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# Overcoming barriers

How do you keep the focus - but continue to live in reality - while pursuing the dream?

Most of us reading this share a dream of a world where women are cared for in a safe, supported, connected way during pregnancy, birth and early parenting. A world where a family grows in the best possible way on every level: physically, emotionally, and psychosocially. Yet, we know that are some very big barriers in the way to achieving this goal.

Although it can be tempting to ignore barriers and focus on the dream, being aware of the disablers helps you to manage them. Barriers come in many forms, and encompass both internal or external factors. It can be particularly challenging when it seems you have little control over obstacles in the external environment.

## Overcoming apathy

One of first barriers you might come across is the apathy of others - or yourself! It’s easy to feel that it’s just all too hard, and that it’s impossible for change to actually occur. But remember all of those inspirational real-life stories of women, midwives, and community groups making a difference? One committed person making even small changes can have a huge ripple effect.

One thing you can do to counteract the apathy of others, and to spread information, is to suggest this free course - sometimes it’s easier to share information by having others learn it themselves. You could also spread the word yourself. For example, let others know the conclusions of the Lancet Series on Midwifery and the impact that changing models of childbirth could have globally. Sharing information about potential impact is one way to overcome the barrier of apathy by increasing motivation for change.

## Handling resistance to change

Remember, there is no one method to overcome all the different barriers. A different approach is necessary for different people and different situations. The key is to anticipate and plan for potential barriers whenever possible in order to increase the likelihood of success.

Resistance to change is one of the biggest barriers we face. Some resistance to making such a significant change to maternity care is almost inevitable - no matter who you are. Resistance can come from colleagues, management or from an unexpected source. It may even come from you! Resistance comes in many forms.

Some resistance will be due to ignorance. For example, women and maternity care professionals alike may be unaware of the benefits of relationship-based care. For the same reason, management and those in charge of designing maternity services may not want change to occur - it may seem easier to keep things as they are, and too hard to implement needed changes. It may simply be a lack of belief that change will create better outcomes. Sometimes resistance is due to fear of the unknown, while others may fear that their power and territory is being threatened. Those with institutional financial responsibility may mistakenly believe that existing services are the most cost efficient.

Let’s talk about the economics of maternity care services. It seems that it would cost more money for every woman to have her own midwife, doesn’t it? This kind of care sounds great, but wouldn’t it cost way too much? For this reason, one of the most commonly cited barriers to implementing a midwifery continuity of care model is economic. People argue that with so many competing maternity health priorities, the focus needs to go on cost-effective, life-saving measures. Here’s what’s amazing:

Midwifery continuity of care models - where each woman has her own midwife, supported by specialists as needed - costs less than standard, fragmented care. Quite a bit less!

• Research in Australia found $927 direct cost savings per woman in the midwifery group practice (MGP) model, where each woman had her own midwife, back-up midwives, and an obstetric and neonatal team where required (Tracy, Hartz et al., 2005). • One to One Midwifery UK found decreased overall costs, with a reduction in resources of 75% (Page, McCourt et al. 1999). The study was repeated in 2001 with the same results – MGP was no more expensive, used less resources, and had improved outcomes - with the associated potential for cost-saving long term benefits (Page, Beake et al 2001). • In Canada - midwifery-led continuity of care vs publicly funded care. Savings:$1172 per woman (O’Brien, 2010).
• Toohill and colleagues (2010) completed a cost comparison in Australia for women accessing a Birth Centre MGP model versus standard hospital care - matched for risk and demographics. Women in the MGP had fewer interventions, more postnatal care, and cost almost $1000 less per woman/baby pair. • In 2016, Roslyn Donnellan-Fernandez examined the cost-effectiveness of a midwifery continuity of care model versus standard fragmented care amongst women with complex pregnancies (moderate to high-risk births). She found a cost saving of around$863.92/woman with the midwifery continuity of care model, along with:
• improved clinical outcomes for women and babies
• improved resource use.

Amazing isn’t it? Relationship-based care that’s supported by an abundance of solid research - care that women, their families, and health care providers are more satisfied with and that provides better outcomes - is no more expensive (and probably cheaper) than standard fragmented care. It’s clear that whatever barriers come up: they’re worth overcoming.

## Over to you

Think about where resistance is most likely to come from in your situation, and what barriers might be there to you achieving your goals. Why do you think people might resist the changes you propose?

Share some of the potential barriers that may impact the goals you want to achieve.

Once you’ve listed some of your own, it’s time to crowdsource advice:

• Have a look at other people’s comments. Do you see any obvious solutions to other people’s challenges?
• Share your tips with them, and see what others suggest to you about the barriers you identified.

## References

1. Tracy, S., Hartz, D., 2006. The Quality Review of Ryde Midwifery Group Practice, September 2004 to October 2005: Final Report. Sydney, Northern Sydney
2. Page, L., C. McCourt, et al. (1999). “Clinical interventions and outcomes of one-to-one midwifery practice.” Journal of Public Health Medicine 21(4): 243-48.
3. Page, L., S. Beake, et al. (2001). “A comparative cohort study of clinical outcomes and maternal satisfaction with One-to-One Midwifery Practice.” British Journal of Midwifery 9(11): 700-706.
4. O’Brien B, Harvey S, Sommerfeldt S, Beischel S, Newburn-Cook C, Schopflocher D. (2010). “Comparison of Costs and Associated Outcomes Between Women Choosing Newly Integrated Autonomous Midwifery Care and Matched Controls: A Pilot Study.” Journal of Obstetrics & Gynaecology Canada. 32(7) 650-656.
5. Toohill, J., Turkstra, E., Gamble, J., & Scuffham, P. (2012). “A non-randomised trial investigating the cost-effectiveness of midwifery group practice compared with standard maternity care arrangements in one australian hospital.” Midwifery, 28(6), E874-E879. doi:10.1016/j.midw.2011.10.012
6. Donnellan-Fernandez, R.E. (2016). “Proceed with Caution – the strength & weakness in reported cost data in South Australia.” Invited presentation for, Enhancing Performance & Cost Effectiveness in Maternity & Women’s Healthcare. Canberra: Women’s Healthcare Australasia. Women’s Healthcare Australasia Annual Benchmarking Meeting. Northside Conference Centre, Sydney, NSW. May 16’th 2016.