Midwife Aotearoa New Zealand

EXPLORING WHANAUNGATANGA IN ALL ITS FORMS BIENNIAL NATIONAL CONFERENCE 2023 P.22 HE MARAMA KA ROKU I TE PAE: REFLECTIONS FROM NICOLE PIHEMA, OUTGOING PRESIDENT P.18

BIRTH IN AOTEAROA 2012 TO 2021: REFLECTING ON INCREASING RATES OF INTERVENTION P.28

ISSUE 111 DECEMBER 2023 I THE MAGAZINE OF THE NEW ZEALAND COLLEGE OF MIDWIVES

CLIMATE CHANGE: AN INDIGENOUS PERSPECTIVE P.34

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YOUR COLLEGE

ISSUE 111 DECEMBER 2023

FORUM

22

FROM THE PRESIDENTS 4.

INTRODUCING YOUR NEW CO-PRESIDENTS

FROM THE CHIEF EXECUTIVE 5.

CONTINUITY OF CARE

8.

BULLETIN

18

10. YOUR COLLEGE 12. YOUR UNION 14. YOUR MIDWIFERY BUSINESS FEATURES 16. NGĀ MAIA 17. PASIFIKA 18. HE MARAMA KA ROKU I TE PAE

34

22. EXPLORING WHANAUNGATANGA: NATIONAL CONFERENCE 27. FIND YOUR MIDWIFE

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28. BIRTH IN AOTEAROA 2012 TO 2021 34. CLIMATE CHANGE: AN INDIGENOUS PERSPECTIVE 37. READING CORNER 38. BREASTFEEDING CONNECTION 42. FROM BOTH SIDES DIRECTORY

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EDITOR Hayley McMurtrie E: communications@nzcom.org.nz

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

ADVERTISING ENQUIRIES Hayley McMurtrie P: (03) 372 9741

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

MATERIAL & BOOKING Deadlines for March 2024 Advertising Booking: 1 February 2024 Advertising Copy: 12 February 2024

Midwife Aotearoa New Zealand 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 of terms. Direct citation of others’ work maintains the original authors’ language, and contributing writers’ language preferences are respected. All advertising content is subject to the Advertising Standards Authority Codes of Practice and is the responsibility of the advertiser. Contents Copyright 2020 by New Zealand College of Midwives. All rights reserved. No article or advertisement may be reproduced without written permission. ISSN: 2703-4546.

ISSUE 111 DECEMBER 2023 | 3

FROM THE EDITOR

FROM THE PRESIDENTS

Welcome to Issue 111 of Midwife Aotearoa New Zealand I am writing this editorial only a few days after the College’s conference at Te Pae conference centre here in Ōtautahi Christchurch. It was an absolute highlight seeing midwives come together after several difficult and trying years, like family reconnecting. The place was alight with hugs and smiles evidenced in the photos on pages 22-26.

This issue also farewells president Nicole Pihema who has served the College in this role for four years. The co-presidency arrangement now in place will ensure a wider representation of the membership at the very highest level and we congratulate Bea Leatham and Debbie Fisher on their appointment of these roles.

Continuity of care is woven through many of the articles, as it is through the profession.

Fragmentation of this fundamental part of midwifery is becoming a concern, not just in maternity but evident throughout the health service. CE Alison Eddy alludes to the complexities of this in her article on p. 5.

2024 will see more focus on cultural safety in practice as the Council seeks consultation on the recertification requirements around this. We are pleased to be working with our Ngā Maia colleagues on this important education, p. 16.

Climate change from an indigenous perspective on p. 34 is a worthwhile read and will conclude our climate change series; we look forward to bringing new content to you in 2024.

This issue also provides a preview of the new Find Your Midwife website, for which I am proud to have been project lead. The revised website is the result of many months of hard mahi from the team here and the IT gurus we have worked with. Thank you to everyone who worked on or informed this project.

Wishing all members a safe and happy festive season and, as always, your feedback is welcome communications@nzcom.org.nz Noho ora mai, Hayley square

HAYLEY MCMURTRIE EDITOR & PUBLICATIONS MANAGER Email: communications@nzcom.org.nz

4 | NEW ZEALAND COLLEGE OF MIDWIVES MAGAZINE

Introducing your new College co-presidents Earlier this year the membership showed overwhelming support of a co-presidency arrangement for the College, which resulted in a change to the college constitution at a SGM in July. We are delighted to introduce your copresidents who will keep you informed with their own column in future editions.

BEA LEATHAM

DEBBIE FISHER

Nei ahau he uri nā ngā kōpara a Rongomaitāpui. Ko Ngāti Porou te iwi, ko Te Whānau a Te Aopare te hapū, ko Pukeamaru te maunga, ko Karakatuwhero te awa, ko Te Paerauta te marae. Ko Beatrice-Ann Materoa Leatham ahau.

Tēnā koutou. Ko Mount Richmond te

Bea is a well-known and respected kahu pōkai with 23 years of experience working in multiple settings across the sector. Bea has practised as both an LMC and core midwife and has also held a position as a lecturer within the midwifery undergraduate education programme at Auckland University of Technology. She has an unwavering commitment to the application of Te Tiriti o Waitangi to healthcare in Aotearoa and this stance is embedded within her practice.

valuable health professionals in keeping birth

Bea is a founding member of Rua Pōkai Ngā Maia i te Rauroha and is a current member of Te Tatau o te Whare Kahu | the Midwifery Council. She has made many contributions to the midwifery profession in her roles as Midwifery Standards Reviewer, mentor within the Midwifery First Year of Practice programme and was on the advisory group for Nga Manukura ō Āpōpō.

Bea is currently a DHSc candidate and working as an LMC midwife in Gisborne/Tairāwhiti. She is an esteemed leader and we are delighted to welcome her as co-president.

4 | MIDWIFE AOTEAROA

māunga. Ko Te Hoiere te moana. Nō Whakatu ahau. Ko Debbie Fisher tōku ingoa. Nō reira, Tēnā koutou, tēnā koutou, tēnā koutoa katoa.

Debbie is a very passionate midwife and believes that midwives are the most normal for our whānau and protecting birth rights for tangata whenua. In Debbie’s words ‘it’s the best job in the world!’

Debbie has been a midwife for 23 years and worked in Aotearoa, Australia and the UK in various roles. These include core midwife, case loading midwife, lactation consultant, midwifery team leader and midwifery advisor.

She is currently the Associate Director of Midwifery-Operations Manager at Te Tau Ihu – Te Whatu Ora Nelson Marlborough.

As well as being a founding member of MERAS, Debbie was a member of Te Tatau o te Whare Kahu | the Midwifery Council for 10 years. She is dedicated to the midwifery workforce, professional development, the rural workforce, and consumer-led service development.

With her leadership experience across the health system and her post-graduate studies in health policy, we are thrilled to welcome Debbie as co-president. square

FROM THE CE

CONTINUITY OF CARE Within a number of discussions that I have been having lately, a question often being debated, raised or discussed is ‘what is happening to midwifery continuity of care?’. Continuity of care is not unique to midwifery, it’s a concept or model of health care which has been described in various settings, particularly in relation to community-based services.

Continuity of care has been described as: • a concept rooted in primary care involving the care of individuals (rather than populations) over time by the same care provider. It encompasses relational continuity, informational continuity and management continuity. In the primary care setting, continuity of care has been shown to reduce mortality and hospitalisations, and increase patient satisfaction (Baker et al., 2020) • concerned with quality of care over time. It is the process by which the patient and his/her physician-led care team are cooperatively involved in ongoing health care management toward the shared goal of high quality, cost-effective medical care (ProCare, n.d.)

Midwifery has its own specific interpretation of continuity of care which is related to the circumstances in which we provide it. Our scope of practice is centred around a time-bound

physiological event – childbirth. Our philosophy of care and educational preparation requires us to work within a broad framework which encompasses the cultural, psychological and social dimensions of birth, alongside the physical and clinical. The relational nature of our care is a critical component, with midwifery continuity of care occurring within an intensive “low volume, high touch” service.

This is what makes us distinct from, for example, continuity of care from a general practitioner or nurse practitioner working in primary care setting, which could be described as a “low touch, high volume” service.

Midwifery is the only profession whose scope of practice enables us to provide relational continuity of care throughout pregnancy, labour and birth and the postnatal period. As we establish the relationship we build our knowledge of the woman, her whānau and her context during pregnancy, the support which surrounds her, her aspirations,

from the chief executive, alison eddy ISSUE 111 DECEMBER 2023 | 5

FROM THE CE

how, by whom and for whom?” (Bradford et al., 2022) reviewed 175 publications from around the world which examined implementation or scaling-up of midwifery continuity of care. Whilst noting the effect on outcomes from continuity of care, the authors concluded that the means through which these effects are caused are somewhat uncertain or speculative.

Some of the conclusions from Bradford et al.’s paper (2022) are worth repeating:

Our history and context in establishing midwifery continuity of care as the predominant model is somewhat unique and, although by no means perfect, we can now look back with the benefit of hindsight to consider what the enablers of success were, what has worked well, what hasn’t worked or isn’t working so well.

her fears and her confidence in her ability to give birth and breastfeed and care for her baby. We take this understanding into our care for her during labour and birth and the postnatal period, enabling us to maximise our effectiveness in that period as we support the establishment of breastfeeding and the developing confidence of the new mother and whānau.

Continuity of care is not simply a “nice to have”. As well as greater satisfaction with care, continuity of care has the potential to reduce unnecessary interventions and to decrease preterm birth and perinatal mortality rates: “A Cochrane systematic review of reviews of interventions during pregnancy to prevent preterm birth also found that these models had clear benefit in reducing preterm birth and perinatal death. Women prefer the personalised experience provided by such models, leading to trust between midwife and woman and empowerment of both women and midwives”. (Sandall et al., 2016)

An extensive paper titled “Midwifery continuity of care: A scoping review of where,

6 | MIDWIFE AOTEAROA

• Midwifery continuity of care is a complex, multi-faceted intervention and teasing out which elements impart benefit to recipients of care is difficult.

• Models of care that provide continuity across the childbearing continuum are complex interventions, and the pathway of influence that produces these positive outcomes is unclear. A number of plausible hypotheses require further investigation.

For example, it could be that midwives provide a mechanism that enables effective and equitable care to be provided by better coordination, navigation and referral; and/or that relational continuity and advocacy engenders trust and confidence between women and midwives, resulting in women feeling safer, less stressed and more respected.

Midwifery continuity of care is therefore an intervention in and of itself, but we don’t yet know exactly why it can be effective at improving outcomes. This review also noted New Zealand was the only country which has managed to scale-up continuity of midwifery care at a national level.

Our history and context in establishing midwifery continuity of care as the predominant model is somewhat unique and, although by no means perfect, we can now look back with the benefit of hindsight to consider what the enablers of success were, what has worked well, what hasn’t worked or isn’t working so well. From this we can consider what we can take forward or adapt for our present circumstances to ensure greatest success in the future within the changes which will unfold through the health system reform.

Continuity of midwifery care evolved in Aotearoa as a response to demands from women who were seeking more choice, more humanised and empowering care, and less medicalisation during birth.

Just as continuity of care sought to enable self-determination for women in their

experience and choices of care, the selfdetermination of midwives providing that care, within the boundaries of professional standards, has arguably been equally important. LMC work is demanding and rewarding at the same time. It requires a significant level of commitment and, to meet that commitment, midwives having self-determination in how services are delivered has been a critical success and sustainability factor.

New Zealand’s midwives were largely left to self-organise continuity of care provision, with models of practice developing organically. Other than the establishment of national frameworks such as Section 94, access agreements and referral guidelines, midwifery continuity of care was established with pretty limited resources or intervention from government or the wider health system. It is only relatively recently that we have achieved some more nationally available structural support (such as the locum service), although some districts offer sustainability packages for rural LMCs, or recruitment incentives.

Establishing effective professional partnerships between midwives within practices has been a key feature of sustainability for the LMC role. Financial sustainability is also essential for any health professional, but unfortunately the outdated nature of Section 94 results in income unpredictability as well as creating perverse incentives. Furthermore, the lack of infrastructure to support LMC practice, with no administration or navigational support for women seeking midwifery care, has meant that although midwifery continuity of care is now ‘establishment’ in Aotearoa, it has not been equitably available, and with present workforce challenges this is the case now, more than ever.

As midwives we are very familiar with the inverse care paradox – those women who have greatest resources are more likely to receive the greatest access to care and the most medical interventions in childbirth. Midwifery continuity of care is also an intervention and we have the same paradoxical situation. Communities or populations with the least resources who are at greatest risk of adverse outcomes also have the least access to midwifery continuity of care. There is nothing unique about midwifery in relation to this inequity; for example, there are fewer GPs per head of population in Counties Manukau than

Remuera, and many GP practices around the country are reportedly closing their books to new patients.

I hear a lot of blame being laid on midwives from some quarters for this inverse care situation, with a belief expressed that the midwifery profession is responsible for inequitable access to care or fragmentation of care. Examples that have been shared include midwives choosing to hand over all of their postnatal care to a ‘postnatal’ midwife; choosing to be on call for labour and births only; picking up the intrapartum care for women who are booked with a hospital-based Monday to Friday service; providing clinic-based postnatal visits only; or declining to book nulliparous women or those who have English as a second language.

Although it is undeniable that these practices are occurring, there is no data to quantify how widespread these examples are and often there is little discussion about examples of success. There is a lack of recognition that the issues impacting midwifery are system-wide, with maternity being one of many health services in which there are simply not enough workers. There is also little acknowledgement of the contribution the fundamentally flawed nature of Section 94 has made to these practices or of the significant health impact of wider systemic inequities.

Our system is under strain and unfortunately the impacts of the inverse care phenomenon become magnified under these circumstances, with those who are already marginalised and experiencing inequities becoming further disadvantaged. If we can get our system settings right, midwifery continuity of care can be part of the solution, as the Bradford et al. (2022) review found: Inequity is a key driver of adverse perinatal outcome, both between and within countries. Some observational studies of midwife-led continuity of care models in socially and economically disadvantaged populations in high-income countries (HIC) have reported significant reductions in preterm birth and caesarean sections in diverse cohorts of women. These studies suggest that women who typically experience a greater burden of adverse perinatal outcome, may derive greater benefit from continuity of care.

Questions for the future centre around how to protect the proven value of the continuity of care model whilst ensuring it evolves to prioritise the needs of our diverse population and priority groups, as well as addressing issues of practice sustainability. The solutions to strengthening and enhancing the model of care are not mysterious – community midwifery practice requires structural support. Delivering on this will have a direct impact on workforce recruitment and retention.

However, our profession also has some of the answers in our own hands. Fragmented care will not deliver the outcomes which we are seeking. The relational continuity which midwifery can offer across the childbirth continuum is our superpower. If we willingly give this away by accepting fragmented care as a norm, then we lose our ability to influence the dial on inequities, or on excess unnecessary interventions. It is within our power to choose how we deliver continuity of care and there are many sustainable models in place.

Finding the balance between maintaining woman/whānau-centred care and practice sustainability is an ongoing, evolving challenge.

We must meet this challenge head on to show that midwifery can provide the solutions that address the aims of our health system reforms, delivering the difference needed for our diverse and changing communities as they grow. square

BULLETIN

Huntly midwife Bernie Miers with Waingaro newborn Peter.

bulletin Huntly and Waihi Birthing units During October, Waikato and Bay of Plenty midwives were notified about the closure of both Huntly and Waihi birthing units.

Although both units are contracted by Te Whatu Ora they are independently provided by separate private entities.

Workforce shortages and lower than anticipated utilisation leading to economic viability issues were cited as various reasons for the closures. Although serving two geographically and distinctly different communities, the impact of closure of both units is the similar. Whānau will have to travel significant distances for birthing options when wanting to birth outside of home.

The closure of the units also creates sustainability challenges for locally based midwives who rely on the units for employment or practical and clincial support for rural LMC practice. The two affected communities and midwives, supported by

8 | MIDWIFE AOTEAROA

the College region and nationally, have been working to mobilise community support and to find solutions to the proposed closures.

The Waihi and Huntly unit communities and midwives have set up petitions to help to lobby for the continuance of the services or for alternative options to be created. square

Establishment of national Chief midwife positions The College is delighted to see the establishment of two further permanent national midwifery leadership positions to complement the existing position (held by Heather Muriwai) in Te Aka Whai Ora. These new positions are national midwifery leadership roles in both Te Whatu Ora and Manatu Hauora (Ministry of Health).

These roles will be well placed to ensure that midwifery is represented at the highest level within all of the national entities which have both operational, strategic and

regulatory influence and accountabilities within our reformed health system.

The College and its members look forward to working with the successful applicants for these essential roles. square

Recertification Consultation Te Tatau o te Whare Kahu | Midwifery Council has recently reviewed the recertification requirements for 2024-2027 and midwives were asked to feedback on the proposed changes to inform the next three years. The main changes proposed by the Council were: • The addition of cultural safety education as a requirement for all midwives, proposed at 8 hours in the first year and 4 hours each year after.

• The addition of preceptoring/mentoring education embedded in refreshing emergency skills.

• A change to the mandatory 8-hour midwifery emergency refresher to become a Safety in Practice Day. The College created a proposal for the membership to consider and give feedback.

From the online portal consultation, the membership: • Supports cultural safety education for midwives, however, has concerns that the structure proposed may pose challenges

BULLETIN

for midwives to access 8 hours of mandatory education alongside the MESR and flexibility was requested.

• Values midwifery emergency education and wants to continue to have emergency care updates with the addition of other safety in practice topics like physiological birth and breastfeeding.

• Values a quality assurance initiative for the profession, however, agreed that the current MSR needs a redesign to meet the needs of midwives.

• Identified challenges in accessing education with severe workforce shortages and rural practice and requested that online and self-directed learning options alongside flexibility to help mitigate equity and access barriers. square

Mama Aroha research report and key recommendations The latest research from a group of wāhine Māori provides new insights into creating relevant, digital breastfeeding resources for whānau and health professionals.

Mama Aroha, the first indigenous designed app for supporting breastfeeding, received praise in the feedback from health professionals and māmā.

Some great suggestions to enhance the app were also received and with additional

funding and expert technical advice from Māori tech company Kiwa Digital, updates and enhancements to the App will be available soon.

number of students did not disclose their

The research team consisted of representatives from Hāpai Te Hauora, the New Zealand Breastfeeding Alliance, Women’s Health Collective, Ngā Wānanga o Hine Koopu, Mokopuna Ora Collective, and Massey University.

and support for professional development

Mama Aroha app can be downloaded from the Apple App Store and Google Play. square

national level. RCM issued a warning that any

Royal College of Midwives (RCM) UK report: State of Midwifery Education 2023 A recent report from the UK has highlighted the need for investment in midwifery educators, students, resources, and partnership working between the National Health Service, training universities, and the midwifery profession. Although there has been a significant increase in student numbers over the past few years in the UK, the number of students graduating does not reflect the higher numbers entering midwifery. The number of students leaving programmes without completing has significantly increased, with ill health being the most common reason, followed by a change of mind about the course. A high

reasons for leaving. Midwifery teaching staff numbers have not kept up with the growth in student numbers. Competitive salaries were described as necessary for attracting appropriately qualified staff. It was also noted that there were fewer midwives in roles where they were able to influence research, policy, and practice at a senior plans to recruit and educate new midwives will be undermined without substantial and sustained investment in midwifery education. www.rcm.org.uk/media-releases/2023/ september/midwifery-education-facingunprecedented-challenges square

The PSRH Biennial Conference will be held 18-22 March 2024 | Holiday Inn, Auckland Airport, Aotearoa The conference considers Sexual reproductive health and rights in the Pacific: a changing climate, a resilient Pacific people.

The Pacific Society for Reproductive health will celebrate the resilience of Pacific communities while addressing the distinct challenges faced by women.

For more information visit www.psrh.org.nz square

ISSUE 111 DECEMBER 2023 | 9

YOUR COLLEGE

your college Farewell Lesley Dixon Midwifery Advisor Dr Lesley Dixon (pictured right) retired from her role at the College at the end of November.

During Lesley’s 17 years working for the College as a Midwifery Advisor, she was instrumental in building the College's research programme and the ongoing development of the College’s academic journal.

Lesley was one of the first midwives to gain her PhD in New Zealand, she researched the neurophysiology of emotions during labour and birth and her thesis received international acclaim. As well as her research and academic contributions Lesley has extensive practice experience as an LMC, core midwife, and midwife manager.

Lesley contributed a midwifery perspective to many multidisciplinary guidelines which the College has been involved in. Her knowledge, sound advice and pragmatism will be missed. We wish Lesley all the best as she shifts her focus to supporting her own family. Claire MacDonald has moved into the research portfolio upon Lesley’s retirement. square

Class action update Work to prepare for the College’s Class Action to be heard in the high court in August 2024 is progressing well.

Approximately 85% of the original midwives who joined the Class Action agreed to the updated terms and conditions, which now include the funding agreement which the College has entered into with OMNIBridgeway. New members have also been invited to join the Class, and over 100 new members joined, making the total now over 1,400.

The focus of activity over this recent period has been the preparation of expert testimony and witness statements on behalf of our case. square

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Midwifery First Year of Practice (MFYP) programme update MFYP has supported 155 new graduates spread across the country through 2023. The team behind MFYP have been adaptable to new graduate needs and implemented 7 cohorts for a staggered start throughout the year.

This was in response to graduates entering the profession at different times of the year. It has been a busy juggle at the back end but these changes have proven to be valuable to the graduates.

The 2023 year of graduates are almost evenly split between core and LMC midwifery workplace settings.

Graduates have attended four workshops delivered throughout the year with focus on “Stepping into Midwifery”, MSR preparation and “Hot Topics”. Mentoring continues to be the gold within MFYP. MFYP in its current and ever evolving form will continue to roll out to the new graduates of 2024 and we look forward to a strong start in January. Moving forward, the College in collaboration with Ngā Maia are currently working on a proposal to explore and redesign a changed new graduate programme for 2025.

Christmas hours at the College The College’s national office will close for the Christmas holidays on Friday 22 December at 12 noon, reopening on Wednesday 3 January.

There will be arrangements in place for any midwife who needs urgent legal advice during this period. Telephone 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

Contact NZBA for all your baby friendly resources info@nzba.co.nz or visit www.babyfriendly.org.nz/resources

YOUR UNION

CAROLINE CONROY MERAS CO-LEADER (MIDWIFERY)

Recognising and valuing employed midwives… the journey continues As we reach the end of another busy year it is a good time to reflect on what we have achieved as a union to recognise and value the work of employed midwives and what’s in store for the coming year.

Much of what has been achieved this year started its formation well before 2023.

The Midwifery pay equity claim for midwives working in Te Whatu Ora reached a final settlement in October after five years of work to demonstrate historical undervaluation based on sex. Whilst the pay equity outcome has boosted pay rates for Te Whatu Ora midwives, there is still work progressing on a midwifery pay equity claim for those employed midwives working in maternity facilities outside of Te Whatu Ora.

Pay Equity

Midwifery Leadership

Recognising and Valuing Midwives

Midwifery Career Pathway

Collective Agreements

Midwifery leadership: The recognition of midwifery as a profession separate from, and equal with, nursing, medicine and allied health within the Te Whatu Ora clinical leadership structure, has been something that has been lobbied for

by MERAS, the College and Midwifery Leaders at every opportunity over many years. Over those years we have seen the increase in, and enhancement of, Midwifery Leadership roles within the DHBs and now Te Whatu Ora. This recognition of midwifery as a separate profession is a journey that began over 30 years ago with the creation of the College, changes to the Nurses Amendment Act, the creation of the Midwifery Council, direct entry midwifery and the MERAS MECA and Collective Agreements. To ensure midwifery is visible and appropriately represented it is vital that there is midwifery leadership at senior levels of Te Whatu Ora as well as regionally and locally.

The Midwifery Career Pathway was one of the outcomes from the Midwifery Accord work that occurred between 2019 and 2021. It was developed to provide a pathway for

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YOUR UNION

OVERVIEW OF CAREER DOMAINS AND PROGRESSION PATHWAYS

CLINICAL

EDUCATION

MANAGEMENT

RESEARCH/QUALITY

Core, community or employed caseloading midwife on QLP Competent Domain

Core, community or employed caseloading midwife on QLP Confident Domain

Core, community or employed caseloading midwife on QLP Leadership Domain

MIDWIFE SPECIALIST

MIDWIFE CLINICAL COACH

CLINICAL MIDWIFE COORDINATOR

RESEARCH MIDWIFE

MIDWIFE EDUCATOR

CLINICAL MIDWIFE MANAGER

MIDWIFE COORDINATOR

MIDWIFE MANAGER

MIDWIFE RESEARCHER OR FELLOW

MIDWIFE CONSULTANT

LEADERSHIP

Associate Director of Midwifery, Midwife Advisor, Midwife Researcher, Midwife Fellow, Midwife Manager

Director of Midwifery/Chief Midwife

midwives that would allow them to achieve their career goals, support the retention of experienced midwives and support a more engaged and motivated workforce.

an increase in the number of Midwife Clinical Coaches to support those midwives returning to practice and the increased number of new graduate midwives joining the workforce.

The pathway identified four main career domains: Clinical, Education, Management and Research/Quality. There is no intention to confine midwives to one domain but to illuminate the pathway to career progression in each domain and across domains. It was recognised that leadership existed in all domains and started from the beginning of a midwife’s career.

Collective agreements that MERAS has negotiated with Te Whatu Ora and birthing centre providers has meant that the needs of midwives have been prioritised in these Collectives. This has seen the creation of continuing professional development funds to support attendance at conferences and workshops, payment of APCs, NZCOM fees, Midwifery Standards Review and QLP. These Collectives are designed by midwives for midwives.

Since the Midwifery Career Pathway was adopted there has been a change in senior midwife job titles at maternity units to align with the titles in the pathway, and an increase in the number of Clinical Midwife Coordinators and Clinical Midwife Manager roles to recognise the importance of experienced midwives on each shift in our maternity services 24/7. There has also been

• Complete the review process as part of the Te Whatu Ora midwifery pay equity settlement • Continue to develop opportunities for midwives within the Midwifery Career Pathway • Ensure equity of pay grades and opportunity for senior midwifery roles across the country • Ensure the growing number of new graduate midwives who choose employment are well supported in their first year of practice square

THE JOURNEY CONTINUES….

There is still work to do in 2024. The priorities are: • Reach a midwifery pay equity settlement for those midwives employed outside of Te Whatu Ora

For MERAS Membership merasmembership.co.nz www.meras.co.nz

ISSUE 111 DECEMBER 2023 | 13

YOUR MIDWIFERY BUSINESS

WAYNE ROBERTSON EXECUTIVE DIRECTOR, MMPO

valuable vehicle considerations for community midwives in Aotearoa For self-employed community midwives, a vehicle serves multiple roles and goes well beyond mere transport. It embodies professional reliability and midwifery care assurance (particularly in the case of an emergency), as well as a mobile workspace and a considerable investment.

This article offers general guidance on what to consider with your vehicle.

1. CHOOSING THE RIGHT VEHICLE

2. VEHICLE SECURITY AND STORAGE

Firstly, vehicle reliability is paramount and directly affects your ability to provide timely and effective midwifery care.

Protecting your significant investment is imperative. Most modern vehicles do come with a level of digital security features but, generally, they are not 100% foolproof. There are many ways to secure your vehicle and locate it if it is stolen, depending on your budget and preferences. Simple steps that can be taken to deter theft include:

Secondly, your choice of vehicle should reflect the work settings in which you provide midwifery care, such as rural or urban.

When considering vehicle performance and reliability, you should also think about the size of vehicle and manoeuvrability, security, storage capacity, fuel efficiency (especially in a rural setting), cash flow impact and technology.

Vehicle technology is continuously advancing, with electric options becoming popular. Electric vehicles (EVs) are environmentally friendly, cost-efficient in operation and may have lower maintenance needs. However, they do pose challenges such as charging times and infrastructure.

Hybrid vehicles merge the economic, environmental and practical benefits of electric and conventional fuels. The most significant advantages of hybrids are their extended range (compared to EVs) and relative fuel efficiency, lower maintenance requirements and related cost saving compared to more traditional fossil fuelreliant vehicles.

14 | MIDWIFE AOTEAROA

• Keep your car locked and your windows closed at all times.

• Use anti-theft devices such as smart car alarms and visual deterrents like steering wheel locks.

• Park your car in well-lit areas, preferably with security cameras or guards.

• Install a GPS tracker device (or, for example, an Apple AirTag) on your car and app on your smartphone to help you locate your car in real time if it is stolen, and to notify the authorities of its whereabouts.

• Ensure your equipment is not visible from the outside of the car – features such as a boot shade are great for obscuring items from view and also provide sun protection.

Given that midwives often carry digital and medical equipment, records and other essentials, vehicle storage is also important

from a capacity perspective. Opt for vehicles with ample boot space or rear storage and, if possible, storage areas that are lockable for added security.

OXYGEN

It is essential that when carrying oxygen, the gas bottles are stored securely, and you consider your personal safety. BOC recommendations: • Restrict the number of cylinders being carried to a minimum • Secure and transport the cylinders in a separate compartment in the vehicle (such as the boot).

• Cylinders should be secured, ideally with a cargo net or fixed with a karabiner and strap.

• There should be adequate ventilation within the car.

• We also advise that you inform your insurance company that you carry oxygen cylinders in your vehicle.

MEDICATIONS

Some medications carried by midwives are recommended to be kept at a certain temperature. A heat-resistant container like a thermos or chilly bag should be used to store medications like uterotonics.

YOUR MIDWIFERY BUSINESS

3. COMPREHENSIVE INSURANCE COVER Insurance isn't just about compliance; it safeguards against unforeseen adversities. For community midwives, this takes on added significance.

A carefully selected insurance policy helps to ensure that not only is any loss minimised but that you are back on the road as quickly as possible with the least interruption to your delivery of midwifery services. General considerations about vehicle insurance include: • The type of policy you wish to take out.

How comprehensive is it? What is covered, where and when?

• What are the policy restrictions or exclusions?

• Given the cost of replacement windscreens, specific windscreen coverage can be beneficial.

• Ensure that all your business and personal items are covered under your policy or that cover for them is available under another policy.

Remember to review your policy (at least annually or when you change your vehicle) to ensure that it aligns with changing risks, your needs and current insurance products.

and finance interest) are tax deductible – proportionately, i.e., based on the business use of the vehicle. The business use percentage is obtained from the records kept in a logbook based on the odometer reading, and separately recorded business and personal travel for a continuous three-month period every three years.

Your accountant will be able to help you make the most effective and efficient vehicle purchasing decision and ongoing structure.

Important note: MMPO offer a market

PARTING COMMENT

leading Midwifery Group Equipment

A vehicle for a community midwife is a critical multifunctional asset.

Insurance Policy at low cost. Contact us if you wish to discuss this further.

4. FINANCIAL AND TAXATION CONSIDERATIONS

• Does your insured value accurately represent your vehicle's worth (at the time) to avoid under-insurance or over-insurance? This requires particular consideration when replacement vehicle prices are fluctuating.

The vehicle’s financial footprint is expansive, and you need to consider such things as initial cost, cashflow funding (do I own or lease?), the expected life of the vehicle, its resale value and its annual maintenance and running costs.

• Familiarise yourself with the excess conditions and amounts, as it can impact on your out-of-pocket expense during a claim.

Another important consideration is how best to maximise the income tax and GST impact of a vehicle used for self-employed business purposes.

• Replacement/rental car cover is vital, ensuring continuity of your midwifery services.

The initial purchase cost (through annual depreciation) and ongoing operational costs (e.g., fuel, repairs, servicing, insurance

By thoughtful considerations, you will enhance your care assurance and delivery, ensure the most positive cashflow impact and safeguard this significant investment. square

MMPO provides self employed community midwives with a supportive practice management system. www.mmpo.org.nz mmpo@mmpo.org.nz 03 377 2485

ISSUE 111 DECEMBER 2023 | 15

NGĀ MAIA

LISA KELLY – NGĀ MAIA NGĀ MAIA CHAIRPERSON

cultural safety in practice As I write this panui it is almost the beginning of a new marama,

competent to gain entry to the register, it has not been visible within

signalling the rising of Te Rima o Kōpu, or the star known as Venus. Kōpu

the recertification programme that the principles of Turanga Kaupapa are

is also the kupu for our womb, Te Whare Tangata, which is befitting for

being applied or integrated into midwifery partnership and practice.

my kōrero around cultural safety in practice.

This is also evident within the release of the Perinatal and Maternal

Te Whare Tangata is the first house of the pēpi. It is a sacred whare, where future Rangatira are nurtured and developed. A whare where the pēpi is surrounded with sights, sounds and feelings that promote growth, hence the importance of our mahi as kahu pōkai, protectors that cloak

Mortality Review Committee report dated 6 December, 2022, which recommends regulatory bodies mandate cultural safety education for all individuals in the maternity and neonatal workforce. According to the report, the system continues to fail Māori and whānau in areas of high

our whānau with support and safe practices. What are you doing to

deprivation, with a clear lack of improvement over the years and ongoing

keep our whānau culturally safe? How are you implementing indigenous

serious systemic issues. “As health care professionals, government

ways of knowing and being into your everyday life at home and at mahi?

officials and regulatory bodies, we all play a part in this lack of

According to the Midwifery Council there are only 375 practising Māori

equitable, or even improved outcomes. Aotearoa New Zealand

midwives across Aotearoa (Midwifery Workforce Survey, 2022), so we

continues to tolerate a health and welfare system that serves Pākehā

need to be realistic in that only a small percentage of our whānau will

better than anyone else, having been built around Western values and

come into contact with a Māori midwife.

bio-medical ideals” (John Tait Chair, OBGYN, chief medical officer). Ngā

While the Midwifery Council states that midwives must be culturally

Maia Trust support the report’s recommendations to create a more equitable, accessible, cohesive and people centred system, prioritising responsibilities to Te Tiriti o Waitangi and ensuring an overarching emphasis on achieving equity.

That brings us to where we now have mutual agreement with Midwifery Council. From 1 April, 2024, all midwives entering the recertification programme will be required to undertake 16 hours mandatory cultural safety education over three years. This is a far cry from the 60 hours recommended, however it’s a positive start to changing the delivery of maternal and perinatal health within a system that continues to disadvantage Māori.

So back to my patai! Kei te aha koe?

Ngā Maia will be delivering Turanga Kaupapa at a region near you, where you will spend 8 hours immersed in the richness of mātauranga Māori.

This will be followed by another 4 hours of ongoing education around cultural safety and 4 hours education around the new scope of practice.

All cultural safety education will be accredited by Ngā Maia and together with the College we will work together to create safe spaces, offering cultural safety education for all levels ultimately leading to best practice.

This is just the beginning. This is life long and life changing. The goal is for our whānau to have the best possible care ensuring the Rangatira growing within the kōpu reaches his or her infinite potential. Mahia te mahi, do the work and be a part of the change to an Aotearoa hou.

Mauriora. square

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PASIFIKA

TISH TAIHIA CLINICAL MIDWIFE MANAGER, NGĀ HAU MĀNGERE

4th National Pasifika Midwifery Fono “Casting the Net” (16-18 August, 2023) Held at WINTEC’s (Waikato Institute of Technology) Te Kopu Marae, the

inter-relations for a Pacific person. A place to be respected within the

growing national body of mainly Pacific students and midwives gathered

midwifery practice of intimacy and tapu ground.

for the first time outside of Tamaki Makaurau for the fono.

Alongside our many non-Pacific guests on day one, we were welcomed

To complete the opening day’s programme we heard from Jasmine Davis (Pasifika Maternal Mental Health Consumer/Perinatal Anxiety

warmly by mana whenua, who gave an interesting history of the land

& Depression Aotearoa), who has been, amongst many other things,

beneath us, being part of the vast gardens that fed Tainui. As always,

providing free training workshops for health providers to support Pacific

we were honoured to have our Te Ara o Hine kaumātua respond on our

māmā, before Ane Fa’aui (Moana Connect Community Lead) highlighted

behalf and, as at every fono, remain over the duration of our gathering.

the work of grass roots networks of community cultural groups under

In keeping with previous conference themes and maintaining a connection to our seafaring ancestors of Te Moana-nui-a-Kiwa, “Casting the Net” captured the descriptive metaphoric journey of Pasifika Midwifery in Aotearoa in exploring our maturing identity and holding space for the next wave of leaders.

In the quality line-up of presenters, most did not work within the maternity sector, but were all a showcase of Pacific leaders, whose primary objective was to inform us on issues that impact on our Pacific whānau and communities.

WHO ARE WE IN A TE TIRITI HONOURING RELATIONSHIP? Keynote speaker Tania Mullane (Head of Pacific Nursing, Whitirea Community Polytechnic) spoke of her Tangata Hourua Framework acknowledging the connections between Māori and Pacific peoples and that “strength in combining” could be likened to the double hulled waka/ vaka of our common ancestral voyagers to reach solutions or better outcomes.

A rousing session with Dr Sereana Naepi (University of Auckland Pacific scholar/lecturer) followed, when she passionately promoted the richness that Pacific women bring to academia through indigenous methodologies, gender and equity lens.

A panel discussing “The Va” (the pan-Pacific notion that describes the spatial and relational context within which secular and spiritual relationships unfold) brought forward this concept that underlies the

the collective “My Baby’s Village” that feature the importance of the role of families to support parents and caregivers of babies, especially in minimising harm and risk like SUDI and family violence.

The following morning saw Jean Mitaera (Chief Advisor for Pacific Strategy at WelTec and Whitirea) portray through her wit, the nuances of “Cultural Resilience” – being able to maintain dignity and pride in whoever we are, or wherever we’re from, because logic and equity are universal (as is a sense of humour).

Up next was a gem through Asenati, who spoke of the many māmā and pēpē that she has assisted through fofō (a Samoan traditional deep tissue massage) over the years. Fortunate were those individuals who received a massage from Asenati and her colleagues that afternoon.

The final day saw Pauline Fuimaono Sanders (National Head of Pacific Workforce, Te Whatu Ora) address the fono as to the role of the Pacific Directorate within TWO and how the Kahu Taurima Strategy would be directly related to maternity and midwifery care provision.

Interspersed throughout, the social events were just as valuable in cementing relationships – a special screening of the Pacific Mother film that was accompanied by director Mijiwa Ozawa, a kava ceremony with Hawaiian dancing lessons and the ukelele workshop which was not for the faint hearted.

Acknowledgements to the National Tapu Ora Coordinators Organising Committee, PMWA, PMTM and the Rev Mua Strickson-Pua for a highly successful fono. square

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FEATURE

NICOLE PIHEMA OUTGOING PRESIDENT

HE MARAMA KA ROKU I TE PAE A MOON THAT WANES ON THE HORIZON COMING TO AN END (MEAD & GROVE, 2003)

There’s beauty and strength in recognising when we’ve done as much as we can.

As tempting as it can be to hold on to the familiar or be seduced by the prestige of a title, I’m realising true growth looks like being able to reflect on a job well done and gracefully stepping aside, for the evolution of the collective.

Looking back over my two terms as President, there’s plenty to be proud of, although it was never my personal aspiration to carry out the role. In 2013, I became the regional chairperson for Te Tai Tokerau, nominated and supported by the Māori midwifery and whānau collective Te Kaahu Wahine, and from this unique viewpoint, I became increasingly concerned about the struggles for Māori midwives and whānau, as well as the unacceptably high attrition rate of Māori midwifery students.

A collaborative vision began to form and along with my Te Kaahu Wahine whānau, then-President Deb Pittam initiated discussions with me around stepping into a more prominent and influential role.

My sense of responsibility and accountability to the communities I served acted as my guide, combined with a strong desire to support others into positions so that we could all work together towards improved outcomes for those who stood to benefit the most.

So in 2019, I found myself embarking on a new haerenga; one which has been full of both trials and tribulations. One of the biggest challenges I faced fairly early on in the piece was the arrival of Covid-19 and I relied heavily on our colleagues at national office to keep us all abreast of developments

and provide a pathway ahead. I didn’t want the arrival of the unknown to hamper progress on one of the other most pressing issues, however. ‘Healing the breach’ or addressing the ongoing relationship breakdown between the College and Ngā Maia needed to be prioritised despite the pandemic, and prioritise it we did.

Like any relationship, it has taken constant and concentrated effort to improve (and we’re still working at it), but it’s worth every ounce of energy because our membership - and ultimately the whānau we serve - will be better off as a result. We are certainly working more collaboratively now than ever before, and my hope is that if we can achieve a more harmonious relationship, this will filter throughout our workforce and into the care we provide.

Another noteworthy achievement has been the overall increase in funding and recognition since 2013. Although I hear some of you baulking at this suggestion, marked progress has been made in terms of pay increases and visibility of the profession as an integral part of the health workforce. Where midwives were once entirely invisible, subsumed by nursing, MPs can now be heard singing midwives’

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praises, and let’s not forget the public apology we received from Keriana Brooking for the Ministry’s breach of agreement, which bolsters our case as we prepare to go to High Court in August 2024. We may not have settled yet, but we are hundreds of millions of dollars better off than we were seven years ago and although I am not solely responsible for these victories, I’m proud to have been part of a negotiating team that has gone in to bat for midwives many times over.

At time of writing, Beatrice (Bea) Leatham, of Ngāti Porou whakapapa, stands unopposed as the Māori co-president and voting is in progress for the non-Māori co-president. A move towards co-presidency

Like any relationship, it has taken constant and concentrated effort to improve (and we’re still working at it), but it’s worth every ounce of energy because our membership - and ultimately the whānau we serve - will be better off as a result.

20 | MIDWIFE AOTEAROA

and indeed co-governance was initially floated as part of discussions focused on restructuring our national board.

The cultural review affirmed co-presidency as the most equitable way forward, so it’s only appropriate that the recommendations of the final report will be handed over to your new co-presidents to be implemented. We are not the first organisation to realise co-presidency, nor will we be the last, but it’s a historic moment for midwifery nonetheless and I look forward to watching the next chapter of our story unfold.

Co-presidency presents a whole new world of opportunities and I hope this partnership can breathe life into the findings of the cultural review, so that it becomes a powerful vehicle for change and not just empty words on paper. It has the potential to be truly embodied through a fresh approach and re-commitment to te Tiriti.

Bea comes with a world of experience in te ao Māori, as well as midwifery experience. Her tūpuna and whānau are all behind her; that’s the Māori way and she wouldn’t have taken the responsibility on lightly. No doubt the nonMāori co-president will have consulted their whānau too and will assume their new role with eyes wide open. I wish you both the best as you take over the reins.

As I sign off, there are a few people in particular I must mihi to. My practice partner Robyn Henare and my wider group practice Peowhairangi Midwives - who have

FEATURE

supported her to support me - deserve my heartfelt acknowledgment. You have all become part of my tuaiwi (backbone) and knowing you have been keeping the ahi kā burning at home in Te Tai Tokerau while I’ve carried out these duties has been invaluable.

E mihi ana ki a koutou. And to my own whānau who, like all of our whānau, have made the ultimate sacrifice so that I could do this mahi, there probably aren’t words to convey my gratitude.

To our CE Alison Eddy, kuia Crete Cherrington, Māori co-president Bea, our non-Māori co-president who is yet to be revealed, the wider College team and of course, our membership, it has been my honour to serve this worthy kaupapa. I’ve matured over these two terms and my focus has shifted, so just as the College leadership enters a new phase, I also transition, cognisant of the fact that I’ve reached my limit and it’s time to take a step back. I’ll be taking some much needed rest, knowing there’ll always be more work to do, but trusting you all to forge on and fulfill the collective vision.

Mauri ora ki a tātou katoa! square

FEATURE

Exploring whanaungatanga in all its forms: Biennial National Conference 2023 After five long years of frustrating delays, Aotearoa midwives finally had the opportunity to reconnect at the 2023 New Zealand College of Midwives Biennial National Conference in early November. The conference theme of whanaungatanga pointed to connectedness and the relational nature of our work and lives; a fitting kaupapa to reflect on in a post-pandemic world. Three of the event’s plenary speakers were generous enough to share their unique perspectives on the concept and how it relates to midwifery, with Amellia Kapa.

Connectedness is something we’re all familiar with, and as midwives the notion of partnership has been well and truly embedded into our collective psyche.

But what if whanaungatanga isn’t just about ensuring connection or relationship at any cost? What if it’s also about questioning the nature of these partnerships and the role healthy boundaries play within them?

Or acknowledging the extent to which our personal relationships - with our own whānau and selves - affect our mahi and vice versa?

Renowned researcher, educator, author, podcaster and former midwife Dr Rachel Reed presented some potentially confronting ideas at the conference, starting with bursting the romantic bubble many of us may have ensconced ourselves in.

AMELLIA KAPA REGISTERED MIDWIFE

22 | MIDWIFE AOTEAROA

“There’s a lot of misinterpretation out there about the role of the midwife over time. So I looked at what our

relationships were, the changes, the role medicalisation has played, and how all of these have contributed to what’s happening now.”

“What’s happening now is new,” she continues.

“It’s not a return to a relationship we once had. What we’re expecting from ourselves as midwives and the relationship we’re meant to develop with women now is completely different to what we had before, and I see midwives struggling to find the balance.”

Rachel suggests midwives are now being asked to perform an unreasonable number of roles. “In the Middle Ages birth was a collective undertaking, so you’d have the 'gossips' - who knew the women - and the midwives functioned more like obstetricians; they didn’t provide the emotional support for women. So, historically, midwives have always worked with doulas, but in the past they were called gossips. Possibly

FEATURE

due to the loss of these gossips and the collective culture of birth, women are now left with just midwives, who need to be everything, including the emotional support - in the Western world at least. As a result, I’ve seen a lot of midwives really struggle with boundaries and sharing too much of themselves.”

Her observations over years of working with and educating midwives have ultimately led her to conclude that midwives can generally be divided into two groups: what she terms “cape-wearers”, or “cliff-walkers” (although midwives can be a combination of both).

“A lot of us enter midwifery because we want to rescue women,” she suggests.

“We’ve either had a really great experience, or not, and our whole approach is about trying to rescue women; to save them from their own decisions, the medical system or the dangers. So we’re wearing this cape, trying to save them all, which doesn’t work.”

Māori nurse, researcher and educator Dr Kelly Tikao (Waitaha, Kāti Māmoe, Kāi Tahu), whose PhD explored traditional Kāi Tahu birthing practices, also points to the significance of relationships when working with or around birth, although the challenges for tāngata whenua are obviously different.

Whanaungatanga, she explains, is an all-encompassing te ao Māori concept. “If you look at the core word, whānau, which is all about relationships, it’s about strengthening that rope or connection between past and present, between generations, between mātauranga and knowledge. And it’s not only about other people, but about our landscape and the whanaungatanga within ourselves. Customary Māori birthing is a

journey inwards; the return back to the whare tangata.”

“It’s hard to explain this concept,” Kelly continues, “because a lot of it can’t be expressed in words. You’ve got to feel, hear and touch these te ao Māori concepts to truly absorb them and then take them into your own body to feel into what they really mean. They’re about developing an individual perspective that will ultimately have a collective outcome and impact.”

Collectivism is innately understood

by Māori, and Kelly acknowledges the significance of this in the pursuit of regenerating ancient tikanga that were nearly lost entirely. “Across the generations for us now, we don’t have enough people who are

“And the cliff-walkers,” she continues, “are those who emotionally over-invest in the outcome. When a woman’s entire birth is derailed and she walks off the cliff and says 'yes' to the unnecessary induction, if you as the midwife walk off the cliff with her, that’s obviously not sustainable. So the question is: how do we point out the cliff - to let the woman know it’s there - without stepping off it with her?”

Not only have the expectations of our role changed, but Rachel points out our accountabilities have changed too, and modern-day midwifery is trickier than ever before to navigate. “We’ve always centered women and been held accountable by the community, but this is the first time in history we’ve asked women to truly step into their power and make all of their own decisions. It’s a really difficult dance.

How do we do this, when we’re employed by institutions or regulated externally?

How do we navigate a relationship where the woman is actually in control? And how do we match our philosophy with our words and actions?”

“Self-knowledge is really important,” she adds. “We bang on to women about developing self-knowledge in order to birth.

If you’re working with birth, you need to know yourself too and know your issues. We need to understand who we are if we’re in a relationship and we need to be honest with women about who we are. With compassion and non-judgment, we’re all flawed, we all have egos, and we all have things to keep an eye on in our relationships.”

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specialised in this body of knowledge, so it’s taking a village to bring this back. I don’t have the skills or knowledge alone, so I seek out people who can do the rejuvenation and through this process, they’re finding out more about their own craft. Taonga pūoro artists, those who work with clay, performers and composers of oriori are all collaborating in these spaces, finding out what it means to them and retracing the whakapapa of these different forms.”

Navigating the relationship between our past and future ancestors is a journey of constant unfolding, as Kelly illustrates. “I’m still learning about how to actually do it in practice and asking myself how we do it not only retaining the mana of the content, but also keeping it accessible and exciting for our whānau to take up. There are so many different layers to rejuvenating ancestral knowledge these days, because everyone’s busy and in their own world. What I’ve discovered is, they’ve got to want it. You can throw all the information at people, but they really only turn up if or when they’re truly in need of it.”

Kelly’s pragmatic approach distils the mahi down into achievable steps, however, for both Māori and tauiwi alike. “It’s about offering an exchange of knowledge in the hope that those who want to hear it can see themselves as allies in supporting the rejuvenation. It’s as simple as being aware and backing our Māori midwives and midwifery students by supporting things like the use of te reo Māori and the need for Māori to potentially have their own kura (school).

It’s also about seeing our practices as real and valid so that we don’t have to keep evidencing them against non-Māori experts.”

Bridging cultural gaps is something another of our plenary speakers knows all too well in her role as a midwifery lecturer at AUT. Talei Jackson, whose whakapapa traces back to Fiji and England, gifted conference attendees with another abstract concept which, like whanaungatanga, must be felt to be understood.

“Vā is hard to explain,” Talei begins, “but it’s a pan-Pacific notion of relational space that connects us to all things. It connects people, time and space, and it’s referring to the relationship between people and the land, as well as people and their ancestors passed. It’s the ‘in-between space’ that exists between all of those elements.”

Currently leading Tapu Ora at AUT - the Pasifika arm of an initiative established to

24 | MIDWIFE AOTEAROA

FEATURE

increase recruitment and retention of Māori and Pasifika midwifery students - Talei has been a midwife for 15 years and completed her Master of Midwifery on enablers for Pasifika midwifery students.

Now working towards her doctorate, Talei’s current research is focused on how Pasifika LMC midwives balance work and family wellbeing. Her conference presentation on valuing vā and voice acknowledged the extent to which our relationships, or the space (and time) between all of our connections, impacts our work and the communities we serve. “When I think about my own personal context, it’s about nurturing relationships within my own whānau, but also those between midwifery colleagues, and then in my Tapu Ora lead role, bridging those gaps between non-Pacific educators and akonga Pasifika. All of those relationships and the connectedness between them are key to harmony, and if they’re out of balance, nothing else will work well.”

Acknowledging cultural traditions and rituals is another way of valuing both vā and voice, as Talei explains. “When I’m talking about valuing voice, I’m referring in part to the fact that we’re oratory people. That’s the way we communicate; talanoa is very natural for Pacific peoples.”

Talanoa, or the exchange of conversation, ideas and narratives, is a simple way of nurturing vā, and as Talei points out, having the opportunity for talanoa, be it with colleagues, midwifery student, or the whānau we are caring for, can be revealing in a multitude of ways. “As a Pacific person, I think about how not every space needs to be filled and as a Pacific researcher, I know there is nuance even in the silence. Even when things are not spoken or said out loud, that’s telling us something as well.”

“You can get a sense of where people are at, even when they’re not telling you things,” Talei continues. “So it’s about being really intuitive and picking up on things that are not being expressed explicitly. And if you have strong relationships at the core, you know that person well and you know when things are not right or their wellbeing has been impacted, because you already have that connection with them.”

As important as it is, Talei is aware of the unfortunate reality that vā isn’t always able to be honoured within the current model.

“When I’m debriefing with students, I often hear that due to workforce shortages and people being so stretched, there are time

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restrictions and they just don’t get the time to talanoa, which is another form of respect giving people that space to tell their story.”

the reclamation of childbirth can only be achieved through collective effort and harmonious connections.

Like Rachel, Talei is acutely aware of the tension between the perceived role of the midwife, the expectations we place on ourselves, and the limitations of our modernday reality. “It’s challenging because as midwives a lot of our work is heart-led and midwives are empathetic, but there’s this real juxtaposition because the pressures of the workforce shortage mean we’re often forced to work in ways that contradict what’s at the core of midwifery.”

Talei’s view is that if we can nurture vā within the workforce at every level, we’ll be in a much better position to surmount the challenges together. “Midwives across all areas are experiencing challenges and frustrations, but I believe maintaining respectful relationships, nurturing the values we hold at our core and applying those to how we act - not only towards each other, but whānau in our care and students we’re mentoring - will enable those relationships to flourish. Otherwise, we harm that vā and balance won’t be maintained. It's much easier to maintain vā than it is to repair it.”

And whilst our plenary speakers may be viewing whanaungatanga through slightly different lenses, all are in agreement:

Kelly’s perspective on the reclaim of indigenous practices is that inclusivity grows and strengthens the collective. “Nobody can do this by themselves. Rejuvenation is an entire kaupapa and we are a collective people. But if you don’t give someone a role, they don’t know how they’re meant to fit in.

When people feel part of something they feel good, so it’s about bringing Māori and non-Māori together and exchanging more information to really ignite this rejuvenation.”

And Rachel sums it all up by reminding us that much like the successful fight for midwives to gain autonomy in Aotearoa, significant change will likely only occur once the most invested group - the birthing population - consciously decide they want something different.

“People say the system is broken, but I’d say it’s functioning exactly as it was set up to,” Rachel proposes. “It was never set up to promote physiological birth or support women, so fiddling with the cogs of that system won’t work. If you plant something, the roots will tell you what the fruit will be and at the moment, we’re expecting different fruit to come from the same tree.

But we actually need to plant a different tree altogether.”

“It’s not going to happen just from the inside by midwives,” she continues, “or just from the outside. It’s on the edge of that; we need to come together in solidarity with everyone and reclaim childbirth from the roots up - from the knowledge through to the language. The promising part is there’s an agitation happening globally, where women are starting to pause and question.

And that’s hopeful.” square

"We need to come together in solidarity with everyone and reclaim childbirth from the roots up - from the knowledge through to the language. The promising part is there’s an agitation happening globally, where women are starting to pause and question. And that’s hopeful.”

26 | MIDWIFE AOTEAROA

FEATURE

HAYLEY MCMURTRIE PROJECT LEAD, EDITOR & PUBLICATIONS MANAGER

FIND YOUR MIDWIFE Te Kāreti o ngā Kaiwhakawhānau ki Aotearoa | New Zealand College of Midwives recent conference saw the soft launch of the new Find your Midwife website. Based on a successful model developed by the Otago region, the first Find Your Midwife website was established in 2013 as a next step to the midwife listings hosted on the College's website.

By the end of that year the website was attracting 10,000 visits a month. The site has continued to grow exponentially in popularity to over 50,000 hits per month achieved this year.

The instant success of the site demonstrated the need within the community for this service and an expectation from women that technology would aid them in finding a midwife. The continued success has been facilitated by upgrades to the site and constant monitoring and interaction with users, both the midwifery community and the women seeking care.

Whilst the site remains an integral tool supporting the pregnancy journey, we saw

ways it could be improved to suit the current environment, specifically midwife shortages and more specific care requirements for women. We had also grappled with the regional search function of the site due to the unique geography of New Zealand.

It has become increasingly obvious over the past few years that some women require supported navigation into the maternity service and we had hoped that we could facilitate this through the site.

Several focus groups informed the changes that feature in the new version which include a full Te Reo Māori version of the site, the ability to search by address, postcode or region, an auto response email to women and a wider selection of language options.

Midwives will see a new ability to list by practice as well as individually, a more refined selection of areas covered and the ability to tailor an auto response based on current workload. More specific information will be collected from women on first contact and the site will offer midwives the ability to share some practice statistics if they choose.

Whilst we have made many significant changes to the site, we would still like to see a tailored referral and navigation system added to the site and intend to continue to upgrade the site after this first stage of changes.

The site will be live by the end of the year and as always, we welcome your feedback, admin@findyourmidwife.co.nz

ISSUE 111 DECEMBER 2023 | 27

FEATURE

CLAIRE MACDONALD MIDWIFERY ADVISOR - LIAISON

birth in Aotearoa 2012 to 2021: Reflecting on increasing rates of intervention Every year, Te Whatu Ora presents National Maternity Collection data in two interactive web tools reporting a set of descriptive statistics for pregnancy, birth and newborn indicators. The Report on Maternity and the Maternity Clinical Indicators was updated in August to include data for births in 2021. This article explores the trends over time and the picture of birth we have for the year after Covid-19 arrived on our shores.

28 | AOTEAROA NEW ZEALAND MIDWIFE

FEATURE

At the College’s conference in 2018, invited speaker and midwife academic Dr Suzanne Miller gave a moving presentation on protecting first birth. Suzanne explored the context of birthplace, the institutional pressures exerted on midwives and women across settings and how these can profoundly affect how labour and birth unfolds. In the five years since that address, a global pandemic has added to health workforce strain, at the same time as the data indicates increasing medicalisation of birth. The reasons for this will of course be multifactorial, involving both health system and wider societal factors. While it is not possible to take a deep dive into these factors with only descriptive statistical information at our fingertips, a tour through the data gives us an opportunity to pause and reflect on what is happening within maternity for birthing women, people and whānau.

DEMOGRAPHICS In 2021, 62,433 women and people gave birth. Table 1 demonstrates the change in demographics between 2012 and 2021.

During the last decade there has been a shift in the composition of the “Asian” umbrella category, with the proportion of Indian women increasing from 3.7% of the birthing population in 2012 to 8.3% in 2021 (Figure 1).

TABLE 1. DEMOGRAPHICS OF BIRTHING POPULATION 2012 AND 2021

2012

2021

Age

%

%

<20

6.3

2.9

20-24

18.5

13.2

25-29

25.7

26.6

30-34

28.2

35.1

35-39

16.8

18.3

40+

4.4

3.9

Prioritised ethnicity Māori

26.1

26.0

Pacific

11.2

9.6

Asian

13.6

18.8

European/Other

49.0

45.6

Deprivation quintile One (wealthiest)

14.0

15.8

Two

15.6

17.5

Three

18.0

18.3

Four

22.1

22.9

Five (least wealthy)

30.3

25.5

<18.5

2.8

2.1

18.5-24.9

45.5

39.1

25.0-29.9

27.9

29.1

≥30.0

23.7

29.7

BMI

FIRST TRIMESTER REGISTRATION WITH AN LMC

Smoking at 2 weeks postpartum No

86.7

92.7

2021 saw the highest rate yet of registration with an LMC in the first trimester at 73.5%, increasing year-on-year from 56% a decade ago. Significant improvements can be seen in first trimester LMC registration for all ethnic groups since 2012 (Figure 2); however, the data indicates an urgent need to invest in navigational support to enable equitable access to midwifery care for Pasifika, Māori and Indian women, young women and those living with deprivation. The College has advocated strongly across multiple government agencies and in submissions for a funded in-person navigation service for priority populations who continue to experience inequities in access to midwifery care.

Yes

13.3

7.3

HOME BIRTH The first two years of the Covid pandemic saw an increase in average annual home birth rates: 4.6% of births were at home in 2020 and 4.3 % in 2021 (in the preceding

FIGURE 1. % OF WOMEN GIVING BIRTH, BY ETHNICITY (ASIAN ETHNIC GROUPS), 2012 TO 2021 9 8

% of birthing women/people

7 6 5 4 3 2 1 0 2012

2013

2014

2015

2016

2017

Indian

Chinese

Southeast Asian

2018

2019

2020

2021

Other Asian

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FEATURE

FIGURE 2. % FIRST TRIMESTER REGISTRATION WITH AN LMC BY PRIORITISED ETHNICITY IN 2012 AND 2021

Māori

Prioritised ethnicity

Pacific

Asian

Indian

Euro/other

0

10

20

30

40

50

2012

2021

60

70

80

90

100

BIRTH OUTCOMES AND INTERVENTIONS

FIGURE 3. % OF WOMEN GIVING BIRTH, BY TYPE OF BIRTH, RESIDING IN ALL NEW ZEALAND, 2012 TO 2021 70

60

% of all births

50

30

20

10

0 2012

2013

2014

Spontaneous vaginal birth

2015

2016

Caesarean section

2017

2018

2019

2020

2021

Assisted birth

Instrumental vaginal birth

FIGURE 4. BLOOD TRANSFUSION FOLLOWING BIRTH 7 6.3

6

% of all births

5.8 5.1

5.1

5.3

3.2

3.1

3.2

5.3 4.9

4.9

5.1

5.2

4

3

2

Within the whole birthing population, spontaneous vaginal birth (SVB) has decreased year-on-year across the decade, from almost two-thirds (65.7%) in 2012 to 57.3% in 2021. Caesarean section (CS) rates have reflected this trend with an increase from 25.3% to 30.1% a decade later (Figure 3).

During this time, among those who did not have an elective caesarean section, trends of increased rates of induction of labour (IOL; from 25.4% in 2012 to 29.0% in 2021), epidural (25.4% to 29.6%) and episiotomy (12.3% to 17.3%) were observed, while augmentation rates decreased.

40

5

decade the rate of home birth ranged from 3.1 to 3.7%). During the lockdown in 2020, rates of home birth doubled from the expected rate for the general population and across all prioritised ethnic groups (MacDonald, 2022). The midwifery model of care and separate community funding stream for LMC services enabled whānau to rapidly change their birth plans and continue to receive midwifery care. This was not the case in the UK, where many regions completely withdrew home birth services during the pandemic response because employed midwives providing home birth services were redeployed into hospitals (Jardine et al., 2020).

3.8

1.9

2.0

3.1 2.9

2.1

2.9

2.0

2.0

2015

2016

3.0

3.1

2.2

2.1

2.1

2017

2018

2019

3.4

2.4

2.5

2020

2021

1

0 2012

2013

2014

Total transfusion rate

30 | MIDWIFE AOTEAROA

Blood transfusion after CS

Blood transfusion rate after VB

A clear decrease can be observed in the rates of small for gestational age (SGA) babies (<10th centile) born at 40-42 weeks, from 41.4% in 2012 to 27.0% in 2021, which may account for some of the increase in IOL. This suggests that midwives are assessing, diagnosing and referring for growth concerns in line with the evolving evidence and guidance about the importance of monitoring fetal growth. However, these data must be treated with caution, as the definition of SGA in the Maternity Clinical Indicators is made according to the INTERGROWTH-21 standard, whereas in clinical practice customised centiles have been used to diagnose and intervene for growth concerns for several years now.

Blood transfusion following birth is used as a proxy indicator for the severity of postpartum haemorrhage (PPH) in the Maternity Clinical Indicators. Rates of blood transfusion following vaginal and caesarean births increased in 2020 and 2021 (Figure 4). The utility of this indicator as a gauge of excessive blood loss and maternal compromise from PPH is limited, due to

FEATURE

FIGURE 5. BREASTFEEDING STATUS AMONG LIVEBORN BABIES 80 70 60

% of all births

variability in the management of PPH, and the anaemia that follows. Different thresholds for blood transfusion have been observed between regions, and IV-iron administration is rapidly increasing following PPH, with or without blood transfusion (Calje et al., 2023).

Estimated blood loss is documented for all births but not reported nationally so we can’t tell from the data whether PPH rates have also increased. Audits are therefore needed to find out why more women received blood transfusions following birth in recent years.

50 40 30 20

BABIES An upward trend of term babies requiring respiratory support is evident across the last decade, from 1.7% in 2012 to 3.1% in 2021.

In their analysis of Australian and Aotearoa neonatal units, Manley et al. (2022) found that the use of non-invasive respiratory support for more than four hours in term babies increased annually between 2010 and 2018, with no apparent benefit. The authors noted variation between individual hospitals in the use of non-invasive respiratory support and recommended local audit of practice to determine what is driving this increase.

10 0 2012

2013

2014

Exclusively breastfed

2015

2016

Partially breastfed

2017

2018

Fully breastfed

2019

2020

2021

Artificially fed

Among all women and people registered with an LMC or then-DHB service, rates of exclusive breastfeeding were stable from 2012 to 2018 but have been trending down since then, while partial breastfeeding trended up over the same period (Figure 5).

MAKING COMPARISONS The Maternity Clinical Indicators provide data on “Standard Primipara” to assess what is happening for a cohort who are “expected to require low levels of obstetric intervention”.

The Standard Primipara group is comprised of those who: • give birth at a maternity facility or have a home birth • are aged between 20 and 34 years (inclusive) at birth • are pregnant with a single baby presenting in labour in cephalic position • have no known prior pregnancy of 20 weeks and over gestation • give birth to a live or stillborn baby at term gestation: between 37 and 41 weeks inclusive (based on gestational age recorded for the baby and exclusion criteria) • have no recorded obstetric complications in the present pregnancy that are indications for specific obstetric interventions

ISSUE 111 DECEMBER 2023 | 31

FEATURE

women in spontaneous labour with their first baby in a tertiary facility. She found that one third of cases where intervention was undertaken to augment labour (artificial rupture of membranes and/or oxytocin infusion) did not follow recommended practice under the hospital’s own guidance.

This meant that a potentially significant proportion of interventions may have been unnecessary. The cascade of intervention was evident through analysis of these case records.

FIGURE 6. TYPE OF BIRTH FOR STANDARD PRIMIPARAE 2012-2021 80 70

% of all births

60 50 40 30 20 10 0 2012

2013

2014

2015 SVB

2016 CS

2017 IVB

2018

2019

2020

2021

IOL

FIGURE 7. PERINEAL OUTCOMES AMONG STANDARD PRIMIPARAE BIRTHING VAGINALLY 2012-2021 35

30

% of all births

25

20

15

10

5

0 2012

2013

2014

2015

Intact lower genital tract

2016

Concerningly, perineal outcomes appear to have worsened for this population. As fewer women and people maintained an intact lower genital tract over the decade, there was a corresponding increase in the episiotomy rate (Figure 7).

There was no demonstrable benefit in terms of 3rd or 4th degree tear rates, although it is not possible to know whether small changes could have occurred without a more thorough analysis.

32 | MIDWIFE AOTEAROA

2018

2019

2020

2021

Episiotomy and no 3rd/4th-degree tear

3rd/4th-degree tear, no episiotomy

Among standard primiparae, birth interventions have increased in the last decade. In 2021, 61.5% of this cohort had a SVB, 19.2% had an instrumental vaginal birth (IVB), 19.1% had a CS and 9.1% had an IOL (Figure 6).

2017

3rd/4th-degree tear + episiotomy

CONSIDERATIONS Te Whatu Ora maternity reports demonstrate increasing rates of intervention in Aotearoa over recent years. Research and audit questions about the “why” proliferate, as well as how the indicators may be associated with outcomes. Are all the interventions clinically indicated? Are we seeing the expected benefits of decreased perinatal mortality and neonatal encephalopathy from increased intervention?

Or have we moved further away from “too little, too late” and towards “too much, too soon”, both of which result in adverse outcomes (Miller et al., 2016)?

In her PhD research, Dr Suzanne Miller (2020) undertook a detailed clinical record review of 239 randomly selected “low risk”

I caught up with Suzanne while writing this article and checked in with her about my memory of her keynote address, which resonates as strongly now as it did in 2018. She shared her notes with me, and her closing thoughts take on additional significance at a time when we are seeing rising rates in intervention in the birthing process and when birth trauma and maternal mental health are receiving much-needed attention.

“Successful first birth, on a woman or person’s own terms, is about so much more than the safe arrival of a baby. It’s a potentially transformative experience for all the people involved. Feeling spiritually, culturally and emotionally intact following birth, however it occurs, is not a ‘nice to have’, it’s a critical fundamental – to a parenting journey, to family wholeness and to community well-being. It makes a difference to that person’s entire maternity future, their birthing choices and their confidence.

It’s so important that we nurture first birth, that we accept its various forms and sensibly step back or step in only when absolutely necessary.”

For some whānau, interventions in birth are indicated or necessary to ensure a healthy outcome and can be part of a positive birth experience with midwifery care that supports a sense of agency during the process. The challenge for the midwifery profession lies in ensuring that birth interventions are applied judiciously with the woman, person and whānau at the centre of care, supporting fully informed choice, positive birthing experiences and the normal physiology of uncomplicated birth and breastfeeding. By offering time and expertise for each whānau to discuss their unique situation and to make an informed plan at each stage of welcoming a new pēpi, and by thinking carefully about the introduction of medical intervention, midwives play a vital role in facilitating safe and positive birth experiences. square References available on request.

CLIMATE CHANGE

IMPACTS OF CLIMATE CHANGE FOR MĀORI REPRODUCED WITH PERMISSION FROM WWW.NRC.GOVT.NZ

Climate change has the potential to radically threaten the cultural, environmental, economic and social wellbeing of Māori. Adapting to the effects of climate change is a more complex matter for Māori, for many reasons. The complex legacy of colonisation, the intrinsic bond with te taiao (the natural world) and role as kaitiaki, cultural values and economic vulnerabilities all influence Māori capacity to deal with climate threats.

Working with Māori as partners to understand, and act on, climate change is essential – as is enabling flexible, Māori-led responses. The close social ties and cultural networks of Māori communities will help improve resilience and develop adaptation responses that reflect their worldview.

TE AO MĀORI VIEW OF CLIMATE CHANGE Māori see the world in a very different light to Pākehā. Climate impacts are felt on the atua (spiritual) level.

Te ao Māori (the Māori worldview) is underpinned by interconnectedness to the natural world through whakapapa to Ranginui (Sky Father) and Papatuanuku (Earth Mother). Māori retain a multi-generational perspective, based on the responsibility to tupuna (ancestors) and generations yet to be born.

For many Māori, climate change is not an isolated risk. It’s intrinsically linked to other issues, such as

34 | MIDWIFE AOTEAROA

social development needs, housing, environmental degradation, access to public services, and poverty.

Māori perspectives are also defined by relationships. In terms of working with councils on addressing the consequences of climate change, they are underpinned by legacy issues relating to colonisation, loss of land and the sometimes fractured relationships with the Crown and councils.

IMPACTS ON MĀORI AROUND THE MOTU PEOPLE

• Historically, many hapū were forced out of traditional lands to occupy sub-optimal areas, such as river or coastal floodplains. This means flooding, coastal erosion, storm surges and regular tidal inundation are more likely to affect Māori communities.

• Rural Māori are often not connected to secure and safe drinking water supplies, so are more susceptible to the effects of drought.

CLIMATE CHANGE

ISSUE 111 DECEMBER 2023 | 35

CLIMATE CHANGE

• The effects of climate change on ecosystems have direct implications for iwi/hapū spiritual connection to taonga and whakapapa, as well as practical issues such as food security.

• Climate change may result in Māori being unable to enjoy the customary use of their whenua.

CULTURE

• Many hapū have strong cultural and historic affiliations with coastal areas that will be affected by climate change, through sea level rise.

• Climate change is likely to threaten the cultural taonga that hapū whakapapa to, as they are frequently located by coasts, and rivers at risk of flooding. This includes cultural infrastructure such as marae and urupā, and places of cultural significance such as wāhi tapu and archaeological sites.

• In some cases, the consequences of planning rules may affect the ability of hapū to implement their own adaptation actions, such as relocating communities or building water storage on land with restricted zoning provisions.

• An increase in mosquito-borne pathogens such as dengue fever and Ross River fever could be a less-visible health impact.

ECONOMIC

• Many Māori communities aren’t serviced by reticulated water or sewage systems. The cost of repairing and maintaining these systems can increase health risks.

• Some whānau Māori, especially those in more isolated areas, experience significant

differences in incomes. This can reduce capacity to afford the costs of protecting against, avoiding, and recovering from natural hazards and extreme weather events.

• Māori are largely employed in primary industries, which are vulnerable to likely weather extremes such as extended droughts, flooding, salt water in water tables, and tidal inundation. This may directly impact whānau incomes.

• Agricultural productivity may change, and access to settlements may become disrupted if roads are at risk of regular inundation due to sea level rise.

According to the International

• Unless emissions reduction policies are developed in true consultation with tangata whenua, and reflect mātauranga Māori, those policies have the potential to disproportionately affect Māori.

Union for Conservation of

WHENUA AND ECOSYSTEMS

Nature , indigenous peoples

• Native flora and fauna will come under threat as the environment alters: their habitats will change, putting them at risk from exotic and invasive species.

make up less than 5% of the world's population, but they safeguard as much as 80% of the world’s remaining forest biodiversity.

36 | MIDWIFE AOTEAROA

• Other expected impacts include changes in biodiversity, ecosystem function, waterways and coastal systems.

• The inseparable links between Māori and te taiao mean all these changes will have cultural and personal effects for Māori.

• In some places, other traditional uses of the land (such as gathering food) will come under increased pressure. Maara kai (planting seasons) are constantly shifting because of climate change.

According to the International Union for Conservation of Nature , indigenous peoples make up less than 5% of the world's population, but they safeguard as much as 80% of the world’s remaining forest biodiversity.

Using a te ao Māori perspective to describe climate risk can bring a holistic, culturally grounded approach to understanding the impacts of climate change. This is more appropriate for Māori communities and brings a diverse range of skills and knowledge that will benefit all.

This perspective acknowledges the need to consider legacy issues such as colonisation, and other socio-economic matters, when understanding and planning for climate risks with Māori communities. It can also make the implications of climate change less abstract, so the problems and issues become more meaningful for all communities. To be truly equitable in the way we adapt to our changing climate, we must incorporate the Māori worldview into our mahi.

At the heart of te ao Māori is the responsibility to be kaitiaki (guardians) of the environment. Māori hold knowledge that can help us all adapt to te ao hurihuri, the ever-changing world. square

READING CORNER

Emerald to Pounamu: A midwife’s odyssey Following a 20-year nursing career, Marie-ann Quin practised midwifery in many parts of New Zealand for over 30 years. Now retired, Marie-ann has put her energies into further research and writing. This background gives her considerable knowledge and an extensive-experience base in which to set a relatable, fictional story about the early maternity and medical services immigrant women and their families experienced in colonial New Zealand.

The storyline starts with a teenage Irish girl travelling by ship over many months to New Zealand and the people she interacts with. It is also where she establishes an interest in attending women in labour.

This interest is further developed when she lands in a very new settlement and the learning she receives from a German midwife in the area.

It is plainly written and therefore an easy read for anyone with an interest in history. Its depiction of life for new settlers is somewhat romantic, despite several challenging descriptions of some of the hurdles people faced in their new land. For this reason, I do think it is a great read for young teenagers as well.

It’s gratifying to see midwives writing about their experiences, fictional or not, and the way Marie-ann incorporates good feelings and hopefulness will be enjoyable for many. I hope she follows up this tale with many others. square

TRUSTED • SAFE • UNIQUE

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

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

EPI-NO Patient Brochures can be requested for New Zealand via info@starnbergmed.co.nz Over 65,000 EPI-NO births in Australia and New Zealand.

Available in over 20 countries worldwide.

www.starnbergmed.co.nz Available online with shipment from Auckland and at selected pharmacies.

‘The human body performs to maximum trained and prepared. Childbirth is no exception.’

Dr Wilhelm Horkel, Starnberg (EPI-NO inventor)

Made in Germany

BREASTFEEDING CONNECTION

CAROL BARTLE POLICY ANALYST

THE CONTINUITY OF MIDWIFERY CARE MODEL – DOES IT SUPPORT BREASTFEEDING? It seems reasonable to envisage the midwife-woman relationship and partnership-based midwifery continuity of care as being likely to improve breastfeeding duration, but there is very little written about this topic, and what is written is unfortunately not substantial. This could reflect the dearth of midwifery continuity of care models around the world, the lack of support for research about breastfeeding and health, or it could also be the problem of inconsistent breastfeeding definitions and varied models of care.

In Aotearoa New Zealand the midwifery lead carer (LMC) model is the cornerstone of the primary maternity service, with LMC midwives taking responsibility for care during pregnancy, labour, birth and up to six weeks following the birth. The Baby Friendly Hospital Initiative (BFHI) in maternity facilities supports core midwives to protect, promote and support breastfeeding, and the intention of this initiative is to get breastfeeding “off to a good start”. BFHIaccredited maternity facilities globally have higher rates of breastfeeding initiation, mother-newborn skin-to-skin contact, and rooming in for mothers and babies, as these practices are key components of the WHO Ten Steps to Successful Breastfeeding. They are also key components of mother-baby bonding and attachment. An important question is whether these positive practices, supported by skilled midwifery care by midwives employed in postnatal settings, can manage to override the obvious contemporary – and historical – challenges in midwifery and maternity systems, such as acuity, birth interventions, staffing shortages and staffing conditions.

38 | MIDWIFE AOTEAROA

Literature that compared midwife-led continuity of antenatal care with other models of care, where researchers had measured breastfeeding duration beyond hospital discharge, was analysed in a systematic review (Shipton et al., 2023).

Shipton et al. found there was insufficient research evidence to draw any conclusions about the relationship between continuity of antenatal care and breastfeeding duration.

They also highlighted the critical need for research that uses internationally agreed, valid and reliable definitions of breastfeeding.

Midwifery care systems that use a continuity of care model have positive outcomes for women and their newborn babies, and the question of where, how, by whom, and for whom this model is implemented, was addressed in a scoping review (Bradford et al., 2022). This scoping review of 163 studies was conducted to understand the global implementation of continuity of care models.

Bradford et al. found that no countries had managed to scale up continuity of midwifery care at a national level except New Zealand.

Along with the issue of unreliable and inconsistent breastfeeding definitions, this

goes some way to explaining why continuity of care and its relationship to breastfeeding has not been robustly investigated.

Exploring further the benefits of continuity of care for women, on the basis that relational care plays a significant part in the support for women to establish and continue breastfeeding, Perriman et al.

(2018) examined what women value in the midwifery continuity of care model.

Thirteen studies were analysed, including two from Aotearoa. The overarching theme to emerge was the relationship between the midwife and the woman, underpinned by personalised care, trust and empowerment.

Women participants talked about midwives “knowing” them and understanding their strengths and concerns, the importance of the relationship developing during the continuum of pregnancy, birth and puerperium (relational continuity), their involvement in decision making, and personalised care. Empowerment was a significant part of the relationship, and women commented about how midwifery continuity of care increased their confidence and facilitated trust. Prioritising the development of the midwife-woman relationship was found to be central to trust, personalised care and empowerment.

A randomised controlled trial with 1,156 women receiving caseload care, and 1,158 women receiving standard care found that women with a low risk of medical complications had higher satisfaction with midwifery caseload antenatal, birth and postpartum care (Forster et al., 2016).

Caseload midwifery was described as all care provided by a known primary midwife with back up provided by another known midwife when necessary. Standard care was described as midwife-led care with varying levels of continuity, junior doctor obstetric care and community-based general practitioner care. Women receiving caseload care in the postpartum period were more likely to report feeling informed, having had an active say in decision making, and that midwives were sensitive, encouraging, emotionally supportive, not rushed when providing care, and that care was safe and competent.

BREASTFEEDING CONNECTION

There are numerous studies which show the negative effect of birth interventions on breastfeeding initiation and establishment.

This suggests that the rising rates of caesarean birth, assisted birth and inductions may have a negative effect on breastfeeding, despite the benefits of relational midwifery continuity of care models. The disruption of birth physiology, and the effects of this on lactation and breastfeeding physiology may be hard to address in maternity systems where issues such as shortages of midwives, high maternal acuity, care provision by unregulated nonhealth professional staff, and early transfer after birth to primary maternity facilities have been embedded as part of the everyday system. Sandall et al. (2016) found that women who had midwife-led continuity models of care were more likely to experience a spontaneous vaginal birth.

Women who had midwife-led continuity models of care were also less likely to experience regional anaesthesia or intrapartum analgesia or to have an episiotomy. There was no difference in the number of caesarean births. Fifteen studies involving 17,674 mothers were examined in this Cochrane Review, which suggested that women who received midwife-led continuity models of care were less likely to experience intervention and were more likely to be satisfied with their care.

Continuity of midwifery care supports the development of a woman-centred therapeutic relationship between the midwife and the woman. Relational care from a midwife fosters trust, thereby supporting maternal confidence which may lead to self-efficacy and empowerment.

BFHI-accredited maternity facilities globally have higher rates of breastfeeding initiation, mother-newborn skin-to-skin contact, and rooming in for mothers and babies, as these practices are key components of the WHO Ten Steps to Successful Breastfeeding.

ISSUE 111 DECEMBER 2023 | 39

BREASTFEEDING CONNECTION

Continuity of care in Aotearoa New Zealand was found to support the development of a respectful partnership through trust, honouring decisions, and empowerment in a new retrospective analysis of 7749 women’s online feedback forms sent to their midwives (Dixon et al., 2023).

Empowerment can be a very overused word, but it has been described as an interpersonal process of providing the tools, resources and environment to build, develop and increase the ability and effectiveness of others to set and reach

Knowing and trusting a midwife who has provided support during pregnancy, labour and birth represents a potential for significant support for a woman’s sense of self agency.

40 | MIDWIFE AOTEAROA

individual goals (Haddad & Toney-Butler, 2023). Empowerment, which is linked to self-efficacy, is also described as an intrinsic motivation made up of four cognitions: meaning, competence, self-determination and impact. Bandura (1977) suggests that belief in personal agency has powerful and positive effects on life outcomes. Personal agency, related to women embarking on their breastfeeding journeys, requires women’s easy access to information, support which scaffolds self-efficacy when needed and the removal of as many barriers as possible to personal breastfeeding success. This means meeting whatever goals the woman herself has set for breastfeeding, based on evidencebased information and strategies to reduce potential barriers. The positive impact of this would be measurable in breastfeeding duration data.

The concept of “believing in yourself ” can be supportive but confidence can easily be shattered when breastfeeding does not get off to “a good start” and barriers to breastfeeding start stacking up. The narrative about women feeling guilty or pressurised into breastfeeding has gone some way to stifling discussion about how important breastfeeding is, and this is not helpful on any level. Evidence clearly shows that supported breastfeeding is good for women’s mental health but for women hoping to breastfeed, but struggling with breastfeeding and not receiving the support needed, the opposite is true. The struggle is not about the information that should be available to all women and their supporters. It is about the difficulties faced in removing barriers to breastfeeding both in the hospital and in the community.

Does an understanding of the significance of breastfeeding to women’s and children’s health, knowledge of the evidence base for breastfeeding and the importance of exclusive breastfeeding enhance self-efficacy?

Knowing and trusting a midwife who has provided support during pregnancy, labour and birth represents a potential for significant support for a woman’s sense of self agency. The BFHI also has the

BREASTFEEDING CONNECTION

• I can always determine that my baby is getting enough milk • I can always successfully cope with breastfeeding like I have with other challenging tasks • I can always ensure that my baby is properly latched on for the whole feeding • I can always manage to breastfeed even if my baby is crying • I can always deal with the fact that breastfeeding can be time consuming • I can always tell when my baby is finished breastfeeding • I can always hold my baby comfortably during breastfeeding • I can always position my baby correctly at my breast latch • I can always take my baby off the breast without pain to myself • I can always monitor how much breast milk my baby is getting by keeping track of my baby’s urine and bowel movements

Tertiary maternity care will include women who need some form of specialised support for labour and birth, and the initiation

Home birth provides some insights into what is necessary for breastfeeding initiation and continuance. Home is a place where physiology can be supported, time pressures do not usually exist and of course continuity of midwifery care is part of this picture for “low-risk healthy women”. The association between home birth and breastfeeding was examined in a cross-sectional study from Ireland (Quigley et al., 2016). Home birth was found to be significantly associated with breastfeeding at birth, 8 weeks, 6 months and exclusive breastfeeding at 6 months in a large cohort of 28,125 mother-infant pairs. Research specific to home birth and breastfeeding in Aotearoa would be significantly valuable.

Continuity of midwifery care and the BFHI are essential to breastfeeding. Should midwives support BFHI and should BFHI support midwives? Absolutely, but they cannot do it on their own. Should the government invest in BFHI, midwives and maternity – including home birth? We all know they should. square References available on request.

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Midwives in all areas of their work are breastfeeding supporters. The baton for breastfeeding and breastfeeding women is passed on from BFHI-accredited maternity facilities and core midwives to community midwives. Despite years of excellent statistics on exclusive breastfeeding in BFHI-accredited maternity facilities in Aotearoa, the rise in birth interventions and the failure of successive governments to invest in maternity and midwifery appear to have contributed to decreasing breastfeeding rates. Core midwives and LMC midwives are trying to manage situations where women and babies are not having optimal beginnings, where manageability for midwives and women is low, and key physiological supports for the initiation of breastfeeding are hard to facilitate.

of breastfeeding for those women may require much more intensive support. But there are many women birthing in tertiary facilities who should not, and do not, require specialised care. Reducing unnecessary birth interventions such as inductions of labour is likely to support physiology and a better start to breastfeeding.

ED • CLI LL

A self-efficacy scale for breastfeeding has been developed which identifies how confident or not confident a breastfeeding woman feels across a range of common issues that she may encounter (http://www. cindyleedennis.ca/research/1-breastfeeding/ breastfeeding-self-efficacy/). The statements in the tool include:

The statements could benefit from the removal of the word “always” when midwives are using them with women – particularly during the early days of learning about breastfeeding – but they provide a useful check list for what a new breastfeeding mother needs to know. Asking women about what supports are/were positive, which supports are/were not helpful, and whether there are/were any supports that could have been helpful are also useful questions, particularly when women have had previous breastfeeding experiences that did not work out how they expected or desired. Continuity of care provides a vehicle to provide information and support to women to address all these statements and questions. Women need to reach the confident place they need to be in to enable their breastfeeding continuance.

Conversations in pregnancy trigger thinking about breastfeeding and what it entails.

BFHI supports the beginning of the period in which these conversations and statements really start to make sense and become coherent for newly breastfeeding women after their babies are born. The BFHI and continuity of midwifery care are brilliant initiatives and complementary models of care that support breastfeeding women. It is difficult for one to be successful without the other; yet the potential of both to protect, promote and support breastfeeding has not yet been realised globally for various reasons well out of the control of BFHI, midwives or breastfeeding women. The blame for low breastfeeding exclusivity and duration rates sits firmly at the feet of governments.

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potential to support this within the Ten Steps. Time and continuity of care have been described as critical resources for implementing BFHI (Pramono et al., 2022). The overarching theme from research

by Pramono et al. was “believing” in breastfeeding. Sub themes were “time as a critical resource”, “continuity of midwifery carer”, “maternity services structure” and “BFHI requirements”. BFHI accreditation was perceived as excellent in principle to ensure and maintain quality maternity care, but challenges with implementation were described – some of these were related to lack of time in the workplace and work allocation. Staffing based on midwife-mother ratios rather than midwife-mother-baby ratios made provision of care more difficult, and this included implementation of BFHI. One study participant said that including babies in staffing ratios would make “a huge difference for midwife satisfaction and women’s outcomes".

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ISSUE 111 DECEMBER 2023 | 41

FROM BOTH SIDES

my midwifery my midwife Yvonne Hiskemuller has been a practising midwife for 33 years and a breastfeeding advocate for even longer, fuelled by unwavering determination to achieve breast milk exclusivity for as many babies as possible.

“I was already very passionate about breastfeeding before I became a midwife,” Yvonne begins. “I’ve always felt that breast milk was the optimal food for babies.”

After completing her midwifery education in the UK in 1990, Yvonne’s first midwifery role revealed just how much work needed to be done.

“I worked in London for two and a half years and during that time I was involved with the breastfeeding initiative, because I couldn’t believe how few women in the UK breastfed,” she explains.

Returning to Aotearoa soon after, Yvonne worked in Invercargill, then Christchurch, and commenced selfemployment as an LMC in the garden city in 1996.

She soon became involved in local breastfeeding advocacy work and, alongside Carol Bartle, was a member of the initial committee responsible for establishing the human milk bank at Christchurch Hospital NICU in 2014.

The intention was always to extend the milk bank out to the wider community, but two years on, a distinct lack of progress propelled Yvonne into further action. “I was already involved with the local Rotary Club, so I reached out to a few members, got a group of very passionate women together including Carol Bartle, and we established the Rotary Community Breastmilk Bank. It took us four years, but now we have our own pasteuriser, with significant support from St. George’s Charitable Trust and a private donor.”

St. George’s have generously provided newly refurbished premises for the bank and not only cover the cost of utilities, but also monitor the freezer temperatures. “Without St. George’s, it would cost us a great deal more. We’re very fortunate to get this help as none of us get paid; it’s all voluntary.”

“The milk bank is set up to support women and babies in their breastfeeding journey,” Yvonne continues. “It’s so important to be able to give people an alternative to formula so they can support their baby’s immune system. We know the benefits of breast milk exclusivity extend well into adulthood. That’s why we’re so passionate about this.”

In addition to her voluntary work, Yvonne cares for a full-time caseload as an LMC and swears by frequent early postnatal visits. “The woman has to really want to breastfeed in order to surmount the challenges, and sometimes you might only be making small gains, but if you leave and don’t come back the next day, things can go backwards.”

Not one to give up easily, Yvonne sticks around for as long as it takes.

“I spend hours helping people with breastfeeding; physically being there is so important, especially in the first week. I sit with them and tell them ‘you can do this: trust in yourself’. And if someone’s really struggling, I defer everything else so I can stay there with that woman until we make some progress.” square

42 | MIDWIFE AOTEAROA

Nagaswathi (Naga) Thallam birthed her first baby in 2022 and was supported through several breastfeeding challenges by LMC midwife Yvonne Hiskemuller.

Naga and her husband were overjoyed to discover they were finally having a baby in 2021, having overcome many setbacks. “I’m from India and came to New Zealand in 2013 with my husband,” Naga says.

“We struggled to conceive for about nine years and I had to have an operation to remove a polyp before I finally got pregnant. It was a long and difficult journey.”

Choosing Yvonne as her midwife was an easy decision for Naga, who’d already heard of Yvonne’s dedication and commitment. “One of my friends was cared for by Yvonne and she told me how strong and supportive she was, which is what I wanted, so I got the contact details and we went from there.”

Giving birth to daughter Viaana via emergency caesarean section after a drawn-out labour added yet more challenges for Naga as she transitioned into motherhood. “When Viaana was born, I think due to such a long labour and the position she was in, she couldn’t stretch her neck, so whenever we put her to my left breast in particular, she would get distressed, crying and biting down on my nipple. The breastfeeding was really difficult.”

Yvonne’s extensive experience helped identify the root cause of the latching issues early on, which Naga is forever grateful for. “Within the first week, Yvonne said she could feel that something was wrong with Vianna’s neck, so she suggested we take her to an osteopath, which we did. Within three treatments, she could turn her head, which started to make things much easier.”

The combination of an emergency caesarean and fertility issues meant Naga’s milk production was somewhat delayed, but the unwavering support she received from Yvonne made all the difference. “My milk didn’t come in for almost a whole week, but Yvonne wouldn’t let me lose hope.

She never stopped trying with us and she had so much patience,” Naga explains.

“I’d often be crying - especially in the first month - and even when I was only producing 20-30mls of breast milk, she constantly reassured me that I was making progress, which helped me to stay positive when it felt like I’d never get there.”

“I had a lot of issues, which made it hard to keep going at times, but Yvonne never forced me. She just kept explaining why breastfeeding was so important, both for Viaana’s health and my own. She also gave us the contact details for the milk donor bank so we could make sure Viaana was exclusively receiving breast milk until I was making enough to keep up with her needs.”

“We got there in the end,” Naga concludes, “and if I have another baby, I will definitely be choosing Yvonne as my midwife. She went above and beyond to support us on our breastfeeding journey.” square

DIRECTORY

New Zealand College of Midwives Directory National Office

Northland

Royal New Zealand Plunket Society

PO Box 21-106, Christchurch 8140

Shelley Tweedie

Zoe Tipa

Ph 03 377 2732 Fax 03 377 5662

tetaitokerauchair@nzcom.org.nz

zoe.tipa@plunket.org.nz

nzcom@nzcom.org.nz www.midwife.org.nz

Otago Jan Scherp, Charlie Ferris

Auckland Office and Resource Centre

otagochair@nzcom.org.nz

Delia Sang, Administrator

Southland

Yarnton House, 14 Erson Avenue

Liz Whyte

PO Box 24487, Royal Oak, Auckland 1345

liz.whyte@netspeed.net.nz

Ph 09 625 9764 Fax 09 625 0187

Student Representatives Penny Martin pennymartin79@live.com Ana Ngatai ana.olsen.ngatai@hotmail.co.nz

Waikato Taranaki

Ngā Maia Representatives

Jenny Baty-Myles

www.ngamaia.co.nz

College Membership Enquiries

chairwaikatonzcom@gmail.com

Dani Gibbs

Lisa Donkin

Wellington

auckadmin@nzcom.org.nz

membership@nzcom.org.nz 03 372 9738 Chief Executive Alison Eddy Co-Presidents Beatrice Leatham

Suzi Hume

Lisa Kelly

nzcomwellington@gmail.com

lisakellyto@yahoo.co.nz

Regional Sub-Committees

Pasifika Midwives Representatives

Hawke's Bay Sub-Committee

Talei Jackson

Linley Taylor

Ph 021 907 588

midwife.linley@gmail.com

taleivejackson@gmail.com

bealeatham@hotmail.com

Horowhenua

Debbie Fisher

Laura McClenaghan

debbie.fisher@nmdhb.govt.nz

midwife.laura@hotmail.co.nz

National Board Advisors Kuia: Crete Cherrington Elder: Sue Bree Education Advisor: Tania Fleming Regional Chairpersons

lesngararo@hotmail.com MERAS / General Enquiries & Membership PO Box 21-106, Christchurch 8140

megan.scott@live.com

www.meras.co.nz

Emma LeLievre

Ph 03 372 9738

emma@LMCmidwife.com

meras@meras.co.nz

Taranaki Sub-Committee

Jacquelyn Paki, Mel Nicholson

nzcom.taranaki@gmail.com Wanganui Sub-Committee

Bay of Plenty/Tairāwhiti

Laura Deane

Cara Kellet

laura.deane@wdhb.org.nz

chairnzcomboptairawhiti@gmail.com

MMPO mmpo@mmpo.org.nz Ph 03 377 2485 PO Box 21-106, Christchurch 8140 Rural Recruitment & Retention Services 0800 Midwife/643 9433

Consumer Representatives

Sheena Ross

Home Birth Aotearoa

chairnzcom.cantwest@gmail.com

Bobbie-Jane Cooke

Central

Ph 021 0269 3460

Megan Hooper-Smith

Ange Hill

Canterbury West Coast

Nga Marsters

Manawatu Sub-Committee

Auckland auckchair@nzcom.org.nz

dani.midwife.maori@gmail.com

bobbiejane.homebirth@gmail.com

rmrr@mmpo.org.nz

Resources for midwives and women The College has a range of midwifery-

Laura McClenaghan

Parents Centre New Zealand Ltd

related books, leaflets, merchandise and

centralchair@nzcom.org.nz

Liz Pearce

other resources available through our

e.pearce@parentscentre.org.nz

website: www.midwife.org.nz/shop

Nelson Marlborough Emma Neal tetauihunzcom@gmail.com

ISSUE 108 MARCH 2023 | 43

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