Midwife Aotearoa New Zealand

TOWARDS EQUITY TE ARA Ō HINE – TAPU ORA P.28 PERINATAL MENTAL HEALTH

ANAEMIA IN PREGNANCY

NOHO MARAE KI KATIHIKU

PART I: OVERVIEW P.16

PRACTICE UPDATE P.20

HIGHLIGHTS P.25

ISSUE 101 JUNE 2021 I THE MAGAZINE OF THE NEW ZEALAND COLLEGE OF MIDWIVES

YOUR COLLEGE

FORUM FROM THE PRESIDENT 4. FOSTERING OPTIMISM FROM THE CHIEF EXECUTIVE

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5. ON THE CUSP OF CHANGE 7. IN MEMORIAM 8. BULLETIN 10. YOUR COLLEGE 12. YOUR UNION 14. YOUR MIDWIFERY BUSINESS

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FEATURES 16. PERINATAL MENTAL HEALTH IN AOTEAROA 20. ANAEMIA IN PREGNANCY

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25. NOHO MARAE KI KATIHIKU 28. TE ARA Ō HINE - TAPU ORA 30. BREASTFEEDING CONNECTION 34. RAINBOW CARE 36. WELL CHILD TAMARIKI ORA 39. NGĀ MAIA 40. POSTGRADUATE PATHWAYS 42. MY MIDWIFERY / MY MIDWIFE 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 September 2021 Advertising Booking: 16 August 2021 Advertising Copy: 23 August 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: 2703-4546.

ISSUE 101 JUNE 2021 | 3

Cover image: The tohu of Te Ara Ō Hine – Tapu Ora, an ipu whenua gifted by College Kuia Crete Cherrington, sits proudly atop a Fijian masi (barkcloth) provided by AUT Pasifika student liaison and lecturer, Talei Jackson. Photo by Tania Fleming.

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ISSUE 101 JUNE 2021

FROM FROM THE THE CEOEDITOR

FROM THE PRESIDENT

from the president, new zealand college of midwives, nicole pihema Nau mai haere mai ki Aotearoa New Zealand Midwife As I write this editorial, I’m still processing the after-effects of an incredible mātauranga Māori noho marae for midwives, that I was privileged enough to attend near Ōtaki recently. The full story and a new te reo Māori translation for the word ‘midwife’ can be found on p.25.

This edition’s cover celebrates the launch of Te Ara Ō Hine – Tapu Ora, the joint project between the Ministry and midwifery education providers which will see $6m invested into Māori and Pasifika undergraduate students over the next four years. For all the details, see p.28.

Three midwives and original College members have sadly passed on in the last six months and we pay tribute to Glenda, Rhondda and Nita on p.7. Thank you to Dawn, Maureen and Juliette for sharing your memories of these wonderful midwives with members.

The first in a series of planned articles on perinatal mental health can be found in this edition, providing an overview of the issue in Aotearoa and its prevalence, and discussing some of the current challenges faced by midwives (p.16).

Guest contributor midwife Esther Caljé provides a comprehensive practice update on anaemia and its management (p.20), whilst the Well Child Tamariki Ora referral process is viewed through an equity lens on p.36.

Ka pū te ruha, ka hao te rangatahi.

As an old net withers, another is made.

A perfect metaphor for the ousting of the currently burdened, inequitable health system, this whakatauki also invites us to be optimistic about the opportunities inherent in endings - opportunities to explore new ideas and new ways of doing.

The Government’s recent announcements regarding the centralisation of health care and the establishment of a Māori Health Authority were timely for midwifery, following hot off the heels of the launch of Te Ara Ō Hine – Tapu Ora. Up until now, there has been little to no accountability on the Government’s part for the unacceptably inequitable health outcomes suffered by Māori, and the creation of the new Māori Health Authority may finally signify the start of positive, long-lasting change.

Unsurprisingly, misinformation surrounding the new Māori Health Authority is rife, with misperceptions circulating purporting the authority to be a completely separate Māori health system. Of course, this is inaccurate; a result of the very same bias that sees Māori accessing health care and receiving treatment later than our non-Maori counterparts, if in fact we receive treatment at all.

Email: communications@nzcom.org.nz square

Though the finer details are yet to be released, what we do know is that the Māori Health Authority will operate in partnership with Health New Zealand, and will have commissioning rights to dictate how money is spent to ensure Māori health outcomes actually improve. In the same vein, the authority will have veto rights to shut down any proposed changes that could further harm Māori. In theory, the two organisations will work together in a truly Tiriti-honouring partnership, to transform the health system into one Māori can trust, and will therefore be more inclined to consult earlier, rather than later.

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Breastfeeding Connection addresses a challenging topic we all know too well on p.30: supporting early breastfeeding on busy postnatal wards, and on p.40 the world of postgraduate study is demystified for those of us who haven’t yet taken the plunge.

As always, we hope members will find this issue informative and interesting, and we welcome feedback and/or article suggestions and submissions for consideration.

Mā te wā, Amellia Kapa, Editor/Communications Advisor

Similarly, the $6m investment by the Ministry into the increased recruitment and retention of Māori and Pasifika midwifery students heralds the beginning of even further change, presenting our profession with a fantastic opportunity to address the inequities that currently exist within our workforce.

Ultimately, increasing the number of Māori and Pasifika midwives in Aotearoa means wāhine of Aotearoa will have more choice, and will therefore be more likely to be cared for by a midwife they recognise as a reflection of themselves.

The significance of this should not be underestimated; as midwives, we all recognise the power inherent in the connections we nurture with wāhine and their whānau throughout the childbearing journey, and what better way to establish these connections, than through common values and worldviews?

As I see it, these systemic developments complement each other beautifully and are symbolic of what I hope is a more fundamental shift as a nation towards true partnership, as was originally intended with the signing of te Tiriti o Waitangi all those years ago. As we know all too well, the numbers don’t lie, and there is no denying that the public health system has been failing Māori since its inception.

But I implore you to remain optimistic.

At the risk of being sorely disappointed, we must keep our hearts and minds open to the very real possibility of positive, permanent change.

This is what it means to truly and completely embody tino rangatiratanga, and I encourage you all to integrate this powerful practice into your daily lives. square

FROM THE CEO

ON THE CUSP OF CHANGE Once again, midwifery finds itself on the cusp of change, as our future (reformed) health system slowly takes shape. As a profession, we have been remarkably resilient in the face of such change in the past, and in spite of our present challenges, I am certain midwifery will display similar resilience in the future.

The process of childbirth is inherently unpredictable, so as midwives, we are used to living with a certain level of uncertainty and can do so quite comfortably. Of all the health professions, midwifery understands that change is constant, and in order to succeed, we need to continually evolve and adapt to our environment.

Midwives and midwifery cannot and do not exist in isolation from the rest of the health system, nor the wider political imperatives or priorities. Similarly, the profession does not exist outside of its historical context, and as we are constantly shown through te ao Māori, knowledge of, and connection to history is what provides us with the very insights and tools we need in order to develop effective strategies which enable growth and transformation in the future.

Applying this to the recently announced reforms of our health system, I’m sure we can all agree that what history is trying so desperately to teach us is that when reciprocity, equity and mutual understanding are not honoured within a partnership, one party will always be worse off. The establishment of the Māori Health

Authority with co-commissioning rights, therefore, represents long overdue recognition of this failing, and the turning of a significant corner.

As Nicole Pihema’s first term as College President draws to an end, I have been reflecting on how her influence, as the first Māori president, has changed the nature of many conversations and helped the College to better understand the journey we need to embark on. Crete Cherrington, as College kuia, and Nicole have a special relationship which precedes their appointments to their respective College roles, and the mutual support they have provided for each other thus far has amplified their collective voice. Sadly, from my perspective, this has also illuminated how much more lonely it is for Māori operating in what is still a very Pākēha world.

This issue of Midwife sees a call for nominations for president and I am thrilled that Nicole has agreed to put herself forward for a second term.

Tūngia te ururua, kia tupu whakaritorito te tutū o te harakeke.

Set the overgrown bush alight, and the new flax shoots will spring up.

(In order to change and do things differently, we may need to leave old ways behind.)

ALISON EDDY CHIEF EXECUTIVE

In terms of the new health system, there is both good news and uncertainty. It is likely that national service frameworks (such as service specifications and funding amounts) will be negotiated nationally, but administered regionally. Below regional levels, localities will be the layer at which services like primary maternity are integrated.

What this means in practical terms and how this will impact on midwives and maternity services remains unclear at this point in time.

ISSUE 101 JUNE 2021 | 5

FROM THE CEO

On International Day of the Midwife this year, the third ‘State of the World’s Midwifery’ (SoWMy) report was released.

This seminal report adds to an existing body of work - including the Lancet Series on Midwifery - which documents the impact of and need for investment in midwifery on a global scale.

Although we enjoy the privileged status of living in a high income country, the SoWMy report sets out how many of our present challenges here in Aotearoa are a result of global issues faced by midwives everywhere:

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I would add to this, that midwives holding “power, agency and status” is also vitally important to retention and recruitment, one of our most pressing challenges. Holding “power, agency and status” directly enables midwives to influence key decisions which affect how women can receive maternity services and the conditions under which midwives work.

The SoWMy 2021 report identified four areas for investment, including midwifery leadership and governance. Specifically, it notes the need to create senior midwife positions and strengthen institutional capacity for midwives to drive health policy advancements.

There is a critical need for elevation of midwifery leadership, particularly within the community midwifery setting, if midwives are to have any hope of more directly and actively influencing health policy in the future. In order to be taken seriously at the negotiating table, the gendered workplace and industry hierarchies highlighted by the SoWMy 2021 report must be exposed, time and again, until equity is achieved.

As a profession of advocacy, which has never shied away from politics, it is imperative that we continue to make our voices heard. Our strength has always been in the collective and now, more than ever, as we sit on the precipice of significant change, we must remain united in our shared desire to see all wāhine, pēpi and whānau in Aotearoa having equitable access to the high-quality maternity care we all know has the power to shift life trajectories, when done right. square

Honouring te Tiriti o Waitangi emerged as the top priority for the College board at its strategic planning session late last year.

Although the College has had a long and enduring relationship with Ngā Maia Māori Midwives Aotearoa (Ngā Maia) over the years, with two places for Ngā Maia representatives on the College board, it is timely for the College to consider whether the current arrangement is sufficient to honour the voice of tāngata whenua within College processes.

To this end, representatives from Ngā Maia and the College met in Wellington on 14 April, with discussions facilitated by Moe Milne, a highly respected kuia from Te Tai Tokerau.

At this hui, the College affirmed its wish to embed a te Tiriti o Waitangi framework into its organisation, and to work with Ngā Maia to identify what steps are required in order to develop the appropriate values and culture that will underpin the transition.

Both the College and Ngā Maia confirmed their shared commitment to the midwifery profession and agreed on its unique role in supporting the wellbeing of wāhine, pēpi and whānau. Together, the two organisations identified opportunities for review of processes at both national and regional levels, and expressed a common desire to work together to embed any changes respectfully and meaningfully. We also collectively agreed on some immediate actions that can be taken to kick-start the journey towards our longerterm objectives. square

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“Occupational segregation by gender is driven by long-standing gender norms that define caring as women’s work and portraying men as more suited to technical specialties, such as medicine. Midwifery, and the role of caring for women and newborns, is often undervalued, leading to midwives having no voice and no place at the leadership table: this hinders respect, access to decent work and pay equity …Midwifery in particular is seen as “women’s work” which often confuses and undervalues

“Gendered workplace hierarchies and social, economic and professional barriers often prevent midwives from working to their full potential, and cause frustration in the workplace, leading to either attrition or further embedding of stereotypes. Midwives can lack professional autonomy within the health workforce if their capacities and skills are unrecognized or undervalued by medical and other institutional hierarchies. Professional autonomy is established in national regulations, such as those on scope of practice, but these regulations may be influenced by medical or other institutional hierarchies. The voices of midwives make it clear that “power, agency and status” are vitally important for midwives if progress is to be made in delivering high-quality care.”

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The College uses its influence to support the needs of all midwives, who have a choice of work setting, and may choose to switch between different settings throughout their careers - to suit their personal and professional needs. Thus, there needs to be relativity between pay and conditions of employed and self-employed midwives.

This need for relativity is why the College and MERAS have been working together so closely, to reach resolution in the MERAS pay equity case for employed midwives.

midwives’ economic and professional contributions to society.

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Importantly for midwifery, although both hospital-based and primary health care services will come under the remit of Health NZ, they will be managed separately.

The community / hospital interface is an extremely important one for New Zealand midwives, as our work traverses both settings.

Not even a ‘perfect’ health system model can make this interface harmonious 100% of the time, and there will always be competing tensions. Creating a seamless interface for women instead relies on us as individuals, and our ability to focus on what we have in common, rather than our differences.

Although it’s true that we are influenced by the environment we live and work in (hospital, community, or both), it’s equally true that as responsible practitioners, we can choose to think and act consciously in every situation, irrespective of our external environment.

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THE BEST PROTECTION FOR BABY

FROM IN MEMORIAM THE CEO

in memoriam nita van boven

rhondda kerins

glenda stimpson

14 September 1951 - 12 March 2021

28 April 1948 - 28 December 2020

12 July 1939 – 6 May 2021

It is a privilege to write about my friend and colleague Nita van Boven, who passed away on March 12th 2021, only months before her 70th birthday.

It was with great sadness that we learnt of the sudden death of our beloved friend, colleague, mentor and midwife to many, Rhondda Kerins, on 28 December 2020.

I would like to offer my condolences to Alison and the family on the loss of dear Glenda.

Nita was born on Norfolk Island, but moved with her family to New Zealand and grew up in Tauranga, where, following in her mother’s footsteps, she began nursing training. Nita married Bob van Boven and together they had two sons, John and George, after which Nita resumed her training, beginning a lifetime of service caring for patients with diligence and skill.

Rhondda was a highly regarded midwife of the Auckland/Tamaki-Makarau region.

Always with a warm and welcoming smile, a twinkle in her eye, encouraging words and hilarious stories, Rhondda touched the hearts of everyone she worked with and was always great fun to be around.

Nita worked in different areas including SCBU, ICU, and maternity, and graduated with an Advanced Diploma of Nursing (Midwifery) in 1988. That year she went to a special interest-group meeting, which I am told was the genesis of the College and autonomous midwifery.

I met Nita in 1991, when she was a Clinical Midwife Specialist. She had high standards, was an excellent role-model and mentor, and garnered respect from midwifery and medical colleagues alike. In 1995, Nita and several colleagues established the Rotorua Independent Midwives United practice (RIMU).

Committed to providing natural labour and birth care, including homebirth, Nita was the last original member remaining, and retired from LMC midwifery after 20 plus years.

Midwifery has lost an exceptional member of our profession and Nita’s friends have lost a textiles genius; a loving, intelligent, funny and generous woman.

- Maureen O’Reilly - Abridged

Her midwifery career of 40+ years spanned the full spectrum of midwifery roles, including Charge Midwife at St Helens, AUT Midwifery Educator, Director of Midwifery at Counties Manukau DHB, LMC, and core midwife at Auckland DHB Labour and Birthing Suite. She was also a founding member of the College.

Her passion for midwifery was only matched by her passion for shoe-buying, red lipstick, and long, lingering baths - from where she often shared her midwifery wisdom with those of us who knew her well enough.

Perhaps Rhondda’s greatest and most enjoyable role was becoming Grandda to Sebastian (Norway) and Margot (Auckland) in recent years; her continued zest for life evident in her interactions with her mokopuna.

Rhondda is an enormous loss to our midwifery whānau, but an even greater loss to her immediate whānau. Thank you to Dennis, Catherine, Annah, Andrea and mokopuna, for sharing Rhondda with us.

Rhondda lives on in our hearts.

Glenda was a midwife at National Women’s Hospital/Health for 43 years and later, elder of the Auckland Regional College Committee.

Also a founding member of the College, Glenda's contribution to midwifery as a strong advocate over the years has been invaluable.

Glenda's commitment to the cause was also illustrated through her photography, capturing countless moments at both a local level and at national midwifery conferences.

Glenda's legacy of photo albums and midwifery library can be explored in Royal Oak, at the Auckland region rooms. Thank you, Glenda, for providing such a wonderful catalogue for students and future midwives to look back on. As you always said, new midwives must know our history.

Glenda's reputation preceded her, as any senior doctor at National Women’s could substantiate; if there is one midwife everyone will remember, it is Glenda.

Perhaps one of Glenda’s most precious qualities as a midwife was her love of a story over a cup of tea. Glenda was always available to colleagues - on the other end of the phone, ready to support any midwife as needed, and even in her later years, Glenda focused on providing pastoral care for midwives.

Thank you, Glenda, for your lifelong commitment to midwifery. Your presence will be greatly missed.

- Juliette Wotton

- Dawn Holland

ISSUE 101 JUNE 2021 | 7

BULLETIN

BULLETIN international day of the midwife 2021 "Follow the data: invest in midwives" resounded around the globe on 5 May as the theme of this year’s International Day of the Midwife.

Set by the International Confederation of Midwives (ICM), this year’s theme aimed to advocate for international investment in quality midwifery care, not only to improve perinatal outcomes, but also to make progress on broader women’s health issues including sexual and reproductive health. This year’s IDM coincided with the launch of the State of the World’s Midwifery(SoWMy) Report 2021. The report, co-led by ICM, UNFPA and WHO, gathers updated evidence and provides a detailed analysis of the positive impact of midwifery care on maternal and newborn outcomes from 194 countries. square

Big Latch On to remain virtual in 2021 After careful consideration of advice from the Ministry and other public health units regarding the implications of hosting a large, multiple-venue in-person gathering, event organisers have made the difficult decision to virtualise the Big Latch On again this year. Planned for 6-7 August 2021, event organisers advise more information will be available soon. square

Reminder: College student grants close June 25, 2021. Refer to College website: College roles and services / Grants and subsidies

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This year’s IDM coincided with the launch of the State of the World’s Midwifery (SoWMy) Report 2021.

The report, co-led by ICM, UNFPA and WHO, gathers updated evidence and provides a detailed analysis of the positive impact of midwifery care.

another midwife gains doctorate The College would like to congratulate another midwife on the completion of her doctoral degree.

Pauline Dawson: What are the barriers to equitable maternal health in Aotearoa New Zealand? (Otago Polytechnic).

Have you recently completed your doctoral degree, or do you expect to complete soon? If so, please let us know by emailing communications@nzcom.org.nz so that we can acknowledge your achievement in a future issue of Midwife. square

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national cervical screening programme receives boost The Government has announced that the 2021 Budget will include an investment of $53 million to enable the National Cervical Screening Programme (NCSP) to introduce human papillomavirus (HPV) screening, with the option of self-testing, from July 2023.

HPV testing has been found to be a more effective, equitable and cost-effective screening method for cervical cancer than the current cytology-based method. Testing for HPV – the cause of 99% of cervical cancers – will replace the existing cervical screening procedure. The option to self-swab enables the opportunity for cervical screening to be offered in conjunction with other healthcare visits and will allow for more flexibility for community-based service provision. Options to further improve access to cervical screening may include mail-outs of self-testing kits, but this has yet to be decided. Public consultation on the inclusion of the self-testing component in guidelines and referral pathways is being undertaken at time of writing. square

PMMRC issues wero in latest report The Fourteenth Annual Report of the Perinatal and Maternal Mortality Review Committee (PMMRC) | Te Pūrongo ā-Tau Tekau mā Whā o te Komiti Arotake Mate Pēpi, Mate Whaea Hoki was published in February 2021.

The College acknowledges the grief and trauma of each family represented by the statistics in the report, and the work that midwives do to support whānau experiencing the loss of a baby or mother. Key findings can be found in the infographic insert included in this issue of Midwife. The report identified that there are ongoing inequities between population groups that represent failures to fulfil te Tiriti o Waitangi responsibilities at a societal level, in social policy settings, and in maternity and mental health services. The PMMRC has expressed frustration at the limited implementation of its recommendations which have been made to improve outcomes. It has therefore issued a wero (challenge) to the Ministry and the maternity sector to implement the recommendations from the last 13 years that remain outstanding.

The full report, including the wero, can be read on the Health Quality & Safety Commission (HQSC) website. The PMMRC webinar Doing things differently was held in February, instead of a conference. The recording, along with captions and an accessible transcript is available on the HQSC website. square

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YOUR COLLEGE

your college maternity guideline reviews Midwifery advisors are representing the College on the steering group for the review of four national maternity guidelines: Guidelines for Consultation with Obstetric and Related Medical Services (Referral Guidelines); Diagnosis and Treatment of Hypertension and Pre-eclampsia in Pregnancy in New Zealand; Screening, Diagnosis and Management of Gestational Diabetes in New Zealand; and the National Consensus Guideline for Treatment of Postpartum Haemorrhage.

An initial survey on the Referral Guidelines was circulated to members in April and further opportunities for feedback will be provided once a draft of the new guideline is available.

Consultations on the other guidelines will follow in due course.

CONTRACEPTION EDUCATION Contraception education standards are being developed by the Ministry and the National Contraception Guidelines Steering Group to reflect New Zealand Aotearoa’s Guidance on Contraception and identify the pre-requisites, programme, and ongoing competence requirements for all health professionals who wish to insert long-acting reversible contraception (LARC). Midwives are represented within this group, and aim to ensure that the education programmes developed can be accessed by midwives and fit their scope of practice. Further information will be provided as this work progresses.

SUBMISSION ON LEADERSHIP MIDCENTRAL The College region and national office has been providing professional support to employed and self-employed midwives in MidCentral DHB at a time of major workforce shortages, including a written submission on the MidCentral leadership change proposal in May.

CLIMATE CHANGE CONSENSUS Climate change is one of the most pressing issues of our time and requires commitment from individuals, organisations and society

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as a whole, to address. The College has developed a climate change consensus statement which has been circulated through the College midwives portal for feedback.

Following this consultation, we are hoping to have this consensus statement ratified at the AGM in November 2021.

ANTI-D PROPHYLAXIS ADMIN DURING PREGNANCY AND EARLY POSTPARTUM Following feedback from member consultation, this statement is being finalised in preparation for ratification. The main points relate to the current NZ Blood recommendations and the need for DHBs to enable provision of the service through appropriate pathways, rather than expecting the community midwifery workforce to provide this without the necessary support/ resources.

pulse oximetry submission The Ministry, along with a multi-disciplinary team which included College representatives, have developed a national guideline for newborn pulse oximetry screening. Pulse oximetry is a simple non-invasive method of measuring hypoxaemia following birth, which may be potentially indicative of critical congenital heart disease, respiratory conditions and other diseases that could have an impact on a baby’s health. Screening has been found to be acceptable to women and their families and reassuring for health professionals.

The College has consulted with members through the College portal and has provided a submission on the discussion document.

Feedback was generally supportive, but concerns were raised related to education and the funding of equipment and consumables.

PROFESSIONAL SUPPORT PROPOSALS FOR EMPLOYED MIDWIVES The College presented two proposals to the Midwifery Leaders Group and the MERAS NRC for professional networking and support of employed midwives: to set up a national, in-person forum for midwives in shift-based

clinical leadership roles - Associate Charge Midwife Managers (ACMM)/Clinical Midwife Coordinators/Clinical Midwife Managers - and to establish a virtual network of midwives involved in DHB maternity clinical guideline development. Midwifery clinical leadership roles are pivotal to the functioning and culture of day-to-day birthing and maternity facilities, with a high level of responsibility in a relatively isolated position.

Discussions with midwives in these roles and the midwifery leadership groups indicated that there is a pressing need for professional support and networking but that it may be logistically difficult to hold an in-person forum. The College has therefore included a workshop for midwives in clinical shift leadership on the importance of their role and as a space to network, at the conference in November. The College is also working on a proposal for Charge Midwife Managers and will progress conversations on a guidelines network as the implications of the health reforms on regional health system structures are made clear.

rural health alliance meeting The College is a member of the Rural Health Alliance Aotearoa New Zealand (RHAANZ), an umbrella organisation which advocates for rural health issues. Each year, RHAANZ hosts a RuralFest meeting, where members meet in Wellington to agree on top priorities (day one) which are then presented to key politicians in Parliament (day two).

At the 2019 RuralFest, the College’s midwife representatives were successful in achieving consensus with meeting attendees that rural maternity issues should be among the priorities presented – a key contributor in achieving the revised Section 88 rural payments which were announced in last year’s Budget. This year, rural midwives Tawera Trinder (Taranaki) and Kendra Short (South Canterbury) were the College RHAANZ representatives. Tawera and Kendra reported ongoing strong support for rural midwives and maternity services in this multidisciplinary forum. square

YOUR COLLEGE

Taranaki midwife Tawera Trinder and her pēpi Kārearea attend RuralFest at Parliament in April 2021.

Covid-19 vaccine update VACCINE FOR MIDWIVES AND STUDENTS The College’s work to support members on Covid-19 related matters has moved to the Covid-19 vaccine in 2021. All individuals have the right to make an informed decision about receiving the vaccine, however it is recommended for health professionals (including midwives and student midwives), in order to protect themselves and the whānau they are providing care for, and as an important public health strategy in managing a pandemic. College advisors worked with the Immunisation Advisory Centre (IMAC) and the Ministry to develop resources for midwives, available on the College website: • Information sheet on the Covid-19 vaccination in pregnancy and lactation • Webinar presentation on the Covid-19 vaccine including information on the vaccine research and development, science and mechanism of action, safety profile, ongoing monitoring and information on vaccination during pregnancy • Information resource with Covid-19 vaccine information for health professionals considering their own vaccination status.

Questions from members have been supplied for expert immunologist responses.

MIDWIVES AS COVID-19 VACCINATORS The Midwifery Council has confirmed that midwives who have undertaken the required education can work as Covid-19 vaccinators for people who are not pregnant or postpartum.

The College confirms that midwives working in this capacity are covered by their professional indemnity policy as part of their membership.

PREGNANT MIDWIVES CONSIDERING VACCINATION The College refers pregnant midwives considering vaccination to the IMAC information and position: “Women who are pregnant and at risk of exposure to SARS-CoV-2 virus can receive a COVID-19 vaccine at any stage of pregnancy. For those at low risk of exposure, it is recommended to delay vaccination until after birth.”

As a pregnant woman, the individual midwife will need to consider their own risk of exposure to Covid-19 in the course of their work, their health profile and the available information about vaccine safety during pregnancy to make an informed decision. Hygiene measures and distancing practices continue to apply. square

ISSUE 101 JUNE 2021 | 11

YOUR UNION

public sector wage freeze a bolt out of the blue The Government’s announcement of a wage freeze for public sector workers earning more than $60,000 came as a bolt out of the blue for MERAS negotiators. When we received the DHBs offer the following day, we expected to be told there would be no pay rise for the next three years.

Instead, the offer did include flat rate increases up to Grade 4 of the senior midwives’ pay scale in both 2021 and 2022.

JILL OVENS MERAS CO-LEADER (INDUSTRIAL)

The DHBs’ position to date has been absolutely no movement for senior midwives on Grade 5 and above, in line with the Government ban across the entire public sector on any pay rises for those earning above $100,000. The latest extension of the wage freeze allows for pay increases to address staffing shortages, such as those experienced

by DHBs with issues recruiting and retaining midwives, but only for those earning between $60,000 and $100,000.

The Government has been arguing that there has been a blow-out in expenditure due to the Covid wage subsidy and other measures, and that any investment in public sector wages needs to go to the lowest paid.

The latest extension of the wage freeze allows for pay increases to address staffing shortages, such as those experienced by DHBs with issues recruiting and retaining midwives.

12 | AOTEAROA NEW ZEALAND MIDWIFE

MERAS had earlier told the DHBs we would accept flat rate increases as opposed to percentage increases, as these put comparatively more money in the hands of those starting out in their midwifery careers with DHBs. In the last round of negotiations, we successfully argued for new midwifery graduates to start on Step 2 of the pay scale.

This lifted their pay from an annual salary of $49,449 before the last MECA increases to $59,222 from August 2020.

As of date of writing, the MERAS negotiating team was considering the offer and responding to the DHBs about areas where there has not been agreement. Despite the fact that the MERAS negotiations occurred before the wage freeze was extended, MERAS remains concerned about the impact of the Government’s position on public sector bargaining and wages.

Lowering the wage freeze to those earning between $60,000 and $100,000 impacts on professions such as teaching, nursing, and midwifery, all of which require a university degree and therefore a personal investment that includes substantial student debt. It will likely increase the gender pay gap, as the public sector is a significant employer

of professions in this wage range that are predominantly performed by women.

According to the Employment Relations Act, all collective bargaining is supposed to be conducted in “good faith”, implying that both parties are open to each other’s claims. However, my experience in public sector negotiations, in both the health and education sectors over 26 years, is that their advocates will not go outside the expectations set by Government.

The DHBs have to submit any outcomes from negotiations through CEs and the Ministry, who can veto anything agreed at the table. In the last round, both NZNO and MERAS members had to take industrial action to force the DHBs to go beyond Government expectations.

MERAS has been held up by such processes for months. We initiated bargaining in December with the intention of settling before expiry on 31 January, but between December and March, the DHBs’ advocates have rescheduled meetings twice, and revoked “offers” made in January.

Since then, MERAS was told an offer had gone to a DHBs’ Workforce Management Group, and then to the Ministry for approval. We hope to settle by the end of May, and if so, members will then vote to ratify the proposed changes to the MECA, including pay rates and conditions.

DISPUTE OVER DHBS' PAY EQUITY PROCESS HEADS TO MEDIATION Mediation to resolve a dispute with the DHBs and Ministry over including employed general practitioners as a potential male comparator in the midwifery pay equity claim has been set down for Tuesday, 1 June.

The DHBs and MERAS were referred to mediation by the Employment Relations Authority after MERAS filed a dispute with the Authority on International Working Women’s Day, 8 March. Ironically the mediation date was agreed on International Midwives Day, 5 May. MERAS has been arguing for inclusion of employed GPs as a male comparator since we started our pay equity process in 2018. In February 2019, this was approved by the bipartite oversight group comprising MERAS, NZNO, PSA and DHB representatives for both the nurses' and the midwives' pay equity claims.

YOUR UNION

L-R: MERAS workplace rep Rosie Sharman, Co-leader Jill Ovens and NRC rep Joyce Croft celebrate International Midwives Day at Kaitaia Hospital in the Far North.

Nurse practitioner members of NZNO also saw the logic of using GPs as a comparator.

Both GPs and NPs have been used as male comparators in pay equity processes, such as the Ontario case and the College’s case for pay parity for LMC midwives. Unfortunately MERAS cannot use NPs as a potential comparator as they are part of the nurses' pay equity claim. A Ministry group chaired

by Dr Ashley Bloomfield vetoed the use of GPs on the grounds that GPs are not male dominated. However, GPs were historically male dominated, arguably the source of their privilege in terms of pay.

In the meantime, the midwifery pay equity process has completed a second round of assessing the work of midwives from interviews conducted in 2019, this time using Equitable Job Evaluation (EJE), a tool developed by the Pay Equity Unit in early 2000. EJE allows for greater differentiation on factors such as knowledge and problem solving. Other factors include interpersonal and physical skills; responsibility for leadership, resources and services to people; emotional, sensory and physical demands, and working conditions.

The factors are weighted 45% each for skills and responsibilities, and 10% for demands.

MERAS has raised concern that this does not put enough weighting on the exceptional

demands of work typically performed by women, particularly the emotional demands.

A range of male-dominated occupations has also been assessed, and the next step is to compare the outcomes of the assessments to identify similar or comparable roles. Reports have been prepared on each occupational group’s remuneration and will be used to assess the extent of the undervaluation that can be attributed to gender.

MERAS will then negotiate with NZNO and the DHBs to establish any pay adjustment, which will be backdated to December 2019 and may be phased in over a period of time. We have been assured that the current wage freeze will not affect the pay equity process, as a separate fund has been set aside for this.What has become apparent is that not all of the pay disparities within the health sector can be directly attributed to gender. For example, sonographers are paid around $40,000 a year more than midwives, yet 70% of them are women. Using a gender equity tool, it is hard to see how midwives would come out below sonographers, who do a three-year health science degree and postgraduate diploma, and have fewer responsibilities and fewer emotional and physical demands.

Reasons put forward for their superior pay and conditions include competition with

the private health sector and a shortage of sonographers. Scarcity has not worked for midwives in terms of increasing their pay, but arguably the holding down by the Ministry of LMC pay can be linked to suppressing the pay of employed midwives.

It may be that within health, those occupations that perform surgery and/or use expensive machinery are more highly valued than midwifery, with its kaupapa based on partnership with women, refinement of skills over time, use of hands as a diagnostic tool, distributive leadership and team work.

The fact that these features of the way women typically work are not currently valued in terms of pay equity has been raised by MERAS with the Public Services Commission, which is currently reviewing pay equity tools. square

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

ISSUE 101 JUNE 2021 | 13

YOUR MIDWIFERY BUSINESS

navigating ACC for self-employed midwives MICHAEL STIRLING FINANCE MANAGER, MMPO

WHO IS ACC? The Accident Compensation Corporation (ACC) is a Crown entity, originally established in 1974, which brought together various compensation schemes and related work-safe laws. Its principal governing Act is the Accident Compensation Act 2001 and the organisation is governed by a board, answerable to the Minister for ACC. WHO IS COVERED BY ACC? ACC provides compulsory insurance cover for personal injury for everyone in New Zealand, whether a citizen, resident, or visitor. This means if you are injured by an accident in New Zealand, ACC may pay compensation, as well as some of your medical and rehabilitation costs.

WHAT STANDARD LEVEL OF COVER DOES ACC PROVIDE? ACC provides 24/7, no-fault personal injury cover for everyone in New Zealand, including a range of cover for motor vehicle, non-work, and workplace injuries. ACC only covers injuries; however, your injury must be the direct result of an accident, and not the result of any pre-existing medical conditions. ACC does not cover illness, conditions from ageing, or emotional issues. If you want specific cover for these particular cases, you will need to consider separate income protection cover, which an insurance broker will be able to advise about. ACC may also assist with full or partial funding towards medical, health and other ongoing rehabilitation and treatment costs resulting from the injury, provided your claim has been accepted.

HOW ARE ACC LEVIES CALCULATED FOR THE SELF-EMPLOYED? ACC uses Business Industry Classification Codes (BIC), assigned to your business

14 | AOTEAROA NEW ZEALAND MIDWIFE

by way of a Classification Unit (CU).

CUs group businesses together with similar levels of risk, in order to determine the levy rate to be paid, ensuring the costs of injuries are shared equitably across industries.

ACC assigns the levy rates to CUs based on historical data from past claims. In general, the higher the occupational risk (based on past claims received), the higher the future levies will be when compared to lower-risk, profiled occupations. Annually, when you file your personal Income Tax Return (IR3) with Inland Revenue, your taxable income details are automatically shared with ACC and the basis for your levy calculation is determined by the business structure you operate under.

HOW MUCH WILL MY ACC LEVY BE FOR THE YEAR ENDED 31 MAR 2022?

Based on the BIC Code of Q853955 and CU Code of 86132 ‘Midwifery Service’, the current prescribed rate set by ACC is $1.78 plus GST per $100 of net profit. Use the range table below in order to determine the approximate ACC levy payable next year

(GST exclusive), based on your annual net earnings derived from performing midwifery services (see below).

HOW DOES THE ACTUAL CLAIMS PROCESS WORK IN PRACTICE? If you need ACC cover for an injury, as soon as practically possible, visit your trusted health provider: be it your doctor, physiotherapist, Medical Centre, or local Emergency Department. A claim will be lodged by your health professional with ACC on your behalf, and if appropriate, a medical certificate issued, noting the period you are unable to work for. ACC will then consider the claim and confirm in writing whether you are eligible or not.

If you are covered, ACC will request proof of earnings by way of previous years’ income tax returns and financial statements, and possibly net income details for the current financial year to date as well. If your claim is considered ‘standard’, ACC allow up to 21 days for processing.

APPROXIMATE ACC LEVY PAYABLE FOR YEAR ENDING 31 MARCH 2022 $2,330

2,500 $2,136 2,000

$1,780 $1,424

1,500 $1,068 1,000 $712 500

0 40,000

60,000

80,000

100,000

120,000

130,911 (maximum)

If you are rightfully approved for weekly compensation, ACC will pay you based on up to 80% of your taxable income, to a maximum level of $130,911. Depending on the situation and claim, ACC may start paying immediately, but typically, payments will start after one week, with income tax generally deducted at source.

HOW LONG AM I COVERED FOR? Once your claim has been successfully approved by ACC, you will be assigned a case manager, whose main responsibility is to professionally assess your injury and assist with co-ordinating your rehabilitation and recovery back into the workplace.

You shall continue to receive weekly compensation from ACC until such time as you are rehabilitated and able to return to normal work duties. If initially, you are only able to revert to light duties, then ACC may reduce your weekly amount, generally pro-rated, based on the number of hours you can physically work.

If you have, or suffer from, a permanent injury, ACC may cover you long-term.

You will need to lodge a separate application for financial support and ACC may agree to either a one-off lump sum payment, or ongoing payments, based on a reassessment process, including the use of impairment thresholds, in order to determine the longterm nature and prognosis of the injury.

WHAT ONGOING TREATMENT AND OTHER OUT-OF-POCKET EXPENSES AM I ELIGIBLE FOR? ACC can only help pay for your treatment when it is: • the most suitable option for your condition • a generally accepted form of treatment in New Zealand • given to you by a New Zealand registered and licensed provider.

ACC will generally assist with home-help costs and may assist with certain out-ofpocket expenses, determined on a case-bycase basis, e.g. travel costs incurred to attend specialist appointments.

Note, many services are not fully subsidised by ACC; in fact in many cases, surcharges apply, meaning the claimant must cover a portion of the cost themselves.

Doctor visits and physiotherapy treatments are prime examples of this, whereby you are expected to pay such practitioners the shortfall that ACC does not fully subsidise.

For more specific guidance, check out ACC’s website, which publishes a wealth of

information on what services they both do, and do not fund.

IS THERE AN ALTERNATIVE TO THE STANDARD LEVEL OF ACC COVER? As soon as you commence self-employment in New Zealand, you are automatically covered

by ACC CoverPlus. However, ACC offers another product, ACC CoverPlus Extra (CPX), which is essentially an insurance policy, whereby a mutually agreed level of cover is negotiated up-front.

In practice, this means if you cannot work due to an injury, you shall receive compensation based on the ‘sum insured’ cover that you have signed up for, with no requirement to supply additional paperwork validating your net income. This is a desirable outcome, particularly at a time when you simply want to focus on your recovery, and not worry about your immediate finances.

Under CoverPlus Extra, the minimum level of cover that can be taken out is $29,453; and the maximum level is set at $130,911. The good news here is, you will not pay any ACC levies on earnings above this maximum, but the bad news is, you will not have any cover for any excess earnings derived above this current threshold.

However, this is where having personal income protection insurance sitting in tandem with your CPX policy comes cleverly into play, given you will be covered under both eventualities of injury and illness.

Income protection insurance is a whole separate topic in itself, not covered in this article, thus, we strongly recommend this is discussed with an insurance broker.

Note: people’s circumstances are different, so there is not a one-size-fits-all approach.

Instead, a broker will be able to tailor a balanced insurance package for you, taking into account all known factors and variables, including a cost/benefit exercise based on your own risk profile, personal finances and family situation. square

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

16 | AOTEAROA NEW ZEALAND MIDWIFE

FEATURE

perinatal mental health in Aotearoa part 1: overview

This article is the first in a series on perinatal mental health and aims to provide an overview of the current landscape in Aotearoa as well as discussing the midwife’s role and screening. Future articles will explore the implications of anti-depressant and anxiolytic medications for wāhine hapū and pēpi, and wider issues around maternal mental health.

The implications of increased maternal mental health needs for both mother and baby are well known, and vary according to the severity of the mental health condition.

The distinction, therefore, between mild to moderate mental health issues and severe disorders, is essential in identifying those at immediate risk, so that appropriate, timely referrals can be made and input from specialist services implemented as early as possible. Mild to moderate mental health conditions include depression and anxiety, and are usually managed at primary care level. Severe mental health conditions include severe depression, bipolar disorder, schizophrenia and psychosis.

Severe mental health disorders affect very few New Zealand women giving birth. These women need early referral to specialist services and there are usually clear pathways to multidisciplinary care in these cases. It is far more common for women to experience mild to moderate perinatal mental health concerns, yet they remain the most challenging for midwives to address, given these conditions do not meet referral

criteria for specialist services, and fall into what has been coined the ‘missing middle’ of publicly funded mental health services.

The main focus of this article is therefore on mild to moderate mental health conditions, with some brief information in Box 1 about recognition and referral for women with severe mental health conditions.

HOW PREVALENT ARE MENTAL HEALTH CONCERNS AMONGST PREGNANT WOMEN IN AOTEAROA? A 2017 analysis of data collected through the longitudinal Growing Up in New Zealand study, by Underwood et al., revealed that over the perinatal period 16.5% of the

11.5% of women reported antenatal depression symptoms (ADS) and 8% reported postnatal depression symptoms (PDS).

5301 women interviewed had experienced significant levels of either antenatal or postnatal depression symptoms. The participants were interviewed during their third trimester of pregnancy and again at nine months post-partum, and depression symptoms were measured using the Edinburgh Postnatal Depression Scale (EPDS), with depression being defined as a score of >12.

Of this cohort, 11.5% of women reported antenatal depression symptoms (ADS) and 8% reported postnatal depression symptoms (PDS). This is consistent with previous international studies which have identified that it is more common for women to experience only ADS than only PDS. Around a quarter of women in the Growing Up in New Zealand study who experienced ADS, went on to have PDS. An analysis found that PDS was most commonly associated with pre-pregnancy depression but not necessarily antenatal depression. For those women who experienced ADS only, the most significant precursor appeared to be anxiety - experienced either before or during pregnancy.

The analysis also revealed women who experienced both ADS and PDS were more likely to have had higher Edinburgh scores at the antenatal interview. It appears that the more severe the ADS, the more likely it was that PDS would follow.

Other pre-pregnancy or antenatal risk factors for this group included higher perceived stress, difficult family or relationship environment during the third trimester of pregnancy, and lack of exercise pre-pregnancy. Clearly, whilst there is some overlap between ADS and PDS, they are two distinct groups, with differing risk factors, and should be treated as such.

Whilst Pasifika or Asian women made up 26% of the study sample, the same group accounted for 37.7% of women who experienced either ADS or PDS and nearly half (46.5%) of the women who reported significant depression at both the antenatal and postpartum time points. The authors acknowledged the need for more

ISSUE 101 JUNE 2021 | 17

FEATURE

BOX 1

Severe mental health disorders

Women with a previous history of severe mental health disorders have a high chance of relapse during the perinatal period and therefore require prompt referral to specialist services.

To aid in identifying women with this level of care requirement early, the following questions, recommended by the Perinatal and Maternal Mortality Review Committee (PMMRC) in its 2009 report, may be useful for midwives in practice.

At first contact with services, women should be asked: • Are you currently receiving, or have you ever received treatment for a serious mental illness such as severe depression, bipolar disorder, schizophrenia or psychosis?

• Have you ever had treatment from a psychiatrist or specialist mental health team in the past?

• Do you have a family history of mental illness including perinatal mental illness?

The Referral Guidelines indicate that women who are “stable and/or on medication e.g. bipolar disorder” warrant a referral for specialist consultation, while those who have acute unstable psychosis are recommended to have their care transferred to specialist services.

The PMMRC states: “Women with a previous history of serious affective disorder or other psychoses should be referred in pregnancy for psychiatric assessment and management, even if they are well. Regular monitoring and support is recommended for at least three months following delivery.”

Other women requiring an urgent referral to secondary specialist maternal mental health services include anyone displaying thoughts of harm to either self or baby, suicidal ideation, or recent significant deterioration in mental state (BPACNZ, n.d.).

18 | AOTEAROA NEW ZEALAND MIDWIFE

research in this area, to explore specific risk factors for these groups.

Interestingly, despite the Growing Up in New Zealand cohort being an ethnically and socio-economically diverse group reflective of Aotearoa’s population - with 12.7% identifying as Māori - the results did not align with a 2017 study by Signal et al., which found that depression and anxiety symptoms, significant life stress, and a period of poor mood during the current pregnancy were all more prevalent for Māori than non-Māori women.

MIDWIFE’S ROLE The pivotal role midwives play in primary maternity care means the profession is well placed to identify when women are living with mental health issues and facilitate early access to primary medical care, community services or specialist services as indicated.

Midwives are encouraged to familiarise themselves with their regional mental health referral pathway/s. As noted in Box 1, the PMMRC recommends mental health screening questions to identify women who are at risk of severe mental illness. It is also recommended that midwives consider general screening questions for all pregnant women to identify mild to moderate depression.

Identification of Common Mental Disorders and Management of Depression in Primary Care, a guideline published by the Ministry in 2008, included a College representative in its working group. It contains a section dedicated to mental disorders in the perinatal period, with recommendations for screening and management, which are still relevant today and midwives may find useful.

The below questions are from the updated Maternity Information System (MIS) and Maternity Clinical Information System (MCIS) currently being used by MMPO midwives and a number of DHBs. At the booking visit and postnatally, possible depression can be identified by asking: • Have you ever experienced any mental health problems?

• Are any of the problems ongoing at the moment?

• During the past month, have you often been bothered by feeling down, depressed or hopeless?

• During the past month, have you often been bothered by having little interest or pleasure in doing things?

• Is this something you feel you need or want help with?

Midwives will also be familiar with the EPDS, which can be used as a further assessment tool, to assist in determining the urgency of issues and/or any follow up actions required.

If the woman identifies that she would like help, midwives need to explore what the woman feels would be helpful and which services are available in the area. The Referral Guidelines indicate that depression and anxiety disorders are primary level referrals.

In ideal circumstances, the woman would have a continuity of care relationship with her GP or primary care nurse practitioner (NP), although this may not be the case, and for some women, cost is a significant barrier.

In some regions, hauora Māori services or non-governmental organisations may offer mental health support during pregnancy.

SHOULD WE HAVE A NATIONAL APPROACH TO SCREENING FOR MENTAL HEALTH ISSUES IN THE PERINATAL PERIOD? Any national screening programme or tool would need to be considered within the unique context of Aotearoa’s maternity system - an important point raised by Mellor et al. in their 2019 study. The authors outline how the continuity of care model allows LMC community-based midwives to build a relationship with wāhine over time, meaning they are well positioned to detect even minor changes in a woman’s mood or behaviour.

It could be argued that community-based midwives are already screening women at every antenatal visit, albeit informally, and Viveiros & Darling (2019) in their review of perceptions of barriers to accessing perinatal mental health care in midwifery caution against the implementation of a formal screening tool as merely a ‘tick box exercise’.

In-depth, meaningful conversations between a midwife and wahine may be more likely to elicit honest responses to questions exploring overall wellbeing.

CHALLENGES Given Aotearoa’s most recent data shows New Zealand women are affected by ADS in higher numbers than PDS, and that the severity of ADS is associated with increased risk of developing PDS, midwives have an important role to play in assisting women, to identify any issues and access the care needed. However, the lack of a streamlined national approach poses challenges, as does the question of whether culturally appropriate resources or services - or any help at all, for that matter will be available to a woman and her whānau once she has disclosed her concerns.

FEATURE

The lack of a nationally co-ordinated policy or screening programme was highlighted by Underwood et al (2017) in their analysis of the Growing Up in New Zealand data, as well as by Mellor, Payne & McAra-Couper in their 2019 qualitative study, which explored midwives’ perspectives of assessment and screening during pregnancy.

Additionally, the question of whether or not to implement a formal national screening programme becomes an ethical one, when the obvious gap in current service provision is taken into account. A theme which emerged from Mellor et al.’s analysis - based on the reports of 27 LMC midwives - found a clear disparity between women’s mental health needs and service provision. Midwives perceived the referral process as unreliable, with the most notable shortfall affecting women with mild to moderate mental health issues, for whom there was a distinct lack of appropriate services.

HOPE ON THE HORIZON The maternity sector has not sat quietly on this issue, with a number of groups publicly articulating the problem and advocating for improvements in availability and accessibility of care for affected women and their whānau.

In its 14th annual report published this year, the PMMRC issued a wero (challenge) to the sector to urgently take action on its recommendations of the past 13 years, which are yet to be fully implemented. It called on the Ministry to invest in maternal and infant mental health, urgently recommending the development and funding of a Maternal and Infant Mental Health Network and clearly identifying the need for a national,

culturally appropriate pathway. Furthermore, the National Maternity Monitoring Group (NMMG) also expressed concern in their 2019 report, reiterating that New Zealand women do not have equitable access to appropriate mental health services throughout the perinatal period.

The College, in collaboration with the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), has also been advocating for action, most recently submitting a joint letter to the Minister and Associate Ministers of Health in April 2021. The letter directly challenged the Ministry on its failure to implement the longstanding PMMRC recommendations, further outlining the sector’s concern that maternal mental health needs have not been specifically prioritised, or even addressed, in the roll-out of the additional funding allocated to mental health at the 2019/20 budget announcement.

He Ara Oranga: Report of the Government Inquiry into Mental Health and Addiction, published in 2018, acknowledged maternal mental health as a major public health issue.

The establishment of the Initial Mental Health and Wellbeing Commission as part of the Government’s response holds promise, as does the most recent announcement by Health Minister Andrew Little, to centralise New Zealand healthcare and establish a Māori Health Authority. The finer details are yet to be revealed, including exactly how additional resources and funding allocated to primary mental health and addictions will funnel specifically into perinatal mental health, and to what degree.

In the meantime, the College acknowledges

that midwives are working tirelessly throughout Aotearoa to keep wāhine, pēpi and whānau as safe as possible, and that women trust their midwives with very personal and sometimes painful disclosures about their mental health. Midwives are well placed to work with women in these circumstances, but need an integrated network of responsive services to wrap the necessary support around each person. This requires the health system to recognise the importance of maternal mental health not only for the wahine, but also her pēpi and whole whānau, and to urgently commit sufficient resources to this care provision. The College understands that until this happens, midwives can sometimes feel isolated, and encourages any midwife in this position to discuss their concerns with a colleague, a College advisor, or a DHB midwifery leader. square

Support Services Perinatal Anxiety & Depression Aotearoa (PADA) - pada.nz depression.org.nz 0800 111 757 or free text 4202 Anxiety New Zealand - 0800 269 4389 Healthline – 0800 611 116 Suicide Crisis Helpline – 0508 828 865

References available on request.

ISSUE 101 JUNE 2021 | 19

FEATURE

ANAEMIA IN PREGNANCY: A PRACTICE UPDATE FOR MIDWIVES IN AOTEAROA ESTHER CALJÉ REGISTERED MIDWIFE, PHD CANDIDATE

Iron-deficiency and anaemia are common problems in pregnancy and postpartum, however, even in well-resourced countries, the management of maternal anaemia and iron status is recognised as inconsistent and suboptimal. This may be due to clinical guidance that was, until recently, very limited.

Many district health boards (DHB) in Aotearoa New Zealand have responded with the development of guidelines, such as Canterbury DHB’s Maternal Blood Optimisation Pathways (MBOP), to assist midwives in managing anaemia and irondeficiency in pregnancy. The development of these multi-disciplinary guidelines may be driven by the increased use of intravenous (IV) iron, and the international focus on improving patient blood management (PBM). PBM is relevant to midwives, as pillar one of PBM aims to optimise blood volume and red cell mass in pregnancy to avoid the requirement - and risks - of blood transfusion around the time of birth. Midwives also understand that the management of anaemia and iron-deficiency in pregnancy and postpartum is important for the health and well-being of women, and their pēpi.

20 | AOTEAROA NEW ZEALAND MIDWIFE

WHAT IS ANAEMIA? Anaemia is a lack of haemoglobin (Hb) and red blood cells, which leads to reduced transport and supply of oxygen to the tissues and vital organs. Although physiological anaemia of pregnancy reflects plasma expansion and haemodilution associated with normal pregnancy, the boundary between physiological anaemia and anaemia as a disorder, is unclear. Internationally, definitions of anaemia in pregnancy are inconsistent, which can be confusing for maternity care providers. Ideally, we would define anaemia in pregnancy based on a large population study of healthy iron-replete pregnant women in Aotearoa, which would give us a statistically established definition of anaemia in our population. However, in the absence of such a population study, it is reasonable to adopt anaemia thresholds based on recognised international guidelines with similar populations (see Box 1).

ADVERSE EFFECTS OF ANAEMIA Anaemia is the most common indirect cause of adverse maternal outcomes and is

associated with fatigue, lethargy, depression, reduced thermoregulation, impaired breastfeeding, bonding and cognition, and reduced physical performance and work capacity. Clinically, maternal anaemia is associated with increased mortality and morbidity, cardiovascular stress, increased risk of infection, poor wound healing, prolonged hospital stays, increased hospital costs and increased risk of interventions such as blood transfusion and intravenous iron.

Furthermore, maternal anaemia is linked to reduced fetal growth and prematurity (especially when the anaemia is from early pregnancy), low neonatal/infant iron stores and infant neurodevelopmental delay.

Conversely, high haemoglobin levels in pregnancy (Hb >130g/L) are associated with hypertension, increased blood viscosity, decreased placental perfusion, reduced fetal growth and prematurity.

WHO DOES IT AFFECT? Worldwide, it is estimated that anaemia in pregnancy significantly affects about half of all women in low-income countries, and 2530% of women in well-resourced countries.

FEATURE

The prevalence of postpartum anaemia is 30% in the United Kingdom (UK). In Aotearoa, the prevalence of antenatal and postnatal* anaemia is unreported, but it is reasonable to consider that they are comparable to the UK. Anaemia is often multifactorial, with multiple determinants of health as contributing factors. Across social strata, many women are at risk of anaemia (see Box 2).

IRON-DEFICIENCY AND OTHER CAUSES OF ANAEMIA

Iron replete women require approximately 1000-1300mg of extra elemental iron over the course of an entire pregnancy, and an extra 1mg per day during lactation; however, most women have insufficient iron stores to begin with, and are therefore ill-equipped to meet the increased demands of pregnancy and birth without the aid of iron therapy.

Following birth, for example, even a normal volume of blood loss can be problematic for a woman whose iron stores are absent or low (see Box 1), as there will be insufficient iron available to make new red blood cells (erythropoiesis), resulting in an inability to replenish blood volume and a concomitant drop in haemoglobin. This is known as irondeficiency anaemia.

Iron-deficiency has a number of causes: low dietary intake (including limited access to iron-rich food and/or food insecurity), intake of dietary iron inhibitors (e.g. tea, coffee, phytates), high demands (e.g. pregnancy, adolescence), decreased intestinal absorption (e.g. coeliac disease, bariatric surgery), and mechanisms associated with inflammation (e.g. inflammatory bowel disease or obesity).

Inflammation (from any cause) affects iron absorption and bioavailability in the body by sequestering or hiding away iron so that iron is not available for erythropoiesis. Ferritin

There are many causes of anaemia other than iron-deficiency: acute or chronic blood loss, megaloblastic anaemia (usually caused by vitamin B12 or folic acid deficiency), haemolytic states (HELLP syndrome, sickle cell disease, malaria), haemoglobinopathies, parasitic infections (e.g. hookworm) and anaemia of chronic disease.

SIGNS AND SYMPTOMS Clinical signs of anaemia include: tachycardia, hypotension, dyspnoea, palpitations, syncope and pallor (of the skin, nails, lips and/or inner membrane of lower eye lids). The most common symptom of anaemia is fatigue; however, symptoms may be non-specific unless the anaemia is severe.

Diagnosing anaemia and iron-deficiency in pregnancy

BOX 1

The term iron-deficiency is often used interchangeably with anaemia, but they are not the same. Iron-deficiency is when there are insufficient iron stores to meet the body’s demands. Iron deficiency is the most common cause of anaemia in pregnancy (50-60%), mostly due to the extraordinary iron demands of the increased red cell mass, placental development and fetal growth.

levels rise in response, reflecting inflammation rather than bioavailable iron stores. Diagnosis of iron-deficiency in the presence of inflammation can therefore be challenging.

ANAEMIA

Women with anaemia may feel lightheaded, heart-racing, shortness of breath, lethargic, low mood, irritable, difficulty concentrating, restless legs, pica (craving nonnutritive substances e.g. ice), and cold hands or feet. Symptoms of iron-deficiency without anaemia are generally vague, and can include fatigue, muscle weakness, or cognitive impairment. However, currently the only way to correctly attribute these symptoms to non-anaemic iron-deficiency (NAID) is if the symptoms resolve after iron therapy.

• 1st trimester: Hb < 110g/L

DIAGNOSIS OF IRON-DEFICIENCY, IRON-DEFICIENCY ANAEMIA (IDA) AND OTHER CAUSES OF ANAEMIA

• Serum ferritin is an inflammatory marker which increases in the presence of inflammation

NAID is the first stage on the spectrum of progression to IDA (see Figure 1).

Haemoglobin is the last red cell indice to drop, reflecting end-stage IDA. By the time haemoglobin levels are low, iron stores are already depleted, which is why haemoglobin testing alone is an insensitive measure of iron status. It is therefore important to diagnose iron-deficiency early, to prevent anaemia during pregnancy and at birth.

• C-reactive protein (CRP) >5 mg/L indicates inflammation

Serum ferritin remains the most accurate, accessible measure of iron stores, although it is an acute-phase protein or inflammatory marker that increases dramatically with

• There is no value in testing ferritin within six weeks of intravenous iron, as ferritin increases dramatically and does not accurately reflect iron stores during this time.

• 2nd & 3rd trimester: Hb < 105g/L • Early postpartum period (24-48 hours after birth): Hb < 100g/L • 1 week postpartum: Hb < 110g/L • 8 weeks postpartum: Hb < 120g/L Iron deficiency: ferritin < 30 mcg/L Absent iron stores (insufficient iron is available for erythropoiesis): ferritin < 12-15 mcg/L

• Diagnosis in the absence of inflammation is straightforward • Inflammation may mask an underlying iron-deficiency • There is no value in testing ferritin for at least one week postpartum, due to inflammatory processes associated with all births

*New research addressing evidence gaps on postpartum anaemia in Aotearoa will be presented to midwives at the 2021 College conference.

ISSUE 101 JUNE 2021 | 21

FEATURE

BOX 2

Risk factors for iron-deficiency and anaemia in pregnancy • Previous anaemia • Low-iron diet • Low socio-economic status • Inter-pregnancy interval < 1 year • Multiple pregnancy; Parity ≥3 • Teenage pregnancy • Smoking / Obesity • Bariatric surgery • Recent history of bleeding

• High risk of obstetric bleeding (e.g. placenta praevia • Gastrointestinal disorders e.g. crohns or coeliac disease • Jehovah’s Witness • Women from ethnic backgrounds at high risk of haemoglobinopathies: Southern Europe, Middle East, Africa, South East Asia, India or Pacific Islands.

22 | AOTEAROA NEW ZEALAND MIDWIFE

inflammation. This can lead to missed diagnoses of iron-deficiency with the appearance of false normal results as a response to inflammation. Some hospital laboratories routinely test C-reactive protein (CRP) concurrently with serum ferritin to detect the presence (CRP >5mg/L) or absence (CRP ≤5mg/L) of inflammation.

Alternatively, midwives can request CRP alongside ferritin testing if inflammation is suspected, or ferritin levels are normal or elevated and haemoglobin is low (see Table 1). One method that the World Health Organisation recommends to account for inflammation-related increases in ferritin, is to raise the cut-off for irondeficiency to 30mcg/L in pregnancy (from 15-20mcg/L previously). This approach has been adopted in international and some DHB guidelines. It is beyond the scope here to detail the pathophysiology and management of anaemia and iron status in the presence of inflammation. Box 1 outlines diagnostic criteria and key practice points for iron-deficiency and anaemia in pregnancy and postpartum.

It is important to interpret all the red cell indices in the complete blood count, when diagnosing anaemia and the possible causes (see Table 1). Normocytic, normochromic

red blood cells (RBCs) have a normal mean cell volume (MCV) and mean corpuscular haemoglobin (MCH). Microcytic (low MCV), hypochromic (low MCH) RBCs are small and pale. Macrocytic (high MCV) RBCs are large, and are associated with megaloblastic anaemia.

Because the aetiology of anaemia is complex and multifactorial, women may have multiple causes of anaemia.

Haemoglobinopathies, for example, are the most common genetic disorder worldwide.

This is significant for midwives in Aotearoa because our birthing population is increasingly multi-ethnic, comprising more migrant women than ever before. Many birthing women come from countries where haemoglobinopathies are endemic (Southern Europe, Middle East, Africa, South East Asia, Indian Subcontinent or Pacific Islands), and are at greater risk of anaemia.

There are many haemoglobinopathy disorders including, α- and β-thalassaemia and sickle cell disease. The clinical characteristics range from being asymptomatic, to requiring regular blood transfusion, and reduced life expectancy. Women with a known haemoglobinopathy require obstetric referral; however, midwives should be aware of the possibility of an undiagnosed

FEATURE

FIGURE 1: THE SPECTRUM AND PROGRESSION OF IRON-DEFICIENCY ANAEMIA

Iron replete Normal Hb; Normal iron stores; Normocytic and normochromic red blood cells (RBCs)

Non-anaemic iron deficiency Normal Hb; Low iron store

Iron-deficiency anaemia (IDA) Low Hb; Low iron stores; RBCs may be microcytic (small, long-arrow-down MCV); and hypochromic (pale, long-arrow-up MCH)

Long standing IDA Low Hb; Low iron stores; RBCs may be microcytic (small, long-arrow-down MCV); and hypochromic (pale, long-arrow-up MCH)

Source: Canterbury District Health Board MBOP Guideline and Practice Improvement Strategy. Reproduced with permission.

TABLE 1: INTERPRETING LABORATORY TEST RESULTS TO ASSESS FOR IRON-DEFICIENCY AND ANAEMIA

DIAGNOSIS

HAEMOGLOBIN g/L

SERUM FERRITIN mcg/L

C-REACTIVE PROTEIN (CRP) mg/L

MEAN CELL VOLUME (MCV) AND MEAN CELL HAEMOGLOBIN (MCH) [with classification]

Iron replete Normal > 30 Normal (normocytic normochromic Non-anaemic iron-deficiency (NAID)

Normal

< 30

Normal (or low)

Iron-deficiency Low < 30 anaemia (IDA)

Low (or normal in early IDA)

NAID

Normal with inflammation

Normal CRP > 5 or elevated*

Normal (may be mildly low)

Anaemia of Low chronic disease

Normal CRP > 5 or elevated*

Normal (may be mildly low)

Thalassaemia Low (or normal) minor

Normal or elevated*

Low (or normal)

Megaloblastic or pernicious anaemia

Low (or normal) Elevated MCV platelet levels may Normal MCH [macrocytic, (folate or vitamin B12 deficiencies be low normochromic] are common causes)

* in the presence of inflammation, ferritin is elevated and is not an accurate measure of iron stores Source: Canterbury District Health Board MBOP Guideline and Practice Improvement Strategy. Reproduced with permission.

ISSUE 101 JUNE 2021 | 23

FEATURE

haemoglobinopathy in women who are from an ethnic group with a high prevalence of haemoglobinopathy. Haemoglobinopathy screening is expensive and time consuming, so as a first step, CBC and ferritin results need to be assessed. If these are normal and there are no unusual red cell indices, continue with routine pregnancy care.

Key practice points for midwives to consider • Introduce advice/information from pre-conception, or in early pregnancy, on increasing dietary iron, enhancing absorption, and minimising inhibiters of iron absorption (e.g. tea and coffee) • Haemoglobin (Hb) alone is an insensitive measure of iron status • For all 1st trimester women: test complete blood count (CBC) and ferritin to establish baseline iron status, and maximise early opportunities to prevent or treat iron-deficiency and/or anaemia • 2nd trimester: repeat CBC and ferritin for all women • 3rd trimester: repeat CBC and ferritin, especially for women at higher risk of anaemia, or women with 2nd trimester iron deficiency or anaemia • Untreated iron-deficiency without anaemia progresses to iron-deficiency anaemia (IDA) • Consider alternate day dosing of oral iron (≥60mg elemental iron) or lower doses of daily oral iron (not less than 40mg) if higher daily doses not well tolerated • At any stage, obstetric referral if Hb<90g/L • CBC 7-10 days postpartum if history of PPH and/or iron-deficiency or anaemia prior to birth • Consider CBC and ferritin at 4-6 weeks postpartum for at-risk women and/or significant PPH • Women who have received intravenous iron should have CBC and ferritin tested 6-12 weeks post iron infusion

24 | AOTEAROA NEW ZEALAND MIDWIFE

For women with a family history of a haemoglobinopathy, seek obstetric or laboratory advice on whether screening should be recommended. For any women who have unexplained microcytic/ hypochromic RBCs, or unexplained anaemia, seek obstetric or laboratory advice on whether a haemoglobinopathy could be present and which screening tests are warranted, given the clinical picture. Include gestation and ethnicity on any referral forms. When haemoglobinopathy screening is indicated, it is optimal to do this in the first trimester, if possible, to allow sufficient time for genetic testing/counselling and appropriate management of pregnancy if required.

HOW TO TREAT IRON-DEFICIENCY AND ANAEMIA Due to the risks of iron-overload, routine iron supplementation is not recommended without a confirmed diagnosis of iron-deficiency or anaemia. Current recommendations for the treatment of IDA are 100-200mg daily of elemental iron (actual iron content). If started early in pregnancy, the treatment for NAID is 40-80mg day. For detailed guidance on which iron supplements are recommended and subsidised, as well as dosages, see Canterbury DHB’s Recommended oral iron preparations for Maternal Blood Optimisation Pathways (MBOP), a highly practical visual resource for midwives and women alike. Iron supplementation is not recommended if Hb ≥ 130 g/L. Elemental iron is the total amount of iron available for absorption in the body, which is different to the total amount of iron ingested in the diet, or the ‘total dose’ of iron in oral iron supplements (read the label carefully).

Recent research in women with NAID has shown that the absorption of multiple, high daily doses of oral iron is impaired due to inflammation in the gut as a result of the high doses of iron. This paradoxically interferes with iron absorption in subsequent doses.

Although this research has not been replicated in pregnant women with IDA, international and local guidelines are recommending that

consideration of a single dose on alternate days may improve absorption, compliance and reduce side effects. Women should also be informed on how to reduce sideeffects and maximise absorption of oral iron supplements: taken on an otherwise empty stomach (one hour before or two hours after a meal) with vitamin C-rich fruit, such as kiwifruit or an orange (also reduces constipation), and without inhibitors such as tea or coffee. Taking an iron tablet before bed can be an easy time to remember.

FOLLOW-UP Women on iron supplementation should have repeat CBC and ferritin testing, and follow-up. When treating IDA, it is recommended to continue with oral iron for three months to replenish iron stores, once haemoglobin levels have normalised.

Non-responsiveness to oral iron is persistent anaemia after 4-8 weeks of regular oral iron where haemoglobin levels rise less than 10-20g/L, and ferritin remains low.

If iron-deficiency or anaemia persists, is unexplained, or difficult to treat despite iron supplementation, further investigations for the underlying cause should be considered.

There may be underlying pathologies beyond iron-deficiency and increased requirements of pregnancy. As well as repeating CBC and ferritin, obstetric or laboratory input is recommended, in order to identify whether further screening is advised, i.e.

CRP, B12, folate, renal function and haemoglobinopathy. Other causes that may need to be excluded are malabsorption from inflammatory bowel disease, coeliac disease, gastrointestinal tract blood loss, or other systemic disease. An obstetric referral is appropriate promptly if Hb <90 g/L. CONCLUSION Although we don’t know the optimal haemoglobin levels for pregnant women in Aotearoa, there is evidence that low and high haemoglobin levels are problematic.

Anaemia is associated with a wide range of adverse clinical and quality of life outcomes.

Maternal iron-deficiency and anaemia are largely preventable and treatable using simple measures in partnership with women, based on timely testing and interpretation of red cell indices and ferritin levels from early pregnancy.

Healthy iron levels in pregnancy and postpartum improve maternal wellbeing and perinatal outcomes, reducing morbidity and the likelihood of requiring intravenous iron or blood transfusions around the time of birth. square References available on request.

FEATURE

noho marae ki Katihiku Capital and Coast DHB midwives were gifted an unparalleled opportunity to absorb the teachings of some of Aotearoa’s most prominent mana wāhine Māori at a noho marae hosted by Ngāti Huia in May. Amellia Kapa was honoured enough to attend the event and shares her experience.

AMELLIA KAPA COMMUNICATIONS ADVISOR

Regardless of how many times I have been called on to a marae, the visceral response within my body as the sound of the karanga reverberates across the marae ātea remains the same. The pōwhiri on to Katihiku marae, just outside of Ōtaki on the morning of May 15 was no different and evoked the same tell-tale goose bumps. Having never analysed this in any depth before, I can now say I have an explanation; Kerensa Johnston, Chair of Ngā Pae o Te Māramatanga – New Zealand’s Māori Centre of Research Excellence, CEO of Wakatū Incorporation, and a speaker at the noho, shared an anecdote during her presentation which, when I heard it, felt like a key turning in a lock.

The pūrākau (story) was told to Kerensa by a kuia, whose own kuia had relayed it to her.

It described the very deliberate action taken by our tūpuna (ancestors) post-European arrival, to close off parts of our consciousness, in order to protect us from the suffering they foresaw for our people. Her reason for

sharing this story? To convey to attendees that as Māori, when we are reconnecting with our whakapapa and refamiliarising ourselves with our reo rangatira, for example, we are doing just that: remembering who we are - awakening aspects of ourselves that were secreted away and not, as some would say, ‘learning’ these things for the first time.

And so began a noho marae which for some, reignited connection with dormant aspects of whakapapa, and for others, offered deep insights into te ao Māori they might otherwise never have been privy to. Attended by both Māori and tauiwi CCDHB staff, the noho was organised by Māori midwife and Maternity Quality & Safety Co-ordinator (CCDHB) Victoria Roper, who honoured the group by inviting them to her own marae, Katihiku, for the immersive experience.

Sharing mātauranga Māori was the main kaupapa of the noho marae and Victoria’s selection of speakers was deliberate. “The intention behind inviting these speakers was

to add fresh voices and perspectives from outside of midwifery into what can sometimes feel like a tired conversation. Māori midwives are overworked and under-recognised, and have been crying out for professional support for some time now. These presenters and the kōrero they stimulated provided much-needed balm for the wairua.

Regardless of how many times I have been called on to a marae, the visceral response within my body as the sound of the karanga reverberates across the marae ātea remains the same.

ISSUE 101 JUNE 2021 | 25

FEATURE

Noho attendees outside Tamatehura (wharenui) at Katihiku marae.

26 | AOTEAROA NEW ZEALAND MIDWIFE

“The line-up of wāhine toa who came to share their mātauranga are all esteemed leaders in their respective fields, and were generous enough to share their time and energy with us. They were beyond inspiring and demonstrated for every Māori midwife present, that their very essence as wāhine Māori is a life force in and of itself, and should never be viewed as a limitation.”

Māori registered nurse and researcher Dr Kelly Waiana Tikao shared her doctoral research journey into Ngāi Tahu customary birthing practices and paid tribute to atua wāhine Māori (Māori female deities), as well as repositioning te whare tangata (womb) as a receptacle of cultural knowledge. Film producer, director and founder of Maoriland Film Festival, Libby Hakaraia, shared her personal story, from being told she would “amount to nothing” in secondary school due to her Māori heritage, to becoming one of the most prominent Māori storytellers of our time.

Kaimirimiri and kairongoā Māori, Joanne Hakaraia reiterated the importance of holistic care that acknowledges all four walls of Te Whare Tapawhā when caring for whānau Māori, and CEO of Kono and former US Trade Commissioner Rachel Taulelei took attendees on a comical journey, inviting participants to create their own superhero alter ego, imagining every detail, right down to hair, costume and superpowers (based on real life attributes). Whilst entertaining, the exercise was powerful in its potential to bring awareness to the glass ceiling many attendees may not have fully appreciated loomed above them.

Precious Clark, managing director of Maurea Consulting Ltd and creator of Māori cultural competency training programme Te Kaa, outlined her company mission to help 10,000 people positively identify with Māori culture. Precious’s workshop included a comprehensive overview of the deeper meanings behind commonly used Māori terms and concepts and most significantly, required the rōpū of attendees to demonstrate their understanding of how these concepts apply in a practical, tangible sense in the midwifery setting. Precious, also a kaitito waiata (composer) and performer, wrapped up the noho by teaching one of her own compositions to the rōpū.

Event organiser Victoria says the noho took on a mauri (life force) of its own as it unfolded. “It exceeded every expectation I had, in every sense, and I couldn’t be more grateful for the speakers’ contributions, the graciousness of our hosts at Katihiku, and all those who attended. The take-away learning for each individual would have been unique, but I’m confident every person left with more than they had when they arrived.”

Perhaps the most unexpected gift to emerge from the noho was delivered by Kerensa Johnston, in the form of a new te reo Māori translation for the word ‘midwife’. Coined by Dr Karena Kelly, a te reo Māori lecturer at Victoria University’s Te Kawa a Māui (School of Māori Studies) and a graduate of exclusive Māori language academy Te Panekiretanga o Te Reo Māori, Karena has offered ‘Tai Tuarā’ as another potential translation for midwife, referring to the person/people who act as the backbone for wāhine, whānau, hapū and iwi. A fitting tribute to the significant role midwives play in the context of the wider community, this new translation will be explored further in the next issue of Midwife.

Other speakers who shared their mātauranga with the group included midwife and mayor of Rotorua, Hon Steve Chadwick; Māori midwife, researcher and director of Tieki Consultancy, Dr Hope Tupara; CE of Ngā Maia Jean Te Huia; general manager of Hāpai Te Hauora Fay Selby-Law and kairāranga (weaver) Jenny Firmin. Event organiser Victoria hopes to turn the noho into an annual event, having received overwhelmingly positive feedback from attendees about their experiences. square

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FEATURE

Right: Ngatepaeru Marsters (left) and Teresa Krishnan (right) holding the ipu whenua that connects the two arms of the project (Te Ara O Hine and Tapu Ora). Photo by Tania Fleming.

$6M BOOST FOR MĀORI AND PASIFIKA MIDWIFERY STUDENTS Te Ara Ō Hine – Tapu Ora, a joint $6m project between the Ministry of Health (the Ministry) and Aotearoa’s midwifery education providers, was launched at AUT University in March and signalled the beginning of a new chapter in addressing midwifery workforce inequities. Amellia Kapa attended the event and sheds light on its significance.

AMELLIA KAPA COMMUNICATIONS ADVISOR

AUT University’s South Campus was abuzz with excitement on the morning of 30 March as midwives, student midwives, midwifery educators, government officials and journalists poured in to celebrate the launch of a national project which represented much more than the dollar amount allocated to it.

Ngā ingoa: The name Te Ara Ō Hine was gifted by highly regarded Hōreke kaumātua, Te Pania Kingi (Te Popoto) and translates to ‘the path of Hine-te-iwaiwa’, referring to the female Māori deity who presides over childbirth, fertility and te whare tangata (womb). Matua Te Pania explained Hine-teiwaiwa was given a hei tiki made of pounamu by the atua Tiki – a symbol of fertility only to be worn by wāhine.

The name Tapu Ora was gifted by esteemed Senior Pacific Advisor Fuimaono Karl PulotoEndemann MNZM JP and acknowledges the sacred space of birth, aligning it with students’ learning journeys and the gaining of midwifery knowledge as equally sacred.

28 | AOTEAROA NEW ZEALAND MIDWIFE

The project, which will see the Ministry invest $6m into Aotearoa’s midwifery education providers over the next four years, will focus on increasing recruitment and retention of Māori and Pasifika midwifery undergraduate students, as well as ensuring these students go on to successfully complete the programme.

Officially launched by Associate Minister of Health Hon Dr Ayesha Verrall, in her speech the Associate Minister recognised the importance of strategising to ensure the midwifery workforce appropriately reflects the diversity of the communities it cares for.

“Part of the investment is funding to increase the number of midwives and ensure the workforce is representative of the populations they’re serving.”

Increased pastoral support for Māori and Pasifika students by way of increasing Māori and Pasifika educators and liaison staff, as well as financial grants awarded directly to students, are just two examples of how the project aims to increase retention within the programmes.

National Lead of the Pasifika arm of the project (Tapu Ora) Ngatepaeru (Nga) Marsters, described the venture as instrumental. “This project is a powerful vehicle for change, with the main goal being to increase the number of Pasifika and Māori midwives entering our currently inequitable workforce. Increasing the likelihood of Pasifika and Māori women being cared for by a midwife whose cultural context they can relate to only stands to benefit our communities.”

College President Nicole Pihema (Ngāpuhi, Te Rarawa) also attended the event and echoed Nga’s sentiments. “Achieving more equitable health outcomes for our Māori and Pasifika communities starts with addressing the gaps in our workforce. I have every confidence that as our workforce shifts to more accurately reflect the communities we serve, the natural consequence of this will be increased wellbeing and improved perinatal outcomes for whānau nationwide.”

In the same vein, National Lead of the Māori arm of the project (Te Ara Ō Hine)

The ipu whenua (pictured right and featured on the cover) was gifted to the project by College kuia Crete Cherrington, who received it from the Waetford whānau (Ngāti Wai, Ngāti Hine) as an acknowledgement of her midwifery care.

Crete describes the symbolism behind the use of ipu whenua as honouring whenua ki te whenua. “It’s about looking at where we’ve come from and the connection to Papatūānuku and Ranginui. We’re a small speck of dust in the spectrum of the whole universe and it’s an acknowledgement of that place we hold in the cosmos.”

She explains the significance of this particular ipu in relation to the project: “It represents the gifting and sharing of obligation. It has no lid: the idea is that it sits in the room and is filled with the thoughts and mātauranga of the students as they develop.”

“The pūpū (referring to the trumpet/conch shell-like shape of the opening) is protective.

The pītau (spiral) represents growth and flow and relates to the evolving practice of the tauira as they progress through each year.

The patterns around the ipu symbolise the ara (path) the students are travelling on and helps direct them, and the mango pare (hammerhead shark design) represents determination, tenacity and endurance so they don’t lose sight of their goals.”

The pūpū or trumpet/conch shell also holds significance throughout the Pacific Islands and therefore provides a tangible link between the two arms of the project: Te Ara Ō Hine and Tapu Ora.

Teresa Krishnan explained this project’s point of difference will be in its consultation process. “Te Ara Ō Hine is going to be created by Māori, for Māori,” she said.

Rather than making assumptions about what Māori students and whānau need, regional hui will be facilitated with Māori students, Māori new graduates and mana whenua, in order to ensure the most relevant voices are heard.

“Evidence tells us that when Māori care for Māori, our outcomes are better. We need our workforce to reflect our whānau needs in the community, and to do that, we need to grow our Māori midwifery workforce, which begins with supporting Māori students to articulate their needs,” said Teresa.

Nga also explained that the change this project seeks to initiate is not only being sought by Pasifika midwives and educators, but the community at large. “Historically,

there has been a certain stigma Pasifika midwives have had to overcome. When I first started practising over 20 years ago, there was this undercurrent of an inherited societal mistrust within our community and our people didn’t have confidence in Pasifika midwives providing their care. But things have progressed significantly and now they do. In fact, they are actively seeking us out.”

“It’s not only about Pasifika families being cared for by their own,” she went on to say.

“It’s also about Pasifika midwifery students and midwives seeing Pasifika in other positions - as midwifery managers or policy influencers. That’s true equity; seeing Pasifika represented not only at the coalface, but throughout all levels of midwifery.”

Professor of Midwifery and Head of AUT University’s School of Clinical Sciences, Judith McAra-Couper, described her vision of “…a workforce that would finally make in-roads to the long-standing inequalities in service

provision and less than optimal outcomes that continue to unduly burden our Māori and Pasifika whānau and communities”.

She went on to say the deliverables of the contract surrounding recruitment, retention and completion are the minimum the educational institutions will be providing. “It would be remiss of us who are tauiwi - and yet another example of us not understanding what it is to be a good Treaty partner - if we do not ensure that the project involves a te Tiriti-honouring journey, working with mana whenua and transforming our educational practices and spaces. This is the only way we’re going to succeed.”

AUT University will hold the contract with the Ministry, and will have memoranda of understanding with the other four education providers: Waikato Institute of Technology (Wintec), Te Herenga Waka - Victoria University, Ara Institute of Canterbury (Ara) and Otago Polytechnic. square

ISSUE 101 JUNE 2021 | 29

BREASTFEEDING CONNECTION

BREASTFEEDING CHALLENGES IN THE EARLY POSTNATAL PERIOD – THE NON-LATCHING INFANT The previous article in the March edition of Midwife discussed the initiation of breastfeeding after birth, skin-to-skin care, innate breastfeeding abilities and the nine infant behavioural stages after birth. The beneficial practice of mother-infant skin-to-skin has demonstrated how critical the period of time after birth is, while also exposing how easily the infant behavioural sequences after birth can be derailed.

INFANTS WHO HAVE NOT LATCHED AT THE BREAST

CAROL BARTLE POLICY ANALYST

Numerous neonatal reflexes, (including rooting, sucking, swallowing, crawling, mouth gape, hand to mouth activity, and head bobbing) which are instinctive physiologic responses to endogenous or environmental stimuli (stimuli that can have positive or negative effects), contribute to the infant’s ability to self-attach at the breast (Schafer & Watson Genna, 2015). Early feeding ability requires recovery from birth, minimal disturbance, and infant-mother-contact. These aspects continue to be significantly important to breastfeeding in the days after birth.

respiration and breastfeeding (French et al, 2016), and unlimited skin-to-skin care can provide additional support for infants who continue to have difficulties breastfeeding in the days following birth. Svennson et al.

(2013) found that skin-to-skin contact during breastfeeding enhanced positive maternal feelings and shortened the time to resolve latching problems in a cohort of infants (n=103) at one to sixteen weeks postpartum.

This article reviews the management of the non-latching infant in the first few days on the postnatal ward, with a view to exploring support for the ongoing initiation of breastfeeding and the challenges presented when an infant is having difficulties feeding.

The challenges for midwives in providing care for breastfeeding complexities in understaffed areas with increased rates of birth interventions is also recognised, and some potential strategies for support for non-latching infants are presented.

All well term infants need to have the time and opportunity to proceed at their own pace through the nine behavioural phases after birth, but ‘derailed’ infants who have had difficult beginnings may take longer to recover from birth and to demonstrate an interest in feeding. Potential contributing factors to infant feeding delay include suction, resuscitation, caesarean birth, ankyloglossia, and any mother-infant

To summarise the previous article, Widström et al. (2020) proposed that the nine behavioural stages are developed and practised by the fetus in utero in the same specific order, which indicates that the newborn has been learning this sequence and is primed and prepared for this experience after birth. Skin-to-skin contact between the mother and infant immediately after birth allows for the development of innate neonatal behaviours such as temperature regulation,

Infants who are having initial latching difficulties are at a significant risk of shortened duration of breastfeeding and loss of breastfeeding exclusivity.

30 | AOTEAROA NEW ZEALAND MIDWIFE

separation. Other infants who may be at risk of a slow start to breastfeeding are early term births (37-38 weeks). A systematic review found an association between early term birth and lower rates of breastfeeding initiation and a shorter duration of exclusive breastfeeding (Fan et al, 2018). Kalmakoff et al. (2018) also found that early term birth was a predictor for feeding supplementation, although the research found that greater than 65 minutes of skin-to-skin contact reduced the risk of supplementation. Clinically recommended practices, along with skin-toskin contact, also include recognition of the importance of autonomous newborn hand use, which is demonstrated by breast seeking activities, hand-to-breast and hand-to-mouth movements, self-soothing, and shaping and moving the breast. Directing or restraining infant hand movements can cause feeding delays (Schafer & Watson Genna, 2015).

INFANTS WHO MAY HAVE FEEDING DIFFICULTIES

Infants who are having initial latching difficulties are at significant risk of shortened duration of breastfeeding and loss of breastfeeding exclusivity. When an infant is not breastfeeding, lactation is fragile and a multi-pronged strategy is needed; feeding the infant; development of a feeding plan with the mother; provision of appropriate support for the infant to move closer towards latching; protecting lactation; and avoidance of further complications from any intervention. At the same time, reassurance and care for the mother is also essential. The need to express breast milk and feed the infant by alternative means, while continuing to work towards achieving a breastfeed can be stressful, and this can compound maternal-infant difficulties by the down-regulation of prolactin.

Identifying the reason/s why an infant may be having difficulties enables a plan to be made to remedy problems, and may make it easier for a mother to understand why her infant is struggling. Sometimes there is no obvious reason that can be identified, but difficulties may also resolve without any specific treatment apart from time, patience, and care. As midwives will be aware, a key aim when offering the infant opportunities to latch at the breast is to keep the infant as calm as possible, as a frustrated infant will be unable to latch. Ideally, taking a break from feeding and calming the infant works well and if supplemental feeds have been started, it can be useful to offer a small amount to the infant at the beginning of the feed to help keep the infant calm. A small amount

BREASTFEEDING CONNECTION

of expressed colostrum, if available, may be enough to settle the infant before a return to the breast. Hand expression of breast milk may remove larger volumes of colostrum than a breast pump in the first few days after birth, and gentle breast massage and hand compression may also increase the amounts of available milk (Academy of Breastfeeding Medicine [ABM], 2017).

TYPES OF BREASTFEEDING SUPPORT The introduction of a physiological approach to breastfeeding initiation made a significant impact on clinical breastfeeding support because of the redirected focus towards activation of maternal-infant instincts (Douglas & Keogh, 2017). This redirects support away from a purely mechanical position and attachment model, which views breastfeeding as an acquired skill, to a relationship-centred breastfeeding focus, incorporating innate breastfeeding abilities (Schafer & Watson Genna, 2015).

No single breastfeeding support intervention focused on positioning and attachment - whether hands-on or hands-off - has been shown to significantly increase rates of maternal breastfeeding self-efficacy, breastfeeding duration or exclusivity (Schafer & Watson Genna, 2015).

Additional support for breastfeeding is recommended for infants who are experiencing difficulties (Fan et al, 2018), but achieving this in a busy understaffed postnatal ward can be challenging. Infant feeding ability is not related to maternal motivation, intention, desire or ‘skill’ but can be related to infant exposure to intrapartum and early postnatal stressors, which can include interruption of skin-to-skin care, as well as exposure to labour medications. Midwives may find that all the mother-infant dyads on their shift-caseload require additional support.

Early feeding difficulties can quickly lead to the need to start breast expression with a resulting loss of maternal confidence. This can increase maternal stress, which can negatively affect the milk ejection reflex and compound any breastfeeding challenges. The iatrogenic effects of introduced interventions, however carefully applied, may also lead to a rapid deterioration into a longer-term mother/ infant ‘hard to fix’ feeding problem, even after the initial infant feeding difficulty is resolved.

BIOLOGICAL NURTURING / INFANT LED NURSING Biological nurturing is a neurobiologic approach based on enhancing neonatal Cont. page 32 >>

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Additional support for breastfeeding is recommended for infants who are experiencing difficulties, but achieving this in a busy understaffed postnatal ward can be challenging.

reflexes and maternal instincts by using positional postures that are beneficial to breastfeeding (Colson et al, 2008; Colson, 2005a; Colson 2005b). A laid back position for breastfeeding compliments a physiologic approach. There are more triggers for primitive neonatal reflexes in biological nurturing postures (laid-back breastfeeding) which suggest that human infants are innately abdominal rather than dorsal feeders. The key for biological nurturing, alongside positioning, is the promotion of an oxytocin friendly environment.

PHYSIOLOGICAL BREASTFEEDING – WHAT HELPS AND WHAT DOESN’T Physiological breastfeeding practices incorporate the creation of privacy, appropriate support, patience and time,

32 | AOTEAROA NEW ZEALAND MIDWIFE

calmness, opportunities to practice breastfeeding and relationship-centred care.

Midwives support women to prepare a birth space to facilitate the physiology of labour (Bradfield, 2019) and the same attention to the environment is beneficial for breastfeeding – creating a physiological breastfeeding space. This is a space to support oxytocin responses, as free as possible from unnecessary interruptions, which is safe, private and warm. Winberg (2005) describes skin-to-skin care as the “maternal nest” which invokes a vision of calmness, closeness, warmth, loving touch, nurturing contact and relaxation.

These conditions support oxytocin response and require protection and facilitation in order to create a scaffold for breastfeeding.

Construction of a maternal nest and creating an ‘illusion of time’ in terms of the midwife being ‘with’ the woman so that she feels there are no time restrictions for the provision of breastfeeding support is important, but challenging. In a busy postnatal ward, creating an illusion of time is complex, but it suggests what is essential to meaningful interactions – creating a feeling of time well spent, relationship building, improving the quality of interactions, satisfaction and reassurance for the woman, and a shared decision-making process.

Burns et al. (2015) described language as an aspect of breastfeeding support that has

received little attention in the literature.

How maternity staff describe the feeding behaviours of infants during the time of breastfeeding establishment was observed during a study conducted at two maternity units in Australia.

Repeated negative references to infant personality and unfavourable interpretations of infant behaviour, implying that newborn infants have the capacity to think and decide whether to breastfeed, influenced how women perceived their infants. Terms used to describe infants included lazy, impatient, cross, cranky and uncooperative.

Burns et al. found that more relationshipbased communication, and focusing on breastfeeding as a relational activity, rather than just a nutritional activity, fostered positive language and positive maternal interpretations of infant behaviour.

SUPPLEMENTATION OF BREASTFEEDS Prevention of the need for supplementation is supported by the Ten Steps to Successful Breastfeeding (WHO), particularly Step 4 (skin-to-skin), Step 5 (support for initiation and maintenance of breastfeeding and management of common difficulties), Step 7 (rooming-in) and Step 8 (responsive feeding/feeding cues). Implementation of Step 6 (no food or fluids to breastfed infants unless medically indicated) and Step 9 (risks of feeding bottles, teats and pacifiers) also support exclusive breastfeeding and recognise

FEATURE

the importance of decisions made about why, what, how much, and when supplementary feeds are given, and how.

When supplementary feeds are medically necessary for the breastfed infant, the primary goals are feeding the infant, while optimising maternal milk supply. Any supplements should be given in a way that preserves breastfeeding, with attention paid to the volumes of milk given (limiting to what is necessary for newborn physiology), and supporting the infant to continue practising at the breast (ABM, 2017).

The optimal supplement is expressed milk from the mother, followed by screened donor milk, with formula being the last choice. If neither expressed milk from the mother or donor milk is available, then formula milk will need to be used. square The next Breastfeeding Connection article will discuss in detail early infant weight loss and feed supplementation.

References available on request.

Key points and strategies Newborn infants need time to recover from birth Skin-to-skin contact is the habitat needed for birth recovery and breastfeeding support immediately after birth and in the postnatal period Time, patience and supportive breastfeeding opportunities are necessary for infants who are having feeding difficulties Birth interventions do not help breastfeeding and always need to be taken into account Facilitate oxytocin releasing conditions – a physiological breastfeeding space (maternal nest), because proximal care (skin-to-skin) develops maternal behaviours, feeding responses, and anxiety regulation in infants and mothers The maternal nest/oxytocin supportive conditions require a warm environment, low lighting, reduced noise, minimal interruptions, and privacy Creation of an ‘illusion of time’ despite the shift caseload – relationship building, satisfying interactions, care with language used and shared midwifewoman decision making.

For excellence in online midwifery education

K06976

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

2021 Semester Two courses Certificate Courses (15 Credits) 12 July to 27 August Midwives and Reproductive Justice, Political and Practical Challenges to Breastfeeding, Infant Mental Health 20 September to 5 November Applied Anatomy and Physiology for Midwives, Diabetes in Pregnancy, Global midwifery: Practical Steps Diploma (Pre-Thesis) Course (30 Credits) 12 July – 5 November Pathway to Thesis: Midwifery Research Methodologies

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

If you wish to complete the Complex Care Certificate in 2022, or would like further information about any of our postgraduate courses, please contact: suzanne.miller@op.ac.nz

0800 762 786 info@op.ac.nz

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rainbow realities Birth for Every Body, an open community forum aimed at gaining insight into the childbearing experiences of LGBTTQIA++ communities, was held at Hutt Hospital in December 2020.

34 | AOTEAROA NEW ZEALAND MIDWIFE

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Right: Andre Afamasaga, New Zealand Human Rights Commission Senior Advisor.

Far Right: Dr Elizabeth Kerekere, activist and expert on rainbow and human rights.

The forum, organised by a taskforce comprised of Hutt Valley and Capital & Coast DHB staff, LMCs, midwifery students and consumer representatives, was attended by over 80 people in person and an equal number of virtual participants.

college activities on rainbow inclusive care

Midwife and lactation consultant, Penny Wyatt, was part of the taskforce and explains the impetus for the event. “There is growing awareness of the reproductive rights of our rainbow and takatāpui families, and a drive to better understand and meet their needs within our services,” she says.

The College is currently developing a consensus statement on rainbow inclusive midwifery care with input from midwives Dr Jeanie Douche and Dr George Parker. College advisors recently participated in a workshop exploring rainbow identities, health and mental health disparities, birthing realities and inclusive midwifery care. We sincerely thank Dr George Parker for their generosity and expertise in facilitating the workshop. As a result, the College will be implementing some of the lessons from the workshop at national office level and expanding the College’s education programme to include rainbow inclusive midwifery practice. The College recognises the need for a consensus statement on cultural safety and this is also currently in development.

With a full programme of presenters sharing both personal and professional perspectives on the day, attendees were no doubt unpacking the thought-provoking content long after the event.

Dr Elizabeth Kerekere, an activist and expert on rainbow and human rights addressed the needs of takatāpui, proposing kaupapa Māori frameworks as a means of better supporting rainbow communities.

New Zealand Human Rights Commission Senior Advisor Andre Afamasaga shared his personal coming-out journey, as well as the work he is doing on inclusion of LGBTTQIA++ people within the church.

Mani Mitchell, the first person to come out in Aotearoa as an intersex person, facilitated the event, and other key speakers included Val Little (Programme Manager - Rainbow Tick) and Jelly O’Shea (Communications and Project Manager at the Intersex Trust Aotearoa NZ).

Penny says the most powerful aspect of the forum, however, was the personal stories shared by parents. The anecdotes, contributed by a gay man, two lesbian couples and a trans man, collectively explored experiences of fertility treatments, surrogacy and adoption, conceptions, miscarriages, and finally, the successful creation of their families in Aotearoa. “The stories were heartfelt and very moving,” she says.

Under the leadership of Hutt Valley DHB Director of Midwifery Karen Ferraccioli, the taskforce is now organising a conference, to be held 26 November 2021, which will focus on empowerment and body positivity in pregnancy.

For more information, or to get involved, contact Karen Ferraccioli: Karen.Ferraccioli@huttvalleydhb.org.nz. square

REGISTRATION FOR MIDWIFERY CARE The College has worked with MMPO to advocate for seamless registration and claiming for midwives caring for pregnant trans and non-binary people. The Ministry advises that under the current business rules, the NHI is automatically checked to confirm it is a 'valid female NHI', therefore when it comes up as other than female (unidentified/male), the registration is rejected. A short-term solution has been agreed upon and a permanent solution will follow.

Short term / When MMPO receives automatic claim rejections for each module, the staff will liaise directly with the Ministry to manually override this and process the claim.

Permanent solution / The Ministry has revised its business rules so that the automated process simply checks that the registration is for a 'valid NHI', not a 'valid female NHI'. This change will come into effect when the new Section 88 Notice is gazetted. The slated timeframe for this is September 2021.

If midwives have any questions about care for members of the rainbow community or experience any issues relating to IT systems when registering a non-binary person or trans man for midwifery care, the College advisors are available to assist by emailing liaison@nzcom.org.nz. square

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working in collaboration:

referrals to Tamariki Ora Well Child services CLAIRE MACDONALD MIDWIFERY ADVISOR

The Well Child Tamariki Ora (WCTO) programme is a universally offered, publicly funded child health and whānau support programme. The programme delivery begins with midwives, who undertake the first four health assessments: at birth to 24 hours, within 48 hours, up to one week, and at 2-6 weeks.

A WCTO provider follows on, with health assessments at 4-6 weeks, through to 2-3 years, and the programme is completed with the B4 School Check, at four years old. The GP team provides a six week check alongside immunisations.

A national review of the WCTO programme was undertaken in 2020, with a report pending. The College had a representative on the Review Advisory Rōpū, the members of which all shared a clear desire: for the programme to support equitable health outcomes and meet Tiriti o Waitangi responsibilities by flexing to meet the needs of whānau, so that they are supported to thrive. While the programme redesign is yet to begin, there are some clearly

36 | AOTEAROA NEW ZEALAND MIDWIFE

identifiable actions for improvement, which will be as relevant and necessary in future as they are now. For midwives, these include information-sharing with whānau about all provider options, and ensuring timely referral to the WCTO provider of choice.

Concepts like equity, access and te Tiritibased care are frequently discussed in the current health context, so what does this mean in practice when it comes to primary maternity and infant/child care services?

The Ministry of Health’s definition of equity is: “In Aotearoa New Zealand, people have differences in health that are not only avoidable but unfair and unjust.

Equity recognises different people with different levels of advantage require different approaches and resources to get equitable health outcomes.”

It is estimated that health care is responsible for around 20-25% of health outcomes, while the social, environmental, cultural and commercial determinants of health contribute significantly more.

Health services, including maternity, have

a responsibility to support optimal health outcomes wherever they can.

Access, and related concepts like acceptability and engagement are about ensuring services are culturally safe, relevant, and available in locations and at times that work for whānau.

In her presentation at the Perinatal and Maternal Mortality Review Committee’s 2021 webinar about Te Taitokerau-based antenatal education programme Ngā Wānanga o Hine Koopu, Raewyn Smith described the programme’s unique approach: “We don’t have DNAs [did not attend], we have DNIs [did not inspire]”. Viewing health care through this lens requires services to adapt to the needs of whānau, rather than using a one-size-fits-all approach that tends to be more focused on the needs of the service provider.

Te Tiriti-based health care uses te Tiriti o Waitangi as the guiding framework for health services. Te Tiriti is the document that guarantees tangata whenua the same rights and protections as tauiwi, including equal health outcomes, and is the document that enabled tauiwi to settle and call Aotearoa home.

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FIG 1. RESULT COMPARISON BETWEEN MĀORI AND NON-MĀORI 100 78%

77%

80 68%

68%

60

HOW DO THESE CONCEPTS APPLY TO THE CONTINUUM OF CARE IN THE FIRST 1,000 DAYS? The WCTO programme review highlighted the need for transitions between services to be strengthened, so that all whānau receive the ongoing care they are entitled to. Currently, only 77% of non-Māori are referred to WCTO by 28 days, and there is a disparity for Māori and Pacific peoples, with even lower referral rates of 68% and 70% respectively.

Prior to discharging whānau from midwifery care, midwives should be confident that the next service has received the referral, and that whānau have already engaged with the provider. Late referrals affect the likelihood of a whānau receiving their first visit before 50 days of age and contribute to further health inequities (50 days is the audit standard, but the first core contact should occur by six weeks according to the WCTO programme).

The data tell us what is happening, but not why, and there are likely to be a number of factors contributing to the referral rates and disparity by prioritised ethnicity.

CHOICE OF PROVIDER In many areas, Plunket is the majority WCTO provider available to all whānau and is contracted nationally. For whānau Māori in most areas, and Pasifika families in some areas, there is also the option of Tamariki Ora and/or Pasifika WCTO providers.

As My Māori Midwife has beautifully illustrated, and national workforce priorities have identified, kaupapa Māori services increase access and engagement for whānau Māori through home visiting, whakawhanaungatanga and the addition of wrap-around support; in other words they are more likely to inspire whānau to engage with services. Tamariki Ora providers are contracted locally, often within a Whānau Ora service and/or as part of an iwi rūnanga. They include health support through WCTO nurses, as well as breastfeeding support services, social and cultural support with the assistance of kaimahi, and many provide home visits to whānau for the duration of the programme. As local services, each has grown and developed to meet the specific needs of whānau within the rohe.

40

20

0 WCTO Referral by 28 Days

WCTO Referral by 50 Days Māori

Non-Māori

FIG 2. RESULT COMPARISON BETWEEN PACIFIC AND NON-PACIFIC PEOPLES 100

80

70%

76%

75%

70%

60

40

20

0 WCTO Referral by 28 Days

WCTO Referral by 50 Days Māori

All options for WCTO service provision need to be offered to whānau. It is particularly important that whānau Māori and Pacific families are given the option of Māori or Pacific WCTO providers where available, as well as Plunket. It is important to note that GPs are not WCTO providers, and do not receive any funding to provide routine WCTO health assessments (apart from the six week check).

Non-Māori

the prescriptive structure of the contract, explaining nurses are expected to see 100 new babies per year in addition to their pre-existing caseload. Each nurse has a caseload of about 500 whānau at any given time, all requiring home visits. If referrals for new pēpi are received late, it becomes near impossible to schedule the first visit by six weeks of age.

TIMING OF REFERRAL Contractually, midwives claiming from Section 88 are obliged to give a written referral to a WCTO provider by four weeks postpartum, or can request WCTO involvement as early as two weeks after birth if the baby or whānau needs further support. This also supports work planning by WCTO nurses who, like midwives, are driven by a clear purpose to provide personalised care to whānau, and as a predominantly women’s workforce, experience similar service delivery pressures.

Dianne Oakley, Team Leader for Tamariki Ora at Te Puawaitanga ki Ōtautahi, describes

It is estimated that health care is responsible for around 20-25% of health outcomes, while the social, environmental, cultural and commercial determinants of health contribute significantly more.

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In the early postnatal period, midwives are often providing intensive support for ‘in the moment’ issues like recovering from birth, infant feeding and settling, adapting to parenting a first baby or a growing family, or mental health.

38 | AOTEAROA NEW ZEALAND MIDWIFE

Although it’s a juggle, Dianne’s team is dedicated to the mahi. “We love the work because we love the women and the babies.

You’ve got to be satisfied that you’ve done a good job. If it was about the money, you wouldn’t be there. It’s about the women.”

antenatal stage, allows us to engage and build the relationships early and provide early intervention if required,” Michelle says.

DISCUSSIONS WITH WHĀNAU ABOUT WCTO

Michelle McGregor, Tamariki Ora Clinical Nurse Leader at Te Rūnanganui o Te Atiawa ki te Upoko o Te Ika a Maui in Waiwhetu, Lower Hutt, describes the importance of te ao Māori lens in developing relationships with both whānau and midwives in the area. “Our whānau like to kōrero. It’s an informal way of engaging and sharing information and you can obtain the required information necessary for an assessment and for care planning. That’s the difference - you don’t start off as clinical, but as manuhiri, gaining trust and developing positive relationships.”

Michelle also points to the importance of knowing who the local Tamariki Ora services are and what they offer. She recommends picking up the phone to have a kōrero and develop a relationship with local services, or to discuss a specific whānau who may need extra tautoko and guidance.

When a referral is received, a kaimahi will visit the whānau to establish whakawhanaungatanga (connection), after which a nurse completes the health assessment. “Our kaimahi and nurses work equally together to support each other in our mahi and in care planning for the whānau. The clinical assessments are a part of the well child assessment; whānau engagement and support is just as important.

Early referral, even if it is verbally in the

In the early postnatal period, midwives are often providing intensive support for ‘in the moment’ issues like recovering from birth, infant feeding and settling, adapting to parenting a first baby or a growing family, or mental health. It is therefore ideal to introduce the continuum of primary care from midwifery to WCTO during antenatal discussions, so the whānau already has a preference when discussing which service to make a referral to once the baby is born. square

Examples include safe sleeping devices, breastfeeding community support, and connecting with rūnanga and marae social services. Being able to describe the WCTO services to whānau when considering their options supports an informed decision.

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Ngā Maia:

midwifery partnership and te Tiriti o Waitangi Over 5000 years ago, people began moving out of South China down into Asian archipelago, thus beginning a migration of peoples to the distant islands of the South Pacific, including Aotearoa (Anderson, 2016).

JEAN TE HUIA CE NGĀ MAIA

Beyond the appreciation of historians, Māori have their own stories, their own mōteatea, their own soul-searching narratives, about who we are, and how we have always been here in Aotearoa, in complete contrast to the romantic notions of navigational opportunity.

Crown relations with Māori assertion of tino rangatiratanga (self-determination) over their kāinga (homes) and taonga (tamariki and pēpi) have recently been tested by the Waitangi Tribunal. Oranga Tamariki and the taking of newborn pēpi have been found to be in breach of Article 2 of te Tiriti o Waitangi. What has this got to do with midwifery, some would ask?

The principle of social justice recognises the injustices - the effects of colonisation on Māori - resulting in disconnection from tribal

lands, traditional family structures, and the realities associated with the loss of these connections/relationships and an ongoing dismissal by many of te Tiriti, that determines the Crown’s obligations to Māori.

Waitangi Tribunal and three independent

It is a sad reality that over the past six years, an annual average of 265 babies under the age of three months have been taken into state custody, with an annual average of 171 of those uplifts being pēpi Māori (Office of the Children’s Commissioner, 2020). The taking of newborn babies at birth violates the UN (United Nations) Convention on The Rights of Children and the Convention on the Rights of Indigenous Peoples. All children have a right to be raised by their parents.

contrast to the Crown’s obligations to

The act of taking newborn babies in Aotearoa has been defined by the

Zealand health professionals, who are also

reviews (Boshier, 2020; Kaiwai, Allport, Herd et al. 2020; Office of the Children’s Commissioner 2020a & 2020b;) as inhuman, incomprehensible and in complete Māori under te Tiriti o Waitangi and in many instances, the uplifts were found to be unwarranted.

Te Tiriti o Waitangi, as the founding document of Aotearoa, sets out the principles of engagement and the practical application of the principles of te Tiriti with Māori. The principles of te Tiriti are the underlying mutual obligations and responsibilities placed on various parties, including New bound by the Health and Disability Act 1994 and The Code of Ethics.

The principles of te Tiriti o Waitangi are applied as a living document, including to circumstances not foreseen when te Tiriti was signed in 1840 between Māori and the Crown. Our role as midwives is to uphold the principles of te Tiriti o Waitangi and in doing so, uphold the midwifery partnership.

How do we as midwives, start the dialogue, and begin our discussions to work together as midwifery colleagues, and as midwives in Aotearoa working with Māori, to uphold the midwifery partnership within a te Tiriti partnership? square References available on request.

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POSTGRADUATE STUDY PATHWAYS FOR MIDWIVES LESLEY DIXON MIDWIFERY ADVISOR

Learning happens throughout our lives in a myriad of different ways. As midwives, we increase our knowledge, skills and expertise through our work with women and the experiences we share with them.

Engaging in the recertification process is designed to support midwives to stay up-to-date with the latest evidence and guidelines and extend their learning and expertise further. Changing roles is another situation where there is often a steep learning curve, and new skills and expertise develop.

A more formal way of increasing learning, knowledge and expertise, is to engage in postgraduate study.

Number of midwives enrolled in post graduate study in 2020: Postgraduate certificate - 44 Postgraduate diploma - 23 Master’s degree - 56 Doctoral degree - 29 Source: Midwifery Council of New Zealand, 2020

Postgraduate study contributes to professional development, extends midwifery skills, and assists midwives in critically appraising evidence for midwifery practice.

40 | AOTEAROA NEW ZEALAND MIDWIFE

WHAT IS POSTGRADUATE STUDY? Postgraduate study for midwives refers to study beyond the midwifery Bachelor’s degree. It requires enrolment in a postgraduate qualification (such as a certificate or diploma) course and undertaking a variety of specialist papers/courses.

Most midwives study towards midwifery postgraduate qualifications, but some may also consider postgraduate study in other areas such as Māori health, public health, education and management. Some midwifery postgraduate papers/courses may focus on these topics too. It is well worth looking at the different papers/courses on offer, whilst also considering what areas would be of interest to you.

Midwifery schools offering postgraduate midwifery education are: • AUT University • Otago Polytechnic • Victoria University of Wellington

POSTGRADUATE STUDY PATHWAYS The postgraduate pathway generally starts with a postgraduate certificate, progressing to a diploma, and finally to a Master’s degree. Midwives may stop after attaining a certificate or diploma, or choose to continue on to Master’s level.

POSTGRADUATE CERTIFICATE (60 CREDITS/POINTS) Designed to extend knowledge in a specified subject, the certificate consists of various specialist papers which may be short (15 points), or longer (30 points).

Each paper accumulates credits, and once 60 points/credits are achieved, the certificate is awarded.

POSTGRADUATE DIPLOMA (120 CREDITS/POINTS) Following on from the postgraduate certificate, the diploma is designed to extend and deepen knowledge further within a specialist field and/or professional practice.

It supports the midwife to be able to engage in rigorous critical analysis and problem solving. Consisting of specialist papers, each paper accumulates credits to achieve another 60 credits, which, when combined with the postgraduate certificate, totals 120 credits at Level 8 as required.

MASTER’S DEGREES (MHSC) (240 CREDITS/ POINTS) OR MHPRAC (180 POINT) A Master’s degree is an advanced specialist degree which is designed to support the midwife to advance her knowledge in a specialist field or practice. It involves learning to critically evaluate evidence, improve understanding of research methodologies and work independently to apply knowledge to new situations. It generally involves doing a research project known as a thesis or dissertation, working with a supervisor.

Entry to a Master’s degree is usually through attaining a postgraduate diploma, although a Bachelor Honours degree will also support entry. The credits from the diploma build into the Master’s, with a further 120 credits required to achieve the Master’s degree.

DOCTORAL DEGREES SUCH AS DOCTOR OF PHILOSOPHY (PHD, DPHIL OR DHSC) (360 CREDITS/POINTS) A doctorate is the highest level of degree attainable. It requires the preparation of a substantial thesis of original research that contributes significantly to knowledge generation and understanding within the discipline. The student works with a primary and secondary supervisor, or may work within a research team. The thesis can include publications written under supervision for the degree. Entry into a doctoral degree programme is based on academic merit (generally through a Master’s degree) with the need to demonstrate an ability to carry out independent research (having already completed a research project through a dissertation or thesis).

WHY DO POSTGRADUATE STUDY? Postgraduate education provides an opportunity for midwives who are interested in moving into different midwifery roles in practice, education, management or

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research, providing the additional knowledge and skills needed for these roles. For others, there is enjoyment in extending their own learning and knowledge further, regardless of future career planning pathways.

Postgraduate study contributes to professional development, extends midwifery skills, and assists midwives in critically appraising evidence for midwifery practice.

It is useful in deepening knowledge about specialist topic areas and keeping midwifery practice up-to-date and relevant. It takes time and commitment, hence most midwives study towards a postgraduate qualification part-time, whilst continuing to work. To cater for the midwife who is combining work, family and study, most postgraduate midwifery courses are offered online.

For those midwives contemplating becoming a hospital midwifery educator or a midwifery manager, postgraduate study towards a Master’s degree is beneficial, because it demonstrates the necessary commitment and knowledge required for these positions. Gaining a doctoral degree is a much more individual decision, and each person will have their own driver for gaining this degree. For midwives who want to teach in undergraduate and postgraduate programmes or become involved in undertaking research themselves, then a doctoral degree is generally a requirement.

Having a postgraduate qualification or a higher degree opens the door to other opportunities for midwives, such as roles as advisors, educators and researchers, and without doubt, extending the body of midwifery-focused research strengthens the profession as a whole. Midwives are increasingly enrolling in postgrad study, thanks in part to funding from Health Workforce NZ. Postgraduate study can be fun, informative and satisfying, but requires time, effort and commitment. Whilst not a necessary part of a midwife’s role, it can enhance her knowledge and skills and therefore stands to benefit the entire profession.

New Zealand Qualification Framework (NZQA, 2016, p.5) Registered midwives who have undertaken a Bachelor’s degree are at Level 7, with postgraduate certificate and diploma increasing this to Level 9. A Master’s degree is classified as Level 9, with a doctoral degree as Level 10.

LEVEL

QUALIFICATION TYPES

10

Doctoral Degree

9

Master's Degree

FUNDING YOUR POSTGRADUATE STUDY

8

Postgraduate Diplomas and Certificates, Bachelor Honours Degree

• Midwives are entitled to apply for a grant towards the cost of their postgraduate study

7

Bachelor's Degree, Graduate Diplomas and Certificates

• Grants are funded by Health Workforce NZ and are administered by the College

6

Diplomas

• Applications are through the College portal system

5

• To apply for a grant, midwives need to approach the tertiary education providers directly to enrol with them, and need evidence of enrolment or initiating the enrolment process to support their application for a grant. square

4

Certificates

3 2 1

ISSUE 101 JUNE 2021 | 41

FROM BOTH SIDES

my midwifery

my midwife

Natasha (Tash) Baillie has been living and working as an LMC in Gore

Kyla Rutland planned for the birth of her eighth baby to unfold at home in

for the past 13 years and says the sense of kinship between women and

Gore, under the watchful eye of Tash Baillie. Ultimately, her prayers were

midwives within her community is what keeps her cup full, despite the

answered, but not without an unexpected turn or two along the way.

challenges of working rurally.

Originally from Christchurch, Tash received her midwifery education in

Listening to Kyla as she relays her birth history, one is taken on a journey. From Christchurch to Timaru, up to the Hawke’s Bay and back

the garden city, but got an insight into Gore midwifery through a clinical

down to Gore, Kyla has not only birthed in various locations across

placement as a student. “There was a real need for midwives down here

Aotearoa, but the settings have been equally diverse, with tertiary

at the time and I liked the quieter lifestyle,” she says.

hospitals, primary units and home births all featuring.

Whilst Tash acknowledges Gore might be more accessible than other

Having experienced the full gamut of Aotearoa’s maternity

remote regions, she maintains that practising in the area isn’t without its

system, Kyla knew exactly what she was looking for when she met

challenges. “We’re not as remote as somewhere like the Coromandel,

Tash in 2020. “I was looking for a midwife who strongly believed in

but our nearest secondary unit is an hour away, so the trials we face in an

women’s rights to make their own decisions. Information and

emergency situation still shouldn’t be underestimated.”

discussions are all great, but our family ultimately makes the decisions

“People think we’re not that rural. But an hour from help is very isolated, and because we’re

about what’s best for us,” she explains.

“I was confident in Tash from the beginning, but

providing care within an hour radius from Gore,

it was reaffirmed as the pregnancy progressed.

we might actually be two hours from a unit at

Rather than just giving me a form for a blood

any given time.”

test, she would ask whether I was intending to

Being based in a small rural community can have a profoundly positive effect on the birthing culture, as Tash explains. “In a tightknit community, people talk. The women talk about how great their experiences were and most women come to us expecting to birth in the primary unit. The nature of the community means primary birthing is advocated for by the consumers themselves.”

A strong advocate for primary birth, Tash says the support of her midwifery colleagues in Gore is second to none. “I really believe in birth location having an impact on the outcomes. So if a woman has a low-risk pregnancy, I obviously promote birthing in the primary unit, and the whole community - including my midwifery colleagues - supports that.”

“We have an amazing team here. I could call any of my midwifery colleagues at any time, and they would be available in any situation. It’s also quite a stable workforce, so everyone is well known to each other, which is another great part of working in a smaller region.”

As the College Regional Chairperson for Southland, Tash is relishing the opportunity to give back to midwifery. “I’m really enjoying doing work for other midwives that nurtures both them, and the profession,” adding, “National Board’s great because it gives insight into all the behind-the-scenes work. You see how much energy and time goes into the development of a single consensus statement.”

Tash embarked on her midwifery education knowing full well, the role

do the screening, and whether I had enough information, rather than making assumptions.”

At 29 weeks gestation, Kyla went into preterm labour. “It wasn’t how I had imagined my pregnancy would go, and that’s when my confidence in Tash came to full fruition,” she says. “Even in that emergency situation, she was still checking in, constantly communicating with me, and it was clear the decisions were still mine to make.”

After transferring to Invercargill and on to Dunedin for specialist care, her labour was halted and Kyla was discharged home a fortnight later at 32 weeks gestation, where she resumed her original birth plan. When Kyla’s waters broke at home at full-term, she called Tash straight away.

“She asked me what I wanted to do. I hadn’t had any contractions yet, so I suggested I'd call back when I felt I needed her. It was my decision.”

Once Tash arrived at Kyla’s home with a second midwife, Kyla describes how non-intrusive the experience was. “She was really aware of when to enter my space. She knew I was more settled when it was just my husband and I and she respectfully worked around that.”

Kyla is quick to point out that all of the midwifery care she has received over the years, from seven different LMC midwives, has been praiseworthy, and changing midwives has only ever been due to changes in circumstances or previous midwives being unavailable. She considers herself fortunate to live in a country with such an empowering maternity system. “Every midwife I’ve received care from has been amazing and

entailed much more than cuddling cute newborns. “I think I always knew

each relationship has been defined by clear role expectations and

it was focused around the woman and the family, so that appealed to me,

ongoing communication. I think those two things are vital, for any

as well as the fact that every day would be different. I loved the variety

relationship between a mother and midwife, to ensure it’s positive

that midwifery would provide, and I’m a sucker for a challenge.” square

and everyone's needs are met.” square

42 | AOTEAROA NEW ZEALAND MIDWIFE

New Zealand College of Midwives Directory President Nicole Pihema Ph 021 609 011 nicolepihema@gmail.com National Office PO Box 21-106, Edgeware, Christchurch 8143 Ph 03 377 2732 Fax 03 377 5662

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

Waikato/Taranaki Tracey Williams chairwaikatonzcom@gmail.com Wellington Siobhan Connor Ph 021 289 4252 nzcomwellington@gmail.com

nzcom@nzcom.org.nz

Regional Sub-Committees

www.midwife.org.nz

Hawkes Bay Sub-Committee Sarah Nation sarahnation.midwife@gmail.com

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

Manawatu Sub-Committee Nikki Murtagh nikkimurtagh@gmail.com Jayne Waite j.waite70@gmail.com Taranaki Sub-Committee Isabel Bedford nzcom.taranaki@gmail.com Wanganui Sub-Committee Jo Watson Ph 021 158 6874 jothemidwife@gmail.com Horowhenua Jennie Ferguson Ph 021 232 1980 thejensterrocks@gmail.com

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

Bay of Plenty/Tairawhiti Kelly Pidgeon chairnzcomboptairawhiti@gmail.com

Home Birth Aotearoa Eva Neely evaneely@live.com

Canterbury/West Coast Davina Geddes chairnzcom.cantwest@gmail.com

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

Nelson/Marlborough Rose O’Connor roseocon@gmail.com Northland Chris Byrne (Interim) tetaitokerauchair@nzcom.org.nz Otago Jan Scherp, Charlie Ferris otagochair@nzcom.org.nz Southland Natasha Baillie Ph 021 258 2701 merakimidwifery@gmail.com

Pasifika Representatives Talei Jackson Ph 021 907 588 taleivejackson@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 Services Rural contact: 0800 Midwife/643 9433 rural@mmpo.co.nz

Consumer Representatives

Auckland Sarah Ballard, Linda Burke auckchair@nzcom.org.nz

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

Colleen Brown colleenbrownlmc@gmail.com

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

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Made in Germany

REGIS T R AT I ON N OW OPEN NEW ZEALAND COLLEGE OF MIDWIVES 16TH BIENNIAL NATIONAL CONFERENCE

Save the date

A conference to reconnect, reenergise and celebrate with your midwifery colleagues

LEBRA

DIVE

R

growing stronger together

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CE

G IN

SI

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04 - 06 November 2021

Otautahi Christchurch midwife.org.nz/conference-2021