Midwife Aotearoa New Zealand

HALF A CENTURY OF MATERNITY CARE MEET ILA NORTHE P.22 MIDWIFERY RECORD KEEPING

COVID-19 FAQS

CARE OF REFUGEE WOMEN

KETEPARAHA/TOOLKIT P.18

THE VACCINE DURING PREGNANCY P.20

RESETTLEMENT IN AOTEROA NEW ZEALAND P.26

ISSUE 103 DECEMBER 2021 I THE MAGAZINE OF THE NEW ZEALAND COLLEGE OF MIDWIVES

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ISSUE 103 DECEMBER 2021

FORUM FROM THE PRESIDENT

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4. OUR CONNECTIONS WILL REMAIN FROM THE CHIEF EXECUTIVE 5. A TESTING TIME FOR MIDWIVES AND WHĀNAU 8. BULLETIN 10. YOUR COLLEGE 12. YOUR UNION 14. YOUR MIDWIFERY BUSINESS

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FEATURES 16. NGĀ MĀIA 17. PRACTICE UPDATE - 10 KEY POINTS: FETAL ASSESSMENT 18. MIDWIFERY RECORD KEEPING KETEPARAHA/TOOLKIT 20. COVID-19 VACCINATION FAQS 22. HALF A CENTURY OF MATERNITY CARE

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26. PRACTICE UPDATE - CARE FOR REFUGEE WOMEN 28. BREASTFEEDING CONNECTION 32. PASIFIKA 33. COLLEGE EDUCATION PLANNING: 2022 34. MY MIDWIFERY / MY MIDWIFE DIRECTORY

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EDITOR Amellia Kapa, P: (03) 377 2732 E: communications@nzcom.org.nz

ADVERTISING POLICY AND DISCLAIMER: The New Zealand College of Midwives maintains a schedule of guidelines to exclude advertisements for products or services that are not aligned with its principles and ethics. Every effort is made to ensure that advertising in the magazine falls within those guidelines.

ADVERTISING ENQUIRIES Hayley McMurtrie, P: (03) 372 9741 E: Hayley.m@nzcom.org.nz

Where advertising is accepted, this does not imply endorsement by the College of the product or service being promoted.

MATERIAL & BOOKING Deadlines for March 2022 Advertising Booking: 14 February 2022 Advertising Copy: 21 February 2022

Aotearoa New Zealand Midwife 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. All advertising content is subject to the Advertising Standards Authority Codes of Practice and is the responsibility of the advertiser. Contents Copyright 2020 by New Zealand College of Midwives.

All rights reserved. No article or advertisement may be reproduced without written permission. ISSN: 2703-4546.

ISSUE 103 DECEMBER 2021 | 3

FROM THE EDITOR

FROM THE PRESIDENT

from the president, new zealand college of midwives, nicole pihema Ki te kāhore he whakakitenga ka ngaro te iwi (Without foresight or vision the people will be lost) - Nā Kingi Tāwhiao Pōtatau Te Wherowhero nau mai haere mai ki Aotearoa New Zealand Midwife

I’m honoured to have been re-elected as President and appreciative of the opportunity to

strength, and it does not serve any of us - as

As another year draws to a close, I wish I

continue this mahi for another term. As both a

individuals, or as a profession - to be divided.

could say it's turned out to be better than

college and a profession, we still have a lot more

The implementation of the Covid-19 vaccination

what we could have hoped for. But I think

work to do in terms of building our capacity for

mandate for midwives has struck a chord for

we can all agree, this year was even more

emerging leaders. We’re all so busy with the day-

many and the polarisation we are seeing within

tumultuous than last, and we are yet to see

to-day work of being midwives, but succession

our workforce is saddening and unnecessary.

how the health sector will fare as Covid-19,

planning needs to be a priority moving forward,

health system reforms and vaccine mandates

and a significant amount of our time and energy

dominate the landscape.

must be channeled into preparing for our future.

Given the topic is ever-present in discussions with whānau, we address some FAQs about Covid-19 vaccination in pregnancy and the postnatal period on p.20, with some helpful suggestions for how to answer the curlier questions.

Every single action we take now, in our various

For some light relief, Ila Northe shares her reflections on 51 years of working in maternity on p.22, and Breastfeeding Connection resumes its focus on supplementary feeding on p.28, honing in on challenges that persist beyond discharge from a postnatal facility.

fortify our profession by increasing capability and

The intersecting stories of Chinese LMC midwife Zeta Zhang and midwifery student Einnoc Chiu are shared on p.34, reiterating once again the significance of cultural safety within the midwifery partnership.

We hope all midwives are able to take a break at some point over the holiday season, to reconnect with whānau and friends, and rejuvenate before 2022 gets underway. As always, we acknowledge the incredible work and dedication of midwives all over the country, who have continued to provide the highest quality of care for wāhine, pēpi and whānau, despite living in a constant state of uncertainty.

positions of leadership - be they within our whānau, communities, workplaces or professional bodies - impacts the future trajectory of midwifery in Aotearoa. My focus for this next term is the same as it always has been; to continue to capacity within, carving out a path for our future midwifery leaders to use as a guide.

The next two years will be quite significant

Historically, unity has always been midwifery’s

It’s more important than ever before to look after each other and keep each other safe.

Though personal views on the vaccination mandate may vary between midwives, there is no place for unkind or intolerant behaviour toward one another. Those of our valued colleagues who are choosing not to be vaccinated at this time are deserving of support, and the knowledge that the door is - and always will be - open, should they decide to return to practice. Our equally valued colleagues who are choosing to be vaccinated at this time also deserve patience and understanding; the reality of workforce shortages

regarding health reform, but given the roll-out

is already upon them, as they prepare for the

of these changes will be occurring over the

imminent increase in community transmission

next 12 months, it remains to be seen how much

and the unavoidable reality of caring for pregnant

of an impact these will have over the remainder

wāhine who contract Covid-19.

of my term, and indeed how much we, as a profession, will also have an influence on the proposed changes.

Other changes closer to home deserve

Thus far in Aotearoa we have managed to avoid the horrors other countries around the world have faced. We haven’t experienced anything even remotely close to the mortality

acknowledgment at this time, and I’d like to

and morbidity rates seen overseas, and for

thank Jean Te Huia for the many years of service

many, I fear seeing is believing. For those of

she dedicated tirelessly to the profession in her

us facing challenges with colleagues, friends

position as CEO of Ngā Māia. Her courage in

or whānau who may be feeling hesitant about

highlighting systemic injustices has affected real

receiving the vaccine, I implore you all to

change for whānau who were previously invisible,

approach discussions with patience, kindness

and we can only hope that systemic review

and compassion. One day, hopefully in the not-

will continue and any resultant changes will be

too-distant future, when Covid-19 is no longer

Mā te wā,

permanent. We look forward to continuing to

the dominant discourse, our connections with

Amellia Kapa, Editor/Communications Advisor

work with Ngā Māia and their new board in a way

one another will remain, and the quality of those

that honours te Tiriti, to make midwifery stronger

future connections will depend entirely on how

and more unified than ever before.

we conduct ourselves today.

Email: communications@nzcom.org.nz

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FROM THE CEO

A TESTING TIME FOR MIDWIVES AND WHĀNAU Aotearoa’s stringent Covid-19 response has impacted significantly on our lives since early 2020; however, in comparison to the majority of the world, we have been able to enjoy relative freedom. Horror stories of prolonged lockdowns or periods of significant restrictions, strained health care systems and high death rates around the world - although shocking - seemed like a remote and somewhat abstract reality.

However, with the arrival of the delta variant in August this year, Aotearoa entered a new phase in its Covid-19 response, with a number of significant changes, including the move from an elimination approach to a suppression strategy, and the announcement of vaccine mandates.

Tāmaki Makau-rau has continued to bear the burden of Covid-19 since August,

with a prolonged lockdown, and Auckland midwives have once again carried out their essential work in a highly professional way, in often very difficult circumstances. As we sit on the cusp of a wave of community transmission throughout the remainder of the country, we will all soon be experiencing what the rest of the world has been living with for almost two years, and our lives will be changed forever.

The past few months have been a testing time for midwives and whānau having babies, as we have had to come to terms with the reality that living with Covid-19 will soon become our permanent state of being.

ALISON EDDY CHIEF EXECUTIVE

Fortunately, the impacts of the ‘new normal’ will be considerably softened, as we will have achieved extremely high vaccination rates by international standards before widespread community transmission occurs.

As a result, hopefully we will not have to live through the ghastly experiences that other countries have, to quite the same extent.

ISSUE 103 DECEMBER 2021 | 5

FROM THE CEO

Reconciling the government’s mandate with our unique professional perspective was always going to require deep introspection and enquiry; weighing up our personal right to choose with the rights of those we care for to have their risk of exposure minimised by their health provider.

Some weeks before the vaccine mandate for healthcare workers was announced, Ministry of Health officials approached the College to seek our feedback on what we considered the likely consequences of such a mandate. Our advice to them was that we did not support mandating vaccination and that an educative, supportive approach was preferable, considering: • The vast majority of midwives were already vaccinated.

• The workforce was already stretched, therefore we didn’t want to lose any midwives.

• Contradicting the informed consent principle sits uncomfortably for our profession and could result in the opposite of the desired effect.

We advised that soon-to-be implemented strategies - like vaccine certificates - were more likely to shift vaccine-hesitant individuals towards acceptance, as the reality of reduced personal freedoms sunk in. Why not let these initiatives have an impact, before considering a mandate?

However, like all things Covid-19, the government’s decision needed to be made swiftly, and although the initial proposed timeframe was unfeasibly tight, the decision itself was not unexpected. The decision aligns with the government’s overall response to the pandemic thus far, which has always aimed to preserve the life and health of New Zealanders, protect our economy, minimise inequities and mitigate any deleterious effects on our health system. Although our culture is one which highly values personal freedom,

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there is strong public and cross-party political support for the mandate. There is also international policy alignment, as vaccine mandates are becoming increasingly common overseas.

As a profession whose history and underpinning tenets are intrinsically linked to advocacy for women’s rights to informed choice, the government’s decision to mandate vaccination for health workers was always going to pose some philosophical questions for us. We have a proud history of standing up for women’s rights to decline medical interventions. Many of these interventions were applied universally during childbirth, without supporting evidence, often for spurious reasons or clinician convenience, as opposed to serving the best interests of the women involved. We are the profession caring for women in all birth settings and we adapt this care in order to respect women’s self-knowledge and expertise.

We know that healthcare choices are deeply linked to personal beliefs, and that the right to choose is an essential element of being autonomous over our bodies, enabling us to feel as though we have agency over our lives and sense of wellbeing.

So, reconciling the government’s mandate with our unique professional perspective was always going to require deep introspection and enquiry; weighing up our personal right to choose with the rights of those we care for.

The College has heard from many members as the reality of what this mandate means has become clearer. Overwhelmingly, the majority of members recognise that vaccination is a strongly evidence-based intervention, which reduces the likelihood of transmitting the virus to others, as well as the severity of its impacts on the individual.

For many of us, Covid-19 has changed the way we view the world and reset our priorities and values, including how we perceive our individual rights in contrast to our responsibilities as health professionals, or even as New Zealand citizens.

Importantly, Auckland midwives have been highly supportive of the mandate, which demonstrates that lived experience of risk of exposure to Covid-19 infection is perhaps a reality check that those of us throughout the rest of the country have not yet experienced.

Strong support has also come from those whose families are based in highly-affected countries overseas.

The experience of Auckland hospitals demonstrates that managing unvaccinated workers following exposure events to

Covid-19 positive patients is problematic.

These workers pose a greater potential risk to health service users than vaccinated workers, and they are also unprotected from Covid-19 infection or its most severe effects (in the case of a breakthrough infection), and therefore need to be managed differently in the workplace.

The College board met to discuss its response to the mandate and their views have already been communicated to members via email. The board recognised that pregnant women are highly vulnerable to the consequences of the delta variant compared to the non-pregnant population, and are also a more vaccine-hesitant population, due to intergenerational and widely communicated concerns about medications during pregnancy. It reiterated that being a midwife comes with a set of professional responsibilities, and personal choice regarding vaccination has consequences beyond a midwife’s own individual situation.

Being vaccinated protects ourselves and those we care for, and this is the overriding professional imperative at this point in time.

The minority of members who are opposed to being vaccinated against Covid-19 cite concerns about informed consent and their rights to refuse health care treatments. The important distinction is that anyone’s rights to refuse vaccination are enshrined in law, and nobody can be forced to receive the vaccine, however if midwives want to remain in the workforce, being vaccinated is now a legal requirement of this privileged position of responsibility. Our role in advocacy for women’s choices and rights in childbirth remains fundamental to our profession and is not diminished by accepting vaccination as a necessary requirement of midwifery practice at this exceptional time.

I have spoken with and heard from members who state an intention to leave, as they do not wish to be vaccinated.

Although I have great sympathy for the argument about informed choice, it is obvious from many of these discussions that concerns about vaccination are heavily influenced by misinformation, which is increasingly well organised, privately funded and sophisticated. The various rationale frequently cite misinterpreted data from scientific papers, unsubstantiated theoretical concerns from discredited ‘experts’, or ‘experts’ with a qualification unrelated to the area they are commenting on. The arguments often demonstrate a lack of understanding about how vaccine development and safety

monitoring is undertaken, from clinical trials, to observational and epidemiological data, to the reporting and separate analysis of vaccine adverse event surveillance data.

This statement is not intended to denigrate the intelligence of anyone who is vaccine-hesitant. Confirmation bias is present in all of us, and social media algorithms send us down rabbit-holes which feed us the information we are seeking, to confirm our point of view as correct. Indeed, the science of vaccine development, testing, monitoring and surveillance is highly complex and its analysis relies on multiple academic studies, which thousands of scientists are working on pieces of globally. It cannot be readily described or understood in brief interactions, but the nature of a chaotic and worrisome event like a pandemic leads us to search for simplicity and certainty.

TAUTOKO ŪKAIPŌ MAI I TŌ TĀTOU AO

We must also acknowledge the impact of colonisation, racism and medicalisation on the level of trust or mistrust in public institutions and ‘mainstream’ medicine. Those who have experienced negative interactions and associated impacts have sound reasons for being wary of recommendations from a system that has caused them harm. Perversely, these groups may suffer further harm through higher infection rates, due to being unvaccinated.

• Non-Māori partnering Wahine Māori • Clinical Case Studies • Adoption, Surrogacy, LGBTQIA • Baby-led Weaning • Changing Baby Sleep Conversations • Relactation Experiences • At-Breast Supplementation • Breastfeeding Twins and Triplets • Benign Breast Disease • Nipple and Breast Wounds • Breastfeeding with HIV • Ankyloglossia: what we know • and much more!

As a midwife, I am proud of my profession’s knowledge and expertise, which is underpinned by the art and science of midwifery. My midwifery knowledge and education, and my Master’s degree in public health have given me the ability to read and critique scientific literature about the Covid-19 vaccine and interpret it in the context of my practice. It has also helped me to understand public health principles and consider midwifery’s role in responses like the one we currently face.

But I am not an immunologist, nor a public health expert.

And just as I expect those specialists to respect midwifery knowledge and expertise, I respect theirs. I believe that these professionals approach their work with the same integrity as midwives. When they approve vaccines, or make decisions about which population groups can safely receive them, I trust that they have the same primary motive as midwives - to do no harm. I do not believe that immunologists, public health experts, independent agencies like Medsafe, or the New Zealand government, would recommend or approve the Covid-19 vaccine unless they were confident that the evidence supported this decision.

I have detected high levels of emotion from midwives across the spectrum, with many upset that public statements made by midwives against vaccination have diminished the credibility of the profession, whilst others are angry that a core principle of their professional worldview is under threat.

The common theme is that midwives hold high ideals and strong views of their professional roles and responsibilities, as natural advocates. It is deeply distressing to lose any midwives from practice; for them personally, and the profession as a whole. We must ensure that the door is left open for them to return to the profession if, over time, they feel ready to return.

For this moment, because of our unique position in the world of being comparatively far less harmed by Covid-19 infection, vaccination is the pathway to the best protection available, for ourselves and our wider communities, including every new whānau in Aotearoa. Square

ISSUE 103 DECEMBER 2021 | 7

Lactation Support Around Our World

NZLCA Conference 2022: Online 11 Feb to 6 March 2022 20 outstanding pre-recorded sessions which can be viewed on-line at any time between 11 February and 6 March 2022!

To meet your ongoing education requirements, NZLCA is offering you a bumper number of education hours at a one-off heavily discounted rate.

IBLCE CERPS pending. Approved up to 20 hours by the NZ Midwifery Council.

BOOK NOW – For details go to www.nzlca.org.nz or email megan@allsortedlifestyle.co.nz

Midwives

Midwifery – for you it’s so much more than a career…it’s a calling.

And now the chance to do what you love, in a location we know you’ll love, is calling your name.

Now is the time to breathe new life, energy and optimism into your career and quality of life, here with us in the Wellington region. So, take a breath, relax and ready yourself for the move of a lifetime.

If there was one word to encapsulate what we have to offer you, it’s ‘options’. Whether it’s core midwifery, community midwifery, primary, secondary or tertiary care... you’ll find an opportunity here that’s sure to suit. It’s in large part to do with the choice of locations we have for midwives across the greater Wellington region. With Wellington Regional Hospital, Hutt Hospital in Lower Hutt, the Kenepuru Maternity Unit at Kenepuru Community Hospital, and

the Paraparaumu Maternity Unit on the Kapiti Coast all potential bases for you, finding your ideal fit will be a breeze. And regardless of where you end up, you can look forward to working with highly supportive, passionate colleagues, caring for diverse multicultural communities.

As well as excellent scope to develop your career while enjoying our unique, patient-focused model of care, the Wellington region is renowned as a true lifestyle hotspot thanks to stunning natural surrounds, modern amenities, less density and the space to just breathe easy.

If you’re an experienced midwife who’s excited at what’s on offer with us, and ready to explore how you could make the move happen, talk to us today.

To apply or find out more go to justbreathemidwives.co.nz

BULLETIN

bulletin prescribing update

The College was invited to the Safer prescribing and dispensing hui convened by the Ministry of Health, along with other health professional and regulatory bodies.

The purpose of the forum was to initiate cross-sector dialogue to support safer person-centred dispensing and prescribing practices. In New Zealand, medical practitioners, nurse practitioners, nurse prescribers, optometrist prescribers, dietitian prescribers, dentists, pharmacist

PRIMARY MATERNITY SERVICES NOTICE 2021 OPERATIONAL

(third, fourth etc) language does not require an interpreter.

• When interpretation is required, it is best practice to use a qualified interpreter, not a family member. Funded telephone interpreting services are being made available for LMC midwives to use via the Ministry of Health.

• If a woman declines the involvement of an interpreter, the midwife documents this and

The Primary Maternity Services Notice 2007 was

may still register the woman and provide

updated earlier this year and the new Notice

care to the best of her ability with the level

2021 was officially implemented last month.

of communication possible.

Significant changes to the notice, including the provision of new modules such as the Additional Care Supplement, and modifications to payments for travel were detailed in the September 2021 issue of Midwife and can be viewed in full on the Ministry’s website.

Changes to the notice regarding interpreting

• If the midwife speaks the woman’s language fluently, the midwife can deliver care in that language and does not require an external interpreter. There is no specific funding available for midwives providing this additional service, however aspects of the Additional Care Supplement will apply,

prescribers and midwives have developed

services are detailed below:

for example, if the woman is from one of

prescribing competencies in isolation from

DA2 Registration - (6) Where English is not

the identified ethnic groups or is a former

each other.

the woman’s first language, information

The hui members identified a number of common priorities across all professions and areas that could be strengthened to support

on the registration form about the services to be provided must be interpreted for the woman. This interpretation discussion must be

safer prescribing across the board. There

documented in the woman’s record.

was a clear impetus for a single standard for

The guide to the notice clarifies that where

prescribing across all groups rather than the

a woman is not proficient in reading, writing

individually developed standards currently

or speaking English, the information on the

being used, and this work will be led by the

registration form (where it is written in English)

Pharmacy Council.

about the services to be provided must be

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interpreted for the woman. This means: • A woman who speaks English as a second

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refugee, and/or if antenatal visits take more than 60 minutes on 2 or more occasions.

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andrea gilkison promoted to associate professor The College congratulates Andrea Gilkison on her promotion to Associate Professor at AUT. As the current Associate Head of Postgraduate in AUT’s School of Clinical Sciences, Andrea is also the co-director of the university’s Centre for Midwifery and Women’s Health Research and her contribution to the field of midwifery

BULLETIN

Associate Professor Andrea Gilkison

education and research over the years has been invaluable. Among many notable achievements, Andrea led the implementation of a narrative-centred curriculum within AUT’s undergraduate midwifery programme in 2005; an approach which continues to underpin the delivery of the programme today.

māmā aroha goes digital

Andrea’s own PhD explored teachers and students’ experiences of this implementation, and her other research interests extend to include sustainable midwifery practices and rural midwifery.

As co-chair of the Trans-Tasman midwifery education consortium, and editor of the New Zealand College of Midwives Journal, Andrea's work has a ripple effect for the entire midwifery community, and the College wishes to acknowledge her dedication to the advancement of midwifery education and

other health professionals to use in assisting

research both nationally and internationally.

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CELEBRATING DOCTORATES

Following the success of the Māmā Aroha breastfeeding talk cards, its digital companion – the Māmā Aroha phone app, has been

make recommendations to management, in order to achieve the College’s strategic goals.

Committee members contribute to the discussions to enable:

launched. Designed to provide a more

• Sound financial oversight

visually informative resource for midwives and

• Consensus on any recommendations made

māmā and whānau to breastfeed for longer, the app is a collaboration between creator and midwife Amy Wray and Hāpai Te Hauora, New Zealand Breastfeeding Alliance, Mokopuna Ora and Kiwa Digital.

Midwives and whānau can download the free

to Chief Executive and/or National Board • Informed strategic direction and advice • Accurate reporting back and/or approval seeking from National Board on major financial and/or strategic decisions • Support for the Chief Executive.

phone app through the App Store (Apple) or

Nominations - including a cover letter and

Google Play (Android).

CV - to be emailed to lynda.o@nzcom.org.nz

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by 4 February 2022.

FINANCE COMMITTEE INDEPENDENT MEMBER: CALL FOR NOMINATIONS

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the President, Chief Executive (ex officio), three

christmas hours at the college

The College’s Finance Committee consists of midwife representatives (each from a different

The College’s national office will close for the

Another two midwives have recently completed their doctorates despite the numerous challenges of working within the confines of a pandemic.

College region), a consumer representative,

Christmas holidays on Friday 24 December at

plus one midwife College member, elected

12 noon, reopening on Wednesday 5 January.

by membership for a three-year term. The

There will be arrangements in place for any

College is now seeking nominations for

midwife who needs urgent legal advice during

The College would like to congratulate the following midwives:

the midwife member role. If more than one

this period. Telephone the office on (03) 377

nomination is received, an online ballot will

2732 and a recorded message will have the

be undertaken.

relevant contact information.

Christine Mellor - Midwives and obstetricians experience of place in relation to supporting physiological birth (AUT) Lynn Chapman - Exploring student-teacher relational connectedness within midwifery education: A phenomenological inquiry (AUT). square

The Finance Committee meets either face-to-face or via Zoom for up to two hours

Staff at the national office wish all members a happy and safe Christmas and New Year.

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prior to each National Board meeting (three times per year).

The committee has delegated responsibility from the National Board to provide advice and

ISSUE 103 DECEMBER 2021 | 9

YOUR COLLEGE

college AGM updates

information on Covid-19 vaccination during

Universal Declaration of Human Rights, the

The following statements were ratified at

pregnancy, which is available in the Covid-19

International Covenant on Civil and Political

section of the College website.

Rights, the Convention on the Elimination of

the recent AGM and will be available on the College website in due course: • Consensus Statement: Climate change, midwifery and environmental sustainability • Position Statement: Covid vaccination for midwives

All Forms of Discrimination Against Women

MINISTRY OF HEALTH MATERNITY GUIDELINES UPDATES The following guidelines have now been through College membership consultation and will be finalised and published in due course:

The fee proposal which members were consulted on was also ratified, with the new member fee structure being implemented from 1 February 2022.

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• National Consensus Guideline for Treatment of Postpartum Haemorrhage | Aratohu Tūtohu ā-Motu mō te Tumahu Ikura Whakawhānau Pēpi • Guidelines for Consultation with Obstetric

COVID-19

and Related Medical Services (Referral

College advisors have continued to receive

Guidelines) | Aratohu Kimi Āwhina ki Te

a large volume of correspondence and calls from midwives (employed and self-employed) and members of the public about Covid-19,

Ratonga Whakawhānau Pēpi, Ratonga Rata (Ngā Aratohu Tuku Atu) • Diagnosis and Treatment of Hypertension

including risk screening, concerns about

and Pre-eclampsia in Pregnancy in

contacts and places of interest, vaccination and

Aotearoa New Zealand: A clinical practice

other issues. We have been working closely

guideline (te reo Māori title yet to be

with midwife members, DHB midwifery leaders,

confirmed)

and the Ministry of Health to ensure midwives’ experiences and concerns are heard. The College has also worked with the Immunisation Advisory Centre to produce video and webinar

We are grateful once again for the time and expertise members have contributed throughout the feedback processes for each guideline and wish to reassure members that the College submission was fully informed by the feedback received.

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college supports baby bridge initiative In October, the College was approached by a group called the Baby Bridge Initiative to advocate for pregnant women and partners of pregnant people to be included in the emergency MIQ allocation criteria.

The College wrote a letter of support for this initiative, citing the importance of antenatal care and family support during pregnancy and birth, along with relevant articles from the

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(CEDAW), and the International Covenant on Economic, Social and Cultural Rights. The Baby Bridge Initiative has now been successful in gaining MIQ places for a number of people, however there are still many more pregnant (or partners of pregnant) citizens and residents of Aotearoa who are still unable to return due to the current settings.

The College also escalated concerns about midwives who were stuck overseas and unable to secure an MIQ place. The announcement of 300 MIQ places per month for health workers is welcome news.

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THE MATERNITY SERVICES CONSUMER SATISFACTION SURVEY The Ministry has regularly conducted surveys to measure and monitor women’s satisfaction with primary maternity services since 1999. The sixth assessment of consumer satisfaction with maternity services is planned and will go live in 2022. In addition to the usual quantitative survey, there will be a set of qualitative focusgroup work to gather more in-depth detail from Māori, Pasifika, disabled women, bereaved women/parents and rainbow whānau. Lesley Dixon is the College representative on the Expert Advisory Group; her role will involve providing advice and guidance.

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NEWBORN PULSE OXIMETRY SCREENING GUIDELINE Public consultation on the draft guidelines to support newborn pulse oximetry screening to detect congenital heart defects was completed in May 2021. Submissions have now been reviewed, with the guideline, algorithm and information sheets currently being updated to ensure consistency and clarity.

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YOUR COLLEGE

taonga tuku iho, knowledge translation for equity in pre-term birth in aotearoa This project aims to develop a national best practice guidance document on the care of women and babies at risk of pre-term birth, and the resources needed for its effective implementation, to ensure consistently improved outcomes. The project is led by a team of principal investigators, with support from the Carosika Project, Taonga Tuku Iho, its steering group and allied groups, societies, clinicians, researchers and consumers. It is funded by the Health Research Council and Ministry of Health through the Maternity Services Research Programme.

College representatives on this project are Lesley Dixon and Violet Clapham, who are members of the review panel and will be contributing to a systematic quality appraisal of current clinical practice guidelines relevant to pre-term birth care and outcomes in Aotearoa. Midwifery representatives on the Carosika Project Steering Group are Jean Te Huia and Beverly Te Huia for Ngā Māia, Claire MacDonald for the College, and Judith McAra-Couper. A Pasifika midwife representative is currently being sought.

There will be several opportunities to contribute to this work over the coming 18 months. Please do get involved as you hear about them, so that we can create the systems, tools and resources that support midwives and other healthcare professionals to provide care that improves and creates equity in outcomes for all women and their babies.

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ISSUE 103 DECEMBER 2021 | 11

YOUR UNION

JILL OVENS MERAS CO-LEADER (INDUSTRIAL)

DHB-employed members celebrate MECA gains MERAS members have seen a pay increase of $5,800, including a $4,000 “down payment” on the pay equity settlement, with more to come when we settle the pay equity claim. There is also a $6,000 pro-rated lump sum, which will come off the final settlement of the pay equity back pay.

Core midwives on Step 7 are now on $84,153 a year (a 7.4% increase) and new graduates will start on $65,022 (an increase of nearly 10%). MERAS members covered by the DHBs MECA have been backpaid to 2 August and have received a $600 lump sum payment, pro-rated for part-timers and casuals.

Those whose base salary is above $100,000 also received the pay rise from 2 August. This had been a bone of contention in light of the Government’s wage restraint requirements across the public sector.

The new MECA rates keep the 1.25% differential for midwives because of the increase MERAS won in August 2020.

Members have welcomed the new Continuing Professional Development (CPD) fund, with $1,000 put aside for every MERAS member. The fund will carry over

for another year if not all has been spent.

Because the money is not individualised, MERAS members can apply for more than $1,000 and a committee that includes MERAS reps will decide on the merits of each application.

entitlement).

The settlement also included:

• Designated senior midwives to be paid

• New safe staffing provisions and an independent review of CCDM (Trendcare).

• A midwifery career pathway and a dedicated gender-neutral process to evaluate new

MERAS workplace reps when they start.

• Coverage of maternity care assistants who are midwifery students working in a housekeeping role, giving them the opportunity to earn money while they are studying for their degree.

• The development of a policy to ensure flight midwives are looked after by the receiving

12 | AOTEAROA NEW ZEALAND MIDWIFE

(this won’t come off members’ sick leave

• Sick leave will not be pro-rated and all 10 days

• New employees to be introduced to the

03 372 9738

events, including paid special leave if needed

Non-union midwives are now paying a bargaining fee to contribute to the cost of negotiating the MECA. A separate ballot had to be held that included non-union midwives, and MERAS members were successful in winning the ballot in every DHB.

and new meal and rest break provisions.

www.meras.midwife.org.nz

• Better support around sentinel/adverse

• MERAS to work with midwifery leaders on

• Inclusion of the MERAS Rostering Guidelines

Email: merasmembership.co.nz

and the College last year.

MERAS members can claim reimbursement of their NZ College of Midwives membership fees from the CPD fund.

midwifery positions.

For MERAS Membership

DHB following a survey conducted by MERAS

flexible work arrangements, including working from home where appropriate. will be paid at relevant daily pay.

• ACC top-up for injuries sustained through workplace assaults (won’t come off sick leave).

• Whāngai recognised in parental leave. overtime for coming in to respond to VRM after hours.

• Encouragement for DHBs to have a designated senior midwife on all shifts and wards in secondary and tertiary units.

MIDWIFERY PAY EQUITY NEGOTIATIONS UNDERWAY Negotiations between the DHBs and the unions (MERAS and NZNO) to settle the midwifery pay equity claim for DHBemployed midwives are underway and are on track to be concluded before Christmas.

MERAS reps on the negotiating team are Jill Ovens, Caroline Conroy, Karen Gray, Victoria Christian (NRC chair) and Michelle Archer (NRC deputy chair).

It has already been established, based on interviews and comparative remuneration data gathered through the pay equity process, that midwives are undervalued and underpaid.

It is acknowledged by the DHBs that this can be attributed to discrimination because midwifery is a women-dominated profession and because midwives’ pay has been influenced by perceptions of the value of ‘women’s work’.

The negotiations are to agree on the extent of the undervaluation and may result in a different salary structure. The pay adjustments could also be delivered in instalments.

Both the MERAS and NZNO MECAs stipulate that any settlement is to be backdated to 31 December 2019.

The negotiations are being held by Zoom because several of the team are from Auckland and not able to travel.

Pay equity settlements need to be renewed to maintain pay equity. Part of what we are negotiating is the question of when the current

Pay equity negotiations in a Covid world - Top Left to Right: Kevin Jenkins (Crown observer), Jill Ovens (MERAS), Lesley Harry (NZNO), Jenny Downes (DHBs). Middle Left to Right: Michelle Archer (MERAS), Dee (Ministry of Health), Caroline Conroy (MERAS), Karen Gray (MERAS). Bottom Left to Right: Glenda Alexander (NZNO), Jane Douglas (DHBs), Victoria Christian (MERAS), Joanna Ramsay (NZNO).

settlement will be renegotiated. This could coincide with the renewal of the two unions’ MECAs (from October 2022 to April 2023).

Once we have agreement with the DHBs on the pay equity claim, DHB-employed

midwives (including MERAS, NZNO and non-union midwives) will vote on the settlement. MERAS will then initiate a claim with non-DHB maternity units to cover other employed midwives. Square

ISSUE 103 DECEMBER 2021 | 13

YOUR MIDWIFERY BUSINESS

WAYNE ROBERTSON EXECUTIVE DIRECTOR, MMPO

building and maintaining better practices One of the tools community midwives have at their disposal, to help ensure continued access to primary maternity care in Aotearoa as well as a sustainable profession, is to form together into midwifery group practices.

Mostly, these practices evolve and grow naturally through relationships built during study or clinical placements, and a clear shared philosophy around the provision of midwifery continuity-of-care.

Key features of a sustainable practice There are some critical components and considerations that need to be built into any practice, to help ensure not only its sustainability, but also that of the midwives within it. These are: • A clear, sustainable, and agreed sense of purpose • Adopting a supportive legal structure for the practice and the individual midwives • Being clear and fair about a way of providing midwifery care and distributing workload evenly amongst the midwives • Connecting and fostering good relationships with the wider maternity team in the area • Identifying and managing risks well • Balanced use of digital technology • Understanding cash flow (including bank accounts, Section 88 revenue, business costs) and taxation.

The main purpose when forming a group practice is to ensure access to quality midwifery care by making sure each community midwife is working as sustainably as possible. This is done through strong collegiality and teamwork, and specifically through managing and sharing time, money, knowledge and risk.

Usually, no two practices are structured or operate in exactly the same way, as each is required to adapt not only to the pregnant population cared for, but also the locality within which this care is generally provided.

WHERE TO START? The optimal time to ensure a practice is set up to be sustainable, is before it’s initiated.

However, whilst there are always new practices being established, most LMC community midwives start their midwifery career by joining an existing practice.

In all situations, the most important element to ensuring a sustainable practice is setting aside specific time to connect with each other and discuss the practice itself.

Many LMC community midwives do this through their regular practice meetings, however currently due to workforce pressure, there isn’t always enough time available to fully discuss important sustainability areas such as those identified above.

More specifically, the questions practice members should be asking themselves are: • How will the practice induct and train new midwives? And how will retiring midwives exit?

• Will the practice share on-call requirements?

And how will this be performed?

• How will the practice support professional development?

14 | AOTEAROA NEW ZEALAND MIDWIFE

• How will annual and other leave (such as sick, emergency and bereavement) requirements be managed?

• If care is to be shared (by agreement or necessity) how will this be paid out?

• Irrespective of the way a practice is formed or currently exists, it is critical that a formal and written record is retained of all practice items discussed and agreed.

This could be in the form of a signed practice agreement that can be easily added to and iterated as time goes by.

OTHER CONSIDERATIONS WHEN SETTING UP AND/OR MANAGING A GROUP PRACTICE? Dependent on the size of the practice and in an ideal world, the responsibility and accountability for safeguarding the sustainability of the midwifery practice does not rest on the shoulders of just one midwife.

Every midwife possesses specific skills and attributes, such as being: • A good communicator • A strong negotiator • An empathetic supporter • An organiser • Finance or business minded • An administrator • A mentor • Uniquely expert or skilled

The success of any practice, therefore, lies in sharing the practice workload wisely by matching each midwife’s unique skillset to a practice need and/or responsibility.

LMC Midwife/Midwives Buller Region SOMETIMES THERE JUST ISN’T ENOUGH TIME In reality, sometimes there isn’t enough time available to work on sustaining the practice, or a required skillset may not exist within a particular group.

There are several ways that these challenges can be managed, ensuring that the right amount of time and money are invested in sustaining and protecting the practice, such as: 1. Using digital applications that are proven to save time (and are cost effective) by automating relevant practice needs and workflows: a. Tiaki app for referrals, practice calendar, actions, and contact/ address navigation b. Xero accounting software for business and finance requirements c. Microsoft Teams for a more central, secure, and private practice connection including video meetings, in-practice messaging, emails, knowledge base, document sharing and

If your idea of a perfect work life balance is being part of a small community with the backdrop of the spectacular West Coast, then this is the role for you!

Your day will be spent providing antenatal and postnatal care to the wāhine of the Buller region as well as supporting homebirths or births in our primary birthing unit at Kawatiri, Buller Hospital and the new facilities when they are complete.

Outside of work, you will have access to some of Aotearoa’s best kept scenic secrets as well as low cost housing and daily flights from Westport to Wellington and Queenstown.

You will also have access to education, training and support from the team at Te Nikau and collegial support from your central and southern colleagues providing LMC care.

You will be eligible to access some great benefits including: • • • •

storage.

2. Employing or contracting a practice administrator (for a minimum number of hours) to perform more indirect midwifery care tasks and manage business and financial needs. This could include: a. Managing and actioning emails as required b. Managing the overall practice calendar, including on-call, leave, practice meetings, key re-certification dates and actions, and professional development opportunities.

a current caseload a sustainability package per woman under your care remote rural mileage (all women qualify) support via the College of Midwives Rural Midwifery Recruitment and Retention Service including nine days locum cover per year + extra locum days paid by WCDHB.

You will need current: • • •

NZ Midwifery Registration and a current practicing certificate Be vaccinated for COVID-19 under the governments mandate A new graduate midwife will be considered.

To apply please call Dawn Kremers 03 7697803 or email: dawn.kremers@wcdhb.health.nz

c. Being the initial point of contact for women seeking a midwife d. Managing and communicating sector updates e. Managing Section 88 claims and payments f. Managing day-to-day banking and Xero transactions g. Managing insurances

WE ARE HERE TO SUPPORT YOU WITH THESE DECISIONS

looking after you supporting your practice

When considering these types of initiatives for any practice, it is sometimes difficult to properly assess the benefits achievable against the expected cost outlay.

The MMPO, together with the College, continue to build a more comprehensive toolkit and supportive framework to help practices and LMC community midwives. If you wish to discuss any aspect of this article further, please email mmpo@mmpo. org.nz or call to discuss on (03) 377 2485. Square

MMPO, the Midwifery and Maternity Providers Organisation provides self employed community midwives with a supportive practice management system.

Complete community midwifery support, including:

www.mmpo.org.nz mmpo@mmpo.org.nz 03 377 2485

• Care data and digital records (including Tiaki) • Notice 21 (Section 88) claiming • Business set up (including Xero) and day-to-day support • • Equipment insurance • Workforce and locum services

ISSUE 103 DECEMBER 2021 | 15

Call 03 377 2485 or visit www.mmpo.org.nz to find out more

NGĀ MĀIA

LISA KELLY CHAIRPERSON NGĀ MĀIA TRUST (NGAI TAI)

Ngā Māia:

He warū ki runga he rarē ki raro.

E te tī e te tā, e ngā kārangatanga maha o te motū, tēnā tātou katoa.

As we leave the first quarter, we recall Matariki’s farewell for our departed ki Hawaiki nui. Heoi anō Ngā Māia Trust Aotearoa - Māori Midwives wish to acknowledge the outgoing trustees, Pauline Allan Downs & Ripeka Ormsby for their years of dedicated service. We also farewell former CEO Jean Te Huia, who has been shifting and evolving with Ngā Māia for the last seven years.

Ngā Māia Trust is proud of Jean’s commitment

Many exciting activities are taking place

mātauranga Māori. A fair and equitable Treaty

to amplify the voices of those whānau

nationwide; Ngā Māia Trust are holding

partner would examine their relationship with

impacted by the poor application of the

important space for tertiary providers and

power and know there is no mātauranga Māori

Vulnerable Childrens Act through our national

the College to create partnerships, and

without Māori practitioners. We encourage

collective. Similarly her dynamic and special

together, realise the professional aspirations

one and all to behave in a way that upholds

character would champion and support

for recruitment and retention of both tauira

the tino rangatiratanga of tangata whenua.

our tauira Māori to navigate the struggles

and kaiwhakawhānau Māori. We aim to

A fair and equitable Treaty partner would be

of institutional & systemic racism. Kāore he

provide transparent and accountable

concerned that wāhine hapū will therefore lose

arikarika ngā mihi mōu e te manawa tītī o

governance while maintaining effective

access to highly skilled and valuable health

Waimarama me tō tira o Kahungunu. Ahakoa

two-way communications with our

resources from their communities. We watch

ngā piki me ngā heke he whānau kotahi tātou.

membership. We will complete a pre-existing

closely to see how birth choices for wāhine

service arrangement with the Ministry of

hapū will be erroded in an already pressurised

kura. Surrounded by koanga (spring) offerings

Health for the benefit of wāhine Māori and

western maternity system.

we are reminded of the potential a fresh

kaiwhakawhānau. Registrations of interest

start brings. Faced with significant internal

for projects will be forwarded to your rōpu/

transitions and worrisome challenges for our

rohe once available, to form sub-committees/

profession, we felt it was justified to turn to our

working groups to achieve these.

Mate atu rā he tētē kura, ara mai anō he tētē

membership for support and direction. After

We are acutely aware of the challenges our

Ngā Māia want to extend their heartfelt aroha to those who will cease to practice from 15 November and encourage all members to show care and compassion at this time.

Equally, we wish to express our aroha and

much deliberation with our kaumātua kuia,

profession is facing as the vaccine mandate

a successful AGM elected four new trustees;

tautoko to those who have made the decision

divides us. We are very concerned that the

we therefore welcome Katarina Komene kei

to be vaccinated and remain in the workforce.

Māori midwifery workforce will be erroded,

Te Taitokerau, Jaydeen Waretini-Beaumont kei

with as many as 50 Māori midwives indicating

We are aware of the immense strain our

Te Waipounamu, Te Rina Joseph kei Tauranga

they will cease practice on 15 November

moana and Tamara Karu kei Waikato, who will

2021, of an estimated total of 100 nationwide,

join myself, Lisa Kelly kei Waiāriki, and Sarah

meaning the Māori workforce will make up 50%

Wills kei Te Waipounamu. We think this full

of those lost. Ironically, this will directly conflict

complement of six trustees is a reflection of

with Pae Ora (Healthy Futures) Bill which seeks

a broader reach and an appetite for change

to design equitable access to health service

within our membership.

and enhance cultural capability through

16 | AOTEAROA NEW ZEALAND MIDWIFE

further reduced workforce will be under and we will do everything in our power to support members through the challenges that lie ahead.

E tautoko ana tō whānau, tō hapū i a koe otirā ki ō ōati, aue mau tonu e.

Kia kaha! Kia māia! Kia manawanui!

square

PRACTICE

practice updates

top 10 points for midwives: assessment and promotion of fetal wellbeing in pregnancy

(GAP) education has been undertaken prior to using them).

6 / In some situations, fundal height measurement may be unreliable, e.g. BMI 35+, large fibroids or polyhydramnios. It is not appropriate to use fundal height measurement to assess uterine growth in multiple pregnancies.

JACQUI ANDERSON

7 / An ultrasound scan referral is

MIDWIFERY ADVISOR

recommended for wāhine when potential growth issues are identified on a growth chart: slow or static growth; growth crossing centile

Following the ratification of the College’s

of the first trimester (12 – 13+6) can be offered

lines or a single fundal height below the 10th

practice guidance document Assessment and

to wāhine to estimate gestation. Evidence

centile; slow or static growth if fundal height is

promotion of fetal wellbeing during pregnancy

does not support early first trimester scan for

not increasing consistently as expected.

in 2021, a selection of the relevant practice

dating purposes only.

points are highlighted below.

1 / Where any risk factors or concerns for

3 / Fundal height and abdominal palpation assessment of fetal growth is most consistent

fetal growth are identified, recommend:

when undertaken by the same practitioner,

•

where possible.

Referral for consultation (as per Referral Guidelines)

•

Increased assessments and monitoring of fetal growth including ultrasound growth scans

•

For wāhine at increased risk of FGR and/or pre-eclampsia, consider commencing low dose aspirin (100-150mg nocte) prior to 16 weeks gestation.

4 / From 26-28 weeks gestation measure fundal height, but not more frequently than every 2-3 weeks, and record in centimetres, preferably on the wahine’s customised growth chart.

5 / When using a customised fetal growth chart to plot fundal height, practitioners are required to be conversant with their conditions (for example a condition for the

2 / If LMP or time of conception is unknown or

use of the Perinatal Institute GROW© charts is

uncertain, an ultrasound scan towards the end

that the Growth Assessment Programme

8 / Provide wāhine with information on what to expect in relation to fetal movements as pregnancy progresses, including the presence of a diurnal pattern and development of longer quiet periods of fetal activity during the day near term.

9 / For all wāhine reporting decreased fetal movements, offer a full assessment including identifying the presence or absence of a fetal heart rate and a period of CTG monitoring.

10 / Growth issues may be indicated

by USS when there is a discrepancy between the head circumference and the abdominal circumference centiles and/or the measurements cross centiles.

square

ISSUE 103 DECEMBER 2021 | 17

FEATURE

ELAINE GRAY MIDWIFERY ADVISOR LIZ JAMES REGISTERED MIDWIFE

SUPPORTING AND ENHANCING EFFECTIVE MIDWIFERY RECORD KEEPING IN AOTEAROA: KETEPARAHA/TOOLKIT Record keeping is an important aspect of midwifery practice and the topic of maintaining health care records is a frequent topic of discussion with midwives when advice is sought from the College midwifery advisors.

The College developed the Keteparaha to reveal processes that we hope enable midwives to reconsider ways of maintaining records, and also to provide tips and tools to support all midwives in practice. We invite all midwives to read the Keteparaha, which can be found on the College website.

Snippets taken from the Keteparaha are shared here, including a table of guiding principles for documentation: RECORDING INFORMED CONSENT FROM THE WOMAN Consider collating resources such as flyers and information sources that you share with wāhine into a resource folder/kete. Midwives are encouraged to include any resources that support health literacy of wāhine. This can be updated annually in collaboration with your practice partners/colleagues. Each year’s resources can be dated and stored with your health care records to demonstrate the information you shared for that year.

PROFESSIONAL STYLE OF WRITING Writing that is spread out is usually easier to follow rather than paragraphs laid out as a

18 | AOTEAROA NEW ZEALAND MIDWIFE

single large block of text. It is recommended that midwives space out their writing to allow for easier review of key points. For example, midwives may choose to indent specific points of care.

ASSESSMENTS, INVESTIGATIONS, AND RESULTS It can be beneficial to step back and take a pause to undertake a holistic assessment of the wahine and/or pēpe. This can be particularly valuable when the woman’s care is complex or new complexities have arisen.

LOCUM WORK AND HEALTH CARE RECORDS As a locum midwife, consider keeping a log of the wāhine you have cared for recording their NHI, date of care provided and whether the care is in the antenatal, labour and birth, or postnatal period. This can support you when you prepare for your MSR. As the locum, you could consider maintaining a running summary of the care you have given. This can be used to write a formal handover when care is returning to the LMC midwife. square

FEATURE

Guiding principles for documentation

ISSUE 103 DECEMBER 2021 | 19

FEATURE

covid-19 vaccination in pregnancy: faqs and how midwives might answer them As the trusted health providers for whānau during pregnancy, birth and postpartum, midwives are well placed to provide clear and accurate information about Covid-19 vaccination during pregnancy and the first few weeks with a new baby.

Covid-19 vaccination is strongly recommended during pregnancy, due to the increasing concern about the adverse outcomes in unvaccinated pregnant and early postpartum wāhine infected with the delta variant. College Midwifery Advisor Claire MacDonald teamed up with Covid Immunisation Education Facilitators Jennifer Andrews and Abbey Palmer from the Immunisation Advisory Centre (IMAC) to provide some answers to questions you may be asked when discussing the recommendation to be vaccinated while pregnant.

CLAIRE MACDONALD MIDWIFERY ADVISOR

20 | AOTEAROA NEW ZEALAND MIDWIFE

FEATURE

HOW DO I KNOW THE VACCINE IS SAFE FOR MY BABY WHEN THERE ARE NO LONG-TERM TRIALS? Comirnaty is safe for the infant; no parts of the vaccine can pass to the baby. Only antibodies from the mother cross the placenta. It’s similar to Boostrix (pertussis containing vaccine), except the Comirnaty vaccine is made by an mRNA technology (McLaurin-Jiang et al., 2021).

The safety of the Covid-19 vaccination during pregnancy is understood in two ways. Firstly, there is a large amount of international data showing no increase in adverse pregnancy

vaccine is performing over time and to help

(Dagan et al., 2021). Furthermore, Covid-19

inform other vaccines that may be developed

infection increases the risk of pre-term birth,

from this platform (Ministry of Health, 2021a).

which has long-term consequences for the baby.

Placebo groups are now being offered the

Being vaccinated reduces the chance of severe

vaccine because it is unethical not to offer them

Covid-19 infection and therefore pre-term birth.

an effective vaccine. Any rare safety concerns detected by now (and have, like myocarditis)

I PREFER TO USE RONGOĀ OR ALTERNATIVE MEDICINES

(Ministry of Health, 2021a).

The best recommendation is that rongoā or

related to the vaccine would have been

SHOULD I WAIT FOR A DIFFERENT VACCINE INSTEAD OF COMINARTY (PFIZER/BIONTECH)?

alternative medicines be used alongside the vaccine, rather than in place of it. Rongoā has amazing benefits to overall hauoratanga, especially for wāhine hapū, but current rongoā

outcomes in those who are vaccinated in

mRNA technology has been around for a while.

and alternative medicines do not have the

pregnancy compared with unvaccinated

Human trials of cancer vaccines using the same

antibodies needed to fight Covid-19 (Te Rōpū

pregnancies. In contrast, there is good evidence

mRNA technology have been taking place since

Whakakaupapa Urutā, n.d.).

that Covid-19 infection can be very serious and

at least 2011. Comirnaty (Pfizer/BioNTech) is a

life-threatening in pregnancy. Secondly, we

messenger RNA (mRNA) vaccine. The vaccine

understand how the vaccine works, and that

provides the instructions to our cells to make

there is no known mechanism by which the

a protein identical to the Coronavirus surface

As with all vaccines on the New Zealand

vaccine could harm the baby from a biological

spike protein. This protein is seen by our immune

Immunisation Schedule, there are no safety

and immunological perspective – this is known

system as foreign and it then responds, creating

concerns about getting the mRNA Covid-19

as ‘first principles’.

memory cells ready for the next time the virus

vaccine while breastfeeding your baby. By

enters our body – either after another dose of

being vaccinated, women can provide some

the vaccine, or due to infection with the virus

protection against Covid-19 for their babies in

(CDC, 2021). mRNA does not enter the nucleus of

their milk (McLaurin-Jiang et al., 2021).

CAN THE VACCINE CAUSE MISCARRIAGE/STILLBIRTH/FETAL ANOMALIES/PLACENTAL ANOMALIES? No. There is good evidence that the vaccine is not associated with any adverse pregnancy outcomes (Zauche et al., 2021a; Dagan et al., 2021).

Covid-19 infection is associated with more severe disease in those who are pregnant.

Infection with the virus in pregnancy is also associated with pre-term birth and pathological changes to the vasculature of placenta, that can lead to poor fetal growth and pregnancy complications such as hypertension and preeclampsia, and a higher rate of caesarean section (Zauche et al., 2021b; Kharbanda et al., 2021). So it is far safer to be vaccinated against Covid-19 than to be infected with Covid-19 in pregnancy.

I’VE HEARD THIS IS AN EXPERIMENTAL VACCINE BECAUSE TRIALS ARE NOT FINISHING UNTIL 2023 – SHOULD I WAIT UNTIL THEN?

the cell (where our DNA is), therefore it does not alter DNA (CDC, 2021).

WHAT ABOUT THE PERTUSSIS VACCINATION DURING PREGNANCY? DO I HAVE TO WAIT BETWEEN THIS AND THE COVID-19 VACCINATION?

WHĀNGAI Ū (BREASTFEEDING): CAN I GET THE COVID-19 VACCINE?

Studies show there are no additional safety concerns or issues with continuing to breastfeed after vaccination (McLaurin-Jiang et al., 2021; Ministry of Health, 2021c).

DOES THE COVID-19 VACCINE AFFECT THE IMMUNE SYSTEM IN WĀHINE HAPŪ?

We are now much more familiar with the

As we know, the immune system is suppressed

side effects of Covid-19 vaccine, therefore

in pregnancy to allow for the fetus to develop

other vaccines can be given at the same

undisturbed. This puts pregnant people at

time, or immediately before or after Covid-19

much higher risk of severe infection if they

vaccination. There is no wait time between

develop Covid-19. What this also means is that

Covid-19 vaccine and other vaccines (except for

the reactivity and immunogenicity is reduced

Zostavax) (Ministry of Health, 2021b).

in pregnancy, so the immune response to the vaccine is not as robust as for those who are not

DO I EVEN NEED THE VACCINE IF I'M YOUNG AND HEALTHY? Covid-19 infection when pregnant - or soon after pregnancy - substantially increases the risk of severe disease. When compared with non-pregnant people, Covid-19 in pregnancy increases the risk of admission to an intensive

pregnant. However, protective antibodies are still produced at a rate that is high enough to significantly reduce the chances of experiencing moderate to severe disease, along with the highrisk tactics the immune system would deploy if it had not been prepared by the vaccine (Bookstein et al., 2021; Falsaperla et al., 2021).

Comirnaty is not an experimental vaccine –

care unit by up to four times. Twice as many

there is lots of safety and effectiveness data

pregnant women of the same age with

after hundreds of millions of doses have been

symptomatic Covid-19 die than those with

given worldwide (Butt et al., 2021). Clinical trials

Covid-19 who are not pregnant (Zambrano et

continue for years after any vaccine has been

al., 2021; Allotey et al., 2021). All those who are

approved for use, and Medsafe will continue to

pregnant are strongly recommended to get the

receive all information from Pfizer as part of an

vaccine. The vaccine protects you and reduces

ongoing process. Comirnaty is fully approved

the risk of being seriously ill from Covid-19. It

by FDA and EMA now. The trials follow long-term

also protects your baby, as there is evidence

effectiveness and secondary endpoints that

that babies can get antibodies through the

to fight the actual disease (IMAC, 2021).

placenta that help protect them from Covid-19

References available on request.

provide more information about how well the

CAN I GET COVID-19 FROM THE COMINARTY (PFIZER) VACCINE? Comirnaty is an inactive vaccine. Inactivated vaccines do not contain live viruses or bacteria, and therefore cannot cause disease. You may feel unwell after having the vaccine, but this is a normal, expected response. This tells us your body is working to produce the antibodies square

ISSUE 103 DECEMBER 2021 | 21

FEATURE

Ila Northe (back row, second from left) and the staff of Napier's McHardy Maternity Home in 1977.

22 | AOTEAROA NEW ZEALAND MIDWIFE

FEATURE

AMELLIA KAPA COMMUNICATIONS ADVISOR

reflections on half a century of maternity care Ila Northe’s career in maternity began in 1970, when she trained as a maternity nurse in Hastings. Today, 51 years on, you can still find her working at the very same hospital where it all began. Ila shares her reflections on half a century of maternity care with Amellia Kapa.

Ila chuckles as she recounts the tale of how she fell into midwifery. In 1970, the 19-year-old was living in her hometown of Napier, working for a finance company, with plans to become an accountant.

But a fateful road trip with a midwife friend would change her life path considerably.

“I went away with the woman who was the head of maternity in Hastings at the time, and I came back from the trip and thought: ‘I might try that’.

So I quit my job, and two weeks later I started my maternity nurse training. She must have really sold it to me,” she laughs.

Eighteen months later, Ila was qualified and started work as a junior maternity nurse at Hawke’s Bay Fallen Soldiers’ Memorial Hospital in Hastings.

“The first baby I caught was birthed by a woman on her hands and knees,” she recalls. “And the second was born in the bath in the prep room. I couldn’t reach the bell because the woman had grabbed on to me. But eventually someone came to my assistance.”

The ‘prep room’, she explains, was where women were taken when they first arrived in labour. “They had a perineal shave and an enema, which was carried out on a board on top of a bath,” Ila says.

“Of course all of the women were looked after by GPs in those days. So we’d let the doctor know they had arrived and when they were fully dilated.”

Progress in labour was assessed differently in her early days. “We used to do rectal examinations then, not vaginal examinations. I didn’t start doing vaginal

examinations until I did my midwifery training.”

Talking it through with Ila over the phone, it appears the rationale for this method wasn’t explained to her at the time, and she didn’t feel it was her place to ask. “In those days it wasn’t like it is for students now. We didn’t question anything,” she says.

Despite the hierarchical structures, Ila looks back fondly on her early experiences, revealing a lighthearted, fun side to her work that’s seldom - if ever - seen today.

“Long antenatal stays for conditions like preeclampsia, antepartum haemorrhage and cardiac conditions were common,” she explains. “We don’t see as many long-term antenatal patients now due to the introduction of new technology and drugs, but we used to get to know patients and their families really well, and lots of tricks were played between the patients and staff.”

Surprises of all kinds were commonplace, due to the lack of technology and monitoring. “I remember there was a woman who had been admitted to the antenatal ward with an abnormal fetal heart rate.

She ended up birthing twins,” she laughs.

She recalls stopping premature labour with alcohol drips, and doctors performing high amniotomies - rupturing the hindwaters with Drew Smythe catheters - to induce labour. Some situations called for a dose of castor oil to get labour started, and “syntocinon sniffs” were par for the course.

ISSUE 103 DECEMBER 2021 | 23

FEATURE

Surprises of all kinds were commonplace, due to the lack of technology and monitoring. “I remember there was a woman who had been admitted to the antenatal ward with an abnormal fetal heart rate. She ended up birthing twins,” she laughs.

Ila celebrated her 70th birthday in October of this year.

As a junior maternity nurse, Ila was told that if she wanted to learn about abnormal pregnancy and labour, she would need to do her midwifery training. So in 1974, she did just that, completing the six-month midwifery programme through St Helens Hospital in Wellington.

explains. “All the women would get together, because we had physio classes in the mornings. Baby bathing would be demonstrated in a group as well. There was that interaction. Some people would make life-long friends on the maternity ward.”

“Most of the women were birthed on their backs or in lithotomy in Wellington,” she notes, in contrast to what she had seen in the Hawke’s Bay, where most babies were birthed in a left lateral position.

Postnatal care on the whole was an entirely different kettle of fish in the ‘70s. “New mothers weren’t allowed out of bed, so we did bed sponges and four hourly ‘perineal toilets’. You’d give them a bedpan and wash their perineum down,” she explains. “Thinking back now, I wonder why. Most women didn’t go home until between 6-10 days postnatal.”

“We ran oxytocin infusions without pumps, but got very good at counting the drops and palpating the contractions manually; documenting every contraction and time on a clipboard. We did have some fetal monitors, but they were only just being introduced. One of the obstetricians liked us to give the oxytocin with crowning, which meant the placenta just about arrived with the baby’s feet.”

“Pain relief in labour, if required, was entonox or pethidine injection and although caesarean rates were low in the 70s, there were a lot more forceps births - particularly high forceps, which are not performed today.”

Ila required sign-off on 40 births and five follow-throughs as part of her midwifery training. “Before we sat our final state exam, we had to do an oral exam in front of a panel of an obstetrician and midwife. I was on night shift for mine and was hastily woken with a knock on my door, as I’d slept in.

Somehow I managed to pass,” she laughs.

St Helens was the first hospital where Ila saw women rooming-in with their babies in single rooms, and although she understood the importance of it, what she observed was the effect of isolation. “I’d never seen so many women in tears.

In shared rooms, if there was a primip sharing with a multip, the more experienced mothers would support the new ones, reassuring them about what was normal.”

There was a sense of connectedness on shared wards, she

24 | AOTEAROA NEW ZEALAND MIDWIFE

Uncovering the true significance of the gut microbiome was still a few decades away, so although breastfeeding was encouraged, it was ironically conditional. “Most babies were handed to their mothers at birth, but not breastfed until a nasogastric tube had been passed and clear fluids of Karilac and water given. All babies were kept in the nursery, and taken out to their mothers to feed four-hourly. We used to put the babies in a white wooden trolley - which held 10-12 babies wheel it down to the postnatal ward, and hand them out to their mothers. The women would have to wash their nipples before feeding and then we’d give them Vaseline squares for afterwards.”

One of the most surprising revelations of all, however, comes at the end of a list of routine interventions for newborns. “Vitamin K wasn’t routinely given to all babies; only forceps and caesarean sections. Eye drops were given to all babies, and Māori babies had iron injections.”

Ila vaguely recalls these iron injections being given as part of a clinical trial, and a quick scour of the internet reveals a journal article dated 1970, entitled Māori infant health: Trial of intramuscular ir to prevent anaemia in Māori babies, with another prospective study, also from the ‘70s focusing on nutritional anaemia in Māori infants. Sadly, abstracts for the articles are not available electronically.

Once Ila completed her midwifery training in Wellington, she returned to the Hawke’s Bay and carried on working at the McHardy Maternity Home, a large old homestead in Napier that was converted into a maternity facility in 1917. Its grand ballroom had been repurposed as an eight-bed maternity ward and Ila has fond memories of her time there. “Working at McHardy was great. We had great team spirit. We all knew not to interrupt the older midwives when they were in their office picking their racehorses.”

In 1978, Napier’s maternity facilities were rehomed in Arohaina, a new unit attached to Napier Hospital. And with new premises, came new rules. “Patients were no longer able to smoke in their rooms," Ila explains. “We had a designated smoking room, or they could smoke on the balcony.”

She describes the introduction of modern technologies such as CTG machines, infusion pumps and ultrasound scanning as hallmarks of the 80s, along with the arrival of epidurals for pain relief and the welcoming of husbands into birth rooms.

The most significant change, of course, was yet to come. In 1991, following the passing of the Nurses Amendment Act 1990, Ila, along with friend and fellow Hawke’s Bay midwife Julie Kinloch, were the first midwives in the region to become LMCs and gain access agreements.

“That was interesting,” Ila says. “Because some midwives were actually against it. It was a huge new step. We got great support from the women and their families; they were the ones who fought for the law change.”

Ila’s perspective on the continuity-of-care model is that its value may have been highest when it was first introduced. “In those days I felt the model really worked. I think because the women who wanted midwives back then would actively come and seek us out. Whereas today, it’s the standard care people receive.”

In her early days as an LMC, one particular experience revealed to Ila just how significant her newly defined role actually was. “It wasn’t until I went back for the second pregnancy that the husband told me the woman had cried every day since I’d left,” she says. “That really made me think; you do play a big part in their lives.”

She’s observed significant changes in the way women view labour and birth over her 51 years too, not necessarily all for the best. “I think they’re more scared now, because they know so much. It’s interesting, because you’ll have a nice normal birth, which from the midwife’s point of view went really well, but the woman may not think so because she didn’t have an epidural, or she didn’t get the water birth she wanted.”

After caring for countless women throughout pregnancy, labour and birth, and the transition to motherhood, she’s firm about how things should be and her role in it. “You shouldn’t be fearful all through your pregnancy that something’s going to go wrong, and I think unfortunately these days, people are more fearful that the worst will happen. Birth should be a positive experience, so I try to make it positive.”

Despite recently celebrating her 70th birthday, Ila isn’t showing any signs of stopping just yet. “Colleagues and friends ask me why I’m still working. It’s because I still like the women and I still like the work.”

And she’s proud of the fact that the long, challenging, but fulfilling path she’s been on has ultimately led her back to the place where it all began. “I’ve done a complete circle by finishing my midwifery career working in the hospital where it all started, in 1970,” she concludes. square

ISSUE 103 DECEMBER 2021 | 25

New Year’s resolution...

Become a published author New and published authors are invited to contribute to the New Zealand College of Midwives Journal, an internationally recognised midwifery journal …and we’re happy to help you get started.

See our writing tips for how to: • Develop an article from your dissertation, thesis or research findings • Craft a compelling argument • Overcome writing roadblocks • Prepare your article for publication See www.midwife.org.nz/midwives/ publications/college-journal/

Indexed in Cinahl and accepted for ProQuest and Scopus Articles are scientifically sound and relevant to an international academic or professional audience.

Scopus, 2020

FEATURE

REFUGEE RESETTLEMENT IN AOTEAROA NEW ZEALAND: GUIDE FOR COMMUNITYBASED MIDWIVES AND THE WIDER MATERNITY TEAM CLAIRE MACDONALD MIDWIFERY ADVISOR CAROL BARTLE POLICY ANALYST

The Ministry of Health first published a handbook for health professionals on refugee health care in 2002, designed to support those working in the field to provide culturally safe and effective care across a range of healthcare settings.

The handbook was last updated in 2012, and since then Aotearoa has increased its refugee quota, expanding the number of resettlement locations from eight towns/cities to fourteen. Until now, midwifery care of former refugee women has largely been provided by DHB community midwives, but with the quota increase, more LMC midwives will also become involved. In 2020, the Ministry approached the College to research and develop a dedicated chapter about midwifery and maternity care for the 2021 handbook update.

Each year, Aotearoa accepts and resettles refugees who have been referred by the UN Refugee Agency (UNHCR) and assessed as having met the appropriate criteria (Government of New Zealand 2018). Under the Refugee Convention, Aotearoa has an obligation to accept refugees, and the annual quota increased from 1,000 to 1,500 places in July 2020. In addition, a smaller number of asylum seekers arrive each year.

The human rights of refugees are specified in the 1951 United Nations Convention Relating to the Status of Refugees (the Refugee Convention) and its 1967 protocol. The International Covenant on Civil and Political Rights (ICCPR) and the Convention Against Torture and Other Cruel, Inhumane or Degrading Treatment or Punishment 1984 (CAT) also contain provisions relevant to refugees and New Zealand has ratified all three treaties (Human Rights Commission, 2010).

Once people are accepted into Aotearoa as refugees, they become residents and ultimately citizens. Because of their status as New Zealanders, the chapter refers, in most cases, to ‘former refugees’ rather than ‘refugees’.

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Our approach to this work was to consult closely with members of the former refugee community and share the development of the chapter as it came together. We undertook focus groups with former refugee women who had experiences of receiving and providing midwifery care in Aotearoa, and they provided feedback on the drafts. We were supported and advised by Sahra Ahmed, Refugee Health Nurse from Pegasus Health, as well as Isabella Smart, Midwife Manager at Counties Manukau Health, who provided valuable insight into the provision of midwifery care to women at Te Āhuru Mōwai by the community midwifery service. The College also engaged a peer reviewer: respected academic Dr Ruth De Souza, who has extensive experience in the areas of cultural safety, maternity, migration and health, and social inclusion.

The chapter aims to provide useful information to midwives and other people who might be supporting women from refugee backgrounds. It explores the frameworks and principles for maternity care in Aotearoa as they apply to care for former refugees, follows the woman’s health care journey from offshore to Te Āhuru Mōwai (Mangere Refugee Resettlement Centre), and on to her resettlement region.

It identifies the midwife’s role and the specific additional aspects of care and considerations for former refugee women, including interpreting services, clinical assessment, health promotion, cultural considerations and specific health issues.

While the chapter is focused on maternity care for women from refugee and asylum seeker backgrounds, much of this information will also be relevant to women who have similar backgrounds to former refugees, for example family reunification migrants, as well as women from other migrant backgrounds and the wider maternity population.

People have refugee status for two years after arrival in Aotearoa, during which time former refugees have the support of refugee resettlement services to facilitate their access to necessary services. For a pregnant woman arriving in Aotearoa on humanitarian grounds following forced migration as a refugee or asylum seeker, maternity care may be the first engagement with the health system in this country. Midwives understand that pregnancy involves significant changes in the lives of women and their families. The growth of a family can signal a new start in a new home for former refugees, but it may also involve the expression of physical, emotional or mental health difficulties reflecting the circumstances that led to the woman’s arrival in Aotearoa. Continuity of midwifery care provides an opportunity for the woman and her family to gain confidence, trust and self-efficacy through positive experiences of the health system in their new home country.

All quota refugees spend time at Te Āhuru Mōwai in Mangere, Auckland, when they arrive in Aotearoa. A health check may have been undertaken offshore prior to arrival, but questions about pregnancy are limited to the estimated due date. A midwife from the Counties Manukau Health

FEATURE

community midwifery team visits the woman onsite at Te Āhuru Mōwai to undertake a full midwifery assessment and commences her maternity record. The Counties Manukau midwifery service undertakes to ensure that all maternity information is transferred to the woman’s chosen GP, once known, in her resettlement area. Prior to departure from Te Āhuru Mōwai, the woman is provided with a copy of her maternity care record-to-date, to take to her next midwifery care provider. Where the need for obstetric or medical involvement in the woman’s maternity care has been identified, a referral to the appropriate service/s is made by Counties Manukau Health to the receiving DHB. At time of writing, the process of navigation from the community midwife at Te Āhuru Mōwai to midwifery care in the woman’s resettlement region is yet to be confirmed.

AUCKLAND REGION WAIKATO

For women who become pregnant when they are already in their allocated resettlement location, there is a reasonable likelihood they will access maternity care from an LMC midwife, having followed referral pathways from general practice, social services and recommendations from their local community.

As a population group, newly arrived former refugee women have significant and distinct health care needs. It is important to recognise that there is no homogenous refugee experience or reality, and that as with all people, experiences of pregnancy are personal and diverse. Some health conditions are more commonly experienced by former refugee populations than the general population, but as described in this chapter it is important to avoid assumptions. The chapter provides specific information about a number of conditions, including: vitamin D deficiency; anaemia; haemoglobinopathies; parasitic infections and diseases; infectious diseases; mental health and trauma; and the impact of socioeconomic status and racism on health. The section on female genital mutilation (FGM), also known as female genital cutting, has been updated by Nikki Denholm from FGM NZ. Many women with FGM have unique reproductive and sexual health needs and studies on the experiences of women affected by FGM in western countries indicate that these needs are often poorly understood. The chapter details important information about FGM, its potential complications, and considerations for pregnancy, labour and birth, and postnatal care for women affected by it.

Midwives have the potential to be powerful and enabling health care professionals, who provide care, refer to specialist services as necessary, link women to local and non-governmental organisations (NGOs), and help women and families to trust and navigate the health system in their new homes. We hope this chapter provides useful information for midwives, and other health workers, which will lead to former refugee women experiencing the health system positively, with minimal barriers to accessing culturally safe and appropriate care. This level of care should be the expectation for everyone accessing our maternity service. square When the chapter is published as part of the Refugee Health Care handbook, we will link to it from the College website, www.midwife.org.nz.

WHANGANUI

MANAWATU

LEVIN

MASTERTON

WELLINGTON NELSON BLENHEIM

CHRISTCHURCH ASHBURTON

TIMARU

DUNEDIN

INVERCARGILL

REFUGEE RESETTLEMENT REGIONS EXISTING SETTLEMENTS

NEW SETTLEMENTS

ISSUE 103 DECEMBER 2021 | 27

BREASTFEEDING CONNECTION

BREASTFEEDING CHALLENGES IN THE EARLY POSTNATAL PERIOD: ONGOING DIFFICULTIES

maternal intrapartum medication, including synthetic oxytocin and fentanyl (Brimdyr et al., 2015; Bell et al., 2013; Torvaldson et al., 2006) may have been resolved in terms of infant interest in feeding, infant feeding cues, and feeding sequence organisation, but latching difficulties may persist and milk supply may be under threat. If the reason for the latching problem seems obvious, this will have provided a useful starting point for resolution, and supportive interventions may have already been introduced on the postnatal ward and a feeding plan developed.

Breastfeeding is considered to be a public health priority because evidence shows it is a major determinant of short and long-term infant health, as well as being significantly important for maternal health. This ongoing series of clinically focused breastfeeding articles in Midwife are designed to support midwives by providing evidenced-based and informed updates.

When the otherwise well, non-latching infant goes home, a four-pronged approach is needed so that the woman’s milk supply is protected, and the infant can be supported to continue practising latching and breastfeeding, while being fed expressed breast milk, donor milk, infant formula, or a combination of one or more of those options. Avoidance of complications from any introduced intervention is the fourth prong. Maternal stress, fatigue, despondency and pain may be compromising oxytocin responses, which exacerbate the primary breastfeeding challenge – whatever that may be. In this sense, the provision of oxytocin-releasing conditions for mothers and their infants could be viewed as the underpinning strategy that supports all four prongs. As described in the May edition of Midwife, the creation of a physiologic breastfeeding space (normal/physiological and not pathologic) to support oxytocin responses, which can be visualised as a ‘maternal nest’ or as described by Monbiot (2018) an “oxytocin tent”, is paramount.

CAROL BARTLE POLICY ANALYST

Key threads woven throughout these articles have been: the critical importance of mother and infant skin-to-skin contact; the need for supportive birth recovery practices; support and protection for the development of infant breastfeeding skills; and the provision of oxytocin-releasing conditions for mothers and their infants. These key issues remain just as important for the support of breastfeeding initiation and establishment after the first few days post-birth. Supporting breastfeeding when challenges remain after discharge from a postnatal facility is the focus of this article.

TAKING A BREASTFEEDING CHALLENGE HOME AFTER A MATERNITY FACILITY BIRTH – THE FOUR PRONGS Early support for challenges is essential to protect breastfeeding, and full breastfeeding assessments to diagnose challenges and identify contributing variables are necessary (Stuebe, 2014). The cornerstones of infant feeding: suckling; swallowing; and breathing, are complex tasks and must work in unison for safe and effective feeding (Wolf & Glass, 1992). The majority of well, term, or near-term newborn infants, will manage to co-ordinate feeding at birth, or after their birth recovery. Research suggests that approximately 1% of children in the general population will experience swallowing

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difficulties, although the incidence rate is higher in some populations, such as in infants with cerebral palsy (Dodrill & Gosa, 2015). Feeding issues related to neurological issues are too complex to include in this article, which is focused on the well, nonlatching infant.

Going home with an infant who is still not latching effectively at the breast, or suckling well, is a challenge for multiple reasons, not the least of which is the expanse of work that needs to be done by the woman (and infant) to achieve breastfeeding, and the amount of support needed from the midwife. A slow start to breastfeeding related to infant exposure to

Going home with an infant who is still not latching effectively at the breast, or suckling well, is a challenge for multiple reasons, not the least of which is the expanse of work that needs to be done by the woman (and infant) to achieve breastfeeding, and the amount of support needed from the midwife.

PRONG ONE: MILK SUPPLY When infants are not actively breastfeeding, lactation is fragile, so support to successfully latch and breastfeed is urgent. When lactation is pump-dependent with minimal, if any breastfeeding, there are multiple issues to consider, such as how effective the breast pump is, how often and how long expressing episodes are, and whether all of the available milk is being removed during this time. Access to a good breast pump is important, but there are many cheap and ineffective pumps on the market, and because cost is prohibitive for some families, issues of inequity and access should be considered by midwives. The longer an ineffective pump is being used as the sole, or main, method of milk removal, the less likelihood there will be of achieving full lactation due to the downregulation of prolactin. Involution of the breast will begin to occur if milk is not removed regularly from the breasts. Morton

BREASTFEEDING CONNECTION

(2009) and Morton et al (2009) found that using a combination of hand expression, breast compression and pumping can maximise milk supply (Fig.1). The Morton technique was primarily developed for mothers of pre-term babies not feeding at the breast, but the principles are applicable when there are milk supply issues for babies of any gestation.

Galactagogues are frequently recommended for the therapeutic management of a low milk supply, when strategies for increasing supply have been exhausted. Prescribing pharmaceuticals for low milk supply is an ‘offlabel’ use of medication which raises ethical and professional questions for the individual midwife regarding the appropriateness of this prescribing. Galactagogues, or substances marketed as galactagogues such as lactation cookies, are likely to be in common use by women in Aotearoa as well as in Australia. A cross-sectional study with 1,876 respondents in Australia found that use was common, with 60% of the participants using galactagogues such as lactation cookies (47%), brewer’s yeast (32%), fenugreek (22%), and domperidone (19%). Perceived effectiveness was described as highest for domperidone, and over 23% of the domperidone users described experiencing multiple side-effects compared to 3% for those taking herbal remedies (McBride et al., 2021). Evidence gaps about effectiveness and safety of galactagogues have been identified (Zizzo et al., 2021).

PRONG TWO: SUPPORTING THE INFANT TO LATCH AND BREASTFEED Easy, frequent, stress-free access to the breast is a key strategy when an otherwise well infant is having issues with latching.

There are maternal and infant factors that impact on latching issues for well, full-term babies. For infants it may be anatomical variations, or iatrogenic causes that can be slow to resolve, such as those caused by birth trauma, or separation from the mother, leading to limited time to ‘practise’ at the breast. Maternal issues include some nipple variations such as inverted nipples, or postpartum stress and/or pain.

Infants communicate their responses to events surrounding feeding by state-behaviour, physiologic and/or motor behaviours, and the environment for breastfeeding needs careful consideration, alongside sensitive responses to a distressed infant. Infant cues for feeding need to be clearly understood, as do signals of distress. A distressed infant will be unable to latch and will need calming and comforting before a breastfeed can be attempted or

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BREASTFEEDING CONNECTION

FIG.1 - MORE MILK USING HANDS + PUMP 1000

Milk Volume (ml)

800

600

400

200

0 1

2

3

4

5

6

7

8

Weeks

Hand expression + pump

Pump and hand

Pump only

From Maximising Milk Production with Hands-On Pumping, by Dr Jane Morton, 2017. (https://med.stanford.edu/newborns/professionaleducation/breastfeeding/maximizing-milk-production.html). Copyright by Dr Jane Morton.

re-attempted. Breast-seeking behaviour is seen in hungry, alert infants, or mildly sleepy and mildly hungry infants, but not in frantically crying infants (Smillie, 2008). Positional stability is an important part of stress-free feeding and the infant needs to be well supported, with complete contact with the mother’s body, including infant foot support.

Svennson et al. (2013) found that skin-toskin contact during breastfeeding enhanced positive maternal feelings and shortened the time to resolve latching problems in a cohort of infants (n=103) 1-16 weeks postpartum.

The laid-back position for breastfeeding has been shown to support effective latching at the breast compared to traditional positions, and may also reduce the incidence of nipple pain and nipple trauma (Wang et al, 2021).

Infant chin contact with the breast is one of the triggers for the inborn neurobehavioural feeding programme, as is skin-to-skin contact with the mother (Watson Genna & Sandora, 2008). A common problem for temporarily disorganised (in the feeding sense) infants is when the tongue is not lowered on the approach to the breast, resulting in an ineffective latch, the infant releasing the nipple, and mothers sometimes thinking the infant does not want to feed. Making time for the infant to practise licking, nuzzling and mouthing on the mother’s chest is helpful.

If the infant starts sucking before latching at the breast, the latch attempt needs to wait until the sucking stops (Watson Genna &

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Sandora, 2008). Another issue to consider is the infant who may have been forcefully pushed on to the breast, who has learned to associate distress with a breastfeeding attempt.

Avoiding any pressure at all behind the infant’s head is critical for these infants and a laidback breastfeeding position is ideal in these situations. For some non-latching infants, another strategy to try is for the mother to stand to breastfeed, as this distraction, and change from the usual position can help.

The infant’s body is supported, but will ‘drop’, vertically placing the infant in an alignment position that may support a latch.

Adding a gentle bounce while standing and breastfeeding can also help an infant continue breastfeeding. Walking while breastfeeding is a recommendation for supporting an infant who is going through a breastfeeding ‘strike’ (Glover & Wiessinger, 2008). In some situations, a well-fitting (for the mother and infant), appropriately used, ultra-thin silicone nipple shield can support infants to latch in the short-term. For some women, including those with bilateral inverted nipples, a longerterm use of nipple shields may be necessary.

PRONG THREE: SUPPLEMENTARY FEEDING When there is a latch, lactation and/or breastfeeding issue, supplementary feeds are going to be necessary until there is a resolution of one or all of the challenges.

The primary goals remain feeding the

infant, and optimising the maternal milk supply. Supplements should be given in a way that preserves breastfeeding, with attention paid to the volumes of milk given (limiting to what is necessary for newborn physiology), and supporting the infant to continue practising at the breast (Academy of Breastfeeding Medicine, 2017). Any feeding plan needs to be developed in consultation with the mother, and take into account manageability, feasibility and sustainability.

For example, it is unrealistic to expect a fiveday old non-latching infant to take all their milk requirements via a spoon or syringe.

For mothers who have a low milk supply and whose infants have managed to latch at the breast and are sucking well, a supplementary system using a tube linked to the supplement can be used during a breastfeed to ensure the infant receives the volume needed, until milk supply increases. For infants who are still unable to latch, there are other devices that can be tried, such as finger-feeding, although the evidence for their effectiveness is limited.

If the only feasible option is a bottle and teat, there are ways to try and minimise any negative effects on breastfeeding, which are addressed in the next section.

PRONG FOUR: AVOIDING OR REDUCING COMPLICATIONS Avoiding or reducing complications of any device used to support latching and breastfeeding requires frequent assessment of the issues; reviews of whether the strategy is working, how the mother is managing, and if and when devices can be removed.

These assessments include: maternal and infant wellbeing; the use of a breast pump; supplementary feeding; use of supplementary feeding tubes, cups, bottles and teats; finger feeding; and nipple shields. Avoiding the use of bottles, where possible, can be supportive of breastfeeding, although there are situations when bottles and teats may need to be used, and in some cases, they may continue to be the only option. Interestingly, a Cochrane Systematic Review (2021) found that for pre-term infants, the use of a cup instead of a bottle increased the extent and duration of full and any breastfeeding in pre-term infants up to six months post-discharge, which is a significant finding (Allen et al, 2021). If using bottles and teats for feeding, it is important to elicit a rooting reflex and a wide mouth gape from the infant before inserting the teat. Mimicking the pace, flow and position of breastfeeding by using paced bottle-feeding is also recommended.

Paced bottle-feeding principles include

FEATURE

responsiveness to infant feeding and other cues, holding the infant in a slightly reclined position, holding the bottle in a more horizontal position, taking pauses during the feed, and moving the infant position from right to left, just as with changing breasts during a breastfeed (Toronto Public Health).

WEIGHT ASSESSMENT AND INFANT OUTPUT After lactogenesis II (which occurs around day three but may be delayed), infant urination frequency and volume over a 24-hour cycle should be increasing on a daily basis. By day five, a minimum of 6-8 wet nappies with clear or pale urine over a 24-hour period is expected. Neonatal output is a strong indicator of weight alterations after lactogenesis II. Scant, dark or strongsmelling urine can indicate poor fluid intake, and subsequent infant assessment and breastfeeding evaluation should be a priority (Laing & Wong, 2002). A systematic review found the clinical findings observed in cases of breastfeeding-associated neonatal hypernatremia were decreased urine output, poor feeding, jaundice, high temperature, and irritability or lethargy (Lavagno et al, 2016). Urates in the nappy after day five and/or failure to progress to transitional stools by day five suggests breastfeeding difficulties, and a thorough breastfeeding and weight assessment is necessary (Academy of Breastfeeding Medicine, 2017).

Weight assessment may be promoted as the only reliable indicator of breastfeeding effectiveness, and weight loss patterns used as a foundation from which clinical decisions about infant-feeding care plans are made (Noel-Weiss et al., 2011). Paul et al., (2016) suggest that the majority of newborns take more than a week to return to birthweight and may take longer. Infants who have had a caesarean birth on average take longer to regain their birth weight than those following normal birth. The National Institute for Health and Care Excellence (NICE UK) Faltering Growth Guideline (2017) states that if infants have lost more than 10% of their birth weight in the early days of life, or they have not returned to their birth weight by three weeks of age, that a referral to paediatric services is warranted, but only if there is evidence of illness, marked weight loss, or failure to respond to feeding support.

Some infants, who have had a slow start to breastfeeding but are otherwise well, may take longer to return to birthweight than 14 days (Gonzalez-Viana et al., 2017).

Weight monitoring is only one indicator

of the health and wellbeing of an infant (Brodribb, 2019). Noel-Weiss et al. (2011) and Noonan (2011) suggest that the reliance on weight assessments alone may result in midwives missing red flags, and inaccurately differentiating physiological from pathological weight loss. Weight assessment should be considered one assessment strategy, incorporated within a holistic breastfeeding evaluation that includes the mother's experience of breast fullness, observing infant breastfeeding behaviour, observing milk transfer, and other indications of adequate infant hydration (Noonan, 2011). Kent et al., (2021) demonstrated that after support from health professionals, women were able to identify the signs that their infant was receiving sufficient breastmilk. This included waking for feeds, alertness when awake, number of wet nappies, attachment and sucking patterns, and recognising changes in firmness of the breast before and after feeding.

Breastfeeding challenges such as delay in transitional milk production or nipple pain can impact on the positive signs that women are looking for. Understanding breastfeeding challenges and how to overcome them is important for midwifery practice.

CONCLUSION For mothers of infants who continue to have latching difficulties, long-term feeding decisions may need to be made at some point, and options explored such as whether to continue expressing breast milk for bottle-feeding. In terms of milk supply issues, sometimes lactation does not increase despite all efforts, and at some point the midwife may need to support the breastfeeding woman with a change of plan. The woman may decide to continue breastfeeding with supplements, or to stop breastfeeding. Combination feeding may be a realistic option for many women if the infant has managed to latch at the breast.

Breastfeeding is important to women who plan to breastfeed and the cessation of exclusive breastfeeding can be experienced as unexpected and devastating, leaving women with grief and feelings of loss and failure (Ayton et al., 2019). Research suggests how important it is to understand women's breastfeeding intentions, as the highest risk of postnatal depression was found among women who had planned to breastfeed but found themselves unable to (Borra et al., 2015). Breastfeeding difficulties, or stopping breastfeeding before being ready, has been associated with an increased risk of postpartum depression

(Dennis and McQueen, 2009). Brown et al., (2016) found that issues with pain and physical breastfeeding were most indicative of postnatal depression in comparison to psychosocial reasons, which highlighted the importance of spending time with new mothers to help them with breastfeeding issues such as latching. The research evidence highlights the importance of providing breastfeeding support to women who plan to breastfeed, and compassionate support for women who intended to breastfeed but either did not breastfeed, or didn't meet their own breastfeeding goals. Enabling mothers to come close to their infant and to feel connected, regardless of whether they are breastfeeding or not, and understanding what experiencing severe breastfeeding difficulties means for women, is important (Palmér et al, 2012). square

Key points • Early support for breastfeeding/ latching challenges is essential to protect breastfeeding, and breastfeeding assessments are important.

• Going home with an infant who is still not latching effectively at the breast, or suckling well, is a challenge.

• A four-pronged approach is needed – (1) protect milk supply, (2) support the infant to latch and breastfeed, (3) feed the infant, and (4) avoid complications from any introduced interventions.

• Scaffold oxytocin responses – facilitate conditions that create a ‘maternal nest’/“oxytocin tent”.

• Weight assessment should be considered one assessment strategy, incorporated within a holistic breastfeeding evaluation.

• Understanding loss of breastfeeding grief and the impact severe breastfeeding difficulties may have on women’s wellbeing is important.

• For detailed information about alternative feeding methods see Toronto Public Health’s Breastfeeding Protocols for Health Care Providers: Protocol #18 Alternative Feeding Methods.

References available on request.

ISSUE 103 DECEMBER 2021 | 31

PASIFIKA

KATHLEEN MAKI MIDWIFERY LECTURER, ARA INSTITUTE OF CANTERBURY (TAHITI, COOK ISLANDS) RUTH CHISHOLM, REGISTERED MIDWIFE (NGĀTI POROU, TONGA)

Pasifika perspectives through a South Island lens We are seeing the convergence of a number of significant social issues that compel us to evaluate the foundational philosophies underpinning our profession and determine whether they still hold true in a modern world.

One such tohu to emerge from these changing

and Māori stakeholder fono, in Ōtautahi. This

that is a blessing on its own. I feel less of an

times is Te Ara ō Hine – Tapu Ora; the first

fono brought together midwives, Māori and

outcast and embraced for who I am.”

initiative of its kind by the Ministry of Health

Pasifika leaders from both inside and outside of

to establish funding for the provision of

Ara, researchers, representatives of key groups,

- Chontelle, 3rd year student, Ara Institute of

targeted support for Māori and Pasifika tauira

elders from Māori and Pasifika communities,

in undergraduate midwifery programmes. It is

learning and engagement services for Māori

clear to us that whatever the support structure

and Pacific students, leaders in the health

design outcome, it’s most crucial that tauira

sector, new graduate midwives and current

feel as though they have received practical and

students. Passionate discussions were held, and

targeted support.

aspirations were clearly defined regarding how

Since its implementation earlier this year, the initiative has provided an opportunity for collaboration between the various midwifery education institutions, as well as the chance to consult with past and present Māori and Pasifika students about what supports they believe will be most valuable in sustaining and retaining tauira within midwifery programmes.

this group could support this kaupapa. Just as importantly, whānaungatanga was facilitated

collectively contribute to the undergraduate midwifery journeys.

Finally, the tohu that is Te Ara ō Hine – Tapu case for developing a midwifery curriculum that honours te Tiriti - an essential and fundamental

assist them - the resounding response is that

objective of this initiative.

helped us, as Pasifika midwives, to identify the agencies, organisations, and groups worth connecting with, whose expertise and resources are needed if we are to adopt a wrap-around support network for tauira.

Subsequent to the student consultation, on 6 July 2021, Ara held the first combined Pasifika

32 | AOTEAROA NEW ZEALAND MIDWIFE

challenges that this virus has presented for our North Island midwives and their communities.

From our takiwā down here in the south, to yours, we wish you kaha and aroha as we Kia manuia. square

representative group could individually and

appropriate ways they believe this funding can

The shared whakaaro from students has

It has been perplexing to observe from afar the

prepare to face our own challenges.

complexities they currently face - and the most

contributing to their overall success.

Covid-19 case has arrived in the South Island.

as well as an understanding of how each

Ora, has reminded us of the urgency of the

with each pillar playing a distinct role in

Sadly but expectedly, as we write this, the first

amongst our Māori and Pacific students,

As these students have considered the

students want a range of different supports,

Canterbury.

“Until the degree, I did not understand the importance of my heritage and how much it meant to me. I never understood why I felt misplaced until I was shown where I fit - within the Pasifika community. I am on the journey of learning about my heritage, who I am, and how to bring this into midwifery. My heart feels whole, and I feel at home when I work with Pasifika women. I have so much to learn, but this degree has connected me to my roots. My family in Fiji know who I am now, and we talk...

EDUCATION

college education planning: 2022 Once again in 2021, we have been presented with an eventful year, full of professional challenges that have invited us to consider new ways of practising within the midwifery space. The repercussions of the Covid-19 delta variant have also been felt in the area of continuing midwifery education and for the first time in nearly 16 years, the College has had to cancel almost all of its face-to-face workshops. Nothing, it seems, has escaped the impact of this virus, however despite this, we have been able to explore new ways of moving forward with the College educational calendar. It seems odd to consider, but this time of great change and challenges has created ideal opportunities for 2022.

10

t h

Next year the College will be hosting two

research forum will move to a one-day format

Illuminate forums: one focused on perineal care,

in 2022. The rationale for this change is so

and the other on maternal mental health and

that it can still be hosted as an online forum,

wellbeing. Planning of the forums is currently

should circumstances necessitate it. The call for

underway and confirmed dates will be shared

abstracts can be found below.

with members in the new year. Each forum will be designed for a multidisciplinary audience

We hope that all forums, alongside our new eLearning platform, will provide midwives

and the College will work with other national

with exciting education and professional

professional bodies.

development opportunities, with something for

We are pleased to announce that the 10th

everyone. Webinar series, podcasts and much

Joan Donley Midwifery Forum will be hosted by

more will be hosted via the new eLearning

the Bay of Plenty region and held in Tauranga

platform, and we look forward to sharing the

on Friday 18 November 2022. Due to the as

full calendar with members in the March 2022

yet unknown full impacts of Covid-19, this

issue of Midwife.

B i e n n i a

l

Joan Donley

m i D W i F e rY

researCh ForUm 18 November 2022

TAURANGA

TRUSTPOWER BAY PARK STAD IU M

For further information and submission guidelines visit our website midwife.org.nz

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CALL FOR ABSTRACTS NOW OPEN The purpose of the forum is to provide an opportunity for midwives and others to share ideas, experiences and knowledge through research, audits and postgraduate studies relating to midwifery and maternity care.

Call for abstracts closes 8 February 2022

ISSUE 103 DECEMBER 2021 | 33

FROM BOTH SIDES

my midwifery my midwife Zeta Zhang provides continuity-of-care to Auckland’s Chinese migrant

Einnoc Chiu, a current midwifery student, has had the pleasure of

community and shares her perspectives on the value of shared language and

receiving both Zeta’s midwifery care as a client, and her guidance as a

culture within the midwifery partnership.

preceptor midwife. Here, Einnoc shares her story of completing the circle

Originally from the city of X’ian in China’s Shaanxi province, Zeta arrived on Aotearoa’s shores 20 years ago and wasted no time studying English and gaining a business degree. But a long-held interest in childbirth would eventually lead her down a different path, to pursue a career in midwifery.

with a treasured mentor.

Twenty years ago, Einnoc was in the USA, studying at university, when the September 11 terror attacks shook the world. Her family, understandably concerned about her safety, encouraged Einnoc to join them here in Aotearoa, where they had recently emigrated from Hong Kong.

Zeta started working as an LMC in East Auckland in 2014 and the majority of her caseload is comprised of Chinese migrant women, whose circumstances she can relate to, and vice versa. “Most of my clients have been here for less than 10 years and don’t understand how the maternity system works, even if they have good English,” she explains.

For these women, the challenges of navigating Aotearoa’s maternity system are many, and being cared for by Zeta is like experiencing the comfort of home in a faraway place. “I speak Mandarin, so it’s easy for Chinese women to communicate with me. But

Arriving in Auckland in 2001, Einnoc finished her arts degree and worked as an interpreter for ADHB for a few years. Then in 2015, she gave birth to her first son Luke, and found herself unexpectedly inspired by the midwifery care she received.

“It was my first baby, so I didn’t expect that I could receive such high quality care, or that it would be so personal. They listened to what I needed and I found them amazing,” she says of her first midwife and backup.

Moved by the experience, Einnoc embarked on AUT’s midwifery degree in 2018 and it wasn’t long before

it’s not just about the language,” she explains.

“It’s also about the connection with our culture.

she crossed paths with Zeta, who supervised her first

China is a big country, with 27 provinces, and each

clinical placement. Little did she know of course, the

province not only has their own dialect, but also a

nature of their partnership would undergo a significant

slightly different lifestyle and even a different diet.”

change soon after.

“We love food,” she goes on to say, “so the topic

“I was on placement with Zeta for five weeks and

naturally comes up in appointments. I often learn new

then towards the end of semester I found out I was

things from women about what dishes are unique

pregnant, so I called her immediately to ask if she

to their provinces, and of course we talk about the

could look after me. I knew how she worked and I

best Chinese eateries in Auckland. But it’s also a

knew how she treated the women she cared for - such

great opportunity to discuss nutrition and a balanced

a professional and responsible midwife. So I knew it

diet. Chinese women are at higher risk of developing

needed to be her.”

gestational diabetes, so I talk to them about

Having already started her own journey towards

carbohydrates and ways to reduce that risk.”

becoming a midwife, Einnoc viewed the midwifery

Zeta’s perspectives illuminate how significant shared values are, in the provision of culturally safe care. “Most Chinese women, even if they’ve grown up outside of China, observe a month of confinement after birth; they stay inside, avoid the cold, and eat specially prepared warm foods and fluids that promote healing and lactation. My advice as a midwife doesn’t contradict what they believe, because I understand it.”

Now in her eighth year of LMC practice, Zeta still enjoys her work and finds that creating meaningful partnerships with her clients is effortless.

“It’s easy to establish that intimacy,” she explains.

Bearing witness to her clients’ journeys is a privilege for this midwife, who still remembers what it felt like to be a newcomer to Aotearoa. “I’m always happy to see a mother grow; to go from having zero understanding of the maternity system, to being able to provide for all of her baby’s needs with confidence by the time she’s discharged from my care. That’s the most rewarding part of the job,” Zeta says.

34 | AOTEAROA NEW ZEALAND MIDWIFE

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care she received from Zeta through a different lens, in comparison to the care she had received in her first pregnancy. “I really appreciated that once Zeta started looking after me, she stopped looking at me as a student and never assumed that I knew anything. She saw me as a client and explained everything in detail, just as she would with any other woman. I had such a great amount of trust in her.”

After taking a year off study following the birth of her second son, Osaze, Einnoc resumed her midwifery programme in 2020 and is currently back with Zeta, completing her final clinical placement under her guidance and thoroughly enjoying it.

Having now completed the full circle with her, Einnoc is well positioned to talk about Zeta’s best qualities. “I think every midwife I’ve worked with has their strengths, and Zeta’s in particular is cultural safety. She respects her clients’ choices, but also advises them appropriately, so that she’s always keeping them safe.”

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DIRECTORY

New Zealand College of Midwives Directory President Nicole Pihema Ph 021 609 011 nicolepihema@gmail.com National Office PO Box 21-106, Edgeware, Christchurch 8143 Ph 03 377 2732 Fax 03 377 5662 nzcom@nzcom.org.nz www.midwife.org.nz College Membership Enquiries Contact Lisa Donkin membership@nzcom.org.nz 03 372 9738 Chief Executive Alison Eddy Auckland Office and Resource Centre Delia Sang, Administrator Yarnton House, 14 Erson Avenue PO Box 24487, Royal Oak, Auckland 1345 Ph 09 625 9764 Fax 09 625 0187 auckadmin@nzcom.org.nz National Board Advisors Elder: Sue Bree Kuia: Crete Cherrington Education Advisor: Mary Kensington

Regional Chairpersons

Consumer Representatives

Auckland Sarah Ballard, Linda Burke auckchair@nzcom.org.nz

Royal New Zealand Plunket Society Carla Kamo carla.kamo@plunket.org.nz

Bay of Plenty/Tairawhiti Kelly Pidgeon chairnzcomboptairawhiti@gmail.com Canterbury/West Coast Bex Tidball chairnzcom.cantwest@gmail.com Central Julie Kinloch Ph 06 835 7170 julie.kinloch.nz@gmail.com Nelson/Marlborough Rose O’Connor roseocon@gmail.com

Wanaka Noanoa Ph 021 139 6496 wanakahr@gmail.com Seraya Turnbull Ph 022 6852383 serayaalucas@icloud.com

Otago Jan Scherp, Charlie Ferris otagochair@nzcom.org.nz

Sarah Wills Ph 021 02551963 sarahandcale@hotmail.com

Southland Natasha Baillie Ph 021 258 2701 merakimidwifery@gmail.com Waikato/Taranaki Tracey Williams chairwaikatonzcom@gmail.com Wellington chair@wellingtonmidwives.com Regional Sub-Committees

EPI-NO is a dual purpose CE approved medical device designed to strengthen the pelvic floor muscles from early in pregnancy, and again postpartum. The perineal stretching exercises commence concurrently after Week 36.

Hawkes Bay Sub-Committee Sarah Nation sarahnation.midwife@gmail.com Manawatu Sub-Committee

EPI-NO Childbirth Training has been accepted in Australia & New Zealand for over 15 years as an effective preparation for women choosing a natural vaginal birth.

Jayne Waite j.waite70@gmail.com Taranaki Sub-Committee Isabel Bedford

EPI-NO Patient Brochures can be requested for New Zealand via info@starnbergmed.co.nz

nzcom.taranaki@gmail.com Wanganui Sub-Committee

Over 50,000 EPI-NO births in Australia and New Zealand.

Available in over 20 countries worldwide.

Jo Watson Ph 021 158 6874 jothemidwife@gmail.com

www.starnbergmed.co.nz

35 | AOTEAROA NEW ZEALAND MIDWIFE

Student Representatives

Ngā Māia Representatives www.ngamaia.co.nz

EPI-NO is clinically proven to significantly increase the chances of an intact perineum, reduce episiotomy, and is safe to use.

‘The human body performs to maximum efficiency in any physical activity when correctly trained and prepared. Childbirth is no exception.’

Dr Wilhelm Horkel, Starnberg (EPI-NO inventor)

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

Northland Christine Byrne tetaitokerauchair@nzcom.org.nz

prepares the perineum

Available online with shipment from Auckland and at selected pharmacies.

Home Birth Aotearoa Eva Neely evaneely@live.com

Made in Germany

Horowhenua Jennie Ferguson Ph 021 232 1980 thejensterrocks@gmail.com

Lisa Kelly lisakellyto@yahoo.co.nz Pasifika Representatives Talei Jackson Ph 021 907 588 taleivejackson@gmail.com Nga Marsters Ph 021 0269 3460 lesngararo@hotmail.com MERAS PO Box 21-106, Edgeware Christchurch 8143 www.meras.co.nz General Enquiries & Membership Ph 03 372 9738 meras@meras.co.nz MMPO mmpo@mmpo.org.nz Ph 03 377 2485 PO Box 21-106, Edgeware, Christchurch 8143 Rural Recruitment & Retention Services Rural contact: 0800 Midwife/643 9433 rural@mmpo.co.nz

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

For excellence in online midwifery education Our flexible, practice-focused programmes and courses are designed to meet the needs of midwives and the requirements of the MCNZ.

Master of Midwifery

PG Diploma

Our discipline-specific Master of Midwifery degree allows you to undertake an original research project in a topic area of your choice.

Pathway to thesis: Midwifery knowledge (February 14 to June 17) Pathway to thesis: Midwifery research methodologies (July 11 to November 11)

2022 COURSES: PG CERTIFICATE FEBRUARY 14 – APRIL 8

APRIL 26 – JUNE 17

JULY 11 – SEPTEMBER 2

SEPTEMBER 19 – NOVEMBER 11

Preceptorship for midwives

Queering midwifery: Sexuality, gender and sex characteristic diversity

Complexities, culture and research around safe sleep for pepi

Applied anatomy and physiology for midwives

Promoting physiological birth

Diabetes in pregnancy

Nutrition for the childbearing woman

Leadership and change in midwifery

Working with tangata whenua: Building equity in maternity care

Perinatal mental health

Sexual health in pregnancy

Midwifery practice in rural and primary maternity settings

Apply now!

If you wish to complete the Complex Care Pathway in 2022, or have any other PG queries, please contact: suzanne.miller@op.ac.nz

years of

Bachelor of Midwifery Graduates K04378

1994-2019