Health Policy, 5 (1985) 111-132 Elsevier 111 HPE 00045 How is the midwife’s training and practice defined in policies and regulations in Australia today? Lesley Barclay The Family Planning Association of South Australia Inc., Kensington, Australia (Accepted for publication 25 May 1985) Summary This paper describes the current definitions of a midwife found in Australian State policies and regulations. It examines these for internal consistency and external comparability. It also discusses the links between nursing and midwifery in Australia and their influence on the midwife’s practice. The basis on which midwifery training programmes are established is examined, particularly in the light of characteristics and career plans of midwifery students and the questionable cost-effectiveness of current training. The assumption that nursing leadership is necessarily satisfactory, fitting or appropriate for midwifery is challenged. midwifery; midwifery training; cost-effectiveness of training; nursing leadership Introduction The word “midwife”is used in various ways in various nations of the world. In many places today, it remains more a social description than a professional designation. Table 1, taken from Health Manpower Planning [l], provides a breakdown of these categories and functions. The World Health Organization accepted the following definition of a midwife in 1966 [2]: “A midwife is a person who is qualified to practise midwifery. She is trained to give the necessary care and advice to women during pregnancy, labour and the post-natal period, to conduct normal deliveries on her own responsibility, and to care for the newly born infant. At all times she must be able to recognize the warning signs of abnormal or potentially abnormal conditions which necessitate referral to a doctor, and carry out emergency measures in the absence of medical help. She may practise in Address for correspondence: Lesley Barclay, Education Officer, The Family Planning Association of South Australia Inc., 17 Phillips Street, Kensington, S.A. 5068, Australia. 0168-8510/85/$03.30 0 1985 Elsevier Science Publishers B.V. (Biomedical Division)
Transcript
Health Policy, 5 (1985) 111-132 Elsevier
111
HPE 00045
How is the midwife’s training and practice defined in policies and regulations in Australia today?
Lesley Barclay The Family Planning Association of South Australia Inc., Kensington, Australia
(Accepted for publication 25 May 1985)
Summary
This paper describes the current definitions of a midwife found in Australian State policies and regulations. It examines these for internal consistency and external comparability. It also discusses the links between nursing and midwifery in Australia and their influence on the midwife’s practice. The basis on which midwifery training programmes are established is examined, particularly in the light of characteristics and career plans of midwifery students and the questionable cost-effectiveness of current training. The assumption that nursing leadership is necessarily satisfactory, fitting or appropriate for midwifery is challenged.
midwifery; midwifery training; cost-effectiveness of training; nursing leadership
Introduction
The word “midwife”is used in various ways in various nations of the world. In many places today, it remains more a social description than a professional designation. Table 1, taken from Health Manpower Planning [l], provides a breakdown of these categories and functions.
The World Health Organization accepted the following definition of a midwife in 1966 [2]:
“A midwife is a person who is qualified to practise midwifery. She is trained to give the necessary care and advice to women during pregnancy, labour and the post-natal period, to conduct normal deliveries on her own responsibility, and to care for the newly born infant. At all times she must be able to recognize the warning signs of abnormal or potentially abnormal conditions which necessitate referral to a doctor, and carry out emergency measures in the absence of medical help. She may practise in
Address for correspondence: Lesley Barclay, Education Officer, The Family Planning Association of South Australia Inc., 17 Phillips Street, Kensington, S.A. 5068, Australia.
hospitals, health units or domiciliary services. In any of these situations she has an important task in health education within the family and the community. In some countries, her work extends into the fields of gynaecology, family planning and child care.”
The Australian definition of a midwIfe
The National Midwives’ Association of Australia adopted the above definition at their Annual General Meeting in Melbourne, 1981. Paradoxically, the rules and regulations set out in most State ordinances do not appear to permit its implementa- tion.
There is not even a useful alternative picture one could create of the Australian midwife from the various State regulations. There are eight individual idiosyncratic pictures that arise out of the dry and difficult words of ordinances current in 1982. Three of these are ghosts. They lack all substance other than the word “midwife” appearing infrequently, never defined or described in any way. So different are the majority, they bear no resemblance either to one another or to the WHO definition.
There is no doubt that in the past, Australian midwives have fulfilled the WHO role. For example, the highly respected Nurse Kirk confined most of the white women of the Kempsey district over many years from the turn of the century onwards [3], and Mrs. McTavish and others confined the majority of healthy women around the Mansfield area from the middle of the last century until this [4].
Today’s midwife, better educated than her pre-World War II sister, is losing the remaining vestiges of her independence and rights to practise in that manner.
The division of labour between midwife and medical practitioner
The inconsistency of the division of labour between medical practitioner and midwife can be seen in publications such as “Maternity Care in the World” [5]. Specific role analyses have been well explored in the United Kingdom [6] and the United States [7]. Kiiver [8] undertook similar but more limited research in New South Wales in 1976. The outstanding and consistent feature of all these studies is the finding that midwifery skills are under-utilized and the dissatisfaction this causes midwives. Social, political and economic systems have impinged further andfurtherinto midwife- ry, so there is very little remaining independent territory for the midwife, except in a subsidiary role. The Australian health care systems are dominated by medical practi- tioners. Society has accorded them the right not only to this control, but also to define the needs of the market place [9]. This combination of social and economic control makes their political influence extremely powerful and difficult to counter. Midwives in New South Wales confined the majority of women well after the turn of the century. They were still confining 18% in the late 1930s. They were demonstrably at least as safe as, and probably more safe than, their medical colleagues [3,10]. Despite this, our conventional social wisdom became “doctors provide a superior service”. We conti- nued to pay them more for their service and our medical insurance systems did not recognize the midwife’s role in delivery, and continued not to reimburse her or her clients for a midwife’s attendance. The influence exerted over Lodges and Friendly
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Societies by medicine and how this developed to further the medical profession’s best interests is well documented by Pensabene [ 1 I].
It appears that what remains today are only tasks not seen as advantageous, desirable or economically rewarding by other groups. As a consequence, the midwife as a strong practitioner with respected opinions and a high degree of skill is disappear- ing. This demise is not localized and British nursing and midwifery journals deplore a similar situation developing in the United Kingdom (see, for example, refs. 12-14).
Concurrently, and more importantly than midwives’ professional concerns, in both Britain and Australia a woman’s chance of experiencing a normal birth is disappearing also (e.g., refs. 15,16).
Domination of midwifery by medicine has been abetted, albeit unintentionally, by the close links between nursing and midwifery. Again there are important parallels with Britain [14].
The links between nursing and midwifery
A tradition has developed this century in Australia that midwifery was necessary to complete one’s training as a “nurse” and was seen as a necessary prerequisite for promotion. This has also occurred in the United Kingdom. The reasons for this are only superficially similar though generally believed to be the same.
The use of nurse-midwives in the United Kingdom parallels the decrease in status of the non-nurse midwife. Many “midwives” who continued to practise subsequent to the 1902 Registration Act were theoretically unqualified but did so for two reasons. First, by “act of grace” [17], and by taking short and inadequate courses to allow them to register. This provision was essential as the numbers of properly trained midwives were far too few to meet the needs of the population. It took, however, a surprisingly long time for such ‘bona fide’ midwives, sometimes woefully ill-equipped practitio- ners, to die out [18]. The second reason was a stigma attached to their existence that was avoided by the professional nurse who undertook ‘proper’ training. The retention of few courses for non-nurse entrants has continued until the present day, but these courses have intensified rather than lessened the prejudice against non-nurse mid- wives. The prerequisite academic standards were often less than required for a nurse, for example, enrolled nurse qualification [19], the standard of training unexceptional, and the graduate viewed, despite evidence to the contrary, as less desirable, or capable, than her nurse-midwife sister [20]. Discrimination exists against such graduates for promotion, and apparently restricts at times their undertaking advanced training [20]. A new move for “direct-entry” programmes of a different type is foreshadowed by the recent approval for a three year course for non-nurse entrants to midwifery.
Australian regulations also provided bona fide midwives with a period of grace. Hospitals that offered midwife-only training tended to follow the English trend of setting lower entrance requirements. Therefore “direct-entry” training produced unexceptional graduates who were less complete or useful in our cottage hospitals so important before World War II. These small district or country hospitals fulfilled both the medical and midwifery needs of the area. They required their limited staff to be able to “turn-to” to help in any emergency or need. Therefore a “midwife” was limited
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where a “nurse-midwife” was most useful. Conversely, a general nurse was also limited in such situations, as the major nurse training schools did not turn out nurses with even limited experience in midwifery. Any nurse who wanted employment other than in the few large general training schools really needed midwifery training. The era of the cottage hospitals disappeared as they were increasingly unable to meet the costs of advancing technology considered necessary for modern medicine [21]. Priorities in nurse training have altered, also, though we still seem to hold to a pre-war notion of the complete nurse being a midwife.
Because nurses’ training was, and generally remains different and separate from other forms of education available in the community, avenues for post-basic education have been very limited. Promotion has been (in the past) tied to one’s ability to gain a second, third, fourth or even fifth certificate in nursing. This may have been appro- priate when nursing occurred in cottage hospitals and the skills matrons needed were a wide variety of nursing experience and housekeeping ability. Today’s nurses need far greater theoretical depth on which to base advanced inter-personal, technical and management skills. Principles of cleanliness, good housekeeping, sympathy and com- mon sense (see Florence Nightingale’s Notes on Nursing [22]) are insufficient for nurses operating either at junior or senior levels. The appropriateness of such cer- tificates in nursing and the limitations they place on educational development and progress for nurses is increasingly under question. This is particularly so when it appears the majority of candidates for nursing achieve and need academic qualifica- tions equivalent to any other tertiary educational institution [23]. Changes in attitude towards nurse education are vital and have far-reaching consequences for the subse- quent development of the profession. It is time assumptions about midwifery educa- tion were stringently re-examined also.
Obviously, in outback Australia nurse-midwives serve the community far more capably and at less cost than could be managed by a nurse and a midwife. The majority of nurses, however, are employed in areas where midwifery is not only useless but irrelevant (see Nursing Personnel: A National Survey [24]). Another important factor that has altered for today’s trained nurse is that she/he is increasingly likely to be trained in a comprehensive or generalist programme that includes a component of maternity nursing. Nurse training is increasingly turning out a more complete ‘genera- list’ graduate than previously. Limited opportunities for employment exist currently where one uses both midwifery and nursing together. Smaller country hospitals provide the most obvious examples of these. With increasing regionalization of medical services, such hospitals are becoming less common.
I believe the time has come to question and analyse the links between nursing and midwifery instead of assuming they are either permanent, proper or insoluble. I believe the woman with a complicated pregnancy, labour, birth or puerperium deserves the best care, and that can only be provided by a medical team and a nurse-midwife. This is a deficiency in the European system, where the complicated situation is handed to nurses and the midwife’s influence is missed [25].
Unlike some European midwives with whom I have discussed this issue, I do not believe nurses cannot make midwives, but I acknowledge the difficulty inherent in changing orientation from therapeutic care to support of health and the promotion of ‘wellness’.
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Our views of non-nurse midwives are determined by professional memory and regionalized limited perception. Direct-entry programmes have proven their value for four hundred years in Europe and modern direct-entry programmes appear to be well received in the United States and the United Kingdom.
What does a midwife do in Australia?
“What is a midwife?” and “What does a midwife do?” These are not the same questions and have different answers in Australia.
In the United Kingdom, the midwife is the senior responsible person at 76% of all deliveries [26], but her role in normal antenatal supervision and postnatal follow-up is decreasing [6]. The opposite situation exists in the United States where the midwife is less likely to be permitted to deliver the infant than perform antenatal and postnatal care [7,27].
In Australia, the practice varies widely with the midwife doing all this and more in isolated areas, and neither where medical services are amply provided. No matter where she works, the midwife manages labour and immediate postnatal care.
Kiiver’s thorough study of two obstetric hospitals in Sydney found that the most highly qualified persons do not necessarily provide the best quality services [8]. It seems that, in the hospitals she studied, Australians were paying more for less value. She used a technique of careful task analysis and factor analysis “clustering” to study various personnel in obstetrics and the tasks they perform. This sophisticated tech- nique allows re-structuring of jobs and educational programmes to ensure efficient manpower use and appropriate training programmes. She found midwives regularly performing tasks below their level of training. Pupil midwives were consistently performing chores and tasks that could have been equally undertaken by less qualified persons and that had no educational component at all. She believes the rapid staff turnover that she noted, and that was frequently complained of by all staff, reflects a lack of job satisfaction. This is caused in turn by a mismatch between training and the performance requirements of the job. A point from her summary deserves quoting ([8], p. 65):
“A larger number of obstetric patients have an uncomplicated pregnancy and labour. The allocation of responsibility for the total care of these patients to qualified midwifery nurses would constitute a considerable saving in terms of inappropriate utilization of skilled manpower and costs.”
The regulations andprocesses used to control midwtferypractice and training in Australia
Australian midwives lost their regulatory bodies to the more recently formed Nurses’ Registration Boards (NRB) during the years 1920-1933 [28]. These combined boards in no formal way protected the representation or rights of midwives. In fact, even today, not all States allocate even one position on the board to a midwife [28]. Those that do contain a midwife member appear to do so as a token gesture. She is not obligated to represent or to report back to fellow midwives [28]. She is considerably outnumbered on the board and has no special privileges or power on midwifery issues [28]. This situation is unique internationally as far as can be established. Even the
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United States and Great Britain, who train predominantly nurse-midwives as we do, retain independent control of both midwifery and nursing practice. There are provi- sions in most States for boards to consult with Midwives’ Working Parties or similar groups on midwifery issues [28]. Boards are not bound to do so, however, and their regulations may ignore, if they choose, recommendations of such groups.
Perceptions, therefore, of midwives and midwifery reflected in Australian regula- tions are more likely to be those of nurses than of midwives themselves. The gaining of a second certificate in nursing without any practical consolidation or experience does not make a midwife. The career structure that developed in nursing in the past meant many of our nursing leaders have, at the least, a limited view of midwifery.
Midwives ambitious to further their careers frequently had to return to nursing to do so. A dearth of midwife leaders allowed nursing to take over decision making. The wisdom of this has rarely been questioned until recently. This situation is unique to Australia. The United Kingdom has retained a pattern of strong independent leader- ship from its battles for recognition in the last century [18]. American midwifery leaders developed strength during their tight to exist. Australian midwifery has neither spur to develop or maintain independence outside nursing. The formation of an active national association of midwives within the last five years suggests midwives are still capable of recognizing their uniqueness and the desirability of a separate identity.
The programmes that train midwives are considered (except for South Australia which is yet to be clarified) so similar that reciprocal registration between States is granted without question. The question of clinical experiences in training dominates discussions over reciprocity to a disproportionate extent. The fact that the inconsisten- cies are hidden in statutory regulations or statistics and are difficult to identify, let alone grapple with, may help explain this. I attempted to tabulate similarities and differences in training across States under the following headings:
A: Minimum hours free from service for educational purposes. B: Stipulated minimum clinical experiences:
time - weeks types - deliveries, antenatal examinations, etc.
C: Qualifications of person planning the course. D: Qualifications of teachers. E: Nurses’ Registration Board control and evaluation of a hospital running a programme. F: Ratio of students to registered midwives. G: Ratio of students to midwifery teachers. H: Length of training. I: Guidelines for curricula, syllabi and the formulation of objectives for the course. J: Student prerequisites.
The headings appeared to be a useful summary of material that could reasonably be expected to be present in all States.
There was such a lack of correspondence between them, it was not possible to compress this information into a useful table. The only two points where tabulated comparison was really worthwhile were Points A and B (Tables 2 and 3). As mentioned earlier, clinical experience is easily quantified and measured, and can be quickly observed. The obvious difference between States’ required clinical experience was South Australia where a midwife may complete her training having undertaken ten
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TABLE 2
Mainland States
N.S.W. Victoria Queensland W.A. S.A.
Number of weeks
Work release
8 (320 hours) 5 5 7 9 (350 hours)
Minimum teaching
200 200 200 280 350
A.C.T. No Nurse Registration Board stipulation N.T. No training schools (at 1982)
“quality deliveries”. All other States stipulate a minimum of twenty deliveries, five of which may be complicated or assisted, as a basic training requirement. Clinical experience required by each State is summarized in Table 3. It demonstrates the areas of greatest agreement under my chosen headings, but shows considerable differences exist even in this area.
Point C - only one State (New South Wales) stipulates the qualifications to be held by a person planning a midwifery course. Queensland stipulates that midwifery be taught only “in an accredited School of Nursing”. It is statutorily possible, though admittedly unlikely, that a midwifery course in that State could be taught by a non-midwife without a teaching qualification!
Point E - only four States mention this point; three of these state the minimum number of deliveries in a training school and one that case studies be kept available for inspection. Only the Victorian and New South Wales regulations clearly state the Nurses’ Registration Board’s right and responsibility to have regular access to facilities and records in training schools to see these are maintained at sufficiently high and appropriate levels.
Point F - three States only mention Point F - two of these are so non-specific and open to wide interpretation they are useless, for example, “sufficient for adequate supervision” and “twenty-four hour cover by registered staff’. Victoria is the only State to unequivocally state a staff ratio of no more than two students to one registered midwife.
Point G - only three States mention the ratio between midwifery teachers and students. This varies also, as does the extent to which non-teaching qualified midwives are used to teach formally in training programmes.
Point I -the quality of guidelines, curricula, syllabi and course objectives also varies. Western Australia, Tasmania, New South Wales, South Australia and Victoria pro- vide different but comprehensive guidelines and course objectives. Queensland’s material is out of date and inadequate, and the Australian Capital Territory vets its two programmes individually and does not provide Nurses’ Registration Board guide- lines or objectives, though moves are in hand to change this system.
Point J - all States (excluding Australian Capital Territory, which has no policy on
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the matter) stipulate that students should be registered nurses. New South Wales stipulates students must have one year’s post-basic experience, while Victoria requires prospective students to have a persona1 interview. No other State imposes any other selection criteria though I am aware many individual hospitals do so (for example, the Queen Victoria Hospital in South Australia requires two years’ post-basic experience (personal communication from the Principal Nurse Educator) and the Royal Women’s Hospital, Melbourne, advertises its courses stipulating one year’s post-basic expe- rience [29]).
Diversity, choice and independence are not the issues at point -the fact that we do not acknowledge they exist and account for them is at least as important. The area of greatest potential problem (more so even it seems to me than the “ten quality deliveries” debate from South Australia) is the contrast in the number of hours devoted to educational purposes between States (see Table 3). Time released from service for educational purposes is described in hours, days or weeks and may be stipulated face-to-face teaching or simply work release. For example, the New South Wales guidelines require a minimum of two hundred hours face-to-face teaching in eight weeks work release of 320 hours. This is likely to be increased by another 40 hours to accommodate the introduction of their proposed new curriculum.
There are four weeks or 160 hours separating the upper and lower extremes in the table, Queensland requiring the least and South Australia the greatest work release. If this difference is reduced to 5 hours’ face-to-face teaching in an &hour day (the remaining time devoted to private study, films or other activities), a srudenf could receive 100 hours less instruction than her interstate contemporary. That is, more than 25% variation could occur in time devoted to theoretical content between States. Put another way, it is a difference of more than one full year’s study of a 3 hour unit in a tertiary institution. It is worth noting at this point, that work release is an important cost as such time is paid at award rates.
The recent South Australian Nursing Manpower Study (Stage 2) of the South Australian Health Commission, 1981 (referred to subsequently in this paper by the compiler’s name, i.e., Beecken [30]) and the Midwifery Manpower Study of the Health Commission of New South Wales, Division of Nursing, 1981 (referred to subsequently in this paper by the compiler’s name, i.e., Bayliss [31]), show that interstate migration is an important contributor to the pool of qualified staff in each State. If a newly qualified Queensland graduate moved to South Australia it is reasonable to assume her academic or theoretical contribution will be of less value than if South Australia retained one of their own more expensively and arguably more thoroughly prepared midwives. Conversely, a new South Australian midwife may be less clinically compe- tent or experienced than a Queensland-trained person.
States also vary in the methods used in evaluating students. New South Wales requires students to master specified skills prior to taking a State examination. Western Australia is the only other State which makes provision in regulations for any alternative assessment other than a Board examination. All other States rely on individual training schools to judge that students are sufficiently skilled to practise as midwives. Despite this responsibility being left to training schools, they do not have the right even to contribute to the academic assessment of their students. What we have
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TABLE 4
Summary table of changes in post graduate education for nurses by institution awarding diploma or degree
Year Number of institutions
Type of institution
a1957 2 Nursing Colleges only
b1968
‘1973
*1976
e1981
Nursing Colleges only
Nursing Colleges only
2 Nursing Colleges 7 other tertiary institutions*
All in orthodox tertiary institutions (no Nursing Colleges remain)
Qualifications awarded: Up to 1980 Diplomas and Associate Diplomas only
1980 Degrees (generally Bachelor of Applied Science [one of a number of nursing options awarded]) in institutions
1981 Increased number and variety of degree courses available in nursing
* Health Colleges, Universities, and Colleges of Advanced Education.
Sources: a A Directory of Courses, Commonwealth Office of Education, 1957. b Directory of Courses, Australian Department of Education and Science, 1968. ’ Directory of Courses, Australian Department of Education, AGPS, Canberra, 1973. * Directory of Tertiary Courses, Department of Education, AGPS, Canberra, 1976. e Directory of Higher Education Courses, Commonwealth Department of Education, AGPS, Canberra,
1981. Publications cited were not produced annually, therefore ‘milestone’ years have been used to demonstrate Stability and Change.
(excluding New South Wales) is a system that is neither totally externally assessed nor totally internally assessed. I am not advocating one or other system at this stage, but highlighting yet another inconsistency and example of difficulties inherent in current hospital-based educational programmes.
There is a further potential problem faced by hospital-based courses not found in non-service based educational programmes. The students’ education may continue to be (as it has been historically in both nursing and midwifery) secondary to the service needs of the training school. Findings presented by the author elsewhere show clearly that this is happening in many schools. Most States do not make even a token effort to recommend clinical placements on educationally sound grounds. Most make no attempt to extend learning outside the institution. South Australia is a noteworthy exception in both cases, recommending (but not compelling) both. That some indivi- dual training schools throughout Australia recognize this need and attempt to do one or both is to their credit and their students’ benefit.
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The basis on which current midwifery programmes are establishedandtheircost-effective- ness
The characteristics and utilization of trained midwives “Nursing Personnel: A National Survey”, published by the Commonwealth Depart-
ment of Health [24], specifies five areas they believe worthy of further research. Two of these relate to the subject matter of this paper:
“The contribution of post-basic qualifications and further academic achievements to the quality of nursing services, the organization and resources required for this education and the associated implica- tions”,
and “Further manpower studies to identify trends and changes over time in nursing personnel characteris- tics, distribution, utilization and supply” [24].
Though the wording of these recommendations is careful, the tables that contribut- ed to these conclusions show alarming wastage of training facilities and resources in midwifery education. These findings are confirmed by more recent State enquiries held in New South Wales [31] and South Australia [30].
Some wastage of midwives from a traditionally female profession must be accepted, particularly when it is noted that most practising midwives are aged between 25 and 29 years [24]. Taylor and Berelson [32] estimate wastage rates may be in the order of 10%. Vederese [33], writing on health planning for WHO, believes this figure may be too high and that the attrition rate of 3 to 5% may be more appropriate for many countries. Australia, for some reason, experiences a far greater wastage rate than this.
New South Wales, for example, had a “pool” of registered midwives of 17 310 at June 1980 [31]. Of this pool, 10 938 were employed in various areas of nursing. Only 1783 were employed in maternity units or with maternity patients. Bayliss estimates the annual supply pool consists of 800-900 graduating students, a migrant intake of midwives of 200-300, and a unknown number of midwives returning to full time employment.
She concludes, in the light of comprehensive study of demand, that this is probably insufficient. If this is the case, New South Wales is looking at a wastage rate of over 50% of trained midwives. This could be lessened somewhat if the wastage rate of students in training, currently about 25%, could be reduced.
The recent South Australian Nursing Manpower Survey (Stage 2) Specific Issues Relating to Midwifery [30] is another State attempt to identify staffing needs in the future. Immigration of midwives appears a more important part of the ‘pool’ of
registered midwives in that State, contributing up to 45% of the total new registrations in the year 1979-80 [30]. The author wisely cautions against depending too heavily on this unpredictable and variable input. South Australian wastage rates in training are less than one third of those in New South Wales with only 7% failing to successfully complete training. Wastage rates of those completing training, however, remain inordinately high. Only 14% of qualified midwives are actively engaged in the equiva- lent of full-time midwifery practice. Nearly 35% of the registered nurse work force hold a midwifery certificate [30]. Again, considerably fewer than 50% of those with mid- wifery training are using this directly.
It seems reasonable to assume most States face a similar situation. Over 2000 midwives are trained annually in Australia and yet of those sampled in a comprehen- sive national survey, only 5926 were directly employed in midwifery [24]. The conduc- tors of this survey estimated that 85% of the registered nurse population responded. An approximation derived from these figures puts the midwifery work force in this country at about 6800.
It is acknowledged that of the 37 746 registrants holding a midwifery certificate [24], many may find midwifery a desirable or necessary addition to their nursing qualifica- tion. If one totals, however, the allied fields where midwifery could contribute to the quality of care delivered (even indirectly) and adds those nurses directly practising midwifery only, approximately one quarter of those trained are in any way benefitting from their training. Conversely, their training is in no demonstrable way contributing to the quality of care within our health services.
Total registrants with midwifery certificates employed in areas where midwifery could contribute to performance:
Infant Welfare 1163 General Community Nurse 570 Paediatrics 574 Administration (excluding ward units) 1772 Hospital-based Nurse Education 736
3815 Midwifery Units 5 926 Total employed in areas where midwifery is necessary or relevant 9741 Total registrants holding midwifery certificates: 37 746
(Figures taken from Nursing Personnel: A National Survey [24])
These figures show nearly one quarter of our training of midwives to be ineffectual in contributing to the quality of the health services.
The Australian situation is not unique and has been addressed globally by the World Health Organization and within some countries. Vederese [33] writing for the World Health Organization, says:
“In order to reduce losses . . . it is necessary to consider the factors involved and endeavour to improve selection, the educational programme and the realities of practice.”
The United Kingdom is currently facing a similar situation to Australia, one aspect of which was made explicit by results of Golden’s enquiry into the career patterns of recent graduates. She found that of those qualifying, seventy per cent had no intention of practising [19]. Unlike Australia, there is considerable public discussion of the
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implications of this. The costs of “extravagantly” training midwives and not retaining experienced staff are being debated. Appropriate financial remuneration for their services and the improvement of a frustrating work environment where midwives are unable to carry out their responsibilities are two factors raised for consideration by Dunn in a Nursing Times editorial [34]. Further research and innovative training programmes such as the recently approved three year direct-entry programme at Derby are seeking to identify and alleviate elements of the situation [20].
The following diagram conceptualizes the circular nature of the dilemma facing the United Kingdom and Australia (Fig. 1).
Golden [ 191, Walker [ 121 and other writers in British publications deplore and face squarely the poor retention rates of graduates. Bayliss [31] and Beecken [30] in otherwise excellent useful documents, do not appear to consider the possibility that fewer midwives could be trained and retention rates of newly qualified and more experienced staff improved. To do so could not only cost less monetarily; the focus of training would more directly become the quality rather than the number of graduates.
A review of British nursing and midwifery journals over the last five years shows many articles directly related to dissatisfaction with current training programmes, concern for wise future development, and the need to re-think a professional identity. A similar review of Australian journals shows very few that could be similarly classified. (Shoebridge [35] is a notable exception.)
The lack of concern in Australia reflects our perception of midwifery as an extension of nursing. English midwifery is an older, discrete and separate entity from nursing, and has its own independent central registering authority whose only functions and responsibilities are those of midwives.
At present, 55 training schools across Australia produce approximately one third of the total employed work force annually (Post-Basic Nursing Courses in Australia, 1980). If training costs are calculated, very conservatively, on the basis of $2500 per
EXCESSIVE WASTAGE OF QUALIFIED MIDWIVES \
(Compensation) INCREASE STUDENT NUMBERS IN AN ATTEMPT TO ACCOMMODATE SHORTFALL
perpetuates
\ (Consequence) ’
Fig. 1.
INAPPROPRIATE sELEcTIoN AND TRAINING OF STUDENTS
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student (estimated after Quine [36]) approximately $5 million was expended on midwifery training from health budgets in 1981-82.
Approximately half of this sum has produced no direct return to the health services because: (a) only 27% of those undertaking training did so to be able to work as midwives [37];
and (b) only 56% of those trained in 1981-82 are currently working in midwifery [37].
A few very basic questions can help us analyze the crisis we face in midwifery training in this country. It is useful to compare the answers to those nearly a century ago, when there were active moves to establish satisfactory midwifery training pro- grammes, with today. A “local” and “national” answer to these questions is postula- ted.
Question I: What were the reasons for establishing theprogramme and how was theneed determined?
1900: The majority of Australian women gave birth without formally “trained” assistance.
1980: Nationally: No policy or philosophy. National Nursing Manpower Survey expressed concern over numbers produced compared to those in practice. New South Wales and South Australia recently concluded State surveys to determine needs for the future. Both concluded that there should not be a reduction in the number trained.
Locally: Various and difficult to analyze. Some suggestions: (a) Older schools established to rectify shortages of trained midwives; (b) To ‘use up’ valuable clinical experience; (c) Prestige associated with training school status; (d) Student work force used to be less costly than training staff, of dubious validity
today.
Question 2: What was the nature of the initial training phase? 1900: Insufficient; early programmes were increased in length and theoretical
content until stabilized across Australia at a twelve month course for registered nurses in 1950. (At this time a 48-hour week was the norm and lectures were taken in “off-duty”.)
1980: Nationally: No national planning. Some States provide useful guidelines for their own programmes. A few States training midwives have inadequate or no guidelines; this reflects marginal or non-existent planning.
Locally: Varied - considerable autonomy given to hospitals in most States: (a) can allow for flexibility and creativity in teaching and learning; or (b) could result in student exploitation and inadequate learning. These depend on the
adequacy of planning and monitoring that programme goals are achieved,
Question 3: What problems is the programme experiencing and how are they being dealt with?
1900: Medical opposition to the establishment of programmes, feared competition from graduates. Number of graduates insufficient to meet community needs.
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1980: Nationally: Failure to retain students on completion of training; dubious cost-effectiveness of training; diminishing areas of practice responsibility within hospi- tals; increasing social pressures for changes in practice, demands for improved systems of nurse education, etc.; rise of a Home Birth movement; increasing theoretical content of programmes necessary to keep pace with the ‘explosion’ of knowledge and techno-
logy * Locally: Varied - New South Wales high failure rate of midwifery examination
candidates; staff shortages in some areas; dissatisfaction expressed with quality of graduates in some States; shortages of midwifery tutors.
Question 4: In what ways is the programme, through its graduates, contributing to the improvement of the health status of the people and to the development of health services in the country?
1900: Results were obvious and graduates highly respected/relied on members of the community.
1980: Nationally: Results are very difficult to assess and separate from other health team contributions. Midwives are the essential “manpower” of the obstetric and midwifery services of the country but receive little public recognition of this fact. They could contribute further and provide a “cheaper” service if the medical system permitted this.
Locally: Individual programmes are informally evaluated on the quality of gra- duate that supplies the local obstetric services. Individual graduates are likely to contribute and be assessed as an obstetric nurse, not a midwife.
It seems that Moores’ [38] suspicions that recruitment into Midwifery Training in the United Kingdom is not based on rational manpower planning holds in Australia also. He deplores the training of 4000 midwives annually to replenish a pool of 20 000 employed. He sees this as a disproportionate investment in training. Australia trains nearly one third of its employed work force annually, an even higher ratio, and arguably a more questionable practice.
“Direct entry” and other methods of training midwives
“Direct entry”, that is, training programmes in midwifery for non-nurses, have only been discontinued quite recently. The Federal Government’s Directory of Courses, 1966, shows all States offering two year midwifery programmes. Subsequent publica- tions no longer show basic courses, so one has to extrapolate between these figures and the Nursing Personnel (Vol. 2) [24], which shows none trained after 1977. Some time over this decade, the courses that were offered ceased. They were seen as ‘poor cousin’ programmes that accepted lesser entry requirements and were producing a less valued product. This prejudice is interesting when one considers that the registration exami- nations taken by both nurse and non-nurse candidates were identical.
Australian statistics showing the career patterns of these midwives are not available. English experience shows, however, that despite limitations of career prospects and
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prejudice, such persons are retained as highly valued members of the work force and in greater numbers than nurse-midwives [39]. There were five English training schools accepting non-nurse entrants in 1982, “. . . they had plenty of candidates, most of whom had ‘A’ levels or degrees . . . ” and they were “. . . a joy to teach” [20]. Ball cites examination results over a five year period where direct entrant candidates achieved superior results on the Central Midwives’ Board examination than did nurses.
It seems a reasonable assumption that motivation to work as a midwife is high in suchcandidates and that wastage rates ofthosewhocomplete trainingarelow.Thisisin stark contrast to my own findings reported elsewhere [37] where motivation of nurse candidates was not high and wastage rates of recently trained midwives were nearly 50%. Increased cost-effectiveness of a longer training period for non-nurses appears to be justified on these two points. Our current system is blatantly not cost-effective and is wasteful of resources. The United Kingdom has a new three year syllabus for these candidates. This is twice the length of their post-basic course in midwifery. It appears that Australia is large enough to tolerate a two-tier system of training, and that benefits of a less mobile, highly motivated work force could be considerable. It must be emphasized that in no way should such a course be, or be seen as, a second-rate option as were earlier courses. Standards must be maintained or comparable which would mean, of necessity, a longer training period. If candidates from both courses were examined on the same criteria, it is hard to substantiate one being ofless value than the other. The midwife who is not a registered nurse would face limitations of promotion within general hospital structures but should not be limited within the area of midwife- ry itself. They are matters of personal choice and would not be structurally or institutionally difficult in a midwifery hospital.
The question of direct entry is not simple. It is being addressed in the United Kingdom and the United States where moves are under way to accept science gra- duates into midwifery programmes (D. Lang, American College of Nurse-Midwives, personal communication). It is a non-issue in Western Europe where the professions are not seen to be closely related. In Holland, nurses wishing to train as midwives receive no reduction in their three year programme because of their nursing training or background (A. Jansma, Midwifery Tutor, Amsterdam Training School, personal communication). In Australia, it is an issue most nurses have not considered except negatively, but it is one worthy of re-examination and re-thinking. The National Midwives’ Association is currently developing a policy statement on the issue.
Midwifery training has remained firmly stuck in the Cottage Hospital era of our history, when a registered nurse needed to be able to “turn to” in any eventuality. This is no longer the case, so why do we continue to train our nurses as if it were? There were more midwives working in medical and surgical wards in New South Wales and Queensland in 1979 than in midwifery units and the position in other States was only marginally reversed [24].
Nursing education has advanced beyond the days when midwifery was essential for nursing practice and the only avenue of gaining further academic qualifications and career advancement.
Post-basic courses for nurses have increased in variety and depth, particularly over recent years (see Table 4). Nurses and the Science of Nursing are moving from
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hospitals into educational institutions for both post-basic and initial training. The latter move has not been as rapid or comprehensive as many nursing leaders would wish, but looks likely to intensify under the present Federal Government policy (see press statements October/November 1983 from Senator Ryan, the Minister for Educa- tion). The development of nursing has improved standards of patient care. Alterna- tives of training style and varieties of practice offer challenge and stimulation to students.
Isolated attempts by writers such as Donoghue [40] and policy statements from nursing leaders (e.g., Goals in Nursing Education and Policy Statement issued by the Royal Australian Nursing Federation and others [41]) attempted to promote graduate programmes in nursing specialities for appropriately prepared candidates. Midwifery training, however, has essentially retained the same form and duration despite three noteworthy exceptions. The first exception to the standard training was an attempt to gain acceptance for a shortened (six months) course for students who had completed a diploma level nursing programme [42]. An independent evaluation concluded that, despite a well designed and run programme, there were reservations about the clinical competence of students who completed it. Despite some local support for the course and suggestions that modifications could overcome the problems, the course has been discontinued.
In New South Wales in 198 1, Cumberland College of Health Sciences attempted to run a two-year part-time midwifery course for candidates with Diploma level nursing qualifications. The number of applicants was insufficient for it to be viable when first offered in 1981 and has continued to be so. It will be offered again in 1985.
The third important and demonstrably most successful move was the introduction of the Bachelor of Applied Science (Advanced Nursing) Midwifery Major at the Lincoln Institute of Health Sciences in Melbourne. This event improves the range of options for nurses who already hold a Diploma of Applied Science, Nursing, and permits them to gain a degree for this further year’s study. The course has been designed to comply with conditions imposed by the Victorian Nursing Council and leads to midwifery registration as well as an academic award (Lincoln Institute of Health Sciences [43]). The course design follows a conventional curriculum and, apart from substantially fewer, but arguable more tightly controlled, hours of clinical experience, appears very similar to a hospital-conducted programme in course design.
Conclusion
The World Health Organization has assisted many countries to establish nursing programmes over the last twenty to thirty years. Concern is now being expressed about their development and outcomes and questions are being asked of newly established programmes such as those used earlier in this paper. It seems that the questions are equally useful when applied to long established training schemes.
It is convenient to dismiss the need for such global evaluation or re-evaluation of what we do as being only relevant to developing countries. Countries with established traditions of education in nursing or midwifery are not exempt from the need for such
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scrutiny. The implication is that today’s programmes must have evolved in an appro- priate way as the system is functional and turns out graduates who are able to perform at a certain level.
We are not exempt from the need to question, in fact we are hampered by our history in a way that disadvantages us beside nations who are able to develop nursing and midwifery programmes using contemporary educational strategies suitable for current social climates. Nursing belongs firmly in Bernstein’s “closed” model [44], to the extent that, in the past, for example, nursing students have general and social sciences “tailored” for their needs and presented to them in isolation from other students of related professions. Its practice and development have also been retarded by its retention of nineteenth century models of subservience to males and medical practice and its acceptance of a “delicacy of female intellect” [45].
Our ethnocentric view of our long traditions of nursing and midwifery education is that we have built something admirable as a result. It appears more accurate to state we have achieved despite the restrictions imposed by our traditions and origins.
We need a global re-evaluation to establish a system of education and practice in tune with today’s social and intellectual world. Our unsophisticated acceptance of a patently questionable system of midwifery education can be demonstrated quantita- tively by statistics and tables used in this paper and qualitatively by the consumer pressures for consultation and change. Some States’ attempts to regulate practice are antiquated and of dubious worth. Others are more valuable. Most show a deference to medical control that was established and is maintained on grounds that remain open to challenge.
The lack of concern expressed on these issues in Australia reflects our perceptions of midwifery as an extension of nursing. It reflects our acceptance that nursing leadership is fitting, appropriate and satisfactory for midwifery. This paper seriously questions those assumptions, and demonstrates that this has not proved adequate in the past.
The urgency of the situation has not been acknowledged in Australia. The lack of concern resembles an ‘ostrich’ response rather than a satisfactory state of affairs.
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