Midwife Aotearoa New Zealand

MIDWIFERY REBORN CELEBRATING THREE DECADES OF AUTONOMOUS PRACTICE P 5 I 14 I 16 CUTTING THE TIES

CAROL BARTLE

MIDWIFERY ON THE MARGINS

CORE MIDWIVES’ PAY WIN I P 10

NEW ZEALAND ORDER OF MERIT I P 26

SERVING MARGINALISED PEOPLE I P 30

ISSUE 98 SEPTEMBER 2020 I THE MAGAZINE OF THE NEW ZEALAND COLLEGE OF MIDWIVES

When the mum-to-be needs iron

The softer oral iron Gastrointestinal side effects to the commonly prescribed ferrous sulphates can be so intolerable, many patients stop taking them.1,2

Fewer side effects vs ferrous sulphate in pregnant women1 60%

30%

be a gentler, more tolerable oral treatment than ferrous

20%

sulphates - without compromising efficacy.1,2

10%

Consider Maltofer * for your pregnant patients ®

who are iron deficient.

Maltofer® 46%

Ferrous sulphate

40%

In a trial of pregnant women, Maltofer® was proven to

Maltofer® can be taken with food.3

56%

50%

29%

28%

23%

17% 5%

2%

0

Any Side Effect

Nausea

Vomiting

Constipation

Multicentre, open-label randomised study of 80 pregnant women with irondeficiency anaemia (IDA) randomised to Maltofer® or ferrous sulphate. p<0.05

The

Fe Iron Experts *Maltofer® is an oral iron therapy, indicated for the treatment of iron deficiency in adults and adolescents where the use of ferrous iron supplements is not tolerated, or otherwise inappropriate and for prevention of iron deficiency in adults and adolescents at high risk where the use of ferrous iron supplements is not tolerated or inappropriate.

References: 1. Ortiz R et al. J Matern Fetal Neonatal Med 2011;24:1–6. 2. Toblli JE and Brignoli R. Arzneimittelforschung 2007;57:431-438. 3. Maltofer® Data Sheet, June 2019.

Maltofer® tablets (100mg iron as iron polymaltose) and syrup (50mg/5mL iron as iron polymaltose) is a Pharmacy Medicine for treatment of iron deficiency in adults/adolescents where use of ferrous iron supplements is not tolerated or inappropriate, and for prevention of iron deficiency in adults/adolescents at high risk where use of ferrous iron supplements is not tolerated or inappropriate. Dosage and administration: Dosage and duration on treatment depend upon extent of iron deficiency. Please refer to data sheet for full dosage recommendations. Precautions: Iron deficiency anaemia: all other causes of anaemia should be considered/treated prior to Maltofer use. Use with caution in patients with infections or tumour, regular monitoring of Hb and serum ferritin levels required to gauge response. Pregnancy Category B1. Use in children <12 years not recommended, limited experience in elderly. Contraindications: Known hypersensitivity to iron polymaltose, iron overload e.g. haemochromatosis, disturbances in iron utilisation, anaemia not caused by iron deficiency. Adverse effects: Very common: faeces discoloured. Common: diarrhoea, nausea, abdominal pain, constipation. Interactions: Concomitant parenteral iron. Maltofer® is a registered trademark for Vifor Pharma used under licence by Aspen New Zealand C/O Pharmacy Retailing (NZ) Ltd, Auckland. NZ-MAL-2000001 TAPS PP5450 - MAR 20. INSIGHT 9741

YOUR COLLEGE

ISSUE 98 SEPTEMBER 2020

FORUM FROM THE PRESIDENT

welcome to aotearoa new zealand midwife

4. NICOLE PIHEMA

This is a very special edition of Aotearoa New Zealand Midwife magazine as it will

FROM THE CHIEF EXECUTIVE

be the last that I edit. I will be retiring shortly and handing over to a new editor,

5. LOOK BACK AND REFLECT

Amellia Kapa, who will bring her own perspective to the magazine. Amellia is a practising midwife who also has a background in media and communications.

8. BULLETIN

My years at the New Zealand College of Midwives have been some of the

YOUR UNION

happiest of my career, learning about the midwifery profession in New Zealand

10. CUTTING THE TIES

as Christchurch was being shaken by the series of earthquakes that destroyed so

and reporting on midwives’ stories. I arrived at the College nearly ten years ago

YOUR MIDWIFERY BUSINESS

many buildings and turned lives upside down. My first College meetings were

12. TECHNOLOGY: THE MIDWIFE’S FRIEND

its 100-year old building. In this edition of Midwife we publish a reflection by Liz

in cafes and colleagues’ homes because the College had been forced to leave Winterbee, a midwife who worked as an LMC in the city through this period. She

FEATURES

explains how the trauma affected her and how she recovered.

14. THREE DECADES OF AUTONOMY

response required to care for women during the Covid-19 lockdown. We include

15. MESSAGE FROM HELEN CLARK

we acknowledge that there are no easy answers, especially at a time when years

A decade later midwives have experienced a different type of trauma in the

16. THEN AND NOW 20. BURNOUT AND BACK

a feature in this edition about coping with trauma and extreme stress although of under-resourcing have put the profession under pressure. At a time when the shape of New Zealand’s health service is once again under review, including the possibility of changes to the way the maternity service as organised, it is worth remembering that midwives and women fought hard to obtain the service we

23. COUNTING THE COST OF COVID

have now. We mark the 30th anniversary of the Nurses Amendment Act in this

26. PROFILE: CAROL BARTLE

the midwife-led system based on continuity of care that is now the norm.

29. PRESCRIBING UPDATE

I have worked on. I will follow your progress as you fight to safeguard our caring

30. MIDWIFERY ON THE MARGINS 34. BREASTFEEDING CONNECTION 37. MY MIDWIFERY 38. DIRECTORY

edition, legislation that restored autonomy to midwifery and paved the way for Thank you to the midwives who have contributed to these and all the stories and woman-centred maternity service.

- Maria Scott Communicatons Advisor Cover: An image from late 1980s publicity to support the campaign for midwifery autonomy, achieved in 1990. The midwife is Sally Pairman, now CEO of the International Confederation of Midwives.

EDITOR Maria Scott, P: (03) 377 2732 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 E: Hayley.m@nzcom.org.nz

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

MATERIAL & BOOKING Deadlines for Dec 2020 Advertising Booking: 9 Nov 2020 Advertising Copy: 16 Nov 2020

Aotearoa New Zealand Midwife 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. 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: 2703-4062.

ISSUE 98 SEPTEMBER 2020 | 3

FROM THE PRESIDENT

from the president, new zealand college of midwives, nicole pihema ‘Hapaitia te ara tika pumau ai te rangatiratanga mo nga uri whakatupu’. Foster the pathway of knowledge to strength, independence and growth for future generations.

Arotake Pūnaha Hauora-Whaikaha Hoki, (Health and Disability System Review) was published in March and acknowledges the need to reshape our healthcare system in Aotearoa in a way that provides equity of access for all.

It particularly acknowledges the need to address the historic absence of equity for Māori.

It should not come as a surprise for anyone that the report admits: “The fact that Māori health outcomes are significantly worse than those for other New Zealanders represents a failure of the health and disability system and does not reflect Te Tiriti [Treaty of Waitangi] commitments.”

The Annual General Meeting for the New Zealand College of Midwives will be held at the Novotel, Cathedral Square, Christchurch on Wednesday 14 October from 7.00pm.

If you would like to give notice of a remit or raise an issue for discussion at the AGM please send details to Lynda Overton lynda.o@nzcom.org. nz or New Zealand College of Midwives, PO Box 21-106, Edgeware, Christchurch 8143.

4 | AOTEAROA NEW ZEALAND MIDWIFE

One of the main recommendations is for the establishment of a new organisation, the Māori Health Authority. It is recommended that this be the principal advisor on all Hauora Māori [Māori health] issues. But the report stops there, recommending the Māori Health Authority as an ‘advisor’. This does not go far enough to action changes that are essential for a real improvement in equity; this includes the right to make decisions about funding and commissioning of services. Heather Simpson, chair of the review panel states that there was no consensus on the extent to which the Māori Health Authority should control the funding and commissioning of services for Māori. All members of the review’s six-person Māori Expert Advisory Group and four members of the seven person review panel envisaged a much more decisive role for Māori and outlined this in an alternative review included in the report.

This is concerning when the Māori Advisory Group is disregarded for the adoption of a more mainstream view; a sign that really there is no real commitment to change and is likely a reflection of the environment in which the Māori Health Authority would be ‘advising’.

The alternative view says that “a comprehensive indigenous commissioning framework should be developed, which uses every enabler and lever, at every level, to ensure the system successfully delivers improved health and wellbeing outcomes for whanau”.

“The commissioning framework should be Tiriti [Treaty of Waitangi] compliant and designed by Māori as an active expression of rangatiratanga [authority, ownership, leadership] and mana motuhake, [self determination, autonomy] in a way that is not possible within mainstream organisations.

The time is right for action around a broader indigenous commissioning framework in Aotearoa, that could be world leading in addressing inequity.”

The lack of consensus indicates that there is still a lack of trust in the ability of Māori to direct funding and commissioning. Partnership implies trust between the parties involved. But when it comes to implementing the partnership in a Te Tiriti re-shaped health service, the trust does not seem to be there.

There are echoes for midwifery in the way that the proposals we have put forward to reorganise the funding model for community midwifery – proposals that have been developed over several years as part of our mediation agreement with the government – seem to have been sidestepped. We welcomed the $242 million funding package the government announced recently for the maternity sector but it is disappointing that there seems to be a lack of trust in the model we have proposed. We will continue to fight for a system that protects our autonomy and the continuity of care for women that midwives in New Zealand have fought so hard to achieve. Likewise Māori will continue to fight for autonomy within a re-shaped health service, something many believe will be essential if we are to achieve equity at all. square

FROM THE CEO

TITIRO WHAKAMURI, KOKIRI WHAKAMUA look back and reflect so you can move forward.

The year 1990 is cemented into the minds of many of Aotearoa’s midwives as the year in which the Nurses Amendment Act (NAA) was passed, once again restoring the right to professionally autonomous midwifery practice. For some of the newer members of our profession, this momentous change may feel a bit like ancient history. An important but fabled or mythical event discussed by wise colleagues but one which may be hard to fully grasp the significance of.

For those who aren’t familiar with the history, a detailed account of the events leading up to and following the passing of the NAA (which occurred on the 22nd of August) is set out in Women’s Business, the story of the New Zealand College of Midwives 1986 – 2010 by Sally Pairman and Karen Guilliland. For those who haven’t read this - and I recommend it the following summarises some of the key background and context.

Through the 1980s (and even earlier) women recognised that their rights for selfdetermination and choice in childbirth care could only be realised if midwifery autonomy was achieved. The consumer movement through this period acted as a catalyst for midwifery activism. Over the previous decades, midwifery had been subsumed by

nursing, and had somewhat lost its identity as a distinct and purposeful profession. The impetus of a strong and principled consumer movement both motivated and activated midwifery to organise itself politically and collectively to seek change.

Due to the deeply gendered nature of the issues (both women’s autonomy over their own childbirth choices and midwifery’s professional autonomy), the dominance and patriarchal power and control of medicine, the events surrounding the change in legislation were inherently political. There was little understanding of the scope, role and nature of midwives’ work within the medical profession – and palpable resistance to midwifery autonomy by some. A coordinated and effective campaign for change by consumers and midwives was required. Women and midwives together formed a movement that was greater than the sum of its parts. The activism of this period also led to the establishment of the College, which became the vehicle for the profession to not only express its collective voice but also to eventually advocate for and develop the professional frameworks which were necessary to support and enable autonomous practice.

It can be easy to look backwards and critique what has been accomplished against what is still to be done. However it’s important that we all take a moment to pause and celebrate what has been achieved.

ALISON EDDY CHIEF EXECUTIVE

There was an incredible effort, political strategising, intelligent analysis, diligence and

ISSUE 98 SEPTEMBER 2020 | 5

FROM THE CEO

practitioners through the Maternity Benefits schedule were required. There was much detailed work needed to put all of these pieces of the jigsaw into place.

“The underpinning belief system that drove change 30 years ago is much the same today. It is that women should have control over their bodies and their decision making. Women and midwives are bound together in this to the benefit of both. The New Zealand College of Midwives was the collective voice of both and provided the united platform that enabled the implementation of the Nurses Amendment Act and the autonomy that continues today.”

KAREN GUILLILAND - FOUNDING PRESIDENT AND FORMER CEO OF THE NEW ZEALAND COLLEGE OF MIDWIVES

sheer hard work by many, over several years leading up to (and also after) the passing of the NAA. There are too many individuals involved to name them all, but it would be remiss of me to not mention specifically the work of Joan Donley, Judi Strid (a consumer who founded Save our Midwives and promoted direct entry education), Karen Guilliland and Sally Pairman. These incredible women (and others) had a vision and a firm belief in what was right, along with considerable perseverance in order to successfully execute the plan!

There was not simply one piece of legislation which needed to change; a long list of other acts and regulations also needed amendment. Prescribing, ordering diagnostic tests, accessing maternity hospitals and receiving payments equal to medical

6 | AOTEAROA NEW ZEALAND MIDWIFE

Although the NAA was spearheaded by the then Minister of Health, Helen Clark, female politicians from across the political divide were supportive of and sympathetic to the arguments for the legislative change.

As female MPs, they had undoubtedly experienced gender discrimination in their own careers.

Opposition from the nursing profession was a significant obstacle that also needed to be overcome. Nursing viewed midwifery as a sub specialty of nursing, and midwifery was regulated by them at that time, via the Nursing Council (which included only minority midwifery representation). This resistance was particularly in relation to the establishment of direct entry midwifery education programmes, which were necessary to prepare midwives for the responsibilities associated with autonomous practice.

The majority of midwives practising today have not experienced anything other than the autonomy which we all now take for granted.

For those who were in practice through this period, both before and after the NAA was passed, your experience highlights what this change meant in real terms. Speaking to colleagues who practised through this period is illuminating. They recount the satisfaction of no longer needing to judge the moment of “when to call the doctor” in order that he or she be present for “the birth of the baby” (whilst the midwife’s clinical judgement and decision making all the way throughout the preceding labour often went unacknowledged), the sense of pride in being afforded the status and recognition commensurate with their skills, the ability to work with women and families and provide continuity of care and the increasing visibility of the profession in the eyes of the public.

It can be easy to look backwards and critique what has been accomplished against what is still to be done. However it’s important that we all take a moment to pause and celebrate what has been achieved.

The ripples that have ensued throughout our maternity system as a result of changing this key piece of legislation have been far greater than any of those involved at the time may have hoped for or realised was possible.

Our foremothers, both midwives and consumers, have every reason to be proud of their work. What must have been a central part of their vision, a women-centered

maternity service which has a midwifery led continuity of care model as a principal component is now ”establishment” in New Zealand. The World Health Organization now recommends this model of care as the optimum arrangement for maternity care, and New Zealand midwifery has influenced many other countries’ health systems, as well as many of the International Confederation of Midwives frameworks (such as its education and regulation standards).

It is highly symbolic that in this 30th celebratory year, a further step towards successfully de-coupling midwifery from nursing has fallen into place. Midwifery union MERAS has achieved the long sought difference in employment conditions between nurses and midwives. From 1 August midwives in the MERAS Multi Employer Collective Agreement (MECA) have received a pay increase that those on the New Zealand Nurses Organisation MECA have not, and all MERAS member graduate midwives will now start on Step 2 of the pay scale. This was possible because of the success and growth of MERAS. Co-leaders Caroline Conroy and Jill Ovens have been key in this success as they, along with MERAS members led a movement for pay equity. MERAS is firmly established as the midwives’ union and it is now involved in many pieces of work that enhance employed midwives’ working conditions, so that they better reflect the professional autonomy which all midwives are legislatively afforded.

However there is still work to be done.

Building an environment conducive to autonomous midwifery practice within complex hospital environments (which can have a tendency to still conflate midwifery with nursing) is an ongoing challenge.

MERAS and the College together work towards this aim on an almost daily basis.

The success of midwifery as an autonomous profession (with the capacity to practise in an LMC community based continuity of care model) is closely tied to contract arrangements for the payment of services, not just the amount paid. It has been demonstrated internationally that these arrangements are a key factor in determining the professional status of midwifery in any particular country.

Although midwives may be legally able to practise autonomously, unless there is a means to pay them in a manner which is proportionate to their responsibility and skill, and funding or payment arrangements which enable autonomous practice, the profession (and consequently a women-centered

FROM THE CEO

maternity service) will not flourish. Although Section 88 isn’t a perfect contract arrangement it has protected midwives’ professional autonomy to date.

farewell maria, welcome amellia

A useful analogy to consider is the development of the nurse practitioner role.

Although there are a growing number of nurses who have achieved this status, many have not been able to secure suitable employment arrangements, as there is no dedicated funding stream. In general, medicine has been reluctant to forgo its economic and professional dominance (as it was with midwifery). Such that to date, although the educational preparation and regulatory frameworks are in place, many nurse practitioners are prevented from being able to fully contribute their valuable skills to our health services.

Maria Scott, the College’s Communication’s and Publications Advisor is leaving for the greener pastures of retirement, after nearly 10 years in the role. Alongside managing (not infrequent and occasionally bizarre) queries from media, Maria’s main responsibility has been the editorship of the College’s magazine.

We await the outcome of the election to find out whether the recommendations from the recent Health and Disability System Review will be adopted, and if they are, their impact on midwifery autonomy and any future contract arrangements. We have made significant progress towards fair and reasonable pay for community LMC midwives, however due to the uncertainty regarding the future contract model, and as professional autonomy is so fundamental to our practice, the College is pursuing its options under our mediation agreement with the Ministry of Health. We need to ensure that whatever arrangements evolve, our system (which both bestows and requires the accountability and responsibility of autonomy) recognises and supports it in every way needed, including through any future contract arrangements.

In its simplest sense, autonomy is about a person's ability to act on his or her own values and interests. In the context of a professional role it is much, much more than that. Autonomy for midwives enables us to define our own professional standards and to be self-determining, but with this autonomy also comes considerable responsibility, most importantly to the women and whānau whom we serve.

Both employed and self-employed midwives are dealing with pay equity issues, although the processes to achieve fair pay have been different for each group. Herein lies a tension for an autonomous profession.

Autonomy requires that our professional frameworks and accountabilities should always determine our practice, regardless of whether we may be somewhat dissatisfied with aspects of our pay, or working

"The change to the legislation enabled midwives to work to their full capacity, to claim their autonomy and work alongside women to provide continuity of care.

It was an exciting challenge.

Midwives working in hospitals were encouraged to set up teams providing care while others were very brave as they went out into the community and that encouraged others.

My hope is that we can continue to understand and recognise how important these changes were.”

JACQUI ANDERSON - MIDWIFE

conditions. Inadequate pay or recognition is no excuse for a lack of professionalism or cutting corners to ration necessary care simply because we feel undervalued. If we let these frustrations define our practice, instead of the pride in doing a good job to the standard that our peers would deem acceptable within the circumstances, we are undermining ourselves as an autonomous profession. This not only reduces our joy in our work, but it affects the women and whānau for whom we are caring.

Regardless of how midwives are paid, whether employed or self-employed, we all value our hard won autonomy.

We recognize it as something which we need to protect and cherish. We owe it to ourselves, to women, and to our foremothers whose work three decades ago established our rights to be self-determining. square

Although prior to joining the College the majority of Maria’s journalistic experience was with publications in the UK including the Observer, Guardian and Times newspapers, she fitted seamlessly into the national office team and was quick to grasp the nuance, quirk and essence of midwifery in Aotearoa. Through Maria’s professionalism, natural curiosity and wide general knowledge she has brought engaging perspectives to the magazine’s content, in ways that have resonated with our unique midwifery world view. The thoughtful accounts of sometimes sensitive topics within the magazine are a tribute to Maria’s journalistic talents and empathetic nature. Maria has left her mark on the College beyond her employment with us, as it was her experience which seamlessly oversaw the relaunch of Midwifery News earlier this year as Aotearoa New Zealand Midwife with its engaging new format.

We wish you all the best in retirement, and will miss you, however we are both fortunate and delighted to welcome Amellia Kapa into the role. As well as a background in communications, Amellia is also a registered midwife.

With Amellia’s oversight in the future, we look forward to continuing to bring fresh and interesting magazine content to members. square

Women’s Business, the story of the New Zealand College of Midwives 1986 – 2010 by Sally Pairman and Karen Guilliland, can be ordered via the College website www.midwife.org.nz.

ISSUE 98 SEPTEMBER 2020 | 7

BULLETIN

BULLETIN baby friendly hospital initiative guidelines updated The BFHI criteria for Aotearoa New Zealand are based on the UNICEF/WHO Baby Friendly Hospital Initiative: Revised and Updated 2018.

The global assessment tool forms the basis of the audit and accreditation procedure for all countries. Amendments and clarifications have been made to the New Zealand accreditation documents. The BFHI documents for New Zealand are presented in three sections. The full document is available as a downloadable PDF, or alternatively, each part is available as a stand-alone PDF at www.babyfriendly.org.nz square

new quit smoking campaign aimed at young Māori women

website resource for bereaved parents

Te Hiringa Hauora/the Health Promotion Agency has launched a new national advertising campaign QuitStrong. The campaign has been developed by Te Hiringa Hauora, in partnership with the Ministry of Health and Homecare Medical.

The Department of Internal Affairs (DIA) now has a website, Whetūrangitia, dedicated to information to support parents and whānau after the death of a baby or child. The information also covers miscarriage.

It follows research commissioned in 2018 by Te Hiringa Hauora into the smoking behaviours of Māori women which found that a key barrier to quitting was the individual’s own thoughts and perceptions about being able to do it.

A range of ideas were tested with Māori women, to challenge these beliefs. The new campaign has a montage of videos of support from real people encouraging someone close to them to quit smoking, or congratulating them for starting their quit journey. The main audience is wāhine Māori (including wāhine hapū), aged 18 to 34-years-old, living in high deprivation situations who are contemplating quitting smoking. For more information visit www.quitstrong.nz

The site contains a wide range of subjects, including Paid Parental Leave, other financial entitlements, memory making, burial and cremation, transportation, and post mortem.

The site has been developed following consultation between government and non government agencies, including the New Zealand College of Midwives and focus groups with bereaved parents.

The website was offered the name Whetūrangitia after consultation with the Māori Advisory Roopu of the DIA. In traditional whaikōrero (oratory speeches) Māori refer to the passing of a person as a ‘star’ that returns to the sky to join their ancestors. Whetūrangitia means “stars that adorn the sky”. The whakataukī (proverb), “Kua whetūrangitia koe”, in this context means, “Return, take your place amongst the stars along with your ancestors that adorn the sky”.

Feedback or suggestions for information that could be added to the site should go to Endoflife@dia.govt.nz square

8 | NEW ZEALAND COLLEGE OF MIDWIVES MAGAZINE

BULLETIN

catherine hamlin dies Catherine Hamlin, the Australian-born obstetrician and gynaecologist who, with her New Zealand born husband Reginald Hamlin devoted her professional life to treating women in Ethiopia for obstetric fistula died in March at the age of 96.

The Hamlins moved to Ethiopia in 1958 to set up a school for midwifery and discovered that the debilitating condition of fistula, injury suffered during obstructed labour, was a common problem for women there. At the time there was no cure and the Hamlins developed surgical techniques to deal with it. The Hamlins remained in Ethiopia for the rest of their lives setting up clinics to treat fistula and a foundation to support their work. Reginald died in 1993.

Catherine received numerous international and Australian honours and awards for her work. square

ministry thanks midwives for screening work The National Screening Unit (NSU) and the maternity team at the Ministry of Health have commended midwives for their work to support the metabolic screening programme during Alert Levels 3 and 4 of the Covid-19 response earlier this year.

The Ministry says that the programme was able to maintain high screening completion rates as a result of the hard work and commitment shown by midwives. The programme was identified as an essential service during Covid-19. However, it was acknowledged that there might be challenges for midwives in collecting the samples required. By working together with the New Zealand College of Midwives and LabPlus, programme improvements were implemented to support midwives in their work. square

midwifery research news Updates on the latest midwifery research, as reported in international journals will soon be available on the New Zealand College of Midwives website. Until now we have published updates in Midwife magazine but in future will be able to provide a wider range of summaries in a more timely way via our website www.midwife.org.nz.

new zealand college of midwives midwifery student grants 2020 The New Zealand College of Midwivesâ&#x20AC;&#x2122; midwifery student advisory committee is pleased to announce the recipients of the Collegeâ&#x20AC;&#x2122;s student grants for 2020 (see below).

The grants assist midwifery students in the Bachelor of Midwifery programmes. Each school has two grants: one 2nd year and one 3rd year. Applicants are required to be members of the College and intending to practise in New Zealand after graduation. Where there are no applicants from a school the grants are shared between students from other schools who have applied. More details on the 2021 Scholarship will be advertised in the March 2021 edition of this magazine.

The grants will be adapted in the future to support students undertaking a four year programme and for students of the new Midwifery School at Victoria University of Wellington.

Name

School of Midwifery

Grant Award

Leigh Brown

ARA

2nd year

Kimberley Hunter AUT

2nd year

new tool to identify at-risk newborns

Wanaka Noanoa

2nd year

DHBs around the country are implementing the Newborn Observation Chart and Newborn Early Warning Score (NOC/ NEWS) tool for identifying newborn babies at risk of neonatal encephalopathy (NE).

Maryanne Marsh Emma Hau

Otago

3rd year

The tool provides a standardised way of assessing and documenting the wellbeing of babies following birth. The early warning system enables primary and secondary maternity care providers to work together with women and their babies as one team. It is a standardised, evidence-informed tool that can be used to identify unwell babies and support early intervention. It was originally developed and piloted by Canterbury District Health Board in 2015.

ACC is now supporting the implementation of the tool across the country. For more information email Lesley.Long@acc.co.nz square

Grace Redman

WINTEC

2nd year

Otago

Laura Richards Seraya Turnbull

WINTEC

2nd year

Monique Owen Kayla Stephen

ARA

3rd year

Otago

3rd year*

Jessie Gemmell Katy Christian

*Rural midwifery student grant

ISSUE 95 MARCH 2020 | 9

YOUR UNION

cutting the ties: 30 years of autonomous midwifery JILL OVENS MERAS CO-LEADER (INDUSTRIAL)

Saturday, 22 August, marked the 30th anniversary of the Nurses Amendment Act 1990, providing statutory recognition for midwives as “safe and competent practitioners in their own right.” In addition, midwives won the statutory right to prescribe drugs, order and interpret diagnostic tests, and train without prior nursing qualifications.

Nevertheless, for the next 30 years DHBemployed midwives continued to be paid on the same pay scales as nurses. That changed on 1 August 2020 when all MERAS members received a pay increase taking the top of the core midwives scale to $78,353 a year, and midwifery graduates who are

MERAS members will start on step 2 of the pay scale on $59,222 a year from now.

To symbolise this break from the nurses’-led pay scales, MERAS has given every member a pair of scissors.

However, there is more work to do.

Although midwives practise autonomously, in much the same way as doctors, we are arguing through the Midwifery Pay Equity process that midwives are undervalued partly because the midwifery model of practice is based on ‘inherent or natural abilities’ of women that are not accounted for in midwives’ pay.

We are also pointing to the method of wage fixing by the DHBs that has tied midwives’ pay into that of nurses, another women-dominated profession that suffers from genderbased undervaluation.

MERAS SETS OUT PRIORITIES IN ‘COVID ELECTION’

Christchurch midwife Tumanako Stone-Howard celebrates midwifery at a picket during the MERAS struggle for recognition in DHBemployed midwives’ pay that resulted in last month’s extra pay rise.

10 | AOTEAROA NEW ZEALAND MIDWIFE

At the Labour Party’s election campaign launch in early August Prime Minister Jacinda Ardern called the 2020 Election a “Covid Election”. Within a fortnight the Election was delayed to 17 October due to the new Covid outbreak.

Covid-19 highlighted strengths in our nation’s ability to respond to a major health emergency. The Government’s prompt introduction of the wage subsidy and business support also helped many families.

However, it is clear that our health system remains vulnerable to Covid outbreaks, and as a consequence the vulnerability of our economy, particularly in relation to unemployment.

MERAS is actively involved in the Council of Trade Unions’ campaign to re-elect a progressive government and the MERAS National Representatives Council has endorsed our campaign to elect a LabourGreens Government.

MERAS is calling on the Government to assign some of the money being put into upskilling workers displaced by Covid-19 into financially supporting university students in areas of national shortage, including midwives. The first instinct of successive Governments in the face of shortages in midwifery, nursing and teaching has been to recruit internationally trained professionals, rather than investing in “growing our own”.

In the past, university students going into teaching were paid generous “studentships” and were bonded on employment as a

YOUR UNION

teacher. MERAS has called for financial support for midwifery students through the Midwifery Accord with an expanded Voluntary Bonding scheme.

Other priorities endorsed by the NRC for our Election campaign are as follows: MATERNITY PRIORITIES • Pay Equity - conclude the pay equity

process for employed midwives

• Prioritise women’s health - adequate

funding of all maternity services, support for new families including extension and improvement of paid parental leave, wraparound services for vulnerable women and their babies, community breastfeeding initiatives

• Funding to support upgrade of maternity facilities and provision of

publicly funded primary birthing centres where needed

• Review of the model and funding of

DHB contracted-out maternity services and facilities.

BROADER SOCIETAL PRIORITIES • Community health and wellbeing - a

focus on whānau and the value of human friendship, as opposed to an emphasis on economic growth

• Prioritise people and our planet -

tackle climate change, biodiversity, waste reduction, clean air, clean water

• Reprioritise investment - invest in health,

education, affordable housing, and services for women and their families such as those services that address family violence

• Reorganise work - living wage, support

and retraining for workers displaced by impact of Covid-19

• Reset our economy sustainably - e.g.

local manufacturing to secure supply chain for essential products such as PPE and pharmaceuticals, food resilience.

WORK ASSESSMENT UNDERTAKEN IN PAY EQUITY CLAIM Assessment of the work performed by selected male comparators and the work performed by midwives was undertaken in August despite a dispute with the DHBs and the Ministry of Health over their exclusion of one of the agreed potential comparators.

That matter is in the hands of our lawyer. However, we agreed to go ahead with analysing the data we have to date for both the Nurses Pay Equity claim and the Midwifery claim in a marathon effort

involving 44 summary profiles of roles based on interviews conducted so far.

The MERAS team, Elizabeth Winterbee, Karen Gray, Caroline Conroy and Jill Ovens, spent more than a week fully dedicated to the process.

The work assessment involved scoring gender neutral factors such as emotional demands, interpersonal skills, services to people, and working conditions to establish the undervaluation of midwives’ work as a result of gender discrimination.

Interviews with participants in maledominated or historically male-dominated occupations continued during the MarchApril Covid lockdown, but not without difficulty. Some had to be conducted by Zoom or similar technology.

An issue during Covid was that many of the potential male comparators are also in essential services, so they were pre-occupied with the Covid response. Seven different occupational groups have been used as midwifery comparators so far.

MERAS lawyer may be next union MP in Parliament

As with the data from the midwives’ interviews, data from the completed comparator interviews was collated into summary profiles which were validated by those with knowledge of the roles.

The unexpected resignation of Auckland Central MP Nikki Kaye put a spotlight on the contest between Helen White, MERAS lawyer, and Chloe Swarbrick, who is a Green MP and highly placed on the Green Party List.

We chose comparators in occupations that were of a reasonable size, and where we could access information about their remuneration so preferably unionised with a collective agreement. They needed to have similar skills and qualifications, including entry requirements and number of years to be fully qualified.

It was a closely contested election in 2017 with Helen only 1500 votes behind National’s Nikki Kaye. With the resignation of Kaye, the race for the electorate is wide open, so Helen has a good chance of winning in October.

At each step of the process we have been careful to avoid the perception of bias and role-holder advocacy. We worked with the DHBs’ team to come up with a robust assessment process based on evidence and because of Covid restrictions, the process was adapted to be held by Zoom.

The College of Midwives has been providing valuable advice on our pay equity claim, including expert evidence the College collected for the 2015 High Court case and subsequent fair remuneration processes for LMC or community midwives.

The final phase in the process is to negotiate and conclude the settlement of the claim. At this stage we will consider the evidence we have gathered to determine whether there is undervaluation of midwives, and whether this was due to gender discrimination. If so, new rates of pay will be negotiated and backdated to 31 December 2019. square

Helen has previously worked for the EPMU as a lawyer and will be one of the few union MPs should she be elected. She understands the issues for employed midwives, having represented MERAS in our DHBs MECA facilitation, and our successful challenge of the St George’s public holidays policy.

Chloe came to public attention with her high profile bid for the Auckland Mayoralty in 2016 and her campaign for cannabis law reform. Chloe also has a good understanding of midwifery issues. square

For MERAS Membership Email: merasmembership@meras.co.nz Call: 03 372 9738

ISSUE 98 SEPTEMBER 2020 | 11

YOUR MIDWIFERY BUSINESS

Why technology is the midwifeâ&#x20AC;&#x2122;s friend WAYNE ROBERTSON EXECUTIVE DIRECTOR, MMPO

The emergence of Covid-19 has led to massive changes in the way people work and for health professionals the way in which care is provided.

In particular, two common themes have emerged: An increase in the use of digital applications, tools, and skills, and an increase in the number of people working from home.

DIGITAL APPLICATIONS, TOOLS AND SKILLS From the outset of the pandemic response the use of digital applications such as Zoom and Microsoft 365 quickly grew together with an unprecedented increase in the use of devices and the internet. Even more apparent was the urgent development and growth in digital skills for meetings, presentations, consulting and just managing multiple digital applications simultaneously.

Personal and face to face interaction was restricted and people were confined to their home environments, reducing travel time.

When looking at technology and its use we should always be considering the balance between the expected benefits and the tradeoffs... will it help me to be more effective or maybe improve quality or efficiency? The inherent ability of technology to help share information with anyone, anywhere in real time is invaluable. Sometimes efficiency gains are made when the process, output or the outcome is standard, exact and can be automated like basic administration and business tasks.

Electronic Section 88 claiming and business accounting and record keeping (Xero) have been made easier by digital technology and

12 | AOTEAROA NEW ZEALAND MIDWIFE

solutions as have scheduling, electronic referrals and prescriptions, digital maps, and digital connections (video conferencing and messaging).

of time) and challenges (decreased human interaction, challenges with body language and emotional intelligence insights) and how these can be balanced for the future.

Using digital solutions (Tiaki and Xero, see below) in these situations makes complete sense and especially in situations such as the Covid-19 response where there are restrictions on physical contact and changes to usual working conditions.

Speech to text applications are interesting and also becoming more prevalent although these do come with a warning label including the risk of imprecise and false understandings, questions about data security for health records and privacy requirements.

Further work is required here on how to best utilise this type of technology.

For community midwives, how you think about and use digital technology is not always as clear cut. The ability to observe, record easily and in a timely way is important but also critical is how you document your soft midwifery skills and insights to contextualise visits (both physical and virtual) and discussions (using many different modes, mediums and devices). This information supports the overall factual record of the pregnancy, your relationship with the woman, and meets your professional requirements.

The MMPO is 100% confident that the MIS is as closely aligned to these professional documentation requirements as possible.

Virtual consultations (invaluable in situations where physical restrictions are imposed) require further reflection and consideration around the benefits (easier real time connections, less travel and better use

Legislation around health data and information directs the community midwife to meet various security and privacy (including informed consent) requirements. It also requires that the health data and information must be properly stored, protected and able to be retrieved for a 10-year period.

At the MMPO we already offer comprehensive digital responses to support community midwives and are committed to continuing to design, develop and build better answers to these challenges.

TIAKI Tiaki, released late last year, has built in functionality for scheduling, electronic referrals and prescribing, virtual meetings (practice) and consults and the ability to

XERO We have been helping and supporting community midwives with their business needs through Xero for more than two years now. Xero certainly meets the digital benefit test discussed above of easy real time data collection, access anywhere any place, and electronic automation of regular tasks allowing more informed choices and better decision making.

During Covid-19 our Xero team has provided even more help and support to community midwives to meet their ongoing business requirements.

LAST WORD… Change is inevitable and the use of digital technology will continue to evolve well into the future especially in health care where innovation, design and development have historically been gradual. But digital technology is not just about being easy, it needs to be tailored and balanced so that it works with the human aspects of midwifery care and never replaces it. square

MMPO, the Midwifery and Maternity Providers Organisation provides self employed community midwives with a supportive practice management system. www.mmpo.org.nz mmpo@mmpo.org.nz 03 377 2485

2021 Semester One courses: Certificate Courses (15 Credits) Feb 15 – Apr 2 Preceptorship for midwives · Exploring maternal obesity: Clinical and critical perspectives · Climate change, health and birth.

Apr 26 – Jun 11 Working with tangata whenua: Building equity in maternity care · Hypertension in pregnancy · Queering midwifery: Sexuality, gender and sex characteristics diversity.

Diploma (Pre-Thesis) Course (30 Credits) Feb 15 – Jun 11 Pathway to Thesis: Midwifery Knowledge

Master of Midwifery Undertake a discipline-specific Master of Midwifery degree in a topic area of your choice.

If you wish to complete the Complex Care Certificate in 2021, or would like further information about any of our postgraduate courses, please contact: suzanne.miller@op.ac.nz.

K04378

message securely and privately from the application. It also includes access to a midwife and practice related calendar and various ways to connect direct from the app in addition to virtual consults and messaging including email, phone, and access to maps.

Our fully online postgraduate courses are perfect for busy midwives who wish to study alongside their midwifery work.

0800 762 786 www.op.ac.nz

Influenza Immunisation Protection for you and your clients We strongly recommend that all pregnant women are immunised against influenza.

But your recommendation to immunise has more impact than any TV ad or poster, and that recommendation can save lives.

Influenza can be serious. Pregnant women and their babies are at greater risk from serious influenza-related complications than women who aren’t pregnant.

As a midwife, choosing immunisation yourself helps protect you and importantly reduces the likelihood of passing influenza on to your clients.

Visit influenza.org.nz for more information.

The influenza vaccine is a prescription medicine.

Talk to your doctor, nurse or pharmacist about the benefits and possible risks or call 0800 IMMUNE.

TAPS NA11991

At the MMPO we already offer comprehensive digital responses to support community midwives and are committed to continuing to design, develop and build better answers to these challenges.

For excellence in online midwifery education

FEATURE

CELEBRATING THE REBIRTH OF MIDWIFERY IN NEW ZEALAND Three decades ago, on 22 August 1990, the Nurses Amendment Act 1990 became law enabling midwives in New Zealand to provide care to a woman through pregnancy, childbirth and the postnatal period, on their own responsibility.

MARIA SCOTT COMMUNICATIONS ADVISOR

Midwives had seen their autonomy gradually eroded over several decades until the Nurses Act 1977 required medical practitioners to take responsibility for the care of women during pregnancy and birth.

Women became increasingly unhappy with a maternity system that they felt was regimented and offered little or no choice over how or where they were giving birth. Many midwives were also dismayed at a system they felt was not supporting women well.

Midwives and women campaigned together for change and Helen Clark, Minister of Health from January 1989 to November 1990 was convinced by their arguments. She introduced the Nurses

The Nurses Amendment Act is "a testament to Helen Clark’s understanding of the power of primary health care and selfdetermination within health”.

14 | AOTEAROA NEW ZEALAND MIDWIFE

Amendment Bill to Parliament in November 1989 and it became law the following year. The legislation restored autonomy to midwifery and paved the way for dedicated direct-entry degree programmes to educate midwives, replacing the former system where midwifery was an add-on to a three year nursing qualification.

Karen Guilliland, founding chief executive officer of the New Zealand College of Midwives and Sally Pairman, writing in Women’s Business, The story of the New Zealand College of Midwives 1986-2010, said that the Nurses Amendment Act was “a testament to Helen Clark’s understanding of the power of primary health care and self-determination within health”.

Writing to the College to confirm the passing of the legislation Helen Clark said: “I acknowledge that legislative change on its own does not necessarily bring about change. What is also required is a change in attitude on the part of health consumers and other health professionals and a willingness on the part of area health boards [predecessors to district health boards] to explore new ways of delivering services.

“I believe these changes will have a significant impact on the health and wellbeing of many New Zealanders, particularly women and their children. I look forward to seeing these developments.” square

FEATURE

a message from helen clark Helen Clark has sent this message to the midwives of New Zealand to mark the 30th anniversary of the landmark legislation.

Congratulations on all that your profession has achieved over these 30 years. Midwives in New Zealand seized the opportunities provided by the Nurses Amendment Act to develop a midwifery-led maternity care system.

There was still much to do after the legislation was passed to re-shape maternity care in New Zealand and you worked successfully with colleagues across the health service to develop a system based on continuity of care and partnership with women. The midwife-led continuity of care model is now endorsed by the World Health Organization, and the system which was set up in New Zealand has been internationally respected and provided inspiration to midwives, and policy makers working in many countries to improve their midwifery services.

Women giving birth in New Zealand today and many of the young midwives caring for them accept New Zealandâ&#x20AC;&#x2122;s midwiferyled service as the norm. Midwives involved in the campaign that led to the Nurses Amendment Act will understand that bringing about changes to the maternity system took commitment, vision, and passion. The underlying motivation to ensure that our maternity system places womenâ&#x20AC;&#x2122;s needs at the centre of care will still be a driver for the midwives of today.

Yet, the status quo cannot be taken for granted. There is still work to do in New Zealand, not least in achieving pay equity for the profession and in ensuring that the system nurtured by midwives over these three decades is protected for the future. This anniversary coincides with the International Year of the Midwife, as designated by the World Health Organization. Please celebrate these events with resolve to protect what you have built. square

ISSUE 98 SEPTEMBER 2020 | 15

FEATURE

16 | AOTEAROA NEW ZEALAND MIDWIFE

FEATURE

Left: Kate Wright, far left, with her baby daughter (Jess Medforth’s mother), grandmother and mother in 1966.

THEN AND NOW Women’s experiences of pregnancy and birth have changed dramatically over the last few decades, driven by social change and the revival of midwife-led care in New Zealand. On the thirtieth anniversary of the law change that allowed midwives to practise autonomously, Annie Oliver speaks to a grandmother and granddaughter about their contrasting experiences.

ANNIE OLIVER JOURNAL ADMINISTRATOR

kate’s story When 73-year-old Kate Wright mentioned to her 19-year-old granddaughter that she was pregnant at her age, her granddaughter was horrified. But this was perfectly normal in the 1960s.

“We were all young when we got married and had our babies,” she says. “If you weren’t married by 21, you were basically on the shelf!”

When Kate realised she was pregnant, she went straight to her GP. “We didn’t have midwives in those days; we always went to the doctor. But I was so lucky with my doctor, he was a lovely man and I felt very well cared for.”

She had monthly antenatal appointments until about seven months, followed by fortnightly appointments, then weekly closer to the birth. She says that doctors didn’t tell pregnant women much about what to expect “but we didn’t worry too much about being pregnant.

There was no fuss or bother; we just got on with it.”

She feels fortunate that her mother was a great support and had had her last baby only three years earlier. So Kate felt a close connection to pregnancy, birth and a new baby.

She and her husband Gavin also attended antenatal classes, so she felt quite prepared at the time and wasn’t anxious about the birth. “Although, looking back, I didn’t really know much,” she admits.

Kate was living in Timaru and recalls the Jean Todd maternity unit in Timaru Hospital as being the only choice of birth place. She knew of no-one having a home birth.

So when labour started she rang the hospital, and the nurses contacted her doctor. Gavin drove her to the hospital and was allowed in the pre-birthing room but not in the theatre, where Kate went once labour was more advanced. As was standard practice at the time, she was ‘prepped’ by being shaved and given an enema.

Of her three children (born in 1966, 1968 and 1970), the births of her eldest and youngest were straightforward, with no complications or pain relief.

Not so with her second baby.

“They let me go too far over. I was three-and-a-half weeks overdue and he ended up being 10lb 2oz (4.6kg).

Twice I thought I was going to have him so Gavin took me to the hospital and they ‘prepped’ me but then they sent me home again as he wasn’t ready to come.

“The third time they took an x-ray to see if my pelvis was wide enough and yes it was, so they decided to induce me. My legs were up in stirrups – they were up in stirrups for all three babies, that’s just how it was then. And the only pain relief was the gas mask – it was great though; it took you to another planet,” she laughs.

After each birth, Kate stayed in hospital for 10 days.

“That’s what new mums did. There was no choice to

ISSUE 98 SEPTEMBER 2020 | 17

FEATURE

Jess and Dave Medforth with their sons Samuel and baby Liam in 2017.

After each birth, Kate stayed in hospital for 10 days. “That’s what new mums did. There was no choice to leave earlier.

Gavin could visit me every day but our older children were only allowed to visit on Sundays.”

leave earlier. Gavin could visit me every day but our older children were only allowed to visit on Sundays.”

I was lucky that I had Mum so close. I felt sorry for women who didn’t have their mother nearby.”

Kate breastfed all three of her babies – the eldest and youngest for several months.

However, after the birth of her second baby she’d lost so much weight that the doctor advised her not to continue feeding him. “It was his decision but I was feeling very weak and was totally ok with that.”

Having seen the experiences of her children and grandchildren, including granddaughter Jess Medforth, Kate says that there is definitely more support for new mothers now. And for fathers, who are now far more involved in pregnancy, birth and early parenting.

Kate was lucky enough to have her own room when in hospital, and her baby would be with her during the day, then taken to the nursery overnight. “Although, thinking about it now, I’m not sure what they did about feeding the babies overnight.

“We had breakfast brought to us in bed and had the other meals in the community room, where it was good to meet lots of other mums. But it was a long 10 days. I had a nice rest but was well ready to come home by the end of it.”

Once home, Kate looked forward to her weekly visits from Plunket, which gave her a sense of security that someone would be there to answer questions.

“On reflection, we probably could’ve had a lot more knowledge and support, although

18 | AOTEAROA NEW ZEALAND MIDWIFE

“As time has gone on, Gavin has felt more strongly about being denied the experience of being at his children’s birth,” says Kate.

“He thinks that men today are so lucky to be able to be part of the birth but, at the time, it wasn’t the practice at all then. It wasn’t even considered.”

jess’s story When Jess Medforth, then 28, discovered that she was pregnant five years ago she started looking for a midwife straightaway as she had heard that it might be difficult to find one.

Living in Auckland but with her family in the South Island, there weren’t a lot of opportunities to hear about the experiences

FEATURE

of her mum, or her nana, Kate Wright. “Also, Mum’s births were all C-sections and I was planning a natural birth,” says Jess.

Jess found a midwife and saw her regularly from eight weeks. “I was one of the first of my close friends to have kids, so mostly I researched a lot on the internet and then went to my midwife with any other questions,” she says.

Although she had moments of uncertainty about the birth, she would talk to Dave and her midwife about how she felt. “I’d hear stories about awful labours because everyone wants to share those with you when you’re pregnant.”

100

While Jess attended most antenatal appointments by herself, she and Dave went to the scans and antenatal classes together and it was a joint decision to have the baby in hospital. When Jess’s waters broke in the night, they tried to go back to sleep but it was short lived, as the contractions started coming pretty quickly.

“They thought I had a third degree tear, so I had to have an epidural and get sewn up.”

She had also haemorrhaged while in the pool. “I lost a lot of blood and ended up having to stay in hospital for five days and had two transfusions. Dave stayed in hospital with Jess and Sam the entire time. “Dave did everything. He was so supportive. I couldn’t feel my legs for 12 hours and then I was hooked up for the blood transfusion, so I mainly stayed in bed and he changed all the nappies and brought the baby to me to feed.”

Dave was equally supportive and involved for the birth of their second son, Liam, two years later.

After the complications with Sam, they planned another hospital birth. But unlike Sam’s birth, when Jess felt that she made decisions throughout, the labour turned “dramatic”.

Again a fast labour – only three hours from start to finish – her midwife didn’t make it to the hospital in time for the birth.

“The hospital midwife said the baby’s heartbeat was too slow and they were worried he wouldn’t breathe when he was born, so I had to have an episiotomy without any pain relief.

“The midwife asked Dave, ‘is it ok to cut her, we have to get this baby out’. I remember him saying ‘yep’ but I wasn’t in any condition to make any decisions about anything.”

Their midwife arrived to do the suturing and, fortunately after an initial low Apgar score of 2, baby Liam bounced back in five minutes.

The three of them stayed the night in hospital, before spending two nights in Birthcare.

Jess feels fortunate that breastfeeding went “pretty well”. She says the hospital midwives were “lovely” and were happy to check anytime that baby was latching on well.Although it was challenging finding a midwife initially, overall Jess and Dave feel extremely grateful for the care and support they received, both antenatally and postnatally.

“Having a midwife and continuity of care definitely made the experience less overwhelming with both my pregnancies,” Jess says. square

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Jess stayed in the pool with Samuel for about five minutes, and then moved to the bed for an hour or so, putting him to the breast. “Then he had cuddles with Dave and they stayed together while I went to the theatre.

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“In the end the midwife didn’t catch him. I just changed positions and he flew out.”

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Dave was as involved as possible. He held the gas mask for her, offered her a drink of water between contractions and together they picked up Samuel out of the water when he was born.

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“So I rang the midwife at 3.30am, we were in hospital by 4am, and Samuel was born at 6.50am.“I ended up having a waterbirth. I said I’d like to try the water for pain relief and I found it was calming so stayed in the water for the rest of the labour. It all went pretty well and I just had some gas towards the end.”

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ISSUE 98 SEPTEMBER 2020 | 19

FEATURE

BURN OUT AND BACK From earthquakes to Covid-19, how much can we take when working under so much pressure?

20 | AOTEAROA NEW ZEALAND MIDWIFE

FEATURE

after the earthquakes It is 10 years this month since Christchurch experienced the first of several devastating earthquakes. The second major quake took the lives of 185 people, laid waste to the city and turned lives upside down. Here, Elizabeth Winterbee describes how the trauma affected her, exacerbating pressures she was already feeling in an increasingly demanding role as a community midwife.

Now living in Nelson and working as a core midwife she explains how she changed her life and recovered to find new meaning in her work.

Many midwives have experienced stress in recent years as the maternity service has come under pressure and this year the pandemic response sleepless nights of course, as added extra demands. On pages 23-25 we look at ways to minimise the risk violent aftershocks continued of burnout and strategies for safeguarding your own health and well being. to hit the region. But there was I was a Lead Maternity Carer (LMC) midwife in Christchurch from 2007 through to 2016. After nine years as an on-call midwife with my own caseload, I was exhausted. I no longer enjoyed my job; I had lost my passion for midwifery. I knew my work as an LMC had left me feeling incredibly burnt out, but I had stopped short of a deeper reflection as to why.

When I enrolled in a postgraduate paper that required me to reflect on normal birth and my role as a midwife, it became clear.

This writing is what resulted - a before, during and after of what accelerated my professional burnout – the Canterbury earthquakes.

BEFORE It wasn’t until my late teens that I first learnt what a midwife was. Immediately, an innate passion for midwifery emerged, but it took over a decade of very hard work for me to realise my dream of becoming one. Twelve years and much hard work later, I graduated and became a registered midwife. The joy and sense of accomplishment I felt for achieving my goal was beyond description.

I moved from my home city to Christchurch, and eagerly began my life as a Lead Maternity Carer. I can still vividly recall the excitement of carrying my bag of newly

purchased midwifery gear and undertaking my first bookings. I took great pride in carrying a pager for something as sacred and special as being a midwife. I told anyone and everyone who asked (or not) that I was a midwife.

My first birth as an LMC was a transfer from primary unit that resulted in a caesarean section for obstructed labour. The next few births included a shoulder dystocia so severe the obstetrician broke the baby’s clavicle, and a post-partum haemorrhage requiring manual removal of the placenta in theatre.

Yet my passion for midwifery did not falter, and nor did I allow these experiences to deter me from encouraging women to birth at home or in a primary unit. I loved being a midwife. I loved midwifery. I was sure nothing would or could ever change that.

DURING In the dark early hours of 4 September, 2010, the first Big One arrived with what sounded like a freight train about to crash into the house, followed by such violent shaking the walls of my bedroom seemingly moved a metre in every direction. Across the region, buildings were destroyed, but there was no loss of life, and only minor injuries. There was anxiety, high levels of stress and many

also a degree of celebration. A large concert held in Hagley Park saw over 100,000 Cantabrians came together to celebrate their resilience and strength.

Tuesday 22 February 2011, 12:51 pm however, marked darkly the start of a ”new normal”. Buildings fell, trapping and killing almost 185 people, some of whom survived the initial quake only to succumb to their injuries in the coming hours as they lay trapped beneath the rubble, waiting for rescue that never came. The next few days were like living in a slow-motion horror movie. The relentless, severe aftershocks, lack

Professionally, the most daunting aspect of being a midwife at the time was being responsible for the wellbeing of others – mums, babies, families - when I was just as afraid and stressed as they were.

ISSUE 98 SEPTEMBER 2020 | 21

FEATURE

it was the norm to feel the ground move most days, and much longer before seismic activity was felt only on a weekly basis. With the larger aftershocks, the inside of houses became scenes from Poltergeist – drawers abruptly flung open spewing out groceries, cutlery and plates; walls and cabinets flinging their contents and smashing onto the still moving ground. None of these sounds could be heard above the sound of the earthquakes themselves, however. Like many others, I resorted to sleeping under my kitchen table in a sleeping bag, purposefully positioned under a doorway, surrounded by the essentials (torches, radio, and stored water) and my beloved dog, who was petrified and barked and trembled with every shake.

of power and running water, reduced fuel supplies, empty supermarket shelves and the presence of New Zealand Defence Forces – army tanks carrying armed soldiers patrolled the inner-city streets enforcing a city-wide curfew. Piercingly loud alarms and sirens all over the region were triggered with every major aftershock. The brightly coloured, falsely cheerful spray painted graffiti that covered the city for months afterwards - left behind by the dozens of international rescue teams who came to help – marked where lives were lost, and the total count of bodies recovered from each pile of rubble.

In Canterbury we adapted, with contingency plans for where and how to contact loved ones in case of another big earthquake. The powerlessness of not being

Yet my work as a midwife provided me with a feeling of purpose, and a degree of control. I might be powerless over Mother Nature, but with midwifery I knew what to do.

22 | AOTEAROA NEW ZEALAND MIDWIFE

able to reach loved ones (due to widespread telecommunication failures) in the hours following the fatal quake, was something no one wanted to experience again. The “new normal” meant never leaving home without your cell phone fully charged. It meant never having less than half a tank of petrol in the tank. Always having thick soled shoes right by the bed so that if you needed to flee for safety in the dark, your feet would be somewhat protected against broken glass, fractured furniture, strewn belongings. It meant continually assessing your surroundings for the fastest escape routes and / or where to hide for cover when the next big one hit and incessantly scanning buildings and overhead structures looking for cracks and more subtle signs of damage. Never parking in carpark buildings, garages, or near overhanging objects; making the wrong decision was potentially a life or death one. Three weeks after the February earthquake I drove past a wrecked car in Riccarton covered with that sickeningly bright spray-paint indicating loss of life. The car had been crushed to knee height.

Thousands of aftershocks continued to hit the city in the coming months, with more than fifty of these of a size magnitude 5.0 or more. After the two major quakes, there were over 200 aftershocks in just the first 24 hours, the ground never still for more than a few minutes at a time. For two years,

Professionally, the most daunting aspect of being a midwife at the time was being responsible for the wellbeing of others – mums, babies, families - when I was just as afraid and stressed as they were. One of my big fears at the time (other than being crushed or trapped in a crumbling building) was being with a woman in labour during another February-like earthquake. I would not be able to simply pack up and go home.

I would need to stay, regardless of what was happening outside in the real world. Any concerns I might have about family and loved ones would have to be ignored for however long it took for the baby to be born and for both to be safe and well. This was a different form of feeling trapped, I suppose, but one with the same sense of powerlessness.

Yet my work as a midwife provided me with a feeling of purpose, and a degree of control. I might be powerless over Mother Nature, but with midwifery, I knew what to do. I knew how to prepare mothers for birth, help them through the highs and lows of labour, assist with breastfeeding, and how to manage the “big stuff” - shoulder dystocia, postpartum haemorrhages. I threw myself into my work, giving it my all. Keeping busy provided a much-needed distraction as the city around us continued to crumble, metaphorically and otherwise.

What I wasn’t prepared for though, was the trauma and sense of powerlessness experienced by other people. Following every significant aftershock, I would be inundated with calls from anxious women reporting reduced foetal movements, abdominal pain, or who were worried they were in premature labour. Mothers with new babies had other fears - formula fed babies had no access to clean water, and power cuts meant no way to sterilise or heat bottles. Breastfeeding mums worried about their milk supply running out,

FEATURE

and every parent lived with the very real fear of keeping their babies and children safe.

The two youngest victims of the February earthquake had been a toddler who died at home after a television fell on him; the other, a young baby, was killed in the arms of her mother as they walked along the street.

And so was the beginning of a pathway to severe midwifery burnout. It took many years for me to recognize it, because for much of that time, the “new normal” was all about living in a constant state of anxiety with high levels of stress, and so the usual warning signs of burnout were well hidden within what was then the everyday, lived experience.

Eventually, I moved from Christchurch and began working as a core midwife in a small city (Nelson) with no high-rise buildings.

My very first day as a core midwife coincided with the fifth anniversary of the February quake. I took it as a positive omen. Being off call, and no longer carrying the responsibility of a caseload of 40-50 women a year, I now have a much better work / life balance. It has given me much needed breathing space.

AFTER Following the earthquakes, the extraordinary efforts of midwives (and others) were highlighted and shared – midwives who rose above and beyond, who collected relief and pamper packages for displaced clients and stressed midwives, who did a fantastic job in supporting those in need.

But little was written about the deeper impact the earthquakes had on the personal and professional lives of midwives. Health professionals are not immune to trauma and are often front-line workers in a major natural disaster, bearing witness to significant suffering, and yet must continue working with little or no time off work. Our maternity system is unlike any other in the world; the nature of our work following the earthquakes differed because of this. That the Canterbury earthquakes were not a single one-off event, but a recurring trauma played out over a prolonged period, is also unique.

From my own experience it wasn’t until I left Christchurch that I was more fully able to process all that had happened, to find some form of meaning from the unimaginable, in both a personal and professional sense.

Perhaps the experience was not too unlike leaving a volatile relationship, where you need to leave or be free of the violence before you can begin to fully understand the impact it has had. Whatever the reason, the Canterbury earthquakes have changed us as women, and as midwives. square

the demands of covid-19 For some midwives the demands of the Covid-19 response may have felt overwhelming in a working environment that was already under pressure. What are the signs that the tiredness you are feeling is more than the everyday wear and tear of work and life? Here we look at the set of symptoms commonly known as burnout and suggest some strategies for dealing with it.

MARIA SCOTT COMMUNICATIONS ADVISOR

The World Health Organization defines burnout as “an occupational phenomenon” and states emphatically that it is not classified as a medical condition. But it is described in the WHO’s International Classification of Diseases as “a syndrome conceptualised by three dimensions”.

These are: • Feelings of energy depletion or exhaustion • Increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job and • Reduced professional efficacy Midwifery, by its nature, is not a profession for the faint hearted. But add on long-standing battles over pay and conditions, the associated staff shortages and gaps in provision in areas of high need and the work can take a heavy toll on individual midwives. This year has been particularly tough as midwives have had to adapt rapidly to the working arrangements required for the pandemic response.

No amount of mindfulness, yoga or bracing exercise can make up for all the stress caused by structural problems in a working environment such as those caused by chronic under-funding. The New Zealand College of Midwives has fought hard to persuade the government and district health boards that the maternity service needs urgent attention. The College hopes that the $242 million recently announced by the government for the sector will alleviate some of the stress on the midwifery workforce.

But what if you feel you are too tired to wait for the funding to trickle down?

There are no easy answers or instant solutions but there is knowledge within the profession to draw on.

CONTINUED ON PAGE 24 CHEVRON-CIRCLE-RIGHT

ISSUE 98 SEPTEMBER 2020 | 23

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Delegate work, if you can, says Chris. Don’t hold on to work because you think you are the only midwife who can do it properly.

haven’t already; use the Xero software system for accounting, for example.”

Delegate work, if you can, says Chris. Don’t hold on to work because you think you are the only midwife who can do it properly.

Covid-19 has effected everyone, directly and indirectly, and at work you may have experienced feelings of energy depletion or exhaustion, increased mental distance, and feelings of negativism or cynicism.

The College workshop Navigating unexpected practice outcomes: Skills & strategies includes advice on coping after births that are traumatic for the midwife as well as the parents involved.

Canterbury midwife Chris Stanbridge is one of the educators, drawing on decades of experience as a midwife in various settings and as a mentor to colleagues. The advice she gives in the workshop can also be applied to the longer term stress experienced recently by many of her colleagues.

“As we grow up we learn though our families, school and society, set ways of coping. Usually these work really well until we come under pressure and sometimes our methods don’t work so well.”

The symptoms that you really are not coping can be subtle. There may be changes in your eating habits, your sleeping, activity levels, relationships and mood. You may get cross very quickly and often with your children, partner or parents. You may feel tired even if you have apparently had a good night’s sleep, admittedly something that is not always easy for midwives.

“You may get frustrated with the women you are caring for. You might feel intolerant during a long labour and want it to speed up and the birth to be over with. You may be unusually critical of your colleagues. You might think ‘I’m sick of the women’ and this is not good if you’re a midwife.”

The earlier you can spot the warning signs, says Chris, the easier it will be to deal with the problem.

Burnout can strike at any age. “There are

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midwives in their seventies who are still practising with passion. You could have a 26 year old who is as weary as a 76 year old.”

If you are not sure whether you are showing signs of burnout speak to colleagues, Chris suggests. “Get some feedback as they may have noticed changes.”

As health professionals, most midwives will be familiar with the basics of a healthy lifestyle, good nutrition, sleep, exercise and relaxation. But many also know that it can be difficult to maintain good habits when you are overwhelmed.

Chris says that you may have to reduce your working hours to find the time and energy to look after yourself. For community-based LMCs this may mean reducing your caseload or working with colleagues to have more time off. For core midwives you may need to reduce your hours or shifts or perhaps moving from a tertiary unit to a primary unit.

“This can be difficult especially if you are the main or only income earner. This is where you may need to look at your lifestyle and decide what you really want to hang on to and what you can let go.”

It can be very useful to go on retreat for a few days with colleagues. “Go away for a few days and talk about what’s happening for you as individuals and the group.”

Chris says that midwives who have kept up their LMC practice for many years or even decades generally have very good support systems.

“I think all the caring professions are vulnerable to workaholism. Often we are perfectionists so feel we are always failing.

This is not good for one’s self esteem. Often successful women feel they are never good enough. We feel we have cheated our way here so are constantly trying to prove ourselves.

“We can grow if we can get some insight into that process.

“You may need outside help from a counsellor perhaps. This might be available through the DHB or your GP or you might have a colleague who is experienced as a mentor.”

The College maintains a list of mentors and Chris points out that mentoring is not supervision. “It is someone working alongside you in an equal relationship. You might need to pay for that but the cost might be worthwhile.

This may be a good time to look at reducing your hours, she says, as the increased funding announced recently by the government will help to improve midwives incomes, especially those who are self employed.

“Take time to think about what recharges you. For some midwives it’s their children so they need to make time for uninterrupted contact with their children. And tap into relationships, your partners for example, and other health professionals. Talk to midwives who seem to be coping well. What are they doing that you’re not?”

LMCs should consider whether they are running their businesses as efficiently as they can. Look at what is on offer from the MMPO (Midwifery and Maternity Provider Organisation), the business support service linked to the College. “Go electronic, if you

And laugh. There are classes available in Laughter Yoga, (yes, really, Google it)

It may also be worthwhile to get a full physical check with your GP or nurse practitioner to look for any symptoms or changes that might be stress related.

FEATURE

structured sessions of laughter aimed at boosting mood.

“Spend time with friends you enjoy and who make you happy rather than those who drag you down,” says Chris.

“Sometimes we sabotage ourselves by saying we don’t have time or money. That’s where you need to think about changing the patterns of the past and re-setting priorities.”

If you are a self employed midwife take a reasonable workload, no more than the College recommendation to book four to five women a month.

Sabine Weil, also an educator for the workshop on unexpected outcomes adds: “We use the analogy of a water tank. If the tank is too low you have nothing to draw on.

“You need to identify what to do to get yourself to a level of wellness where you have enough in your tank to cope with small or daily challenges.”

You need to identify what is stressing you, says Sabine, and sometimes stressors will be coming from inside rather than outside.

“It can be challenging to acknowledge that this is something you are doing to yourself.”

Midwives tend to be achievers and many suffer from what she calls the “burnt chop syndrome”, the tendency to always serve yourself the worst of what is on offer.

When you have decided that you need to make changes, Sabine urges midwives to take small steps towards improving well being.

This could be as simple as a 20 minute walk each day. Once you have established this habit you can add to it.

If you have been through an intense period of work or a traumatic incident, don’t be afraid to take time out. Have open conversations with practice partners or managers about the support you might need to recover. Do this early in the working relationship so colleagues are clear about what you are likely to need in this situation.

“Then you won’t feel guilty because you will have been clear with your colleagues. It helps to put down those baselines.

“Ultimately, you will be helping yourselves, your team and the women.

“Superwoman hasn’t been born yet. We are still waiting for her.” square Note: The College regrets it has been unable to run the Navigating unexpected practice outcomes; Skills & strategies workshop this year due to the disruption caused by the Covid-19 response. We plan to resume these workshops next year.

Liz Winterbee (far left) with colleagues Glenda Baigent, Bronwyn King and Morag Whyte.

liz’s story Burnout can creep up slowly. For midwife Liz Winterbee, the realisation that something was seriously wrong came five years after the acute trauma of the Christchurch earthquakes (See Liz’s reflection on page 21).

“I went on holiday in 2015 and within days I felt worse than before the holiday. I just wanted out. I don’t think I even wanted to be a midwife.”

Liz was working as a self employed LMC covering a large semi rural area on the outskirts of Christchurch. In retrospect she realises that she threw herself into her midwifery work despite the intense fear she felt during and after the shaking of the earthquakes.

“I was able to compartmentalise. Whenever the phone rang I could do my job which is probably why I was able to keep going. I wasn’t turning up to work shaking and crying but when I lost weight it was obvious something was not right.”

Liz thinks she may already have been working too hard when the earthquakes struck, tipping her towards burnout.

“I was so happy and excited to be a midwife because I loved my job. I think when I started in 2007 it was quite normal to make yourself available to women all the time. I didn’t have to reply [to all the messages] but I did.

Perhaps I could have had better boundaries. This was the era when we didn’t get pay rises for years. Business expenses were rising and colleagues were starting to reduce visits to clients.”

After the turning point in 2015 Liz decided she would look for work in a different field. “If I could have paid my mortgage working for the SPCA I would have been happy with that.”

But she saw a job as a core midwife with Nelson Hospital advertised in November and was appointed in December. She sold her house in Christchurch and started a new life in Nelson. The move has worked out well.

The set hours of her core role have allowed Liz to develop interests outside work, to exercise regularly and eat well. She also had counselling and says: “Talking to people is key; not being afraid to ask for support.

“If you are struggling and can barely keep it together you won’t be the only one. It’s OK to reach out for help and support.” square

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As someone recognised in the most recent Queenâ&#x20AC;&#x2122;s Birthday Honours List for her work in breastfeeding education it may come as a surprise that Carol Bartle thinks that women need much more than education to breastfeed unhindered...

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FEATURE

Breastfeeding – it’s not all about education MARIA SCOTT COMMUNICATIONS ADVISOR

“It’s not just about educating woman” says Carol, “it is about removing barriers.”

“I think most women know that breastfeeding is important. They might know all the reasons why but they don’t have the means to do it.

“It’s not all about will, it is more about capacity. I take my hat off to all women who manage to breastfeed for a long time.

“Breastfeeding is a privilege. For a lot of women there are many barriers that make it difficult. Many women want to breastfeed but do not have the social structures around them to support them.”

The more social capital, or privilege, you have the more likely it is that you will be able to breastfeed your baby at work, for example.

Carol points out that many women are not able to feed at work and even for those with well-paid careers may be reluctant to ask for support to feed in the workplace.

For other women there may be issues related to child protection or custody. Carol says she has dealt with many queries from women who are no longer living with the fathers of their children where the fathers wants to have the babies all night when the mothers are still breastfeeding.

“A judge might assume that the woman can use a breast pump easily and doesn’t have to stay with the baby all night but in reality, many women find that maintaining breast

milk supply when separated from their babies is challenging.These barriers are based on the lack of value around women when they breastfeed. Breastfeeding is not free because someone is investing in allowing that process to happen,” says Carol.

The “awful” phrase, “breast is best” does not protect or promote breastfeeding because it ignores the societal structures that need to be in place to make breastfeeding possible.

Carol, policy analyst at the New Zealand College of Midwives was named a member of the New Zealand Order of Merit (MNZM) in this year’s Queen’s Birthday Honour List.

This recognised her services to health and breastfeeding education in particular.

While economic and social pressures play a huge role in the ease, or otherwise, with which women can breastfeed, education is of course part of the mix and Carol has worked extensively with women and health professionals to broaden understanding of infant feeding and to provide practical support.

But the education needs to include an acknowledgement of the barriers women may face. “I try to underpin the education in the right framework. So rather than just talk about how easy it is to breastfeed we need to talk about the things women might encounter in the first six weeks, for example, that might present obstacles.”

Carol began her career as a nurse in Bradford, England and later trained as a

midwife there. She moved to New Zealand in 1975 and after a short period working in a geriatric ward at Burwood Hospital, Christchurch moved to the Neonatal Intensive Care Unit (NICU)at Christchurch Women’s Hospital. She worked at the unit over two separate periods for more than 20 years in total and became increasingly interested in breastfeeding and infant nutrition.

She also trained as a Plunket nurse and worked for Plunket for several years. Carol has also worked as a community midwife, as a family support worker in the Early Start Project in Christchurch, as a casual midwifery tutor at Christchurch Polytechnic (now Ara Institute)as an antenatal and breastfeeding educator for midwives and parents and as an assessor and educator for the Baby Friendly Hospital Initiative.

“I think most women know that breastfeeding is important. They might know all the reasons why but they don’t have the means to do it. It’s not all about will, it is more about capacity."

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“There is tension in feminism about women not being defined by their biology. And there has been the push to get women back to work.

Why can’t we support women who want to be at home?” to work. Why can’t we support women who want to be at home?”

Carol, policy analyst at the New Zealand College of Midwives was named a member of the New Zealand Order of Merit (MNZM) in this year’s Queen’s Birthday Honours List.

She was a founding member of the committee that developed the NICU milk bank in Christchurch. Carol continues to be involved in numerous committees and advisory groups related to her expertise in infant nutrition, including La Leche League. She has been a member of the International Lactation Consultants Association International Code and Ethics Committee and the World Alliance for Breastfeeding Action. She volunteers at Christchurch Women’s Prison providing breastfeeding and infant feeding support in the mother and baby unit and is on the management board of the West Christchurch Women’s Refuge.

As her interest in infant nutrition and child health developed Carol pursued post graduate studies, obtaining a postgraduate Diploma in Child Advocacy from the University of Otago in 2000 and a Master of Health Sciences at the university in 2006.

She has written extensively on midwifery and infant feeding, contributing chapters to numerous books and research journals.

In her role for the New Zealand College of Midwives she leads and writes responses to policy proposals from government and other organisations.

Carol has a strong and longstanding interest in environmental protection and advocacy and she sees promotion of breastfeeding as a

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vital aspect of environmental sustainability.

“I had an older cousin in the UK who was the very first person I saw breastfeeding and she was an activist. She started my interest in the environment.”

But even as breastfeeding is promoted, messages can become mixed and confused, says Carol. Women are encouraged to pump breastmilk so they can fit feeding in with work and schedules and other demands on their time. “Our commercialised society has pushed us into buying paraphernalia such as breast pumps. Breastfeeding is promoted as being free but when women think they have to pump, it’s not free.”

“The least time-consuming way to feed your baby is simply to breastfeed.”

Carol is frustrated by the perception often reflected in the media that midwives are hostile towards women who do not want, or cannot breastfeed.

“I don’t know any midwives who are mean to women who bottle feed.

“It’s about giving women the best information you can no matter how they want to feed their babies.”

So why has breastfeeding apparently become such a fraught topic in the media?

“There is tension in feminism about women not being defined by their biology. And there has been the push to get women back

Carol has combined her career as a midwife, breastfeeding educator and advocate, writer and researcher with a deep interest in dance and the performing arts. She has been involved in many dance and theatre groups and productions, as a performer, choreographer and director.

“I had always wanted to dance and got involved with a class when I came to New Zealand and I got hooked.

“My performance skills have really helped with my teaching work.”

Dance is related to labour and birth, she says. “When the baby descends and turns it is like a form of choreography and the woman improvises with her own movements. Belly dancing was a way to bring the baby down.”

She combined her knowledge of birth and dance in Dancing Birth: Choreography and Improvisation, a chapter in the book The Art and Soul of Midwifery, edited by Lorna Davies. Carol dances for pleasure and relaxation; tango and adult ballet.

Carol’s achievements are impressive and formidable by any measure but, like many women she admits she has suffered from ‘imposter syndrome’, wondering at her own success. It was no surprise to colleagues when she thought the letter announcing her membership of the New Zealand Order of Merit was a hoax. She was eventually persuaded otherwise and hopes that the recognition will help to promote the causes she cares deeply about. square

prescribing update

let’s kōrero

panadeine®

The language of reform in health and disability services within Aotearoa

The Medicines Classification Committee has changed the classification of medicines containing codeine. As of the 5th November 2020 allcodeine containing medicines will be classified as prescription only medicines.

System Review. To see the full report visit www.systemreview.health.govt.nz

WHAT DOES THIS MEAN?

Iwi ----------- Tribe

Any medication that contains codeine can only be provided through a prescription. Previously Paracetamol and codeine phosphate – also known as Panadeine – could be provided as a pharmacy only medicine as well as a prescription medicine.

Hapū -------- Sub-tribe

WHAT IS PANADEINE® AND WHAT IS IT FOR?

Kaupapa Māori -------- Synonymously linked to mātauranga Māori and

Paracetamol 500mg and codeine phosphate 8 mg.

Panadeine® is an analgesic and provides temporary relief from pain.

underpinned by Te Tiriti o Waitangi; self-determination; cultural validity;

CAN MIDWIVES PRESCRIBE PANADEINE® AND WHAT CAN THEY PRESCRICBE INSTEAD? No, when compounded with another medicine (such as Panadol) Codeine is classified as a C6 controlled drug. Codeine on its own is classified as a Class C2 controlled drug. Both fall outside of the permitted controlled drugs which can be prescribed by a midwife. For most women following a normal birth Paracetamol 1 g QID (maximum of 4gm (8 tablets) within 24 hours) is generally sufficient as ananalgesia.

For women with perineal trauma, oedema and perineal repair additional analgesia may be required. Diclofenac slow release (75mg BD) or Ibuprofen 400mg TDS can be used for mild to moderate pain and inflammation.

Both Diclofenac and Ibuprofen are non-steroidal anti-inflammatory drugs (NSAIDs). These drugs reduce prostaglandin production by inhibiting cyclooxygenase resulting in analgesic, anti-inflammatory and anti-pyretic effects. They should be avoided if a woman has asthma, heart failure or gastro-intestinal ulceration, bleeding or perforation. square

New Zealand. Drawn from the recently-published Health and Disability

Arotakengia -------- Evaluation, development of scientific understandings Hauora Māori -------- Māori health, holistic health and wellbeing

Kaiarataki -------- Steward Kaitiakitanga -------- Guardianship Kaumātua -------- Elderly Māori

culturally preferred teaching; socioeconomic mediation of Māori disadvantage; whānau connections; collective aspirations; and respectful relationships underpinned by equality and reciprocity Kaupapa Māori Services -------- Led, owned and governed by iwi, pan-tribal, or Māori organisations that are specifically designed with Māori in mind Kaupapa Māori health providers -------- Iwi, pan-tribal, or Māori-led organisations Kaupapa Māori methodologies -------- By Māori, for Māori, with Māori developed methodologies Mana motuhake -------- Self-determination, autonomy Mana whenua -------- Customary authority exercised by an iwi or hapū in an identified area Mātauranga Māori ----------- Māori knowledge systems: reflecting indigenous ways of thinking, relating, and discovering; links indigenous peoples with their environments and is often inspired by environmental encounters; and is conveyed within the distinctiveness of indigenous languages and cultural practices Ngā rautaki haumi -------- Investment strategies Pēpi -------- Baby Rangatiratanga -------- Authority, ownership, leadership Rohe -------- Territory or boundaries of iwi (tribes)

fluconazole The Medicines Adverse Reactions Committee has issued an updated advisory notice regarding fluconazole oral antifungal treatment in pregnancy.

Fluconazole oral treatment is contraindicated at any dose, throughout pregnancy. Further evidence of the potential for an increased risk of spontaneous abortion (miscarriage) and cardiac septal closure anomalies adds to the existing advice from the Medsafe data sheet and NZ Formulary advice. Midwives are advised to prescribe topical treatments according to NZ Formulary directions and precautions, and seek further advice as needed. square

Rūnanga -------- Iwi authority Tangata whenua -------- In relation to a particular area, means the iwi or hapū, that holds mana whenua over that area Te Ao Māori ----------- Māori world view Tikanga Māori -------- Protocols and customs. Approaches and protocols embedded in Māori customary values and practices Tikanga / ritenga -------- The correct way to do things Whakawhanake ngā kaimahi -------- Developing the workforce Whānau -------- Family, extended family Whānau ora -------- Healthy Families Whānau rangatiratanga -------- Whānau decision-making, participation and voice

ISSUE 97 JUNE 2020 | 29

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RIght: Tertia van der Walt with children in Kurdistan.

midwifery on the margins Tauranga midwife Tertia van der Walt has volunteered as a midwife in several countries, an interest that began when she worked with her husband, a dentist, when he was volunteering in Kosovo. “This ignited my passion for serving marginalised people,” she says. “When I became a midwife I wanted to use my skills towards this purpose.”

Tertia was a secondary school teacher before becoming a midwife and particularly enjoys the teaching elements of voluntary work. She described two of her assignments for a midwifery standards review and this is an edited version of her reflections.

KURDISTAN, IRAQ I arrived in Kurdistan on 17 July 2019 to work in a refugee camp on a placement with Frontier Alliance International, a Christian aid organisation. In my last conversation with the team at Frontier Alliance before I left home, they stressed that the health system in the refugee camps was “unstable, dysfunctional and uncontrolled” as a result of the ISIS attacks as well as regular air strikes from hostile neighbouring countries.

Prejudice among ethnic groups led to ill treatment and sometimes there was no care available for the sick and for pregnant women My “job” was mainly to educate and train staff members and pregnant women regarding antenatal, labour and birth and postnatal care. I was to pay special attention to a healthy lifestyle, natural birthing, breastfeeding and identifying post natal depression (PND). I was told that as there was a lack of postnatal care, breastfeeding rates were low.

The mortality rate was high because of poor birth practices, inadequate referrals, emergency obstetric care and a high incidence of anaemia.

I was overwhelmed by the receptiveness of the

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women who turned up for the education and training sessions. Working with a translator was new to me and sometimes I was so carried away with what I shared with the women that I had to stop to give the interpreter the opportunity to explain.

I focused on being open, present and aware of my body language and mannerisms so that I could communicate clearly and acknowledge each woman with respect. The women were eager to know more and I often wished that I could spend more time answering all their questions.

They would, without being offended, interrupt me if I suggested something that was not culturally appropriate for them. For example, when I recommended that they should go out for short periods of time postnatally to get Vitamin D from the sun and to socialise, they stated that they have to stay in the house for six weeks after their babies are born. I also learned that words like bra, vagina and breast were to be used very discreetly.

I met with a local obstetrician to gain more information regarding birthing practices. She explained that all women made use of obstetric care antenatally and for the labour and birth although one in five really needed obstetric care. She said that the C-section rate was about 35% because women were free to choose a C-section and with the lack of information available to them, they considered it the easiest option. She mentioned that she had done a C-section on a woman the previous day who had already had eight babies

by C-section and that everything went well. That of course was an exception as placenta previa, lesions, accreta and hysterectomy rates were high.

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Working with a translator was new to me and sometimes I was so carried away with what I shared with the women that I had to stop to give the interpreter the opportunity to explain.

Contraception was not widely accepted as wealth was often measured in the number of children. The availability of beds in hospitals for women in labour was limited and the staff often had little to no training.

It was standard practice to do an artificial rupture of membranes at four centimetres and commence syntocinon augmentation, but as infusion pumps were limited, most were running free, controlled by only the drip rate. Women were asked to bend their arms if the contractions were getting too severe to cut off the flow of syntocinon. Active third stage was standard practice, again because of the lack of trained people to handle a possible haemorrhage. Research has shown that postpartum haemorrhage is the leading cause of maternal mortality in the developing world and while a 500ml blood loss may have little impact in wellnourished women, women who are poorly nourished and anaemic may not survive.

Women usually stayed a maximum of one night after a birth (C-section included). Tolerance of disabilities is low. Mental health assistance is taboo with a high incidence of PND as a result.

We regularly visited a family with nine children to help with supplies. There were initially five children but when the woman fell pregnant again she gave birth to quads. They were not receiving any government support and lived in a three roomed house. The mother was always friendly and welcomed us when we visited; I did not hear her complain once. It was very interesting to see the way babies sleep in Kurdish culture. They are strapped to “sideless” cots which limit their movements and eyes are often covered in order to sleep better in the shared areas. I am sure this would not go well in our culture.

Culture of course also plays a big role in the way that new ideas and research are utilised. Women in Kurdistan, as in many countries, are suppressed and remain uneducated as a result. But I saw hunger for better outcomes and education which filled me with hope that nothing is stagnant and change is possible.

Gandhi once said: “It is good to swim in the waters of tradition, but to sink in them is suicide.”

32 | AOTEAROA NEW ZEALAND MIDWIFE

I have reflected a great deal on all the information I received and things I noticed when interacting with the women in Kurdistan. These women, just as any others, want to be appreciated, cared for, nurtured, supported and loved. As mothers, they have the right to a health care system which will protect them and their babies. However, life for them is mostly about survival, because as displaced as many of them are, they struggle to enjoy being pregnant or being a mother. A recent study by the International Institute of Health found that PND is up to four times higher amongst refugees and displaced families than in host community families. No holistic postnatal follow up service is available to families. My thoughts wandered to the privileged women in New Zealand and the care they often take for granted.

I really admired these women for the “simplicity” of their lives, with few material possessions, their humbleness, generosity and resilience. It was easy to fall in love with the people of Kurdistan. They are the largest group of people who do not have a homeland of their own, a people waiting to be born into the family of free nations. I enjoyed sharing knowledge with these women. I would like to return to give more support towards these women, especially those in the refugee camps who are forcibly robbed of so much that makes life tolerable and meaningful.

BETHLEHEM, PALESTINE During a visit to Palestine in the Middle East in September 2017, I had the opportunity to shadow health care professionals in their work with pregnant women in Bethlehem. I was warmly welcomed and invited to visit and share in the work of the dedicated midwives.

The Holy Family Hospital in Bethlehem specialises in gynaecology and obstetrics and offers the only place for women of the region to give birth in a setting which provides obstetric care. The hospital, a beautiful stone building, is immaculately clean with all the necessary facilities. The cost of treatment and birth are determined by the woman’s socio-economic situation. For those unable to pay, charges are reduced or waived. The hospital’s operating costs are sustained by the French Association of the Order of Malta which runs the hospital. It was a privilege to witness the high quality maternity care given to all women, regardless of race, religion, culture or social standing.

The director of the hospital shared its vision and expectations and how proud it was of the service provided to pregnant women. She inquired about the PROMPT (Practical Obstetric Multi-Professional Training) workshops for emergency obstetric are that we have in New Zealand and hoped to introduce something similar to the midwives there to enhance their skills. While following the head midwife in the antenatal and postnatal wards, she pointed out that

FEATURE

they have a high daily turnover of women coming and going and as many as 26 postnatal discharges can take place on any given day. The fertility rates in Palestine are amongst the highest in the world. An average of 450 babies are born in the hospital each month.

Women are allowed to stay for only 24 hours after birth. I was introduced to a woman who was induced at 38 weeks because of retina displacement, two women with PPROM, (preterm premature rupture of membranes) three women with gestational diabetes and many more. While walking through the wards, I once again realised that women are women no matter where we live; we have the same needs, desires and necessity for quality care.

Not all women are lucky enough to reach the hospital in time to give birth as the more than 500 checkpoints across Palestine can extend a journey that should take minutes into hours. As many as 10% of pregnant Palestinian women may be forced to endure labour or childbirth at a checkpoint.

I shadowed three midwifery students in the labour ward and was touched by their dedication, professionalism and their pride in every task performed. A four year midwifery degree equipped the students to qualify as midwives and to work an average of four shifts per week in the hospital with payment of about 4000 Israeli shekels (NZ$1600) per month. All midwives were committed to continuing education as a means of ensuring quality patient care.

It is standard procedure for each baby to be examined/ checked by a paediatrician after birth. A vitamin K injection, Hep. B vaccination and eye ointment are routinely administered to every newborn. Premature birth is a common phenomenon and is often the result of women’s lifestyles that may include poor nutrition, smoking, hard physical work in fields and walking long distances with cattle for grazing. Advanced technology in the hospital’s neonatal intensive care unit makes it possible for the medical team to adequately care for these premature babies. There is no policy or strategy in place to stop smoking during pregnancy as it is such an embedded part of the culture and commonly accepted in most public places.

Breastfeeding is a familiar practice in Palestine at a rate of about 97%. Therefore, pethidine as pain relief

Not all women are lucky enough to reach the hospital in time to give birth as the more than 500 checkpoints across Palestine can extend a journey that should take minutes into hours.

Tertia admired the women of Kurdistan for their generosity and resilience.

during labour is a big no-no because of the effect it can have on breastfeeding after the birth. I was told that Tramadol IV was used successfully for pain relief instead as it has less marked maternal sedative effects and less neonatal depression for the baby (and there is the belief that it shortens labour). Epidural analgesia is also available to women at a very low cost.

I also accompanied an obstetrician, paediatrician and midwife in a mobile clinic to distant Bedouin villages where they do antenatal visits and baby checks on a regular basis in an equipped minivan. Every woman’s blood pressure is taken while the obstetrician does a scan of the baby on a mobile scanner. The obstetrician informed me that the women regard the scan as a very important part of each antenatal visit. He also shared that, although not evidence based, he believes that giving an enema to a woman once she is in labour, shortens labour by at least an hour.

I admired the commitment of the health professionals to their patients in the midst of political turmoil and poverty. It was a huge privilege to have a little peep into such a proud midwifery setting and to see the similarities with what we experience here.

Postscript: Tertia was hoping to volunteer at a new health centre in Gaza, Palestine during July and August but her travel plans were disrupted by the Covid-19 pandemic. “Hopefully flights may become available soon,” she says. square

ISSUE 98 SEPTEMBER 2020 | 33

BREASTFEEDING CONNECTION

MILK SUPPLY – PERCEPTION, REALITY, ASSESSMENT AND FEEDING OUTCOMES Qualitative and quantitative research indicates that maternal perception of insufficient milk supply can lead to supplementation of breastfeeds and shortened breastfeeding duration (Kent et al, 2012). If perception of milk supply is a potentially modifiable factor for breastfeeding continuance, is it important to assess the difference between perception and reality, and also to recognise the difference between a primary breast milk supply issue and a secondary issue? And, can low supply be turned into abundance in some situations?

CAROL BARTLE POLICY ANALYST

Using words like low supply, as opposed to the terms inadequate, insufficient and failure can have an impact on how a woman feels about “breastfeeding and her breastfeeding body” (Burns et al, 2016) as choice of language can have a positive or negative impact.

Knowing what factors can support lactation, breastfeeding initiation and breastfeeding establishment can assist women to meet their own breastfeeding goals. For example, Sandhi et al. (2020) found that high levels of maternal perceived breast milk supply were positively linked to skin-toskin contact or rooming-in, the experience of positive infant suckling behavior, and/ or self-efficacy in breastfeeding women.

The study highlighted the importance of maternal perception of milk supply to positive breastfeeding outcomes. Galipeau et al. (2017) found that maternal self-efficacy had an impact on perception of low milk supply and suggested interventions should be directed at increasing maternal confidence.

One of the most frequent reasons for not breastfeeding is described as a previous unsuccessful experience by Burns et al.

(2020) and midwifery continuity of care and breastfeeding support, which includes peer counsellors, can increase women’s confidence and provide psychosocial benefits.

Low milk supply can be related to what are termed primary issues, and these can be linked to the amount of glandular tissue in

34 | AOTEAROA NEW ZEALAND MIDWIFE

the breasts, hormonal issues, previous breast surgery, or a severe postpartum haemorrhage.

Secondary issues can occur alone, or alongside primary issues, and when both occur it may be difficult, if not impossible, to resolve issues of low milk supply. Secondary issues usually occur in women who do not have a primary reason and are caused by factors interfering with the usual lactogenesis process which should usually result in ample milk supply. Birth interventions, sleepy babies who are exposed to labour medication, separation of mother and baby, latching problems, scheduling feeds, pacifier usage, using breast-milk substitutes, lack of information and support, and early hormonal contraception have all been implicated.

Using words like low supply, as opposed to the terms inadequate, insufficient and failure can have an impact on how a woman feels about “breastfeeding and her breastfeeding body”

Full milk production needs sufficient breast glandular tissue, synchronised balanced hormone production, intact nerve pathways and frequent effective removal of milk from the breast.

In terms of real or perceived issues with milk supply many women think they do not have enough milk when in reality it has been reported that approximately 2 to 5% of women may have a ‘real’ problem with their supplies. Perceived can quickly become real, however and as suggested

by Stuebe (2012) it may not really matter whether real and perceived are counted together as, “… mothers are suffering, whether they lack glandular tissue, and/or they lack self-efficacy and support.”

Lactation, and its intimate companion breastfeeding, can be seriously compromised when a baby is not feeding directly at the breast which is why separation of mothers and babies can be damaging to breastfeeding. For a woman with an actual low milk supply, assessment and where possible rapid resolution of underlying issues, getting the best latch, using breast compression to support milk flow and implementing strategies to increase supply may be necessary. This will likely include at some point mixed strategies such as hand expression, breast compression, direct breastfeeding, supplementary nursing systems, using a breast pump, and in some cases galactagogues. Mother baby skin to skin contact is a first line action as is full evaluation of breastfeeds.

Where women have had previous difficult breastfeeding experiences and /or low milk supply it is particularly important to ensure uninterrupted skin-to-skin contact after birth, minimal disturbance of mother and baby, and support for the baby to proceed through the nine stages after birth while in skin-to-skin contact (Widström et al, 2011).

This supports pre-programmed behaviours for bonding and breastfeeding. Attention to time and space, observation, and avoidance of interruption are recommended for all mothers and babies (Widström et al, 2019).

Supplementary nursing systems have been used successfully by many women for varying lengths of time and some women have continued to use them, with either donor milk or formula, for the duration of their breastfeeding journeys. Women who have low milk supplies, which have not increased to be able to fully meet their babies’ needs, may have planned to exclusively breastfeed, and facing their feeding realities may cause a degree of grief, sadness and disappointment.

BREASTFEEDING CONNECTION

Midwives can support women to come to terms with the reality of mixed feeding by providing compassionate and non-judgmental care and support, practical information about mixed feeding and assurance that providing some breast milk to a baby is very worthwhile. Some women may decide to fully formula feed and also need full support for their decisions.

Midwives can support women to come to terms with the reality of mixed feeding by providing compassionate and nonjudgmental care and support, practical information about mixed feeding and assurance that providing some breast milk to a baby is very worthwhile. Some women may decide to fully formula feed and also need full support for their decisions.

Olza et al. (2020) discuss birth as a neuro-psycho-social event and describe the neurobiological processes orchestrated by endogenous oxytocin release that facilitate labour and birth. These physiological experiences of labour are described as transformative and facilitative of the transition to motherhood, with human touch, support and reassurance facilitating oxytocin-mediated reduction of fear, stress and pain as well as the promotion of joy and empowerment.

Striving for the same physiological experiences, reassurances and transformation of breastfeeding events, within a â&#x20AC;&#x153;feminist and humanistic attitudeâ&#x20AC;? (Olza et al, 2020), may go some way to supporting women to either meet their own goals for breastfeeding, or assist women, who will continue to have milk supply issues, to reconcile their modified infant feeding plans and to combination feed if they wish to do so. square References available on request.

ISSUE 98 SEPTEMBER 2020 | 35

FEATURE

THE FUNDING PACKAGE FOR MIDWIVES - DOES IT ADD UP FOR YOU? The Government recently announced $242 million of funding for maternity services. New Zealand College of Midwives chief executive Alison Eddy speaks to Maria Scott about what it means for self employed midwives after their five-year struggle over pay and conditions.

The headline figure of $242m seems impressive and has been described as the “largest ever funding boost for primary maternity services”. Is it all that it seems?

Yes and no. These funds are intended to be spread over four years; this current year and the following three. Not all of it is going directly into midwives’ pockets through Section 88 payments. Also, the headline figure includes some funding the government had already announced, including the $2,500 for each eligible self employed midwife to cover the extra costs of practising during the Covid response.

What can self employed midwives expect to see in their pockets and when?

This will depend on the nature and location of your practice and your caseload.

At the time of writing the College was still working on the detail with the Ministry but by the time Midwife magazine reaches you in mid September we hope to have a much clearer idea.

Funding of $85m will go into Section 88, equivalent to $21.25m a year this year and the next three. This is on top of the already announced 2.18% increase to Section 88 payments from 1 July this year. There will be further increases of 2.18%, in addition to the annual $21.25m increase for a further three years after this financial year.

Modules within Section 88 for LMCs, most of whom are midwives, cost approximately $160m in the year to 1 July.

So this additional $21.25m equates to an approximate increase of 15% in the LMC Section 88 budget.

Can you give us more information about how the different modules will be boosted?

The 2.18% rise mentioned above is applying across all modules. But the new funding

36 | AOTEAROA NEW ZEALAND MIDWIFE

of $21.25m for this and the next three years will be targeted to midwives working in rural areas and with women who have greater needs. The intention is to add new modules of care to address the needs of these midwives and one aspect of this will be a new definition of rurality. The Ministry is required to undertake a formal consultation process to make substantive changes to the Primary Maternity Services Notice and it is anticipated this process will have commenced by the time Midwife magazine reaches members. So there will be a new Section 88 Notice eventually but this is not due to be ratified until 1 April next year.

So do self employed midwives have to wait until then to see their incomes rise?

No. The College has been in discussion with the Ministry on an interim solution so that funding can be claimed before that.

This funding has to be targeted to the areas allocated in the budget: rural midwives and women with complex needs. In the short term this means an increase in rural travel and to the third trimester modules. The arrangements for these payments are part of the discussions underway at the time of writing and which the College hopes to have been able to confirm by the time this edition of Midwife is published. We will be keeping members informed.

So will any of the $21.25m - $85m over four years - go towards increases across all modules or will all be directed to areas of high need?

In the short term, until the new Notice is ratified, the answer is no, it will just go to rural travel and third trimester modules. In the longer term (post 1 April) we simply don’t know the answer to that, until we have seen the new Notice proposal and how funding will be allocated across its modules.

We have been fighting for five years for improved pay and a new funding model. Do you think this is a fair deal for community midwives?

Overall, we do not see this $242m as full and final settlement to our long standing concerns over pay and conditions. Our court case led to mediation and a legal agreement with the government that we expected to result in a new funding model for midwifery.

This appears to have been shelved although not all of the work undertaken by the profession to develop proposals for this model has been wasted. We understand that it has been used to reshape the modules now under development. We still want to see a very different funding model for the future.

We understand that there will be another business contribution payment this year but are unhappy that there does not appear to be any intention to continue this beyond this financial year. We understood that this was allocated for two years with a view to having a new payment model in place by now and this has not happened. We will continue to raise this with the Ministry.

However, we are very mindful of the wider circumstances New Zealand finds itself in now as a result of the pandemic response.

We know that midwives are aware that many families are facing significant hardship.

Where do we go from here?

We will continue to look at our options for legal redress over the failure of the government to meet the terms of our mediation agreement. The government has allocated $35m from the $242m towards the Maternity Action Plan, an outline plan announced some time ago. It is not clear to us what the aim of the plan is and what the government is trying to fix with it.

From what we have seen so far we are not convinced that the money wouldn’t be better spent on better pay for midwives and existing services.

We will also be watching the development of proposals for new maternity service initiatives, in line with the recentlypublished Health and Disability System Review recommendations for which $60m of the $242m has been allocated. We think the review points towards more influence for DHBs over the community midwifery workforce, including funding. We think this could undermine resourcing and the continuity of care model that we know works so well for women. So, yes, there is much more to do. square

FEATURE

Shaqaiak Masomi is a caseloading community midwife based mainly at Greenlane Clinical Centre, Auckland, providing antenatal and postnatal care for refugee and former refugee women from the Middle East and South East Asia. She also works one day a week at Auckland Hospital on the maternity wards. Here Shaqaiak discusses her career and the role midwives have played in her own life.

MY MIDWIFERY I am originally from Afghanistan. I came to New Zealand with my mother and sister in 1997. My father was a high school teacher and he was teaching girls and boys. When the Taliban invaded they burnt the schools and the teachers’ lives were at risk because they were educating girls and women. My father wanted us to leave the country but we couldn’t all leave together. He wanted my mother, my sister and myself to leave first. We fled to Pakistan and then Iran and on to Indonesia where we were stuck for a couple of months. By this time we had lost contact with my father. When we were told we were leaving Indonesia we had no idea we were coming to New Zealand. We landed in Wellington in May, very cold and frightened and with no luggage. We went to a camp and an Afghani family came to see us and helped us to settle. My mother discovered that her older brother was living in Auckland; she had previously lost contact with him. We were reunited with our uncle and he helped us to enrol at school in Auckland and for my mother to find a part time job at a bakery.

We eventually established contact with my father again and my mother saved money and organised for a lawyer to help apply for a visa for him. The school that my sister and I attended was aware of the story and the staff and parents of students helped with donations.

We were reunited with my father in 2000.

My mother had two children after we arrived here. She had post traumatic stress disorder (PTSD) and I saw the midwife visiting her and all the services that were involved in her care. I thought about my mum’s journey and though ‘why can’t I be that person to help other refugees and women new to New Zealand; to give them a start’.

Often for refugee women, when they get pregnant, this is an entry point to the New Zealand health care system. My mother’s

midwife did this for her and went beyond her job description. She would pop in to check on her and sometimes come with a food basket.

It felt like she was a member of the family.

Many of the women I work with have been through traumatic experiences in war zones and seen terrible violence. PTSD is common.

Women may have been victims of sexual violence or domestic violence. As a midwife you have to find a way of asking questions that will help a woman to open up and see if she has risk factors for PTSD and postnatal depression. Often this does not happen on the first visit; it can take five or six.

One of the aspects of my job that I like most is the impact that you can have on a woman’s life. Midwives can bring positive changes to a woman and her family. It is so rewarding when you see a woman in the community whom you have encouraged to take English classes or to learn to drive later taking her children to play groups and to the GP. I feel I have helped that woman to get on her feet in New Zealand.

One of the main challenges in my work is dealing with traditional gender dynamics.

Women who have arrived within the last few years may not be able to get to the clinic without their husbands so the challenge is trying to help them to gain some independence. The husbands often wait in the waiting room and don’t want to engage.

I usually make a point of inviting them into the room for the visit to help them feel more involved and included. Sometimes the husband or partner answers all the questions and I have to stop him and see if the woman can express her feelings. This also allows me to assess the woman’s level of communication in English. I speak Farsi which is the common language of Iran and Afghanistan but if I do not speak a woman’s language I

work through an interpreter. Women can be reluctant to communicate this way. Their communities in New Zealand are small and they may know the interpreters so this can take a lot of negotiating.

Sometimes I see resistance from husbands who don’t want their wife or partner to step into society, purely based on their experiences coming from male dominated countries.

Over time with education and guidance they come to realise that in a country like New Zealand it is safe and appropriate for a woman to drive and be out there in society learning a new language and being more involved in the community. There can be cultural tensions when families from different cultures settle here. You don’t see many girls going on to education beyond high school in Afghanistan and women don’t generally work after they get married. They have children and stay at home. But I have seen a lot of change in the community here in the last few years. I have seen so many Afghan and Somalian women thriving in the community.

When I see women like this it makes me so happy and proud of their achievements.

I graduated from Auckland University of Technology in 2014 and in the first year after I completed my midwifery degree I tried to set up antenatal and parenting classes for the Afghan community. I wasn’t able to get funding but I am still working towards that.

I work with a wonderful team of midwives at Auckland Hospital and Greenlane Clinical Centre. The team of community midwives based at Greenlane have been an immense support to me and are the backbone of my achievements and goals and I would like to thank them. My father told me and my siblings that New Zealand was a land of opportunity and to ‘go for it’. I feel that refugee children who get opportunities tend to thrive. square

ISSUE 98 SEPTEMBER 2020 | 37

Directory New Zealand College of Midwives Inc. President Nicole Pihema Ph 021 609 011 nicolepihema@gmail.com National Office PO Box 21-106, Edgeware, Christchurch 8143 Ph 03 377 2732 Fax 03 377 5662 nzcom@nzcom.org.nz www.midwife.org.nz College Membership Enquiries Contact Lisa Donkin membership@nzcom.org.nz 03 372 9738 Chief Executive Alison Eddy Auckland Office and Resource Centre Delia Sang, Administrator Yarnton House, 14 Erson Avenue PO Box 24487, Royal Oak, Auckland 1345 Ph 09 625 9764 Fax 09 625 0187 auckadmin@nzcom.org.nz National Board Advisors Elder: Sue Bree Kuia: Crete Cherrington Education Advisor: Mary Kensington Regional Chairpersons Auckland Sarah Ballard, Linda Burke auckchair@nzcom.org.nz Bay of Plenty/Tairawhiti Kelly Pidgeon kelly.pidgeon@hotmail.co.uk Canterbury/West Coast Davina Geddes chairnzcom.cantwest@gmail.com

Otago Sheridan Massey sheridan@milkhoney.co.nz Southland Natasha Baillie Ph 021 258 2701 merakimidwifery@gmail.com Waikato/Taranaki Tracey Williams chairwaikatonzcom@gmail.com Wellington Siobhan Connor Ph 021 289 4252 nzcomwellington@gmail.com Regional Sub-Committees Hawkes Bay Sub-Committee Sarah Nation sarahnation.midwife@gmail.com Manawatu Sub-Committee Amanda Douglas Ph 027 333 3280 amandadouglas@xtra.co.nz Rebekah Matsas Ph 027 465 7241 rebekamatsas@outlook.com Taranaki Sub-Committee Isabel Bedford nzcom.taranaki@gmail.com Wanganui Sub-Committee Jo Watson Ph 021 158 6874 jothemidwife@gmail.com Horowhenua Jennie Ferguson Ph 021 232 1980 thejensterrocks@gmail.com Consumer Representatives

Central Julie Kinloch Ph 06 835 7170 julie.kinloch.nz@gmail.com

Royal New Zealand Plunket Society Carla Kamo carla.kamo@plunket.org.nz

Nelson/Marlborough Rose Oâ&#x20AC;&#x2122;Connor roseocon@gmail.com

Home Birth Aotearoa Eva Neely evaneely@live.com

Northland Priscilla Ford Ph 021 222 2428 priscillaford@xtra.co.nz

Parents Centre New Zealand Ltd Liz Pearce Ph 04 233 2022 extn: 8801 pearce@parentcentre.org.nz

38 | AOTEAROA NEW ZEALAND MIDWIFE

La Leche League Trudy Hart Ph 07 549 5644 hartyhealth@live.com Student Representatives Wanaka Noanoa Ph 021 139 6496 wanakahr@gmail.com Seraya Turnbull Ph 022 6852383 serayaalucas@icloud.com Nga Maia Representatives www.ngamaia.co.nz Sarah Wills Ph 021 02551963 sarahandcale@hotmail.com Colleen Brown colleenbrownlmc@gmail.com Pasifika Representatives Talei Cummins Ph 021 907 588 taleicummins@gmail.com Nga Marsters Ph 021 0269 3460 lesngararo@hotmail.com MERAS PO Box 21-106, Edgeware Christchurch 8143 www.meras.co.nz General Enquiries & Membership Ph 03 372 9738 meras@meras.co.nz MMPO mmpo@mmpo.org.nz Ph 03 377 2485 PO Box 21-106, Edgeware, Christchurch 8143 Rural Recruitment & Retention Service Rural contact: 0800 Midwife/643 9433 rural@mmpo.co.nz Resources for midwives and women The College has a range of midwiferyrelated books, leaflets, merchandise and other resources available through our website: www.midwife.org.nz/shop

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