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MIDWIFERY WORKFORCE CHALLENGES
CLAIRE MACDONALD MIDWIFERY ADVISOR
MIDWIFERY WORKFORCE CHALLENGES – HELP IS AT HAND
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.
CURRENT STATE OF THE MIDWIFERY WORKFORCE 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+
CURRENT ACTIONS AND ADVOCACY 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.
TE ARA Ō HINE - TAPU ORA
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.”
MIDWIFERY FIRST YEAR OF PRACTICE (MFYP) PROGRAMME
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.
MIDWIFERY CLINICAL COACHES
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.
WORKFORCE TASKFORCE
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.
WHAT ELSE IS NEEDED?
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.
MIDWIFERY CLINICAL AND PROFESSIONAL LEADERSHIP
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.
PAY EQUITY AND FAIR PAY FOR ALL MIDWIVES 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.
COLLEGIALITY AND PROFESSIONALISM
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.”
WHAKAARO FROM OUR KUIA
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
