Models of maternity care in rural environments: Barriers and attributes of interprofessional collaboration with midwives

Objectivesinterprofessional primary maternity care has emerged as one potential solution to the current health human resource shortage in many developed nations. This study explores the barriers to and facilitators of interprofessional models of maternity care between physicians, nurses, and midwives in rural British Columbia, Canada, and the changes that need to occur to facilitate such models.Designa qualitative, exploratory framework guided data collection and analysis.Settingfour rural communities in British Columbia, Canada. Two rural communities had highly functional and collaborative interprofessional relationships between midwives and physicians, and two communities lacked interprofessional activities.Participants55 participants were interviewed and 18 focus groups were conducted with midwives, physicians, labour and delivery nurses, public health nurses, community-based providers, birthing women, administrators, and decision makers.Findingsin models of interprofessional collaboration, primary maternity care providers – physicians, midwives, nurses – work together to meet the needs of birthing women in their community. There are significant barriers to such collaboration given the disciplinary differences between care provider groups including skill sets, professional orientation, and funding models. Data analysis confirmed that interprofessional tensions are exacerbated in geographically isolated rural communities, due to the stress of practicing maternity care in a fee-for-service model with limited health resources and a small patient caseload. The participants we spoke with identified specific barriers to interprofessional collaboration, including physician and nurses' negative perceptions of midwifery and homebirth, inequities in payment between physicians and midwives, differences in scopes of practice, confusion about roles and responsibilities, and a lack of formal structures for supporting shared care practice. Participants expressed that successful interprofessional collaboration hinged on strong, mutually respectful relationships between the care providers and a clear understanding of team members' roles and responsibilities.Conclusions and implications for practiceinterpersonal conflicts between primary maternity care providers in rural communities were underpinned by macro-level, systemic barriers to interprofessional practice. Financial, legal, and regulatory barriers to interprofessional collaboration must be resolved if there is to be increased collaboration between rural midwives and physicians. Key recommendations include policy changes to resolve differences in scope of practice and inequitable funding between rural midwives and physicians.     

Rural Maternity Care

ObjectiveTo provide an overview of current information on issues in maternity care relevant to rural populations.EvidenceMedline was searched for articles published in English from 1995 to 2012 about rural maternity care. Relevant publications and position papers from appropriate organizations were also reviewed.OutcomesThis information will help obstetrical care providers in rural areas to continue providing quality care for women in their communities.Recommendations1. Women who reside in rural and remote communities in Canada should receive high-quality maternity care as close to home as possible.2. The provision of rural maternity care must be collaborative, woman- and family-centred, culturally sensitive, and respectful.3. Rural maternity care services should be supported through active policies aligned with these recommendations.4. While local access to surgical and anaesthetic services is desirable, there is evidence that good outcomes can be sustained within an integrated perinatal care system without local access to operative delivery. There is evidence that the outcomes are better when women do not have to travel far from their communities. Access to an integrated perinatal care system should be provided for all women.5. The social and emotional needs of rural women must be considered in service planning. Women who are required to leave their communities to give birth should be supported both financially and emotionally.6. Innovative interprofessional models should be implemented as part of the solution for high-quality, collaborative, and integrated care for rural and remote women.7. Registered nurses are essential to the provision of high-quality rural maternity care throughout pregnancy, birth, and the postpartum period. Maternity nursing skills should be recognized as a fundamental part of generalist rural nursing skills.8. Remuneration for maternity care providers should reflect the unique challenges and increased professional responsibility faced by providers in rural settings. Remuneration models should facilitate interprofessional collaboration.9. Practitioners skilled in neonatal resuscitation and newborn care are essential to rural maternity care.10. Training of rural maternity health care providers should include collaborative practice as well as the necessary clinical skills and competencies. Sites must be developed and supported to train midwives, nurses, and physicians and provide them with the skills necessary for rural maternity care. Training in rural and northern settings must be supported.11. Generalist skills in maternity care, surgery, and anaesthesia are valued and should be supported in training programs in family medicine, surgery, and anaesthesia as well as nursing and midwifery.12. All physicians and nurses should be exposed to maternity care in their training, and basic competencies should be met.13. Quality improvement and outcome monitoring should be integral to all maternity care systems.14. Support must be provided for ongoing, collaborative, interprofessional, and locally provided continuing education and patient safety programs.     

Interprofessional Obstetric Ultrasound Education: Successful Development of Online Learning Modules; Case‐Based Seminars; and Skills Labs for Registered and Advanced Practice Nurses,Midwives, Physicians,and Trainees

Ultrasound is an important aid in the clinical diagnosis and management of normal and complicated pregnancy and childbirth. The technology is widely applied to maternity care in the United States, where comprehensive standard ultrasound examinations are routine. Targeted scans are common and used for an increasing number of clinical indications due to emerging research and a greater availability of equipment with better image resolution at lower cost. These factors contribute to an increased demand for obstetric ultrasound education among students and providers of maternity care, despite a paucity of data to inform education program design and evaluation. To meet this demand, from 2012 to 2015 the University of California, San Francisco nurse‐midwifery education program developed and implemented an interprofessional obstetric ultrasound course focused on clinical applications commonly managed by maternity care providers from different professions and disciplines. The course included matriculating students in nursing and medicine, as well as licensed practitioners such as registered and advanced practice nurses, midwives, and physicians and residents in obstetrics and gynecology and family medicine. After completing 10 online modules with a pre‐ and posttest of knowledge and interprofessional competencies related to teamwork and communication, trainees attended a case‐based seminar and hands‐on skills practicum with pregnant volunteers. The course aimed to establish a foundation for further supervised clinical training prior to independent practice of obstetric ultrasound. Course development was informed by professional guidelines and clinical and education research literature. This article describes the foundations, with a review of the challenges and solutions encountered in obstetric ultrasound education development and implementation. Our experience will inform educators who wish to facilitate obstetric ultrasound competency development among new and experienced maternity care providers in academic and clinical settings. This article is part of a special series of articles that address midwifery innovations in clinical practice, education, interprofessional collaboration, health policy, and global health.     

Group Prenatal Care for Women Receiving Medication‐Assisted Treatment for Opioid Use Disorder in Pregnancy: An Interprofessional Approach

Opioid use disorder among pregnant women is common and rapidly increasing nationwide. Group prenatal care is an innovative alternative to individual care for pregnant women and has been shown to improve women's and health care providers’ satisfaction and adherence to care. We describe a novel group prenatal care program colocated in an opioid treatment program that integrates prenatal care, substance use disorder counseling, and medication‐assisted treatment. Our interprofessional model draws on the unique contributions of physicians, midwives, nurses, and mental health professionals to address the complex needs of pregnant women with opioid use disorder. Participants reported increased trust and engagement with health care providers and peers, improved prenatal care and birth experience, and increased resilience for relapse prevention. Group prenatal care is an accepted and promising model for women with opioid use disorder in pregnancy and has the potential to improve outcomes for women and newborns.     

Ontario Care Providers’ Considerations Regarding Models of Maternity Care

ObjectiveThere is currently a crisis in the delivery of maternity care in Canada, in part due to the significant decline in the number of professionals who provide intrapartum care. This study was undertaken (1) to elicit care providers’ opinions regarding seven proposed models of maternity care, (2) to explore barriers to collaborative interprofessional practice, and (3) to identify factors that would encourage the practice of intrapartum care.MethodsA survey seeking opinions about models of care, perceived barriers to interprofessional collaboration, and factors that might encourage practising intrapartum care was mailed to all registered midwives (N = 322) and obstetricians (N = 647) in Ontario and to a stratified random sample of family physicians (N = 750) in Ontario.ResultsCompleted questionnaires were received from 80% of midwives, 64% of obstetricians, and 66% of family physicians. Midwives and obstetricians endorsed uniprofessional models and indicated an interest in multiprofessional practice. Family physicians were reluctant to choose any models that would have them practising intrapartum care. However, family physicians currently providing intrapartum care would consider the uniprofessional model in which they delivered the babies of the women they were caring for unless they were signed out. Midwives identified different philosophies of care as the main barrier to collaborative interprofessional maternity care (60.7%); obstetricians and family doctors identified liability and insurance issues (60.3% and 38.7%, respectively). An adequate on-call arrangement was the key factor potentially encouraging midwives and obstetricians to provide intrapartum care (70.3% and 70.0%, respectively). For family physicians, good medical and obstetrical back-up was the first priority (70.8%), followed by on-call arrangements.ConclusionA variety of models for providing intrapartum care must be available, as no single model meets the needs of all maternity providers. Attention must be given to eliminating barriers to collaborative interprofessional practice, coupled with enhancing factors that facilitate the delivery of intrapartum care.     

Developing midwifery and complementary medicine collaboration: The potential of interprofessional education?

A higher percentage of referrals to complementary and alternative medicine (CAM) by midwives can be linked to their affinity with CAM. However, midwifery education does not commonly include CAM as part of the curriculum leaving potential for misinformation and unsafe practice. An approach to CAM education which encourages collaboration between all care providers is needed to ensure safe, woman-centred maternity care. Whilst a number of models have been considered in health education they are not without their limitations when aiming to promote interprofessional collaboration. It is proposed through this paper that improved communication between midwives and qualified CAM practitioners may be developed through employing the interprofessional education model. This model develops attributes for collaborative practice and improves the delivery of interprofessional care. Achieving this collaboration is vital for safe, woman-centred care for the many pregnant women accessing CAM and conventional care for their pregnancy and birth.     

A focus group study of women’s views and experiences of maternity care as delivered collaboratively by midwives and health visitors in England

Background

Research suggests that collaboratively delivered maternity care can positively impact health outcomes. However, women’s perspectives on models of care involving interprofessional collaboration between midwives and health visitors are not well understood. Accounts of women’s maternity care experiences are key to improving maternity services. This study considered women’s views and experiences of maternity care as collaboratively provided by midwives and health visitors in England.

Methods

A qualitative focus group study with an exercise exploring women’s ideal maternity care pathway was conducted. Three focus groups were conducted in London, England between June and August 2017 with women who had had a child within 18?months prior to the study. The participants (n?=?12) were recruited from two Children’s Centres in London, England. Data were analysed using thematic analysis.

Results

Four themes were identified: ‘Women’s experiences of maternity care from midwives and health visitors’, ‘Midwife-health visitor communication’, ‘Midwife-health visitor collaboration for tailored care’, and ‘Women’s ideal maternity care pathway’. Regarding women’s experiences of interprofessional collaboration between midwives and health visitors, this was rarely encountered, but welcomed by women. Women’s observations of limited tailored care and co-ordination led to several suggestions to improve maternity care, including secure, shared medical recordkeeping systems, clarity on midwives’ and health visitors’ roles, as well as increased communication.

Conclusions

Maternity care that is collaboratively delivered by midwives and health visitors, from the perspectives of the women in this study, is not routinely provided. However, women recognise the potential benefits of midwife-health visitor collaboration. Future research should explore service configurations that support integrated maternity care pathways, and evaluate the impact of midwife-health visitor collaboration on health and service outcomes.

     

Innovative Uses of Technology in Online Midwifery Education

Women's health care in the United States is at a critical juncture. There is increased demand for primary care providers, including women's health specialists such as certified nurse‐midwives/certified midwives, women's health nurse practitioners, and obstetrician‐gynecologists, yet shortages in numbers of these providers are expected. This deficit in the number of women's health care providers could have adverse consequences for women and their newborns when women have to travel long distances to access maternity health care. Online education using innovative technologies and evidence‐based teaching and learning strategies have the potential to increase the number of health care providers in several disciplines, including midwifery. This article reviews 3 innovative uses of online platforms for midwifery education: virtual classrooms, unfolding case studies, and online return demonstrations of clinical skills. These examples of innovative teaching strategies can promote critical and creative thinking and enhance competence in skills. Their use in online education can help enhance the student experience. More students, including those who live in rural and underserved regions and who otherwise might be unable to attend a traditional onsite campus, are provided the opportunity to complete quality midwifery education through online programs, which in turn may help expand the women's health care provider workforce. This article is part of a special series of articles that address midwifery innovations in clinical practice, education, interprofessional collaboration, health policy, and global health.     

A Mirage of Change: Family‐Centered Maternity Care in Practice

Abstract: Background: Since the 1970s, the movement to “humanize” birth in North America has evolved into “family‐centered maternity care,” which has focused on providing evidence‐based maternity care that is responsive to the needs of women and their families. The objective of this research was to explore women’s birth experiences within the context of the numerous changes that have occurred in perinatal care and to determine how information and knowledge acquired about pregnancy and birth influenced women’s birth experiences. Methods: Semi‐structured interviews were conducted in prenatal health clinics in Montreal and Vancouver with 36 women before and after birth. Results: Most study participants were unaware of the range of available providers and birth settings. Of the women who were more aware of their options, those selecting a birth center or home birth and midwives had different notions of risk than those who planned a hospital birth. Study participants felt generally well informed, but thought that information sharing, collaborative decision making, or both were inadequate during labor and birth within the hospital setting. Conclusions: Despite positive changes in recent years, family‐centered maternity care in Canada still needs to be improved. Women’s ability to use their acquired prenatal knowledge to feel satisfied by their birth experience continues to be undermined by a system of care that does not prioritize women’s informed choice. Further systemic change is required to align maternity care with the needs of Canadian birthing women and their families. (BIRTH 37:2 June 2010)     

Introduction of CenteringPregnancy in a Public Health Clinic

CenteringPregnancy is a promising group visit prenatal care innovation that provides substantial health promotion content. Elements unique to group care include peer support and self‐management training and activities. CenteringPregnancy was introduced at a large public health clinic serving predominantly low‐income African American pregnant women. All prenatal care at this clinic was provided by certified nurse‐midwives, and all providers were trained in the CenteringPregnancy model. One hundred and ten women received prenatal care in CenteringPregnancy groups. Focus groups of pregnant women, providers, and health center staff reported that the program benefited women despite implementation challenges such as scheduling changes. Compared to women in individual care, women in CenteringPregnancy had significantly more prenatal visits, increased weight gain, increased breast feeding rates, and higher overall satisfaction. This pilot project demonstrated that CenteringPregnancy can be implemented in a busy public health clinic serving predominantly low‐income pregnant women and is associated with positive health outcomes.     

Postnatal unhappiness: who should direct support?

Depression following childbirth is a common, distressing but frequently underreported disorder. It involves a spectrum of symptoms, some of which may be self-limiting, while others can have major mental health implications in the post partum period. A range of health professionals, including midwives and mental health nurses, come into contact with women who suffer from postnatal depression; however, there is often little attempt made to integrate maternity and mental health care approaches. More collaborative frameworks of care are vital if health professionals are to adequately meet the needs of 'unhappy' women in the postnatal period.     

Anatomy of a training seminar. Teaching and learning in Angola

Training and service delivery in maternal and child health are high priorities for Angola's national health system. Maternal and infant mortality are very high, and there is a severe shortage of physicians. Most reproductive health care is provided by nurses and midwives. Appropriate education, resources, and support can assist these professionals in their struggle to improve mother and infant outcomes. A teacher training seminar for experienced nurses and midwives was carried out in Luanda, Angola in the summer of 1988. Content focused on family planning, sexually transmitted diseases, and human sexuality. Teaching methodology emphasized participation, active learning, group work, and practice teaching sessions. The steps involved in the training process are described--including needs assessment, planning, implementation, and evaluation of the seminar.     

ANATOMY OF A TRAINING SEMINAR

Training and service delivery in maternal and child health are high priorities for Angola's national health system. Maternal and infant mortality are very high, and there is a severe shortage of physicians. Most reproductive health care is provided by nurses and midwives. Appropriate education, resources, and support can assist these professionals in their struggle to improve mother and infant outcomes. A teacher training seminar for experienced nurses and midwives was carried out in Luanda, Angola in the summer of 1988. Content focused on family planning, sexually transmitted diseases, and human sexuality. Teaching methodology emphasized participation, active learning, group work, and practice teaching sessions. The steps involved in the training process are described—including needs assessment, planning, implementation, and evaluation of the seminar.     

Transforming Communication and Safety Culture in Intrapartum Care: A Multi‐Organization Blueprint

Effective, patient‐centered communication facilitates interception and correction of potentially harmful conditions and errors. All team members, including women, their families, physicians, midwives, nurses, and support staff, have roles in identifying the potential for harm during labor and birth. However, the results of collaborative research studies conducted by organizations that represent professionals who care for women during labor and birth indicate that health care providers may frequently witness, but may not always report, problems with safety or clinical performance. Some of these health care providers felt resigned to the continuation of such problems and fearful of retribution if they tried to address them. Speaking up to address safety and quality concerns is a dynamic social process. Every team member must feel empowered to speak up about concerns without fear of put‐downs, retribution, or receiving poor‐quality care. Patient safety requires mutual accountability: individuals, teams, health care facilities, and professional associations have a shared responsibility for creating and sustaining environments of mutual respect and engaging in highly reliable perinatal care. Defects in human factors, communication, and leadership have been the leading contributors to sentinel events in perinatal care for more than a decade. Organizational commitment and executive leadership are essential to creating an environment that proactively supports safety and quality. The problem is well‐known; the time for action is now.