6 Planning and implementing mainstream midwifery group practices in a tertiary setting 
Introduction
This chapter focuses on how we planned and implemented a mainstream Midwifery Group Practice (MGP) in a tertiary setting in an urban city in Australia. We explain the significant influence of local conditions, policy, relationships, and existing health system infrastructure in affording both opportunities and constraints in the implementation of midwifery group practices. As you will have read in Chapter 3, it is important to cultivate an understanding of the local conditions and context in which you plan to set up. We (the authors) are the Divisional Director of Midwifery and Nursing (Chris), and two Joint Midwifery Unit Heads for Midwifery Group Practice (Roz and Anne).
Context
The Women’s and Children’s Hospital (WCH), of the Children, Youth and Women’s Health Service (CYWHS) in Adelaide, is the largest publicly-funded tertiary referral teaching hospital for maternity, neonatal and paediatric services in the state of South Australia. The hospital is located in the city centre of the state capital and provides centralised specialist services for approximately 4600 births per annum. This is more than half of the public health system births for the state. Retrievals and referrals from rural centres are also accommodated. The client mix is culturally and socio-demographically diverse. Prior to implementation of the first two Midwifery Group Practices at WCH in 2004, the hospital had an integrated Birthing Centre with midwifery staff working on a roster basis to provide antenatal and birthing care for approximately 500 self selected women per annum, who met ‘low’ risk pregnancy screening criteria. Operating for 12 years with its own dedicated midwifery staff, the Birthing Centre had its own well-established culture, norms, protocols and relationships within the WCH.
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.
The vision
Another concern was the impending midwifery workforce shortage—we understood that we needed to use our midwives in the most effective way. Midwifery shortages in rural and remote areas were already apparent and urgent and well documented (Barclay et al. 2003) , and we knew that the metropolitan areas would soon be feeling those shortages as well.
In October 1995, Professor Lesley Page’s visit to the WCH inspired a small group of midwives, who made a commitment to develop a model of continuity of midwifery care and carer. A group of committed midwives began to meet in late 1995. None of us could have imagined that it would take 5 years before the proposal was finally written and another 4 years before commencement of our model in January 2004! One of the midwives involved in the early stages of our model (Ali Teate) reminds us of the challenges—the highs and lows—that are faced in achieving implementation of new models of midwifery continuity of care (Box 1).
Planning
The development of this industrial framework is a significant milestone within the Australian context as it currently enables midwives within public sector employment a salary and working conditions based on caseload midwifery. That is, it accommodates patterns of midwifery work to meet the needs of women and midwives, rather than ‘nursing’ style work based around the service needs of an institution. This enables newly evolving models of care that capitalise on the full use of midwifery skills and women’s requests for improved access to these models (NHMRC 1996, NMAP 2002).
The importance of the support of the Australian Nursing Federation (ANF) cannot be underestimated in the development of the Annualised Salary Agreement. Without this Agreement the model would not be as effective, nor would the midwives be able to respond to the needs of the women as they now do. The Annualised Salary Agreement developed for MGP at WCH has now been incorporated into the South Australian Public Sector Enterprise Bargaining Agreement for any public hospital in the state to use in implementing similar models of care.
Box 2 Key features of the MGP Annualised Salary
This was the Midwifery Caseload Practice Agreement in July 2005:
While this 9-year period of development was lengthy, there were advantages to this lead-time. An extensive review of the literature was undertaken and similar models in Australia and internationally were reviewed (Flint 1993, Flint et al. 1989, Homer et al. 2001b, Page et al. 1995, Rowley et al. 1995, Shields et al. 1998, Turnbull et al. 1999, Waldenström 1998, Waldenström & Turnbull 1998). This extended period also allowed time for everyone throughout the organisation to get used to the concept, to discuss it broadly, and to overcome any fears they had about moving in this direction.
Key arguments for implementing the model
Through our planning and researching of midwifery continuity of care projects, we were aware that these had been the subject of much research and had been shown to be safe and cost effective with good clinical outcomes. For this reason, we decided not to implement our model as a pilot or research project but rather as a reorganisation of our service, which would, of course, be evaluated. The aim and objectives of our proposal are in Box 3.
