LOOK BACK AND REFLECT

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.

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

“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 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.

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

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

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.

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

farewell maria, welcome amellia

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.

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.