Presentation 1: Models of Maternity Care in Rural Environments: Barriers and attributes of interprofessional collaboration with midwives

Presenters: Sarah Munro, Jude Cornelsen, Stefan Grzybowski

Background: Interprofessional Collaboration

- interprofessional collaboration is defined as women-centred, team-based, collaborative maternity care

- gained traction during early 2000s in recognition that family doctors were leaving maternity care practice

- interprofessional care presented as a solution to fill the gap

- in BC, currently only 3 models of interprofessional practice

- model used in this research project: an ad hoc model where doctors and midwives came together on their own in response to need

- this study explores the barriers to and facilitators of interprofessional models of maternity care between physicians, nurses, and midwives in rural BC

- 4 research communities, all fewer than 15000 people

- 2 had a history of midwifery practice

- one of these communities had parallel practice between doctors, and midwives

- the other community had a shared care practice

Questions asked:

- what were physicians’ and midwives’ experiences working together

- how did interprofessional collaboration work

- what barriers existed (regulatory, financial, professional or ideological)

- what resources/activities are necessary for interprofessional collaboration to work?

What did we learn?

- there are ongoing challenges, even in communities with a history of collaboration

Key findings:

- barriers reported by midwives:

- limited access to hospital privileges

- negative views of midwifery practice led, in some cases, to the midwife being barred from hospital practice

- stemmed from concerns about home births (and the dangers that might be associated with home births) and funding models

- misunderstandings about what midwifery is (assumptions that it is unregulated, unlicensed, performed by lay practitioners)

- scope of practice

- midwives offer very different services than physicians. How do you reconcile different scopes of practice?

- billing schedules

- doctors paid by fee-for-service, midwives paid per patient

- reconciled in cases where the doctors and midwives applied to health authorities for a different funding model or pooled their funding

- lack of a formal funding model discouraged shared practice

- labour and delivery nurses saw overlapping scope of practice and felt threatened by midwives

- public health nurses saw midwives’ involvement as an opportunity to support PH activities (eg. assisting with breastfeeding support)

- birthing women wanted choice of care provider, overwhelming desire for midwifery models of care in rural areas (some would travel 2-3 hours to access a midwife)

- saw some problems with integrated models of collaborative care. If they share a practice, what kind of care would you receive? The care they had come to appreciate from their physician/nurse/midwife, or the care offered by another service provider they were unfamiliar with?

- follow-up by the research team:

- visited communities to share findings and discuss

- invited midwives, nurses, decision-makers, physicians to discuss findings and recommend changes that might be needed

- developed recommendations from these meetings

Recommendations:

- “One size does not fit all”

- not all rural communities are the same and the models studied here may not work everywhere

- systemic changes can support teams that want to work together

- funding models need to be created

- hospital privileges need to be extended to midwives

- regional departments of midwifery are appearing and managing hospital privileging

- changing models of care

- at the time of study, physicians were not encouraged to attend home births. This is now changing and may encourage them to work with midwives

- learning from successful models

- several communities have successful models that we can learn from

- need to share their experiences with other communities

Questions:

1) Where have you taken these recommendations? (esp. around systemic changes). Where is that piece going?

Midwives have been most interested in these recommendations. There has been some movement in making changes during contract negotiations that could lead to systemic changes. We are seeing increased support for rural midwives and physicians attending home births. In regards to hospital privileging, some health authorities were surprised to learn that physicians were in charge of determining hospital privileges for midwives. Upon discovering this, they supported midwives creating regional departments of midwifery to manage hospital privileging. In terms of funding supports, there is no discernable change at this point. This would require changes at the level of the BCMA and the government changing the system of payment.

2) We have been discussing collaboration vs integration. This project was defined in terms of collaboration. Was there any discussion of integration?

Integrated practice existed in one case where there was a shared care/funding model. Physicians and midwives were changing their styles of practice and care to have a similar model of care for their patients. This required some give-and-take on both sides. One issue is home births: midwives have to give women that option but no physicians were giving that option in the communities studied. In rural areas where there are very few health professionals, they tend to lean on each other more and share duties when required so there are more opportunities for collaboration.

3) In some communities there may be very few births each year. If there are few births, is it possible that there may not be enough for a midwife to keep her skills up and meet the minimum number required to keep certification?

Midwives perform 40+ births a year. They must have a practice partner, so one practice will do 80+ births a year. In rural areas there are many transfers required in cases where they are high-risk and can’t deliver in their low birth community. In these cases there must be ~110 births to sustain a midwife practice. Those communities with smaller birth numbers make it difficult for a midwife to sustain her practice. If they cannot meet 40 births per year, they may travel to a high-volume community where they may spend a week performing deliveries to get their numbers up. (Only one or two examples of this in the province).

3b) Can midwives involved in training other midwives apply that towards their requirements to keep certfication?

Requirement to remain certified is approximately only about 15 deliveries over two year, 5 must be home birth. Knowledge exchange occurs in many settings, but there is not necessarily a formal mechanism to measure this.