Midwife Aotearoa New Zealand

WITH WOMEN IN A CORRECTIONS FACILITY P.24

A HOMECOMING FOR MIDWIFERY’S ‘BIG VISIONARY’ P.28

ANTENATAL IMMUNISATION: GROWING THE MIDWIFERY ROLE P.32

ISSUE 116 MARCH 2025 I THE MAGAZINE OF THE NEW ZEALAND COLLEGE OF MIDWIVES

VAPING IS PERCEIVED AS SAFER, BUT IS IT? P.36

ISSUE 116 MARCH 2025

24 28

FORUM 4.

FROM THE CO-PRESIDENTS

5.

FROM THE CHIEF EXECUTIVE

8.

YOUR COLLEGE

Welcome to Issue 116 of Midwife Aotearoa New Zealand In this edition, we explore both the challenges and the joys of providing midwifery care for women in one of New Zealand’s three women’s correctional facilities. We also shed light on the

10. BULLETIN

increasing number of incarcerated women

12. MIDWIFERY PRACTICE GUIDANCE

and the factors contributing to this rise. Our regular breastfeeding column complements

18. YOUR UNION

this discussion and examines the barriers to

20. YOUR MIDWIFERY BUSINESS

breastfeeding and bonding while in prison.

FEATURES

Dr. Sally Pairman (p.28) and celebrate her

We extend a warm welcome home to immense contributions to midwifery—both

21. PARENTS CENTRE

in Aotearoa and around the world. Her leadership and vision have been invaluable,

22. NGĀ MĀIA

and we eagerly anticipate her next steps.

23. PASIFIKA MIDWIVES 24. WITH WOMEN IN A CORRECTIONS FACILITY 28. DR SALLY PAIRMAN 32. ANTENATAL IMMUNISATION 36. VAPING IN PREGNANCY 38. VANUATU EARTHQUAKE 40. TE AO MĀORI: WOVEN INTENTIONS 42. BREASTFEEDING CONNECTION

The Practice Guidance section covers key

32 36

topics: • Cytomegalovirus (CMV) (p.12) • Postnatal analgesia (p.14) • Pelvic floor health and assessment (p.16) I especially valued the opportunity to speak with the amazing wāhine leading the wahakura wānanga for the te ao Māori section of this issue (p.40). It was inspiring to learn about this intentional practice, which weaves a sense of connection

46. TAKU WĀHI MAHI I MY MIDWIFERY PLACE

alongside a safe sleep space for pēpi.

DIRECTORY

the incorrect image that appeared within

Finally, we would like to apologise for the Antenatal and Childhood Screening Programme advertisement about changes to Newborn Metabolic Screening in the

EDITOR Hayley McMurtrie E: communications@nzcom.org.nz ADVERTISING ENQUIRIES Hayley McMurtrie P: (03) 372 9741 MATERIAL & BOOKING Deadlines for June 2025 Advertising Booking: 1 May 2025 Advertising Copy: 12 May 2025

last issue of Midwife Aotearoa (Issue 115, December 2024, p.15); we regret that this error was not identified before printing.

40

As always, we welcome your feedback at communications@nzcom.org.nz.

Ngā mihi nui, Hayley Square

HAYLEY MCMURTRIE COMMUNICATIONS MANAGER Email: communications@nzcom.org.nz

FROM THE CO-PRESIDENTS

FROM THE CO-PRESIDENTS BEA LEATHAM CO-PRESIDENT

people to enquire within themselves and open

kuia all managed their pregnancies and births

up to new perspectives.

in the heat of summer. My grandmother told

This will no doubt be helped along by the newest iteration of our Tūranga Kaupapa

“Waiho kia kakati te namu i te whārangi o te pukapuka, hei kōnei ka tahuri atu ai” - Te Ruki Kawiti, 1846.

“When the sandfly nips at the pages of the book (He Whakaputanga me Te Tiriti o Waitangi), at that time, you must arise and resist.”

Toitū te Tiriti mobilised Aotearoa last year,

framework, developed by Ngā Maia and due to be rolled out as a compulsory component of midwifery education over the next few years. It’s

new Standards of Competence, which point to

the Principles of the Treaty of Waitangi Bill

attributes like kaiarahitanga, manaakitanga and

acknowledged this. Thank you to members who

tiakitanga as qualities we expect to see Aotearoa

provided feedback on the submission and if you

midwives embody.

haven’t read it yet, I urge you to. Understanding

The same ideals should be applied when

also on a less visible level, as we grappled

reflective of these values, individual midwives

with the proposed Principles of the Treaty of

– or collectives of midwives – will be enabled

Waitangi Bill and its potential ramifications for

to express these attributes more meaningfully,

our nation.

because they’ll be working within a system that supports them to do so. Like all worthy causes, it will require kōtahitanga and vision, which we can aspire to collectively.

Ngākau nui, ngākau whakaiti. Square

through to unpacking Te Tiriti as an adult –

profession is no different; some are still very

understanding.

The College made a submission opposing the Bill, which most of our membership were

constitutional status of Te Tiriti o Waitangi and, as a result, negatively impact on all people and our future, is important. Your ancestors may have been a bit like mine and traditionally not shared a lot about their understanding of Te Tiriti o Waitangi. I know it’s now my responsibility to lean in; to learn, to understand, to question and to reflect on my own cultural biases and be accountable as a tangata Tiriti partner.

Completing the education on our revised Scope of Practice and Standards of Competence has the public hold around the cultural safety of

DEBBIE FISHER CO-PRESIDENT

confronted by this conversation and others are hungry for more knowledge and

why the proposed Bill would reduce the

been helpful in understanding the expectations

has been both challenging and activating.

The progress we’re making as a country and

generation to generation.

Our past always informs our present, and

once our entire maternity service becomes

Treaty of Waitangi in secondary school,

ability to pass down wisdom and tradition from

the College’s recent critical submission on

tangata Tiriti united through the hīkoi, but

most rudimentary of education about the

greatest strengths of whānau or family is the

front and centre, working in synergy with our

considering our responsiveness to whānau need;

our founding agreement – from receiving the

years and I treasure them so much. One of the

heartwarming to finally see mātauranga Māori

not only physically, as tangata whenua and

Like many others, my own journey with

me so many stories and traditions over the

midwives.

I also feel very honoured to have experienced a taster of the new Tūranga Kaupapa workshop

Kia ora, Hello, Mālō e lelei, Talofa lava, Taloha ni, Kia orana, Fakaalofa lahi atu, Namaste, Ni sa bula.

developed by Ngā Māia and delivered at our last College Board meeting, held at Te Mahurehure Marae. We are all in for a rich, transformational, reflective learning experience as the workshops roll out across the motu. Thank

in support of. This is the least we can do; a midwifery profession that doesn’t fight

As I write this, it’s a hot summer’s day and my

you to Ngā Māia for sharing this taonga with our

to protect the most basic rights of its Indigenous

thoughts go out to all pregnant and birthing

midwifery profession. As Te Tiriti partners, we all

population cannot call itself whānau-centred,

women in this heat! Thankfully, I was only

have the responsibility to stand up and be the

nor can it claim to be based on a foundational

half-way through each of my own pregnancies

partners we need to be to honour those who

cornerstone of partnership. And while this

over summer, but my thoughts meander over

have shared their wisdom and gone before us,

conversation may continue to be confronting for

the seasons for birthing women and how our

and those who are yet to be born and who will

some of our workforce, I hope it will also inspire

mothers, grandmothers, great-grandmothers,

lead our future. Square

4 | MIDWIFE AOTEAROA

FROM THE CE

Dame Tariana Turia

A VISIONARY WOMAN AND LEADER

It was with sadness that I learned of the passing of Dame Tariana Turia, a visionary woman and leader who was guided by her principles and led a movement of transformation, inspired by her belief that whānau could define their own solutions and determine their own futures.

As an invited speaker at our national conference in Hamilton in September 2000, Tariana spoke of the cultural and spiritual significance of birth for whānau Māori, of the crucial role midwives have in supporting healthy pregnancy outcomes, physically, emotionally and culturally, and of her high regard for our profession, which had been garnered in part from her knowledge of the care her whānau members had received from midwives (she had 97 mokopuna and attended all of their births!).

The words she spoke at the conference recognised the importance of cultural knowledge being valued and included within the provision of clinical care, and of her perception that the midwifery workforce had “made yourselves culturally safe by being aware of who you are and therefore being able to respect

the cultural beliefs of the mothers to be who may be culturally different to you”.

And, of course, she also spoke of societal inequalities, which, at that point in time, had grown faster in New Zealand over the prior 20 years than in almost any other developed country. She discussed that Māori (and other population groups) bore the brunt of these disparities, of the need for policies which corrected them, and that midwives had a vital role to play in enacting these policies.

She also made reference to the political rhetoric of the time, stating, “We need to be concerned about these people who [are] playing on fears and are seeking to divide Māori against other New Zealanders by creating the impression that Māori somehow will gain an unfair advantage over them with the policies being pursued by this government”.

ALISON EDDY CHIEF EXECUTIVE

ISSUE 116 MARCH 2025 | 5

FROM THE CE

Reading the speech again made me reflect on the fact that this situation has not substantially changed in the two decades since she delivered it at our conference.

This is evidenced by the proposed Treaty Principles Bill which has recently undergone public consultation in preparation for the Select Committee process.

In December the College provided a draft submission on the proposed Bill for members to comment on through our membership consultation process. The College’s draft submission opposed the Bill on the basis that Te Tiriti o Waitangi provides the foundation for enduring relationship between Māori and non-Māori in Aotearoa. If passed, the Bill could reinterpret the Tiriti, undermine Māori sovereignty and have negative implications for Māori in the way in which health services are organised, funded and delivered. The Bill also has the potential to have a negative impact for Māori on the wider determinants of health, such as education, housing and poverty (which collectively can have a greater impact on health outcomes than the delivery of healthcare itself ). This wider context was the impetus for the College making its submission.

The College received a significant number of responses from members to the consultation, all of which were fully considered before the submission was finalised. The vast majority of member responses were in strong support of the stance taken in the draft submission. However, a

As a membership organisation, the College upholds the importance of democratic processes. Its work is driven and led by members’ needs and perspectives and our constitutional objectives, with the board providing direction and leadership. Healthcare is inherently political and healthcare outcomes and inequities are not a result of the healthcare system alone.

minority of members who provided feedback stated their opposition to the College taking a position on what they perceived to be a political issue which is outside of the realm of what the College as a membership organisation, had a mandate to make a submission on.

As a membership organisation, the College upholds the importance of democratic processes. Its work is driven and led by members’ needs and perspectives and our constitutional objectives, with the board providing direction and leadership.

Healthcare is inherently political (few professions know or understand this better than midwifery) and healthcare outcomes and inequities are not a result of the healthcare system alone. The determinants of health, government policies and political decisions all have an important role to play in how equitable (or not) our societies are. Societal inequities can often disproportionately disadvantage women and children, so advocating against a Bill which has the potential to entrench inequities is in line with the College’s objectives.

The College has always involved itself in political issues which can affect midwifery practice and which relate to wider women’s health or rights, societal equity or fairness.

For example, over recent years the College has provided submissions on a range of issues such as Oranga Tamariki legislation, smokefree environments and tobacco regulation, the sale and supply of alcohol, climate change legislation, public health legislation and healthy housing legislation.

The College takes a democratic and values-based stance when developing a position on politically sensitive issues on which there may be diverse views amongst our members. One example is the College’s submission on abortion law reform. The vast majority of members were strongly in favour of the College taking a position which supported the law change (to remove abortion from the Crimes Act and legislate it within the context of health services), while a minority of members strongly opposed this position. To honour members’ feedback, the College’s approach was to ensure that our position reflected the views of the majority, whilst acknowledging within our submission (as we did in our Treaty Principles Bill submission) that a minority of members held a different view.

As an almost entirely female profession we can be quick to criticise ourselves or internalise the criticism of others, and not

6 | MIDWIFE AOTEAROA

always quick to celebrate or congratulate ourselves on what we do well. The words Tariana shared at our conference drew a line between a midwife’s individual practice and professional interactions with women and whānau, and the wider political and systemic issues which underpin societal inequities.

Developing culturally safe practice at an individual level is an ongoing process of learning and reflection, and clinically and culturally safe midwifery care has much to offer in reducing disparities. For example, international observational research has demonstrated that caseload midwifery care to high needs or ”vulnerable” populations (in countries where this model is not universally available) has reduced the incidence of preterm birth. While midwifery care can act as a buffer to inequities to a degree, individual midwives are not responsible for the wider political policies or societal conditions which have created disparities.

Colonisation, the various policies of successive governments, and international and national economic conditions have all created our current societal inequities. It is the College’s role to raise our voice on behalf of the profession to advocate for change at political and policy levels, so that we can make progress towards eliminating health inequities at a systemic level.

It can feel almost impossible to achieve change in a positive direction at times, particularly at present within the health system, where political imperatives are apparently more intent on reducing costs and increasing efficiency than the quality of care. However, recently Health New Zealand has allocated funding for midwives to provide maternal immunisation. This is welcome news and a result of some sustained advocacy by the College on behalf of the profession. There are some instances where midwives have already been successful in establishing and providing maternal immunisation services in community and hospital settings (see the article on p. 32).

This funding will enable midwives who wish to provide antenatal immunisation services (and where it is logistically feasible) to be enabled to do so, to improve women’s access to antenatal immunisation for pertussis and influenza.

Further positive news was the final clinical leadership structure for Health New Zealand, announced at the end of 2024. The final agreed model (which was advocated for by the College in our submission on the proposed restructure) means that every

district in New Zealand will now have district level senior midwifery leadership positions which will not be required to report through nursing. No midwifery leadership positions are being disestablished, and midwifery leadership capacity will be increased in some districts.

New regional midwifery leadership roles will also be established.

This is no small feat, given the overarching drive to reduce spending in the health system by reducing the number of positions in many professions.

Although these are reasons to celebrate (and an acknowledgement of the effective role advocacy can play), there are further challenges on the horizon in 2025, with the proposed major restructure or ”reset” within nationally employed Health New Zealand teams (including Hauora Māori, data and digital, public health and commissioning), as well as the health workforce plan recommending the establishment of a midwifery assistant role.

These restructuring proposals suggest a significant loss of national capacity and a rapid move to a more regional approach for the system overall. It feels as if there is still a long way to go before we have a system which will be able to work in a co-ordinated way in a regional model. Without careful planning there is a risk of having four different regional approaches and losing national consistency. The detail in the health workforce plan about the proposed midwifery assistant role is scant; however, it is concerning that this proposal has been signed off without any apparent consultation with the sector. The need for the profession and the College to remain aware of and respond to the wider context, guided by our objectives and principles, is as pressing as ever. Square

Contact NZBA for all your your baby friendly resources www.babyfriendly.org.nz/resources

Newborn Metabolic Screening Programme update

SMA is now one of the disorders screened for in newborn screening We are delighted to let you know that newborn screening for spinal muscular atrophy (SMA) started on 12 February 2025. It has been added to the panel of disorders screened for in the Newborn Metabolic Screening Programme. Screening for SMA will improve outcomes through early detection and timely access to treatments that have recently been funded by Pharmac.

Thank you again for your dedication and important contribution to better outcomes for pēpē and their whānau through your support of newborn screening.

The pamphlet, Your newborn baby’s blood test has been updated to include SMA as one of the disorders screened for. When gaining informed consent for newborn screening please make sure whānau are aware of the disorders being screened for , as outlined in the pamphlet.

Please ensure you order and give whānau the new pamphlets ASAP and dispose of any old versions so whānau have the most up to date information to inform their choice for screening. It can be downloaded or ordered from HealthEd at healthed.govt.nz/products/your-newborn-babys-blood-test- the-newbornmetabolic-screening-programme Supporting information on SMA is available on the Health NZ website tewhatuora.govt.nz/health-services-and-programmes/newborn-metabolic-screening-programme/spinal-muscular-atrophy/ A webinar that provides information on SMA and newborn screening is available to watch on the New Zealand College of Midwives website, midwife.org.nz/ Other guidance and reminders are on the Health NZ website tewhatuora.govt.nz/health-services-and-programmes/newborn-metabolic-screening-programme/guidelines-updates-practice-reminders/

YOUR COLLEGE

YOUR COLLEGE ACC births injuries online lodging The College has recently raised its concerns to ACC that after nearly 2 years since the passing of the Maternal Birth Injuries amendment to the ACC bill, midwives are still unable to lodge ACC45 claim forms online. If an ACC45 form for a maternal birth injury is lodged at the time of birth when the injury was sustained, women are able to access funded or ACC subsidised treatment at a later stage. Currently if a midwife wishes to lodge a claim she needs to complete a paper version of the ACC45.

ACC have confirmed that they are working to enable online claim lodging for midwives, but as yet have not confirmed the timeframe for this to occur. We will keep members updated. Square

Updated consensus statements and format coming soon The College has been updating its consensus statements through an organised work programme. As part of the update, we have revised the presentation and format of the statements. Please keep an eye out for the updated versions which will go through our usual member consultation processes. Square

all lead maternity carer providers must inform women of the entitlement to 72 hours minimum inpatient care. As midwives already operate within a fully informed model of care, we consider a legal mandate for this information to be excessive and unnecessary. Square

Call for nominations – Independent Finance Committee member The College’s finance committee consists of the co-presidents and four midwife representatives (three representing their regions and one elected independent member). The independent finance committee member is elected by the membership for a three-year term. The College’s Chief Executive and Business and Finance Advisor also provide ex-officio support to the committee. The College is now seeking nominations for the independent committee member role. If more than one nomination is received, an online ballot will be undertaken.

The finance committee meets either face-to-face or virtually, for up to two hours prior to each national board meeting (three times per year) with virtual meetings in between these times as necessary.

The finance committee has delegated responsibility from the national board to provide advice and make recommendations to management

Restructuring submissions

in order to achieve the College’s strategic goals. Committee members

The College provided written submissions to Health New Zealand on

by providing high level oversight and strategic advice on financial

several of its recent restructuring proposals. These proposals were seeking to disestablish a number of positions across the Hauora Māori services, the national Public Health service, the Data and Digital team and the national Commissioning team. The College’s submissions highlighted the need for sufficient capacity to ensure there is no disruption to services which are currently provided by many of the roles which the proposals were seeking to disestablish. Examples of some of the roles which the proposals were seeking to disestablish include; backroom data and digital support, support for the roll out of the national maternity digital system and roles which ensure the functioning of antenatal and newborn screening programmes. Square

The Pae Ora (Healthy Futures) (3-Day Postnatal Stay) Amendment Bill A new Government Bill proposes to increase access to postnatal care for all women in maternity facilities up to 72 hours as an expected entitlement. The College has provided feedback which highlighted

contribute to the discussions to enable sound financial oversight management, reporting, risk management and audit.

Nominations – including a cover letter and CV – to be emailed to Lynda.o@nzcom.org.nz by 6 April 2025. Square

Whakatāne maternity service transition In January this year, Whakatāne hospital transitioned from a secondary to a primary maternity facility due to the resignation of its four obstetricians. Health NZ I Te Whatu Ora has made assurances that recruitment for obstetricians is underway with the aim of transitioning back to a secondary service in 12-18 months.

Community and hospital midwives working in the Eastern Bay of Plenty continue to provide a high-quality service while adjusting to the logistics of accessing necessary acute obstetric services in Tauranga hospital.

Whānau and community members are understandably concerned about longer travel times, particularly for those residing further east.

The College is working with the midwives in the region who have risen

the importance of policies and legislation that improve the maternity

to the challenge and demonstrated leadership to ensure their services

system, while also pointing out the chronic issues facing our maternity

are sustained and whānau are reassured they will continue to receive

systems in terms of midwife shortages, limited bed spaces and the lack

safe care. The College is also advocating for Bay of Plenty midwifery at

of support for primary birthing by successive governments. The Bill omits

a district and national level with Health NZ I Te Whatu Ora, to ensure

recognition of the lead maternity carer system which provides postnatal

prompt re-establishment of the obstetric service and clear policies,

midwifery care in the community, but it includes the requirement that

processes and support are available. Square

8 | MIDWIFE AOTEAROA

FORUM

Farewell Lisa Donkin (left), welcome Julie Williams (right).

FAREWELL LISA, WELCOME JULIE The bags are almost packed and the travel plans in place, we are sad to see Lisa Donkin leave the College after eleven years taking care of membership. Lisa says she will miss her colleagues but it is the members who have kept the role interesting over the years.

Lisa joined the College in 2014 and intended to stay for a ‘couple of years’. Not sure where the time has gone, Lisa is excited to embark on a two month trip around Europe with husband Cliff, followed by a ‘life on the road’ back here in New Zealand.

We wish Lisa all the best and welcome Julie into the role. With some pretty big shoes to fill we know Julie Williams will continue to serve members with the same pride and passion as Lisa has. Julie’s background in customer services, most recently with the Waimakariri District Council, will enable her to slot into those shoes easily. Julie likes to spend time in the garden of her North Canterbury property where she lives with her husband and two adult children. Julie’s work history also includes time at an electical firm and several years with Telecom (now Spark).

Julie is looking forward to meeting the membership over the phone and via email, once she learns the ropes and I am sure you will all join me in saying a huge welcome. Square

We wish Lisa all the best and welcome Julie into the role. With some pretty big shoes to fill we know Julie Williams will continue to serve members with the same pride and passion as Lisa has.

ISSUE 116 MARCH 2025 | 9

BULLETIN

BULLETIN Voluntary Bonding scheme on hold Health New Zealand has confirmed that no decisions have been made regarding the Voluntary Bonding Scheme (which provides payment following a minimum of three years’ service) for health professional graduates.

At the time of this magazine going to print no decisions had been made by Health Workforce about the scheme for 2025, or about funding for those who have applied for the programme in 2024. The College continues to advocate for provision of this funding support for our midwifery graduates. Square

College representatives meeting with midwives affected by the vaccine mandate On July 30th 2024, representatives from the College met with members of Aku Huia Kaimanawa (AHK) in Tauranga for a facilitated meeting. AHK is a grassroots midwifery collective formed in 2022 to represent some of the midwives who were required to leave practice when the Covid-19 vaccine mandates came into effect. The College was aware that some midwives who had been impacted by the mandate had felt unsupported by

10 | MIDWIFE AOTEAROA

the College at the time the mandate was implemented and subsequently felt alienated from the wider profession. The meeting was sought with the intent to hear these concerns and to rebuild relationships and trust between the College and its members.

This hui provided an opportunity for the College to hear the experiences of midwives, women and whānau significantly impacted by the vaccine mandate, and to discuss and clarify some of the College processes, decision making and position around that time.

During the hui midwives from AHK shared

Carosika collaborative update The Carosika Collaborative was established in 2020 to address inequities and improve outcomes in preterm birth across Aotearoa.

In 2024, they launched their website, designed for midwives, healthcare professionals, and whānau seeking evidence-based guidance on improving preterm birth care.

A key focus of the Collaborative is the development of Taonga Tuku Iho | Best Practice Guide for Equity in Preterm Birth in Aotearoa. This guide, currently in progress, responds to the need for national guidance

that they continue to feel a deep sense of

on best practice in preterm birth care.

grief and loss at having to leave practice, and

The rollout began with the launch on 13

talked about their perceived lack of support

November 2024, with additional guidelines

from the College and a disconnect between

and resources being introduced over the

the mandate and the foundational principles of

next 6-12 months.

autonomy and informed decision making.

At the conclusion of the hui, AHK suggested

The process being adopted by the guideline development group does not allow

a number of actions that they would like

the College to follow its usual process of

the College to facilitate. These actions were

member consultation and feedback.

presented to the College board in November.

However, the College has representation on

A working group of representatives from

the steering group and the Best Practice Guide

AHK and the College has been formed to

review panel.

discuss how these will be considered. Both

Visit the Taonga Tuku Iho website,

groups agreed that it is important to use this

where you can explore resources and

experience to inform the College’s future work,

follow updates https://bestpracticeguide.

particularly in the event of another pandemic. Square

carosikacollaborative.co.nz. Square

Practicalities of mentoring in Aotearoa The College has developed this course as a resource to inform and support you in a professional mentoring relationship.

Te Tiriti o Waitangi This course delves into Aotearoa’s rich past and present, offering insights that foster understanding and support informed, thoughtful decisions for the future.

COLLEGE eLEARNING PROGRAMME The College is currently offering two eLearning courses, with more planned for launch over the next few months. The courses available are Practicalities of Mentoring in Aotearoa and Te Tiriti o Waitangi. We are receiving great feedback about both courses.

Te Tiriti o Waitangi is subsidised for members and can be applied to the Midwifery Council’s mandatory cultural safety education requirements for the 2024-2027 cycle. This course includes an online learning module, followed by an on-line community session where participants can explore the eLearning content in greater depth and engage in the elements within the eLearning and have the opportunity for open discussion.

Practicalities of Mentoring is a pre-requisite for any mentoring programme with the College and has a great deal of useful information for any midwife supporting another professionally. This eLearning course is fully funded for College members. The courses are available through the College website education tab. Square

PRACTICE GUIDANCE

WHAT IS CYTOMEGALOVIRUS? VIOLET CLAPHAM MIDWIFERY ADVISOR

KEY MESSAGES • Cytomegalovirus (CMV) is the most common viral infection in pregnancy and is the leading cause of non-genetic hearing loss in infants and one of the main causes of childhood disability • Vertical transmission of CMV may occur from mother to baby during pregnancy • Past infection with CMV does not confer complete protection against reinfection or

HOLLY TEAGLE, AUD UNIVERSITY OF AUCKLAND THE HEARING HOUSE

ANGELA DEKEN, RM NEWBORN HEARING SCREENING PROGRAMME COORDINATOR

infected people, and children under the

Secondary infection with CMV (also

age of two (particularly those in day care

referred to as reinfection or reactivation

environments) will carry the highest viral loads

of latent infection) during pregnancy is

(Cannon et al., 2011). CMV can be transmitted

associated with a 1-3% risk of fetal infection;

from bodily fluids to hands, then to mucosal

however, when fetal infection does occur

surfaces (such as the mouth).

during a secondary maternal infection

Cytomegalovirus is destroyed by soap and water

IMPACT OF CMV INFECTION

with CMV, the potential for and severity of morbidity for the baby is similar to cases of primary infection. Although we don’t have reliable prevalence rates of CMV seropositivity in Aotearoa, in Australia

Most healthy adults and children who become infected with CMV will be asymptomatic and will not experience any long-term effects.

Some infected people may display flu-like symptoms. If women contract CMV during pregnancy, the infection can pass directly from the mother to the baby (vertical transmission), and the earlier in pregnancy this occurs, the more risk there is to the baby. The highest likelihood of mother to baby transmission is following maternal primary infection in the first trimester (32% risk of intrauterine transmission; Leruez-Ville et al., 2024).

the rate of seropositivity is 40-60% within the

cCMV infection carries a significant burden with a 0.64% global prevalence (Leruez-Ville et al., 2024). cCMV is the most common infectious cause of disabilities in newborn babies and is associated with an increased risk of stillbirth, sensorineural hearing loss, visual problems, cerebral palsy, physical impairment, autism and learning disability.

echogenicity, ventriculomegaly and

recommended hygiene measures. Women

virus. CMV is extremely common and is

Meta-analysis shows that although long-term sequelae, especially sensorineural hearing loss (SNHL), are more common in those with clinically detectable disease at birth, they are also found in 13% of those without clinical features attributable to cCMV on initial

found throughout all geographical locations

examination (Dollard, Grosse, & Ross, 2007).

reinfection or congenital CMV.

congenital CMV • Risk of mother to baby transmission of CMV is highest in the first trimester of pregnancy • CMV is not currently part of routine antenatal or newborn screening in Aotearoa • Midwives should discuss CMV with whānau at first antenatal appointment • Hygiene measures considerably reduce the risk of contracting a primary maternal CMV infection • Whānau with a child in daycare (or those working with young children) carry the highest risk of exposure to CMV Human cytomegalovirus (CMV) is part of the herpes family and is the most common congenital viral infection. The CMV virus can remain dormant in the body over a long period after initial infection and women who have been exposed to CMV prior to pregnancy may have naturally acquired immunity.

Transmission of CMV occurs through direct contact with bodily fluids (such as saliva, urine, blood, semen and breast milk) from individuals who are actively shedding the

and socioeconomic groups. Congenital common congenital infection globally and has

PRIMARY VERSUS SECONDARY INFECTION

potentially severe consequences for infants.

The highest likelihood of adverse perinatal

cCMV is the leading cause of non-genetic

outcome occurs following maternal primary

hearing loss in infants and one of the main

infection during the first trimester (associated

causes of childhood disability.

with a 30-40% risk of intrauterine transmission;

cytomegalovirus (cCMV) infection is the most

CMV is excreted in the bodily fluids of

12 | MIDWIFE AOTEAROA

RANZCOG, 2023).

childbearing population (RANZCOG, 2023).

SCREENING Although universal serological screening for CMV is not currently recommended in Aotearoa, early pregnancy screening with CMV IgG may be considered for women who are at high risk of infection. This includes women who work with young children, those displaying flu-like symptoms during pregnancy, and those who receive abnormal ultrasound results (such as periventricular intraparenchymal calcifications). CMV is included within a TORCH screen.

Early determination of CMV serostatus may help in distinguishing between primary infection and reactivation/reinfection during pregnancy if clinically indicated, but does not remove the need to follow with suspected CMV infection in pregnancy should have CMV serology testing for IgG and IgM (and IgG avidity if CMV IgG and IgM are positive). Past infection with CMV does not confirm complete protection against

Immunoglobulin M (IgM) antibodies are short-lived and their existence in the blood confirms that a new (primary) infection is present.

Immunoglobulin G (IgG) antibodies express their predominant activity during a secondary antibody response.

PRACTICE GUIDANCE

HOW TO AVOID INFECTION WHILE PREGNANT

WASH HANDS OFTEN WITH SOAP AND WATER

CLEAN TOYS AND SURFACES CHILDREN HAVE PLAYED WITH

DON'T SHARE FOOD AND DRINK WITH CHILDREN

AVOID KISSING CHILDREN ON THE MOUTH. KISS ON THE HEAD

The European Congenital Infection Initiative

on the basis of maternal serology or

pregnancy and when a baby is being

(ECCI) advocates for implementation of

fetal ultrasound abnormalities. NB: Acute

tested for cCMV (including completing a

universal antenatal screening for CMV, followed

infection with CMV is a transfer under these

risk factor form)

by anti-viral therapy for mothers with a primary

guidelines

CMV infection in the first trimester of pregnancy (citing evidence of a 71% reduction in vertical CMV transmission, (Leruez-Ville et al., 2024). For further guidance on diagnosis

• recommend PCR testing (saliva or urine) for babies of mothers diagnosed with primary

CMV and ensure that a hearing screening risk factor surveillance form has been

risk of progressive hearing loss.

(for babies older than three weeks the newborn metabolic heelprick sample can

Statement ‘Prevention of congenital

be used to test for cCMV but this method

cytomegalovirus (CMV) infection’, available

has lower sensitivity)

PRACTICE GUIDANCE The College recommends that midwives: • inform women about CMV at the first antenatal appointment • offer resources to provide further information about CMV, risk factors and preventative measures (see below for links to resources) • ask women if they are in frequent contact with young children (especially those in day care) and, if so, explain the increased risk of CMV infection • discuss how women can reduce the risk of infection (see infographic) • consider the possibility of CMV infection if women present with a flu-like illness during pregnancy • consider offering serological testing for high-risk women (close contact with children or those flu-like symptoms) • as per the referral guidelines, recommend referral to an obstetric specialist when congenital CMV infection is suspected

providers of a diagnosis of cCMV Antiviral treatment for infants with cCMV is only recommended if started in the first four weeks of life. Infants older than three weeks with symptoms of cCMV should still be investigated as their ongoing management may be informed by this diagnosis. Babies diagnosed with cCMV should be offered specialist follow up and are followed up in audiology until the age of five, due to the high

CMV infection during pregnancy

and management see the RANZCOG

from www.ranzcog.edu.au

• inform general practitioners and Well Child

• recommend paediatric consultation for babies diagnosed with congenital

completed • ensure the local newborn hearing screening team are aware when a mother has had a primary CMV infection during

ADDITIONAL CMV RESOURCES Resource Hub: www.cerebralpalsy.org.au CMV Australia: www.cmv.org.au CMV Action: www.cmvaction.org.uk

POSSIBLE SYMPTOMS OF cCMV IN NEW BORNS

CMV Foundation: www.nationalcmv.org

Petechiae

References available on request.

Congenital jaundice Fetal growth restriction Hepatosplenomegaly

RANZCOG guideline: www.ranzcog.edu.au Square

OCCUPATIONS AT HIGH RISK OF EXPOSURE TO CMV Primary caregivers of pre-school

Microcephaly

aged children

Lethargy or hypotonia

Childcare workers

Poor suck

Paediatric health workers

Eye inflammation

Midwives

Seizures

Teachers

ISSUE 116 MARCH 2025 | 13

PRACTICE GUIDANCE

POSTNATAL ANALGESIA CLAIRE MACDONALD MIDWIFERY ADVISOR

Postnatal pain assessment and management

2017). Effective postnatal pain management

anti-inflammatory drugs (NSAIDs) –and if pain

are important aspects of midwifery care, both

is therefore important to support the

persists, a weak opioid is added as step 2.

immediately after birth and during the following

birthing woman’s/person’s recovery, rest,

This is changed for a strong opioid for

days and weeks. This practice update covers

breastfeeding and parenting journey.

moderate to severe pain as step 3. The

some of the midwifery considerations and

Before making a pain management plan,

concurrent use of analgesics with different

it is essential to fully assess what is causing

modes of action is known as multi-modal

the pain, and to reassess over time. Post-birth

analgesia (BPACnz, 2018). As pain levels

pain from a perineal or caesarean section

decrease during the recovery period, the

wound is anticipated and should gradually

opioid should be stopped first, while non-

require less analgesia. Ongoing visual

opioid analgesia is continued until pain has

perineal trauma (tears or episiotomy),

assessment of wound healing is important to

resolved.

caesarean surgery, afterpains, breast pain

detect signs of infection or poor healing,

and musculoskeletal pain (e.g. coccyx).

which may require additional treatment

Ongoing and poorly managed pain may delay

(e.g. antibiotics). Abdominal discomfort

recovery and return to usual function and

may be related to afterpains, but could also

activities. It can negatively impact mother-

signal retained placental tissue, endometritis,

baby attachment, breastfeeding and maternal

constipation or a urinary tract infection.

psychological wellbeing (Roofthooft et al.,

Making a full assessment is necessary,

2021). Pain which is not well managed can also

including the woman’s symptoms, clinical

increase the risk of sensitisation to pain and

findings (palpation, observations, visual

the development of chronic pain and postnatal

assessment) and laboratory investigations if

depression (Fahey, 2017; Gamez & Habib, 2018).

required. Determing the cause of pain enables

When pain impedes mobility, the risk of other

appropriate treatment to be provided.

current evidence when offering medications for pain management. While non-pharmaceutical pain relief options are important, they are not the subject of this article.

Postpartum pain includes pain from

postpartum complications is increased (Fahey,

Before making a pain management plan, it is essential to fully assess what is causing the pain, and to reassess over time. Post-birth pain from a perineal or caesarean section wound is anticipated and should gradually require less analgesia.

14 | MIDWIFE AOTEAROA

When planning analgesic dosing with postpartum women and people, consideration should be given to recommending fixedinterval, rather than on-demand, paracetamol and NSAIDs (ibuprofen or diclofenac).

This is particularly important for post-surgical pain. One randomised control trial found that compared with on-demand analgesia, the patient group assigned to receive analgesia at six-hourly intervals had lower mean pain scores, higher satisfaction rates, more breastfeeds and less use of supplemental

POSTNATAL ANALGESIA

formulas, with no adverse effects reported

Midwives have a responsibility to prescribe

this means explaining that paracetamol and

appropriately, according to the individual’s

NSAIDs are most effective when taken at

needs and informed consent. Midwives are

regular intervals, rather than waiting for pain

encouraged to familiarise themselves with

to emerge. Regular paracetamol and NSAIDs

the Principles for quality and safe prescribing

should be continued if an opioid analgesic

practice, a joint publication by Te Tatau o te

is also needed; not only do they reduce the

Whare Kahu | Midwifery Council and six other

need for higher doses of opioid analgesia, but

regulatory authorities.

some evidence indicates that paracetamol

The World Health Organization’s pain

for neonates (Yefet et al., 2017). In practice,

has a synergistic effect on other analgesic

ladder has been in use for four decades and

medications (particularly opioids) – making

provides a useful framework for clinicians

them more effective

planning an analgesic regimen with a client/

(Freo, 2022).

patient. The enduring approach is a three-step

Women who have had a surgical birth should

process whereby pain is treated with first-line

receive appropriate prescriptions for postnatal

analgesics – paracetamol and non-steroidal

analgesia from the obstetric or anaesthetic

PRACTICE GUIDANCE

service for discharge home. If midwives are in the position of needing to prescribe a multi-modal analgesic regimen, as always, they should prescribe within their knowledge and expertise. This includes understanding the effects, side effects, interactions and contraindications of the drugs (New Zealand College of Midwives, 2014), and gaining the woman’s informed consent for prescribed medications.

The NZ Formulary is the authoritative resource for current prescribing information (nzformulary.org). The only opioid within a midwife’s scope of practice to prescribe is tramadol. If required, it should be prescribed as a short course (Waitaha Canterbury guideline recommends a maximum of 20 x 50 mg tramadol) to be used as an adjunct to regular paracetamol and NSAIDs. Midwives may need to assure whānau that postnatal analgesia is safe to take while breastfeeding. Midwives can support postpartum women/people to know what to take and when, with a written analgesia plan.

Written medication plans help to minimise medication errors and optimise pain management with regular, adequate dosing (BPACnz, 2018). BPACnz recommends that the most important aspects to include in an analgesia plan are: • The regular dose, frequency and dosing interval for each medicine, including medications that could be taken for breakthrough pain • Adverse effects that may occur and how these should be managed, e.g. taking with food or seeking medical advice • The likely timeframe for pain resolution and instructions on how to reduce the dose and stop medicines as pain improves • Non-pharmacological treatments and comfort measures can be added to the pain management plan.

If pain persists, worsens or takes longer to resolve than expected, a full clinical reassessment is necessary. Square

Are you a dedicated LMC with a passion for rural care, eager to join a close-knit, small rural team based in Dannevirke?

Tararua Health Group offers a 3-bed maternity unit within the Dannevirke Community Hospital. We provide comprehensive continuity of care for women throughout antenatal, labour, birth, and rural/remote postnatal care.

About your new role: Roster: A balanced schedule with a 24-hour roster of 4 days on/4 days off.

Accommodation: The option to stay at our Maternity Cover House at no cost.

Team: Be part of a supportive and welcoming team committed to exceptional rural and remote care.

Travel: If you’re from out of town and need assistance with your travel expenses, we’re happy to discuss a travel allowance.

You will have the following skills: Experience: An experienced midwife seeking a move to a rural environment.

Skills: Strong clinical skills and a compassionate approach to care.

Professional Requirements: Current APC, Indemnity and Vulnerable Children’s Check.

You will be a team player with a sense of humour, excellent bedside manner and bundles of enthusiasm. Your energy and understanding will be vital in providing exceptional care for our newest arrivals and their mothers.

Apply today and become a valued member of our team to tanya.holak@omnihealth.co.nz or call Tanya on 027 320 5616.

References available on request.

ISSUE 116 MARCH 2025 | 15

PRACTICE GUIDANCE

PELVIC FLOOR HEALTH AND ASSESSMENT BRIGID BEEHAN MIDWIFERY ADVISOR

The pelvic floor is a vital anatomical structure

incontinence, dyspareunia and chronic

that supports the bladder, uterus and bowel.

pelvic pain. Psychosocially, many women/

Pregnancy and childbirth can place significant

people experience embarrassment, isolation

strain on the pelvic floor, leading to issues

and diminished self-worth, which can

such as incontinence, pelvic organ prolapse

negatively impact relationships and mental

and sexual dysfunction. These conditions can

health. Midwives are uniquely positioned to

have far-reaching physical and psychosocial

provide individualised whānau-centred,

impacts, including reduced quality of life,

holistic care in the home.

intimacy challenges and mental health concerns such as anxiety and depression.

Untreated pelvic floor injury and dysfunction can impact the planning of future pregnancies for whānau.

Research highlights that among women who have given birth, one in three will experience urinary incontinence following birth, and one in 12 will experience pelvic organ prolapse during their lifetime. In the postnatal period, timely assessment and intervention can prevent these complications, yet pelvic floor health is often under-assessed.

Midwives play a pivotal role in bridging this gap, ensuring early identification of concerns and empowering women/ people to engage in preventative and

The continuity of care model in Aotearoa, which enables midwives to support women/people throughout the perinatal period up to six weeks postpartum, offers midwives unique opportunities for education and screening throughout the period.

CULTURAL SAFETY A culturally safe approach is critical in providing equitable and responsive care to improve outcomes in pelvic floor health.

Guided by Tūranga Kaupapa, midwives can create culturally safe environments, where they acknowledge and respect cultural values, incorporating input from whānau according

SUPPORTING ONGOING PELVIC FLOOR HEALTH Pelvic health awareness is ongoing during pregnancy, birth and post-pregnancy recovery, and midwives can lay the foundations for access to information, guidance and support for whānau. This includes encouraging all women to prioritise their health by incorporating pelvic floor exercises into their daily routine. This also includes ensuring they know how to access additional pelvic health care if they experience ongoing or new symptoms of incontinence, discomfort or prolapse.

Despite challenges such as the current inequities of access to care, midwives can make a difference in normalising regular conversations about pelvic health. This in turn will help reduce whakamā | embarrassment and instead encourage women to ask for help, with the aim of preventing long-term dysfunction and improving their health and quality of life.

restorative care.

to the wishes of the wahine.

KEY MESSAGES

ACC MATERNAL BIRTH INJURY COVER

INEQUITIES TO ACCESSING SERVICES

• Promoting pelvic floor health is an integral

In 2022, ACC introduced Maternal Birth Injury

Ensuring equity in access to services,

Cover to support those who sustain specific injuries during childbirth. This includes funding for injuries such as perineal tears, pelvic floor trauma and prolapse. Midwives have a

particularly for disadvantaged and underresourced populations, remains a vital focus of midwifery care.

However, there are significant inequities

part of midwifery care.

• Normalising conversations about pelvic floor health can reduce whakamā | embarrassment that some wāhine | women may feel.

responsibility to inform clients about this cover

in accessing publicly funded pelvic health

• Culturally safe care is essential.

and lodge claims (using ACC45 form) early

physiotherapy following a birth injury.

after injury diagnosis.

• Early identification, information sharing

Health NZ | Te Whatu Ora services have

and management of pelvic floor issues can

long waitlists; there is a shortage of pelvic

significantly improve outcomes.

For detailed information, refer to the ACC Maternal Birth Injury Quick Guide

THE IMPACT FOLLOWING BIRTH

health physiotherapists, especially in rural communities; and the co-payments charged for physiotherapy all contribute to significant inequity. Healthpoint and Physiotherapy NZ offer directories of both public and private pelvic health physiotherapy

The physical effects of pelvic floor trauma

services. Midwives can provide this information

following birth can include urinary or faecal

to support improved access to care.

16 | MIDWIFE AOTEAROA

• Pelvic floor assessment is critical to preventing long term complications following birth.

• Midwives have a vital role in lodging claims for birth injuries with ACC. Square References available on request.

KEY PRACTICE POINTS FOR MIDWIVES Antenatal and postnatal assessment: Incorporate pelvic floor assessments into routine antenatal and postnatal care. Ask questions about urinary and bowel function, pain and sexual health. Normalise these discussions to reduce stigma.

Referrals: Recognise when to recommend referral to pelvic health physiotherapists and or specialists. Referral guidelines, 7012 Vaginal or perianal prolapse, require a midwife to offer a consultation following birth.

ACC claims: Proactively discuss the ACC Maternal Birth Injury Cover in the antenatal period. Assist in documenting birth injuries and submitting claims in a timely way to ensure postnatal women/people can access available support in the short and long term. Consider the benefits of lodging a claim for every birth injury covered by ACC to ensure easy access to care in future years.

Culturally safe care: Embed Te Tiriti o Waitangi framework into midwifery practice, ensuring equitable and culturally responsive care in the assessment and support of pelvic floor healthcare. Recognise the unique needs of Māori and Pasifika people, migrant communities, low-income families, rainbow communities and other groups facing ongoing healthcare access barriers in Aotearoa.

Psychosocial support: Be attuned to the emotional impact of pelvic floor trauma. Provide a safe space for women and people and their whānau to share concerns and consider referrals to mental health support services when needed.

Education: During antenatal and postnatal care, educate about pelvic floor health and the benefits of pelvic floor exercises.

Use resources like the Continence NZ Pregnancy Guide to guide conversations. In the postnatal period, advise waiting at least three months before high-impact activities, as these can worsen pelvic floor dysfunction or lead to prolapse. Use trusted resources from websites such as Physiotherapy New Zealand, Continence NZ, and Pelvic Floor First for guidance on exercises and recovery post birth and for the years ahead.

Upskilling: Consider engaging in professional development opportunities focused on pelvic floor health, such as workshops or webinars, to strengthen skills in assessment and care provision. The College workshop ‘A- Z of Perineal Care’ provides midwives with skills and knowledge in managing and assessing pelvic health, covering the spectrum of care through the antenatal, intrapartum and postnatal periods.

YOUR UNION

MIDWIFERY-LED CARE IN A HOSPITAL SETTING WHAT ARE THE OPPORTUNITIES FOR EMPLOYED MIDWIVES? CAROLINE CONROY MERAS CO-LEADER (MIDWIFERY)

Late in 2024 an emerging obstetric workforce shortage started to be evident in some of the country’s secondary maternity units. There is also a shortage of LMC midwives in some communities, with a corresponding increase in women receiving care from Health NZ midwifery services.

The Maternity Service tier 1 specifications anticipate services that support continuity of care. Even when women/people receive care from Health NZ maternity services, there are opportunities to support continuity of care through the provision of midwiferyled services provided by employed midwives.

In some districts there is a wide range of midwifery-led services provided; yet, in other districts these opportunities are not being fully realised. Maximising the provision of midwifery-led services not only enables continuity of care to be provided for women/people receiving hospital maternity services, but also allows midwives to utilise their scope of practice more fully and eases pressure on obstetric staff.

Midwifery-led care does not need to be limited to community and outpatient settings, as there are opportunities for the provision of midwifery-led care within primary, secondary and tertiary facilities. In some districts there are not local primary maternity facilities available, and women/ people only have the option of a secondary or tertiary maternity unit unless they choose to birth at home.

Just because women/people receive care at a secondary or tertiary facility, it does not necessarily mean that they then meet the criteria for consultation or referral to an obstetrician. Midwifery-led services should be available in these settings, with midwives

18 | MIDWIFE AOTEAROA

providing care within their scope of practice and only consulting or referring to obstetric and other secondary care services when there is a clinical need. There is nothing in the maternity specifications that requires obstetric oversight of all women in a secondary or tertiary setting.

THE MERAS COLLECTIVE The MERAS Collective anticipates that MERAS will work closely with midwifery leaders across districts and nationally to support the development of employed midwifery-led services where these are needed. MERAS can ensure there is a consistent approach to midwifery roles, that these are consistent with the Midwifery Career Pathway (appendix c MERAS SECA), that there are appropriate pay grades applied (MERAS SECA 10.1 and 10.2) and there is consistency in terms and conditions.

MERAS Collective clause 1.2: MERAS

and Te Whatu Ora share a strong interest in getting health workforce development right by building a midwifery workforce and work contexts that are flexible, productive, sustainable, and able to deliver on health goals. The parties recognise the value of working co-operatively and constructively together to achieve the over-arching goal of maintaining and advancing the midwifery workforce that takes shared responsibility for

providing high quality healthcare on a sustainable basis.

The range of Health NZ midwifery-led services varies across the country. Table 1 shows examples of what can be included.

EXTRACTS FROM THE MATERNITY SERVICE TIER 1 SPECIFICATIONS • Maternity Services funded by DHBs include primary, secondary and tertiary maternity care for pregnant women and their babies until six weeks after the birth (The Service).

The Service supports continuity of care, and is delivered in community, outpatient and inpatient settings.

• The definition of LMC includes practitioners funded under the Primary Maternity Services Notice and practitioners funded by DHBs to provide an LMC model of primary maternity care.

• The Service may be provided in community, outpatient and inpatient settings. a. The community setting includes private residences, community clinics and other community settings, including marae. b. The outpatient setting includes primary, secondary and tertiary maternity facilities. c. The inpatient setting includes primary, secondary and tertiary maternity facilities.

YOUR UNION

TABLE 1: MIDWIFERY-LED SERVICES Caseloading

These are midwifery teams of two to four midwives providing

midwifery services

continuity of antenatal, postnatal and intrapartum care. Some of these teams have been established to focus on meeting the needs of particular women/people, including those wanting to birth at primary maternity units, wāhine Māori or rural women/people.

Community

These services provide continuity of antenatal and postnatal

midwifery services

care and are often the first to be established when there is a shortage of LMCs.

Midwife specialists

These midwives provide midwifery care for women/people with more complex pregnancies, alongside obstetric and medical colleagues. The midwives coordinate the care and provide ongoing

Secondary Maternity Services are those

follow up of women with diabetes, high risk pregnancies and other

provided where women or their babies

complexities.

experience complications that need additional maternity care involving obstetricians, paediatricians, other specialists and secondary

Midwifery-led

These services have become an increasingly common way of

care teams.

• Day assessment units

providing ongoing outpatient and acute maternity care to women/

Secondary Maternity Services are provided to women and babies, based on clinical need,

• Acute assessment care/ units

until six weeks following birth.

people between antenatal appointments. They can be provided at primary, secondary or tertiary facilities.

In primary facilities and smaller secondary facilities the services may be combined and may be provided as part of the overall

Secondary Maternity Services include routine

inpatient service. In larger secondary and tertiary units these

and urgent specialist consultations, elective

services may have designated rooms and midwives allocated

and emergency caesarean sections, vaginal

each shift.

and assisted deliveries, all treatment required

• Day assessment units tend to provide scheduled

in emergency situations, allied health services,

appointments for services such as ferritin injections, BP &

and support from a lactation consultant

CTG monitoring, and follow up from SMO clinics during

for women and babies who experience

weekday hours.

breastfeeding complications.

• Acute assessment units or beds focus on acute presentations

IN CONCLUSION

such as reduced fetal movements and SRM assessments and

At a time of workforce shortages and budget constraints it makes sense to enable Health NZ midwives to practise to the full scope of practice. There are clear consultation and referral guidelines to guide practice and indicate when obstetric and other medical consultation or transfer of clinical responsibility is needed.

If you can see opportunities for more midwifery-led care in your maternity service, discuss with your local MERAS workplace representative, your Director of Midwifery or the MERAS Co-Leader (Midwifery). Square

are available 24/7. These services reduce the busyness of the birthing suite.

Midwifery-led labour and

Women/people receiving care from employed community

birthing services

midwifery services should still be able to birth at primary, secondary or tertiary maternity services with midwifery care from the midwives on duty that shift. They should not need to be reviewed by obstetric staff unless they meet the consultation or referral guidelines.

Midwifery-led

Women who have required consultation or referral to obstetric care

postnatal services

during the antenatal or intrapartum period can usually be handed back to midwifery care as they leave the birthing suite or within 24 hours, unless they continue to be medically or obstetrically unstable.

For MERAS Membership merasmembership.co.nz www.meras.co.nz

Midwifery-led care on a maternity ward enables more timely transfer to primary maternity facilities or assessment of the overall wellbeing of the mother/parent and baby before a midwifery discharge home.

ISSUE 116 MARCH 2025 | 19

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FEATURE

PARENTS CENTRE TRUST CLOSING CAROL BARTLE POLICY ANALYST

The College was saddened to hear the devastating news in November that the Parents Centre Trust was closing at the end of 2024. The College has had the privilege of being in a strong partnership with Parents Centre for 35 years, with Parents Centre Christchurch becoming a member of the College in 1989. This vital service which has been provided for parents for many years will be a significant loss.

Parents Centre has been active for over 70 years in Aotearoa and is a

of the late twentieth century and co-founder of the Parents Centre

charitable trust that has provided childbirth and early parenting classes

movement in the 1950s.

across the country. Fifteen volunteer-led independent Parents Centres across the country provide additional services in their local communities and will hopefully be able to continue operating these services.

The roots of Parents Centre go back to the 1950s and involve women

Another key figure is Christine’s friend Helen Brew, a trail blazer who strongly believed women should be given choices about pain relief, information about natural birthing techniques, and the opportunity to have a say in how their babies were born. Helen was a speech

such as Nancy Sutherland who was a children’s rights champion,

therapist, child psychologist, parent, actress and documentary film

consumer advocate, political activist, and advocate for natural childbirth,

maker. She met the psychiatrist R.D. Laing in 1972 in London and again

breastfeeding and midwifery. Nancy died age 93 in 2002 and in her

the following year when he lectured at Victoria University. Laing was

New Zealand Herald obituary there is a story about how she was the

critical of “modern” birth practices such as induction and cutting the

first mother in New Zealand to use the Grantly Dick-Read method of

umbilical cord too soon. Their shared views on birth led to Helen making

natural childbirth, and how she was separated from her full term healthy

the film Birth with Laing in 1978 (see www.nzonscreen.com/title/birth-

newborn twins after their birth in 1938. The twins were brought to Nancy

with-dr-rd-laing-1977). The film aimed to use shock tactics to draw

on day three and the matron is reported to have said, “here are your

attention to childbirth issues and show that vigilance and protest were

babies”, to which Nancy replied, “but how do I know they’re mine?”

still needed (Dobbie, 1990).

Nancy’s advocacy for natural childbirth has been part of the positive

Mary Dobbie’s book is a fascinating history about the development

changes for women and babies in the New Zealand maternity system.

of Parents Centre groups all around New Zealand, of women and their

Another key figure in Parents Centre history is Mary Dobbie, who

supporters fighting for their rights in childbirth, maternity politics and

wrote The Trouble with Women, commissioned by the Federation of

reform, support for midwives and midwifery, and issues such as the

NZ Parents Centres to ensure its history was recorded before records,

long fight for mothers to visit their hospitalised children. Parents Centre

and memories, were lost (Dobbie, 1990). Of interest to midwives is that

has continued to support childbirth and parenting and as described on

Joan Donley shared her resources with Mary while she was working on

their website they have been “weaving communities of informed and

her own book, Save the Midwife. Mary’s book has a foreword written

connected parents”. In the 138 pages of Mary Dobbie’s book there are

by the then Minister of Women’s Affairs, Associate Minister of Education

too many extraordinary and courageous women and men to mention but

and former member of Parents Centre, the Hon Margaret Shields, who

we should be eternally grateful for what they did for childbirth, mothers,

noted how timely the story of Parents Centre was because the book was

babies, children and families.

published in 1990 when the Nurses Amendment Act was passed. Shields said the Act marked, “… an important turning point in the availability of birthing choices in this country” and it “will allow a midwife to take responsibility for the care of a woman through her pregnancy, childbirth and the post-natal period. I cannot think of another time in a woman’s life when the continuity of care and the support of another woman is more important” (Dobbie, 1990, p. viii).

Hard to understand that women had to fight to access their sick children in hospital, hard to imagine that mothers did not see their newborn babies for three days, and hard to believe that women were anaesthetised in second stage of labour without their consent. The loss of Parents Centre is tragic, and we should never forget the significance of this social movement as we have a lot to thank them for. It matters to remember history. Square

There are many other key figures in the history of Parents Centre, including Christine Cole Catley who was a leading independent publisher

References available on request.

ISSUE 116 MARCH 2025 | 21

NGĀ MĀIA

TŪRANGA KAUPAPA EDUCATION PROGRAMME: WORTH THE WAIT TAMARA KARU NGĀ MĀIA GENERAL MANAGER

Ngā Māia is thrilled to announce the launch of the Tūranga Kaupapa

applying Tūranga Kaupapa in practice. Bring your questions and

Education Programme on 1 March 2025. While the debut has been

deepen your understanding.

slightly delayed, we believe the adjustments—driven by stakeholder feedback—underscore the importance of making CPD more

CONVENIENT SCHEDULING

accessible, affordable and practical without compromising high-quality

Over 50 sessions will be made available from March to November 2025,

learning. The Council has generously allowed midwives three years to

scheduled on Tuesdays, Wednesdays and Thursdays from 9:30 am

fulfil their compulsory requirements for Cultural Safety, including

to 1:30 pm. Look out for early bird incentives once the portal is ready!

Tūranga Kaupapa.

LIVE SESSIONS To ensure your professional development fits seamlessly into your busy life and to reduce overheads, we've tailored an 8-hour programme for

WE'RE HERE TO HELP Our team will be on hand to provide technical support and ensure a smooth online experience.

midwives:

EVALUATION & RECERTIFICATION

• Module One: 4 hours of self-directed learning. Engage with e-learning

To qualify for recertification, you must complete the full 8-hour

packages at your own pace, featuring video lectures, readings and guided reflection assessment.

• Module Two: 4 hours of online live wānanga. Join live, interactive sessions with national facilitators who will guide you through

programme, Modules 1 and 2.

REGISTRATION PROCESS Our online registration portal is under development and will include a payment pathway, access to self-directed learning packages and links to live sessions. In-person 8-hour sessions are available upon request, at your cost.

UNIQUE BENEFITS: •

Cost-effective and resource-efficient, right to your home

•

Convenient and accessible

•

Small, welcoming sessions with a maximum of 25

•

Designed by midwives for midwives

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Newly developed resources to support your practice

participants

We are excited to embark on this journey with you in 2025-2027, enabling midwives nationwide to blend the latest knowledge with practical tools to enhance Tūranga Kaupapa in midwifery practice —a need more vital now than ever. Stay tuned for more details, and visit our website or contact the Ngā manaakitanga, The Tūranga Kaupapa Education Programme Team at admin@ Tamara’s grand-daughter (@2 hours) Ngā Ueaurongo-a-Hineraukatauri Manuirirangi born at home.

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ngamaiatrust.org for feedback or inquiries. Square

PASIFIKA MIDWIVES

INTERNATIONAL STUDENTS: A THREAD IN AOTEAROA'S CULTURAL FABRIC NGATEPAERU MARSTERS AUT PASIFIKA EDUCATOR

International students are part of New Zealand’s economy – their presence and inclusion a thread in Aotearoa’s cultural fabric.

According to Education New Zealand | Manapou ki te Ao there were 37,685 international tertiary students | tauira in 2023 an increase almost 30% from the previous year. Although recovery has been slow postCovid, the momentum generated has seen a 67% increase in total international student enrolments (2023) compared with the previous year, with midwifery a small contributor.

The international tauira pathway is not the normal route of Pasifika peoples in midwifery but has been for Jein Waker. Originally from Puncak Jaya, Jein was raised in Wamema, West Papua – a large town in the Western New Guinea region of Indonesia, with an estimated population of approximately 66,000.

Wa kinaonak (hello) Jein, who is one of the five international midwifery students enrolled at AUT and in her final year. Ngā mihi nui for sharing your story.

Jein pointed out that West Papua is not seen as a Pacific nation but part of Indonesia. This fact underpins the ongoing political unrest, as indigenous Papuans have strived for decades to become an independent state. The formation of Free Papua Movement in the early 1960s has seen a growing force, with offshore support.

West Papua’s health system is very basic and maternal and fetal death is common. She shared that there is a lack of understanding why these deaths occur. What is accepted is the cultural belief that it’s the woman’s fault because she must have done something to deserve that, a frustrating aspect for Jein. Ancient superstitions are still a living part of their belief system.

Jein has a desire to use her midwifery knowledge to educate her people, but her immediate goal is to complete the degree and work in Aotearoa – ideally, in a rural location as a more appropriate context to consolidate practice before returning home. To enable her to work at home, Jein will have to complete a bridging RN qualification to become a nurse/midwife. This nurse/midwife role is the norm across most Pacific nations due to their remoteness and broad clinical context.

Jein’s final words are of home and her mother, a single parent.

“A goal is to build a house for Mum,” she says. Square References available on request.

As a scholarship recipient of an Indonesian government initiative established in 2014 and with a broad kaupapa of exploring educational opportunities, Jein arrived with four other students in mid-2017. She became a Year 10 student at Edgewater College (east Auckland), boarding with a host family whom she continues to live with today.

Political neutrality has to be maintained to safeguard her scholarship, which covers tuition-related costs, living expenses and a small koha.

She also works part-time to meet transport costs for clinical placements.

Jein’s journey in Aotearoa began with severe homesickness that affected her physical and mental wellbeing, causing hair loss.

The pressure of a western society’s expectations saw a high-achieving student from West Papua interpreted as underachieving against New Zealand’s academic standard. Jein’s cultural transition from living in a communal way of sharing with neighbours to a foreign individualised suburban existence has taken some adjustment. Fortunately, improved technology in her 2nd year has meant more accessible communication with whānau, especially her grandparents who raised her.

Jein’s midwifery calling is typically driven, like many, to serve her people. However, her experience is not typical of her classmates, as

Jein Waker, who one of five international midwifery students enrolled at AUT.

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WITH WOMEN IN A CORRECTIONS FACILITY AMELLIA KAPA REGISTERED MIDWIFE

As midwives, being ‘with women’ is our natural state. But what happens when the working environment is externally controlled, restrictive, and the women we’re caring for are facing unimaginable complexity? Kelly McConville has been caring for women in Auckland Regional Women's Corrections Facility (ARWCF) since 2014 and shares her unique perspectives with Amellia Kapa.

Kelly McConville did her first booking visit in ARWCF 10 years ago, following a secondment to the Counties Manukau community high risk midwifery team. It wasn’t the first time her nonjudgmental, easy-going nature had caught the attention of her colleagues, who approached her about working in the prison; a role which had historically been challenging to fill.

“It’s a logistical nightmare,” Kelly begins.

“If you're an LMC, or community midwife, you can't take your phone inside the facility. So who backs you up while you’re in there? Plus, you might go in with the intention of seeing five women that day, but only end up seeing two. Or you might see none at all, because all sorts of things can happen on any given day and prison is a complex place to navigate. So it's just not an efficient place for a midwife to work.”

Midwives might not be surprised to discover the number of pregnant women Kelly cares for annually has risen over time. “When I first started, the caseload was quite small. I saw about 28 people in my first year.

Now, I see around 40-50 women a year and those numbers have been consistent for about eight years now. However, the pregnancy outcomes once women in ARWCF engage in midwifery care are very good.”

Anecdotally, based on the experience she has accumulated over the past decade, Kelly lists a

number of possible reasons why numbers have been on the rise. “Women living in poverty; women living with addiction; increasing mental health issues; the experience of family violence and the impacts of physical and sexual abuse.”

She also points to specific substances and the devastating effects they are having on whānau and entire communities as a result. “Before 2000, we didn't have a problem with methamphetamine in this country and very few women used opioids.

Methamphetamine has become the drug of choice since about 2010. So I believe that's a major contributor, because more women are now involved in crime as a result.”

Many of the complications of pregnancy she sees among her clients can be attributed to drug misuse.

“We have a high rate of previous and current SGA, IUGR, pre-term birth, as well as women with a history of stillbirth – at times more than one stillbirth.

Anxiety, self-harm, emotional dysregulation along with previous suicidal ideation and attempts are also common.”

Kelly also notes a couple of lesser known, but no less concerning, trends. “We’re seeing increasing rates of psychosis and cardiomyopathy associated with methamphetamine use. It's not unusual to find maternal tachycardia often related to high use of methamphetamine.”

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Although the vast majority of midwives in Aotearoa may never work within the physical confines of a prison, Kelly is keen to remind other midwives that they are interacting with these women, whether they’re aware of it or not. She highlights the sensitivity that’s required when working with all women, “because, actually, these women are also in the community.

What Kelly has been exposed to over the last decade has undoubtedly influenced her approach to midwifery care and she highlights the very beginning of the journey as crucial. “When I began working in the prison, I used to try and book women the first time I met them. But I don't do that anymore because I’ve learned how important it is to focus on whakawhanaungatanga.

Providing a meaningful meet and greet with a woman is important, as they're often in quite a vulnerable space.”

The initial visit with Kelly can be understandably emotional for incarcerated women, as she highlights. “It's not unusual for me to meet women for the first time and they'll cry. And they might not cry with anyone else. They don't cry in their cells, they don't cry with their whānau, but they meet me and that's an opportunity. The door closes and I say ‘Hi, my name's Kelly, I'm a midwife’, and then the tears start flowing.”

Kelly’s intuition around what to do, and when, has developed over time and, as she explains, it’s practice wisdom that can’t necessarily be taught. “I individualise my approach depending on the woman and her circumstances. Some women are happy to

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see me, and I know I can book those women straight away, because they’ll open up and tell me their life stories. And then with others, I'm more cautious. Some women don't trust people, maybe because they've never had a trusting relationship in their whole lives. So it takes them a little while to get to know me and to talk about what's important for them.

And it might be that I see some of those women two, three or even four times before I actually do their booking.”

elucidates. “Quite often, these women will not present because there are things going on their lives that are more important to them, or they face barriers that mean they're unable to engage straightaway. I suggest that these women represent some of our most at-risk families nationally and many will have complex health risks and social concerns.

They’re described as vulnerable, but actually I believe I work with some of the most resilient women in the country.”

“Some women can come across as quite aggressive, or intimidating, but when you've dealt with women like that before and you've got that experience behind you, it's really helpful,” she continues. “If I'm with someone, for example, and I can see that they're distracted and getting agitated, I can pick up on that and suggest that we've done enough for that appointment. I’ve had women in clinic ask me when they can leave, and I tell them they can leave right away if they want to. Instead of insisting they stay in order to finish the visit, you learn to be flexible and you realise how important it is to know when to end the conversation. That's just as important as knowing when to start a conversation in this environment.”

Resilient or not, however, women in prison are isolated – disconnected from their usual support networks – the reality of which is probably most pronounced postnatally. “I usually do an average of about 11 postnatal visits in ARWCF, because women don't have their whānau around them,” Kelly explains. “It's a totally different process for these women, so even though it's obviously really important to maintain a professional relationship when working with prisoners, I think the caring relationship probably goes a little bit deeper.”

Although the vast majority of midwives in Aotearoa may never work within the physical confines of a prison, Kelly is keen to remind other midwives that they are interacting with these women, whether they’re aware of it or not. She highlights the sensitivity that’s required when working with all women, “because, actually, these women are also in the community. Whether midwives are aware of their full history or not, they are meeting these women all over the country.” She reiterates how experience has taught her that a booking is not necessarily the first point of contact a midwife needs to make with women. “It's actually about saying ‘Hi, who am I? Who are you? And what do you expect to gain out of this relationship?”

For women whose babies remain in their care, Kelly says breastfeeding rates are high and shares her view on why the outcomes are so positive. “Babies in Corrections rarely lose weight in their first week and it’s made me question whether the weight loss we’ve come to accept as normal is actually due to the social impact of the kind of lives we live – due to having other children for example, or other responsibilities. Women who have babies in a Corrections facility are there 24 hours a day, seven days a week and their sole purpose is to feed and care for their babies. Most babies either maintain their weight in the first week, or put weight on, which is really interesting and may surprise some people.”

“I think that's a really important way to start off,” she continues, “because the overwhelming majority of women who present at Corrections are un-booked, regardless of their gestation. Whether they present in their first, second or third trimester, over 90% of them are un-booked.

I suggest that, nationally, these could be women who might present somewhere in labour, having been unable to access antenatal care.”

While not all women’s babies remain in their care, there are provisions for the dyad to be kept together. “Over the last six weeks, I've had seven women give birth. Of those seven women, three are in the Mum and Baby Unit in the Corrections facility, which means they have their babies with them 24/7. This self-care unit is made up of two houses within the prison complex and each can accommodate three women and three babies. So you can have up to six women and six babies living in those houses at any given time. The whole idea of the unit is that women can reside there with their babies up until they’re two years of age.”

Having a non-judgmental approach and even reviewing the language we’re using as midwives is also vital, as Kelly further

Women apply to go into the unit and a multidisciplinary team, of which Kelly is a part, reviews the applications, actively

FEATURE

looking for reasons to support it. “But if a woman isn’t approved for the Mum and Baby Unit”, Kelly explains, “they can apply for ‘feeding and bonding’, which means someone can bring their baby into prison so that they can spend periods of time with them, either breastfeeding or formula feeding. It's an opportunity to still bond with their babies.”

Recently, Kelly advocated for a woman whose baby was being removed to alternative carers by Oranga Tamariki. She advocated for the baby to remain with mum for at least 24 hours following birth, until a caregiver had been arranged. “Postnatally, I asked the woman how the experience was for her and she's actually over the moon. She's more accepting now of what happened. She knew her baby wasn't going to be in her care, but now she's working to see whether her whānau can have her baby and if, when she's released, she can go back and be part of that baby's life. So it’s been an enabling experience for that woman. Kelly stresses that it's important to respect women who are in Corrections. “They should have the same rights to dignity, privacy and confidentiality as any other woman.”

Advocacy is a constant in Kelly’s role but, as she illustrates, the work is rewarding. “It's not easy at times, but I've combined efforts with Corrections staff to improve equity to healthcare. For example, I worked with the administrator to improve access to ultrasound scanning outside of prison because, when I first started, women in prison were not being given appropriate access to scans. We worked hard to make sure they were done in a timely manner and Horizon Radiology understood the logistical nightmare of arranging community-based scans for pregnant women being escorted from a Corrections facility.”

And whilst there have been some wins, Kelly is acutely aware that the reality for these women doesn’t necessarily change, or improve, once they are released. She makes a plea to her colleagues, to go the extra mile for these women once they’re outside prison walls. “When women are released from prison, they often don't have a phone, so I can't pass on a contact number, and I'm relying on the address I’ve been given from the court, which may not be current by the time they’re picked up by an LMC or community midwife. What I’d love to

see is midwives in the community doing everything they can to engage these women for care after their release. These women have complex psychosocial issues and they’re facing huge barriers, so physically knocking on their doors to see whether they'd like to connect for some healthcare is hugely valuable. I know it's tough for everyone out there and many midwives are working in areas with staff constraints, but it’s important to remember that these women aren’t going to actively seek care. They are facing a very unique set of circumstances, so exercising compassion and understanding, tailoring the care to these women’s lives would be really great to see.”

After a decade of working with women in Corrections, Kelly acknowledges the profound impact they have had on her, as both a woman and a midwife. “I wouldn't be the person I am today if I hadn't had the opportunity to care for these women; they’ve taught me a lot about communication and compassion. Women in prison engage well and value the role of a midwife, and I’ve appreciated the opportunity to work in partnership with them.”Square

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A HOMECOMING FOR MIDWIFERY’S ‘BIG VISIONARY’ DR SALLY PAIRMAN RETURNS TO AOTEAROA ZAHRA SHAHTAHMASEBI JOURNALIST

Across four decades, Dr Sally Pairman has been an absolute trailblazer for both midwives and women, not just in Aotearoa but across the globe, says Karen Guilliland, friend and colleague for over 40 years.

Sally’s credentials speak for themselves, spanning midwifery practice, education and regulation.

She holds a Master’s and a Doctorate degree in midwifery and spent 16 years at Otago Polytechnic in a variety of roles, including Head of the School of Midwifery, Professor of Midwifery and Director of Learning and Teaching.

Sally and Karen met in 1984 when both women joined a training course to become midwifery educators. Together they went on to establish the College of Midwives in 1989. They were instrumental in the law change that saw midwifery become an autonomous profession in 1990. They also played a vital role in reforming the education system to create Bachelor and Master’s midwifery degrees.

“Sally is honestly an incredible intellect, and a big visionary. Her whole passion at the time was education. She was just passionately aware that we needed to change,” says Karen.

After completing their educator training, Sally and Karen, together with Karen’s sister, a physiologist, established that there needed to be more science in the midwifery curriculum – because without the knowledge of how a body works, you were no different from anyone else showing up to the birth, says Karen.

“Sally was amazing, she just wrote the curriculum essentially. Her vocabulary, her way of expressing

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herself, she was really good at that and she could articulate her plan, write it and put it into a framework.”

As well as setting up a direct entry Bachelor of Midwifery programme and later a Master’s programme, Sally also spent five years as the president of the College and nine years as the first chairperson of the Midwifery Council. She was also co-chair of the International Confederation of Midwives’ (ICM) Regulation Standing Committee from 2008 to 2017 and has been a member of ICM’s Scientific Professional Programme Committee.

For the last eight years, Sally has been at the helm of ICM as Chief Executive (CE), based in The Hague in the Netherlands, where she has transformed the 100-year old confederation from a small organisation of five. With very little money, to a team of over 20 with core funding from global organisations and regular contracts.

Now it’s time for Sally to return home to Aotearoa and take the opportunity to reminisce on how her midwifery journey unfolded.

It all started after she completed a Bachelor of Arts degree, majoring in English Language and Literature, at the University of Otago in 1976.

She says, “Then, I didn’t really have a clue what I would do”. Sally looked to nursing, which she thought

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The first stop was for a shave and an enema, before being put in a gown and moved somewhere else for labour, then into a theatre to give birth.

“The bell would ring and all the students would roll in and line up against the wall to watch and the woman was never asked.

The doctor would come in wearing a rubber apron and gumboots,” says Sally.

“It was awful in the sense of the lack of women-centredness and lack of informed choice and consent. But it was the childbirth process itself I was really interested in.”

The combined voices of women and midwives (before government) made a powerful movement that couldn’t be dismissed as just professional interest. So, while it was a challenging time, there was nothing more reassuring than the knowledge they were pushing in the right direction.

would be a good ticket to travelling the world.

But midwifery caught her eye during a six-month obstetric rotation in the third year of her nursing programme. The tutor, a British midwife, regaled students with stories of working in London during the Great Depression – how they coped with a lack of both iron-rich foods and meat, and how people cooked and ate their placentas postbirth.

Sally was attracted to the autonomy the midwives seemed to hold, as well as the connections they forged in the community.

She also enjoyed being with women during birth; however, birthing looked quite different in the 1970s compared to now. With maternity care very medically dominated in both New Zealand and Australia, women would arrive in hospital and be bounced from room to room, clinician to clinician.

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So, she went to London to complete an 18-month midwifery training programme.

At the same time, mindsets were starting to shift towards birth being a normal life event, and the second wave of feminism was sweeping the globe.

“In New Zealand, women were really ramping up their protests about the maternity service that they had access to.

Women started complaining about the maternity service back in the ‘20s even, but by the mid-80s, there were quite a few consumer groups set up to try and bring about changes,” says Sally.

These consumer groups in particular, Parents Centre, Home Birth Aotearoa and Save the Midwives, saw midwives as professionals who could provide care to women on their own responsibility, right through pregnancy, labour, birth and postnatally up to six weeks.

there was nothing more reassuring than the knowledge they were pushing in the right direction, Karen says.

Both Sally and Karen acknowledge thenMinister of Health, Helen Clark, who pushed through the necessary changes in the Nurses Amendment Act, achieved pay equity and paved the way to direct entry midwifery education. They also acknowlege the female politicians from both sides of the house who supported their efforts.

“All the men sat down and voted with the women in their parties – it was pretty cool actually,” says Karen.

Of Sally, Karen can’t state enough how impressive she is: “She is a hard taskmaster but of course that’s why she gets there.

She’s relentless about getting to the end, whereas I’d probably have given up a couple of times.

“We used to go along and I’d be the bad cop and she’d be the good cop, and it was actually the opposite. I mean I’d fall over no trouble but Sally wouldn’t give in no matter what.

“I’d say, ‘I’m not standing for this, this is just not good enough,’ and Sally would go, ‘I think we could probably address it if we looked at this,’ and so they all turned to Sally and did what she wanted,” Karen laughs.

After lengthy political action, the Nurses Amendment Act was passed in 1990 and it stated that a woman could have a medical practitioner, or a midwife, or both – “in short, they could choose,” says Sally.

When Sally returned to New Zealand from the UK and met Karen on that fortuitous day in educator training, their goal became to reinstate midwifery as its own profession.

Of course, a lot of other legislation had to be changed to make the Nurses Amendment Act a reality, but it was those three words “or a midwife” that granted midwives autonomy, she adds.

This meant pulling away from the New Zealand Nurses Association and creating the New Zealand College of Midwives in 1989, where Karen served as CE until 2018.

It also caused a wave that saw obstetric care fall out of routine education for both nurses and GPs – something Sally never anticipated but it reflected what women wanted.

Simultaneously, Sally and Karen worked with other midwives and consumer and women’s groups across Aotearoa to try and reinstate midwifery autonomy.

“We had midwives and women together and we’d normally go in pairs and regularly visit every politician in the country and talk to them about why the maternity service needed to change,” says Sally.

The combined voices of women and midwives made it a powerful movement that couldn’t be dismissed as just professional interest. So, while it was a challenging time,

“When women could choose, they literally walked with their feet and they chose midwives. Because they wanted birth to be a normal life event, they wanted the relationship of having the same person or small group of midwives that they could get to know throughout the whole process,” says Sally.

Previously, maternity care had been routine, anonymised and lacked continuity. So, when given the option of personalised care, it was a no brainer for women, she adds.

Throughout the 1980s, the ICM had been a source of inspiration for Sally – she

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frequently looked to the confederation and its scope of practice statement.

“ICM’s core focus is to support midwives’ associations, to help them be the voice for the profession and help them strengthen the professional framework in their country,” explains Sally.

“Every association is in a different place, depending on where they are in the world, but there are core elements that all midwives hold strongly to.”

It describes midwifery models of care where the main care providers for women and newborns are educated, licensed and regulated midwives who practise autonomously. They use an approach that is person-centred, values the relationship between woman and midwife, optimises physiological, biological, psychological, social and cultural processes and uses interventions only when indicated.

These core elements speak of birth as a normal life process, that women should always be placed at the centre of care and of the partnership between mother and midwife.

This work is ongoing but Sally can see the thread back to her history here in New Zealand and to other countries that have demonstrated that midwives provide a different quality of care.

And it’s these tenets that formed the foundations of the midwifery model in Aotearoa, says Sally.

“There’s a lot of political will in countries at the moment to make changes, which is really fantastic,” says Sally.

As CE of ICM she was able to take her experience of completely changing midwifery back home and share those learnings with the world – a fact that kept her grounded throughout her time in The Hague.

“For example, the Egyptian government recently invited ICM to help with a

re-establishment of a whole midwifery profession. They want to revitalise and bring back a professional midwife because they believe that will improve their maternity services.”

When Sally returns to New Zealand, she’ll continue working as a consultant for ICM but apart from that she’s looking forward to spending time with her friends and family.

“We have a new granddaughter who will be just on a year when we come back... just being able to be with friends again, take a little bit more time in my life.

“But a lot of it is unknown, what will I get into? Because I can’t imagine just sitting around,” says Sally with a laugh.

Welcome home Sally and thank you for all you have done for midwifery globally and at home. We look forward to seeing what the future holds. Square

One such learning was the political power of women’s organisations, she says.

“And so I’ve been spending a lot of time encouraging midwives, professional organisations and countries to locate and work with women’s groups to get this political activity happening,” says Sally.

While Sally’s time at ICM has come to an end, she looks back on the last eight years with pride.

“Sometimes you do feel like you’re hitting your head against a brick wall because there’s so much gender inequity, there’s so much domination of nursing, women as second class citizens, midwives as second class professionals. These things are alive in many, many countries.

“But in the last few years, there seems to be more of a recognition, partly due to the ICM leadership, of the importance of midwifery and its impact on preventable maternal and newborn mortality and morbidity, and improving the services and satisfaction of women,” says Sally.

The ICM team are members of the WHO’s midwifery models of care working group, whose purpose is to encourage ministers of health around the world to change their maternity services and use midwives more effectively.

WHAT IS INTERNATIONAL CONFEDERATION OF MIDWIVES (ICM)?

Established over 100 years ago, the International Confederation of Midwives (ICM) is a global organisation, representing over 130 midwifery associations from around the world. ICM’s vision is a world where every childbearing woman has access to a midwife’s care for herself; its mission is to strengthen midwifery associations and advance the profession globally.

HOW DOES IT SUPPORT MIDWIVES? ICM works with its member associations and key partners (including organisations such as the World Health Organization) to grow, strengthen and promote the midwifery model of care. It works to embed midwife-led care into health systems, inspire leadership and improve midwifery education, ultimately leading to better sexual reproductive maternal and newborn health outcomes.

WHAT ARE SOME OF ITS KEY RESOURCES? ICM provides midwives, midwifery associations, regulators and governments around the world with the tools they need to strengthen and develop the profession in their own setting. Its resources include definition and scope of practice of a midwife, essential competencies for midwifery practice, global standards for midwifery education and regulation, professional framework and many guidelines and implementation resources, all of which are freely available on its website internationalmidwives.org.

Last year, the working group developed a global position paper, Transitioning to midwifery models of care, which provides guidance to countries looking to do just that.

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ANTENATAL IMMUNISATION GROWING THE MIDWIFERY ROLE CLAIRE MACDONALD MIDWIFERY ADVISOR

In early 2023, three whānau grieved the loss of their babies to pertussis, a vaccine-preventable disease also known as whooping cough. This was despite relatively low levels of the disease in the community at the time, and no evidence of any unusual strains of the bacterium that causes pertussis infection.

Pertussis is always circulating in the community, but waves of increased cases occur in cycles every few years. Concern had been rising, since the Covid-19 pandemic eased, that a pertussis epidemic was on the way; low antenatal and infant immunisation coverage further raised concerns that young infants would be at higher risk of severe disease. Antenatal TDaP (tetanus, diphtheria and pertussis) immunisation, introduced in 2013, provides babies born to immunised mothers with significant protection against pertussis infection and death during the first six weeks, before they can receive their infant immunisations. Pertussis cases began increasing in 2024, and the expected epidemic was announced in November. Sadly, a baby died from whooping cough over the recent Christmas period. Antenatal pertussis immunisation is extremely important for all pregnant women and people this year.

In addition, pregnant women are at greater risk of influenza-related complications than non-pregnant women of reproductive age (Prasad et al., 2019; Marshall et al., 2016). In a population study covering 16 years of births, Aotearoa researchers found that women who had a hospital admission with influenza had a greater risk of preterm birth and low birthweight. Across the whole pregnant population, antenatal influenza vaccination was associated with a reduced risk of preterm birth, low birthweight and stillbirth compared with unimmunised women (Duque et al., 2023). Introduced in 2010 following the H1N1 (swine flu) pandemic, antenatal influenza vaccination offers protection for both pregnant women and babies, and is recommended by the World Health Organization.

Antenatal immunisation rates are too low and are inequitable (Figures 1 and 2). The College has

therefore engaged in sustained advocacy for the government to prioritise antenatal immunisation for pertussis and influenza. With a representative on the National Immunisation Taskforce, the College identified a lack of national governance and systematic approach to prioritising antenatal immunisation. We recommended that a National Immunisation Technical Advisory Group (NITAG) and a national antenatal immunisation working group be established to take a strategic focus on increasing immunisation coverage in pregnancy. The College has also advocated for maternity facilities (particularly rural) to be enabled for vaccine provision, including cold chain maintenance; the establishment of a funding mechanism for midwives who self-identify as having capacity and capability to be able to offer antenatal immunisations; and access to the Aotearoa Immunisation Register (AIR), including both active (for vaccinating midwives) and view-only access.

Positive and ongoing working relationships have been established with Health NZ I Te Whatu Ora National Public Health Service, the National Immunisation Programme team, the Immunisation Advisory Centre and regional public health leaders.

Progress is now being made on these initiatives, which will enable more midwives to be funded to meet the needs of their communities (see Funding and development on next page).

TAKING VACCINATION TO THE COMMUNITY Auckland-based research, led by midwife Ady Priday (2023), made the point that, “Given intersections of inequity, there is a strong social justice argument for the development of strategies which seek to actively facilitate equitable access to antenatal vaccines.”

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FIGURE 1. TDaP PREGNANCY COVERAGE 2022-2024 100

Pregnancy Tdap Immunisation Coverage

80

60

40

20

0 SEP-22

MAR-23

SEP-23

MAR-24

SEP-24

Birth Cohort Month Dotted lines represent previous year

The researchers identified the need to take “vaccination to the community”, rather than requiring women to go “to the vaccine” and found that “Participants appreciated the convenience and familiarity of being vaccinated in localities and centres with which they were familiar and that they frequented for other reasons.” Vaccination provision by midwives or co-located with midwives is therefore an equity adjuster.

There are some excellent models already underway to learn from and scale up, as many midwives around the motu have recognised the need in their communities FUNDING AND DEVELOPMENT • Funding has recently been budgeted for by government to increase antenatal immunisation coverage.

• An expert working group has been established to inform the work programme, including College representation.

• The resourcing is expected to include a funding mechanism for LMC midwives and supporting primary maternity units to be key facilities in antenatal immunisation service provision.

• Primary maternity units in regions that have the lowest rates of antenatal immunisation uptake will be prioritised.

34 | MIDWIFE AOTEAROA

Māori

Pacific Peoples

Asian

Other

National Coverage

and have been proactive in their efforts to establish accessible and acceptable antenatal immunisation services, despite the barriers they encountered.

MIDWIFERY PROVISION OF ANTENATAL IMMUNISATIONS The Midwifery Resource Centre (MRC) in Ōtautahi Christchurch is a hub with two LMC midwife antenatal clinic rooms and a drop-in service where women can access free pregnancy tests and help with finding a midwife. Recognising their capacity to further serve the community, the MRC team has worked hard to establish an antenatal immunisation service, and has recently added anti-D prophylaxis to its offerings.

Antenatal immunisations are available from midwives who are directly contracted by the MRC, and also from the LMC midwives who hold clinics there and have opted into to providing immunisations. The MRC worked through several requirements (see Table 1), including negotiating for funding from Te Whatu Ora region, to break ground as the first community midwifery immunisation service in the area.

CO-LOCATED ANTENATAL IMMUNISATION SERVICE The importance of antenatal immunisation availability at the time of women’s other appointments is clearly highlighted by Linda Burke from Niu Life Midwives, a Pasifika practice in Tāmaki Makaurau. In 2022,

Linda and the team added immunisation to the other co-located, wraparound services their practice offers. Counties Manukau provided unspent funds from the Covid-19 response and a vaccinator for four full days a week to provide antenatal and infant immunisations. The midwives discuss maternal immunisation with all whānau during antenatal appointments, and vaccinations can be accessed alongside midwifery care. Niu Life Midwives is a busy practice providing multiple additional services, so do not have the capacity to vaccinate themselves. They recognise that whānau are also busy and simply do not have time to add another appointment for immunisation at a different time and place. Furthermore, as Linda explains, women's trusting relationship with their midwives and the vaccinator increases the likelihood of vaccine uptake – an approach backed up by Aotearoa research (Young et al., 2023). The easy access to vaccination and the whānau-friendly atmosphere at the practice contributed to Niu Life having the highest maternal immunisation rates in the country under this contract. Women report that they prefer being immunised in the midwifery practice than going to a pharmacy where they don’t know the clinician and often have to be in a small side room without enough space for their other tamariki.

When the Covid funding ended in June 2024, the immunisation service at Niu Life was reduced to two days a week with shorter hours, so women who have their antenatal visits when the service is not running have to return on another day. This has resulted in a decrease in immunisation numbers, which further illustrates the importance of being able to access immunisation as a one-stopservice alongside midwifery care.

FACILITY-BASED CORE MIDWIFERY ANTENATAL IMMUNISATION SERVICES Several maternity facilities and employed community teams are providing antenatal immunisation services, including Papakura Birthing Unit, Te Nīkau Hospital in Greymouth, Nelson community midwives and (imminently) Motueka birthing unit.

Some facilities offer drop-in or by-referral immunisation services. Women often access these services when they have their midwifery antenatal appointment on site, or when they have their anatomy scan (the radiology department in Greymouth is on the same campus).

FEATURE

TABLE 1. REQUIREMENTS TO BECOME AN ANTENATAL IMMUNISATION SERVICE Requirement

Actions for midwives who wish to offer immunisation

Generating health system

Midwifery practices who wish to establish vaccination capability on their premises are encouraged to engage with

support

regional College and district midwifery leadership. Infrastructural support is best approached at a regional level so it can be applied across multiple community midwifery sites and services.

Education

Midwives are authorised prescribers under their scope of practice, including for vaccines and do not need to be credentialled separately as vaccinators. Midwives are encouraged to access education on immunisation to refresh their knowledge, specifically on vaccine pharmacology, and to understand the cold chain system. IMAC’s e-learning course titled Maternal immunisation essentials for midwives is fully funded for midwives to access, and provides 4-5 hours of elective education.

Access to Aotearoa

Midwives have been enabled to onboard to AIR, both for active use as vaccinators and for view-only access

Immunisation Register (AIR)

(this can help in conversations about immunisations if women are not sure which vaccinations they have had).

See www.tewhatuora.govt.nz

Cold chain

Contact the local or regional immunisation for provision of onsite training and support. A vaccine fridge is required and clinicians are responsible for their part in cold chain maintenance (e.g. regular fridge temperature recording).

Ability to order vaccine stock

Regional immunisation co-ordinators can support midwifery services to set up accounts for ordering TDaP and influenza vaccines.

Resuscitation equipment

Standard midwifery adult resuscitation equipment is required at the immunisation service, along with adrenaline.

and supplies Funding for vaccine

A national funding mechanism for LMC midwives is in development. The College will keep members updated

administration

on progress.

In conclusion, while some midwives will be well-placed, willing and able to offer antenatal immunisations themselves, this is not feasible or expected of all midwives. It is important, however, that all midwives share high quality, nationally consistent information with all whānau, who can only make a decision about antenatal immunisation if they know it exists. As midwives, we all have a role to play in this.

FIGURE 2. MAP OF TDaP PREGNANCY COVERAGE (DISTRICT LEVEL DATA) FOR INDIVIDUALS WHO GAVE BIRTH BETWEEN JULY AND SEPTEMBER 2024

KEY MESSAGES: • Midwives who wish to provide antenatal immunisation services will be enabled to do so if feasible • Immunisation protection for pēpi starts during pregnancy • All midwives have a responsibility to discuss antenatal immunisation with wāhine hapū and whānau: -

Whooping cough and influenza are serious infections

-

Antenatal immunisation is safe and recommended and offers

-

How maternal immunisation works to protect babies

-

Vaccines are free-of-charge

-

Where to get immunised - midwives, pharmacies, GPs

effective protection for newborns and women

• TDaP vaccination during pregnancy is safe and a recommendation from a health care professional is an important

40%

80%

part of whānau decision making.

• On-time infant immunisation is crucial at 6 weeks, 3 months, 5 months and onwards as per the National Immunisation Schedule. Square

ISSUE 116 MARCH 2025 | 35

FEATURE

VAPING IS PERCEIVED AS SAFER, BUT IS IT? TE PAEA MIDWIFERY ADVISOR

Vaping has taken the world by storm over the

Vaping refers to the use of an electronic

found daily e-cigarette use during pregnancy

last decade. By 2017 it became a $10 billion

device (also known as an e-cigarette) that

increases the prevalence of low birthweight:

industry (McCubbin et al., 2017). It has been

heats a liquid turning it into an aerosol

10.6% for users versus 6.1% for non-users. In

reported that, “in the USA 25% of 8-year-

(vapour) which the user inhales. The contents

addition, preterm birth prevalence increased

olds are now vaping daily” (Mitchell, 2024).

commonly include nicotine, propylene glycol,

from 7.6% for non-users to 12.4%. for users.

In Aotearoa daily vaping among adults has

vegetable glycerol, nickel, lead and flavouring

These findings were supported by a large very

increased from 3.5% in 2019/20 to 11.1% in

(Ministry of Health, 2023).

recent systematic review that found vaping

2023/24 (Figure 1).

Although vaping is now regulated (Health

This represents an estimated 480,000

NZ, 2024), a New Zealand study in 2022 found

to be associated with low birth weight, preterm birth and small for gestational age; it also reported 53% higher odds of decreased

people vaping daily (Nip et al., 2024).

that harmful products are not always disclosed

The decline in cigarette smoking prevalence

on the packaging but were evident when

over the same period could suggest some

analysed. Furthermore, higher levels of nicotine

The list of risks continues, with Mescolo,

people who smoked now use vapes as a

were discovered than what was stated on the

Ferrante and La Grutta (2021) stating there

substitute nicotine product. But, whilst it

packaging (Unu, 2022). It is understood the

is evidence that using e-cigarettes can

may reduce harm for those on a smoking

“amount of nicotine in e-cigarettes has nearly

cause both short- and long-term respiratory

cessation pathway, research is emphasising

tripled since they first hit the market, a single

problems in the paediatric population. A

it is not harmless – especially in pregnancy

pod from one vape manufacturer contains

retrospective cohort study using the United

as vaping is associated with adverse birth

0.7mls of nicotine which is about the same as

States national longitudinal data from 2013-

outcomes.

20 regular cigarettes” (Mitchell, 2024). It is not

2018 has also (shockingly) correlated a higher

surprising that vapes are highly addictive.

risk of infant death with the usage of mint/

In Aotearoa health inequities are of grave

breastfeeding (Deprato et al., 2025).

menthol flavouring.

concern and vaping is another example of

Nicotine is known to have a negative effect

inequity. Vaping is more prevalent among

on the function of the placenta and smoking

18-24 year olds, Māori and Pacific peoples

is a major concern in Sudden Unexpected

emerging on the effects of vaping in pregnancy,

(Figure 2), and people living in more deprived

Death Infant (SUDI) prevention (Mitchell,

there is little about the effects on breastfeeding.

neighbourhoods.

2024). Similarly, a study by Regan et al. (2021)

Health NZ recommends vaping and other

Although there is a plethora of research

nicotine replacement therapy as part of a smoking cessation pathway for pregnant women but strongly discourages any non-

FIGURE 1. TRENDS IN VAPING AMONG NEW ZEALAND ADULTS (≥15 YEARS OLD)

smoker starting in pregnancy. The message is clear; vaping is less harmful than smoking but it

35.0

is not harmless (Health NZ, 2022).

30.0

Midwifery messaging should be congruent

% of population

30.0

with this. The best thing women can do for their and their baby’s health is to quit

25.0

smoking. It can be difficult to quit smoking

20.0

but there are different tools and services that can help. These include many pregnancy-

15.0

specific smoking cessation services around the 10.0

motu, as well as the national Quitline service ph. 0800 778 778, and the use of nicotine

5.0

replacement therapy (NRT). Although our 0 2017/18

2018/19

2019/20

2020/21

Ever tried, just even once

2021/22

Current use

Daily use

2022/23

2023/24

focus has been on smokefree pregnancies, and vaping has been used as a safer alternative, it is not without risks which women and whānau need to be informed about.

36 | MIDWIFE AOTEAROA

FEATURE

USEFUL LINKS Health NZ | Te Whatu Ora (2024) vaping

FIGURE 2. TRENDS IN DAILY VAPING BY ETHINICITY IN NEW ZEALAND ADULTS (≥15 YEARS OLD)

information: healthpromotion.govt.nz/mental-

35.0

health/alcohol-and-drug-addiction/vaping

30.0

Protect your breath – about young people and vaping: protectyourbreath.co.nz

30.0

Time for the Government to act: phcc.org.nz/ briefing/rise-and-rise-specialist-vape-storestime-government-act

% of population

The rise and rise of specialist vape stores:

25.0 20.0 15.0

Asthma and Respiratory Foundation NZ: asthmafoundation.org.nz/your-health/ecigarettes-and-vaping/vaping-some-more-facts Te Whatu Ora Health Promotion posted a video in 2024 on NRT therapy in pregnancy: youtube.com/watch?v=CFcHi9mZFH0. Square

10.0 5.0 0 2017/18

2018/19

2019/20 Māori

2020/21 Pacific

Asian

2021/22

2022/23

2023/24

European/Other

References available on request.

ISSUE 116 MARCH 2025 | 37

FEATURE

‘IT CAME WITHOUT WARNING’

VANUATU MIDWIVES’ TIRELESS EFFORTS FOLLOWING MAJOR EARTHQUAKE ZAHRA SHAHTAHMASEBI JOURNALIST

When the magnitude 7.3 earthquake struck Vanuatu in

However, Port Vila Central Hospital’s neonatal care

December, Harriet Obed was at the ANZ bank in Port

unit was impacted by the four-day power cut and also

Vila. She ran outside along with everyone else to stand

when part of the ceiling fell off and hit an incubator.

on the road amongst the capital city’s tall buildings,

Harriet is unsure whether the baby survived.

until someone shouted “move to higher ground”, and the crowd made for a nearby hill.

Harriet is a midwife, president of the Vanuatu Midwifery Society and acting national coordinator for Vanuatu’s Reproductive, Maternal, Neonatal, Child and Adolescent Health (RMNCAH) programme. She says the earthquake came without warning and was a very different experience from cyclones, for which there are warnings and people can prepare.

The earthquake destruction has had a major impact on Harriet and her midwifery colleagues, who work across the hospital and community settings. Her colleagues are “trying to fix their homes and be at work because their family depends on them too,” she says.

Members of the Vanuatu

While a lot of pregnant women were due to give

Midwives Society outside the

birth, fortunately none of them were injured or

Women’s Health Clinic at Vila

experienced pregnancy complications as a result of the

Central Hospital, Port Vila.

earthquake, says Harriet.

The Vanuatu Midwifery Society, made up of volunteers, tried to stay in touch post-earthquake, but communication lines were down for nearly two weeks and damage to roads and bridges meant they couldn’t travel to meet each other either.

Harriet describes how most maternal and child services were decentralised immediately without much information or instruction, which left many confused and scared. Although this model of care is a goal that Vanuatu had been working towards, she says health clinics in the suburbs were unable to be upgraded before the earthquake hit.

“We were not prepared, we did not upgrade the facilities to be ready to receive women and so everyone comes running to the main hospital. You can just imagine the workload with only two midwives per shift.”

The two midwives rostered at the hospital look after admission, labour, birth and postnatal, as well as caring for patients pre- and postcaesarean section; Meanwhile, midwives in the community provide maternity and child health services, general outpatient care and are on call 24/7.

In the aftermath of the earthquake, midwifery shifts at Vila Central Hospital were extended to 12 hours to cope with demand, but this quickly became too much and they soon returned to eight hours.

Harriet says the Vanuatu Midwifery Society made a request for support to the Ministry of Health, which was able to obtain the valuable services of four Fijian midwives, sponsored by the United Nations Population Fund.

While Harriet speaks to the passion she and her midwifery colleagues have for their work, she also notes the challenges that they face on a daily basis, including

38 | MIDWIFE AOTEAROA

FEATURE

staff and resource shortages, which have worsened post-earthquake. Despite these difficult circumstances however, Vanuatu midwives continue with their tireless efforts.

Harriet highlights her gratitude for the New Zealand College of Midwives for taking note of Vanuatu’s plight.

“We are so honoured and grateful for the opportunity that we can be heard somewhere,” she says.

EMERGENCY DISASTER RELIEF FUND – SUPPORTING MIDWIVES FOLLOWING NATURAL DISASTERS In 2023, the College established an Emergency Disaster Relief Fund (EDRF) as a means to support midwives who were significantly affected by the severe weather events in New Zealand in January 2023. Donations from College regions and individual members into this fund enabled support to be provided to a number of midwife members who had suffered significant loss to property and livelihoods as a result of these events.

Following the recent earthquake in Vanuatu, the College has been in contact with the

FACTS

Vanuatu Midwifery Society and understands that midwives there have been suffering with

• The Vanuatu archipelago can receive two to

disruption to communications and damage to homes, property and hospital facilities.

three cyclones a year. Earthquakes are not entirely unknown in the region but have very rarely caused death.

• The major earthquake on December 17 resulted in at least 18 deaths, 265 people injured, 85,000 people affected and nearly 1,500 displaced from their homes.

• Buildings and roads have been damaged significantly by the earthquake and the

We know from our experience here in Aotearoa that recovery from significant natural disasters is a long and slow process, which can take years or even decades. The impacts are far reaching and they are felt in our homes, our families, our communities and, as midwives, in our professional lives.

The Vanuatu Midwifery Society is a fledgling association, which is working hard to strengthen midwifery in Vanuatu. The College is opening its EDRF to enable New Zealand midwives to make donations which we will provide to the Vanuatu Midwifery Society so midwives there can experience support from the international midwifery community at a time of stress and crisis. Every bit counts.

resulting landslides; water supply has been affected and supermarkets closed.

• Aftershocks have been occurring regularly,

Donations can be made to: The New Zealand College of Midwives 12-3191-0008921-53 please ensure that donations are coded (i.e. Vanuatu)

up to magnitude 6.3. Square

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Photo by Angela Scott Photography

TE AO MĀORI

WOVEN INTENTIONS HAYLEY MCMURTRIE COMMUNICATIONS MANAGER

Ka whānau mai te pēpi, ka takaia ki te harakeke. Ka noho te harakeke, hei kākahu, hei rongoā, hei mea tākaro, hei oranga mōna, a mate noa ia. | When a child is born, the child will be wrapped in the muka of the flax plant. The flax shall provide a means for living, for flourishing, for health and wellbeing throughout their life journey.

Te ao Māori places significant emphasis on the relationships between people and nature, offering a holistic perspective with focus on interconnectedness, and rooted in tikanga (customary values), lore, and mātauranga (knowledge). Practices, values, and principles derived from te ao Māori unite ancestors and communities, fostering deep connections with whenua (land) and taiao (environment). The wahakura (woven harakeke bassinet) is a powerful representation of the whakapapa (ancestry) and tikanga (customs) of te ao Māori.

Across Aotearoa, whānau are coming together at wahakura wānanga (workshops) to connect, learn and create.

These wānanga, where hapū māmā and their whānau gather, have a profound impact.

Though introduced relatively recently, primarily as a safe shared sleeping space for pēpi in their parents' beds, the wahakura has been widely adopted and can contribute to a reduction of Sudden Unexpected Death in Infancy (SUDI). For Māori, however, the process of creating a wahakura holds deep cultural and spiritual significance, reflecting tikanga and strengthening whānau bonds.

Across Aotearoa, whānau are coming together at wahakura wānanga (workshops) to connect, learn and create. These wānanga, where hapū māmā and their whānau gather, have a profound impact. They embody the Māori principle of bringing together ancestral knowledge, connection, and whānau, creating something beautiful that not only keeps newborns safe but also nurtures and nourishes them, fostering a cycle of wellbeing that transcends generations.

Hayley McMurtrie speaks with some of the kaikaranga, (weavers) holding these wānanga about the process of creating the wahakura and the nourishment it brings to the entire whānau, forming a safe sleeping environment while also creating a connected, extended family unit where pēpi can thrive.

Jenny Firman, a skilled kaikaranga, describes

40 | MIDWIFE AOTEAROA

the process of making a wahakura as a pathway to wellbeing. “Most people think they are just coming to weave a wahakura, but when they leave after the weekend, they have produced a beautiful moenga (sleeping place) and what they have taken away with them is so much more.”

Whaea Jenny adds that “through the wānanga there are many lessons, many layers. On day one we get the weavers and the health professionals together (midwives, child health practitioners, anyone who is connected to the wellbeing of our babies and whānau). We introduce them to the harakeke bush, how to cut, where to cut and some of the tikanga that will apply to them for the day. We get them to reflect on their work practices, their own bias, an opportunity to think about best practices, we look at our purpose and our intentions.

It makes us stop and think and gives us permission to reset.”

“Then the whānau come in, each whānau has an experienced weaver and a health professional that we try and fit with the whānau needs. The whānau can be anyone who is connected to that baby, usually the hapū māmā and she drags along the pāpā,” Jenny laughs, “often there are grandparents and aunties and uncles too.”

TE AO MĀORI

“We talk about intentions, what is your intention as a māmā, as a pāpā, as an uncle, as a nanny. Sometimes the intention from the māmā and the pāpā is to change something from their childhood. ‘I want to be a better father’ and I will say – that’s awesome, what does that mean for you? 72 times they are thinking about this, with each piece of harakeke. This can often be a healing process for those new parents as they consider their own upbringing and what they would like to do differently.”

“It makes the parents think about their partnership, what does that look like? If they are on the same page this can only benefit the pēpi.”

Jenny talks passionately about the way pāpā go from being closed and not necessarily wanting to be here to ‘get out of the way, I’m doing this’. She says, “We talk about the male’s role, what he can do to support the hapū māmā. How does she like to be miri miri – pampered”.

“At each stage we reflect. The process is empowering, one of the questions we ask is ‘how do you want to be communicated with?’. We have women realising that maybe they don’t like the way their tāne is talking, they have permission to decide what is working for them.”

Through the creation of their own wahakura, participants gain a deeper understanding of their role as a parent and as a partner, which strengthens all of the relationships that support the hapū māmā and ultimately the pēpi. “They all learn to weave and they all learn how to safely sleep their mokopuna, the additional intrinsic messages woven into the wahakura is the icing on the top.”

Shelley Bell, a kairaranga living in Tāmaki Makaurau, reflects on the process for many whānau who have attended her wānanga.

“The wahakura strengthens bonds and allows us to practice te ao Māori. As we weave we are linking and binding whakapapa, whānau and whenua and it links us to our atua, our higher being”.

Shelley creates many wahakura herself, and these are presented to māmā Māori at Middlemore Hospital and primary maternity facilities in Counties Manukau.

“Whilst it is important that these māmā have access to the wahakura, it is not the same as parents creating their own. Through the creation they learn about safe sleep practices, the benefits of being smoke free and about nutrition, but the most beautiful

part of the journey is when they gain a deeper understanding of what it is to be Māori and the strength they take from that. Especially the pāpā, they take away a deeper sense of responsibility for the pēpi.”

Describing the time when māmā from both the hapū māmā side and the pāpā side come together, Shelley says, “It’s the connection that creates the really special moments, that’s when the magic happens.

Sometimes they’ve never met before. It starts a really special relationship, which we call whanaungatanga, creating a wider protective unit for our tamariki.”

Keita and Lamon share their enthusiasm for attending a wahakura wānanga prior to having their third pēpi: “It was way better than I imagined, I just thought I was there to make a wahakura but it was so much more, it’s not just about the weaving it’s the korero, the guidance that comes with it,” says Keita.

Lamon adds, “For me it was the opportunity to sit and think about your

intentions as parents, about what you want for your baby. The space that is provided for you to do that is a beautiful thing. We are third time parents and we learned so much.”

Keita and Lamon were gifted a wahakura for their first baby and, whilst they received the safe sleep messaging along with the moenga, they both agree that the wānanga provided the opportunity to instil mauri – life force and energies – into every strand.

“Every strand held our intentions”.

The creation embodies the essence of te ao Māori - strengthening relationships, nurturing wellbeing and weaving ancestral knowledge into everyday practices.

The challenge is quantifying the investment and, much like parenting, the benefits of this investment will unfold over years and generations, leaving a legacy of connection and care. Square With thanks to Hāpai te Hauora | Māori Public Health

ISSUE 116 MARCH 2025 | 41

BREASTFEEDING CONNECTION

MOTHER AND BABY UNITS IN PRISONS CAROL BARTLE POLICY ANALYST

The Corrections (Mothers with Babies) Amendment Act 2008 made it possible for mothers who meet certain criteria to keep their babies with them in prison until the child is two years old (NZ Government, 2008). This is to provide for the best interests of the child by enabling bonding, feeding and maintaining continuity of care. Legislation requires prisons to have facilities that provide a healthy and supportive environment for the child.

Mothers with Babies Units (MBUs) opened in New Zealand women’s prisons in 2011. Day units, described as “feeding and bonding” facilities, also became available to enable babies and children under 24 months of age, who are being cared for in the community, to visit their mothers (Department of Corrections, undated A). MBUs were developed to enable the mother-baby relationship to develop, to facilitate responsible parenting, to provide for infant health and to provide intervention in breaking the cycle of intergenerational abuse and incarceration (Carlson, 1998).

The chance to develop an early close relationship between a mother and newborn baby sets the stage for bonding and attachment, breastfeeding, health benefits for the baby and the mother, and a more secure involvement of the mother in parenting. There is also research which indicates a reduction in reoffending when

42 | MIDWIFE AOTEAROA

mothers keep their babies with them in prison (Blanchard et al., 2018; Carlson, 2018; Tuxhorne, 2021; Walker et al., 2021). This supports a key principle of our prison system – reintegration, which means that prisoners are prepared for release into the community and helped to reduce the likelihood of reoffending (Office of the Inspectorate, 2023).

PREGNANT WOMEN AND MOTHERS IN PRISON Aotearoa has three women’s prisons, the Auckland Region Women's Corrections Facility, Arohata Women's Prison in Wellington and Christchurch Women's Prison. All have MBUs, although the unit in Wellington was unused from 2014 to 2022 (Hatton, 2022).

Pregnant women in prison should have access to midwifery continuity of care but finding a midwife is difficult due to restricted internet access. If a pregnant woman has

already booked with a midwife prior to incarceration, ideally, she should be able to continue to receive care from this midwife, although in some circumstances this is not possible. The Auckland region corrections system works well and the article in this issue of Midwife Aotearoa (p.24) about midwife Kelly McConville provides more detail about this initiative. Understanding women’s prisons, the Corrections system and what pregnant women and mothers face when incarcerated is essential to care and advocacy provision. The Mothers Project, a New Zealand initiative of independent volunteer female lawyers, was set up to help imprisoned mothers connect with their children and they estimate that 85% of imprisoned women in Aotearoa are mothers. The number of incarcerated mothers who are separated from their young babies is unknown.

The Chief Inspector of Corrections, Janis Adair, commissioned a thematic inspection to review the operating environments of the MBUs. The aim was to focus on and strengthen efforts in managing pregnant women in prison, mothers with babies in prison, or mothers with children in the community (Office of the Inspectorate, 2023). The report described how mothers arriving in prison were not informed about the availability of MBUs or the feeding and bonding rooms, and that there was limited support for drug and alcohol issues.

Other issues for consideration were reviewing options for transporting breastmilk from women in prison for their babies in the community, privacy for breastfeeding in prison if required, and access to maternity/ breastfeeding clothing.

BREASTFEEDING AND BEING A MOTHER IN PRISON “For a baby the environment is the mother”.

Gallagher (1992)

Because successful breastfeeding in any context requires regular removal of milk from the breasts (preferably via breastfeeding), barriers remain for breastfeeding mothers within the prison environment.

BREASTFEEDING CONNECTION

The chance to develop an early close relationship between a mother and newborn baby sets the stage for bonding and attachment, breastfeeding, health benefits for the baby and the mother, and a more secure involvement of the mother in parenting. There is also research which indicates a reduction in reoffending when mothers keep their babies with them in prison.

The effective expression of breastmilk may assist in maintaining lactation for some women but breastfeeding is optimal for both breastfeeding exclusivity and duration, and for mother-baby bonding/attachment. The logistical constraints of correctional settings can make both breastfeeding and breastmilk expression challenging – the key barrier being any mother-baby separation. There is a significant difference between lactation and breastfeeding, and the effective expression of breastmilk requires: • regular access to an effective breast pump or skilled regular hand expression • hygienic conditions • adequate and appropriate storage containers • facilities for storage and freezing • reliable safe transportation of expressed breastmilk into the community

The Office of the Children’s Commission report on Arohata Prison in Wellington contained narratives from women who described being hungry while pregnant or breastfeeding and not receiving extra food when they requested this (Hatton, 2022).

Women also reported being restrained with handcuffs, some while in hospital prior to the birth of their babies, and again after the birth. Breastfeeding needs to get off to a good start after birth with uninterrupted motherbaby skin to skin contact, and handcuffs interfere with contact and breastfeeding initiation. Although Corrections reported

ISSUE 116 MARCH 2025 | 43

BREASTFEEDING CONNECTION

in 2022 that there is now a policy stating that mothers over 30 weeks, giving birth or immediately post-birth are not to be handcuffed, handcuffs at any time while breastfeeding and while mothers are getting to know their babies is inappropriate.

Continuing the advocacy to improve care for

Midwives are aware of the importance of breastfeeding, BFHI policies and the support breastfeeding women need.

When a pregnant or postnatal woman is in prison there are barriers and challenges to overcome and specific individualised information will be needed about breastfeeding.

pregnant women and mothers with babies in prison is an ongoing project in many countries, including New Zealand.

Women in prison have described the personal significance of breastfeeding.

Narratives in one study referred to the importance of bonding, optimal feeding choice and part of achieving a new start through motherhood (Huang et al., 2012).

Conflicts described included fears of separation, concerns about a potential lack of support and how a poor health status could prevent breastfeeding. This included beliefs that breastmilk could be tainted, worries about unhealthy diets and feelings of guilt about previous substance abuse and smoking. Most issues described by women were not evidence-based contraindications to breastfeeding, which highlights the importance of providing accurate information in pregnancy.

BFHI RECOMMENDATIONS All women using maternity facilities in Aotearoa are entitled to receive the same standard of healthcare regardless of their legal status. The Ten Steps to Successful

44 | MIDWIFE AOTEAROA

Breastfeeding (BFHI) assert that all mothers should be offered uninterrupted skin-to-skin contact with their babies after birth for a period of at least one hour and assisted as necessary with the first breastfeed. Individual breastfeeding assessment and care may include advocacy for the creation of some private time for a mother and baby without prison officers in the room, if this is acceptable to the custodial agency and if there are no security issues or other adverse circumstances.

Support for breastfeeding should be available 24/7. This includes the management of common early difficulties with lactation or breastfeeding, and information about how the use of bottles, teats and pacifiers can interfere with the establishment of milk supply and breastfeeding. Helping women with the key skills of recognising infant cues for feeding, and how to handexpress breastmilk are also part of clinical practice. Information about the expression of breastmilk needs to be tailored to the individual needs of the mother and dependent on her situation. This may include

100

CONCLUSION Midwives are aware of the importance of breastfeeding, BFHI policies and the support breastfeeding women need. When a pregnant or postnatal woman is in prison there are barriers and challenges to overcome and specific individualised information will be needed about breastfeeding, maintaining lactation and the logistics of storing and transporting expressed breast milk when there is mother-baby separation. Pregnant women may need information about applying for compassionate release after childbirth. They may need support to make an application for a place in an MBU or an application for time in the feeding and bonding rooms. The UN Convention on the Rights of the Child is focused on the “best interests” of the child (UNCROC, 1989).

As described by Gribble and Smith (2019) there are ways to support mothers and babies to stay together and to facilitate breastfeeding. If there are no options for home detention or compassionate release, mother and baby units are the next best option. Breaking the cycle of disadvantage can start with helping incarcerated mothers to provide care to their babies and to breastfeed if they plan to do so. Alternatives to prison wherever possible for pregnant women and mothers deserves more consideration in the best interests of the child – and the mother. Square References available on request.

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Women’s decisions about infant feeding should be respected, and coercion in terms of MBU eligibility is inappropriate.

There may be situations when a woman returning to prison may not plan to breastfeed. Women who are going to be separated from their babies may feel there is no point in even establishing lactation. Fears of breastfeeding creating a further baby bond when separation is inevitable was described by one woman as causing greater pain (Abbot & Scott, 2017). Barriers to breastfeeding include geographical difficulties, often related to prison location and where the baby is being cared for (Rush, 2000). Unwillingness of caregivers to transport babies to visit their mothers has also been identified, along with inabilities to afford transport costs (Baldwin, 2022). Prisoners meeting visitors in meeting rooms may also have to wear overalls which makes breastfeeding impossible (Dept of Corrections, undated B). Some mothers may be reluctant for any contact with their babies or children due to unease about the baby being exposed to a space of punishment (which for some women feels inappropriate or shameful), or to the pain of separation when the baby or child has to leave. Mothers have described prison visits from their children as a source of both joy and pain, a mixed blessing and bittersweet (Baldwin, 2022).

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managing overfull breasts using hand expression if mother and baby are staying together, or the maintenance of lactation if mother and baby will be separated after discharge from the maternity facility.

Discussion about what mechanisms will be available to support the transport of expressed breastmilk to babies in the community may be needed. Breast-care advice and possibly information about suppression of lactation may be necessary in some situations. In terms of support for breastfeeding after a mother and baby are discharged to a prison MBU, LMC postnatal care will continue for up to six weeks as usually expected.

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Made in Germany

Rosie and team from Bay of Islands Hospital Maternity Unit.

TAKU WĀHI MAHI MY MIDWIFERY PLACE AMELLIA KAPA REGISTERED MIDWIFE

Rosemary (Rosie) Sharman is the Clinical Midwife Manager

Wherever possible, we’ll do that assessment because we

at Bay of Islands Hospital Maternity Unit in Northland. Her

know LMCs are best placed serving our community, in the

love of the region and the integrated team she leads shines

community. The support goes both ways; when LMCs are

through, as she shares what she’s most proud of.

on site they jump in and help if needed, which is crucial in

After training in Queenstown, Rosie relocated to Auckland to complete her new graduate year at Middlemore Hospital

Intentionally employing local midwifery students

but found herself spending most weekends diving and

as maternity care assistants (MCAs) in the unit further

spearfishing in Northland. She decided to move to the

strengthens the team, bringing the future firmly

fisherwoman’s paradise permanently in 2020, settling on Bay

into the present. “Making students feel as though they’re

of Islands Hospital Maternity Unit after first working across

part of who we are from the beginning is hugely beneficial

the region’s maternity facilities to gain an overview.

and it’s growing our local Māori workforce, which is

As clinical midwife manager of the primary unit since 2022,

essential.”

she describes the integration between the LMC workforce

Jojo Wehi (Ngatitetarawa, Ngāti Hine), currently a 3rd year

and facility team as one of the unit’s greatest strengths.

midwifery student, is an MCA and loves it. “It feels like a true

“Everyone here is invested and that pre-dates me being in

whānau,” she says. “The team is incredibly supportive, tight-

this role. It was one of the things that made me want to work

knit, and genuinely cares, making you feel valued from the

here in the first place; it feels different here, there’s no ‘this is

moment you walk in. It’s a place that ignites my passion for

my job and that’s your job’ type of thinking – we are here for

midwifery and gives me a deep sense of belonging, deeply

the community,” she explains.

rooted in Māori values of whanaungatanga, manaakitanga

“The mutual respect between core staff and LMCs is really apparent,” she continues, “possibly because most

46 | MIDWIFE AOTEAROA

emergency situations.”

and aroha.”

As a tauiwi midwife working in a region with a high Māori

midwives here have worked both roles, so there’s a solid

population, Rosie pays homage to her tangata whenua

understanding of how we can best work together. The truth

colleagues and the vital role they play in the success of the

is, we can’t function without each other. It’s fundamental to

unit. “We can’t acknowledge the strength and continuity

keeping whānau at the centre of care.”

of our services without acknowledging our local Māori

Extending a helpful hand also goes a long way, as Rosie

midwifery collective, Te Kahu Wāhine, and in particular,

illustrates. “An LMC might ring us, needing to send a woman

the work Whaea Crete Cherrington and Joyce Croft are

in for assessment, but they might be an hour’s drive away.

constantly doing to advocate for whānau-centred care.” Square

New Zealand College of Midwives I Te Kāreti o Ngā Kaiwhakawhānau Ki Aotearoa Directory National Office

Northland

Student Representatives

PO Box 21-106, Christchurch 8140

Ange Yendell

Ph 03 377 2732

tetaitokerauchair@nzcom.org.nz

Paytra Buckrell

nzcom@nzcom.org.nz

Otago

www.midwife.org.nz Auckland Office auckadmin@nzcom.org.nz College Membership Enquiries Julie Williams membership@nzcom.org.nz 03 372 9738

Jan Scherp, Ali Barkman otagochair@nzcom.org.nz Southland Janelle Carse sthldnzcom@outlook.co.nz Waikato Taranaki Michele Lord

paytra_browne@windowslive.com Te Rina Apelu tee_apelu@hotmail.com Ngā Māia Representatives www.ngamaiatrust.org Jasmine Gray jasmineanamidwife@gmail.com Te Anna Hema

chairwaikatonzcom@gmail.com

hemawhanua@gmail.com

Chief Executive

Wellington

Pasifika Midwives Representatives

Alison Eddy

Suzi Hume

Talei Jackson

Co-Presidents

nzcomwellington@gmail.com

Ph 021 907 588 taleivejackson@gmail.com

Beatrice Leatham

Regional Sub-Committees

bea.tangatawhenua.copres@nzcom.org.nz

Hawke's Bay Sub-Committee

Debbie Fisher

Linley Taylor

debbieF.tangatatiriti.copres@nzcom.org.nz

midwife.linley@gmail.com

National Board Advisors

Horowhenua Sub-Committee

MERAS

Laura McClenaghan

PO Box 21-106, Christchurch 8140

Kuia: Crete Cherrington

Ngatepaeru Marsters Ph 021 0269 3460 lesngararo@hotmail.com

Elder: Sue Bree

midwife.laura@hotmail.co.nz

Education Advisor: Tania Fleming

Manawatu Sub-Committee

meras@meras.co.nz

Megan Hooper-Smith

www.meras.co.nz

Regional Chairpersons Auckland Jacquelyn Paki, Tania Webb auckchair@nzcom.org.nz Bay of Plenty/Tairāwhiti Cara Kellet chairnzcomboptairawhiti@gmail.com Canterbury West Coast Becky Bangma chairnzcom.cantwest@gmail.com

megan.scott@live.com Emma LeLievre emma@LMCmidwife.com Taranaki Sub-Committee Vacant

Ph 03 372 9738

MMPO PO Box 21-106, Christchurch 8140 Ph 03 377 2485 mmpo@mmpo.org.nz

nzcom.taranaki@gmail.com

Rural Recruitment & Retention Services

Whanganui Sub-Committee

0800 Midwife/643 9433

Laura Deane

rmrr@mmpo.org.nz

laura.deane@wdhb.org.nz

Central

Consumer Representatives

Laura McClenaghan

Home Birth Aotearoa

centralchair@nzcom.org.nz

Bobbie-Jane Cooke

Nelson Marlborough

bobbiejane.homebirth@gmail.com

Emma Neal

Whānau Awhina Plunket

other resources available through our

tetauihunzcom@gmail.com

Zoe Tipa

website: www.midwife.org.nz/shop

Resources for midwives and women The College has a range of midwiferyrelated books, leaflets, merchandise and

zoe.tipa@plunket.org.nz

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.

Midwife Aotearoa New Zealand is published quarterly for the New Zealand College of Midwives. 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. The College acknowledges and respects diversity of identities through the language used in this publication. Te reo Māori is prioritised, in commitment to tāngata whenua and te Tiriti o Waitangi. To maintain narrative flow, the editorial style may use a variety of terms. Direct citation of others’ work maintains the original authors’ language, and contributing writers’ language preferences are respected. All advertising content is subject to the Advertising Standards Authority Codes of Practice and is the responsibility of the advertiser. Contents Copyright 2025 by New Zealand College of Midwives. All rights reserved. No article or advertisement may be reproduced without written permission. ISSN: 2703-4546.

ISSUE 108 MARCH 2023 | 47

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