Midwifery continuity of care for specific communities

10 Midwifery continuity of care for specific communities image



Caroline Homer, Pat Brodie, Nicky Leap



Introduction 182

Midwifery continuity of care as primary health care 182
Aboriginal Birthing Program in South Australia 183

Working with Indigenous women in remote Australia 185

Midwifery continuity of care in an isolated area of New Zealand 187

Midwifery continuity of care in a remote Scottish island 189

Continuity of place, culture, history, community in Inuit Canada 190

Midwifery continuity of care for vulnerable or disadvantaged women 191

Conclusion 193

References 193


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.


We invited a number of people, who we knew were involved in providing care to specific groups of women, to contribute. The authors come from Australia, New Zealand, Scotland and England. We asked them to talk about their challenges, strategies for implementation, and sustainability. The stories have common themes. In particular, they address the need for midwifery to be a public health strategy and take a primary health care approach. Some of the stories you may find challenging and even disturbing. We acknowledge this and trust you will use this reflection to gain an understanding of the different challenges and issues facing midwives in these ways of working.



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).


Primary health care is an important concept for maternity service planning, organisation and delivery, and also for guiding the education and training of the health workforce. Primary health care principles imply that:


• health care services should be equally accessible

• maximum individual and community involvement should occur

• the focus should be on illness prevention and health gain

• only appropriate technology that is scientifically valid and adapted to local needs is used, and this is affordable and acceptable to the community who use it

• health care is only one aspect of total health development; education, housing and nutrition are all essential to overall wellbeing (WHO 1978, 1986).

In other words, these principles encompass equity, access, the provision of services based on need, community participation, collaboration and community-based care. Primary health care involves using approaches that are affordable, appropriate to local needs and sustainable.


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).


Midwives working in these areas are often faced with ethical challenges for which there are no clear guidelines and, in many instances, no easy answer. They are frequently the only skilled maternity service provider resident in a community providing a service for Aboriginal women. Ideally, to increase their effectiveness in the community, they will work side by side with Aboriginal Health workers, though there is a current shortage of these professionals also. In many instances the women do not want to leave their communities for birth, yet they do what is advised, believing it is best for their baby, despite their worries and concerns. Others will avoid antenatal care so as not to be sent away from their families for birth. Some women will tell you early in their pregnancy that they are staying in the community for birth, no matter what. Others will be sent out at 38 weeks, returning before their babies are born and presenting to the Health Centre in strong labour, too late to be transferred back to town. In some instances, midwives who work with women and provide birthing assistance on site have been targeted as ‘dangerous practitioners’ who ‘collude with women’ who are ‘taking their life in their hands’.

Related posts:

  1. Effective collaboration with medical colleagues: making it happen
  2. Understanding your context: preparing for change
  3. Midwifery continuity of care: the future
  4. Politics, policy and the press: crucial pieces in the maternity reform jigsaw

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Jun 18, 2016 | Posted by in MIDWIFERY | Comments Off on Midwifery continuity of care for specific communities

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