
6 minute read
MAKING THE FIRST 2,000 DAYS COUNT
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”.
ALISON EDDY CHIEF EXECUTIVE
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