Individualised midwifery care and genuine inter professional collaboration producing high levels of satisfaction and enviable clinical outcomes in a small Australian setting. Why is sustainability so difficult?

Topic Area: Returning birth to normal : Successes and barriers to Innovative Collaborative Midwifery Practice  Description:  In 2017 less than 10% women in Australia have access to continuity of care in public or... [ view full abstract ]

Topic Area: Returning birth to normal : Successes and barriers to Innovative Collaborative Midwifery Practice 

Description:  In 2017 less than 10% women in Australia have access to continuity of care in public or private sectors. This small private practice in Queensland employs 4 caseload midwives with public hospital admitting rights, mentoring graduate midwives and is clinical site for midwifery students. Birth outcomes (2011 to 2017) : 308 births of which home births 33% (first birth 30%), spontaneous labour 91%, spontaneous birth 84%, caesarean section 11% (Emergency LSCS in labour 8%), VBAC 78%, preterm birth 4%, low use of pharmacological analgesia (morphine 7 women, epidural 27 women), breast feeding at 6 weeks 93%. Statistics and details of the model will be provided and compared with national outcomes and standard models of care. Few midwives (< 100) have opened Medicare funded private practices, and < half have co-operative relationships with local health services. These midwives continue to face many obstacles to sustainability, and practices are also closing. Current barriers can be classified as financial, professional and society attitudes.

Discussion: National and Queensland maternity service reviews early 2000's reported women's dissatisfaction with standard medicalised choices and demanded change. Increased professionalisation and public recognition of midwifery emerged with direct entry Bachelor of Midwifery courses and private practice midwives in community. Australian government Medicare funding made available to all women for private midwifery services from November 2010. Despite this funding assistance, women's satisfaction and positive clinical outcomes few midwives have opened Medicare funded private practices.  

Financial : Low Medicare rebates for midwifery services and no government funding for home birth; equipment and usual business costs; private health insurance (held by 40% Australians) preferentially fund private obstetrics but not private midwife services. 

Professional issues : Fear and poor understanding of normal birth (doctors and midwives); Risk culture pervading childbirth "creating pathology from normal physiology"; uncertainty related to high levels of changeable midwifery regulations; insurance restrictions; obstetricians and hospitals unwilling to negotiate the necessary collaborative arrangements with midwives; absence of inter professional lack of clinical consensus; threat of private O&G loss of income; loss of midwifery skills, reduced competence and confidence associated with high rates of interventions; midwives' satisfaction with pay and hospital shift-based staffing model generating resistance to "on call" and disinclination to move into a role perceived to have more responsibility and accountability. 

Societal: Public acceptance of high levels of intervention as normal part of maternity care; low level of knowledge and high level of fear of normal birth; poor recognition of midwives as accountable professionals for normal birth; long term medical and media depictions of home birth as dangerous.

Conclusion: On measures of women's satisfaction and clinical outcomes, one small scale "all risk" caseload midwifery service working in collaboration consistently produces enviable results over 6 years. This model could be widely reproduced but solutions are urgently needed for on-going barriers. 

Preferred presentation : Oral