As discussed earlier, a range of health workers are involved in the provision of maternity care. These include obstetricians, procedural GPs (obstetricians and/or anaesthetists), midwives, nurses, anaesthetists, paediatricians, Aboriginal Health Workers, allied health professionals and lactation consultants.
The maternity workforce, as with the overall health workforce, is faced with existing and worsening shortages. The ageing of the population and the increase in chronic illnesses are placing increasing demands on an ageing health workforce. Traditional professional boundaries can reinforce traditional roles of health professionals and limit the flexibility of responses to meet increasing demands for health services. Rural and remote Australia has experienced medical workforce shortages for a considerable period, particularly in terms of general practice services and some specialist services, such as obstetrics and gynaecology.
In 2006, there were 1,241 specialists who spent most of their time as obstetric and gynaecology clinicians in Australia.101 This number has remained fairly constant over recent years, despite population growth: 1,119 specialists in 2002; 1,179 specialists in 2003; 1,137 specialists in 2004; and 1,168 specialists in 2005.
Twenty per cent of rural and remote GPs are proceduralists, providing non-referred services normally in a hospital theatre, maternity setting or other appropriately equipped facilities. GP proceduralists often provide services that in urban areas are typically provided by specialists, most commonly in the fields of surgery, anaesthetics and obstetrics. Rural Health Workforce Australia publishes an annual minimum dataset report on medical practice in rural and remote Australia. Its report for 2007 shows that 896 rural GPs undertook procedural work. Of interest to this Review is the fact that, between 2002 and 2007, the number of procedural GPs providing obstetric services fell from 706 to 599. In 2007, 290 procedural GPs provided obstetric services only, 154 provided obstetric and anaesthetic services, 75 provided obstetric and surgery services, and 80 provided obstetric, anaesthetic and surgery services.102
The midwife population is reasonably well distributed on a per capita basis in regional and remote parts of Australia compared with metropolitan areas, especially when compared with the distribution of other health professionals such as doctors and dentists. Nevertheless, access to midwife services in rural and remote areas is also affected by distance. In 2005, there were 18,297 registered midwives employed in Australia. Remote centres employed 77.2 registered midwives per 100,000 population; major cities, by comparison, employed 88.8 registered midwives per 100,000 population. The supply and distribution of health professionals, in particular throughout rural and regional areas, parallels to a great extent the distribution of state and territory health services across Australia.103
The ageing of the maternity workforce is a major issue; the proportion of health professionals approaching retirement age is increasing. The average age of clinicians employed in obstetrics and gynaecology is 51.3 years. The average age of midwives is 45.6 years, and almost two-fifths (39.6 per cent) of midwives are aged between 45 and 54 years.104
Figure 10 shows an indicative distribution of the maternity workforce for major cities and regional and remote areas.
Figure 10: Indicative maternity services workforce
Sources: Midwife numbers are from Australian Institute of Health and Welfare 2008, Nursing and midwifery labour force 2005, National health labour force series no. 39. Cat. no. HWL 40, Canberra: AIHW, additional spreadsheet Registered nurses—clinical area by selected characteristics, table 2; GP numbers are from Australian Institute of Health and Welfare 2008, Medical labour force 2006, National health labour force series no. 41. Cat. no. HWL 42, Canberra: AIHW, spreadsheet table 2.2; obstetrician/gynaecologist numbers are from Australian Medical Workforce Advisory Committee (2004), The Specialist Obstetrics and Gynaecology Workforce—An Update 2003–2013, AMWAC Report 2004.2, Sydney, p 31, and refers to 2003 data for capital city, other metro and rural/remote areas.
Since 2006, there have been increases in the number of university places for medicine and nursing to address workforce shortages as well as initiatives to encourage nurses back into the workforce. Increases in numbers do, however, require an equivalent investment in clinical training to ensure all graduates receive the appropriate level of experience during their education.
The majority of currently practising midwives are registered nurses with an additional postgraduate qualification in midwifery. The introduction of direct entry undergraduate midwifery programs, for people without an undergraduate nursing qualification, is relatively recent; the first programs were introduced in 2002. Midwives are represented professionally by both the Australian College of Midwives and the Royal College of Nursing, Australia. The Australian College of Midwives operates the Midwifery Practice Review, a peer review mechanism that is part of the College’s continuing professional development framework.
Educational requirements and continuing professional development for health professionals are regulated by relevant professional colleges and state and territory registration boards. A National Registration and Accreditation Scheme is scheduled to commence in July 2010.
What the Review Team Heard
- The availability of a suitably skilled workforce was considered the key to maintaining or improving maternity services. In the forums, the fact that an effective workforce was a prerequisite to providing adequate maternity care was a consistent theme. A lack of overall workforce planning was also highlighted by a number of stakeholders.
- Shortages of midwives were identified by a number of submissions and forum participants. At the same time, participants highlighted the possibility of attracting midwives back into the profession if opportunities to work under different models of care were available.
- Also highlighted to the Review was the important role played by procedural GPs (obstetricians and anaesthetists) in providing maternity services in rural communities. The issues involved in attracting and retaining GPs to these positions in rural communities were also considered.
Obviously such an army of professionals will be only available in the most advanced urban units. In suburban and particularly rural and remote Australia, the team might only consist of a single midwife and a GP obstetrician with the possibility of anaesthetic cover also available. While the range and number of professionals available may vary, the principles of teamwork, cooperation and assessable, up-to-date practice must remain constant.105
- Issues involving cultural sensitivity for some overseas-trained doctors were raised by some contributors.
- The RDAA suggests that maintaining a rural maternity workforce requires adequate training and proper incentives, remuneration and support (both professional and personal).106
- The need to encourage obstetricians to regional centres, and the pressures faced by the public sector in attracting obstetricians, were raised.
- The important role played by Aboriginal Health Workers in providing care for Indigenous women and their babies was raised. The need to train more Indigenous people as Aboriginal Health Workers, midwives and doctors was emphasised in the Indigenous Perspectives Forum.
- Alongside issues of workforce availability, the range of supports, such as locum relief, and accessible training were highlighted as being essential to maintain the workforce in rural areas.
- The importance of appropriate professional standards for all health professionals involved in maternity care was raised.
- Submissions suggested that within the nursing and midwifery profession there is some disagreement about the most appropriate training pathway and related education standards for midwives—whether through a direct entry midwifery program or via nursing with a graduate midwifery qualification.
Education of midwives currently follows two differing paths with undergraduate direct entry Bachelor of Midwifery programs being available in some areas and postgraduate Diploma or Master of Midwifery programs for registered nurses also available. There are also a variety of courses which have varying durations and requirements. The Australian Nursing and Midwifery Council are in the process of developing national standards for midwifery education. There is concern that the finalised standards will not achieve international comparability in terms of course length and mandatory clinical experiences … The pathway through nursing to midwifery is fraught for a number of reasons. 107
RCNA urges the Maternity Services Review to recognise the need to ensure that the Australian health system continues to be supported and sustained by comprehensively educated registered nurse/midwives. It is a health care imperative that this model remains the preferred option for the bulk of midwifery education to ensure that the midwifery workforce is not just flexible but well equipped to provide holistic family-centred services. 108
- Many submissions from consumers, midwives and their representative organisations advocated comprehensive access for midwives to MBS rebates, referring and ordering and Pharmaceutical Benefits Schedule (PBS) prescribing rights, and hospital admitting rights. There was also a view put forward by some midwives and medical practitioners that the qualifications and experience of some midwives were insufficient to support the scope of practice that may be implied by direct access to these schemes—and that, in a manner similar to that established for nurse practitioners, advanced practice needed to be linked to additional qualifications and experience.
- Issues were also raised regarding the availability of appropriate clinical placements for midwifery students, including placements that allow continuity of care and access to delivery experience.
- In the context of poor interprofessional relationships that are reported to exist in some areas, the need to improve harmony within the maternity workforce is a high priority in achieving maternity reform.109
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Recent Related Initiatives
The issues of ensuring an adequate health workforce to meet our future needs have been recognised by Australian governments. At the COAG meeting on 29 November 2008, Commonwealth and state and territory governments responded to the challenges posed by health workforce shortages by committing $1.6 billion to a health workforce reform package. This includes the establishment of a National Health Workforce Agency and health workforce statistical register to drive a more strategic, long-term plan for the whole of the health workforce. This investment will have a focus on improvements for the health workforce in rural and regional areas.
The recent decisions by COAG on 29 November 2008 address a number of the issues relating to the maternity workforce raised in the Review. For example, the need for more clinical placement opportunities will be addressed as new clinical placement arrangements for undergraduate students, including doctors, nurses and midwives, are introduced as part of the COAG Workforce Package.
However, in the shorter term, the workforce, particularly but not exclusively in rural and remote Australia, remains under pressure. If, as suggested in this Report, new arrangements to encourage an expanded role for midwives within collaborative models of care are developed and implemented, it is nevertheless uncertain that there will be sufficient midwives with the appropriate skills and training for this role.
Procedural GPs (obstetricians and anaesthetists) will be key to improving services in rural Australia. Improved access to training and ongoing support will encourage GPs to improve their skills in relation to the provision of maternity care.
It is important that all members of the maternity care team meet appropriate professional standards for registration. The credentialing process for a GP or obstetrician wishing to access Medicare-funded services, for example, involves completion of postgraduate studies and clinical placements with the relevant medical college.
Currently, midwives work within their full scope of practice as defined by the Australian Nursing and Midwifery Council (ANMC) National Competency Standards for the Midwife (2006). The Australian College of Midwives (ACM) encourages midwives to participate in its Midwifery Practice Review every three years.
The Review Team noted that midwives work in a variety of settings—for example, in hospitals, birthing centres, employed by medical practitioners and in private practice—and that the skills required may therefore vary. However, if new Commonwealth funding arrangements were implemented, the Review Team considers that midwives accessing those arrangements would need to meet an advanced practice level of professional education and experience to ensure the requisite level of professional knowledge and skill.
The Review Team noted that this will be an important issue to be addressed as part of the introduction of the National Registration and Accreditation Scheme. This Scheme will, for the first time, create a single national registration and accreditation system for ten health professions, including nurses and midwives. The Review understands from the consultation paper on the proposed registration arrangements for the Scheme that the nursing and midwifery register will have separate divisions for midwives, registered nurses and enrolled nurses. In addition, ‘midwife’ is proposed as a title to be protected under legislation. Further consideration by governments is being given to additional titles to be protected in the nursing and midwifery profession, such as ‘nurse practitioner’.
The Review Team concluded that:
- Further strategies are required to attract and retain health professionals for maternity services in rural and remote areas.
- Leadership by the professional organisations is vital in encouraging an understanding of the benefits of national cross-professional guidelines for collaborative maternity care. Interdisciplinary continuing education activities are an important factor in improving interprofessional collaboration in clinical care.
- Between governments and within the nursing and midwifery professions, issues relating to professional education will need to be addressed for national registration and to facilitate a greater role for midwives in maternity care.
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