Women's views and experiences of a new Midwifery Group Practice model in rural Australia.

BACKGROUND: Women in rural Australia often have limited maternity care options available, and in Victoria, like many Australian states, numerous small hospitals no longer offer birthing services. AIM: To evaluate women's views and experiences of maternity care at a local rural hospital that re-established birthing services with a Midwifery Group Practice (MGP) model of maternity care. METHODS: Women who booked into the new MGP model from May 2021 to June 2022 were invited to complete an anonymous online survey and participate in an optional additional semi-structured interview to explore their views and experiences. Descriptive statistics were used for quantitative data, and open-ended survey and interview responses were analysed using a general inductive approach. FINDINGS: Sixty-seven percent (44/66) of women completed the survey and five also completed an interview. Women were highly satisfied with the care they received. They felt respected, empowered, and had a sense of agency throughout their pregnancies, labour and birth, and post-birth. They reported low levels of anxiety during labour and birth, and felt that they coped physically and emotionally better than they anticipated. They felt well supported by midwives and highly valued the continuity of care within the MGP model. CONCLUSION: Women's voices play a critical role in informing maternity care provision, particularly for those in rural communities who may have limited access to care options. The findings support and expand on existing research regarding the value of midwifery continuity of care models, and can inform other rural maternity services in introducing similar models.

Identifying women with a disability in Australian maternity services: Time for a change.

It is estimated that over 1 billion people worldwide have a disability. In Australia, 9% of women of childbearing age have a disability, but data on disability status for women accessing maternity services are not routinely collected and data collection processes are inconsistent. Maternal disability may affect perinatal outcomes, but to understand what factors might be amenable to interventions to improve outcomes, accurate data collection on disability status is essential. This opinion piece reflects on disability identification within maternity services in Australia, identifying areas for policy and practice change.

Comparing the views of caseload midwives working with First Nations families in an all-risk, culturally responsive model with midwives working in standard caseload models, using a cross-sectional survey design.

PROBLEM: Little is known about midwives' views and wellbeing when working in an all-risk caseload model. BACKGROUND: Between March 2017 and December 2020 three maternity services in Victoria, Australia implemented culturally responsive caseload models for women having a First Nations baby. AIM: Explore the views, experiences and wellbeing of midwives working in an all-risk culturally responsive model for First Nations families compared to midwives in standard caseload models in the same services. METHODS: A survey was sent to all midwives in the culturally responsive (CR) model six-months and two years after commencement (or on exit), and to standard caseload (SC) midwives two years after the culturally responsive model commenced. Measures used included the Midwifery Process Questionnaire and Copenhagen Burnout Inventory (CBI). FINDINGS: 35 caseload midwives (19 CR, 16 SC) participated. Both groups reported positive attitudes towards their professional role, trending towards higher median levels of satisfaction for the culturally responsive midwives. Midwives valued building close relationships with women and providing continuity of care. Around half reported difficulty maintaining work-life balance, however almost all preferred the flexible hours to shift work. All agreed that a reduced caseload is needed for an all-risk model and that supports around the model (e.g. nominated social workers, obstetricians) are important. Mean CBI scores showed no burnout in either group, with small numbers of individuals having burnout in both groups. DISCUSSION AND CONCLUSION: Midwives were highly satisfied working in both caseload models, but decreased caseloads and more organisational supports are needed in all-risk models.

Accurate identification and documentation of First Nations women and babies attending maternity services: How can we 'close the gap' if we can't get this right?

BACKGROUND: Policies and strategies addressing the health inequities experienced by First Nations peoples are critical to ensuring the gap in outcomes between First Nations and non-Indigenous peoples is closed. The identification of First Nations peoples is vital to enable the delivery of culturally safe and sensitive health care. Complete and accurate health data are essential for funding and evaluation of such initiatives. AIMS: To describe the processes used and accuracy of identification and documentation of First Nations mothers and babies during the period of the implementation of a culturally responsive caseload model of maternity care at three major metropolitan maternity services in Melbourne, Australia. MATERIALS AND METHODS: A cross-sectional study was conducted using administrative and clinical data. RESULTS: There was variation in when and how First Nations identification was asked and documented for mothers and babies. Errors included 14% of First Nations mothers not identified at the first booking appointment, 5% not identified until after the birth and 11% of First Nations babies not identified in the Victorian Perinatal Data Collection documentation. Changes to documentation and staff education were implemented to improve identification and reduce inaccuracies. CONCLUSIONS: To improve disparities in health outcomes, mainstream health services must respond to the needs of First Nations peoples, but improved care first requires accurate identification and documentation of First Nations peoples. Implementing and maintaining accuracy in collection and documentation of First Nations status is essential for health services to provide timely and appropriate care to First Nations people and to support and grow culturally appropriate and safe services.

Evaluating the impact of a maternity and neonatal emergencies education programme in Australian regional and rural health services on clinician knowledge and confidence: a pre-test post-test study.

INTRODUCTION: Almost 78 000 women gave birth in the state of Victoria, Australia, in 2019. While most births occurred in metropolitan Melbourne and large regional centres, a significant proportion of women birthed in rural services. In late 2016, to support clinicians to recognise and respond to clinical deterioration, the Victorian government mandated provision of an emergency training programme, called Maternity and Newborn Emergencies (MANE), to rural and regional maternity services across the state. This paper describes the evaluation of MANE. DESIGN AND SETTING: A quasi-experimental study design was used; the Kirkpatrick Evaluation Model provided the framework. PARTICIPANTS: Participants came from the 17 rural and regional Victorian maternity services who received MANE in 2018 and/or 2019. OUTCOME MEASURES: Baseline data were collected from MANE attendees before MANE delivery, and at four time points up to 12 months post-delivery. Clinicians' knowledge of the MANE learning objectives, and confidence ratings regarding the emergencies covered in MANE were evaluated. The Safety Attitudes Questionnaire (SAQ) assessed safety climate pre-MANE and 6 months post-MANE among all maternity providers at the sites. RESULTS: Immediately post-MANE, most attendees reported increased confidence to escalate clinical concerns (n=251/259). Knowledge in the non-technical and practical aspects of the programme increased. Management of perinatal emergencies was viewed as equally stressful pre-MANE and post-MANE, but confidence to manage these emergencies increased post-delivery. Pre-MANE SAQ scores showed consistently strong and poor performing services. Six months post-MANE, some services showed improvements in SAQ scores indicative of improved safety climate. CONCLUSION: MANE delivery resulted in both short-term and sustained improvements in knowledge of, and confidence in, maternity emergencies. Further investigation of the SAQ across Victoria may facilitate identification of services with a poor safety climate who could benefit from frequent targeted interventions (such as the MANE programme) at these sites.

Who is at risk of burnout? A cross-sectional survey of midwives in a tertiary maternity hospital in Melbourne, Australia.

BACKGROUND: Burnout is an occupational phenomenon with the potential to affect a person's physical and mental health, job satisfaction and quality of work. There is evidence of burnout occurring in the midwifery profession, but inadequate data on the prevalence of, and the factors associated with, burnout. AIM: Identify the prevalence of burnout in a population of midwives and explore what individual and workforce characteristics, and what occupational stressors, were associated with burnout. METHODS: A cross-sectional survey of permanently employed midwives was conducted in a tertiary maternity service in Melbourne, Australia in 2017. Data collected included individual and workforce-related characteristics and occupational stressors. Burnout was explored using the Copenhagen Burnout Inventory. Univariate and multivariate analyses were conducted to ascertain associations between respondents' characteristics, stressors, and burnout levels. FINDINGS: A total of 257/266 midwives (97%) responded. There were significant levels of exhaustion and fatigue among respondents; 68% of midwives were experiencing personal burnout, 51% work-related burnout, and 10% were experiencing client-related burnout. Being aged ≤ 35 years, and/or having inadequate support was associated with personal and work-related burnout. Having inadequate acknowledgement was associated with client-related burnout. CONCLUSION: Health services need to understand the risk factors for burnout among midwives, identify and support groups that are most vulnerable, and address areas that are amenable to intervention. In our context this means ensuring midwives receive adequate acknowledgement and support, particularly younger midwives. These findings need to be tested in other settings to help inform a broader understanding and ensure the sustainability of the midwifery profession.

Perinatal outcomes of women with a disability who received pregnancy care through a specialised disability clinic in Melbourne, Australia.

BACKGROUND: In Australia, it is estimated that 9.5% of women of childbearing age have a disability; however, little is known about their perinatal outcomes. Disability status is not routinely recorded in perinatal datasets. AIMS: To compare the outcomes of women with a disability who received pregnancy care through a specialised disability clinic at the Royal Women's Hospital (the Women's) in Melbourne, Australia with hospital-wide perinatal outcome data. MATERIALS AND METHODS: Routinely collected perinatal data for women who received pregnancy care from the 'Women with Individual Needs' (WIN) clinic from 2014-2018 (N = 111) were analysed and then compared with routinely collected electronic hospital data obtained from all women who had given birth at the Women's in 2017 and 2018 (N = 15 024). RESULTS: Women who attended the WIN clinic were more likely to have a caesarean section birth (52% vs 32%; P < 0.001) and give birth preterm (17% vs 4%; P < 0.001) than those in the hospital-wide cohort. Their infants were more likely to be low birthweight (20% vs 9%; P < 0.001), require resuscitation (35% vs 11%; P < 0.001), be admitted to the Neonatal Intensive Special Care Unit (29% vs 13%; P < 0.001) and receive formula in hospital (54% vs 28%; P < 0.001) compared to infants in the other group. CONCLUSIONS: Routine maternity data collection should include identification of women with a disability to enable appropriate support and to allow further exploration of potential poorer outcomes on a larger sample, to help identify factors amenable to interventions that may improve outcomes.

Using the Kirkpatrick Model to evaluate the Maternity and Neonatal Emergencies (MANE) programme: Background and study protocol.

INTRODUCTION: Over 310 000 women gave birth in Australia in 2016, with approximately 80 000 births in the state of Victoria. While most of these births occur in metropolitan Melbourne and other large regional centres, a significant proportion of Victorian women birth in local rural health services. The Victorian state government recently mandated the provision of a maternal and neonatal emergency training programme, called Maternal and Newborn Emergencies (MANE), to rural and regional maternity service providers across the state. MANE aims to educate maternity and newborn care clinicians about recognising and responding to clinical deterioration in an effort to improve clinical outcomes. This paper describes the protocol for an evaluation of the MANE programme. METHODS AND ANALYSIS: This study will evaluate the effectiveness of MANE in relation to: clinician confidence, skills and knowledge; changes in teamwork and collaboration; and consumer experience and satisfaction, and will explore and describe any governance changes within the organisations after MANE implementation. The Kirkpatrick Evaluation Model will provide a framework for the evaluation. The participants of MANE, 27 rural and regional Victorian health services ranging in size from approximately 20 to 1000 births per year, will be invited to participate. Baseline data will be collected from maternity service staff and consumers at each health service before MANE delivery, and at four time-points post-MANE delivery. There will be four components to data collection: a survey of maternity services staff; follow-up interviews with Maternity Managers at health services 4 months after MANE delivery; consumer feedback from all health services collected through the Victorian Healthcare Experience Survey; case studies with five regional or rural health service providers. ETHICS AND DISSEMINATION: This evaluation has been approved by the La Trobe University Science, Health and Engineering College Human Ethics Sub-Committee. Findings will be presented to project stakeholders in a deidentified report, and disseminated through peer-reviewed publications and conference presentations.

Operationalising caseload midwifery in the Australian public maternity system: Findings from a national cross-sectional survey of maternity managers.

BACKGROUND: Despite high-level evidence of the benefits of caseload midwifery for women and babies, little is known about specific practice arrangements, organisational barriers and facilitators, nor about workforce requirements of caseload. This paper explores how caseload models across Australia operate. METHODS: A national cross-sectional, online survey of maternity managers in public maternity hospitals with birthing services was undertaken. Only services with a caseload model are included in the analysis. FINDINGS: Of 253 eligible hospitals, 149 (63%) responded, of whom 44 (31%) had a caseload model. Operationalisation of caseload varied across the country. Most commonly, caseload midwives were required to work more than 0.5 EFT, have more than one year of experience and have the skills across the whole scope of practice. On average, midwives took a caseload of 35-40 women when full time, with reduced caseloads if caring for women at higher risk. Leave coverage was complex and often ad-hoc. Duration of home-based postnatal care varied and most commonly provided to six weeks. Women's access to caseload care was impacted by many factors with geographical location and obstetric risk being most common. CONCLUSION: Introducing, managing and operationalising caseload midwifery care is complex. Factors which may affect the expansion and availability of the model are multi-faceted and include staffing and model inclusion guidelines. Coverage of leave is a factor which appears particularly challenging and needs more focus.

Understanding the 'work' of caseload midwives: A mixed-methods exploration of two caseload midwifery models in Victoria, Australia.

BACKGROUND: Caseload midwifery models are becoming more common in Australian maternity care. Little is known about how caseload midwifery compares with mainstream models of midwifery care in terms of both the organisation of the work and the meaning of the work for caseload midwives. AIM: To explore caseload and standard care midwives' views and experiences of midwifery work in two new caseload models in Victoria, Australia. METHODS: A mixed-methods approach was used. Quantitative data were collected using two cross-sectional surveys of midwives at the two study sites at the commencement of the caseload model and after two years. Qualitative data were collected using in-depth interviews with caseload midwives six months and two years after commencing in the role. Content analysis was used to analyse open-ended survey questions, and interview data were analysed thematically. Themes arising from these data sources were then considered using Normalization Process Theory. FINDINGS: Two themes emerged from the data. Caseload midwifery was a 'different' way of working, involving activity-based work, working on-call, fluid navigation between work and personal time and avoiding burnout. Working in caseload was also perceived by caseload midwives to be 'real' midwifery, facilitating relationships with women, and requiring responsibility, accountability, autonomy and legitimacy in their practice. Perceptions of caseload work were influenced by understanding these differences in caseload work compared to mainstream maternity care. CONCLUSION: Increased understanding of the differences between caseload work and mainstream maternity models, and introducing opportunities to be exposed to caseload work may contribute to sustainability of caseload models.

Comparing satisfaction and burnout between caseload and standard care midwives: findings from two cross-sectional surveys conducted in Victoria, Australia.

BACKGROUND: Caseload midwifery reduces childbirth interventions and increases women's satisfaction with care. It is therefore important to understand the impact of caseload midwifery on midwives working in and alongside the model. While some studies have reported higher satisfaction for caseload compared with standard care midwives, others have suggested a need to explore midwives' work-life balance as well as potential for stress and burnout. This study explored midwives' attitudes to their professional role, and also measured burnout in caseload midwives compared to standard care midwives at two sites in Victoria, Australia with newly introduced caseload midwifery models. METHODS: All midwives providing maternity care at the study sites were sent questionnaires at the commencement of the caseload midwifery model and two years later. Data items included the Midwifery Process Questionnaire (MPQ) to examine midwives' attitude to their professional role, the Copenhagen Burnout Inventory (CBI) to measure burnout, and questions about midwives' views of caseload work. Data were pooled for the two sites and comparisons made between caseload and standard care midwives. The MPQ and CBI data were summarised as individual and group means. RESULTS: Twenty caseload midwives (88%) and 130 standard care midwives (41%) responded at baseline and 22 caseload midwives (95%) and 133 standard care midwives (45%) at two years. Caseload and standard care midwives were initially similar across all measures except client-related burnout, which was lower for caseload midwives (12.3 vs 22.4, p = 0.02). After two years, compared to midwives in standard care, caseload midwives had higher mean scores in professional satisfaction (1.08 vs 0.76, p = 0.01), professional support (1.06 vs 0.11, p <0.01) and client interaction (1.4 vs 0.09, p <0.01) and lower scores for personal burnout (35.7 vs 47.7, p < 0.01), work-related burnout (27.3 vs 42.7, p <0.01), and client-related burnout (11.3 vs 21.4, p < 0.01). CONCLUSION: Caseload midwifery was associated with lower burnout scores and higher professional satisfaction. Further research should focus on understanding the key features of the caseload model that are related to these outcomes to help build a picture of what is required to ensure the long-term sustainability of the model.

Sources of information used by women during pregnancy to meet their information needs.

AIM OF THE STUDY: to explore the information sources used by women during pregnancy to meet their information needs regarding pregnancy, birth and the postpartum period. DESIGN: a cross-sectional postal survey of all eligible women who birthed at the Royal Women's Hospital, Melbourne, Australia between November 2010 and January 2011. Surveys were sent at four months post partum. FINDINGS: forty-seven per cent (350/752) of eligible women returned the surveys, of whom 62% were primiparous. 'Discussion with a midwife' was the source of information used by the greatest number of women during pregnancy (246/350, 70%). Less than half of the women used the internet to access information (154/350, 44%), and group information sessions were the least preferred information format (8/330, 2.4%). Women from non-English speaking backgrounds (NESB) were less likely to use written and online resources. One-third of the women had unmet learning needs, particularly in relation to breast feeding and postnatal recovery. Overall, women rated books as the most useful source of information (57/332, 17.2%). The model of pregnancy care influenced the source women rated as most useful. Women who received most of their pregnancy care from a midwife described discussion with a midwife as their most useful source of information (42/150, 28%). In contrast, of the group who received most of their care from a doctor in antenatal clinic, the largest proportion reported that the internet was their most useful source of information (10/57, 28%). CONCLUSION AND RECOMMENDATIONS: discussion with midwives is an important source of information for women. The internet did not play a significant role in information seeking for more than half of the women in the study. Existing sources of information may not meet the needs of women from NESB, either because women do not access the multilingual resources currently available or because resources may only be provided in English or a few other common languages.