September 18, 2021

Midwifery

Group Clinical Supervision for midwives

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Midwives are leaving the profession, many of them at the beginning of their careers. A new trial of group clinical supervision is underway in Australia to see if it makes a difference to burnout, perception of workplace culture and midwives’ intention to leave.

Midwives are pivotal to the wellbeing of women and their babies. Indeed, there is an urgent global call to upscale midwifery to address the rates of women and babies who are injured or die in childbirth. However, in Australia, similar to other high-income countries, there is another type of crisis occurring that we can no longer ignore – midwives in significant numbers are leaving the profession.

Many midwives are feeling demoralised, disempowered, and overwhelmed. Some of the reasons for this are an over-medicalisation of the workplace, a lack of autonomy and under-staffing, like in this recent article. These factors are leaving midwives emotionally fragile and feeling unsupported by their managers (Catling & Rossiter, 2020; Hunter et al, 2018; Pezaro et al. 2016).

Blogs such as ‘midwife diaries’[1] are heartbreaking to read and confirm the results of the Work, Health and Emotional Lives of Midwives (WHELM) study (Hunter et al, 2018). The WHELM study surveyed the wellbeing of nearly 2000 midwives in the UK and found significant levels of emotional distress, burnout, stress, anxiety, and depression. Two thirds of participants stated that they had thought about leaving their profession in the last six months, and alarmingly, early career midwives were over-represented in those leaving (Harvie et al, 2019).

Australian research echoes findings about midwives who have left the profession (Matthews, 2021), along with similar findings about work-related distress (Creedy et al, 2017; Catling & Rossiter, 2020). A Royal College of Midwives document Why midwives leave – revisited (2016) reported that 88% of midwives who had left the profession might consider returning if there were appropriate staffing levels. Eighty percent of midwives said they would return if their workplace culture was changed for the better, although this report did not outline what a positive workplace culture was.

Positive workplace culture

We suggest the following list (although not exhaustive) highlights some important things that midwives want from maternity services:

  • fully staffed ward/unit with adequate resources for staff to do their jobs;
  • visible managers who provide support to their staff to excel and flourish
  • support to engage in educational opportunities, support to attend conferences / seminars / complete higher degrees
  • emotional support following adverse events
  • timely feedback and assistance with relationships in the workplace including zero tolerance for bullying behaviour
  • autonomy in practice with multi-disciplinary assistance when indicated
  • opportunity to work in midwifery continuity of care

In essence, a positive workplace culture would have trust in, and collegiality with, work colleagues and knowledge that your work with women was high-quality and valuable.

How can we support midwives?

Clinical supervision is a well-known supportive strategy that has been used in many health disciplines to help promote staff professional development and health and wellbeing. Transforming Maternity Care Collaborative’s (see transformingmaternity.org.au) Director of Workforce, Associate Professor Christine Catling, gained a National Health and Medical Research Council investigator grant over the next 5 years to investigate whether group clinical supervision makes a difference to Australian midwives and the midwifery workplace culture. We know Clinical Supervision reduces burnout from observational studies, but it has not been studied extensively and experimentally before in the midwifery discipline. For more information on what Clinical Supervision is please go to the Australian Clinical Supervision Association site here.

The trial of group clinical supervision

The cluster randomised controlled trial (for maternity units in Greater Sydney) will involve 12 maternity sites (the ‘clusters’). Each cluster will be randomised to either receive the intervention (group clinical supervision) or not.

The trial will measure midwifery burnout rates (using the Copenhagen Burnout Inventory), the perceptions of their workplace culture (using the Australian Midwifery Workplace Culture (AMWoC) tool, and intentions to leave the profession. For the intervention sites, the efficacy of the clinical supervision will be measured through using the Clinical Supervision Evaluation Questionnaire (CSEQ) (Horton, 2008).

The results of this 5-year study are forthcoming. This year the research team will conduct a review of all available research evidence (both qualitative and quantitative) on group clinical supervision. In the meantime pending the study results, midwives and managers of maternity units could think about their workplace culture and what aspects to focus on to build an environment where staff want to work in, feel supported and safe.

Christine Catling PHD, Centre for Midwifery, Child and Family Health, Faculty of Health, University of Technology Sydney.

This article is reproduced from the TMCC blog with permission from the author.

References

Catling, C. & Rossiter, C. 2020, Midwifery workplace culture in Australia: A national survey of midwives, Women and Birth, 33(5) 464-472.

Creedy, DK., Sidebotham, M., Gamble, J., Pallant, J. & Fenwick, J. (2017) Prevalence of burnout, depression, anxiety and stress in Australian midwives: a cross-sectional survey, BMC pregnancy and childbirth 17 (1), 1-8.

Harvie K., Sidebotham, M. & Fenwick. J. 2019, Australian midwives’ intentions to leave the profession and the reasons why, Women and Birth, 32(6) e584-e593.

Horton S, de Lourdes Drachler M, Fuller A, de Carvalho Leite JC. (2008). Development and preliminary validation of a measure for assessing staff perspectives on the quality of clinical group supervision. Int J Lang Commun Disord. 43:126–34.

Hunter B, Henley J, Fenwick J et al (2018). Work, Health and Emotional Lives of Midwives in the United Kingdom: The UK WHELM study. School of healthcare Sciences, Cardiff University.

Matthews, R. (2021). Impact of Stage of Career on Burnout and Experience of Work for Midwives and Neonatal Nurses Working in a Tertiary Service, conference presentation, PSANZ Congress, 2021.

Pezaro, S., Clyne, W., Turner, A., Fulton, E. & Gerada, C. 2016, ‘Midwives Overboard!’ Inside their hearts are breaking, their makeup may be flaking but their smile still stays on, Women and Birth, 29(3) June e59-e66.

Royal College of Midwives, 2016, Why midwives leave – revisited. RCM, London.

[1] Blogs such as https://midwifediaries.com/whlem-study/

Midwives are delivering above and beyond

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Despite a challenging pandemic enveloping our globe, midwives have continued their selfless roles delivering thousands of babies around the clock, while also campaigning for safe staffing ratios in NSW.

On International Day of the Midwife (5 May), the NSW Nurses and Midwives’ Association (NSWNMA) is honouring the resilience of its midwifery members and their determination to support mothers and babies, despite the tough working conditions.

NSWNMA President and midwife, O’Bray Smith, said on International Day of the Midwife it was important to thank midwives for keeping mothers and babies safe, and to support their calls for midwife-to-mother ratios across NSW.

“Day in day out, you are giving every single part of you to the women and babies in your care so there is nothing left. We see you and we are so grateful,” said Ms Smith.

“When you go home at the end of a shift with the faces of the mothers and babies you looked after etched into your minds, concerned about what’s going to happen to them on the next shift because it’s short-staffed, or distressed and devastated by what’s just happened to them on your shift.

“You need to tell your stories to those people who can legislate ratios – make them hear you.”

NSWNMA General Secretary, Brett Holmes, said the efforts of midwives during public health crisis had not wavered and it was time the NSW government honoured their commitment to the community.

“Midwives did not shy away from the multiple challenges this pandemic has thrown at them, or their support of the mothers and babies in their care,” said Mr Holmes.

“We’ve exposed some pretty horrendous under-staffing that’s occurring in maternity services across our public hospitals and there’s plenty of examples where more improvements are needed.

“Not only do we need more midwives and for newborns to be counted in patient numbers, we also need increased clinical support and respectful pay rates to encourage midwives to stay in the profession.”

NSWNMA Assistant General Secretary, Judith Kiejda, said midwives are extraordinary at performing under pressure and are constantly putting mothers and babies first.

“Midwifery is a physically demanding role, from support during a delivery to helping mums with breastfeeding, midwives are instrumental in the care journey,” Ms Kiejda said.

“Unfortunately, we’re seeing too many burn out because they’re constantly short-staffed or working overtime. It’s not sustainable and our government is accountable.”

The NSWNMA is currently seeking staffing improvements to maternity services and fair pay for midwives in NSW public hospitals.

Push to overhaul maternity staffing

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The NSWNMA award claim for 2021 seeks to overhaul maternity unit staffing with minimum ratios for postnatal wards and updates and improvements to the Birthrate Plus® tool used to calculate required numbers of midwives.

Campbelltown Hospital midwife Rachel Lown, a member of the NSWNMA’s Macarthur branch, says Birthrate Plus® has some major flaws.

“It does not count babies as patients and fails to take into account the increasing acuity of mothers,” she says.

“We do about 4000 births a year and the acuity of women has increased, so we are taking on many more high-risk cases, which are not factored into your workload.

“For example, I’ve had three ladies immediately after they returned from recovery from caesarean section. Having three post-op women and their babies to look after is very full on.

Rachel says management undertook a major recruitment drive in 2019, which led to a temporary improvement in staffing and workloads.

“However, so many staff have decided to go elsewhere because Campbelltown is so hectic.

“Our main issue isn’t finding staff, it’s retaining staff.”

She says Birthrate Plus® does not adequately provide for “like for like” replacement of staff who are on long-term leave or have taken managerial positions or retired.

“Some of our senior people have been replaced by very junior staff.

Rachel says nurses and mid-wives need a fair pay increase after only getting 0.3 per cent last year, when they had to cope with increased workloads due to bushfires followed by the pandemic.

Regarding the union’s claim for free parking for hospital staff, Rachel believes it’s unfair to make hospital staff pay for parking.

“We should get it for free. It’s the least the government could do for those who serve their communities.”

Heroic efforts of Lismore midwives’ honoured

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The courage of two local midwives who bravely put mothers and babies’ lives before their own as a severe storm lashed Lismore Base Hospital almost six years ago, has been recognised in today’s Australian Bravery Decorations.

When scaffolding collapsed onto a temporary maternity building in late November 2015, Leanne Chamberlain and Mary-Ann Hyde, leapt into action to shield five mothers and newborns from debris as the ceiling fell in.

Despite being injured, the two NSW Nurses and Midwives’ Association (NSWNMA) members responded to the calls of distressed mothers, moved everyone to safety inside the ward and continued to care for them until emergency services arrived.

NSWNMA General Secretary, Brett Holmes, said today’s ‘Commendation for Brave Conduct’ awarded to Leanne and Mary-Ann was apt recognition for the lengths both midwives went to.

“Both of these midwives went well above and beyond what would normally have been expected of any nurse or midwife in such difficult circumstances,” said Mr Holmes.

“The fact that Leanne immediately threw herself across one mother and baby to shield them from the falling debris is remarkable. Leanne ignored her own injuries and put the safety of her patients first.

“Mary-Ann’s efforts during the crisis were incredible. Surrounded by debris and water, she managed to wade through it and slide across a fallen wall to reach the mothers and babies and support Leanne.”

NSWNMA Assistant General Secretary, Judith Kiejda, said the agility of the two women in such trying circumstances was extraordinary.

“It takes enormous courage, in a situation of heightened danger, to not hesitate when a ceiling is collapsing around you and you’re battling all the elements of a severe storm cell,” said Ms Kiejda.

“No one heads into a shift thinking they’ll be performing the heroics these two midwives delivered so courageously. It was beyond belief and they conducted themselves selflessly.”

The NSWNMA and its Lismore Base Hospital Branch nominated both members for the bravery awards with input from local authorities.

One-on-one midwife care linked to lower risk of premature birth

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Women who have a midwife as their main carer throughout pregnancy and birth are around 23% less likely to have a premature baby than women whose care is shared between different obstetricians, GPs and midwives, a new systematic review published by The Cochrane Library has found.

Midwife-led continuity of care – in which a pregnant woman sees the same midwife during pregnancy and labour – is also associated with a lower risk of fetal loss before 24 weeks’ gestation and reduced likelihood of labour interventions such as episiotomies (a surgical cut) or use of forceps.

The latest Cochrane review, based on a systematic review of 13 trials involving 16,242 women, concluded that most women, unless they have significant risk factors, should have the option of midwife-led continuity of care.

“Most women should be offered midwife-led continuity models of care and women should be encouraged to ask for this option, although caution should be exercised in applying this advice to women with substantial medical or obstetric complications,” the authors concluded.

“The majority of included studies reported a higher rate of maternal satisfaction in the midwifery-led continuity care model. Similarly, there was a trend towards a cost-saving effect for midwife-led continuity care compared to other care models.”

Stunning outcome

Hannah Dahlen, Professor of Midwifery at University of Western Sydney, said the most significant finding was association between one-on-one midwife care and a significant reduction in the risk of preterm birth.

“Preterm birth is the major cause of early death and major disability for babies. So that’s a stunning outcome,” she said.

“If midwifery care was a tablet you could get at a pharmacy, the companies would be millionaires because everyone would take it.”

Professor Dahlen said that one-on-one care with a familiar midwife often reduces stress and anxiety for pregnant women.

“It’s the top level of scientific evidence that says women cared for by midwives they know have enormous advantages and no disadvantages. There are fewer babies dying, there are fewer things going wrong in labour.”

Some Australian hospitals offer midwifery-led continuity of care for pregnant women but demand for such programs often outstrips the number of places available.

Professor Dahlen said around 80% of pregnant New Zealand women have midwife led continuity of care but in Australia the figure is thought to be between 3 – 5%.

Cost effective

Sally Tracy, Professor in Midwifery at the University of Sydney, and conjoint Professor, School of Women’s and Children’s Health, Faculty of Medicine, UNSW, Midwifery and Women’s Health Research Unit, Royal Hospital for Women, said there was a perception that one-on-one midwife led care of pregnant women cost the health system more.

“But in fact, by the end of it, it costs less because of an accumulation of little things: less pain relief, fewer inductions, and women don’t stay as long in hospital,” she said.

Alec Welsh, Professor and Head of Maternal Fetal Medicine at the University of New South Wales and director of the Australian Centre for Perinatal Science said “you do see good continuity of care in private obstetrician practice as well.”

“But certainly the midwife-led models are associated with decreases in use of epidurals and decreased rates of intervention,” he said.

Hospitals and area health services should not view one-on-one midwife care as an expensive, boutique service and pregnant women should be made aware of the benefits of such schemes, he said.

“We need to get education out there that paying a lot of money for care doesn’t necessarily mean you will get the outcome you want.”

Andrew Bisits, Associate Professor (Conjoint), School of Women’s and Children’s Health at University of New South Wales and Medical Co-director of Maternity at the Royal Hospital for Women, Randwick, said that “at a policy level, more should be done to set up systems of care like this.”

“They are as safe as standard models of care and lead to benefits in the right direction and probably even more than this review even suggests,” he said.The Conversation

Sunanda Creagh, Editor, The Conversation

This article is republished from The Conversation under a Creative Commons license. Read the original article.

‘Like a piranha’: how midwives’ descriptions of breastfeeding affect women’s attitudes

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The World Health Organisation (WHO) promotes exclusive breastfeeding as the optimal way to feed infants. Most Australian babies – 96% – start out breastfeeding. But this figure drops to 61% exclusive breastfeeding at one month, 39% at three months and a very low 15% at five months.

The reasons women stop breastfeeding are widespread. They include pain and discomfort during early establishment, lack of support, fear the baby is not getting enough milk, plans to return to work, and worry about the baby’s enjoyment or fulfilment.

A woman’s confidence with breastfeeding can be impacted by her baby’s behaviour and the perceived quality and quantity of milk. Mothers often look to health professionals in the first few days after birth for help in making these assessments.

But a study my colleagues and I conducted in New South Wales found that the sometimes negative language that health professionals use, when describing normal behaviour while feeding, is far from helpful.

If health professionals’ interpretations of baby’s behaviours are negative, a woman may question whether breastfeeding is meeting her baby’s needs. The language used to describe the baby matters. Women who are not enjoying breastfeeding, or think their baby is not enjoying breastfeeding, are more likely to wean early.

Blaming the baby

Published in the journal Maternal and Child Nutrition, our research observed the breastfeeding interactions between 77 women and 36 midwives or lactation consultants at two New South Wales hospitals in the first week after the women gave birth. We also interviewed some of the midwives and the women separately.

At times health professionals attempted to shift blame for breastfeeding difficulties away from the mother. But in so doing they inadvertently placed blame onto the baby.

Midwives used terms such as “impatient” and “lazy” to describe the infant. Babies were deemed impatient, for example, if they were crying at the breast and not sucking. This was attributed to inheriting an “impatient personality”, demonstrated when the milk was not flowing fast enough for them at their first sucking efforts.

Some babies were considered “lazy” if they were not sucking for long enough or not acquiring sufficient breastmilk at each breastfeed.

In the first week after birth, health professionals took on the role of “infant interpreter” and offered what they thought the baby was “thinking”. The implication was that newborn babies had the capacity to think, make decisions and choose whether to cooperate with breastfeeding or not.

There was a definite impression that the baby had a “job” to do during breastfeeding. In this setting, a baby who “cooperated” with breastfeeding, and performed their “job” properly, was labelled “good”, “clever” and “smart”. Yet if the staff member felt the baby had “decided” not to “cooperate”, they used negative language.

Babies who were unsettled and “uncooperative” were described as being “cross”, “cranky” and “angry” during breastfeeding because the milk was not flowing fast enough for them. Babies were described as “complaining”, having “temper tantrums”, getting themselves into a “tizz” or using their mother as a “dummy”.

These kinds of repeated negative references to personality and unfavourable interpretations of baby behaviour ultimately influenced how some women perceived their babies.

The following quote demonstrates how the words health professionals use can become embedded in a woman’s own language. While this woman was in hospital, she told the midwife that she had sore nipples. The midwife replied:

Your nipples are a bit tender because you’re not used to having this little piranha hanging off them every five minutes.

Six weeks later, I interviewed the same woman at home and asked her to describe her early breastfeeding experience. She replied:

With the latching on and that, she’s a bit like a piranha. She grabs straight on…

Comparing the newborn baby to a harmful creature with a voracious appetite could have significant implications for the mother-baby breastfeeding relationship.

Mother and baby are both learning

We found that more positive language and interpretations of baby behaviour during breastfeeding emerged when health professionals viewed the mother and baby as two participants in a reciprocal relationship.

In these interactions, the baby was seen as an instinctual being who was learning how to breastfeed, and so was the mother.

The language that emerged normalised baby behaviours and reflected more positive interpretations. It also facilitated the mother “tuning in” to the needs of her baby.

At times when women themselves used negative language to describe their babies, the midwives focused on the relationship and encouraged a different interpretation. In one example, a mother interpreted her baby as “a stubborn little bugger” who “doesn’t make decisions real quick”.

The midwife shifted the focus to a more positive reading of the baby: “he just may not be quite ready yet” and “just do some skin-to-skin with him”.

When it comes to supporting women to breastfeed, language is very important. It can positively, or negatively, influence the developing relationship between mother and baby. Language should aim to enhance, rather than undermine, the mother-baby relationship and should facilitate the mother “tuning in” to her baby by identifying normal newborn behaviours.The Conversation

Elaine Burns, Lecturer in Midwifery, Western Sydney University

This article is republished from The Conversation under a Creative Commons license. Read the original article.