Midwifery Group Practice (MGP), is an evidence-based, publicly funded model of care where a woman receives continuity of care from a primary midwife or a small team of midwives throughout pregnancy, birth and the postnatal period. MGP is consistently associated with improved outcomes for women and babies compared with fragmented maternity care models.

Women receiving continuity of care through MGP have lower rates of intervention, higher satisfaction with care and a reduced incidence of birth trauma.[1] There is also evidence of benefit for midwives working in MGP. These benefits are often linked to the relationships developed with women and their families. However, work–life balance is frequently identified as a challenge to the sustainability of the model.[2]

The need to expand access to MGP was highlighted during the NSW Legislative Council inquiry into birth trauma where there were over 4000 submissions, by women, detailing personal birth trauma stories. Current reporting indicates that 42 per cent of services in NSW offer MGP, with many programs operating on a small scale within larger maternity services. This suggests that access remains limited for a substantial number of women. Recommendations 9 and 10 of the inquiry emphasise the importance of improving access and supporting expansion of MGP, and were supported in principle by the NSW Government.[3]

The ongoing challenge is sustainability. Efforts to expand and introduce new MGP models will depend on addressing workforce and service factors that influence the long-term viability of this model of care.

What did we do?

The NSW Nurses and Midwives’ Association (NSWNMA) and the Australian College of Midwives (ACM) collaborated to examine what supports, and what undermines, MGP sustainability. This work was initiated in response to issues raised by NSWNMA members working in MGP. The project began with three focus groups to capture in-depth perspectives from a range of settings. Separate groups were held for midwives working in regional, rural and remote settings, midwives working in metropolitan areas, and midwifery managers. In total, nine metropolitan midwives, 11 regional, rural and remote midwives, and seven managers participated. These discussions informed development of a survey distributed to members of both organisations. The survey aimed to test whether the themes emerging from the focus groups reflected the experiences of a broader cohort. Ninety-five midwives responded.

Among respondents, two identified as Aboriginal and six identified as culturally and linguistically diverse. Thirteen participants were endorsed midwives. Most respondents were practising midwives, with a smaller number identifying as managers or as working as both clinicians and managers. There was a strong geographic spread across responses; regional, rural and remote midwives were well represented and accounted for approximately half of the sample. This enabled meaningful comparison between practice settings.

Model of care challenges

On-call demands emerged as the most common model of care challenge. One respondent captured the impact clearly, describing the on-call requirement as “making it an unsustainable job for women who have babies/young children, or wanting a work life balance”. While this issue did not arise in the regional, rural and remote focus group, it was strongly evident in metropolitan discussions. Participants pointed to higher caseloads and limited access to part-time roles as key contributors to pressure. These demands were further compounded by expectations that MGP midwives cover core staff shift vacancies. Being used as escalation to address core staffing shortfalls was identified as a major model of care challenge.

Perceptions of flexibility within the MGP model differed sharply between settings. Midwives in regional, rural and remote settings identified part-time positions as an important strategy for sustainability, allowing continuity of care for women while supporting midwives’ wellbeing through protected time off. In contrast, metropolitan participants reported limited flexibility as a concern, with some midwives describing the role as becoming unsustainable over time. Consistent with this, lack of flexibility featured as one of the most significant challenges identified in the survey.

Caseload was raised as a concern in the metropolitan focus group but was not a prominent issue for regional, rural and remote midwives, who reported smaller caseloads supported by part-time arrangements. While caseload was identified as a challenge, it did not rank among the most significant concerns.

Logistical challenges

Across both focus groups and survey responses, midwives consistently identified limited administrative support, inadequate infrastructure and insufficient backfill arrangements as ongoing barriers. Access to appropriate clinical spaces for appointments was a common concern, as were challenges maintaining service delivery during planned and unplanned leave. Managers also identified difficulties securing backfill for vacant positions, further increasing pressure on existing staff. Proposed solutions identified in focus groups included improved access to administrative support for scheduling and managing appointments, as well as for retrieving pathology and ultrasound results. Participants also highlighted the need for designated clinic rooms equipped for antenatal and postnatal care, and access to car parking to support the mobile nature of the role.

Strategies to support workforce sustainability included the provision of backfill through other continuity of care models for clinical appointments. Rotational positions within MGP were also suggested, enabling midwives from outside the model to gain familiarity with its structure and processes, with the aim of increasing willingness and capacity to provide backfill when required.

Workplace culture challenges

Workplace culture within MGP was generally described in positive terms. However, many midwives raised concerns about communication and professional relationships between MGP and core staff. A perceived imbalance in expectations was evident, particularly around the provisions of backfill support without reciprocal assistance. These concerns were most pronounced in metropolitan settings.

Focus group members put forward targeted education to improve understanding of MGP to help strengthen professional relationships. This included initiatives such as providing insight into “a day in the life” of a MGP midwife to promote awareness of the role and model of care. Attendance at ward rounds, where feasible, was also identified as a means of strengthening teamwork and shared learning. Increased presence in these settings was seen as an opportunity to enhance collaboration and improve understanding of MGP across multidisciplinary teams.

Lack of support was identified as a significant problem, arising from multiple sources. Midwives reported limited support from core staff following periods of on-call work, as well as from obstetric colleagues and some levels of management. Concerns regarding senior management reflected a perceived lack of understanding of the MGP model and its departure from traditional nursing frameworks. As one participant observed, “This model does not work with nursing management principles.” One manager participating in the focus groups described improving senior management understanding of the model via regular reporting of outcomes and achievements at monthly management meetings.

Manager perspectives

MGP managers spoke positively about the midwives in their teams, describing them as passionate, independent practitioners who deliver high-quality care and achieve positive outcomes for women. One manager summarised this clearly: “They are intelligent and provide professional and considered care.” Feedback highlighted consistently high levels of satisfaction among women receiving MGP care. At the same time, managers identified several challenges, including limited understanding of the model at senior organisational levels, insufficient support for new graduates entering MGP and ongoing tensions between MGP and core staff.

Most respondents reported that MGP was overseen by midwifery managers, which was viewed positively. However, around half of these managers held broader portfolios beyond MGP, limiting their capacity to provide dedicated oversight and support.

Pay and conditions

Under current arrangements, midwives working in MGP in NSW receive 29 per cent loading intended to account for shift work, overtime and on-call commitments. This is the lowest loading nationally. Remuneration ranked as the second most significant concern in survey responses, after on-call demands, and raised across all focus groups as a key factor affecting sustainability. Participants consistently emphasised the need for pay that reflects the complexity of the role, the high level of clinical skill required and the impact of extensive on-call commitments on personal life. As one midwife stated, “Better pay for the on -all hours we work!” Another noted the need for “better remuneration to reflect complexity and high skill set, protection from working well over contracted hours”.

What now?

This project highlights several areas for further exploration. The perspectives captured were limited to MGP midwives and managers. Key voices remain under-represented, including core maternity staff and midwives working in other continuity of care models. Understanding these perspectives will be essential to build a more complete picture of sustainability and model suitability.

Interestingly, working to full scope of practice did not emerge as a priority issue. While MGP is recognised as supporting full scope practice, participants did not identify it as a challenge or driver of sustainability. It is unclear whether this reflects strong support for full scope practice within the model, or whether it is more often considered at a policy level than in clinical work. This warrants further exploration.

Participants identified priorities for both the NSWNMA and the ACM. Midwives highlighted the importance of continued advocacy to recognise and promote midwifery as a distinct profession. There was strong support for establishment of a community of practice, with opportunities to share knowledge and experiences across maternity services. Ongoing advocacy regarding remuneration, working conditions and caseload composition was also identified as essential.

The recent appointment of a Chief Midwife in NSW is expected to strengthen senior midwifery leadership and positively influence senior management structures more broadly. Greater visibility at this level may improve understanding of MGP across organisations, including recognition that it operates differently from traditional nursing models. Improved awareness and leadership support are likely to contribute to the ongoing sustainability of the model.

Conclusion

The findings show that the sustainability of MGP is shaped by the interaction of model design, workforce conditions and organisational context. On-call demands, particularly in metropolitan settings, remain a major pressure point and are closely linked to staffing shortfalls and expectations that MGP midwives backfill core services. Limited flexibility and access to part-time work further contribute to perceptions that the model is becoming unsustainable.

Differences between metropolitan and regional, rural and remote settings highlight the importance of adaptable model design. Greater access to part-time arrangements in regional, rural and remote settings support both workforce wellbeing and maintaining continuity of care. Ongoing challenges with administrative support, infrastructure, backfill, organisational understanding and remuneration continue to undermine sustainability. Management support is critical. For the NSWNMA, these findings reinforce the need for strong industrial protections, clear staffing models and sustained advocacy. Without system-level action to address these issues and align pay with role demands, MGPs are unlikely to achieve sustained growth or required to offer continuity of care benefits to both mothers and midwives.

Author Gemma Deng BMid MMid, Professional Officer NSW Nurses and Midwives’ Association

With thanks to Aya Emery, Midwifery Advisor ACM, who co-authored the study.

[1] Hewitt L, Dadich A, Hartz DL, Dahlen HG. Midwife‑centred management: a qualitative study of midwifery group practice management and leadership in Australia. BMC Health Services Research. 2022;22(1):1203. doi:10.1186/s12913-022-08532-y.

[2] Hewitt L, Dadich A, Hartz DL, Dahlen HG. The sustainability of midwifery group practice: a cross-sectional study of midwives and managers. Women and Birth. 2024;37(3):101602. doi:10.1016/j.wombi.2024.101602.

[3] New South Wales Parliament, Legislative Council, Select Committee on Birth Trauma. Birth trauma. Report No. 1. Sydney: Parliament of New South Wales; 2024 May.