A glance of Midwifery ‘down under’

What is it like working in Australia? In this article Samantha Mashiri, Midwife, shares her experience of moving into midwifery practice and compares with life in the UK.

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Life in Australia offers a unique blend of natural beauty, cultural diversity, and a laid-back vibe. From the stunning beaches, the spectacular rugged outback landscapes, exploring the Great Barrier Reef, hiking the mountains and diverse outdoor activities such as camping, surfing, and barbecuing- there is something for everyone. Work-life balance and relaxation are highly valued. Nine years ago, we made the ultimate decision to leave the UK for the life down under, sunny and vibrant Australia. 

Having worked as a Nurse, Midwife and Health Visitor I had gained experience in both hospital and community settings. In Australia most of the maternity care occurs in hospitals and mainly provided by midwives and doctors working in collaboration with the public health system, or with an obstetrician leading private maternity care. The different possibilities of care are:

Maternity Model of Care:

Private Obstetrician (specialist) care

Private Midwifery care

General Practitioner Obstetrician care

Shared care

Combined care

Public hospital maternity care

Public hospital high-risk maternity care

Team Midwifery care

Midwifery Group Practice caseload care

Remote area maternity care

Private Obstetrician and Privately Practising Midwife joint care   

(Watkins et.al 2023)

My international midwifery journey started at a private hospital with private obstetrician led care. The obstetrician would provide all antenatal care and make decisions on the plan of care in labour and deliver the baby. I slowly watched myself becoming an ‘Obstetric Nurse’ and not utilising my basic midwifery skills in vaginal examinations, delivering a baby, catheterisation, receiving a baby in theatre etc. Private practice didn’t align with my midwifery philosophy and was very distinct from my UK midwifery practice. The scope and opportunity to apply my skills was significantly lowered. The rate of LSCS was significantly higher. Baby-Friendly Hospital Initiative (BFHI) (WHO, 2018) was excitingly fully implemented. Skin to Skin was initiated within a minute of birth resulting in high excellent breastfeeding rates. Skin to skin or breastfeeding was not interrupted and there was no pressure from bed managers to get the woman washed and transferred to postnatal ward. Women would stay in on postnatal ward together with their birthing partners, for up to five days which was great especially for the primiparous women. As a midwife, this was simply your only time to build a relationship with the woman, their partner and family. Although working at a private hospital had negative and significant skills impact of not doing as many hands-on skills, e.g suturing, Obstetricians were more flexible, and it was important as a skilled midwife to display your competence at assessments and decision-making discussions which resulted in more autonomy. 

Watkins et al 2023 noted that “Little is known about the breadth of midwifery scope within Australia, and few midwives work to their full scope of practice”. Significant disparities between models of maternity care currently exists, which presents a challenge to the review of outcomes from individual models of care. To enhance my international midwifery journey, I took on a Casual/ Bank role at a public maternity hospital. The UK’s midwife to patient ratio currently stands at 1:8 with healthcare assistants within the ward, while Australia is working to half of that with a ratio of 1:4 without healthcare assistants or Nursery Nurses. As a midwife in Australia you will perform your own vital signs, assist with personal care and meal follow ups. Arguably, this often limits the time spent delivering actual midwifery care. My role predominantly reflected the urgency to build a relationship with the woman in labour. Working within medically led health services was challenging as there were limitations to my full scope of UK midwifery practice. Additionally, Watkins et.al 2023 also states: “Midwives in Australia are educated and professionally accountable to work in partnership with childbearing women and their families, yet they are currently hindered from practicing within their full scope of practice by contextual influences such as fragmented care, medical dominance and the low status of midwifery within organisations, community and inter-professional dynamics themes”.

In both the current Australian and International midwifery context, conflicts have arisen from various sources that include differing philosophies of care, scope of practice, professional autonomy and collaboration with other healthcare providers. Looking at a Medical Model vs Midwifery Model: Midwives often emphasize a holistic, woman centred approach to care, focusing on promoting natural childbirth and supporting the physiological process of labour and birth. However, conflicts can arise when there is a clash between this midwifery model of care and the medical model, which may prioritise interventions and medical procedures. These challenges restrict the full potential of midwifery scope of practice such as facilitating continuity of care, relationship building with women, and potentially result in midwifery burnout. It has been reported that “Midwifery leadership and professional representation (or lack of) at an executive level has been identified as crucial to enable midwives to work within their full scope of practice, or in models of care supported by best evidence” (Thumm and Flynn, 2018). Furthermore, results of a systematic review revealed that: “A lack of midwifery leadership was detrimental to the midwifery practice climate within an organisation in the domains of work engagement and quality of midwifery care” (Thumm and Flynn, 2018). There continues to be an ongoing concern of midwives being “underrepresented on key government boards, consultive groups, expert panels and decision-making committees” (Thumm and Flynn, 2018).

I had the opportunity to work and support pregnant Indigenous women in the rural and remote communities. Approximately 86% of the Australian continent is classified as remote and only 2.3% of the population lives in these areas (Australian Bureau of Statistics, 2019). Unfortunately, only low risk pregnant women can be cared for within their communities. In some instances, a district hospital is within walking distance but with no birthing services. In such, the regional referral hospital could be 1-4hours travel time by car and airport for emergencies. This fuelled debate over the need for midwives working in rural and regional Australia to also be educated as nurses. It was argued that the effectiveness of midwives who are not nurses in rural health services would be restricted and not meet workforce needs. Pregnant women face geographical barriers such as long-distance travel to healthcare facilities, lack of transportation and high cost of service delivery. Women requiring advanced maternity care far from home are often separated from families. As midwives it was focal to support women psychologically and ease the pressure of isolation. I had a positive experience working in the rural service as I was able to apply both my nursing and midwifery skills. The nursing needs of the women were met which justifies the need for midwives to have nursing education prior to midwifery education. Addressing poorer outcomes in maternity care for Indigenous women remains a priority for midwifery education in Australia.

Deciding which country is a beneficial place to work as a midwife and settle as a family, whether it is Australia or the UK, rests on various considerations that are distinctive to each individual or family. Although Australia offers excellent opportunities, including competitive salaries, access to high-quality healthcare facilities, brilliant lifestyle and manageable cost of living; there are some variances to consider when it comes to the work culture and application of skills. My midwifery experience down under has been an eye-opener. Obstetricians are very educated and do advocate ‘best practice’ in terms of Intrapartum care. Respectfully they are ‘more medicalised’ in their rational and less emphasis on the fineries of midwife led care and this is simply because they are used to a medical model of care. I worked with some amazing Aussie-trained midwives, and they embrace the medicalised system far easier than those of us from the UK and I believe it’s simply because we know of a midwife led system of care and can advocate for ‘normal midwifery’ far easier.

My advice to any midwives considering relocation down under would be to stay open minded, research on the differences between public and private healthcare system, explore midwifery group practices and low risk birthing units. Most importantly, knowing the midwifery model of care for your chosen maternity unit is fundamental to accommodate your skill set and offer you the opportunity to enhance and advance. Larger maternity units will have you working at full skill level, but the smaller medicalised units will have you tearing your hair out. 

References:

Australian Bureau of Statistics, 2008 Australian Social trends, 2008. https://www.abs.gov.au/statistics/people/people-and-communities/australian-social-trends

Thumm, E.B; Flynn, L. (2018). The five attributes of a supportive midwifery practice climate: a review of the literature- J. Midwifery Women’s Health, 63 (1), pp. 90-103 

Watkins, V.; Nagle, C.; Yates, K, et al 2023. The role and scope of contemporary midwifery practice in Australia: A scoping review of the literature. Women and Birth: Volume 36, Issue 4, pp.334-340.

Samantha Mashiri, Midwife

March 2024