Bachelor of midwifery graduates well educated to provide care in rural maternity units

In a recent editorial for the Australian nursing journal ‘Collegian’ argued that compared with Bachelor of Midwifery (B Mid) degrees, graduate diplomas in midwifery for registered nurses or double degrees are of equal quality in preparing the midwives for practice. They also argued that “the reality of small regional, rural and remote health care facilities is that numbers of births will not support a health professional with midwifery skills only” (p.187): an argument that I challenge here in this editorial. I have also written a letter to the editor of Collegian.

In writing this editorial I am speaking from over 25 years as an academic of which 20 have been in senior positions. During my career I have taught in, and been part of committees accrediting pre-registration graduate diplomas in two states; New South Wales and Queensland. Preregistration courses for registered nurses to become midwives are short: generally have only 6 midwifery specific units (out of a total of 8 units). The total course length of a graduate diploma is usually 12 months full time equivalent (whilst the students are usually concurrently employed full-time as RNs in maternity units). The real danger here is that in spite of the expertise and best intentions of the midwifery academics what most usually happens is that students are moulded as cogs that fit neatly into the obstetric wheel that operates in the hospitals. In that model it is very easy to slip into the role of an obstetric nurse rather than meeting the ACM philosophy of midwifery.

In contrast in the new B Mid degrees it is common for 16 out of 24 units to be midwifery specific: i.e. 10 additional units of midwifery knowledge, attitudes and skills when compared with graduate diploma students. I agree with the authors that it is possible to complete degrees that have less midwifery specific content, however, my concern is that graduate diploma courses leading to registration as a midwife may not be able to meet the essential minimum requirements for practice as a midwife. It is very difficult for graduate diploma students, and those enrolled in double degrees in nursing/midwifery to meet the ANMAC requirements as only the B Mids have sufficient focused midwifery time to allow students to easily meet these requirements (e.g. 20 follow through experiences, 100 antenatal visits, 100 postnatal visits, 40 ‘being with women’ during all four stages of labour and 40 complex care cases as well as time in Special Care Nursery).

In my opinion, B Mid graduates are the best prepared staff for small rural maternity units. New B Mid graduates have the best education and training to be able to provide high quality midwifery care. In comparison, new graduates from graduate diploma and double degree courses have studied much less midwifery content and their practice experience is less diverse.

With all due respect, nurses, even very senior nurses, who have not been educated as contemporary midwives, do not have the necessary discipline specific understanding of what constitutes excellence in midwifery care nor how it may best be provided in rural communities. The College of Midwives is well placed to know how to provide best practice evidence-base maternity care. Caseload models are more cost effective for the health service and far fewer qualified individual midwives are required because maternity units do not have to be staffed when there are no women in labour. The small rural units should not be trying to overturn the educational standards of the midwifery profession. Rural Directors of Midwifery and Nursing should, instead, be introducing different models of maternity care where midwives can be employed to provide caseload continuity of care in small teams where no shift work or rostering is required. All low-medium risk maternity care (the type offered by rural hospitals) can be provided under caseload models which would allow rural units to maintain and extend their maternity services. Only in this way will women really gain the benefit of having midwives who have been educated to the full extent needed to be able to function autonomously. New graduates of Bachelor of Midwifery courses are the graduates who are best placed to enact the full role and scope of the midwife with a clear understanding of the role of the midwife as distinct from the role of the nurse.