Our model of midwifery group practice

In 2007, four Midwifery Group Practices (comprising 24 full-time equivalent (FTE) midwife positions and 2 unit head positions) provided a caseload model of care to approximately 1000 women and babies per annum across all risk categories, within a defined geographic area, in collaboration with other specialist services as required. The midwifery caseload care encompasses antenatal, labour and birth, and postnatal midwifery services to 4–6 weeks after birth. Women have a named primary midwife, and midwives back each other up within their practices as well as across the practices for on-call work. MGP midwives can order relevant laboratory and diagnostic investigations for their clients, and consult and refer according to the Australian College of Midwives (ACM) ‘National Midwifery Guidelines for Consultation and Referral’ (ACM 2004). Care takes place at home, in the community and in the hospital. MGP is an innovative reconfiguration of midwifery workforce and maternity service delivery in South Australia and the largest ‘all-risk’ model of its type in a tertiary hospital setting in Australia.

Persistence and determination

It was essential, once we had envisioned our midwifery group practice model and how it would work, that we persisted in our intent to commence such a model. While there were many times when it seemed too hard and some doubted the value of trying to make such change (after all, results in the traditional system were ‘good’—why change?), it was critical that those of us committed to the change continued to support each other. Without this network of support we would never have moved to the point of implementation. After several years of planning, we were more determined than ever to succeed as too much time and effort had been invested to consider letting it go.

Convincing others

To implement such a model, particularly in a tertiary referral centre, there is a significant number of people and stakeholders to convince and get on board. In negotiations or discussions with all interest groups when implementing such models, it is essential to use clear and understandable language. Particularly with non-clinicians, it is essential to translate the principles of the model into very clear concepts using plain language.

Consumers were already engaged and had been supportive for years. The midwives committed to this model of care were on board. Many other senior midwives at WCH, who were not interested in working in the model themselves, had also been involved in the planning, so they were supportive of the model. There was a broad commitment to the service being available for all women, no matter what their risk status.

The medical staff needed a good understanding of how it would work and how it would affect them and their role in supporting it. Senior medical staff, obstetricians and neonatologists, were briefed at every stage of the planning. Sessions were convened for them to discuss how it would work and to keep them up-to-date with developments. Copies of the final proposal were forwarded to them and much informal discussion took place. The fact that the midwives would be working within the same WCH clinical guidelines as everyone else was a key selling point. It was emphasised that we were really only ‘restructuring’ the midwifery workforce.

Administrators and Department of Health staff had to be convinced that the new model was not going to cost more and part of the proposal to implement included a cost analysis. There was an initial cost for some equipment, but in terms of ongoing goods and services costs, the cost was estimated to be similar to the traditional service. If clinical outcomes demonstrated less intervention, then cost savings could be made.

Salary costs as per the Annualised Salary Agreement were planned to be higher than for midwives working rostered shifts, to compensate for the disruption to the midwives’ lives through working flexibly around the needs of the women. However, calculations indicated that midwives in the MGP model would care for significantly more women per year than midwives working in the traditional model on rostered shifts, which would offer cost effectiveness. Numerous calculations were done on potential work patterns of MGP midwives to demonstrate the costs of working under the existing Award of the Enterprise Bargaining Agreement for Nursing (which governed Awards for midwifery work) compared with an annualised midwifery salary. Costings were done on ordinary hours, potential ‘penalty rates’, ‘call back’, ‘on-call’, ‘leave loading’⁵ and public holiday payments to make comparisons.

During this period of planning and development of the proposal, there were significant changes to the members of the WCH Executive. It was difficult to convince non-midwives of the benefits of these models without a midwife at Executive level, as Executive members were not familiar with the differences in models of care or what they offered to women. They did not understand the need for system change at clinical service delivery level, or the expectations and needs of women to have choice and control of their childbearing experience. Once a midwife with a background in continuity models joined the Executive and re-assured them that it was a sound model, the Executive accepted and supported implementation of MGP.

Staffing the model

Recruitment of Midwifery Unit Heads from outside the WCH enabled an initial ‘job-share’ appointment between two midwives to implement the MGP model. One was an Australian midwife (Roz Donnellan-Fernandez) who had a 10-year history of working within a midwifery continuity framework as a private provider in the community with admitting rights, clinical privileges and established practice links to South Australian maternity hospitals, including local regulatory and industrial experience. The second was a midwife from Canada (Anne Nixon) who had experience in pre-legalisation midwifery, direct-entry midwifery education in Canada and New Zealand, the implementation of community midwifery caseload practices in Ontario, and recent project work in identifying frameworks for improving birthing outcomes within Aboriginal communities in South Australia. This arrangement and skill combination was instrumental in providing mutual support for dealing with challenges in the setting-up phase within the institution, and also in capitalising on building cross-sectoral partnerships. Networks were developed for clinical placement opportunities at WCH for midwifery students to work in a midwifery continuity of care model. These students were from the inaugural 3-year Bachelor of Midwifery Program conducted from the two universities in South Australia. The selection process for the midwives happened in two stages. Midwives who were recruited from the Birthing Centre undertook an interview to enable a discussion with the new joint Midwifery Unit Heads. The remaining midwife applicants were interviewed and the preferred candidates selected.

Preparing the organisation, workforce and facing industrial challenges

In addition to local context, the identification of relevant stakeholders, with whom to collaborate and agree the principles and practical strategies that will enable success and sustainability within that context, is an important consideration. Broadly grouped, five key areas have been identified as underpinning the principles and practical strategies for success and sustainability in a Midwifery Group Practice (Donnellan-Fernandez 2006):

Earlier published work by Page et al. (1995), Warwick (1996), Sandall (1997), Brodie (1996) and the previous Handbook written by the editors of this book (Homer et al. 2001a) were useful in guiding some of the planning and practical implementation strategies for setting up the MGPs. A particularly useful resource was the text Effective group practice in midwifery: working with women edited by Lesley Page (1995). Practical caseload experience in the Canadian, New Zealand and British contexts, as well as the Australian independent midwifery context, assisted the Midwifery Unit heads in putting structures, mechanisms and principles for the MGPs into practice. These resources also assisted with creative approaches to change management and strategies for organisational transformation within the context of a tertiary hospital facility.

A few years before the commencement of MGP, a Graduate Certificate in Continuity of Care was established at the Women’s and Children’s Hospital in partnership with Flinders University of South Australia. The course was accessed by a number of core staff, who identified that it enabled them to understand the context and support the development and implementation of the MGP. This course set the scene, provided theoretical background and explored the practicalities for midwives wishing to work in midwifery continuity of care or support others working in this way.

A draft implementation plan with identified milestones and a timeline was agreed between the Divisional Chief of Midwifery at WCH, the MGP Unit heads and the midwives. The long lead-in time for MGP at WCH facilitated communication with established core staff in different units and departments, and was a significant component in supporting clinical credibility and trust.

Interviews and recruitment of the initial midwifery workforce occurred 12 months prior to commencing service delivery, due to ongoing negotiation in the development and formalisation of the Annualised Salary Agreement. This delay necessitated flexible timelines that were adjusted accordingly. One advantage of this delay was the ability to organise several funded study days for the recruited midwives. These days focussed on identified learning needs, which had been solicited by the administration of a ‘self-assessment tool’. The wide range of clinical skills required in a continuity model for MGP midwives spans the antenatal, intrapartum and postnatal period to 6 weeks for maternal and infant care. We initiated a process that helped us to group the learning needs of midwives and to respond to those collectively and individually in guided sessions. Team building was also a crucial feature of these early study days, whereby the midwives were facilitated to choose their work partnerships and group configurations, develop workable on-call rosters, finalise the MGP philosophy of care, and articulate group norms, service specifications and informed choice documents based on a shared vision.

Not only did these activities contribute to promoting the service, they helped to build and develop relationships with other staff and units in the hospital, facilitating early recognition and implementation of well-defined midwifery practice parameters such as the Australian College of Midwives National Midwifery Guidelines for Consultation and Referral (2004). These collaborative approaches with other providers and services set the scene for later development of specific skill development programs and tools that have now become a part of established practice in MGP, such as the Well Newborn Assessment Program, Neonatal Resuscitation Skill Program, and a Written Documentation Tool for negotiating care, provider role and responsibilities, and informed consent for ‘management plans in consultation with women’ with complex pregnancies.

Keeping the vision prominent

Having a ‘vision’ for the service that is regularly ‘shared’ with stakeholders is important both as a strategy at set-up, and during implementation and expansion, particularly as difficulties and challenges arise. Making this vision explicit and utilising a variety of communication strategies to keep all stakeholders updated and informed of your progress is necessary. Some of the approaches we used at implementation and over the course of the past three years included:

Some other practical tips are listed in Box 5.

There are also a number of ‘levers’ that are needed to support midwifery continuity of care. In our situation we were able to use these to support our processes (Box 6).

Midwifery workforce considerations

A significant challenge or consideration for continuity models is attracting midwives who have an interest in working across the full scope of midwifery practice and are willing to work in an on-call lifestyle, while assuming a level of autonomy and clinical decision making that has not often been available to midwives in Australia (outside of remote settings and private practice). Our service has been effective in attracting many midwives over the past few years, often from other services where they felt restricted in their role or felt that they had always wanted to work to the full scope of midwifery (as identified in the international definition of the midwife) but had been prevented from doing this by common employment models that kept them working in one fragmented area of midwifery care.

Some midwives, unsure about working in ‘caseload’, have spoken to us about their anxiety or lack of confidence in their ability to work across the full scope of midwifery practice. We have found that commitment to the model of care and enthusiasm are the most important elements, as midwives can generally be encouraged, supported and mentored to gain and consolidate skills in areas they may not have had previous exposure to. Identifying ‘teachers’ and ‘learners’ in relation to differential skill sets within MGP has been a useful strategy in supporting the whole team, and enabled a level of skill sharing for each midwife that has been an important component of labour force support in an all-risk midwifery model.

Midwives working in MGP do not wear uniforms, as much of their work takes place outside of hospital and there is no rationale to ‘identify’ them with a corporate uniform, since they build individual relationships with the women they care for and who are known to them. This has had an interesting effect often commented on by MGP midwives, who have stated that they feel as though they are treated with more respect as a person and a professional, particularly by medical staff, once they are not wearing a generic midwifery uniform.

‘Systems’ support and change management considerations

One area of increased autonomy and clinical decision making is evident in the facilitation of MGP midwives to order and interpret relevant tests (laboratory and diagnostic) for the women they care for. This is a key component of the assumption of responsibility for providing care as an autonomous primary caregiver. From a ‘systems’ perspective, WCH is an institution large enough to have an in-house laboratory, which has enabled our service to facilitate midwives to order routine diagnostic tests without the need for a medical officer to ‘sign for’ the requisitions. Each MGP midwife is issued with an internal WCH Referring Provider Number. This is an interim stop-gap strategy until state and federal legislation reforms enable adequate funding or reimbursement mechanisms that appropriately recognise the comprehensive role of midwives in maternity care in Australia. Unfortunately this strategy to facilitate ordering of tests for public health clients in a tertiary referral centre is currently unavailable to smaller services in rural and regional areas, or settings that commonly rely on diagnostic and laboratory services from private operators.

Additionally, the ACM ‘National Midwifery Consultation and Referral Guidelines’ (2004) underpinned the context for collaborating in the care of clients with medical colleagues. Our service has ‘made a space’ for midwives to exercise appropriate clinical decision making, across the scope of midwifery, consulting and referring as and when appropriate and necessary, based on midwives’ clinical judgement.

As a tertiary referral centre, there is wide range of specialist services available to MGP midwives for consultation (often available by phone or pager), including physicians, neonatologists, haematologists, infectious disease specialists, social workers and perinatal mental health specialists. This has been very helpful in the process of building successful working relationships, supporting midwives to build skills and knowledge, and in demonstrating effective collaborative care in our all-risk model. Achieving success in the tertiary setting builds confidence for expanding this model to other, smaller services across the state.

Clearly defining the role of the MGP midwife via agreed written guidelines with respect to each relevant unit in the hospital, including community agencies, offered its own range of challenges with different groups of providers and services, all of whom, it seemed, had a view about how the midwives and MGP ‘should’ be working! However the opportunity and necessity for ongoing dialogue and regularly scheduled meetings, particularly where roles and responsibilities were in question, often improved relationships with these providers and services, as well as promoted clarity, collegiality and trust around maternal and infant care, where the objectives for implementing comprehensive midwifery services were clearly identified. Instituting and fine-tuning a series of mechanisms over the first years of the operation of MGP to build collegial relationships and demonstrate reflective practice has been a defining feature of the model. Some of these mechanisms include:

Adaptation of the MGP model to respond to feedback and rising ‘system’ challenges has been crucial. Issues, such as accessing test results and case notes off-site, and facilitating strategies for the hospital switchboard to cope with significant increases in on-call paging volume with each MGP expansion, have necessitated some creative approaches and streamlining with regard to on-call rostering. A significant early systems development in the first year of service delivery was identification of a specific role for a ‘MGP bookings midwife’. Women are recruited to MGP through the regular antenatal outpatient midwifery triage process at WCH, where they identify interest or a preference for this model of care. Demand for MGP places constantly exceeds supply so the bookings midwife provides a timely and efficient filter in allocating and communicating with women and MGP midwives on the available places, which are dependent on client and midwife geography, booked annual leave and required caseload numbers. This occurs on a regularly weekly basis and has streamlined bookings since the doubling of MGP volume over three years with the expansion to three group practices in 2005 and four in 2006.

From the beginning of the MGP model, an evaluation team laid the groundwork for a review of the service at 18 months of operation. This process created a publicly credible and useful piece of research to support the ongoing operation of MGP and its further expansion (CYWHS 2005). While Level 1 evidence already supports midwifery continuity of care models, it was strategically and practically important to have a local reflection of the experience of a new model. Qualitative data from this evaluation concerning the experiences of the midwives in MGP contributes important information for midwifery recruitment and retention concerns. We have made a series of presentations of this research to key audiences, including the Minister of Health in South Australia. This was another important strategy for consolidating support for, and recognition of, the positive effects and outcomes of the model. A series of publications stemming from the evaluation are in progress.

Resource and infrastructure needs

It is important that changes in models of care anticipate the changed nature of the service in terms of space use and needs, infrastructure and support, particularly if the model expands in scope or volume. Initially MGP incorporated the two-room space of the previous Birthing Centre as the physical hub of our service. The beginning of MGP unfortunately coincided with a sharp increase of births at the WCH, which grew by nearly 700 in the first year of our operation. Space has been at a premium in the hospital and we have had great difficulty securing appropriate premises, affordable parking, space to conduct clinical visits, or adequate working spaces for midwives who are increasingly expected to have access to computerised systems to order tests and check results. We are committed to midwives working off-site in community settings linked with the hospital, and are continuing to explore options for this. We have had success with MGP midwives working from Child Youth Health sites in some areas of Adelaide, but infrastructure for computer access to clinical reporting systems needs to be improved for this to be fully facilitated as a working reality.

As we have expanded, it has been crucial to implement dedicated clerical support for the service. This has enabled appropriate interactions with clients around flexibility with changes to appointment times, an inevitable reality of caseload models as midwives must make themselves available for clients in labour. Understandably, appropriate administrative support has also been a significant factor in improving morale among the MGP midwives. Additional funding was sought for the clerical support and it was successfully argued that it is more cost effective to employ clerical staff for administrative work than to pay midwives to do non-midwifery work.

It has been important in the process of setting up an innovative service to recognise our roles as change-agents and to understand that we needed to engage with people who might not be able to imagine a change happening to a large, functioning system—or who might resist it. We have relied to a large degree on maintaining a sense of humour and resilience, and on a decision that the Joint Unit Heads made initially to work as a job-share in order to provide support to each other.

Policy opportunities and obligations

Midwifery Group Practice on the scale undertaken at the WCH offers both opportunities and challenges. The current size of the model whereby care is provided for almost 1000 women per year with 24 FTE midwives and 2 FTE unit head positions means this service has a significant mainstream presence that is both robust and visibly making a difference to a large proportion of the hospital’s clientele. It has also been instrumental in providing a place for parallel change that influences birthing services for women on a broader scale than just those women currently receiving MGP services. For example, the opportunity to advance the development of state-wide public health policy guidelines for both water birth and homebirth, in addition to supporting appropriate clinical exposure for Bachelor of Midwifery students, has been possible in the South Australian context.