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.

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.

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

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.

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.

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:

“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 midwives’ economic and professional contributions to society.

“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.”

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

committing to a te tiriti framework

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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