Welcome to Issue 118 of Midwife Aotearoa New Zealand
It is a real honour for me to take up the position of editor of Midwife Aotearoa –especially for my first edition to feature the College Conference and its theme of manaakitanga.
Writing the story about Conference gave me the opportunity to speak with the international midwifery research superstars and local Māori thought leaders who gave keynote presentations.
It was inspiring to see the breadth of research presented, practical clinical guidance offered, and robust discussion of key issues for the profession. I hope you enjoy the story – and the beautiful images of midwives who attended – as much as I enjoyed writing it.
This edition contains articles on emerging issues such as the recent Coroner’s Court ruling that resulted in the naming of an individual midwife, and decisions for College regions relating to the new Incorporated Societies Act. We also have a story about midwifery in Fiji, a moving story about birthing on a marae, and one on the reopening of the country’s only Māori owned, kaupapa Māori birthing unit on the East Cape.
As we head into spring and the warmer months, I hope this edition of Midwife Aotearoa offers a moment of reflection and inspiration.
Ngā mihi nui, Kim Square
KIM THOMAS EDITOR
FROM THE CO-PRESIDENTS
BEATRICE LEATHAM CO-PRESIDENT
To all those who attended our conference, thank you. You all contributed to its success and the amazingly inspiring mātauranga shared from Aotearoa and beyond.
Our theme manaakitanga stimulated some deeper reflection. Manaakitanga came through strongly in my recent research; expressed eloquently by kahu pōkai as they shared their lived experiences. Their purākau showed a proficient ability to navigate multiple, often opposing, worldviews. Their practice encapsulated a restorative approach to intergenerational experiences of assimilation, oppression and trauma and was underpinned by an interconnectedness to ancient realms of whakapapa, tikanga, and mātauranga. I have talked previously about mokopuna being the ones who guide kahu pōkai in practice, and my research findings reinforced this.
Beyond this idea, manaakitanga has been described in relation to the intricate balance between humanity and Papatuānuku along with the undeniable power wāhine hold in the continuation of humankind. When we consider our taiao and humanity, wāhine are the central point of connection, as this whakataukī implies “He wahine he whenua mate ai te tangata” frequently translated as “for women and land, men die”. However, Waerete Norman of Ngāti Kuri and Ngāti Rehia concluded her in-depth examination of this whakataukī by offering this understanding; “without women and without land mankind would die”.
Before his passing, I had the privilege of being in the presence of Ngāti Porou tohunga Amster Reedy, who said, from the moment a child is conceived, they are nurtured and those that envelop the mother do this with aroha for her developing whānau and the potentiality
of that pēpi in te ao Māori. This displays manaakitanga in its deepest sense. Midwives are an integral part of this potential.
Another great tohunga who has influenced my way of understanding te ao Māori, especially birthing mātauranga, is Papa Hōhepa De La Mere. He would define manaakitanga in this way; mana is in whakapapa, āki or aki aki is to encourage, and tanga refers to the nature of doing something. Therefore, when you encourage in the mode of manaaki you are encouraging of the mana that is bestowed by whakapapa. Given that humankind are but part of the whole, inter-dependent to all living things, intertwining manaaki into daily practice enhances our balanced viewpoint.
Many kahu pōkai acknowledge the privilege of birth resides in the ability to value each mokopuna born, as if they were our own. For me, this is fundamental to being a midwife and the affirmation of manaakitanga. Leonie Pihema wrote: “Manaakitanga is, in essence, the affirmation and enhancing of mana through the processes and practices that we undertake in the care and nurturing of others; the respect and generosity that we show others; and the reciprocity that is embedded within that practice”.
Ngākau nui, ngākau whakaiti Square
DEBBIE FISHER CO-PRESIDENT
Although you will be reading this in the flush of a new season, we experienced a drenched winter. Nelson-Tasman region faced severe storms and floods, showcasing an incredible spirit of unity and resilience. Our communities, including midwives and their families, have come together in remarkable ways to support each other through these challenging times, truly embodying the essence of manaakitanga.
Fittingly, manaakitanga was the theme for our spectacular conference in Kirikiriroa, Waikato. Thanks to the organisation committee, who worked tirelessly to bring us a gathering filled with fresh experiences, new opportunities, pioneering research, and engaging discussions on current midwifery issues.
The theme of manaakitanga is at the heart of our mission, highlighting mutual support, responsibility, and reciprocity. In midwifery, we see manaakitanga in action through our care for communities, nurturing of colleagues, and safeguarding the well-being of midwifery within our health system. Upholding manaakitanga ensures the collective wellbeing by protecting the indispensable role midwives play.
On a more pragmatic note, have you had the chance to discuss your region's formal status as an Incorporated Society or registered charity? While it may not be the most exhilarating topic, it is undeniably crucial. Ensuring your local professional College structure operates effectively for you and your colleagues is essential. If improvements are necessary, now is the perfect time to review and align with the upcoming Incorporated Societies Act requirements by early next year.
In closing, I want to extend a heartfelt shout-out to our national board members –your regional chairpersons, our Ngā Māia and Pasifika representatives, our kaumatua and elder, student representatives, and consumer organisation representatives. Their dedication to representing your views, addressing regional and representative issues, and bringing valuable diversity to our board is commendable. I encourage you to support your regional chairperson or representative as we explore the best options for national board governance and strengthen regional College committees. Together, we will navigate these challenges and look forward to brighter days ahead. Square
THE NEW INCORPORATED SOCIETIES ACT
KEY DECISIONS AHEAD FOR COLLEGE REGIONS
The Incorporated Societies Act 2022 (ISA) represents a significant legislative overhaul; modernising the legal framework under which many organisations in Aotearoa New Zealand operate. As a national organisation with a regional structure - where both the national body and half of its regions are Incorporated Societiesthese changes prompt important decisions for the College.
Under the ISA all existing Incorporated Societies must re-register by April 2026 to continue operating. The requirements for re-registration are more comprehensive than in the past and include updated constitution standards, clarity around officer duties, dispute resolution processes, annual reporting and other compliance obligations. While these changes are intended to improve governance and transparency, they also place a greater responsibility, administrative and compliance burden on smaller or volunteer-led entities.
At a national level the College will remain as an Incorporated Society with charitable status.
An updated national constitution which ensures that the College is compliant with the requirements of the ISA was ratified at the AGM in August in preparation of re-registration by April 2026.
DECISION TIME FOR THE COLLEGE REGIONS
With the new Act in place, each incorporated region of the College must make a fundamental decision:
• Re-register under the 2022 Act and continue as a legal entity by April 2026, taking on the new increased compliance responsibilities and accountabilities for office bearers; or
ALISON EDDY CHIEF EXECUTIVE
TABLE 1 – KEY DIFFERENCES: INCORPORATED VS UNINCORPORATED
Legal Status
Separate legal entity; can enter contracts, own property, employ staff or contract people
Governance Must have 3+ officers; formal constitution; AGM and reporting required
Compliance High: must reregister by April 2026, submit financial and service performance reports annually
Financial management Can maintain own bank accounts to directly administer membership capitations. Legal entity status protects individuals who are authorising payments on behalf
Funding Can apply for grants independently
Liability
Support
Limited liability for members
Not a legal entity; cannot own property or enter contracts in its own name
Local constitution or rules required; democratic processes still expected
Low: fewer reporting requirements, supported by national body
Not suitable to maintain separate regional bank accounts. No legal protection for individuals authorising payments from a regional bank account
Must apply through the national body
Members may be personally liable unless covered by national body insurance
Responsible for managing own legal/accounting affairs Receives legal/accounting support from national body
Asset ownership Can own and manage assets directly
The College’s current national and regional structure reflects its origins as a membership-based organisation founded in 1989, during a pivotal time for midwifery’s development in Aotearoa. Before digital communication, College regions played a crucial role in fostering in-person connections, building networks and partnering with consumer groups. These efforts were essential in growing membership and establishing midwifery as a distinct profession.
Assets held on behalf of the region by national body, for the benefit of the Region
• Relinquish their incorporated status, instead operating as an ‘Unincorporated Society’ or regional ‘branch’ of the national College, without separate legal standing.
COLLEGE REGIONS AND THEIR ENTITY STATUS - JULY 2025
The College’s current national and regional structure reflects its origins as a membershipbased organisation founded in 1989, during a pivotal time for midwifery’s development in Aotearoa. Before digital communication, College regions played a crucial role in fostering in-person connections, building networks and partnering with consumer groups. These efforts were essential in growing membership and establishing midwifery as a distinct profession. The structure supported democratic, regionally autonomous activities rooted in feminist values like relational connection, solidarity, and collective action.
The College’s national governance structure mirrors these principles, featuring a large, inclusive and representative board. However, by 2025, the College has evolved into a mature professional body with over 4,000
members. New ISA requirements present an opportunity to not only reassess the regional structure to ensure it meets members’ needs at a regional level but also to explore a revision of the College’s national governance model.
CONSIDERATIONS FOR REGIONAL DECISION-MAKING
Before determining the ideal regional structure for the College, it's essential to understand that College regions are critical in implementing the organisation’s objectives locally. They foster inclusive member engagement, collaborate with local Ngā Māia rōpū and consumer groups, organise educational events, represent midwifery interests, liaise with district level maternity services and education institutes, and support national initiatives through feedback and recommendations to the national board. Additionally, regions receive 15% of member fees as capitations to fund activities aligned with national and regional goals, including honoraria for regional office bearers, education, member and student support, conference
COLLEGE REGIONS AND THEIR ENTITY STATUS – JULY 2025
Incorporated Society
Incorporated Society with Charitable Status (includes national College)
Charitable statusUnincorporated
attendance, and support for community services (like local milk banks, for example).
Currently five of the College’s 10 regions are Incorporated Societies and five are not. By and large, the regions which are not currently incorporated have functioned in the same way as those which are incorporated. Although there is little observable distinction between the two options at a functional level, there are some key differences. (See Table 1)
Some regions are registered charities to gain tax benefits, but this status is only advantageous if they have significant savings or external funding, since membership fees are already tax-exempt for Incorporated Societies. Up to $1,000 income annually from other sources is also exempt from taxation. In reality, there is limited, if any, benefit to maintaining this status at a regional level, given charitable status entails annual financial reporting requirements.
Each region and some sub-regions (including those that are unincorporated) currently operate independent bank accounts, requiring them to maintain a treasurer position and keep financial records and submit reports. Although unincorporated regions have been managing bank accounts independently, it is not best practice
Te Tai Tokerau/Northland (no written constitution)
Auckland
Waikato/Taranaki
Nelson/Marlborough
Southland
Canterbury/West Coast
Otago
Bay of Plenty/Tairawhiti
The proposed new national governance model recommends regional chair people are no longer automatically members of the national board. It is essential a strong connection between the regional chairs and the national governance body (whatever form it takes in the future) is maintained.
as it leaves the individual members who are acting as signatories to these accounts personally liable. A safer option would be for the national office to set up separate bank accounts for each unincorporated region and establish systems to administer funds on those regions’ behalf. This would remove any personal liability on members but still ensure that regions had decision making rights over how their capitations were used. Individuals who are acting as bank signatories on behalf of incorporated regions have the protection that the entity status offers, so do not hold personal liability for their actions in representative roles.
As the ISA will impose more administrative responsibilities on regions who choose to be incorporated, a critical consideration is volunteer fatigue. Reduced ‘volunteerism’ at a societal level and midwifery workforce shortages have presented challenges for some College regions in maintaining consistent appointment in office-bearing roles. Internationally, midwifery associations have noticed similar challenges.
PROPOSED NATIONAL GOVERNANCE CHANGES AND THEIR RELATIONSHIP TO THE COLLEGE REGIONAL STRUCTURES
Presently, every regional chairperson is a member of the College’s national board. The College’s board commissioned an independent governance review last year that has recommended significant changes to the College’s current governance model, including reducing the number of board members from 26 to 9.
The proposed new national governance model recommends regional chair people are no longer automatically members of the national board. It is essential a strong connection between the regional chairs and the national governance body (whatever form it takes in the future) is maintained. Regular in-person and virtual forums for regional chair people to connect with each other and with the board (so that issues from a regional level can be connected nationally) would be established. It has been proposed that a regional chairs committee or forum is created, chaired by one or both Co-Presidents. Regional issues would be a regular standing item on the board’s agenda. The board will soon share recommendations on proposed national governance changes for members to consider, though necessary constitutional updates to implement these changes won't be completed in time for this year's AGM.
SUPPORTING AN INFORMED PROCESS
As I have been meeting with midwives at regional meetings to discuss the impact of these changes, three main themes have emerged.
Autonomy – How can a region retain its autonomy in how it operates if it chooses to relinquish its Incorporated Society status? In practical effect, by and large, regions who are unincorporated will be able to retain autonomy over their day-to-day functions apart from managing independent bank accounts. These regions can still determine how funds are spent, however it is advisable that the administration of the accounts is undertaken by the national office, so that individuals are protected from liability.
Sustainability - Regional office bearers are practising midwives in the main. Maintaining the functions of a regional committee such as managing communications, representation requirements, arranging and chairing meetings, events, liaison with midwifery leaders, supporting members, coupled with taking on the national governance responsibilities as a national board member requires time and energy. Workforce shortages have meant that time is a precious commodity for many midwives. The regional representative roles workload differs region by region, dependent on how well supported the roles are by local committees. Proposed changes to the national governance model would ease the governance workload of regional chair people, however a wider
discussion about the sustainability of and support needed for regional College roles needs to continue so that these roles are maintainable and desirable leadership positions for our profession.
Connection and representation – Within a reformed national governance model how can the College ensure that the voices of its members are heard, so they can continue to steer, inform and influence the direction and decisions of the organisation? Many midwives I have spoken with agree that our large and representative national governance structure is no longer the right one to govern our organisation in 2025, at the same time expressing concern about how the College can maintain its connection to its members views and voices, which is currently enabled through our highly representative board structure. Taking the time to get the right building blocks in place, working through the issues in a well informed and methodical way, listening and responding to members feedback as we move into a new model in the future will be essential.
The national organisation is committed to supporting each region through the decision-making process about the best regional structure. We developed a regional governance discussion document, which was available on the members portal. We have attended regional meetings and offered legal and governance advice to help regional leaders weigh their options carefully.
Whatever path is chosen, our shared goal remains the same: to maintain strong, vibrant regional connections that support our members and uphold the mana and values of our profession across the motu. Square
KEY CONSIDERATIONS FOR REGIONS IN DECIDING THEIR STRUCTURE
1. Governance capacity: Does the region have the volunteer base and expertise to meet the new governance and reporting requirements expected under the ISA?
2. Financial administration: Does the region wish to continue directly administering its own bank account?
3. Member support: What structure best enables the delivery of localised support to members?
KINGS BIRTHDAY HONOURS
When Ngatepaeru Marsters learnt she’d been awarded a New Zealand Order of Merit in the King’s Birthday Honours list, she almost turned it down.
Her first reaction to the award for significant contributions to midwifery and Pacific communities was: “Oh my gosh, you do the work because it needs doing not for the recognition. I’ve always thought of my work as service of the Pacific community.”
Despite her initial reluctance, after a chat with a close friend, Ngatepaeru decided to accept the honour in the hope it attracts more people to the profession, particularly Pacific People, Māori, and those from the many cultures that make up women birthing in Aotearoa New Zealand today.
Of Cook Island and Māori ancestry, Ngatepaeru began her career as an LMC before moving into midwifery education at the Auckland University of Technology (AUT). She is currently co-chair of Pasifika Midwives Aotearoa, on the board of the College, and involved in several initiatives to boost and develop the Pacific midwifery workforce.
She’s a staunch advocate for development of a midwifery workforce that reflects the communities it serves and culturally grounded care.
Ngatepaeru is proud there are now approximately 85 Pasifika midwifery students across Aotearoa. The largest cohort (65 students) is in the four-year midwifery programme at AUT’s South Campus, based in the heart of Pacific communities. It’s a far cry from a decade or so ago when the number of practising Pacific midwives numbered barely a dozen.
While supporting and mentoring midwifery students is an integral part of her everyday mahi, Ngatepaeru also believes in sharing the often-tough reality of the job.
“When you are working as a midwife, you have to bring your ‘A game’ every day, no half pie. Look after families to the best of your ability, without judgement, and give them the care everybody deserves, no matter what the challenges are in your life.”
This year marks half a century since Christine (Tina) Gilbertson entered the midwifery profession.
Hitting that milestone is right up there, she says, with the King’s Service Medal she was awarded for services to midwifery in the 2025 King’s Birthday Honours List.
A founding member of the College, Tina has worked in the Southern region as a midwife, health system leader and midwifery educator.
Despite the accolade, Tina is modest about her achievements – preferring to focus on what it could mean for other midwives.
“The value of midwifery is immense. Recognition of the service and commitment of midwives to women, their whānau and communities is essential. I am honoured if my personal contribution shines a light on the mahi of all midwives.”
Receiving the award gave her cause to reflect on changes in midwifery over her time in the profession and the College’s important role.
“Working in partnership with women is an incredible privilege. Receiving the award made me immerse myself once again in the work of the College of Midwives and revisit all the principles and pillars of the profession that have been developed by incredible leaders within our profession. This reflection greatly gladdened my heart, as did all the many messages I received from colleagues, friends and whānau.”
Top: Ngatepaeru Marsters awarded the New Zealand Order of Merit. Bottom: Tina Gilbertson awarded the King’s Service Medal
OBSERVATIONS IN THE IMMEDIATE POSTNATAL PERIOD
ALISON EDDY CHIEF EXECUTIVE
A recent Coroner's finding about the tragic death of a baby in the immediate postnatal period in 2015 has caused some discussion and concern amongst the profession. The purpose of this article is to clarify existing published guidance for midwifery care in the immediate postnatal period and how these relate to the Coroner's recommendations in this case.
A collaboratively developed consensus statement Observation of mother and baby in the immediate postnatal period: consensus statements guiding practice - was published by the Ministry of Health in 2012. Participating organisations included the New Zealand College of Midwives, RANZCOG (New Zealand Committee) with the support of the Ministry of Health and endorsed by the National Maternity Guidelines Working Group. This document is available on the Health New Zealand | Te Whatu Ora and College of Midwives websites. The document was developed
CLAPHAM MIDWIFERY ADVISOR
as a consensus statement as it is based on ‘agreed expert opinion’ rather than strong clinical evidence. The purpose of a consensus statement is to provide practical guidance and unify practice in areas where formal guidelines may not yet exist. Although it carries professional endorsement it is flexible and context specific.
Regardless of whether a document is a consensus statement or a guideline, if it is formally endorsed by a professional group, it should effectively be the standard of practice which a reasonable practitioner should meet. The 2012 consensus statement notes that “continuous, active observation of both mother and baby” should occur “for at least one hour post-birth”. It also notes that “Observation may be delegated to family/ whānau if clinically appropriate, with clear instructions on what to monitor and when to seek help”. The consensus statement also notes that facilities have a responsibility to “ensure adequate staffing to support midwives and allow extended observation when needed”.
observations and knowledge to inform decision making about care needs, including when and for how long it may be necessary or appropriate to leave a birthing or postnatal room so that essential care can be provided. Midwives work in partnership with women and whānau to build mutual trust, understanding, and to support informed decision making.
Factors which will impact midwifery decision making in the immediate postnatal period include the clinical condition of the mother and baby/s, pregnancy, labour, and birth events, the presence of whānau members (and their ability to take responsibility for observing the mother and baby). These factors will also inform the midwife’s decision on whether it is appropriate to leave the room. The consensus statement notes that whānau can be handed responsibility to observe a mother and baby in the postnatal period if a midwife deems it appropriate and the whānau are aware of what they need to be observing.
Factors which will impact midwifery decision making in the immediate postnatal period include the clinical condition of the mother and baby/s, pregnancy, labour, and birth events, the presence of whānau members (and their ability to take responsibility for observing the mother and baby).
Midwives sometimes need to leave a labour, birth, or postnatal room to facilitate necessary care. This could be for a range of reasons, for example to access resources such as medications, linen, food, equipment or to speak to other health practitioners or staff.
Sometimes it's necessary to leave the room to give the whānau some privacy – midwives will only do this when they are reassured there are no clinical concerns.
Ongoing assessment of both the mother and the baby/s is an expected component of midwifery care during the immediate postnatal period. However, ongoing assessment doesn’t mean midwives are required to be physically continuously present. It means using assessments,
Unfortunately, the recent Coroner's findings in this case have made recommendations that are somewhat unclear and confusing. They appear to seek to extend the ‘immediate postpartum period’ to an undefined period of time and seem to place confusing and unmeetable expectations on midwives. The College is communicating these concerns to the Coronial Service.
We are also clear that the current 2012 consensus statement sets the agreed standard for midwifery practice, that care during the immediate postnatal period is dynamic, and that midwives use their professional judgement to determine when and how care is provided to enable clinically and culturally safe care for all. Square
VIOLET
SUMMARY OF KEY ADVICE/ RECOMMENDATIONS CONTAINED WITHIN THE OBSERVATION OF MOTHER AND BABY IN THE IMMEDIATE POSTNATAL PERIOD: CONSENSUS STATEMENTS
GUIDING PRACTICE 2012
PRACTITIONER RESPONSIBILITIES
Continuous, active observation of both mother and baby for at least one hour post-birth
Support physiological transitions (e.g., skin-to-skin contact, first breastfeed)
Monitor baby’s colour, tone, and breathing – especially during skin-to-skin
Be prepared for emergency interventions and know when to escalate concerns
Ensure all staff involved are trained and competent in recognising abnormal signs
FAMILY/WHĀNAU INVOLVEMENT
Educate on safe sleeping practices (face-up, clear airway, smoke-free)
Observation may be delegated to family/whānau if clinically appropriate, with clear instructions on what to monitor and when to seek help
FACILITY/EMPLOYER RESPONSIBILITIES
Ensure adequate staffing to support midwives and allow extended observation when needed
RATIONALE
Sudden Unexpected Early Neonatal Deaths (SUEND) are a recognised risk
Risk factors include unsupervised skin-to-skin contact and maternal fatigue or medication effects
All mothers and babies are considered at risk during this period, regardless of other factors
Mother; Monitor wellbeing, uterine tone, blood loss, vital signs, pain, consciousness, and bonding; Support early breastfeeding and skin-to-skin contact safely; Special considerations for mothers with epidural/ spinal anaesthesia
Update on Class Action
The College acknowledges that many members who are participants in the College’s Class Action case and many within the wider membership are awaiting the judgment following the case’s trial which was heard in the High Court in Wellington last August and September over a 6-week period. As there is no prescribed time within which the High Court is required to deliver a judgment, we are unable to provide certainty to participating midwives and members as to when the findings will become known. It is usual practice for High Court judgments to be released to the parties and the public at about the same time. This means that the College is likely to be informed about the outcome of the case when the findings are published.
As the case was complex, it is likely that the Judge's findings, when they are released will be lengthy and detailed. The College can reassure members that they will be informed as soon as the College has any information about the findings and that we will be working quickly to ensure that members have the opportunity to understand what they mean for midwives.
The College’s Legal Advisor Carla Humphrey who provided in-house counsel legal advice throughout the case, attended the College’s conference in Kirikiriroa | Hamilton to participate in an informal Q&A session which provided participants with the opportunity to raise any questions about the Class Action. Square
College AGM Update
Current Co-Presidents Beatrice Leatham and Debbie Fisher were re-ratified for a second two-year term.
UPDATED CONSENSUS STATEMENTS
Updated consensus statements on climate change, umbilical cord blood banking and infant feeding in emergencies and disasters were ratified.
MEMBERSHIP CATEGORIES AND FEE CHANGES RATIFIED
• Clearer, more objective means of determining correct membership category for members primarily employed but simultaneously undertaking self-employed work
• Annual earnings threshold for low earner fee discount increased from $25,000 to $30,000 gross per annum. All graduate midwives in their first year of practice remain entitled to low earner discount regardless of income
• Student membership definition updated to include students studying towards a Master of Midwifery Practice
• Journal-only membership category removed as the College no longer publishes a hard copy journal.
UPDATED CONSTITUTION RATIFIED
The accepted changes brought the Constitution into alignment with the Incorporated Societies Act 2022 (ISA) and its new legal requirements for Incorporated Societies. This ensures the College remains compliant with legislation and continues to operate with transparency, accountability, and integrity. While the core philosophy, objectives and governance arrangements of the College remain unchanged, the updated Constitution includes improvements such as:
• Clearer definitions and governance structures
• Enhanced processes for membership, elections, and meetings
• Strengthened provisions for financial management and dispute resolution
• Formal recognition of regional relationships through contractual arrangements. Square
LEGAL ASPECTS OF NAME PUBLICATION
CARLA HUMPHREY LEGAL ADVISOR
This article discusses, in a general way, the principles that apply regarding publication of a midwife’s name in both Health and Disability Commissioner (HDC) and Coronial cases. The approach taken by each body differs. In my experience, midwives take their role to be accountable to society in these forums very seriously and, in a responsible manner, spend considerable unremunerated time in this challenging framework, to ensure these bodies are provided with high quality information upon which to base a reasonable decision. The publication of the midwife’s
name in such circumstances, particularly if it is considered the decision was wrong in some way and unfair to the midwife, can, to her and others, sometimes feel like a naming and shaming exercise.
Below, I set out the two very different legal approaches to name publication.
HDC
The HDC assesses whether a health provider has provided care in accordance with the Code of Health and Disability Services’ Consumers’ Rights. The question is usually whether the care was ‘adequate’ or ‘reasonable in the circumstances’.
competing interests of the public interest in having transparency against the privacy of individual practitioners.
In summary, the HDC will name Health NZ | Te Whatu Ora hospitals and regions and also group providers such as medical centres and pharmacies but not if that would unfairly compromise the privacy interests of an individual working within any of those settings.
The HDC assesses whether a health provider has provided care in accordance with the Code of Health and Disability Services’ Consumers’ Rights. The question is usually whether the care was ‘adequate’ or ‘reasonable in the circumstances’.
The HDC may escalate a case to civil liability (monetary damages) or disciplinary steps. The HDC role does not extend further to determine if the care or lack of care caused any injury or death. If a health provider is found to have breached the Code, the HDC will decide whether to publish the provider’s name according to its current naming policy (August 2023).
The HDC has no legal power to make name suppression orders however it has a very wide discretionary power to set policy concerning it operations and reports to the public. This flexible power has enabled the HDC to balance, in a manner it considers fair, the
The HDC policy is not to name individual health practitioners, as its view is that it is these individuals who “have the strongest privacy interests in protecting their professional reputation and livelihood”. There are some circumstances under the naming policy that would justify the public interest in transparency overriding the privacy interest; although each decision is still case dependent. These circumstances very rarely exist, however, therefore the vast majority of individual health practitioners will not be named by the HDC. The naming policy includes the following reasons to publish a name:
• Where there has been a ‘willful disregard’ for consumer rights (for example reckless, intentional lack of care)
• Where there continue to be public safety concerns (for example the practitioner is
refusing to undergo further training or fails to engage or comply with their regulatory body, such as the Midwifery Council competence programme or conditions on practice)
• Where there have been three breaches of the Code during a 5-year period.
Because the HDC decision not to publish a name is not the same as a name suppression order, the health practitioner’s name can still find its way to a public forum, for instance if the consumer complainant decides to release the name to the media or on social media. In such circumstances however, the health practitioner is still entitled to certain rights such as not to have false information published, nor to be harassed or targeted in a way intended to cause them emotional harm.
CORONER
The Coroner’s role differs from that of the HDC, in that the Coroner is required to determine the cause of death; referring to the physical immediate cause. The Coroner may also make recommendations about the surrounding circumstances such as systems or individual practices with the purpose of preventing deaths of that nature occurring in the future. This is often the area where the midwife’s care may come into question. The Coroner is not, however, unlike the HDC, entitled to determine civil liability or disciplinary consequences for any party such as a health practitioner. However, the Coroner, like a Judge in court, can, and is expected to make findings of fact – that is, what actually occurred factually in the Coroner’s view. The Coroner can assess witnesses on the stand and prefer the evidence of one over the other. It is difficult to appeal Coroner’s assessments of this nature.
In terms of publication, a Coroner will generally start on the premise that there is a right to freedom of speech under the NZ Bill of Rights Act 1990 and, as with all other courts in New Zealand, that the principle of open justice must be upheld unless there is an overriding reason to infringe those rights. The principle is, once the Coroner has determined what the facts are and determined cause of death and the circumstances around that death, then the public is entitled to know as a matter of transparency.
The College legal section wishes to confirm to members that each and every midwife involved in a Coronial case will be asked by their lawyer if they wish to apply for
an interim or final non-publication order; and that if they wish to do so, applications will be made to the Coroner. To obtain a non-publication order, the individual health practitioner must put forward evidence in affidavit form containing the grounds for their application. The case law that has developed in this area, and in particular the 2013 High Court decision of Gravatt v The Coroners Court at Auckland and Auckland District Health Board, means that it is often an uphill battle to obtain a non-publication order in the Coroner’s court. The Gravatt decision involved a health professional seeking non-publication. Some general legal principles were established and developed over time in subsequent cases. For example, bare or general assertions of the following will not be sufficient to justify non-publication:
• That the health practitioner will subjectively experience distress
• That the health practitioner considers publication will cause them reputational harm or interference to their relationship with patients and business
• That there is concern the media will misreport the case.
The above reasons are however, often sufficient to justify an ‘interim’ nonpublication order in the early stages of a Coronial inquiry. This is because the facts have not yet been determined by the Coroner
and there is more chance of unfairness and faulty conjecture on the basis of “where there’s smoke there’s fire”. However, after the Inquest is concluded and the Coroner is in a position to publish the actual facts (as they may be determined by the Coroner), there is theoretically less likelihood for misreporting or conjecture by the media.
To provide evidence of reputational harm and emotional harm will usually require more than a subjective belief. As examples, it may require medical evidence of actual and significant mental health harm to the midwife or a member of their family or actual evidence regarding reputational harm. As many Coroner’s cases are years after the events in question, it is sometimes more difficult to prove one’s community will hold any Coronial finding against the local midwife who has worked assiduously and well in that community in the intervening time and has a good reputation to their credit.
HDC and Coronial cases can naturally cause understandable distress and concern for the midwife involved. Unfortunately, under current law, there are significant limitations as to when permanent nonpublication in a Coroner’s court will be ordered. The position would only be likely to change by either Act of Parliament or, taking a case to higher court authority. Square
EXPANDED PRACTICE: EMBRACING THE EVOLVING SCOPE OF MIDWIFERY
VIOLET CLAPHAM MIDWIFERY ADVISOR
The revised midwifery scope of practice by Te Tatau o te Whare Kahu | Midwifery Council of New Zealand was gazetted in October 2024. Designed to reflect the dynamic realities of midwifery practice in our communities, the updated scope provides broader boundaries – enabling midwives to respond to changing health needs with cultural safety, professional confidence, and autonomy. But what does this mean in practice?
ELAINE GRAY MIDWIFERY ADVISOR
UPDATED MIDWIFERY SCOPE OF PRACTICE
The revised midwifery scope of practice affirms midwifery is not a static list of tasks but a responsive, evolving practice grounded in education, competence, and context. It reflects what many midwives already know – the needs of women, babies and whānau often extend beyond
traditional boundaries and require midwifery care that is innovative, informed, and holistic.
To support this, the Expanded Practice Policy (2024) (available at www. midwiferycouncil.health.nz) provides essential guidance for midwives exploring new or emerging areas of practice. This includes episodic care, provision of services to priority populations, and the integration of new skills to improve access and equity.
WHAT DOES THE COUNCIL EXPECT?
The College team have reviewed the Expanded Practice Policy and understands the Council’s position is that midwives are responsible and accountable for their own scope of practice, and any expansion must be underpinned by formal education, demonstrated competence, and an ongoing commitment to safety. In some instances, the Council have been specific about which education they expect midwives to undertake before they can participate in expanded practice, whereas in others, they suggest midwives should take responsibility to determine their own education and ongoing competency requirements. Expanded practice is not mandatory nor is it expected of all midwives.
Midwives are advised it is essential they check the Council’s education and ongoing competency expectations before they participate in expanded practice activities. Taking this step will ensure midwives expanded practice activities are included in their professional indemnity cover.
The Expanded Practice Policy explains that midwives working in expanded practice must:
• Complete education or clinical training specific to the new skill or role
• Check with the Council as to whether they have satisfied requirements for education in this area of expanded practice
• Document their competence in their midwifery portfolio
• Participate in outcome evaluation (e.g. clinical audits or case reviews)
• Be prepared for a Council Recertification Audit to assess ongoing safety and competence.
The Council states they will also begin asking questions about expanded practice in the annual practising certificate (APC) application, including whether the midwife has completed appropriate education and maintains current competence in any area of expanded practice.
LOOKING AHEAD
Expanded practice recognises the reality that midwives in Aotearoa often serve in diverse
WHAT COUNTS AS EXPANDED PRACTICE?
roles across varied settings – from rural clinics to urban hospitals, from whānau homes to kaupapa Māori services. It provides a pathway for growth, advocacy and career progression; while ensuring safety, cultural responsiveness and professional integrity remain at the heart of every decision.
The Midwifery Council encourages midwives to explore areas of expanded practice that align with their values, their communities, and their professional aspirations. With appropriate education, credentialling, and reflection, expanded practice empowers midwives to do what they do best – provide high quality care that meets the needs of our communities. Square
The College has received requests for advice from midwives interested in learning more about expanded practice and, in particular, which elements of care might be included in this. Some examples of expanded midwifery practice might include:
AREA OF PRACTICE DESCRIPTION
Midwifery-led ultrasound services
Early medical abortion (EMA)
Some midwives are now providing early pregnancy ultrasound scans. Following completion of a Midwifery Council-approved education programme, midwives can undertake early pregnancy point of care ultrasound scanning
Long-acting reversible contraception (LARC)
Increased access to EMA in primary settings has created opportunities for midwives to support women requesting early pregnancy abortion services. With appropriate education in pharmacological protocols, consent, and aftercare, midwives can provide early abortion care as a midwifery-led service
Midwives may choose to become educated in the insertion and removal of contraceptive implants or IUDs. This role complements postnatal care provision and supports women’s reproductive autonomy
Partner prescribing Partner prescribing for treatment of chlamydia is an example of expanded practice that enhances continuity of care and reduces health inequities (especially in communities where access to sexual health services may be limited).
Prescribing for partners is one of the more complex areas of expanded practice, for which there is not yet clear guidance for midwifery practice. To support optimal wellbeing of wāhine and pēpi, midwives should always follow the principles of safe prescribing
EDUCATION OPTIONS
Australasian Society of Ultrasound Medicine (ASUM) provide an accredited online theory course. Following this, midwives need to complete a Certificate of Allied Health Professional Basic Early Pregnancy Ultrasound course
Otago University provided a pilot programme for 10 midwives earlier this year and is planning another later this year
NZ College of Sexual and Reproductive Health Modules 1 and 2 of this e-Learning course: bpac.org.nz/ema/
Sexual Wellbeing Aotearoa sexualwellbeing.org.nz/about/clinical-training
No education is currently available for midwives. The College is working with the Midwifery Council to address this gap. Further information will be shared when available
The College has developed a new eLearning package for midwives (fully funded) about syphilis and other STIs in midwifery, available on the College website (www.midwife.org.nz/midwives/education/elearning)
AN UPDATE ON ULTRASOUND SCANNING
BRIGID BEEHAN MIDWIFERY ADVISOR
Ultrasound scanning is an important assessment tool in maternity care, however, significant inequities of access to services persist. Midwives play a vital role in ensuring ultrasound referrals are clinically indicated and represent appropriate use of this limited resource. This update reminds midwives of responsibilities under the Primary Maternity Services Notice and outlines opportunities to expand practice through early pregnancy ultrasound provision.
EQUITY OF ACCESS
Access to ultrasound services is inequitable. Health NZ | Te Whatu Ora funds radiology services at a set rate, which often does not cover full provider costs. In many regions, whānau are asked to pay a surcharge.
KEY PRACTICE POINTS FOR
MIDWIVES
Provide a clear and accurate clinical indication that aligns with funded maternity codes for ultrasound. Explain the purpose and timing of scans to whānau and avoid unnecessary referrals
Document all referrals, results, and followup discussions in the clinical record
Non-clinical or ‘souvenir’ scans are not publicly funded
A separate dating scan is not required for MSS1 screening when pregnancy dates are known. Opportunities are available for midwives to expand their practice and complete education to provide early pregnancy ultrasound services
Public hospital ultrasound services are frequently at capacity and unable to offer routine scans, while rural areas face additional barriers to access. These inequities disproportionately affect Māori, Pacific, migrant, and rural communities, delaying recommended screening and compromising timely care. Midwives can support equitable access by:
• Checking local ultrasound charges and provider availability before referring
• Advocating for funded scan options where possible
• Supporting informed decision-making around recommended screening, costs and timings
• Recognising ultrasound screening is a limited resource, and injudicious use may exacerbate reduced access for those with true clinical indications.
ULTRASOUND AND THE PRIMARY MATERNITY SERVICES NOTICE
The Primary Maternity Services Notice (2021) provides funding for clinically indicated scans (that match one of the approved ultrasound referral codes). While radiology providers are responsible for applying the correct code to access the
funding, they rely on accurate referral coding and information from midwives. Clear and specific clinical descriptions assist radiology providers to apply the correct funding code, ensure the scan is funded, is appropriately prioritised, duplicate or unnecessary scans are avoided, and whānau are not faced with unexpected costs.
Vague referrals, for example, ‘early dating’ without explanation, risk miscoding or full priced charging to whānau.
PRACTICE TIP: DATING SCANS AND CRL MEASUREMENT
1. Early dating scans requested without a funded clinical indication may result in additional costs to whānau. A full list of funded indication codes can be found in the New Zealand Obstetric Ultrasound Guidelines.
2. A separate dating scan is not required for first trimester combined screening (MSS1). If the woman’s last menstrual period (LMP) is known within 1–2 weeks’ accuracy and the pregnancy is uncomplicated, the NT scan at 12–13+6 weeks will provide the crown–rump length (CRL) needed for screening calculations.
ROUTINE PREGNANCY SCANS
There are two routine pregnancy ultrasound examinations recommended by Health NZ | Te Whatu Ora. With an uncomplicated pregnancy, these may be the only two scans offered.
NT 12–13+6 weeks Nuchal translucency assessment for MSS1 screening, assessment for gestational age, diagnosis of multiple pregnancy
AN 18–20 weeks Comprehensive assessment of fetal anatomy, confirmation of gestational dates and placental position
3. The screening laboratory uses the CRL from the NT scan to accurately calculate results. A dating scan may be considered if:
- the LMP date is unknown
- there is discordancy between LMP and uterine size
- there are clinical concerns related to the pregnancy.
In September 2023, Te Tatau o te Whare Kahu | Midwifery Council recognised basic early pregnancy ultrasound as part of the midwifery
scope of practice. This is considered an area of expanded practice. Registered midwives with a current practising certificate may perform basic early pregnancy scans (e.g., confirming intrauterine pregnancy or viability) if they have:
• completed an endorsed education programme (currently the ASUM CAHPU Basic Early Pregnancy Assessment), and are engaged in ongoing credentialling and supervision.
This education does not replace formal diagnostic scans by sonographers. Midwives must continue to refer for advanced imaging when needed.
In April 2025, 10 rural midwives attended a pilot workshop at the University of Otago. This programme, designed specifically for midwives in rural settings, aims to:
• improve timely access to early pregnancy scanning
• reduce delays in confirming pregnancy or viability
• ease demand on community ultrasound services
• support informed decision making for women considering abortion.
The University is considering offering another education programme in late 2025. Square
WHY COMPLETING TRENDCARE DATA IS SO IMPORTANT
Most MERAS members working in Health NZ inpatient maternity services will now be very familiar with Trendcare, an acuity based, demand capture staffing tool. The data collected enables visualisation of acuity demand hours required and care hours available; it informs the type of patients and whether the current roster model is fit for purpose.
This data can be used to support quality improvement in care provision, workforce models, workforce wellbeing and best use of our resources. This data is used for annual roster model reengineering and calculation of the FTE required.
This year a nationally consistent process for annual (full-time equivalent) FTE calculations has been detailed in standard operating procedures (SOPs) with separate ones for maternity and nursing ward areas. This was in response to variations across districts. The maternity SOP should be available on the Health NZ intranet in the Safe Staffing section.
Data inputs that enable FTE calculations to progress include:
• 12 months of accurate and complete Trendcare data: Over 90% of categorisations and actualisations need to be completed for the year. Missed data means the care provided by midwives for those patients that shift has not been acknowledged and is therefore invisible
• Allocate staff screen data: coordination hours, time in theatre, clerical and
For MERAS Membership membership@meras.co.nz www.meras.co.nz
housekeeping tasks undertaken by midwives, time spent seeing maternity patients in other wards or ED, ambulance/ flight escorts to other hospitals
• ‘Staffing available hours assumptions’: leave provisions (sick, annual, public holidays etc), professional development and training hours
• Inter rater reliability (IRR) testing completed for all staff on the ward
• One-to one care hours for birthing suites.
All these factors are required for FTE calculations to be undertaken, and this is why it is so important Trendcare data is completed for all women and babies that shift. Too many missed categorisations (selection of patient type) or actualisations (actualising data each shift) and the ward will not meet the data quality requirements for FTE calculations that year.
It is important each midwife completes their own Trendcare data, rather than the coordinating midwife completing it, as only the midwife providing the care knows all the care that was required.
The maternity patients least likely to be categorised or actualised are those admitted in the last hour of the shift. Sometimes there is a delay in these women being admitted and their admission might not be visible until after the shift has finished. If they are admitted close to the end of the shift and
little care was provided, they can be marked as ‘absent for the shift’. It is helpful if at handover or the beginning of the shift the coordinating midwife checks back that all patients were actualised the previous shift.
This year there were a few maternity areas that did not have FTE calculations completed because they did not meet some aspects of the criteria. For some there were good reasons to delay, but for others, aspects of data quality were not to the standard required and they will have to wait another 12 months for any improvements to their roster model that might have eventuated.
Provisions within the MERAS Collective are factored into the FTE calculation process including minimum midwifery staffing levels for clinical areas. These minimum provisions are important as they identify the base midwifery staffing that must be rostered. This is especially important for the smaller secondary maternity units on night shift, when at least two midwives are needed on duty for clinical safety.
The data period for the FTE calculations will be from January to December each year, with the plan that FTE calculations will be completed in the early part of the year to inform budgets and the new financial year which starts 1st July.
The introduction of the new national SOPs this year meant a delay in FTE calculations commencing at local districts. At the time
CAROLINE CONROY
MERAS CO-LEADER (MIDWIFERY)
THERE IS STILL WORK TO DO
MERAS is pushing for Trendcare to be introduced into the 3–4 primary maternity units that still do not have it
Work is needed so all districts admit women for ‘acute assessments’ (those who stay less than 3 hours) so these episodes of care are captured in the bed utilisation data and have a patient type and acuity attributed to them rather than midwife time on the allocate staff screen
The MERAS SECA safe staffing clauses include agreement to ‘progress consistent implementation of CCDM across all Te Whatu Ora maternity services’. To date, only in-patient maternity services have benefited from an acuity-based staffing tool. MERAS is keen for acuity-based staffing models to be rolled out to maternity day assessment units, hospital employed community, caseloading and clinic midwifery services
Data quality improvements are on-going and updated Trendcare patient types are anticipated in the next software upgrade. This will better reflect the care needed for women having misoprostol inductions and transitional care babies
of writing this article, districts were still waiting to hear if any budget increases identified for their ward areas had been approved by the Regional Deputy Chief Executives and national executive leadership team.
Trendcare has brought visibility to the work that midwives do within in-patient maternity services and shown how busy those services are. The data has highlighted the ‘front-door’ acute aspect of maternity services and bought visibility to the acute assessment works that occurs for patients who are not admitted.
Women seen on birthing suites, in assessments units, and at primary maternity units for ‘acute assessments’ were a hidden workload for maternity services as they were generally not ‘admitted’ and therefore did not feature in the bed utilisation or occupancy figures. Some maternity services can now admit these women, and this better reflects the number of women being seen by duty midwives in a 24-hour period.
In summary, the safe staffing process, which includes Trendcare, has bought visibility to the work midwives do in the in-patient maternity setting.
There have been significant uplifts in budgeted FTE for midwives in many ward/clinical areas. Some of this is yet to be fully realised as the recruitment of midwives has been challenging. As the number of midwives entering the workforce each year continues to increase and more units become fully staffed with midwives there is the opportunity to bring greater focus on the quality improvement aspect of CCDM and the data could be used to show how maternity services are able to flex staffing to respond to peaks and changes in acuity and demand and the difference having more midwives in the service makes to patient outcomes. Square
SUPPORTING THE HEART OF MIDWIFERY: THE MMPO, THEN AND NOW
WAYNE ROBERTSON GENERAL MANAGER, MMPO
Since its establishment by the New Zealand College of Midwives in 1997, the Midwifery and Maternity Provider Organisation (MMPO) has consistently supported community-based midwives across Aotearoa.
For many midwives, MMPO is synonymous with digital claiming and clinical notes. But in 2025, our role is much broader – and more flexible – than some may realise.
The MMPO provides a suite of services designed to support any College midwifery members. Whether you are in a small
www.mmpo.org.nz
E: mmpo@mmpo.org.nz P: 03 377 2485
practice, part of a larger collective, rurally based or newly transitioning into Lead Maternity Carer (LMC) work, MMPO is here to provide practical, professional, and financial tools to help make midwifery work more supported and sustainable.
A VALUES-BASED PARTNERSHIP WITH THE COLLEGE
One of the reasons the MMPO exists is to reduce administration burden and help sustain the workforce delivering midwiferyled care in Aotearoa. While the organisation is wholly owned by the College, access to MMPO tools and services is entirely optional – there is no obligation to engage. However, if you are a College member, you will have access to many of MMPO’s offerings – even if you have not used them yet.
WHAT THE MMPO OFFERS ALL COLLEGE MEMBERS
The MMPO provides a wraparound suite of inclusive, scalable, and friendly supports –
offering real help to all midwives, no matter where or how you practise. You choose what works for your practice – MMPO simply helps make the path smoother. These services include:
Workforce Support
• Emergency locum cover – For all LMC Midwives for unexpected events such as illness or bereavement
• Non-emergency leave – For rurally based LMC midwives including funded annual leave
• Support for locating or establishing services to rural areas which need midwives
• Support for transitions – Onboarding and advice for midwives new to practice, returning to LMC work, or moving between locations
• Maternal vaccination administration support – Support for establishing services and accessing payment and reimbursement for delivering maternal vaccinations.
Aotearoa New Zealand's midwife-centred support partner.
Business Support Tools
• Xero for Midwifery and Hnry Connection –Introductory and personalised support for sole traders
• Group Equipment Insurance – Discounted cover for essential midwifery and digital equipment
Real People, Responsive Help
• Access to a dedicated expert help desk and one-on-one onboarding support
• Workshops on accounting, taxation, business planning, and digital systems. We are looking to reintroduce the MMPO Business Workshops later in the year.
BUILT TO SERVE, DESIGNED TO EVOLVE
• NEW – Access to a tailored and value for money digital communication package with Spark Health Practice and Clinical Tools (Your choice)
• BadgerNet Clinical Notes System –A nationally recognised digital notes system that ensures secure, accessible clinical records that align with key parts of Aotearoa’s maternity system
• Tiaki – MMPO’s own digital platform designed for LMCs, integrating referrals, electronic prescribing, calendars, alerts, claiming, clinical notes, and secure communication – all in one place
• MSR and COMCORD Reporting – Annual benchmarking and outcome reporting tools to support reflection, participation in recertification and quality improvement.
MMPO takes a partnership-focused approach, collaborating with our key stakeholders including midwives, the College, Health NZ | Te Whatu Ora, and other networks (such as data and digital, research, and service development) to help strengthen midwifery systems and sustainability.
We are always looking for better ways to support you – particularly in the digital space. Keep an eye out for important announcements in this area over the coming weeks.
WHY THIS MATTERS IN 2025
As midwives continue to face growing demands, complex digital transitions, and workforce pressure, MMPO’s purpose is simple: to make things easier, not harder. Everything MMPO offers is built around:
• Reducing time spent on administration
• Supporting professional wellbeing and business viability
• Enabling woman and whānau-centred care
• Respecting autonomy and choice.
We are always looking for better ways to support you — particularly in the digital space. Keep an eye out for important announcements in this area over the coming weeks.
Every MMPO service is underpinned by the standards and frameworks that define professional midwifery in Aotearoa. From clinical records to financial systems, the MMPO helps ensure midwives have access to tools that support the provision of safe, high-quality, woman-led care – while meeting, for instance, their obligations under Section 94.
Importantly, the MMPO’s systems, advice, and infrastructure are designed by midwives, for midwives.
STILL NOT SURE WHAT'S AVAILABLE TO YOU?
If you are a College member the MMPO team is available to help. To talk to us to learn more, join, or reconnect call us on 03 3772485 or visit www.mmpo.org.nz Square
PROTECTING MĀTAURANGA MĀORI
The 2024 Midwifery Scope of Practice has ignited the conversation about the intersection between midwifery and mātauranga Māori. But cultural safety, informed decision-making, and partnership with Māori are not new expectations. These rights, upheld by the Midwifery Council, have been enshrined in the Health Practitioner Competence Assurance Act 2003 and Te Tiriti o Waitangi Act 1975. Ngā Māia offers this advice on our obligations to whānau.
Cultural safety is a guaranteed consumer right under Health Practitioner Competence Assurance Act 2003
Research shows cultural safety in midwifery goes beyond simply including cultural elements as additives. It requires midwives to critically examine their knowledge, attitudes, and biases when working across cultures. Self-reflection must be ongoing and responsive to feedback from whānau about their care. Whānau voice is critical to cultural safety. This aspect upholds the power of whānau to define their own aspirations and expectations for the care they receive.
Support people or persons is a guaranteed consumer right under Health Practitioner Competence Assurance Act 2003
Professional protocols and policies often focus on institutional rather than whānau need, for example, strict and inconsistent visitor policies in units across the country. Many impose on pregnant people’s greatest advocates and support system – whānau – and can alienate them from the clinical setting, especially Māori and Pacific whānau –
which contradicts both the HDC Code of Rights and the collective essence of well-being central to Māori (Kenney, 2011; Stevenson et al., 2020).
Recognition and support of Māori knowledge and approaches is a legal requirement under the Pae Ora Act 2022
Chief Midwife Hauora Māori Nicole Pihema insists on careful monitoring of western biomedical use of mātauranga Māori. For example, when muka is placed on birth trolleys or supplied like any other clinical item, it becomes disconnected from mātauranga Māori and becomes a modern convenience – severing its sacred connections and potentially becoming a scapegoat for lack of clinical skill.
Partnership, participation, protection and equity are guaranteed rights to Māori under the Treaty of Waitangi Act 1975
Whānau are heartened when mātauranga Māori is upheld in partnership and with integrity. The gains are symbiotic. The skill of tying umbilicus, once lost to a generation relying solely on plastic clamps, has improved with increased uptake of muka. Traditions and choices have been sidelined in clinical settings, when western institutional priorities dismiss Māori as unscientific or irrelevant, and perpetuate institutional racism and power imbalances. Erosion of informed choice diminishes trust and engagement, further embedding suspicion and fear from Māori communities (Wihongi, 2010; Stevenson et al., 2020). The commodification of cultural practices risks severing sacred knowledge transmission and undermining Māori sovereignty (Cleaver, 2023). Tiriti honouring partnerships enables protection of taonga like mātauranga Māori – without confiscating it.
Governments come and go. Māori will always be here
The future of culturally safe midwifery in Aotearoa depends on evolving professional frameworks like the scope of practice and the standards of competence to uphold and align the profession to the minimum legal requirements of health professionals. However, the health system needs to recognise Western biomedical limitations and adopt a Tiriti honouring model that honours Māori knowledge, rights, and aspirations – a minimum legal requirement. This creates space for whānau Māori to flourish from the very start. The upcoming Tūranga Kaupapa Education Programme 2027 embodies this vision, providing a powerful framework to guide individual practitioners when working with Māori and their mātauranga. Square
TAMARA KARU NGĀ MĀIA TRUST GENERAL MANAGER
Hauora Māori providers beside Te Awa Waikato, promoting protective factors of SUDI, such as wahakura.
TAPU ORASACRED SPACE
Tapu Ora is a story of a quiet and humble achievement. It is a workforce initiative that, coupled with its Māori counterpart Te Ara o Hine, helped the workforce rise significantly over a 4-year period.
Tapu Ora’s story grew out of need – commitment to equity, service and a vision from the ground up. The impetus from within Aotearoa’s Pacific heartland of Tāmaki Makaurau tonga, the instigator and driver.
The pilot contract finished 31 December 2024 and Health NZ committed to a further two years funding during a time of uncertainty within Manatu Hauora.
Pacific research group Moana Connect was commissioned to provide a final contractual review and report of the Tapu Ora pilot for Health NZ. The gathering of data and talanoa | korero has peoples’ voices woven throughout.
Following are details and excerpts from the Evaluation of the Tapu Ora Pacific Midwifery Students Programme.
TAPU ORA AS A MODEL
OF CARE
The Tapu Ora model of care is exemplary and seeks to address the systemic barriers faced by Pacific midwifery students by applying holistic, culturally grounded strategies. It integrates holistic support mechanisms – academic (e.g., tutoring), mentoring (e.g., Aunties, mentoring), financial (e.g., koha | aroha Support), and cultural (e.g., Pasifika Midwifery Liaison) – into Pacific midwifery students’ journey. This helps to ensure students are equipped to succeed while contributing to the health and well-being of their communities. The provision of this much-needed wrap around support reflects the Health Workforce Plan’s emphasis on removing systemic barriers for under-represented groups in the workforce.
The model of care also emphasises cultural safety and responsiveness, enacting this through the central role of Pasifika Midwifery Liaisons. The Pasifika Midwifery Liaisons foster environments where Pacific values, languages and traditions are honoured. This ensures that Pacific midwifery students experience belonging, feel as though their culture is valued, and have opportunities to share their culture throughout their study pathway. It also aligns with the Pacific Health Workforce strategy’s call for culturally competent care to improve outcomes for Pacific peoples.
Overall, the model of care provided by Tapu Ora aspires to create community and workforce transformation through investment in an education-to-employment pipeline for Pacific midwives. By bridging
education and healthcare, Tapu Ora not only supports students but also addresses the health needs of Pacific communities. It exemplifies how culturally anchored, community-driven solutions can transform systems and achieve long-term equity.
LOOKING AHEAD
The report recognised the dynamic process of change that was continuous throughout the 4 years – its responsiveness and ability to pivot.
The impact for students, schools, Pacific liaisons and the national coordinator was about honouring the kaupapa of intent. What is undeniable is its worth – to achieve an equity vision and to have midwifery representation that is culturally safe for Pacific communities. How can Tapu Ora shape the next 18 months to become truly transformative? It requires the same commitment – creating opportunities, listenimg to each other and remembering our WHY.
To move away from the deficit model lens and measure incremental changes such as Pacific midwifery workforce statistics. Midwifery Council data on midwives identifying as Pacific ethnicity shows: 2021 – 2.59%, 2022 – 2.9%, 2023 – 3.3% and 2024 – 3.7%. This represents an increase of 39 midwives.
It’s about whānau; improving their experiences and ensuring better engagement and outcomes to change the Pacific narrative. Square
NGATEPAERU MARSTERS TAPU ORA NATIONAL LEAD
MIDWIFERY AND MANAAKITANGA NATIONAL CONFERENCE 2025
KIM THOMAS EDITOR
In its simplest form, manaakitanga means showing kindness, respect, and generosity to others so they feel supported and valued. Manaakitanga is an important concept in te ao Māori and it underpins all work carried out by midwives - whether in the community, maternity units or in education and advocacy.
Manaakitanga safeguards collective wellbeing and was a fitting theme for the 2025 Biennial New Zealand College of Midwives Conference where kindness and respect were evident in large doses as more than 500 midwives, students, women, invited guests and others invested in the profession came together at the end of August in Kirikiriroa | Hamilton.
There was also an abundance of generosity as keynote speakers, and those leading plenary and concurrent sessions and workshops, shared their varied and valuable knowledge and mātauranga. Before the official opening of the conference programme began, midwives from around the motu had the chance to attend a series of pre-conference workshops that included the latest
information on optimising pelvic health, anaemia, selfcare for midwives, and the Ngā Māia-led Tūranga Kaupapa workshop.
Conference began with a powerful opening ceremony, including a warm welcome from Tainui mana whenua, an address by the Honourable Casey Costello (Associate Minister of Health), a warm welcome from the Waikato region, opening reflections by the College’s Co-Presidents, and an uplifting kapa haka performance by Te Wharekura o Kirikiriroa.
The first day included a panel discussion focused on Birth in Aotearoa in 2025. Panellists explored a broad range of topics including the diversification of the birthing population in Aotearoa, the experience
of birthing without family and access to usual cultural practices as a new migrant, navigating the maternity service, the work of the National Maternity Clinical Network, an obstetrician’s perspective on intervention rates, and responsive midwifery care for whānau choosing to decline aspects of maternity care. The day concluded with a fun (but very relevant) debate that posed the question: Humans vs Robots: Who’s in Charge? Debaters in the ‘nothing-is-off-limits’ session had the audience variously in stitches and contemplation while arguing the potential –and pitfalls – of AI technology in the ancient, human-centred profession of midwifery.
The Humans team stole the day, winning the audience vote, despite the Robots team putting up a solid case in favour of technology. Final speaker for the Humans team, Lara Hopley (Chief Clinical Informatics Officer, Health NZ | Te Whatu Ora) summed up the role of AI in health care aptly with a description that resonated strongly with the audience “It’s like a medical student who has read all of the text books but never laid a hand on a patient, it can’t interpret that look in a patient’s eyes, it doesn’t have that intuition that something isn’t right, even if the recordings or observations are normal”.
Day two began with midwifery elder Bronwen Pelvin delivering the Joan Donley oration, reminding the audience that relational connection is one of midwifery’s most important superpowers. The inaugural Māori midwifery oration, named after Māori midwife Becky Fox, was delivered by Korina Vaughn. Korina talked about Becky’s drive to support Māori midwives – she was instrumental in collectivising midwives from around the motu to found Ngā Māia. She was instrumental in establishment of the first direct entry midwifery programme at Wintec and worked tirelessly to support midwifery students to succeed. Korina reminded us that so much of Becky’s work continues today and challenged us to live up to her legacy.
The conference provided an opportunity for international luminaries of midwifery research – Professor Caroline Homer (Order of Australia) and Professor Saraswathi Vedam – and Māori visionaries Tina Ngata and Dr Ihirangi Heke to share their kaupapa on some of the most important issues in midwifery, health, and the impacts of colonisation. Editor Kim Thomas spoke with each of the keynote speakers before their well-received keynote addresses.
Professor Homer is Australia’s leading midwifery researcher. For the past decade she has worked on numerous international projects including with the United Nations
Population Fund (UNFPA) on their ‘State of the World’s Midwifery’ global reports, which in 2021 identified a shortage of almost a million midwives globally. Caroline’s keynote address highlighted the vital role that midwives play in preventing maternal mortality. She shared a powerful analogy – stating that the number of women dying in childbirth each day is equivalent to the amount of people in two jumbo jets. “Imagine the outcry and international attention if two jumbo jets crashed each day, yet we are losing this many women in childbirth, and many of these deaths are preventable if women had access to midwives.” UNFPA, with Caroline’s support, recently published a report on the Asia Pacific region. “Based on raw data, the number of midwives relative to birth rate in countries like Australia and New Zealand looks pretty good,
Manaakitanga was a fitting theme for the 2025 Biennial New Zealand College of Midwives Conference where kindness and respect were evident in large doses as more than 500 midwives, students, women, invited guests and others invested in the profession came together.
but when you start delving down, do we have enough midwives in the right places, doing the right work? No one does.”
Caroline highlighted continuity of care as the biggest shift in midwifery globally right now. In May 2025, the World Health Organizaton (WHO) released implementation guidance on midwifery models of care to help countries around the world ‘kind of do what New Zealand's has done’, while acknowledging the different contexts. “It's complicated, as you know in New Zealand, none of it is easy, but we all know we need to improve access to midwifery care to meet women’s needs. Changing the system so women know the midwives who are caring for them, and midwives work in ways that are flexible and that meet the needs of the women.”
Dr. Saraswathi Vedam is Lead Investigator of the Birth Place Lab and Professor of Midwifery at University of British Columbia in Canada. She grew up between India and the United States in an extended family with several obstetric specialists. “My midwifery education began in my mother’s home, which was a ‘mecca’ for pregnant and nursing mothers in the growing Indian community at Penn State University. Five of my extended family in India are in obstetrics and from my teens they took me along when they cared for families, sometimes in the slums, in rural settings, and in tertiary care hospitals. I was immersed in pregnancy as normalcy and exposed to women working with women.”
From this formative experience – and many years working as a community midwife –grew a commitment to serve families across birth settings and cultures, and importantly to support self-realisation through birth and pregnancy. A major piece of work for Saraswathi and the Birth-Place Lab is a study involving community members that seeks to demystify decision-making in pregnancy and birth and empower women. “People want to lead decisions about their bodies, their babies, and where and how to give birth, including options for care. They report a lack of autonomy, pressure to accept unwanted interventions and procedures, and a lack of complete and truthful information about their options for care.”
Birth Place Lab’s ‘Giving Voice to Mothers’ research project surveyed more than 1,700 women in the United States across four aspects of the childbirth experience: communication and decision-making autonomy, respect, mistreatment, and time spent during visits. Researchers analysed differences between those cared for by a midwife at a community
birth, a midwife at a hospital birth, and a physician at a hospital birth.
They found, no matter where they birth, people who got midwifery care reported greater respect, higher autonomy, more privacy, and more dignity overall than those who received care from a physician. Those who birthed at home or in a birthing unit reported having the most control. Saraswathi and her colleagues found women of colour were twice as likely to be pressured or have a procedure or test performed against their will.
“We have a saying in our lab, if you meet the needs of the most vulnerable, everyone will benefit. Exemplary midwifery means walking with families as they negotiate the health care system, remaining mindful of their own cultural context, and advocating for the preservation of the essentials of undisturbed birth. The quality of our mutual regard and confidence means everything, as together we explore the research and options for care, react to expected and unexpected events, or embrace the spirituality inherent in birth, and in abiding friendships.”
Tina Ngata (Ngāti Porou) has formally chaired the Global Indigenous Womens’ Caucus at the United Nations and holds a Masters in Indigenous Studies. Her current kaupapa is focused on dismantling of the Doctrine of Discovery, and rematriating Indigenous peoples to their lands and waters. Early in her career Tina worked on the E Hine longitudinal research study which shone a light on the range of barriers young pregnant Māori women encountered on their journey through pregnancy and the first year of life of their infant. As well as being a research taonga, the study was a hugely important experience for Tina and she remains involved with many wāhine involved in the study today.
Tina’s Master’s thesis was on the Doctrine of Discovery which, as she explained to a rapt audience to her keynote speech, was an international legal concept originating out of the Vatican in the 15th and 16th centuries, giving British and European monarchies the right to conquer and claim lands and convert or kill the native inhabitants of those lands. “Those legal entitlements had whole economies and political systems built around them and today are a global economic and political meta-system we all live under. Some core tenets from this history that have come to shape and influence our world are that Indigenous land is the rightful property of colonisers; indigenous people can and should be contained and controlled; people who are non-European are lesser; and profit is more
important than human rights, she explained. The Doctrine permeates every aspect of society today, including maternity. “At its heart is acknowledgement of the process of denying sacredness unless it comes in the form of patriarchal, Christian domination over land, water and belief systems. There is a clear history of how this has played out for women. In Europe, it has led to persecution and violence towards female spiritual leaders, healers and midwives, and still exists today as misogyny towards women in leadership roles.
“All systems today have an inherent patriarchal nature, including the health system, which is based on what men think is best for women. It is commercially orientated and individualised, which in health care means the system can be focused on wellbeing of māmā and pēpē but not relational wellbeing that is inclusive of whānau and partner.”
Tina reminded midwives of their whakapapa; “Throughout history midwives have been sites of resistance, protecting sacredness in a world that was bent on desecration. And that is a radical act.” Providing and advocating for culturally safe, whānau-centred care was framed as a “deeply political act of resistance”, a continuation of an ancient legacy. And midwives are not alone – around the world solidarities are emerging in many sectors to restore sacredness. At the conclusion of Tina’s address, she led the conference in a rousing call and response: Toitū te whenua tapū! Toitū te whare tangata! Toitū te mana wāhine! Toitū te Tiriti o Waitangi!
Dr Ihirangi Heke (Waikato Tainui) is a pioneering Māori scholar who transforms environmental wisdom from te ao Māori into health-motivating frameworks. His Atua Matua model inspires sustainable behaviour change through reconnection with te taiao | environment and whakapapa. Raised in Te Waipounamu, Ihirangi had an opportunity as a young man to live and work in the alpine environs of Queenstown in winter and the Milford Sound national park area in summer. Obtaining academic qualifications, including a PhD in population health and a postgraduate diploma in environmental management, he combined this with a deep connection to te taiao and te ao Māori to create the Atua Matua model. His kaupapa has taken him around the world to universities and most recently Google’s international headquarters in San Francisco. There, he is advising the tech giant on addressing unconscious bias to ensure indigenous knowledge is included in the development of artificial intelligence. Atua Matua, and all of Ihirangi’s mahi, is about revisiting and exploring pre-European ways
of thinking. “The fundamental difference and exciting prospect of the Atua Matua model is moving to an indigenous knowledge basis rather than a deficit-based model. ‘It’s about whakapapa, which is connected to the environment. You can get a lot more traction and gains with population health if it’s viewed in this way. It’s moving Māori away from nonMāori structures that are individualistic and focused on blame.”
As Ihirangi explains, when you first meet Māori, especially in powhiri, they will make three greetings – tēnā koutou, tēnā koutou, tēnā koutou katoa – to acknowledge tinana (physical), hinengaro (psychological) and wairua (spiritual) aspects of being. A lot of Ihirangi’s work involves growing people’s understanding, including the relationships of atua Māori to the environment and the human body, demonstrating how human beings are part of (not separate from) the natural world. This connection brings reciprocal healing – as we care for the environment, we build our own wellbeing, in all ways. Ihirangi reflects that it has been interesting to see an increase in the use of pounamu instead of tuhua for the cutting of the pito. "While the role of pounamu has long been for the cleansing of sites healing from war it has always been tuhua that was used to cut the pito but we are seeing a change in the role of pounamu that may not be valid either historically, culturally or even practically”. Ihirangi's mahi also involves sharing Māori knowledge platforms. Whilst many know of mātauranga, fewer understand the critical role of mohiotanga and maramatanga. “Mātauranga is environmental knowledge. Mohiotanga is capacity building and māramatanga is dynamic capability, a speciality of Māori that allows them to recreate ancestral information into contemporary locations. "What does this all mean?," asks Ihirangi. Māori will continue to develop cultural nuances for contemporary application. Midwifery is another way for Māori to pursue immortality for their people by the ongoing contemporary application of ancestral information. Square
Throughout history midwives have been sites of resistance, protecting sacredness in a world that was bent on desecration. And that is a radical act.
LABOUR AND BIRTH AUDIT
WITH THE TEN-GROUP CLASSIFICATION SYSTEM
CLAIRE MACDONALD MIDWIFERY ADVISOR - RESEARCH
After more than a decade of year-on-year increases, one in three women in Aotearoa now give birth by caesarean section; in some facilities it is pushing towards half. This, of course, means spontaneous vaginal birth rates have decreased. This pattern of change is underpinned by a complex interplay of factors, and it has significant implications for whānau, clinicians, hospitals and health resources.
Standard two of the College’s Standards of Practice states “The midwife utilises midwifery skills that facilitate the physiological processes of childbirth and balances these with the judicious use of intervention when appropriate”. In light of the increasing rates of caesarean section, is it time for a national, interprofessional conversation about what ‘judicious use of interventions’ looks like and how we support physiological birth in today’s context?
This article considers how this question is being asked using quantitative data in our regualar maternity audits, and how these audits are evolving. It highlights the importance of midwifery and whānau involvement.
High quality health data is an essential tool for monitoring clinical outcomes and equity at a system level. Reporting, however, is only one part of the process; it does not improve outcomes without action. Careful data analysis and interpretation; effective implementation of data-informed and evidence-based
recommendations for change; and evaluation of the effect of changes is necessary. Together, this is known as continuous quality improvement. To be successful, professional and clinical leadership, interprofessional collaboration and whānau voice are needed in quality processes. In practice, informed decision-making and consent must always remain central as key tenets of respectful, culturally safe, woman, person and whānau-centred care.
Since 2009, Aotearoa New Zealand has benchmarked maternity clinical indicators using the ‘standard primipara’ definition: nulliparous women 20–34 years old, birthing singleton, cephalic babies at 37–41 weeks who have no recorded obstetric complications that are indications for specific obstetric interventions (Health New Zealand [HNZ] | Te Whatu Ora 2024). In other words, this is a ‘low-risk’ cohort for national and district-level MQSP reporting.
In 2015, the World Health Organization proposed the Robson Ten-Group Classification as a “global standard for assessing, monitoring and comparing
It is essential that midwives and whānau are involved in audit planning and the thoughtful analysis and interpretation of the data.
caesarean section rates both within healthcare facilities and between them” (WHO 2017). As an audit tool, data from all women’s and gender diverse people’s births are allocated into one of ten mutually exclusive categories (with two optional sub-categories) based on five clinical characteristics - parity, singleton or multiple pregnancy, previous caesarean section, onset of labour, gestational age, and fetal presentation.
For several years, some hospitals in Aotearoa have used the ten-group classification alongside standard primipara reporting. In 2024 a national meeting brought hospital representatives together in Palmerston North to present and compare their maternity outcomes, with a particular focus on group one – nulliparous women in spontaneous labour. The National Maternity Clinical Network has adopted the format with a follow-up day scheduled this year.
Facility or district-level audit presentations include an explanation of local labour guidance. Rates of labour and birth events and outcomes are stratified into the ten groups. To nuance analyses further, stratification is possible within the ten groups, for example by ethnicity, age, planned place of birth or obstetric risk factors.
Auditing birth interventions and outcome rates using the ten-group classification enables a more specific understanding of where midwives and obstetricians can focus their efforts to improve care (Robson, 2015; Smith et al., 2019, Robson et al. 2025). For example, if an audit reveals that nulliparous women in spontaneous labour at term are experiencing unexpectedly high caesarean rates, an assessment can be made of how well evidence-based practices to optimise women’s potential to have a spontaneous vaginal birth are being offered and practised and where they could be strengthened.
ROBSON TEN-GROUP CLASSIFICATION
1 Nulliparous women, single cephalic pregnancy, term (≥37 weeks), spontaneous labour
2 Nulliparous women, single cephalic pregnancy, term (≥37 weeks), induced or caesarean section before labour
3 Multiparous women (no previous caesarean), single cephalic pregnancy, term (≥37 weeks), spontaneous labour
4 Multiparous women (no previous caesarean), single cephalic pregnancy, term (≥37 weeks), induced or caesarean before labour
5 Multiparous women with at least one previous caesarean, single cephalic pregnancy, term (≥37 weeks)
6 Nulliparous women, single breech pregnancy
7 Multiparous women, single breech pregnancy (including previous caesarean)
8 Women with multiple pregnancies (including previous caesarean)
9 Women with single pregnancy in transverse or oblique lie (including previous caesarean)
10 Women with single cephalic pregnancy, preterm (<37 weeks), including previous caesarean
The classification facilitates benchmarking, allowing comparison between facilities or services and identifying what works (Savchenko et al., 2022). Over time, regular hospital audits using this system can support a culture of reflection and continuous improvement, which can contribute to service-level improvements in care to promote spontaneous vaginal birth and limit caesareans to when they are necessary (WHO, 2017). It is also possible for midwives and midwifery practices to analyse their practice-level outcomes using this framework.
A key focus of ten-group classification labour and birth audits (in their current format) is the management of prolonged labour/labour dystocia with oxytocin augmentation for women in spontaneous labour. It is worth taking a moment to consider some of the factors which have been demonstrated in midwifery and obstetric literature to improve women’s experiences and likelihood of spontaneous
2a: Induced labour 2b: Caesarean before labour
4a: Induced labour 4b: Caesarean before labour
vaginal birth (and decrease the likelihood of prolonged labours and avoidable caesarean sections). The following is a nonexhaustive list:
• Midwifery continuity of care within an integrated maternity service including timely access to necessary obstetric care (Sandall et al. 2024)
• Antenatal education and support programmes, including those focused on recognising and responding to anxiety, stress and fear with relaxation and selfmanagement techniques (WHO 2018)
• Physical activity during pregnancy (Shojaei et al. 2021; Watkins et al. 2023)
• Continuous support during labour (Bohren et al. 2017; WHO 2014)
• One-to-one midwifery care in labour (Buerengen et al. 2022; McLachlan et al. 2012)
• Upright positions and mobility in the first stage of labour (Lawrence et al. 2013; WHO 2014)
TEN-GROUP AUDIT PRESENTATION DETAILS
Local guidance on labour processes:
How [active] labour is diagnosed
Indication for artificial rupture of membranes
Frequency of vaginal examinations
Diagnosis and management of dystocia
Use of oxytocin augmentation
Events and outcome rates:
Epidural
Oxytocin augmentation
Spontaneous vaginal birth
Operative (instrumental) birth
Episiotomy
Availability of analgesia including epidural OASI
Fetal monitoring
• Planned birthplace of home or primary birthing unit (Birthplace in England Collaborative Group, 2011)
• For hospital birth, admission to hospital in active labour (avoiding early admission) (Mikolajczyk et al. 2016). This is facilitated by a home visit for the initial midwifery labour assessment
• Implementation of and adherence to evidence-based clinical practice guidelines for labour and caesarean section indication, combined with audit and feedback. This includes recognising prolonged labour and commencing oxytocin augmentation appropriately (WHO 2018)
• Second opinion from a senior clinician (for example SMO) for caesarean indication (WHO 2018)
• Maternity service culture: shared aim to optimise spontaneous vaginal birth and caesarean section rates and an agreed approach to achieving this (Hildebrand, Nelson, & Blomberg 2020).
In one of the only countries in the world that has systematically implemented some of
Caesarean section
Caesarean section at full dilation
Apgar <7 at 5 minutes
PPH ≥ 1000ml
Baby weight ≥ 4kg
Hypoxic ischaemic encephalopathy (HIE)
Neonatal unit admission
the most efficacious elements identified in the international literature: woman and whānaucentred, midwifery continuity of care in an integrated maternity service, one-to-one midwifery care in labour, and whānau access to home and primary unit birth, it could be considered that a paradox exists in Aotearoa. Since 2009, caesarean section rates for all women have increased from 24% to 32% in 2022 and for standard primiparae from 15% to 20%.
On the flipside, spontaneous vaginal birth rates have decreased from 67% to 56% in the same time period for all women, and 70% to 59% for standard primiparae (HNZ 2024). The pattern persists when stratified by any available demographic factor: age, ethnicity, deprivation quintile, parity and geography – in some regions more than others. Why are we seeing these rates of medicalised birth despite the protective factors in our model of care? And how can we ensure these protective factors are available to all whānau equitably?
Quantitative data is a powerful tool for understanding what is happening and can
contribute to data-driven solutions. Like all data analysis, careful interpretation requires an understanding of both its strengths and limitations. One limitation is that audit data is not captured for planned birth in primary settings including home birth in all regions of Aotearoa. This means that stratifying by planned place of birth is not always possible, and lessons about spaces that promote birth physiology might not be part of the conversation. Improvements in data availability from all settings will hopefully enable such analyses in future.
Another is the limited set of data items reported. Notably, from the list above, only oxytocin augmentation is captured in a standard ten-group birth audit, which means the other factors receive less (or no) attention. A possible risk is that apparent correlations in the available data could drive practice changes in isolation of a deeper consideration about a) the diversity of factors driving intervention rates, and b) which measures could be (re)introduced that respect and enhance women’s physiological processes. Synthetic oxytocin has an important place in managing labour dystocia rather than proceeding straight to caesarean surgery and needs to be commenced at an appropriate time to optimise the likelihood of vaginal birth. The picture would be more complete by also attending to the multiple ways midwifery practices and birth environments can support or slow women’s labours.
As this audit cycle continues to roll out across our facilities in Aotearoa, there is a lot to unpack. It is essential that midwives and whānau are involved in audit planning and the thoughtful analysis and interpretation of the data. Strategic conversations between midwives, obstetricians and whānau collectively about the goals of maternity services could shape continuous quality improvement processes to achieve those aims. If used effectively as part of the National Maternity Clinical Network’s focus on improving equity and aligning clinical guidance across the motu, a continuous audit cycle - with an internationally recognised tool like the ten-group classification - provides an important opportunity for the maternity service to take stock. In doing so, we can ask searching questions from multiple perspectives to contribute to a positive pathway forward. Square
References available on request
BIRTHING ON MARAE - A RETURN HOME
TE PAEA BRADSHAW MIDWIFERY ADVISOR
Me mihi ka tika ki a Takutai Kemp, kua whetūrangitia ia. Nāna ahau i tautoko, nā te iwi Māori ia i whakapau werawera ai. Moe ma rā e kui.
When Aroha Harris-Tutaki, a Kahu Pōkai | Māori midwife, nō Te Taitokerau ki Muriwhenua, raised in Mangere Bridge and based in Tāmaki Makaurau | Auckland, began her journey into midwifery, she knew she was called to care for whānau Māori. That knowing became a mission: to indigenise her practice, her spaces, and the systems she worked within. That mission led to a revolutionary initiative – returning birth to the marae.
WHAKATŌ TE KĀKANO | PLANTING THE SEED
After graduating, Aroha attended Ngā Manukura o Āpōpō and Mahi Atua training, while working within a standard clinic setting in Botany. She began reflecting on how disconnected these environments felt for many whānau Māori, “They were using words like mataku | fear; the space didn’t reflect us.” Aroha began advocating and was successful with small changes: carving out a corner of a large clinic and creating a space filled with mahi toi | Māori art, kupu Māori | Māori words, and native plants.
The transformation was immediate. “Whānau would come in apprehensive. Then they’d step into that little space, and I could see the tension melt away.”
That success sparked a question: What if I could do this at home? Home, in this context, being within the embrace of a marae.
THE BIRTH OF AN IDEA
Aroha had longstanding ties with the late Takutai Kemp, then CEO of Manurewa Marae. After some time apart during the disruptions
of COVID-19, they reconnected. When Aroha shared her vision – birthing on a marae – Takutai immediately responded, “Yes, nau mai, haere mai | come.”
“Manurewa Marae made sense. It’s where most of our Māori whānau in Auckland reside. The space already felt like home.”
The space was originally built for a Puna Reo | Early childhood education, complete with secure fencing and space for tamariki –perfect for whānau juggling appointments, children, and busy lives.
The clinic was designed to look and feel like a kāinga | home. “There’s a bed, couches, even a kitchen where whānau can cook kai | food if they want. The CTG machine and blood pressure monitor are there but tucked away.” The space is warm, familiar – where tikanga is honoured, not compromised.
RECLAIMING TIKANGA, RECLAIMING BIRTH
“Some of the biggest challenges have come from the way our own tikanga has been infiltrated by colonial systems,” Aroha reflects. “Even marae have developed a hesitancy around birth – OSH regulations, safety concerns, outside expectations.” But as she points out: “We have our own systems. We have tikanga.”
“When birth happens on marae, the whānau healing is profound.”
One of the first births hosted at Manurewa Marae brought together four generations.
Aroha Harris-Tutaki
“The grandparents were visibly moved,” she recalls. “You could see the grief of what had been taken from them – but also the healing. They were witnessing their mokopuna being born into a space of sovereignty, safety and dignity. That birth started conversations across the generations, about whenua, about te reo, about reconnecting.”
Another whānau shared how the marae enabled access that would have otherwise been impossible. A māmā, home-schooling her autistic, non-verbal daughter, found typical clinic spaces overwhelming. “But at the marae, her daughter felt safe. She’d run up the driveway clapping her hands in joy. That’s the kind of space we need.”
MANA MOTUHAKE | SOVEREIGNTY IN PRACTICE
For Aroha, birthing on the marae has ignited how she moves in her own sovereignty and feels blessed to be practising alongside other amazing wāhine such as Te Waiora Mason and Ebony Rapana, who bring their own lived experiences of mātauranga and kura kaupapa. While Aroha feels practising as a Māori midwife is an honour, “We’re so
assimilated from our degrees. It’s BP readings and checklists before we even say ‘kia ora’ to the baby.” But on the marae, that changes.
The booking visit is a whānau hui with whakawhanaungatanga | building connections in a relational manner that is familiar to Māori.
The space has also become a hub for tauira | student midwives. “We cook kai together, play Kahoot, make poi. They see what’s possible when we practise from our own tikanga.”
While Aroha is growing a rōpū | group practice she is excited to share her story and the future potential. “Imagine if every hapu and iwi had spaces like this – we’d grow our own midwives, our own leaders.”
ADVICE FOR OTHERS
The path hasn’t been easy. There’s constant scrutiny. “Everything gets watched more closely – our training, our documentation, even our equipment.”
To other Māori midwives considering similar journeys, Aroha says: “Be brave. Start the conversations. You never know where they’ll land.”
When Aroha shared her vision – birthing on a marae – Takutai immediately responded, “Yes, nau mai, haere mai | come... Manurewa Marae made sense. It’s where most of our Māori whānau in Auckland reside. The space already felt like home.”
She cautions against becoming entangled in funding contracts that diminish your vision. “Our ahi, our fire just needs oxygen. Let it breathe.”
Her final whakaaro is powerful: “Bringing birth back into our hands changes everything. How we parent. How our pēpi grow. The ripple effect is endless. When we uphold the mana and mātauranga of birthing, oranga | wellbeing will follow.” Square
BIRTHING IN FIJI
More than 95 per cent of the 16,000-plus babies born in Fiji every year are attended by a midwife. Eleni Kata is a representative for the country at the ICM’s Western Pacific Region Professional Committee and coordinates the postgraduate midwifery program at one of the two midwifery schools in Fiji. She shares with Midwife Aotearoa how midwives become qualified, where they work, and upcoming changes to the midwifery curriculum.
“To be a midwife in Fiji, you must first do your threeyear Bachelor of Nursing degree then work for five years as a nurse. After that, a registered nurse can apply to the Ministry of Health, the employer, to undertake postgraduate training at one of the two nursing schools here in Fiji,’’ Eleni explains.
Between 30 and 40 midwifery students graduate in Fiji every year. Eleni works at the Sangam College of Nursing and Health Care Education where 14 students are currently doing the one-year postgraduate diploma of midwifery programme. The rest are at Fiji National University, along with some students from other countries.
The programme was previously funded by international aid but last year the Fijian Ministry of Health took over most of the funding. The midwifery programme was developed and implemented in 2009 by a collaboration of the Ministry of Health, World Health Organisation, James Cook University and the Nurses, Midwives and Nurse Practitioners Board.
Six Pacific Island countries, including Fiji, are currently reviewing their midwifery curricula to align with global standards, namely the ICM 18-month post-nursing midwifery programme. This initiative has been supported by United Nations Population Fund and facilitated by the Burnet Institute.
Right: Midwifery students at the Sangam College of Nursing and Health Care Education in Fiji.
Like everywhere, Fiji faces a shortage of midwives. “Senior midwives are leaving the workforce, most for greener pastures, and some retirees have been re-employed to counter the shortage of midwives. Most retirees are employed at the only government-supported birthing unit. Even though training is conducted every year, the shortage gap will be there for some time.”
In Fiji, women are encouraged to come into hospitals to birth, as most midwives are stationed there. Subdivisional hospitals, that serve rural communities, have doctors and midwives working there, and they attend to normal maternity cases, throughout pregnancy, labour, birth and postnatal period. All high-risk cases are referred to tertiary level facilities.
Once referred, women are asked to stay close to tertiary level care, to continue follow-up until birth. This means women must leave their families and stay with family in urban areas awaiting birth - or in the challenging situation of having no close family near the hospital, stay with friends or distant relatives.
A growing issue in Fiji is the rising rate of HIV infection amongst young adults. The main method of transmission is through sexual transmission, but IV drug use is also a method of transmission now evident in Fiji.
“We are in a HIV pandemic. Infections are on the rise. It’s a big problem for our communities and it’s something midwives are having to face.” Despite issues such as this, it’s an exciting time for midwifery in Fiji, as it continues to grow and thrive. “We are very proud of our profession and will continue to ensure we provide respectful, compassionate, safe, and evidence-based care.” Square
TE TOHU WAIHONGA | AOTEAROA NEW ZEALAND CLINICAL PRACTICE
GUIDELINE FOR NEONATAL HYPOGLYCAEMIA AND BREASTFEEDING
This article explores a conditional recommendation from Te Tohu Waihonga | Aotearoa New Zealand Clinical Practice Guideline for Neonatal Hypoglycaemia.
Recommendation 8: ‘Prioritise breastfeeding where possible rather than expression of breastmilk for preventing or treating neonatal hypoglycaemia in the first 48 hours after birth’, in the context of midwifery care aimed at protecting infants from hypoglycaemia while also protecting 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 is the obvious aim of clinical guidelines for neonatal hypoglycaemia. Other critically important aims are the protection of exclusive breastfeeding and reducing unnecessary interventions and admissions to neonatal or special care baby units, which usually result in mother-baby separation. Uninterrupted mother-infant skin-to-skin care after birth and providing a supportive environment for the first breastfeed are significant for all infants, but particularly for those at risk of neonatal hypoglycaemia.
The aim of all health guidelines that potentially impact on exclusive breastfeeding, and duration of breastfeeding should
consider what protection, in the context before and after birth, means in practice. The NZ Clinical Practice Guideline for Neonatal Hypoglycaemia recommends supporting mothers to effectively breastfeed their newborn infants and recognises breastfeeding/breast milk as ideal for postnatal neonatal metabolic adaptation. Fully breastfeeding is seen as a 'critical outcome' and exclusive breastfeeding as 'important'. A reminder of the NZ Ministry of Health definitions:
• Exclusive Breastfeeding – The infant has never, to the mother’s knowledge, had any water, formula or other liquids or solid food. Only breastmilk, from the breast or expressed, and prescribed medicines have been given from birth
• Fully Breastfeeding – The infant has taken breastmilk only, no other liquids or solids except a minimal amount of water or prescribed medicines, in the past 48 hours.
Fully breastfed means that the baby has at some point after birth been given commercial milk formula but has then been breastfed or breast milk fed for the subsequent 48 hours. Feldman-Winter et al. (2020; 2024) describe how the nutritional and immunologic properties of human milk, and clear evidence of dose-dependent optimal health outcomes for mothers and infants provide compelling rationale for the support of exclusive breastfeeding. They also note how exclusivity may be compromised when actions that hope to avoid feedingrelated neonatal complications, potentially affect the continuation and duration of breastfeeding. Proactively identifying potential challenges to avoid losing breastfeeding exclusivity is recommended.
WHAT CONDITIONAL RECOMMENDATIONS MEAN IN THE AOTEAROA NEW ZEALAND CLINICAL PRACTICE GUIDELINE FOR NEONATAL HYPOGLYCAEMIA
The term ‘conditional recommendation’ is used when there is either a close balance between the benefits and down sides, 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.
RECOMMENDATION 8. PRIORITISE BREASTFEEDING WHERE POSSIBLE RATHER THAN EXPRESSION OF BREASTMILK FOR PREVENTING OR TREATING NEONATAL HYPOGLYCAEMIA IN THE FIRST 48 HOURS AFTER BIRTH. [CONDITIONAL RECOMMENDATION]
Prioritising of breastfeeding over expression of breast milk in the first 48 hours after birth is an optimal recommendation that requires breastfeeding protection measures to facilitate infant recovery, such as infants being supported to have longer periods of uninterrupted skin-to-skin contact with their mothers to assist with birth recovery and the stimulation of instinctual pre-programmed
CAROL BARTLE POLICY ANALYST
Prioritising of breastfeeding over expression of breast milk in the first 48 hours after birth is an optimal recommendation that requires breastfeeding protection measures to facilitate infant recovery, such as infants being supported to have longer periods of uninterrupted skin-to-skin contact with their mothers to assist with birth recovery and the stimulation of instinctual pre-programmed feeding reflexes.
feeding reflexes. The ‘uninterrupted’ process of the immediate post birth period and mother-infant skin-to-skin contact is a key consideration.
There are potential maternal risk factors for delayed lactation that need to be considered 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) which means infants need unrestricted time at the breast, and observation of all breastfeeds to support effective latching. Women with risk factors for delayed or low lactation, and babies who have got off to a difficult start, need particular attention. For some women expressing breast milk as well as breastfeeding may support not only exclusive breastfeeding but breastfeeding continuation. Individualised care needs to take into account the wishes and plans of the mother.
The discussion about recommendation 8 in the neonatal hypoglycaemia document cites very low certainty evidence from one
From a midwifery perspective, prioritising exclusive breastfeeding and, if needed, expressed breastmilk or donor milk, need to remain the key messages. To protect exclusive breastfeeding the Academy of Breastfeeding Medicine recommend ensuring access to professional support and management with breastfeeding and using donor breast milk as a bridge when supplementation is necessary.
randomised controlled trial (RCT) that suggested dextrose gel or supplementation of breastfeeding with formula, but not mother’s own breastmilk, may increase blood glucose concentrations in hypoglycaemic infants in the first 48 hours after birth.
The cited RCT (Harris et al., 2017) examined various treatments for hypoglycaemia – dextrose gel, formula, expressed breast milk and breastfeeding.
Expressed breast milk was given to treat 117 of 295 episodes of hypoglycaemia (40%) in 105 of 227 infants (46%). Breastfeeding and expressed breast milk feeding did not increase blood glucose concentration compared with dextrose gel and formula feeds. The median volume of expressed breast milk given to the infants was 0.5 mL/kg (range 0.0-7.3). The study authors recognise the volume of expressed breast milk available in the first 48 hours was low and considerably less in amount than the formula that was given to other infants. This is reflected in the absence of changes in blood glucose concentration after expressed breast milk was given.
The study authors then go on to state that “nevertheless, clinicians should understand that expressed breast milk is unlikely to be effective as a sole treatment in a hypoglycaemic baby” (Harris et al., 2017, p. 139). This statement does not account for the possibility of providing extra support to the mother /infant for effective breastfeeding, optimising expression of breast milk, and the use of donor breast milk to increase the total amount of breast milk given. Although Harris et al. suggest that clinical management should be focused on supporting breastfeeding rather than expression of breast milk one action does not preclude the other, if carefully and sensitively managed, nor does it eliminate the possibility of supplementation with donor breast milk if considered necessary.
Breastfeeding alone as a treatment in the Harris et al. study was associated with a reduction in the need for a second treatment, independent of the initial blood glucose concentration. Harris et al. also reported that the early breastfeeding of infants whose mothers were diabetic (within the first 30 minutes), resulted in higher blood glucose concentrations than those who received infant formula or those who were not fed. Infants who were breastfed for > 20 minutes soon after birth had less hypoglycaemia in the following 8 hours suggesting that breastfeeding may have a slower but more sustained effect on blood glucose. These are all compelling reasons to provide extra support for mothers whose infants are at risk of hypoglycaemia which include the essential and irreplaceable practices contained in the BFHI Ten Steps to Successful Breastfeeding such as Step 4 which is to facilitate immediate and uninterrupted mother-infant skin-to-skin contact and support mothers to initiate breastfeeding as soon as possible after birth.
DONOR BREAST MILK
A study by Rees et al. (2021) was cited in the neonatal hypoglycaemia guidelines and reported there was a significant increase in blood glucose concentrations of 0.5 mmol/L when breastfeeding was supplemented with donor human milk. The guidelines recommend further research on the effectiveness of donor milk for preventing and treating hypoglycaemia and the effectiveness of expressed breastmilk (mother’s or donor milk) for treating neonatal hypoglycaemia. This requires more national support for formal donor breast milk banking and in situations where there is no bank access, the use of donor milk from securely screened women. Access to a donor breast milk bank and access to donor milk is currently inequitable in Aotearoa New Zealand. Harris et al. (2024) reported peer-to-peer donation in New Zealand is a popular alternative for mothers seeking to donate breast milk, or for parents seeking to receive donor milk to avoid unnecessary exposure to infant formula. Brown et al. (2024) found mothers had mixed experiences
when donating milk to a bank. Donating helped some women to heal from trauma, including infant loss, and mothers who donated felt a sense of achievement while some who could not donate felt excluded, frustrated and rejected. Reasons for being unable to donate were not just related to reasons such as medication or lifestyle issues, but also due to a lack of awareness of milk banks, geographical barriers and a lack of response to enquiries. Because the main recipients of donor breast milk from milk banks are mainly extremely-low-birth-weight, very-low-birth-weight, low-birthweight and growth-restricted infants the criteria for receiving donor milk may not always cover infants at risk of hypoglycaemia in postnatal services. Milk bank priority lists are necessary due to the limited number of donors and often fragile supply of donor breast milk. Expanding services to reduce inequity and to cover infants such as those with hypoglycaemia on postnatal wards who do not meet the milk bank criteria will require consideration of the barriers highlighted by Brown et al. (2024) as well as solving issues such as the high costs of screening donors who are outside of the formal milk bank structure. Donor mothers and midwives should certainly not be required to meet those costs themselves.
PROTECTION AND PRIORITISING OF EXCLUSIVE BREASTFEEDING AND CONCLUSION
From a midwifery perspective, prioritising exclusive breastfeeding and, if needed, expressed breastmilk or donor milk, need to remain the key messages. To protect exclusive breastfeeding the Academy of Breastfeeding Medicine recommend ensuring access to professional support and management with breastfeeding and using donor breast milk as a bridge when supplementation is necessary. Recommendations for supplementation if needed are described in order of preference as, expressed mother’s own milk, donor milk and commercial milk formula. (Feldman-Winter et al., 2024).
Prioritising breastfeeding where possible rather than the expression of breast milk for preventing or treating neonatal hypoglycaemia in the first 48 hours after birth is only feasible when we fully recognise what prioritisation means in this context. The effects of immediate and continuous mother-infant skin-to-skin should be recognised as a key practice to protect breastfeeding. Optimising oxytocin releasing conditions are essential and part of what Bergman (2024, p. 15) describes as an ‘oxytocin paradigm’. 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. Oxytocin production can be influenced through the sensory nervous system and can be increased or inhibited dependent on a variety of factors (Uvnäs Moberg, 2011; 2016). Positive influences include touch, companionship, a quiet environment, feelings of security, and warmth, while stress and anxiety, fear, pain, cold and being rushed will negatively affect oxytocin response. Women who are in stressful situations have reportedly fewer peaks of oxytocin release (Uvnäs Moberg et al., 2020). Support structures to enhance and increase the release of endogenous oxytocin during labour, birth and breastfeeding initiation are easily identified. Creativity and resourcefulness on the part of midwives can provide a safety net to protect physiology and the wellbeing of mothers and babies. Square
References available on request.
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The first pēpi born at Te Puna Wai, Autoia Kynan Te Ihorangi Sharman, born on 8 June 2025.
TAKU WĀHI MAHI MY MIDWIFERY PLACE
KIM
THOMAS
EDITOR
On a beautiful Autumn day in Te Puia Springs on the remote East Cape, whānau and community members gathered to celebrate the reopening and renaming of Aotearoa’s only Māori-owned, kaupapa-Māori birthing unit. The occasion marked the return of a vital service to the East Cape and the beginning of a new chapter. Originally known as Te Puia Primary Birthing Unit, the Ngāti Porou-owned birthing unit was renamed ‘Te Puna Wai’ – the Spring of Water, at a special hui held on May 22.
After years of closure due to extensive damage from Cyclone Gabrielle the unit has reopened to provide maternity care for the community, staffed by three Māori midwives.
Te Puna Wai now offers a full wraparound maternity service, complemented by kaiawhina and a rongoā Māori practitioner, who work in traditional, wairua-based healing systems. Within three weeks of the reopening, the first pēpi was a born at Te Puna Wai with a birthing team of two midwives and the Koka Whakawhānau Rongoā Practitioner.
Nāti Pēpi General Manager Caroline Thompson said the reopening was a milestone for the region. “Babies should be born here. What better for our wāhine than to come here and have their babies, on their own whenua with their own people and reo.
“Many incredible wāhine have walked this path, and we honour them all. From the midwife who once rode out on horseback to reach a māmā, to those who have worked tirelessly, often alone, through storms, long nights, and shifting health systems – they have each carried the kaupapa
with strength, aroha, and unwavering commitment. We acknowledge every one of them.”
Following the unit’s closure, the decision was made in 2023 to relocate the last remaining midwife to Gisborne. Since then, whānau had been forced to travel an average of 200km round trip to have their babies – a situation Caroline describes as ‘unacceptable’.
“In November 2024, the iwi secured philanthropic funding to support the reopening of the unit. As soon as the mahi to restore the space began, something remarkable happened.
After years of trying to recruit we began receiving enquiries from midwives wanting to return. By January 2025, we had three experienced Ngāti Porou midwives who had returned home to contribute to this kaupapa.”
These midwives – Ruth Chisholm, Nicola Swann, and Vicky Henry are now part of the team providing care at Te Puna Wai. For Vicky Henry returning to the East Cape has been deeply meaningful.
“I knew when I did midwifery that I wanted to come home and give back to the whānau. I started as a new graduate midwife up here when the maternity unit was in a state of disrepair.
To see it reopen and be part of that has been amazing – it’s been life changing for me moving back home."
She said the hope is whānau across the rohe know they have a safe place to come and birth how they want to."
“Te Puna Wai be open 24/7, 365 days of the year. It belongs to the community.” Square
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Midwife Aotearoa New Zealand is published quarterly for the New Zealand College of Midwives. The articles and reports printed in this newsletter are the views of the authors and not necessarily those of the New Zealand College of Midwives, its publishers or printers. This publication is provided on the basis that New Zealand College of Midwives is not responsible for the results of any actions taken on the basis of information in these articles and reports, nor for any error or omission from these articles and reports and that the College is not hereby engaged in rendering advice or services. New Zealand College of Midwives expressly disclaims all and any liability and responsibility to any person in respect of anything and of the consequences of anything done, or omitted to be done, by any such a person in reliance, whether wholly or partially upon the whole or any part of the contents of this publication. The College acknowledges and respects diversity of identities through the language used in this publication. Te reo Māori is prioritised, in commitment to tāngata whenua and te Tiriti o Waitangi. To maintain narrative flow, the editorial style may use a variety of terms. Direct citation of others’ work maintains the original authors’ language, and contributing writers’ language preferences are respected. All advertising content is subject to the Advertising Standards Authority Codes of Practice and is the responsibility of the advertiser. Contents Copyright 2025 by New Zealand College of Midwives. All rights reserved. No article or advertisement may be reproduced without written permission. ISSN: 2703–4546.
