An interactive decision-making framework (i-DMF) to scale up maternity continuity of carer models

Abstract

Background

Low numbers of women in Queensland receive continuity of care across their maternity episode. The Office of the Chief Nursing and Midwifery Officer was tasked with strengthening maternity service delivery by reviewing and improving Maternity Models of Care and Workforce.

Aim

Develop a decision-making framework (DMF) to increase maternity continuity of carer models.

Method

A literature review of models, specific to the public health maternity system, including suitability to rural areas and culturally appropriate to Aboriginal and Torres Strait Islander women was undertaken. Stakeholders informed development of the framework and toolkit. A prototype was built, tested and refined following input from rural, regional and metropolitan facilities.

Results

42 questions guide services to contextualise delivery of continuity of carer to local circumstances. Three rural sites have applied the i-DMF and toolkit. One used the tool for quality assurance of their existing midwifery continuity model, another has developed a midwifery continuity-of-carer model for Aboriginal and Torres Strait Islander women, the other is looking to establish a local rural birth service.

Conclusion

The i-DMF has potential to grow and sustain best practice maternity care, and particularly enable more women to receive relationship-based care with a known midwife.

Background

Improvement and reform to the maternity system is high on the Australian health agenda (Australian Government, 2018). A national strategic direction to guide the delivery of high-quality maternity care in Australia was published on 5 November 2019 (COAG Health Council, 2019). Internationally, maternity services similar to that offered in Australia have undergone significant change (for example in New Zealand and Canada) or are planning for significant change (England, Scotland, Ireland) to align care with best evidence and meet the needs of local communities. These system changes focus on primary care, delivering woman-centred care, providing care close to home, and realigning the maternity workforce to continuity of carer models with women having access to a midwife for their maternity journey (Department of Health Social Services and Public Safety, 2012; National Health Service, 2017; Scottish Government, 2017). It is expected that Australia’s direction for maternity services will not be at odds with international work, given the high level of transferable evidence now available to guide the provision of care (Renfrew et al., 2014; Sandall et al., 2016).

Australia as a developed nation is considered a safe country to have a baby (Australian Health Ministers’ Conference, 2011; Organisation for Economic Co-operation and Development, 2018). However, there are significant differences between services within Australia in respect of clinical outcomes (Australian Commission on Safety and Quality in Health Care, 2017; Toohill et al., 2013), and in the maternity models accessible to women in their local communities (Homer, 2016; Kildea et al., 2015; Tracy et al., 2014). Of women who give birth each year without adequate or local maternity services, Aboriginal and Torres Strait Islander women comprise 24% compared with 2% of the remaining remote population (Kildea et al., 2016). It has been identified that in Australia there are 11 predominant models of care operating (Donnolley et al., 2016) and that access to maternity care within rural and remote areas needs to be improved (Australian Health Ministers’ Conference, 2011; Longman et al., 2017). At the national level, the Australian government provides direction to the jurisdictions of expected care, however responsibility for planning and delivery of healthcare sits with the eight Australian states and territories.

In Queensland during 2016, concerns were raised by clinicians, consumers, professional and industrial bodies about the adequacy of maternity care across the state. A statewide forum was convened to identify mechanisms to improve provision of care for women and babies. This resulted in the formation of a steering committee to oversee four maternity service action groups (MSAGs) commissioned to address and improve (a) the collaborative leadership culture, (b) identification and management of risk in pregnancy, (c) maternity models of care (MMoC) and workforce, and (d) to develop a culturally appropriate maternity strategy for Aboriginal and Torres Strait Islander women (Department of Health, 2016). This paper outlines the work of the third group (MSAG3) tasked with identifying a mechanism for guiding best practice in the area of MMoC and workforce. Specifically, this paper describes the development and socialisation of an interactive maternity decision-making framework (i-DMF) to support services to scale up and roll out continuity of carer models in Queensland and make best use of the maternity workforce, including sustaining rural services (see Box 1).

Maternity services in Queensland – context

Queensland is situated in the north eastern aspect of Australia and covers a large land area of 1.2 million square kilometres with a distance of 2400 km from the northern to southern border of the state. The majority of the populations live, and the larger health services are situated, within the coastal areas. In 2016, women gave birth to 63,000 babies with around 74% of these births occurring in public hospitals. The Department of Health provides systems management for 15 Hospital and Health Services (HHS) offering a public maternity service. In addition, the Mater Mothers’ Hospital in Brisbane, a not-for-profit organisation and one of four tertiary centres (referral hospitals) in the state, is funded to provide public care to around 10% of the births, resulting in 42 sites providing public birth facilities. Six HHS across the state also have a birth centre providing care for approximately 2% of the population. While mortality and morbidity rates in Queensland compare well against other Australian jurisdictions, Aboriginal and Torres Strait Islander women and their babies have overall poorer maternal and neonatal outcomes compared with non-Indigenous women and babies (Queensland Health, 2018a). Aboriginal and Torres Strait Islander women represent 6.7% of the state’s birthing population compared with 4.4% nationally (Australian Institute of Health and Welfare, 2018).

In early 2017 approximately 16% of Queensland Health employed midwives worked in a caseload midwifery model and provided continuity of carer to around 19% of women across pregnancy, intrapartum and up to 6 weeks postnatal. Clinical capabilities of maternity facilities vary according to locality and resources. Rural and remote services are clinically networked to higher level services and supported by a statewide retrieval service linked to road and air ambulance transport. Clinician support is facilitated by statewide clinical guidelines (Queensland Health, 2018b) and a telemedicine support unit.

In 2016 around 1% of births occurred outside a birth facility (65 at a health facility not offering intrapartum care, 506 births prior to arrival at a hospital, with 161 occurring at home) (Queensland Health, 2016). Public-funded homebirth is not offered in Queensland. All Queensland non-birthing hospital sites provide education to staff to facilitate unplanned births. However, due to a reduction in the numbers of maternity rural sites maintaining comprehensive maternity services, communities want maintained birthing facilities, or to have rural maternity birthing facilities reopened where closures have occurred (Barclay and Kornelsen, 2016; Rural Doctors Association of Queensland, 2018). Maternity service closures impose economic, psychological and social burdens on women and their families and furthermore threaten the sustainability of other local health services (Barclay and Kornelsen, 2016).

Aim

To develop an evidence-informed interactive decision-making framework (i-DMF) to support HHS within Queensland to review, redesign and implement maternity continuity of care/r models.

Rationale

The maternity i-DMF aims to provide a systematic and transparent mechanism towards best practice models of care in consideration of evidence, change management principles and inclusive stakeholder engagement. Inconsistent approaches to change can elicit criticism and claims of bias in respect of both objective and subjective decisions (Guindo et al., 2012). The i-DMF aims to support communication and accountability in the decision-making process.

Method

The Office of the Chief Nursing and Midwifery Officer (OCNMO), Queensland Health was tasked with MSAG3 and leading the development of the i-DMF. Following a tender process, external contractor PriceWaterhouseCoopers was employed to assist with the project. The concept included a tool that would support services to review the existing maternity model and assess organisational readiness for redesign and implementation of a new model where indicated. The maternity model was to be consistent with best evidence and the framework, and provide services with sufficient flexibility to contextualise models to local circumstances. To this end, a number of activities were undertaken.

Stakeholder engagement

Firstly, in October 2017 two stakeholder groups were established to guide progress of the MSAG3 work. The leadership and the reference groups comprised consumers, midwives, obstetricians, general practitioners (GPs) and representatives of the Department of Health who were the conduit for their respective representative groups. Stakeholders, including consumers, were drawn from 2016 forum participants who had indicated they were interested in further participation. HHS were also asked to nominate local consumers, and the umbrella consumer group Maternity Choices was contacted to ensure broad consumer representation.

Design workshop

In November 2017 a design workshop was convened, inclusive of approximately 60 additional stakeholders (consumers, clinicians, industrial and professional organisations, academics and administrators of HHS) from across the state, to share ideas and brainstorm priority areas and elements for inclusion in the i-DMF (see Figure 1).

Figure 1.

Stakeholder identification of elements for a decision-making framework.

Literature review

A targeted and accelerated review of national and international literature was undertaken to determine evidence and outcomes of models defined in the Maternity Care Classification System (MaCCS) as they applied to public health services in Queensland. The MaCCS represent the 11 major maternity models operating within Australia (Donnolley et al., 2016). Models that aligned to the recommendation of the National Maternity Plan to improve access to continuity of care/r models were the specific focus of the literature review (Australian Health Ministers’ Conference, 2011).

Evidence of best practice models from developed countries (Canada, UK, New Zealand and the Netherlands) and those with Indigenous populations were sought (Canada and New Zealand). In addition, a review of perinatal outcomes pertinent to each HHS within Queensland was conducted to identify differences in demographic and geographic characteristics that might predicate the most suitable model of care for Queensland women based on the literature. The literature review and key findings were circulated for comment from the leadership- and reference group membership, with agreement this would inform direction for the models of care in the i-DMF.

Existing models and workforce

Immediately prior to this project, the OCNMO had conducted an audit of MMoC in Queensland public hospitals (excluding the Mater Mothers’ Hospital) and sought to identify the workforce within standard care and midwifery continuity models. This work was not repeated. An audit of the medical workforce dedicated to maternity care within the state was undertaken as part of the current project.

Interactive Decision-making framework

Based on the outcomes of the preceding activities, broad themes were identified to assist services, in partnership with their stakeholders (consumers, midwives, GPs, obstetricians and others), to develop and transition towards continuity of care/r models for their local context. These themes, and associated key questions generated from within these themes, also identified tools for inclusion in a library of resources that would support HHS in their decision making and in building a business case and operational plan. More than ninety questions were initially developed and subsequently refined by the leadership group and HHS partners. The literature review and recommendations were circulated for feedback from the leadership group and, with agreement, a prototype for the i-DMF was developed.

Three-step confirmation of the i-DMF prototype

A toolkit was developed consisting of the i-DMF prototype questions, the interactive library of associated resources, and an operational plan exemplar. One Queensland HHS, having recently undertaken a major maternity redesign, was invited to test the toolkit. Adjustment was made before seeking early adopters for the i-DMF and introducing the toolkit into a rural, a regional and a metropolitan HHS for each to apply the toolkit to one of their maternity facilities. Further minor amendments were made before seeking the independent appraisal of an HHS not involved in development of the toolkit. Minor changes were subsequently made prior to introducing it to three more HHS. No further changes were required.

Findings and outcomes

Existing continuity of care/r models in Queensland

Ten of the 11 major Australian MMoC across Queensland are provided within public health services (Table 1). The models that provided either continuity of care or carer in the public system were shared care, team midwifery, midwifery group practice caseload care, private obstetrics and private practice midwifery. Around 1:5 Queensland women have access to a named midwife across their continuum of care in a continuity of carer model. The large majority of remaining women receive standard hospital care following care in the community with a GP, or in a hospital or community clinic attended by a hospital health professional.

Table 1.

Major maternity models in Queensland Health public maternity services.

Model classification	Number of facilities across 15 Hospital and Health Services providing a MaCCS model of care
Private obstetrics	2
Shared care	19
Public hospital: high risk	4
Remote area care	11
Private practice midwife	11
Combined care	5
Team midwifery	2
Private obstetrics & private practice midwife joint care	0
General practitioner with obstetrics care	4
Public hospital maternity care	31
Midwifery group practice caseload care	27

MaCCS = Maternity Care Classification System.

Identifying best practice model for Queensland from available evidence

Outcomes for models of care that offer continuity of care and/or carer during pregnancy, childbirth and in the postnatal period that are publicly available to women in Queensland were evaluated for safety of clinical outcomes, women’s satisfaction, suitability to rural and remote locations, suitability to Aboriginal and Torres Strait Islander women, and cost compared with other models. From the literature reviewed, the quality of evidence was highly variable for 3 of the 11 major maternity model categories (MaCCS) available to women accessing public maternity hospitals within Queensland. These models were shared care (in Queensland shared care might overlap the combined care model outlined in MaCCS), team midwifery and caseload midwifery. Women receiving care from a private midwife or private obstetrician either self-fund or are funded through private health insurance. Therefore, the literature was reviewed for the three publicly funded models providing continuity of care or continuity of carer to inform development of the i-DMF. Box 1 presents definitions of the continuity models.

Box 1.

Definitions of continuity models.

Continuity of care	A team of caregivers working within the same philosophy and framework and sharing information; however there is an absence of a designated named carer
Continuity of carer	Defined as ‘relational continuity’ or ‘one-to-one care’ provided by the same named caregiver who is involved throughout the period of care even when other caregivers are required. A defining requirement of ‘continuity of carer’ model is that the care is provided or led over the full length of the episode of care by the same named carer

Continuity of care

There was limited, variable-quality literature available to determine outcomes for the models providing this model of care (combined care/shared care and team midwifery). However, there was evidence of women’s satisfaction with GP antenatal care (Lucas et al., 2015) and culturally responsive care for Indigenous women in midwifery shared-care models (Brown et al., 2015), and good evidence demonstrating a reduction in the number of caesarean sections (Homer et al., 2001a) and reduced costs in a community-based team midwifery model (Homer et al., 2001b).

Continuity of carer

High-level evidence for midwifery continuity of carer, otherwise referred to as caseload midwifery or midwifery group practice (MGP) were identified, along with supportive evidence of improved access to quality care for women living in rural settings (Josif et al., 2014; Kruske et al., 2015) and improved outcomes for Aboriginal and Torres Strait Islander women (Corcoran et al., 2017; Homer et al., 2012). Evidence of this model obtained from within Australia concurred with that of the international literature (Sandall et al., 2016). In addition there was evidence of reduced caesarean section rates, regional analgesia and admissions to nursery (McLachlan et al., 2012; Toohill et al., 2012), improved numbers of women breastfeeding to 6 months (Tracy et al., 2014), at least comparative outcomes for women with obstetric risks (Tracy et al., 2013), significant benefits for first-time mothers (Tracy et al., 2014) and cost reductions (Gao et al., 2014; Toohill et al., 2012; Tracy et al., 2013; Tracy et al., 2014).

Interactive decision-making framework (i-DMF)

Four overarching themes to guide local maternity facilities in reviewing their service were identified and 42 questions were included in the i-DMF to assist administrators in determining readiness and actions for local maternity model redesign (see Table 2). The themes were as follows:

• Strategy (14 questions): identifies evidence of why continuity of carer models represent best practice and how this can apply locally to Queensland.

• Structure and process (12 questions): outlines the key aspects of implementing a model of care, including project management, infrastructure and safety, and quality. It also captures other factors to be considered in developing models, such as socioeconomic and demographic features of the local community.

• Our people (12 questions): considers key aspects of stakeholder engagement, leadership, change management, culture, and workplace planning.

• Technology (4 questions): technological considerations are vital to ensure change is aligned with the facility, HHS, and the statewide digital strategy.

Table 2.

Overarching themes and associated questions to guide services in transition to continuity of carer model/s.

Decision-making framework questions	Theme
1. The proposed change to Maternity Models of Care aligns with the Hospital and Health Services (HHS) strategic plan.  2. There is a well-defined governance structure enabling the delivery of maternity services at the facility.  3. There is a well-defined clinical governance structure enabling the delivery of maternity services at the facility.  4. The executive will understand why this change is important for the community and our staff.  5. The senior leadership of our facility/HHS (e.g. director of maternity services and HHS executive) will be supportive of this project.  6. The leaders at our facility (e.g. maternity directors, maternity unit managers, HHS executive) ensure change is embedded into ‘business as usual’.  7. Change can be achieved in our facility without a significant shift in attitudes or behaviour from our staff.  8. In general, maternity department staff understand the purpose of this change and potential benefits from the change.  9. Consumer groups/consumers have been engaged and support a move to continuity of carer. 10. There is regular maternity-specific case conferencing between key stakeholders (e.g. obstetricians, midwives, allied health, paediatricians, anaesthetists, general practitioners (GPs) etc.). 11. There are regular maternity morbidity and mortality meetings. 12. There is a high degree of collaboration between maternity professionals to deliver services in the facility. 13. Our team has the skills to develop the business case to justify investment in this project 14. There is an understanding of the documentation required to support union engagement.	Strategy
1. The proportion of women with low socioeconomic status (Socio-Economic Indexes for Areas quintiles 1 and 2) cared for at our facility is <10%.  2. The proportion of Aboriginal and Torres Strait Islander women cared for at our facility is <6%.  3. The proportion of culturally and linguistically diverse women cared for at our facility is <18%.  4. The proportion of women <16 years old cared for at our facility is <5%.  5. The proportion of women >35 years old cared for at our facility is <20%.  6. The proportion of women smoking before 20 weeks gestation at our facility is <15%.  7. The proportion of women with a body mass index >30 cared for at our facility is <20%.  8. Our facility understands what our current Clinical Services Capability Framework (CSCF) level is.  9. Our facility understands the process for moving to the next CSCF level. 10. Our facility is within Modified Monash category 1, 2, 3 or 4. 11. Our facility has a consistent process to transfer and handover care to another facility and/or clinician. 12. There is a clear process to escalate clinical risk.	Structure and process
1. Our facility is able to recruit midwives that meet our skill-mix requirements.  2. Our facility is able to recruit obstetricians that meet our skill-mix requirements.  3. Our facility is able to recruit obstetric registrars that meet our skill-mix requirements.  4. Our facility has appropriate midwifery staffing levels to maintain a sustainable service.  5. Our facility has appropriate obstetric staff levels to maintain a sustainable service.  6. Our facility has appropriate registrar staffing levels to maintain a sustainable service.  7. In general, our maternity workforce turnover rate is <15%.  8. In general, absenteeism in the maternity workforce is <5%.  9. In general, the midwifery workforce works to full scope across antenatal, intrapartum and postnatal care. 10. In general, the maternity workforce has adequate opportunities to upskill and maintain maternity emergency skills. 11. In general, our facility has a suitable clinical support network for exchanging and developing skills. 12. In general, the maternity workforce has adequate access to learning and development resources.	People
1. Our facility has a digital health strategy.  2. Our facility has a telehealth strategy.  3. Our facility effectively shares information within our HHS, with other HHS and with other external parties (e.g. GPs).  4. Our facility effectively receives information within our HHS, with other HHS and other external parties (e.g. GPs).	Technology

The i-DMF is an interactive Excel file designed for services to progress through each question and respond in the affirmative or negative; if a negative response to a question is generated, icons become illuminated to indicate areas where further work is required of the service in progressing development of a new model. A summary page is created in response to the 42 guiding questions. In addition, the illuminated icons guide users to the library, where resources and tools are available, under the four overarching themes, to assist services and their stakeholders to determine a locally appropriate model and to develop an operational plan for the new model.

Rollout of the i-DMF

Thirteen of fifteen HHS across the state were introduced to the i-DMF through attendance at any of three facilitated workshops offered between March to November 2018. Ongoing support for use was available through OCNMO with HHS asked to share with OCNMO operational plans produced following use of the i-DMF.

Evaluating uptake

Eleven of these health services developed operational plans to review or introduce continuity of carer models. One rural site utilised the i-DMF as a quality assurance tool for an existing continuity of carer model; a second rural service implemented a new midwifery continuity of carer model specific to Aboriginal and Torres Strait Islander women’s needs; a third non-birthing remote facility developed plans and has been approved to establish a birthing service. These two new services in the state are a result of the rollout of the i-DMF, indicating utility. A forum in mid-2019 reported on these achieved outcomes and of the four MSAGs since the maternity forum in 2016. Qualitative comments from HHS staff included finding the i-DMF easy to navigate, timesaving due to the linked library of tools, and useful for all disciplines to understand the process and governance in redesign.

Alignment with best practice

In addition to the literature review, professional guides, business and change management tools, and resources from MSAG1, MSAG2 and MSAG4 are also included in the i-DMF library. Resources produced by the MSAGs compliment the overarching intention of providing a safe maternity service. These include a leadership programme to improve culture within maternity services and guidelines to support women who may decline recommended care. Overall, more than 100 resources are contained in the library. The i-DMF and associated library were also mapped against the Maternity Services Framework – an evidence-informed framework for maternity and newborn care (Renfrew et al., 2014) – and was found to meet the essential elements required for delivering high-quality maternity care.

Discussion

Numerous maternity system reviews at both the national and jurisdictional level occurred in Australia over a 20-year period leading up to the Queensland Rebirthing Report in 2005 (Bogossian, 2010). The Rebirthing Report identified six principles for maternity care: care is safe and feels safe, care is open and honest, care is local or feels local, care is integrated, care belongs to families, carers work together and communicate (Hirst, 2005).

The latest Australian review in 2009, aimed to provide a national approach to maternity services. Ten principles and four priority areas were identified to align Australian maternity services and workforce with contemporary and best practice standards:

1. increase women’s access to pregnancy information and local care including in rural and remote settings;

2. ensure high-quality evidence-based culturally appropriate service delivery;

3. develop a woman-centred and collaborative workforce; and

4. an infrastructure of safety be implemented over 5 years (2010 to 2015) (Australian Health Ministers’ Conference, 2011).

At the time of reporting in June 2016 (Australian Health Ministers’ Advisory Council (AHMAC), 2016), it was found significant work had been achieved against the 45 actions stemming from the four priority areas, that is, 31 of 45 actions had been completed, six actions were incomplete, four actions were in progress, and only four actions were still to be commenced. The areas where work had not commenced were:

1. to improve information between the carers of mothers and their babies as they transition from acute maternity services back to community care;

2. development of a rural and remote health framework;

3. a gap analysis of antenatal information resources for women and families; and

4. identification of a professional indemnity insurance product for private midwives.

While recommendations stemming from all previous reviews have had a similar direction (Bogossian, 2010), and dedicated work has been undertaken (AHMAC, 2016), little change has occurred to re-orientate maternity care to appropriate primary- and community-based care. This includes access to local care in rural areas.

There is growing literature in respect of women and the maternity workforce being exposed to unnecessary traumatic events and experiencing trauma symptoms (Beck et al., 2013; Creedy and Gamble, 2018; Leinweber et al., 2017; Smith, 2017). Often, this stems from overmedicalisation of maternity care and of ‘doing too much too soon’ (Renfrew et al., 2014), witnessing disrespectful interactions between maternity practitioners and women and/or disrespectful interactions between maternity carers (Priddis et al., 2018; Toohill et al., 2019). The benefits of relationship-based care, most particularly in midwifery continuity of carer models, is well documented in relation to improving maternity and perinatal outcomes (Sandall et al., 2016), including benefits for care providers such as being more satisfied with their work (Collins et al., 2010; Fenwick et al., 2018). The benefits for communities (improving social and emotional outcomes for women, developing additional health services and attracting workforce), particularly in rural areas, of being provided local primary care from midwives and GPs, including those with obstetric qualification, are often underestimated (Hoang et al., 2014; Kildea et al., 2015). When rural services are reduced, so too is access to training for clinician’s to maintain their skills, leaving little choice for many but to leave the rural area (Kildea et al., 2015; Hoang et al., 2014).

Improving access to continuity of carer is important to women, however, it is unclear how many women have access to continuity of care/r models. In 2015, an Australian survey reported that 19% of women were receiving continuity of carer from a midwife, however it was also highlighted that the sample may not have been representative of the general community (AHMAC, 2015). Another Australian publication cited the rate of continuity of carer to be as low as 8% (Homer, 2016). Therefore, in 2016, when Queensland was challenged to consider the provision of safe, quality maternity care, it was determined that a new approach be taken in lieu of another review or report that may or may not result in improvements. As such, the i-DMF and library of resources that could be used to determine local needs, and develop tangible outcomes for communities was developed.

At this early post-rollout period of the i-DMF across Queensland, positive responses have been received from services that used the toolkit, as evidenced in the period March to November 2018. Three rural areas have shared their use of the tool in reviewing or developing new continuity of carer models, with sites from 11 of the 13 HHS introduced to the i-DMF having developed operational plans towards continuity models.

Promotion of woman-centred care is central to the i-DMF; it also supports best use of the workforce according to demographic and geographic circumstances, with an understanding that one size does not fit all. The i-DMF and toolkit provide for local communities and services to make local decisions about their models through a systematic method supported by comprehensive resources. Furthermore, the toolkit has the potential to address gaps in rural and remote services that have remained unaddressed following the review of outcomes from the National Maternity Services Plan (AHMAC, 2016). Also of note is the inclusion of a dedicated programme to improve maternity culture, and the acknowledgement and guidance of clinician care for cases where women’s choices vary from those of accepted clinical guidelines. Through this proactive tool, it is hoped that women’s access to culturally safe and quality care that provides continuity of carer, with the woman being central to her care, will be achieved.

However, to maintain momentum of this goal and to close the gap for Aboriginal and Torres Strait Islander women, it has been recommended that continuity of carer targets be instituted across the state, and that birthing on country sites be identified. The i-DMF provides support to achieve this. In addition to existing legislative and regulatory requirements in Australia for registered health practitioners, the i-DMF contains the evidence-based elements required for safe maternity and newborn care (Renfrew et al., 2014).

Recommendations

Given the relatively low numbers of women receiving continuity of midwifery care, to realise the full benefit evidenced from this model, continuity of carer targets are required to encourage growth, specifically to close the health gap for Indigenous women and babies. Moreover, to attract and retain midwives in rural locations and facilitate growth of continuity models, living incentives similar to those enjoyed by doctors are required.

Skill mix is an important component of quality systems that ensures the right care is available at the right time. As such, midwifery and obstetric staff should be mapped to services, according to clinical capability levels, birth numbers and distance to higher level services. Once completed, this may provide guidance in relation to the appropriate numbers of maternity staff required for care across the state as more services transition to continuity of care/r models.

It was not possible to map the medical workforce audit within the time frame available for this project; this needs to be completed. Furthermore, it is imperative that ongoing outcomes of maternity models be monitored and that the MaCCS be included in state and national perinatal data collection as a priority.

Conclusion

Midwifery continuity of carer is well established as providing exceptional outcomes for women and babies. However, transitioning from traditional models requires careful planning and consideration around the trajectory for rollout and ways to demonstrate the concept and benefits of the model to staff and the executive. The i-DMF consists of questions aimed to provoke thoughtful consideration around an organisation’s readiness for change as well as considerations about population characteristics, workforce, geography and technology that are likely to affect the way the proposed model of care is delivered. The i-DMF links to a suite of resources that collectively provides an MMoC toolkit to assist services in their change journey.

Key points for policy, practice and/or research

• Birth close to home is important to all women, particularly to women living rurally and to Aboriginal and Torres Strait Islander women.

• Rural maternity services are critical to sustaining broader local primary health services.

• Midwifery continuity of carer models provide improved maternity outcomes, represent best practice, yet low numbers of women have access to this care.

• A decision-making framework can assist rural areas to scale up and roll out maternity continuity of carer models.

Biography

Jocelyn Toohill is an experienced midwife of 30 years and has worked clinically in rural and tertiary maternity facilities across public and private health insured models. She is an experienced health manager, educator and researcher. Currently as Director of Midwifery for Queensland Health her focus is to support collaborative interdisciplinary partnerships to sustain primary maternity models, promote safe birth options for women close to where they live, and advocate for midwives to work to full scope of practice. She is an Adjunct Professor with Griffith University and a member of the Transforming Maternity Care Collaborative.

Yogesh Chadha is senior staff specialist (pre-imminent obstetrician/gynaecologist) at one of Queensland’s tertiary maternity hospitals providing care to around 5,000 women and babies annually. He is the state obstetric advisor to the neonatal retrieval emergency service, and is active in modelling collaborative leadership, with a keen focus to clinical safety. His research interests relate to health service research and reducing the incidence and impact of stillbirth on families. Dr Chadha is also a senior lecturer with the University of Queensland.

Shelley Nowlan, Chief Nursing and Midwifery Officer for Queensland Health, has over 30 years’ nursing experience in a range of health settings. She has a passion for identifying and promoting clinical innovation, and leading strategic planning and nursing workforce commissioning. Shelley has a strong interest in supporting rural and regional communities to ensure nurses and midwives are able to meet the needs of a contemporary healthcare system. Her strong advocacy for nursing and midwifery informs policy development at state and national level, clinical practice innovation, research and workforce development. Shelley Nowlan is an Adjunct Professor in the School of Medicine Griffith University and School of Nursing and Midwifery University of Queensland.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethics

This was a quality improvement activity, HREC was not required.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Jocelyn Toohill https://orcid.org/0000-0001-9202-6651