Midwife Aotearoa New Zealand

BIRTHING IN AOTEAROA A PICTORIAL CELEBRATION

P 26

ABORTION REFORM

CANNABIS IN PREGNANCY

MÄ€ORI MIDWIFERY SYMPOSIUM

WHAT DOES IT MEAN I P 18

WHAT DO WE KNOW I P 21

HIGHLIGHTS I P 24

ISSUE 99 DECEMBER 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

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ISSUE 99 DECEMBER 2020

FORUM COVER IMAGE: Lorraine MacDonald, having birthed baby Amber with the support of husband Kenny and midwife Jess Cathro. Photo by Sharon White.

FROM THE PRESIDENT 4. LOOKING WITHIN FROM THE CHIEF EXECUTIVE 5. A YEAR IN REVIEW 7. PRIVACY POINTERS FOR MIDWIVES

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8. BULLETIN 11. YOUR COLLEGE 12. YOUR UNION 14. YOUR MIDWIFERY BUSINESS FEATURES 16. THE MIDWIFE AND THE POSTAGE STAMP

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18. ABORTION LAW REFORM 21. CANNABIS IN PREGNANCY 24. MÄ&#x20AC;ORI MIDWIFERY SYMPOSIUM 26. BIRTHING THROUGH LOCKDOWN 28. COLLEGE GIVES STUDENTS FINAL BOOST 29. READING ROOM

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30. PRACTICE UPDATE 32. BREASTFEEDING CONNECTION 34. SECTION 88 STOCKTAKE 35. NZCOM JOURNAL UPDATE 37. MY MIDWIFERY/MY MIDWIFE 38. DIRECTORY

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EDITOR Amellia Kapa, 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 March 2021 Advertising Booking: 15 Feb 2021 Advertising Copy: 22 Feb 2021

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 99 DECEMBER 2020 | 3

FROM THE PRESIDENT

from the president, new zealand college of midwives, nicole pihema "Te ahurei o te kaiwhakawhānau i a mātou mahi” The uniqueness of midwifery guides our work

Nau mai haere mai ki Aotearoa New Zealand Midwife As the new editor of Aotearoa New Zealand Midwife, it’s safe to say production of my debut edition has been tinged with both excitement and nerves, as the prospect of filling the enormous shoes left behind by previous editor, Maria Scott, became a reality. Maria’s contribution over the last 10 years, and recent oversight of the revamp of the magazine have been invaluable to the College and in many ways, made my transition into the role a simple case of continuing to steer the course. Thank you, Maria, for your guidance and support.

Before training to be a midwife, my background was in media and communications, therefore this new role has provided me with a rare opportunity to combine my love of storytelling with the midwifery knowledge and experience I’ve gained thus far in my first five years of practice.

In this edition, we dive into the issue of cannabis in pregnancy, knowing its relevance to practice remains, irrespective of any referendum outcome. We explore the recent changes to abortion law and what this means for midwives, as well as highlighting important amendments to the Privacy Act affecting midwives’ daily work.

Practice updates on syphilis and wound care aim to inform and a Q&A with CE Alison Eddy about Section 88 provides a snapshot of where we’re at.

A visual diary from lockdown and beyond showcases an LMC’s passion for birth photography, whilst an extract from an academic paper tracks the history of midwifery as depicted by the humble postage stamp.

As time passes and I reflect on my first 18 months as President, it becomes harder to separate Covid-19 from the experience.

There’s a feeling - for all of us, I suspect - of being stuck in this pandemic. Yet I still believe some good has come from it. We’ve had to look within; not just within ourselves - to find strength, creativity and resilience we weren’t entirely sure we possessed - but within our workplace and profession, within our communities at large, and within our nation as a whole.

Almost overnight, our world became infinitely smaller, as we shut our borders and hunkered down, hoping for the best. And as the rest of the world followed suit, we realised how isolated we were, in so many ways. Our capacity to import was dramatically affected and we found ourselves on the back foot, unable to order equipment and skills we had previously taken for granted. Of course, we found new ways of doing things. But in reality, they weren’t new ways at all; they were simply old ways we had forgotten.

Lockdown forced a shift in perspective, and options like home birth suddenly became more desirable to women and whānau as they decided home was, in fact, the safest place to be. And while we hope to continue to eliminate this virus, taking a moment to celebrate shifts such as these – however impermanent – provides us with the midwifery sustenance we need to carry on.

Email: communications@nzcom.org.nz

My Auckland DHB role has allowed me to be part of other positive shifts within the profession; looking at how we can support midwives returning to practice, and how we can better serve the needs of midwifery students. Auckland-based students in particular have faced more challenges than usual this year, with Covid-19 restrictions disadvantaging this cohort as they returned to alert level 3 in August, dropping back to level 2 in September, before finally returning to level 1 in October. Both midwives and schools have been forced to once again look within; to re-evaluate how we are passing on

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We hope you can find time in your busy lives to take a break this festive season; to sit down with this issue and reflect on what’s been a year of unprecedented trials and tribulations and to celebrate midwives everywhere, who rose to the challenges of 2020.

Mā te wā, Amellia Kapa, Editor/Communications Advisor square

both the art and science of midwifery in an ever-changing landscape, and how best to move forward in these uncertain times.

Furthermore, the progress I’m seeing towards achieving equity for Māori midwives, wāhine, pēpi and whānau is encouraging.

The Māori Midwifery Symposium, held in July, highlighted key research findings and validated what Māori midwives have long known, but never had the solid evidence to quantify. Of course these insights aren’t unique to midwifery; they are universal across the Māori health continuum, and it would have been hugely beneficial for DHB leadership teams to attend this event. The final proposal submitted to Health Workforce New Zealand informing Māori maternal and child workforce priorities included practical recommendations on ‘closing the gaps’ and we await the Ministry of Health’s response.

There are also seemingly insignificant changes in the air, such as the more frequent use of ‘te Tiriti’ as opposed to ‘the Treaty’; a nod to differences in translation – the implications of which should not be overlooked, given we are still seeing the effects of these oversights today. Dare I say it, these changes may well reflect a shift synonymous with the initiation of the Wai 2575 - Health Services and Outcomes Inquiry. Regardless, these baby steps are promising, and should not be minimised.

I had the privilege of joining an International Confederation of Midwives (ICM) webinar in September; a discussion panel including participants from Mexico and Canada, which stimulated fascinating kōrero from all around the world. The experience highlighted the importance of indigenous midwifery for indigenous populations, and left me feeling hopeful about the future.

With the end of the year upon us, I sincerely hope most of the challenges of 2020 are soon to be firmly behind us, but the mahi must continue, and as always, babies will continue to be born. Remember - that will never change, but we possess immense power to positively influence the journey for all those in our care. square

FROM THE CEO

A YEAR IN REVIEW

As the year draws to an end, I am sure many of you are reflecting on what a year it has been. As the designated International Year of the Midwife and 30 years since the passing of the Nurses Amendment Act, 2020 promised to be a year to invigorate midwives, with many celebratory events and activities to look forward to.

How could we have anticipated a global pandemic - which until this year has always seemed a theoretical rather than real threat for Aotearoa - would disrupt not just our professional lives, but also our personal lives, so definitively? Such an event, like others we have experienced in the not too distant past (the Christchurch earthquakes, and mosque attack) forces us to reflect on what is truly important.

For many of us, it is our whānau and loved ones from whom we draw comfort and meaning. In our midwifery lives, it is our work as a proud and purposeful profession.

As an essential workforce providing necessary ‘in-person’ care during the pandemic, the importance of our profession and its impact

on the wellbeing of women was highlighted yet again. Although the lockdown was an extremely stressful period for many midwives, the essential nature of our work is a reason to hold our heads high. An unexpected but serendipitous consequence of the pandemic is the undergraduate schools of midwifery all reporting an overwhelming flood of applications for places in the midwifery programmes next year, which they believe in part is due to the enhanced status of essential workers.

To celebrate the 30 years since the passing of the Nurses Amendment Act, the College hosted a webinar in September, Emancipating Midwifery, Reflecting on 30 years of Midwifery Autonomy featuring

International Year of the Midwife 2020 Celebrating midwives As designated by the World Health Organisation, 2020 was the International Year of the Midwife, in recognition of the global contribution midwives make to the health and wellbeing of women and babies. As the year draws to a close and we reflect on how challenging 2020 has proven to be, it’s worth reminding ourselves - and each other of the profoundly positive impact we have on wāhine, pēpi and whānau in Aotearoa. Here we share a selection of tiles (above) featured on social media throughout the year, from women sharing their messages of gratitude.

ALISON EDDY CHIEF EXECUTIVE

ISSUE 99 DECEMBER 2020 | 5

FROM THE CEO

Helen Clark, amongst other speakers. The link to the recording can be accessed here: https://www.midwife.org.nz/news/webinaremancipating-midwifery-reflecting-on-30years-of-midwifery-autonomy/ The webinar speakers discussed the barriers that had to be overcome in order to pass the legislation, including an inherent mistrust in the idea of a women’s profession gaining autonomy, as well as opposition to the concept of women having self-determination over the powerful physiological and somewhat mysterious process of giving birth.

A midwife in the house The College congratulates midwife Sarah Pallett on her recent election to Parliament as Labour MP for Christchurch’s Ilam electorate. In an amazing victory, which saw National’s Gerry Brownlee ousted from the position after a 23 year stronghold, Sarah won by a convincing margin of 3,463 votes.

“We’re just thrilled. We worked very hard for every vote - we didn’t take anybody or anything for granted and we had no expectations”, Sarah says of her party’s success. “We were just trying to show people what else we could bring to the electorate and I think we did that well.”

A practicing midwife for 10 years, Sarah has worked both as an LMC - in North Canterbury - and a core midwife at Christchurch Women’s Hospital.

More recently, she held a position as a midwifery lecturer at Ara Institute of Canterbury, where her strong sense of social justice was also expressed, as President of the majority union representing academic staff.

As the only midwife currently in Parliament, Sarah recognises the significance but remains clear about her wider responsibilities. “I think it’s very important we have primary health representation in Parliament. Midwifery is really valuable for the whole community, so whilst I’m not there (in Parliament) as a midwife, I’ll be able to bring that really clear understanding of both the challenges and delights of being a midwife into all conversations.”

The College wishes Sarah all the best over the coming term and will be following her journey with anticipation and pride. square

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How far we have come in 30 years. We now have a women-centred, midwifery led maternity service, considered to be ‘mainstream’ care for the majority of women; a robust education model; highly educated midwifery graduates; legislation which enables us to work autonomously and across the full scope; a maternity service model which promotes continuity of care, and finally, choice of work setting - community practice or hospital. Much of this is not possible for midwives in other parts of the world, yet taken for granted by New Zealand midwives and women. In spite of all this, our midwifery world is not perfect. We have been struggling with adequate recognition, pay and conditions for both employed and self-employed midwives; we have workforce shortages, inequitable outcomes, institutional racism within our health care institutions and ongoing challenges with medicalisation of birth.

Funding models need to evolve over time, as practice and health care needs change.

Presently, we are on the cusp of further systemic health care change and it feels as though we are at another pivotal moment in our history. The Ministry of Health has developed an as yet unpublished Maternity Action Plan, which the College understands sets out the policy direction for maternity services over the next few years. This, along with the Health and Disability System review recommendations presents opportunities, but also potential threats to our professional role.

Whatever structural, contractual or funding changes eventuate, we mustn’t lose sight of the fact that our women-centred maternity service and continuity of care provide the best outcomes for women and babies.

Unfortunately, due to the protracted, unsatisfactory and unresolved nature of the negotiations for LMC pay and conditions, I fear we can tend to become overly focused on what is not right in our world. I increasingly hear midwives are applying rigid

interpretations of what they consider their roles or responsibilities to be, based on what contract they are working under; putting boundaries around what they will and won’t do, rather than keeping professional standards front and centre. I understand why midwives have chosen to do this, however I believe we can hold on to what we have achieved, have a sustainable workforce and maintain professional standards at the same time.

With potential changes afoot, there has never been a more pressing need to protect our autonomy. We need to reframe our language and stop talking about ‘primary’ or ‘secondary’ care, ‘epidural’ or ‘synto’ and more about collegiality, professional respect, workforce sustainability, and the needs of women. By reducing our care to a series of tasks, we threaten the professional autonomy our foremothers fought so hard to achieve.

Undoubtedly, further improvements need to be made to our working conditions in order to practice sustainably. However, thanks to the work of the College and MERAS, we have a few more tools in our kete, including a second midwife fee, increased Section 88 funding, the Midwifery Accord (which sets out a range of strategic actions to support recruitment and retention of core midwives), the MERAS pay equity claim in progress, and a potential new funding model for LMC midwives under the terms of the mediation agreement. Let the organisations which represent you collectively - the College and MERAS - take on the burden of these issues.

As an individual midwife, the most valuable thing you can do – for yourself and the community as a whole - is to keep the joy of being a midwife in your heart, providing care that is professionally satisfying, and to continue to model the practice and behaviour we need our newest midwives to emulate. In 2020, women need midwives more than ever and we would be best served by keeping this question in the forefront of our minds: what legacy do we wish to leave for the midwives who will follow us in 30 years’ time? square

By reducing our care to a series of tasks, we threaten the professional autonomy our foremothers fought so hard to achieve.

LEGAL

privacy pointers for midwives The College’s legal section provides confidential medico-legal services to members. In this article, the College’s legal advisor, Carla Humphrey discusses the significance of the new Privacy Act 2020 as it relates to midwifery practice, together with some general pointers on privacy law and ethics.

CARLA HUMPHREY LEGAL ADVISOR

PRIVACY ACT 2020 Midwives have professional and ethical obligations to protect the privacy of women and their whānau under the College’s Code of Ethics and the Midwifery Council’s Code of Conduct. Additional and separate obligations under the Privacy Act 2020 include compliance with the Health Information Privacy Code 1994 which is a Code of Practice issued by the Privacy Commissioner, giving extra protection to health information due to its sensitivity. A new Privacy Act 2020 came into force on 1 December 2020 that strengthens privacy protections and promotes early intervention and risk management by agencies such as DHBs and self-employed LMCs. Many of the privacy principles remain the same; however a key change relevant to midwifery practice is the new requirement to report what is termed a “notifiable privacy breach” to both the people affected by the breach and also to the Privacy Commissioner.

Failure to report the breach when required may result in a fine of up to $10,000.

Any privacy breach now requires a careful consideration of the appropriate steps to take after the breach, and an assessment of whether the breach causes, or is likely to cause, serious harm.

The steps to consider include: • Any action taken to reduce the risk of harm following the breach • The sensitivity of information • The nature of harm that may be caused • Identifying who has obtained or may obtain the information

• Identifying and assessing any security measures in place for the information • Other relevant matters depending on the circumstances of the individual case.

Midwives with professional indemnity cover are entitled to receive free legal advice and assistance after a privacy breach and the College’s legal advisor will guide you through the appropriate steps to take in order to mitigate any potential or actual harm and reduce the risk of a complaint. In addition to a fine, if a notifiable breach goes unreported, privacy breaches can also result in monetary compensation payable by the health professional; therefore it is important to contact the legal section promptly to ensure the matter is managed appropriately.

OTHER PRIVACY TIPS The legal section frequently receives requests for advice by members who have received a request for information about a woman under her care, or about a woman’s family.

These requests are often from Oranga Tamariki; the Police; the Ministry of Social Development; or a lawyer for an ex-spouse or partner, but they may be from other parties as well. Just because the request comes from someone who appears to be associated with the law, or who may present as entitled to the information requested, this does not necessarily mean they are entitled to it.

Midwives report to me that they often feel “pressured” to provide the information, and to provide it promptly.

Under such pressure, midwives sometimes disclose private information in breach of privacy laws. There are many legal ways to

provide information safely and appropriately depending on the circumstances and I urge midwives to contact the legal section to discuss the appropriate response to the request for information. In my experience, there are few instances where a midwife cannot first contact the legal section for advice. Midwives making an appropriate report of concern under the Tamariki Oranga Act 1989 are protected by law, so we would generally not expect midwives to seek legal advice first; although professional advice from a colleague or Midwifery Advisor may be helpful.

If you have any questions or concerns regarding privacy and your practice, please do not hesitate to contact us at the College’s legal section. square

A key change relevant to midwifery practice is the new requirement to report what is termed a “notifiable privacy breach” to both the people affected by the breach and also to the Privacy Commissioner. Failure to report the breach when required may result in a fine of up to $10,000.

ISSUE 99 DECEMBER 2020 | 7

BULLETIN

BULLETIN

Judith McAra-Couper honoured with new title “Professor: A title recognising distinguished and internationally acknowledged academic leadership within an academic field and a sustained outstanding contribution and impact in research and/or practice; teaching, assessment and curriculum design; and in service, both to the University and the external community.” (Professorial Appointments Handbook 2020, AUT)

The College wishes to congratulate Judith McAra-Couper, Head of Midwifery at AUT, on her recent promotion to Professor. Made clear by AUT’s definition above, the appointment recognises Judith’s long-standing and exceptional contribution to midwifery research, education, and the community as a whole.

Professor Judith McAra-Couper, Head of Midwifery at AUT

Midwives gain doctorates despite the odds A number of midwives have overcome adversity and completed their doctorates, despite the many challenges faced throughout the past year. The significance of these contributions not only nationally, but to the international body of midwifery research is to be celebrated, and the College would like to congratulate the following midwives on completing their theses: • Suzanne Miller - Moving things forward: Birthing suite culture and labour augmentation for healthy first-time mothers • Billie Bradford - Fetal movements in normal and complicated pregnancies • Christine Griffiths - Working through complexity: How women living in areas of high socioeconomic deprivation in New Zealand access and engage with midwives • Robin Cronin - Late stillbirth: The contribution of maternal sleep practices and maternal views • George Parker - Mothers at large: Governing fat pregnant embodiment

Midwifery research news Updates on the latest midwifery research, as reported in international journals, are available on the College website www.midwife.org.nz/midwives/research square

Judith’s career in midwifery began at St Helen’s and Middlemore hospitals in Auckland, after which she spent five years working as a midwife in a village in Bangladesh. In 2009, the World Health Organisation employed Judith to write a midwifery curriculum and syllabus for nurse-midwives and she has returned to Bangladesh many times over the years to implement this programme and continue developing the curriculum towards direct entry midwifery education.

Joining AUT as a midwifery lecturer in 1996 and completing her PhD in 2007, Judith was appointed Head of Midwifery Department in 2013 and became an Associate Professor in 2014. With particular research interests in the areas of maternal mental health, sustainability of midwifery practice and place of birth, Judith has also fulfilled a number of other roles including Chairperson of Auckland Regional NZCOM 2008-2011, and Chair of NZ Midwifery Council 2011-2018. square

Judith’s career in midwifery began at St Helen’s and Middlemore hospitals in Auckland, after which she spent five years working as a midwife in a village in Bangladesh.

Fax no more December 2020 is the cut-off date outlined by the Ministry of Health and ACC as the time by which all health agencies should be implementing one of the following digital alternatives to the use of analogue fax for external communication: • Migrate use of analogue fax to fully digital, security assessed, communication solutions such as e-mail of scanned documents, secure messaging or cloud hosted secure collaboration platforms; or • Utilise the ‘scan-to-e-mail’ capability on a multi-function device (MFD) to scan documents and send them as e-mails (compliant with the secure e-mail requirement in point above).

The Ministry of Health should be advised when agencies have migrated, by e-mailing itsecurity@moh.govt.nz

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BULLETIN

Ministry of Social Development updates The Ministry of Social Development has implemented various temporary changes in response to Covid-19 and also wishes to clear up an area of confusion regarding the Disability Allowance. Key messages for midwives:

Dr Megan Gibbons, Otago Polytechnic CE (left) and Dr Celia Grigg.

Distinguished alumni award The College acknowledges Dr Celia Grigg, who has received the Otago Polytechnic Distinguished Alumni Award for her outstanding contribution to midwifery.

Celia has worked in the Canterbury area as a midwife for 20 years (12 as an LMC), and has contributed significantly to midwifery research, including leading the NZ arm of the Australasian prospective cohort study Evaluating Maternity Units (EMU) and completing a two year post-doctoral research fellowship at the University of Nottingham.

More recently, she was a Research Fellow on the vaginal seeding study (ECOBABe) at the Liggins Institute, University of Auckland, which focuses on how early life events affect later health. Celia’s research has led to the publication of 14 papers in international midwifery journals. square

New information about pregnancy and anti-seizure/ mood stabilising medicines ACC, the Health Quality and Safety Commission, the Ministry of Health (MOH), and Foetal Anti-Convulsant Syndrome New Zealand (FACS NZ), have released two updated resources about the benefits and risks of anti-seizure/mood stabilising medicines for women who could become pregnant; one for health professionals and one for women taking the medicines, as well as a flyer suitable for waiting rooms. They can be viewed and ordered at no cost at https://www.acc. co.nz/for-providers/treatment-safety/. ACC has also published new guidelines about injuries caused by exposure to sodium valproate in pregnancy: https://www.acc.co.nz/assets/provider/injuries-in-uteroexposure-sodium-valproate-acc8203.pdf square

• Initial Work Capacity Medical Certificates (WCMC) for pregnant women seeking a benefit are still required to be completed by midwives; however, subsequent certificates have been deferred until 31st July 2021 and are therefore no longer required • WCMCs are not required for new benefit applications during Covid-19 Alert Levels 3 or 4 • Midwives cannot complete medical certificates for the Disability Allowance, however women with long-term (non-obstetric) health conditions or disabilities may still be eligible for this additional financial support, therefore information-sharing regarding this may still be relevant for midwives in practice. square

Prescription pads: change of hands Previously administered by Michelle Prier, prescription pads for midwives have changed hands and are now distributed by the Midwifery Resource Centre in Christchurch. Please continue to email prescriptionpads@gmail.com to place your order; however, refrain from paying until you have received an invoice advising of the correct bank account details for payment. The cost of pads remains the same at $9/pad.

New online immunisation course for midwives The Immunisation Advisory Centre has launched a new online course for midwives, providing evidence-based knowledge for midwives to:

• Safely administer vaccines within their scope of practice • Provide immunisation communication for the protection of women and their whānau The course provides eight hours of continuing midwifery education, approved by the Midwifery Council of New Zealand and can be accessed via the centre’s online learning platform, IMAC Learning: https://www.immune.org.nz/health-professionals/education-training square

ISSUE ISSUE 99 DECEMBER 95 MARCH 2020 | 9

BULLETIN

aotearoa midwifery project JACQUI ANDERSON MIDWIFERY ADVISOR

In February 2020 the Midwifery Council initiated a review of the regulatory framework for midwives and midwifery practice, called the Aotearoa Midwifery Project.

The impetus for the review includes a number of recent legislation changes and amendments including the Health Practitioners Competence Assurance Amendment Act 2019 (HPCAA), the Abortion Legislation Act 2020 and the proposed Therapeutic Products and Medicines Act, along with the Health and Disability System 2020 review and the Midwifery Council’s commitment to supporting a Te Tiriti o Waitangi partnership.

The purpose of the Aotearoa Midwifery Project is to review: • the scope of practice of a midwife • the competencies for entry to the register of midwives • pre-registration standards for midwifery education.

Further development of the regulatory framework is required to support the midwifery profession into the foreseeable future. Key outcomes for this review include incorporating regulation that facilitates equitable maternal and newborn health outcomes and meets the needs of all communities in Aotearoa New Zealand.

The Aotearoa Midwifery Project Collaborative Reference Group (CRG) was established to inform the review and identify a model for the development of a Te Tiriti partnership framework that strengthens and balances the relationship between Māori and non-Māori. The review seeks to facilitate equitable access to quality healthcare and prioritises the cultural competence of midwives in Aotearoa New Zealand.

The project team is liaising with the College both at regional and national levels and has

10 | AOTEAROA NEW ZEALAND MIDWIFE

spoken to the National Board throughout the year. There will also be opportunities for consumer views to be sought.

We would urge you to take any opportunities to learn about the project and to have your say.

The review of the regulatory framework for midwives will have far reaching implications for midwives in Aotearoa New Zealand, including how students are educated and what midwifery practice will encompass in the near future.

Follow the link to the Midwifery Council site for more information on the project: www.midwiferycouncil.health.nz/aotearoamidwifery-project square

Further development of the regulatory framework is required to support the midwifery profession into the foreseeable future.

YOUR COLLEGE

your college A snapshot of some of the work the College has been doing on behalf of members over the last quarter.

MERAS VALUES PROJECT MERAS is currently developing a set of values to guide the core work of the union.

A College representative is involved with the working group, alongside MERAS National Representatives Council members. Thanks to Karen Ferraccioli for instigating this project and to Victoria Christian for chairing the group to move the project forward.

ENGAGEMENT WITH THE NATIONAL AMBULANCE SECTOR OFFICE (NASO) Currently, approximately 1% of all ambulance transfers are maternity-related.

Whilst this is a small number, it invariably involves two individuals (mother and baby).

Midwives have reported a number of issues in relation to using ambulance services and the College has been invited by NASO to provide midwifery-specific input to national discussions on ambulance and flight transfer equipment.

GROWTH ASSESSMENT PROTOCOL ACC WORK GROUP The Growth Assessment Protocol for New Zealand (GAP NZ) is the Perinatal Institute’s education for New Zealand practitioners who wish to use GROW customised growth charts. The work group includes College representation and is carrying out a baseline audit of the rate of detection of small for gestational age (SGA) prior to the introduction of GAP.

INTERMITTENT AUSCULTATION (IA) GUIDE FOR PRACTICE AND VIDEO The College’s IA guide for practice has been ratified and an explanatory video recorded.

These are now published and available on the College website under ‘Practice Guidance’.

MINISTRY OF HEALTH CODE IN NEW ZEALAND COMPLIANCE PANEL The College is represented on this Ministry committee, which reviews reported breaches of the Infant Nutrition Council Code of Practice and the Health Workers’ Code of Practice. The overall objectives of the Compliance Panel include contributing to the wider policy environment which supports the provision of safe and adequate nutrition for New Zealand infants, in order to effectively implement and monitor the WHO International Code in New Zealand.

BIRTH IN THE TIME OF COVID-19 The College is involved in a research collaboration with schools of midwifery (AUT University and Otago Polytechnic), exploring the impact of the Covid-19 pandemic on midwives, midwifery students

and pregnant and birthing women. A Health Research Council of New Zealand funding application has also been made to continue this work, to further explore the wellbeing of pregnant women and women who have given birth during the time of the pandemic.

EFFECTS OF POVERTY A research collaboration between the Maternity Equity Alliance (MEA) and the College is investigating the effects of poverty on midwives, midwifery care and women.

Three research papers are currently being prepared for publication.

MEETING WITH NEW MINISTER We welcome the recently appointed Minister of Health, Hon Andrew Little to his new role and look forward to working with him.

The College will be seeking an early meeting with the Minister to ensure the importance of the maternity service and midwives’ role within it is understood and recognised, and that he has a clear understanding of the commitments made under the mediation agreement, to deliver on fair and reasonable pay and develop a new contract model for LMC midwives. square

The GAP champion conducts a regular ‘missed case’ audit (also known as false negatives), to identify factors that could lead to improved SGA detection, and the College continues to raise the need to audit false positives as well as false negatives. Productive discussions about a way forward took place at the last GAP work group meeting. Access to ultrasound scans is an ongoing concern, and the Ministry of Health representative has advised the work group that dedicated time has now been allocated to focus on this issue.

ISSUE 99 DECEMBER 2020 | 11

YOUR UNION

positive outcomes emerging from CCDM & TrendCare for maternity In the last 18 months there has been an increased focus on the implementation of Care Capacity Demand Management (CCDM) and TrendCare across all 20 DHBs. In most DHBs maternity has been one of the last areas to be included in the programme but the final couple are now introducing CCDM and TrendCare.

CAROLINE CONROY MERAS CO-LEADER (MIDWIFERY)

One of the commitments within the Midwifery Accord was for the parties (unions, DHBs and MoH) to work in partnership, to progress the implementation of CCDM and TrendCare into maternity services by 30 June 2021.

CCDM includes a suite of initiatives to support safe staffing in ward areas. The suite includes TrendCare (acuity software package) the Variance indicator system (VIS) and Variance response management tool (VRM); escalation plans, core data set and staffing methodology/FTE calculations.

To support the implementation of CCDM there is oversight and support at both a national and local level. The support includes:

CCDM MATERNITY ADVISORY GROUP CCDM MAG supports the roll-out of CCDM and TrendCare into maternity services. The MAG encourages the sharing of resources and advice amongst maternity services. They also ensure that material developed as part of CCDM is fit for purpose for maternity and midwifery is visible within the various CCDM documents and reports.

NATIONAL CCDM MATERNITY COORDINATOR In June 2019, Jules Arthur, Director of

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Midwifery at Hawkeâ&#x20AC;&#x2122;s Bay was seconded to be the national CCDM Maternity Coordinator. The introduction of this role provided increased support, advice and progress for CCDM and TrendCare within maternity services.

SAFE STAFFING HEALTHY WORKPLACE GOVERNANCE GROUP This group provides governance oversight for the implementation of CCDM into DHBs. The group includes representatives from the MOH, Directors of Nursing, Directors of Midwifery, DHB CEOs, MERAS, NZNO, PSA and Allied Health.

MERAS is represented by Caroline Conroy and the Directors of Midwifery by Paula Spargo (DoM, Midcentral DHB).

DHB CCDM COUNCIL MEETINGS AND WORKING GROUPS Each DHB has CCDM and TrendCare co-ordinators, who lead the implementation of CCDM and TrendCare across their DHBs. Each DHB has a CCDM Council and a range of working groups to support the implementation. MERAS is involved in the various meetings with both Caroline and MERAS workplace representatives involved alongside the DoM and midwife managers.

WHAT ARE THE BENEFITS OF CCDM & TRENDCARE? In the early days of CCDM there was concern within the maternity sector around how well CCDM and TrendCare would reflect the work of midwives and maternity services.

TrendCare has undergone several upgrades and refinements and now better reflects the work of midwives within in-patient areas.

Through the DHB CCDM Council meetings, the acuity and work of maternity services are now more visible to the rest of the hospital.

FTE CALCULATIONS Several maternity services with at least 12 months of reliable TrendCare data have been able to complete FTE calculations. These

As FTE calculations are completed and demonstrate the need for additional midwifery staffing, the challenge is to find midwives to fill the new positions created.

YOUR UNION

Variance Response Management (VRM) tool or Variance indicator score (VIS)

Members of the CCDM MAG - Back row: Liz Lee Taylor, Claire MacDonald, Jon Buchan, Caroline Conroy MERAS Co-Leader, Rachael Peek, Emma Williams. Front row: Michelle Archer, Jules Arthur, Carolyn Coles. Not Present: Kate Weston, Michelle Cotton.

calculations show the staffing needs based on the TrendCare data, hence why it is so important TrendCare data is as accurate as it can be, especially on busy shifts. The FTE calculations completed so far in maternity have shown a need for increased staffing levels either on certain days of the week, or certain shifts. Though it can be difficult to recruit additional midwives in the shortterm, the FTE calculation process provides recognition of the work that midwives do and the unpredictable and busy shifts they encounter.

GETTING THE MOST OUT OF TRENDCARE The ‘Allocate Staff’ screen is important in the maternity setting. This screen captures the range of work that occurs in maternity and if not completed accurately, it can have a negative impact on data.

TIPS FOR USING THE ‘ALLOCATE STAFF’ SCREEN • Clinical in department: hours

should only be included in this section for inpatient work on the ward where the midwife is based. When midwives leave the ward to go to theatre, complete acute assessments, or undertake housekeeping tasks, the time should be moved from ‘clinical in department’ to a more appropriate section.

• Housekeeping: it

is important that the hours spent by midwives or maternity support staff doing housekeeping tasks over the course of a shift such as cleaning, making beds and re-stocking rooms is recorded here. some maternity units a significant part of the day can include providing care to women who are ‘out-patients’ and may attend for a CTG, BP check, early labour assessment etc. It is important that the total hours for this work are reflected in the appropriate sections.

• Co-ordination: make sure you indicate who

is ‘in charge’ each shift and add hours for co-ordination.

• E-learning: if

you do ‘on-line learning’ during your shift, ensure these hours are recorded here.

• 12-hour shifts: 12

hour shifts tend to overlap two time periods. Make sure the total hours available for work add up to 11.30 hours to reflect the 2 x 30 minute meal breaks (one paid, the other unpaid) that occur.

This is an important tool for maternity.

VRM/VIS will highlight the busy shifts and when additional support is needed. It is important that the shift co-ordinator updates the VIS/VRM to reflect changing acuity during a shift.

An escalation process should outline actions that can occur (such as delaying elective work) as part of VIS/ VRM if the ward is in yellow, orange, or red status. The Duty Manager should provide support to the ward in orange or red status. The VIS/VRM statuses are reported at CCDM meetings and there are discussions between union representatives and midwife managers to ensure episodes of orange or red are managed well and the time in orange or red is minimised. square

CHALLENGES As FTE calculations are completed and demonstrate the need for additional midwifery staffing, the challenge is to find midwives to fill the new positions created.

Until those positions are filled, it makes it appear that the midwifery vacancies within the service have increased. However, these FTE calculations will provide a clearer picture of the number of new graduate midwives needed each year to provide a sustainable midwifery workforce within the DHB maternity services. As TrendCare has been introduced into more and larger maternity units, it has shown the areas where a consistent approach is needed (1:1 care); where enhancements may be needed (babies with more complex needs and post-caesarean women) and review of current provisions is required (shift co-ordination). These are the current areas of focus for the CCDM MAG. To view the quarterly reports, or for further information on CCDM, visit the MERAS website, your DHB intranet or the CCDM website. square

mauve Excess capacity.

green Available staffing matches care needed on the ward.

yellow - early escalation A busy shift. Plans should be activated to return to Green. This may include deferring elective work or bringing in an extra staff member for next shift.

orange – significant deficit Available staffing and/or capacity does not meet the demands on the ward.

Escalation plan will be activated. Plans should aim to return situation to Green.

red - critical deficit

• Acute assessments: in

Significant over-demand on available staffing and capacity. Senior staff called into unit to provide co-ordination and support. Plans should aim to move out

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

of red as quickly as possible.

ISSUE 99 DECEMBER 2020 | 13

YOUR MIDWIFERY BUSINESS

connecting rural midwives A recent research article published in the New Zealand College of Midwives Journal, giving voice to rural midwives’ perspectives and daily realities, has highlighted the diversity of the rural communities in which midwives practice in Aotearoa.

SHANTI DAELLENBACH LOCUM SUPPORT CO-ORDINATOR

This is captured in the adage “if you have seen one rural community, you have seen one rural community” (Daellenbach et al.

2020). The diversity and uniqueness of rural practice is something well appreciated by the Rural Midwifery Recruitment and Retention Service (RMRRS), a service delivered by the MMPO, and supported by the College since 2009, which connects with rural midwives across Aotearoa on a daily basis.

• Time and costs associated with travel over large distances and varying terrain

access to birth and postnatal midwifery care within communities.

• The impact of geographic isolation on transfer times, proximity to emergency services and back-up midwife, with more restricted access to local social services and collegial networks

OUR ROLE AT THE RMRRS

We understand that alongside the myriad of barriers to making and keeping their rural midwifery practice sustainable, there are many aspects which are deeply rewarding, both professionally and personally, about practicing midwifery in a rural space, alongside rural women, wāhine and whānau.

We are conscious too, of the unique skillset and temperament required for rural practice, because we are regularly asking locums to step into the shoes of rural or remote rural midwives, often at short notice and in areas they are unfamiliar with.

• Withdrawal of local community health resources including the closure of rural primary maternity units.

While many of the challenges have remained the same in rural midwifery over the years, we also note new changes happening within the rural midwifery landscape and expect more on the horizon.

CURRENT SITUATION The rewarding and challenging aspects of being a rural midwife are well documented, however their impact on sustainability has yet to be adequately or fully recognised by government or reflected in funding and policy. Persistent barriers to sustainable rural practice for midwives include:

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• Rural and urban population shifts that impact caseload sizes and demographic characteristics of birthing women

A critical but less discussed factor is the socio-economic deprivation in rural areas and its impact on rural health equity. Recent mapping of the current distribution of rural primary maternity units found that of the 40 rural units currently open, 60% are located in Decile 8-10 communities on the NZ Index of Socioeconomic Deprivation (NZDep). Furthermore, of the six rural units that have been permanently closed in the last five years, five were located in remote rural communities.

In our opinion, the under-funding and closure of rural primary maternity units is a health equity issue, especially as research shows that women who plan to birth in a primary unit are younger, more likely to live rurally and more likely to identify as Māori (Griggs et al. 2017). In our view, to improve equity of midwifery care, rural units need to be funded and expanded to better support rural communities by incorporating a greater (not reduced) range of maternity services while also ensuring fair

The RMRRS is currently funded by the Ministry of Health to support sustainable rural midwifery practice through services including the Rural Locum Service (Leave and Emergency), Rural Mentoring Programme, Rural Relocation and Practice Establishment Grants, and Rural Midwifery Workshops. We work hard to accommodate and personalise support for the diverse realities of rural practice in Aotearoa, but within the current funding envelope and our contractual obligations to the Ministry.

In the past 12 months, 302 rural midwives signed up to access rural locum cover. They used 3,492 days of paid cover and were supported by 216 rural locums.

A positive trend is that the number of midwives carrying a predominantly rural caseload appears to be increasing, particularly during the last two years - while a number of areas still continue to experience a shortage.

In the last year, we have seen a rise in relocation grant applications and approvals across Aotearoa. This suggests new movement in the rural workforce to support rural areas of shortage. An increase in requests from rural midwives for a midwifery mentor is another positive sign, demonstrating an awareness of the importance of collegial relationships and support networks in working towards sustainability.

In recent times, RMRRS have also become increasingly involved in extending support in

In the past 12 months, 302 rural midwives signed up to access rural locum cover.

They used 3,492 days of paid cover and were supported by 216 rural locums.

the form of sharing our knowledge, networks and systems to ensure women retain access to primary maternity services in their area when acute workforce shortages occur. We recognise how much the presence of a rural primary maternity unit can contribute to the sustainability of rural midwifery practice and that loss of local birthing and postnatal options represents both an equity and sustainability issue in many areas.

LOOKING FORWARD Despite these ongoing challenges, and with changes to the Section 88 notice on the horizon, the RMRRS remains confident about the future of rural midwifery. Research in Aotearoa has shown the current Section 88 notice does not always work for rural maternity services. The current consultation process presents the possibility of change and hopefully an opportunity to expand RMRR’s scope and funding to provide a more comprehensive service that fully recognises the challenges, and values the unique and diverse realities of rural midwifery practice in Aotearoa.

What sustains the RMRR team is rural midwives’ tenacity in challenging environments, and their commitment to rural women, wāhine and whānau. We will continue to advocate for rural midwifery and negotiate with decision makers on initiatives that better support rural community midwives, and the infrastructure needed to support equitable access to primary maternity care in rural Aotearoa. square References available upon request.

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FEATURE

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FEATURE

The midwife and the postage stamp Ken Dawson, of Victoria University’s Health Faculty, has produced a paper titled ‘The Midwife and the Postage Stamp’, highlighting aspects of midwifery that have been celebrated by postage stamps throughout the years. With Ken’s permission, the following extracts and images have been reproduced from his paper.

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The adhesive postage stamp was first introduced into Great Britain in 1840 by Sir Rowland Hill. It soon became evident that it could have a host of other uses such as education, commemoration and propaganda.

The year 2020 is the International Year of the Midwife and the occasion has been celebrated by a new set of postage stamps from the Isle of Man (1). In 1970, the 50th anniversary of the midwifery school in Iran was commemorated(2), and a more realistic presentation celebrates the 22nd International Confederation of Midwives Conference held in Kobe, Japan in 1990 (3).

Many stamps have been directed at the importance of the postnatal establishment of breastfeeding.

These have not only been issued from low-income countries, but wealthy nations also. All, however, recognise the importance of establishing breastfeeding and hence the role played by midwives (Creedy et al.,2008) (4,5,6,7,8).

Aspects of the practice of midwifery of an historical nature are well represented. The Apgar score for the assessment of the newborn is familiar to every midwife and was devised by Virginia Apgar and introduced in 1952. Apgar was a distinguished American anaesthetist and was celebrated by a United States stamp in 1994 (9).

The row of willow trees shown in a Swedish stamp of 1973 is a reminder of the use of chewed willow leaves for analgesia in childbirth and for puerperal fever (10).

The development of the fetus and the subsequent assessment and growth of the baby have all been recorded philatelically. An impressive stamp from the Netherlands Antilles shows stages of fetal development in an original way and this leads on to the use of ultrasound to monitor fetal growth and formation, and the important discovery of ultrasound imaging was recognised by a Great Britain issue in 1994 (11,12,13).

By 1977, major advances saw midwives supporting

women to give birth to babies produced by in-vitro fertilization, as represented by a ‘test-tube’ baby on a UK Millennium stamp (14).

An historical figure of great importance in the field of midwifery is that of Hungarian, Ignaz Semmelweiss, whose birth centenary was celebrated by a stamp from that country in 2018. It was Semmelweiss who recognised the importance of antisepsis during childbirth and the importance of hand washing. By these steps, he was able to steadily reduce the death rate of puerperal sepsis from its peak rate of 7.6%, for all deliveries, in Vienna in 1848. The recognition that Group A Streptococcal infection was an important cause of this grave disease led to further advances, with the introduction and development of penicillin after the initial work of Alexander Fleming (15,16,17).

Two distinguished midwives have been celebrated by postage stamps for their contribution to the field: Mary Breckinridge (19) was an American midwife who provided care to the mountain people of Kentucky, USA, and Lily Warren (20), a Pitcairn Islands midwife, was awarded the British Empire Medal for her selfless and outstanding work for the mothers and babies of Pitcairn. And in 1988, a stamp from Denmark highlighted the transition from fetal to newborn circulation after birth (18).

Postage stamps can be important reminders of the history of professions and significant advances in patient care. The postage stamp lends itself well to health promotion and as this appears to be an increasing function of midwives - in addition to their traditional role of promoting normal birth and the establishment of breastfeeding - it could be argued that stamps still have an important role to play. With increasing pressure being placed on midwives to counsel with regards to tobacco, alcohol and other drug use in pregnancy, as well as promoting immunisation, these could be potential subjects for future maternity-related postage stamps. square

ISSUE 99 DECEMBER 2020 | 17

FEATURE

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FEATURE

ABORTION LAW REFORM

WHAT DOES IT MEAN FOR MIDWIVES? The Abortion Legislation Bill received Royal Assent on March 23, 2020, removing abortion from the Crimes Act 1961 and amending the Contraception, Sterilisation, and Abortion Act 1977 to include the new provisions.

CLAIRE MACDONALD MIDWIFERY ADVISOR

Under the new legislation, abortion is situated as a health issue where the woman’s autonomy and self-knowledge are privileged in decision making. The provisions of the new legislation that have direct relevance to midwifery practice are outlined here.

A number of barriers to safe abortion have been repealed: • There is no longer a need for authorisation by two certifying consultants. In other words, the decision to have an abortion now rests solely with the person seeking the abortion when less than 20 weeks, or as a joint decision with a health provider at more than 20 weeks.

• Women are no longer required to have a medical or mental health risk to be eligible for abortion.

• The Abortion Supervisory Committee has been disestablished.

• Women no longer require referral from a health practitioner to an abortion service.

• Abortion has been removed from the Crimes Act. • Previously, only doctors could be certifying consultants or perform abortions.

References to doctors (incidentally, always referred to with the male pronouns ‘he’ and ‘him’) have been replaced with ‘qualified health practitioner’, which

broadens the pool of health professionals who can discuss, refer for, and provide abortion services. The designation of ‘qualified health practitioner’ includes midwives.

The Midwifery Council has determined that the provision of abortion care sits within the midwifery scope of practice. A statement and an explanatory FAQ document are available on the Council’s website.

Including abortion services in the midwifery scope of practice is supported by the International Confederation of Midwives and the World Health Organisation. The College’s Code of Ethics and Philosophy provide a clear values-based framework for midwifery care that applies to the diversity of women’s experiences of pregnancy, including when a woman does not wish for the pregnancy to continue. Midwifery privileges women’s rights to autonomy and self-determination and to receive care that meets their specific needs. The Midwifery Council’s Code of Conduct also provides clear expectations of midwives in the context of abortion care.

Until now, midwives in Aotearoa New Zealand may have been familiar with advising women how to access abortion services, and

How does the Midwifery Council statement on abortion sit within the competencies for entry to the Register?

Competency 3.5 states that the midwife demonstrates an understanding of the needs of women/wāhine and their families/whānau in relation to infertility, complicated pregnancy, unexpected outcomes, abortion, adoption, loss and grief and applies this understanding to the care of women/wāhine and their families/whānau as required.

Midwives as authorised prescribers can prescribe within their gazetted scope of practice.

As it has been agreed that the provision of abortion care to women sits within the midwifery scope then the prescribing of medicines to facilitate this also sits within the scope of practice of a midwife.

Midwifery Council 2020. The Midwifery scope of practice: Abortion services (March 2020) FAQs. Available at www.midwiferycouncil.health.nz/ midwives/practice-issues/midwiferyscope-practice-abortion-servicesmarch-2020-faqs

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FEATURE

the woman’s physical health, mental health, overall well-being, and the gestational age of the fetus.

The Midwifery Council has qualified that these women will require multi-disciplinary care, meaning the midwife must refer to and/or work in collaboration with obstetric services. Foeticide, a procedure undertaken to ensure that a baby is not born alive when the abortion is taking place beyond the gestation of potential viability, remains a skill performed only by maternal fetal medicine specialists.

• The midwife must advise the woman of the availability of counselling services • Counselling is not mandatory for the woman as a condition of obtaining an abortion.

CONSCIENTIOUS OBJECTION MIDWIFERY RESPONSIBILITIES

Including this skillset in the midwifery scope of practice means midwives have the ability, but not the obligation, to provide abortion services. with the provision of some care in abortion facilities or as part of secondary/tertiary services. However, it is a significant change in practice for midwives to be empowered to offer and provide abortion services on their own responsibility, when a woman is less than 20 weeks pregnant. Including this skillset in the midwifery scope of practice means midwives have the ability, but not the obligation, to provide abortion services.

Education is currently being developed, as specified by the Midwifery Council, to support all midwives to understand the legislation and their responsibilities under both the Health Practitioners Competence Assurance Act and the Abortion Legislation Act. Those midwives who choose to offer abortion services (including prescribing medications for abortions) will be required to undertake additional education.

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For women less than 20 weeks pregnant who request an abortion from a midwife: • Either the midwife must advise the woman how to access the closest provider of abortion services (considering both location and timeliness of service availability); OR the midwife may offer abortion care services (if she has undertaken the requisite education and meets the Ministry of Health abortions standards as a provider. The standards are currently being updated) • The midwife must advise the woman of the availability of counselling services • Counselling is not mandatory for the woman as a condition of obtaining an abortion.

Midwives have the right to conscientiously object to providing abortion services. In this case, the midwife must inform the woman of her conscientious objection and at the earliest opportunity, of how to access abortion services. Employers must accommodate any employee’s conscientious objection, unless it would disrupt the ability of the service to provide abortion care.

If an emergency occurs as part of the woman’s abortion process (or in any circumstance), midwives may not decline to provide prompt and appropriate assistance on the grounds of conscientious objection.

In this scenario, midwives have a professional and legal duty of care to the woman.

OTHER CONSIDERATIONS

For women more than 20 weeks pregnant who request an abortion from a midwife:

All abortions must be notified to the Director General of Health within one month of service provision and must not identify the woman’s name.

The legislation stipulates that a qualified health practitioner may only provide abortion services to a woman who is more than 20 weeks pregnant if the health practitioner reasonably believes that the abortion is clinically appropriate in the circumstances.

They must consult at least one other qualified health practitioner and have regard to all relevant legal, professional, and ethical standards to which the qualified health practitioner is subject; whilst considering

The Contraception, Sterilisation and Abortion Act 2020 revision states: “This Parliament opposes the performance of abortions being sought solely because of a preference for the fetus to be of a particular sex”. The Director General must review whether there is any evidence of abortions for sex selection within five years, and if found, make recommendations for preventing such a practice. Women are not required to provide a reason for seeking an abortion. square

FEATURE

CANNABIS IN PREGNANCY WHAT DO WE KNOW?

Cannabis law has been reformed in various countries around the world, with some countries decriminalising cannabis altogether, some legalising its medicinal use and others legalising it for recreational purposes. New Zealand recently undertook a referendum on the legalisation of recreational cannabis, and the majority of New Zealanders voted against the reform. This article is not about the pros or cons of legalising cannabis, but aims to update midwives on the current knowledge and evidence surrounding cannabis use in pregnancy.

LESLEY DIXON MIDWIFERY ADVISOR - PRACTICE ADVICE AND RESEARCH

WHAT IS CANNABIS? Cannabis comes from the Cannabis Sativa plant and is used to alter the mental state. It contains more than 120 chemicals known as cannabinoids. There are two well studied cannabinoids – these are: • CBD (cannabidiol) • THC (Δ9-tetrahydrocannabinol)

CBD is a non-intoxicating cannabinoid and has more of a medical benefit effect. It is thought to reduce anxiety, movement disorders and pain.

THC is the main psychoactive compound and is responsible for the altered mental state and ‘high’. It is distributed rapidly to the brain and metabolised by the

Research into cannabis use in pregnancy is challenging (due to its legal status) making it difficult to be certain about the specific effects during pregnancy.

liver; the half-life is 20-36 hours for occasional users and 4-5 days for heavy users. THC crosses the placenta and also appears in breastmilk. The proportion of THC and CBD in cannabis varies, dependent on the strain and growing conditions of the cannabis plant.

CANNABIS USE WITHIN THE NEW ZEALAND POPULATION A large number of people in New Zealand have tried cannabis, with use more common amongst tobacco users.

• 15 % of the population used cannabis in the previous 12 months in 2018/2019, which has increased from 8% in the 2011/12 year (Ministry of Health data explorer website).

• 29% of people aged between 15 and 24 years of age have used cannabis in the last 12 months (Ministry of Health data explorer website).

• A longitudinal study of a cohort of 1265 children born in Christchurch during 1977 found that 76.7% had used cannabis by the age of 25 (Boden, Fergusson, & John Horwood, 2006).

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We don’t currently have any statistics on the number or proportion of women who use cannabis during pregnancy in New Zealand, and therefore need to look at overseas studies to identify a potential prevalence.

THE ENDOCANNABINOID SYSTEM The endocannabinoid system (ECS) is a complex cell signalling system which plays a role in regulating a range of functions such as sleep, mood, appetite, memory, reproduction and fertility. It involves endogenous cannabinoids (endocannabinoids), endocannabinoid receptors, and enzymes.

There are two endocannabinoids identified (to date) known as anandamide (AEA) and 2-arachidonoylglyerol (2-AG).

These are hormones produced by the body, to help ensure the smooth function of the central nervous system (CNS), among other activities.

Cannabinoids influence the CNS through cannabinoid receptors. There are two known cannabinoid receptors (CB1 and CB2) which are designed to respond to endocannabinoids within the neural system.

• Studies are currently exploring the links between the ECS and pregnancy implantation, placentation and fetal neurological development.

• Animal studies have found that endocannabinoids are related to normal fetal brain development.

• The ECS in the fetus develops as early as 14 weeks gestation.

• Using exogenous cannabinoid (cannabis exposure during pregnancy) may disrupt normal brain development and function.

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addiction. It can lead to anxiety, sleeping problems, depression and appetite changes during withdrawal. One in five people who use cannabis develop CUD, although this increases if it is used at a younger age, used frequently, or more potent cannabis is used.

PREVALENCE OF CANNABIS USE DURING PREGNANCY? Research into cannabis use in pregnancy is challenging (due to its legal status) making it difficult to be certain about the specific effects during pregnancy. Generally, women will not voluntarily disclose their cannabis use if it is illegal. In addition, results are frequently confounded by tobacco use, other illicit drug use and socio-economic status, which limit the ability to identify an independent association. Studies are also often reliant on self-reports and/or recall bias. Frequency, timing and potency further muddy the waters for researchers.

We don’t currently have any statistics on the number or proportion of women who use cannabis during pregnancy in New Zealand, and therefore need to look at overseas studies to identify a potential prevalence. In most studies, the self-reported use during pregnancy ranges from 2-5% with use increasing over time.

A study from the USA involved 367,403 women screened for self-reported cannabis use before and during pregnancy as part of standard antenatal care (Young-Wolff et al., 2019). The authors found the prevalence of cannabis use during pregnancy had increased over the period 2009 to 2017 from 1.95% (95%CI, 1.78%-2.13%) to 3.38% (95%CI, 3.15%-3.60%).

WHY DO SOME WOMEN USE CANNABIS DURING PREGNANCY? Pregnant women may use cannabis as a way of managing stress and depression. YoungWolff et al. (2020) examined the association of depression, anxiety and trauma symptoms with the use of cannabis during pregnancy in a cohort of Californian women. They found higher odds of cannabis use associated with depression, anxiety and trauma and suggest that pregnant women were using cannabis to manage mood and stress. The odds of using cannabis increased with co-occurring depressive and anxiety disorder and a greater severity of depression.

CANNABIS EXPOSURE AND MATERNITY OUTCOMES At present there is no evidence to suggest that cannabis use is related to stillbirth or congenital anomalies.

A Canadian study (Ontario) used a retrospective cohort analysis, involving 661,617 women who gave birth between 2012 and 2017 (Corsi et al., 2019). They found that 9427 (1.4%) reported cannabis use during pregnancy. The primary outcome of interest was pre-term birth and they found pre-term birth was significantly higher (12%) for cannabis users compared to non-cannabis (6%) users. The matched cohort analysis found cannabis exposure was significantly associated with a risk difference (RD) of 2.98% (95%CI, 2.63%-3.34%) and an RR of 1.41 (95%CI, 1.36-1.47) for pre-term birth of less than 37 weeks gestation.

Cannabis exposure also appeared to increase the risk for the secondary outcomes of small for gestational age, placental abruption, neonatal transfer to neonatal care and a neonatal 5 minute Apgar score of less than 4 when compared to women who did not report cannabis use. The authors report that there could be potential confounding due to potential under-reporting of cannabis exposure.

A study from the USA explored the association of cannabis use during pregnancy and outcomes, for 5588 nulliparous women in a prospective cohort study (Leemaqz et al., 2016). They found that continued maternal cannabis use at 20 weeks gestation was associated with spontaneous pre-term birth independent of tobacco use and socio-economic index. When adjusted for maternal age, cigarette smoking, alcohol and social economic index, continued maternal marijuana use at 20 weeks gestation had a greater effect size [adj OR 5.44 (95% CI 2.44–12.11).

IMPACT ON BREASTFEEDING THC is excreted into breastmilk in small quantities (Baker et al., 2018), which raises concerns that cannabis use may have an impact on the baby’s nervous system development and endocannabinoid-related functions, in that growth, motor skill

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development and intellectual development may be affected. At present, there is insufficient long-term data to identify whether these concerns are warranted.

TALKING TO WOMEN AND GETTING HELP It is important that midwives provide clear messages to women about cannabis use: • Ask if the woman is routinely using drugs such as cannabis • Provide brief advice - identify the importance of stopping cannabis (or other drug) use during pregnancy and throughout breastfeeding • Explain that you are there to provide support for her • Explore the reasons for her cannabis use and whether cessation is being considered • Refer to support services – see box • Follow-up at subsequent appointments

IN SUMMARY Women who are pregnant should be advised to discontinue cannabis use during pregnancy and whilst breastfeeding. The use of cannabis during pregnancy appears to increase the likelihood of pre-term birth, and may also increase the risk of having a small for gestational age baby, the likelihood of a low 5-minute Apgar score, and the need for neonatal intensive care. Cannabis use may also disrupt the cannabinoid nervous system and may negatively affect longer term brain development for the baby. square

SUPPORT SERVICES New Zealand Alcohol Drug Helpline 0800 787 797 Pot Help – an online support resource for those struggling with cannabis use Drug Help – an online website providing information and support about alcohol and other drug use References available on request.

ISSUE 99 DECEMBER 2020 | 23

FEATURE

Right: Leigh Paparoa, Clinical Nurse Director Maori Health - Counties Manukau Health (left) and Hinewirangi Kohu-Morgan.

Māori midwifery research symposium highlights mātauranga Māori AMELLIA KAPA EDITOR, COMMUNICATIONS ADVISOR

In 2019, the Ministry of Health tasked Te Rau Ora with developing an evidence base to inform Māori workforce development priorities - with a specific focus on Māori women, babies and whānau. A collaboration was formed between Te Rau Ora, Ngā Maia o Aotearoa and Counties Manukau Health and the research insights spurred the creation of a new platform.

Te Aronga-a-Hine Māori Midwifery Symposium, held in July 2020 at Auckland’s Middlemore Hospital, was the first event of its kind. Māori midwife Heather Muriwai (Ngāti Ruanui, Tangahoe) hosted the event on behalf of Counties Manukau Health and says it exceeded her expectations. “The wairua, tautoko and manaakitanga unique to Māori midwifery events was palpable and uplifting.”

Officially opened by Minister of Māori Development, Hon Nanaia Mahuta, Heather describes the event as an opportunity for four key pieces of research to be presented:

For many of the Māori midwives present, the research findings presented what we have known forever. Our mātauranga Māori is evidenced within a multitude of Māori research frameworks.

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• Rapua te Aronga-a-Hine: a literature

review of the Māori Midwifery Workforce in Aotearoa (Te Rau Ora - Dr Hope Tupara & Megan Tahere)

• Kimihia te Aronga-a-Hine: qualitative

and quantitative surveys of the workforce industry (Te Rau Ora - Dr Kahu McClintock & Rachel McClintock)

• Whaia te Aronga-a-Hine - Nga Kaiwhakawhānau Māori: qualitative focus

group of Māori midwives (Ngā Maia O Aotearoa – Katarina Jean Te Huia )

• Whaia te Aronga-a-Hine - Nga Māmā:

kaupapa Māori analysis of the qualitative findings shared by māmā Māori of their experience of maternity care (Ngā Maia O Aotearoa – Beverly Te Huia) The initial literature review, Rapua te Arongaa-Hine, identified a multitude of barriers inhibiting the retention and advancement of Māori midwives within the profession.

The report highlighted a “severe underrepresentation of Māori across the midwifery sector”, stating Māori make up just 9.83% of Aotearoa’s midwifery workforce as of 2019.

Rapua te Aronga-a-Hine discusses Health Workforce New Zealand’s (HWNZ) projected 2029 goal - of Māori midwives comprising 17% of the total number -

stating this would require an increase of an additional 37 Māori midwifery students commencing the degree per year, from 2021.

Kimihia te Aronga-a-Hine suggests the development of strong partnerships between midwifery schools, HWNZ and iwi Māori communities is the surest way to ensure not only increased Māori participation in midwifery programmes, but successful retention of these students once they have commenced study.

The same report calls for cultural supervision and professional development opportunities such as support to learn te reo Māori as retention strategies for keeping more Māori midwives in practice. It also implies that in order to further develop the Māori health workforce engaging with Māori mothers, babies and whānau, improvement is needed in recruitment and retention processes, by incorporating te Tiriti o Waitangi and prioritising the cultural competency of all health workers.

This recommendation comes after the report reveals only around two-thirds of respondents to the workforce survey recall being asked about te Tiriti o Waitangi during the recruitment process, and only 59.6% recall having their cultural competency assessed.

While Heather, Counties Manukau Health

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Clinical Lead Advisor – Māori Midwifery, says many of the insights gleaned from the research were unsurprising, she highlights the value of evidence when building a case.

“For many of the Māori midwives present, the research findings presented what we have known forever. Our mātauranga Māori is evidenced within a multitude of Māori research frameworks.”

Attended by 103 participants, most of whom were midwives and student midwives, the audience also included other health professionals working with Māori women, babies and whānau, such as Māori mental health professionals, NGO providers and health researchers.

Heather says the symposium also served as a stage for other wāhine Māori to share their insights, such as Hinewirangi Kohu-Morgan’s presentation on spiritual health, based on te ao Māori and her life experiences. “Every presentation was powerful in its own unique way, adding richness to both the Māori midwife and Māori midwifery experience”, says Heather.

New Zealand College of Midwives President Nicole Pihema attended the event, and says it was a great opportunity to celebrate Māori researchers. “It’s not just about the contribution they make to the profession, but ultimately, to women.”

Heather, who has been a midwife for 23 years, says one of the highlights of the symposium was having the “hardships and value of Māori midwifery” recognised at a national event, as well as having the honour of hearing Hon Nanaia Mahuta share her personal journey of pregnancy, birth and motherhood with the attendees.

The final proposal presented back to HWNZ suggests the establishment of a National Māori Maternal and Child Health Workforce Strategy, which Heather explains would attempt to “ameliorate the Māori health and workforce differences, by expanding the Māori maternal health care continuum”. Heather states the feedback from MOH thus far indicates the purpose of providing an evidence base for future workforce development has been fulfilled, and the ball is now firmly in their court. square

ISSUE 99 DECEMBER 2020 | 25

FEATURE

Birthing through lockdown and beyond THROUGH A MIDWIFEâ&#x20AC;&#x2122;S LENS Queenstown-based LMC Sharon White (bottom right) has branched out into birth photography this year and generously offered to share a collection of moments captured throughout 2020. During lockdown in particular, with homebirths on the rise, Sharon was able to explore the art and science of birth through a new lens.

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ISSUE 99 DECEMBER 2020 | 27

FEATURE

Top to bottom: Emma Hau, Kayla Stephen, and Monique Owen.

college gives students final boost AMELLIA KAPA EDITOR, COMMUNICATIONS ADVISOR

Each year, the college awards undergraduate grants to midwives in the making - in recognition not only of their hard work, but the loss of income they endure over the course of their education. Three students nearing the finish line share how these grants have made a difference.

Monique Owen is in her third and final year of study and admits her emotions as she approaches the next stage of her midwifery journey are mixed. “I’m quite nervous about the reality of being a registered midwife and the level of responsibility I’ll be taking on, but I’m also excited.”

Hailing from the sunny Hawkes Bay, Monique has made the wise decision to keep her grant money aside, for costs she knows will arise at an already stretched time of year. “I’m saving it for the national exam fee and the cost of my first annual practicing certificate. Wintec has forewarned us about the expenses at the end of the degree, and obviously I won’t have been earning. Plus it’s around Christmas time. So I’m saving the grant for that.”

Emma Hau, also in her final year of study, used her grant to gain new clinical insights.

The College grant has helped ease the burden, says Kayla, as she enters the final phase of her midwifery student journey.

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Usually based in Taranaki DHB, Emma completed three months of clinical placement in West Auckland with a busy LMC practice this year, and says the grant helped her to cover the associated costs of travel and rent. “I think that’s the whole point – the grant allows you to do those things. In terms of my learning, it’s been really valuable.”

Emma says the grant also enabled her to catch up on clinical requirements like facilitated births – something she may not have been able to achieve quite as easily, had she not travelled to Auckland. “I managed to get all my clinical numbers while I was up there, so that’s been a huge relief. I also had the chance to work with a more diverse range of women from different cultures, which I really enjoyed.”

Like fellow student Monique, Emma also experiences a spectrum of feelings about the next stage. “Some days it’s surreal.

Other days I just can’t wait to be done.” She plans to complete her MFYP programme as a core midwife in a secondary facility, where she believes she can consolidate her knowledge. “I want a broad knowledge of everything and to understand both worlds – normal and complex.”

Christchurch based third-year student Kayla Stephen also received a College grant

this year and has taken a leaf from both Monique and Emma’s books, using part of it to cover national exam fees, and the remainder to cover additional costs associated with her rural placement.

Speaking from the South Island’s remote West Coast region at the time of this interview, Kayla explains: “the logistics of being in the West Coast means I’m doing a lot of travel in my own car - which translates into high petrol costs”.

Kayla is a mother of one and says despite having a wonderful family support system, childcare costs are still a factor, further stretching an already tight budget. “Overall it’s such an expensive degree. And most people have already drained their savings by third year - so to have the additional costs makes it very hard.”

The College grant has helped ease the burden, she says, as she enters the final phase of her midwifery student journey. “It is a bit surreal and very daunting”, she says, adding “there are still a few hurdles to jump over, but when I look back at what I’ve achieved, I’m so proud”.

Kayla’s parting words in our interview were heartfelt. “I’m immensely grateful for the grant and want to thank the College. It’s been hugely helpful.” square

reading room A selection of recently published books on a variety of midwifery-related topics SQUARING THE CIRCLE: NORMAL BIRTH RESEARCH, THEORY AND PRACTICE IN A TECHNOLOGICAL AGE - EDITED BY SOO DOWNE AND SHEENA BYROM A collection of chapters with a global focus, written by clinical and non-clinical academics.

Includes updated understandings of childbirth physiology, birth environments, the technological and political context of childbirth, and a section on making change happen.

Authors include New Zealand midwifery scholars Lorna Davies and Susan Crowther.

SUSTAINABILITY, MIDWIFERY AND BIRTH EDITED BY LORNA DAVIES, REA DAELLENBACH AND MARY KENSINGTON This new edition has been revised to include the latest models of sustainable midwifery practice, as well as new chapters on rural midwifery, social justice and compassion. Written by a collection of international experts, the book explores the politics of midwifery and sustainability, ecological approaches to parenting and much more. The editors are New Zealand midwifery educators.

BIRTHING OUTSIDE THE SYSTEM: THE CANARY IN THE COAL MINE - EDITED BY HANNAH DAHLEN, BASHI KUMAR-HAZARD AND VIRGINIA SCHMIED Explores the decision made by many women worldwide each year to birth with an unregulated care provider or completely unassisted.

Examining the drivers of these decisions and bringing both legal and ethical perspectives to the discussion, the book also draws on the latest research regarding high-risk homebirth.

OVERDUE: BIRTH, BURNOUT AND A BLUEPRINT FOR A BETTER NHS - AMITY REED Amity Reed shares a well-known tale of becoming a midwife with ideals of best serving the women whose lives she would touch, only to have those dreams shattered by the stark reality of working in the under-resourced NHS. This book asks the question in the forefront of many midwives’ minds: how can we honour our calling without burning out, when the system is broken at its core?

INFORMED IS BEST: HOW TO SPOT FAKE NEWS ABOUT YOUR PREGNANCY, BIRTH AND BABY - AMY BROWN This book aims to guide women as they navigate the sea of information available to them regarding pregnancy, labour, birth and the postnatal period, by sharing advice on how women can best evaluate research or evidence and cut through to what really matters to them and their families.

LET’S TALK ABOUT YOUR NEW FAMILY’S SLEEP - LYNDSEY HOOKWAY A holistic guide to sleep for families which aims to empower parents, encouraging calm and compassionate parenting. This book prioritises infant and child mental wellbeing and attachment, whilst remaining practical about the realities of parenting in a modern society.

UNDERSTANDING ANXIETY, WORRY AND FEAR IN CHILDBEARING - EDITED BY KATHRYN GUTTERIDGE Aimed at midwives and clinicians working in maternity settings, this book reviews the evidence around how modern maternity is responding to women’s fear surrounding childbirth. Includes exploration into the potential causes of increasing maternal anxiety levels and provides practical advice for practitioners.

EXAMINATION OF THE NEWBORN AND NEONATAL HEALTH: A MULTIDIMENSIONAL APPROACH - EDITED BY LORNA DAVIES AND SHARON MCDONALD This second edition contains comprehensive information on the evidence, care and treatment of the newborn, with a focus on normal anatomy and physiology and what to expect during the routine newborn assessment. Concepts such as epigenetics and the microbiome are explored along with the potential psychosocial and emotional impacts for families in the event of unexpected findings. Authors include a number of New Zealand midwives and educators. square

ISSUE 99 DECEMBER 2020 | 29

FEATURE

practice update considering wound care in midwifery practice ELAINE GRAY MIDWIFERY ADVISOR

Over the past couple of years at the College’s A-Z of perineal care and Safety and sensitivity in postnatal workshops, it has become increasingly evident midwives are seeking up-to-date guidance on wound care.

There is limited literature specifically for midwives on postnatal wound care, and whilst there is more guidance relating to perineal wound care, information relating to caesarean wounds up to six weeks postnatal is particularly limited. As midwives, it is imperative we have a clear understanding of the physiological processes involved in wound healing and our role in wound care.

In addition to highlighting the importance of this aspect of midwifery care, this article is an opportunity to introduce a new e-learning opportunity under development in FlexiLearnz. The e-learning module will explore wound healing; optimal healing conditions including nutrition and its impact and the immune system, with a specific focus on perineal injury and caesarean section wounds. The aim of the e-learning will also be to promote general wellbeing after birth, which supports wound healing, and will address common complexities such as sepsis and wound dehiscence. Infection control practices and prescribing of analgesia will also be revisited in the module.

WHY IS IT IMPORTANT? Midwives have an important role to play in the postnatal care of women who have perineal and/or caesarean section wounds.

Sepsis after childbirth can lead to significant maternal morbidity and maternal wounds are a potential source of infection. Whilst it is hoped that not many midwives will see or provide care to women with serious wounds, the increasing rate of caesarean

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sections and assisted births in maternity indicates midwives are monitoring more postnatal wounds now, than ever before.

The latest Clinical Indicators (MOH, 2020), show primigravida women are increasingly likely to have a wound following childbirth: either a perineal injury or caesarean section.

The 2017 Report on Maternity (MOH, 2019) highlights that approximately 44% of all women birthing in 2017 had either a caesarean or perineal wound.

WHAT IS A WOUND? A wound is defined as a bodily injury caused by physical means, with disruption of the normal continuity of structures; basically any break in the skin can be called a wound (Steen, 2007).

HOW DO WOUNDS HEAL? There are three ways in which wounds can heal: • Primary intention: This

occurs when the wound edges are brought together by

suturing or staples. This ensures that there is close approximation of the tissue and no 'dead' space, therefore there is minimal granulation tissue necessary.

• Secondary intention: Occurs

where there is tissue deficit, requiring the formation of granulation tissue and wound contraction.

This can result in increased amounts of dense, fibrous scar tissue and as such, healing also takes longer.

• Third intention: This

type of healing occurs when a contaminated wound is initially kept open by packing, allowing a good inflammatory response. This usually occurs when there is delayed primary healing.

Wound healing can be considered as the restoration of function of injured tissue.

Whilst wound care practices are constantly being reviewed, our understanding of the physiology of wound healing appears to have remained constant. There are four stages to wound healing, and as midwives it is

STAGES OF WOUND HEALING The impacts of wounds following childbirth are associated with increased pain, which can vary from mild to severe. The long-term morbidities of either caesarean section or perineal wounds can have long-lasting effects for women and it is imperative that any deviations from the norm are identified quickly, to prevent any further complications. Midwives are the key health care providers for women in the postnatal period and considering wound care will enhance and support women and their wellbeing.

STAGE 1: HAEMOSTASIS

STAGE 2: INFLAMMATION

STAGE 3: PROLIFERATION

STAGE 4: REMODELLING

PRACTICE UPDATE

important to consider how we can inform/ support women to maintain healthy wound healing and recognise the significance of the different stages. Each is a complex process, which can be affected by a multitude of other factors, and the final stage of remodelling usually commences around three weeks; but it can also take up to two years. Understanding the healing process will also enable midwives to support decisionmaking in future pregnancies and consider the woman’s perspective. A full exploration of wound healing will be shared and discussed in the e-learning. We will inform all members once FlexiLearnz is 'live'. square

syphilis in pregnancy: new guidelines CLAIRE MACDONALD MIDWIFERY ADVISOR

The New Zealand Sexual Health Society (NZSHS) recently published its antenatal management guidelines for maternal and congenital syphilis. The NZSHS sought College of Midwives feedback throughout and incorporated all suggestions; the final result is a comprehensive, multidisciplinary guideline which can be read in full via the College website. This article focuses on the specific points relevant to midwifery practice.

Syphilis is caused by Treponema pallidum, a highly motile, spiral-shaped Gram-negative bacterium. It is transmitted by direct contact with an infectious lesion, for example during sexual activity, or by vertical transmission (transplacental) during pregnancy. Syphilis is a multi-stage, multi-system disease.

Complications of syphilis during pregnancy include increased rates of miscarriage, stillbirth, premature birth, neonatal death, low birth weight, small size for gestational age, and congenital syphilis.

Congenital syphilis includes a spectrum of developmental, medical, nervous system, skeletal and morphological anomalies. The risk of congenital syphilis is directly related to the stage of syphilis (primary, secondary, latent, or tertiary) during pregnancy and the duration of exposure for the fetus. Early diagnosis and treatment is therefore critical to successfully reduce the short and long-term risks to the woman and baby.

Congenital syphilis was, until very recently, extremely rare in Aotearoa New Zealand.

However, since 2015 there has been a significant and rapid increase in the incidence

of syphilis infections in the community, and congenital syphilis cases have started to re-emerge with 14 cases reported since 2016.

Furthermore, this is an equity issue that speaks to our collective responsibility as health practitioners under Te Tiriti o Waitangi, with a disproportionate burden of congenital syphilis experienced by whānau Māori.

TEN POINTS FOR MIDWIVES FROM THE GUIDELINE 1. Recommend screening for syphilis to all pregnant women at the midwifery registration visit as part of the first antenatal screen, if this has not already been done.

2. Make an urgent referral of all women who have reactive syphilis serology in pregnancy to a clinician with expertise in managing syphilis. This will typically be to the local Sexual Health Service or Infectious Diseases Service.

3. The treating clinician service is responsible for undertaking ESR (Institute of Environmental Science and Research) notification and contact tracing. Midwives and other primary maternity service practitioners, who order syphilis screening as part of pregnancy care, are not expected to complete the ESR notification for positive results but are expected to refer to a specialist service.

4. Syphilis during pregnancy is a consultation level referral in the Referral Guidelines.

This means that at the time of the consultation, the responsibility for maternity care remains with the LMC. The specialist works in collaboration with the LMC and makes a care plan including treatment and neonatal follow-up, in a three-way conversation between the specialist, the LMC and the woman.

5. Women who are treated for syphilis in pregnancy can expect to have usual intrapartum care for labour and birth.

6. Standard contact precautions are recommended for all women during birth, including newborns with suspected or confirmed congenital syphilis. Contact precautions should be taken when caring for women or babies with congenital, primary, and secondary syphilis with skin and mucous membrane lesions until 24 hours of treatment has been completed.

nurses, contact tracers (public health), obstetricians, paediatric and neonatal teams, primary care teams’ social workers, community care workers and Well Child Tamariki Ora nurses.

10. Because syphilis can be acquired at any time, it is recommended that midwives have a low threshold for offering rescreening to pregnant women. There is no consensus at this stage about routine re-screening. In the interim, the following indications have been identified where there is potentially a higher risk, and re-screening should be recommended. square

INDICATIONS TO RECOMMEND ADDITIONAL SYPHILIS TESTING (AFTER FIRST ANTENATAL SCREEN) RE-SCREEN AT 28-32 WEEKS IF: Nil or inconsistent antenatal care.

A sexually transmitted infection (STI) diagnosed during the past year.

Current recreational drug use.

Incarceration in the past year.

Currently experiencing homelessness or no fixed abode.

Multiple sexual partners.

A sexual partner who has any of the following risk factors: STI in past year, multiple sexual partners, current recreational drug use, recent incarceration, homelessness or is a man who also has sex with men.

SCREENING AT OTHER TIME POINTS Any woman who has had a stillbirth at 20 weeks gestation or later. Test at the time of birth.

Any pregnant woman admitted to a maternity hospital without a documented syphilis test result. Ensure testing is undertaken prior to discharge.

Any time at the request of the pregnant woman.

7. The guideline provides advice on care and handling of the whenua/placenta.

8. Breastfeeding is recommended unless there is an active syphilis lesion on the breast.

9. A successful outcome requires a coordinated multidisciplinary approach involving midwives, sexual health or infectious disease physicians, sexual health

ISSUE 99 DECEMBER 2020 | 31

BREASTFEEDING CONNECTION

BREASTFEEDING CONNECTION This edition of Aotearoa New Zealand Midwife offers a selection of current breastfeeding articles which may be of interest to midwives.

CAROL BARTLE POLICY ANALYST

interventions for preventing mastitis after childbirth Crepinsek, M. A., Taylor, E. A., Michener, K., Stewart, F. (2020). Interventions for preventing mastitis after childbirth. Cochrane Database of Systematic Reviews, Issue 9. Art. No.: CD007239.

DOI: 10.1002/14651858.CD007239.pub4.

alternative therapies, suggests these may be little better than routine care for preventing mastitis but our conclusions are uncertain due to the low certainty of the evidence.

ABSTRACT

Future trials should recruit sufficiently large numbers of women in order to detect clinically important differences between interventions and results of future trials should be made publicly available.

Objectives: To

Full article: https://www.cochranelibrary.com/

assess the effectiveness of preventive strategies (for example, breastfeeding education, pharmacological treatments and alternative therapies) on the occurrence or recurrence of non‐infective or infective mastitis in breastfeeding women post‐childbirth.

Authors' conclusions: There

is some evidence that acupoint massage is probably better than routine care, probiotics may be better than placebo, and breast massage and low frequency pulse treatment may be better than routine care for preventing mastitis.

However, it is important to note that we are aware of at least one large trial investigating probiotics whose results have not been made public, therefore, the evidence presented here is incomplete.

The available evidence regarding other interventions, including breastfeeding education, pharmacological treatments and

Over recent years the concept of “posterior” tongue tie as a reason for feeding difficulties in newborns appears to have gained popularity, particularly among various online parenting forums and breastfeeding support networks.

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cdsr/doi/10.1002/14651858.CD007239.pub4/full

posterior tongue tie: the internet phenomenon driving a lucrative private industry Fraser, L., Benzie, S., & Montgomery, J. (2020).

Posterior tongue tie: the internet phenomenon driving a lucrative private industry. The BMJ Opinion, October.

EXTRACT Division of a tongue tie is a fairly wellestablished and safe procedure and involves division of the visible frenulum using sharp dissection scissors, usually in an ENT outpatient setting. A Cochrane review from 2017 suggested a reduction in maternal nipple pain, but recommended further randomised controlled trials of high methodological quality to investigate further the impact on infant breastfeeding.

A recent Canadian review suggested that tongue-tie division likely has a positive impact on maternally reported or perceived breastfeeding effectiveness in the short-term, but that benefit is less clear for long-term outcomes and objective measurements of breastfeeding effectiveness.

Over recent years the concept of “posterior” tongue tie as a reason for feeding difficulties in newborns appears to have gained popularity, particularly among various online parenting forums and breastfeeding support networks. Definition varies, but the

concept is generally thought to represent a tight non-visible submucosal band of tissue at the very base of the ventral tongue that is palpated rather than seen. This is very different from the classically reported “anterior” tongue tie which is usually easily visible and simple to divide. As yet, there is no definitive anatomical study or robust definition within the literature, nor evidence to prove a causal relationship of posterior tongue tie with feeding difficulties in affected babies. For this reason, posterior tongue tie is generally not recognised or treated currently by professionals within the NHS setting.

Despite this, there appears to be a large industry of private practitioners in the UK that have emerged who offer to deal with the ailment, usually for a fee of several hundreds of pounds. A quick online search uncovers scores of private practitioners willing to travel to assess and treat newborns for posterior tongue tie, offering hope to struggling mothers desperately researching online for ways to help their baby feed better.

Full article: https://blogs.bmj.com/ bmj/2020/10/02/posterior-tongue-tie-theinternet-phenomenon-driving-a-lucrativeprivate-industry/

mistakes from the HIV pandemic should inform the COVID-19 response for maternal and newborn care Gribble, K., Mathisen, R., Ververs, M., & Coutsoudis, A. (2020). Mistakes from the HIV pandemic should inform the COVID-19 response for maternal and newborn care. International Breastfeeding Journal, 15(67): https://doi. org/10.1186/s13006-020-00306-8

ABSTRACT Background: In

an effort to prevent infants being infected with SARS-CoV-2, some governments, professional organisations, and health facilities are instituting policies that isolate newborns from their mothers and otherwise prevent or impede breastfeeding.

Weighing of risks is necessary in policy development: such policies are risky as was shown in the early response to the HIV pandemic where efforts to prevent mother to child transmission by replacing breastfeeding with infant formula feeding ultimately resulted in more infant deaths.

In the COVID-19 pandemic, the risk of maternal SARS-CoV-2 transmission needs to be weighed against the protection skinto-skin contact, maternal proximity, and breastfeeding affords infants.

BREASTFEEDING CONNECTION

Conclusion: Policy

makers and practitioners need to learn from the mistakes of the HIV pandemic and not undermine breastfeeding in the COVID-19 pandemic. It is clear that in order to maximise infant health and wellbeing, COVID-19 policies should support skin-to-skin contact, maternal proximity, and breastfeeding.

Full article: https:// internationalbreast feedingjournal.biomedcentral.com/ articles/10.1186/s13006-020-00306-8

knowledge and practice of induction of lactation in trans women among professionals working in trans health Trautner, E., McCool-Myers, M. & Joyner, A.B. (2020). Knowledge and practice of induction of lactation in trans women among professionals working in trans health. International Breastfeeding Journal 15(63): https://doi. org/10.1186/s13006-020-00308-6

ABSTRACT Background: Breastfeeding

is emerging as an important reproductive rights issue in the care of trans and gender nonconforming people. This study sought to understand the tools available to professionals working in the field of trans health to help trans women induce lactation and explore the concept of unmet need.

Results: We

surveyed 82 respondents (response rate 10.5%), the majority of whom were healthcare professionals (84%). Average age of respondents was 42.3 years old. They represented 11 countries and averaged 8.8 years of work at 21.3 h/week with trans populations. Healthcare professionals in this sample primarily specialized in general/int ernal medicine, psychology, endocrinology, and obstetrics/gynaecology.

One-third of respondents (34%) stated that they have met trans women who expressed interest in inducing lactation. Seventeen respondents (21%) knew of providers, clinics, or programs that facilitated the induction of lactation through medication or other means. Seven respondents (9%) have helped trans women induce lactation with an average of 1.9 trans women in the previous year. Two protocols for lactation induction were mentioned in free text responses and 91% believe there is a need for specialized protocols for trans women.

Full article: https://internationalbreast feedingjournal.biomedcentral.com/ articles/10.1186/s13006-020-00308-6 square

ISSUE 99 DECEMBER 2020 | 33

SECITION 88 UPDATE

SECTION 88 STOCKTAKE WHERE ARE WE AT?

The Ministry of Health has just closed a consultation on proposed changes to the Section 88 contract, as a means to administer an additional $21.25 million per annum of primary maternity funding. Amellia Kapa speaks to College CE Alison Eddy about the consultation.

AMELLIA KAPA EDITOR, COMMUNICATIONS ADVISOR

To inform its response to the Ministry (of Health) on the Section 88 proposal, the College: Provided members with a briefing paper, summarising the proposed changes and comparing them with the changes put forward under the mediation agreement in 2019; conducted a member survey; consulted members on our draft submission and attended regional Zoom meetings, to engage directly with and hear from members about their views on the proposal.

When the Section 88 consultation was first announced, self-employed midwives had high hopes. Although this is not what the profession was expecting, and the pace of progress towards a new contract model has been slow, what has been achieved to date?

Firstly, it’s worth pointing out that prior to the Ministry’s proposed changes to Section 88, a number of gains had already been made as a direct result of the College’s work under the mediation agreement.

Since 2015, when the College first lodged the court case against the Ministry, there have been a number of percentage increases across the board - to all midwifery funding modules within Section 88. The 2nd midwife fee and business contribution payment have been introduced, and further price increases for rural travel and 3rd trimester care have been claimable since 1st July.

Many of the recommendations from the

34 | AOTEAROA NEW ZEALAND MIDWIFE

co-design actually have, or are, being adopted. The Ministry has picked up on a number of the issues the College has highlighted in the recent consultation. For example, the Ministry’s proposed changes to Section 88 sought to address a number of aspects of currently unpaid work; the poor timing of payments, and the lack of reimbursement for care provided to women with complex needs.

Our mediation agreement with the Ministry required them to have a new primary midwifery contract - as an alternative to Section 88, with a blended payment model - in place by 1st July 2020. Clearly, the Ministry has breached its agreement with the College yet again, and as per the terms of the mediation agreement, the College is meeting with them formally in early November.

At the time of writing, no outcome is available, but members can be assured

the College is doing all it can to hold the Ministry to account.

In your opinion, which areas of Section 88 require the most review?

It’s clear women with more complex needs are not at all well served by the current one-sizefits-all structure of Section 88 - particularly in the antenatal period. Overall, antenatal care is very poorly paid, considering the amount of work that goes into that aspect of midwifery practice. So the Ministry’s proposals to improve the timeliness of payments; to include a registration payment, and to recognise miscarriage/early pregnancy loss, are welcomed. The proposal also sets out additional modules for women who require more visits in pregnancy. The feedback from the College’s member survey on the Section 88 consultation was clear; that the thresholds set by the Ministry to enable these modules to be claimed were too high. Members also noted

SECITION 88 UPDATE

concerns that the number of visits alone does not adequately reflect the complexity of care, nor the actual time spent providing the service.

The strongest feedback from members concurred with the College’s long-standing concerns about the lack of acute call-out payments for non-labour related urgent needs.

This is a major omission on the Ministry’s part and something the College advocated strongly for in our feedback.

In some instances, the labour and birth module creates issues at the interface between self-employed midwives and core staff. What are the potential solutions?

It’s important to view this through a historical lens. I know from my own experiences as an LMC in the late 90s-early 2000s; it was expected that LMC midwives would provide continuity of care during labour, regardless of labour length or complexity. Over time, sadly, women’s needs have become more complex and the expectation of LMCs to continue to practice in this manner is unreasonable and unsustainable.

Access agreements require midwives to state their intentions in relation to the provision of epidural care and/or oxytocin augmentation or induction. Over time, this has translated into more LMCs choosing not to provide this care in order to practice sustainably; however, the flip side of this is an erosion of continuity of care (which evidence strongly indicates improves intrapartum outcomes for women) and an increased workload for the already under-staffed core workforce. In some regions, the withdrawal of LMCs from this care has been a lightning rod for friction at the interface.

A strong theme in the member survey feedback was ‘fair pay for work done’. Many midwives commented that they felt aggrieved they were being paid the same amount as their colleagues, who, for example, may have only provided care for two hours - until the woman required an epidural, at which point they handed over and left the facility. I think as a profession, we have allowed these secondary care tasks to become our focus, rather than the woman’s needs. The College strongly supports the LMC’s rights to hand over care to a secondary/tertiary service; however, we need to consider the unintended consequences of this becoming the norm in every labour where an epidural or oxytocin administration is required.

Amongst the work completed in 2019 under the mediation agreement, the College and Ministry developed an additional labour and birth module, (alongside the existing one)

enabling collaborative care (LMC working alongside core colleagues when women have more complex needs), with a graduated payment schedule, dependent on the time spent by the LMC. The Ministry did not take up this suggestion in its proposed changes and has instead proposed that midwife LMCs should be able to claim a reduced labour and birth fee (as obstetrician LMCs currently do) for attending the birth only. The College considers this would undermine continuity of care for women and create more friction at the interface. Member survey feedback indicated support for a more timely and graduated payment model over the Ministry’s suggestions. Neither solution is perfect, with disadvantages to both options. The College submitted that further consultation was needed to finalise this aspect of the Notice.

The MoH are proposing that the access agreement be removed altogether from the notice. What are the possible ramifications of this?

Prior to the current arrangement of the access agreement being a nationally mandated document through the notice, DHBs had many and varied requirements and interpretations of what should be required of LMCs to be able to gain an access agreement.

It was fraught and many practitioners were unjustifiably denied access to facilities, which resulted in difficult and protracted processes to try to address this. There needs to be a simple, fair and straight-forward process for LMCs to gain access to facilities, and discussions regarding workforce issues and interface tensions between community-based care and hospitals need to occur elsewhere.

Removing the access agreement from the notice would shift the negotiation power to DHBs. It is unclear what the process for negotiating the access agreement would be, or that it would remain a national document.

The College strongly opposed this change.

Travel costs for self-employed midwives have risen significantly over the years and Section 88 makes no allowances for this.

What’s the solution?

It’s great to see the Ministry proposing reimbursement for travel costs; however, members have expressed concerns about the administrative feasibility of the Ministry’s proposal. There are also issues with the eligibility criteria for this funding; for example, it’s proposed that travel to labour and birth attendance will not be claimable, yet rural midwives often travel great distances to either primary units or base hospitals to attend labours. It’s also proposed that reimbursement only applies to travel to

the midwife’s usual clinic location. This will also disadvantage rural midwives, who often have multiple clinic locations.

Members also identified in their feedback that without knowing the proposed amount of reimbursement, it’s impossible to know whether it will sufficiently cover the costs.

What was the general feedback from rural midwives about the proposed changes?

Given the recent short term increases into Section 88, a number of rural midwives are uncertain whether the proposal will mean they are better or worse off in the longer term. Out of the $21.25m allocated into the budget per annum, $6m is supposed to be specifically for rural maternity care provided by midwives. It’s unclear how the Ministry intends to achieve this with its current travel reimbursement proposal. Many midwives noted that the current postnatal rural travel fee is a proxy or adjuster for rural practice, not just for rural postnatal care. The College, through its research, notes the GP rural ranking scale (points system - based on the rurality of the practitioner as opposed to the domicile of the woman) has real potential to be adapted for rural midwifery. This is a change from the current model in Section 88, which assigns a fee to the woman’s rurality, as opposed to the practitioner’s rurality.

Incentivising rural midwives to live and work within rural communities is what we should be aiming for; neither the current model, nor the Ministry’s proposed model will achieve this, but a rural ranking scale will.

Where to from here?

Overall, once the $6m rural funding is taken out, leaving $15.25m per annum, this equates to approximately an additional $300 per pregnancy. This doesn’t seem anywhere near enough to accommodate all of the new modules and reimburse midwives fairly for travel costs and other expenses. Midwives have indicated they would prefer to have the business contribution payment continuing and this would be a good solution from the College’s perspective, as it fits with the co-design recommendations. The Ministry is proposing that once the consultation on the Section 88 service specification is complete, there will be a negotiation about the prices assigned to the modules.

At this stage, the College has no sense of how much money the Ministry is intending to allocate against the various modules. The intention is to have the new notice in place by 1st April 2021. The College considers that the proposal needs considerable further work, and a deadline of 1st July 2021 is more realistic. square

ISSUE 99 DECEMBER 2020 | 35

SCOPUS UPDATE

Scopus database to include the New Zealand College of Midwives Journal in 2021 Strong grip

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Scopus is a widely used and well known research database that helps researchers to find relevant research when searching for evidence. It is easy to navigate and includes up to 194,000 books and 24,600 peerreviewed journals. Subjects covered in Scopus are health sciences (25%), life sciences (16%), social sciences (32%) and physical sciences (27%).

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The editors of the journal are pleased to announce the inclusion of the journal in the Scopus abstract and citation database. This will increase the visibility of the journal and make it more accessible to an international audience.

As part of the acceptance process, the journal was assessed by the Content Selection & Advisory Board (CSAB) who stated:

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The editorial teams over time are to be commended on their ongoing development of the journal. This is a major achievement.”

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• The journal has scholarly relevance as evidenced by citations in other journals currently covered by Scopus.

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• The abstracts are generally clear and provide an excellent summary of each article’s content.

• The articles are consistently of high academic quality, consistent with the journal’s stated aims.

• The articles are generally well written and understandable.

• Excellent citedness (cited by other authors) of the papers in this journal over a period of time. Papers have stood the test of time.

HAVE YOUR PAPER PUBLISHED IN THE JOURNAL The editors are interested in publishing work from midwives undertaking post-graduate papers as well as from those involved in masters and doctoral research. The journal editorial team can provide support for those who are new to writing for journal publication. For submission guidelines, go to https://www.midwife.org.nz/midwives/ publications/college-journal/how-to-submit/ PRINTING OF THE JOURNAL Historically, the journal has been printed and distributed with the Midwife Aotearoa New Zealand magazine (previously Midwifery News) in December of each year, however as with many other publications, the College Journal has gradually been moving toward an online format. The Journal Editorial Board has now made the decision to discontinue the printed edition of the journal, in the interest of environmental sustainability. Each paper is now published and sent to members electronically as soon as it has been accepted for publication.

All papers and journal editions are accessible on the College website at https://www.midwife.org.nz/midwives/publications/collegejournal/journal-issues/

FROM BOTH SIDES

my midwifery my midwife Fa’afana Temese-To’omaga is a community midwife at Wellington Regional Hospital, whose initial involvement with the Pacific Breastfeeding Service set her on a path to make a midwifery dream a reality... "Ole ala i le pule o le tautua” - The way to authority is through service.

Born and raised in Wellington, Fa’afana, or ‘Fana’, as she is affectionately known amongst her colleagues, always knew she wanted to be a midwife, but says she didn’t think she had what it took to become qualified. “So I just sat on it for years”, she explains. It was only after joining the DHB’s Pacific Breastfeeding Service (PBS) that she met the midwife who would become her biggest support.

“During my time with PBS I worked with Ligi Igasia Holford, LMC, LC and Pacific community leader. As well as my friend, she became my mentor and pushed me into applying to Otago Polytech to do my midwifery study.”

Raised by her Samoan mother, whose heritage can be traced to the villages of Moata’a, Fagaloa and Vavau, Fana has now been practicing midwifery for five years, recently taking up a role in Capital & Coast DHB’s community midwifery team, after previously working as a core midwife.

The change has presented its challenges, says Fana, such as adjusting to working in a different environment. “Although we are a strong, wellfunctioning team of 15 experienced midwives working autonomously within a supportive group framework - we work alone most days. This has probably been the biggest surprise for me.”

“Being on the floor meant always being surrounded by colleagues - having face-to-face support when needed. I’m a team player and really enjoy working with my colleagues as well as working with women.”

Fana - a mother of five – particularly appreciates the opportunity to work with women and families she can relate to, and who can relate to her. “I love working in my community and working with Pacific and Māori families. I am one of them”, she says.

Fana is constantly aware of the gap in the midwifery workforce, where more Pacific midwives should be. “Obviously there are not enough Pacific midwives in Wellington”, she says, “but I’ve chosen to channel my energy into building and strengthening the Pacific midwives we currently have; developing my own leadership capacity and taking whoever is keen along with me. I choose to view my midwifery through a Pacific lens; in order for change, we must explore how we might practice as Pacific midwives in a way that incorporates different ways of knowing.”

Recently completing her Postgraduate Certificate and Diploma in Specialty Care (Pacific Health), Fana is now considering embarking on a Masters in Professional Practice (Pacific Leadership) in order to continue her exploration of midwifery through her unique lens.

“Indigenous peoples have different ways of knowing that are both valid and legitimate, and I think it’s important to recognise and include these perspectives in a professional capacity. It’s who we are.” square

Teresa Isaako gave birth to her second baby, Theron, in June, some 16 years after birthing her first. Cared for by Wellington Regional Hospital’s community midwifery team and core staff, including Fana, Teresa shares her challenging, yet positive journey.

“I was considered high risk”, Teresa begins. “I’m diabetic; I had high blood pressure - all of the worries, basically. I was also an older mum this time. All of my fear was surrounding my baby and the possible complications once he was born.”

After an anxious third trimester, 43-year-old Teresa says being admitted to delivery suite for induction of labour was a relief. “Once I got to that hospital, they had it under control. Knowing the team knew exactly what to do brought me comfort.”

Teresa’s daughter Torren was born via caesarean section 16 years earlier and despite the complexities affecting this pregnancy, Teresa still wanted to try and avoid interventions if she could. “I wanted to try and have a natural birth.

The team did all they could to support me. They went out of their way to try and make my wishes happen, while making sure I knew that if it didn’t work, I had to have another c-section.”

Teresa, who is of NZ Māori, Cook Island and Italian descent, says she was looked after by multiple midwives over the course of her hospital stay, but never felt her care was lacking. “They were really caring and kind. I met about 12 different midwives, but I never felt they were coming in without knowing my history. I said to them, ‘your notes must be quite in-depth’, because I never had to repeat myself. I didn’t have to worry about anything.”

One of Teresa’s clearest memories from her labour was of Fana’s watchful and protective nature. While being examined for progress, Teresa recounts: “I don’t think he (doctor) realised how painful it was. I clenched my hands, but Fana saw my face. She saw my reaction and told the doctor to wait. All I had to do was concentrate on getting through the pain, because I knew Fana was watching.”

Ultimately, Teresa’s son was born via c-section, but because she felt heard and so well cared for, Teresa says she felt no grief. “Because they tried so hard and went right out of their way, I was fine and I said, ‘let’s go’ (to theatre).”

“I had total confidence in them that they would take care of me and my baby. I was so impressed with the whole team. They catered specifically to me.” square

“I wanted to try and have a natural birth. The team did all they could to support me. They went out of their way to try and make my wishes happen, while making sure I knew that if it didn’t work, I had to have another c-section."

ISSUE 99 DECEMBER 2020 | 37

New Zealand College of Midwives Directory President Nicole Pihema Ph 021 609 011 nicolepihema@gmail.com

Wellington Siobhan Connor Ph 021 289 4252 nzcomwellington@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

Regional Sub-Committees

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 chairnzcomboptairawhiti@gmail.com Canterbury/West Coast Davina Geddes chairnzcom.cantwest@gmail.com Central Julie Kinloch Ph 06 835 7170 julie.kinloch.nz@gmail.com Nelson/Marlborough Rose O’Connor roseocon@gmail.com Northland Priscilla Ford Ph 021 222 2428 priscillaford@xtra.co.nz Southland Natasha Baillie Ph 021 258 2701 merakimidwifery@gmail.com Waikato/Taranaki Tracey Williams chairwaikatonzcom@gmail.com

38 | AOTEAROA NEW ZEALAND MIDWIFE

Hawkes Bay Sub-Committee Sarah Nation sarahnation.midwife@gmail.com Manawatu Sub-Committee Amanda Douglas Ph 027 333 3280 amandadouglas@xtra.co.nz 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 Royal New Zealand Plunket Society Carla Kamo carla.kamo@plunket.org.nz

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 midwifery-related books, leaflets, merchandise and other resources available through our website: www.midwife.org.nz/shop

Home Birth Aotearoa Eva Neely evaneely@live.com Parents Centre New Zealand Ltd Liz Pearce Ph 04 233 2022 extn: 8801 pearce@parentcentre.org.nz 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

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