 Gemma Macmillan. Gemma is actually Scottish of origin. She qualified as a midwife in 2008 from the University of the West of Scotland and then worked as a registered midwife in Scotland and Ireland before moving to Australia in 2012. She lives in Townsville that's in North Queensland with her husband and three young children. She's a clinical midwife and project officer for the Townsville Hospital Health Services and currently the project lead for the Ingham birth project. Her passion is to advocate for women in all women's health matters and to educate on the benefits of continuity and caseload models of care within mid in mid and midwifery and so now I am going to turn it over to Gemma Macmillan and we'll be very interested in hearing her talk about the return to role. Thank you very much Catherine. Can you hear me okay? Excellent. Hello everyone. I'm glad that you can hear me. If the volume is too loud or too low please just let me know. Someone has wonderful and I can adjust that. Is that a little better? Excellent okay. So as Catherine said my name is Gemma Macmillan. I am coming to you from Australia but yes this is a very Scottish accent. I'd just like to firstly welcome you all to today's conference and a very happy International Day of the Midwife to each and every one of you. I'd like to thank you for logging on today to hear about our project. As a team we feel very honored that so many of our beautiful colleagues from around the world have taken an interest and I look forward to sharing what's going on in our little corner of the globe with you. Please don't be afraid to tell me if I'm speaking too fast or if you need me to sort of calm my accent down a little bit. It does tend to get away from me from time to time. So I am a clinical midwife and temporarily I'm a project officer at the Townsville Hospital Health Service here in North Queensland. The Townsville Hospital Health Service is made up of 18 hospitals of which the Ingham Hospital is one. There's also some community health campuses and two residential aged care facilities. The Townsville Hospital Health Service covers an area roughly two and a half times the size of France just to give you a bit of an idea and it has around 5,000 employees. So I joined this amazing project in October last year and I'm really excited to tell you more about it but firstly I'd like to begin today by respectfully acknowledging the traditional custodians and first people of the land on which I stand. I'd like to pay my respect to the elders past and present and I would like to extend my respect to the Aboriginal people, colleagues, staff and students who are present at today's conference. I would also like to say at this point that I am a practicing midwife and not an academic by any means. This is really a storytelling presentation through which I'd like to tell you a little about the redevelopment of the maternity service at a rural hospital in North Queensland. In the spirit of today, International Midwives' Day, I'd mostly like to highlight the benefits to be gained from a local birthing service to the community with particular emphasis on the continuity of care model that is being implemented. Okay so what are we doing here? The Ingham Birth Project has been given the title although it encompasses many things of the redevelopment of the maternity services with the reintroduction of low risk birthing at Ingham Hospital. The project sponsor is the Rural Hospital Service Group within the Townsville Hospital Health Service. The project officer is myself. I'm Gemma McMillan as we've said and we are located in Ingham in glorious North Queensland Australia. The picture that you can see of the hospital at the top there is actually the new building. The hospital was rebuilt in 2009 and the beautiful picture below it is some of the artistic glasswork that sits at the entranceway to the hospital. I have obviously identified myself as the project officer but I would really like to emphasize that while I am I have the title of project officer I'm really only a bit of a facilitator to pull everyone together. There are lots of little mini project officers involved in this process and without them none of it would really be happening. Okay so I wanted to tell you a little bit about the beautiful community that we have here. Ingham is a really picturesque beautiful Riverside town. It's about 110 kilometers northwest of Townsville from where I am today. It's one of the oldest postcodes in Queensland set on a coastal plain and it's enclosed by some quite dramatic steep ranges either side. And the township was surveyed in approximately 1878 and around about that time there were some mills and plantations in the area. The Queensland government recruited Northern Italian settlers to fix the problem of lack of labour with the cane farming in the area in the early 1890s and Ingham quickly became known as Australia's sugar bowl because of all the cane farming that goes on in the region. When our birthing service starts our projected births will probably be between 80 to 120 per year. The details from that projection come from perinatal data that was collected by the Townsville Hospital. We would love to have 80 births in our first year but we were just happy to start somewhere at this point. The town is a population of around 12,000 people. The birth history for the area is very patchy. The reason I say patchy is because it historically has always really depended on who was in the town at the time. And it's always been affected by who is coming and going. So sometimes there would be quite strong well thought out services running and at other times they would be quite scant and things would have to be kind of scaled down to whoever was available. The midwifery group practice in the area covers a very vast and varied landscape. It's approximately 97 kilometres long the area that the midwives cover. Across all of these terrains you can see in the photographs. It's a very beautiful job but very challenging at certain times of the year. To get to Ingram from Townsville is about an hour and 15 minutes by car which may not seem like long to travel but the road can be very dangerous particularly at night. It is affected at various times of the year with flood water and roaming wild animals which I'm sure you can imagine we get quite a lot of in Australia. I'm sure as you can see from the pictures it is very green and luscious most of the time with some beautifully dramatic scenery. So that is a little bit about our community. I will talk some more about timeline and birth history in the next few slides. Okay so how did we get to where we are? It's a million dollar question really. So I have created a bit of a timeline here for you but obviously today we want to keep the conference moving along so I didn't want to go back too far. So in pre 2005 the maternity services in the town were delivered by local GPs and there were some very skilled general practitioners in the town throughout the years often having more than one skill so some of the GPs may have advanced skills and aesthetics as well as advanced skills and obstetrics. So there could be sometimes quite a comprehensive service available. Obviously always working in conjunction with the midwives at the hospital. The model pre 2005 had huge issues with fatigue and accommodating leave and covering leave for any medical staff who may be leaving the area for a period of time. The rural workforce is notoriously difficult to recruit to and maintain which was very evident during this time as well and a big complaint was that there was a lack of work-life balance. There was a mix of midwives available at this time and all mostly dual trained registered nurses and registered midwives and who worked a kind of a traditional shift pattern model and so they would be on shift at the hospital when women presented. In 2005 sadly the majority of rural birthing services were closed and due to all of the issues highlighted previously and services closed almost overnight which left staff and the community devastated as you can imagine. From 2005 to 2013 quite a big period of time obviously and antenatal and postnatal services were available in Ingham to local women but these women had to relocate at 36 weeks gestation to birth in Townsville or if some women preferred to birth in Townsneed or other family then they could do so but most women relocated to Townsville. I don't think we can underestimate the implications of this relocation. Huge financial implications when you're paying for accommodation for potentially up to six weeks. These women are leaving their support systems behind family, friends and midwife that they've come to know and love and often having to leave other children behind while they attend school. These women often have to leave without their husbands as well because this is a farming community and there's some a lot of business owners and it's just not an option to take six weeks away to present to another facility to await the birth of your baby. This is a huge impact on the emotional well-being of these women and also an effect on the maternity care experience and outcome. So in 2013 to 2014 the Midwifery team in Ingham got some new members or some who were really old members who came back around full circle and at this time these midwives were obviously very mindful that the model in place wasn't meeting the needs of the community so they were supported by management to change from a traditional model of maternity care to a caseload model of care where midwives were on call and women had a named midwife for the whole pregnancy journey. This meant that there was no registered midwives on shift at the hospital so caseload midwives did present and currently do still present for all client assessments as well as any unexpected presentations to the emergency department. During 2013 to 2014 there was a huge push to reinstate rural birthing services and it was certainly something that the Ingham community said from the very start they would push to have returned and they luckily never gave up on it. A rural birth summit was held in Townsville in 2013 and at that summit the community of Ingham showed up on mass with their local GPs and midwives. The community came to look for answers and I was actually present at that summit having only been in Australia for a year and I remember vividly feeling quite moved by their united front. At this summit there was a united commitment to return rural birthing services and they just had to figure out the complete. Oh dear, we seem to have lost Gemma. There she is. Are you back? These are one of the joys of virtual conferencing. Oh good now Gemma. Hello. Oh good. Okay, where did I get up to? We're just starting to talk about you've been to the conference. Okay so 2013 there was a rural birth summit which happened in Townsville and I was present at that summit. I don't know if you heard me say that. I had only been in Australia for a year and I remember vividly feeling quite moved at the united front that was put on by the Ingham community and at that summit there was a commitment to return rural birthing services and they just really had to figure out the complete model. So the Ingham community have been unwavering in their determination to bring birthing services back to their town. They're very fortunate to have committed motivated midwives who are truly the community's biggest advocates. In 2014-2015 the rural hospital service group director wrote a brief for the Ingham birth project. This obviously involved a lot of collaboration with the community and with the staff at the health service. A proposed model was eventually agreed upon and funding was secured. It sounds very simple when you put it in a little box and 2015-2016 there was some further model planning. An implementation plan was drafted. A project officer was appointed. There has been a huge amount of recruitment continuing and ongoing quite deep engagement with the community and consumers and lots and lots and lots of training and the reason for that is that we have a goal to reinstate the birthing service at Ingham by the 1st of July 2016. We obviously realise as a team that we're in a very fortunate position that we come under the Townsville Hospital Health Service and all the wealth of support and knowledge that that brings to our project. As I said the rural hospital service group within the Townsville Hospital Health Service has worked really closely with the people and health service staff in all matters of this redevelopment. We're backed by a truly phenomenal midwifery and obstetric team within the Townsville Hospital. I should probably mention that the Townsville Hospital is our tertiary facility here in North Queensland and the management there have really been huge supporters of ours and establishing this service they constantly ask how can we help what do you need and I'm sure sometimes they wish they hadn't asked the question but they're always happy to provide support. So on to some nitty-gritty. Let's have a look at our chosen model of care. There's obviously a lot there and so it was probably easier just to write some pin points there. So this is what the Ingram Maternity Service Model looks like on paper anyway. It is very much a person-centered care approach with consumer engagement all the way. We really don't want women to travel if not necessary so we'll provide as much care as possible locally which will include an all risk antenatal and postnatal service but only low risk birthing will occur on site. Not included in this picture that you can see on the slide is that a few other features of the model are that we as a low risk birthing model that will include early postnatal discharge so a maximum of six hours for postnatal discharge and then women can go home. The other thing that the model includes is six weeks of postnatal care with the same midwife continued at home for that transition into motherhood and then some collaborative working with child health as that baby grows a little bit more. Another thing that's included in the service is the availability of water birth. It was certainly something that the community felt that was very important and we were obviously more than happy to support them with that. So that will be a feature that's obviously not up on that slide. A few unexpected things have happened. One of them being that the Women's Health Clinic which was pre-existing in the town has grown and has expanded as a result of the project. We have a nurse practitioner who travels to Ingham once a month and she was just sort of working on her own but with the recruitment of the six rural generalists who've come to support the model from a medical side she has been able to expand the services that she offers and we're really fortunate that the six rural generalists that we have, three of them have advanced skills in obstetrics and three have advanced skills in anesthetics which gives us the ability to run a 24-7 on-call theatre team. We really feel that the core of the model is continuity and we'll have a bit of a look at the reasons why shortly. The community have waited a really long time and campaigned hard and they deserve a service for the future so sustainability is right up there as one of our big priorities within this model. Okay so what does continuity of care provide? I'm not going to annoy you all with lots of them evidence that I'm sure you're already very familiar with. I just wanted to highlight a few key points. The first one being the massive Cochrane review which looked at 15 studies involving over 17,000 women at various levels of risk and this review found that continuity of care models were associated with various benefits all because women had a named midwife and had that relationship with them. Some particular highlights of the report that 24% of women are less likely to experience preterm birth and 19% are less likely to suffer miscarriage before 24 weeks if they receive continuity of care from the same midwife or a small group of midwives throughout their pregnancy. Another report there the relationships the pathway to safe high quality maternity care reports written by Professor Jane Sandow acknowledges that while introducing new continuity models can have start-up costs it can lead to shorter hospital stays or if you have a six hour discharge policy no hospital stay a fewer tests and interventions making them cost effective in the future. The 2010 maternity care reforms in Australia are certainly encouraging the expansion of access to continuity of midwifery care and recognizing that this gives women increased control it recognizes midwives as primary care providers who are responsible for their own practice and able to access public funds as a result. So with all the evidence the question should really shift to why not adopt a continuity of care model rather than why should we. I just wanted to point out here that while midwives are very passionate about continuity our medical officers in Igam also love being involved in continuity of care while they don't have the opportunity to the same extent as the case load midwives they do love they do work very hard and love to provide a collaborative care approach and we as we have a small case loads is a very close-knit relationship and which the medical officers are very keen to be part of and I'm sure will benefit the women in the future. So I thought I might point out some of the challenges were faced along the way and in this slide we have some pictures of some very beautiful Igam babies all shared with them parents permission. So where there is change there will always be challenges and that's just part and parcel of the journey. I've put politics in here as a challenge and but by politics I don't really mean government politics what I'm looking at here is politics in terms of people management. So everyone is invested and everyone wants a little bit of ownership. I like to think of this now in a positive light when I can and accept that everyone is passionate and wants this project and service to succeed. Fortunately we all have a common goal which is a safe sustainable birthing practice birthing service sorry for the community. The next challenge that I wanted to mention was media. Media is often how we communicate with the public and our consumers. It's how we provide project updates and it really has to be the right kind of media which is often the challenge. I was really well supported in my first few weeks as project officer by my nursing director and my service group director in this area and they encouraged me to draft a media and communications plan which I did in conjunction with the public affairs department here at the Townsville Hospital Health Service and that has really outlined where and when to use media and how to use it effectively. Community expectations as a challenge is quite a big one. A lot of similarities here as with people management. The community have a vested interest and are passionate about bringing their service back. We wouldn't really expect anything less after 10 years of imagining what it would look like when they did return birthing to the town. The mayor of Ingham has said that this service isn't just about delivering babies. It's about sustainability of rural living so no pressure there then. So community expectations I think as long as people feel heard it becomes less of a challenge and obviously provides you with a bit more guidance. Engagement was the next big one. Luckily I'm a talker. I engage with everyone and I'd be sad if I thought I missed someone out. I understood that engagement was a key element in project work but I don't think I had given it enough of a pedestal. I just thought it would be something I would do along the way and I've really learned that I've had to make it a big focus. I just love listening to our consumers' hopes and dreams for their service. I know that the midwives in Ingham do too and they often feed them back to me. Keeping them informed as we've reached milestones is vitally important. I thought I would write down a few of the groups that I have engaged with over the past six, seven months. It takes up most of a page but to name a few I have the indigenous consumer group. We have a stakeholder group who meet once a month. We have a steering group who meet every second week. We have the Ingham maternity consumer group. We have maternity choices Australia who have a wonderful local rep who engages with us and we engage with her regularly. There's also engagement with a lot of the support services around the project and the redevelopment of the service such as the Queensland Ambulance Service, Retrieval Services Queensland, the Townsville Hospital, Obstetrics, Surgical, Theatre Departments, Education, Infection Control, Public Relations. You name it, we want to engage with them. I think when we have been engaging or when we are engaging well we notice big leaps and then get into our end goal. Another challenge has been model planning. So much of this was done before I took my post and that in itself can be a challenge because you're taking something on after the fact. Luckily as soon as I read the project outline I was completely on board. There's obviously elements of the service model that not every team member or consumer is happy with. I like to think of that as being okay because that's why we evaluate in order to change, improve and expand. The core of the model should be respected but services have to alter and adapt to meet the community's needs. Budget. Now I'm rubbish at budget and it's something I have to be aware of it and constantly seek guidance on. My dad's could tell you many stories of my shocking budgeting or lack of as a uni student and my husband would probably back him up. Luckily for me I'm well supported by people in the know within the rural hospital service group. People who work with budgets and numbers and you know really are able to keep an eye on it. It's something they do every day. Budgets has really been a major challenge. As you always are continually asking yourself is this a necessity or a wish list item? I suppose it's one of the many benefits of having a stakeholder group and steering committee because they really do help you to focus. Education and upskill. This has been a challenge because it's required a huge commitment from everyone across the board. In the first month of taking on the role I created a 12 month education planner with the Ingham Hospital nurse educator. I wanted to get that title right. But it affected everyone. There was registered nurses who hadn't maybe been exposed to any maternity care for 10 years. There were registered nurses who had to be trained in anesthetics and as scrub scouts for theatre so that we could build a theatre team. Many of the midwives in Ingham had to come to the tertiary facility to be exposed to some elements of midwifery that they maybe hadn't been exposed to since the birthing service had closed down locally. And it really has been one of the biggest challenges. But I'm very proud to say that in some areas we've set the bar as a rural facility and once again been overwhelmed by the support of the tertiary hospital. Really I think by engaging with everyone they've been keen to help and in many instances gone out of their way to do so. Okay our hopes for the future and we have many of them. So overall we want to grow a safe and sustainable collaborative continuity of care model for the Ingham community in terms of maternity. We also want to continue to work closely with the Aboriginal and Torres Strait Islander healthy to provide culturally appropriate care to our Aboriginal and Torres Strait Islander women within the local community. We really want to meet and exceed our KPIs and our clients expectations. Who doesn't? We really hold collaboration and benchmarking in high regards. It's something that we have found has been lacking in rural settings. The midwives in Ingham and some other rural midwifery group practices have started to get together once every three months to just talk and share and ask each other how they're going and really move things forward from that perspective. As I mentioned earlier on in the presentation recruiting and maintaining a rural workforce is notoriously very very hard. To combat that we would like to develop a local student in midwifery position to train within the NGP team and from that perspective we'd really be growing our own. As mentioned in the nursing midwifery Queensland office document there's a strong communication culture and processes supportive and flexible management and good understanding of the model that we're trying to implement and women's needs all contribute to sustainability. And quite importantly we want to continually engage with our consumers to ensure that the women's centered approach to our service is never lost or overlooked. Ultimately we want this service to be a model that's held in really high regard and one where people want to work and want to be cared for. We wanted to succeed and be sustainable and be reflective of our communities needs. Obviously issues with maintaining a rural workforce grow your own if you can that would be the ideal. There's been a huge effort from all involved as I've mentioned throughout and we all have that shared common goal which brings us back that women should be able to birth surrounded by friends and family and with care providers that she knows and who know her. People who respect and understand her wishes and only want the best for her and her baby. Now I could go on and on and on as I'm sure you've gathered but sadly I have a time limit. So for any further information I'm always happy to be contacted to talk around this project and yeah there's some details there for some references that I've alluded to today. I'd just like to thank you all once again for allowing me to share the project and our vision for the service with you. I am special thank you to the VIDM organisers and a very happy International Midwife Stati all. Thank you. Sounds very exciting. Would any of the participants like to comment or ask up specific questions? Raise your hand and I will give you the microphone. So how many midwives do you anticipate having in the service? So we have actually recruited, we've thought a little bit outside the square here. We had 4.5 FTE and to make it a little bit more appealing we have broken that up between six midwives and so some of the midwives all of the midwives work part-time and their caseloads reflect their how much they work their FTE. Question in the chat box about how many births do you anticipate a year? I think you had that on one of the early slides but do you want to remind us of what your anticipated caseload will be? Yes, sure. From the perinatal data collected we would anticipate between 80 and 120 births per year but obviously that has to grow over time. So if we got 60 to 80 births in our first year we would be delighted. But somewhere between 80 and 120 is what we're aiming for. So there's a question about opportunity for new graduates in your project? Well, great question. The last midwife joined our team on Tuesday the 26th of April. A lovely midwife called Jo who came to us as a first year of practice midwife from South Australia. She actually moved her whole family from South Australia to Ingham for the project because she felt that it was really a model that she wanted to work in. So we do have a graduate midwife and we're really looking forward to seeing where that goes and the plan would be to keep that as a feature of the team. We have someone typing. Okay, happy to hear. She's happy to hear that. That's great. It's wonderful to have that opportunity available. Thank you. There was a really interesting comment from Tiffany Zimmerman earlier too. She said that one of the things that prevented her from applying to the Ingham project was that a lack of appropriate rentals in the area. So that might be one of the factors she might want to consider. Absolutely. And it is something we have talked about at great length and certainly it is something that our new graduate midwife is going through at the moment. And we have escalated that up to the management here at the rural hospital service group. We do tend to provide accommodation within the hospital grounds but not for long-term employees. So maybe a period of one to three months for medical officers who were coming to train or for locum staff or for staff that were only coming to the facility for a short period of time. But when you're moving to an area with your family and you want to submerge yourself in that community, you really need your own place and you really need somewhere to come home. So it is certainly something that we are looking at. So Glenda wants to know if you could briefly be a little more specific on the political challenges. I was a bit apprehensive about using the word political but I couldn't really think of anything equivalent to replace it with. So with politics, I suppose what I'm alluding to there is really who's job is it? Who's taking responsibility for that? Because people are so invested in this working and so it's quite an admirable thing that people want to take responsibility for big areas of the project and I think it's something that I do try to encourage when it's appropriate but the politics can come from the sort of power struggle. It could be as basic as is that a midwifery thing or a medical thing. It could be the old adage you know that's the way we've always done it here and it's just sort of changing that culture and a bit of people management to push through that particular challenge because ultimately we have a goal. And then Samantha would like to an estimate of what proportion of births you envision being for indigenous families? Okay I don't actually have a percentage for you. The midwives currently have indigenous families on the case load delivering antenatal and postnatal care but we are working quite closely with the Aboriginal Torres Strait Islander health team at the Ingham Hospital around education because one of the things that they highlighted to me is that there is a there's a limited understanding on what being categorized as low risk is and the challenges faced by the indigenous women often move them out of that low risk bracket. So things like BMI, gestational diabetes, previous preterm birth and you know just various things that are more acutely affecting that group that cohort. So we're working quite closely with the Aboriginal Torres Strait Islander health workers around education and so the birth service is open to anyone who we can still continue to provide all risk antenatal and postnatal care but moderate and high risk women will have to come to the tertiary facility for birth. Those women who are low risk and continue to be low risk throughout their pregnancy will be welcome to birth in Ingham. So I don't actually have a figure for you yet but it is one of the things that we will be evaluating as the service goes on. Right and then Tiffany wants to know and then we're going to have to wrap up. This is going to be the last question about women who need longer than six hours stays at the birthing facility. Yeah, so the midwife will follow those women through. In terms of postnatal care the case load midwife will remain with that woman until she is stable and that may involve calling in the second midwife or you know if it's in the middle of the night it might be a heads up to the person who's coming on call first thing in the morning. The nursing staff at the hospital are doing a huge body of education, things like obstetric emergency workshops and familiarising themselves with paperwork and what's normal postnatally in order to care for these women when the midwife is not there. But we like to call it the phone a friend option will always be there. So if at any time the nursing staff are not happy or do not feel that the postnatal women is within their capabilities the midwives will come back. But there is going to be an element where nursing staff non-midwifery staff will be required to be involved in postnatal care. That is wonderful. It just seems like such a very well thought out project and I think we all want to stay tuned after July 1st and and hear from you about how it's going. So thank you so much Gemma. Thank you all very much for your time. They can get their certificates and evaluate the presentation and all that good stuff and then vacate and then get the room ready for our next presentation. Okay, thank you very much. Thank you.