11 Politics, policy and the press: crucial pieces in the maternity reform jigsaw 
Introduction
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
The invisibility of midwifery
This invisibility is reinforced by the current regulatory arrangements in Australia (Barclay & Brodie 2001). Most midwives are registered as nurses, in some states this even includes those who hold no qualification in nursing. Midwives lack visiting access to hospitals, professional indemnity insurance and prescribing rights. Midwives’ choices about where and with whom they work are highly constrained. Ninety-nine per cent of the midwifery workforce depends on an employer (typically a public or private hospital) for professional indemnity insurance and access to relevant drugs and tests for the women they provide care for.
Another profoundly important feature of Australia’s maternity care environment at present is the sheer dominance of private obstetrics. Like many other developed nations with similar demographics, Australia has low rates of maternal and perinatal mortality. These low rates have remained fairly constant over the past two decades despite an unprecedented escalation in the rates of obstetric interventions in labour and birth (Tracy & Tracy 2003). The most recent data available nationally shows rates of induction of labour at 25.3%, rates of augmentation of labour at 19.5% and rates of caesarean section at 29.4% (Laws et al. 2006). Obstetricians in private practice provide more than half of all obstetric services. Most hospitals providing maternity care rely upon at least some of their obstetric services being provided by private obstetricians. More than one-third of women are choosing care by private obstetricians and the federal government is spending millions each year on funding their services and subsidising their premiums for medical indemnity insurance.
This environment—invisibility to women, the dominance of nursing education as preparation for midwifery practice, registration as a nurse, and the political and practical dominance of private obstetrics in virtually every maternity service—profoundly influences how midwives see themselves and their levels of confidence in their own professional expertise. Most midwives neither see themselves, nor are they seen by others, as autonomous health professionals, acting on their own responsibility to care for women and involving doctors only when the needs of individual women dictate. Most midwives provide care to women in contexts that are strongly shaped by obstetric protocols and philosophies of care. Employers vigorously reinforce such protocols, even where they are demonstrably not based on evidence. Individual midwives who dare to question or challenge such protocols are not infrequently punished, sometimes to the extent that they leave the profession. It is hardly surprising that there is currently a workforce shortage of midwives in Australia, estimated at more than 1800 (AHWAC 2002), or that rates of attrition, particularly among new graduates, are unsustainably high. It is also unsurprising that many midwives regard midwifery continuity of care services with caution or even overt fear.
On the road to reform
On the education front, seven universities now offer Bachelor of Midwifery (BMid) programs and a number of others are planning to do so within the next year or two. People wishing to join the midwifery profession are queuing up to access such programs, with more than 700 applications for 30 places at one university recently. Importantly, these programs provide their students with hands-on experience in providing continuity of care. The BMid standards developed by the ACM (2001, 2006) include a requirement that students follow 30 women through their episode of care, even when the woman herself is cared for by multiple midwives and/or doctors. The length of the BMid programs is twice that of postgraduate (after nursing) entry to practice programs. As such, they provide students with greater time to build both knowledge and skills, and to gain confidence in their midwifery practice before entering the profession.
Midwifery has also gained more prominence in policy circles over the past 10 years as a distinct profession from nursing. A number of peak bodies whose activities influence the midwifery profession have officially changed their names from being nursing bodies to ‘nursing and midwifery’ ones, such as the Australian Nursing and Midwifery Council, the Council of Deans of Nursing and Midwifery, and the Australian Peak Nursing and Midwifery Forum. Likewise, many universities have also changed the nomenclature of their nursing schools to specifically flag midwifery as a part of their responsibilities. Such changes have been more than symbolic. They have reinforced a profound shift in the way midwifery is viewed within these organisations as well as by other key stakeholders like government agencies. They have also legitimised resources being dedicated to specific projects that address the unique needs of the midwifery profession.
Talk is one thing. Action is another. Over the past decade, women’s access to midwifery continuity of care has been expanding, although it is still the case that fewer than 5% of women can access care by a known midwife, whether via the public or private health systems (Laws & Sullivan 2005). However there is now at least one publicly-funded continuity of midwifery care service in every state and territory, and many more than one in some states. At least half of the state and territory governments (which have primary responsibility for providing maternity care services) have recognised that giving women greater access to midwifery continuity of care is a desirable policy goal (NSW Health 2000, Victorian Health 2004). Since 2005, there has also been a growing chorus of support for midwives to have direct access to national health funding, known as Medicare, which, if granted by the national government, would allow midwives to offer government-funded services to women through private group or solo practices as is the norm in New Zealand. While there is no immediate prospect of Medicare funding being provided directly to midwives on their own responsibility, the new federal Labor government, while in opposition, had endorsed a policy that includes exploring a commitment to Medicare for midwives.8
Meanwhile, some Australian midwives have been creative in their attempts to establish private practices through collaborative relationships and systems. One example is Liz Wilkes, an independent practising midwife in south-western Queensland, Australia. She most recently worked in collaboration with a local obstetrician and tells her story in Box 1.
Perhaps one of the most significant changes in recent years has been that midwives themselves are becoming more aware of their professional identity and are increasingly keen to participate in reform of their local maternity service to provide greater continuity of care to women. Every month news comes through that a new midwifery group practice is being established somewhere in Australia. From the centre of suburban Sydney to the heat and dust of Alice Springs in the heart of Australia, there is a growing sense of energy and enthusiasm for restructuring services or creating new ones to enable midwives to work in partnership with women they know. While there will always be a need for midwives willing to provide expert care while working rostered shifts, an expansion in the number of services offering continuity of midwifery care also provides more choices for midwives about how they work, instead of obliging them to provide rostered care in only one area of midwifery practice (antenatal, labour or postnatal care) simply because there is no alternative.
