COUNTING THE COST OF COVID

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

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 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.”

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.

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 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.

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.

“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?”

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.

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

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

As someone recognised in the most recent Queen’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...

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."

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 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 “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 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