The MLA also assists with problems or concerns about negotiating contracts for community rotations.

The MSC’s role is to ensure that the students have preceptors or mentors to work alongside, provide supportive education, and provide support whilst on the job and to ensure that the students are acting safely within their clinical placements.

If either one of these is not present or not up to the challenges they face while supporting students in remote areas, then the student inevitably suffers.

During the first month of the midwifery placement, some students are lucky enough to be strongly supported by senior midwives working in the units. Students are not assigned to preceptors or mentors. This they find extremely challenging in the first few weeks of their entry. At the same time, these students are rostered as part of normal staff because they are registered nurses.

Whilst some students are fortunate to have wonderful and supportive MLA’s, some from other universities are not. This may frequently contribute to drop-out rates in the program within the first few months of training.

A deficit in cultural training has been on the forefront of discussions, and has been a main focus for many universities. Australia has a vast number of immigrants from many different cultures living here, and many of the pre-existing programs barely skim the subject of cultural awareness. The rewritten programs are now provide curricula in which cultural practices, diversity and awareness is emphasised.

Some of the reasons why students choose specific universities are because some of these universities have designed their program to focus on rural, remote and indigenous studies. This course and the rural rotations have been useful in helping students to develop a more rounded, and culturally competent midwifery practice. The reality is that no matter where you live, you will always encounter people of different races, cultures, belief and tradition. If we can’t provide culturally sensitive care, then we are falling short in our responsibility to the woman and her family.

Continuing professional development for midwives
Though the state governments have made funds available for professional development for nurses and midwives, there were no specific midwifery continuous professional development programs available until the launching of MidPlus in 2007.

MidPlus, which is a national CPD launched by the Australian College of Midwives is to help midwives plan and participate in continuing professional development activities that are relevant to their learning needs and their practice role.

The program also establishes a national validated process for assessing the ongoing competence of midwives and will help to reinforce responsibility and accountability in the provision of quality midwifery care through safe and effective practice⁷.

Conclusion
There is a need for midwives to ensure consistent standards of training and practice, and for midwives to gain the trust and respect that they deserve.

Midwives need to develop their skills, be more confident in order to take more responsibility towards the care of the pregnant women and assume a more advocacy role and be able to help women make informed decisions.

Amidst all the frustration, midwives are turning things round for the better.

The recent commissioning of birth centres in some parts of the country is giving them the opportunity to work confidently to their full potential, away from the shadows.

To enable midwives to function better, state governments needs to review and replace traditional hierarchies and rivalries with a collaborative relationship.

This will ultimately promote a better team working environment and safer and fulfilling maternal care.

References

1. Australian Bureau of statistics (2006)
2. Reiger K. Neoliberal quickstep contradictions in Australian midwifery care policy. Health Sociology Review (Oct. 2006) vol.15 (4) 330-340.
3. Lane K. The plasticity of professional boundaries: a case study of collaborative care in maternity services. Health Sociology Review (Oct 2006) 15(4) 341-352.
4. Creswell A. Doctors firm against role of midwives, The Australian (Jan. 2009)
5. Glover P. Midwifery practice in Australia. British Journal of Midwifery (June 2002) 10(6) 397.
6. Brodie P. Addressing the barriers of midwifery: Australian midwives speaking out. Australian College of Midwives Journal (2001) 15 (3) 5-14.
7. Griffiths M. Homer C. Developing a review process for Australian midwives: A report of the midwifery practice review project process. Women Birth (2008) 21(3) 119-25.