As Jennifer Haxton and Kathleen Fahy1 rightly suggest in Women and Birth, advanced midwifery practice is a controversial notion in midwifery, particularly at present in Australia. The proposed changes in legislation around access to the publicly funded Medical Benefits Scheme (MBS) and the Pharmaceutical Benefits Scheme (PBS) in 2009–2010 have meant that the issue of advanced midwifery practice has again taken prominence.2, 3 In particular, linking midwifery access to MBS and PBS to a safety and quality framework that includes an ‘advanced midwifery credentialling framework’.4 The Haxton and Fahy paper is timely as it enables a reflection upon these issues and encourages debate and discussion about exactly what is midwifery, what are we educating our students for and is working to the full scope of practice practising at advanced level? This paper seeks to address some of these questions and open up the topic for further debate through the Letters to the Editor section of Women and Birth.
At the outset, we would like to pay tribute to the project that Haxton and Fahy1 describe in their paper. Bringing out sustainable organisational change in health settings is no mean feat. The process described to bring about change in the Delivery Suite of a large hospital is extremely useful to others. The example of undertaking this as a clinical practice improvement project provides an important framework for others to emulate. Equally, the topic area and the eventual outcome are significant. It has always been astonishing to us that women sit in birthing units/delivery suites for some hours waiting for a resident medical officer to see them just so that they can go home. This is likely to be after the midwives have undertaken a comprehensive assessment and made a number of clinical decisions, often which, due to restrictions such as the inability to legally order relevant pathology tests, they cannot follow through. This initiative certainly met its goal, which was to safely and effectively reduce the length of stay of pregnant women presenting with pregnancy concerns who were managed as outpatients in the birthing unit/delivery suite.
For us, the discussion has a few central elements that we would like to explore relating to fundamental questions of, ‘what is a midwife?’ and ‘what is a midwife educated to do?’ With these questions in mind, a useful starting point is the International Definition of the Midwife (page 1).5 The definition includes the statement that:
The midwife is recognized as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife's own responsibility and to provide care for the newborn and infant. This care includes preventive measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical or other appropriate assistance and the carrying out of emergency measures.
It could be argued that this definition supports the view that ‘a midwife is a midwife is a midwife’. Meaning that midwives are educationally prepared to practice according to the full role and scope of the midwife from day one and that there are no levels of practice.6, 7, 8 If the midwife is educationally prepared to practice within the full role and scope of midwifery, there is a belief that the midwifery graduate should be able to ‘hang up their shingle’ as soon as they are registered.8 Historically, a shingle was a small signboard that was hung to indicate the office (or home in the case of many midwives) of a professional. The term suggests that from day one of midwifery registration, the midwife should be capable of autonomous midwifery practice and that they should be considered a practitioner in their own right, therefore negating the concept of advanced practice in midwifery.
The arguments regarding advanced practice centre on issues of competency and professional preparation. Debate continues within health care professions around, ‘What is competency?’ The two most common positions argue that competency can be viewed either as a binary scale or in sequential stages.9 When viewing competency as a binary scale, the professional is either seen as being competent or not competent. There are no degrees of performance considered when taking this view of competence.9, 10
If you were to view competency on the binary scale of competent or not competent, you would believe that ‘a midwife is a midwife is a midwife’. In this view, a midwife is deemed competent to enter the profession by demonstrating that he/he meets the profession's competency standards. Given that often the concept of competency is one of reaching a required standard, it could then be argued, that one does not become more competent as the end-point has already been obtained.11, 12
More commonly, particularly in health professions, is the sequential stages view of competence. When competence is viewed in sequential stages, the professional progresses from a base competence or novice stage through to the expert stage. This sequential view is based on the well-recognised Dreyfus Model of Skill Acquisition that Benner applied to the profession of nursing.6, 7 Benner10 asserts that the student or new graduate [nurse] starts at the novice stage and through experience and application of theory, moves through the following stages; advanced beginner; competent; proficient; and finally to expert practitioner.
This view of competency supports those in the midwifery profession who suggest that, upon graduation, the new midwife has a base level of competence, and through practice and experience, that level of competence improves. This suggests that the new graduate demonstrates competence at an ‘entry to practice’ or ‘novice’ level and is a ‘beginning practitioner’. Continued experience and exposure to practice would then allow them to practice at an ‘advanced’ or ‘expert’ level. This implies that levels of practice exist within midwifery. Perhaps this ‘either–or’ view is too narrow and we should consider whether a combination of binary scale or in sequential stages is more useful.
There is no clear definition or agreement on what advanced midwifery practice entails over and above the normal or full scope of practice of the midwife in Australia. The terms enhanced and expanded are also used, sometimes interchangeably with advanced, adding to the lack of clarity. In other countries, the issue of advanced practice been discussed and clear consensus reached. For example, in the UK, the midwifery profession asserts that midwives do indeed work at a specialist or advanced level on qualification, due to the currently accepted scope of practice which includes autonomous practice.7 Both the professional body, the Royal College of Midwives (RCM) and the midwifery regulatory body, the Nursing and Midwifery Council (NMC) in the UK, insist that it is not necessary to introduce levels of practice, referred to in the profession of nursing, as Higher Level Practice (HLP). This is due to the belief that, upon registration into the profession, midwives practice at a specialist or advanced level. This was debated at length by the UKCC Statutory Midwifery Committee.13 Detailed mapping of the competencies for HLP against those of initial midwifery registration demonstrated that there was little justification for such a practice level in midwifery. A well-defined scope of practice for midwifery that includes autonomous practice provides support for this decision. In addition, comparisons with the profession of nursing further sustain this debate, due to the nursing profession having clear consensus and regulation concerning generic practice on qualification as a nurse that can lead to advanced or specialist practice.14 The situation in New Zealand (NZ) is similar to that in the UK. Midwives are recognised as autonomous practitioners, who practice according to the international definition of the midwife. In NZ, upon graduation, a midwife, in her own right, is able to provide complete maternity care in partnership with women. The notion of advanced practice in the midwifery profession in NZ is not discussed.
The situation in midwifery in Canada is somewhat different. The profession of midwifery is not regulated nationwide and some provinces and territories do not recognise midwifery as a profession. There is however a push towards a national approach and there is a consortium that has developed Canadian competencies for midwives.15 These competencies refer to ‘entry level’ midwives. They also recognise and list ‘advanced competencies’. There is a statement within the competencies that says that some of the ‘advanced competencies’ may be considered ‘entry level’ competencies in some provinces and territories, so there is no clear consensus on what might constitute advanced practice. Examples of ‘advanced competencies’ include a range of skills from epidural monitoring and application of scalp electrodes to performing vacuum extractions and suturing 3rd degree tears.15 In midwifery in Australia, the first two would be considered normal scope of practice and the latter two considered outside of the scope of midwifery practice.
The midwifery advanced practice argument in Australia is articulated in the Australian College of Midwives (ACM) position statement that was developed in response to the introduction of the advanced practice award of Midwifery Practitioner.14 The recognition of advanced practice in Australia has been embraced by the profession of nursing through Nurse Practitioner status. A Nurse Practitioner is defined as ‘a registered nurse educated and authorised to function autonomously and collaboratively in an advanced and extended clinical role’ (page 1).16 In contrast, the ACM assert in their position statement that midwives who work within the full role and scope of practice of the midwife are not working at an advanced or specialised level; they are merely fulfilling the defined role and full scope of practice of a midwife.14
Midwifery in Australia is in a transitional phase and in each state and territory there are moves towards midwives working according to the internationally defined role and scope of practice of a midwife in partnership with women providing continuity of care throughout pregnancy, birth and the early weeks of parenting. This role is not ‘advanced’ or ‘extended’ midwifery practice—it is fundamental to fulfilling the comprehensive role of a midwife. It seems likely that advancement in this context is more about the development of higher level thinking and critical evaluation of practice. It could be argued that this would be expected over time for most midwives and is therefore a feature of continuing professional development.
Within Australia, there is widespread recognition that midwives should be educationally prepared to work according to the full role and scope of practice of a midwife upon registration and at any time in their career. This however is not always the reality. In the last 25 years, barriers that prevent midwives working to their full scope have been repeatedly identified, discussed and debated, but often not resolved.17, 18, 19, 20
The Australian Midwifery Action Project (AMAP) reported a range of issues that hindered Australian midwives from practising to the full role and scope of midwifery practice including inconsistent regulation, inconsistent midwifery education and limited availability of the midwifery models of care that support midwives to practice fully according to the internationally accepted definition of the midwife.19 More recently, Gamble and Vernon20 revisited the same issues in their discussion on barriers to comprehensive midwifery practice in Australia. Similar issues were again identified this year, in the Commonwealth Government's Review of Maternity Services discussion paper and report.21, 22
The Australian midwifery profession is working towards addressing many of these issues. We are hopeful that the advent of national registration and national accreditation of midwifery courses using newly developed national standards for midwifery education will lead to improved standardisation and clarity about what midwives are educated to do.23 We would argue, counter to Haxton and Fahy,1 that midwives should be, and indeed some currently are, educated to perform speculum examinations; assess Bishop's Score on vaginal examination; perform venepuncture and intravenous cannulation; and, test reflexes. In addition, as legislation allows, midwives should be educated to independently order and interpret all relevant pathology tests and prescribe and administer a range of medications. These skills are part of the role of the midwife, indeed the international definition of a midwife states that ‘This care includes…the detection of complications in mother and child, the accessing of medical or other appropriate assistance and the carrying out of emergency measures’ (page 1).5 We suggest that we should be working towards ensuring that all midwives are educated in these activities during their pre-registration program.
Two other areas of contention remain for us in this discussion. Firstly, are midwives working in midwifery-led models of care working at an advanced level? Secondly, is this argument about role substation (that is, midwives working for doctors) or is it about midwives working to the full scope of practice?
The implementation of midwifery-led or midwifery managed (or a variety of other terms) models of care are increasingly supported by evidence24 and national recommendations.22 We prefer to use the phrase ‘midwifery continuity of care’ to encompass the range of models of care that health services provide. These include midwifery group practices in different settings (for example, from small stand-alone units all the way to practices within large tertiary referral hospitals); birth centres (either stand-alone or as part of a hospital) and homebirth models of care (either publicaly or privately funded). These initiatives have been occurring for more than a decade in Australia. They follow trends in many developed countries that have supported the move from fragmented ways of providing care to models that provide continuity of care and carer.
When midwifery care started to move from fragmented, system-based care provision to models that provided midwifery continuity of care, there was recognition that the midwives who moved into the new models of care might be considered somehow different or ‘elite’. Moving to working within a continuity model of midwifery care provided midwives with the opportunity to practice to the full scope of midwifery practice. It was acknowledged, however, that due to the organisation of many of the initial models, radical changes to the way midwives traditionally worked were required.25 These changes meant that some midwives are unable, or unwilling, to work in this way.25, 26, 27 While these issues were identified 10–15 years ago, they are still current today. Recent dialogue in this Journal highlighted a debate about whether the models of care support women or midwives.28 For instance, midwives with children and limited social support can find the on-call and flexible hours difficult to manage; they therefore choose to work in a ‘shift-work’ model. Sandall25 claimed that this situation could create a two tiered midwifery workforce. She discusses the possible division of midwifery into the ‘rank and file midwife who may be expected to pay the price for the professionalising elite’.25 In similar vein, we argue that creating levels of practice, where midwives who practice in continuity models or those supported to incorporate wider aspects of the full role and scope of practice, such as the midwives in Haxton and Fahy's1 paper, are seen as advanced and midwives who work in fragmented shift-work models are not, is both unhelpful and unsustainable.
This brings us to our final point of contention, that is, role substation. Haxton and Fahy1 decided to use the term ‘advanced practice’ to refer to midwives who were relieving for doctors in caring for women who may have high risk pregnancies. We would argue that working in interdisciplinary ways does not lend itself well to role substitution, rather an emphasis should be made on developing new ways of working that fully utilise the skills and knowledge of all health professionals. Substitution for doctors is not a long-term strategy—we should be arguing that initiatives like these enable midwives to work according to their full scope of practice.
Advanced practice as a notion is not going to go away. As members of the Australian midwifery profession, we need to consider how the needs of women and the community can be best met. Our opinion is that we should ensure that midwives are educated for, and are supported to work towards, the full scope of practice. This could be an effective long-term strategy to ensure safety for women and babies and a sustainable midwifery workforce. We commend Haxton and Fahy1 on undertaking this important project and highlighting the current challenges. Their work illustrates that the Australian midwifery profession is in a time of transition and we trust that, in the future, all midwives will be able to provide such a service across all maternity units in this country.
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