Ep 74 Sara Bayes on empowering preparation for cesarean sections and translating research into practice

Ep 74 (ibit.ly/Re5V) Sara Bayes on empowering preparation for cesarean sections and translating research into practice

@PhDMidwives  #MidTwitter  @EdithCowanUni @MidwivesACM @CurtinUni
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When Sara Bays, a seasoned midwife and Professor at Edith Cowan University, stumbled upon "Spiritual Midwifery" during her backpacking travels, her life took an unexpected turn. From a nursing career in palliative care to the birth rooms of midwifery, Sara's story is a testament to the profound moments that shape our journeys. This episode is a deep dive into the world of midwifery through Sara's eyes, exploring the emotional and professional highs and lows, and the innovative strategies that are reshaping how we think about birth.

Our conversation with Sara reveals the untold stories of cesarean sections and the groundbreaking work being done to bring expectant mothers closer to the birthing experience. Her research not only highlights the challenges women face during planned cesareans, but also showcases interventions that are redefining the role of surgical patients in the birth process. From specialized classes to the removal of the surgical drape, Sara's insights offer a new perspective on how to empower women during one of life's most significant events.

As we cast a lens on the future of midwifery in Australia, Sara paints a picture of an evolving landscape, where the role of midwifery unit chairs becomes indispensable in bridging the gap between academia and clinical practice. The emergence of these pivotal roles promises to bolster the profession, advancing both healthcare outcomes and the growth of midwives themselves. 

Transcript

Journey Into Midwifery and Aromatherapy

Speaker 1 0:27

Thank you very much for joining me, as per usual. Can you introduce yourself, please?

Speaker 2 0:32

Yeah, my name is Sarah Bays and I'm Professor in Midwifery at Edith Cowan University in Western Australia.

Speaker 1 0:39

So let's go back to where we start for everyone. How did you get into midwifery?

Speaker 2 0:44

Well, differently probably to a lot of other people, I'd had no great desire to be a midwife. Probably to a lot of other people, I'd had no great desire to be a midwife. That was until I was bombing around the US as a backpacker in my late teens and came across a copy of Spiritual Midwifery in a San Francisco bookstore, loved the picture on the front cover and by the time I was halfway in that was going to be my career. So in the UK at the time you had to be a nurse first. So I did that and actually loved nursing, I have to say so. I did it for a long time and I ended up specialising in palliative care and then you sort of burn out of that a little bit and need a bit of change. So that's when I became a midwife in my late 20s yeah, changing from one end of the life extreme to the other To the other and there's lots of similarities actually, yeah.

Speaker 1 1:37

I always tell my first-year students, whenever I'm doing any orientation with students, that there are two times when you are the most privileged to be involved in somebody's life the moment they're born and the moment they die. So true, yeah, yeah and it happens to everyone, and if you're there at that moment and I've done palliative nursing as well- and that, that honor, absolute privilege of being there at that time still kind of yeah it takes a special person to do it yeah, I think so, but, as you say, it's so humbling and it is such a privilege, isn't it?

Speaker 2 2:12

I mean, what a treasure of a moment that is to be there when someone enters the world or leaves it. Yeah, absolutely. And, as I say, I think the stark kind of you know, light bulb moment, I suppose, is when I saw my first birth and saw that baby come out and the spark of life come into it and I thought, oh my gosh, this is what I've been doing all this, all this time in reverse yep, yep, and we have to admit that on some days it does happen on the same day.

Speaker 1 2:45

Oh yes, you have that cycle of life happens so fast. Yeah, in front of you, that is just not expected. So where did you do your initial? I keep calling it training and I've got to change myself. Where did you do your midwifery education?

Speaker 2 2:59

because it's not training, it's education oh, at curtain university here in perth. Oh, so trained as a nurse in the uk and then moved to the to australia as a specialist palliative care nurse. And then an opportunity came up, so it was the paid employment model so I could retain my salary as a registered nurse, join a maternity unit and do training or education on the job with some time in university. So it was fantastic. I absolutely loved it. Trained with some great people that I'm still in touch with today. In fact, I think zoe bradfield was in my cohort, who you may know yes, yes, so he's a researcher over here in wa as well and a couple of other people who are just doing some great things.

Speaker 2 3:47

So they said great head, of course, was janice butt. How much better could it be, you know? So it was just a great experience, yeah that?

Speaker 1 3:57

where did you go after you finished that training? Did you stay within that venue for a while?

Speaker 2 4:02

uh, no, I didn't. I so that was, and it was a great unit. It was a private hospital maternity unit and I wanted to experience the public system as well. Um, because that was a private hospital maternity unit and I wanted to experience the public system as well, because that was a unit that I trained in that received people from higher acuity services when they'd sort of had their high acuity stuff worked out. So I wanted to be able to tell women the story. So I went then to the tertiary maternity service in WA which there was only one at that time, king Edward and did a lovely sort of graduate year there, and at the same time I did my. You could top up your postgrad diploma with another semester to get a master by coursework.

Speaker 2 4:47

So I did that then as well, just was keen to keep going with a couple of projects. You know, when you, when you graduate, you've got things that irritate not irritate you but spark your, spark your curiosity, shall we say. Um, so the coursework masters was a sort of project unit really, and just let me explore a couple of things that I was very interested in under the supervision of Jenny Fenwick, who was here at the time.

Speaker 1 5:15

Yeah, so what type of things did you explore then?

Speaker 2 5:19

oh well, I was a clinical aromatherapist anyway, so I was interested in you know whether or how feasible it would be to put some aromatherapy into labour and birth care. So I was very fortunate to have the clinical midwife lead I think she was at the time in labour and birth suite said yeah, we absolutely want to think about how we can get a policy together for that. So that was nice. Actually, that sort of got me thinking about implementation of research as well as research itself, because I realised quite early it's all great to do the research, but then what do you do with that? The challenges and the drivers are not always obvious.

Speaker 1 6:01

So and we have a delay. We have a depending on where you're anywhere between 15 and 17 year delay, exactly, and that lag is like that's a life, that's a human life yeah, a generation, yeah.

Speaker 2 6:17

So there's a great field of science now implementation science. I know I'm sure you know of it. That helps us expedite those things. So that's sort of jumping the gun a bit, but that's where I'm working at the moment in that space.

Speaker 1 6:29

That's right. Everything comes full circle and COVID was a good example of how working together rapid reviews. It could happen a lot faster than what it has been if we're not so proprietary over our images and actually share the information.

Speaker 2 6:44

Exactly, and most of the stuff I do and the people I work with do. We are committed to having it out there in the world as creative commons tools and what, why wouldn't you? It's all all about, you know, improving the experience for people, and we should all put more in there.

Speaker 1 7:01

Yeah, well, that would be a really interesting discussion. A panel to discuss creative commons versus ai issues in the future, that's, that's. That's something kind of that would be really interesting, though. So yeah, what type of aromatherapy? Because, like clary sage, like there's a whole pile lavenders and things like that. What are the ones that you were able to introduce?

Speaker 2 7:24

uh, rose. So essential oil of rose is a really good analgesic, um, so it's for it. So we looked at for comfort, really. So you know my very early sort of naive fumblings into creating some kind of key stakeholder group to advise on these things. So, unsurprisingly, anaesthetists who, um, thought midwives were kind of overtaking their turf, weren't that keen. And then when I sort of said, no, no, I'm not preventing people having an epidural, this is about comfort, you know. And so for women who wanted that sort of experience, it was around sort of calming, creating an environment that's, you know, conducive to relaxation, really for hormonal optimization, I guess.

Speaker 2 8:17

So, um, uh, there were four. So, uh, geranium essential oil of geranium mandarin is another one that's just a very calming, uh, aromatherapy Rose, for the same thing. And then frankincense is the other one. So frankincense is a potent analgesic, but also it's got that very calming property about it. So that one is the only one that you wouldn't mix with an oil and put on the skin. It's one that you put on a drop on a tissue or a cotton ball and then you sort of rub it between your hands and warm it up a bit and inhale it, so it can really help when, um, you know, an emergency scenario section's been called or whatever, and it's absolutely dead set the right thing to do. But oh, how do we all calm ourselves down? It works for the women, works for the down. It works for the women, works for the partners and it works for the midwives.

Speaker 2 9:17

Win, win win.

Speaker 1 9:18

I'm just thinking maybe we need to be kind of having some of that on hand when students have exams Exactly.

Speaker 2 9:21

Yeah, it could be really helpful, I think. So I didn't go much further down that road because there's only so far you can go with that. But yeah, look, it's a nice little project.

Speaker 1 9:34

So where did you head off after that?

Speaker 2 9:39

So I stayed at King Edward for quite a while and I was clinical and then, after I finished my master by coursework, I said to Jenny okay, what now? And she went well, I've just got some funding for this project, do you want to be a research assistant? And I went yeah, yeah, how hard can it be, you know? So, um, landed that sort of gig. So I dropped my hours to part-time clinically and then did this thing with Jenny as a research assistant and that was a really interesting project.

Speaker 2 10:10

So with Jenny as a research assistant, and that was a really interesting project. So it was an exploratory study to understand the impact of fear in pregnancy, of childbirth, on women's childbirth outcomes, and sort of cross examine that, I suppose with the model of care that women were in yep. So that was published and I was very lucky to have my very first little publication with that. I analysed some qualitative data, learning on the run, but obviously got hooked because there was some data there that Jenny said you know, this could be a PhD. And I'm sort of, yeah, okay, good, you know. And she went well, are you gonna? Are you gonna do it? Um, oh, oh, uh, yeah, okay then. So I'll cycle back a little bit. I was invited to leave school at 15 with no qualifications yeah academic dud.

Speaker 2 11:08

Uh, I thought there was no academic future for me. So you know, to get to be a qualified anything, but then with a master's, oh my goodness. And then somebody's asking me if I want to do a PhD. I don't think so, you know. So all of that that I'm sure you've heard a million times before, is the imposter thing. Self-belief, self-doubt, all of that, yeah it's really.

Speaker 1 11:32

It's really surprising and I think that's probably one of the biggest things that I found doing this podcast and kind of now doing 70, probably 74 interviews, 75 interviews. That and the conversations that I have which is kind of why I started it was I'm not smart enough to do a PhD. It's like you are If you've got your midwifery qualifications, you're smart enough to do it. But what people don't realise is they keep remembering of their undergraduate days or the way they came through. But postgraduate is very much different and if you get a good supervisory team, it is the make or break um and that support network that you create with other postgraduate students, um, that help you along as well. So, yeah, it's a very surprisingly common thing. That's like, yeah, I'm not smart enough to do it and I wouldn't even dream of that um, but you are and you have and you did.

Speaker 2 12:31

I did. I did in fact. Yes, there you go, and no one's more surprised than I am still, you know.

Speaker 1 12:39

13 years on. So what kind of qualitative data did you explore then for your PhD?

Challenges of Cesarean Section Experience

Speaker 2 12:48

It was a qualitative study, so it was a grounded theory, a Glazerian grounded theory. If that makes any difference to anybody, not really. That's the original version. And so I, as I say, I was working on that project around childbirth fear and didn't discriminate between you know, basically I was sitting in an antenatal clinic waiting room chatting to people about that. They were filling in a questionnaire that we had about it and I was coming. So in the state of WA at that time and still there's at least a 30% cesarean section right across the board. That hospital had about that number of women going through with a cesarean section, quite a few of which were planned because of medical conditions or whatever. And the women started saying to me I don't feel like I'm giving birth now, I feel like I'm going for an operation.

Speaker 1 13:43

Yeah.

Speaker 2 13:43

So my study was about women's experience of a scheduled or a planned cesarean section, because there was quite a bit in the literature at the time of women's experience of an emergency or a non-elective section and all of that. But this was a very different thing, you know. It was almost as if when they were advised or recommended that they would need a section, that they became a surgical patient that was having something removed that was troublesome. So they lost access to birth education classes, the tour of the space they were going to birth in, all of that kind of thing and just sort of given a date. And not that that wasn't done kindly, it was. It was just that you're not having a baby now in the traditional sense.

Speaker 2 14:30

Priority changes yeah, and so out of the study we found I say we because I count the supervisors in that we came up with some interventions that would reintroduce them as birthing people to the hospital. So there was a birthing class for them where they could make a birth plan, you know, just like if you were having a vagina birth, they could have a tour of the operating theater, all of those kinds of things. So the hospital was so supportive and that is still in place today. The other thing that was pretty revolutionary was when women went into the operating room. No drape was put in front of them. So one of the big things was they felt they were on the other side of a wall to their baby being born, and the removal of the drape got rid of all of that. They were part of their birth experience, not that they lifted their baby out or anything, but they could hear, see, be part of the experience.

Speaker 1 15:31

So not even a clear drape, just no drape pulled up on the IV stands at all, just tapped up to their chest area.

Speaker 2 15:38

Yeah, yeah, which is so easy to do. So easy to do. And when I went back to the reason for why the drape was put up in the first place, it went right back to sort of wartime, when it was literally just to keep the place clean. You know, um, which with modern suction, there's no real need for that. There's no infection control benefit. All it does is separate a woman and a woman, um, so I got women to draw sketches for me and I drew some sketches of the operating room for that study, and one of the women drew themselves as being in a magician's box, being sawed in half. Oh, it was so poignant and I thought, yeah, that kind of characterizes it. So, yeah, that was a great study to do and some great things came out of it.

Speaker 1 16:27

Yeah have you put those drawings as an exhibition somewhere or displayed them?

Speaker 2 16:34

no, they're in the thesis. I've still got the pencil drawing, so that one was on a napkin doesn't matter the medium, as long as it gets. Yeah, yeah, yeah, but they're in the thesis and they're in the papers that followed, so I know a lot of people still use them as teaching. In fact, I spoke to jenny fennick last week and she still uses those drawings in teaching. Uh, students, about cesarean section.

Speaker 1 16:58

That would be a really cool being like a little website also and of course, everything costs money to host, yeah, but to have some kind of digital representation because those pictures are so powerful, yeah, when you look at them. First, here's where what we asked women to do, and then here's their story and this is what they felt like and that brings in that art and science of midwifery which kind of? Can portray so much more, and also some hidden stuff you don't realize until you unpack it yeah, and it's, it's true.

Speaker 2 17:32

Like so, when an academic said to me, I use them because the picture says the thousand words, you know, it's that whole uh thing, isn't it? Um, I don't know, maybe I'll contact the midwifery history society or something and see if they want them yeah, oh that, or the acm history page they've got. Yeah, that's what I mean.

Speaker 1 17:49

Yeah, yeah, they're always looking for stuff and that's kind of a nice central place to put it. Yeah, I'm a big believer in sharing those resources because it's our history, it's our past and if the students of the current future look back at what we've done, it's not reinventing the wheel, but it's showing that there is more than one way to do things as well.

Speaker 2 18:10

Yeah, and this is how it was, yeah.

Speaker 1 18:13

You almost had kind of like a creative component to your PhD. Yes, yeah, and the examiners were appreciative, I think that there was a bit of breaking up of the text. Read, read, read. Oh, something different, yeah yeah, yeah, so that was really nice yeah, okay, so apart from the drawings, or it may still link to that, it's been a while since you've had your head in that space. What's one thing that kind of really surprised you about your PhD in the data and what you found. That still kind of resonates strongly with you now.

Speaker 2 18:50

Look, I just remember, because I interviewed women as soon, well as soon as I could, after they'd found out they were going to have to sort of switch. So the first thing is that almost everybody fully expected they would have a vaginal birth. Never entered their head that they would be one of the 30, even though% of women have a cesarean and WA or did at that point Yep, and so that that they wish that they weren't more ready, that that could be them, if you see what I mean. So I just love that, that, that that optimist kind of assumption. And but the challenge with that was I guess that you know there was a little bit.

Speaker 2 19:34

I won't it's not trauma, but it was the sadness and the grief and the loss, and I was used to grief and loss from my previous work and that surprised me. In the course of having a fairly normal pregnancy, giving birth to a baby that wasn't going to be particularly unwell, that we knew of, there was still grief and loss in the childbearing journey, and it wasn't related to death, you know. So it's a really interesting. Yeah, yeah.

Speaker 1 20:00

Because so often we think about grief and loss purely because it is death. But it's that loss of potential, loss of experience, loss of what I was, yeah, that grief is so much more encompassing.

Speaker 2 20:15

And I think putting that to women and saying, look, these feelings that you're telling me about, you know also happen for people that have had a loss and that's how they were characterising it. Yeah, I feel like I've lost something. I had an imagined kind of expectation for how this was going to go and all the rites and rituals that go with that going to a class, doing the tour, making the dash at midnight to the hospital, because I've been, like, you know, all gone.

Speaker 1 20:42

You know so they would get the baby and of course, that's the most important thing, but there's all that stuff that comes with it and I think that was the most poignant sort of thing that stays with me, you know because it is a very sterile thing of walking in, checking in, getting your wristband, getting a cannula in kind of moving across, kind of getting your spinal, and then it's just in theater when everyone lights and it's a weird, absolutely weird. So having the tour and knowing that you're going to have multiple people here and they're going to be standing here and as a partner you're going to be sitting here and, yeah, the partner's putting their head around the curtain and around the drape and they're kind of like, so they've got their partner's head there, they're holding their hand, but around there they're watching them being cut open.

Speaker 2 21:31

Yeah.

Speaker 1 21:33

In any other world, you would kind of go. That's just not right. No, but it's like oh, it's like, because that drapes there, you can separate.

Speaker 2 21:43

Yeah, and the cot, of course, the baby cot. Even though the baby cot's on wheels and there are plug sockets all around the room, the baby cot's at the foot end of the woman usually.

Speaker 1 21:54

I can't see.

Speaker 2 21:54

So that was something else that you know. We asked them to bring the cot up to the woman so that the baby could be, because when I interviewed them, I also interviewed them postnatal about six weeks I think. And it was interesting because when I interviewed the women, they would say oh, it feels like I lost a whole chunk. There's a whole chunk of time that I don't know what happened. It was minutes, minutes, and then the staff that I interviewed went. Well, it's only a minute.

Speaker 2 22:26

Everything that's important to you is not important to you. You know it's a different kind of valuing and you are in a very different time warp.

Speaker 2 22:35

Yeah, exactly, and I get it. I've been both sides, you know, so I do understand that. But understanding the meaning and the implication of that and it's when I first got interested in post-traumatic stress or birth-related stress is when you know those women more than a few said I've had a real problem getting connected to the baby because I've still got what happened there going round and round in my mind. And then, you know, I went back to the work that Cheryl Beck did around post-traumatic stress and that sort of replaying the story, trying to make sense of it, it and it all sort of dropped into place for me then, yeah, and the importance critical importance of having a person there actually, yeah, almost like narrating what's happening so they've got that linkage.

Speaker 1 23:27

Yeah, if you have silence, you fill the gap in with the worst-case scenario.

Speaker 2 23:32

Oh yeah, and waiting for the baby to take its first cry because you can't see what's happening, all of that stuff, yeah, so I suppose it really reiterated for me the importance of moments and how long moments are when exactly that you don't know what's going on or you can't help. Yeah.

Speaker 1 23:52

Yeah, we don't kind of think about that. That was a bit of a long answer sorry, there's nothing wrong, there's no such thing as anything. Um, it's interesting where you go, because it's interesting what you remember when you're thinking about it. And you haven't thought about it for a while, because it is that deep, meaningful stuff that kind of comes out that sticks with you yeah it, it changed me.

Navigating the PhD Journey With Supervisors

Speaker 2 24:14

It definitely changed me how I think. Just in that it was a new appreciation, because I think when you're a midwife clinically, you know you develop that experience and that insight into being clinically competent and confident. But I don't know that I'd ever really stopped and appreciated different birth experiences than the one birth experience I personally have had. So you know, when really do we get chance to talk to women at length like that now and hopping on the bed in the middle of the night as part of that study and just, you know, chatting when women were ready. It was just such a privilege.

Speaker 1 24:55

But I learned so much about print practicing clinically as well, yeah, yeah and that is that we learn with every conversation and every woman to kind of keep a change. How did you go? I mean, you got jenny kind of had the funding, had the data said, had the insight and the foresight to go. This is a PhD, yeah, how did you go about getting your other supervisors?

Speaker 2 25:18

Oh well, that was easy because in WA at that time there were two midwives with a PhD and I needed two supervisors, so I got what was available. Yeah, so it was the beautiful Jenny Fennec and the gorgeous Yvonne Houck, who's now retired, but what an A-team. I did not, I didn't know anything about doing a PhD, I just bimbled along and after I finished I realized how lucky I was with those supervisors because, oh my goodness, they were exactly what anyone needs, you know, good, good cop, bad cop, when they needed to be so nurturing, really trusted my insights and respectfully treated me as part of the team. You know, it was just everything it should be, yeah.

Speaker 1 26:09

So what have you taken from them now? Because you've got quite a few students and completions under you now for the next generation what have you taken from your experience as a student, then, to give to your students?

Speaker 2 26:23

All of it really, I think, you know, wanting to be in the relationship is the first thing and we all have our off days where we feel like we're overwhelmed and that can let go a little bit. But I really try hard to all of that engender that kind of sense that we are a team. It's not, I know, you do sort of thing, trusting the student for sure, and that can mean that we have a longer than perhaps we anticipated candidature period because they're just settling on their thing and their methodology and they have to do the work they have to do. But you know what, over the years it all kind of works out that it takes the same amount of time, however long you take to settle on your thing, because the the clearer you are about it, the quicker you zip down the other side. Really, absolutely, because the blueprint's so nutted out, you know, whereas I think you know there's no point rushing it really.

Speaker 2 27:27

So I think it's that it's just not panicking because there's a milestone coming up or whatever. We'll just apply for an extension. It's absolutely fine, I know you can finish. It's great, you know. I think also it's 99, well, for me it's been 99% working with women who generally have got other commitments family work or whatever so it's being very accommodating and flexible around that, which was the case for me. I had a nine-year-old when I did a phd, nine till 13.

Speaker 1 27:59

did you do yours full-time or part-time?

Speaker 2 28:03

I look, I did it part-time um, but I did manage to do. Yeah. I was working part-time um and I had a stay-at-home partner, so my son's dad stayed at home. So it was tight in some ways, but it was so good in others, you know, because the support person was really supportive in a practical, practical way and I structured my study so that I worked at kind of 5am till 7am, 8pm till 11pm and all day Saturday, and that's just what we did for four years, just about yeah, um. So yeah, I think that you know, working with students to help them make a workable study plan, that means they're going to stay and sometimes that might mean that I have to step in. It's like a dance, isn't it? Sometimes I have to lead, sometimes I have to follow, sometimes I have to be at the side, you know. So I think it's just yeah, trusting the process, really loving the people and the projects that I work with and, um, not a lot kind, there's not a lot more to it, really yeah.

Speaker 1 29:17

So, with the getting up early in the morning and then kind of working in the evening, it allowed you to have your family time and work time. Yeah, how did you keep your sanity, though? Because there are times when you just feel like rocking in the corner. There's times when you feel like that. I just cannot understand this. What were your things, that you were doing to keep your sanity during that time?

Speaker 2 29:43

yeah, what was the things I was doing? I think, look, I think because, as I say, like Tom was four when I started my master's, nearly six when I finished it, nine when I started my PhD, 13 when I finished it. So I had a lot going on as a mum, you know, as a school mum, quite involved with school stuff, and you know, I suppose the cost to me was good night's sleep so.

Speaker 2 30:09

I did sleep, obviously, but I think there is that thing sort of underlying a lot of us that do this, where you've got something to prove to yourself and you're going to do it, so that's what keeps you going. But also you've got a little child who's, you know, depending on you, so I did carve time out with him. So Saturday was gone but Sunday was all for family, definitely took holidays, actual proper holidays, at least a week at a time. I think that's so important. It's from everything. And you know, clinical work still fed my soul, so that you know, like a lot of midwives, work-life balance is actually work-life blend, you know. So that was very nurturing for me, the community was very nurturing, but no formula really just getting through it.

Speaker 1 31:03

There is no formula. I don't think that's possible.

Speaker 2 31:06

And if I don't do it today because MasterChef's on or whatever, well, that's another day on me. It's like labour, isn't it? If you don't do this contraction, there's another one on the. It's like labor, isn't it? If you don't do this contraction, there's another one on the other end.

Speaker 1 31:17

You know, yeah, and sometimes I show you need to have that time where your brain goes on cruise control and you're watching something else. It's busy percolating and making some of those connections yeah, are the ones that usually get you up at three o'clock in the morning, or in the shower. It's like oh, what about this?

Speaker 2 31:36

yeah, yeah, absolutely yeah. So, yeah, some of the most left field conversations and suddenly the penny would drop, and actually a couple of those were when I was refereeing basketball or you know, on the soccer field or whatever, for the, for the kids, and yeah, because you're not, as you said, actively trying to nut it out, it just comes to you and it's the muse, isn't it? And I talk to my students a lot about the muse. Uh, don't worry, if you're not feeling it, just let it come back to you and don't sweat it. That's my lesson.

Speaker 1 32:08

Yeah, I think it's important that we also remember that academia and this is going to sound bad is such an artificial environment.

Speaker 1 32:16

We have so much pressure on ourselves to do the PhD. We're globally like 1% of people have PhDs. It is the abnormal thing to do. But at university is the expected entry level. So there's all of this pressure and you'll be taken seriously once you've done your phd and and you just sit there and kind of go, I need to talk to normal people.

Speaker 1 32:39

Yes, remember how to talk to normal people in words that don't have five syllables, because that's when you start and they kind of you have it. You've got to be able to describe it to them interestingly, and I've just listened to an ethics workshop where our chair, ethics chair said well, here's your ethics committee. But what I want you to think about is I want you to take I want you to think about taking your grant and your ethics application down to McDonald's and great people down there. If they can understand it, then you've written it well, yeah, great, yeah, and I thought it's such a beautiful way of writing, of putting it. And having those conversations with other people means you do lose all the kind of the terminology and the officialness and you can actually tell them that well. So why is this important?

Speaker 2 33:26

yes, it's going to change so yeah, yeah other events and activities are critically important and certainly in the last 10 or 15 years, what research communication is has changed radically from when I first started. So you know I was blessed to have Jenny and Yvonne saying to me we don't need the fancy pants words. This is not an exclusive club, you know. This should be about making a change, so visionary. And now, of course, it's all about right for the 12 year old, right for your family. That's never been to a university, you know. So I had another piece of advice that I give students is just keep it simple. Yeah, absolutely, mcdonald's.

Speaker 1 34:08

What a great idea I cracked up like laughing, I just kind of went. I actually used it on a student master's student this afternoon when we were going through her ethics changes and I was like, oh right, yeah, that's really cool, I got that now, yeah, so what did you do to celebrate?

Speaker 2 34:24

Oh well, I handed my PhD. I was determined to get it in before my 40th birthday and I got it in five days before. So I had a little birthday coming up and I didn't do anything particular. I did go out for dinner with the supervisors and a few other people because at that point I was the next only midwife, apart from the two supervisors, to have a PhD in the state. So that was really lovely. It was great. I mean that, so next generation and now of course there are lots more and it's fantastic.

Speaker 2 34:59

But it was something not for me because it was me, but because it was the thing like we just there was a lot of celebration of that and that was so beautiful. But because I had a birthday coming up, I was gifted by my family SLR camera and so that was a every time. So the first thing was I celebrated never doing nights again because I was going to a postdoctoral fellowship in the UK, which I'll tell you about in a minute. But the second thing was every morning and evening when I used to ride, I would go out and take photos. Oh, a golden hour.

Speaker 1 35:33

Yeah.

Speaker 2 35:35

Yeah, so it was great and I still do it. I've still got that camera, yeah.

Speaker 1 35:41

See once again the creative side comes out.

Speaker 2 35:43

Yes, yeah, you've got to do it. Look for the beauty.

Speaker 1 35:46

Yeah, it's great out. Yes, yeah, you gotta do it.

Speaker 2 35:49

Look for the beauty, oh absolutely yeah.

Speaker 1 35:50

So then let's go to the postdoctoral then. So what happens?

Speaker 2 35:55

uh. So my son turned out to be a fairly talented soccer player, so he was invited to go over to the uk and join a bit of a program for developing soccer players. So I wanted to give him that opportunity, but it would depend on me being able to find a job anywhere. I landed this beaut of a job, which was a postdoctoral fellow at a university in the UK but working with the National Institute for Health Research as an implementation science fellow, oh nice. So it meant that I worked on existing programs of work but developed implementation methodologies. For the results it was the best thing. So we all went as a family, two years in the uk and, um, all that learning has like.

Implementing Change in Midwifery Practice

Speaker 2 36:47

I did work hard but I got so much more out of it that I still use now, because at that point it was other disciplines that were using that stuff and I wanted it for midwifery, because how long has it been languishing that we know continuity of care works. Water birth works any of it, yeah.

Speaker 2 37:07

So I thought well, well, if there's anything I can do to contribute to moving that on, I would like to do that. And look, yeah, it led me to doing a lot of action research now, where we develop and test a thing and then we implement it and test its implementability at the same time. So it was such a great decision. Yeah, yeah, he didn't get a soccer career, but that's fine, because he's a mental health nurse now.

Speaker 1 37:39

Okay, that was going to be my question, and we're going to see him play for the Socceroos.

Speaker 2 37:42

No, no. It got to the point where you had to forego your social life and your diet and he was like no.

Speaker 1 37:50

Fair enough. It's a big sacrifice at that level. Absolutely. That still takes a while to get the financial rewards.

Speaker 2 37:57

Yes, indeed, to go through.

Speaker 1 37:59

Yeah, so with implementation, because it is the future in getting change across. We know that there are some studies that kind of come out that seeming to change overnight the practice that we do, it just seems to take just no time at all.

Speaker 1 38:15

But, as you're saying, continuity of care. We've known for decades that it has been an advantage for so many reasons. Um, and even kind of like it's almost coming up to 10 years since the Lancet series and we had research in that that was kind of 10-15 years before then going through. So what are the, what are the barriers then to changing? I know this is a question that's a PhD worth a thousand years yeah what are some of the biggest barriers that you're finding, because I know it's multiple levels?

Speaker 2 38:50

yeah, so one of the first pieces of work when I came back to australia so uh was a study where I um canvassed midwives across australia to find out if they'd been trying to implement something as a practice change or evidence-based practice improvement in their workplace. What was their experience? And some of the things we got back were pretty predictable. So you know, no money, no space if they wanted to do another clinic or something like that. But it started me along the path of looking at things in terms of spheres of influence. So there's the personal, the person that's resistant.

Speaker 2 39:36

There's always a change, resistant person or people oh yeah uh, and then out to the managerial level in a health service. Then you've got the sort of wider organizational or statewide policy and then you've got global influences sort of thing. So there's a lot goes on at those levels and the biggest surprise not really, but it shouldn't have been a surprise, but it kind of was to see it so starkly laid out was the biggest challenge to midwives is other generations of midwives oh yeah so going both older and younger.

Speaker 2 40:16

Yeah, resistance to change yeah, usually either her peers or those coming in or those who are. You know, it was generations, so it was five years above, five years below, something. Um, yeah, just very obvious that, um, there's the we've always done it this way. What's wrong with that? Yep, there's also the sort of you know I can't think what it's called now, I should know, but it's pretty well sort of you know, you're frozen in the thing that you're doing. It's too uncomfortable to change because that's going to cost you some time, effort, maybe some embarrassment because you don't know. You know all of those things, but the biggest thing was was is it going to make my life easier? Yes, great, no, I'm not doing it. Yeah, so, and not that there's anything wrong with that. It's about people having time to accommodate the energy that goes into doing something differently.

Speaker 1 41:25

And we are humans.

Speaker 2 41:26

Yeah, we're humans and you know why are you going to make life difficult for yourself. So there's quite a few checklists now in general health circles for what we're calling context analysis, so analysing in the practice, environment, at those levels, those spheres of influence, what's going to stop your thing being taken up and sustained if you want to put it in, and that is going to save midwives a whole world of pain and energy and time and disappointment. Because if you do that pretty early on, when you're thinking about introducing something new and there is a million doors that are shut to you, work on opening those doors before you try and put the thing in.

Speaker 1 42:10

you know it's almost like a spot analysis exactly, just a more nuanced one where you're looking at your strength, your weaknesses, your opportunities, but the first thing you do is you attack your threats exactly, yeah, yeah.

Speaker 2 42:26

But and also also what's surprising for some people is we also ask them to look for drivers like you might find a hidden ally, but you don't know that you've got an ally. That's a very big influencer. So do the analysis first, and that's the pre number one step zero in any action study. So, um, the the tools that are out there are really fabulous. Um, but they're not really specific to the midwifery practice environment. So I've got a phd student now developed actually, she's developed it uh, that's a context assessment tool for midwifery practice settings.

Speaker 1 43:03

Fabulous, yeah, that's on its way yeah, so when is that going to be released into the wild?

Speaker 2 43:09

She has presented on it, she's published one paper. She's just testing its effectiveness at the moment in Australia and a couple of other countries and then it will be out probably. You know however long it takes, yeah end of the year.

Speaker 1 43:26

Probably those guidelines helps people who see something that they want to change. Yeah, I'm not sure how to go about it. Yeah, but if they have something, it's like oh, here's a step-by-step process, let's kind of use this and that's going well. This has been tested by other people, so we know it works yeah, yeah yeah, finding those change champions, those people that have got the energy and the vision that want to be innovative. Um gives them a set-by-set process, which I think is going to be fabulous yeah, hopefully.

Speaker 2 44:03

Yeah, so that tool is just the tool to assess the sort of environment and tick off yes, this is. You know, they can sort of add a score up and say, yeah, broadly, this is an environment that's ready to implement a change. If not, there's one or two things or there's 10 things, have I got the time? Energy and resources yes, no, all right, let's shelve it sort of thing. Sources yes, no, all right, let's shelve it sort of thing.

Speaker 2 44:30

And I've got another phd student who finished actually, she's post-doc now. She finished about 18 months ago and she did develop that toolkit that you've just talked about where there's a go to woe. So it's the e-mid kit. And we've just finished the feasibility study. The ACM helped us with that and they hosted it on an ACM sort of URL, you know, so that midwives in the study could go in and access the toolkit, try it with a change that they were trying to implement and now they're giving us the feedback on what needs to change about the tool or the toolkit and then that will be out in the world. Yeah.

Speaker 1 45:11

So do you think that's something that undergraduate students I'm thinking third-year students would be good to be introduced to?

Speaker 2 45:19

Yes, yeah, absolutely yeah, because we teach them research, so they have research content in their course, but they don't have evidence implementation. Really that's not in our code of you know practice. So that's where my sort of passion lies really is getting them to be ready to, because the other thing we know is the more ownership midwives feel of their practice and practice environment, the more likely they are to stay, and at the minute we're barely keeping graduates past their first year. So we need to give them something that empowers them and that's as good a thing as any.

Speaker 1 46:00

And if we want to live up to standards both nationally and internationally about doing evidence-based practice and evidence-based care, we need to know how to implement it.

Speaker 2 46:13

Yes, exactly, yeah.

Speaker 1 46:15

So it's kind of it makes sense that you need to have that implementation knowledge.

Speaker 2 46:21

Yeah, and every service has got their quality improvement. Yeah, you know pretty well everybody knows to do the plan, do study, act thing. You know that works, it really works. But what is in the plan, what is in the doing, what is in the studying? So the e-mid kit tells everybody that, gives them a toolkit really to do that.

Speaker 1 46:42

Yeah, it's just a complementary thing to what everybody's doing so well yeah, and see that excites me because it's something that is can be easy. People like structure, yeah, especially when they're learning something, yeah, and so if you have something that's easy to remember or gives you the rationales. One of the things that I loved was I think it was a children's, royal Royal Children's in Melbourne they put all of their procedures online and so it was free access procedures, but what they had is they then linked it to the rationales that are down the bottom of the page so anyone could access this. It was free access, but you could go in and go well, here's why we clean and then they'd kind of link right down to the rationale. Rationale this is why we clean, so people could understand why each step was each step, and they're brilliant for understanding and learning yeah, fantastic.

Speaker 2 47:36

Yeah, so this is. I mean she designed it, co-designed it with midwives. You know, it's been through all of that sort of phase level, uh, theoretical design and now we're just sort of phase-level theoretical design and now we're just sort of trying it in the real world and hopefully not too much needs to change. But that will be out as a Creative Commons. You know that's an example. Those things will be out for anybody to use. We'll do the publications, but still the things themselves will go out to free. You know, use yeah.

Speaker 1 48:06

Because that's when we talk about the global impact of the research that we have is what works well in a well-resourced country, and this is why, when you look at the icm guidelines and their essential competencies, they're written in a way that can be addressed by any country. Yeah, that's kind of like the minimum standards, but it's all. You can't do this, you can't do that, but what can we do what? And it goes back to principles based yes, yeah, yeah, yeah, yeah.

Speaker 2 48:36

So we're excited to test it. So this will, this will be in um you know well, oecd countries really, so we are excited to test it in very low income resource countries. I think anecdotally it's gonna fly. But we, but we just need to test it, yeah still it's a start.

Speaker 1 48:57

What else are you involved in?

Speaker 2 49:00

Well, I'm very fortunate to be in a full-time research role and I know there are not many of those in midwifery, so I count my blessings every day. I can't believe my luck, really. So I have a programme of work that I'm working on together with a beautiful postdoc fellow in midwifery, kate Buchanan, and we have a broad focus, I suppose, on optimizing the practice environment for midwives so that they will stay. So it's anything to do with making midwives jobs, satisfying, doable with all the other commitments they've got, uh, safe, and when I say safe, I mean psychologically and emotionally, yeah, and spiritually, um, fulfilling all of those things.

Speaker 2 49:48

Because we want, we spend a lot on educating midwives. They invest a lot in hands, heart and head. Absolutely we want them to stay. So it's broadly based on that. There's a side sort of theme that relates to it, which is around safe, quality midwifery care and I deliberately call it midwifery, not maternity care, because it is about midwifery work, midwifery interventions, midwifery doing, complemented by and with the interdisciplinary team, of course. But I think what we need is evidence to say things in midwifery work because we don't want to get usurped by other professions, you know.

Speaker 2 50:28

So we have to sort of make it evident for why we're different and special, I suppose.

Speaker 1 50:33

yeah, which we do, I suppose yeah, yeah, which we do, but we need to. It's getting other people to listen. Yes, yeah yeah, because we're soft, but it's the other power brokers.

Future of Midwifery in Australia

Speaker 2 50:48

Yes, yeah, yeah, yeah. And look, we did a few sort of pro projects there Di Bloxham, who I know you've met as well, and I have done a few projects around midwives in midwifery in terms of leadership. And you know, we did a fun little project looking at midwifery job adverts in Australia and so many midwives have to report to nurses. I am a nurse, I'm not bagging nurses but I don't think midwives generally think nurses understand midwifery. So there's another thing that we probably need to have a conversation about that at different levels, because ideally, midwives would manage and lead midwives, but we also need nurses to say no, I won't take a midwifery leadership job. That midwife should do that. You know we need allies, so that's a work in progress, I think, but calling these things out is part of it.

Speaker 1 51:47

Yeah, and we are still waiting on tender hooks for the announcement of the Queensland.

Speaker 2 51:54

Yes.

Speaker 1 51:55

Chief midwife as well, which is an exciting step forward. Yeah, I keep telling my students my third years now that the changes that they're going to see in midwifery in Australia in the next five to ten years are going to be astronomical if we keep moving the way that we want to move.

Speaker 2 52:11

Yeah.

Speaker 1 52:12

And we can achieve the things we want to achieve. But it's going to take change champions, it's going to take people standing up and calling out and a lot of what has happened in the past doesn't get shown and doesn't get kind of talked about into the fighting because it's like they keep forgetting that midwifery is political on the personal level for the woman, is political on the personal level for the woman, but also on the state and the and the kind of the national and the international level as well absolutely yeah, and exactly as you said, like they are going to see exponential change.

Speaker 2 52:47

But I also feel like I've seen exponential change since I started, like I could not have imagined when I graduated seeing midwives in private practice having visiting rights at hospitals. That is phenomenal to me. It makes me cry every time I think about it. You know because, wow, you know, and I'm not thinking it's perfect yet, but it is happening. You know, continuity of care is happening. Women can have a water birth at some places. I couldn't have them at any places when I started. You know continuity of care is happening. Women can have a water birth at some places. I couldn't have them at any places when I started, you know.

Speaker 1 53:18

So, um, yeah, it's, it's getting there we're such a young profession, when we're looking at the body of research that we have produced yeah like the people and the midwives who became our first midwives with PhDs, like the majority of them, are still alive and still engaged in research and have retired. Well, they say they've retired, but they haven't retired. And it doesn't matter what country they come from. They're kind of yeah, I retired and then COVID happened and now I'm on this professor. Panel that's all over the world and we're still talking like four years later. Panel that's all over the world and we're still talking like four years later. But that shows you the fact that we are so new in the research body that we're still looking at 19. So we got 50 years of research. Yeah, it's really new. But we've still got multiple generations. Like you were the third the bronze medal in Australia and now you've got a whole generation below you. Yeah, have you got any? Do you know if you've got any second generations yet?

Speaker 1 54:21

yeah, we have yeah yeah, so yeah, your students who've become supervisors, who have now got their own students who've got their own.

Speaker 2 54:29

so that's that within a decade and a half, yeah, capacity building at its finest, and I think that's where we've had to focus. And you know, it's not just capacity building, getting people to get their PhD, it's keeping them in and developing their skills to lead their own program of work, because there's enough for all of us, for sure, you know. So that's the other key thing, I think, is keeping them in in that world.

Speaker 1 54:57

When you know less than one percent of midwives getting an h and mrc grant, you know all of that stuff it's hard, it's hard and that's where the argument and the discussion is that we need whatever you want to call them academic clinicians, clinicians yeah, we need definitive roles, and even with a paper that kind of came out, I think, 2015, that looked at 11 countries and it was looking at the prof doc, it was looking at the PhD, it was looking at the DNP and we've now got the DNP, so the Doctor of Midwifery Practice. Starting up, there was all of this confusion over what this advanced role could actually do and where they could do it, and so until that has been settled that terminal qualification, I've got this level. It doesn't matter what cap I've got. I've reached my qualification level. What can we do, where can we do it and how do you find a place and actually use it?

Speaker 2 55:54

that's going to be a big discussion, I think, in the next five to ten years as well, because otherwise we will lose people who will just, yeah, and I, you know, I finished my phd and I, you know, for me I had already sort of got a thing in my back of my mind that I was going to go overseas. But if I hadn't, jenny went then to new south South Wales, uh, and Yvonne went to a different university and I don't know where I would have got that mentorship, you know. So it is really important that they were brilliant at sort of setting me up to get started, um, but then had other priorities, of course. Uh, I did work with Yvonne for a little while, but there's only so much Yvonne to go around, you know. So it's that kind of, you know, building the capacity to build the mentorship capacity as well as anything else.

Speaker 2 56:45

And actually we've just in WA, established a West Australian midwifery research network for that reason. So that's got generations, and at each sort of the big hospitals we've got internship programs going. That's fabulous. Yeah, midwives doing RA work for us just to learn on the job. You know it is crucial, yeah, yeah.

Speaker 1 57:09

That exposure, that early exposure, yeah, yeah, that positive early exposure, exactly, exactly, exactly yeah, so critical, because so many students kind of go, when you joke about doing honours or kind of they do a research topic, go, oh, you can explore that more in honours or postgrad. They're going I'm not doing that. That's the point in doing that. It's that changing that mindset to go. You don't have to do it straight away, but it is a pathway that you can do. That's not going to take away from your clinical, it's actually going to enhance and, especially, as you said, that the impact for you was it actually changed your practice exactly, yeah, it makes you a better clinician.

Importance of Midwifery Unit Chairs

Speaker 2 57:46

I really believe that and you know, interestingly. So I started the job I'm in in july last year and it came with an honorary research fellow at one of the bigger hospitals in WA and I started this little internship program just for a couple of midwives at a time anyone interested you know and within a couple of months of the first two starting, they were looking critically at policies and guidelines, trying to find out where they can get involved. Because why is that referenced with another guideline? You know all of that like starting to think differently, practice differently, and the benefits are innumerable. Like you can't measure that stuff. So, um, I really trust it. Yeah, I really trust the process.

Speaker 1 58:31

Yep now we just need it to roll out in every state and territory, Get the ACM to kind of do some stuff as well. I mean, there's so many things that we can do.

Speaker 2 58:40

We've just got to work out how to get there and just do it slowly step at a time, and situating people like me in a labour and birth suite is such a brilliant way to do it, because people can just wander past. You get wind of what's going on and what might be something that you could help midwives influence. You know, absolutely priceless. It's brilliant, annette briley here.

Speaker 1 59:02

Um at flinders she's got a half-time position at lyle mckeown and northern at harriet. So same thing she's there and she's talking to them all and getting them involved and getting them involved in her projects, but finding out what they want to do as well, and getting them involved when she's doing stuff. So absolutely we should have those chairs. They've had them in medicine for decades yeah, had them in nursing for kind of quite a long time.

Speaker 2 59:24

We definitely need them in midwifery across the board yeah, yeah, there's a few, there's quite a few in victoria that's where I've just come from so the latrobe crew. So so Della Forster and Helen McClough are doing it, chris East is doing it out at Mercy, linda's doing it, linda Sweet brilliant Zoe's doing it, actually in WA as well. So we're getting there. It's just about modelling it and demonstrating the benefits across the board, I think.

Speaker 1 59:51

And again that retention, retention.

Speaker 2 59:54

You know it becomes a magnet hospital if you put sorts of things like that in place.

Speaker 1 59:58

That's all you need to do, yeah make people happy yeah yeah, thank you so much for your time tonight great pleasure, thank you.