Midwife Aotearoa New Zealand by Collegeofmidwives

MIDWIFERY CONTINUITY OF CARE

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38. TE AO MĀORI: KAPA HAKA

40. BREASTFEEDING CONNECTION

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46. BRIDGING THE ULTRASOUND GAP DIRECTORY ISSUE 117

EDITOR

Hayley McMurtrie

E: communications@nzcom.org.nz

ADVERTISING ENQUIRIES

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P: (03) 372 9741

MATERIAL & BOOKING

Deadlines for September 2025

Advertising Booking: 1 August 2025

Advertising Copy: 11 August 2025

Welcome to Issue 117 of Midwife Aotearoa New Zealand

This edition introduces a new International Midwifery feature, which will appear alongside our regular sections, including Te Ao Māori, Breastfeeding and My Midwifery Place. This provides an opportunity to spotlight global midwifery perspectives and connect with shared challenges and successes from overseas.

Our feature article on hyperemesis sheds light on this often-debilitating condition, sharing the personal experiences of two wāhine and offering practical advice and current clinical guidance. A powerful reminder of the experiences women face, and the value of the compassionate, evidence-based care that midwives provide to support them.

It has been a privilege to serve as kaitiaki of Midwife Aotearoa over the past two years—balancing this responsibility alongside my broader role. One of the highlights for me has been developing the Practice Guidance section, ensuring relevant, up-to-date information is front and centre for members. We are working to make these resources available on the College website, giving members easier access to essential guidance.

Whilst I will continue to support the magazine in my role as Communications Manager, I am delighted to hand over the editorial reins to Kim Thomas. Kim joins the College in a contracted role as writer, media liaison and magazine editor. She brings a wealth of experience and is looking forward to connecting with members and hearing your ideas.

As always, we welcome your feedback. Tell us why your team should be featured in My Midwifery Place!

Ngā mihi nui, Hayley Square

HAYLEY MCMURTRIE

COMMUNICATIONS MANAGER

Email: communications@nzcom.org.nz

PUTTING PATIENTS FIRST?

A CONCERNING REINTERPRETATION OF THE ROLE OF REGULATION IN PROTECTING PUBLIC SAFETY

Reform of the law which regulates health professions has been on the political agenda for some time now, with active policy work undertaken by the previous government continuing under this one. In March the current government’s intention became clearer when the Ministry of Health released a consultation document, Putting Patients First – Modernising health workforce regulation.

The views articulated in this document are somewhat alarming, signalling that the government considers a fundamental re-framing of some of the assumptions underpinning health professional regulation is needed. If the changes are enacted as it appears the government wishes or intends, concerningly, many of the protections within our current regulatory framework could be dismantled.

The primary function of health professional regulation is to protect the public. The way in which regulators currently achieve this aim is through the Health Practitioners Competence Assurance Act 2003 (HPCA Act). This requires regulators to set scopes of practice, develop standards of competence and conduct, set standards for undergraduate or pre-service education, monitor and audit the

delivery of this education, register practitioners, set the requirements for continuing competence, and manage complaints and discipline related to competency or conduct and fitness to practice.

As a result of this system, when a member of the public accesses care provided by a regulated health professional, that person can be assured that the health professional is sufficiently educated and competent to perform the services or provide the care that their regulator has authorised them to. It means that there are legal mechanisms which hold practitioners to account if there are any concerns about their competence or conduct.

In order to undertake their responsibilities, regulators need to work with independence, exercise objective decision making and have sufficient

ALISON EDDY CHIEF EXECUTIVE

Within the consultation document, regulators were framed as part of the problem, rather than part of the solution, with implied views that regulators are too slow to act, patch protective, overly bureaucratic and not responsive to the needs of the public. Public safety was reframed by arguing that workforce shortages which lead to care access issues are matters which regulators should take responsibility for.

now 18 professions regulated under the HPCA with the recent additions of Chinese medicine and paramedicine.

A bit like a 1950s’ holiday bach which has room after room added to its structure so that it eventually becomes unliveable, simply creating more and more regulators under the HPCA Act to accommodate new types of workers will be become unwieldy and financially unsustainable. The possibility of consolidating regulators was suggested in the consultation document.

New options for regulation, such as accreditation or credentialling, were also presented within the consultation document, although these were not explored in depth. Developing approval processes for specific, isolated tasks (which is broadly how credentialling or accreditation could be described) independently of wider professional frameworks could lead to fragmented and lower quality care.

Health professional regulation is about more than public safety. Each health profession has a specific body of knowledge. Decision making, clinical judgement and professional autonomy all sit within profession-specific ethical and philosophical frameworks that underpin practice and professional identity. For example, our midwifery scope of practice reinforces our profession’s philosophy that pregnancy and birth are a continuum and normal physiological process, which midwifery protects through the care it provides. Regulation reinforces and gives visibility to the unique aspects of each profession, enabling autonomous practice within respective scopes of practice.

Historically in New Zealand (and still today in many countries around the world), midwifery was subsumed by nursing and not considered a distinct profession. The passing of the HPCA Act in 2003 saw the establishment of the Midwifery Council, which, along with the establishment of MERAS in 2002, were the final pieces of the puzzle for New Zealand midwifery to secure its position as a separate, autonomous profession, completely distinct from nursing.

With this history in mind, the possibility of no longer having a dedicated midwifery regulator is concerning. Hopefully we have passed the point where midwifery is at threat of losing its recognition and rights as a distinct profession but, with changes of the scale the government is proposing, there are threats as well as potential opportunities. Square

YOUR COLLEGE

College Consensus Statements

The College has made changes to the process for developing guidance for the profession (including consensus statements, practice guidance and toolkits). In March 2024 the College Board approved a new framework for assessing the need for new and updated statements and guidance, which has enabled a programme of work to be established to not only progress the publication of new College guidance but also to systematically update existing statements. The format and style of the statements is also changing, with new branding elements being incorporated and a shift to a more narrative style. A further Board decision in February 2025 enabled publication of final drafts of statements which are awaiting ratification at an AGM.

The College team now has several guidance statements in progress, and the first two, updated under the new framework, have been published on the College website (Cultural Safety and Climate Change).

Members can engage with the development of guidance via portal consultation (members are notified of each consultation in a College member communication email). The next updated statements to be published will be Cord Blood Banking, Infant Feeding in Emergencies, and Unregulated Workers in Maternity. Square

Nominations for president

College Co-presidents Beatrice Leatham and Debbie Fisher have put themselves forward for a second term as president (as is their right under the College’s constitution). Nominations are now called for any candidates who wish to stand against Beatrice and Debbie.

The closing date for nominations is 25 July 2025. If there are any opposing candidates, an election will be held by online ballot. If there are no opposing candidates, Beatrice and Debbie will be re-elected unopposed. Please contact Lynda Overton Lynda.o@nzcom.org.nz for further information. Square

Professional Indeminity and expanded practice within the midwifery scope of practice

The Midwifery Council | Te Tatau o te Whare Kahu has published its policy about expanded practice within the midwifery scope of practice (available on the Council’s website).

Annual General Meeting

Currently the College professional indemnity policy covers midwives who are practising within the midwifery scope of practice, as long as they are within the correct membership category.

There may be implications for indemnity cover, if a midwife chooses to practise in an area that is determined by the Council to be outside of the midwifery scope of practice. We recommend that midwives undertaking any work that may be seen as expanded practice within the midwifery scope of practice, ensure that they are familiar with the Council’s policy on expanded practice and have met its requirements and:

• the expanded practice is already approved on the Midwifery Council’s website or,

• if it has not yet been considered by the Council, to personally contact the Council to seek such approval in writing

Professional indemnity cover will also require midwives to ensure they follow Council’s educational and other requirements to practise and maintain competency within an expanded scope of midwifery practice.

Posters available for download

Posters to encourage women and colleagues to feed back on their midwifery care are now available to download on the College website: https://www.midwife.org.nz/midwives/midwifery-standards-review/ Square

The College Annual General Meeting will be held on Wednesday 27 August, 7pm, Claudelands – Hamilton.

PROFESSIONAL INDEMNITY INSURANCE

REMINDER OF POLICY CONDITIONS

CARLA HUMPHREY LEGAL ADVISOR

The College offers a range of insurance packages for members, including Professional Indemnity insurance. This insurance is an automatic benefit of membership, provided that:

• the appropriate membership fee was paid at the time of the incident that gave rise to the claim and the midwife has continued as a member since that time

• other insurance policy conditions are met

All insurance policies have conditions. The purpose of this article is to emphasise a key condition that midwives need to be aware of to avoid jeopardising their entitlement to insurance benefits.

The reason that the policy requires the Legal Advisor to be notified promptly is to ensure that the medico-legal landscape is managed to reduce risk for the midwife. It is in the midwife’s best interests to notify the Legal Advisor as soon as concerns arise regarding her practice to ensure she receives appropriate advice.

The most important condition to remember is that the policy requires midwives to promptly advise the College’s Legal Advisor of any claim, potential claim or adverse outcome. This includes:

• any allegation of wrongdoing, whether it relates to clinical practice, conduct or fitness to practise

• any complaint

• any communications suggesting concerns from either the Midwifery Council, Coroner, Police, ACC, HDC, Te Whatu Ora or a consumer

Some midwives may not realise that responding directly to complaints or concerns without first seeking legal advice can prejudice their position. In such cases the insurer may refuse to provide cover. Similarly, ignoring complaints or delaying notification to the Legal Advisor can also create issues with coverage.

The College’s publication Unexpected Outcome, Information for midwives, available

on the College website, is a useful source of information on the processes involved.

In addition to providing advice on specific complaints, the Legal Advisor can assist midwives in complying with medico-legal requirements that may arise in the future. Examples of this type of advice are numerous but include:

• Appropriate responses to requests for information from third parties such as the Police

• Understanding obligations under various legislation, including seeking exemptions from Jury service

• Navigating concerns such as declined consultation recommendations or requests for higher-risk birth plans

• Determining when termination of a partnership is appropriate

• Guidance on processes for internal hospital reviews

• Health and safety obligations

• Rights and options when a midwife is defamed or threatened

The Legal Advisor is happy to assist – if in doubt please feel free to call to schedule an appointment or send an email to legalpa@ nzcom.org.nz.

The Insurance Policy has a number of other conditions. If you have any questions please contact the Legal Advisor at the email address above. A copy of the policy is available upon request. Square

BULLETIN

Explore the magic of birthing at home

Home Birth is a heartfelt and empowering documentary created by home birth midwife Sarah Dow and director Isaac Te Reina. The documentary is a great new resource for midwives and whānau and is now available to watch free online.

Funded by Health New Zealand Central Region’s Maternity Quality and Safety Programmes, Home Birth explores the magic of birthing at home, and shares stories and experiences of whānau who choose to welcome their babies into the world in the comfort of their own home.

Through personal stories, midwifery perspectives and a te ao Māori lens, this documentary aims to empower and inspire birthing women and people to make confident, informed decisions around place of birth.

The documentary was well received by whānau and midwives at 12 screenings around Aotearoa earlier this year, when it was hosted

by Home Birth Aotearoa, College regions and other local home birth supporters.

By making this documentary freely accessible, Sarah Dow hopes to dispel some myths around home birth and provide a resource for people curious to understand more.

She hopes that the documentary will prove to be a valuable tool for midwives and educators to spark conversations and guide whānau in their journey toward informed decision-making.

Sarah encourages sharing the link with whānau early in pregnancy to open the conversation about place of birth.

You can watch and share Home Birth for free online at: https://info.health.nz/pregnancymaternity/labour-and-birth/where-to-givebirth. View the trailer here: www.youtube. com/watch?v=yfbZwLpGOXU

For free resources such as a poster to display in your clinic email homebirth documentary@gmail.com Square

Carosika education day

The Carosika Collaborative Annual Education Day will be held on Thursday 17 July, 9am –5pm at the University of Auckland Grafton campus www.carosikacollaborative.co.nz Square

The Medicines Amendment Act: Section 29A Exemption for funded alternative medicine

The College made a short submission for the Medicines Amendment Act consultation and strongly supported the inclusion of registered midwives as approved prescribers of funded alternative medications when medicine supplies are disrupted. Midwives have previously been affected by supply shortages when an alternative

TERINA JOSEPH MĀORI MIDWIFERY ADVISOR

Kotahi te aho ka whati, ki te kāpuia e kore e whati – One strand of flax is easy to break, but many strands together will stand strong. This is the whakataukī that resonated for TeRina Joseph when she applied to be the College’s new Māori Midwifery Advisor. It speaks to the strength of the collective when we work together. The metaphor also seems to extend to TeRina herself; her strength comes from her whānau, her whakapapa threads throughout the motu and all the māreikura midwives who surround her with a korowai of aroha in her mahi.

Hailing from Ngati Ranginui, Ngai te Rangi, Tainui, Ngā Puhi, Patuharakeke and Te Arawa, TeRina can find connections with almost anyone she speaks with in te ao Māori. As well as her own iwi and hapū, she is connected through her husband and tamariki to Whakatōhea and Ngāti Kahungunu. And then there are ancient connections to other iwi through the Tākitimu waka which stopped all around Aotearoa.

TeRina will be co-leading the Midwifery First Year of Practice programme with Elaine Gray. Whanaungatanga and connection will be central to how she does this. “It breaks down barriers to be able to kōrero to a Māori

midwife who comes from where I come from – I can understand the connection to the whenua, to whānau, to marae. It’s those iwi connections that help me to help Māori midwives in particular.” TeRina wants to be a resource for non-Māori midwives as well; “If they’re living in an area that I might whakapapa to and they want information or traditional Māori birthing practices that’s where I might be resourceful for those midwives as well. I want to tautoko all my sisters across the country as a part of the advisory team who support our members every day.”

TeRina recalls the benefits of mentoring she experienced herself. “I had an amazing mentor and she saw my needs and she took me to the ngahere and took me to the moana”. TeRina is looking forward to seeing through the programme’s next evolution. “I have aroha for the new graduates, it can be pretty mindblowing in your first year going out into practice. Whatever we can do to support those new midwives - what an honour for me to be in that position”.

Prior to becoming a midwife, TeRina’s work as a patient advocate for whānau in the hospital system enabled her to see both

sides of the healthcare relationship – the experiences of patients and of the clinicians who were trying hard to provide good care. She saw that positive change needs to be driven by good leadership and system-level action. This contributed to the appeal of a national role.

TeRina commenced in the role on 12 May and has already enjoyed connecting with many of you. Square

Top: TeRina with husband Dougie. Bottom: The College welcomes TeRina with a mihi whakatau.

NEW COLLEGE ELEARNING COURSES

The College is thrilled to launch two brand new eLearning courses: Syphilis and other STIs in midwifery and Midwifery Care for Former Refugee Whānau — both are now live on the College website.

The courses have been created in collaboration with expert midwives, women, multidisciplinary clinicians and academics. These courses are fully funded for College members and provide up to 4 hours of continuing midwifery education.

These new eLearning courses add to the College's current offerings:

• Te Tiriti o Waitangi – Subsidised for members and counts towards the Midwifery Council’s cultural safety requirements for 2024–2027.

• Practicalities of Mentoring – A must-do for anyone mentoring through the College, and packed with great tips for supporting colleagues. Fully funded for members.

All courses are available now via the Education tab on our website https://www.midwife.org.nz/midwives/education/elearning/ Square

TEST RESULT RESPONSIBILITY

VIOLET CLAPHAM MIDWIFERY ADVISOR

Responsibility for receiving and reviewing screening and test results is an essential element of the midwifery role. Whilst lines of responsibility may be clear where the midwife is the only practitioner providing care to a woman at the time of test, the situation can become confused when women are moving between community and hospital locations, and tests may have been ordered by one practitioner but are reviewed by another. There have been a number of cases in Aotearoa where people have been adversely affected by this lack of clarity, and the Health and Disability Commissioner has called for improved safety in this area of practice.

PRINCIPLES

In response to these safety concerns, Health NZ | Te Whatu Ora has developed a set of principles which promote the safe follow up of test results. These principles (in summary) are:

1. The clinician who orders an investigation (the requestor) is responsible, either personally or delegated through defined team processes, for reviewing and actioning the results regardless of subsequent transfer of care, unless explicitly agreed to and documented otherwise.

2. Where information is shared to add value to care and continuity, copying results to other clinicians or service providers is appropriate, but clear separate communication is required if the recipient is expected to act on the result.

3. Any clinician copied into a result which is significantly abnormal needs to ensure appropriate action has been taken.

4. Requirements for regular monitoring and follow up must be agreed between the referring and receiving clinicians.

CONTEXT

A midwife who requests a test has a duty of care towards the person to ensure that all test results are reviewed in a timely manner and that any appropriate action is taken. If the midwife is unable to do so, they must organise appropriate cover within their team or practice group.

Copying results to another clinician is not a transfer of care and results should not be routinely copied to any other clinician at the time of request. This ensures that ongoing responsibility lies unambiguously with the requester. If a handover of responsibility is requested, this needs to be clearly communicated in writing and with closed loop communications (i.e. by phone call, which is then also documented). It is inappropriate to expect other clinicians to be

responsible for results that require specialist knowledge or intervention.

For hospital-based clinicians, it cannot be assumed that community-based clinicians (e.g. LMCs) will follow up outstanding test results. This requires either a discussion with them or their team to ensure they are prepared to accept responsibility or that explicitly agreed delegation for the responsibility is documented in the discharge summary. It must also be remembered that a “normal” result may, in some clinical circumstances, be very concerning and that the responsible clinician must be aware of any such implications.

MIDWIFERY GUIDANCE

LMC midwives who order tests for women or babies who are then going into the hospital care system should ensure results are reviewed and communicated to their hospital colleagues. The same principle applies if an LMC requests a test and their client then goes to a primary care facility or provider (such as a GP, After Hours provider, WellChild Tamariki Ora, or lactation consultant). If LMCs order tests that require specialist review they should ensure the results are reviewed and actioned by the relevant specialist.

Hospital-based midwives who order tests for women or babies who then discharge home should ensure results are reviewed and communicated to the relevant communitybased provider (e.g. LMC or GP).

Midwives can refer to the Health NZ Test Result Responsibility publication on the Health NZ | Te Whatu Ora website www.tewhatuora. govt.nz/publications/transfer-of-care-and-testresults-responsibility Square

UNDERSTANDING PRACTITIONER SUPPLY ORDERS

BRIGID BEEHAN MIDWIFERY ADVISOR

Practitioner Supply Orders (PSOs) are an important but sometimes misunderstood mechanism that enables midwives and other authorised prescribers to access medicines without writing individual prescriptions. This article offers a practical overview of PSOs for midwives and highlights key considerations when ordering and using medicines not funded under the PSO schedule—using tranexamic acid (TXA) as an example.

WHAT IS A PRACTITIONER SUPPLY ORDER (PSO) AND WHEN CAN IT BE USED?

A PSO is a written order made by an authorised prescriber—such as a midwife—for the supply of pharmaceuticals for emergency use in the community, for teaching or demonstration purposes, or for administration where an individual prescription is not practical. Medicines supplied under a PSO must be intended for use within the midwife’s scope of practice and administered to clients under their care.

The legal basis for PSOs is outlined in the Medicines Act 1981 (Section 25). Midwives must sign and date the order form, clearly list the medicines and quantities, and include their practice address. At this time, PSO forms cannot be submitted electronically and must be completed using a paper form approved by the Ministry of Health (this can be supplied by the pharmacist).

WHAT MEDICINES ARE FUNDED UNDER PSO?

Pharmac maintains a list of funded PSO medicines on its Pharmaceutical Schedule. This list includes medicines midwives commonly use, such as local anaesthetics, antibiotics, vitamin K and uterotonics. For a medicine to be funded under a PSO, it must:

• Appear on the PSO list

• Be used for an approved purpose and within the midwifery scope of practice for:

- Emergency use

- Teaching and demonstration

- Provision to certain patient groups where an individual prescription is not practical

- Administration of products that require specialist handling or techniques

• Be ordered in line with quantity restrictions outlined in the Schedule.

CAN MIDWIVES ORDER MEDICINES NOT ON THE FUNDED PHARMACEUTICAL SCHEDULE ON A PSO?

Yes, if a medicine is not on the funded schedule, midwives can still order it on a PSO, but the cost may need to be covered by the midwife or their practice.

EXAMPLE OF A NON-FUNDED PSO: TRANEXAMIC ACID (TXA)

TXA is an antifibrinolytic agent used in the treatment of postpartum haemorrhage (PPH). The National Consensus Guideline for Treatment of PPH (2022) recommends early administration of TXA (within three hours of the onset of bleeding) to reduce the risk of hysterectomy and maternal mortality.

Although TXA is not currently listed as a funded item on the schedule, it can be legally ordered by midwives via PSO when needed for emergency care in the community. This is particularly relevant for midwives practising in rural or homebirth settings.

Key considerations when ordering PSO medicines like TXA:

• The PSO form must clearly state the medicine is for use in emergency care and is within the midwife’s scope.

• The supplying pharmacist must be confident that the order is reasonable, safe and lawful.

• Midwives or their practices may be invoiced for the full cost unless the medicine qualifies for rural funding provisions. The pharmacist determines the cost of non-funded PSOs.

The College is advocating for TXA to be added to the PSO so midwives can access it for no cost. Pharmac is currently undertaking consultation on this, and we await their decision.

WORKING

TOGETHER: UNDERSTANDING THE PHARMACIST’S ROLE

Pharmacists have a professional and ethical responsibility to ensure that any medicine supplied under a PSO—whether funded or not—is clinically appropriate, justified, safe and within the prescriber’s scope. This goes beyond funding rules and includes compliance with legal and ethical standards. Pharmacists may seek clarification or justification for PSO orders, particularly for non-funded medicines. Midwives should be aware of these responsibilities to support clear communication and avoid misunderstandings.

TIPS FOR PRACTICE

• Build relationships with local pharmacists. Clarify your role, scope and the legal basis for PSOs.

• Be specific on PSO forms. Clearly indicate intended use and the clinical context.

• Stay informed. Check the Pharmac PSO list regularly for updates and to confirm current funding status. The College is working with Pharmac to have TXA added to the funded pharmaceutical schedule.

• Document appropriately. In accordance with professional standards of practice, keep a record of what was ordered, why it was needed and how it was used.

For further information, refer to the College’s prescribing guidance and Pharmac’s PSO schedule. Questions about specific cases can also be directed to the College advisors or a trusted pharmacy colleague. Square

PSOs allow midwives to legally access and supply selected medicines without writing individual prescriptions, provided the medicine is for emergency use, teaching or specific clinical contexts.

Only funded medicines listed in the Pharmaceutical Schedule are subsidised under a PSO. Other medicines can still be ordered but may not be funded.

Midwives must prescribe within their scope of practice when ordering or using medicines via PSO, and must be competent in their use.

Pharmacists have a duty to ensure the medicine and quantity supplied are appropriate and may seek justification, especially for non-funded items such as tranexamic acid (TXA).

TXA is not currently funded via PSO in urban areas, but can be ordered on a PSO form for emergency PPH care—costs must be discussed with the pharmacist.

Clear communication, documentation and collaboration with pharmacists are essential for safe and compliant use of PSOs.

References available on request.

KEY PRACTICE POINTS FOR MIDWIVES

REBRANDING WITH PURPOSE: A JOURNEY WITH OHO

Tēnā tātou,

At the amazing 2024 Hui-a-Tau in Ōtaki participants were introduced to the local, talented Māori business consultant, my sister Rachel Taulelei

Following on from a discussion at the previous Hui-a-Tau, this AGM would progress our rebranding journey. Rachel's consultancy OHO, specialists in crafting brand identities, offered to guide the process, reminding us that it's more than a mere change of ingoa (name) and tohu (logo); it's an evolution of our kaupapa and an expression of our purpose.

ABOUT OHO

OHO brings a wealth of experience in branding strategy and design, known for their collaborative approach that respects cultural nuances and emphasises authenticity. They understand that a brand is a perception of your kaupapa and your purpose, extending beyond just making money to evoke emotion and empathy and to connect with your audience on a deeper level.

THE PROCESS OF WĀNANGA

Central to our rebranding effort is the process of wānanga, where three expert consultants have been running wānanga with method, ensuring

every decision is informed by an insight and understanding of our members. This approach is particularly significant since our identity is strengthened by our whānau. OHO facilitated a range of wānanga as intentional engagements with members throughout Aotearoa. The contributions were inspiring. All participants brought unique and personal insight for OHO to include into developing the rebrand.

UNDERSTANDING BRAND STRATEGY

A solid brand strategy is crucial. Your purpose informs and shapes the perception you want people to have of Ngā Māia. For Māori, this is intuitive, we already possess a strong sense of purpose and a desire to build long-term relationships both internally and externally. Our depth unites us and fosters a rewarding relationship between brand and people.

CREATING A STRONG BRAND IDENTITY

Beyond strategy, the Ngā Māia brand needs to encompass all elements that express our kaupapa, ensuring a shared understanding. This includes personality, tone, voice, imagery, colours, fonts, layouts and logos. It's about creating a system of recognisable assets that resonate with our audience.

KNOWING OURSELVES

Identity and specification of brand avoids over committing and under delivering. Sometimes being all encompassing and driven by kaupapa can spread us thin or risk becoming a jack of all trades, masters of none. It can be helpful to think of our “what we do” as water and the “what we want” as the walls of the vessel or bucket that holds the water. The better we know what we want, the higher the sides of the bucket and the more depth we achieve. Without a clear and shared understanding of “what we want”, the sides of the walls are lower and the less water we retain. Without a vessel, we're pouring water out onto the ground. Our “what” loses its depth and has no destination.

WHAT’S NEXT?

As the team from OHO prepares the final brand strategy, this will be presented back to our Ngā Māia whānau, trustees and membership. We are excited to see what the future looks like on this brave new adventure.

Ngā mihi Square

VICTORIA ROPER NGĀ MĀIA OPERATIONS

Tabitha Harris and Rachel Taulelei

‘PINEAPPLE PIE IN THE SKY’

NGATEPAERU MARSTERS

PASIFIKA MIDWIVES AOTEAROA CO-CHAIR

Tarai ia te vaka no te au tere ki mau

Carve your canoe for the journey ahead

Nga Hau Māngere is a name gifted by mana whenua to describe the gentle breeze that blows across the Manukau harbour and to bless the last birthing centre built by the Wright Family Foundation.

It is located in Māngere, home to the largest demographic of Tagata Moana—people of the Pacific—at 66.1%, according to Stats NZ.

Reflecting back nearly a decade, Pasifika Midwives Aotearoa dreamt of our ‘pineapple pie in the sky’. It’s a playful spin on English labour activist and songwriter Joe Hill’s reference of something yearned for but beyond reach.

A primary birthing unit in Māngere? We committed those words to paper, spoke them out loud and actively sought a location. Coincidentally, that building became the venue for stakeholder engagement meetings called by the late philanthropist Chloe Wright (CEO, Wright Family Foundation) to discuss a birthing centre in Māngere. She brought her home baking, the building plans and a sense of positivity to the kōrero. The dream did materialise and Nga Hau Māngere Birthing Centre opened in May 2019.

After three years Chloe Wright chose to move in a different direction, endorsing Pasifika midwives to take the helm of Nga Hau. Chloe’s belief was humbling, as was her unexpected passing. It brought motivation, as the best way to honour her generosity was to continue her legacy.

Over the past six years the romanticism of the Pacific notion has remained—the belief of a bespoke service that is reminiscent of a village, where people gather and share the highs and lows of their lives—a haven. Keeping the kaupapa has been constant from whānau, midwives and the community—rallying their voices to keep this service buoyant.

In 2023, Tagata Moana Maternity Trust was formed to take up Chloe’s mantle. Those involved in the trust have all served the Counties Manukau community for a number of years:

• Dinah Otukolo is of Tongan descent and a LMC from the group practice Southside Aiga Midwives. She is embedded in primary birthing at Nga Hau and homebirths. She helped with Nga Hau’s set up.

• Eleanora Bukateci was also involved in setting up Nga Hau. She is a proud Fijian and currently Midwife Manager of Whānau Ngā Uri/ Primary Birthing Unit at Te Toka Tumai (Auckland).

• Ngatepaeru Marsters is National coordinator of Pasifika midwifery workforce initiative Tapu Ora and part of AUT’s team. Her whakapapa is to the Cook Islands.

• Namulua’ulu Tish Taihia is Clinical Midwife Manager at Nga Hau and brings her warmth and leadership skills to the role. Namulua’ulu references her Samoan matai title.

• Tokarahi Vaetoru has extensive midwifery experience and recently joined Counties Manukau as a Clinical Midwife Specialist Diabetes. Her Pacific links are to the Cook Islands.

• Pat Snedden is well-known for his social justice advocacy roles and belief in operating from a high trust model. He is a past chair of Counties Manukau DHB and his reach as a conduit to progressing this mahi was inspiring.

Chloe had advised us to find a partner and Turuki Health Care is a great fit. Their roots are from the former Māori midwifery practice Putea o Pua, formed in 1995. Today, Turuki has a broad suite of services that includes Kahu Taurima. The synergy of our complementary alliance strengthens an integrated approach built on kaupapa Māori principles and embracing Pacific village values too.

It has taken two years for Tagata Moana Maternity Trust and Turuki Health Care to navigate the ebbs and flows of a changing health landscape with new government priorities, but together we have achieved public funding for Nga Hau Māngere Birthing Centre’s continuation. Nga mihi nui Turuki Health Care.

Nga Hau Māngere Birthing Centre entered a new chapter on 5 May— International Day of the Midwife—under the leadership of Tagata Moana Maternity Trust—the universe speaks. A tohu.

Arohanui Chloe Wright—we did it. Your legacy lives on.

E hara taku toa I te toa takitahi engari he toa taikitini My success is not my own, but from many others. Square

HYPEREMESIS GRAVIDARUM

A SERIOUS PREGNANCY ISSUE

WHAT IS HYPEREMESIS GRAVIDARUM?

Hyperemesis gravidarum (HG) is a severe form of nausea and/or vomiting during pregnancy (NVP) that affects approximately 1.1% of pregnant women (Lowe et al., 2019). It is considered the extreme end of the NVP spectrum and is characterised by persistent, intractable vomiting that can lead to dehydration, weight loss, malnutrition and electrolyte imbalance. HG is a debilitating condition with significant impacts on maternal and fetal health.

There is no universally accepted definition of HG, which complicates diagnosis and management. Assessment often involves the use of validated scoring tools like Pregnancy-Unique Quantification of Emesis and nausea (PUQE), which quantifies the severity of symptoms. Laboratory tests, including electrolyte levels and liver function, may be undertaken in severe cases to rule out other conditions. Ketonuria, often considered a sign of severity, has not been reliably associated with HG.

WHAT DOES THE EVIDENCE TELL US ABOUT HG?

HG is more commonly diagnosed in women in India, Pakistan, Asia and New Zealand, compared to European and Indigenous American populations (Verberg et al., 2005). One study (assessing 8 million pregnancies) found that women admitted to hospital with HG were younger, of lower

socioeconomic status, were more likely to be of Asian or African ethnicity, were more likely to be carrying a female baby and were more likely to be having a multiple pregnancy (Fiaschi et al., 2016).

The aetiology of HG remains unclear but is likely to be multifactorial (Bustos et al., 2016). Conditions with higher HcG levels (such as trophoblastic disease and multiple pregnancy) have been associated with increased severity of NVP. Other associations include Helicobacter pylori infection, deficiency of trace elements, excess thyroid hormones, gravidity, fetal female sex, and psychiatric and dietary factors.

Recent research has identified a complex interplay between hormonal changes and genetic predispositions in HG development. Genetic variants in genes such as GDF15 and IGFBP7 (related to placental proteins) and hormone receptors (such as GFRAL and PGR) have been implicated (Fezjo et al., 2024). Women whose mother suffered HG are three times more likely to be affected (Vikanes et al., 2010). Trials are underway for drugs that could make a significant difference to women suffering hyperemesis in pregnancy.

HG has been historically under-researched and there is limited evidence as to the most effective dietary and medical approaches. Research gaps include the nutritional intake of women with HG and its impact on perinatal outcomes, as well as the long-term health

VIOLET CLAPHAM MIDWIFERY ADVISOR

LIZZIE PIKE LMC MIDWIFE

PUQE: PREGNANCY-UNIQUE QUANTIFICATION OF EMESIS AND NAUSEA

Circle the answer that best suits your situation for the last 24 hours

1. On average in a day, for how long do you feel nauseated or sick to your stomach?

≥ 6 hours: 5 points 4–6 hours: 4 points 2–3

2. On average in a day, how many times do you vomit/throw up?

≥ 7 times: 5 points 5–6 times: 4 points 3–4 times: 3 points 1–2 times: 2 points Not at all: 1 point

3. On average in a day, how many times have you had retching or dry heaves without bringing anything up?

≥ 7 times: 5 points 5–6 times: 4 points 3–4 times: 3 points 1–2 times: 2 points Not at all: 1 point

Total Score (sum of replies to 1, 2, and 3): Mild NVP ≤ 6; Moderate NVP 7-12; Severe NVP ≥ 13

Quality of life question: On a scale of 0–10, how would you rate your wellbeing: 0 (worst possible) 10 (As good as you felt before pregnancy)

PUQE form modified from: Koren G, Boskovic R, Hard M, Maltepe C, Navioz Y, Einarson A. Motherisk-PUQE (pregnancy-unique quantification of emesis and nausea) scoring system for nausea and vomiting of pregnancy. American journal of obstetrics and gynecology. 2002; 186:S228–31, with permission.

of children born to affected mothers— although there is some evidence to suggest an increased risk of psychological and behavioural disorders, and decreased insulin sensitivity (Mullin et al., 2011; Veenendaal et al., 2011).

The Society of Obstetric Medicine of Australia and New Zealand (SOMANZ) provides evidence-based guidelines for managing NVP and HG, emphasising individualised patient care (Lowe et al., 2023). Recommendations include:

Physical effects of hyperemesis may be so severe that women have to stop work, and they may need support caring for other children. They are likely to lose enjoyment of eating and drinking, and may feel like they are surviving on a cocktail of drugs.

• Early identification and appropriate scoring of symptoms

• The judicious use of antiemetics and fluids

• Avoiding unnecessary treatments while ensuring sufficient management of severe cases

• Clear protocols for escalation to hospitalbased care if outpatient management fails

WHAT IS THE IMPACT OF HG?

HG is associated with increased risk of maternal complications, including dehydration, nutritional deficiencies, psychological distress and placental abruption (Jansen et al., 2024). Fetal risks include low birth weight, preterm birth, admission to NICU and long-term developmental issues.

Unmanaged HG can lead to rare but serious neurological complications such as Wernicke encephalopathy due to thiamine deficiency. HG is the most common reason for hospitalisation in the first half of the pregnancy and second only to preterm labour throughout the whole of pregnancy (Gazmararian et al., 2002).

Physical effects of hyperemesis may be so severe that women have to stop work, and they may need support caring for other

children. They are likely to lose enjoyment of eating and drinking, and may feel like they are surviving on a cocktail of drugs. Women suffering from HG are often unable to tolerate certain smells (cooking smells and cleaning products are common triggers) and they are unlikely to be able to tolerate oral medicines (such as Lactulose) or the oral glucose preparation for gestational diabetes screening. Bowel dysfunction is a common side effect of antiemetic treatment (e.g. constipation, haemorrhoids and anal fissures).

The impact of HG on maternal mental health can be significant. During the affected pregnancy, women may develop negative feelings towards their baby (and the associated guilt that brings) and may feel a profound relief when the baby is born. Although HG usually resolves at birth, the pregnancy experience can impact on bonding with baby post birth.

The experience of HG can also impact on future pregnancy plans, and may cause a longer interval between pregnancies. Post traumatic stress disorder may develop, and some couples will opt for a surrogate pregnancy in order to avoid another experience of HG in pregnancy.

EQUITY OF ACCESS AND TREATMENT APPROACHES

Management of HG varies widely and often includes a combination of dietary modifications, medical intervention and supportive care. Across Aotearoa, women may experience differences in the care pathways they encounter with HG, and variable access to treatment. The evidence-based recommendations for management of HG include:

• Lifestyle and dietary changes: Adjustments such as eating smaller, more frequent meals and avoiding triggers may help alleviate symptoms.

• Antiemetics: See page 29.

• Fluid and electrolyte management: Intravenous fluids are essential for severe dehydration. Parenteral nutrition or enteral feeding may be necessary in severe cases.

• Thiamine supplementation: Thiamine administration may need to be considered when vomiting is severe and persistent.

• Acid suppression and laxatives: These may be used as adjunct treatments to manage gastrointestinal symptoms associated with HG.

Complementary therapies such as ginger and vitamin B6 have shown some benefit for NVP, but evidence for their efficacy in HG is limited.

INFORMED DECISION MAKING

Midwives can support informed decision making by offering resources and information to help navigate options. Mothers will often feel concerned about the potential impact of drug therapy on their baby, and will balance potential risks and side-effects of drug therapy with the need for daily survival and quality of life. Resources and support for women with hyperemesis can be found at: www.hgadvocacy.org.nz; www.hyperemesis.org; www.healthify.nz; www.somanz.org.nz; www.medsafe.org. nz; Facebook: Hyperemesis Peer Support NZ

WHAT CAN MIDWIVES DO TO SUPPORT WOMEN DEALING WITH HG?

The most important thing midwives can do is to recognise and diagnose HG when it occurs. Early diagnosis can support earlier access to treatment and stabilising therapies, and can help prevent deterioration in the woman’s condition. Continuity of care is very supportive for women suffering from HG, and emotional support and debriefing form important aspects of midwifery care. Midwives have a unique insight into the lived reality of HG for pregnant women, particularly given the isolating nature of the condition.

Midwives should be familiar with their local referral and treatment pathways for hyperemesis. Offering a prompt diagnosis and comprehensive referral to medical

LIVED EXPERIENCE: NINA’S STORY

I have experienced HG with all three of my pregnancies. The first time I really didn’t know what to expect. I remember feeling like my body was failing, I was being ‘dramatic’ and ‘overly sensitive’. It wasn’t until my third visit to ED needing fluids that they informed me about HG. I started taking Ondansetron which came with its own unpleasant side effects. I remained on this medication for the duration of my pregnancy. There was nothing medicationwise that really helped me to function. During my last pregnancy I was on Ondansetron, Metoclopramide, Cyclizine and Doxylamine (I ordered that from the USA in desperation) and it made very little difference. I was still vomiting constantly and could not eat any foods, and if I did it was brought back up within 20 minutes. I could never stomach the normal multivitamins they suggest to women. I literally would watch the clock and be proud of myself for making the last five minutes without vomiting.

I do wonder, if I was still SO sick on all that medication is there any point taking it? It's really frustrating having no control over my body's response to pregnancies. As someone who hasn’t experienced depression it was scary when the dark thoughts felt so strong and overwhelming. I didn’t dare speak them out. It was terrifying to find myself wishing I wasn’t pregnant, or better yet, hoping for a miscarriage or abortion to end the misery I was in. Those thoughts in themselves completely broke me, and went against my own personal beliefs. I felt I was a terrible wife to my husband. I was snappy, he could never do anything right and no matter how hard he scrubbed his teeth, showered and even changed his normal deodorant HE STUNK, I was utterly repulsed by the man I love.

With my third pregnancy the antenatal depression and anxiety were much stronger. I was much sicker and completely debilitated. In the first fifteen weeks I had 21 doses of IV fluids and was admitted to hospital where I was placed on a potassium drip. I was completely exhausted; my body ached all over. It was like a terrible flu that you can't get over.

My four year old was absolutely terrified of me. She wouldn’t hug me, and I was lucky if I could sit beside her on the couch and read her a story. I think she was overly sensitive to my sickness and the vomiting really scared her. My wider whānau provided essential support with the kids, and a friend would take turns with my husband driving me into ED for fluids.

I did not feel I came out from ‘under the cloud’ of HG officially until the baby was born. The vomiting stopped around the 18 week mark, but the nausea never left me until birth. My experience with HG did affect the way I bonded with my first baby. I think in hindsight I had postnatal anxiety. I was a young mum and right up until birth my experience was nothing like I thought it would be. There was a lot of processing, and grieving my lost pregnancy experience. I did, however, have a wonderful birth experience and that was healing.

I think it would be really helpful for women suffering HG to have more options to access IV treatment without having to constantly go to ED. It was game changing when the local primary maternity unit said I could go there for fluids.

We spaced our pregnancies to prepare for HG happening again. I had a 2.5 year age gap between my first two, and then a 4.5 year gap before we conceived number three. Unfortunately, we lost our third baby in the second trimester. I had just been back at work for one week after having to take three months off. I am now eight months postpartum, and we are certain we will not have another baby. I feel like people think it's because of the miscarriage, it's not. It's because of the sickness. I feel terrible and just don’t bother explaining it to people because I really don’t think they understand the depth of HG and the implications it has on your hauora. Right now, my husband and I are enjoying life with our two daughters, both at school.

LIVED EXPERIENCE: RUBY'S STORY

I don’t think there are enough words to describe the emotional and physical turmoil of an HG pregnancy. It’s a lonely, isolating condition that you truly can’t comprehend unless you’ve experienced it. You become nothing more than a vessel to bring your baby into the world, and it’s an experience I wouldn’t wish on anyone. Your body becomes so weak from starvation, dehydration, and muscle wasting. You can barely walk across the house without needing to rest. Some days, you crawl to the nearest bowl, sink, or toilet to vomit. On others, you just sleep on the bathroom floor, knowing it won’t be long before you're sick again.

You can’t keep down a single sip of water without vomiting. Even when there’s nothing left, your body keeps trying to force something out. It happens again and again, often to the point where you can’t breathe. Most people don’t realise HG isn’t just one or two vomits a day. It’s relentless. Each episode might be once, or 30+ times, followed by brief relief, before it starts again.

You miss out on so much during those months of illness. It feels like you're trapped in your own body. It’s not just food that triggers it—every sense betrays you. Sights, smells, sounds, lights, and even your own saliva can cause nausea and vomiting. I couldn’t even hug my husband when I needed him most, because we both knew it would make me throw up. He used to joke that I shouldn’t cry while pregnant because I was wasting valuable water—but I cried so much during my three HG pregnancies.

I had to stop working and go on early parental leave for medical reasons. My husband worked 12–14 hour days and still came home to care for me, manage the house, and take me to the hospital. There were many hard days for both of us—frustration, exhaustion, and sadness—but we made it through, and it strengthened our relationship.

During my first HG pregnancy, I received overwhelming sympathy. My second pregnancy, however, was worse. I had to move in with my husband’s parents, while my sister-in-law raised my eldest because I was too sick to care for her. I was given NG feeding tubes to get nutrition into my body. These rarely lasted more than a few days—the vomiting was so forceful, it dislodged them, and I’d need a new one placed. Having a tube pushed down your throat through your nose with no numbing spray is agonising. Because my stomach was empty, I also had to get abdominal X-rays to confirm placement. After vomiting up five of them, I asked for alternatives.

Eventually, it was decided a nasojejunal feeding tube would be better. But even after six failed attempts, the vomiting was still too strong. They tried a rare procedure: suturing the feeding tube to my intestinal wall. Still, it didn’t hold. After that, I was hospitalised permanently until the baby arrived.

We knew if we had a third, we’d have to get through it mostly alone. That pregnancy was emotionally the hardest. There was a constant sense that people were less sympathetic because we’d “chosen” to go through it again. I avoided hospital out of fear they’d insist on another feeding tube. I suffered through it, doing the best I could at the expense of my own wellbeing.

Aside from my husband, my LMC was my one unwavering support. She cared for me through all three pregnancies. I trusted her deeply, and I’ll always be grateful she stayed by my side. What helped most were sleep, starting medication early, and IV antiemetics at the hospital. Ice-cold, sour foods became my lifeline. I grew three beautiful babies on frozen cokes from McDonald’s and sour fruits or lollies.

Mentally, I don’t know if I’ll ever fully recover from it. I feel robbed of the joy pregnancy should bring. I loved my belly babies, but I hated being pregnant. It was difficult to feel connected to them while I was barely surviving. But the second I held my babies, there were no bonding issues. I fell in love the moment I saw them. Everything I endured became worth it. If anything, HG made me love them even more because of everything I had to sacrifice to meet them.

I’m terrified that one day my three girls might face their own HG pregnancies. I just hope that by then, better treatments exist—and no one else has to suffer like this.

services is crucial. Offering flexible treatment options is also helpful, including investigating access to IV fluid therapy in other locations (such as in a primary maternity unit, GP surgery, midwifery clinic or home). IV fluids will often need to be repeated frequently.

Offering home visits for antenatal care is supportive for women suffering HG, particularly if they have other children to care for. Getting creative with nutritional intake is important too, as many women will struggle to keep food or tablets down. Nutritional drinks (such as Fortisip) can be helpful, and making small adjustments can make them more palatable (such as adding ice).

Referring women to a dietitian, mental health support and home help services can also be beneficial. It is useful to monitor weight change for women experiencing HG to inform the wider clinical picture.

DRUG THERAPY RECOMMENDATIONS

There are a variety of medicines that may be offered to treat hyperemesis in pregnancy, including sodium chloride 0.9%, metoclopramide, cyclizine, prochlorperazine, ondansetron and steroids. Midwives generally work collaboratively with their medical colleagues when drug-based therapies are needed to treat hyperemesis (see p.29).

Drugs that are not currently in widespread use in Aotearoa, but may prove effective in treating HG, include doxylamine/pyridoxin and Mirtazapine (an antidepressant).

Ondansetron is commonly used offlabel for HG but requires further research to confirm its safety compared to other treatments. Medsafe NZ (2024) states that Ondansetron should only be used during the first trimester of pregnancy if the benefits of use clearly outweigh the risks of harm to the woman and the baby. Ondansetron is suspected to cause orofacial malformations when administered during the first trimester of pregnancy. The available epidemiological studies on cardiac malformations show conflicting results.

The SOMANZ guideline offers comprehensive advice on pharmacological treatment of HG and can be accessed at www.somanz.org.nz. The HER Foundation offers a wealth of tools and information for healthcare providers, including advice about HG medications, see www.hyperemesis.org. Square

References available on request.

ANTIEMETICS TO TREAT HG

First line

Second line

VITAMINS AND MINERALS

Folic acid (first trimester)

Iodine

Pyridoxine (Vitamin B6)

Thiamine (Vitamin B1)

National Women's Health (2018)

(IV, orodispersible wafers)

– 8 hourly

IM 100mg daily

MIDWIFERY CONTINUITY OF CARE

STRENGTHENING RELATIONSHIPS, OUTCOMES AND EQUITY IN AOTEAROA NEW ZEALAND

VIOLET CLAPHAM MIDWIFERY ADVISOR

ALISON EDDY CHIEF EXECUTIVE

Continuity of midwifery care is internationally recognised as the gold standard in maternity services, and in Aotearoa it is a cornerstone of the current midwifery-led model. This model places the woman and her whānau at the centre of care, supported by a Lead Maternity Carer (LMC) midwife who provides or co-ordinates continuity throughout pregnancy, birth and the postnatal period. As pressures mount on the maternity system and the midwifery workforce, recent research and policy initiatives continue to reinforce the importance of preserving and strengthening midwifery continuity of care.

Midwifery models of care are a way to optimize service delivery to better meet the needs of women and newborns before, during and after pregnancy. In this model, high quality care is coordinated by midwives who make autonomous decisions across their full scope of practice, as part of interdisciplinary teams. The best results are achieved when care is provided by the same midwife or team of midwives during pregnancy, birth and the postnatal period (continuity of midwife care).

- The Midwifery Accelerator (2025)

This article explores key findings from recent reports, including the 2023 study by Dixon et al. on women's experiences of continuity, a recent scoping review of what women want from maternity care (Faktor et al., 2024), the World Health Organization's report on midwifery models of care, the UNFPA Midwifery Accelerator Report, and key messages emerging from the Kahu Taurima Technical Advisory Group. These sources collectively underscore the transformational power of midwifery

continuity of care and the urgent need for system-level support to sustain it.

WHĀNAU-CENTRED, MIDWIFE-LED: A MODEL BUILT ON TRUST

The unique midwifery model in Aotearoa enables most pregnant women to choose a community-based midwife who offers continuity of care across the maternity journey. This relational model not only ensures consistency and trust but also embeds cultural safety and responsiveness to diverse needs.

In the 2023 study Building positive respectful midwifery relationships (published in Women and Birth), Dixon and colleagues analysed narratives from 305 women who had experienced midwifery continuity of care. The study found that the quality of the relationship between midwife and client significantly impacted women's emotional wellbeing, confidence and sense of empowerment. When care was consistent and respectful, women felt safe, heard and valued.

Importantly, the study highlights that continuity enables midwives to tailor care to each individual,

The World Health Organization (WHO) has consistently promoted midwifery continuity of care models as a means of improving maternal and newborn health outcomes. In its latest report on models of care, WHO underscores the benefits of continuity, including reduced rates of preterm birth, higher satisfaction with care and decreased interventions during labour and birth (WHO, 2023).

rather than adopting a one-size-fits-all approach. Participants noted how their midwives took the time to get to know them, respected their autonomy and were present during critical moments. These findings reaffirm the relational, rather than transactional, nature of continuity care.

A 2023 scoping review conducted in Australian populations from 2012 to 2023 (a context in which continuity of care is not universally available) found that women in Australia consistently want access to midwifery continuity of care as an enabler for addressing their maternity care needs (Hollindale et al., 2024). Australian policy makers and service planners are working to increase the availability of continuity of midwifery care models, with a focus on establishing services for priority populations (such as Aboriginal and Torres Strait Islanders) who experience inequitable outcomes (Faktor et al., 2024). Data is demonstrating that these models are making a positive difference to outcomes.

GLOBAL EVIDENCE: WORLD HEALTH ORGANIZATION (WHO) ENDORSEMENT OF MIDWIFERY CONTINUITY MODELS

The WHO has consistently promoted midwifery continuity of care models as a means of improving maternal and newborn health outcomes. In its latest report on models of care, WHO underscores the benefits of continuity, including reduced rates of preterm birth, higher satisfaction with care and decreased interventions during labour and birth (WHO, 2023).

The WHO report also stresses that midwifery-led continuity models are more cost-effective and sustainable than fragmented models of care, especially in settings where resources are constrained. By centring the midwife-client relationship, these models facilitate early detection of complications, timely referrals and more appropriate use of interventions.

WHO cites Aotearoa’s midwifery-led model as an example of international best practice, particularly in its commitment to equity and whānau-centred care. However, the report also cautions that without adequate investment, workforce support and structural integration, continuity models can be undermined by systemic pressures.

ACCELERATING MIDWIFERY CARE: INSIGHTS FROM THE UNFPA MIDWIFERY ACCELERATOR REPORT

In April 2025, the United Nations Population Fund (UNFPA), in collaboration with global partners (WHO, International Confederation of Midwives, UNICEF and Jhpiego), launched the Midwifery Accelerator report. This initiative aims to expand access to quality midwifery care worldwide, recognising midwives as pivotal in improving maternal and newborn health outcomes. Key findings from the Midwifery Accelerator report include:

• High impact of midwifery care: Approximately 60% of maternal and newborn deaths and stillbirths could be averted by achieving universal coverage of care provided by midwives by 2035, including family planning services.

• Economic and social benefits: Every $1 invested in midwifery yields a 16-fold return in economic and social benefits, underscoring the cost-effectiveness of investing in midwifery services.

• Critical workforce shortage: To meet global needs by 2030, an estimated

900,000 additional midwives are required, highlighting the urgency of investing in midwifery education and workforce expansion.

The report outlines three strategic pillars to accelerate progress:

1. Commit - Invest: Strengthen policy frameworks and increase domestic and global investments.

2. Educate - Deploy - Retain: Ensure quality education and professional development for midwives, deploy midwives strategically, and retain midwives by creating a safe, supportive and accountable workplace.

3. Advocate - Empower: Build midwife leadership, strengthen coalitions and amplify voices of women and communities for effective advocacy and accountability.

These pillars align with Aotearoa's goals of enhancing midwifery continuity of care, emphasising the need for robust investment and systemic support to sustain and grow the midwifery workforce.

The Midwifery Accelerator offers a unified, evidence-driven approach, catalysing collective efforts for maternal and newborn health and well-being by expanding access to care provided by midwives, in line with Transitioning to Midwifery Models of Care: Global Position Paper (WHO, 2024).

EQUITY, ACCESS AND INTEGRATION: INSIGHTS FROM THE KAHU TAURIMA TECHNICAL ADVISORY GROUP

Kahu Taurima is a policy initiative aimed at creating a cohesive maternity and early years system that is culturally grounded and equitable. A technical advisory group (TAG) has been established, with the specific aim of developing high level guidance on a Maternity Commissioning Framework that will eventually lead to new ways of primary maternity services being developed and funded. Kahu Taurima has emphasised that midwifery continuity of care is central to achieving these aims.

The TAG advocates for an integrated approach that brings together maternity, hauora Māori, child health and social services to support seamless transitions across care providers. Midwives, as trusted community-based professionals, are viewed as critical connectors in this model. Ensuring continuity of care is not only a clinical imperative but a cultural one, aligning with

Te Tiriti o Waitangi and obligations to uphold equity for whānau Māori.

While the benefits of continuity are well-evidenced and internationally supported, the model in Aotearoa faces significant challenges. Depending on the setting or context, midwives can sometimes work long hours with limited backup, navigating on-call demands that affect their own wellbeing. In some areas, particularly rural or high-deprivation communities, there are currently not enough midwives to provide full continuity of care or to enable whānau to choose the midwife that will best meet their needs. In some areas, fragmented approaches to care have become increasingly normalised.

Access to continuity is also inequitable, with population groups who experience the greatest disparities in maternity outcomes having the least access to this model of care, often due to the timing of booking, when LMC caseloads are already full. Policy changes must consider how this inverse care law can be reversed.

The funding model for LMC midwives has long been criticised as inadequate, and urgent attention must be paid to ensuring future funding models are fair and equitable and promote workforce retention. The College has consistently advocated for ongoing improvement to the Section 94 Primary Maternity Services Notice and improved structural supports for the LMC workforce. However, sustained investment and innovative solutions co-designed with midwives and communities are needed to ensure future commissioning of primary maternity services meets the needs of whānau and is sustainable for midwives.

FUTURE COMMISSIONING:

PROTECTING CONTINUITY THROUGH RESOURCING AND STRUCTURAL REFORM

As Aotearoa's health system shifts toward regional commissioning and integrated service delivery, there is a critical opportunity—and responsibility—to embed midwifery continuity of care as a protected and well-resourced pillar of the future system. Commissioning models that prioritise outcomes, equity and cultural safety must centre the universal right to access midwifery continuity within a wider integrated system, recognising its unique capacity to deliver whānau-centred care across the maternity continuum.

Future commissioning arrangements must ensure that continuity is not eroded by fragmentation or administrative complexity. To prevent this, funding structures must reflect the true scope and depth of midwifery work. This includes appropriately resourcing time for relational care, travel, clinical decisionmaking, cultural engagement, interdisciplinary collaboration, and integration.

A reformed commissioning framework should also invest in wraparound supports that enable midwives to sustain continuity care without personal sacrifice. These may include access to locum cover, peer mentoring, clinical supervision, digital tools and regional networks of support. Flexible funding mechanisms—such as bundled payments, capitated models or team-based funding pools—could be explored to better align with the holistic nature of continuity care.

Structural support also includes ensuring that midwives are active partners in decision-

making, system design and evaluation. Commissioning bodies need to work collaboratively with midwifery leaders, midwifery educators, iwi and hapū and consumer representatives to co-design solutions that are culturally responsive and community driven.

Importantly, future models must redress inequities in access to midwifery continuity of care, particularly for rural, remote and Māori communities. Commissioning needs to prioritise the development of kaupapa Māori-led services, grow the Māori midwifery workforce, and support midwifery models that align with tikanga and mana motuhake for Māori.

Ultimately, commissioning must move beyond short-term fixes and embody a long-term vision that recognises midwifery continuity as an essential health equity intervention. Protecting and enhancing this model is an investment not only in the wellbeing of women and babies, but also in the resilience and cohesion of whānau and communities throughout Aotearoa.

LOOKING FORWARD: STRENGTHENING CONTINUITY FOR FUTURE GENERATIONS

The evidence is clear: midwifery continuity of care leads to better outcomes, stronger relationships and a more equitable maternity system. Dixon et al's research (2023) offers a compelling reminder that what matters most to women is feeling known, respected and supported. WHO affirms that continuity models are not only effective but essential. The Kahu Taurima TAG provides an opportunity for a culturally grounded roadmap for embedding continuity of midwifery care within a broader whānaucentred vision.

To preserve and grow the model of care in Aotearoa, stakeholders must act decisively. This includes investing in the midwifery workforce, supporting kaupapa Māori initiatives, addressing rural inequities and reducing the burden on individual practitioners.

Continuity of care is more than a model—it is a philosophy that honours the whakapapa of birth, the mana of wāhine and the transformative potential of relational care. In honouring and strengthening this approach, Aotearoa reaffirms its commitment to the health and wellbeing of all whānau, now and in the generations to come. Square

References available on request.

WOMEN’S RIGHTS, BIRTH AND MIDWIFERY IN AFGHANISTAN UNDER TALIBAN RULE

CLAIRE MACDONALD MIDWIFERY ADVISOR

“Sisters, today is not the day to be silent.” Women did not slip into silence quietly when the Taliban forcibly re-took power after the withdrawal of Western troops from Afghanistan in 2021. This quote is from a text message sent while women were organising to protest (George, 2022). Knowing the return of this oppressive regimen would signal the end of many hard-won women’s rights of the last century, urban Afghan women mobilised to protest and demand their rights to education, employment and voice.

Almost four years later, the Taliban has violently suppressed these protests and passed more than 50 decrees which have systematically targeted women’s basic rights and segregated the country by gender, erasing women’s presence and even their voices from public life. Women are no longer allowed to work in most occupations, must be veiled on leaving the house and their voices must not be heard in public. Singing, in particular, is banned. Resistance has become extremely dangerous for women, and many have fled overseas to continue their campaign publicly. The UN Security Council has recognised that, under the current Taliban regime, Afghanistan is the most repressive country in the world for women and girls.

Dr Fahima Saeid practised obstetrics and gynaecology as the only doctor in a town of 60,000 in a rural area, before she was forced to leave Afghanistan when the Taliban first took power more than 20 years ago. Fahima is CEO of the New Settlers Family and Community Trust (NFACT) in Auckland, an organisation she co-founded after arriving in Aotearoa as a refugee. NFACT supports former refugees, especially women and girls, to overcome war-related trauma and develop self-reliance.

Fahima remains deeply connected to Afghanistan, with colleagues and family still there, and speaks of “we” and “us” when discussing the realities of life there. “This is one of the darkest times for Afghan women and girls—so many of us are following the news in shock and disbelief as the situation continues to unfold.”

The “draconian restrictions on the rights of women and girls” (UNAMA, 2023) take many forms. Education is banned for girls over 12, meaning they are unable to attend secondary school or university. The only exemptions were for midwifery and nursing education—a lifeline for both pregnant women and the midwives themselves. However, in December 2024, the Taliban ordered the closure of all midwifery and nursing institutes. Writing in The Lancet in April, the former Afghan Minister of Health has called the ban a “public health emergency” which requires urgent action. The International Confederation of Midwives’ (ICM, 2024) Statement Condemning the Ban on Afghan Women Accessing Midwifery Education demonstrates the value of midwifery and what is at stake:

According to a 2023 report by the Afghan Midwives’ Association and UNFPA, the number of midwives in Afghanistan has grown from 467 (2002) to 6376 (2020). This was accompanied by a dramatic drop in maternal mortality, from 1600 per 100,000 (2002) to 638 per 100,000 (2019). Improvements were also seen in neonatal survival over the same period. This work was possible thanks to individual efforts, but also because midwives have established a strong national professional association, and a national regulator.

Banning women from studying midwifery threatens to undo all the progress made. It will make the already critical shortage of midwives even worse. Ultimately, it will mean more women giving birth alone, and more women and newborns dying of preventative causes, or facing lifetime health challenges because there are no midwives available to care for themICM (2024).

Even though the maternal mortality rate has decreased by 2.5 times since 2002, it is still one of the highest in the world and much more work needs to be done to further improve safety for women and babies. Despite this, UN Women (2024) estimates that by 2026 the impact of the Taliban’s decrees will instead see maternal mortality increase by at least 50%.

There are multiple intersecting, contributing factors to high rates of maternal and infant mortality in Afghanistan. Fahima’s

stories of life and obstetric practice articulate many of the same factors identified in UN reports and the academic literature. In rural regions especially, where it is common for girls to be married when they finish school, the prohibition of secondary school and university education for girls means earlier marriage and childbearing at younger ages, which increases risks of obstructed labour, obstetric fistula and death. When leaving the house women must be with a male, including for acute pregnancy and labour concerns, and some women have died because no male was available to accompany them to the hospital for emergency care.

Beliefs about the lower value of women and girls contribute to a lack of resource allocation to women’s health services and a lack of accountability in the health system for adverse maternal outcomes. Taliban local commanders monitor health staff behaviour, which has a chilling effect on asking questions or raising concerns—Fahima recalls, “you need to be extremely careful for your own life and for health and safety in your staff members”. Without enough midwives, a large proportion of women receive no antenatal or postnatal care and more than 40% of women birth at home without a trained birth assistant.

Environmental issues centre around the intergenerational poverty and lack of roading, transport and hospital infrastructure

as a result of 50 years of war and conflict, together with drought and, recently, major earthquakes (which killed mostly women and children who were at home in fragile dwellings). This means that, as well as endemic maternal malnutrition, transport to (and between) hospitals can take many hours on rough roads in either a rickshaw or a fourwheel drive vehicle. Many women have died during these long drives to receive midwifery or obstetric care.

To compound the lack of new midwives being educated under the latest decree, Fahima also points to a “brain drain” which is occurring as many educated women leave Afghanistan with their families to give their daughters a chance at education in another country.

International aid withdrawals have resulted in reductions to the already severely limited women’s and children’s health services which were reliant on this funding. Although the Taliban is the de facto authority, it is not recognised internationally as the legitimate government of Afghanistan, in part because of its abuses against women and girls. International aid was reduced when the Taliban re-took power, as funders did not want to support an un-elected and unrecognised government. Compounding this issue, the US president’s withdrawal of USAID funding this year has forced the closure

of 206 World Health Organization health facilities, including maternal and child health services.

Women’s resistance has taken different forms since the Taliban forcibly quelled public protests. Some veiled women have taken to singing songs of resistance and posting them to social media. Afghan women journalists continue to report at Zantimes.com and TheAfghanTimes.com, as well as on social media and other platforms, to get their stories to the world. Secret schools and online classrooms have been set up in some areas to continue girls’ education after the age of 12, at great risk to the teachers and the students.

Midwives recognise the urgent need to stretch themselves as far as possible, given there are currently no new midwives being educated. Midwife-led units, such as those funded by Search for Common Ground (2024) and the European Union, are a literal lifeline to women in rural areas where they have been established.

Afghan women speaking out want our attention. “In a country like Afghanistan, advocacy by women for women looks like playing with fire. One day, we will be killed or detained by them but still we are trying. Our request is that the international community stand with Afghan women” (UN Women, 2024a).

This includes supporting the UN case that the Taliban’s treatment of women and girls constitutes crimes against humanity; and pushing for women to be involved in any international negotiations with the de facto authorities (Taliban) so that women’s realities are heard.

The UN and Amnesty International have named the regime’s actions “gender apartheid”. Fahima, together with other Aotearoa Afghan and Iranian community leaders, is urging our government to recognise this reality.

The New Zealand College of Midwives, as a member organisation of ICM, supports the ICM’s work in humanitarian settings, including its

statement condemning the ban on midwifery education in Afghanistan.

Nadia Anjuman wrote a poem (see below) in protest against the first Taliban takeover in 1996, which two sisters have sung in protest against this regime; its words carrying the despair and hope of women who continue to resist oppression (Khamoosh, 2024). Square

How can I speak of honey when my mouth is filled with poison? Alas my mouth is smashed by a cruel fist… Oh for the day that I break the cage, Break free from this isolation and sing in joy.

- Nadia Anjuman

References available on request.

APPLY NOW TO BECOME A CALMBIRTH® EDUCATOR IN AOTEAROA NEW ZEALAND; calmbirth.nz

Changing Birth Culture One Birth At A Time

Dates for the training are on consecutive Thursday’s 18th September, 25th September, 2nd October, 9th October & concluding on the 16th Oct 2025

Photo by Angela Scott Photography

KAPA HAKA, MOTHERHOOD AND THE HEART OF THE WHĀNAU

TE PAEA BRADSHAW MIDWIFERY ADVISOR

For many, kapa haka is more than just performance—it’s a way of life, a deep connection to whakapapa, language and identity. But for one wahine toa, the journey through competitive and non-competitive kapa haka has been shaped not just by passion, but also by sacrifice, joy and motherhood, and being pregnant did not stop her.

Kara Huata, from Bridge Pā Ngāti Kahungunu is a busy mother of three, now aged 10, 8 and 1. She is no stranger to the prestigious Te Matatini stage, having performed with Tūhourangi Ngāti Wāhiao for a decade and this year standing with Te Kapa Haka o Kahungunu.

Kapa haka has long been a fire in her soul. “It sets my heart on fire,” she says. “It brings me happiness. Outside of being a māmā and a partner, kapa haka is something I do for myself. That might sound selfish, but it makes me happy.”

Kapa haka sets my heart on fire, it brings me happiness. Outside of being a māmā and a partner, kapa haka is something I do for myself. That might sound selfish, but it makes me happy.

TE MATATINI

Te Matatini, often called the “Olympics of Kapa Haka,” is Aotearoa’s premier Māori performing arts festival, held biennially to celebrate the richness of haka, waiata and cultural identity. Since its beginnings in 1972, it has become one of the most significant events in te ao Māori, drawing tens of thousands of attendees and millions of viewers. Whānau, performers and supporters dedicate months of preparation and sacrifice for the chance to reach the pinnacle of finals, Te Matangirua, and stand among the best in the country.

TWO WORLDS: COMPETITIVE VS. SOCIAL KAPA HAKA

There’s a stark difference, she says, between competitive kapa haka and the more relaxed, community-based performances. On the competitive side, the intensity is relentless. “You’re striving for that finals spot in Te Matangirua. It’s high pressure,” she explains. “I never took my kids to those practices—too stressful. You make sacrifices, like leaving them behind at home, and that’s hard.”

In contrast, non-competitive kapa haka like Pā Haka, and Haka Huia feels like a homecoming. “Those are my favourite. The kids can be with me, jump on stage if they want, roam around. It’s more whānau-based. At practices, I can be with them—it’s just easier and more joyful.”

This year was transformative—competitive kapa haka but within her Kahungunu rohe. “The last two years, I’ve come back to Kahungunu for kapa. I bring the two big ones to practice. It makes me so happy to see them unconsciously learning the waiata I’m learning.”

She recalls some moments with pride: “At Matatini this year, my son was recording us—just going hard with the kupu while filming. He knew all the words. The whakawhanaungatanga with the other tamariki—they love it. They don’t even want to go home after practice, even if we’ve been there from 9am-11pm!”

Kara acknowledges it wouldn’t be possible without the strong support network behind her. She’s especially grateful to the “villages” who step in to look after the tamariki during the intense haka season, allowing kaihaka

Rural Student Midwifery Grant

to fully commit to practices and performance. “A huge mihi to my partner, my mum, my sisters, and my mother-in-law,” she says. “They always make themselves available so I can be where I need to be. Without them, it wouldn’t happen.”

KAPA HAKA THROUGH PREGNANCY

Kara shares her uniquely powerful kapa haka journey: performing while pregnant. “I didn’t know I was hapū at first, but once I did, I kept going. With some rōpu, they don’t allow wahine hapū to stand, but Tūhourangi did, the tutors were really supportive."

The physically demanding nature of kapa haka offered unexpected benefits. “I wasn’t exercising because I had morning sickness— but kapa haka kept me active. I think people underestimate how physical it really is. And the baby, in the womb, was surrounded by waiata. He came out loving it.”

She performed in two campaigns while pregnant, including on stage at Te Matatini. “I was seven months when I stood with him. He was so active every weekend, and once Matatini ended, I could feel him even more. It was like he missed it.”

ADVICE FOR OTHER MĀMĀ

Her guidance for other hapū māmā considering kapa haka is clear: “Know your rōpu and their style; some are more supportive than others, and the physical style of some kapa would be more challenging for hapū māmā to perform. Stay active, continue with normal life and rest when you need to. If your kaiako supports you, it can be beautiful.”

And to the midwives supporting wāhine like her? “Just trust us. I had good midwives. I was confident in myself.”

Whether under the stage lights of Te Matatini or within the gentle embrace of her whānau, kapa haka remains a heartbeat—one that keeps rhythm with identity, motherhood and joy. Square

Mary Garlick, a retired long standing rural midwife has generously granted a sum of money to the College to administer as an annual grant for midwifery students who intend to practise rurally on graduation.

Applications will be accepted from students who are enrolled in the final year of a New Zealand Bachelor of Midwifery programme in 2025

Applications must be submitted via email to lynda.o@nzcom. org.nz by 23 July 2025, noting ‘Rural student grant application’ in the subject line. Further information and application forms are available on the College website www.midwife.org.nz

Midwifery students are eligible to apply for the annual grant if they meet the following criteria:

• Applicant must be a College member and enrolled as a final year student of an approved New Zealand Bachelor of Midwifery programme for 2025.

• Applicant must intend to practise as a rural midwife in New Zealand on graduation. Preference may be given to those intending to practise as an LMC.

To apply, applicants must:

• Demonstrate a commitment to rural midwifery practice on graduation

• Complete the application form and ask two referees to complete the relevant form. One referee must be a lecturer at the midwifery school in which the student is enrolled and the other, a midwife who the student has completed a clinical placement with.

Student Midwifery Grants 2025

The College is offering grants to assist students at each midwifery school who are currently undertaking a Bachelor of Midwifery programme. Grants are available for each school of midwifery. Please refer to the College website for further information: www.midwife.org.nz

Applications open on 23 June 2025

The Midwifery Student Rural Grants Advisory Committee awards the grant.

Kara Huata with her children.

NEONATAL HYPOGLYCAEMIA AND BREASTFEEDING

The consequences of mild hypoglycaemia (which is usually asymptomatic) are not as certain as the rare, but severe, cases of hypoglycaemia that can cause brain injury and be life threatening. Balancing practices and interventions to prevent harm from untreated or hidden hypoglycaemia, whilst also protecting breastfeeding and reducing unnecessary interventions and admissions to neonatal or special care baby units –which usually mean mother-baby separation – is the aim of the recently released Te Tohu Waihonga - Aotearoa New Zealand Clinical Practice Guideline for Neonatal Hypoglycaemia (2025). This evidence-based guideline represents the culmination of a robust consultative process involving a multidisciplinary team of healthcare professionals, researchers and consumers.

Neonatal hypoglycaemia occurs mainly in the first hours and days after birth, while the infant transitions from receiving glucose via the umbilical circulation to breastfeeding. Most babies adapt metabolically without developing clinically significant hypoglycaemia. Full term infants considered to be at risk of hypoglycaemia, and who require screening, include those who have low fat stores due to fetal growth restriction and those with mothers who have diabetes of any type or who are on maternal antidepressant medication, alpha or beta blocker medications, amphetamines or anti-psychotic medications. Preterm or unwell infants, infants with hypothermia, or those with delayed or poor feeding also require screening. The guideline (p. 8) also recommends screening infants with clinical signs that could be related to

hypoglycaemia – for example, jitteriness, seizures, poor feeding, lethargy, irritability, cyanosis, hypotonia, apnoea, tachypnoea, hypothermia, respiratory distress, asphyxia, abnormal cry, pallor and vomiting.

While the guideline recommends supporting mothers to effectively breastfeed their newborn infants and recognises breastfeeding/breast milk as ideal for postnatal neonatal metabolic adaptation, some birth experiences can make this hard to achieve. Given the importance of early breastfeeding, supporting reluctant infants to breastfeed is a key midwifery skill. Simple solutions are often the most effective and cause the least negative unintended consequences. Motherinfant skin-to-skin care and the first breastfeed are significant for all infants but particularly for those at risk of neonatal hypoglycaemia.

GUIDELINE RECOMMENDATIONS

“Conditional recommendations” are for when there is either a close balance between the benefits and down sides, there is uncertainty or variability in the value consumers place on the treatment outcomes, or the cost or burden of the proposed intervention may not be justified. The ten recommendations that impact on breastfeeding and lactation are all described as conditional recommendations; four of these are discussed below.

Recommendation 1. Expression of breastmilk may be considered after 36 weeks’ gestation in pregnant women whose baby is likely to be at risk of neonatal hypoglycaemia and who have no contraindications. [Conditional recommendation]

This ties in with Step 1b of the Ten Steps to Successful Breastfeeding which covers maternity facility policies, and Step 3 which is about antenatal education for pregnant women and their whānau. It also links to Step 6 which is about not providing breastfed newborns any food or fluids other than breastmilk, unless medically indicated. Colostrum harvested during pregnancy may be sufficient to avoid the use of commercial milk formula until lactation increases. The recommendation states that antenatal hand expression of colostrum may lead to a small reduction in neonatal hypoglycaemia, a moderate increase in fully breastfeeding at hospital discharge, a moderate decrease in the duration of the initial hospital stay, and it may encourage mothers to breastfeed.

In the guideline, expressing colostrum is not advised in “at risk” pregnancies, although oxytocin stimulation triggering premature labour appears to be a theoretical risk. Based on a pilot trial, Simonsen et al. (2025) found that antenatal breastmilk expression did not induce preterm labour when performed by healthy, nulliparous pregnant women, from week 34 of pregnancy. Sex and breastfeeding both release oxytocin but are generally considered safe while pregnant. A systematic review concluded there is not enough scientific data to say that breastfeeding during

CAROL BARTLE POLICY ANALYST

pregnancy is contraindicated (Stalimerou et al., 2023). The need for caution in women at risk of preterm birth should not preclude further individualised exploration of the risks and benefits of antenatal expression. The intensity, duration and frequency of hand expression also require consideration.

Moorehead et al. (2024), in an Australian study, investigated whether expressing from 36 weeks of pregnancy for low-risk women with diabetes increased exclusivity and maintenance of breastfeeding. They found that although antenatal expression was promising for increasing exclusivity of breastmilk feeding in hospital, there was no association with breastfeeding outcomes at 12-13 weeks.

While antenatal expressing may lead to a reduction in neonatal hypoglycaemia, the Moorehead et al. study indicates that support to deal with ongoing breastfeeding difficulties is necessary. Difficulty latching the baby at the breast, concerns about the amount of breastmilk and infant sucking problems were described by women. The New Zealand

midwifery continuity model of care may be better placed to provide this ongoing support than the Australian system.

Recommendation 5. Encourage skin-toskin contact between mother and baby as early as possible after birth. [Conditional recommendation]; Recommendation 6. Keep the baby dry and warm after birth. Prioritise skin-to-skin contact with the mother. [Conditional recommendation]; Recommendation 7. Feeding should be initiated in the first hour after birth. [Conditional recommendation]

These three recommendations have been clustered together for this article as these practices co-occur within the same immediate time frame after birth. They link to Step 4 of the Ten Steps to Successful Breastfeeding which is to facilitate immediate and uninterrupted mother-infant skin-toskin contact and support mothers to initiate breastfeeding as soon as possible after birth.

The guideline states that there is a low certainty of evidence showing “skin-to-skin contact may result in a large reduction in neonatal hypoglycaemia and duration of hospital stay, a small reduction in admission to NICU, less separation from the mother for treatment of hypoglycaemia before discharge home and a large increase in breastfeeding”.

It needs to be noted that the lactation and breastfeeding benefits only occur when the skin-to-skin is with the mother, so policies

need to clearly state mother-infant skinto-skin when this is a critically important descriptor – as in prevention of neonatal hypoglycaemia, thermal regulation support and for lactation and breastfeeding benefits. The “low certainty of evidence” could be due to an unrecognised dose response and a variety of reported mother-infant skinto-skin practices which could range from what could be considered “token” through to optimal. As midwives, if we concentrate “only” on mother-infant skin-to-skin contact after birth, we may be missing essential components of the support infants need during skin-to-skin, to progress through from birth to latching at the breast. Widström et al. (2011) conducted observational research on infants to analyse behavioural sequences that begin immediately after birth and end with latching at the breast, suckling and falling asleep. This provided significant evidence of how critical this time is, and demonstrated how easily the behavioural sequence could be derailed. The “uninterrupted” process is a key consideration.

As a short recap, the nine developmental stages are: birth cry, relaxation, awakening, activity, crawling, resting, familiarisation, suckling and sleeping. Rest periods are interspersed with active stages, and during the rest/relaxation periods the infant does not demonstrate rooting reflexes. These quiet and inactive pauses need to be protected; if the newborn is disturbed, this can delay

progress through the stages (Widström et al., 2019). Because labour medications can affect newborn feeding reflexes, medicated infants may demonstrate longer rest periods and take a longer time during the familiarisation stage (Brimdyr et al., 2015). This needs to be considered not only for the protection of breastfeeding but also when infants are at risk of neonatal hypoglycaemia. An effective first feed is critically important.

SUPPORTING THE FIRST FEED

Newborn infant feeding ability requires an uncompromised and patent airway, a degree of coordination, the ability to cue for feeds, and recovery from birth. Midwives need to recognise the infant who is well but reluctant to feed, as opposed to the infant who is demonstrating feeding issues that suggest illness. Hawdon et al. (2017) examined successful legal claims related to rare, serious cases of hypoglycaemia in infants over 36 weeks’ gestation and found that the most common risk factor was low, or borderline low, birth weight, and the most common reported presenting sign was abnormal feeding behaviour.

The actions that support infant birth recovery are key to breastfeeding initiation and therefore potentially avoiding hypoglycaemia risk for some infants. In settings where birth interventions are high, infants may need longer periods of uninterrupted skin-to-skin contact with their mothers to assist with birth recovery and the stimulation of instinctual preprogrammed feeding reflexes. Bergman (2024) suggests that instincts, which are highly conserved neuroendocrine behaviours, have not always been accepted as important by clinical practitioners, and that reflexes which can be elicited by appropriate stimuli are more accepted as they can be observed. What is required to support infant instinctual behaviour and reflexes is a quiet, unhurried environment and mother skin-toskin contact.

While the infant is in immediate skin-toskin contact with the mother, drying the infant’s head and body will help to maintain body temperature. A dry covering can be placed over the infant’s back while skinto-skin continues. Remedial interventions for well term infants are relatively simple. If an infant has been exposed to labour medications, experienced an induction or a long labour, or has been born after an instrumental or caesarean birth, the most effective support that can be given for

breastfeeding initiation is time and infant contact with the mother. All well term infants need to be given the time and opportunity to proceed at their own pace through the nine behavioural phases after birth, but infants who have had difficult beginnings may need longer to recover from birth and to demonstrate an interest in feeding. Potential contributing factors to infant feeding delay also include suction, resuscitation and any mother-infant separation. There are potential maternal risk factors for delayed lactation that need to be considered during breastfeeding care such as diabetes, mode of birth, high BMI, retained placenta and polycystic ovarian syndrome. Insulin-managed diabetes has also been associated with infant immature sucking patterns (Bromiker et al., 2006). Women with risk factors, and babies who have had a difficult start, need particular attention.

Oxytocin response is essential for a range of breastfeeding and bonding behaviours. The infant oxytocinergic system is triggered by the mother, and the infant simultaneously triggers the maternal oxytocinergic system (Bergman, 2024). The oxytocin milieu is essential for the milk ejection reflex (MER) and breastfeeding, but it is dampened down by stress, cold and mother-infant separation. Less than 4% of the available milk in the breast will be available if the MER is not triggered (Kent et al., 2003). Mother-baby skin-to-skin contact supports infant thermoregulation, which is protective as cold stress is associated with hypoglycaemia. Lorde et al. (2023) suggest that skin-to-skin contact promotes vasodilation of the mother’s cutaneous blood vessels, increasing maternal skin temperature. Oxytocin also controls maternal temperature in a pulsatile manner (Bergman, 2024) and is increased by touch, gentle pressure and warmth during skin-to-skin and during breastfeeding (Bigelow & Power, 2020). The sensory visual, auditory, olfactory and tactile pathways that are given and received by both mother and newborn activate the oxytocinergic system in response to skinto-skin contact (Moberg et al., 2020). Mother-baby skin-to-skin contact is not just for the first hour after birth. It can be extended wherever possible in the birthing room – particularly in situations where the infant is slower to initiate breastfeeding. It can also be continued or re-initiated in postnatal settings. It should be noted that all mothers and infants should be supported to experience optimal skin-to-skin contact, regardless of feeding method.

This article has discussed four recommendations from the Te Tohu Waihonga - Aotearoa New Zealand Clinical Practice Guideline for Neonatal Hypoglycaemia and expanded the discussion into midwifery care that can potentially protect infants from hypoglycaemia and protect breastfeeding. The effects of immediate and continuous mother-infant skin-to-skin are part of what Bergman (2024, p. 15) describes as an “oxytocin paradigm” and optimising oxytocin release is a key aim in labour, birth and breastfeeding. The environment in which skin-to-skin contact and breastfeeding are initiated is significant – a birth environment where expediency has become a normal part of the culture does not support an unhurried, uninterrupted start to breastfeeding initiation. Creativity and resourcefulness on the part of midwives can provide a safety net to protect physiology and the wellbeing of mothers and babies.

To view the complete guideline visit: www.auckland.ac.nz/assets/liggins/docs/neonatal-hypoglycaemiaguidelines/te-tohu-waihonga.pdf Square

References available on request.

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TAKU WĀHI MAHI MY MIDWIFERY PLACE

ZAHRA SHAHTAHMASEBI JOURNALIST

As of mid-January, maternity care at Whakatāne Hospital transitioned from a secondary service, offering obstetrics and gynaecology, to a midwife-led primary birthing unit.

The change came following the resignation of the hospital’s obstetricians late last year. Health NZ Bay of Plenty | Te Whatu Ora Te Hauora a Toi plans to reinstate services following the recruitment of permanent staff. In the meantime the closest acute obstetric services are 90 kilometres away. Three midwives share stories about providing care to whānau across the Eastern Bays within the new service arrangement.

ALWAYS HERE, NO MATTER WHAT: BAY OF PLENTY MIDWIVES REMAIN DEDICATED TO THEIR COMMUNITY

“The last few months have been challenging”, says Whakatāne Hospital midwife manager Imogen Davis, “but while the secondary obstetric service has gone, the special care baby unit remains and every other aspect of maternity care remains led by a strong team of midwives”.

Imogen is confident in her team and knows they can thrive as a primary unit, providing quality care, “And when we get the obstetricians back, we will be able to embrace them into the whānau and continue on.”

Until then, local midwifery teams have been focused on increasing and improving their services to offer the best care they can for the community, says Imogen.

At the hospital’s Ko Matariki maternity unit, these services include vaccinations, inserting long-acting reversible contraceptives, supplying pregnancy tests and discussing pregnancy options, and providing care and supporting clients with early medical abortions.

Losing obstetrics has removed many opportunities for women to have their babies locally, says Imogen. Women requiring scheduled or acute secondary care must now travel to Tauranga, a 1.5-2 hour drive from Whakatāne, but Imogen says the team is working hard to provide a midwife-led service and provide quality care for those who choose to stay.

“Midwives have the skills required within their scope and their education, we just need to adjust and familiarise ourselves with care parameters when we don’t have obstetricians available to attend onsite. As midwives, recognising if there’s any way we can touch women’s lives and promote women’s health in our space, then that’s what we do.”

Following a move to Whakatāne 18 years ago, Imogen has been based at the hospital for 12 years and has been the midwife manager for the last eight. Upholding Ko Matariki as a safe space for women has been one of her highlights in

Below: Imogen and her team, Ko Matariki Whakatane staying strong through change.

that time. “It starts in the reception, where two pictures of trees list the team members with a one-sentence definition of their role – showing how they all work together as Ko Matariki whānau, there is no hierarchy,” she says.

Twenty one full- and part-time midwives are employed to cover the hospital and primary community service. Due to a shortage of LMC midwives, the primary team provides care to 450 of the 600 women birthing in Whakatāne, who come from Whakatāne district, Ōpōtiki and the East Cape.

For those who need to birth in Tauranga, travel, food and accommodation support is provided by Health NZ Bay of Plenty | Te Whatu Ora Te Hauora a Toi. For those who wish to have a postnatal stay in Whakatāne, the Ko Matariki team loves to welcome māmā, pēpē and whānau back. “Many of the team were born or raised in Whakatāne and whakapapa to the whānau we care for,” says Imogen.

Regarding the change in service provision, Whakatāne LMC midwife Brogen McBeth points out that, “The community hasn’t had to understand the difference between primary and secondary maternity care before – both have always been available.

“For women, it’s about trusting their ability and our skills. Even with an obstetrics and gynaecology service, midwives are always first in line. Any kind of change is tricky, but we are adapting and the increased collaboration that has come as a result of the service transition has been positive.”

While Whakatāne LMCs have always worked closely with their colleagues at the hospital, they’re now seeing these relationships extend to the maternity team based in Tauranga. Everyone is part of a multi-disciplinary team, with many opportunities to check in with each other and to ensure that both the woman and clinical team are kept up to date.

While Whakatāne and Bay of Plenty midwives continue to advocate for their women to have equitable access to care, Brogen says that women have been giving birth rurally for a long time with midwives by their side – and that’s not about to change.

“We are here fighting for them, but also have the ability to help them in the community. We’re trained to be adaptable. So when the storm comes, we take a deep breath and continue to ensure the voices of women are heard.”

Lisa Kelly is an LMC midwife living in Tōrere and is one of three midwives working along the East Coast. Her caseload extends from Ōpōtiki to Cape Runaway - over 100 kilometres of coastline. “With the trip to Tauranga Hospital up to a twohour drive for those living outside Whakatāne, many women feel at a loss of what to do,” she says.

The eastern Bay of Plenty has primary birthing centres in Ōpōtiki and now Whakatāne, but first-time mums in particular gravitate towards birthing in hospital, which no longer feels like a straightforward choice, explains Lisa.

“We are having to really educate and have good lengthy conversations with our clients and our whānau about where they’re having their baby and the challenges and risks involved with choosing to go or to stay at home.

“There are so many things to weigh up. When a mum’s making those decisions, she’s not just making them for

herself and her pēpē, she’s thinking about her whole whānau, her other kids,” says Lisa.

As a homebirth midwife, those lengthy discussions are mostly about the potential of needing to transfer from their homes to Tauranga Hospital, she says.

“If there is a transfer, there’s lots of admin time spent on the phone, making sure they’ve got their travel vouchers, making sure the accommodation is booked, do they need anything from Māori health, mental health?

“When our clients are going to Tauranga, we’re not going with them all the time – they’re travelling on their own, or with their whānau in the ambulance... if we are able to go, we have to have back up here in the community.”

Despite the challenges, Lisa has been using the situation to raise awareness of how safe homebirth is for those with a low risk pregnancy.

She tears up sharing the story of a young woman who booked in for a homebirth for her first baby, after being present at two of her mum’s home births.

As the due date got closer, the woman started to get nervous but Lisa supported her through the uncertainty, constantly reminding her of the options, the benefits of homebirth and the Māori birthing practices she was going to incorporate.

When she went into early labour while out in Ōpōtiki, she made the decision to travel back home along the coast and birthed her baby at home with her whānau all around.

“It felt right for her whānau, it felt right for her and her partner to be there in that place, and birth on that sacred whenua in Te Kaha,” says Lisa. “It was so empowering.” Square

BRIDGING THE ULTRASOUND GAP

NEW ULTRASOUND TRAINING PROJECT FOR RURAL MIDWIVES

In April, ten midwives from across rural Aotearoa gathered in Dunedin for a pilot workshop in Point of Care Basic Early Pregnancy Ultrasound for Midwives. Hosted by the University of Otago’s Department of General Practice and Rural Health, this workshop has been specifically designed for midwives working in rural settings in Aotearoa.

The workshop is the product of a nine-month collaboration between the New Zealand College of Midwives, the University of Otago and the Rural Midwifery and Maternity Chapter of Hauora Taiwhenua I Rural Health Network. It is a proactive response to a pressing issue—the substantial barriers many rural whānau face in accessing early pregnancy ultrasound, a fundamental aspect of safe and responsive maternity care.

Timely access to ultrasound in early pregnancy can be used for assessing fetal viability, confirming gestation and planning appropriate care, including abortion care. Yet, access remains inconsistent. While rural hospitals and clinics are often equipped with portable ultrasound machines, a national shortage of trained sonographers has impacted rural communities where access to local ultrasound services were already limited. Long travel distances, waitlists and limited appointment availability can result in delayed or missed scans, making this a rural health equity issue.

In September 2023, the Midwifery Scope of Practice was expanded to include Basic Early Pregnancy Ultrasound. This was intended to improve care access; however, uptake of this expanded scope has been hindered by the lack of a New Zealand-based training pathway, and by the fact that

midwives are not currently able to claim for the service via the Primary Maternity Services Notice (2021). As such, the potential of this scope change remains unrealised.

The ultrasound training pilot seeks to address the training pathway, offering both theoretical and practical components of the Certificate of Allied Health Performed Ultrasound (CAHPU) in New Zealand via the Australasian School of Ultrasound Medicine (ASUM), which is the accreditation pathway approved by the Midwifery Council of New Zealand. Participants in the pilot hail from Te Tai Tokerau to Southland and will use their training to provide early pregnancy ultrasound in areas with known access issues. In a rural setting, where an urban-based appointment can involve hours of travel or logistical planning, this is a game-changer.

The potential benefits for rural communities have also been recognised by rural primary care organisations and Health NZ | Te Whatu Ora. Midwives’ course and attendance costs have been generously supported by Health Workforce New Zealand, Pinnacle Health, Palmerston North City Council, Waitaha Primary Health Trust and WellSouth Primary Health Network. If successful, it is hoped that the University of Otago workshop will evolve into a regular offering, helping to grow a workforce of ultrasound-capable midwives across Aotearoa.

Ultimately, the vision is clear: equitable, local, midwife-led care that meets the needs of rural whānau—ensuring that they are supported in the earliest and most vulnerable stages of pregnancy. Square

Above: University of Otago pilot workshop midwife participants and tutors.

Midwife Aotearoa New Zealand

MIDWIFERY CONTINUITY OF CARE

Welcome to Issue 117 of Midwife Aotearoa New Zealand

PUTTING PATIENTS FIRST?

A CONCERNING REINTERPRETATION OF THE ROLE OF REGULATION IN PROTECTING PUBLIC SAFETY

YOUR COLLEGE

College Consensus Statements

Nominations for president

Professional Indeminity and expanded practice within the midwifery scope of practice

Annual General Meeting

Posters available for download

PROFESSIONAL INDEMNITY INSURANCE

REMINDER OF POLICY CONDITIONS

BULLETIN

Explore the magic of birthing at home

Carosika education day

The Medicines Amendment Act: Section 29A Exemption for funded alternative medicine

TERINA JOSEPH MĀORI MIDWIFERY ADVISOR

NEW COLLEGE ELEARNING COURSES

TEST RESULT RESPONSIBILITY

PRINCIPLES

CONTEXT

UNDERSTANDING PRACTITIONER SUPPLY ORDERS

WORKING

TIPS FOR PRACTICE

REBRANDING WITH PURPOSE: A JOURNEY WITH OHO

ABOUT OHO

THE PROCESS OF WĀNANGA

UNDERSTANDING BRAND STRATEGY

CREATING A STRONG BRAND IDENTITY

KNOWING OURSELVES

WHAT’S NEXT?

‘PINEAPPLE PIE IN THE SKY’

HYPEREMESIS GRAVIDARUM

A SERIOUS PREGNANCY ISSUE

PUQE: PREGNANCY-UNIQUE QUANTIFICATION OF EMESIS AND NAUSEA

WHAT IS THE IMPACT OF HG?

EQUITY OF ACCESS AND TREATMENT APPROACHES

INFORMED DECISION MAKING

WHAT CAN MIDWIVES DO TO SUPPORT WOMEN DEALING WITH HG?

LIVED EXPERIENCE: NINA’S STORY

LIVED EXPERIENCE: RUBY'S STORY

DRUG THERAPY RECOMMENDATIONS

MIDWIFERY CONTINUITY OF CARE

STRENGTHENING RELATIONSHIPS, OUTCOMES AND EQUITY IN AOTEAROA NEW ZEALAND

GLOBAL EVIDENCE: WORLD HEALTH ORGANIZATION (WHO) ENDORSEMENT OF MIDWIFERY CONTINUITY MODELS

FUTURE COMMISSIONING:

PROTECTING CONTINUITY THROUGH RESOURCING AND STRUCTURAL REFORM

WOMEN’S RIGHTS, BIRTH AND MIDWIFERY IN AFGHANISTAN UNDER TALIBAN RULE

Changing Birth Culture One Birth At A Time

Changing Birth Culture One Birth At A Time

KAPA HAKA, MOTHERHOOD AND THE HEART OF THE WHĀNAU

TE MATATINI

TWO WORLDS: COMPETITIVE VS. SOCIAL KAPA HAKA

Rural Student Midwifery Grant

KAPA HAKA THROUGH PREGNANCY

ADVICE FOR OTHER MĀMĀ

Student Midwifery Grants 2025

NEONATAL HYPOGLYCAEMIA AND BREASTFEEDING

GUIDELINE RECOMMENDATIONS

SUPPORTING THE FIRST FEED

TAKU WĀHI MAHI MY MIDWIFERY PLACE

BRIDGING THE ULTRASOUND GAP

NEW ULTRASOUND TRAINING PROJECT FOR RURAL MIDWIVES

Directory