It can be tricky in regional Australia to sustain what's known as midwifery group programs (MGP), where women get to see one or two midwives their entire pregnancy, but one model in regional Victoria has proved it's more than possible.
Regarded by many as the "gold standard" in maternity services, MGPs are a continuity of care model and result in lower rates of intervention, lower risk of preterm birth and fetal loss, and higher rates of maternal satisfaction — and they cost hospitals less as well.
But a mix of barriers, including staffing, attitudes and resources mean establishing these programs in regional Australia can be hard.
However, Northeast Health in Wangaratta has proved these programs can thrive.
The midwifery group program there has been a permanent fixture since the late 1990s, making it one of the longest-running programs in regional Australia.
Since its inception, close to 4,000 babies have been delivered through the program.
So, what's the secret to creating, and keeping, a program like this in regional Australia? The midwives who work there could help shed a bit of light.
Tailored programs
Wangaratta's midwifery program was launched as a pilot program in the mid '90s by a team of four midwives after a state government report highlighted the benefits of midwifery-led continuity of care.
One of those midwives was Dr Helen Haines, now an independent federal MP, who said getting it off the ground wasn't easy.
"In those days in Wangaratta, where I lived, there was no public antenatal clinic, everything was run through private GP rooms or through a private obstetricians clinics.
"So we set about doing something completely different to that, where a small team of midwives would have a caseload of women and women would choose to have a midwife look after them."
These days, the midwifery program can offer care to around 160 women per year, that's around a fifth of all births annually at the hospital.
Flexible work
Karli Vincent began working in the midwifery group program fresh out of university in 2010 and has been there ever since.
She thinks one of the reasons the program has lasted is because of its dual emphasis — it suits both the needs of mothers as well as the midwives involved.
For example, there are currently six midwives in the program all of whom are working part-time, making it family-friendly for staff.
"We have quite a young workforce," Ms Vincent explained.
"I myself throughout my 12 years there have gone on to have my own three babies and I haven't felt like I've missed out on a lot in my parenting journey while still being able to really have a fulfilling career.
"We get that real work life balance and are able to work around our families."
Ms Vincent admits that when it comes to staffing, the program has been lucky that a lot of people who grew up in Wangaratta have returned with their families and have joined as midwives, particularly during the COVID -19 pandemic.
But she also said that even when finding staff has been tough, the part-time nature of their model and the flexibility that continuity of care offers has been a draw card.
"Having that designated time off call more often than some models do … has just been really sustainable and means people are really able to have that work life balance and it has worked quite well in retaining staff."
Midwife and academic Dr Elysse Prussing said her research into barriers to regional models showed the need to dispel the myth among midwives who hadn't worked in a midwifery group program before that they would be on call 24/7.
"There's a lot of research coming out now demonstrating that [for] midwives who work in continuity of care models, it's been a protective factor against work related stress, burnout and depression when they compare it with midwives who work in a traditional hospital setting."
Empowered staff
Northeast Health's relatively young workforce could also be contributing to its success.
Dr Prussing and her team at Newcastle University found young or recent graduates in regional areas who'd learned about continuity of care in their training were more likely to embrace and seek out those models.
But they also found the opposite, that those less familiar with midwifery group program, weren't as keen to be a part of one.
"Participants also observed that in regional areas an ageing midwifery workforce is contributing to a culture of resistance [to continuity of care models]," Dr Prussing's research found.
In many cases, part of the resistance was that many experienced midwives had grown confident in a specific area they'd worked a lot in, like delivery or the postnatal ward.
"Then when they were asked or presented with the opportunity to work in a different area, they felt like they had lost their confidence in the skills that they hadn't used for a long period of time," Dr Prussing said.
"So that was another real barrier for midwives who understood the evidence, they knew [continuity of care] was important … but they felt a real lack of confidence in themselves, and had lost that confidence to work their full scope of practice."
However, Dr Prussing and her team's research found that barrier could be overcome by individually supporting those midwives to build their confidence or refresh their skills.
With midwives already run off their feet in most hospitals, Dr Prussing's research alsostrongly identified the need for a dedicated role — called either a project officer or project manager — to work on getting the continuity of care programs started.
"That project officer is key to designing and working with those midwives as they transition into a new model of care and it really does need to work for those midwives in that area and for the community," Dr Prussing said.
"That will look very different across diverse regional settings and populations."
Communication
One of the tools Ms Vincent says has been invaluable to the Wangaratta program's success is, on the surface, pretty simple — a weekly team meeting.
"We discuss sort of the operational matters within the team and also the women that are coming up to being due and any new bookings and all of those sorts of things," she said.
"But we also use it as a little bit of a debrief and venting time as well, which has been one of the real strengths of the team and has been something that's been a real stable of it, since well before my time."
She said it was an easy way of making sure any issues people had, that could lead to staff feeling disaffected and going elsewhere, were aired and worked through as a team.
"It's such a simple concept, but is often the first that gets left to the side in times of stress," Ms Vincent said.
"When you operate quite independently we found that's really crucial, and when that falls away the cracks tend to appear."
Good communication between staff isn't the only thing that can help regional continuity of care models.
'Make a bold decision'
Like the initial push to get the Wangaratta model off the ground, state and territory government's have to be willing to put their support — and their money — behind these regional programs.
That, and hospital executives and all the different players in maternity services need to be on board.
"We need to look much more creatively around how our how our funding models work," Dr Haines said.
"There's ways you can do this, but it does take it takes a legislator or a policymaker being able to look at the evidence and make a bold decision, actually."
Ms Vincent said her team has "great support" from North East Health and the obstetric team as well.
Dr Haines suggested both the government and hospitals need to be willing to give midwifery group programs a go.
"You know, the example I gave you about the hospital giving me and my colleagues permission … that's hard to let go of that kid of control if you're, you know, the administrator of that hospital," she said.
"[Governments] need to hear clearly calls from community that this is what they want and then government working with, with departments of health and consumers needs to be brave enough to change the status quo."
Dr Prussing said that women's voices could also play a powerful part in this.
"Women often really underestimate the power of the consumer voice in being able to contribute to maternity service changes," she said.
"[They] don't often know that this is another option of care that they could be asking for."
Through her research, Dr Prussing found that in some areas where the maternity service was at risk of closing because they couldn't get obstetrics staff, midwifery-led models were successfully offered as an evidence-backed alternative.
"In those areas, when that was often happening, [midwives were] rallying together with the women in the community and sharing that evidence and promoting it at a hospital executive level, to, I guess, increase awareness that actually we don't need to close our maternity service," she said.
"We can still keep it running as a fully midwifery-led continuity of care, and it's a safe option for our women."
