Stapleton (1998) builds on the idea of mutual trust and respect as essential attributes of collaboration, and explores the notion of professional maturity. She believes that ‘individuals who feel secure and competent professionally can communicate their discipline’s strengths, value, limitations and contributions to colleagues from other disciplines’ and adds that this requires ‘a high level of professional maturity and confidence in one’s professional knowledge and clinical skills’ (Stapleton 1998, p 14). Effective communication is another crucial prerequisite for working together. It requires that ‘members listen to each other’s perspective yet are assertive in presenting their point of view’ (Henneman et al 1995, p 106).

Midwives participating in a reflective midwifery partnership are in a position to have a positive impact on women’s experiences in situations where referral is required. In addition to honouring the woman’s own knowing about herself and her body, midwives can assist the woman to educate herself well, so that the consultation is not one in which the ‘specialist’ is the only ‘expert’. Thus a woman will ask the questions that will meaningfully aid her decision-making, rather than following a predetermined protocol that may not reflect her values or beliefs. While it is true that some obstetricians find this challenging, it can only serve to expand their horizons and increase their understanding of childbirth not just being about the removal of a baby from a woman’s uterus.

Midwives need to remain mindful of the fact that within midwifery there is an enormous resource and body of knowledge, and that sometimes it is to our colleagues that we should turn for discussion and advice. A recent (unpublished) study by one of the authors (SM) uncovered how collaboration between midwives can be protective of women’s experiences in a labour context. This study explored labour and birth outcomes of first-time mothers in different birth settings. It revealed that when a woman’s labour became complex and required additional input from the obstetric service, in situations where a second midwife was also involved in the woman’s care she was more likely to achieve a spontaneous birth (68%) than when only an obstetrician was consulted (51%) (Miller 2008).

Experienced midwives know well how judicious one needs to be about some indications for referral—the ‘large-for-dates’ baby, for example. We need to be clear that the experience of consultation will not negatively affect the woman’s confidence in her ability to birth normally when the obstetrician has told her she has a high likelihood of needing a caesarean section. We are of course obliged to discuss the recommendation for referral with the woman, and support her decision to consult or not, as the case may be. But we need to balance the content of her obstetric consultation with midwifery knowledge about moulding, pelvic mapping, optimal baby positioning, working with labour pain, and mobility in labour to enhance her likelihood of normal birth.

Sometimes the woman may request referral, or may self-refer to healthcare professionals other than obstetricians/paediatricians/anaesthetists. It might be an acupuncturist, osteopath, homeopath or naturopath who can best assist with the particular issue the woman faces. A respectful collaborative process can be achieved here also. Indeed, because of a greater appreciation for holism displayed by complementary therapists, many midwives find working alongside these practitioners very fruitful and mutually satisfying for all involved.

COLLABORATION IN THE CONTEXT OF THE AUSTRALIAN MATERNITY REFORMS 2009

In Australia, following the introduction of the Health Legislation Amendment (Midwives and Nurse Practitioners) Bill 2009 on 24 June 2009, the Minister for Health Nicola Roxon proclaimed that midwives wishing to provide treatment under Medicare and prescribe certain medicines under the PBS would need to demonstrate that they met the eligibility requirements and that they had collaborative arrangements in place, including appropriate referral pathways with hospitals and doctors to ensure that patients receive coordinated care and the appropriate expertise and treatment as the clinical need arose. In the context of the Australian reforms, the nature of collaboration is discussed very briefly below.

Collaboration in healthcare occurs when experts from different disciplines work together in a combined effort to improve patients’ needs (Martín-Rodríguez et al 2005; Saxell et al 2009). Although the proposed maternity reforms intend to make interprofessional collaboration mandatory, it is usually by its very nature a negotiated process founded on all of the following key components: interprofessional willingness to collaborate; trust; mutual respect; and good communication. Successful collaborative practice in midwifery is based on two broad categories of collaboration: interprofessional collaboration and patient-centred (or more specifically ‘woman-centred’) partnership. Both aspects are integral to the safety of midwifery practice.

Interprofessional collaboration occurs when two or more experts from different disciplines take joint ownership of decisions and collective responsibility for outcomes when working across professional and functional boundaries, for example within the hospital setting (Liedtka et al 1998). A collaboration of healthcare professionals share responsibility for outcomes, see themselves playing a crucial role within a larger social system (healthcare service), and manage their relationships across organisational boundaries (Cohen et al 1997). Successful collaboration in healthcare teams can be attributed to several key elements, including interpersonal relationships within the team and favourable conditions within the organisation and the system within which collaboration takes place (Martín-Rodríguez et al 2005).

Few studies have investigated the influence of all these determinants of collaboration on interprofessional collaboration. However, an Australian randomised controlled trial of collaboration in the maternity services published by Homer and colleagues (2001) demonstrated that a community-based model of continuity of care provided by midwives and obstetricians improved maternal clinical outcomes, in particular a reduced caesarean section rate. Collaboration with medical colleagues in that study demonstrated how working together strengthened the ability of midwives to work to their full scope of practice, providing safe, high-quality care. Research published in 2003 and funded by the Australian Research Council and four state Departments of Health as industry partners found that in Australia one of the major barriers to collaborative practice is the competitive approach that exists both between professionals and between healthcare institutions (Barclay et al 2003). Traditional medical and nursing department structures have tended to concentrate and optimise the provision of care within their ‘silos’ from a provider perspective, rather than optimising the larger system from the patient’s perspective.

The second key element of collaboration in midwifery practice relates to the relationship formed between women and midwives in a collaborative partnership. In the midwifery model of care, women are at the centre of their pregnancy and birth care and from that point all decisions are made. In this way, collaboration plays a central role in coordinating care across the continuum of sites and services. For example, in the hospital setting resources are organised around the provision of care for women and their families, rather than around various specialised departments. In order that women participate in informed decision-making, information-sharing occurs in a context where her values and philosophical beliefs are respected and upheld.

PROFESSIONAL COLLABORATIONS

The midwifery profession is becoming increasingly involved in building relationships with the professional bodies of other healthcare disciplines. This is to ensure that those involved in the production of clinical guidelines for practice and in policy discussions are aware of the full scope of midwifery practice. This ‘top-down’ approach also ensures that the voice of pregnant women is heard at the highest levels, as an expectation of consumer involvement operates at this level also.

Two examples of this in New Zealand have been the participation by midwives in the GBS New Zealand Consensus Working Party, which has produced guidelines for risk assessment and treatment approaches for Group B Streptococcus infection (MOH 2005), and the New Zealand Guidelines Group, a collaboration between midwives, obstetricians, consumers, paediatricians, general practitioners, maternity managers and midwifery and medical educators, which has produced best-practice guidelines in relation to the care of women with breech presentation or previous caesarean birth (NZGG 2004). These documents contribute much to our understanding of evidence-based care and will lead to increased consistency of advice to pregnant women faced with making decisions about aspects of their care.

THE NEW ZEALAND REFERRAL GUIDELINES

In New Zealand, since 1 July 2007, the Referral Guidelines sit alongside the Primary Maternity Services Notice (Section 88) (Ministry of Health 2002). This notice is pursuant to Section 88 of the New Zealand Public Health and Disability Act 2000. Although previously appended to the Section 88 Notice, it was felt that in order to facilitate frequent review of the Guidelines they needed to sit outside the legislation, as otherwise any changes would require an Amendment to the Act. It is anticipated that the Guidelines will be reviewed at two-yearly intervals.

The stated purpose of the Guidelines is that they be ‘used to facilitate consultation and integration of care, giving confidence to providers, women and their families’ (Ministry of Health 2007, p 1). Circumstances in which the Guidelines may be varied are outlined, acknowledging the fact that midwives and others providing maternity services have a wide range of skills, and that where one’s level of expertise allows, departures from the Guidelines may occur. In this instance, the midwife should be able to justify her course of action, and documentation reflecting the process of information-sharing and decision-making with the woman should appear in the clinical record.

The process of referral can take many forms. In general, the booking interview is often the time when the woman will disclose a situation that may require referral. If this is because of something in her medical or maternity history, the midwife can discuss the recommendation for referral and, with the woman’s informed consent, initiate the process immediately. Other indications for referral may arise later in the pregnancy—for example, the discovery of a twin pregnancy, or breech presentation that persists near term. Referral will occur in such instances as the particular issue arises.

If after discussion of the recommendation for referral the woman consents to consult, the midwife is responsible for writing a letter to request a consultant review. This letter should provide enough pertinent information to enable the obstetrician to adequately assess the woman’s situation. At the very least, the letter will contain: