The struggle for contested boundaries in the move to collaborative care teams in Australian maternity care

Abstract

Background

the maternity services reforms announced by the Australian government herald a process of major change. The primary maternity care reforms requires maternity care professionals to work collaboratively as equals in contrast to the current system which is characterised by unequal relationships.

Aim

critical discourse analysis (CDA) using neoliberalism as an interpretive lens was employed to determine the positions of the respective maternity care professionals on the proposed reform and what purpose was served by their representations to the national review of maternity services.

Method

a CDA framework informed by Fairclough, linking textual and sociological analysis in a way that foregrounds issues of power and resistance, was undertaken. Data were collected from selected written submissions to the 2008 national review of maternity services representing the position of midwifery, obstetrics, general practitioners including rural doctors and maternity service managers.

Findings

maternity care professionals yielded several discourses that were specific to the discipline with a number that were shared across disciplines. The rise in consumerism has changed historical positions of influence in maternity services policy. The once powerful obstetric position in determining the direction of policy has come under siege, isolated in the presence of a powerful alliance involving consumers, midwives, sympathetic maternity service managers and some medical professions. The midwifery voice has been heard, a historical first, supported by its presence as a member of the alliance.

Conclusion

the struggle for contested boundaries is entering a new phase as maternity care professionals struggle with different perceptions of what multidisciplinary collaboration means in the delivery of primary maternity care.

Introduction

Maternity services in Australia are in the process of a major programme of reform in response to findings of three consecutive reviews of maternity services and a number of inquiries undertaken by state and territory governments (New South Wales, 2000, Brown et al., 2002, Victorian Government, 2004, Brown et al., 2005, Queensland Government, 2005, Northern Territory, 2007, South Australian Government, 2007, Tasmanian Government, 2007, West Australian Government, 2007). In contrast to the current system characterised by unequal relationships between maternity care professions the proposed reforms require obstetricians, GPs, rural doctors and midwives work as professional equals with different and complementary skills and knowledge (Lane, 2006). Primary maternity services offer women continuity of primary carer with a midwife or general practitioner with procedural obstetric qualifications (GPO) in a collaborative relationship with an obstetric specialist when required (Commonwealth of Australia, 2008, Commonwealth of Australia, 2009). Multidisciplinary collaborative care teams are expected to shift the focus of service from the interests of the service to those of the consumer (Lane, 2006), thus achieving a women centred approach and in doing so create a shift in existing professional boundaries.

Shifting professional boundaries are a necessary feature in achieving complimentary domains of practice where healthy pregnant women, formerly included into obstetric load in an expensive secondary or tertiary hospital environment, are redefined under collaborative strategies to non-obstetric based GPO/midwifery-led services (Lane, 2006). Whereas contemporary health policy initiatives increasingly promote multidisciplinary teamwork and collaboration the difficulty involved in achieving this ideal is glossed over (Reiger and Lane, 2009). The introduction of genuinely collaborative multidisciplinary maternity care teams requires resources and management of professionals who have been locked in conflict over contested professional boundaries for decades (MacColl, 2009, Reiger and Lane, 2009). A further source of contention relates to conflicting interpretations of ‘risk’ and the veto power of decision making retained by obstetricians on the understanding that it is they who will be held professionally accountable for adverse outcomes should they arise (Lane, 2006). This situation remains unchanged in the collaborative multidisciplinary team structure of the proposed reforms and is an ongoing source of contention. In this context it is of interest to examine discourses associated with each professional discipline included in the collaborative primary maternity care team in the struggle for contested professional boundaries.