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Centre for Nursing and Midwifery Research, James Cook University, Queensland 4814, AustraliaTownsville Institute of Health Research and Innovation, Townsville Hospital and Health Service, 100 Angus Smith Drive, Douglas, Queensland 4814, Australia
Little is known about the breadth of midwifery scope within Australia, and few midwives work to their full scope of practice.
Background
Midwives in Australia are educated and professionally accountable to work in partnership with childbearing women and their families, yet they are currently hindered from practicing within their full scope of practice by contextual influences.
Aims
To perform a scoping review of the literature to map out the role and scope of contemporary midwifery practice in Australia
To identify any key issues that impact upon working within the full scope of midwifery practice in the Australian context
Methods
A scoping review of the literature guided by the Arksey and O’Malley’s five-stage methodological framework, and the ‘best fit’ framework synthesis using the Nursing and Midwifery Board of Australia’s Midwifery Standards for Practice.
Findings
Key themes that emerged from the review included Partnership with women; The professional role of the midwife; and Contextual influences upon midwifery practice.Discussion
Tensions were identified between the midwifery scope of practice associated with optimal outcomes for women and babies supported by current evidence and the actual role and scope of most midwives employed in models of care in the current Australian public healthcare system.
Conclusions
There is a mismatch between the operational parameters for midwifery practice in Australia and the evidence-based models of continuity of midwifery carer that are associated with optimal outcomes for childbearing women and babies and the midwives themselves.
An impending shortage of midwives is predicted for Australia for age-related and other attrition reasons.
What is already known
Little is known about the breadth of midwifery scope within Australia, and few midwives work to their full scope of practice. Being able to work to the full scope of their role is a key factor in midwives’ retention in the maternity care workforce. There is an urgent need to review models of maternity care in Australia to facilitate growth in midwifery continuity of carer, relationship building, and partnership to optimise perinatal health and wellbeing, and to reduce midwifery burnout.
What this paper adds
This paper provides a contemporary review of midwifery scope of practice in the Australian context. Using the rigor of the ‘best fit’ framework to explore midwifery scope of practice, barriers to Australian midwives working to their scope of practice are discussed in terms of professional and structural challenges.
1. Introduction
In Australia, midwifery scope of practice is defined by the Australian College of Midwives (ACM) [
], based upon the international definition and scope of practice of the midwife agreed by the International Confederation of Midwives (ICM), and within a professional framework of autonomy, partnership, ethics and accountability [
]. Midwives in Australia are educated and professionally accountable to work in partnership with childbearing women and their families to provide support, care and advice throughout pregnancy, labour and birth and the postnatal/ neonatal period on the midwife’s own responsibility [
]. The professional standards for midwifery practice in the Australian context are regulated by the Nursing and Midwifery Board of Australia (NMBA) under the Health Practitioner Regulation National Law (2009) [
Studies have reported that midwives are currently hindered from practicing within their full scope of practice by contextual influences such as fragmented care, medical dominance and the low status of midwifery within organisations, community and inter-professional dynamics [
]. Worryingly, poor workplace culture and role dissatisfaction have been identified as key factors in midwives intention to leave the midwifery workforce [
]. The aim of this study was to perform a comprehensive scoping review of the peer-reviewed published literature to map out the role and scope of contemporary midwifery practice in Australia in terms of the activities and tasks performed and models of maternity care, and to identify any key issues that impact upon working within the full scope of midwifery practice in the Australian context.
2. Methods
A scoping review of the literature was undertaken guided by the Arksey and O’Malley five stage methodological framework [
] (Table 1). Unlike a systematic review and metanalysis, the scoping review methodology facilitates the collation of a “diversity of relevant literature and studies using different methodologies” [
]. The scoping review methodology was selected to identify the themes associated with role and scope of contemporary midwifery practice in Australia, to enable identification and mapping of the themes and concepts related to midwifery scope of practice from the evidence-based literature, and to uncover and explore any areas of complexity or controversies or gaps in the literature. The framework of Arksey and O’Malley [
] enabled flexibility to clarify concepts related to the scope of midwifery practice by using exemplars from empirical studies. Comprehensive searches were conducted of key databases, including CINAHL Complete, Medline Complete, APA Psycinfo, and Scopus, followed by a hand-search of key journals and examination of the reference lists of included studies. Studies published in the international literature were included in the search strategy and these were reviewed using the international definition of the midwife [
]. These studies were included to augment the available Australian studies, to provide context and / or further explore identified issues. Publications from midwifery professional and regulatory bodies were also examined and used to provide structure for identification and interpretation of empirical evidence from peer reviewed publications.
Table 1Stages of the Arksey and O’Malley scoping review framework.
]. The results were summarised and mapped onto an evidence table to facilitate analysis and synthesis of the findings. The criteria for inclusion of studies for this scoping review are as follows: original research study; peer reviewed; published between 2016 and 2020; full text available; and pertaining to midwifery practice. The date delimiter range was chosen to book-end the systematic literature review 2006–2016 [
] undertaken to inform the development of the NMBA Midwife standards for practice. Studies exclusively related to the experience of consumers or organisational /contextual issues unrelated to midwifery scope of practice were excluded.
2.1 Research questions
Broad research questions were used to underpin the literature search on the scope of midwifery practice in relation to the current context in Australia. These included:
1.
What are the activities and tasks that midwives are educated/regulated to undertake?
2.
What activities and tasks do midwives do, when and where?
3.
What activities and tasks do midwives do in comparison to those performed by nurses?
4.
What is the role and scope of contemporary midwifery?
5.
What is the history that has led to the current context of maternity care in Australia?
6.
What models of maternity care exist in the Australian context?
7.
What are the key issues that impact upon contemporary maternity care in Australia?
2.2 Database search strategy
A combination of key terms and Boolean operators were used to comprehensively review and refine the searches of key databases. A three-step search strategy was utilised (Table 2).
Table 2Database searches.
Date
Databases
Search strings
Limiters
Hits
Papers Retrieved
10/10/2020
CINAHL Complete
midwife OR midwives OR midwifery OR midw* OR nurse-midwife AND scope of practice OR roles OR regulation OR standards OR standards for practice OR registration standards OR competency standards OR professional standards NOT obstetrics OR doctor OR medicine
English language, published between 2016 and 2020, abstract available, academic journals, research article
164096 hits, 500 abstracts screened
86
15/10/2020
CINAHL Complete, Medline Complete, APA PsycInfo, Scopus, Hand search of reference lists
midwife OR midwives OR midwifery OR midw* OR nurse-midwife AND scope of practice OR roles OR regulation OR standards OR standards for practice OR registration standards OR competency standards OR professional standards NOT obstetrics OR doctor OR medicine OR dental OR pharm* OR allied health
English language, published between 2016 and 2020, abstract available, academic journals, research article, peer reviewed
1288 hits, 1288 abstracts screened
510
21/10/2020
Historical Abstracts with Full Text
midwives or midwife or midwifery AND history of AND Australia OR Australian OR Australians OR Queensland
The first step undertaken was a limited search of the CINAHL Complete database to allow analysis of the text words contained in the title and abstract, and of the index terms used to describe the research papers. For the second step, the search terms and limiters were then refined to enable a more effective search strategy of the CINAHL Complete, Medline Complete, APA Psycinfo, Scopus databases. A hand-search of key journals and examination of reference lists was also conducted. The third step was conducted to provide an understanding of the context of midwifery practice in Australia. A search was conducted on the historical abstracts with full text to provide a background to the development of the midwifery profession in Australia.
2.3 Data analysis and synthesis
To address the research questions, the Midwife standards for practice, and the International and Australian definitions applied to midwifery scope of professional practice [
“The midwife is recognised 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 the infant. This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures. The midwife has an important task in health counselling and education, not only for the woman, but also within the family and the community. This work should involve antenatal education and preparation for parenthood and may extend to women’s health, sexual or reproductive health and childcare. A midwife may practise in any setting including the home, community, hospitals, clinics or health units. (ICM, 2017)
Midwifery scope of practice: “refers to the boundaries within which the profession of midwifery is educated, competent and permitted to perform by law”. The actual scope of the individual midwife’s practice will vary depending on the context in which the midwife works, the health needs of women and the baby or babies, the level of competence and confidence of the midwife and the policy requirements of the service provider.”
Wallace E.M. Report into an Investigation into Perinatal Outcomes at Djerriwarrh Health Services. 〈https://www2healthvicgovau/∼/media/health/files/collections/research%20and%20reports/e/djerriwarrh%20-%20wallace%20report%20-%20executive%20summarypdf〉: Victorian Department of Health; 2015.
] and areas of contextual variation, emerging areas of practice and gaps in understanding associated with the scope of practice and role of the midwife in Australia were identified. Midwifery scope of practice was recognised to include: ‘woman-centred and primary health care; safe, supportive and collaborative practice; clinical knowledge and skills with inter-personal and cultural competence’ [
Following review of abstracts, 517 published studies were retrieved, and synthesis of evidence from the extracted data of 96 papers was included in this review (Fig. 1).
Historical papers provided the background to the current context of Australian midwifery practice, and the empirical studies were mapped into themes. The domains of practice of the midwifery profession emerged as predominantly relationship based. At an analytical level, Partnership with women emerged as the central tenet of midwifery care [
Lewis G. The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer- 2003–2005. The Seventh Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. In: CEMACH, editor. London; 2007.
], facilitated by the Professional roles of the midwife, and mediated by Contextual influences.
3.1 The influence of history on contemporary midwifery practice in Australia
The current context of midwifery practice in Australia has evolved from models of maternity care formed during the early era of European colonisation of Australia. Review of historical documents revealed that in the nineteenth century, women within Australian communities assisted each other with childbirth, or called upon ‘handywomen’ or midwives who had experience in confinements [
]. The provision of maternity care was postulated to be attractive to general practitioners as a lucrative means to build up the clientele of individual practices [
In 1881, nurses from the United Kingdom (UK) began the professional training of Australian nurses in Melbourne, Victoria, in the style of Florence Nightingale [
]. Tasmania was the first Australian state or territory to implement statutory regulation of midwives in 1902, followed by Queensland (1911), Western Australia (1913), Victoria (1915), and New South Wales (1926) [
]. Regulation of midwives in Queensland as ‘midwifery nurses’ (instituted in 1912) is argued to be ‘the point at which the practice of midwifery by midwives in Queensland began a transition from lay practice in the home to qualified status in the hospital’ [
Davies R. 'She did what she could". A history of the regulation of midwifery practice in Queensland 1859–1912: Queensland University of Technology; 2003.
]. Following this, the midwifery profession was subsumed within the regulatory jurisdiction as a specialist branch of the nursing profession. Consequently, in line with the military-style hierarchy of hospitals at the time, midwives were considered subordinate to the medical profession [
Davies R. 'She did what she could". A history of the regulation of midwifery practice in Queensland 1859–1912: Queensland University of Technology; 2003.
In Australia in recent times, most of the maternity care occurs in hospitals and is mostly provided by midwives and doctors working in collaboration in the public health system, or with an obstetrician leading private maternity care. However, significant heterogeneity between models of maternity care has been found to exist, which presents a challenge to the evaluation of outcomes from individual models of care [
More than a name: heterogeneity in characteristics of models of maternity care reported from the Australian Maternity Care Classification System validation study.
]. To address this issue, the attributes of 129 current maternity models of care were reviewed and classified into one of eleven overarching broad model descriptors (Major Model Category) [
More than a name: heterogeneity in characteristics of models of maternity care reported from the Australian Maternity Care Classification System validation study.
Table 4The major model categories from the maternity care classification system.
Major Maternity Model of Care Categories
Private Obstetrician (specialist) care Private Midwifery care General Practitioner Obstetrician care Shared care Combined care Public hospital maternity care Public hospital high-risk maternity care Team Midwifery care Midwifery Group Practice caseload care Remote area maternity care Private Obstetrician and Privately Practising Midwife joint care
More than a name: heterogeneity in characteristics of models of maternity care reported from the Australian Maternity Care Classification System validation study.
3.2 The role and scope of contemporary midwifery practice in Australia
As identified during the most recent update of the midwifery standards, midwifery practice is ‘not restricted to the provision of direct clinical care and extends to any role where the midwife uses midwifery skills and knowledge’ [
]. Midwifery practice shares similarities to the practice of the nursing profession insofar as it includes aspects of working in clinical environments within an acute hospital setting or an ambulatory community context; as well as non-clinical working in management, administration, education, research, advisory, regulatory, and policy development roles [
]. At a descriptive level, three broad themes emerged from the evidence base in relation to the activities and tasks undertaken by midwives. These included: The scope of midwifery practice, Leadership and education, and Extended midwifery practice (Table 5). Influenced by the literature reviewed, this comprehensive map of midwifery skills and scope of practice is not exhaustive.
Table 5Descriptive list of activities and tasks undertaken by midwives.
Scope of midwifery practice
Education and Leadership
Extended midwifery practice
Health promotion Salutogenesis Pregnancy, childbirth, and parenting education Physical examination, surveillance, and assessment – woman/ foetus/ newborn Psychosocial screening and referral Interpretation of pathology and radiology Phlebotomy and cannulation Communication, collaboration, and shared decision-making Consultation and referral Psychological, social, and physical support Support during perinatal loss/ bereavement Non-pharmacological methods pain relief Normal labour and birth Intrapartum water immersion and waterbirth Home birth Support during transition to extrauterine life Recognition and response to clinical deterioration and escalation of care Management of obstetric emergencies Basic life neonatal/adult/ maternal support and stabilisation Lactation initiation and support Support transition to parenthood Immunisation Contraception counselling
Professional Leadership Research and evidence-based practice Professional advisory representation for hospital organisational and Governmental executive boards Undergraduate and postgraduate clinical teaching Preceptorship and mentorship Emergency procedures training and assessment (obstetric emergency/ advanced neonatal/adult/ maternal life support) Human resources management Clinical governance, quality improvement, and risk management Financial, budget and business management
Endorsement for ordering and interpretation of pathology and radiology Endorsement for prescribing defined medications and vaccines Private midwifery practice External cephalic version International Board-Certified Lactation Consultant (IBCLC) Registered Nurse Immuneiser Advanced neonatal/adult/ maternal life support Sexual and gynaecological health Genomics Genetic counselling Child and family health nursing
Note: This list reflects the evidence reviewed and is comprehensive but not exhaustive.
Findings of the scoping review reveal the domains of practice of the midwifery profession are predominantly relationship-based. At an analytical level, Partnership with women emerged as the central tenet of midwifery care [
], facilitated by the Professional roles of the midwife, and mediated by Contextual influences (Table 6).
Table 6Themes and subthemes that emerged from the scoping review.
Partnership with the woman
Professional roles
Contextual influences
Empowering relationships Respect for autonomy and personal context of the woman Professional knowledge, skills, and expertise Evidence-based information sharing Shared decision making Advocacy for the woman’s informed choices Promotion of equity and social inclusion, tackling vulnerability and inequality Maintaining engagement with healthcare services Promotion of public health
Professional midwifery leadership and representation Engagement with research and evidence -based practice Integrity and honesty Competence and confidence Autonomy and accountability for midwifery practice Proactive behaviour Navigation between paradigms of health promotion and risk avoidance Flexibility and mediation Supporting informed choice Planning and documentation Consultation, referral, and collaboration
Professional midwifery leadership Implementation of evidence-based models of midwifery care Positive, respectful interprofessional collaboration Respect for midwifery self-determination, independence, and self-governance Respect for human rights and woman centred practice Continuity of relationships Effective communication processes Positive organisational context Policy/ funding models supportive of professional autonomy Relational continuity of carer
]. Midwives are educated and regulated to support the health and wellbeing of childbearing women and their families throughout the childbirth continuum, with autonomy over midwifery practice for promotion of the normal process of and prevention of complications in childbearing, and in collaboration with others when complexities arise [
]. Support and advocacy for the woman’s informed choices are key to midwifery practice and are utilised to facilitate access and engagement of the woman and her family with health care services [
The impact of caseload midwifery, compared with standard care, on women's perceptions of antenatal care quality: survey results from the [email protected] randomized controlled trial for women of any risk.
]. Compared to standard care, models of continuity of midwifery-led care have been shown to reduce the need for interventions in childbirth such as regional analgesia, instrumental birth and episiotomy [
Continuity of midwifery carer during childbearing has also been shown to have protective effects against the impact of postnatal maternal stress during natural disasters [
]. As a measure of retention of staff and midwifery satisfaction, working in continuity models of midwifery led care has been associated with lower levels of stress and burnout compared to standard models of hospital-based care [
Comparing caseload and non-caseload midwives’ burnout levels and professional attitudes: a national, cross-sectional survey of Australian midwives working in the public maternity system.
]. In rural settings in Scotland and New Zealand, the development of relationships between midwives and members of the local community was associated with increased sustainability of the midwifery role [
Salutogenesis, and the orientation of maternity care practice toward health (rather than avoiding illness), has been proposed as the means for midwives to support the wellbeing of women and babies, and to avoid of overtreatment during childbearing associated with medical paradigm of risk avoidance [
]. Wellbeing in the perinatal period is theorised to be a multi-dimensional and dynamic construct, based upon the woman’s individual experience with physical/embodied, affective, and psychological/cognitive aspects [
]. However, in the current context in Australia, the medical paradigm of risk avoidance or harm prevention has emerged from the evidence as the predominant discourse during the perinatal period [
In several studies, midwives have highlighted the importance of their supportive role to enable women to understand and judge their own risks in order to make informed choices in their maternity care [
]. Findings from focus groups with midwives and childbearing women indicated that high quality midwifery-led care was facilitated by fostering connection, providing flexibility, and the woman having a sense of choice and control [
], characterised by midwifery philosophy, the relationship between the midwife and the woman and her partner, and empowering midwifery practice across the continuum of maternity care [
]. However, midwives’ experiences of working in maternity models of care where the women are unknown to them reflect a perceived urgency to build a connection with the woman, and acknowledge the challenges of working with woman within the demands of the public hospital system [
Several challenges to working within the full scope midwifery practice emerged during the scoping review. Individual midwives working within the constraints of existing hospital-based, hierarchical, or medically led health services experience challenges to fulfil their role within their full scope of practice [
The strategic implementation of woman-centred care within regional and rural communities were evaluated as onerous during interviews and focus groups with key staff, due to the absence of informed leadership; lack of knowledge of contemporary models of care; inadequate clinical governance; poor workforce planning and use of resources; fallacious perceptions of risk; and a dearth of community consultation [
Midwifery leadership and professional representation (or lack of) at an executive level has been identified as crucial to enable midwives to work within their full scope of practice, or in models of care supported by best evidence [
]. Results of a systematic review revealed that a lack of midwifery leadership was detrimental to the midwifery practice climate within an organisation in the domains of work engagement and quality of midwifery care [
]. In the UK, a lack of consistency in terminology for role of the most senior midwives was identified as detrimental to the representation of the midwifery profession [
]. Furthermore, very few midwives in senior leadership roles (4.5%) were found to have a position on the hospital or organisational executive board, which necessitated the reporting and discussion of matters related to midwifery scope of practice to the executive board by non-midwives, for example senior nurses, department heads or medical staff [
]. Despite the protected title of ‘Midwife’, within federal, state and territory jurisdictions in Australia, there is no requirement for Chief Nurse and Midwifery Officers to hold a midwifery qualification [
]. Midwifery qualifications are not required within health service for Directors of Nursing and Midwifery nor within universities for Professors of Nursing and Midwifery in Australia [
This scoping review of the current evidence related to midwifery scope of practice in Australia using the NMBA Midwife Standards for Practice as an analytical framework, has revealed the pivotal role of midwifery partnership with women; midwifery autonomy and advocacy in the provision of woman-centred care; and the balance of risk avoidance in childbearing with a salutogenic, health promotion paradigm to facilitate choice for women. Continuity of midwifery care has been proven to be a safe, cost-effective model of care, with potential benefits for all women regardless of level of obstetric risk.
However, tensions were identified that challenge the full potential of midwifery scope of practice in the both the current Australian and international midwifery context. A mismatch has been identified between recommendations from the evidence-based published literature and the current administration and funding of health care policy, and models of publicly funded maternity care provision in Australia. There is an urgent need to review the representation of the midwifery profession at the leadership, executive and policy levels to support the role of the midwife for provision of evidence-based maternity care. This includes support for midwives to practice with professional autonomy within their full scope of practice to facilitate continuity of carer, relationship building and partnership with women, and to reduce midwifery burnout.
Wallace E.M. Report into an Investigation into Perinatal Outcomes at Djerriwarrh Health Services. 〈https://www2healthvicgovau/∼/media/health/files/collections/research%20and%20reports/e/djerriwarrh%20-%20wallace%20report%20-%20executive%20summarypdf〉: Victorian Department of Health; 2015.
Lewis G. The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer- 2003–2005. The Seventh Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. In: CEMACH, editor. London; 2007.
Davies R. 'She did what she could". A history of the regulation of midwifery practice in Queensland 1859–1912: Queensland University of Technology; 2003.
More than a name: heterogeneity in characteristics of models of maternity care reported from the Australian Maternity Care Classification System validation study.
The impact of caseload midwifery, compared with standard care, on women's perceptions of antenatal care quality: survey results from the [email protected] randomized controlled trial for women of any risk.
Comparing caseload and non-caseload midwives’ burnout levels and professional attitudes: a national, cross-sectional survey of Australian midwives working in the public maternity system.
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