CLIMATE: REDUCING OUR ENVIRONMENTAL IMPACT

DR RUTH MARTIS MIDWIFE CONSULTANT RESEARCHER

can midwives in Aotearoa reduce the environmental impact of their practice?

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.

GREENHOUSE GASES 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 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 MIDWIFERY EDUCATION, PROFESSIONAL DEVELOPMENT AND MEETINGS 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.

EQUIPMENT 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.

COMMUNICATION TOOLS 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 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 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

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.

References available on request.