4 Introducing continuity of care in mainstream maternity services: building blocks for success
Previous chapters have provided an overview of the ways that midwifery continuity of care can be provided, the evidence to inform development, and a mapping process that could be used in the planning phases. Chapter 3 took you through a step-by-step process to understand your context or environment before you start the process of change. The next step is the actual process of getting started. That is the focus of this chapter, which draws on examples and experiences from different settings.
One of the first steps in planning and putting down the building blocks for success is understanding your community and then preparing your organisation and midwives. Adequate preparation of the midwives who are going to work in midwifery continuity of care is essential and one of the keys to success. The heart of the continuity of care model is the ‘relationship’. Developing the skills to work in a close relationship with women, midwives and others is not always simple or straightforward. There may be learning that needs to occur to achieve professional relationships that do not become co-dependent or unnecessarily burdensome. For many midwives, working in a close relationship with women and other midwives in a group practice or team is a new experience. There are important skills to develop in order to ensure that partnerships are effective and not co-dependent. These issues are addressed in some detail later in this chapter.
In planning any new midwifery continuity of care model it is important to involve women who use maternity services. This means engaging women in your planning process who have used, currently use or potentially will use services. We suggest you avoid a situation where you have one token consumer on a steering group or working party if you are serious about consumer representation and participation; at least four is a more suitable number and in some situations it may be appropriate to have at least half of your steering group made up of local maternity service users. You can approach local voluntary or non-government organisations for representatives, but advertising in the local paper or putting up notices in a community centre or health centre can be useful. You may also want to think about approaching women who have recently given birth with your service and inviting them directly, particularly if you want to involve women from specific culturally and linguistically diverse (CALD) communities.
Finding out what women want from maternity services can be fraught with difficulty if women have not had the opportunity to know what might be possible and have never experienced midwifery continuity of care or the service you are considering setting up. It is sometimes hard to imagine a type of care if you have never had it or even heard about it. Sometimes you need to develop an information leaflet describing options and addressing potential concerns. This was particularly important when we were implementing a project that included homebirth as an option in an area where it had only previously been available privately through independent midwifery services. The information leaflet in Box 1 was designed by a multidisciplinary steering group that included four consumers. This group met regularly for two years in order to set up the first publicly-funded homebirth service in one Australian state. Many people, including consumers, midwives, obstetricians, the ambulance service, the risk management group and the occupational health and safety service, were consulted about the leaflet. The leaflet draws on the MIDIRS ‘Informed Choice’ leaflets (MIDIRS 2007), a useful resource whenever you have the task of designing an information leaflet. As you can see, it also provides websites so that people can search for more information if they wish to.
Box 1 Sample information leaflet developed for women accessing publicly-funded homebirth services
According to research, homebirth is as safe as hospital birth for women who do not have complications, including women having their first babies. Where homebirth is backed up by a supportive hospital system, there is no evidence to suggest that choosing to give birth at home is unwise for the majority of women with straightforward pregnancies. In South East Sydney Illawarra Area Health Service, we can now offer women who have a healthy pregnancy and are anticipating a normal birth the option to plan for a homebirth with known midwives.
Deciding where you will feel most comfortable and safe to labour and give birth is an important individual decision. In Australia, people tend to assume you will have your baby in hospital. For a long time, it was mistakenly thought that hospitals were safer than home and so now homebirth has become a rare event. It is sometimes hard to keep sight of the fact that birth is a normal, healthy, life event and that giving birth at home is a perfectly reasonable choice for most women.
When making choices about where you will feel safe to have your baby, it is important to remember that midwives are trained to deal with emergencies in any setting. In the very unlikely situation where an emergency arises at a homebirth, midwives have all the necessary equipment and emergency drugs with them to respond safely. Two midwives will attend your birth. They will have good support from the ambulance service and from doctors in the hospital, should transfer to hospital be necessary. It may be worth remembering that women who give birth at home find it much easier to manage their pain in the comfort and security of their own homes. They describe a sense of control in their familiar surroundings and a feeling that birth at home is very much a ‘family event’.
Occasionally women develop complications during pregnancy, in labour, or in the period following birth, where they need access to specific care that is only available within a hospital environment. Therefore, even if you have chosen to have your baby at home, if complications arise at any stage your midwife will discuss the situation fully with you. She may advise consultation with an obstetrician or transfer to the hospital. In addition, there may be situations due to unforeseen circumstances such as staffing issues when the hospital is unable to accommodate birth at home and you will be requested to come to the hospital for the birth. It is anticipated that these occasions will be rare and we request your patience and understanding if the situation arises. The midwives will inform you as soon as they are aware of the possibility.
During your pregnancy you will be receiving antenatal care from a small number of midwives. You will be allocated a primary midwife who will take responsibility for coordinating your care. She will ensure that another midwife is on-call for you whenever she is unavailable.
If your decision is to give birth at home, your midwife will ask you to sign a form indicating that you have read this information leaflet and that you are informed about the benefits and risks associated with place of birth. In addition, it is advised that, in order to build up a trusting relationship with your midwives, you commit to attending your antenatal visits.
When you are about 36 weeks pregnant, your midwife will come and visit you at home for your antenatal visit. This will give her a chance to see where you live and to make plans with you for the labour and for support in the days following birth. It is your responsibility to ensure your home environment is safe for the midwives to work in and to alert the midwives to any possible dangers. At this visit, she would like to meet anyone else who will be attending the birth. Please make sure your support people also read this information sheet so that they can be fully involved in discussions. We will ask them to sign a form acknowledging that their role is to provide physical and emotional support during labour and/or to take care of any children who may be present.
Two midwives will always be available for you during your labour. Once you feel that labour is established and that you would like the midwives to be with you, they will come to your home. There are a lot of advantages in staying at home, such as sleeping undisturbed while labour is getting established, watching television or listening to music, using a water pool, bath or shower, and moving freely around your home.
The midwives will bring with them all the equipment that is needed for a safe birth. They will be observing your labour and your baby’s heart rate. If they are concerned about the progress of your labour or the health of your baby, they will discuss this with you and may recommend transfer to hospital. The most common reason for transferring is a labour that does not appear to be progressing. In this situation women usually need help in the form of medication to make the contractions stronger, and often they proceed to have a normal birth in hospital.
The midwives will stay with you in the immediate period after the birth to provide support especially during the baby’s first feed. The midwives will then continue to visit you at home after the birth. They will come every day in the first couple of days and then less frequently depending on how everything is going. Most women will have visits up to 10 days. The postnatal visits can extend if you are having any difficulties with the baby. After this the child and family health nurse will be available for you at your local clinic.
If you want to talk more about homebirth, please feel free to discuss this with your midwife or doctor. If you want to read more about the research regarding homebirth, you can access the Cochrane Library online on http://cochrane.org/index.htm (please note: in Australia there is free access to the Cochrane Library but this may not be available in all countries) and then type in ‘home versus hospital birth’ in the search space. This review will give you the latest evidence about homebirth.
In addressing local need, you do not necessarily need to do a specific study in order to gather women’s views. Conducting surveys, even small ones, is a big undertaking and if you decide that this is necessary, make sure you find some assistance or support in the design, conduct and analysis. At a minimum though, you should consider the demographics of your area or region and have an idea of what women generally want from maternity services and what is already on offer.
Demographic information can be obtained from annual reports or statistics from your hospital, census documents, in the national reports on maternal and child health, or from a general review of the type of women who access your service. Data might include the average age of women, parity, country of birth, language spoken at home and private–public distribution. This information will help you work out what the new project will need to address. For example, if you have a high proportion of women from a particular cultural or linguistic community, you will need to tailor your new project to specifically meet their needs.
Examining research that indicates what most women want from maternity services will help your planning and development process. There are a number of excellent reports in relation to women’s views about maternity care. In Australia, the research from the Centre for the Study of Mothers’ and Children’s Health in Melbourne has provided valuable insights into women’s views about their maternity care over the last decade (Brown et al. 1999, Brown & Lumley 1994, Laslett et al. 1997). Examples in the United Kingdom include ‘Are women getting the birth environment they need?: a report of a national survey of women’s experiences’ published by the National Childbirth Trust (Newburn & Singh 2005) and ‘Recorded delivery: a national survey of women’s experiences of their care 2006’ (Garcia et al. 2007). In New Zealand, the views of 2909 women who gave birth in February and March 2002 were reported in ‘Maternity services consumers survey’ (NZ Ministry of Health 2002). Finally, in Canada, more than 6000 women responded to a national survey about knowledge, experiences and practices in relation to maternity service provision (Canadian Perinatal Surveillance System 2007).
All of these surveys and reports highlight women’s appreciation of midwifery continuity of care and are useful documents to explore, particularly when making the case for developing a new project. Along with citation of local health department policy documents, the results of surveys often form an important part of your argument in a proposal. The starting point always has to be related to improving services for local women with an emphasis on the advantages of midwifery as a public health strategy (Foureur 2005).
Another way to gather information on what the women in your area want from maternity services is to engage in a process of community consultation. This might mean you holding a meeting in a local hall and inviting members of the community to come along and present their views and ideas. You may want to involve your local council, church groups, women’s groups or playgroups. You could also hold a discussion group in your maternity unit or write an article in your local newspaper asking the community for their opinions. Again, this process should involve making sure that women are able to access information setting out potential possibilities in order to avoid the oft-quoted phrase ‘Women don’t know what it is they don’t know’.
Working in partnership with women to bring about changes to maternity services can be very powerful. For example, in New Zealand, midwives joined with women to bring about significant changes to midwifery and the provision of maternity care. In 1988, the New Zealand College of Midwives was formed with a conscious decision to involve consumers as partners within the organisation (Donley 1985, 1989, 1998). Women and midwives worked together to bring about legislative changes which ultimately meant that women would be able to choose a publicly funded, lead maternity carer (LMC) for their total care throughout pregnancy, labour and birth, and the postnatal period. The LMC may be a midwife, general practitioner or obstetrician. The changes in funding arrangements meant that midwives would be able to practise autonomously, and gain independence from the medical profession (Guilliland & Pairman 1995). The New Zealand experience of women and midwives working together is a powerful example of the value and importance of consumer partnership (Leap & Pairman 2006, Pairman & McAra-Couper 2006).
More information about the process of understanding your community, including addressing hurdles, barriers, professional boundaries, relationships, structures and transitions can be found in Chapter 3.
Before getting started, or even making a plan, it is useful to review your own organisation in terms of what might be feasible or even possible. Many of the best laid plans get lost along the way if careful thought and consideration has not gone into the planning phase.
One way to review your organisation is to do a SWOC analysis, which consists of working out the strengths, weaknesses, opportunities and challenges of your organisation. Sometimes this is called a SWOT analysis (strengths, weaknesses, opportunities and threats). We prefer to think about ‘challenges’ rather than threats, hence SWOC rather than SWOT.
The strengths might include the number of midwives who want to change to working in a continuity of care project, your supportive manager and the one obstetrician or general practitioner who believes it is a good idea. A weakness might be the fact that you only have four midwives with enough recent experience to practise across the full scope of midwifery practice. An opportunity could include the recent review conducted in your area that recommended the implementation of midwifery continuity of care. Consumers can also be your opportunities. For example, the support of women in your community could be a useful and important strength and an opportunity. Your challenges might be a group of colleagues or managers whose actions have threatened previous changes, or the ongoing challenge of budgetary problems.
The SWOC analysis will not solve your problems but may help you to be clear about where the difficulties lie ahead and be useful when you start to develop your strategies for implementation. Knowing where the difficulties are before they arise may also help you plan a strategy to lessen the problems.
In the planning phase, it is useful to establish a working group. In our experience, the working group provides a forum for exchanging information and ideas regarding the implementation and integration of the new project. The working group can also help to address issues arising from the new project that cannot be resolved at a local level. A regular meeting pattern should be established, for example on a monthly basis, with dates made well in advance.
Membership of the working group should include everyone who might be affected by the new project. As previously mentioned, it is important to include local women who use maternity services in the working party or in any group involved with planning and implementing from the very start. You may also include a representative from a consumer organisation who will be nominated by the organisation.
You may also choose to include in your working group (see Box 2) some of the people who you decided could potentially be challenges in your SWOC analysis. Once people are involved in the process of design and implementation it is more difficult for them to be obstructive. Also, the experience of being exposed to evidence and enthusiasm may help change attitudes and beliefs.
Box 2 Possible membership of your working group
Depending on the type of project you are setting up, membership of the working group may include:
The working group can also be a way to gather support and ideas and to have ongoing consultation and discussion. Minutes should be kept and circulated to everyone in the group and made available to staff in the unit, for example, put into the communication book at ward level. The responsibilities of the working group are usually to decide upon the structure of the new project, plan the implementation and evaluation, and solve problems or challenges once the project is up and running. It is useful to draw up Terms of Reference in the form of dot points at the beginning so that everyone is clear about the responsibilities of the group.
The Terms of Reference should include the leadership of the working group and outline who is responsible for arranging the meeting dates, finding a venue, minute taking and circulation of minutes. A discussion about the decision-making processes within the group (how decisions will get made and who will carry them to the next stage) is also important to have at the beginning. There need to be clear lines of communication from the working group to other groups or leaders within the organisation, to ensure that information is shared and decisions can be acted upon.
When designing midwifery continuity of care projects there are a number of issues you need to consider including:
It is also important to consider the SWOC analysis that you performed earlier. Taking advantage of the strengths and opportunities and working out ways to minimise or strategise around the weaknesses and challenges is vital to your ultimate success. Discussion of these issues should take place in the working group and with interested and affected stakeholders.
Designing a project that will be sustainable is important. This means that if you can establish your new service within your existing budget and staffing numbers, it is more likely to be sustainable. Implementation within an existing budget means the project will be embedded in the organisational structure from the outset and make it less vulnerable to discontinuation in times of budgetary constraint. Establishing a project within existing budget is described later in this section.
It may take a number of meetings and discussions to decide on the project you hope to develop. It would not be unusual to take at least six months or longer to get to a point where the group can actually write a clear proposal about the project (we took two years of planning to get a publicly-funded homebirth model up and running in Sydney and Chapter 6 describes a process of planning that took nine years). The planning phase is an opportunity for discussion, negotiation, information sharing and collaboration, all of which are essential to the success of new projects. Remember that midwifery continuity of care projects are often ‘works in progress’ and will change as you get started, depending on the experience in your unit. Challenges will always need to be faced, even when you have been meticulous in your planning. Just when you think you have anticipated everything, the unanticipated happens. Flexibility in enabling the project to evolve and change over time is also important. Over the first couple of years, it may change quite considerably as midwives find their way and grow in confidence. In light of this, it may be necessary to delay your initial evaluation or ensure that you re-evaluate once the project is settled. Any major evaluation, for example, one that might contribute to a meta analysis, or systematic review, should be delayed until the project is well established.
It is helpful to keep a diary record of the journey that you take during the process of planning, development and implementation. This serves a number of purposes. It is an important source of data when you are writing the evaluation of your project. You will forget where the trials and tribulations were along the way and these are usually the most useful tips to pass on to others embarking on a similar exercise. It is also beneficial to have your story recorded, particularly on the ‘bad days’. It can be very heartening and encouraging to read over where you have come from, and remember how much has really been achieved.
Establishing your new project within an existing budget probably means that it is more likely to survive in difficult financial times. In this section, we draw on our experiences in a number of different settings.
In the 1990s, we were involved in the development of team midwifery models. While some of these have evolved over the last decade to be caseload midwifery group practices, we talk about the development process here as there are some useful lessons that are still relevant.
When we were working out the development of team midwifery, we started by working out the midwife hours required to care for 30–35 women per month. It was estimated that, in order to conduct community-based antenatal clinics, two midwives would be required for a minimum of 4 hours, twice a week. In the delivery suite a midwife would be required 24 hours per day. In the early stages of development it was suggested that care in labour would be provided in 8-hour shifts, which meant three shifts were required per day. When the model was actually implemented it involved two 12-hour on-call shifts that enabled midwives to cover care during labour and birth. Postnatal care, either in the community or in hospital, would be provided by one midwife on a day shift in the postnatal ward. These estimations enabled the calculation of the number of full time equivalent (FTE) positions required from each area in the maternity unit to establish a team. The FTE calculations are displayed in Box 3.
Box 3 An example of the proportion of FTE positions required from each area in the maternity unit to establish one team midwifery project
Practice area | Amount of time required | FTE |
---|---|---|
Antenatal clinic | 16 h per week | 0.42 |
Delivery suite or birth centre | 8 h × 3 shifts × 7 days per week | 4.42 |
Postnatal ward | 8 h per day | 1.47 |
TOTAL | 6.31 |
Once the estimates were made, the FTE positions were moved from the rosters in each area to make up the first team. The second team was created in much the same way. In reality, this meant that managers ‘lost’ midwives from their standard rosters in the antenatal clinic, delivery suite and postnatal ward as these midwives were moved onto a separate team roster. While there were fewer midwives on the roster in each area, there were also fewer women to be cared for as each team catered for around 360 women per year. This took some time for everyone in the unit to ‘get their head around’. Make sure you have time during your planning process for this cultural change to occur.
When we were working out the caseload practice project almost a decade later, similar principles still held. We started out by determining how many women could be cared for, knowing the numbers of midwives who wanted to work in this way. It was important to make sure the caseloads were not too big, as the risk is that midwives will get tired and be unable to work to their full potential. Of course the opposite also holds true: it is important to have the midwives working to their full capacity to ensure that the models of care are cost effective.
In working out the number of midwives and the caseload or number of women, it is important to consider the women who will be cared for (do they have high physical, social or emotional needs?) and the geographic area (will the midwives need to travel considerable distances to provide care in women’s homes?) and the particular service the model will provide. For example, some midwifery continuity of care models provide some, or all, antenatal care at home while others have antenatal care provided from a central location. Another service factor to consider is the length of postnatal care that will be provided (if this is not already dictated by statute). In some places this will be up to 6 weeks postpartum, while in others this is not possible and up to 10 days is all that can be considered feasible.
Once you are clear about your model of care and how you think it will be developed and implemented, it is important to write it down in the form of a proposal. Suggestions for proposal writing are presented later in this chapter.
There will be times when you do not have adequate funding to implement the midwifery continuity of care project. This might still occur, even if you are establishing your new project within an existing budget. Sometimes it is difficult for managers and health or hospital administrators to even conceive of how a new project could be implemented without additional costs. Potentially increasing costs is usually a scenario that administrators are keen to avoid, even if this means stifling innovation and the incorporation of evidence into practice. Broader efforts to influence macro and micro economic reform might also be necessary to ensure that change can occur. This might mean lobbying for a commitment to innovation and change higher up the hierarchy or from your department or ministry of health, or through your professional colleges. Involving the media in lobbying for change might also be a strategy to think about. More on these political strategies is outlined in Chapter 11.
Working in a midwifery continuity of care project will be a new experience for midwives in some countries. For example, most midwives in Australia are familiar with working in a particular clinical area (such as antenatal clinic or labour ward) and less familiar with following women through pregnancy, labour and birth, and the postnatal period. Many midwives have not had the opportunity to work in midwifery continuity of care projects and this will pose challenges.
We are often asked: ‘What sort of midwife can provide continuity of care?’ Essentially we think that all midwives can provide continuity of care, providing they have adequate support and are enthusiastic about practising according to the full potential of their role. This means that all midwives have the capacity to provide continuity of care, however we acknowledge that not all midwives may want to work in this way.
Many years of experience as a midwife is not necessarily the best criterion to use when selecting or inviting midwives to work in continuity of care. In our experience, newly graduated midwives are excellent candidates to work in innovative midwifery projects as they have had little socialisation into an institutionalised style of care. New graduates are usually enthusiastic and keen, with up-to-date knowledge, all of which makes them ideally placed to provide continuity of care (Passant et al. 2003). In many instances newly graduated midwives have had some experience providing continuity of care (or learning about continuity of care) during their pre-registration education. This may have included being placed with midwives providing continuity of care or through structured ‘follow through’ approaches (ACM 2006b). There is more about the follow through experience as a strategy around midwifery continuity of care in Chapter 11.
Clearly, experienced midwives are also important to include in your new project. These midwives will provide invaluable support, role modelling, education and expertise to less experienced midwives. However a midwife with 10 years of experience in a labour ward situation may find antenatal and postnatal care very challenging, and may themselves need additional support in these areas.
A general principle around selecting midwives, particularly in the beginning, is to let midwives select themselves (McCourt et al. 2006). Calling for ‘expressions of interest’ for the new project within your unit is a good place to start. Before you distribute an ‘expression of interest’ you may need to do some education within the unit about what midwifery continuity of care is all about and how it might work. Hopefully this would have occurred during the process of designing your project as you discussed the implications with all the stakeholders. Nonetheless, you may need to conduct some formal and informal education sessions to ensure that all prospective midwives understand what is involved in the new project. This might also dismiss some of the myths that may have arisen, for example, around the amount of on-call or the number of women an individual midwife will care for each year.
Part of this process, particularly in a caseload group practice, is to enable situations where the midwives choose who they want to work with (Leap 1996, McCourt et al. 2006). Working closely with a small group of midwives means that a certain level of trust and camaraderie will need to exist or develop, and midwives should have some control over the people with whom they choose to work.
In the past few years we have developed a recruitment process that incorporates a group discussion as a new way of selecting midwives to work in caseload midwifery group practices. This process mirrors the ways that midwives work together in a group practice. Midwives need to respect one another’s similarities and differences as well as be able to discuss issues, share uncertainty, negotiate solutions and embrace compromise. Having a group interview process where these skills and attitudes are demonstrated and group dynamics can be seen has been very useful for applicants and interviewers. Midwives already working in the group practices have also said they have appreciated being part of the process to select future group practice midwives as they will ultimately work closely together. Box 4 provides a description of the group interview process and outlines the three components of the process. We have included a more detailed explanation in the appendices.
Box 4 A selection process that could be used for midwives applying to work in midwifery group practice
The applicants, existing midwives in the practice, and facilitators come together in a group to participate in a discussion (see also Appendix 4).
The discussion is an informal process with the other applicants for the position and the current group practice midwives present. One of the two or three facilitators will lead the process. Each applicant in turn is asked to tell a story of a situation that she has found particularly challenging and then lead a discussion about the issues the story raises. This enables the applicant to tell a story about how she works in partnership providing evidence-based, woman-centred care, and how she collaborates with colleagues, particularly around engaging with uncertainty. The story needs to be relevant and concise, not longer than 5 minutes. The applicant is expected to respond appropriately to any discussion raised from the others present with reference to her story.
The discussion encourages midwives to reflect on the value of possible strategies for practice informed by current evidence. The applicant retains all the material she has prepared for the discussion. It is essential the confidentiality of any person(s) described in the scenarios be maintained.
The facilitators observe the process and assess the applicant on how she:
At the end of the session (once all the applicants have left the room), the existing group practice midwives have an opportunity to give feedback to the facilitators.
A hands-on workstation allows the applicant to demonstrate how she is able to respond to emergencies in terms of knowledge and practical skills. The applicant demonstrates her abilities to respond to a situation that includes one of the following:
The applicants are assessed by one of the facilitators, using a midwife from the group practice as their ‘assistant’. Assessment is concerned with the midwife’s skills in an obstetric emergency situation and her ability to work effectively in a team situation.
The final phase of the selection process is an individual interview with the facilitators in which the midwife is given the opportunity to present the reasons why she is the most suitable person for the position and why she wants to work in this way. A time limit of 5 minutes is allocated to each applicant.
Including midwifery students in midwifery continuity of care projects is essential. This is one effective way that students understand continuity and can prepare to work in this way on graduation. We have had students who have said that they did not really understand continuity of care until they were placed with a caseload midwife from a midwifery group practice.
In education programs where students are supernumerary, it is often easier to ensure that students can be placed with midwives working in continuity of care than it is if they are employed as part of the maternity service workforce. This does not mean that all opportunities for student midwives to experience midwifery continuity of care should not be explored. The student can be ‘buddied’ with a caseload or team midwife so that they can follow the midwife and see what continuity of care means in practice.
In Australia, the concept of ‘follow through’ experiences has been incorporated into midwifery curricula. These were introduced as it was acknowledged that the opportunities for midwifery students to experience continuity of care was limited. The concept of ‘follow through’ experiences was therefore introduced as ‘placements with individual women’ as opposed to ‘placements with institutions or practitioners’. This was a strategy to enable students to have some experience of relational continuity with women, regardless of the setting of the woman’s care or her care provider. Wherever possible, the student would be able to provide some of the care under supervision, particularly towards the end of their course. This is similar to the idea of students having a ‘caseload’ in their final year, as occurs in some United Kingdom programs, in other European countries, and in New Zealand and Canada. There is more about the follow-through experience in Chapter 11.
Other students would also benefit from exposure to midwifery continuity of care, including medical students. Opportunities should be explored to ensure that the obstetricians and general practitioners of the future have an understanding of the role of the midwife and, in particular, the importance of midwifery continuity of care.
Once you have selected the midwives who will be part of the new project, the next step is to ensure that they are well prepared to fulfil their role.
There are a number of ways to assess what preparation or additional development opportunities midwives might need. One of the areas to explore is the skills, knowledge and attitudes of the midwives. When moving from a fragmented care system, some midwives may need updating on some of their skills. We have used a self-assessment process to determine which practice-based skills need further development. This started out as a skills inventory and was adapted with permission from research in the Midwifery Development Unit in Scotland (McGinley et al. 1995). The Australian College of Midwives subsequently developed the inventory into a ‘Practice development resource: a self-assessment tool for midwives’ that enables midwives to assess their own professional development needs in terms of skills, knowledge and experience. The resource is available from the Australian College of Midwives (2006a).
A self-assessment process using any tool can enable midwives to reflect upon how they need to ‘update’. This gives them an opportunity to address the necessary skills and knowledge they will need to have prior to commencing on the project. Information from this self-assessment process could be used to plan a professional development program to meet the needs of each midwife.
Skills are not the only areas that might require additional development. Some midwives may have a high level of practice-based ‘skills’ but have difficulty working in a team or collaboratively across disciplines. Some midwives may lack confidence in their decision-making capacities or in the way they interact with women and their families. These issues may not be identified in a self-assessment process that concentrates on skills so an alternative means is needed to identify and address this. We have found various workshop activities useful for this. In the appendices are examples of scenarios for small group discussion, which can be built into preparation, recruitment processes or ‘team building’ activities.
Once you have determined the needs of the midwives in terms of development and experience, a program can be planned to ensure they receive the necessary preparation. Many new projects start by recruiting women early in pregnancy so that they can receive continuity of care through the antenatal period. If you have midwives who need to update their experience with labour and birth, they can be rostered on to provide care in the labour ward and be released to attend antenatal visits. A similar system can be organised for midwives who need experience in antenatal or postnatal care or in the community. Once midwives start seeing women in early pregnancy, it will usually be around five to six months before the midwives will be needed to provide care during labour and birth. This time can be used to enable midwives to identify their needs and ‘up-skill’ if necessary, without removing them completely from practice.
While clinical skills are important and need to be assessed, ‘process’ skills are also essential for the midwives who will be part of a new project. At the outset we suggest setting up regular team meetings with all the midwives who will work in a new project, as this is a valuable process. Initially the meetings may be on a weekly or even monthly basis while planning and establishing the project. Ideally midwives should meet every week as a group once the project is running, so the period of preparation is good groundwork for what will become an ongoing process of support and sharing of ideas and information. The meetings will also include regular case reviews and reflection on practice.
In the establishment phase of your new project, it is important to clarify ‘what the project is’ and ‘what it is not’. Involving everyone in the process of development will help this clarification. This will also ensure that everyone is aware of the process undertaken to make decisions around the eventual project, and the issues and considerations that have gone into the design. Right from these early discussions it is important to involve users of the maternity service in the process. This will ensure your project remains woman-centred and relevant to the community.
Early discussions might centre on the personal philosophy of the midwives in relation to woman-centred practice and midwifery. Issues around choice, control, sharing of information and care during pregnancy, labour and birth, and the postpartum period are some of the issues that could be addressed. The listening skills and capacities of the midwives might be areas to explore, as would the ability to translate evidence into discussions with women. Other topics might include the opinions and attitudes of the midwives to interventions, including ultrasound, promoting homebirth, analgesia in labour, elective caesarean sections, and community postnatal care. Collaboration with the medical profession and being part of a peer review process are also important issues to discuss with the midwives, in the early stages of the project and as an ongoing activity. For some midwives, these process skills will need further development.
The process of taking professional responsibility should also be addressed. This is often different to the responsibility that midwives have held in their previous roles. Responsibility to the woman becomes paramount in midwifery continuity of care, and this can change the way many midwives perceive their practice and relationship with women and other professionals. The changes in allegiances that have been reported by midwives working in continuity of care (Brodie 1996, McCourt et al. 2006) should be discussed with all midwives in the unit as this issue will impact on all staff.
Other ‘process’ skills to be considered include communication with core staff, mentoring of other midwives and working with student midwives. These may be addressed in general terms with all midwives, as they are important skills for all involved in midwifery practice.
In midwifery continuity of care projects, the idea is to work together within the smaller group but also with the larger team in your maternity unit or community. Setting up midwifery continuity of care projects that leave midwives feeling isolated with little support from others is not helpful and is likely to be unsustainable. Regular meetings to build a sense of a ‘team’ are necessary to establish and sustain your new project. Whether your project is based on ‘team midwifery’ or caseload practice, the principles are the same. In the appendices of this book, we have outlined some strategies you might use to support midwives moving from rostered shiftwork to caseload practice.
Many midwives move from working in rostered shiftwork systems on a ward to working in a group. This can be challenging and may also evolve over time. Box 5 is a story from Ali Teate, a midwife in a birth centre at St George Hospital in Sydney, New South Wales, Australia. Ali is a caseload midwife in this model of care, the only publicly-funded homebirth model in this state of Australia.
Box 5 Working in a group providing midwifery continuity of care
I began working at the Birth Centre at St George Hospital in 2002 where the TANGO model had been running for over 6 months. TANGO stands for Towards A New Group practice Option. The hospital has a number of midwifery continuity of care models, all of which have dance theme names—STOMP (St George Outreach Maternity Program), RAP (Risk Associated Pregnancy Team) and WALTZ (Working all together). TANGO was a continuation of this light-hearted tradition.
In 2002 there were two teams of midwives in the Birth Centre who worked side-by-side and supported each other. These teams were made up of four midwives each. The team members for the ‘south’ team were all new midwifery graduates and the team members for the ‘north’ team were all experienced midwives. Each 12-hour shift, whether it was a rostered shift or an on-call shift, therefore had a new graduate midwife and an experienced midwife working side-by-side. This provided guidance and support for the new graduate midwives and allowed them to enter their midwifery careers directly into a continuity of care model.
As an experienced midwife who had worked in an array of different models of care I was eager to see how TANGO operated. I had always been involved with continuity of midwifery care programs that only allowed experienced midwives to work in them. TANGO was a great model to work in and to witness the development of the new graduate midwives was a fantastic experience. It was such a successful model of care for both provision of midwifery continuity of care and the development of midwifery knowledge that by the end of 2002 all the midwives were keen to move on to a caseload practice.
Consequently, TANGO moved from a team midwifery program into a midwifery group practice with each pregnant woman having a known midwife and a back-up midwife. A ninth midwife was employed with the commencement of the group practice to assist with annual leave relief and to cater for the demand for the model. TANGO has continued to work out of the Birth Centre at St George, and continues to enable new graduate midwives to work in a midwifery continuity of care program. The model is self managed by the midwives and is extremely flexible in how it works. Issues such as staffing and the commencement of the homebirth project have challenged the midwives, but TANGO continues to be a successful and fulfilling way in which to work.
Many midwives working in group practices have identified the importance of having some say in who they work with. There are several ways that managers might like to facilitate this. In a situation where new group practices are being set up in a maternity unit where the midwives know each other, we have successfully used a confidential system that allows midwives to identify their preferences to one person who works out the allocation accordingly. Filling out the preferences form in Box 6 below does not guarantee that these preferences are met but does enable some sense of choice. This system works best when the person who allocates the midwives is not their immediate manager; it could be someone who is facilitating a training day. It requires a high level of trust on the part of the midwives that the person coordinating the exercise will ensure confidentiality and will destroy the preferences forms.
Box 6 Preferences for midwifery group practice: combinations
Preferences for midwifery group practice: combinations
The midwives I would most like to work with are:
Please name anyone that you feel that you would have real problems working with.
Anything else you would like to be taken into consideration.
In preparing for working in a group practice it is important to involve the midwives in deciding how they will work. We have found great benefit in the provision of a number of team building days or workshops. A typical agenda for a workshop day is presented in the appendices.
The midwifery continuity of care model that you ultimately design will depend on the industrial relations issues in your context. In some countries, industrial relations issues are more challenging than in others. For example, in many parts of Australia the notion of being ‘on-call’ and not having a roster is hard for some industrial systems. At the present time, in most states and territories in Australia, midwifery comes under a Nursing Award for the purposes of salary, grading and industrial conditions. In most instances midwives are paid on hourly rates with clearly defined rules around hours of work, hours off between shifts, on-call arrangements and days off. For the most part the nature of Nursing Awards, with their inherent inflexibility, is incongruent with much of the philosophy around continuity of care and carer. This means that either your model is in line with the arrangements in your particular state or locality—or you negotiate a salary agreement that is mutually acceptable and suitable.
In other countries, the challenges regarding working conditions and remuneration are unique to the local context. In addition, if you are self-employed or contracting into a public health system your negotiations will be different. Essentially, however, in all models and contexts a negotiation about how much ‘activity’ for how much ‘salary’ is reasonably fundamental. What varies is whether this negotiation is on an individual or a collective basis. The specifics of what constitutes ‘activity’ and what is included in ‘salary and conditions’ will also vary across contexts.
In many parts of Australia midwives working in caseload projects have successfully negotiated an ‘enterprise’ or salary agreement. These agreements are negotiated between the health service or provider and the industrial union. The agreements usually make provision for certain special allowances and for their future adjustment, and midwives are then paid on an annualised basis based on an agreed caseload. You can read about how an industrial award was negotiated in South Australia in Chapter 6.
Other countries will have different arrangements in relation to agreements about salary and conditions and you will need to seek these out in your context.
It is possible to implement midwifery continuity of care projects without a specific salary agreement. For example, at St George Hospital in Sydney the team midwifery program operates within the State Award for nurses and midwives. Seven full-time midwives (known as FTE or fulltime equivalent in some places) are responsible for the care of 360 women (all risk) per year. The roster requires six full-time midwife positions with the seventh position providing annual leave cover. The midwives are rostered to cover the antenatal clinics, the postnatal ward and community visits and to provide on-call (12-hour periods) for labour care. Midwives are responsible for writing their own rosters and within the rostering process they negotiate the spread of on-call to ensure that it is equitable. The midwives operate a tally sheet system to accommodate their on-call shifts. When on-call, they are paid for 8 hours regardless of whether or not they come in to work. If they are not called in, then they ‘owe’ 8 hours on their tally sheet. If they are called in for 12 hours, then the additional 4 hours is taken off their tally sheet. They do not get paid overtime but are paid an on-call allowance. Midwives are not on-call on their days off. They work four weeks of day shifts (including at least two on-call shifts) followed by two weeks of night duty (eight on-call shifts). This system is permissible under the State Award.
Our experience has shown that in such a model, team midwives usually ‘owe’ the organisation 20–30 hours at any one time. It is felt, within the organisation, that this is an appropriate situation. Morale seems to be higher when midwives owe hours rather than the reverse. In addition, in times of necessity, for example sick leave that cannot be filled or a lack of experienced midwives on any one shift, the team midwives can be asked to work an extra shift in order to repay some of their hours.
When you start designing your model and working out the logistical arrangements of how it will work, it is worth having a meeting with a representative from your industrial organisation (if there is such a group in your country). You will need to have a clear proposal and idea about what you hope to achieve and how you would like the project to work before this meeting. It is also helpful if the midwives who are going to work in the new project are also included in the meeting. This is an important part of ensuring that a transparent process exists in the development of the project and that choosing to work in this way does not disadvantage the midwives.
The midwives who are going to be working in the new project need to meet regularly (at least once a week) during the period of negotiation and planning. This ensures that they are fully involved in the planning and decision-making process and they ‘own’ the project.
Writing down how your new midwifery continuity of care model will operate in the form of a short proposal will help develop your ideas, and explain the planning and implementation process to others. Writing a proposal is also a good way to become clear about the new project and what it will involve. The process of writing the proposal and then sharing it with others is a good way to gather support for the idea and for the implementation process. Circulating a proposal wide and far is also a good way to inform others about midwifery continuity of care.
A written proposal is important if you want to apply to have an industrial agreement with your union. Industrial bodies may want to know exactly what the project is and how midwives will be required to work.
The proposal does not need to be very long; 2–3 pages is often enough. If you have not written a proposal before, you may choose to use our series of headings to help you structure the document (see Box 7).
Box 7 Suggested template for a proposal for a midwifery continuity of care project
Aim (What do you hope to achieve?): For example, to establish a new midwifery continuity of care project that will provide women with a known midwife through pregnancy, labour and birth, and the postnatal period.
Background (What has informed this new project?): You might briefly describe the evidence (or literature) around continuity of care and why it has been shown to be beneficial (see Chapter 2).
Proposed project (What is the project that you want to implement?): Describe your new project and explain how it will operate. You should describe the group of women you hope to cater for; the type of project; the proposed caseload or number of women; and the number of midwives and the way in which they will work, including their on-call time, annual leave, sick leave and maternity leave cover.
Implementation (How will the project be put into practice?): Describe the process by which the project will be implemented and the timeframe for this process. You might also include some of the difficulties you foresee and your suggested strategies. You could explain how you propose to recruit midwives to the project and the strategies for up-skilling and ongoing professional development.
Evaluation (How will you know that you have met your aims?): Describe how you will evaluate the success of your new project. Chapter 9 has some useful strategies and approaches to guide your evaluation.
Writing the proposal takes time, as does refining and making your ideas clearer and more succinct. In our experience up to ten drafts is not uncommon, so do not despair if you find you have to keep changing your proposal. Show your proposal to others in your maternity unit and talk through their feedback. If someone in your unit does not understand what you are trying to say in your proposal, then an outside person will probably also have difficulties. Remember to write for your audience: the proposal will look different depending on for whom it is written. A proposal for the industrial organisation will be ‘pitched’ slightly differently to one for the doctors in your unit or to obtain some funding to help the evaluation.
This chapter has provided many practical tips and some useful strategies to help ensure your success when introducing midwifery continuity of care in mainstream maternity services. Many of the strategies could also be applied if you are changing your current midwifery continuity of care model.
Careful attention to the process of selection and support of the midwives has been highlighted as essential. It is also necessary to make sure the organisation is ready for the changes you are implementing. The tips and ideas we have suggested will be different depending on your context and what you already have in place.
In Chapter 5 we look closely at further strategies for success that relate to the building of collaborative relationships to ensure effective care for women and familles.
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