In the context of maternity care, ‘collaboration’ is defined as a shared partnership between a birthing woman, midwives, doctors and other members of a multidisciplinary team (National Health & Medical Research Council, 2010). Collaborative practice is based on the philosophy that multidisciplinary teams can deliver care superior to that which could be provided by any one profession alone (National Health & Medical Research Council, 2010). Indeed, there is evidence to suggest that collaborative maternity practice does improve outcomes for women, including both clinical outcomes and consumer satisfaction with care (Hastie & Fahy, 2011). Collaborative practice is particularly important in Australian rural and remote maternity settings, which are characterised by fragmented, discontinuous care provision (Downe et al., 2010). As such, both the Code of Ethics for Midwives in Australia (for midwives and obstetric nurses) and the Collaborative Maternity Care Statement (for obstetricians and other doctors) require that a collaborative model of care be adopted in Australian maternity settings. However, inconsistencies between and among midwives and doctors about the definition of ‘collaboration’, and subsequent ineffective collaborative practice, remain key causes of adverse outcomes in maternity settings in Australia (Hastie & Fahy, 2011; Heatley & Kruske, 2011). This paper provides a critical analysis of collaborative practice in Australian rural and remote maternity settings.
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Rural and remote maternity care in Australia
It is estimated that one-third of birthing women in Australia live outside of major metropolitan centres – defined for the purpose of this paper as ‘rural and remote regions’ (National Health & Medical Research Council, 2010). However, the number of facilities offering maternity care to women in these regions is just 156 and declining (2007 estimate) (Australian Government Department of Health, 2011). Australian research suggests that the decreasing number of rural and remote maternity services is resulting in more women having high-risk, unplanned and unassisted births outside of medicalised maternity services (Francis et al., 2012; McLelland et al., 2013); indeed, one recent study drew a direct correlation between these two factors (Kildea et al., 2015). Additionally, statistics suggest that both maternal and neonatal perinatal mortality rates in Australia are highest in rural and remote regions (Australian Government Department of Health, 2011).
High perinatal mortality rates and lack of services in rural and remote communities mean that many rural and remote women are transferred to metropolitan centres, often mandatorily, for birth (Josif et al., 2014). This system has resulted in fragmented, discontinuous care for many rural and remote women – which is itself a poor outcome (National Health & Medical Research Council, 2010; Sandall et al., 2015). Many women find such models of care to be significantly disempowering, which again may result in poorer outcomes (Josif et al., 2014). Indeed, many women, and particularly Aboriginal women, may resist engaging with medicalised maternity services to avoid being transferred ‘off-country’ for birth (Josif et al., 2014). Furthermore, those women who are transferred ‘off-country’ for birth bear a significant financial, social and cultural burden (Dunbar, 2011; Evans et al., 2011; Hoang & Le, 2013).
Australian maternity services reform
In response to these issues, in 2009 the Australian government commenced a major reform of maternity care. This reform included attempts to shift maternity services provided to rural and remote women to more collaborative, continuous, community-centred models (Francis et al., 2012). These new models of care require midwives to work collaboratively with general practitioners, obstetricians and rural doctors to care for a rural or remote woman in her own community to the greatest extent possible (McIntyre et al., 2012a). Evidence suggests that rural and remote women desire to be cared for in their local communities provided the maternity services offered are safe (Hoang & Le, 2013). Indeed, there is evidence to suggest that women, and particularly Aboriginal women, who birth within their communities have an increased likelihood of positive outcomes (Commonwealth of Australia, 2009). However, the National Guidance on Collaborative Maternity Care, which resulted from the government reforms, notes there are a number of unique and significant challenges to achieving collaborative practice in rural and remote community settings (National Health & Medical Research Council, 2010).
Collaborative care in Australian maternity settings – challenges and complexities
The fundamental aim of collaborative services in Australia is the provision of ‘woman-centred care’, where women are empowered to be active partners in the provision of their care (National Health & Medical Research Council, 2010). It is well-established that the delivery of woman-centred care in a maternity setting produces the best outcomes, in terms of both clinical outcomes and consumer satisfaction with care (Pairman et al., 2006). In a recent Australian study, Jenkins et al. (2015) suggest that collaboration is fundamental in the achievement of woman-centred care in rural and remote settings in terms of continuity of care – including consistency in communication between care providers – across often vast geographical regions. However, conflicting definitions and interpretations of the concept of ‘woman-centred care’ between midwives and doctors are a key barrier to achieving collaborative practice in Australian maternity settings (Lane, 2006). These problems are magnified in rural and remote settings, where transfers of care between midwives and doctors often occur abruptly when women are transported ‘off-country’ to deliver (Lane, 2012).
Differences in understandings of the concept of ‘woman-centred care’ between midwives and doctors – and, therefore, impairments to effective collaboration – are underpinned by midwives’ and doctors’ differing perceptions of ‘risk’ in childbirth. Indeed, a study by Beasley et al. (2012) identified incompatible perceptions of best-practice strategies to mitigate risk as the key factor underpinning the lack of collaborative practice between midwives and doctors in Australian maternity settings. Whilst midwives focus on normalcy, wellness and physiology in birth, doctors place an emphasis on intervention – both valid approaches to risk mitigation in birth, but fundamentally contradictory (Lane, 2006; Beasley et al. 2012; Downe et al., 2010; Lane 2006). These differing philosophies of care have resulted in increasing tensions in maternity settings, and this has been exacerbated by sensationalist media reporting, particularly following the Senate Inquiries into Media Reform of 2008/09 (Beasley et al., 2012). The concept of risk is particularly important in rural and remote settings, given the decision to transfer a woman ‘off-country’ is often made on the basis of risk.
The reforms to the Australian maternity system – including the introduction of the Nurses and Midwives Act 2009 – have resulted in significant increases to midwives’ scope of practice and autonomy (National Health & Medical Research Council, 2010; Beasley et al., 2012). This is particularly important in rural settings, where midwives are often required to be ‘specialist generalists’ with a diverse suite of clinical skills (Gleeson, 2015). However, this expansion in midwives’ scope has further challenged the achievement of collaborative practice in Australian maternity settings. Tensions have occurred because doctors often perceive themselves to be solely accountable for the outcomes of maternity care and, therefore, legally vulnerable when practicing under midwifery-led models of care focusing in risk-mitigation strategies to which they may be unaccustomed or opposed (Lane, 2006; Beasley et al., 2012). These issues are particularly obvious in rural and remote maternity settings, where the referral of the care of birthing women by midwives to doctors may occur primarily during obstetric emergencies. Doctors in Australia have been particularly vocal about the fact that there is poor evidence to support the safety of midwifery-led models of care, including in rural and remote maternity settings (Boxall & Flitcroft, 2007).
The expansion in midwives’ scope of practice has also challenged the achievement of collaborative practice in Australian maternity settings in other ways. Australian research suggests doctors fear the expansion of midwives’ scope will result in them becoming redundant in, and therefore, excluded from maternity settings, and that a decline in clinical outcomes will result (Lane, 2012). As noted by Barclay and Tracy (2010), despite the recent increases to midwives’ scope of practice, both midwives’ and doctors’ continue to have a distinct scope in terms of caring for a birthing woman and both remain legally bound to practice within this scope. However, many doctors continue to oppose the reforms to the maternity system on the basis of changes in midwives’ scope – and also because these reforms may not be evidence based, may fail to meet the needs of women (and particularly the unique needs of rural and remote women), and are driven by service providers rather than consumers (Boxall & Flitcroft, 2007; McIntyre et al., 2012b; Hoang & Le, 2013). Again, doctors’ opposition to changes in midwives’ scope significantly impairs the achievement of collaborative practice in Australian maternity settings.
These issues are further complicated by the fact that Commonwealth law now requires midwives practicing in Australia to have ‘collaborative arrangements’ with a medical practitioner if they are to receive Medicare-provider status (Barclay & Tracy, 2010). This particularly affects private-practice midwives practicing in rural and remote areas of Australia. However, as noted by Lane (2012), such legislation – which effectively forces midwives and doctors into a collaborative relationship – is fundamentally inconsistent with the concept of collaboration as a professional relationship based on equity, trust and respect. Further, these reforms impose collaboration and compel midwives and doctors to form collaborative relationships are unworkable in many rural and remote maternity settings. Often, midwives practicing in these settings work with doctors who are fly-in fly-out locums, who are on temporary placements or who are located in regional centres many hundreds of kilometres away, making the establishment of genuine collaborative relationships a highly complex process (Barclay & Tracy, 2010).
Collaborative care in Australian maternity settings – opportunities and achievement
Despite these significant issues, however, research suggests that collaboration can be achieved in Australian rural and remote maternity settings. The first step in achieving collaboration in this context is for both midwives and doctors to undergo a ‘shift in perception’ with regards to each other’s’ professional roles and boundaries (Lane, 2006; McIntyre et al., 2012a). This will particularly involve doctors’ increasing acceptance of midwives’ expanding role in rural and remote maternity care provision. Rural and remote maternity services in particular provide positive examples of midwifery-led models of maternity care providing maternity services which are both safe and effective (McIntyre et al., 2012a); indeed, one study concludes that shared but midwifery-led models are the best way to achieve continuity of care in rural and remote maternity settings (Francis et al., 2012). Therefore, evidence from these models may be used to bolster doctors’ confidence in the efficacy of midwifery-led approaches to maternity care. However, for this to be achieved, incompatibilities in care philosophies between midwives and doctors must be overcome. This may commence with midwives and doctors recognising that both professions share the same basic goal of achieving the best outcomes for women (Lane, 2006).
Communication is also fundamental to the achievement of collaborative practice in Australian maternity settings (National Health & Medical Research Council, 2010). Indeed, Lane (2012) notes that effective communication between midwives and doctors is one of the ‘minimal conditions’ which must be met if collaborative practice in maternity settings is to be achieved. However, there are a range of barriers to effective communication between midwives and doctors in rural and remote maternity settings, the most significant of which is geographical distance. ‘Telehealth’, which involves the use of telecommunication technologies to facilitate communication between clinicians – and particularly those who care for ‘priority consumers’ such as mothers and babies’ – in geographically diverse regions of Australia may be useful in promoting collaborative practice in rural and remote maternity settings (Australian Nursing Federation 2013). The National Health & Medical Research Council (2010) also identifies written documentation – including pregnancy records, care pathways and a transfer / retrieval plan – to be important in fostering collaborative practice in in rural and remote maternity settings.
Collaboration, or practice based on a shared partnership between a birthing woman, midwives, doctors and other members of a multidisciplinary team, results in improves outcomes for birthing women. As such, codes of practice for both midwives and doctors in Australia require that collaborative practice be utilised in Australian maternity settings. Research evidence suggests that due to the unique challenges posed by rural and remote maternity settings in Australia, collaborative practice is particularly important in this context. However, in Australia in general – and in rural and remote maternity settings in particular – collaborative practice is both lacking and challenging to achieve. This paper has provided a critical analysis of collaborative practice, with a particular focus on Australian rural and remote maternity settings. It has concluded that whilst it may be challenging to achieve, collaboration in Australian rural and remote maternity settings can – and, indeed, should – be achieved in order to promote the best outcomes for birthing women in these regions.
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