Time to recognise midwives
20 December 2019
Opinion: Medical student Emma Espiner confronts her prejudices about midwifery after meeting midwives who are frustrated they are being prevented from providing the care they believe the women of New Zealand deserve.
We did not want a midwife for the birth of our daughter.
It’s difficult to cast myself back to a time when I wasn’t yet a mother. A time when I slept whenever I felt like it and could leave the house simply by opening the door and stepping over the threshold, carrying only my dreams and credit cards. Not having to negotiate with a small and wildly unreasonable person, then carry their shoes, a spare change of clothes, wet wipes, snacks and activities. I loathe activities.
I wanted ‘the best possible care’ and it didn’t even cross my mind that the best care would be anything other than a doctor. I didn’t want a water birth, a hypno birth, candles, whale song, an orgasmic birth (it’s a thing - look up Ina May Gaskin). I had intuited – apropos of nothing – that all of these things were part of the midwife secret agenda. I wasn’t quite brave enough to wear the political consequences of an ‘elective’ caesarean but honestly, I was grateful when my labour turned into an emergency c-section. I was very half-hearted about the whole vaginal delivery thing generally so when our obstetrician said we needed to operate I acquiesced gratefully, bemused in an epidural fog.
I’m writing this down because I was too afraid to admit it directly to the midwives I’ve been talking to for this story. I’m going to turn my phone off once the article is published and change my surname and place of address. It’s been nice knowing you all.
Because they’re not to be trifled with, I’ve found. They’re fiercely committed to the wellbeing of women and whānau and they’re getting increasingly pissed off about the lack of understanding by people like me, and the government, about the importance of their work.
[Midwives are] fiercely committed to the wellbeing of women and whānau and they’re getting increasingly pissed off about the lack of understanding... about the importance of their work.
Frustrated after four years of negotiating with the Ministry of Health, the New Zealand College of Midwives has taken its demands public with a campaign. They’ve got a hashtag #backmidwives and a rallying cry that any copywriter worth their pun licence would be pleased to have penned: “It’s time to push.” They launched a petition which reached 10,000 signatures in four days.
In a press statement earlier this year, Minister of Health David Clark acknowledged the workforce is under pressure across the country and that the challenges are widespread; they include safe staffing, recruitment, retention and training. It’s not a simplistic matter of resourcing. Money matters but midwives believe there is a fundamental issue with the way we’ve integrated our midwifery-led care system, borne of a lack of recognition of what midwives do.
I met South Auckland Lead Maternity Care midwife Ady Priday and some of her colleagues who work across the greater Auckland region when I was researching a column about access to contraception earlier in the year. It’s because of Ady that I spent last Thursday afternoon chasing hundreds of pieces of paper around my house after a wind gust blew her Masters thesis off my table. This was an in-depth look at the experiences of eight women in South Auckland who had 25 children between them. I learned a lot by reading it, including the legislated role of midwives in our health system that I was oblivious to back when I was worried about being forced to birth with whale songs under a curtain of amethyst crystals. When I did an obstetrics and gynaecology rotation earlier in the year and actually met some midwives, I found they were a group of regular professional women, highly qualified and inordinately generous to a medical student nervous about attending her first births. No crystals in sight, just a lot of specialist health expertise and a reassuring pragmatism about which births could continue without intervention, and those that needed escalation.
Seven years ago I went to the GP to confirm my pregnancy. After the dozens of home pregnancy tests I’d taken – to be SURE sure. Most people do, and that’s okay. But you can also go straight to a midwife. That was shocking to me because – what if you didn’t want to continue with your pregnancy? A midwife’s role doesn’t include advice around terminations, surely. Wrong again.
I put some of my newfound revelations to Ady who, with remarkable patience, explained to me that ignorance of midwives’ scope of practice is behind all of the issues they’re experiencing. She said:
“Even when we’re talking to the Ministry we’re having to articulate and justify our breadth and robustness as a profession. We have to show that continuity of care – the absolute foundation and importance of our role – looks like everything from prenatal vitamins and nutrition advice, wellbeing and risk assessment, referrals to GPs and obstetricians through to conducting births, suturing, cannulation, emergency care when needed and then postnatal infant feeding and wellbeing assessments, contraception and family planning advice. Our system is the envy of the world in terms of good outcomes and yet not everyone here seems to value it.”
Our system is the envy of the world in terms of good outcomes and yet not everyone here seems to value it.
I fact-checked this position and found a range of evidence to support it. Data from 2017 show that, in New Zealand, the rate of stillbirth after 28 weeks is lower than the rate in Australia, where pregnancy care is predominantly led by specialists. A report commissioned by the Ministry of Health in 2012 found that our outcomes were similar or better than other countries across an even broader range of measures.
I was at risk of writing a column that was just a tour through all the things that I didn’t know about midwifery and how I’m sorry for being a dick about it, but I had to look deeper because we’re at an interesting time socially. Issues like abortion, immunisation coverage, and the availability of maternity services all coalesce around midwives and the role they fought for.
The story of modern midwifery in New Zealand revolves around Aunty Helen. My colleagues and I at medical school found that a sure way to get some interesting chat under way with obstetricians on our clinical attachments was to mention the reforms in her early parliamentary career which saw dramatic changes to maternity care in New Zealand. I thought I’d go one step further and contact Helen Clark to see what she had been thinking at the time. Fortunately, our former Prime Minister was easily accessible and at home.
Helen told me that as a young Member of Parliament she came to know some of the few domiciliary midwives operating in central Auckland at that time. They convinced her that, as in the Netherlands, midwives should be able to work to their level of professional competence, and autonomously, to provide continuity of care to women through pregnancy, childbirth, and the immediate period beyond that. Further, Helen was convinced there should be direct entry midwifery training, rather than the entry point being through nursing training. Changes to the law were prepared accordingly and passed in the Nurses Amendment Act 1990. They included the right of midwives to prescribe pharmaceuticals.
It occurred to me that the strict regulatory regime that midwives operate under was implemented precisely because they needed to justify their presence in a medical system that was just getting to grips with the idea of informed consent - a central tenet of midwifery in New Zealand. Let’s not be coy about the fact that it’s a women-led profession in the service of women. That’s not an easy fit with an historically paternalistic and male-dominated health system.
I live just down the road from our Minister for Women Julie-Anne Genter. She’s someone that even my laser-honed cynical views of politicians has failed to penetrate. She’s an old-school Green. One of those irritating people who walks the talk. A few years ago she put a lot of energy over text message into helping me become a person who bikes. She even offered me one of her own to try. She failed because I have a temperamental allergy to physical activity in general, but it wasn’t for lack of effort on her part. Unlike me, Julie-Anne chose a midwife as her lead maternity carer. So far, so Green. I wanted to know why Julie-Anne had gone for a midwife and what her experience was like. Julie-Anne isn’t just a mum with a story to tell, in this context. She also has the power to influence change in our system. I wrote to her and asked what she thinks about the midwives' frustration. She wrote back:
“I’m frustrated too. I know how hardworking and dedicated our midwives are – I’ve experienced it.
“I chose to have midwife as my LMC because that is what most women in New Zealand do. The clinical evidence from here and around the world suggests healthy women with normal pregnancies have better outcomes and less medical intervention with midwife-led care.
“Despite our aspirations for a natural birth, I did end up with an induction at 42 weeks, and a forceps-assisted delivery at Auckland Hospital. I am incredibly grateful for the standard of medical care that was available to me in our public system, and that we had a safe arrival of our son (who was experiencing distress during the labour).
“I was fortunate that my midwife LMC was extremely experienced in both hospital and natural births. She had been clinical director of midwifery at Auckland Hospital for many years, and only recently stepped back and had a very small caseload as a community midwife LMC.
“Because she was travelling overseas for international work on midwifery training, I also was seen by two other back-up midwives during my pregnancy. I was struck by the number of responsibilities they were juggling. We don’t expect other medical professionals to do the amount of facility negotiation, travel, paperwork or rescheduling appointments that midwives undertake for themselves.
“I want to see significant improvements in maternity services, and I believe paying midwives more is part of that. We must also protect our continuity of care model which places women at the centre, and make it possible for midwives to have the time to support mothers and babies, especially complex cases that have additional needs.
“For example, I am aware of how difficult some midwives have found dealing with DHBs that haven’t prioritised or enabled facilities for midwives to provide services.
“I picked up the maternity delegation in health in July of this year. Since then, I have visited midwives around the country, held public meetings about maternity, and met with the key stakeholders as well. I am aware of the huge strain that our maternity services are under. We are working on solutions, but there is not one silver bullet.
“I don’t think everything will be fixed in the upcoming Budget, it has been broken for far too long for that. We have made progress on important changes, like the second midwife payment, but we still need to go further and faster.”
I want to see significant improvements in maternity services, and I believe paying midwives more is part of that. We must also protect our continuity of care model which places women at the centre, and make it possible for midwives to have the time to support mothers and babies, especially complex cases that have additional needs.
Regular readers of this column will be hanging on the edge of your seats wondering where the equity plug is. That train is never late –our Māori, Pacific Peoples, immigrant, and rural communities are suffering the most from issues across every frequency of the access spectrum: cultural safety, geographic, financial, and education. You always need to be cautious when you read any government policy about ‘priority populations’. It’s code for ‘people we’ve let down’. For starters, it’s a Treaty issue. Lack of services in the places where Māori women want to give birth means a breach of the agreement with the Crown. Our rural mothers – irrespective of ethnicity – can’t get midwives nor suitable birthing units, forcing them to travel vast distances to receive appropriate care.
Ady told me about women who have recently arrived in our country, refugees and new migrants, who don’t know what to do with their pregnancies because the Ministry hasn’t done its job in promoting the role of midwives in the way that it has promoted other health professionals such as Plunket/WellChild services and GP services. This is a group of professionals who have the ability to make a huge difference in people’s lives but who aren’t being backed to do so by our own government.
This time next year I’ll be a doctor, and thanks to these midwives I’ll be much less of a dick as a colleague. Hopefully by the time I graduate, their concerns will have been meaningfully addressed by the Government and we can get on with the job of caring for our communities together.
Emma Espiner is a Part V MBChB student in the Faculty of Medical and Health Sciences.
This article reflects the opinion of the author and not necessarily the views of the University of Auckland.
Used with permission from Newsroom Emma Espiner: Time to recognise midwives 19 December 2019
Nicola Shepheard | Media adviser
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