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The role and scope of contemporary midwifery practice in Australia: A scoping review of the literature

Open AccessPublished:January 09, 2023DOI:https://doi.org/10.1016/j.wombi.2022.12.001

      Abstract

      Problem

      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.

      Keywords

      Statement of significance

      Issue

      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 [,
      • ICM
      International Definition of the Midwife.
      ]. 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) [

      Health Practitioner Regulation National Law Act. In: Counsel Q.P., editor. Queensland: Queensland Health; 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 [
      • McCormack B.
      • McCarthy G.
      • Wright J.
      • Coffey A.
      Development and testing of the context assessment index (CAI).
      ]. Worryingly, poor workplace culture and role dissatisfaction have been identified as key factors in midwives intention to leave the midwifery workforce [
      • Pugh J.D.
      • Twigg D.E.
      • Martin T.L.
      • Rai T.
      Western Australia facing critical losses in its midwifery workforce: a survey of midwives' intentions.
      ]. 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 [
      • Arksey H.
      • O'Malley L.
      Scoping studies: towards a 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” [
      • Pugh J.D.
      • Twigg D.E.
      • Martin T.L.
      • Rai T.
      Western Australia facing critical losses in its midwifery workforce: a survey of midwives' intentions.
      ,
      • Peterson J.
      • Pearce P.F.
      • Ferguson L.A.
      • Langford C.A.
      Understanding scoping reviews: definition, purpose, and process.
      ]. 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 [
      • Arksey H.
      • O'Malley L.
      Scoping studies: towards a methodological framework.
      ] 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 [
      • ICM
      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.
      StageProcess
      1Identifying the research question
      2Identifying relevant studies
      3Study selection
      4Charting the data
      5Collating, summarising, and reporting the results
      Note. Source:
      • Arksey H.
      • O'Malley L.
      Scoping studies: towards a methodological framework.
      Empirical studies and professional documents were critically appraised for inclusion using tools from the Joanna Briggs Institute (JBI) [

      JBI. Joanna Briggs Institute (JBI) Critical Appraisal Tools. 2021. 〈https://jbi.global/critical-appraisal-tools〉 (accessed 02/02/2021 2021).

      ] and Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) extension for Scoping Reviews standards [
      • Tricco A.C.
      • Lillie E.
      • Zarin W.
      • et al.
      PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation.
      ]. 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 [
      • Nagle C.
      • McDonald S.
      • Morrow J.
      • et al.
      Informing the development midwifery standards for practice: a literature review for policy development.
      ] 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.
      DateDatabasesSearch stringsLimitersHitsPapers Retrieved
      10/10/2020CINAHL Completemidwife 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 medicineEnglish language, published between 2016 and 2020, abstract available, academic journals, research article164096 hits, 500 abstracts screened86
      15/10/2020CINAHL Complete, Medline Complete, APA PsycInfo, Scopus, Hand search of reference listsmidwife 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 healthEnglish language, published between 2016 and 2020, abstract available, academic journals, research article, peer reviewed1288 hits, 1288 abstracts screened510
      21/10/2020Historical Abstracts with Full Textmidwives or midwife or midwifery AND history of AND Australia OR Australian OR Australians OR QueenslandEnglish language12 hits, 12 abstracts screened7
      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 [,
      • ICM
      International Definition of the Midwife.
      ,

      Nursing and Midwifery Board of Australia (NMBA): Professional Standards 2018. 〈http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx〉 (accessed 12th February 2018).

      ] (Table 3).
      Table 3Scope of midwifery practice.
      Definitions of Midwifery Scope of Practice
      International Confederation of Midwives
      • ICM
      International Definition of the Midwife.
      “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)
      Nursing and Midwifery Board of Australia

      Nursing and Midwifery Board of Australia (NMBA): Professional Standards 2018. 〈http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx〉 (accessed 12th February 2018).

      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.”
      The Midwife standards for practice [

      Nursing and Midwifery Board of Australia (NMBA): Professional Standards 2018. 〈http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx〉 (accessed 12th February 2018).

      ] were informed by a structured scoping review of the published literature between 2006 and 2016 [
      • Nagle C.
      • McDonald S.
      • Morrow J.
      • et al.
      Informing the development midwifery standards for practice: a literature review for policy development.
      ]. A ‘best fit’ framework synthesis was used to test, reinforce and build on an existing published model [

      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’ [
      • Nagle C.
      • McDonald S.
      • Morrow J.
      • et al.
      Informing the development midwifery standards for practice: a literature review for policy development.
      ].

      3. Findings and discussion

      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 [

      Kirkup B. The Report of the Morecambe Bay Investigation; 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.

      ], 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 [
      • Strachan G.
      Present at the birth: midwives, 'handywomen' and neighbours in rural New South Wales, 1850-1900.
      ]. Doctors in Australia in this era were often naval or military surgeons, or medically qualified ex-convicts, now working as general practitioners [
      • Lewis M.J.
      Medicine in colonial Australia, 1788-1900.
      ]. The social prestige of medical doctors working in general practice was reported as low [
      • Lewis M.J.
      Medicine in colonial Australia, 1788-1900.
      ], and doctors had to compete financially with other low paid vocational healthcare providers [
      • Fahy K.
      An Australian history of the subordination of midwifery.
      ,
      • Willis E.
      Medical Dominance: The Division of Labour in Australian Health Care.
      ]. 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 [
      • Bogossian F.
      A review of midwifery legislation in Australia- History, current state and future directions.
      ,
      • Summers A.
      A different start: midwifery in South Australia 1836-1920.
      ].
      In 1881, nurses from the United Kingdom (UK) began the professional training of Australian nurses in Melbourne, Victoria, in the style of Florence Nightingale [

      Inglis K.S. Hospital and community: a history of the Royal Melbourne Hospital / [by] K.S. Inglis. Carlton, Vic: Melbourne University Press; 1958.

      ]. 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) [
      • Bogossian F.
      A review of midwifery legislation in Australia- History, current state and future directions.
      ]. 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 [
      • Symon A.
      • Pringle J.
      • Downe S.
      • et al.
      Antenatal care trial interventions: a systematic scoping review and taxonomy development of care models.
      ,
      • Donnolley N.
      • Butler-Henderson K.
      • Chapman M.
      • Sullivan E.
      The development of a classification system for maternity models of care.
      ,
      • Donnolley N.
      • Chambers G.
      • Butler-Henderson K.
      • Chapman M.
      • Sullivan E.
      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) [
      • Donnolley N.
      • Chambers G.
      • Butler-Henderson K.
      • Chapman M.
      • Sullivan E.
      More than a name: heterogeneity in characteristics of models of maternity care reported from the Australian Maternity Care Classification System validation study.
      ] (Table 4).
      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
      Note. Source:
      • Donnolley N.
      • Chambers G.
      • Butler-Henderson K.
      • Chapman M.
      • Sullivan E.
      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’ [
      • Nagle C.
      • McDonald S.
      • Morrow J.
      • et al.
      Informing the development midwifery standards for practice: a literature review for policy development.
      ]. 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 [
      • Nagle C.
      • McDonald S.
      • Morrow J.
      • et al.
      Informing the development midwifery standards for practice: a literature review for policy development.
      ]. 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 practiceEducation and LeadershipExtended 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 [

      Nursing and Midwifery Board of Australia (NMBA): Professional Standards 2018. 〈http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx〉 (accessed 12th February 2018).

      ,
      Nursing and Midwifery Board of Australia (NMBA)
      ], 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 womanProfessional rolesContextual 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

      3.3 Partnership with women

      Midwifery identity and legitimacy are centred around a primary health care partnership with the woman [
      • Nagle C.
      • McDonald S.
      • Morrow J.
      • et al.
      Informing the development midwifery standards for practice: a literature review for policy development.
      ]. 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 [

      Nursing and Midwifery Board of Australia (NMBA): Professional Standards 2018. 〈http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx〉 (accessed 12th February 2018).

      ,
      • Larner L.
      • Hooks C.
      Against the grain: midwives' experiences of facilitating home birth outside of guidelines.
      ,
      • Madeley A.-M.
      • Williams V.
      • McNiven A.
      An interpretative phenomenological study of midwives supporting home birth for women with complex needs.
      ,
      • Jenkinson B.
      • Kruske S.
      • Kildea S.
      Refusal of recommended maternity care: Time to make a pact with women?.
      ,
      • Feeley C.
      • Thomson G.
      • Downe S.
      Caring for women making unconventional birth choices: a meta-ethnography exploring the views, attitudes, and experiences of midwives.
      ].
      A wealth of evidence to support the development of the midwife-mother relationship through relational continuity was identified in the literature [
      • Callander E.J.
      • Creedy D.K.
      • Gamble J.
      • et al.
      Reducing caesarean delivery: an economic evaluation of routine induction of labour at 39 weeks in low-risk nulliparous women.
      ,
      • Chapman A.
      • Nagle C.
      • Bick D.
      • et al.
      Maternity service organisational interventions that aim to reduce caesarean section: a systematic review and meta-analyses.
      ,
      • Cummins A.
      • Coddington R.
      • Fox D.
      • Symon A.
      Exploring the qualities of midwifery-led continuity of care in Australia (MiLCCA) using the quality maternal and newborn care framework.
      ,
      • Bradfield Z.
      • Duggan R.
      • Hauck Y.
      • Kelly M.
      Midwives being ‘with woman’: an integrative review.
      ,
      • Allen J.
      • Kildea S.
      • Stapleton H.
      How optimal caseload midwifery can modify predictors for preterm birth in young women: integrated findings from a mixed methods study.
      ,
      • Allen J.
      • Kildea S.
      • Tracy M.B.
      • Hartz D.L.
      • Welsh A.W.
      • Tracy S.K.
      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.
      ,
      • Sandall J.
      • Soltani H.
      • Gates S.
      • Shennan A.
      • Devane D.
      Midwife-led continuity models versus other models of care for childbearing women.
      ]. 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 [
      • Chapman A.
      • Nagle C.
      • Bick D.
      • et al.
      Maternity service organisational interventions that aim to reduce caesarean section: a systematic review and meta-analyses.
      ,
      • Sandall J.
      • Soltani H.
      • Gates S.
      • Shennan A.
      • Devane D.
      Midwife-led continuity models versus other models of care for childbearing women.
      ]; to reduce the rate of caesarean section [
      • Callander E.J.
      • Creedy D.K.
      • Gamble J.
      • et al.
      Reducing caesarean delivery: an economic evaluation of routine induction of labour at 39 weeks in low-risk nulliparous women.
      ,
      • Chapman A.
      • Nagle C.
      • Bick D.
      • et al.
      Maternity service organisational interventions that aim to reduce caesarean section: a systematic review and meta-analyses.
      ]; to reduce the risk preterm birth in young women [
      • Allen J.
      • Kildea S.
      • Stapleton H.
      How optimal caseload midwifery can modify predictors for preterm birth in young women: integrated findings from a mixed methods study.
      ,
      • Sandall J.
      • Soltani H.
      • Gates S.
      • Shennan A.
      • Devane D.
      Midwife-led continuity models versus other models of care for childbearing women.
      ]; to improve neonatal outcomes for babies of Aboriginal descent [
      • Bertilone C.
      • McEvoy S.P.
      • Gower D.
      • Naylor N.
      • Doyle J.
      • Swift-Otero V.
      Elements of cultural competence in an Australian Aboriginal maternity program.
      ,
      • Bertilone C.
      • McEvoy S.
      Success in Closing the Gap: favourable neonatal outcomes in a metropolitan Aboriginal Maternity Group Practice Program.
      ]; and to be cost effective [
      • Callander E.J.
      • Creedy D.K.
      • Gamble J.
      • et al.
      Reducing caesarean delivery: an economic evaluation of routine induction of labour at 39 weeks in low-risk nulliparous women.
      ].
      Continuity of midwifery carer during childbearing has also been shown to have protective effects against the impact of postnatal maternal stress during natural disasters [
      • Kildea S.
      • Simcock G.
      • Liu A.
      • et al.
      Continuity of midwifery carer moderates the effects of prenatal maternal stress on postnatal maternal wellbeing: the Queensland flood study.
      ], and with subsequent positive effects upon the neurodevelopment of the infant [
      • Simcock G.
      • Kildea S.
      • Kruske S.
      • Laplante D.P.
      • Elgbeili G.
      • King S.
      Disaster in pregnancy: midwifery continuity positively impacts infant neurodevelopment, QF2011 study.
      ]. 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 [
      • Newton M.S.
      • McLachlan H.L.
      • Forster D.A.
      • Willis K.F.
      Understanding the ‘work’ of caseload midwives: a mixed-methods exploration of two caseload midwifery models in Victoria.
      ,
      • Dawson K.
      • Newton M.
      • Forster D.
      • McLachlan H.
      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 [
      • Crowther S.
      • Deery R.
      • Daellenbach R.
      • et al.
      Joys and challenges of relationships in Scotland and New Zealand rural midwifery: a multicentre study.
      ].

      3.4 The professional role of the midwife

      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 [
      • Levac D.
      • Colquhoun H.
      • O'Brien K.K.
      Scoping studies: advancing the methodology.
      ]. 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 [
      • Wadephul F.
      • Glover L.
      • Jomeen J.
      Conceptualising women's perinatal well-being: a systematic review of theoretical discussions.
      ]. 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 [
      • McCauley H.
      • McCauley M.
      • Paul G.
      • van den Broek N.
      'We are just obsessed with risk': healthcare providers' views on choice of place of birth for women.
      ,
      • Mattison C.A.
      • Lavis J.N.
      • Hutton E.K.
      • Dion M.L.
      • Wilson M.G.
      Understanding the conditions that influence the roles of midwives in Ontario, Canada's health system: an embedded single-case study.
      ,
      • Lundborg L.
      • Andersson I.-M.
      • Höglund B.
      Midwives’ responsibility with normal birth in interprofessional teams: a Swedish interview study.
      ,
      • Vedam S.
      • Stoll K.
      • McRae D.N.
      • et al.
      Patient-led decision making: Measuring autonomy and respect in Canadian maternity care.
      ,
      • Hansson M.
      • Lundgren I.
      • Hensing G.
      • Carlsson I.-M.
      Veiled midwifery in the baby factory — A grounded theory study.
      ,
      • Barker M.
      • Fenwick J.
      • Gamble J.
      Midwives' experiences of transitioning into private practice with visiting access in Australia: a qualitative descriptive study.
      ,
      • Jenkinson B.
      • Kruske S.
      • Kildea S.
      The experiences of women, midwives and obstetricians when women decline recommended maternity care: a feminist thematic analysis.
      ].
      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 [
      • McCauley H.
      • McCauley M.
      • Paul G.
      • van den Broek N.
      'We are just obsessed with risk': healthcare providers' views on choice of place of birth for women.
      ,
      • Jenkinson B.
      • Kruske S.
      • Kildea S.
      The experiences of women, midwives and obstetricians when women decline recommended maternity care: a feminist thematic analysis.
      ,
      • Hollander M.
      • Holten L.
      • Leusink A.
      • van Dillen J.
      • de Miranda E.
      Less or more? Maternal requests that go against medical advice.
      ]. 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 [
      • Cummins A.
      • Coddington R.
      • Fox D.
      • Symon A.
      Exploring the qualities of midwifery-led continuity of care in Australia (MiLCCA) using the quality maternal and newborn care framework.
      ]. Similarly, being with woman has been reported as the ‘anchoring force’ of midwifery professional practice [
      • Bradfield Z.
      • Duggan R.
      • Hauck Y.
      • Kelly M.
      Midwives being ‘with woman’: an integrative review.
      ], 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 [
      • Bradfield Z.
      • Duggan R.
      • Hauck Y.
      • Kelly M.
      Midwives being ‘with woman’: an integrative review.
      ]. 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 [
      • Bradfield Z.
      • Hauck Y.
      • Kelly M.
      • Duggan R.
      Urgency to build a connection: Midwives' experiences of being 'with woman' in a model where midwives are unknown.
      ].

      3.5 Contextual influences upon midwifery practice

      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 [
      • Nagle C.
      • McDonald S.
      • Morrow J.
      • et al.
      Informing the development midwifery standards for practice: a literature review for policy development.
      ,
      • Bradfield Z.
      • Hauck Y.
      • Kelly M.
      • Duggan R.
      Urgency to build a connection: Midwives' experiences of being 'with woman' in a model where midwives are unknown.
      ,
      • Gray M.
      How Australian dual registrants identified as midwives to meet national registration-renewal requirements.
      ,
      • Longman J.
      • Kornelsen J.
      • Pilcher J.
      • et al.
      Maternity services for rural and remote Australia: barriers to operationalising national policy.
      ]. These challenges include the ‘systems’ approach to childbearing prevalent within standard models of care within the public hospital system [
      • Bradfield Z.
      • Duggan R.
      • Hauck Y.
      • Kelly M.
      Midwives being ‘with woman’: an integrative review.
      ,
      • Bradfield Z.
      • Hauck Y.
      • Kelly M.
      • Duggan R.
      Urgency to build a connection: Midwives' experiences of being 'with woman' in a model where midwives are unknown.
      ], poor leadership with a lack of support for contemporary midwifery models of care that traverse the full continuum of midwifery care [
      • Longman J.
      • Kornelsen J.
      • Pilcher J.
      • et al.
      Maternity services for rural and remote Australia: barriers to operationalising national policy.
      ], and ‘fragmented and policy-driven medical models associated with midwives being with institution rather than with woman [
      • Bradfield Z.
      • Duggan R.
      • Hauck Y.
      • Kelly M.
      Midwives being ‘with woman’: an integrative review.
      ].
      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 [
      • Longman J.
      • Kornelsen J.
      • Pilcher J.
      • et al.
      Maternity services for rural and remote Australia: barriers to operationalising national policy.
      ].
      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 [
      • Thumm E.B.
      • Flynn L.
      The five attributes of a supportive midwifery practice climate: a review of the literature.
      ,
      • Read J.
      The profile of professional midwifery leadership in England.
      ]. 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 [
      • Thumm E.B.
      • Flynn L.
      The five attributes of a supportive midwifery practice climate: a review of the literature.
      ]. 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 [
      • Read J.
      The profile of professional midwifery leadership in England.
      ], as most units had a designated ‘Head of Midwifery’ rather than a the more strategic and policy-influencing role of ‘Director of Midwifery’ [
      • Read J.
      The profile of professional midwifery leadership in England.
      ]. 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 [
      • Read J.
      The profile of professional midwifery leadership in England.
      ]. 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 [
      • Adcock J.E.
      • Sidebotham M.
      • Gamble J.
      What do midwifery leaders need in order to be effective in contributing to the reform of maternity services?.
      ]. 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 [
      • Adcock J.E.
      • Sidebotham M.
      • Gamble J.
      What do midwifery leaders need in order to be effective in contributing to the reform of maternity services?.
      ].

      4. Conclusion

      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.

      Ethical statement

      None declared.

      Funding

      None declared.

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