There are cu rrently opportu nities for midwives to work in our health district at the Royal Hospital for Women, St George Hospital and Sutherland Hospital .
Ou r health d istrict is one of the most desi rable i n Australia – stretchi ng from the vi brant city of S yd ney, the iconic beaches from Bond i to Cronu lla, down to the breathtaki ng Royal National Park We pride ou rselves on providi ng exceptional health care to ou r patients and commu nity Ou r midwives can expect to work i n modern and world class faci lities, withi n a dynamic and i nnovative team with opportu nities to conti nue thei r professional development
ww w.seslhd.health.nsw. gov.au
seslhd-nursingandmidwifer y@health.nsw. gov.au
We have exciting opportunities for recently graduated Registered Midwives to join our core midwifery team. Working within Te Whatu Ora Wairarapa you will become part of an enthusiastic, dynamic and committed team of health professionals providing an innovative and culturally safe approach to the care of hapū māmā and whānau, with the bonus of a healthy balanced lifestyle and opportunities for professional development. As a new graduate you will have the support of an amazing team of passionate midwives and a Midwife Clinical Coach offering knowledge and expertise as you embark on your journey of a Registered Midwife.
The Wairarapa has a proven track record of developing innovative models of care through collaboration of primary and secondary health providers. Our maternity service Wairarapa Ata Rauru provides care for women in the Wairarapa region with approximately 500 births per annum. Midwives have the opportunity to work across their scope of practice by, providing care to ante and postnatal inpatients,
intrapartum care for hapū māmā that don’t have an LMC and working alongside their Midwife LMC colleagues to provide support and secondary care.
We have available fixed term part time positions, working 64 hours per fortnight, rostered and rotating shifts. The fixed term is for a period of up to 12 months, with the possibly of an extension to the role or the role being made permanent following the completion of the 12 month period.
We want to hear from you if you have a passion to provide midwifery care in partnership with other care providers, and you want to work in a friendly and supportive environment. You will need to be registered with the Midwifery Council of New Zealand and hold a current Annual Practising Certificate.
For further information please contact Kirsty Mitchell, Midwife Manager on (06) 946-9800 ext 4111 or (027) 675-5931.
The Wairarapa region offers a fantastic lifestyle for all. With quality schools, strong community spirit, great beaches and rivers world class vineyards, and mountain ranges, this is a place you can call home. Wairarapa Hospital, based in Masterton, is a little more than an hour from Palmerston North Airport, Wellington International Airport and Inter-Island ferry connections. Daily rail services link Wellington with Wairarapa towns.
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or services that are not aligned with its principles and ethics. Every effort is made to ensure that advertising in the magazine falls within those guidelines. Where advertising is accepted, this does not imply endorsement by the College of the product or service being promoted 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. The College acknowledges and respects diversity of identities through the language used in this publication. Te reo Māori is prioritised, in commitment to tāngata whenua and te Tiriti o Waitangi. To maintain narrative flow, the editorial style may use a variety
Workforce issues take centre-stage this issue, with a thorough assessment of our current situation on pg. 28, including a comprehensive account of the work being done by many behind the scenes, to relieve the pressure. Help is at hand, as the article details, and although we still have a way to go, much has already been achieved.
Recent health system reforms continue to dominate the healthcare landscape and the College’s member survey - which sought to uncover what midwives wanted from the reforms reveals members’ top priorities, and how many midwives are working multiple roles. Check out the report on pg. 22.
Information regarding how midwives lodge ACC maternal birth injury claims is shared on pg. 18 and Carol Bartle invites us to re-evaluate our approach to blocked ducts on pg. 38, with a thorough review of the Academy of Breastfeeding Medicine’s updated clinical protocol on the mastitis spectrum.
Dr Ruth Martis promotes the environmental friendliness of homebirth on pg. 34, challenging us to consider the high use of disposable plastic in maternity care and its potential harms.
From Both Sides celebrates Aotearoa’s first Māori and Pasifika director of midwifery: Te Tairāwhiti’s Nerissa Walters. Featuring Nerissa’s voice and that of LMC colleague Beatrice Leatham, the spotlight is on a small community leading the way in the journey towards achieving true equity.
Wishing all midwives throughout the motu a joyful holiday season!
Mauri ora, Amellia Kapa, Editor/Communications Advisor
Email: communications@nzcom.org.nz square
As members will all be aware, the College is currently undergoing a cultural review. Being reflective requires radical self-honesty and has to be one of the most challenging tasks we face as humans and midwives. Doing this as individuals can be confronting and it’s no different doing it as a profession. The benefit, therefore, of outsourcing this mahi to external reviewers lies in their ability to view the situation with fresh eyes, emotionally unattached.
I look forward to the preliminary findings of the review, which will give us an indication of what changes we can begin to implement sooner rather than later, to evolve as an organisation. It’s crucial we reflect on what we’re doing, why, and how, honouring our Tiriti obligations to all members, every step of the way.
Te Tiriti isn’t a toy to be picked up and played with when we want to impress our friends, then put back on the shelf when it’s inconvenient. It’s a constant recommitment to a way of living and being.
Recently, I’ve found myself sitting with the word whānau. A reflection of te ao Māori values, whānau isn’t just referring to a nuclear family unit. Whānau includes all of Ranginui and Papatūānuku’s children, encompassing our forests, waterways - the entire eco-system. In fact, there probably couldn’t be a more inclusive term.
So my challenge to members who think it’s exclusive of women, is to go and experience it, rather than trying to grasp it intellectually. Take the time to visit a marae. Wash the dishes. Speak to the elders. If there is a hapū wānanga in your area, attend it. I can promise that if you do these things, your
understanding of the word whānau will change and you won’t believe you ever thought wāhine or pēpi sat somewhere outside of it.
My other challenge relates to the planning of a Māori midwifery kura. There is similar confusion surrounding this kaupapa, with some believing this approach is separatist and could lead to division. This could not be further from the truth. Whilst it is many years away, the moemoeā (dream) is to have a truly kaupapa Māori driven way of learning and knowing; an immersion in culture and midwifery, and a truly authentic Te Tiriti-led programme that will meet the currently unmet needs of whānau.
Until the work is done, avoid the trapdoor leading to regression and miscommunication. It is not separatist, nor even race-driven. It is an acknowledgment of the sacrifices made by many, particularly our tūpuna and their uri in the name of ‘New Zealand’ and reinforces the rights that existed pre-1840, reaffirmed by Te Tiriti (Article II). Contrary to popular belief, we did not cede sovereignty, so if there was ever a time to support a way forward for all of our futures, this is it.
A kaupapa Māori midwifery kura is about respect; respect of our culture, tikanga and each other. So keep your hearts and minds open. Rather than perceiving Māori kupu, spaces, or individuals as intimidating because they are unfamiliar, my suggestion is to address why these spaces - both physical and metaphorical - are still so foreign to you. Opportunities to engage are all around you, and if you’re brave enough to reach out, you might be surprised by just how warmly and openly you are embraced and welcomed in. square
“E kore a muri e hokia” The past cannot be returned to (Smith, 1896:45 as cited in Mead & Grove, 2021)
After many months of anticipation, Te Pae Tata Interim New Zealand Health Plan 2022 has finally been published. This document sets out the initial plan to establish the foundations of our new health system and will be followed by delivery of a comprehensive plan under the Pae Ora (Healthy Futures) Act 2022 in early 2024.
As well as outlining six key priority actions (see Bulletin pg. 8), five specific priority areas have been further identified within the plan for “service change and innovation”, to support improved equity and outcomes:
• Pae ora | Better health in our communities
• Kahu Taurima | Maternity and early years
• Mate pukupuku | People with cancer
• Māuiuitanga taumaha | People living with chronic health conditions
• Oranga hinengaro | People living with mental distress, illness and addictions.
The section of the document which sets out the intentions of the Kahu Taurima | Maternity and early years section discusses the importance of investing in the early years of a child’s life - from conception to five years old - “so every child gets the strongest start to life”. The intention is to “drive the integration of maternity and early years services for a child’s first 2,000 days”.
Two of the specific actions noted for completion include:
• Redesign the universal model of care, working with LMCs and Well Child Tamariki Ora providers to implement a more flexible and responsive model.
The Kahu Taurima | Maternity and early years section discusses the importance of investing in the early years of a child’s life - from conception to five years old - “so every child gets the strongest start to life”. The intention is to “drive the integration of maternity and early years services for a child’s first 2,000 days”.
Equity is quite rightly front and centre of these reforms, and the dominant narrative is that health services have failed to provide equitable outcomes for Māori and other groups. Maternity outcomes are no exception to this, however, the causes of inequity cannotbe laid entirely at the feet of our health system.
• Design and commission Te Ao Māori, whānau-centred and Pacific whānau centred integrated maternity and early years services.
The detail is scant, and it is far from clear what ‘redesigning’ the universal model of care will mean for midwives, or indeed what is meant by ‘integrated models of care’.
Equity is quite rightly front and centre of these reforms, and the dominant narrative is that health services have failed to provide equitable outcomes for Māori and other groups. Maternity outcomes are no exception to this, however, the causes of inequity cannot be laid entirely at the feet of our health system. They are deep-rooted and linked to the detrimental effects of colonisation, poverty, and institutionalised racism within our education, health and other public institutions. There is a widely held understanding that the healthcare system can only mitigate about 20% of inequitable health outcomes, as the other 80% relate to the wider social determinants of health. I’m not trying to imply that there is ‘nothing to see here’; midwifery and maternity services undoubtedly have work to do to adapt to present-day challenges and decolonise themselves.
However, there are many elements of our midwifery model of care and maternity service which have the right foundational
building blocks. When we read and understand what the health system reform is asking of us, it seems midwifery and maternity services already have many of the necessary components.
Midwifery works within a flexible relationship-based responsive model, which centres on the needs of the woman and whānau, wherever they are or whatever those needs may be. Our community-based service contract model (self-employment through Section 88) enables the delivery of a ‘flexible and relationship-based’ service. Unfortunately, it appears there is a view amongst some that our maternity system is somehow broken and that transformational change must happen.
A more nuanced consideration is needed. What is actually meant by ‘model of care’ - a frequently used term, which is infrequently defined? When midwives hear or talk about ‘model of care’, we understand this to mean midwifery-led continuity-ofcare, within the context of a well-integrated wider referral and maternity care system.
The evidence for this ‘model’ continues to grow. Surely this must remain a fundamental element of our maternity care system, and any proposed changes should support and strengthen this core element, not weaken or dismantle it.
If we asked those currently ‘under-served’ by our health care system what they want from maternity care, their response would likely feature:
• An easily accessible, well-educated, regulated midwife who is resourced and supported to provide culturally and clinically safe, sustainable, continuityof-midwifery-care across the scope of practice, with whom the whanāu can establish a relationship of trust and reciprocity.
• The needs of the whānau being centred within this relationship-based partnership; the wahine retains bodily autonomy, and is supported to make informed choices throughout her pregnancy, birth and postnatal journey.
• The removal of institutional, cultural or financial barriers to accessing maternity care.
• Smooth referral pathways, timely access to a higher level or additional care and support, with easy transitions between services.
• Services which enable and support whānau Māori to achieve an equitable, clinically and culturally safe birthing experience, with sufficient Māori midwives available to provide care for all whānau Māori.
Continuity-of-care can and does enable many of these to be achieved. Why, then, are the ‘under-served’ missing out, and what do we need to do to change this? I would argue that the system enablers or settings around the midwifery model are not right (and in fact haven’t been for some years now). It’s not the model of care itself, but what supports it, that is lacking. Something a midwife recently said sums up the core issue extremely well: “it feels like midwifery is entering the Grand Prix of the health reforms driving a Lada”. This analogy feels very pertinent when we consider how our maternity care model has been systematically undermined by policymakers and politicians over the years, through lack of support and resourcing, lack of strategic planning, lack of investment in developing support systems around the profession, and lack of investment in midwifery workforce development.
If we want to ensure midwives can continue to deliver flexible and responsive care more effectively for everyone, the answer is not employment of all communitybased midwives by our already inaccessible institutions or collapsing maternity and Well Child/Tamariki Ora services into a single ‘integrated’ service in every setting or community.
Something else someone recently said also resonated strongly with me. "When the going gets tough, double down on your principles and values. They are the touchstones that ground you." The answer then, is to ensure we have the right incentives to drive professionalism; to stir and ignite our midwifery hearts. Working within a continuity model ensures midwives are invested in delivering the best outcomes through the care they provide. Continuity enables and supports midwives to be connected to and invested in, their communities. Midwifery is perfectly poised to deliver the aspirations of the health reforms, but cannot do it with an empty tank, or in a Lada. A well-resourced and supported midwifery workforce must be prioritised by this government if it aims to make a meaningful impact on the health of tamariki in their first 2,000 days. square
Margret Norris, much-loved matriarch of midwifery known affectionately as 'Marg', passed away on 9 August after a short illness. Marg's journey within the Bay's healthcare system spans decades and she was known by many in the different roles she had. However, Marg's heart was always working in midwifery.
Marg worked as a registered nurse and diabetes educator before commencing employment as a midwife in 1996. Throughout her career as both an LMC and employed midwife, she helped hundreds of mothers birth their babies and start their journeys into motherhood.
In 2000, she became the BOPDHB clinical midwife manager and in 2006 progressed to the role of midwifery leader within the Woman Child and Family Service. Marg was a respected contributor at both local and national nursing and midwifery leadership levels and in 2012 was appointed to the inaugural National Maternity Monitoring Group. Marg briefly left the BOPDHB in 2017, to work as a clinical director for a private birthing service, and completed her Master of Health Sciences at this time. Her heart remained in clinical midwifery though, and she returned to where she started when re-joining Ko Matariki as a staff midwife. Her final contribution was establishing a hospital-based primary care service for the community in Whakatāne.
Staff at Ko Matariki will miss Marg's sense of humour, huge energy, enthusiasm, optimism, smile, and direct approach within the unit. Her knowledge, experience and consistent attitude of going above and beyond will leave a big gap within our service. In all her roles she was always the matriarch to the Ko Matariki team. Marg had thought about retiring on several occasions, but the call to serve the women and whānau of the Eastern Bay kept her within the maternity service. Marg will be sorely missed by all who knew her.
Midwifery Team - Te Whatu Ora Hauora a Toi (Bay of Plenty) squareThis document, which replaces the previous 20 district annual plans, outlines the first two years of operation for Te Whatu Ora and Te Aka Whai Ora.
The plan notes six key priority actions:
• Place whānau at the heart of the system to improve equity and outcomes
• Embed Te Tiriti o Waitangi across the health sector
• Develop an inclusive health workforce
• Keep people well in their communities
• Develop greater use of digital services to provide more care in homes and communities
• Establish Te Whatu Ora and Te Aka Whai Ora to support a financially sustainable system.
Of significance for midwifery, Te Pae Tata also identifies Kahu Taurima | Maternity and early years, as an area for service change and innovation (see pg. 5 for further details). square
Mahi a Rongo | the Helen Clark Foundation hosted a workshop style meeting in September to inform their ongoing work on Āhurutia Te Rito | It takes a village. This report - released in April 2022 - analyses what contributes to perinatal distress in Aotearoa and identifies opportunities to better support new parents and their babies. The workshop participants (which included College representation) provided direction to Mahi a Rongo on how the aims and vision of the report can be achieved. The importance of well-resourced and accessible health care services, as well as the need to centre and
value the role of new parents and whānau at a wider societal level were key areas of consensus for participants. square
Updated Diagnosis and Treatment of Hypertension and Pre-eclampsia in Pregnancy in Aotearoa New Zealand guideline
Now published, this guideline includes the latest evidence to guide clinical practice for treatment of hypertensive disorders in pregnancy (HDP). The aim is to support a consistent approach to management and treatment, as well as recognising the health professional’s clinical judgement, expertise and knowledge. The guideline and evidence statements can be found on Te Whatu Ora website.
The publication of the Referral Guidelines has been delayed due to the need to ensure that all IT systems are updated so they support the guidelines. These changes are being urgently implemented and publication is expected in early 2023.
The first meeting of the multidisciplinary group to review the evidence and update the Diabetes in Pregnancy guideline will take place in December. College representatives are midwifery advisors Claire MacDonald and Brigid Beehan. square
The 15th PMMRC report is published online on 6 December, reporting mortality and morbidity data for 2019 and 2020. Information about outcomes in the first year of the Covid-19 pandemic has been anticipated across the sector, and reassuringly the report found no statistically significant differences detected in perinatal and maternal mortality outcomes in 2020. However, as the Chair notes, Covid-19 infection became much more widespread in the community from 2021 and continued monitoring is imperative.
The overarching emphasis of the 15th report is on achieving equity. Urgent priority has been given to recommendations that focus directly on promoting equitable outcomes
for whānau Māori, Pacific peoples and Indian families and whānau, mothers under 20 years old, and those living in high areas of deprivation.
Midwives and all health workers in maternity services are encouraged to read the report and do what they can within their roles to put the recommendations into practice. A PMMRC webinar about the report is planned for early 2023. square
The National Abortion Telehealth Service project decide.org.nz was introduced by the Ministry of Health in 2022. This service has been staggered in three phases: offering referrals and information about abortion services since April; follow-up care and counselling since July; and now telemedicine has been the additional service offered from 1 November.
The new telehealth early medical abortion service is free to pregnant women eligible for publicly funded healthcare in Aotearoa and will improve access to early abortion services, enabling women to access the health care and support they need
in the first 10 weeks of pregnancy, when their choice is to have an abortion. This telehealth service will provide clinical consultations for early medical abortion requests, send out medications and link those over 10 weeks or with additional risk factors to other services.
The service, accessed via the 24/7 hotline 0800DECIDE, provides clinical care, support, advice and counselling for women undergoing abortions as well as offering consults for new patients during work hours. The telehealth service will be hugely beneficial in improving equitable access to abortion care, especially for those in rural areas and those who are financially disadvantaged. square
The College’s national office will close on Friday, 23 December at 12 noon, reopening on Wednesday, 4 January. There will be arrangements in place for any midwife who needs urgent legal advice during this period. Phone the office on (03) 377 2732 and a recorded message will have the relevant contact information. Staff at the national office wish all members a happy and safe Christmas and New Year. square
A joint MERAS and College celebration was held on parliament grounds on 20 October, to celebrate 50 years since the passing of this pivotal legislation (top right).
Midwives attending the event were buoyed by the presence and words of MPs Camilla Belich (Labour), Marama Davidson and Jan Logie (Greens) who all acknowledged that in spite of progress, equal pay was not yet a universal reality.
MERAS Co-Leaders Jill Ovens and Caroline Conroy, College CE Alison Eddy and MERAS member Liz Winterbee, all gave impassioned speeches reflecting on the journey to date, including key milestones and events such as the 1993 Maternity Benefits Tribunal and MERAS pay equity claim. square
Tēnā koutou to all members who have participated in the College’s cultural review. Reviewers Moe Milne, Linda Thompson and Koha Aperahama have conducted a number of hui and interviews with members and other stakeholders around the motu, as well
Planning is underway to welcome graduate midwives entering the profession in 2023. Following feedback from current graduates and mentors, the College continues to strengthen MFYP.
as conducting an online survey. Initial findings were presented to the College’s board at its November meeting, with a full report anticipated early next year. square
Progress has been made on a navigation process to support access to midwifery care for pregnant women who arrive in Aotearoa as refugees. Under the quota system, former refugees spend their first five weeks in South Auckland at Te Āhuru Mōwai before being resettled to their new homes in regions around the country. The College has signed an agreement with Te Whatu Ora to support the Counties Manukau community midwifery team and regional refugee navigation services to link pregnant women with midwives in the resettlement regions, and to support secure transfer of clinical records. We will be contacting members in the new year to set up a network of midwives who have a special interest in working with former refugee families. square
Ten months since its inception, the Covid-19 vaccine mandate for health workers ended on 26 September. However, the government’s announcement was qualified by indicating that employers may put vaccination policies in place under Health and Safety at Work legislation. Te Whatu Ora did not have any position or policy ready for the end of the legal mandate, so the Chief Executive advised districts to continue with their own regional policies until a national policy could be agreed. This created
confusion and variable understandings around the country, and the College worked with members and districts to support midwives to return to practice. At time of writing, we understand that issues with access agreements have now been resolved, however midwives affected by the mandate have not been able to apply for employment with Te Whatu Ora facilities in most areas. A national vaccination policy is currently in development, however the College has not yet been consulted on any drafts.
The College warmly welcomes all returning midwives back to practice and is available for support if required. square
Planning is underway to welcome graduate midwives entering the profession in 2023. Following feedback from current graduates and mentors, the College continues to strengthen MFYP. This year we are implementing new and exciting initiatives to increase professional and educational support for graduates. We anticipate approximately 150 midwives will join MFYP by November 2023 and we look forward to welcoming them to our profession. square
JOAN DONLEY MIDWIFERYIt has been many years since we have been able to gather and reconnect with our colleagues and friends. The College made the decision to hold the forum this year to celebrate midwifery knowledge and research in Aotearoa. The forumheld in November in Tauranga and hosted by the Bay of Plenty region - saw over 300 midwives and students come together from across the country. We would like to thank all of the presenters who shared their research and thoughts with us all. Presentations were varied and included practice initiatives, challenges and much more. The forum demonstrated how kaupapa Māori research, practice wisdom and professional practice continues to evolve and inform us all as we move forward together professionally. square
For those working in Te Whatu Ora in-patient maternity services,
Trendcare is now a very familiar part of a midwife’s documentation. But just how important is it? The answer: crucial.
The data midwives enter into Trendcare each shift contribute significantly to the full-time equivalent (FTE) calculations, which influence the roster and number of midwives on each shift. Whilst it is currently challenging to fill many of the additional midwifery positions that have emerged from the FTE calculation process, it does increase the staffing budget, so that as midwives do become available, they can be recruited. It also provides additional midwifery budget to support the midwifery workforce.
It is not unusual to hear midwives say they have been too busy to complete Trendcare data and this is reflected in some of the material reported each month showing the percentage of actualisations or patient categorisations. If the actualisations or categorisations do not occur, the hours of care provided by that midwife that shift are not captured, and consequently the work of the midwife is not acknowledged.
Along with local MERAS workplace representatives, I’ve recently been involved in several FTE calculations. In some of these calculations there have been up to 20% of patients not categorised and only 80% actualised. This can equate to hundreds of hours of annual work by midwives not being included in FTE calculations.
The data provided for the FTE calculations demonstrates how busy a maternity ward or unit is. The following example of a patient churn graph shows the admissions and
discharges (churn) of a birthing suite. The more red the tile is, the more churn, and unsurprisingly, there are multiple admissions and discharges over the 24 hour period.
The ‘allocate staff’ screen is very important in maternity services and shows where midwives’ working hours have been focused during the shift. In most maternity units, the senior midwife on shift is responsible for ensuring this screen is completed, but to do this they need to be kept informed of the work midwives are doing. In some maternity units, a small whiteboard or laminated form is placed by the computer or phone so midwives can mark down the work they are doing as the shift progresses, meaning the ‘allocate staff’ screen can be updated during the shift. The tiles you are most likely to use should be listed on the ‘short screen’. These typically include:
OP care or pregnancy assessment: This is where time providing care to acute assessments or scheduled outpatient (OP) care is shown. Midwives should check with their local Trendcare champions around the use of this tile and the patient type ‘AN short stay’.
OP phone: Midwives can spend quite a lot of time in a shift responding to phone calls from women in the community or LMCs. If the total time by all midwives responding to these phones is 30 minutes or more in a shift, the
cumulative time should be shown against the name of at least one midwife.
Theatre: The time midwives spend away from the ward in theatre or collecting patients from theatre should be recorded here.
Escort: This tile should be used when midwives escort a woman or baby in an ambulance or flight to another hospital. Usually the senior midwife on the shift will need to make sure these hours are added, as the midwife will be absent from the ward and this time may carry over more than one shift.
Pt transfer: This is used to show the total time on a shift that midwives are transferring women or babies from one ward to another, or to another service, for example from birthing suite to the maternity ward.
Midwife consult: This is used when midwives go to another ward or department to provide midwifery care or advice. This might be ED, ICU, or other ward areas where pregnant or postnatal patients might be located.
Housekeeping or environment: This is typically used to show the hours midwives spend cleaning rooms, making beds and restocking when there are no support staff available. In some units housekeeping is used for the HCA hours and environment for midwife hours, in others just one or the other is used for all staff.
Equipment: This is used to show the time midwives spend checking the emergency equipment each shift such as resuscitaires, emergency trolleys, or bags. Even if this work is divided amongst the midwives on duty, the cumulative time (at least 30 minutes) is recorded against the name of one midwife. Paid meal break: This tile is used to reflect the paid meal break time on some 12 hour shifts.
Time allocated to the tiles within the ‘allocate staff’ screen needs to be a minimum of 30 minutes and is deducted from the clinical in-department hours. This highlights how much time midwives might spend off the ward or dealing with other work that takes them away from in-patient care. The hours
added to these tiles will often highlight the need for additional health care assistant support after-hours, or the need for dedicated midwifery time during the day for acute assessments that are deemed ‘out-patients’.
Choosing the right patient type is also important. As the women we care for become more complex, there is often a greater need to use the high dependency options for at least the initial 12-24 hours post-admission or post-birth. Due to the impact of staffing shortages, it has recently been agreed nationally that the care predicted within the maternity ward areas should be the care needed by the patient, not just the care that is able to be provided by the available staff. Likewise in birthing suite, staff should actualise the care that should be provided, i.e. one-to-one care during active labour.
At a national level, the CCDM Maternity Advisory Group* provides oversight, ensuring a consistent approach to the implementation of CCDM across maternity services, upgrades to Trendcare software which better reflect the New Zealand maternity setting, and the provision of templates across the different components to support effective use of the programme. The advisory group provide reports to the Safe Staffing Governance Group and are effective in ensuring midwives and maternity services are appropriately reflected in CCDM.
The Maternity Advisory Group is close to concluding work on the best patient type for the transitional care and more complex babies on postnatal wards and are encouraging the continued establishment of Maternity CCDM working groups at district hospitals so that MERAS workplace representatives, Trendcare champions, midwife managers and the directors of midwifery can review the maternity data and ensure it appropriately reflects the work of the maternity service and the midwifery workforce.
CCDM and Trendcare have made a difference for maternity services. The data produced for the FTE calculations has highlighted the actual midwifery staffing levels needed for the increasingly complex women and babies we care for in today’s maternity services. When FTE calculations have been completed, most units have seen:
• an increase in midwifery staffing budgets
The following chart is representative of the churn from a birthing suite. The heat map uses colours based on the value of the cell - periods of low activity being dark green and red cells indicating the periods of maximum churn. The colour range is based on the lowest to the highest level of activity. In smaller units or those with a low patient turnover, the colours may misrepresent the degree of actual activity.
Monday
07:00 89 84 67 74 94 84 82 08:00 113 129 151 133 121 132 114 09:00 191 184 176 172 189 154 157 10:00 175 215 222 223 209 149 170 11:00 233 204 223 216 209 176 173 12:00 193 233 193 232 213 152 151 13:00 191 227 197 208 196 150 151 14:00 206 247 234 228 230 162 156 15:00 218 242 229 220 244 151 169 16:00 215 253 212 225 206 161 154 17:00 200 236 209 218 202 146 147 18:00 193 237 220 192 179 144 130 19:00 228 265 218 240 228 195 177 20:00 213 244 201 239 204 168 170 21:00 144 178 169 187 179 148 145 22:00 148 168 157 153 136 154 139 23:00 138 123 139 149 129 129 123 00:00 229 222 267 266 256 241 235 01:00 104 118 123 124 114 126 120 02:00 95 113 99 103 105 110 88 03:00 88 94 96 89 73 89 93 04:00 95 81 87 107 76 87 97 05:00 95 83 95 88 89 77 92 06:00 83 90 106 84 84 83 113
• an increase in health care assistant or clerical hours as the time midwives are spending doing this work is highlighted
• the data used to support clinical midwifery leadership roles 24/7.
We now have objective, measurable data to demonstrate the staffing needed for our maternity services and whilst it might not be perfect, it is certainly better and fairer than the previous ways midwife managers and directors of midwifery had to try and show a need for more midwives.
The data emerging from the annual FTE calculations also allows directors of midwifery and the schools of midwifery to better determine the number of midwifery graduates needed to provide a sustainable midwifery workforce. square
*The CCDM Maternity Advisory group membership includes myself as the MERAS Co-Leader (Midwifery), Karen Gray (MERAS organiser), Holly Wescott (CCDM Co-ordinator), Jules Arthur (CCDM National Maternity Advisor), Samantha Davenport (Director of Midwifery), Claire MacDonald (College Midwifery Advisor), Julia Anderson (Profession Nurse Advisor, NZNO) and two other directors of midwifery (appointments currently being made). The group is co-chaired between MERAS Co-Leader (Midwifery) and a director of midwifery.
For MERAS Membership merasmembership.co.nz www.meras.midwife.org.nz
It’s been nearly a year since changes were made to the former Section 88, now referred to as Notice 21. Whilst these changes have allowed community midwives to receive additional benefits including better care and related work recognition and cashflow, there is still some way to go.
One of the specific changes made in November 2021 was the introduction of the Additional Care Supplement Module (ACS).
Since 2007, the basic modular fees within Notice 21 (formerly Section 88) for antenatal, labour and birth, and postnatal care have historically reflected midwifery care requirements for straightforward pregnancies, with little recognition of the time and work required when the maternity journey deviates from the normal physiological process.
Today, many pregnancies require some form of additional care, and the ACS module was established to help recognise this extra midwifery work and ensure the allowable additional payments are received by the community midwife.
Additional payments are dependent on the profile of the māmā and pēpi being cared for and the following criteria are used to determine whether additional payments are due: ethnicity (and language requirements); age (teenage pregnancy); multiple pregnancies; number, location, duration, and purpose of visits (including acute or out-of-hours); multi-disciplinary meetings; and transitions in care (non-emergency and emergency consultations and referrals).
ACS claims are submitted during the pregnancy at the end of each module of care, including antenatal (at the end of the third trimester), labour and birth (at the end of the birth) and postnatal stage (at handover) based on information recorded in
the clinical record. If the midwifery care ends earlier for whatever reason, the ACS claim will be lodged then.
Today, many pregnancies require some form of additional care, and the ACS module was established to help recognise this extra midwifery work and ensure the allowable additional payments are received by the community midwife.
• Claims can only be submitted once per module, per midwife, at the end of each of the antenatal, labour and birth, and postnatal periods.
• If you have overlooked something and have not yet been paid the module maximum, you can ask Te Whatu Ora to reverse the historical ACS claim and resubmit an updated claim. In the case of community midwives using the MMPO, please contact us and we will assist.
• For the ACS “number of visits” claim, the number of visits excludes the First Assessment Registration and Care Planning (FARCP) visit and/or any pregnancy loss visits.
• If a visit meets multiple criteria (for example a long acute visit at the māmā’s home) this can be populated against all relevant criteria (i.e., home visit; acute visit; long visit).
• Ethnicity is determined by the māmā in the antenatal and labour and birth periods, and either the māmā or the pēpi in the postnatal period.
• If the antenatal/postnatal care ends earlier than the expected date and time for the submission of the claim, you may still be entitled to an ACS antenatal partial payment.
• Recommended claiming best practice would be to complete a manual review of the ACS questionnaire and related claim in its entirety at each module milestone (for reasonableness) and before the ACS claim is submitted, even if the questionnaire and claim display a $0 fee. This will not only ensure a valid claim is submitted and paid, but also provide good evidence for any future Te Whatu Ora audit and compliance reviews. square
Criteria to be met Antenatal Labour/Birth
Ethinicity (Māori, Pasifika, Indian)
Language/Interpreter Service required (Yes)
Age at registration (19 years or younger)
Refugee status
Visit considerations (excluding First Assessment Registration and Care Planning (FARCP) and/or pregnancy
First Trimester (2 or more only) $50
Second Trimester (5 only or >=6) $50 (5) $90 (>=6)
Third Trimester (10 only or >=11 only) $50 (10) $90 (>=11)
Labour and Birth (2 or more only during early labour)
Postnatal (11 or >=12 only)
Type and purpose of visit
Home visit (2 or more) $90
Acute and/or out of hours (1 only or >=2)
Multidisciplinary meetings (1 or more) $50
Duration of visits
Antenatal >60 minutes (2 or more) $90
Postnatal >75 minutes (2 or more)
Transitions in Care (referrals) inlcuding Consultation, Emergency or Transfer of clinical responsibility
MMPO, the Midwifery and Maternity Providers Organisation provides self employed community midwives with a supportive practice management system.
www.mmpo.org.nz mmpo@mmpo.org.nz 03 377 2485
Multiple babies (pēpi)
Reflecting on this past year as the Chairperson of Ngā Māia, there have been many challenges that we have faced and overcome, as the health reforms have stepped up another level in Aotearoa. The word equity is uttered over and over again, but much like the phrase “closing the gaps” from the 90s, I’m left wondering whether people actually know what the word means, let alone how it can be achieved?
Ngā Māia has been approached from all angles - to sit on boards, panels and advisory committees left right and centre, as it seems the difference between equity and equality is still not well understood. What is not required is equal representation; rather, a panel or board which prioritises treatment and care based on need. Therefore, wouldn’t it be pertinent to have the right people from inception, who ensure Māori are prioritised and central to forming advisory groups, rather than a last minute call to action because there aren’t enough brown faces at the table? As discussed last issue by my colleague Tamara Karu, honest conversations about racism and a commitment to policy and procedures are required moving forward, in order to ensure our people’s needs are put first.
We know there are not enough Māori midwives to fulfil the needs of whānau
Māori as they enter into the most important journey of their lives: parenthood. Last count, according to Midwifery Council Workforce Survey 2022, there were 370 practising kahu pōkai Māori throughout the motu providing care across the scope. This is a far cry from the 17,000 pēpi Māori born in Aotearoa in 2021 according to Statistics NZ and only a small increase from the 285 midwives who identified as Māori in 2016, meaning the Māori workforce has increased by just 85 midwives over the last six years, equating to an average of 14 additional Māori midwives per year. Equitable? Hardly.
Apart from growing midwifery leaders to champion anti-racism, Ngā Māia are looking to the taonga of our tipuna, “nga taonga a o tatou matua tipuna”, the highly prized practices and beliefs of our forebears, our ancestors (Rangimarie Rose Pere, 1991). This will form the foundation for a Māori midwifery kura, or as it’s been proposed, a Bachelor of Health Sciences - Māori Midwifery; a wharekura where whānau will strive and excel beneath a korowai that is inherently Māori in every facet. Whānau will be safe in the knowledge that no one gets left behind and they will be entering into a workforce that is
protective, nurturing and sustainable, leaving the kura not as midwives that are Māori, but as Māori midwives.
This is by no means an easy feat in this western world, however the path our tauira are currently on is one of trauma and neglect and needs to change for the future of our rangatira yet unborn. This is how equity is achieved; whānau Māori need Māori midwives - Māori midwives who put the whole whānau at the centre of care, who are culturally competent, see this world through a te ao Māori lens, believe in the importance of whakapapa, and uphold whānau, hapū and iwi values and beliefs. A Māori midwife for every whānau. square
The word equity is uttered over and over again, but much like the phrase “closing the gaps” from the 90s, I’m left wondering whether people actually know what the word means, let alone how it can be achieved?
Following many years of planning, the College established an Auckland liaison position in early 2020, in response to the unique needs of its 1,000 Auckland members. Spread across three DHBs and caring for Aotearoa’s most diverse birthing populations, the region had been requesting the establishment of a midwifery advisor role for some time, in particular to support members who had been experiencing severe workforce issues.
Brigid Beehan was employed part-time to help strengthen the Auckland region's connections to the national office and its stakeholders. Alongside this, Brigid worked to support the Auckland co-chairs and committee. Within three weeks of the role being established, Covid-19 lockdown Level 4 was announced, sending Aotearoa midwives into an unprecedented world of uncertainty, as they were expected to find a ‘new normal’ whilst continuing to support whānau. The chairs and the Auckland liaison were key supports for the membership during this time and acted as a conduit to the national office. Over the next two years, the role proved invaluable in supporting the chairs and Auckland membership during the most acute phases of the national pandemic response, playing a vital role within the advisory team at the national office. Over this time, Brigid has led the development of a collaborative arrangement between AUT and the College in the delivery of Auckland-based continuing midwifery education.
In 2021, the national board agreed to make the role permanent, and Brigid joined the national office advisor team based in Tāmaki Makaurau. After the retirement of long-serving and highly respected college advisor Jacqui Anderson, Brigid has taken on the portfolios of the Midwifery Standards Review and resolutions committees and now has a national-facing role in the advisory team.
The College acknowledges Brigid for the experience and expertise she brings to the team and looks forward to continuing to nurture the connection between Auckland’s midwives and the national office. square
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Recent changes to ACC cover now mean injuries sustained from the ‘force of birth’ are defined as accidents. Of the 85% of women who sustain some type of birth injury, most are not severe and heal well without further intervention; however, more severe injuries can result in people living with life-changing disabilities and co-morbidities. It is hoped that the legislative changes will begin to address the inequities being experienced by some whānau in accessing support and ongoing care for birth injuries, with funded rehabilitation and treatment services set to make a major difference.
Midwives will now be able to lodge ACC claims for people who sustain a birth injury within their scope of practice to diagnose. Ngā Māia, the College and other professional organisations have been part of the advisory group which assisted ACC in identifying which injuries should be included and the treatment and support services offered. Much of the profession’s feedback was taken on board, but gaps still remain between what the College recommended and ACC’s final decision.
Following consultation with the Midwifery Council early in the implementation process, ACC determined that the birth injuries within a midwife’s scope to diagnose are: labial, vaginal, vulval, clitoral, cervical and rectal injuries, as well as all grades of perineal tears.
Under the new legislation, anyone who sustains a birth injury included in the list can make an ACC claim to access health and support services to restore and support
their wellbeing, not only from public hospital services but also from private providers in the community contracted to ACC. Unfortunately, the cover is not retrospective, and as specified in the legislation, ACC cannot accept claims for injuries caused by labour or birth that occurred before 1 October 2022. However, injury as a result of treatment during birth may be eligible for treatment injury cover at any time before or after 1 October (as per existing ACC treatment injury provisions).
The legislation sets out a specific list of 12 injuries now eligible for coverage. These are:
• Anterior wall prolapse, posterior wall prolapse, or uterine prolapse
• Coccyx fracture or dislocation
• Levator avulsion
• Obstetric anal sphincter injury tears or tears to the perineum, labia, vagina, vulva, clitoris, cervix, rectum, anus, or urethra
• Obstetric fistula (including vesicovaginal, colovaginal, and ureterovaginal)
• Obstetric haematoma of pelvis
• Post-partum uterine inversion
• Pubic ramus fracture
• Pudendal neuropathy
• Ruptured uterus during labour
• Symphysis pubis capsule or ligament tear
• If a birth requires an emergency caesarean section, it may also be eligible for cover if the injury is caused by an internal force.
LMC midwives will need to register online with ACC as a health care provider in order to lodge claims. In the short-term, claims should be lodged by filling in a paper ACC45 claim form and emailing/posting to ACC. Online options for community midwives lodging claims are expected to be available in 2023.
Lodgement of ACC-covered injury claims is not a new process for hospitals. Employed midwives can lodge birth injury claims within their district hospitals using the
existing lodgement processes. It is likely LMC midwives will also be able to use these existing lodgement processes when birth occurs in hospital. District hospitals are now rolling out education and training to staff.
MMPO is also investigating a way to facilitate the lodgement of claims through Tiaki.
Not every maternal birth injury will require an ACC claim. However, it is optimal to do so if it is likely the person will benefit from further support to help them recover. For example, it is unlikely you will need to lodge a claim for a first or second-degree tear that you anticipate will heal without complications and within the expected timeframe. However, if a claim is not lodged within the timeframe of postnatal midwifery care, it is important to consider and inform the woman of how to access these services and lodge a claim later if required. A written handover to a GP/Nurse Practitioner (NP) including the extent of the birth injury will help make this process stressfree for whānau down the track if there are
continued symptoms beyond the expected recovery time.
WILL
The lodgement of claims does not mean midwifery services will be further funded outside of the Primary Maternity Services Notice Section 88. Midwives are already paid as part of the postnatal module for perineal wound assessment, pelvic floor education and care, referring if necessary for complications.
HOW WILL I KNOW IF A CLAIM HAS BEEN LODGED FOR A BIRTH INJURY IF I WAS NOT AT THE BIRTH, OR THE INJURY WAS NOT WITHIN THE MIDWIFERY SCOPE TO LODGE?
When a claim is lodged, the woman will receive notification of the lodgement and whether the claim has been accepted. The midwife can also check within the ACC system whether a claim has been lodged.
If it is suspected that the claim has not been lodged, or the woman has experienced
one of the listed injuries but was not diagnosed, the midwife should refer to a specialist, physiotherapist, GP or NP, so they can diagnose the injury and submit a claim.
The College has raised concerns regarding the differences in the list of injuries midwives can diagnose and lodge claims for in comparison to GPs, NPs and nurses. ACC has determined that midwives are only able to
Following consultation with the Midwifery Council early in the implementation process, ACC determined that the birth injuries within a midwife’s scope to diagnose are: labial, vaginal, vulval, clitoral, cervical and rectal injuries, as well as all grades of perineal tears.
L-R: Midwifery Advisor Claire MacDonald, Minister for ACC Carmel Sepuloni, and MP Sarah Pallett at the launch event for the Birth Injuries Amendment legislation.As part of their postnatal care, midwives are skilled in postnatal assessment and can identify early whether an injury has caused further morbidity and is likely to need additional treatment and support. This is an opportune time to help navigate women into services in a timely manner to avoid long-term morbidity and distress later after birth.
lodge claims for birth injuries which fall within the midwifery scope of practice to diagnose. Two issues have been raised by the College with ACC:
• Some injuries which are covered by the MBI legislation and are within a midwife’s scope to diagnose are not included in the list of injuries ACC has enabled midwives to lodge. Specifically, these are lower genital tract haematomas (vulval, perineal and vaginal; Read code L345). We have asked ACC to review this to ensure these injuries are added to the list of injuries midwives can lodge claims for.
• RNs are able to lodge claims for all of the injuries listed within the MBI legislation, yet it is unlikely that it is within the nursing scope of practice to diagnose any of them. The rationale for this is that all nursing staff are employed and work in a collegial relationship with the practitioner who diagnoses the injury, so will lodge a claim for the medical practitioner.
The College considers this inequitable and has requested further clarification as to why midwives cannot lodge claims for all birth injuries in the same way nurses can.
WHAT
Depending on the severity of the birth injury, ACC will consider requests for:
• Treatment e.g. pelvic health physiotherapy, surgery
• Rongoā Māori services
• Transport to access treatment
• Equipment in the home for showering, toileting etc
• Home help
• Childcare to help the injured person care for children
• Attendant care in the home if needing help with activities of daily living
• Counselling and therapy sessions (if a consequential emotional or psychological injury has occurred as a result of the birth injury).
ACC is responsible for the assessment and identification of necessary or appropriate care provision in relation to the injury claim and has committed to ensuring that only female staff will manage maternal birth injury claims. Information is available on the ACC website to help guide whānau around recovery after a birth injury and what services they can access for support and treatment.
As part of their postnatal care, midwives are skilled in postnatal assessment and can identify early whether an injury has caused further morbidity and is likely to need additional treatment and support. This is an opportune time to help navigate women into services in a timely manner to avoid long-term morbidity and distress later after birth. Knowing what local services are available will be helpful in assisting people to access them. ACC will not hold a list of pelvic health physiotherapists or rongoā practitioners; it will be up to the whānau to find treatment and support and check they are ACC-registered. Self-referrals are possible, or midwives may offer guidance to assist access to the appropriate treatment to support recovery.
The Pelvic, Women's and Men's Health Special Interest Group of Physiotherapy New Zealand recommends the following definition for physiotherapists who use the term 'pelvic health physiotherapist': physiotherapists who have undertaken post-graduate training in how to complete vaginal and
rectal examinations; regularly use internal examinations in the assessment and treatment of pelvic health patients in clinical practice; treat women, men, and/or children for issues related to pelvic health; offer comprehensive treatment for urinary and anorectal issues, pelvic organ prolapse, sexual dysfunction, pelvic pain conditions, pregnancy-related dysfunctions, post-partum birthing injuries, and provide pre- and post-surgical treatments for prostate, urological, gynaecological, colorectal, and cancer surgery.
As there is no formal postgraduate training pathway in Aotearoa for pelvic health physiotherapists, training is undertaken using a variety of short courses, work experience, mentoring, self-learning, and international course attendance. Pelvic health physiotherapists will have individual levels of knowledge, clinical skills, and experience in this field. It is up to the individual physiotherapist to ensure ongoing competency in this field.
Mental health injury is a known consequence of many birth injuries. Services related to mental health like counselling and psychology are available as they are for any accident. Once a claim for a maternal birth injury is lodged and accepted, cover can also be considered for other consequential mental or physical injuries that are caused by the birth injury. For example, this might be significant psychological trauma such as PTSD. A formal assessment is required by a mental health professional in order for ACC to accept the claim for this sort of consequential injury.
The provisions for injury to pēpi have not changed and are assessed in the same way they are currently (as a treatment injury).
A treatment injury is an injury that has occurred because of a failure - either in treatment provision, or due to a lack of appropriate treatment. Episiotomies are not covered under maternal birth injury as they are the result of treatment; however, an episiotomy that extends would be able to be claimed as a birth injury. Midwives do not have the ability to lodge claims for treatment injuries; these must be lodged by a medical practitioner or nurse practitioner. square
The College’s Midwifery Student Advisory Committee are pleased to announce the recipients of the student grants for 2022. This year we have adapted the grants to enable the College to support 4th year students, and for the first time, we are excited to support a 3rd year student from Victoria University.
We will continue to adapt and evolve the student grants for the future, which will be advertised in the March 2023 issue of Midwife. We encourage as many students as possible to apply for the grants, from all five institutions offering undergraduate midwifery education.
We would also like to take this opportunity to congratulate rural students Ariana Harris, Callie Lamont and Christine Sinclair, who were successful recipients of the rural midwifery grants which are sponsored by a generous donation from retired rural midwife Mary Garlick. The College wishes all students nationally a successful and fulfilling year in their studies and midwifery practice. As always, we look forward to welcoming all graduate midwives to the profession next year. square
Student name
Makira Cornish
Midwifery Educational Institution Grant awarded
AUT 3rd year
Louise Ogle ARA 3rd year
Tyra Fitisemanu AUT 3rd year
Hayley Phillips Victoria University 3rd year
Jade Van der Hoorn Otago Polytechnic 3rd year
Rebecca Bunnik WINTEC 3rd year
Alexandra Seymour ARA 3rd year
Vaisiliva Manuofetoa AUT 3rd year
Ariana Walker ARA 3rd year
Vicky Henry WINTEC 3rd year
Mellisa Marsters AUT 3rd year
Elizabeth Tully Otago Polytechnic 3rd year
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On 1 July 2022, Aotearoa moved to a new national health system and established Te Whatu Ora and Te Aka Whai Ora. This new health system has been designed to support national planning of regionally delivered and locally tailored health services. It is expected that little will change initially, but over time changes will be made to support equity and consistency for everyone.
Any changes to the health system could have implications for midwifery practice in Aotearoa, including potential changes to how healthcare services are governed, funded and delivered both regionally and nationally.
The College developed a survey in collaboration with Ngā Māia, Pasifika Midwives and MERAS, to explore members’ views on future practice in Aotearoa. We needed to identify the important issues currently affecting midwives and clarify what midwives want from the health service reforms, to ensure any future changes will benefit the whole workforce – both employed and self-employed (community) midwives.
The survey had a large number of questions, and a full report is being prepared. This article will provide some of the most important findings for the profession.
A total of 1,421 midwives responded (49% of practising midwifery membership) from a range of work settings, geographical areas and ethnicities. 65% of participants identified as NZ European; 9% identified as Māori; 1.5% Pasifika and 3.3% Asian. There were 7.6% who identified as ‘other’, of which some were Australian, British/Irish, Canadian, Fijian Indian, Jamaican, Pākehā, or identified as more than one ethnicity (Table 1).
Midwives from all regions of the College participated in the survey, with 27% from Auckland, 10.9% from Waikato and 13.7% from Canterbury, reflective of the College membership. The survey asked midwives about their work settings and practice experience. There was a range of work settings, although the majority (47.3%) worked as community or LMC midwives, 33% worked in a maternity hospital (primary, secondary and/or tertiary) and 5.8% were student midwives. Others worked in education, management, research and advisory roles. There was a range of practice experience, with 42% having less than 10 years’ practice experience.
The survey asked midwives what they thought were the three main challenges currently facing the profession (Fig.1). The top three results were fair pay and pay equity (69.4% n= 986), workforce shortages (67.7% n =962) and stress and burnout within the profession (63.8% n= 906).
With workforce shortages clearly an important issue for the profession, the
TABLE 1. SURVEY PARTICIPANT DEMOGRAPHICS - ETHNICITY* N %
Māori 127 9.0
Lack of recognition of profession Institutional racism
Insufficient support structures Fair pay / pay equity Stress and burnout Retention of midwives
survey also asked what support was considered important for student midwives to help them complete their undergraduate education.
The majority of the student midwives (78.8%) identified the need for travel and accommodation support during clinical placements and study blocks, as well as increased funded support for midwives taking students for clinical placements (66.7%), with a further 64.3% wanting the undergraduate degree to be fully funded for all.
The survey asked respondents to identify whether they were employed or self-employed, with specific sets of
questions related to the different work settings. There were 541 employed midwives who responded to this section. We asked what the main benefits of employment were; the majority (88.7%) identified that collegial support was an important benefit, along with the regular salary (74.2%) and funded leave entitlement (87%).
We also asked for comments about what employed midwives most and least enjoyed about their role. Working with their colleagues and being with women during labour and birth were frequently identified as positive aspects of the role.
“Being with women and being able to help them find the skills to become a confident parent.”
“Always a privilege to work with women and families and to be present at births. Also enjoy midwifery colleagues and knowing my job matters.”
Issues that caused concern and midwives least enjoyed were the workforce shortages, which caused stress, the need to fill roster gaps, or working late, as well as the inability to provide better quality care to birthing people and whānau.
“Being called when things are manic and seeing women either missing out on care or getting sub-par care, e.g. no time spent on breastfeeding support, listening to their concerns etc.”
“Being asked to do extra shifts, finishing a shift late to support my colleague.”
We asked whether midwives worked in more than one role and found 47% of midwives who responded worked in additional roles. Of the employed midwives, 43.6% (n=236) worked additional shifts over their usual full-time equivalent (FTE) role, 2.2% provided second midwife services, locum services (3%) or postnatal care (5%). 101 midwives (18.7%) identified other additional work and in their text responses explained that they did a variety, or all of these additional roles (Fig.2).
When asked what the benefits of the move to a single entity - Te Whatu Oramight be, the majority identified consistency of guidelines and care pathways across settings (69% n= 419). A further 64.6% (n=393) selected standardisation of the IT systems between hospital settings, and 57.3% (n=345) selected equitable distribution of resources.
Midwives were asked to rank a list of options to indicate which additional resources were most and least important to help in their role. The majority identified the need for more midwifery staff as being very important (94%), along with increased administrative and health assistant support (Fig.3).
There were 668 midwives who identified as being a community or LMC midwife. Of those who responded, nearly 47% worked
in an urban area, with a further 33% both urban and rural, 12% rural and 4.6% remote rural. The majority had a caseload of between 41-60 clients, with similar proportions (21%) having a caseload of between 21-40 clients and >60 clients (Fig. 4).
When asked about the main benefits of their role, the majority identified providing continuity-of-care (74.5%), with 54.8% finding being able to determine the size and composition of their caseload important, and 46.5% being able to be flexible in scheduling routine work. In the open text responses to what midwives most or least enjoyed, the autonomy of the role and continuity-of-care were the most common themes.
“I most enjoy the autonomy I have in my work. I can decide who I work with and how I work.”
“Being with whānau/families for their entire journey as they grow themselves.”
The parts of the role they least enjoyed were the long working hours, administration, missing out on family time and the impact of the hospital staffing shortages.
We asked both LMC/community midwives and employed (hospital) midwives whether LMC/community midwives should be employed or self-employed. The vast majority (88.5%) of midwives working as LMCs would prefer to continue to be selfemployed (Fig.5).
For employed/hospital midwives, 45% agreed that LMCs should be self-employed, whilst a smaller proportion (32%) thought LMCs should be employed (Fig. 6). The remaining 23% selected ‘other’ and provided a text response with many suggesting that both options should be available, while others stated they couldn’t comment because they had never worked as an LMC midwife. Many also stated the need for LMC midwives to be able to retain their autonomy, regardless of employment status.
LMC midwives were also asked if they would continue to work as an LMC/ community midwife if employment was the only option; the majority were unsure, with 32% stating they would not continue to work as an LMC (Fig.7).
When asked who would be a preferred contract holder in the future, the majority of
FIGURE 5. DO YOU PREFER TO BE EMPLOYED OR SELF EMPLOYED? (LMC midwives' responses)
Self employed - 88.5%
Employed - 11.5%
FIGURE 6. SHOULD LMC MIDWIVES BE EMPLOYED? (Employed midwives' responses)
Yes - 32% No - 45% Other - 23%
FIGURE 7. WOULD YOU CONTINUE TO WORK AS AN LMC COMMUNITY MIDWIFE IF EMPLOYMENT WAS THE ONLY OTPION?
Yes - 22.3%
No - 32.7% Not sure - 45%
LMC community midwives (71%) indicated they would prefer to be self-employed/ contracted through a new contract model, which included funding for administration, workload management and other supports to promote sustainability. A majority (59%) also stated a midwifery-led organisation should hold the contract in future (Fig. 8).
The survey has provided the College with helpful information as we move forward into a time of transition and change. Pay, stress, burnout and workforce shortages are challenges currently facing the profession, causing anxiety and frustration for midwives wherever they work. It is clear that we need more midwives in the workforce and the lifting of the vaccination mandate along with the re-opening of the skilled migrant visa category may help to alleviate workforce issues in some regions in the short-term, however longer term strategies are also needed.
A potential strategy could involve more funding support for student midwives so that they are able to complete their undergraduate degree with less financial stress. Our survey has identified the need to prioritise funded travel and accommodation for students during clinical placements and study blocks and the need to improve the funding support for midwives taking students during clinical placements as important first steps.
One of the most significant findings of the survey was that nearly half the workforce is working in more than one role. Many employed midwives are working additional shifts in maternity facilities. But they are
also working in support roles for LMC (community) midwives by providing locum services, second midwife support and/or postnatal care support. These midwives are clearly providing important support for women at a time of workforce shortages and are filling a vital and necessary role.
There have been a number of rumours circulating related to a potential for future employment of community LMC midwives. The College has advocated for the right to choose self-employment and there has been no indication that LMC midwives will all be employed under the new Te Whatu Ora structures. The survey responses have identified that the majority of the workforce supports our LMC/community midwives to retain the option of being self-employed contractors. The College has shared these results with Te Whatu Ora and will continue to advocate for the profession. Flexibility will be important as we move forward with employment often necessary in regions that are hard to staff and where there are insufficient LMC midwives. There has always been a need for employed community midwifery teams in some settings, and this will continue to be necessary in the future.
The LMC responses identified the strong preference for a new contract model, with the contract held and negotiated by a midwiferyled organisation. Important aspects of this will be the need to provide additional administration, workload management and support for sustainability, for both community and hospital midwives.
The issues currently facing the profession have been aggravated by workforce shortages,
The survey has provided the College with helpful information as we move forward into a time of transition and change. Pay, stress, burnout and workforce shortages are challenges currently facing the profession and causing anxiety and frustration for midwives wherever they work.
but with change come both challenges and opportunities. Now is the time to consider the opportunities and advocate for future changes that will sustain the midwifery profession's needs. square
Recent health system reforms in Aotearoa have resulted in a raft of new terms and renamed entities. For clarity, we’ve compiled a glossary of the terms midwives are most likely to come across or use in their daily mahi, and provided short explanations for each.
Te Whatu Ora | Health NZ: the overarching organisation responsible for New Zealand’s national health service, including funding and delivery of services. It will work closely with its partner, Te Aka Whai Ora | Māori Health Authority.
Te Aka Whai Ora | Māori Health Authority: an independent public health agency responsible for enhancing tino rangatiratanga, strengthening mana motuhake for hauora Māori and ensuring greater influence throughout the entire health system, to support whānau to take control of their own health and wellbeing.
Manatū Hauora | Ministry of Health: the chief steward, regulating the health system, setting its direction and policy, advising government on funding and system settings and monitoring health outcomes.
Hauora Māori Advisory Committee: advises the Minister of Health on matters relating to Te Aka Whai Ora - Māori Health Authority Board and to the Public Health Advisory Committee. The role of the committee is also to ensure that the voices of Māori are heard at all levels of decision-making in the new health system.
Kahu Taurima: a joint approach between the Māori Health Authority and Health New Zealand, which will drive the integration of maternity and early years services for a child’s first 2,000 days, from conception to five years old, across Aotearoa.
Te Pae Tata | Interim NZ Health Plan: sets out the first two years of health system transformation to improve the health and wellbeing of all New Zealanders.
Whakamaua | Māori Health Action Plan 2020-2025: implementation plan for He
Korowai Oranga, New Zealand’s Māori Health Strategy, which focuses on achieving better health outcomes for Māori by setting the government’s direction for Māori health advancement over the next five years.
Pae Ora legislation: the Pae Ora (Healthy Futures) Act 2022 took effect on 1 July 2022.
Te Whatu Ora localities: geographical areas that make sense to the people who live in them. This change is a fundamental part of the new health system reform and replaces the previous DHB and PHO-focused approach. Everyone in Aotearoa will fit into a locality that reflects their community.
Te Whatu Ora districts: have replaced DHBs.
Iwi-Māori partnership boards: enable iwi, hapū and whānau to exercise rangatiratanga in their rohe. They ensure tangata whenua voices are heard and local health services reflect those who need and use them.
National Public Health Service: a new entity which will bring together the functions of the 12 former public health units, Te Hiringa Hauora Health Promotion Agency and the Ministry of Health. It will work closely with Te Aka Whai Ora and the Ministry of Health, and the Public Health Agency to work alongside whānau, communities, and other sectors, drawing on mātauranga Māori and data to provide health promotion, prevention and protection at local, regional and national levels.
Public Health Agency: sits within Manatū Hauora (Ministry of Health); leads and strengthens population and public health, policy, strategy, regulatory, intelligence, surveillance and monitoring functions, with a greater emphasis on equity and the wider determinants of health such as income,
education and housing. Plays a key role in providing advice to ministers on all public health matters.
Commissioning: the process of assessing needs, planning and prioritising, purchasing and monitoring health services, to get the best health outcomes.
Commissioning Framework: places people at the centre of commissioning, and aims to achieve equitable outcomes for everyone, wherever they live and whatever their circumstances.
National service networks: service-based networks to drive consistency in delivery of specialist and hospital services. These service networks will ensure that the quality and outcomes of care are consistent across Aotearoa, while recognising some variance can help tailor care to community needs.
Regional hospital and specialist networks: a regional network will operate as ‘one hospital’ on many sites. Those in the regional networks will ensure 24/7 hospital and specialist services are available and sustainable everywhere. They will minimise unnecessary duplication, clarify referral and discharge pathways, co-ordinate care, improve quality and reduce waste. They will also oversee collective workforce plans.
Te Korowai | The Health Charter: a document which will guide the culture, values and behaviours of the health sector. It will guide how health providers - including Te Whatu Ora and Te Aka Whai Ora - will relate to each other and together serve our whānau and communities to improve health outcomes and build towards Pae Ora. The Charter is currently in draft form and due to be consulted through the sector. square
After many years of under-investment in midwifery, it’s no secret the midwifery workforce is under immense strain. This article takes a frank look at the current state of the midwifery workforce in Aotearoa, actions underway, College advocacy on behalf of its members and the role of the newly established Workforce Taskforce.
The College spoke to members in positions of leadership across the profession and with the leaders of the Workforce Taskforce about supporting and rebuilding the health workforce. We gratefully acknowledge those who contributed their time and expertise for this article.
In 2022, a total of 3,085 midwives had an annual practising certificate (APC) - 198 fewer than in 2021 (NZ Midwifery Council). The most common reason cited for not practising was parental leave, followed by the Covid-19 vaccine mandate, working conditions, family responsibilities and retirement.
The number of APCs only tells part of the story, given the range of working hours, skill mixes in different settings, increasing acuity in maternity facilities and the pressures on midwives as more nurses fill gaps in maternity. Understaffing has been exacerbated by unusually high levels of winter sick leave and midwives are feeling the strain of holding the maternity service together.
The current health workforce situation has been described as a ‘crisis’, and Julie Patterson, co-leader of the nascent Workforce Taskforce Midwifery Programme, confirms midwifery is the most acutely understaffed workforce in the health sector. Te Whatu Ora and Te Aka Whai Ora have responded by establishing the Workforce Taskforce, chaired by Ailsa Claire, Interim Workforce Lead, Te Whatu Ora, and Anna-Marie Ruhe, Interim Workforce Commissioning Lead, Te Aka Whai Ora.
Workforce shortages create a vicious cycle of understaffing which affects patient care, workforce strain, and loss of
confidence in the health system, leading to more staff attrition and difficulty recruiting. “We hear the midwives,” Ailsa says. “We know. We absolutely understand the situation that people are in. And it’s heard by everyone in the system up to Ministerial level, and yes, we are trying to do something about it.”
43.1% of the workforce have been in practice for up to 10 years
25.3% of the workforce have been in practice for 11 to 20 years
33.4% of the workforce have been in practice more than 20 years
Average time in workforce: 15.1 years
By prioritised ethnicity, 12.2% of the workforce are Māori and 2.9% are Pasifika
42.5% of the workforce is aged 20-44
50.6% of the workforce is aged 45-64
6.9% of the workforce is aged 65+
leaders have stated that the extensive work already undertaken across the midwifery sector in recent years will form the basis of new initiatives as solutions are developed and implemented, and midwifery will lead much of that work.
The College’s 2015 legal claim of sex-based discrimination under the Bill of Rights resulted in appreciable gains in LMC resourcing, including increases to Section 88 and extensions to the locum service.
Under the 2017 settlement agreement, the College engaged extensively with the membership in order to accurately represent contemporary practice realities in the design of a fit-for-purpose funding model. Practice sustainability enablers were factored into the proposed funding model to support the retention of the workforce, but the Ministry’s failure to implement the agreed model has undoubtedly contributed to current workforce issues. A class action is now underway, seeking to remedy the breach of the second settlement agreement and enabling dialogue with policymakers which would otherwise have been unlikely. The College’s previous work on solutions for the LMC workforce will inform next steps with the Workforce Taskforce.
The College, District (formerly DHB) Midwifery Leaders and MERAS have been listening to midwives’ concerns and loudly advocating for a workforce strategy, improved conditions and increased full-time equivalent (FTE) capacity of employed midwives, for years. Midwifery leaders have been managing staffing within significantly resourceconstrained environments and escalating their services’ needs regionally and nationally.
Unfortunately, in most districts midwifery is not present at the most senior level of the organisation and struggles to be heard.
The College has provided multiple submissions to advocate for the development and elevation of midwifery professional leadership positions within former DHBs, with some success as evidenced by the increasing number of director of midwifery positions established. However with the health reforms now underway, the future scope and nature of these positions is uncertain. The College is advocating for urgent investment in midwifery leadership positions in both hospital and community settings, to ensure the solutions work for midwives and the whānau they serve.
MERAS co-leader Caroline Conroy has been working closely with MERAS workplace representatives and midwifery leaders to identify initiatives that support the local recruitment and retention of midwives.
MERAS also established the Midwifery Accord in 2019 and the outcomes from it are starting to bear some fruit: midwifery clinical coaches have been appointed in every district; there is greater support for midwives on return to practice programmes; the Midwifery Career Pathway has opened opportunities for leadership positions; FTE calculations from the Care Capacity and Demand Management (CCDM) and Trendcare programmes have resulted in midwifery FTE increases (even if midwives are not yet available); and a Māori and Pasifika student support strategy has been actioned. Some of the most chronically understaffed facilities are experiencing increased recruitment as a result of these initiatives.
Workforce Taskforce leaders have stated that the extensive work already undertaken across the midwifery sector in recent years will form the basis of new initiatives as solutions are developed and implemented, and midwifery will lead much of that work.
In March 2021 Te Ara Ō Hine – Tapu Ora was launched to support Māori and Pasifika student recruitment, retention and completion. Eighteen months in, the programme is demonstrating its value.
National Māori Midwifery Co-ordinator of Te Ara Ō Hine, Joyce Croft, is pleased most of the schools have now appointed Māori liaisons and that the number of Māori students is increasing. The Pasifika arm of
the programme, Tapu Ora, is headed by Ngatepaeru Marsters. Ten Pasifika midwives graduated last year and there are currently about 50 students at AUT alone, with more across the country. AUT Pasifika Liaison Lead, Talei Jackson, is upbeat. “We’re growing exponentially compared to 10 years ago when there were one or two Pasifika graduates per year.”
The programmes continue the mahi of many Māori and Pasifika midwives and tūpuna who have gone before. As Lisa Kelly, Ngā Māia Māori Midwives Aotearoa chairperson points out, “for Ngā Māia, for Māori midwives, when you’re working with whānau in the community you’re always trying to recruit. You’re looking at the babies and teenagers and thinking, you’d be a good midwife. We’ve done that since mai rā anō. They would hand-pick these tamariki and guide them on that huarahi – that’s what our tūpuna used to do.”
Established in 2007, the MFYP is currently supporting an average of 140 graduates per year. The structured support is a key tool in ensuring graduate retention and embedment within the professional frameworks. This year graduate numbers have increased from Otago Polytechnic, Ara and Wintec, and 65 AUT graduates from the first 4-year degree cohort have boosted the Auckland region. Victoria University’s first graduates will also join the workforce next year.
The College continually adapts the MFYP programme to meet the needs of graduates and the wider workforce, and is exploring ways of strengthening the programme to enhance support for Māori and Pasifika graduate midwives.
After 15 years of MFYP, there is a rich pool of highly experienced mentors who are well-placed to be involved in the evolution of further professional support mechanisms for midwives across the practice spectrum - this is a key priority for the College.
Across all districts, midwifery clinical coaches have hit the ground running and established a network chaired by Jade Wratten, to develop a shared understanding of the role. The Council-mandated supervision role supports internationally qualified midwives (IQM) and midwives returning to practice (RTP), providing opportunities for midwives to debrief, check in, and present case reviews.
The coach roles also complement the support offered to new graduate midwives by MFYP mentors and professional colleagues, offering site-specific orientation, socialisation to the midwifery team, and confidence-building in complex hospital care situations.
As the roles evolve, clinical coaches may be in a position to enable confidence-building as midwives increasingly work to the top of their scope of practice.
Te Whatu Ora and Te Aka Whai Ora Workforce Taskforce has been established to provide strategic leadership on health workforce issues in the short-, medium- and long-term, in alignment with Te Tiriti and with an explicit pro-equity focus. Central to the process are the Hauora Advisory Committee and Iwi Partnership Boards (see p.27 for an explanation of health system entities and terms).
Next steps are to establish a Midwifery Programme Steering Group and specific working groups to focus on services, education and graduate support, recruitment and retention. The College will have representation at each level and expects midwifery stakeholders from across all professional domains to be involved. We will keep members updated and able to contribute as the work progresses.
Several Workforce Taskforce initiatives are planned for the whole health workforce: the International Recruitment Centre will lead a nationalised campaign and provide immigration, relocation and resettlement services for health workers and their families; Te Aka Whai Ora is leading work on what international recruits need to understand about the Aotearoa cultural context. Education initiatives include a national student placement system, enhanced recognition of prior learning within regulated health professional education, developing the kaiāwhina workforce (unregulated workers) through micro-credentialling, support for retention of Māori health students, and publishing information about $70m worth of health scholarships.
Focus areas are about working to the top of scope; the taskforce sees micro-credentialling as a way of building up the kaiāwhina and clerical workforce to pick up administrative and routine tasks that currently take up health professionals’ time. The College has cautioned that midwives need to be able to provide holistic, relational care, and that itemising roles into tasks comes with risks, which need to be carefully considered. Rural environments are being looked at to recognise the extensive scope midwives can work within when there is no ready access to medical staff – then considering how this level of practice can be supported in large, urban teaching hospitals as well.
As a highly networked membership organisation, the College hears members’ concerns, issues and ideas in multiple forums. On the College’s national board, representatives from the regions, Ngā Māia, Pasifika Midwives Aotearoa, community organisations, the schools of midwifery, our kuia, elder, Chief Executive and President set the College’s strategic plan and direction. The College also has representation on multiple groups within the midwifery and wider health sectors. It was therefore not surprising that the themes raised in conversations to prepare this article aligned with the College’s priorities and advocacy.
The 2022 Midwifery Council workforce survey indicated the main factors that would encourage non-practising midwives to return to practice were improved conditions. Examples included better remuneration, working environment, work sustainability and value/respect for midwives.
Lisa Kelly is pleased Te Aka Whai Ora has invited Ngā Māia to formulate the position description for a Māori midwife clinical leader. The College has strongly advocated for a parallel position to be established within both Te Whatu Ora and Manatū Hauora, as there is currently no policy leadership or ministerial communication line for midwifery.
At a district level, Deb Pittam, Director of Midwifery at Te Whatu Ora Te Toka Tumai Auckland, Chair of the national Midwifery Leaders Group and former College President, cites midwifery leadership as key to changing the culture from medical-led to midwifery-led within maternity services. “My honest belief is that a big part of the problem with the workforce is that people’s expectations about what they can do and what value they can add isn’t their experience when they get there. They don’t feel their skills and expertise are valued, don’t feel able to work across the full scope of midwifery. They come out of their training with enthusiasm and a great level of knowledge, ready to be the autonomous practitioners they are trained to be. Then they just stop. They get into the [tertiary] environment and just have to do the tasks. That’s incredibly hard on any profession.”
Deb suggests we need to work together as a profession to take back what is ours, by empowering midwives to work to their full
scope of practice and be valued as equals for the expertise they bring. For example, when midwives identify concerns, they need to be able to make a full assessment and diagnosis, then consult for a plan without having a junior doctor or registrar repeat the assessment. This means recognising the midwifery skillset; we are experts in birth from normal to the highest level of complexity.
Helen Becconsall is a MERAS workplace representative for Christchurch Women’s Hospital and a member of the National Representative Council. With 30 years of midwifery experience, Helen is among the 6.9% of our profession in the 65+ age bracket and shares her view. “The thing that keeps midwives there is the love for what they do. It’s a different thing that calls you to midwifery than for people who are driven by the big bucks. You are doing it in a service role to make people’s lives better, not to make them feel worse because we can’t provide them with the service they need when they need it.”
A key aspect of any retention strategy must be financial recognition of the value midwives bring to the health service and people’s lives. “The pay does not reflect the intensity of the work, by any stretch of the imagination,” Helen says, citing pay equity as the circuitbreaker in the vicious cycle of understaffing and attrition. “If we pay midwives properly, they’re not going to leave.”
Fair pay and pay equity processes are well underway for self-employed and employed midwives and resolution is urgently needed in 2023. The College’s class action is progressing. The MERAS pay equity claim for employed midwives has implemented a legal strategy following a stalemate in bargaining.
A theme that emerged in preparing this article was the need for kotahitanga |unity, respect and support for one another within the profession. When we are stretched thin to provide care to whānau in under-resourced environments, it is natural to look inwards to our own needs; we are in survival mode. However, the pressures come from the structures and environments we work within. Our colleagues are our main supports, not our adversaries.
Victoria Christian, the newly appointed Clinical Midwife Manager at Taranaki Maternity, the immediate past Chair of the MERAS National Representative Council, points to the importance of unity and
professional engagement. “It’s simple: it’s about being optimistic and being heard. You can’t let other people do the job for you. We have to do this as a group. You can’t sit back and say it’s the College or MERAS who has to do it. We all have a responsibility. Tell people how wonderful we are and how well we do, how we work as a team. Keep being loud, keep the conversation alive, not taking no for an answer. Always pushing but being aware that these things take years.”
The final word goes to our kuia, Crete Cherrington. After almost 30 years of midwifery, people often ask what has sustained her in practice. She points to giving ourselves permission to take a rest. “Often we don’t give ourselves permission because we think we’re so needed.”
“We need to celebrate more – I don’t think we do it enough. Celebrate what we do and who we are. Celebrating the small things we do well – doing something to honour that. Being together. Having fun, we’ve forgotten how to have fun. Remind ourselves the nature of the business we’re in, and it’s not the nature of money, it’s the nature of wairua. Reclaim the essence of the beauty of creation. And remind ourselves that everyone that we’ve touched in some way or form has got this amazing cellular memory of ancestry that goes back into time.”
Looking beyond workforce-specific activity, Crete reflects on the broader move towards Tiriti-based relationships in regulatory, professional and health service structures, and reminds us that midwifery is a journey. “For some of us we think, ‘I’ve done my journey and that’s all I need to do – I’m a midwife now’. The journey will always give you opportunities to strip away the layers and it might not always be pretty. But that’s ok - that’s where the gems are – the pounamu. Then you shine it up.”
As we move forward, we must honour our midwifery knowledge and model to ensure the role is not further fragmented. Midwifery is the predominant workforce in maternity and we will always have a central, integral role. However we evolve and adapt to the changing settings in our health system model, we will always need a well-educated, regulated and well-supported workforce. The College is the only organisation which has an overview of the entire profession and will continue to engage with members and advocate for midwives as we work with the Workforce Taskforce Midwifery Programme. square
Deb (Pittam) suggests we need to work together as a profession to take back what is ours, by empowering midwives to work to their full scope of practice and be valued as equals for the expertise they bring.
On a crisp spring day in September, those who work intimately with Pacific women and their whānau in the maternity space and beyond gathered under the majestic beams of Fale Pasifika at Auckland University, to explore issues through talanoa, hear about research and best practice, and make new connections.
Headlining the forum was esteemed health advocate and educator Fuimaono Dr Karl Pulotu-Endemann, well known for his groundbreaking Fonofale model for Pacific health (1984). It has been recognised as the holistic framework for Pacific wellbeing within the tertiary sector over several decades.
More recently, Fuimaono, together with Aotearoa’s only Pacific forensic psychiatrist, Dr Leota Lisi Petaia, launched the Kalisi model in June 2022. This model further enhances Fonofale, as it uses two women and their life journeys, reflecting and recognising the two worlds/communities that the Pacific diaspora faces in the New Zealand context.
Already adopted by a selection of South Auckland schools, it has been the foundation for innovative work with Pacific youth to encourage talanoa about mental wellbeing without stigma.
This forum presented itself as a great opportunity to co-present with midwife LMC Dinah Otukolo (Tongan/Pakeha), to speak about the village model of care at Ngā Hau Mangere Birthing Centre (NHMBC) and why the uniqueness of the centre lends itself toward being a viable solution going forward, for improved services for all women and midwives.
A 2018 study discussing choice of birthplace for Pasifika women in Counties Manukau found low-risk Pasifika women were overwhelmingly choosing to have their babies at Middlemore Hospital rather than in a primary maternity unit. Whilst 10% of the women commenced labour in the primary unit, even less birthed in that setting. The findings stated they were heavily influenced by their community and midwife.
Culture and care are intrinsically linked and since 2019 when NHMBC opened in a suburb with Pacific demographics of 75%, it is no surprise that 52% of the births have been Pacific whānau and a further 27% Maori. The number of Pacific LMCs facilitating births at the centre is also the highest of any maternity unit in Aotearoa.
The kaupapa at Ngā Hau Mangere is to provide a high standard of clinical care with respect and kindness, preparing families for what’s ahead. This care translates into an environment that accommodates a support person to stay overnight in comfort. It is peaceful and quiet to recuperate, with
good nutrition, evidence-based advice on parenting, and excellent breastfeeding support. Yet step outside its doors on a Saturday morning and you land in the heart of the Pacific. The aroma of ethnic food and music from the local market stalls embrace you and arrest your senses.
The fono presentations generated lots of discussion throughout the day in the open talanoa. The relativity of social inequities of poverty, poor housing, intimate partner violence, substance abuse and the plethora of other social outcomes could not be ignored as contributors to anxiety and depressive disorders amongst Pasifika women.
But of equal importance were the positive external factors of appropriate service providers, understanding cultural values to assist with choices through education, quality care and the inclusion of family, community, and an acknowledgement of a spiritual belief system. Collaborations are essential in the formation of a ‘village’ of support.
Fa’afetai lava le avanoa!
Ehara taku toa i te toa takitahi, engari he toa takitini.
Success is not the work of an individual, but the work of many.
In the face of the concerning climate and biodiversity crises, working together is more important than ever. While midwives have the professional responsibility to reflect on what they use in their practice and how these impact on the environment, it can at times feel overwhelming. This article attempts to provide some guidance, suggestions and reflections on how midwives can reduce their environmental impact in Aotearoa. There is no one, practical, sustainable solution for addressing the environmental impact of maternity care, but we can all consider how we minimise our impact as individuals.
Carbon dioxide (CO₂) is one of several greenhouse gases in the atmosphere. They are referred to as greenhouse gases because, like the glass of a greenhouse, they let visible light from the sun pass through the atmosphere, but absorb longwavelength infrared energy from the Earth and keep the atmosphere warm (Earthathome, 2022). CO₂ is therefore only one of the greenhouse gases. Methane, nitrous oxide and chlorofluorocarbons (CFCs) are others. CO₂ emissions are the result of activities such as manufacturing, heating
and transportation, involved in the production of goods and services (Selin, 2022). For midwives and maternity, this means any usage of pregnancy and birth equipment, disposables such as plastic-based wrappings and containers, transport, and administration of non-reticulated nitrous oxide (Entonox®) (Bolton, 2018; Burrell, 2022). An article focused entirely on nitrous oxide use in maternity care and its potentially harmful effects, written by anaesthetist Dr Rob Burrell, was featured in the June 2022 issue of Midwife for those interested in further reading on this topic.
Transport emissions are the fastest growing source of greenhouse gas emissions (CO₂) in Aotearoa, accounting for 20% of all emissions produced. Nearly 70% of all transport CO₂ emissions are from cars, SUVs, utes, vans and light trucks. The Clean Vehicles Act came into force in February 2022, with targets for reducing CO₂ emission in Aotearoa (Ngā Waka Mā Clean Cars, 2022) and includes incentives for purchasing and using electric cars, fuel efficiency testing, and increasing the import of low or zero CO₂ emission cars.
There has been considerable discussion and debate about what car type and usage is most environmentally friendly. While electric vehicles (EV) are being recommended as the answer to reducing carbon emissions, noise and air pollution, community midwives need to consider economy, load space, reliability, safety, maintenance and upkeep, and access to fuel or electricity. Rural and urban practice require further considerations, such as whether the midwife has a busy city practice with many short trips and frequent stopping, or if the practice is mainly rural, requiring negotiation of difficult terrain (Martis, 2020).
There is no one, practical, sustainable solution for addressing the environmental impact of maternity care, but we can all consider how we minimise our impact as individuals.
Some suggestions to lower the environmental impact of using a car are provided below:
• Driving smoothly and anticipating traffic conditions to minimise the use of braking and accelerating to stay in the flow of traffic will reduce gas emission.
• Turning off the air conditioning when it is not needed reduces the load on the engine and will use less fuel.
• Reducing the drag resistance of the vehicle by keeping the tyres properly inflated, removing the roof rack if not in use, and/or taking all heavy equipment out of the boot will use less fuel.
• Choosing a car that is promoted as being reliable, with long service intervals, that is mostly recyclable, is kinder on the environment.
• Ensuring equipment for the car can be repaired rather than thrown away leads to less waste.
• Ensuring regular maintenance of the car to prolong its life reduces environmental impacts.
For many midwives in Aotearoa, working without a car would be difficult, but there may be opportunities to use e-bikes instead of cars, for some. E-bikes have the capability to reduce car CO₂ emissions by 24.4 million tonnes per annum according to statistics from the United Kingdom and its carbon reduction capability is greatest in rural areas (Philips, 2022). A life cycle assessment of Wellington’s e-bike usage supports the UK statistics, especially when using electricity companies who provide renewable electricity generation (Elliot, 2018).
Motorcycles and motor scooters use less fuel when compared to other transport methods and could be another consideration to reduce carbon emission (de Rome 2011).
Car-pooling or public transport provide further alternative options for reducing greenhouse gas emissions and may be viable options for employed midwives working shifts (Cairns 2008). Offering homebirths could also reduce vehicle use by whānau. Of course, walking produces zero carbon emissions and is always worth consideration.
Online conferences and education sessions clearly reduce carbon emissions. According to Australian statistics, planes pump out eight times more CO₂ per passenger mile
than a train. Aircraft emissions go directly to the stratosphere and therefore have more than twice the global warming effect than emissions from cars at ground level. Apparently, a return flight from London to Sydney will release as much CO₂ as all the heating, light and cooking for a house in a year (McCarthy 2010).
Online conferences and education like webinars are disliked by many midwives, as it can feel lonely in front of a screen at home, with little opportunity for networking. However, the Covid-19 pandemic has shown us what’s possible and if midwives are serious about reducing carbon emissions, completing professional development, education, meetings and consultations online should be embraced. For online conference or professional development sessions, midwives could consider gathering with other local midwives and watching the sessions together over shared kai, partially fulfilling the faceto-face relationship and networking needs so desired by many midwives.
Several Aotearoa midwifery undergraduate and postgraduate education providers have already introduced blended learning; a mixture of online modules and face-to-face teaching, reducing the environmental impact of education on global warming.
Promoting and supporting normal birth is at the core of the midwifery ethos. The focus, therefore, should be on using appropriate low-impact assessment tools and carrying out interventions only when clinically required.
Midwives use their hands, eyes, ears and hearts to assess pregnant women in their care (Tritten 2008). Refocusing on these tools will not only reduce the environmental impact of our practice but could lead to more meaningful connections with whānau and increased work satisfaction (Martis, 2020).
The following suggestions could be considered:
• Touch women with hands for abdominal palpation to ascertain the baby’s position and well-being, as opposed to using technologies like ultrasound transducers.
• Listen to the baby’s heartbeat with a genuine sound detection tool, like a pinard, rather than using electronic monitoring tools that use energy and potentially produce harmful sound waves.
• Support and encourage home birth, or birth in a local primary unit (this supports birth with fewer interventions, as well as reducing travel for the family).
• Promote upright, mobile labour and birth positions, removing some of the need for expensive technologically advanced delivery beds.
• Use water immersion, massage and words of encouragement instead of pharmaceutical products for pain relief and the associated plastic equipment requiring incineration.
• Practice continuity-of-care.
It has been argued that the midwifery continuity-of-care model can reduce environmental impact because it provides one-to-one care for whānau (Homer, 2019), enabling effective use of the midwifery tools discussed above. For example, observing and assessing labour and knowing the birthing woman can reduce the need for frequent vaginal examinations. This would mean less use of sterile gloves and plastic sheets and the disposal process of those, which requires incineration.
When considering use of equipment in maternity care (including cars), the best approach is to assess a product’s life cycle, rather than just the impact of the product when it is used (He, 2019). This includes what is used to manufacture the product; its raw material, the energy used to make it, the packaging, transport, as well as its reusability, or disposal requirements.
Reading the manufacturer’s product description to understand whether the product has a low environmental impact and/or searching for verification of ecolabels on the product are efficient ways of finding this information. Te Whatu Ora (2019) has produced a starting guide for sustainability in the health sector and whilst not necessarily helpful for individual products, it provides thoughtful actions for sustainability and how to ensure it is successful, supported by several case studies. Midwives may also consider locating their nearest recycling facility, to be able to dispose of products with the least environmental impact, advising whānau accordingly.
Disposable plastic items are frequently used by midwives, often to prevent crosscontamination; sterile gloves, syringes, cord clamps, protective sheets/liners, IV tubing, and disposable second grade stainless steel instruments, to name a few. These products are frequently marketed as cheaper and cleaner than equipment that could be resterilised. While autoclaving does have an impact on the environment, the overall life cycle of a product reveals its true level of environmental impact.
Disposable plastic - referred to as biohazard plastic - reduces landfill, but
when incinerated, emits dioxins. This is so because most biohazard plastic is made from polyvinyl chloride (PVC), which is the least recyclable plastic and therefore requires incineration. The accumulation of dioxin has been shown to cause cancer and has been associated with decreased birth weight, learning and behavioural problems in children and the disruption of hormones (World Health Organisation, 2016). The question is, do midwives in Aotearoa know how the incineration process works in health facilities, or how dioxin emission is minimised in their area? How can midwives reduce the use of biohazard plastic and incineration processes?
• Offer home or primary unit births, where less plastic and other equipment are used.
• Use washable, reusable linen rather than disposable plastic/paper sheets.
• Use clean cotton towels and face cloths in labour and birth and for drying the baby, rather than paper towels.
• Plastic cord clamps could be replaced by natural products, such as plaited cotton, muka ties (flax fibre), or silk cord ties.
• Consider the option of lotus birthing the whenua/placenta, where the cord is not cut until it falls off.
• Instead of using the biohazard human waste system in the birthing facility for the whenua/placenta, discuss burying it as a biodegradable option for families, as is often custom for whānau Māori.
• Use recyclable glass containers for testing and measuring body fluids, not disposable plastic containers.
• Limit the use of paper-based resources for information-sharing or documentation.
• Critically examine the contents of birthing kits/packs to reduce waste to a minimum. Hospital birthing packs include sterile containers, linen and instruments which are seldom used. Can they be wrapped separately?
• Consider sharing equipment between community midwives, for example sonic aids or oxygen cylinders.
Computers and mobile phones are an everyday communication tool for midwives and whānau. While we all have an awareness now about paperless communication and documentation, mobile computers and phones contribute considerably to global warming, which is often overlooked. Like many countries, Aotearoa has an
Environmental Protection Authority (EPA) –Te Mana Rauhī Taiao - which aims to protect the environment and people who live and work in it. It provides guidelines and updated information, including standards for eco-friendly computers and other mobile devices. They are encouraging computer manufacturers, for example, to register their compliance with them. EPA suggest asking the following questions when purchasing a computer:
• Does the computer identify as energy efficient; is it using less than 100 watts, LED (light-emitting diode) lamps for buttons that need to light up, or the use of non-light buttons?
• Can the computer casing be recycled?
• Is the packaging recyclable?
• Can it be easily up-graded, which means the computer is being used for longer?
• Are the instructions for how to set up and use the computer digital, rather than printed on paper?
• How can the computer be recycled when the computer is no longer useable? Do the instructions come with safe recycling options?
• Does the manufacturer state the levels of cadmium, lead and mercury used in the production of the computer? Or at least state that they are to standard or lower levels?
• Does the manufacturer state that the computer is at least carbon neutral?
Mobile phones are now an intrinsic part of life for midwives and whānau in Aotearoa and require precious metals (e.g., gold, silver, copper) to be manufactured (OECD, 2010). They are also discarded at a phenomenal rate, contributing to non-biodegradable landfill waste (Wansai, 2018). When mobile phones reach the landfill, they can leach toxic chemicals into the ground with the potential of contaminating the ground water, posing an environmental threat to humans and wildlife. It is estimated that worldwide, 5.3 billion mobile phones will be thrown out in 2022, according to the Waste Electrical and Electronic Equipment forum (WEEE, 2022), with only a few discarded in an environmentally friendly way. Mobile phones are one area where midwives can make a difference; if a mobile phone is unable to be repaired, recycling it responsibly is strongly encouraged. This is also important information to share with whānau. It is estimated there are now over 400 drop-off
The Covid-19 pandemic has shown us what’s possible and if midwives are serious about reducing carbon emissions, completing professional development, education, meetings and consultations online should be embraced.
locations across the motu, not including local recycling centres. There are also options to freepost to some locations, as well as opportunities to host a collection box.
Carbon neutral footprint is defined as calculating the total climate-damaging carbon emissions by an individual or organisation and their endeavours to remove the same amount of carbon dioxide from the environment as it is released (Cambridge Dictionary, 2022). There are several carbon footprint calculators available and in Aotearoa, the Toitū site calculator is frequently used. Removing the same amount of carbon dioxide (offsetting the carbon) usually means that people or organisations plant - or pay for the planting of - new trees or invest in ‘green’ technologies such as solar and wind power. The carbon neutral approach is currently debated as being fundamentally flawed as an effective approach to climate change. It does not address attitudinal changes and seems to support ‘business as usual’. This does not lead to any real reduction of the environmental impact (Tomson, 2015). This is food for thought and therefore has not been recommended in this article.
It is encouraging to notice that in Aotearoa several midwifery practices in the community, hospitals and birthing units are seriously attempting to reduce their impact on the environment. We are recognising that together we can make a difference; we are part of the legacy for future generations to reduce the impacts of maternity care on the environment. To strengthen this, it may be time to establish a strong global or national network forum assisting midwifery to be at the forefront of sustainable best practice. Who wants to start? square
References available on request.
The Academy of Breastfeeding Medicine (ABM) recently updated their clinical protocol about the mastitis spectrum (Mitchell et al, 2022). This new protocol #36 has replaced the ABM previous mastitis protocol (#4) and also the engorgement protocol (#20).
As midwives are well aware, mastitis is an inflammatory condition of the breast and a relatively common condition in women who are breastfeeding. It does contribute to early cessation of breastfeeding, but a systematic review suggests that the substantial burden of mastitis might be preventable (Wilson et al, 2020). A study in Scotland found that out of a cohort of 420 breastfeeding women, 74 [17.6%] experienced at least one episode of mastitis (Scott et al, 2008). The majority of these women with mastitis experienced the first episode within the first six weeks post-birth, and 10% received inappropriate advice and were advised to stop breastfeeding from the affected breast, or to discontinue breastfeeding totally. A prospective cohort study in Melbourne with 346 participant women found that 20% (70/346) developed mastitis (Cullinane et al, 2015). An increased risk of developing mastitis was associated with nipple damage, over-supply of breast milk, nipple shield use, and expressing milk several times a day. Staphylococcus aureus on the nipple also increased the risk.
Midwives and other health practitioners have followed recommendations for the treatment of blocked ducts and mastitis using breast massage, a breast pump to remove more milk from the affected breast, and hot compresses as treatment. The latest ABM evidence-based guidance challenges these practices and recommends a fresh approach. The breast in lactation is dynamic, responds to both internal and hormonal stimulation, and regulates
milk via a feedback inhibition process. The new guidelines pay more attention to lactation physiology, and present evidence that traditional recommendations have lacked.
The ABM identifies mammary dysbiosis – disruption of the milk microbiome – as resulting from a complex interplay of factors including maternal genetics and medical conditions, exposure to antibiotics, use of probiotics, regular breast pump use and caesarean birth. Narrowing of the ductal lumens in mastitis can be associated with oedema and hyperlactation. Intravenous fluids given during labour can exacerbate oedema and engorgement, and minimising the amount of fluid used is recommended. Inflammatory mastitis develops when ductal narrowing persists or worsens, and inflammation progresses. ABM emphasise
Midwives and other health practitioners have followed recommendations for the treatment of blocked ducts and mastitis using breast massage, a breast pump to remove more milk from the affected breast, and hot compresses as treatment.
the importance of a healthy milk microbiome in the prevention of mastitis and the need to address the risk factors for dysbiosis. They also emphasise that a systemic inflammatory response may occur in the absence of infection.
A summary of the mastitis spectrum-wide ABM key recommendations is presented below. The protocol is 16 pages long with a large number of images, and condition specific recommendations, including recurrent, and sub-acute mastitis and galactocele, so directly accessing the full clinical protocol is advisable.
ABM RECOMMENDATIONS: “ANTICIPATORY GUIDANCE AND BEHAVIOURAL INTERVENTIONS”
• Providing reassurance to mothers that many mastitis symptoms will resolve with conservative care, counselling and support. Rest is recommended, and is the lone survivor of the three suggestions in the commonly used blocked duct/mastitis ‘mantra’, which were ‘heat, rest and empty the breast’.
• Supporting continuation of breastfeeding, strategies to decrease stress, increased opportunities for rest, and help to resolve early signs of inflammatory mastitis are recommended.
• Pain, feelings of discomfort and palpable glandular tissue are often interpreted as a diagnosis of a plugged area. Experiencing breast fullness or palpable lumps is not abnormal and reassurance is advised. Sweating and hot flushes can be caused by hormonal shifts and may mimic a fever.
• Another key point is that infection does not develop quickly over several hours. Pain and redness that may be present after a period of sleep without breastfeeding activity is described as representing alveolar distension, oedema and inflammation, rather than infection. Provision of information about normal breast anatomy and physiology is recommended.
• Responsive, cue-based feeding is recommended, with a reminder that the breast does not require ‘emptying’.
Increasing milk removal increases production. A cycle of hyperlactation is a major risk factor for increasing inflammation and oedema.
• Deep massage of the breast causes increased inflammation, oedema and microvascular injury. Oedema may resolve faster with the use of ice and gentle lymphatic drainage. (See page 21 of the protocol for a pictorial explanation of lymphatic drainage).
• Gentle breast compressions can provide an effect similar to hand expression, but excessive manual force should be avoided.
• Small amounts of milk can be hand expressed for comfort until milk production down-regulates to match infant needs.
• Minimising the use of a breast pump is recommended. If a pump is used, expressing should mimic physiological breastfeeding in terms of frequency of pumping and milk volumes removed.
• Avoid the use of nipple shields.
• Therapeutic ultrasound can reduce inflammation and reduce oedema.
• Women with a history of anxiety and depression experience higher rates of mastitis. Previous experiences with breastfeeding challenges can cause anxiety about breastfeeding, and milk supply, and this can contribute to the overuse of expressing/breast pumps.
The protocol describes clinical interventions to reduce both oedema and inflammation, including the use of ice and non-steroidal anti-inflammatory medications (NSAIDs). Frequent application of ice and ibuprofen 800mg every eight hours is recommended. Paracetamol is also recommended - 1000mg every eight hours in the acute setting. Hale and Baker (2018) discuss the preferred NSAID for breastfeeding as being ibuprofen, as levels found in breast milk are very low, with less than 0.7% of the maternal dose transferring to the infant. Paracetamol taken at the recommended dosage is also described as compatible in terms of lactation risk by Hale and Baker, as the relative dose of paracetamol an infant will receive via breastfeeding is 8.824.2%, which is considered safe.
Heat is also described as potentially worsening symptoms but also as providing comfort for some women. Warm showers did not improve symptoms in a randomised controlled trial by Kvist et
ABM emphasise the importance of
milk microbiome in the prevention of mastitis and the need to address the risk factors for dysbiosis. They also emphasise that a systemic inflammatory response may occur in the absence of infection.
al (2007). Sunflower oil or soy lethicin orally 5-10mgs daily is recommended to reduce inflammation in the ducts and to emulsify breast milk. The ABM protocol also recommends not to ‘unroof’ any associated nipple blebs but to use oral lethicin and a topical moderate potency 0.1% steroid cream applied to the nipple which can be wiped off before a breastfeed.
The treatment of an oversupply of breast milk may be necessary as hyperlactation can lead to congestion and inflammation. The Academy of Breastfeeding (ABM) Protocol #32 (Johnson et al, 2020) describes hyperlactation as being self-induced, iatrogenic, or idiopathic. Self-induced can occur with excessive pumping in addition to breastfeeding. It may be associated with maternal concerns about insufficient milk supply, and also in situations where women are trying to store high volumes of milk for future use – such as a return to the paid workforce. Iatrogenic causes include situations where medication to increase milk supply has been prescribed without close follow-up or guidance. Idiopathic hyperlactation describes mothers who have high oversupply without clear aetiology. The ABM suggests that hyperlactation can be distinguished from engorgement by the lack of interstitial oedema and persistence of symptoms beyond 1-2 weeks after birth. Management includes behavioural interventions and counselling to prevent self-induced and iatrogenic hyperlactation, block feeding under supervision (which involves restricting feeding on one breast for three hours or longer blocks of time before feeding on the other breast) (van VeldhuizenStaas, 2007), and a recommendation for cases of persistent idiopathic hyperlactation
to utilise herbal therapies and/or prescription medicines. The ABM Protocol #32 provides detailed information about the pros and cons of herbal therapies and medications. In terms of behavioural interventions, the need for individualised and contextual advice regarding breastfeeding and expressing milk when necessary, rather than prescriptive advice, is recommended. This includes addressing maternal misconceptions about breastfeeding and the avoidance of unnecessary galactogogues.
It is recognised that mastitis is associated with nipple trauma but the data is limited, and new evidence has found that mastitis is not caused by a retrograde spread of pathogenic bacteria from nipple trauma. Bacterial mastitis is represented by a progression from ductal narrowing and inflammatory mastitis to a condition requiring more than conservative treatment.
There is no evidence that supports poor hygiene as a cause of bacterial mastitis. Bacterial mastitis presents as cellulitis –worsening erythema and induration – in a specific area of the breast that may spread further. Persistent systemic symptoms > 24 hours such as fever and tachycardia need evaluation and treatment. In cases where there are no systemic symptoms, but where conservative measures have not elicited relief from oedema and inflammation, a diagnosis of bacterial mastitis should also be considered. No interruption to breastfeeding is required.
This represents a progression from bacterial mastitis to an infected collection of fluid
that requires drainage. Amir et al (2004), report that the incidence of breast abscess has often been estimated, and reported as 11% of women with mastitis, but accurate estimates are difficult due to the varied definitions of mastitis used in studies. In a study of 1,193 Australian breastfeeding women, 207 [17%] experienced mastitis and six [3%] of those women with mastitis developed a breast abscess (Amir et al, 2004).
Clinically, with the progress to abscess, there is a progressive induration and erythema, and there may be a palpable fluid collection in a well-defined area. If the initial systemic symptoms and fever resolve, this may be due to the body walling off the infection process, or symptoms may resolve and then reoccur. Symptoms may worsen until the area is drained (Mitchell et al, 2022). Management with needle aspiration enables a faster recovery, and facilitates continued breastfeeding (Amir et al, 2004). The ABM recommends continued breastfeeding from the affected breast, after aspiration or drain placement.
Antibiotics used for inflammatory mastitis disrupt the breast microbiome and increase the risk of a progression to bacterial mastitis. The relief that women with inflammatory mastitis may feel when taking antibiotics may be due to the anti-inflammatory properties of antibiotics and antifungal medications. Because there is a serious and growing global problem with antimicrobial resistance, the non-selective use of antibiotics should be avoided. In cases of bacterial mastitis when antibiotics are necessary, ABM suggest dicloxacillin, or flucloxacillin 500mgs QID for 10-14 days.
a healthy
Amir et al (2016) examined the marketing of probiotics for mastitis after becoming aware that health professionals in Australia were receiving marketing related to the prevention of mastitis, when probiotic/mastitis trials were still in progress. At that time, only one trial of probiotics for treating mastitis had been published. High-quality randomised controlled trials to assess the effectiveness of probiotics for both the prevention and treatment of mastitis are needed, and each bacterial strain requires individual testing as efficacy is species and strain-specific (Amir et al, 2016). Some controversy regarding the recommendation in the ABM protocol of specific probiotics has occurred due to a protocol author’s link with the infant formula industry, and the associated research related to probiotic strains. The ABM did make a disclosure statement about this conflict of interest, and also stated that the evidence for the use of probiotics is mixed, that strong recommendations for probiotics could not be made, that studied trials had limitations, and it was suggested that the use of probiotics warrants further research. A recent systematic review and meta-analysis about the preventative and therapeutic effects of probiotics on mastitis (Yu et al, 2022) concluded there remained a need for high quality RCTs as there was still a lack of uniformity and scientificity in the selection of probiotic strains and intervention doses, and there was inconsistency in the diagnostic criteria and efficacy indicators for lactation mastitis.
square
Prevent mastitis, or reduce mastitis symptoms, by reducing iatrogenic interventions and using simple management techniques.
Prompt and effective treatment will halt progression from inflammatory mastitis to infective mastitis, and to abscess.
Most women with inflammatory mastitis have complete resolution of symptoms without need for interventions.
Address previous experiences with breastfeeding challenges which can cause anxiety about milk supply and overuse of a breast pump.
Responsive cue-based breastfeeding physiological breastfeeding.
Caution needed when using a breast pump. Manage oversupply issues.
Rest.
Ice packs and cold compresses can reduce inflammation.
Heat can exacerbate inflammation.
Gentle lymphatic massage.
Anti-inflammatory medication such as ibuprofen.
Mastitis is often inflammatory and not bacterial - selective use of antibiotics.
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Nerissa Walters, Director of Midwifery - Te Whatu Ora Tairāwhiti (Gisborne), is the first Māori and Pasifika midwife in Aotearoa’s history to be appointed as a director.
As a 16-year-old, Nerissa (Ngāi Tāmanuhiri, Ngāti Kahungunu ki Heretaunga, Rotuman) was invited to attend her Aunty’s birth and something clicked into place. “I watched her midwife, saw her qualities, felt her wairua, and knew I could do that. I really wanted to pursue it, but it wasn’t the right time, for a number of reasons.”
More than twenty years and six children later, the opportunity to study as a satellite student through Wintec allowed Nerissa (above) to remain in Gisborne with her whānau while she gained her qualification, so she signed up and never looked back.
Heading straight into employment at Gisborne Hospital after gaining her midwifery registration 10 years ago, Nerissa’s focus has always been on serving her tight-knit community. “I love being a core midwife; you’re on the front line. I’ve grown up with these people; I’m from this area culturally, so I take responsibility for them.”
Earlier this year, an opportunity to apply for the director of midwifery role was presented and Nerissa applied after receiving strong nudges from her community to step up. “I didn’t aspire to become the director of midwifery, but the position did come up and a number of Māori midwifery colleagues encouraged me to apply. They talked about the importance of our leadership here reflecting our community.”
“I knew they were right,” she goes on to explain. “How can our young Māori and Pasifika women and men aspire to leadership positions if they don’t see us in them? It’s never been on my radar before, but the position came up and I did feel that I should apply.”
“I’m not an island on my own,” she reiterates. “My application was supported by my husband and children, and endorsed by our iwi; I am one of them and I represent my island culture too, so that’s what I carry. In all decision-making processes that I’m a part of, those are my first considerations.”
For Nerissa, being appointed as the first Māori and Pasifika director of midwifery in Aotearoa contains within it the power to transform the word equity from a meaningless token, into lived reality for her community. “I think if we were to talk about inequities, the statistics say our people are on the backburner. So I feel like it’s important for me to be in a position to make decisions that are effective for my people. To be at this level and have a say in decision-making is crucial if real change is ever to be experienced for our whānau.” square
Beatrice Leatham is an LMC in Te Tairāwhiti and celebrates Nerissa’s appointment as a win for all whānau in the rohe.
Beatrice, more commonly known as Bea, is of Ngāti Porou descent and has been a midwife for over 20 years. She returned home to Gisborne in 2019 to be closer to whānau, after working as an LMC in West Auckland for 15 years.
The midwifery landscape and culture in Te Tairāwhiti are unique, as Bea (below) explains. “We have about 14 Māori midwives here, give or take. We have more Māori LMCs in this rohe than non-Māori, and most of them are homegrown. Not just born and bred here, but most also trained here and are now working here. That’s about connection to whenua and whānau whānui.”
Connection, or whakawhānaungatanga, is of utmost importance when working with whānau Māori, and the appointment of a Māori midwife in leadership is long overdue, particularly when the birthing population in Te Tairāwhiti is predominantly Māori.
“Now we’ve got a director who is Māori and Pasifika and is very much in tune with the community, inside and out. Nerissa really does know this community and they know her. The benefits of that for our whānau are invaluable,” Bea explains.
As a member of the Aotearoa Midwifery Project Collaborative Reference Group and now a Midwifery Council board member, Bea is well aware of what is needed for whānau Māori - including Māori midwives - to thrive. Put simply, when those in decision-making roles have lived experience of being Māori, they are much more likely to act in the best interests of their people.
“The bigger picture is: Nerissa’s Māori, representing a region with a high Māori population. That’s huge, because knowing Nerissa, every step she takes, she’s considering how it affects whānau. That has a ripple effect for us as Māori midwives, because she’s higher up at the decision-making level.”
Being able to broach subjects like ensuring midwifery students of Ngāti Porou descent can return home to complete their clinical placements, regardless of which institution they are studying through, is an example of what is now possible. “These are the kinds of conversations I can have with Nerissa, because she’s Māori and she gets it. She understands what the needs are, what the barriers are, and how she can smash them down,” Bea explains.
Finally, in Te Tairāwhiti, equity is graduating from a buzzword into a lived reality. “Let’s not keep bleating on about equitable outcomes if we’re not demonstrating it in our own leadership,” Bea warns. “There are so many documents floating around out there talking about equity and it’s been that way for years; empty kōrero and no action. But this is the real beginning of it. This is the true meaning of equity.” square
President
Nicole Pihema Ph 021 609 011 nicolepihema@gmail.com
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Alison Eddy
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Wanganui Sub-Committee Susan O'Connell susan.cleland@hotmail.com
Horowhenua Jennie Ferguson Ph 021 232 1980 thejensterrocks@gmail.com
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Student Representatives
Penny Martin pennymartin79@live.com Ana Ngatai ana.olsen.ngatai@hotmail.com
Ngā Māia Representatives www.ngamaia.co.nz
Jay Waretini-Beaumont midwifejay@gmail.com
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Talei Jackson Ph 021 907 588 taleivejackson@gmail.com
Nga Marsters Ph 021 0269 3460 lesngararo@hotmail.com
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Resources for midwives and women
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