Continuity of Care Programs in midwifery education support future midwives

Photo: Christopher Hopkins

It is a marker of high-quality midwifery practice.2 The approach nurtures trust, communication, and often better birth outcomes and experiences for both women and babies.3 Midwifery continuity of care has a strong evidence base as well as government and policy backing in Australia but has been challenging to implement universally. Midwifery students start learning about and participating in Continuity of Care Experiences (CoCEs) during their studies with a requirement that every student engage with at least ten women within a structured program of study.4 This experience helps midwifery students to learn valuable skills in professional practice and benefits the mothers, babies, and families they care for.5

Learning by Doing

Continuity of Care Experiences, also known as Follow-Through Experiences and Continuity of Care Programs, allocates students of midwifery alongside the woman who is at the centre of their own pregnancy journey. The student has the privilege to become part of this journey and to provide care and support commensurate with their level of education. Women opt into these programs during pregnancy and are paired with a student. This relationship helps to develop trust and familiarity and underpins the provision of woman-centred support throughout pregnancy, labour, birth, and the early postpartum period. The timeframe enables a unique learning opportunity that exposes students to the full continuum of midwifery care. Students will always be supervised by experienced midwives, however, their level of clinical participation will change over the duration of the program. Commencing students will be involved mainly in an observer role but as their knowledge and skills develop, students are able to provide midwifery care more autonomously, enabling them to understand the full scope of midwifery practice.

Student Reflections on Participation in a Continuity of Care Program

As a midwifery student, I have participated in many continuity of care experiences that have enabled me to gain confidence, improve clinical skills share the knowledge that I have gained within the scope of midwifery practice and build professional competence which enhances my growth as a future healthcare practitioner. I have developed meaningful relationships with women and families in my care, always focusing on the women’s individual needs, advocating for the woman and providing a familiar face throughout their perinatal journey.

The CoCE program facilitates a symbiotic relationship between the student and the woman and their family. The benefits for me as a midwifery student include developing communication skills, hands-on skill practice and an ever-growing enhancement in providing a holistic and individualised woman-centred approach. My skill set has moved along a continuum from limited input initially, to the present where I provide all care with minimal direction and supervision. The benefit for the woman and their families I care for, is the availability of a trusted advisor who can be an extra set of eyes and ears throughout their appointments. They are able to connect with me at any time, ask questions, clarify what has been discussed and explore options that are being considered, enabling them to make an informed decision on their care.

As a student, I was exposed to a wide cohort of experienced midwives over the program who I used as resources to expand upon my knowledge and accelerate my professional competency which will facilitate a smooth and less daunting transition from student to registered midwife. I will cherish the relationships I have built with the women and their families throughout the program for the rest of my life and I am forever grateful to them for allowing me to share their journey and develop into the student midwife I am today.

Building Professional Confidence and Competence

Continuity of care programs are a cornerstone of midwifery education in Australia and some overseas jurisdictions.6,7 There are many benefits for students.8,9 In these programs, midwifery students develop practical clinical skills under the supervision of experienced midwives, performing tasks like taking blood pressure, listening to the fetal heart, performing examinations, and assisting during birth. Students also gain experience and interpersonal skills by working in multidisciplinary teams and with a diverse population of women and families, which helps to build relationships, trust, and communication skills with professional and client groups. Within the ethos of woman-centred care, students advance their understanding of individual needs and preferencesas they learn to tailor care to the unique needs of each woman, appreciating the diversity of experiences and preferences for care within pregnancy and childbirth. Adaptability and problem-solving skills are also enhanced, as students are exposed to real-life experiences of pregnancy and birth and sometimes unexpected, rapidly changing situations. This helps students to develop critical thinking and problem-solving skills in safe, supervised environments. Ultimately, students prepare for future careers as midwives by building confidence and familiarity with professional practice through caring for women and helping them navigate the pregnancy journey.

Enhanced support for mothers and families

While student learning and transition to professional practice is a core aim of continuity of care programs, significant benefits might also apply to the women and families who participate.10,11,12 The continuity of care experience means that women receive reliable support from a familiar person throughout pregnancy and beyond birth, which fosters trust, promotes a more positive birth experience, and helps to ameliorate anxiety during a stressful period where care is sometimes fragmented. The additional support provided by students under the supervision of experienced midwives also enables more personalised care for women. Working with experienced midwives, students can offer women information and education, which helps to empower them to make informed decisions about the kinds of care that are right for them.

Considerations for program success

As with other elements of midwifery education,13 while further research and evaluation is required to comprehensively understand best practices within continuity of care programs induing their pedagogical intent and learning outcomes,4,14 careful planning and implementation are essential for success. In most programs leading to registration as a midwife, the midwifery student can recruit women to follow through (usually through encounters in antenatal clinics) following the process outlined by the university to ensure there is no coercion and the woman can exit the program at any time. Alternatively, women apply to the education organisation, usually through a website, to request a midwifery student. Some key considerations for continuity of care programs include the preparation of students including academic achievement, interpersonal skills, and an understanding of continuity of care and the professional relationship.

Supervision must also be of high quality within the midwifery education program and in clinical settings. Qualified midwives should closely supervise students throughout the program, ensuring both client and student safety, providing guidance around the maintenance of professional boundaries, and providing clinical guidance. Likewise, these experienced midwives must be appropriately supported themselves to be able to provide high-quality supervision within their already busy working time. It is vital that women considering participation in a program receive clear information about the program’s structure, student role, and supervision arrangements to ensure that expectations can be managed and consent to participate is clear.

Evaluation

Program evaluations are important to ensure that CoC programs meet quality and safety outcomes and can be reflected on and enhanced if needed. At the University of South Australia (UniSA) an annual maternal survey of women who have requested a midwifery student through the “Call the Midwifery Student” website (26% response rate n= 29) found women expressed a high level of satisfaction with the midwifery students’ woman-centred approach and working in partnership. Some of the comments in the free-text section conveyed the importance of this opportunity for women.

[Name of student] was absolutely amazing. She was recommended to me from a friend who also had her as their student midwife. She advocated for me throughout my antenatal care but most importantly was there for me as soon as I called her and needed her to advocate me during early labour. I am so absolutely grateful that I had her in my team and she should be commended for her professionalism, skills and ability to advocate for labouring mothers.”

“My student midwife was my saving grace in my pregnancy. I was an anxious mess due to my previous birth trauma and recent recurring miscarriages and recently discovering my current pregnancy was high risk due to my son having a heart defect. My student midwife went above and beyond to connect with me and support me through the hardest time in my life. She was a huge reason my mental health remained strong during this pregnancy, and she never failed to make me smile and reassure me. I will forever be grateful for her and speak about her often to my son as I want him to grow up knowing who she was and what a huge role she played in welcoming him into the world.”

As well as demonstrating the positive experiences that women have had in the program, feedback also helps to ensure programs are operating smoothly and are effective. Feedback from a few women reminded the midwifery students of the importance of maintaining communication through the program including when they were unable to attend appointments and to ensure it was clear to women how to contact the Program Coordinator if they were concerned about a midwifery student.

The Future of Continuity of Care

Continuity of care programs are valuable models for educating midwifery students and preparing them as future midwives. By providing students with hands-on experience in a supportive real-world environment, these programs help cultivate skilled and compassionate practitioners as they learn to practice as midwives across the perinatal journey. Students can also develop enthusiasm about being part of models of care that enhance continuity of care and experience great professional and personal satisfaction from participating in these models.15

Continuity of care opportunities have shown benefits for women and students, however, more high-quality studies are needed to demonstrate cost-effectiveness of both student programs and continuity of care models delivered by fully qualified midwives.16 The current health and maternity care funding landscape is however untenable for adequately supporting CoCE programs in midwifery practice, as organisations receive more funding for women who require interventions.17,18,19 Continuity of Care programs offer women an opportunity for enhanced support from familiar midwives and the potential for a greater positive birth experience from the relationship of trust and confidence. As the midwifery profession continues to strive to provide high-quality, woman-centred care in more jurisdictions around Australia, CoCE programs should be supported, and enhanced to play a central role in shaping future generations of professional midwives.

References

*In this paper, while we have used the terms ‘woman/women’, we acknowledge and respect that not all birthing people identify as women. This might also include people who identify as non-binary. As an important part of person-centred, individualised care, the pregnant person’s preferred pronouns should be used, and this should be communicated to the healthcare team.

1 Council of Australian Governments Health Council. Women-centred care: strategic directions for Australian maternity services. Canberra (AU): Department of Health; Aug 2019. Available from: https://www.health.gov.au/sites/default/files/documents/2019/11/woman-centred-care-strategic-directions-for-australian-maternity-services.pdf

2 Homer C, Brodie P, Sandall J, Leap N. Midwifery continuity of care: a practical guide. 2nd ed. Elsevier Health Sciences; 2019.

3 Homer CS. Models of maternity care: evidence for midwifery continuity of care. MJA. 2016;205(8):370-4.

4 Australian Nursing and Midwifery Accreditation Council (ANMAC). Midwife Accreditation Standards 2021. Canberra (AU): Australian Nursing and Midwifery Accreditation Council (ANMAC);2021. Available from: https://www.anmac.org.au/standards-and-review/midwife

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7 Hainsworth N, Dowse E, Ebert L, Foureur M. ‘Continuity of Care Experiences’ within pre-registration midwifery education programs: A scoping review. Women Birth. 2021;34(6):514-30.

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11 Tickle N, Sidebotham M, Fenwick J, Gamble J. Women’s experiences of having a Bachelor of Midwifery student provide continuity of care. Women Birth. 2016;29(3):245-51.

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13 McKellar L, Graham K, Sheehan A, Fleet JA, Sidebotham M, Sweet L. Examining the transformation of midwifery education in Australia to inform future directions: An integrative review. Women Birth. 2023;36(2):155-66.

14 Tierney O, Sweet L, Houston D, Ebert L. The continuity of care experience in Australian midwifery education—what have we achieved? Women Birth. 2017;30(3):200-5.

15 Evans J, Taylor J, Browne J, Ferguson S, Atchan M, Maher P, Homer CS, Davis D. The future in their hands: Graduating student midwives’ plans, job satisfaction and the desire to work in midwifery continuity of care. Women Birth. 2020 Feb;33(1):e59-e66.

16 Donnellan-Fernandez RE, Creedy DK. & Callander EJ. Cost-effectiveness of continuity of midwifery care for women with complex pregnancy: a structured review of the literature. Health Econ Rev. 2018;8(1):32.

17 Fox H., Topp SM, Callander E. et al. A review of the impact of financing mechanisms on maternal health care in Australia. BMC Public Health. 2019;19:1540.

18 Toohill J, Turkstra E, Gamble J, Scuffham PA. A non-randomised trial investigating the cost-effectiveness of Midwifery Group Practice compared with standard maternity care arrangements in one Australian hospital. Midwifery. 2012;28(6):e874-9.

19 Callander EJ, Shand A. & Nassar N. Inequality in out of pocket fees, government funding and utilisation of maternal health services in Australia. Health Policy. 2021;125(6):701-8.

Authors

Associate Professor Micah DJ Peters is the Director of the ANMF National Policy Research Unit (Federal Office) based in the Rosemary Bryant AO Research Centre, Clinical and Health Sciences, University of South Australia.

Sharon Rance is the Bachelor of Midwifery Program Coordinator and Continuity of Care Experience Coordinator, Clinical and Health Sciences, University of South Australia.

Rachael Handberg is a third-year undergraduate student in the Clinical and Health Sciences Bachelor of Midwifery Program, University of South Australia.

Jarrod Clarke is a Research Assistant in the ANMF National Policy Research Unit (Federal Office) based in the Rosemary Bryant AO Research Centre, Clinical and Health Sciences, University of South Australia.

Professor Jenny Fereday is the Clinical Professor of Midwifery and Discipline Lead, Clinical and Health Sciences, University of South Australia.

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