Introduction

Establishing midwifery continuity of care services is rather like putting together a complex jigsaw puzzle—there are lots of pieces that must be fitted together to get the service in place and then to sustain it over time. The challenge, then, for anyone interested in establishing a midwifery continuity of care service, public or private, is to identify which pieces are needed to make a local service possible and what strategies are needed to get each piece into place.

Other chapters of this book have dealt with a number of these jigsaw pieces, such as strategies for gaining the support of management and local doctors, sourcing midwives with the skills and interest to work in the service, pinning down the guidelines for collaboration with obstetricians and other health professionals, determining remuneration and working conditions for the midwives, and so on. This chapter deals with a different cluster of pieces in the puzzle—the wider regulatory and political environment in which the service needs to operate.

It is a truism to say that every service offering midwifery continuity of care—no matter which country, and no matter which model (public or private, hospital or community based)—operates within a wider social and political environment. What may not be so widely recognised is the ways in which that environment influences how midwifery continuity of care is provided, and how both the women and the midwives experience the service. Indeed the socio-political environment may even determine whether or not the service gets established in the first place.

This chapter focuses, therefore, on those parts of the puzzle that relate not to the immediate challenges of setting up a midwifery continuity of care service but to influencing the wider environment in which the service is to operate so that it can be successfully established and maintained. In particular, it looks at how midwives and consumers have sought to influence government policy to support continuity of midwifery care as a mainstream choice for pregnant women. It also looks at the regulatory and education frameworks needed to support midwifery continuity of care. Importantly, it also looks at the challenging issue of engaging with the mass media to raise community awareness of the benefits of midwifery continuity of care for women and their families.

To shed light on what strategies are effective and also on how political structures in different countries shape maternity care reform, the chapter explores these themes using our experiences in Australia as a case study. While the case study is specific to Australia, many of the lessons and experiences of professionalisation, education reform, consistent standards, advocacy and media exposure will be the same in other similar countries. There are also other texts to highlight many of the crucial pieces in the jigsaw. For example, the opening chapter in Midwifery: Preparation for Practice (Guilliland et al. 2006) has an excellent overview on the changes that have occurred in New Zealand in the past 15 years and the political processes involved in achieving these. The policy agenda and campaigns in the United Kingdom are also well described in the first chapter of The New Midwifery (Newburn 2006) and is also worth reading in conjunction with this chapter.

Slow and steady wins the race: maternity reform in Australia

Reinventing midwifery education in Australia

It has long been recognised that the way in which midwives are educated has a vital role to play in shaping the future of the profession and of maternity care. In the late 1990s, the ACM decided to develop new national standards for 3-year undergraduate or so called ‘direct entry’ midwifery education programs. To appreciate the significance of this move, it needs to be noted that they did this at a time when there were no such courses in Australia, either planned or in reality. Midwifery was firmly entrenched as a specialty of nursing, and the only route to enter midwifery was via an education in nursing followed by a postgraduate course in midwifery. In some states, midwifery postgraduate studies had moved from hospital apprenticeship to university course only a few years before.

Furthermore, the power to set standards for midwifery education rested then, as it still does, with nursing regulation boards in the eight states and territories. So there was no guarantee that once the ACM developed the BMid standards, universities would take them seriously and prepare curricula to meet them or that they would be applied to curricula by the various regulatory boards.

Much discussion and debate preceded the publication of the standards in 2001. It was widely agreed that the new standards should be internationally comparable. Australia was well out of step by continuing to educate midwives in less than 12 months following a nursing degree. One of the areas where there were more divergent views related to the issue of whether a Bachelor of Midwifery should prepare students to work in the fragmented and medically dominated industry that prevailed at the time (and still does), or to provide care in a less fragmented, more holistic way: in other words, should it reflect ‘what is’ or pave the way for ‘what should be’. Out of such debate, a proposal emerged to include an innovation not found in the international standards on which the ACM was basing its work: the provision that students would follow a given number of women through their entire episode of care including pregnancy, labour, birth and early parenting. ‘Follow-throughs’, as they became known, held out promise of providing students with experience of midwifery continuity of care even if the woman experienced fragmented care from multiple caregivers. The student would effectively have a small caseload of women to follow, including being on-call for their labours and births, and receive the necessary supervision from whichever midwife was providing the woman’s care. Box 2 provides more information about the follow-throughs as they are defined and used in the Australian context (ACM 2006).

The Australian College of Midwives ‘Standards for the Accreditation of three-year Bachelor of Midwifery Programs’ was first published in 2001. The path from the visionary publication of these standards to today, where BMid programs are steadily spreading across Australia and becoming a normal feature of midwifery education, has not been smooth. Only one of the eight nurse regulatory boards formally adopted the ACM’s BMid standards, although others have chosen to informally use them to inform their decisions about curricula. The five universities that initially ran BMid programs commencing in 2002 had mixed experiences of trying to run the programs. Among the problems was the challenge of finding ways of linking students with women, ensuring appropriate supervision of the students during follow-throughs, and accounting for the clinical experience the student gains from following women. Students have also reported finding it difficult to balance the demands of what amounts to a small caseload practice with the rest of their student load, and with their own family’s needs. Yet most students also report finding the follow-throughs to be the most valuable part of their course, as they learned from the women they followed about the power and boundaries of a professional relationship nurtured over time.

Debate about the BMid standards continues. The ACM has been active in seeking to create opportunities for all stakeholders in the BMid to have their voices heard and their concerns addressed. For example, following the completion of the first intake of students into BMid programs, the ACM convened a national workshop in early 2005 with all key stakeholders represented. It was a day of vigorous and frank discussion, anticipated by many who attended with a degree of anxiety. But while certain principles like international comparability were non-negotiable for the ACM, it was pragmatic enough to accept arguments for some revisions to the standards to make them more workable in the Australian maternity and education systems. On the basis of feedback and advice from participants, the BMid standards were revised and republished in early 2006. The revisions sought to ensure the standards keep pace with changing international consensus on midwifery education as well as providing clarification on several points over which there had been confusion. But the revisions stopped short of imposing some elements of international standards that cannot currently be met within existing funding structures for university education.

Whatever their strengths and weaknesses, the creation of standards for Bachelor of Midwifery programs in Australia is a good example of a strategy for change in action. Despite an unfavourable environment at the time, the ACM pressed ahead with standards that were strongly underpinned by a vision for the future. The reforms to midwifery education have played an important role in generating an ever-growing workforce of midwives with direct experience of providing continuity of care, and an appetite for reform of services that fail to offer this opportunity.

The next challenge is to gain agreement across the profession to a single set of standards for all programs leading to entry to midwifery practice, regardless of the duration or prerequisites for the course or the title of the qualification gained (Bachelor, Graduate Diploma). The ACM is already active in meeting this challenge. It has commenced a national dialogue within midwifery, with a view to obtaining consensus ahead of the reforms of Council of Australian Government to accreditation of education programs for all health professionals due to be in place by mid-2008. Active engagement with a wide range of other key stakeholders, including consumers, students, employers, regulatory bodies, and state and territory health officials, is already underway. While there is no guarantee of the outcome, what is certain is that such engagement and painstaking dialogue with stakeholders is vital to success. If we fail to honestly engage with all relevant stakeholders then we might as well save our time and energy, as without broad support for the final midwifery education standards there is little chance they will be applied. Like labour for childbirth, the process used to achieve national standards is just as important as the outcome.

Tackling the legal shackles

This is often the hardest piece of the jigsaw to get into place. Achieving legislative reform can seem nigh impossible sometimes, particularly when you’re starting from a base where midwives are all but invisible to legislators—who assume midwives are nurses—and who cannot see the need for change (Brodie 2003). The challenge of achieving legislative reform in Australia is even harder than in some other countries, where a single national government has responsibility for determining things like the registration and authorisation to practise of health professionals. In Australia, there is a clumsy mix of responsibilities for health care between the national government on the one hand and the eight state or territory governments on the other. A federal health minister of the former Liberal government once confessed that ‘we have a dog’s breakfast of a system’ and that one would never design such a system deliberately if starting from ‘scratch’.

Midwifery, presumed to be a specialty of nursing since the 1940s, has long been regulated at the state and territory level. This means that to achieve reform, for example to allow midwives to prescribe Syntocinon, requires eight parliaments to amend their Poisons Acts. In essence, this means the momentum for reform takes a lot longer to establish. Having established and won legislative change in one jurisdiction is no guarantee that others will follow suit. Local volunteers with the interest, time, knowledge of the issues, and courage to engage with the often drawn-out political process of legislative reform have to be found and mobilised eight times over. This is a tall order.

In light of these challenges it is remarkable that midwife and consumer advocates have succeeded in securing legislative reforms in half of the eight states or territories over the past 10 years, with reform on the agenda in a further two. This advocacy has focussed firmly on securing improvements in the regulation of midwifery, particularly registration and accountability for midwives as a distinct profession from nursing. It is worrying that such hard-won reform might be lost in the current moves to replace the state-based registration system with a national one. The ACM has been actively seeking to ensure that the national reforms to registration protect and extend the gains made so far, but some of the officials involved have been slow to recognise midwifery as a distinct profession from nursing and the outcome at this point in time is unclear. However, it is significant that, in making this case to COAG officials, the ACM has been vocally and actively supported by peak nursing organisations. This in itself is testimony to the benefits of building alliances wherever possible with organisations that are far larger and more powerful than one’s own.

Another key area of legislative reform needed in Australia is amendment to relevant state and territory laws to provide for midwives to be authorised to order and interpret tests, and administer drugs routinely used in midwifery care, and to do so on their own responsibility rather than for and on behalf of a doctor. In reality this is happening every day, albeit with a charade of having a doctor sign a piece of paper some hours or days after the drug is administered and often without seeing the woman concerned. The nonsense of such arrangements was highlighted 10 years ago by a respected national health body, the National Health and Medical Research Council (1998). However its recommendation that state and territory governments move swiftly to address this misnomer has been ignored by all jurisdictions. This remains a major campaign needing to be waged—again eight times over—when the ACM can marshal the time, and people, to do so.

This legal context has significant implications for continuity of midwifery care in Australia. Without rights to admit women to hospitals, prescribe relevant drugs and order and interpret routine tests, midwives remain dependent on the support of individual doctors, not just for obstetric care of women, which of course is fundamental, but also for basic administrative support. Midwives in private practice, who have traditionally been the champions of continuity of care for women, are obliged to find a ‘friendly doctor’ to provide them with access to Syntocinon and oxygen, for example. Even employed midwives wanting to establish continuity of care services must contend with the rules and regulations that hospitals necessarily impose to comply with state laws, which result in there needing to be medical oversight of routine midwifery practice, even if only on paper. This is why the legislative piece of the puzzle is so vital in shaping midwifery continuity of care models of the future. Although these constraints can be managed, continuity of care services could work somewhat differently (and more efficiently) if similar laws prevailed as they do in the United Kingdom and New Zealand.

Quality assurance and confidence building

It is very hard to achieve structural change in the provision of midwifery care without having midwives ready and able to make the transition from providing care to multiple women while working rostered shifts in segmented wards, to providing care to known women throughout their maternity episode, on an annualised salary or in private practice. For this reason, one of the key objectives of the ACM is to ‘support all midwives to reach their full potential’. This does not mean that the ACM is seeking to have all midwives work in continuity models instead of shiftwork. Rather it means that the ACM is seeking to raise the collective confidence of the profession, so that all midwives feel able to make choices about how and with whom they wish to work at different times during their career, rather than feeling unable to make such choices because they lack confidence in their own abilities to work in a different area or model of care. Much of the advocacy in the past has focussed on choice for women. There also needs to be choice for midwives—freedom to practise according to their own professional philosophy—especially if we are to make any inroads to the workforce shortages.

It is easy to see why many midwives feel less than confident in their practice, given the context described earlier where most midwives are not educated to see themselves as autonomous health professionals within their own scope of practice, and are pressured to follow (medical) protocols even where such protocols may not reflect contemporary evidence. Add to this the persistent and well-documented problem of bullying by midwives of each other (Gillen et al. 2004, Gould 2004, Keeling et al. 2006, Mander 2004), and it is easy to appreciate the challenge of supporting midwifery as a profession to be strong and confident.

A number of strategies have been employed to tackle this challenge. One strategy has been concerted effort to identify and cultivate potential midwifery leaders, and to lobby for the creation of positions of authority for midwives within universities and health services. A number of Australian universities offering midwifery education, for example, now have a Chair in Midwifery of some description, sometimes funded as a clinical position collaboratively with a state health service. The efficacy of this approach varies depending on the abilities and resources of different individuals in such positions. But in general this approach is having an effect in raising the profile of the profession, not only among other health professionals and policy makers, but also within the midwifery profession itself. It certainly does not hurt, either, to have a title of ‘Professor’ when proselytising to a journalist about the benefits of midwifery care!

Effective midwifery leaders are also vital on the ground in individual services. Many midwives work in units managed by non-midwives, often a professional nurse manager, some of whom are infamous for their hostility to midwives and midwifery. More individual midwives who gain such management positions are taking a stand, insisting their position descriptions be changed from ‘Nurse Unit Manager’ to ‘Midwifery Manager’, and seeking to mentor their colleagues rather than control their staff. Such changes take personal courage and conviction, but over time they are vital to helping change the status and visibility of midwifery.

The creation of Bachelor of Midwifery standards and courses is another strategy that should be briefly flagged here. It has helped to build a new generation of midwives who have had the opportunity to consolidate their professional skills that bit more before they need to negotiate a space for their midwifery practice within medicalised systems of care.

Many of the strategies I have detailed are somewhat localised in their effect, influencing mainly the individual midwives who are involved. In an effort to provide support and build professional confidence on a wide basis to all Australian midwives, the ACM has recently completed two key projects, both funded by the Australian government. These projects have led to the creation of a national program to support midwives with their continuing professional development (CPD)—called ‘MidPLUS’—together with a separate but related program (Midwifery Practice Review, described in Chapter 7) to give midwives the opportunity to review their practice with the support of a trained panel of peers and consumers (see website for more information).

Midwifery is one of the last health professions in Australia to develop a CPD program. Prior to the MidPLUS program, midwives have had little or no guidance in identifying what learning needs they may have and how to address these needs during their career. Many midwives have relied on their employer to dictate what skills workshops they attend. Since many enterprise agreements make no provision for midwives to have paid leave to engage in CPD, the only way they access a CPD activity on paid time is by attending employer-sponsored activities. It would be interesting to see research into the impact of such arrangements on professional confidence. Anecdotally, it would seem that these systems of education are adequate for meeting midwives’ needs for basic skills updates in the area(s) of care for which they have immediate responsibility, but could do more to support midwives to develop confidence in their professionalism as a midwife across the full scope of midwifery practice.

The MidPLUS program is intended to help address these shortfalls by giving every midwife a framework within which to take responsibility for their own professional development. The program has drawn on insights from existing CPD programs both within and outside health. It offers midwives a series of toolkits and pro-formas, as well as a professional portfolio, to support their ongoing participation in a professional Learning Cycle that involves identifying and prioritising their learning needs, participating in CPD activities, and reflecting upon the implications of what they learn for their midwifery practice. Care has been taken to ensure the program is relevant to all midwives, regardless of their current role or responsibilities, their age or experience, or their future career plans.

The Midwifery Practice Review program is related to the MidPLUS program in that participating in a practice review is billed as one of many CPD activities a midwife may wish to engage in. Midwifery Practice Review provides midwives with a supportive, albeit rigorous, mechanism to review their own practice. It comprises a number of steps, one of which is participating in a face-to-face review discussion with a peer and a consumer. The reviewers are trained and accredited. The midwife reviewers are all practising midwives who themselves undergo practice review. The program is modelled on the Standards Review system developed by the New Zealand College of Midwives (see website for more information). Although midwives often find reviews a daunting experience when they first prepare for it, pilot testing has confirmed that most if not all find it to be a very rewarding experience and are better able to recognise and value their own professional skills afterwards, as well as prioritise their future learning needs. Participation is voluntary at this time, but there is heartening interest in the program across Australia. More about the Australian Midwifery Practice Review process and New Zealand’s Midwifery Standards Review is in Chapter 7.

The efficacy of these programs in helping to build the collective confidence and professionalism of midwives remains to be seen—both will be evaluated over time. Both programs have been developed through extensive consultation with the profession, as well as with representatives of consumers, obstetricians, regulators, employers and others. Feedback from such groups has already indicated that the very existence of such programs is helping to raise the esteem in which midwives are held. Doctors’ groups, for example, have long pointed to the processes currently used by the nursing regulatory boards to re-register midwives each year—which typically requires only a declaration ‘yes I’m still competent’ and payment of a fee—as evidence that the profession does not take seriously enough the responsibility to provide quality care and midwives therefore need medical supervision. Setting aside the objectionable politics behind such arguments, they do have a point. It is in the interests of the midwifery profession, and the women and babies they care for, to show a strong and active commitment to quality assurance in midwifery care. Such tangible evidence of quality assurance goes a long way to supporting advocacy in favour of midwives having greater professional autonomy and responsibility for women’s care than they generally do now.

Selling the benefits of midwifery care

One of the biggest hurdles of reform to maternity care is ignorance. If women don’t know who midwives are and what midwives do, they won’t know they want (and need) access to midwifery care. If women don’t have the opportunity to experience continuity of midwifery care, then they’re not going to answer a survey about their satisfaction with existing fragmented maternity services saying they want a known midwife. If legislators and policy makers are equally ignorant about midwifery care and its potential as a public health strategy, then they are not going to give any priority to maternity reform ahead of the myriad of other issues on their plates. Thus raising awareness in the community at large of midwifery and what it offers women and babies has to be a core objective in any strategy to achieve and sustain reform. This is true whether the issues are macro, about government policies or issues like national caesarean rates, or local, about the issues surrounding a particular service or proposal for a service.

Raising awareness in the community at large is easier said than done. Individuals and groups with a powerful vested interest in the status quo typically have many more resources to throw at the public relations game than midwifery and consumer organisations urging reform. There is also the perennial prejudice of journalists to overcome, many of whom unquestioningly assume all commentary by medical spokespeople is factual and trustworthy just because they are doctors, and all commentary by non-doctors is non-expert and therefore unreliable.

Media attention is a fickle thing. There is always the risk that journalists will convey a story that is hostile to midwifery care. When one midwifery continuity of care service was first opened a few years ago, the local paper gave headline coverage to a general practitioner who declared ominously that ‘I wouldn’t let my cat have kittens at this service!’. Another service that had been running for 10 years and was the subject of relentless opposition from the powerful doctor’s union was described by the union’s president as ‘the killing fields’. Such extreme remarks make for good copy for journalists, with flashy headlines, but they can be challenging for those involved in working within a service attacked in such ways. However, the media can also be a very powerful ally. In broadly distributing news of the venom that prompted the ‘killing fields’ accusation, the media unwittingly gave rise to a groundswell of popular protest, promoting more than 3000 people to attend a rally a week or two later in support of the midwifery service. Mothers, fathers, babies, toddlers, grandparents, uncles, aunts and parliamentarians, all turned up to the rally, which was faithfully relayed on every state television news program that night. The community support for the midwifery services was palpable and the comments of the doctor’s union were seen for what they were—rhetoric from the pulpit of vested interest.

It is rare that a new midwifery continuity of care service is established in Australia without attracting some media interest. Such services are still a novelty, and not well understood in most communities. The idea that a midwife would be responsible for care without being supervised by a doctor is an unfamiliar one for many journalists and their audiences. So it is wise for anyone involved in the establishment or ongoing management of a midwifery continuity of care service to anticipate media attention at some point or other.

In my experience, one of the key things to keep in mind when seeking to engage with the media is that the journalists themselves are vital members of your audience. If, through reasoned and sustained discussion, you can persuade an individual journalist of the merits of your case, you are far more likely to get a story relayed to the public that at least gives a fair hearing to your views and arguments, if not a favourable account of them.

One of the challenges in doing this is that it is rare to come across a journalist who does not have their own (sometimes strongly held) views about childbirth and maternity care. Just about everyone has experience of maternity care in one way or another. With such high rates of medical intervention it is a fair bet that if the journalist or producer you are talking to has children, they have had experience of a caesarean section, for example. If they have not had a child themselves, it is still likely they have a sister-in-law, friend or acquaintance whose baby ‘would have died if it hadn’t been for the obstetrician’. So it is always wise to tread carefully until you get a feel for where the person asking the questions is coming from. At the very least it is ethical to do so, since sometimes people with their own gruelling story of maternity care can be quite emotional in their response when you describe evidence of medical over-servicing, for example. In my experience, some become angry or hostile. Others are persuaded by the evidence and rush to share their own story in significant detail with you. Either way, having an ear to the personal perspective being brought by the interviewer to this story is important for getting your issues into the paper the next day or onto the radio or television in a meaningful way.

The art of dealing with the media is not one that can be learned from reading a book. For most midwives and consumers who take the plunge to speak to journalists and radio and television producers and anchors, it is simply a matter of baptism by fire, learning by doing. There are typically limited resources to provide media training. The first few times you speak to the media can be very daunting, and endless revisiting of what you said and what you could have said can distract you for some time afterwards. But like everything, it gets easier with practice. Certainly one of the things I have come to hold onto over the years is the adage that ‘no publicity is bad publicity’. Media reporting is so temporary—words go out into the ether and are noticed for such a brief time—that even when an interview doesn’t go as well as you hoped it would, you can put it down to experience, learn what you can from it, and plan for the next opportunity.

I was heartened some years ago by a journalist who explained to me that the colloquial term used among journalists for the people they interview is ‘the talent’. This highlights the extent to which there is actually a two-way exchange involved in most media stories—you need to convey certain information or issues to the journalist, and they need a story to print or broadcast, often by a given deadline. This story is often just one of several that particular journalists must produce that day. So the more you can do to give them pithy quotes and reliable information in a format that can be easily digested the better. Herein lies the challenge. Many of the issues affecting the provision of maternity care are complex. There are lots of factors that influence, say, the climbing percentage of women undergoing major abdominal surgery for the birth of their baby. But there isn’t time or space for the full complexity to be conveyed, and even if there were, nobody would read it in their rush to get ready for work over the morning paper. So the challenge is to find a way of getting across two or maybe three key points at most, in as succinct a way as possible, while still presenting a credible and defensible view of the reasons. To do this you have to know your facts, and any relevant research, really well.

There are a number of strategies for preparing for and getting the most out of a media interview. One is to spend some time before the interview asking the producer or journalist about why they are interested in this story. This gives you a feel for the angle they might bring to how they piece the story together, and what argument they might make in reporting it. It is also a good idea to delay responding to the interview, or have someone to field media inquiries and someone else to give the interview. This gives the person to be interviewed some time to prepare two or three key dot points about the message they want to convey. Otherwise it can be easy to be distracted by the interviewer into using up precious seconds and minutes of the interview on material that is not really central to what you want to get across. More than once I’ve had an interviewer say ‘well, thanks for that’ thereby ending the interview following a few questions I would regard as being relatively unimportant, and I’ve lost the opportunity to get a key piece of information or evidence across. So by getting as much background about the reason for their interest first, and preparing a few dot points for the interview itself, you are less likely to fall into this trap.

It is also a good idea to ask who else they are interviewing. Most journalists will seek to get a ‘balance’ of views, which in maternity articles typically means they will ask an obstetrician to balance the comments by a midwife or midwifery advocate. And journalists will also often take the easy route of approaching commentators who are frequently cited in other media, such as the head of an obstetrician’s organisation. So it is a good idea to find out who else they are also talking to. You can even ask what that person has said to them, then address your points to respond if need be. Since they will often ask the same commentator, you can become familiar with that person’s arguments, and counter them if need be without being asked to by the journalist. Where possible it can also be beneficial to cultivate obstetricians who are comfortable with midwifery care and are prepared to speak to the media if called upon. You can then provide contact details for such people to the journalist if they have not already identified an obstetric spokesperson. This strategy can help to remove the temptation for journalists to portray midwives and obstetricians as being in opposing camps. The media seems to thrive on conflict. Good news stories don’t sell, as the saying goes. This is something you have to be on guard against whenever you engage with the media. Such ‘us and them’ portrayals are very unhelpful, and risk alienating women who might read or hear the news item. No advocate for midwifery services ever proposes that midwifery is an alternative to obstetrics. Rather the argument is for collaboration between midwives and obstetricians, focussed on women, to ensure women receive care that is appropriate to their individual needs. Midwifery and obstetrics are complementary fields of expertise. All women need midwifery care, and some will also need obstetric care.

Many midwives are constrained in their ability to talk to the media directly due to clauses in employment contracts prohibiting this unless approved by the employer, so some of the above may be redundant information. However, this means that membership of your professional organisation is even more vital. The professional organisations are in a unique position of being able—even expected—to speak vocally on midwifery issues. It can be briefed on relevant issues and run a media campaign without identifying employees or clients of a particular service. Anyone therefore interested in creating and sustaining a midwifery continuity of care service stands to benefit when handling the media, from good links and communication with their peak professional body.

Conclusion

This chapter has focussed on parts of the puzzle that relate not to the immediate challenges of designing, establishing and sustaining midwifery continuity of care but to the wider environment in which the service is to operate. I have argued that the wider policy environment in which a service is created has a profound influence on how each service is established, and on the opportunities for midwives to provide continuity of care to women. I have used the Australian experience over the past decade as a case study to demonstrate the different aspects to each ‘jigsaw piece’ that defines that wider environment.

In particular, I have concentrated on how midwives and consumers have sought to influence government policy to support midwifery continuity of care as a mainstream choice for pregnant women. I have also focussed on the constraints and opportunities posed by the regulatory and education frameworks. These frameworks affect the availability of midwives to provide continuity of care, as well as the arrangements that are needed to support prescribing, ordering and interpreting of tests, visits with women and other such practical aspects of any continuity of care service. I have also briefly sketched my own experiences of engaging with the mass media to raise community awareness of the benefits of midwifery continuity of care for women and their families.

In conclusion, the following points are lessons I have learnt about how to get reforms to happen, or at least to begin. There is no doubt a whole body of research literature out there can deliver more profound insights into strategies for initiating and sustaining effective reform. The following tips are anecdotal only, and are offered in the possibility they might be helpful to others embarking upon or in the middle of a reform process.