10 Midwifery continuity of care for specific communities
Introduction
The evidence presented in Chapter 2 demonstrates that women benefit from midwifery continuity of care and argues that this has implications in terms of access and equity. The benefits of continuity of care are often social, psychological and emotional, as well as physical. It seems likely, therefore, that women who are socially isolated, or from marginalised and vulnerable communities, will particularly benefit from this type of care. This chapter provides a number of vignettes or short stories of examples of how midwifery continuity of care can be designed to meet the needs of these specific groups of women. We also focus on stories from midwives who work with Indigenous communities and those who practise in rural or remote settings.
Midwifery continuity of care as primary health care
This chapter explicitly highlights some examples of midwifery as a public health strategy and the value of a primary health care approach. Primary health care is often misunderstood as only referring to care in the community or care for healthy, low risk women. We believe that midwifery continuity of care is fundamentally about primary health care, regardless of location or target group (Brodie 2003).
As we explained in the Introduction, we believe that primary health care is one of the fundamental underpinnings of midwifery continuity of care. The Australian Competency Standards for the Midwife (ANMC 2006) have primary health care as one of four essential domains, again highlighting the importance of this. Box 1 explains how we see midwifery continuity of care can fulfil primary health care principles and is adapted from the Australian Competency Standards for the Midwife (ANMC 2006).
Box 1 Midwifery as primary health care
Midwives understand that health is a dynamic state, influenced by particular socio-cultural, spiritual and politico-economic environments. The midwife has an important advocacy role in protecting the rights of women, families and communities while respecting and supporting their right to self-determination. Midwives have a commitment to cultural safety within all aspects of their practice and act in ways that enhance the dignity and integrity of others.
Midwifery practice involves informing and preparing the woman and her family for pregnancy, birth, breastfeeding and parenthood, including certain aspects of women’s health, family planning and infant wellbeing. Midwives have a role in public health that includes wellness promotion for the woman, her family and the community.
While midwives have the skills ‘to do’ they also have an ability to develop relationships with the women for whom they care as well as others with whom they interact in their professional lives. The midwife works collaboratively with health care providers and other professionals, referring women to appropriate community agencies and support networks.
When you read the stories highlighted in this chapter, you may like to think about how they address primary health care principles, ensuring that midwifery continuity of care is a public health strategy.
Aboriginal Birthing Program in South Australia
The first story comes from Australia. Anne Nixon, Deanna Stuart-Butler and Cheryl Boles describe the Family Anangu Bibi Birthing Program in Port Augusta and Whyalla, South Australia. This model is a wonderful example of how midwifery continuity of care can be developed for a specific community in partnership with women and other health care providers.
Anne Nixon starts the story. Anne is the Midwife and Coordinator of the ‘Improving Aboriginal and Torres Strait Islander Birthing Outcomes Project’, Aboriginal Health Division, South Australia. Anne is also a co-author of Chapter 6.
Box 2 Family Anangu Bibi Birthing Program in SA
Perinatal outcomes for Aboriginal women and infants in South Australia have been consistently much poorer than those for non-Indigenous women and infants. A state-wide consultation was undertaken in the context of a project I coordinated for the Aboriginal Health Division. In 2003 a framework was developed at an Aboriginal women’s workshop for the creation and support of models of maternity care for Aboriginal women that could make a difference in health outcomes. Feedback from meetings and gatherings with Aboriginal women and communities resulted in the following important consensus statement:
‘Healthy Pregnancy and Birthing is a life process and is an important issue for the health of all of our communities. This issue should be a priority in health planning processes, with appropriate and adequate ongoing funding. Aboriginal and Torres Strait Islander women want to be cared for by Aboriginal and Torres Strait Islander midwives and Health Workers.’
Encouraged by examples of midwifery continuity of care models and effective models of maternity care for Indigenous women in other countries and interstate, and building on years of community demand for culturally appropriate care, a group of dedicated people in the northern communities of Port Augusta and Whyalla proposed to develop a new model of care. Support and in-kind contribution to the program came from the local hospital services, Aboriginal community health services, the Child Youth Health service, as well as some top-up Commonwealth Alternative Birthing Services Program funding.
The project piloted a dedicated role for Aboriginal health workers in maternal and infant care, which they called the ‘AMIC’ (Aboriginal Maternal Infant Care) Worker. The Family Anangu Bibi Birthing Program provides antenatal, intrapartum and postnatal care to women and their infants by AMIC Workers in partnership with midwives. The first 18 months of this Program have been evaluated and its success has led to the recommendation that it be expanded across country regions of South Australia. Two of the care providers in the Family Anangu Bibi Birthing Program explain why it works below.
Deanna Stuart-Butler, Aboriginal Maternal and Infant Care Worker in the model, describes the principles.
‘The Family Anangu Bibi Birthing Program model is based on the principles of continuity of care. What makes this particular model unique is that the caseload care is coordinated by Aboriginal Maternal and Infant Care Workers who are backed up by a team of midwives. Aboriginal women are cared for by Aboriginal women. We target 20 women per year here in Port Augusta. Our clients are young Aboriginal and socially disadvantaged women with priority given to high-risk obstetric situations. Our program is also overseen by a community-based Aboriginal Women’s Advocacy Group that ensures the service respects cultural safety.
‘Personally, I feel the Program works firstly because Aboriginal women are getting what they have always wanted after years of consultation—they want to be cared for by Aboriginal women, to have consistent, known caregivers. Secondly, we work in partnership with midwives. We could not be successful without the midwives sharing their clinical expertise and they couldn’t do it without us, sharing our cultural knowledge. It’s not about us taking away the role of the midwives, but it’s about sharing that knowledge, so as to make a difference in the service delivery for Aboriginal women in mainstream hospitals. We are concerned about the problems reflected in the South Australian Birth Outcome Statistics and wanted to make a difference for our women and children—now and hopefully with future generations.’
Cheryl Boles is the midwife who works in the model with Deanna. She says:
‘I agree with Deanna, I think the model works because of the commitment to working as a team. As team members we work as equals with each person bringing a special skill and experience that is valued and respected by the whole team. No one is perceived as being in charge. We are all very clear that it takes both sides of the team, both AMIC and Midwifery, to deliver a service that is culturally and clinically safe. Commitment to open communication at fortnightly team case conferencing meetings has also been a cornerstone to our success.
‘I also think our model works because it is based on 10 years of consultation with the local community. The people who contributed to the application for funding have also been the same people (both AMIC Workers and midwives) to implement and work in the program. I think that this has been important in achieving the commitment that has been required.
‘What makes us different to other continuity of care models is that we are holding hands with the AMIC Workers to deliver a style of care that would not be possible for midwives to do on their own.’
The principles so well described in this vignette include partnership, primary health care, and community engagement and access.
Working with Indigenous women in remote Australia
Our next story describes an example of midwifery continuity of care in a remote Australian setting. Sue Kildea is a midwife, educator and researcher in the Northern Territory, Australia. Sue has been working with women, midwives, nurses and doctors in remote settings in Australia for the past decade. This is one of her stories.
Box 3 An example of midwifery continuity of care in remote Australia
Over the last 40 years across remote Australia, women have increasingly been relocated from their homes to give birth in regional centres. Typically, they will leave their homes at 36–38 weeks gestation to await birth, usually alone, in the regional setting. Women state they do not like to be away from their families for weeks at a time as worrying about the children left behind and other family members causes immense stress (Biluru Butji Binnilutlum Medical Service 1998, Fitzpatrick 1995, Hirst 2005, Kildea 1999). Many remote areas no longer have the infrastructure, staff or insurance cover to support on-site birthing. These policies are driven by a belief that birth in remote areas is too ‘risky’. Important contributors to a positive experience of maternity care are often lacking in this model, namely: continuity of care, choice of care and place of birth and the right to maintain control (Homer et al. 2001). It is clear that the model of care is not socially or culturally acceptable to women and their families, nor is it satisfying for the health care providers (Biluru Butji Binnilutlum Medical Service 1998, Carter et al. 1987, Fitzpatrick 1993, Kildea 1999, 2006, NSW Health 1998).

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