A PROFESSION AT A CROSSROADS

MIDWIFERY: A PROFESSION AT A CROSSROADS

Many midwives I speak to around Aotearoa agree, it feels as though the profession is at an evolutionary crossroads. There are numerous challenges and changes afoot: workforce shortages; generational shifts within the profession; dissatisfaction with pay and conditions; a health system reform on the horizon; and increasing development in ensuring te Tiriti responsibilities are being met by individual practitioners, and the sector as a whole.

Midwifery is a single profession, and at the same time, there are multiple workforces operating within it. These workforces are bound by what attracted us all to the role in the first place; a common recognition of the potential inherent in the processes of pregnancy, labour, birth and motherhood, to become transformational events for women and whānau. Our workforces are in fact not separate, demonstrated by their symbiotic relationship; they rely on each other at the interface to provide care to women, and we need sufficient numbers and the right balance of midwives working in facility and community-based settings, for our service to function.

Our maternity system enables midwives to change their work setting throughout their careers to support different stages of their lives, and it is not uncommon to hear of experienced senior DHB employed midwives moving into LMC practice, and vice versa. Although changing work setting may alter our day-to-day responsibilities, it doesn’t change our scope of practice, our accountability to the women we provide care to, nor our accountability to each other.

Midwifery is a demanding but incredibly rewarding profession. Not a job for the faint-hearted, it takes courage and tenacity - attributes which require nurturing. In order to sustain and retain midwives in the workforce, some key elements must be present:

• A workload which affords midwives the professional satisfaction of providing quality care within the relational model in which we are educated to practice

• Sufficient financial recompense (relative to the responsibility and demands of the role)

• Satisfactory work-life balance

• Supportive work environments where midwifery expertise is respected, midwifery leadership is visible, and collegial relationships with peers and members of the medical team are the norm.

Unfortunately, for many midwives these elements are not present, thus their professional practice and personal wellbeing Midwifery is a single profession, and at the same time, there are multiple workforces operating within it. These workforces are bound by what attracted us all to the role in the first place; a common recognition of the potential inherent in the processes of pregnancy, labour, birth and motherhood, to become transformational events for women and whānau.

ALISON EDDY CHIEF EXECUTIVE

are suffering. This deeply concerns the College, from both the perspective of the sustainability of the workforce, and the quality of care that women receive.

Appropriate remuneration and reasonable working conditions are among the most vital elements required by all midwives, and the College has been working closely with MERAS to support its pay equity claim. The College has also involved Jill Ovens in its formal mediation meetings with the Ministry of Health. By working collaboratively, we can better ensure that any benefits achieved for one group of midwives will also be realised for the other.

MERAS’s pay equity process has been fraught with the same bias and discrimination that the LMC process has faced. MERAS has struggled to have their perspective understood, resulting in formal mediation with the Employment Relations Authority (ERA). MERAS invited me to attend the ERA meeting, where I spoke about the work undertaken to date comparing LMC midwives to GPs, and the specific professional responsibilities and challenges faced by employed midwives. As a result of the ERA mediation process, I was appointed to the Pay Equity Quality Review Panel, and thus had further input into how midwifery roles were assessed as part of the claim.

The health reforms offer an opportunity to reconsider the way both LMC contracting and employed midwife MECA arrangements are negotiated with Health NZ in the future. This could be a win-win situation; by reiterating the connection between employed and LMC midwives’ working conditions and pay, MERAS could distinctly and overtly uncouple their negotiations from nursing, and LMCs could potentially benefit from some of the working conditions that employed midwives can access.

However, such change would take time, and there are pressing issues for LMC contract conditions, which cannot wait. Whilst there have been significant gains in the improvement of Section 88, which would not have occurred to the same degree without a legal process (the mediation agreement) running in the background, they alone are not enough.

The national board has determined that it will pursue further legal action against the Ministry of Health for breach of the second settlement agreement. There are two main reasons why the College’s board has taken this decision:

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1 / The current Section 88 is a legislative document, and although the College has a level of influence on its terms and conditions, we do not ‘sign off’ on the final version; this right is reserved for the Ministry of Health and Minister. Simply increasing payments in Section 88 does not address the core issue. The settlement agreement promised a new contract model by July 2020, which would ensure sustainable practice models for LMC midwives, and this has not materialised.

2 / As a result of the health system reforms, there is uncertainty about future arrangements for community LMC midwives. In order to have any influence over our future, we need to use all of the tools in our kete, and enforcing the terms of the legally binding settlement agreement between the College and the Ministry is one of these.

The College has sought extensive legal advice to inform the best approach. Enforcing the contractual promises made by the Ministry in the settlement agreement with the College is legally straightforward. The terms of the settlement agreement are clear; the Ministry committed to delivering a new national midwifery contract by July 2020, reflecting a blended payment model, alongside determining ‘fair and reasonable’ pay for LMC midwives. Holding the Ministry to those contractual promises is the most expedient route, which the College will be pursuing.

Sadly, many midwives I speak with comment that the necessary focus on our inadequate pay and working conditions over the past few years has had a profoundly negative effect on the profession’s morale; leading to a sense of dissatisfaction, an inward focus, and a loss of joy related to our work. It’s disheartening that DHB negotiators and Ministry officials are dismissive of our concerns and midwives are leaving the profession because their cries for help have fallen on deaf ears.

Despite this, there are positive examples of midwives taking their power back. I recently had the pleasure of attending the 30-year celebration of Midwifery Associates - an LMC practice I was briefly a member of. This practice has had 26 midwife members throughout its history, with one original midwife remaining.

There are some key ingredients which have made this practice and its model so successful: it has always had roughly six to eight members; there is an agreed system of regular time off; caseload sizes are mutually agreed; regular practice meetings are held; a system exists to manage contact from women seeking to book; cross-practice financial arrangements have been agreed upon, and most importantly, members share a philosophy of care and practice standard, including a commitment to provide cover throughout the enitre year.

This, and many other similar examples are highly sustainable and successful; the midwives themselves have defined the arrangements that work for them. They have not been imposed upon them, and selfemployment has enabled midwives to come and go from the practice over the years on the terms that suit their needs. The health system reform provides an opportunity to support these successful models by developing contract arrangements that further strengthen them, such that resourcing is provided for structural support to enable group practice models (and midwives) to flourish and integrate with wider maternity and other health services.

When I ask midwives what they want to change - what would bring back the joy to their work, what would make their work more sustainable and improve retention - invariably their responses reflect their desire to have job satisfaction; making a positive difference for the women, whānau and people they care for, and feeling valued and respected for doing so. That is not too much to ask and is exactly what we should be aiming to achieve for all midwives, regardless of where they work or who pays them. square