Burning nurse’s hats, forgone champagne and post-COVID maternity care: interview with midwife leader

Four Australians have made the 2020 List of 100+ Outstanding Nursing and Midwifery leaders around the world.

The list was announced to mark last year's International Year of the Nurse and Midwife and is a joint venture from the World Health Organization (WHO), United Nations Population Fund (UNFPA), Nursing Now, International Council of Nurses (ICN), International Confederation of Midwives (ICM), and Women in Global Health (WGH).

The list features the achievements of nurses and midwives from 43 countries and across six global regions, to recognise these women and the millions of nurses and midwives around the world.

Nursing Review caught up with one of the Aussie honourees, Professor Caroline Homer, the co-program director of maternal, child and adolescent health at the Burnet Institute and Visiting Professor of Midwifery at the University of Technology Sydney.

NR:  How does it feel to make such a prestigious list?

CH: It's a great honour. It's always pretty humbling when you look at the people on that list. In the sort of work that I do, I've always done things with people, lots of colleagues. So it always feels weird to be recognised individually when these things are collective exercises.

The last year has really highlighted particularly the work of nurses, but all healthcare workers. And that's been a good thing. I think there's been huge recognition of the work of nurses, midwives, all healthcare workers, but certainly in Australia we have 26,000 midwives – and that's a lot of midwives – who don't get recognised every day for the work that they do, even though most of the work that they do is pretty remarkable.

And nurses, we have 200,000 odd nurses and all of them don't get recognised so I'm very fortunate. I've had a very lucky career in many ways and I'm very grateful for the opportunities that I've had and for the mentors and leaders who I've had as well because you don't get to these sorts of roles just by accident in a way, you get the people around you who help you and support you and sponsor you, that sort of thing.

You use the word humbling, which is a common word for all of the nominees I’ve spoken to. I would imagine doubly so in the last year it was for last year and last year was the Year of the Nurse and Midwife. And the weird irony of it being that year and then a global pandemic. Does that make it all the more profound in a way?

Yeah, I mean this time last year, or even a little bit earlier, we were planning the year, it was all going to be fun. We had all these amazing conferences and celebrations and international year, the Day of the Midwife and International Nurses Day and all these things we were going to do, there was going to be a lot of champagne drunk and a lot of fun. And in reality, none of that happened.

But actually what happened was better, because what happened has highlighted the work of the health workforce. And for us, highlighted the work of nurses and midwives, and really put us front and centre and as you say, the irony of being that year and also because it was Florence Nightingale's 200th birthday.

And Florence was a pretty tough cookie for a woman of her time, the 1830s, 1840s. And she was an epidemiologist, one of the first epidemiologists. So, for her to have understood handwashing, understood infection control, understood the importance of collecting data and doing graphs and charts, which actually now everybody knows how to read these days in the media. And it was amazing through that last year that Florence had pioneered so much of that work. And here we all using it on a daily basis to make decisions in our lives.

It was pretty special to be recognised in that year.

Well, I hope you did break out some champagne when you found out that you were on the list.

I did drink champagne through the year, let me promise you that. Not in the way that I thought I would.

How has the last year been for you professionally?

These days, mostly I do research. I bunkered down at home and got working really. I work in the Burnet Institute, which has a history of being an infectious diseases institute from the days of HIV, so we went into serious overdrive. We were front and centre of the COVID research in Victoria and have done huge amounts of work. I established a network in the state. We've now got a network across the country of people who are doing COVID work. Ironically, mostly the COVID research has focused on Victoria because of where the cases have been.

But we've brought together big groups of people who've been doing interesting work in midwifery and maternal health to do surveys around the country of what's been happening with women, what's been happening with women having babies, stillbirth rates, breastfeeding rates. We're currently still collecting all that data because we had to wait for the whole year. On a global front I'm part of a group that produces a report every three to five years called State of the World's Midwifery and we were going to release a report in 2020 but then COVID came up and that all got delayed and we're just currently finalising the report to release this year, but we've collected a lot of information about COVID across the world and worked with international organisations to understand how COVID affects midwives, how COVID affect maternal healthcare. And what we can do to build back better. So not just get back to where we were, but how we can, post COVID, get back better than where we were. How can we make maternity care better even than it was?

Are you worried about the outcomes of children who were born during the pandemic and mothers and their mental health going on. Is this going to be a big area of research and health work in the next year, two years?

We know some things already. We know that women who had a baby in 2020, post-March, had a lot more stress and anxiety.

And we know that for many women, they had different kinds of care. So instead of having face to face care a lot of the care was on the phone. There was a whole lot of anxiety for women around the time their babies were being born, would their partners be allowed in, would their support people, would their doula be allowed to come – really stressful, stressful things.

And then also in that postnatal period and more importantly when women went home, a lot of women missed out on child and family health visits from nurses in those early days and weeks because services were shut down.

So we are worried about all of that. We're certainly concerned about mental health and some of the surveys that have been done at the moment are showing higher mental concerns around women's mental health and families. Whether they are long-term impacts we don't quite know yet, there have been some reports from other countries about higher rates of stillbirth but lower rates of preterm birth.

The prevailing theory for preterm births was that lockdowns forced women to actually definitely rest. Is that still the thinking?

Look, it's quite possible. So it's possible that women rested, women didn't run around so much.

But they also weren't exposed to other pathogens – less flu, less whooping cough, less other things going around. That's perfectly feasible, but the increased stillbirth, we haven't seen it in Australia across the board from what we know so far, as I said we haven't done 2020 data yet, but we don't think those rates have gone up, but they certainly have in other countries because women did not access care when they should have. They were frightened to go to the hospital or the hospitals had been turned into a COVID hospital, not a maternity hospital. So, we know that's happened around the world, but probably hasn't happened to that degree in Australia.

But we do know that the mental health, the social support issues have been hugely concerning. There have been some upsides. We know from the research and particularly in that postnatal period after women had their babies, things are very quiet in hospitals. There are not people rushing around, there's no visitors; it’s all very quiet and peaceful. And a lot of women really like that – no other distractions, just their baby.

And also usually it's the woman at home with the baby. That didn't happen. Partners stayed at home because everyone was working from home so many women have told us that actually those early weeks and months were lovely because they were home together.

And we don't know what the long-term impacts of the negative or the positive side. What we want to do is to try and understand both the negatives and the positives and work out how to keep the positives and get rid of the negatives.

Give us a brief rundown of your career, how you started and how you've ended up where you are?

I'm a hospital trained nurse. I still don't have an undergraduate degree; I keep thinking I should go and get one. But I trained as a nurse at the Royal Brisbane Hospital in Queensland in the days where we were sort of apprentices – we worked on the wards.

You didn't have to wear one of those big funny hats, did you? We're that far back?

We did. I wore the big funny hat for first year and at the end of the first year we had a big protest about a parking lot that wasn't going to be built and we wanted it built for safety. And so, we burned our hats. We were very rebellious, and we refused to wear them ever again.

That's brilliant.

I was a bit sad because the status at the time was you got a stripe on your hat the more senior you became and I'd just got my first stripe so I thought I was terribly special. And then we burned our hats and that was the end of that.

Then I came to Sydney and I worked as a nurse for quite a few years, five years, I guess, and then decided to do midwifery. And I did midwifery at the Royal Hospital for Women in those days in Paddington and really loved midwifery, decided it was a very good thing for me.

And not long after that, I went to Africa and worked in a mission hospital in Malawi. That kind of sorted me out really. And I came back from Africa and I worked at the Royal in the labour ward for a couple of years and then went into research.

So I've been doing research for about 20 years, but for almost all of that time, until about two years ago, I still provided clinical care to women, mostly through St George Hospital in Sydney.

When you've become a midwife or a nurse your capacity to make a difference to one person at a time is huge. You can make sure that a patient or in my case, a woman having a baby has the best experience possible. But for me, ultimately, one woman at a time wasn't enough. I needed to be able to influence the care for more women at once. So education and research enables you to start to change the service delivery, change the model of care, change the experience that women get at a broader level.

How have you seen the role of the nurse and the midwife evolve over your career?

The big shift in Australia over my career is the recognition that nursing and midwifery are separate professions. We're happy to walk alongside together and some people like me came from nursing and went into midwifery. But the big shift, basically in the last 15 years, is to recognise the two disciplines and enable people to become midwives without already being nurses.

These days I'm not registered as a nurse, although I'm a very proud former nurse, because I can't demonstrate competence as a nurse anymore. It's been so long since I worked as a nurse, I just couldn't, I wouldn't know anything about anything.

So its safer for the public that people like me aren't registered as nurses, but I'm safe to be registered as a midwife, I'm a perfectly capable midwife. But that's been a big shift, that took national law changes a decade ago to understand the distinction.

The other big shift for midwives in Australia in my career has been the recognition that midwives can be a well-educated profession who can look after women without having medical doctors telling them what to do.

Now we have midwifery models of care where, if they're well and healthy, women can be cared for by midwives throughout their pregnancy, labour and birth and after they have their baby without needing to see a doctor.

And we've seen fantastic midwifery models of care across the country, in every state and territory, very innovative ways of delivering services in the city and in rural areas and in remote settings now in Aboriginal Torres Strait Islander communities.

And I think the recognition that every woman needs a midwife and some women need a doctor too has become much clearer in the last decade. And that's an important mantra, I think, that we're not saying we're better than doctors; we're not, we need doctors, we need to work with them to make things better for women.

Going into this year, into the future, what do you see as important areas for the profession?

I think in Australia for midwives, it's this notion of what do we take from the COVID time going forward? So how do we build maternity services better? If women liked the peace and quiet in maternity wards and the quiet time at home, how do we make sure that's normal?

I think more broadly across the profession we need more women to have access to continuity of care, midwifery continuity of care. We've now got really good evidence, half of the evidence has come from Australia, big systematic review of more than 17,000 women around the world but half from Australia, showing better outcomes if women have midwifery-led continuity of care and it's really time that every woman in the country had an opportunity to have that. And we haven't managed to make that happen. It's probably somewhere between 10 to 20 per cent of women have that opportunity now – it needs to be 80 per cent or 90 per cent.

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