Rejoinder to Smith, R., Leap, N. & Homer, C Advanced midwifery practice or advancing midwifery practice?

We are pleased that our paper, “Reducing the length of stay for women who present as outpatients to delivery suite: a clinical practice improvement project”1 has generated debate. Smith et al.2 applaud the work of the midwives we reported on who are providing independent care for women when they present to delivery suite with pregnancy-related concerns. These authors have however, challenged our use of the term ‘advanced practice midwife’. We acknowledge that the choice of the term ‘advanced practice midwife’ is contentious given the different professional philosophical views held around the notion of levels of midwifery practice. Our justification for doing so lies in the reality that currently midwifery exists under regulatory and legal frameworks, including industrial awards, which recognise higher levels of appointment and higher levels of payment. In our report we were writing about midwifery practice as it exists today in large tertiary settings. The majority of Smith et al's discourse does not address the substance of our paper. Rather they have used the paper as a spring board for a philosophical discussion about what, ideally, should be the role of the midwife and scope of midwifery practice. Additionally Smith and colleagues argue the importance of separating midwifery from nursing by not going down an advanced practice pathway.

In making their argument Smith et al.2 refer to the full scope of the ICM definition3 of the role of the midwife to claim that the midwives in our quality assurance study were functioning within the full scope of midwifery practice; and not at an advanced level. The ICM role of the midwife includes the phrase ‘the detection of complications in mother and child, the accessing of medical or other appropriate assistance’ (p. 1). It is this phrase that seems to be the key matter of contention. Whilst we accept that all midwives must be able to detect complications and access medical assistance, we suggest that the midwifery clinical practices outlined in our paper, such as ordering and interpreting tests, making diagnoses (normally considered medical), and prescribing treatments (including IV fluids), is not covered by the ICM definition nor is it standard midwifery practice. Smith et al., we believe, are writing about an ideal situation where the skills of the midwives that we reported upon will be standard midwifery skills. Smith et al. claim that in the future all newly graduating midwives will be able to: perform speculum examinations, assess bishops scores, independently order and interpret all relevant pathology tests, prescribe and administer medications and IV fluids, perform venepuncture and IV cannulation and test reflexes including the detection of clonus. This idyllic state may or may not come about; we hope it does. In the meantime we assert that midwives, who are currently practising at a level that is more advanced than is usual for beginning midwives, should be recognised and valued by their profession as having advanced practice skills.