Midwife Aotearoa New Zealand

SPECIAL EDITION

WHAT WE DID IN LOCKDOWN P 18 YOUR STORIES P 30

COVID AND THE CORE

VIRTUAL CELEBRATIONS

COLLEGE SURVEY

HOW HOSPITAL MIDWIVES WERE AFFECTED P 8

INTERNATIONAL DAY OF MIDWIFE IN LOCKDOWN P 12

REVEALING THE IMPACT OF COVID RESPONSE ACROSS THE PROFESSION P 24

ISSUE 97 JUNE 2020 I THE MAGAZINE OF THE NEW ZEALAND COLLEGE OF MIDWIVES

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1 Visscher, M., Odio, M., Taylor, T., White, T., Sargant, S., Sluder., … Bondurant, P. (2009) Skin care

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Neonatology, 96(4):226-34. doi: 10.1159/000215593.

2 Visscher, M. O., Adam, R., Brink, S., Odio, M. (2015) Newborn infant skin: Physiology,

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Clinics in Dermatology, 33(3). 271-80. doi: 10.1016/j.clindermatol.2014.12.003.

3 8 out of 10 HCPs agree WaterWipes is the purest baby wipe in the world with only 99.9%

of purified water and a drop of fruit extract. 96% of midwifes consider WaterWipes to be the purest baby wipe. Source: A survey conducted with 100 Midwifes and Public Health Nurses as part of a study by Behavioural & Attitudes in July/August 2019.

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YOUR COLLEGE

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ISSUE 97 JUNE 2020

FORUM FROM THE PRESIDENT 4. NICOLE PIHEMA FROM THE CHIEF EXECUTIVE 5. WHERE TO FROM HERE? YOUR COLLEGE 6. COVID-19 UPDATE YOUR UNION 8. THE IMPACT OF COVID-19 YOUR MIDWIFERY BUSINESS 10. MIDWIVES GO EXTRA MILE

FEATURES 12. INTERNATIONAL DAY OF THE MIDWIFE

18 24

14. SO, HOW DID WE DO? 18. LOCKDOWN DIARY 24. THE IMPACT OF COVID ON MIDWIVES 29. THE MIDWIFE'S STORY RESCUED 30. YOUR STORIES 34. QUEENSTOWN MIDWIVES & MOTHERS

30

37. MIDWIVES RISE TO THE CHALLENGE 38. STANDING UP FOR COMMUNITY MIDWIVES 43. LET'S KÅŒRERO COVID 44. BREASTFEEDING IN THE PANDEMIC 46. DIRECTORY

34 Aotearoa New Zealand Midwife is published quarterly for the New Zealand College of Midwives.

EDITOR Maria Scott, P: (03) 377 2732 E: communications@nzcom.org.nz ADVERTISING ENQUIRIES Hayley McMurtrie, P: 03 372 9741 E: Hayley.m@nzcom.org.nz

MATERIAL & BOOKING Deadlines for Sept 2020 Advertising Booking: 17 Aug 2020 Advertising Copy: 24 Aug 2020

ADVERTISING POLICY AND DISCLAIMER: The New Zealand College of Midwives maintains a schedule of guidelines to exclude advertisements for products or services that are not aligned with its principles and ethics. Every effort is made to ensure that advertising in the magazine falls within those guidelines. Where advertising is accepted, this does not imply endorsement by the College of the product or service being promoted. The articles and reports printed in this newsletter are the views of the authors and not necessarily those of the New Zealand College of Midwives, its publishers or printers.

This publication is provided on the basis that New Zealand College of Midwives is not responsible for the results of any actions taken on the basis of information in these articles and reports, nor for any error or omission from these articles and reports and that the College is not hereby engaged in rendering advice or services. New Zealand College of Midwives expressly disclaims all and any liability and responsibility to any person in respect of anything and of the consequences of anything done, or omitted to be done, by any such a person in reliance, whether wholly or partially upon the whole or any part of the contents of this publication. All advertising content is subject to the Advertising Standards Authority Codes of Practice and is the responsibility of the advertiser. Contents Copyright 2019 by New Zealand College of Midwives.

All rights reserved. No article or advertisement may be reproduced without written permission. ISSN: 2703-4062.

ISSUE 97 JUNE 2020 | 3

FROM THE EDITOR

FROM THE PRESIDENT

from the president, new zealand college of midwives, nicole pihema welcome to this special edition of aotearoa new zealand midwife We are excited to be presenting you with this special edition of Aotearoa New Zealand Midwife.

This issue is devoted to stories and commentary about how the nation’s response to the Covid-19 pandemic has affected midwives and the women you care for. We were unable to produce a print version of Midwife because of uncertainty over the availability of printing facilities during lockdown. So, this edition has been produced as an electronic copy.

The content includes a selection of stories from around the motu about the experiences of midwives and women over recent months.

We know that this has been an extraordinary and often stressful time but there have also been many positive reports, such as women’s decisions to birth at home when they would not otherwise have done so. And midwives have noticed that many mothers and babies have thrived with time to breastfeed without distractions. We also provide a snapshot of what the College’s midwifery advisors were working on behind the scenes to ensure midwives had the information and equipment they needed to continue in their vital roles. And we report on this year’s ‘virtual’ celebrations for International Day of the Midwife. There were many vibrant and heart-warming messages of support for midwives from women and their families and from public figures.

We think the design of Midwife is attractive and readable in the online format. We think you will find it useful to be able to access the magazine while on the move and with a variety of devices.

We look forward to hearing your views. square Email: communications@nzcom.org.nz

4 | NEW ZEALAND COLLEGE OF MIDWIVES MAGAZINE

E hoa mā, ngā kaiwhakawhanau o Aotearoa.

Ngā mihi ki a koutou mō tō mahi kei waenganui o te mate urutā. Thank you all for simply being midwives during the extraordinary events of recent months. There is nothing simple, of course, about being a midwife but you have continued to do your jobs as always.

Despite the disruption to your professional and personal lives you have provided excellent care in our communities, primary units and hospitals. The College has worked hard to support you and we do not take your efforts for granted. We recognise that for many years midwifery and the maternity service have not had equity of access to national resources.

Equity is a concept that is featuring increasingly in our understanding of how our society works. In the aftermath of the epidemic response, where we are expecting economic hardship for many, it is likely that we will hear more about it. As the Covid crisis was breaking in New Zealand I took up a new role at Auckland City Hospital as Associate Director of Midwifery (Māori Health & Equity) responsible for helping to make equity of access for maternity care and women’s health a reality rather than an aspiration. The role involves working strategically and collaboratively across the Auckland District Health Board to reduce inequity for Māori. As the threat from Covid-19 loomed it was clear that it

4 | AOTEAROA NEW ZEALAND MIDWIFE

would hit our more susceptible whānau and hapori the hardest. We could not allow this pandemic to have the same devastating impact on Māori as did the influenza pandemic that followed the First World War. We needed to act quickly. At the ADHB it has been very satisfying to get projects underway that we hope will mitigate the effects of the crisis on the health of women and their families in the city. These projects will have lives well beyond the Covid crisis but it would probably have taken longer to get them up and running had it not been for the pressure to act quickly.

So, this has been a positive outcome from the experience.

I spent part of International Day of the Midwife this year interviewing to fill midwifery roles at Auckland City Hospital.

It is good to know that we are recruiting new colleagues but as midwives throughout the country know, there is a desperate need to fill vacancies throughout the maternity service.

This is a result of under-funding over many years and we are now desperately trying to catch up.

But the Covid crisis has put a spotlight onto the roles of midwives and other frontline health workers. How satisfying it would be to see us decide as a society after this experience that we truly value a wellfunded health service where resources are accessible and spread equitably to all.

He waka eke noa has been used quite regularly in recent months and whilst we hope our waka is certainly moving as one, we must continually reflect and ensure to keep our waka in good shape, and that includes the kaihoe (paddlers). square

FROM THE CEO

WHERE TO FROM HERE? That is a question on many minds as New Zealand emerges from the acute phase of its pandemic response. It is a question for government and policy makers and for individuals as we consider the political, financial and social consequences of what has happened. For many, the consequences are deeply personal. New Zealand’s death toll from Covid-19, at 22, is small by international comparison but huge, of course, for the families of those who have been lost.

For others the pain has come from the loss of jobs and businesses.

Midwives are also feeling the effects of our pandemic response. As we report throughout this special edition of Aotearoa New Zealand Midwife, midwives working in hospitals, birthing units and in the community were severely stretched by the demands of their jobs in this extraordinary environment. The stories collected in this edition reflect the joy of midwifery as a profession but also the frustration of College members that we are still struggling to resolve resourcing problems, particularly for community midwives.

The College lobbied hard for a special allocation of funds to assist community midwives with Covid-related costs. We were delighted to hear, just as we were completing this edition of the magazine, that there is to be a payment for this purpose. But uncertainty remains over the

re-shaping of our outdated funding model and resourcing for it. We know that $46 million has been allocated by this year’s Budget for the maternity services but, as I write, we still have not been told how this is to be spent. Of course, the pandemic emergency has required a huge government effort and mobilisation of funds which will affect the economic landscape for the foreseeable future. Another complication is the recently-completed (but at the time of writing, yet to be released publicly) Health and Disability System Review report and how this might affect the maternity service.

Our expectation is that the government will engage collaboratively with us to discuss how we can protect our model of care at this time of great uncertainty. As this digital edition of Midwife becomes available the College will be starting discussions with members to take stock and to seek guidance about how we move forward.

This year’s Queen’s Birthday Honours List included a reminder about the vital contribution of midwifery to the health of mothers and babies in Aotearoa New Zealand. Warmest congratulations to the College’s policy analyst Carol Bartle who has become a member of the New Zealand Order of Merit (MNZM) for her services to health, particularly breastfeeding education. Carol will be profiled in the next edition of Midwife. square

The College lobbied hard for a special allocation of funds to assist community midwives with Covidrelated costs. We were delighted to hear, just as we were completing this edition of the magazine, that there is to be a payment for this purpose.

ALISON EDDY CHIEF EXECUTIVE

ISSUE 97 JUNE 2020 | 5

YOUR COLLEGE

YOUR COLLEGE

changes to midwifery first year of practice programme The profession welcomed 150 graduates to the midwifery profession in New Zealand this year, roughly half in January (Cohort 1) with the remainder (Cohort 2) starting in April. Due to the Covid-19 emergency and its restrictions for face to face gatherings the College has been reorganising the workshops and other meetings it runs as part of the Midwifery First Year of Practice Programme (MFYP).

Zoom educational meetings have replaced the face to face workshops that would normally have been held around New Zealand to welcome graduate midwives and their mentors to the MFYP. Kate Clark, MFYP national coordinator says it has been challenging to reorganise the programme but new graduates are accustomed to remote learning as most have experienced it during their undergraduate degree courses.

The national response to the Covid-19 emergency has also affected the availability of education and other events nationally that graduate midwives would normally attend to fulfill the educational requirements of the programme. Most of these are run by the College and district health boards.

The College is working to support all midwives with their educational requirements and is considering other methods of delivery. Unfortunately the College’s biennial conference has been postponed from October this year until September next year. The conference would usually have been a component of many new graduates’ educational obligations for the year.

New graduates are also required to complete Midwifery Standards Reviews during their MFYP years. The College is offering the option to have these conducted by Zoom or similar means or for members to postpone their reviews.

EDUCATION UPDATE The College, along with many other education providers, has had to postpone face to face workshops until the end of June. We are hoping to be able to resume workshops in July and to reschedule postponed workshops later in the year. For more information please visit www.midwife.org.nz/midwives/education/ continuing-midwifery-education.

The impact of Covid-19 has enabled the College to reconsider the full educational calendar for 2020 and beyond, exploring new and innovative ways of providing education nationally. We will provide more information later in the year. FlexiLearnz, the College’s eLearning platform, is developing rapidly and will be available for all members shortly. We are also considering the possibility of holding one or two Illuminate forums (multidisciplinary educational events) near the end of the year and will keep members informed about this.

The Midwifery Council has placed the requirements for the current recertification programme and its educational component on hold until the end of this year. For more detail about what this means for you please visit the Council’s website at www. midwiferycouncil.health.nz.

On behalf of the College’s education team we will look forward to seeing you in the not too distant future either in the virtual world or in-person. square

6 | AOTEAROA NEW ZEALAND MIDWIFE

Kate says that it is possible that some members of this year’s MFYP group may not be able to complete the programme in the required time because of the disruption. The College will continue to monitor this and advise accordingly and will continue to support all graduates should this be the case. All graduate midwives will be supported by their peers in practice, their mentors and the MFYP. “New graduates are understandably anxious about the disruption to the programme but we have been advising them to focus on their practice for now and consider their education later once Covid-19 restrictions reduce. We are aware of the impact the changes will have on the programme and will work to minimise this. We will continue to keep participants of the MFYP updated.” square

New graduates are also required to complete Midwifery Standards Reviews during their MFYP years. The College is offering the option to have these conducted by Zoom or similar means or for members to postpone their reviews.

100

CLI

% S NICA AFE L TY LY P REC RO OR V D E EN ST. 199 2

The MSR administrator Saili Tuitaupe had her work cut out to identify reviewers and reviewees who were comfortable to do virtual reviews and to set up the processes. This was a logistical challenge which was initiated rapidly and Saili has done an amazing job to organise this. We also got our IT developers to develop a way for midwives to load their review material into the member’s portal as postal services were not going to be reliable. It is amazing what can be achieved in a crisis. This option will remain into the future.

We have had mixed feedback on the acceptability and success of virtual reviews with some liking it but others finding it didn’t support the important conversations that occur at reviews.While this was a ‘quick fix’, the vagaries of internet access and connectivity caused some frustrations.

The propensity for the connection dropping out or freezing demonstrated that virtual platforms have their draw backs on a number of fronts. Once the pandemic situation resolves the College will be investigating future review processes.

We will further explore virtual options but we remain committed to face to face reviews as the evidence is very clear on the benefits for professional practice and development.

I want to acknowledge and thank the reviewers and reviewees who adjusted to the new normal rapidly and enabled midwives to complete their reviews. Everyone’s willingness and flexibility was extremely supportive and appreciated at a time of immense stress and concern. square

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CALLY P NI O

ED • CLI LL

We sought advice from Netsafe on the best platform (at the time) to ensure virtual reviews would be private. As you can imagine, and just like all midwives, we had to adjust quickly. Midwives were offered the opportunity to delay their reviews until the face to face option was available again or to go ahead with a virtual review.

Many midwives chose to go ahead as they had already put the work into preparation.

• Ensures swaddling, sleepwear, Sleepingbag use is safer and cosier

VER

25 Years

VEN • S RO

The priority for MSR has always been face to face and the evidence continues to strongly support this as the most effective way to have professional discussions of this nature. However, as this could not happen during the lockdown we needed to provide the option of virtual reviews especially for those midwives who had already prepared for their MSR.

• Natural, free limb and hip movement

E • TRIA

The Covid-19 Level 4 lockdown required the College to rapidly institute changes to the Midwifery Standards Review (MSR) process to enable reviews to continue.

• More restful, safer sleep

AF

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Notification of special general meeting The New Zealand College of Midwives notifies members of the intention to hold a special general meeting.

Proposed remits 1. Constitution changes Clause 3.8. Updated to reflect te reo version of te Tiriti “Commits to and upholds the articles of the Te Tiriti o Waitangi by recognising Māori as Tangata Whenua of Aotearoa”.

Clause 8.0. Addition of the following sentence: “All board members need to be current members of the College”.

2. Ratification of the Colleges Practice Guidance “Intermittent Auscultation for the Assessment of Intrapartum Fetal Wellbeing”

When and Where: Wednesday 22 July, 6:00pm Jetpark Auckland Airport Hotel, 63 Westney Road, Mangere

YOUR UNION

the impact of covid-19 on hospital midwives CAROLINE CONROY MERAS CO-LEADER (MIDWIFERY)

Since March we have all been focussed on risks that Covid-19 presented and rapidly adapting our lives and workplaces in response to the lockdown and precautions introduced. Our lives changed suddenly when Level 4 lockdown was announced, and our conversations changed.

We all tuned into the daily updates from Jacinda Ardern and Dr Ashley Bloomfield, keen to hear how many new cases there were each day. Collectively as a nation we all started to feel a sense of relief as the number of new cases started to decline. We learnt to do the social distancing dance in the supermarket and in our workplaces. We adapted to Level 4 lockdown leaving the safety of our ‘bubbles’ and going to work on quiet roads, screening women for Covid risk factors and wearing PPE. We cleaned our work-areas and we washed our hands …a lot.

saw the introduction of virtual clinics, telehealth and phone calls instead.

But through all this, babies continued to be born, women needed care during pregnancy and support to establish breastfeeding. For most midwives, work continued very much as usual with the addition of Covid screening and PPE donning and doffing. Unlike many areas of the hospital, our wards and workplace areas did not close, and electives were not cancelled.

Women seemed to go home more quickly in the postnatal period and reports seem to indicate that women were able to focus on establishing breastfeeding and the needs of their babies without the usual distractions of visitors and juggling multiple work and family commitments. As a result, anecdotal reports from midwives indicate that mothers were relaxed and babies had good weight gains. There are also reports of an increased number of home births occurring during Level 4. It will be interesting to see overall birth statistics for this period.

Questions were raised about the availability of PPE and once it became more visible in our workplaces, we felt more reassured that it was there when we needed it. Maternity services reconfigured their services to create ‘red’ and ‘green’ areas so they could separate those with risk factors for Covid-19 and those without. Those working in community and clinic roles reduced face to face visits and

8 | AOTEAROA NEW ZEALAND MIDWIFE

Some maternity units have seen better staffing with some midwives reducing annual leave or cancelling plans to travel overseas and others were more available to pick up extra shifts due to partners being home to care for children. Other maternity services experienced more impact on their staffing due to midwives who met the criteria as vulnerable workers either needing to work in ‘category 2’ areas such as the maternity ward or having to remain at home.

A NATIONAL FOCUS ON COVID-19 PLANNING There was also a lot happening at a national level. The DHBs had agreed to take a

national approach in their discussions with health unions around the provisions needed to support health care workers and keep them safe during this period. In the first few weeks of the lockdown Jill Ovens, MERAS co-leader (industrial) and I were on daily Zoom meetings along with our other health union colleagues to agree the provisions in relation to Special Leave for those in selfisolation and those who met the criteria as vulnerable workers, as well as payments for casual workers. There were also discussions about the provision of accommodation should those staff caring for patients with Covid-19 wish to isolate themselves from their families.

A group was also established between union representatives and the chief nurse at the Ministry of Health to discuss issues related to PPE and to provide feedback on draft PPE posters that were being developed by the Ministry. This group met three times a week and I was one of three union officials with clinical backgrounds that represented the health sector unions, the other two union representatives were Deborah Powell (Association of Professional and Executive Employees and the Resident Doctors Association), and Kate Weston (New Zealand Nurses Organisation). Our first priority was to ensure that PPE was available to staff in their workplaces.

YOUR UNION

There were also separate discussions with the Ministry’s maternity team, the New Zealand College of Midwives, MERAS, Royal Australian and New Zealand College of Obstetricians and Gynaecologists and representatives and the Ministry infection control and prevention committee to agree the PPE provisions for maternity services.

continued provision of health services.

The consultation process that would normally occur between DHBs and unions when changes in the workplace are planned was not possible. The DHBs have agreed that any changes made during Level 4 and 3 would return to practices in place prior to Covid-19 or a proper consultation process should occur if the changes have been positive and worth continuing with.

Local engagement forums between union representatives and individual DHBs were established to ensure the decisions being made at a national level were being implemented smoothly at a local DHB level with a particular focus on PPE availability, vulnerable worker assessments, limiting the movement of staff between wards and encouraging ‘pod rostering’. Jill and I were kept busy juggling these meetings as DHBs discovered Zoom.

There have been some positive changes that have emerged as a result of Covid-19 planning. One of the most significant of these has been the use of Zoom for meetings.

In addition to meetings with the DHBs and MoH, Jill and I have used Zoom to connect with MERAS members during the lockdown. The use of Zoom by all DHBs for their meetings has made it a lot easier to attend several meetings a day at different DHBs around the country. Now that Zoom is in place at most workplaces there are opportunities for midwives to continue using this platform for staff meetings and other forums.

Through the discussions that occurred at a national and local level MERAS, midwifery leaders and the College of Midwives were able to raise the profile of maternity services and the role of midwives. Recognition was given to the birthing suite as a ‘front door’ service of the hospital and that the work of maternity services continued largely ‘business as usual’ plus Covid-19.

There were also weekly Zoom meetings between the midwifery leaders, the College, MERAS, the Midwifery Council and Ministry maternity team representatives to share ideas. We wanted to ensure there was a coordinated response to Covid-19 and the actions that maternity services needed to take to keep midwives, women and babies safe whilst they continued to provide care.

We made much greater use of our MERAS website to provide the latest information for MERAS members about Covid-19 and the website was regularly updated with information from the Ministry and other sources. The MERAS Facebook page also provided a way for members to share information and articles about Covid-19 and experiences of the Covid-19 response from their workplaces.

HEALTH AND SAFETY CONCERNS HIGHLIGHTED As well as initial concerns about the availability of PPE, midwives were also concerned about the risks of asymptomatic or pre-symptomatic transmission, based on what was being heard from international sources. A MERAS media statement about these concerns was largely ignored by the media, but the risk is now widely recognised.

The country was fortunate that we did not have the community transmission that was initially feared.

There have been some positive changes that have emerged as a result of Covid-19 planning. One of the most significant of these has been the use of Zoom for meetings.

Though we had a few incidents of midwives being stood down after possible exposure to Covid-19, there were no cases of workrelated Covid transmission among midwives that we know of. Other health care workers were not as fortunate as highlighted in cases at Canterbury, Waikato and Waitemata DHBs. Although DHBs conducted their own internal investigations, MERAS and other health unions are calling on WorkSafe to investigate these workplace incidents and that lessons learned from these incidents are fully understood and disseminated.

OPPORTUNITIES THAT COVID HAS PRESENTED There were many initiatives introduced quickly during Level 4 to support the

There have been changes to out-patient services and the greater use of virtual consultations or tele-health has reduced the need for women to attend in person.

This approach to providing midwifery and obstetric clinics needs to be evaluated but may well be provide some long-term opportunities in the way that these services are provided to women.

There was a high degree of collegiality across the maternity sector with midwives supporting midwives in all our roles to ensure that we remained safe in our work as well as keeping women, babies and their whānau safe. Hopefully, this sense of collegiality will continue as we now start to plan for the longer-term. square

For further information on PPE or Covid-19 FAQs visit the MERAS website.

If you have any questions or concerns please email or phone Caroline Conroy at caroline.conroy@meras.co.nz, 027 6888 372 or Jill Ovens at jill.ovens@meras.co.nz, 021 598530. For MERAS Membership email: merasmembership@meras.co.nz Call: 03 372 9738

ISSUE 96 JUNE 2020 | 9

YOUR MIDWIFERY BUSINESS

midwives go extra miles to cover for colleagues SHANTI DAELLENBACH LOCUM SUPPORT COORDINATOR

Primary midwifery care in the community continued as an essential frontline service as Aotearoa New Zealand responded to the arrival here of Covid-19. Many community midwives across the country have had to go into temporary self-isolation due to overseas travel, flu symptoms, close contacts and testing. MMPO Locum Support has been responsible for facilitating funded locum cover for caseloading community midwives who have found themselves in this situation.

COVID-19 CHALLENGES AND THE RESPONSE

FIRST RESPONSE

By the end of the month, Covid-19 specific cover had jumped to 437 days, for reasons including self-isolation and testing due to close contact with confirmed or suspected cases of Covid-19, symptoms, and vulnerability (e.g. underlying health condition).

Community midwives’ awareness and high level of concern for ensuring safe and uninterrupted midwifery care for women meant that they were extremely proactive about getting tested right from early March 2020 and then if required arranging a locum to replace them.

All other entitlements including usual leave and urgent cover for non-covid related reasons remained available and in use during this time.

A key concern for the MMPO service was that it needed to be prepared if faced with having to replace entire midwifery practices in the event that Covid-19 became widespread

MMPO Locum Support started receiving requests for Covid-19 related locum support from as early as 6 March, for midwives returning from overseas or following close contact with people arriving from category one countries.

The MMPO and New Zealand College of Midwives were in early contact with the Ministry of Health and as a result were able to secure emergency funding to support paid locum cover for community midwives affected by Covid-19. This funding was made available for “special circumstances where midwives need to self-isolate because of potential exposure to the Covid-19 virus”.

This early preparation and confirmation of funding allowed the service to respond quickly when the move to Alert Level 4 was announced.

Covid-19 has resulted in a need for locum support that is unprecedented in the 10 years the service has been operating. After just four days at Alert Level 4, the service had booked 223 days of Covid-19 specific locum cover across the country. The majority of this initial cover was for midwives who had returned from overseas in the previous 14 days.

10 | AOTEAROA NEW ZEALAND MIDWIFE

In the early weeks and throughout the Alert Level 4 lockdown, community midwives reported a number of challenges that were impacting their need for cover. The most common were timely access to Covid-19 testing, and access to Healthline and/or GP advice which was sometimes contradictory.

SNAPSHOT: COVID-19 LOCUM COVER AT ALERT LEVEL 4 109 Midwives

734 Days of cover

115 Locums

426 Days (58%) Urban 308 Days (42%) Rural

RESPONSIBLE FOR: 5,793 Total women 1,517 Total visits 228 Total expected births (ACROSS ALL 20 DHBS)

Most affected: Canterbury, Waitemata, Waikato

YOUR MIDWIFERY BUSINESS

in the community. On the first day of lockdown we put out a call for prospective locums to come forward with their availability in preparation for any worst-case scenario that could eventuate.

The response from midwives was incredible and as a result approximately 98% of those needing Covid-19 cover were able to access a locum either from within their practice or their immediate region with minimal difficulty.

In remote rural areas where there were no midwives to provide cover locally, locums travelled in from other regions to ensure these midwives and their communities were supported. In some cases this included using personal campervans as the only accommodation options available or undertaking 10 hours of travel simply to reach the affected area.

Not only were midwives quick to step in to cover their colleagues, healthy and well midwives in enforced self-isolation sought to reduce strain on the workforce by continuing to do what work they could from home, allowing locums to focus on the necessary care in the community. As other face to face primary health services were withdrawing, community midwives did all they could to continue to provide high quality frontline primary maternity care to the women of Aotearoa.

Our staff feel privileged and proud to have been able to help and support this essential frontline workforce through these unprecedented times.

Kia Kaha

The New Zealand College of Midwives is offering the following grants to assist midwifery students in Bachelor of Midwifery programmes:

MMPO LOCUM SUPPORT The kaupapa of the service is to help ensure continued access to high quality midwifery care for all pregnant women in Aotearoa by supporting sustainable practice for community midwives.

MMPO Locum Support offer workforce support including paid locum cover and other support for rural community midwives and urgent locum support to urban midwives with funding from the Ministry of Health.

Each year, the service supports approximately 600 rural and urban community midwives with locum cover. The service can be contacted by calling 0800 MIDWIFE.

REFLECTING AND LOOKING FORWARD

• A grant of $750 for a second year student at each of the four schools of midwifery (four scholarships in total) • A grant of $1000 for a third year student at each of the four schools of midwifery (four scholarships in total) • A ‘Special Circumstances’ grant of $500 is available to one second or third year student To apply, applicants must: 1. be a College member 2. intend to practise in New Zealand on graduation 3. provide two referees

The pressures of an increased workload, a different way of working so far under Covid-19, together with the need to manage and support their own isolation bubble at home has obviously been extremely challenging.

statements/letters: i) one from a lecturer at your midwifery school ii) one from the local College regional Chairperson

The MMPO and its Locum Support team connect with community midwives from across the country every day and have a long relationship with many.

or delegate 4. provide a short statement

on how the grant will benefit

your studies

Please continue to call with your stories as the information we receive from community midwives each day is vital in our discussions with the Ministry of Health particularly as we continue to negotiate and push for increased workforce supports. square

Please email your application to lynda.o@nzcom.org.nz

The Grants Advisory Committee will award the grants

Applications are open until 28 June 2020

MMPO, the Midwifery and Maternity Providers Organisation provides self employed community midwives with a supportive practice management system. www.mmpo.org.nz mmpo@mmpo.org.nz 03 377 2485

Midwifery Student Grants

Some midwives drove their campervans to locum assignments where accommodation was not available.

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FEATURE

international day of the midwife 2020: our virtual celebration 12 | AOTEAROA NEW ZEALAND MIDWIFE

FEATURE

Midwives could not celebrate in the usual way this year and The New Zealand College of Midwives organised video messages and Facebook posts to help mark the day. Women, their families and public figures joined in enthusiastically.

Above are some images from the day.

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FEATURE

RIght: The College was closely involved with the Ministry of Health in producing guidance on the use of PPE so it reflected the work of midwives adequately.

SO, HOW DID WE DO? Alison Eddy, Chief Executive of the New Zealand College of Midwives talks to Maria Scott about the College’s response to life in lockdown and how midwives in New Zealand rose to the challenge.

WHAT WERE YOUR FIRST THOUGHTS ABOUT THE COLLEGE STAFF AND MEMBERS WHEN YOU LEARNED THAT THE COUNTRY WAS MOVING INTO A SITUATION THAT ONLY WEEKS AGO WOULD HAVE BEEN UNIMAGINABLE?

As calls began coming in from midwives who were dealing with Covid related issues in their practice, we quickly realised that this was going to be something we had never experienced before. Information from overseas about the pandemic wave in China and then Iran started to filter through. As our health sector started gearing up, there were lots of questions, and as none of us had experienced anything like this before, the answers were hard to find.

When the rules for returning travellers were put in place, and midwives began needing locum cover to self isolate, the potential enormity of what might lie ahead for the population and the midwifery workforce started to become truly apparent.

Looking back (with the benefit of hindsight which is always a wonderful thing!) it was obvious that we were going to end up in lockdown, however the speed at which it occurred took most of us by surprise. The uncertainty over the number of cases which might present in those early weeks, and the fact that core midwives would be required to look after any women who had Covid who presented in labour must have been incredibly frightening for them.

Part of the buzz of going to work in a secondary or tertiary hospital environment is knowing that every day will be different,

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from shift to shift. But when everything in your work environment is gearing up for a catastrophic event, going to work must have been pretty scary.

Community midwives were really impacted by the changed environment too, the need to implement the screening processes, social distancing and hygiene requirements, virtual or telephone consults, in such a short period of time, and the lack of structural support around them to assist in making the adaptations needed were huge, not to mention the PPE issues.

It’s simply in our DNA to cope and this is to our disadvantage in many ways. As a capable group of women, getting on with the job, we fly ‘under the radar’.

As far as the College’s national office functions go, we were able to pretty quickly adapt to working from home, as so many of our systems are online now. As a small organisation with a strong core purpose, the national office team have always worked in a very integrated way and we have close relationships as colleagues, so we were relatively quickly able to adapt.

The fact that midwives adapted to these changes was just another example of how midwives ‘just get on and do’ when the going gets tough.

The administration team are a capable group and were able to ensure seamless services for our core membership functions throughout.

The rapid move to online mediums for some of our activities like education workshops and Midwifery Standards Reviews were more challenging to deal with.

WHEN DID IT BECOME CLEAR THAT THE NEW WORKING ENVIRONMENT WAS PRESENTING HUGE CHALLENGES TO MIDWIVES, ESPECIALLY THOSE IN THE COMMUNITY?

It was pretty clear from the outset that the new normal was a major disruption for midwives and maternity services. The statistics about the number of babies born in New Zealand during the lockdown – approximately 7,000 during the Level 3 and 4 lockdowns - have really resonated with the media, politicians and even those throughout the health sector in other areas. They tell the story in stark reality of what midwives and women were experiencing.

Ironically, the health system was gearing up for a major influx of people who would need health care for Covid related illness, and this didn’t happen. As these services were resourced and supported to scale up to accommodate a large number of people needing care, it felt very much like the services which had to continue business as usual (BAU) and even increase their workload, such as maternity services, were almost overlooked. The rapid withdrawal of other in-person health and social services left an enormous void which midwives had to fill, and this simply added to the stressors on an already under resourced workforce who were also dealing with rapid change.

The pandemic response disadvantaged communities which are already experiencing inequities, and midwives, as one of the only – if not the only health service still having

FEATURE

in-person contact with women, and entering homes, were at the pointy end of this.

Midwifery is a holistic service, as well as the physical assessments, acute care, including labour and birth, we also understand and respond to women’s emotional needs including their anxieties and fears, which were enormous for many. This added to midwives’ workloads and to the stress that many were experiencing in their personal lives.

I fear it has come at an emotional cost for some of the profession who was already at breaking point. The sense of uncertainty for midwives in practice in those first weeks of the lockdown must have been overwhelming for many.

Access to PPE must be number one on the list.

For many midwives, particularly community midwives it was simply not available.

Although there were the promises from the Ministry of Health that there was plenty for everyone, PPE was like a unicorn, something magical that didn’t actually exist!

Not only were midwives deeply concerned with the potential risks that they may pose to the women and families by being a potential vector unwittingly transmitting infection, they were also concerned about their own and their families’ wellbeing. The College’s national office staff were in daily contact with Ministry staff and politicians advocating for midwives’ access to PPE, as well as negotiating the guidance documents around the use of PPE in maternity settings so that it reflected the work of midwives adequately.

The ability of regions to respond to members’ needs was impressive and I am so grateful to regional and sub-regional chairs and the many midwives who stepped in to do the mahi during this time.

The speed of change, the need to develop guidance documents for midwives as well as deal with the enormous amount of phone queries, and what felt like a tsunami of email communications required quick and nimble

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Overseas reports about health care workers contracting Covid and dying were starting to flood the media. Those early weeks were hugely stressful for front line health workers like midwives, who were also concerned about keeping their own families and bubbles safe.

WHAT WERE THE BIGGEST CHALLENGES IN SUPPORTING MEMBERS TO COPE WITH THE NEW WORKING CONDITIONS?

YOUR UNION

work by the team of College advisors, who were also adapting to working from home.

Like many midwives, we worked long hours to keep pace with what is needed in a rapidly changing world.

The amazing team of College advisors simply rolled up their sleeves and got on with the job at hand. Although things were happening at speed, the circumstances that we found ourselves in demanded out of the ordinary responses. A lot of guidance documents were developed in a short space of time and we also identified the need to use different formats such as “FAQs” and mediums such as video messages, as the amount of information coming across emails was too much for many to take in and absorb into practice.

As well as disseminating Ministry and other documents, the College was also a conduit for information from other agencies too such as the Pharmacy Council and Ministry of Social Development. The Ministry was in pandemic mode and had set up a national health co-ordination center (NHCC) to manage their response. Their process required all their documents to be signed off by the NHCC and they specifically asked the College not to publish any of our own advice until we could be certain that it was consistent with their guidance.

There was a reason for this – consistent messaging was one of the strengths of the New Zealand Covid-19 response, but the resulting information void in the first few days was incredibly frustrating for members and College staff alike.

The power of the College website and social media platforms came into its own during this period. A big shout out to Hayley McMurtrie our website manager who worked overtime to keep content up to date. A lot of the national office team work part time including Hayley, and yet she responded at all hours and worked over and above to make sure members could access information as soon as it was finalised.

HOW DID THE COLLEGE’S STRUCTURE WITH ITS 10 REGIONAL CHAIRS PROVIDE SUPPORT?

We relied heavily on our regional chairs to forward information by email as we couldn’t access the office to email members directly and I know that this added to their already busy workload. Many midwives turned to their regional structures to seek information, support, advocacy and liaison, and the regions met those needs.

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When the chips are down our common purpose is what holds us all together and the overwhelming need to keep the service working for women, babies and whānau.

The need to connect up, not only for information but also to have contact with others who were experiencing the same anxieties, issues, problems, and to seek solutions motivated this. The usual means of connecting up became unavailable overnight, so attendance at regional Zoom meetings filled the void. The level of communication, liaison with DHBs, practical problem solving and connection between members through the regional and sub-regional College structures was something that has probably never been experienced before.

AS IT BECAME CLEAR THAT THE EXTRA WORK FOR MIDWIVES WAS EXACERBATING THE EXISTING PROBLEMS IN THE WORKFORCE IN RELATION TO FUNDING, WHAT DID THE COLLEGE DO TO LOBBY GOVERNMENT FOR EMERGENCY FUNDING?

The need for an increase in locum funding was really obvious early on, and thankfully it was pretty quickly granted by the government via Health Workforce. The additional stress on the workforce also became apparent early on. We were in close communication with senior Ministry staff, and Minister Julie Anne Genter, Associate Minister for Health and Minister for Women, providing detailed information to her and her staff about the sorts of costs (time and out of pocket) that community midwives were experiencing as well as the PPE issues.

We also flagged these issues to the media to ‘tell the story’, by releasing media statements and using media contacts opportunistically to raise these issues.

When additional funding was announced for general practice very early on, it appeared that midwives were being treated inequitably (yet again) and that (yet again) we would have to apply political pressure to get any traction with the issues. As soon as we understood that there was no political agreement that

financial support would be forthcoming for midwives, I sought the opportunity to appear before the Epidemic Response Committee, and this was valuable to highlight how the current situation had exacerbated already long standing issues, and how inequitably midwives were being treated - yet again!

HOW HELPFUL WERE MINISTERS AND THE MINISTRY? HOW DISAPPOINTED WERE YOU WHEN NO ADDITIONAL FUNDING FOR COMMUNITY MIDWIVES WAS FORTHCOMING? HAS THE EXPERIENCE CONFIRMED THE NEED FOR A ‘PROVIDER ORGANISATION’ TO SUPPORT COMMUNITY MIDWIVES?

Neither the College nor the Midwifery and Maternity Provider Organisation (MMPO) are provider organisations, in that they don’t have direct responsibility for community midwives’ service provision.

Between the College and the MMPO (who were also working above and beyond to support community midwives) we are simply not resourced sufficiently to provide the level of support that midwives needed at this time. By way of contrast or example, budgets for Primary Health Organisations (who support general practices) are around 15% to 20% of the service delivery costs for primary care services. So if we go by those sums as a measure, the College and MMPO should be funded somewhere in the $10s of millions to provide the same level of support to midwives as general practice receives from PHOs. So while PHOs organised virtual platforms for general practice, assisted them to change their service delivery model, procure and distribute PPE and so on, the College and MMPO had to do as much as they could with a very small team of staff based in Christchurch and Auckland, and a network of regional volunteers, essentially running on the smell of an oily rag. Only midwives were interested in the needs of midwives; PHOs and other services did not show any interest, they had enough of their own issues to deal with. There was a lot of frantic and hard work by College staff and volunteers (regional chairs and others) alike that we are simply not equipped for in the same way and I know that this was frustrating for midwives. For me, this was a really clear example of why the College has been advocating for a national provider entity whose scope of support and co-ordination would meet midwives’ needs more effectively.

It is such a glaring gap in the matrix of support around community midwives,

YOUR UNION

and the absence of such a structure really challenged midwives to keep their heads above water, particularly in those early weeks.

HAVE THE CORE AND COMMUNITY WORKFORCES WORKED WELL TOGETHER OR HAVE THE CONDITIONS REQUIRED FOR THE COVID-19 RESPONSE EXPOSED TENSIONS? HAVE DHBS RESPONDED CONSTRUCTIVELY FOR MIDWIVES – CORE AND COMMUNITY?

Overall, this experience has seen a ‘coming together’ of the workforces, and I really want to acknowledge the DHB midwifery leaders who embraced the community midwives in their local planning and activities.

The working environment for core midwives was turned upside down as wards were reorganised to accommodate potential Covid cases, they took on more acute assessment work to relieve the community workforce from having to attend hospitals, put in place teaching about PPE and dealt with stressed women who were not able to have support people or visitors in the postnatal wards.

The need to work together in adversity also meant that usual delineation of roles or areas of contention seemed less important than making sure the service was delivered as needed.

International Day of the Midwife celebrations on 5 May (which were necessarily different due to social distancing requirements) felt really emotional for me this year. A number of other midwives I have spoken to have noted similar feelings. I think the recent experiences we had all shared, and the timing of the day in relation the pandemic curve (the case numbers were now heading in the right direction) meant that it felt like a collective sigh of relief. Oddly, the fact that we couldn’t have our usual in-person get togethers, seemed to strengthen the sense of connection, shared purpose and pride as there was a plethora of online creativity which moved many of us to tears.

WHAT HAVE YOU MOST ADMIRED ABOUT THE RESPONSE OF MIDWIVES TO THE CRISIS?

I have so much admiration for midwives who have worked through this period.

We didn’t know what the trajectory of the pandemic would be at the outset, there was no PPE to be found for love nor money, and as other health care services rapidly withdrew access to face to face or in-person care, the nature of midwifery care meant that midwives simply didn’t have that luxury.

Midwives had to keep turning up each day because maternity care is time-critical and essential.

Some of the stories of appreciation from women about what midwives have done to support them are heart warming and speak to the commitment of the profession.

WHAT DO YOU THINK THE CRISIS, WITH ITS CRASH COURSE IN FINDING NEW WAYS TO COMMUNICATE AT A PROFESSIONAL LEVEL AND WITH WOMEN, TAUGHT US?

It’s hard to evaluate the impact of virtual technology on health care delivery when it’s been implemented quickly and reactively, as opposed to proactively. I have mixed feelings about its use as I suspect many midwives do too. I think what it might have taught us, is that we value relationships with women and that although these technologies have some advantages and may reduce access barriers for care for some women, they are not as useful in picking up nuance or non -verbal communication cues. As a service which has established itself on its relational nature, I fear we will sell ourselves short if we embrace virtual care as our predominant means of care into the future, I’m not saying that it doesn’t have a place, but we should be measuring its impact in a non-pandemic environment to really understand whether it is an improvement or merely a convenience for the provider.

WHAT DO YOU THINK THE WOMEN AND THEIR FAMILIES MAY HAVE LEARNED ABOUT BIRTH AND CARE FOR NEWBORNS DURING THIS PERIOD?

A friend sent me a meme which encapsulates the silver lining of this time “JOMO- Joy of Missing Out – Feeling content with staying in and disconnecting as a form of self care”. For some this has been a time of reflection and connection with immediate loved ones. There have been anecdotal accounts of fantastic newborn weight gains and babies thriving because mothers have had to connect with their newborns and sit and breastfeed with few distractions. These were unintended positive consequences for some. Another shift was the increased demand for homebirth and the fact that women chose to prioritise access to whānau and social supports over access to hospitals.

This gave me hope that at a societal level more women now understand birth in that context as opposed to it being a ‘medical’ event that needs to necessarily occur in a medical environment.

MIDWIVES HAVE CONTINUED TO PROVIDE A HIGH LEVEL OF CARE DURING THE CRISIS. HAS THEIR DEDICATION ONCE AGAIN BEEN TAKEN FOR GRANTED BY POLICYMAKERS? WHAT MESSAGE WOULD YOU LIKE HEALTH SERVICE POLICYMAKERS TO TAKE FROM THE DEDICATION OF MIDWIVES DURING THIS EXTRAORDINARY PERIOD?

Reading from overseas midwifery journals, and from information collated by the International Confederation of Midwives, it’s clear that all over the world midwives hold universal concerns about the impact of this pandemic on women and babies, their access to and experiences of maternity care. Of course in a global context our issues in Aotearoa New Zealand seem almost insignificant, but when you look at the commonality of the themes emerging, they are overwhelmingly similar.

Midwives are concerned that maternity services have not been prioritised during this period, that not only the physical health care needs of women have been affected, but the social support that women normally draw around them when they have a baby has also been profoundly altered. There will be consequences as a result of this that we don’t fully understand yet. A fundamental role of midwives is to advocate for women’s rights in childbirth, and many, many midwives will have gone above and beyond during this period to minimise potentially negative consequences on women, as we care deeply, not only individually but as a collective, about this.

If nothing else, this pandemic has taught us the value of life, connectedness and the importance of community. Midwives are there at the beginning of life; our job is to build strong mothers, who in turn build strong families and strong communities.

The importance of acting as a ‘national community’ to beat the virus has shown that New Zealanders believe in a collective spirit, otherwise we wouldn’t have been so successful in flattening the curve.

So my message to the politicians is quite simple, you have a committed and capable workforce whom you cannot continue to take for granted. By valuing midwives you will demonstrate that you value the things which all New Zealanders have held onto during these difficult times. By valuing midwives, you will demonstrate that you value women, families, and communities: the building blocks of our collective spirit. square

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Alice Buzan, administrator, Kerry Blackwood, administrator (top right), and Kate Clark, MFYP support (bottom right) from the New Zealand College of Midwives working from home.

WHAT WE DID IN LOCKDOWN Our Covid diary – how the College worked for midwives during the emergency MARIA SCOTT COMMUNICATIONS ADVISOR

The year was already shaping up to be busy when the New Zealand College of Midwives, along with the rest of the world, was plunged into preparation for a pandemic described by the United Nations as the defining health crisis of our time. The College was preparing to mark 2020 as the International Year of the Midwife, as designated by the World Health Organization, while ramping up its long-

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running campaign to win a new pay deal for community midwives. Early in March the College hosted a celebration breakfast at Parliament in Wellington to highlight the work of midwives and separately presented a petition of nearly 26,000 signatures to the government appealing for financial recognition for community midwives. This is what happened next:

WEEK ONE – 22 TO 28 MARCH

On Saturday, 21 March Prime Minister Jacinda Ardern addresses the nation and explains that New Zealand would start to operate under a series of four ‘alert levels’ to control the spread of Covid-19. As of that day we were at Level 2 requiring, among other things, working from home where possible. Soon after the announcement, College Chief Executive Alison Eddy and Office Manager Lynda Overton text all staff to instruct them to work at home from Monday. On that day, the Prime Minister announces that we are moving to Level 3 and up to Level 4 in 48 hours’ time, midnight Wednesday 25 March. At this point, some travel and public activity is still permitted, enabling staff who need to collect equipment from the office to do so before Wednesday.

The College IT advisor starts working with those who need help to get set up.

Lynda co-ordinates the shut-down of the national office. Jacqui Anderson is acting

Chief Executive while Alison Eddy is on bereavement leave. Media calls start coming in asking how the Level 4 restrictions, which minimise face to face consultations and result in many other restrictions on the delivery of health care, will affect pregnant women and midwifery care.

McBeath at home across Christchurch. The administrators are involved in most aspects of College services, from the booking and organising of workshops, administration of membership fees and records, the Midwifery First Year of Practice Programme (MYFP) and College accounts.

The media proves to be a powerful tool for telling midwives’ stories during the emergency and our response is led by Media Advisor Ali Jones. Ali takes more than 30 requests for interviews from the media – television, radio, newspapers, magazine and websites – before we leave the Level 3 lockdown. Alison Eddy, College midwifery advisors and midwives working in the community and hospitals are involved in the media response. We also issue several media statements about issues of urgent concern.

The College’s midwifery advisors, Jacqui Anderson, Lesley Dixon, Elaine Gray, Claire MacDonald and policy analyst Carol Bartle start regular morning and afternoon meetings by video conferencing service Zoom to discuss issues that are coming up and strategies to support members.

By the start of lockdown on Thursday we are set up to take phone calls as usual by re-routing them to the College’s admin and support team, Kerry Blackwood, Saili Tuitaupe, Lisa Donkin, Kate Clark and Fiona

Calls started to stream in from College members around New Zealand and from women about how midwifery care will proceed under the rules for the ‘Level 4’ lockdown and the recommendation for ‘social distancing'.

Questions start to come in from midwives and media about use of Personal Protective Equipment (PPE) and it is soon clear that midwives are having difficulty obtaining supplies of masks and other equipment.

This proves to be a major concern for midwives, especially in the early days of the emergency measures.

midwifery practice during the Level 4 alert; there are many questions, from how midwives can maintain care while curtailing face to face consultations to how women’s options for place of birth might be affected.

Discussions start with the Ministry of Health about supplies of PPE and best

It becomes clear that the College’s view about when PPE should be used is at odds

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WEEK THREE – 5 APRIL TO 11 APRIL College advisors hold a Zoom meeting with the College’s regional chairs who have been playing an important role in supporting members regionally and disseminating College messages and emails to local members. It is clear from the meeting that midwives are working even harder than usual.

College midwifery advisor Claire Macdonald (second left, top row) ‘Zooming’ with midwifery leaders.

with Ministry guidelines and that the Ministry’s public reassurances there are delays in the distribution of equipment.

Over the weekend, the College issues a media statement calling for better supplies of PPE and guidelines appropriate for midwifery care, including care provided in the community. College advisors commence regular video conference meetings with the district health board midwifery leaders.

Midwifery advisors and policy analyst Carol Bartle continue work that had begun the previous week on a series of guideline documents and Frequently Asked Question summaries to post on the College website for community and hospital midwives about all issues related to care of mothers and babies during the Covid-19 emergency. They also prepare guidelines for women and a series of FAQs. In line with the College’s usual method of working, documents are shared and critiqued by all advisors to ensure they are accurate, reflect best practice and are easily understood.

Throughout the week updates are posted on the College website as they are ready.

The website, managed by Hayley McMurtrie and the College Facebook page are to become a vital source of information for women.

A specific email address, also set up the previous week for members’ questions, is flooded with queries. Advisors take turns in responding and set up a rota to cover weekend enquiries.

Jacqui Anderson records a video message updating members on the College’s response that is posted on the website.

WEEK TWO – 29 MARCH TO 4 APRIL Chief Executive Alison Eddy returns to work. Work starts under Jacqui Anderson, midwifery advisor (quality assurance) to re-schedule the many midwifery standards 20 I AOTEAROA NEW ZEALAND MIDWIFE

review appointments booked throughout the country. Midwives booked for review are given the option to postpone or to have their reviews conducted by video call. This involves many hours of work for Saili Tuitaupe, who administers the process, establishing what types of computer equipment and video links are suitable to set up the three-way meetings required for reviews.

The MoH has issued guidelines on where women who have been exposed to Covid-19 or have the virus can birth. Most DHBs are allowing only one support person for women during labour and birth and allowing no visitors during postnatal stays.

College members are asking for specific guidance about care during the antenatal and postnatal periods, working within the recommendations for reduced face to face contact and social distancing.

College advisors begin drawing up more detailed guidance including easy-to-follow flow charts.

The College, led by Alison Eddy, begins discussions with the Ministry about extra financial assistance for community midwives.

Alison and colleagues, including Wayne Robertson, Executive Director of the MMPO, produce a document setting out the case for assistance which is presented to Julie Anne Genter, Minister for Women and Associate Minister of Health on 31 March.

Christchurch community midwife Violet Clapham, who also works part time as a midwifery advisor at the College, records a video message to women reassuring them about the care midwives will provide during the emergency.

Alison Eddy records a message for members acknowledging the difficult and extraordinary circumstances midwives are working in and updating them on the work the College has been doing to answer their questions and address their concerns.

The extra calls on their time and skills include postpartum follow-ups (that would normally be done in hospital) on women discharged early after caesareans, transporting specimens to laboratories because of disruption to the usual lab services and extra practical support for women and their families especially those in vulnerable circumstances.

Chief Executive Alison Eddy and Midwifery Advisor Violet Clapham are interviewed by TVNZ about the challenges of providing midwifery care during the emergency. They highlight the extra workload for midwives at a time when community midwives are still waiting for a settlement over their pay.

Midwifery advisors complete work on detailed guidance for ante and postnatal appointments and care and this is posted on the College website.

Initial feedback from midwives and reviewers who have conducted midwifery standards review meetings electronically are generally positive.

Nicole Pihema and Alison Eddy meet via video conference with Minister Genter to discuss issues related to maternity care during the pandemic, including PPE access and additional workloads for midwives.

In addition to the workload for midwives, questions are coming up about the loss of payments for LMC midwives where they have been unable to accompany women to hospital for care they would normally provide for them there, such as epidurals. Some

Midwives are not saving time through virtual working. The new methods of working require time and energy and midwives miss the direct contact with the women they are caring for which is such an integral aspect of midwifery.

There is anecdotal evidence emerging that, as feared, family violence is increasing as families are confined to their homes. It is also clearer than ever that midwives working in deprived areas have some of the most challenging workloads. hospitals are restricting the number of carers gaining access to maternity units leading to losses for midwives.

The Ministry of Health issues new guidance on PPE for frontline health workers. The guidance acknowledges the need for health professionals to use their clinical judgement about when to use PPE but stops short of recommending the use of masks in all face to face consultations. The College issues a media statement acknowledging the Ministry position but supporting midwives to use the PPE they deem necessary for the situation they are working in. Meanwhile the problems with supply seem to have eased but not before some midwives have sourced and paid for their own protective equipment.

We are now half way through the four week period that the government forecast would be required at Level 4. The trends in the spread

of the virus throughout New Zealand are encouraging but there is no suggestion Level 4 will be lifted early. The midwifery advisors start planning for guidance to move to Level 3 and beyond. Advisors share the work involved in reviewing the documents they have prepared for Level 4.

There is an emerging issue over the availability of scanning facilities because many of the private radiology clinics have apparently closed or laid off staff. It seems there are still facilities at the DHBs but this involves going into hospitals, not something being encouraged at present except for the really ill. Advisors agree to seek clarification from the Ministry.

There is some confusion about the medical certificates midwives are issuing for pregnant women in the workforce, especially health workers, nurses and others.

There seems to be a concern amongst midwifery and nursing leaders that staff are being ‘signed off’ the workforce unnecessarily because they’re pregnant.

The advisors agree to write some guidance on the midwife’s role and responsibilities with medical certificates.

Word is expected soon from the Ministry about financial assistance for the midwifery workforce to compensate for the extra demands of the emergency environment.

Some sectors of the health service, notably GPs have already received assistance because their income has fallen as face to face consultations have been virtually eliminated.

The College is hopeful that its appeal has been successful.

College midwifery advisors open a discussion with RANZCOG, (Royal Australian and

New Zealand College of Obstetricians and Gynaecologists), about criteria for referring pregnant women with Covid-19 for obstetric or specialist assessment. The advisors are concerned that RANZCOG’s current view is putting too much onus on midwives to make judgements about care.

WEEK FOUR – 12 APRIL TO 18 APRIL Advisors have a well-earned break over Easter although they continue to share monitoring of the Covid-19 email line and to take telephone enquiries. The College is increasingly hopeful that financial assistance for LMC midwives’ Covid related costs will be forthcoming. There is also to be an announcement about which businesses and services can re-open when we move to Level 3, the next level of restrictions down the Covid control scale.

College President Nicole Pihema and Alison Eddy are to meet this week with RANZCOG to discuss issues related to care of the placenta during the crisis including cultural practice (care of the whenua/ placenta,) and the infectivity risk from the placenta.

Advisor Elaine Gray and Auckland Midwifery Advisor Brigid Beehan are to meet representatives from the National Screening Unit regarding access to ultrasound services (given that so many clinics have closed). Also on scans, the Ministry has produced guidance on scans during the crisis and the College is unhappy about the apparently strict recommendations and the reduced times recommended for scans. Alison and advisors are to discuss this with the Ministry.

Alice Buzan and co-workers at home.

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Alice Buzan's daughter Mila.

Anthony Hill, Health and Disability Commissioner, whose office investigates complaints about health care, has requested a meeting with the College to discuss the implications for midwives relating to access to scans, the reported increase in home births and the conduct of face to face consultation.

This aim is thought to be to pre-empt questions or complaints that might come up as a result of changes to care protocols.

The advisors are working on FAQs for midwives and women about home birth

Media enquiries continue as women begin to publicly voice their concerns and anxieties, especially about where they will give birth. There seems to be increasing interest in home birth as women decide it may be safer to birth at home than going to Hospital.

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during the Covid crisis as it becomes clearer that many more women are choosing to birth at home. There is some concern that midwives may come under pressure from women to birth at home when they would not normally be advised to do so.

On Thursday, the Prime Minister announces more detail about how New Zealand will operate under a Level 3 alert system. It seems likely that we will move from Level 4 to Level 3 the following week.

Alison and advisors agree that little will change for midwives and maternity services in Level 3 so it seems likely that midwives will continue to bear a heavy workload.

Meanwhile it is clear that midwives are beginning to feel the strain of their extra workloads and changed environment, and that morale is falling. Work starts on a video message to recognise the work midwives are doing in difficult circumstances.

There has been a public statement that the Christchurch conference centre Te Pae, which was to be the venue for the College’s 2020 conference will not be finished in time for the event, which was scheduled for October. The aim is to reschedule for September 2021 and all prospective participants are contacted to break the news.

Discussion starts on production of a special digital-only version of our new magazine

Midwife to go out to members in a ‘turn page’ version in June. Our print company BNS in Christchurch has been closed during the Level 4 lockdown and it is unclear what their position will be under Level 3.

Anecdotal reports emerge that some mothers and babies are thriving during lockdown, apparently because there is time available for women to establish and concentrate on breastfeeding.

Midwives continue to comment on the increased demand for home births providing an insight on the way women and families are re-assessing their views on risk. Suddenly Hospital seems a risker place to have a baby than the home. Midwifery advisors observe that New Zealand’s maternity system offers home birth as a standard option and is showing itself flexible enough to cope with the increased demand.

Reports are reaching the College that it has become virtually impossible for women to have Non Invasive Pre-natal Screening (NIPS) because the private clinics providing the service have closed during lockdown.

Midwives are referring women who need specific screening to fetal medicine units at hospitals.

Advisors agree that despite the stress of recent weeks midwives are ‘settling’ as far as is possible into the new routines demanded by the conditions of lockdown.

WEEK FIVE – 19 APRIL TO 25 APRIL

advocacy. Her presentation is widely reported in the media.

College representatives meet with members of the Midwifery Council to discuss how to enable midwifery students to safely resume clinical placements again. Students have remained in their programmes but this has resulted in extra work for teachers.

The Ministry sets up a telephone advice line for health professionals to answer queries on the Covid response. The College’s midwifery advisors have already fielded hundreds of calls and emails from members but supports the initiative and recommends midwives with suitable experience to staff it.

It is becoming clear that even under the restrictions of a Level 3 alert midwives’ workloads will remain significantly higher than normal.

It becomes clear that no additional funding to support midwives for Covid related costs will be forthcoming. This is a major blow.

Alison Eddy, midwifery advisors and regional chairs discuss the College’s response and Alison requests a meeting with the Minister for Health, David Clark but no appointment is forthcoming.

There is caution about appearing to lobby excessively but the College decides to continue to use media to spread the midwives’ message as opportunities arise.

Advisors and support staff are working on ‘virtual’ events to mark International Day of the Midwife on Tuesday, 5 May. Normally midwives throughout the country would celebrate with get-togethers and social events but this year it’s different. There will be photographic messages of support from women and families, videos of midwives at work and other messages to share through social media and on the College website. There will be a media release and

opportunities for journalists to interview midwives and mothers. The event is an opportunity to further publicise the efforts of midwives during this extraordinary time and to draw attention to their case for fair pay and a new funding model. On the day, a highlight is the special mention for midwives

by Prime Minister Jacinda Ardern and director general of health Ashley Bloomfield at their daily briefing to the media. Next morning, Alison is interviewed by Kathryn Ryan on her Nine to Noon programme on RNZ. She says the hope is that after a five-year struggle to win a new deal for community midwives, the Budget, to be delivered on 14 May will finally bring good news for the profession.

New Zealand starts to look forward to the prospect that we will move to the less restrictive Level 2 the following week. Bring on the new normal. square

Alison applies to appear before the Epidemic Response Committee, chaired by former Leader of the Opposition Simon Bridges and designed as a mechanism to review the government’s response to the pandemic while Parliament is not sitting in the usual way.

Alison’s request is accepted and she starts work on a written briefing paper to present to committee members before she appears in person. The media will be approached to publicise the College’s presentation.

The Prime Minister announces that New Zealand will move to Level 3 on 27 April.

Advisors still do not expect significant relaxation to practice as it has been applied under Level 4.

Wellington midwives Andrea Sarty and Sarah Gilbertson write an open letter to the Prime Minister explaining how the emergency has affected midwives and appealing for recognition. Work starts on a survey of midwives to gather information on the impact of working conditions during the crisis.

WEEK SIX – 26 APRIL TO 2 MAY Alison appears via video conference at the Epidemic Response Committee (ERC) and succinctly relates the experiences of community midwives working through lockdown, pointing out that approximately 5,000 babies have been born during that time.

She explains that the workforce of 1,300 community midwives was already under severe pressure before the Covid crisis because of the long-running deterioration in pay and working conditions. Many College members watch the ERC broadcast live and congratulate Alison on her articulate

Administrator Lisa Donkin.

ISSUE 97 JUNE 2020 I 23

college survey confirms the impact of covid response on midwives It was clear soon after New Zealand locked down to fight the virus that midwives were under pressure. There was anecdotal evidence of the extra work they were doing and their struggles to obtain Personal Protective Equipment. The New Zealand College of Midwives developed a survey aimed at identifying the impact of the Covid 19 pandemic and the alert status levels 3 and 4 on the work of members.

LESLEY DIXON MIDWIFERY ADVISOR: PRACTICE ADVICE AND RESEARCH

24 | AOTEAROA NEW ZEALAND MIDWIFE

FEATURE

A total of 781 midwives responded which gave a response rate of 26.8% of practising midwifery members. We received responses from a broad range of midwives from throughout New Zealand.

FIGURE 1: WORK SETTINGS

When asked about their main work setting 369 (47.2%) worked as a self-employed LMC midwife, 71 midwives (9.1%) were employed to work in a tertiary unit, 98 (12.5%) worked in a secondary maternity unit, 37 (4.7%) worked in a primary maternity unit and 91 (11.7%) worked in the community as employed case-loading midwives (FIG.1).

The rest identified a variety of other roles such as management, education, and research. We have divided these work types into the following work settings: • Hospital midwives (primary/secondary/ tertiary employed midwives) (n=206; 28% of respondents) • Community midwives (employed caseloading midwives & LMC midwives) (n= 460; 64% of respondents) • Other (employed education, management, research etc. (n= 60; 8% of respondents)

Community Midwife - 64% Hospital Midwife - 28% Other - 8%

FIGURE 2: IMPACT ON WORKING ENVIRONMENT 50

40

30

50.5%

49.6% 43.4%

30.7%

30.9% 28.3% 15.4%

21.5% 20

12.1%

10

7.1% 4.4%

WHAT DID WE FIND?

0 Hospital Midwife

The vast majority of hospital and community midwives agreed that the Covid-19 alert level 3 and 4 had impacted on their work environment (FIG.2).

Midwives across all practice settings identified the need to reassure women (89.5%), update on guidelines (86.9%), attend education on personal protective equipment (PPE) (70.5%), and the need to change ways of interacting with women and families (91.7%) as impacting on their working environment.

The changes in work environment also increased the workload for many midwives (FIG.3), with more community midwives than hospital midwives agreeing with the statement that overall their workload increased. There were 450 (60.8%) midwives who reported an increase in the number of hours they worked - of which 331 (73.6%) were community midwives, 77 (17%) were hospital midwives and 42 (9.3%) had other roles.

3.9%

Community Midwife

A great deal

A lot

Other

A moderate amount

A little

FIGURE 3: OVERALL MY WORKLOAD HAS INCREASED 100

80

60

40

20

0 Strongly Agree

Agree

Neither Agree/Disagree

Community Midwife

Hospital Midwife

Disagree

Strongly Disagree

Other

Midwives strongly agreed/agreed that women and their families needed more time and reassurance than usual (75.3%), that providing care took longer because of PPE (66.6%) and the need to clean equipment and the environment (90.4%).

ISSUE 96 JUNE 2020 | 25

FEATURE

ACCESS TO PPE

FIGURE 4: ACCESS TO PPE

The survey asked members whether they were able to access PPE when they needed it in the first two weeks of the Covid-19 Alert Level 4 and in the second two weeks. Responses indicated that a significantly higher proportion of community midwives were unable to access the PPE they needed in the first two weeks of Alert Level 4 when compared to hospital midwives. 61.7% of hospital midwives were able to access PPE as needed compared to only 26.5% of community midwives during this time (FIG.4).

100

80

60

40

20

0 Hospital Midwife

Community Midwife Yes

Hospital Midwife

Community Midwife

This situation changed in the second two weeks of Alert Level 4 when 82.4% of community midwives and 89.3% of hospital midwives were able to access PPE when needed.

No

FIGURE 5: HOSPITAL MIDWIVE'S ANTENATAL/LABOUR & BIRTH More time screening for Covid-19 risk factors

PROVIDING CARE TO WOMEN WITH SUSPECTED, PROBABLE OR CONFIRMED COVID-19

More time providing labour care due to more handovers More time talking about support during labour More time discussing changes to birth plans 0

20

60

40

Strongly Agree

80

Agree

IMPACT ON EMOTIONAL WELLBEING

FIGURE 6: HOSPITAL MIDWIVES' WORK POSTNATAL

Providing an essential service during the Covid-19 Alert Levels 3 and 4 increased anxiety levels for midwives with 553 (76.4%) identifying that they had felt anxious about their own health and wellbeing as essential health workers during the pandemic.

More time providing breastfeeding support More time doing maternal and neonatal assessment Women with C-Sections have discharged earlier

IMPACT ON FAMILY

More women have discharged early from Hospital 0

25

80

50

Strongly Agree

100

Agree

THE IMPACT ON MIDWIVES FAMILIES

“Changed bedrooms around to ease my access to shower/washing machine after shifts. Also spent a night in a motel away from my kids after caring for suspected case.“ 26 | AOTEAROA NEW ZEALAND MIDWIFE

There were 199 (27.4%) midwives who reported that they had provided care to a woman who was a suspected, probable or confirmed case of Covid-19; 87 were hospital midwives (42% of hospital midwife respondents) and 99 were community midwives (21% of community midwife respondents).

The majority of midwives (81.1%) also felt anxious about the wellbeing of their family/ whānau because of the essential nature of their work. 332 midwives (43.7% hospital midwives, 47% community midwives) changed their home and living arrangements during this time.

TIME OFF Although the majority of midwives were able to take their usual time off, 16.2% were not able to due to Alert Levels 3 & 4. Of these 20.2% were community midwives and 8.3% were hospital midwives.

FEATURE

IMPACT ON THE WORK OF HOSPITAL MIDWIVES The survey had a section that had specific questions designed to identify the impact on the work of hospital midwives.

Statements were provided for which midwives were asked to identify if they agreed, strongly agreed or disagreed/strongly disagreed or neither. The following figures identify the responses that were strongly agreed or agreed to these statements.

A large proportion of the hospital midwives who responded (FIG.5) agreed that they spent more time than usual asking screening questions for Covid-19 risk factors (67.7) discussing who could provide support for women during labour (53.2%)%), discussing changes to birth plans (40%), and agreed that they spent more time providing labour care due to more handovers than usual (39.3%).

In the postnatal period, (FIG.6) there were high levels of agreement that women were discharged earlier from hospital than usual (82.4%), which included women who had C-sections (64.6%). However, for those women who remained in Hospital the hospital midwives provided more of the daily maternal and neonatal assessment for the LMC midwives (56.8%) and more breastfeeding support (38.7%). It is likely that early discharges also meant that pre-discharge checks and education had to be undertaken in a shorter and more pressured timeframe.

There were two statements (FIG.7) where there was disagreement, these related to contact time with women. 56.8% of the hospital midwives disagreed that they were able to minimise contact time to less than 15 minutes and 50.7% disagreed that they spent less time providing face to face care during labour than usual.

FIGURE 7: BEING WITH WOMEN-HOSPITAL MIDWIVES

Spent less time with women during labor (F2F) than usual Able to minimise my contact time to less than 15 minutes

0

20

60

40

Disagree

80

Strongly Disagree

FIGURE 8: COMMUNITY MIDWIVES' WORK: ANTENATAL CARE More women discussing home birth More time discussing changes to birth plans More difficult to identify issues with phone/video contact Telephone/video call and face to face contact take more time More time organising ultrasound scans than usual 0

25

50

Strongly Agree

80

100

80

100

Agree

FIGURE 9: COMMUNITY MIDWIVES' WORK: LABOUR AND BIRTH More home birth care

More care during labour at home

More time discussing childcare

IMPACT ON THE WORK OF COMMUNITY MIDWIVES In the section exploring the impact of Covid-19 Alert Levels 3 and 4 on the work of community midwives (FIG.8, 9 and 10) we found that 357 (77.1%) reported that administration and non-clinical work was increased, and 90% experienced an increase in mobile phone/internet costs. A further 92.8% also needed to set up new digital equipment or software to help with video calling and 77.3% agreed that doing a telephone/video call and face to face appointment took more time than usual. It was also clear that phone/ video contact made identifying maternity issues more difficult (85.2%).

More time talking about support during labour and birth 0

25

50

Strongly Agree

Agree

THE IMPACT ON MIDWIVES FAMILIES

“Changing clothes before coming home, changing and showering as soon as I get home, cleaning all equipment, no family hugs etc until after clean.

ISSUE 97 JUNE 2020 | 27

FEATURE

and the workload of midwives. In most instances the workload increased due to the expectations and demands of Alert Levels 3 and 4.

FIGURE 10: COMMUNITY MIDWIVES' WORK More women discharged early from Hospital Women with C-Section discharged early More time breastfeeding support More tim providing postnatal care Longer care provision due to lack of Well Child Services 0

25

Strongly Agree

Midwives reported that they spent more time discussing home birth (69.6%) and birth plan changes (94%) than usual. They also reported that organising ultrasound scans took more time than usual (60.2%).

For labour and birth (figure 9) high proportions of the community midwives agreed with the statement that they provided more home birth care (46.2%) than usual and more care at home during labour (47.3%) (for women going to a birthing unit or hospital for birth). The majority also agreed that they needed to spend more time discussing child care (69.8%) and labour support (90.3%).

28 | AOTEAROA NEW ZEALAND MIDWIFE

80

50

100

Agree

There were also high levels of agreement that more women were discharged early from hospital (91%) (including women post C-section (77.6%) and that they spent more time providing breastfeeding support (77.1%) and postnatal care (72.2%) (FIG.10). Lack of face to face Well Child services also impacted on the workload of community midwives as they needed to provide postnatal care for longer than usual (68.8%).

SUMMARY The Covid-19 pandemic has had a major influence on the working environment

During this time midwives played a central role in providing information and support to women and whÄ nau as they navigated what it meant to be pregnant and become parents during this uncertain time. Requirements to screen women, access and use PPE and minimise face to face contact all took time to set up and implement. As essential workers, midwives were required to continue to provide care which resulted in increased anxiety for themselves and their families.

The pandemic response also resulted in increased time and financial costs for midwives, particularly those based in the community, as they paid for increased mobile data and also PPE in the early part of Alert Level 4. For hospital midwives, care requirements for pregnant and postpartum women commonly meant that contact could not be reduced to less than 15 minutes. In addition, hospital midwives appeared to have a higher potential for exposure to women with suspected, probable or confirmed Covid-19 and provided more of the labour care for these women when they were handed over by community midwives.

A full report on the survey will be available on the College website as soon as it is finalised. square

For excellence For excellence in distance distance midwifery midwifery eductation education Our flexible, practice-focussed

Our flexible, practice-focused programmes and courses are programmes and the courses designed to meet needsare of designed to meet the needs of midwives and the requirements midwives and the requirements of of the the MCNZ. MCNZ.

We offer offer these postgraduate papers in 2020: We theseonline online postgraduate papers in 2020:

Certificate Courses (15 (15 Credits) Certificate Courses Credits)

There was intense interest from the media about how midwives were coping during the Covid-19 lockdown. There were many requests to interview midwives, among them from Lynley Ward a journalist with Woman’s Day magazine.

Lynley interviewed Canterbury midwife Bex Tidball about her work during the Level 4 restrictions. The media industry was being engulfed in its own Covid crisis at the time as advertising plummeted. Bauer Media Group, which owned Woman’s Day, abruptly closed this and all its other New Zealand titles before Lynley’s story could be published. Lynley has shared her report with Aotearoa New Zealand Midwife. It captures the atmosphere of those early weeks in lockdown.

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Bex was one of several midwives who gave their time to be interviewed for news coverage during the emergency. The College would like to thank them all for bringing the vital work of midwives to public attention in this way.

Your Midwifery Career Opportunities are with Counties Manukau Health

LYNLEY WARD’S REPORT FOR WOMAN’S DAY

• Be part of a new Women’s Health Division with a new leadership team

She’s already brought three babies into the world in her first week of lockdown but as an essential worker on the frontline of public health care, North Canterbury midwife Bex Tidball is still finding time to put worried mums’ minds at ease during these unsettling times.

“They’re calling for things they possibly may not have called up about before,” says Bex, 45, who’s been ‘catching’ babies for five years. “We’re just having to be that grounding for them. We know that fear is not helpful for labour and birth and we’re doing everything we can to keep mums and babies safe. These babies will come regardless of Covid-19.”

Bex says as a health professional they already take infection control measures and hand hygiene as a matter of course. “That hasn’t changed. Now we’re just screening people and making sure they’re not showing any signs of cold or flu or additional Covid-19 risk factors.

“I’ve got four children and it absolutely plays on my mind about that risk of bringing something home but I have to trust myself that I am doing all that I can when it comes to infection control."

She adds, “We know how this virus is spread. We know how we can stop that movement of it. We just need to be vigilant and keep going with it." square

• Help create a service where the women and babies of Counties Manukau are at the forefront of everything we do • Join our collaborative, high energy teams and be part of setting the vision for our future “Our aim at Counties Manukau Health is to support the provision of quality midwifery care which is woman centred, safe and equitable for all mothers and babies.”

Counties Manukau birthing community is unique in New Zealand with a rapidly growing and culturally diverse population, this makes working here exciting and rewarding as you have a real influence in the future of New Zealand. As a New Zealand registered midwife you would get the opportunity to work across specialities of your choice, including primary, secondary or tertiary services or work within our community. With over 7500 births per annum we have lots of flexibility to meet your needs.

Some of our benefits include: - relocation allowance for those moving from out of Auckland - a learning environment focused on supporting your career pathway - flexibility with shifts and locations of work

For more information please contact Taiana Fainga’a in the Recruitment Centre on (09)259 5007 or apply online at www.countieshealthjobs.com

K04330

the midwife’s story rescued from media’s covid crisis

Jul 28 Midwifery Midwiferypractice practiceininrural ruraland andprimary primary settings Jul 13-Aug 13-Aug 28 settings ··NEW! midwifery:Sexuality, Sexuality,gender genderand andsex sexcharacteristic characteristic NEW! Queering Queering midwifery: diversity · Diabetes in pregnancy diversity · Diabetes in pregnancy Sep 14-Oct 30 Perinatal mental health · Leadership and change in Sep 14-Oct 30 Perinatal mental health · Leadership and change in · Diabetes midwifery in pregnancy

FEATURE

Below: Sila Halaufu (right) and colleague Talei Cummins.

your stories We have collected stories from midwives and women throughout Aotearoa New Zealand about their experiences as the nation locked down to fight the spread of Covid-19. We begin with this moving account by Hamilton LMC Sila Halauafu, who is of Tongan descent, which beautifully encapsulates the experiences of many, if not most of her colleagues and the women they have been caring for.

“I have heard of LMCs leaving midwifery due to burning out. I think I witnessed what those LMCs were experiencing during this pandemic. There were many professional challenges.

As a midwife, my main goal is to safeguard mums and babies in my care. My biggest challenge was my fear of spreading Covid-19 to women, babies and their families as well as bringing it home to my own family after visiting many people in multiple bubbles.

Trying to accommodate the needs of women in the different situations was also challenging.

Clear communication and informed consent was vital so women and whānau were informed and involved in their care.

I used texts, calls, emails and video calls to communicate with women during lockdown.

I let them know that I was working between different bubbles and that it was up to them if they wanted a face to face visit, or an appointment via phone call or other method.

However, all postnatal women still wanted me to visit them face to face.They had different issues

and needed help, support and reassurance, especially first time mums.

There were lots of challenges in the postnatal period as many women didn't have any support available to them other than their husband or partner. The border restrictions stopped parents and other family members from coming over to help out during labour, birth and the postnatal period.

These women therefore experienced first hand the hardships of being a mum, whilst in isolation. I got a lot of phone calls asking for help with breastfeeding, expressing to avoid mastitis, reassurance about cluster feeding and checking on C-section wound. One of my clients who had a c-section chose to go home within 24 hours post op for whānau support. She didn’t feel that she was getting the help that she needed at the hospital.

Many of the usual support services were unavailable during lockdown, so I got lots of calls from women feeling stressed about the situation. I had to take extra time to offer reassurance, do lots of tender loving care talk, as well as screening to make sure that they were okay, and not needing referral.

There were lots of challenges in the postnatal period as many women didn't have any support available to them other than their husband or partner.

On all occasions however, they just needed someone encouraging to talk to, and have their concerns listened to. On one occasion we needed help from a lactation consultant and luckily a rural midwife LC kindly came to Hamilton and helped this new mum.

I felt isolated working alone during Covid-19. I wore many additional hats and tried to help in any way I could.

Even things like just holding a baby so the mum and dad could quickly eat their dinner - before I headed home to see my own family.

On another occasion, I transported a mum and her baby home from the birth centre as her husband had to stay home with the other children. She had arrived by ambulance for the birth and had no other way of getting home.

Another big challenge that I faced during lockdown was caring for five first time mums in labour, who had long latent phases (contracting more than 24 hours) and needed epidurals when no staff were available to run them. I had to instead run a PCA (patient controlled analgesia) pump and wait until a midwife could relieve me.

Although this wasn’t my fault, I was the one facing these women, and their partners, who were in pain, crying, and in distress.

At these times, I had often been awake for 12-24 hours and was very tired too. Despite this, I tried not to show these families any signs of it, as I didn’t want to add even more pressure or take away from their birth experiences.

My ultimate challenge during the Covid-19 pandemic was trying to juggle being a midwife and a mother, while taking care of myself and getting enough rest. I always looked forward to my weekend CONTINUED ON PAGE 33 CHEVRON-CIRCLE-RIGHT

CONTINUED NEX

twins in lockdown

choosing to birth at home Yve Haenga-Ashby, of Huntly, Waikato was one of many women who decided to give birth at home during lockdown.

This was Yve’s second pregnancy although it was 12 years since her first. She had to travel to Auckland City Hospital for a scan soon after cases of Covid-19 started to appear in New Zealand and says that the hospital visit was “scary”. Yve’s baby was due on 27 March, a few days into the Level 4 lockdown. Yve had planned to birth at a local primary but she decided she would stay at home for as long as possible during her labour. She had completed two years of a midwifery degree in the past and had a good understanding of the physiology of birth and “I knew my body would be relaxed at home”. She also knew that she couldn’t have more than one support person with her at the birthing unit and she wanted her daughter to be present as well as her husband. “We had just finished playing a game of Yahtzee when my waters broke. I decided to stay at home and my husband spread a tarpaulin on the floor.” Midwife Korina Vaughn birthed Yve’s daughter Iroh-Lee and Yve says: ” The whole experience was pretty relaxing. Your body just does what it does.” square

The prospect of giving birth to one baby during the Covid emergency was daunting but Cheryl Shearer was expecting twins.

Cheryl lives with her husband and family on a dairy farm in Havelock, in the Marlborough Sounds. She gave birth to twins Joash and Chloe on 31 March at Nelson Hospital, a week after New Zealand moved into Level 4 lockdown. This was Cheryl’s fourth pregnancy and she was healthy throughout. She was induced two weeks before her due date and her LMC midwife Wendy De Groot birthed the babies. “Wendy wasn’t allowed in until I went into active labour but the midwives on the ward were amazing and when Wendy arrived she took charge and everything went well. My biggest fear was that everyone would be in full PPE gear making me feel like a diseased person but they weren’t. I wanted it to be as normal as possible. Wendy looked after me during my third pregnancy and I was glad I had her when I found out I was having twins. It is great to have a supportive midwife.” square

midwife life in covid Kimba Allison is a rural and remote rural midwife working in the Waipā district in Waikato and the King Country. She wrote a blog about her daily life as a midwife during lockdown. Early in lockdown she wrote this about sourcing PPE: “No PPE. That’s ridiculous. I get that there’s a rush on and I’m happy to buy my own if I could find it although I’m not happy to pay $150 for a box of masks. So who should rescue me in this situation? Not the local childcare (I asked them as they are closing and there was a hopeful rumour, but already used up), not the supermarket for sure, not my own DHB. My [paramedic] hubby can’t even sneak me one from his ambulance as they are in short supply and see sicker people than me. No, none of them. It was a brickie! Yes, a bricklayer, my mate Bevan gave me his last two dust masks as he can’t work. He placed them on the ground two metres in front of me and backed off. I have three people to visit tomorrow in their homes, with their families. I have two masks.

Even I can do that math.”

the driveway clinic Joy Wadham is an LMC working in the Eastern Suburbs of Wellington. She set up drive-in clinics for clients in her driveway after seeing television reports about drive-in Covid testing clinics overseas. Her usual clinic had been closed and she was concerned about travelling widely herself and asking women to come to her home. “I contacted the women first to ask what they thought about the idea and they were all more than happy about it. I think women were afraid too and didn’t want to break their bubbles. They could have their partners with them in the cars. My driveway is bordered by trees so would be private and I suggested the women bring a towel for when we did abdominal palpation. They would wind down the window so I could do their blood pressure and recline their seats so I could do a palpation, listen to the baby and do the fundal height. For urine tests I gave them sticks to take home and asked them to photograph the results so I could read them.” square

Read Kimbas blog here. square

ISSUE 97 JUNE 2020 | 31

FEATURE

don't forget your own needs

fear and frustration A community/LMC midwife who asked to remain anonymous says: “I’m not going to lie. I really struggled in the first two weeks with anxiety and fear which I have never experienced before. I found it really difficult hearing all the “stay at home” messages and then having to leave home many times to go to multiple places; my clinic, hospital, birth centres and multiple homes for postnatal visits. Because we didn’t know the extent of community spread during those first two weeks, I found that really scary and was very worried that I was potentially bringing home the disease to my family. “More recently the anger has set in; the total lack of support from the government, Ministry of Health and to a certain extent the District Health Board. It has finally and irrevocably dawned on me just how undervalued the work I do is. “Funding deficits are one thing, but they cared nothing for our protection, still have no understanding of what our work entails and how much money we actually save the health system by doing what we do while literally throwing money at other health care workers. It’s truly not about the money for me anyway. It is just the total lack of respect and the understanding that this is purely because we are women caring for women. So I am seriously re-thinking 2021 and whether or not I continue in this role and that’s the first time I have ever had those thoughts.” square

32 | AOTEAROA NEW ZEALAND MIDWIFE

Fiona Coffey, a Lower Hutt-based midwifery educator with wide experience as a core and LMC midwife has been reflecting on the “emotional load” for midwives.

“There has been a lot of background worry for midwives about the women they’re caring for,” she says. The restrictions on face to face contact have made it more difficult to pick up signals about problems such as family violence. Midwives are concerned about poverty and deprivation, says Fiona, aware that women on maternity leave may be vulnerable to losing their jobs in the economic downturn. “But we cannot care for women in a way that is damaging to our own well-being.” It is important for midwives to have relationships with colleagues that help them to keep a sense of perspective. “I would like to see funding made available for all midwives to have mentors so they can draw on this type of support.” square

antenatal education online Kelly Mahuika is a midwife working as pregnancy and parenting advocate for Nelson Marlborough District Health Board. She organises and teaches at antenatal classes throughout the Nelson and Marlborough regions. Normally these are face to face sessions over five weeks attended by 24 to 28 couples. “When Covid arrived and everything started shutting down I started working quickly to put the classes on line. It took about two weeks to get up and running.

Now parents can work through the sessions at their own pace and each week I do a Zoom session so we can go through general questions. If there are no queries I have topics I can expand on. These sessions last for an hour to an hour and a half. I thought it might be awkward but it’s better than doing it face to face. The parents are at home and are more relaxed and engaged, especially the dads and are more likely to get involved in the conversation. It’s been pleasantly surprising and a lot of fun. This has shown that we can adapt quickly if we have to.

Despite the challenges it’s been a great experience and we’ve had great outcomes.” square

the scramble for information Paraparaumu based LMC locum and core midwife Lynley Davidson has been collecting reports from across the Wellington region from LMCs. One of the first things she picked up, she says, was the uncertainty about how to adapt care to the restrictions of the Level 4 lockdown. Midwives were seeking information from many sources and sharing with each other phone calls, various messenger apps, and Zoom meetings. “They were very inquisitive.”

For the future, Lynley would like to see a more streamlined flow of information and guidance for midwives. “Midwives did feel a bit overwhelmed at times. There was a lot of information coming from a lot of sources and it was difficult at times for them to know what applied to them.” Midwives also reported the support they had from their communities especially when they were trying to obtain supplies of PPE. Beauticians and children’s day care centres were helping out with PPE supplies and women were baking for them. Midwives were innovative in the ways they connected with women and they used technology well, says Lynley. “And they loved being able to do prescriptions electronically, and would like this to be ongoing." Another positive aspect of the experience was collegial support. “Many of the LMC midwives talked about how the core and DHB staff worked collaboratively with them in this time of adversity.” square

CONTINUED ON PAGE 33 CHEVRON-CIRCLE-RIGHT

off to spend time with my family and catch up with my sleep before going back into the 24/7 cycle again once back on call.

Being Pasifika, I just held onto my faith and trusted that the Man above would protect me and get me through everything.

The positive aspect of the experience for me and for women was that I did my job to a high standard despite the challenges I faced. I supported women and whānau in their journeys and all were happy, safe and well and enjoyed the new additions to their families. I got the ‘thank you - couldn’t have done it without you….’ but I reminded the women and their whānau that they did it, and I was glad to be a part of it. square

how the leaders led Debbie Fisher, Associate Director of Midwifery at Nelson Marlborough DHB was planning and intelligence lead for the DHBs emergency operations centre which she says “was an amazing learning opportunity”.

“The biggest challenge was that I was worrying 24/7 to ensure that each midwife under my responsibility in the community and hospital had the information they needed, the PPE and equipment they needed

and the emotional support needed to get through this. The speed at which this needed to occur made it very challenging. “Trying to keep on top of the work that was needed to create safe processes and service plans was a huge job. I am deeply grateful to several midwifery members of the team for stepping up and supporting me with all of the work needed to look after each other and women and their families.”

Emma Farmer (pictured above), Director of Midwifery at Waitemata DHB says: “The sum of us is far greater than any single individual. Communication was crucial and it was hard to be clear when the situation was so fluid. One mantra I developed was ‘this is the decision for today and we can expect the situation to change’.

I am deeply grateful to several midwifery members of the team for stepping up and supporting me with all of the work needed to look after each other and women and their families.

“I am incredibly impressed with how our midwives coped. I think we demonstrated how flexible and adaptable our profession is and how courageous midwives are in providing care for women in the face of so much that was unknown.” square

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FEATURE

RIght: Micha Palmer gave birth to son Noah at the Ramada Hotel, Queenstown.

queenstown midwives and mothers improvise as covid closes maternity unit Midwives and women throughout New Zealand had to adapt rapidly to new ways of working during the Covid lockdown, perhaps none more so than in the resort town of Queenstown.

MARIA SCOTT COMMUNICATIONS ADVISOR

The town was an early “hotspot” for Covid-19 cases and Queenstown’s Lakes District Hospital was temporarily closed after two nurses tested positive for the virus. The maternity unit was moved to a dental clinic across the road but the dental unit had no builtin shower facilities. A temporary shower unit was set up outside the building and a baby was birthed at the unit there shortly after it was opened but midwives were concerned that the facility was not adequate.

There was no space for a birthing pool and, says Queenstown midwife Mikkayla Godfrey: “We didn’t feel right offering the dental unit for births.”

For many pregnant women in the town, home birth was not an option because their homes or flats were not suitable. Midwives arranged to use rooms at the nearby Ramada Hotel, paying a special rate of just under $200 a night for three-bedroom suites out of their home birth fees.

The midwives attended births at the hotel in the same way as for births at home and Mikkayla said this involved extra work to begin with to order and assemble the equipment necessary.

Several babies were born at the hotel and Mikkayla said: “The silver lining was that it was nice to see people realise that you can have a baby at home or in a hotel. They were seeing birth as a normal process.

That’s been nice for us as midwives.”

Micha Palmer had never considered having a baby at

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home but her positive birthing experience in the midst of an extraordinary crisis has changed her view.

Micha, who lives in Cromwell, had been due to give birth at Lakes District Hospital. When she heard about the Ramada option she was “sceptical” but was pleasantly surprised. “When we got there we put the lamps on and my midwife Mikkayla put some music on. It was really cosy.

“I wanted a natural birth and to be in a place that I felt was safe. As soon as I got to the Ramada I knew it would be fine. “There was no point where I felt my experience was hindered by the circumstances. The midwives made sure of that. It all felt very normal.”

Micha went into labour in the late afternoon of 2 April, arrived at the hotel about 9.45 pm with partner Nathan Low and son Noah arrived at about 4 am the next morning. Micha needed sutures after the birth and was transferred to the temporary maternity unit in the dental clinic.

“Micha's birth was so early in the lockdown we had ordered Entenox but it didn't arrive in time for her birth,” explained Mikkayla. “We moved into the dental unit to do the sutures to make sure she was as comfortable as possible. Our next birth at the Ramada went really well and we had the Entenox for that one which was great - the women was able to be in bed with her baby and partner while I sutured her in the room.”

Photograph of Micha and Noah by Ryan Lucas

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FEATURE

“It has made me feel more confident because of the midwifery care I received and I realise that you don’t need to be in that (hospital) environment to be safe and confident. I would definitely consider having a baby at home in future.”

to fill the birth pool and by the time Sharon arrived Xavier had been born.

women giving birth at home or in the next-best-thing, the Ramada.

“This has given me confidence for next time. Sharon is very confident as a midwife which gave me a lot of confidence. I felt really supported by Sharon and she made me feel very secure.”

“It’s been empowering for us and for women. The question is now whether we will return to the status quo after this is over.”

Sharon said that the early days of the lockdown, with the changes required for practice and preparations for home birth had been the most stressful time in her career but it had been a very positive experience seeing

The outside shower unit set up at the dental clinic-turned-maternity-unit eventually attracted negative media attention as local women began to complain about the facilities. The maternity unit at Lakes District Hospital was reopened early in May. square

Micha said that she was comfortable at the dental clinic. “I think the midwives there had done everything they could to make it feel comfortable.

“They were aware that Noah, being my first baby wasn’t feeding that well and they made sure I stayed in and was comfortable before I went home to Cromwell on the Saturday.”

Sharon White, one of Mikkayla Godfrey’s practice partners had birthed a baby at the Ramada Hotel in the past, before the Covid crisis, and thought it would be a suitable alternative to the dental clinic.

She said the staff at the Ramada had been very supportive and offered a good rate for the rooms. “They helped us to create a nice environment.”

She said that Heather LaDell, director of midwifery for Southland District Health Board had also been very supportive to local midwives in their efforts to make alternative arrangements for women.

Another Queenstown woman, Faye Cooper, had her second child at home during lockdown, having earlier planned a hospital birth. Faye planned a home birth with her first baby but was transferred to hospital after complications developed. When she had to review her choice for her second baby because of the disruption at the Queenstown maternity unit she was nervous about trying for a home birth again.

“But as time went on and my midwife Sharon (White) was confident about it, I felt reassured. Faye went into labour at 10pm on 6 April and son Xavier was born about five hours later, arriving quickly after Faye started to take a shower. She did not even have time

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Faye Cooper and family shortly after her home birth.

FEATURE

NEW MIDWIVES RISE TO THE CHALLENGES OF PRACTICE IN PANDEMIC MARIA SCOTT COMMUNICATIONS ADVISOR

Just over 150 newly-graduated midwives have started work since the beginning of this year and it is difficult to imagine more challenging circumstances in which to enter the profession than those of recent months.

72 graduates entered the profession in New Zealand in January and a further 80 in April.

These new midwives are working in hospitals and maternity units throughout New Zealand and as lead maternity carers based in community practices.

Cindy Page, an LMC in Tauranga, pictured at her ninth birth since she began practising earlier this year, is among them. “I know what I signed up for in midwifery,” says Cindy “but if I said it hasn’t been challenging I would be lying. It has been very rewarding seeing first hand how strong women are even with these forever changing circumstances.”

“I’ve definitely become more confident as a result of this experience” she says.

It has also been satisfying to see women consider having their babies at home when they would not otherwise have done so. Cindy had attended women to birth at home, at her local primary unit Bethlehem Birthing Centre and at Tauranga Hospital by the time the restrictions of Level 4 arrived. When we speak early in the Level 4 lockdown she has already attended a woman who opted for a home birth, having not previously considered this.

Women have needed more emotional support and reassurance from their midwives during this time, says Cindy.

Often they have not been able to see their usual support network whether that was their families or friends and with several support agencies having reduced services, women have come to their midwives for advice and reassurance. “Our workload has definitely increased.”

“We had to educate ourselves on how to correctly use the PPE. Some women progress in labour very quickly and you need to be able to put the PPE on quickly.

It is warm in the labour room and especially with the equipment on and your goggles fogging up it made for an interesting experience. Physical distancing is near impossible for midwives, especially when you are with someone who is in labour.”

Cindy says that she was able to maintain rapport with women despite the PPE. “I could still be myself and support the woman to birth her baby. “ Emily Barltrop started work recently as a core midwife at Christchurch Women’s Hospital. She says that women coming into the hospital to labour and birth were especially unsettled by the rule – applied at most hospitals – that partners had to leave shortly after their babies were born.

It was challenging learning new routines for antenatal care and reducing face to face contact with women whilst trying to maintain strict clinical judgement.

They needed extra reassurance and, says Emily and this was emotionally demanding for her as a midwife. “I’ve had to give a bit more of myself.”

“This was done with a lot of support from my amazing colleagues,” says Cindy. Her practice partners are Melissa Seed, also a new graduate, Cara Kellett and Sian Boston.

Colleagues and her Midwifery First Year of Practice (MFYP) mentor had been very supportive in helping her to deal with this.

One of the most difficult aspects of working in the early days of Level 4 was obtaining PPE. “We had to pay out of our own pockets to begin with for our PPE and it was quite hard to source. Our community rallied and supplied us with PPE which we distributed amongst local midwives.

“We were wearing face masks with all clients in antenatal and postnatal visits and then full PPE at late first stage and during the second and third stages of labour.

Sophie Dillon is an LMC midwife working in the seven-strong Christchurch practice Ōtautahi Midwives. In common with other LMCs, Sophie needed to quickly adjust to the special rules for care including telephone and video consultations. But, at 21 and having grown up with mobile phones, agrees that she adapted well to using technology in this way. .

Like Cindy and Emily, colleagues had helped her to cope with the extraordinary circumstances. square

“She wanted to have family from her bubble at her birth. She did amazingly well and I believe this is because she was in her own environment where she felt safe with the people she loves surrounding and supporting her.”

“It has been really satisfying supporting women through this life changing event at a time when there has been so much uncertainty.”

Photograph by midwife Mel Gunderson

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FEATURE

STANDING UP FOR COMMUNITY MIDWIVES A huge part of the College’s work in recent weeks has involved lobbying the Government to compensate community midwives for the extra work involved in caring for women under pandemic conditions.

The College has communicated its concerns through a variety of channels including the Epidemic Response Committee, set up to review the government’s management of the Covid-19 crisis in New Zealand. The committee was chaired by Simon Bridges, former leader of the National Party. The College submitted a briefing paper to members of the committee on 28 April ahead of Chief Executive Alison Eddy’s presentation in person. This is an edited version of the briefing paper.

SUMMARY • As an essential primary health service, with time critical ‘hands on’ physical assessment and ‘in person’ attendance a necessary component of their care, community midwives have continued to provide a

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mixture of face to face and virtual contacts under Alert Levels 4 and 3.

• Many other services have withdrawn completely or significantly reduced access to face to face care, during this period.

• Community midwives have noted an increase in their workloads, as a result of the reduced access to other services for the whānau and communities they serve and in response to the adaptations needed to meet Covid-19 infection prevention requirements.

• Under the current community midwifery funding model there is no mechanism for additional Covid-19 related work or costs to be recognised or reimbursed.

• The Ministry of Health has long acknowledged that the current funding

model for community midwives is broken and midwives have been in negotiation with the Ministry since 2015, seeking fair and reasonable pay and an updated, fit for purpose funding model.

• The New Zealand College of Midwives is signalling concerns about the longer term impacts on an already stretched service if there is no immediate support.

Morale is already very low due to the protracted nature of existing negotiations and workforce shortage exists. It is essential that the government recognises the value of the service and that there is assurance that progress towards fair and reasonable pay and the revised contracting and funding model are not compromised by the Covid-19 pandemic circumstances.

FEATURE

Alison Eddy, Chief Executive, New Zealand College of Midwives.

ACTION • Fund an interim package of support measures, to reimburse community midwives for Covid-19 related out of pocket expenses, travel, additional care requirements, locum relief and structural support needs.

• Future-proofing for any ongoing pandemic issues by expediting the implementation of the proposed new contract arrangements for community midwives. This includes structural changes to the way in which community midwives are paid, enhanced support arrangements and a pathway to fair and reasonable pay.

HISTORICAL ISSUES ARE COMPOUNDING CURRENT CONCERNS Although the focus of this Epidemic Response Committee hearing is not to address historical issues related to funding arrangements for community midwives, the Covid-19 pandemic has exacerbated existing shortfalls, thus they are very relevant to the current concerns.

In 2004, 77% of all women registered with an LMC for primary maternity care

(75% of which were midwives ). By 2017 92% of women registered with an LMC, 94% of which were midwives . This has meant that over time, midwife LMCs have increasingly been required to care for women with complex pregnancies or co-morbidities.

It is worth noting that over 50% of women giving birth in New Zealand live within our most deprived communities, quintiles four and five, and that deprivation is associated with poorer pregnancy outcomes. These women have greater care needs which have been further exacerbated under the Alert Level 4 conditions.

As a result of increased workload and insufficient remuneration, the New Zealand College of Midwives has been in negotiation with the Ministry of Health since 2015, seeking fair and reasonable pay, and a new funding model which better recognises the work required in 2020.

The proposed changes include a new contract model which would enable additional work (and associated costs) to be recognised, and address the current structural inequity through the establishment of a dedicated entity that can oversee the service delivery and co-ordination activity for community-based midwives.

In early March 2020, prior to the Covid-19 outbreak, a New Zealand Institute of Economic Research report noted considerable inequities in the way community midwives were funded. It found that the a combination of caseload size and complexity, and inadequate conditions under current contract arrangements, meant that midwives are working up to 26% more than was expected of a full time equivalent (FTE). The report also noted that current contract arrangements do not support the government’s goals to reduce health outcome inequities.

Overall the community midwifery workforce morale has been significantly negatively affected by the protracted nature of the negotiations, leading to workforce shortages and service coverage issues in some DHB regions and rural settings.

IMPACT OF THE PANDEMIC Maternity services were deemed an essential service under Alert Level 4. As a significant proportion of maternity care is ‘time critical’ many of the physical assessments or ‘hands on care’ cannot be safely deferred.

At Alert Level 4 community midwives had to rapidly adapt how they provide care to

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FEATURE

accommodate a mixture of face to face and virtual assessments and make alternative arrangements for care, on an individual basis, according to women’s gestation and health profile.

The New Zealand College of Midwives and the Midwifery and Maternity Provider Organisation (MMPO) have worked extremely hard over the past weeks to

Over 50% of women giving birth in New Zealand live within our most deprived communities, quintiles four and five, and that deprivation is associated with poorer pregnancy outcomes.

support community midwives to adjust to the new requirements. This included developing extensive guidance and frequently asked questions documents for midwives and women, as well as answering a high volume of calls from midwives and members of the public about care provision and PPE during the lockdown. However, the basic level of support available through these two organisations to community midwives is in stark contrast to the comprehensive support available to other primary health care services, all of which have had the benefit from greater investment over a number of decades (eg. primary care services offered by general practices, via PHOs, whose overhead payments are roughly 15% to 20% of the primary care budget).

A glaring example of this inequity in support structures, are the Personal Protective Equipment (PPE) access and supply issues community midwives have experienced.

DHBs prioritised the distribution of PPE to their own staff and PHOs were able to negotiate and access PPE early on for their workforces. Community midwives were

required to purchase their own, sometimes at inflated prices with no ability to bulk purchase and no forewarning from DHBs or the Government that there would be a need to do so to cover the period until supply and distribution issues were resolved.

The lack of access to PPE created considerable stress amongst the community midwifery workforce as it is impossible to avoid potential exposure to droplet transmission during the provision of midwifery care, particularly during labour and birth or during various procedures. Despite this, it took weeks for the Ministry of Health to recognise that maternity was a context where PPE would be required in more circumstances than other primary care provision.

A further example of this inequity was the pandemic support package allocated to GPs and pharmacy as affected primary health providers, but not allocated to midwives who provide primary care during pregnancy, birth and postpartum.

Self-isolation requirements have seen an CONTINUED ON PAGE 42 CHEVRON-CIRCLE-RIGHT

Midwifery post-graduate education grants Health Workforce New Zealand provide grants to subsidise the full cost of fees and some travel and accommodation costs.

Applications are administered by the New Zealand College of Midwives.

Applications for the first round of semester two grants close on the 21st June 2020.

There will be a further opportunity to apply for Semester two grants in September 2020. Applications prioritised on a first come first served basis. Apply online at www.midwife.org.nz.

Apply online www.midwife.org.nz

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FEATURE

additional care requirements experienced by community midwives during alert levels 3 and 4 ADAPTATION IN RESPONSE TO PANDEMIC • Review caseload to assess care needs, implement new service delivery model (mixture of virtual/telephone contacts, or virtual/telephone contact + face to face assessment), including sourcing virtual solutions, necessary equipment and resources • Source and access PPE and cleaning equipment (scarce and expensive) • Familiarisation with new and rapidly changing guidance and practice requirements • Reconfiguring clinic spaces and clinic arrangements • Implementing augmented cleaning procedures and modifying equipment use to minimise cross infection and observe social distancing requirements • Implementing mandated screening procedures, prior to each face to face contact with women • Responding to considerable volume of increased contacts from women seeking reassurance or information, related to risks of Covid-19 in pregnancy and/or the impacts of Alert Level 4 resulting in reduced access to social support networks

PREGNANCY CARE • Providing home-based antenatal care (at direction of Ministry of Health) for women who are suspected, probable or confirmed Covid-19, in spite of this not being funded through Section 88 • Logistical and organisational work to ensure women can still access necessary and time critical ultrasound and laboratory tests • Taking blood samples and delivering to labs due to reduced availability of phlebotomy services • Additional time explaining and reassuring women about changed service configuration of radiology and lab providers and reassuring women about the safety of these services • Providing increased monitoring for women for secondary care needs, as the majority of obstetric consultation being provided virtually required LMC midwife to provide follow up physical assessments, ordering and reviewing follow up tests etc • Supporting families to navigate access to additional support and services (eg. travel assistance for secondary care appointments), food, housing etc • Increased time to screen and support women who are experiencing family violence due to increased rates of domestic violence during lockdown and reduced as to availability to face to face services during Alert Level 4

negotiating access to second midwife/ practitioner to attend birth. Additional time and care required to mitigate risks to midwives of ‘bubble hopping’ families for labour and birth support • Undertaking acute assessments and follow up care in the community as reduced access to hospital level referral services and care

POSTNATAL CARE • Providing a greater number of postnatal home face to face contacts in response to the trend of early hospital discharge following birth, including post-surgical care for women discharged early following caesarean sections • Undertaking acute assessments in the community as reduced access to hospital level referral services and care • Undertaking additional monitoring and assessment for neonatal and maternal needs in the postnatal period due to a high rate of early discharge from Hospital, before it would normally occur, and reduced access to paediatric face to face assessments and care, including neonatal blood testing and follow up for neonatal conditions • Managing need for ongoing care, beyond 4 to 6 weeks postnatally, in response to withdrawal of face to face Well Child services, in response to expectations from families, and other service providers.

• Increased time to access referral service (eg. mental health services) due to reduced availability during Alert Level 4 • Undertaking acute assessments in community settings as reduced access to hospital level referral services and care

LABOUR AND BIRTH CARE • Increased time needed to negotiate changing birth plans/birth planning with women who wished or were required to change original plans • Managing increased demand for home births, requiring organisation, planning, sourcing equipment including PPE,

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• Resource the additional work undertaken by the New Zealand College of Midwives and the MMPO over the past months to ensure community midwives are supported to adapt to the pandemic environment • Send a clear signal that midwives’ work is valued as an essential primary health care service, which is one of the few services that has continued to be provided in a face to face capacity throughout Alert Level 4. Compensation for lost costs and additional work • Reimburse midwives for out of pocket expenses, and recognise time spent providing additional care.

SOLUTIONS - MEDIUM TERM The New Zealand College of Midwives has repeatedly raised concerns about the impact of workforce shortages and access to primary maternity care if long standing funding issues remain unresolved. The profession has no certainty that proposed solutions which require cabinet approval and Budget 2020 decisions will be implemented. The need to make these changes now is more imperative than ever.

Māori Development Minister Nanaia Mahuta MP - Hauraki-Waikato has acknowledged the tireless mahi of our midwives, who ensure our pēpi are brought into this world, safely and securely.

increased need for locum relief cover for community midwives. The MMPO provides an LMC locum service, funded by Health Workforce New Zealand. Some immediate additional funding has been provided to enable cover for these events, but the service has not had a price increase since 2009, and it is becoming increasingly difficult to secure locums as a result of the poor remuneration.

Locum relief is under pressure as many midwives are reluctant to put themselves and their whānau at increased risk for highly inadequate recompense, particularly in rural and high deprivation areas.

Existing funding within this contract will be insufficient to meet the needs for locum cover going forward.

As well as rapidly adapting how they provide care, community midwives consistently reported an increase in their workloads to both accommodate pandemic requirements, and the need to fill gaps left by the withdrawal of other services during the Alert Level 4 period. See table (p.41) for overview.

Many provider groups have had to undergo rapid transformation in how they provide services during this period. However, as

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community midwives have a contractual and professional responsibility to co-ordinate and provide primary maternity care (including a 24/7 acute response service) they have been required to maintain modified face to face contact with women and remain on call and available. As a result of other services closing or ceasing to provide face to face consultations (for example Well Child providers, GPs, obstetricians, phlebotomists/ lab services), Community midwives have had to expand the breadth of services provided over this period in order to ensure minimum safe care requirements were met.

As the current funding model (Section 88) does not contain any mechanisms to reimburse the additional costs incurred or time spent by midwives responding to the Covid-19 requirements, an alternative means or solution is needed. If the proposed new ‘fit for purpose’ funding model was already in place, the need for additional support would have been mitigated.

SOLUTIONS - SHORT TERM • Resource the locum service so it can continue to provide vital back up

If the proposed funding model had been in place, the need for additional support at this time to recognise Covid-19 related work would likely not be needed.

Expedite the implementation of the proposed new contract arrangements for community midwives, including structural changes to the way in which community midwives are paid (including enhanced support arrangements) and a pathway to fair and reasonable pay.

Increasingly, many of our most deprived and vulnerable citizens will face economic hardship as the economy moves into recession, despite all the efforts of the government to mitigate this impact. There is a significant risk that this environment will entrench existing health and social inequities. Health services need to be enabled to respond to these challenges in a manner which minimises these unacceptable consequences.

The Community midwifery workforce provides care to many of our most vulnerable whānau at a transformational life stage.

However, its funding model is not fit for purpose. Not only does this create risks for workforce sustainability and service coverage, it also means that there is considerable risk that whānau with the greatest needs will be less likely to have access to the maternity care that they need in the future. square

let’s kōrero covid Mate Korona, KOWHEORI-19 -------- Corona Virus KOWHEORI-19, Mate Korona -------- Covid-19 Whakatewhatewha Pānga -------- Contact Tracing Whakaritenga ----------- Measures Kiripākai Tinana -------- PPE Patuero ā-ringa -------- Hand Sanitiser Tikanga akuaku -------- Hygiene Practices Huaketo -------- Virus Maremare -------- Cold Rewharewha -------- Flu Noho taratahi -------- Self-isolation Taratahi -------- Quarantine Tū Tīrara -------- Social Distancing Tohu Mate ----------- Symptom Hēmanawa -------- Breathlessness Tinana Mamae -------- Aching Body Korokoro Mamae -------- Sore Throat Rūhā/Ngenge -------- Fatigue Mare Tauraki -------- Dry Cough Kirikā -------- Fever Whakatau ----------- Diagnose Rere ā-Hapori -------- Community Transmission Rere ā-Whare -------- Household Transmission Rere Hūrokuroku -------- Sustained Transmission Rūhā/Ngenge -------- Fatigue Mare Tauraki -------- Dry Cough Kirikā -------- Fever Ngā Pae Mataara ----------- Alert Levels Whakarite ------- Prepare Whakaiti -------- Reduce Rāhui -------- Restrict Whakakore -------- Eliminate Ngā Tūmate ------- Medical Conditions Urutā -------- Outbreak Kāhui -------- Cluster Kia atawhai -------- Be Kind Me toro ki ētahi atu -------- Check-in on others Āwhinatia ētahi atu ------- Help Others Rongoā whakanoa -------- Antiviral Patu Huaketo ------- Disinfectant Te Taura Whiri i te Reo Māori / Maori Language Commission

ISSUE 97 JUNE 2020 | 43

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BREASTFEEDING & INFANT FEEDING IN THE PANDEMIC After the initial safety concerns about breastfeeding and Covid-19, it became apparent relatively quickly via research studies, although data was limited, that the virus had not been transmitted via breast milk and that breastfeeding remained the recommended optimal method of feeding infants, even for women with suspected or confirmed Covid-19 infections.

CAROL BARTLE POLICY ANALYST

As yet there has been no clear evidence of vertical transmission from mother to baby reported globally. Initial discussion about using the precautionary principle, separating mothers and infants and avoiding breastfeeding, were rapidly challenged as being without sound evidence and ignoring the importance of breastfeeding (Davanzo, et al 2020).

The Ministry of Health in Aotearoa New Zealand issued guidance for continued breastfeeding with specific hygienic precautions (MOH, 2020). The World Health Organization recommended that infants and mothers with suspected or confirmed Covid-19 infections should not be separated, and should continue to have skin-to-skin contact after birth, breastfeed, and room-in within maternity facilities, while practising strict hygienic precautions (WHO, 2020). Breastfeeding recommendations in other countries did not necessarily support breastfeeding and suggested separation of mothers and infants.

As described by Stuebe, while the aim of recommendations to separate mothers and infants was to minimise the risk of viral transmission, the negative impacts of separation and potential loss of breastfeeding were “additional considerations” and “first do no harm” was a primary concern (Stuebe, 2020).

What changed during the Covid-19 lockdown period in Aotearoa New Zealand was not the recommendations for breastfeeding and infant feeding, but the circumstances in which women gave birth

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and the support women received for breastfeeding in the community.

The New Zealand College of Midwives published information about breastfeeding and infant feeding for midwives and for parents on its website, and midwives rapidly incorporated new ways of working which included managing consultations via phone and video calls, as well as continuing face to face visits in homes. Apart from midwifery care, support for breastfeeding in the community after midwifery care concluded, appears to have been limited to on-line, video consults and phone calls from other services. This represents a significant deviation from the usual support systems

Aotearoa New Zealand was well placed to continue to support women and infants to have skin-to-skin contact and early initiation of breastfeeding as the Baby Friendly Initiative is well embedded in midwifery practice and valued within maternity facilities here.

in place for breastfeeding women and new mothers. Women were also likely to be separated from whānau support, as well as social support during lockdown. Inequity also needs to be considered as services delivered remotely have the potential to discriminate against whānau and the communities with less access to technology (King, et al 2020).

King et al. describe how equity “must be embedded from the outset, and cannot be an add-on or retro-fitted.”

At the conclusion of midwifery postnatal visiting it is unclear at the moment as to how women who developed breastfeeding issues accessed the support they needed and whether it was appropriate or sufficient.

Interestingly, there have been some anecdotal reports from midwives of breastfeeding getting off to a good start and infants gaining more weight and establishing breastfeeding well. The reasons for this are unclear but the reduced interruptions to mother-infant proximity and breastfeeding in maternity facilities, and the lockdown conditions enforcing limited movement outside the home and no visitors into the home, have been suggested as potential positive factors. Future research examining women’s and midwives’ experiences during these times will be valuable alongside data about infant health and well-being.

There have been some reports that parents using infant formula were concerned that panic buying of products prior to lockdown and limited re-stocking of supermarket supplies would mean reduced or no choice when purchasing milk for their infants. The College included information about bottle-feeding and formula usage in their published guidance and also information about increasing breast milk supply for those women who were mixed feeding and wished to, or were able to, increase their lactation to enable a reduction in the use of formula. Again, information about all aspects of experiences of infant feeding during the pandemic will provide useful data for future reference, particularly related to preparation for infant and young child feeding in future disasters and emergencies.

As previously mentioned, face to face clinical breastfeeding and infant feeding support in the community following midwifery care did not seem to be a service priority during the Covid-19, which was reminiscent of what happened to support services other than midwifery following the devastating Christchurch earthquakes.

Addressing these issues now before the

FEATURE

The development of noncommercial milk banking services throughout Aotearoa New Zealand could play a significant role in protecting infant health in any future pandemic or disaster. next emergency is paramount. As Smith (2020) points out, the impact of Covid-19 on health and health services will last longer than the virus itself. Smith was expressing concerns about breastfeeding being limited in some neonatal intensive care units in Ireland alongside the limited access to donor human milk, but the comment about impacts on health could also apply to the potential aftermath of reduced support for breastfeeding. Regarding human milk banking and donor milk, it was inexplicable that the Rotary Community Breast Milk Bank (RCBMB) in Christchurch was not immediately designated as an essential service.

Research evidence from the Covid-19 pandemic has found that the virus is inactivated by pasteurisation (Shenker, N 2020).

Breastfeeding is a public health issue and O’Connell et al. (2020) point out the significance of midwives to public health, “Covid-19 has shown us (again) how the world, now more than ever, needs a robust proactive investment in public health infrastructures, for which midwives are key in reproductive health strategies globally.”

Midwives and midwifery services are essential at all times including during pandemics, and as Biro (2011) notes, “It is timely to acknowledge the important contribution midwives make to maternal and infant health and to highlight that midwifery practice can and does have a profound impact on the health of the population.” square References available on request.

ISSUE 97 JUNE 2020 | 45

Directory New Zealand College of Midwives Inc. President Nicole Pihema Ph 021 609 011 nicolepihema@gmail.com National Office PO Box 21-106, Edgeware, Christchurch 8143 Ph 03 377 2732 Fax 03 377 5662 nzcom@nzcom.org.nz www.midwife.org.nz College Membership Enquiries Contact Lisa Donkin Email: membership@nzcom.org.nz 03 372 9738 Chief Executive Alison Eddy Auckland Office and Resource Centre Delia Sang, Administrator Yarnton House, 14 Erson Avenue PO Box 24487, Royal Oak, Auckland 1345 Ph 09 625 9764 Fax 09 625 0187 auckadmin@nzcom.org.nz National Board Advisors Elder: Sue Bree Kuia: Crete Cherrington Education Advisor: Mary Kensington Regional Chairpersons Auckland Ady Priday, Sarah Ballard, Christine Mellor auckchair@nzcom.org.nz Bay of Plenty/Tairawhiti Kelly Pidgeon kelly.pidgeon@hotmail.co.uk Canterbury/West Coast Davina Geddes chairnzcom.cantwest@gmail.com Central Julie Kinloch Ph 06 835 7170 julie.kinloch.nz@gmail.com

Otago Sheridan Massey sheridan@milkhoney.co.nz Southland Natasha Baillie Ph 021 258 2701 merakimidwifery@gmail.com Waikato/Taranaki Sheryl Wright Ph 027 282 4784 sheryl@birth.net.nz Wellington Siobhan Connor Ph 021 289 4252 nzcomwellington@gmail.com Regional Sub-Committees Hawkes Bay Sub-Committee Sarah Nation sarahnation.midwife@gmail.com Manawatu Sub-Committee Amanda Douglas Ph 027 333 3280 amandadouglas@xtra.co.nz Rebekah Matsas Ph 027 465 7241 rebekamatsas@outlook.com Taranaki Sub-Committee Isabel Bedford nzcom.taranaki@gmail.com Wanganui Sub-Committee Jo Watson Ph 021 158 6874 jothemidwife@gmail.com Horowhenua Laura McClenaghan midwife.laura@hotmail.com Consumer Representatives Royal New Zealand Plunket Society Carla Kamo carla.kamo@plunket.org.nz

Nelson/Marlborough Rose O’Connor roseocon@gmail.com

Home Birth Aotearoa Eva Neely evaneely@live.com

Northland Priscilla Ford Ph 021 222 2428 priscillaford@xtra.co.nz

Parents Centre New Zealand Ltd Liz Pearce Ph 04 233 2022 extn: 8801 pearce@parentcentre.org.nz

46 | AOTEAROA NEW ZEALAND MIDWIFE

La Leche League Trudy Hart Ph 07 549 5644 hartyhealth@live.com Student Representatives Wanaka Noanoa Ph 021 139 6496 wanakahr@gmail.com Seraya Turnbull Ph 022 6852383 serayaalucas@icloud.com Nga Maia Representatives www.ngamaia.co.nz Sarah Wills Ph 021 02551963 sarahandcale@hotmail.com Colleen Brown colleenbrownlmc@gmail.com Pasifika Representatives Talei Cummins Ph 021 907 588 taleicummins@gmail.com Nga Marsters Ph 021 0269 3460 lesngararo@hotmail.com MERAS PO Box 21-106, Edgeware Christchurch 8143 www.meras.co.nz General Enquiries & Membership Ph 03 372 9738 meras@meras.co.nz MMPO mmpo@mmpo.org.nz Ph 03 377 2485 PO Box 21-106, Edgeware, Christchurch 8143 Rural Recruitment & Retention Service Rural contact: 0800 Midwife/643 9433 rural@mmpo.co.nz

Resources for midwives and women The College has a range of midwiferyrelated books, leaflets, merchandise and other resources available through our website: www.midwife.org.nz/shop

Influenza Immunisation Protection for you and your clients We strongly recommend that all pregnant women are immunised against influenza.

But your recommendation to immunise has more impact than any TV ad or poster, and that recommendation can save lives.

Influenza can be serious. Pregnant women and their babies are at greater risk from serious influenza-related complications than women who aren’t pregnant.

As a midwife, choosing immunisation yourself helps protect you and importantly reduces the likelihood of passing influenza on to your clients.

Visit influenza.org.nz for more information.

The influenza vaccine is a prescription medicine.

Talk to your doctor, nurse or pharmacist about the benefits and possible risks or call 0800 IMMUNE. TAPS NA11991

When the mum-to-be needs iron

The softer oral iron Gastrointestinal side effects to the commonly prescribed ferrous sulphates can be so intolerable, many patients stop taking them.1,2

Fewer side effects vs ferrous sulphate in pregnant women1 60%

30%

be a gentler, more tolerable oral treatment than ferrous

20%

sulphates - without compromising efficacy.1,2

10%

Consider Maltofer * for your pregnant patients ®

who are iron deficient.

Maltofer® 46%

Ferrous sulphate

40%

In a trial of pregnant women, Maltofer® was proven to

Maltofer® can be taken with food.3

56%

50%

29%

28%

23%

17% 5%

2%

0

Any Side Effect

Nausea

Vomiting

Constipation

Multicentre, open-label randomised study of 80 pregnant women with irondeficiency anaemia (IDA) randomised to Maltofer® or ferrous sulphate. p<0.05

The

Fe Iron Experts *Maltofer® is an oral iron therapy, indicated for the treatment of iron deficiency in adults and adolescents where the use of ferrous iron supplements is not tolerated, or otherwise inappropriate and for prevention of iron deficiency in adults and adolescents at high risk where the use of ferrous iron supplements is not tolerated or inappropriate.

References: 1. Ortiz R et al. J Matern Fetal Neonatal Med 2011;24:1–6. 2. Toblli JE and Brignoli R. Arzneimittelforschung 2007;57:431-438. 3. Maltofer® Data Sheet, June 2019.

Maltofer® tablets (100mg iron as iron polymaltose) and syrup (50mg/5mL iron as iron polymaltose) is a Pharmacy Medicine for treatment of iron deficiency in adults/adolescents where use of ferrous iron supplements is not tolerated or inappropriate, and for prevention of iron deficiency in adults/adolescents at high risk where use of ferrous iron supplements is not tolerated or inappropriate. Dosage and administration: Dosage and duration on treatment depend upon extent of iron deficiency. Please refer to data sheet for full dosage recommendations. Precautions: Iron deficiency anaemia: all other causes of anaemia should be considered/treated prior to Maltofer use. Use with caution in patients with infections or tumour, regular monitoring of Hb and serum ferritin levels required to gauge response. Pregnancy Category B1. Use in children <12 years not recommended, limited experience in elderly. Contraindications: Known hypersensitivity to iron polymaltose, iron overload e.g. haemochromatosis, disturbances in iron utilisation, anaemia not caused by iron deficiency. Adverse effects: Very common: faeces discoloured. Common: diarrhoea, nausea, abdominal pain, constipation. Interactions: Concomitant parenteral iron. Maltofer® is a registered trademark for Vifor Pharma used under licence by Aspen Pharmacare C/O Pharmacy Retailing (NZ) Ltd, Auckland. NZ-MAL-2000001 TAPS PP5450 - MAR 20. INSIGHT 9741