INVISIBLE WOUNDS:
HOW CAN MIDWIVES SUPPORT WOMEN WITH A HISTORY OF SEXUAL ABUSE? P.18 CLIMATE CHANGE
MATERNITY OUTCOMES
ISOLATED CLEFT PALATE
GLOBAL HEATING - A HAZARD FOR PREGNANT WOMAN AND THEIR BABIES P.22
KEY OUTCOMES AND TRENDS SINCE 2009 P.26
CONSIDERATIONS FOR MIDWIVES IN PRACTICE P.32
ISSUE 104 MARCH 2022 I THE MAGAZINE OF THE NEW ZEALAND COLLEGE OF MIDWIVES
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YOUR COLLEGE COVER ILLUSTRATION: Daryna Tofanchuk, Senior Designer, Publica.
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ISSUE 104 MARCH 2022
FORUM FROM THE PRESIDENT
22
4. NAVIGATING THE LABYRINTH FROM THE CHIEF EXECUTIVE 5. A WORKFORCE IN MORAL DISTRESS 8. BULLETIN 10. YOUR COLLEGE 12. YOUR UNION 14. YOUR MIDWIFERY BUSINESS
26
FEATURES 16. NGĀ MĀIA: HE WAKA EKE NOA 17. BIRTH FILMING: YOUR RIGHTS AS A MIDWIFE 18. INVISIBLE WOUNDS 22. CLIMATE CHANGE: GLOBAL HEATING 26. MATERNITY OUTCOMES 2019
42
32. ISOLATED CLEFT PALATE 36. BREASTFEEDING CONNECTION 39. PASIFIKA 40. COVID-19 / MATE KORONA E-RESOURCE 42. MY MENTOR / MY MENTEE 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 June 2022 Advertising Booking: 16 May 2022 Advertising Copy: 23 May 2022
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 104 MARCH 2022 | 3
FROM THE EDITOR
FROM THE PRESIDENT
from the president, new zealand college of midwives, nicole pihema
nau mai haere mai ki Aotearoa New Zealand Midwife As this issue of Midwife goes to print, Omicron cases are surging and Aotearoa is seeing figures in the thousands for the first time since the beginning of the Covid-19 pandemic. Midwives throughout the motu are adapting to further shifts in the landscape and the future is even more uncertain than it was two years ago. Much of the distress and anxiety currently being experienced by midwives and whānau is being outwardly expressed, but what can any of us do about the distress we can’t see? I share a personal story of supporting a woman with invisible wounds inflicted by sexual abuse on p.18, in an attempt to raise awareness for the sake of other women who have suffered similar trauma. The hazards of global heating for pregnant women and their babies (p.22) is the first topic to be explored as part of a new, regular feature on climate issues, and p.26 outlines key outcomes and trends from the Ministry’s latest Report on Maternity. Wairarapa-based midwife Fiona Girdwood shares her insights into isolated cleft palate and how midwives can identify it sooner on p.32, and the many achievements and contributions of retired Tongan midwife Fine Matoto are celebrated on p.39.
E kore e ngawhere, he maire tū wao, mā te toki e tua (It will not give way easily; it is the forest-standing maire which requires an axe to fell it) Recently I was asked how we’ve been
message to midwives is simple: just because we
delivering care in Te Tai Tokerau throughout
feel disorientated and disheartened every time
Covid-19 restrictions. It was a genuine enquiry
a staircase moves or we find we are walking
about what modifications we have made to our
upside down, that doesn’t mean we should just
processes in order to maintain safety. But it still
give up on ever reaching Toby.
stumped me. How have we been delivering care? The same way we have always delivered it, of course. Admittedly, through lockdowns we carried
Our worlds have probably never been riddled with this much uncertainty, but the wisdom of our tūpuna reveals that the key to our future lies in our past. Our individual motivations for
out virtual or phone appointments, but we still
becoming midwives may vary, but we all had a
met with women kanohi ki te kanohi if they
common goal before Covid-19 came along, and
were hapū with their first baby, or for essential
reminding ourselves of our original intentions is
visits. And now, our usual pre-Covid practice
what will fortify us to rise above the widespread
has resumed, with the extra steps of Covid-19
fear and anxiety in such trying times.
screening before appointments and the wearing of face masks. We have all become familiar with the term
It’s essential that as we go into the eye of this storm, we hold on more tightly than ever before, to our midwifery integrity and
‘post-Covid’ and whilst it’s important to
sense of whānaungatanga – the connectedness
acknowledge that indeed, we are living in a
we are all meant to feel in order to take others
different world to some extent, it occurs to me
as a part of ourselves and protect those we
that there is no place for such a thing as ‘post-
have been given the privilege of caring for.
Covid midwifery practice’.
The opening whakatauki mirrors this notion; a
Yes, it has been challenging. Yes, care
maire standing alone does not have the same
provision has been affected to a degree. And
strength as one in the forest, or in other words,
yes, each time we’ve thought we had a grasp
a person with many supporters has more power
on Covid-19 and what would happen next, the
than one acting alone.
ground beneath us has shifted. At times it’s felt
I acknowledge midwives all over Aotearoa
From Both Sides (p.42) focuses on the unique partnership formed between an MFYP mentor and mentee, and the positive ripple effect this can have for midwifery as a profession, when graduate midwives are made to feel safe from the beginning.
as though collectively, we’ve been stuck in the
currently grappling with challenges;
maze from the movie Labyrinth: when older
questioning what midwifery looks like and
Mā te wā,
reach him.
Amellia Kapa, Editor/Communications Advisor Email: communications@nzcom.org.nz
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4 | NEW ZEALAND COLLEGE OF MIDWIVES MAGAZINE
sister Sarah is desperately trying to rescue her baby brother Toby from the goblin king, but finds the stairs move or change direction every time she thinks she can see a clear path to Care provision and the rules surrounding
why, and desperately searching for something to hold on to for security and stability. And I implore midwives to dig deeper. We alone hold the keys to our inner peace, and we owe it to the whānau we care for to find it, so that we can serve as pou - unwavering in the storm
vaccination and potential exposure to the
- for whānau to tether themselves to, as they
virus have changed many times over, but my
navigate their own journeys.
4 | AOTEAROA NEW ZEALAND MIDWIFE
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FROM THE CEO
A WORKFORCE IN MORAL DISTRESS As 2021 drew to a close and we prepared to welcome 2022, I felt a small surge of optimism; that the new year ahead might somehow be different to - and better than the last two. During the latter part of 2021 we wrapped our heads around the move from Covid-19 elimination to ‘learning to live with Covid’; the difficult weeks leading up to the implementation of the vaccine mandate had settled somewhat, and some robust New Zealand guidance on maternity care for those who contracted Delta during pregnancy had been developed. We were as prepared as we could be for the next stage of the pandemic. Alongside this, at last, there seemed to be a glimmer of understanding at a political level that the workforce issues in midwifery would require systemic long-term attention and investment. Some progress towards this had been made with the introduction of two significant midwifery workforce initiatives: Te Ara Ō Hine - Tapu Ora, and retention funding for clinical coach roles and midwives returning to practice.
Perhaps 2022 would be the year we would turn the pandemic corner and finally see the materialisation of robust, long-term investments and solutions to address the deeply complex, multi-layered issues that have plagued our workforce for too long. Sadly, my optimism was short-lived. Just as we thought we had grasped what ‘living with Covid’ meant, along came Omicron, which, although thankfully less severe than Delta (it appears), brings service disruption due to its high transmissibility and impacts on staffing levels, with midwives having to self-isolate when they are contacts or test positive for Covid-19. Once again, the goal posts have moved, leading to the return of uncertainty and the familiar struggle of clutching at anything we perceive to be stable, reliable and constant in our worlds professionally and personally.
The difficult weeks leading up to the implementation of the vaccine mandate had settled somewhat, and some robust New Zealand guidance on maternity care for those who contracted Delta during pregnancy had been developed. We were as prepared as we could be for the next stage of the pandemic.
ALISON EDDY CHIEF EXECUTIVE
The reality of potential staff shortages and service disruption is very concerning. Increasingly stretched maternity units have had to switch to crisis management mode in order to maintain service delivery in the
ISSUE 104 MARCH 2022 | 5
FROM THE CEO
Midwifery does not shy away from change when it’s required; the profession has risen to the challenges and quickly adapted to the public health and clinical care requirements thrust upon us by the pandemic.
face of extremely short-staffed wards or units. These times are challenging for all; midwives need to work together across the community and at hospital interfaces, to ensure all are supported and able to provide critical maternity care to those who need it. Midwifery does not shy away from change when it’s required; the profession has risen to the challenges and quickly adapted to the public health and clinical care requirements thrust upon us by the pandemic. The indispensable nature of maternity care has necessitated that midwives continue to work in the face of Covid-19 restrictions despite workforce shortages, often requiring creative solutions. However this approach may have come at a cost, leading to a level of ‘moral distress’ within the profession. The concept of moral distress as it applies to health professionals first appeared in the literature around a decade ago. Within the context of midwifery, it has been described as: “a psychological suffering following clinical situations of moral uncertainty and/or constraint, which result in an experience of personal powerlessness where the midwife perceives an inability to preserve all competing moral commitments” (Foster et al., 2021, p. 1).
or more simply, defined as occurring: “…when clinicians are unable to translate their moral choices into moral action” (Rushton, 2006, p. 1).
6 | AOTEAROA NEW ZEALAND MIDWIFE
My interpretation of these erudite descriptions is more simply that moral distress is what midwives experience when they are unable to provide the care they feel is professionally and ethically right, because there is neither the time nor capacity to provide it. I imagine this is also being experienced by midwives who have chosen not to be vaccinated; not being able to reconcile one’s belief in the right to bodily autonomy with the requirement to be vaccinated in order to continue the very work which bolstered that belief, must be a morally distressing situation one deserving of empathy. The rapid practice adaptations our Covid-19 public health response has required, coupled with our significant workforce issues, have profoundly impacted some of our professional norms. As a highly relational profession, the necessity of reduced physical contact with each other and those we care for, as well as the implementation of PPE and other infection prevention requirements, have placed an additional burden on midwives as we have continued to support women and whānau throughout. Many of these whānau have understandably experienced pandemic-related anxiety and uncertainty - yet another complexity midwives have had to grapple with amongst trying to keep ourselves and our own whānau calm and safe. This, along with workload related pressures, is undoubtedly leading to attrition within our workforce. For some midwives, managing these challenges has meant taking charge of what is within one’s locus of control by reducing FTE/caseload, or at worst, leaving the profession altogether. Sadly, some of the necessary solutions to our current environmental challenges have equated to a gradual but steady move towards a more fragmented system of maternity care and we are at risk of the initial short-term measures - put in place to fill the gaps - becoming entrenched in practice. Solutions such as rationing care, adopting a task-based approach, widespread use of virtual or telehealth appointments, disjointed care models, a reduced schedule of contact with women, and clinics replacing home-based postnatal care have morphed into longer-term strategies, with no evidence yet published to help us gauge the potential impact of these changes on the workforce, intervention rates, or outcomes. Midwives understand that the quality of maternity care throughout pregnancy particularly around the critical and sensitive period of childbirth - significantly influences
a woman’s transition to motherhood and a newborn’s start to life. The work we do has the potential to have long-term impacts on the wellbeing of mothers, newborns and their wider whānau. And the ability to provide high-quality care is integral to achieving a sense of professional satisfaction - a powerful retention tool in its own right. An anecdote recently shared by an employed midwife illustrates the significance of the relational nature of our practice. The midwife described how she had provided postnatal care to a room of women and their newborns, wearing a mask for the entirety of her shift. As she prepared to say goodbye, the women asked her to remove her mask. They said they wanted to see the face of the midwife they had established a connection with - whose care had made a difference to them, so that they could remember her. This story highlights how meaningful the human connection and relational aspects of maternity care are for women and whānau, regardless of where they experience care, or their clinical outcomes. For the midwife, I imagine this exchange felt validating for her practice and demonstrated how such reciprocity can sustain midwives through the hardest of times. At a strategic level, the health system reform is asking us to consider what change is required in order to meet the needs of populations experiencing ethnic and socioeconomic inequities. Yet on an individual level, at various points during the pandemic response, midwives have been asked to manage care requirements virtually, or have reduced in-person contact with whānau, thereby devaluing the relational elements of midwifery care and perhaps further entrenching such inequities. How do we, amongst the uncertainty, and the pressure of responsibility surrounding us at the present time, hold on to our sense of professional identity and what grounds us as midwives? Although continuity-of-care has been framed as the rod breaking our backs, an unachievable standard, or a ‘nice to have’, it is the very foundation upon which our professional standards have been built. It can occur in many ways and settings, from shift to shift in maternity facilities, to group LMC practices in the community. Its contribution to midwives’ wellbeing and sense of work satisfaction when provided within sustainable models is something we must keep sight of amongst the chaos and instability we are constantly living with in this era. square
H 1 0T
BIENNIA L
Joan Donley
TRUSTPOWER BAYPARK STADIUM
TAURANGA
MIDWIFERY RESEARCH FORUM DAY ONE: THURSDAY 17 NOVEMBER 9.00AM
Whakatau and welcome/housekeeping
17-18 November 2022
DAY TWO: FRIDAY 18 NOVEMBER 8.45AM
WĀHANGA TAHI / SESSION ONE 9.20AM
The Views of Women, Clinicians and Other Stakeholders on Moderate-toSevere Postpartum Anaemia and its Treatment in Aotearoa, New Zealand. Esther Caljé, Joy Marriott, Charlotte Oyston, Lesley Dixon, Frank Bloomfield, and Katie Groom
9.40AM
Te Rau Tāne; How do we understand, include, and uphold the mana of tāne Māori during the pregnancy, labour, and birth journey? Camille Harris
10.00AM
A hermeneutic phenomenological study into the midwife-woman relationship – it’s all about trust. Elizabeth James, Elizabeth Smythe, Deborah Payne and Caroline Young
10.20AM
Kōrerorero: Session 1 presenters
10.30AM
MORNING TEA WĀHANGA RUA / SESSION TWO
11.10AM
How is perinatal mental health screened in Aotearoa New Zealand and in the global context? A scoping Review. Michele Lomax, Andrea Gilkison, Susan Crowther
Opening Of Day Two WĀHANGA RIMA / SESSION FIVE
9.00AM
I don’t know why I want a Māori Midwife, I just do! Waimarie Onekawa
9.20AM
Exploring student-teacher relational connectedness within Midwifery Education: Findings from a phenomenological Inquiry. Lynn Chapman
9.40AM
The microbiota of the vulva and vagina: ways of washing to optimise the protective function of the vulvo-vaginal microbiota during pregnancy. Louise Banga
10.00AM
Midwifery Continuity of Care: A scoping review of global implementation initiatives. Caroline Homer, Billie Bradford, Cristina Fernandez Turienzo, Anayda Portela
10.20AM
Kōrerorero: Session 5 presenters
10.30AM
MORNING TEA WĀHANGA ONO / SESSION SIX
11.10AM
Midwives’ and obstetricians’ experience of place in relation to supporting physiological birth. Christine Mellor
11.30AM
What was the effect of Covid-19 lockdowns on place of birth, birth interventions and maternal and neonatal outcomes in Aotearoa New Zealand in 2020? Claire MacDonald, Phil Hider, Jonathan Williman, Rose Crossin
11.50AM
Women’s Knowledge and Perception of Fetal Movements During Late Pregnancy: Findings from a Aotearoa-New Zealand Survey. Robin Cronin, Billie Bradford, Chris McKinlay, Nimisha Waller, Annabel Johns, Tania Webb, Likhit Dukkipati, Tania Cornwell, Lorna Bowles, Judith McAra-Couper, John Thompson, Lesley McCowan
11.30AM
Weaving the mat: Enablers for Pasifika midwifery students. Talei Jackson, Karen Wakelin and George Parker
11.50AM
Progressing transgender and non-binary inclusion in midwifery in Aotearoa: Preliminary findings from a national research study. George Parker, Suzanne Miller, Sally Baddock, Alex Ker, Jaimie Veale and Elizabeth Kerekere
12.10PM
Care, Connection and Social Distancing: The challenges of baby loss during a pandemic. Billie Bradford, Robin Cronin, Tosin Popoola, Sergio Silverio
12.30PM
Kōrerorero: Session 2 presenters
12.40PM
LUNCH
12.10PM
Kōrerorero: Session 6 presenters
WĀHANGA TORU / SESSION THREE
12.20PM
CLOSING ADDRESS
1.40PM
Investigating incidence and prevalence of preeclampsia globally and within New Zealand: An integrative review. Rachel Taylor, Rachel Lamdin
12.30PM
FORUM CLOSES
2.00PM
Becoming tangata Tiriti in midwifery education. Annabel Farry, Judith McAraCouper, Jacquie Kidd, Tania Fleming
2.20PM
The New Zealand Pregnancy Cohort: A tool for medication use and safety studies in New Zealand. Sarah Donald, Katrina Sharples, Dave Barson, Simon Horsburgh, Lianne Parkin
2.40PM
Kōrerorero: Session 3 presenters
2.50PM
AFTERNOON TEA
3.30PM
4.50PM
A Māori perspective on mentoring in midwifery. Nicole Pihema, Shanti Daellenbach, Jean Te Huia, Lesley Dixon, Elaine Gray, Christine Griffiths, Mary Kensington, Dinah Otukolo Learning to Grow: Early career midwives’ experiences working in maternity hospitals and what supports their continued professional development. Brigid Beehan A weighty issue: The implications of an ultrasound prediction of a large baby in pregnancy. Cara Baddington, George Parker, Karen Wakelin An exploration of sleep experiences during late pregnancy and creative strategies used to maintain wellbeing. Sally Baddock, Suzanne Miller, Emma Bilous, Jean Patterson Kōrerorero: Session 4 presenters
5.00PM
CLOSE OF DAY ONE
WĀHANGA WHĀ / SESSION FOUR
3.50PM
4.10PM 4.30PM
To register and for more information visit
www.midwife.org.nz Registration fees: New Zealand College of Midwives Member Non-member Undergraduate or consumer
$230 $280 $85
All fees include GST. Please note limited numbers, strictly first in, first served basis.
BULLETIN
bulletin health research council grant enables sustainability research
continuity-of-care from community-based
to achieving the necessary improvements, with the key levers being: Kia Manawanui Aotearoa: Long-term pathway to mental wellbeing; Whakamaua: Māori Health Action Plan 2020–2025; and the health and disability system reforms. While the long-term strategy has therefore been articulated, the detail of what this means in practice is still to be determined.
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midwives, little is known about the impact on the wellbeing of midwives’ own families. square
midwife honoured with queen’s service medal
to collaborate with the New Zealand College
MATERNAL MENTAL HEALTH SERVICE PROVISION IN AOTEAROA: STOCKTAKE OF DHB SERVICES
of Midwives, Rua Pōkai Ngā Māia i te Rauroha,
Following repeated Perinatal and
and Pasifika Midwives Aotearoa, to investigate
Maternal Mortality Review Committee
sustainability challenges in community-
recommendations, the government agreed
based midwifery. AUT Business School’s Dr
in 2021 to complete a stock take of maternal
Tago Mharapara will lead the research team,
mental health services provided by DHBs.
comprised of midwives Dr Janine Clemons,
The report is based on a survey of DHBs
Dr Lesley Dixon, Stacey Gillard-Tito and Talei
and was published in November. Its findings
Jackson, as well as other researchers from
acknowledge the importance of mental
of Health to form a new pay structure for
AUT’s management and employment relations
health in mothers’ and fathers’ adaptation to
community midwives and was also involved
departments.
parenting and to infant and child wellbeing.
in pay parity negotiations for nurses and
AUT researchers have received a $1,364,660 grant from the Health Research Council (HRC)
The project will investigate how community
The report identifies the need for action at
The College wishes to congratulate Claire Eyes, who has been awarded a 2022 Queen’s Service Medal for services to midwifery. Claire has worked as a midwife for more than 40 years, mostly in primary settings, and has dedicated the last 30 of those to community LMC practice, based at Pukekohe Maternity Unit in the Franklin area. In the 1980s, Claire assisted the Ministry
midwives around that time. As the elected spokesperson of the working
midwives and their whānau manage the
a systemic level, to enable better and earlier
disruptive nature of community-based
mental health care provision by primary
party opposed to the closure of the Pukekohe
midwifery work and the impact this might have
providers, to expand kaupapa Māori service
Maternity Unit in the 1990s, Claire was integral
on the future of the workforce. While existing
provision and to support equitable access
to its survival and function as the heart of
research demonstrates significantly better
among currently under-served groups. Longer
primary birthing in the Franklin region. Along
health outcomes for wāhine and pēpi receiving
term system transformation is seen as the road
with another LMC colleague, Claire also
8 | AOTEAROA NEW ZEALAND MIDWIFE
Claire Eyes
There’s no birth like a Calmbirth
®
Calmbirth is being funded again by the Auckland District Health Board for pregnant couples who meet the following criteria: · Live within the Auckland DHB catchment area · Plan to birth at Auckland Hospital · Plan to have a normal birth (ie, a vaginal birth versus a planned Caesarean Section). SPACE IS LIMITED – To register for a class go to www.pepi.adhb.govt.nz
Image: Natural Focus Birth Photography
established the Pukekohe Maternity Resource Centre 12 years ago and has assisted others to emulate the service in other regions. As part of a Rotary International Maternal & Child Health funded initiative, Claire led three teams of Pacific midwives and health workers to attend leadership courses in Australia between 2016-2018 and organised fundraising for the purchase of 35 fetal heart ultrasound dopplers for those attending the courses to take back to their workplaces.
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WELCOME TO OUR NEW MIDWIVES Congratulations and welcome to all newly qualified midwives launching their midwifery careers in 2021. The College wishes you all the best for the coming year and many more successful, fulfilling years of midwifery practice beyond this one. We also welcome midwives who are newcomers to Aotearoa and encourage you to link in with your College region for support and involvement in collective decision-making processes for your profession. Nau mai, haere mai.
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congratulations to newly appointed clinical coaches DHBs around the motu have been establishing the new clinical coach roles in their services. This is a key professional role within maternity facilities which complements the support offered to graduate midwives (both employed and LMC) in the MFYP programme, as well as supporting return to practice and overseas-qualified midwives. The roles have been established to support retention within midwifery and present a new and exciting role for midwives exploring potential career pathways. square
ISSUE 104 MARCH 2022 | 9
T 5% OF SALES DONATED TO REGISTERED CHARITIES
YOUR COLLEGE
endorsement of the PPH guideline The National Consensus Guideline for Treatment of Postpartum Haemorrhage 2022 update has been completed and endorsed
ACCIDENT COMPENSATION (MATERNAL BIRTH INJURY AND OTHER MATTERS) AMENDMENT BILL Submissions on this bill closed in February 2022. The main objectives are to provide more equitable coverage for injuries
by the College and other professional organisations involved
covered by the Accident Compensation Scheme. The College
in maternity care, and the documents will be published on
made a number of critical points in its submission, including
the Ministry of Health website in due course. The College was
commenting on the list of maternal birth injuries that were
represented on the steering group and College members
described in Schedule 3A of the bill. The College considered
were consulted during the development process. Thank you
that this list was not sufficient and that all birth-related maternal
to those who provided their valuable feedback; the insight
injuries should be covered by this amendment bill. Failing to
from midwives practising across Aotearoa strengthened the guideline and ensured it is relevant to practice across the range of maternity settings. A key change within the document is
include all injuries will compound existing inequities in access to treatment and care. The College recommended the more inclusive and equitable
the inclusion of tranexamic acid into the treatment pathway earlier than the previous version, as a result of the strengthening
approach would be to remove the list and enable health
evidence base supporting its use in PPH care if administered
professionals to diagnose birth injuries. We also recommended
within three hours of the PPH occurring.
that psychological/emotional trauma resulting from birth, and
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all birth-related injuries to newborns are also included in this
PAE ORA (HEALTHY FUTURES) BILL
proposed legislative change. Treatment, care and support for all
The College wrote a submission on this bill, which focuses on
appropriate and safe. Timely management of these injuries will
birth injuries should be accessible, available, timely and culturally
the restructure of the health system. Improving the health of
not only result in improved quality of life for women and whānau,
all New Zealanders now and in the future, and achieving equity
but will also reduce health care costs in the future.
by reducing health disparities, particularly for Māori, is overdue and urgent. Amongst other points, the College described the
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neonatal transitional care working group
negative impact of the environments that many people live in and the need to address this in order to support physical, emotional, social, and environmental health and wellbeing.
to age two - and the College supported all the key indicators
The College is involved in a multidisciplinary working group looking at the principles, scope and guidelines for neonatal transitional care. The current working group has three midwife members plus one College representative. The scope of neonatal transitional care across different size units, review of the model of care, clinical criteria, key performance indicators, and staffing requirements are amongst the topics
described in this framework. The College emphasised maternity
under discussion.
The structural barriers to health created by colonisation and systemic racism indicate that a transformative health strategy requires a primary focus on equity. The 'first 1,000 days' global initiative prioritises the wellbeing of women and children in the first 1,000 days - from pregnancy
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issues and a focus on the health and wellbeing of women and babies. We also included issues related to climate change.
BREASTFEEDING A–Z
A ‘fingerprint of climate change’ has been described as starting before a baby is born, due to pregnant women already experiencing environmental crises that their children will be exposed to after birth. A ‘fingerprint’ caused by poverty, deprivation, racism, and inequity also begins before a baby is born, and addressing climate change and the social determinants of health cannot be separated from a health system restructure. This submission closed in December 2021.
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A comprehensive national resource in the format of an A-Z has been developed for inclusion on the College website to support midwives with access to reliable, up to date, commercial free information about many aspects related to breastfeeding and infant feeding. Links are to articles, podcasts, videos and downloadable information sheets. Included under each A-Z category are carefully reviewed links for midwives to share with their clients when necessary. square
Midwifery Opportunities Australia St John of God Health Care is one of the largest private providers of health care services in Australia, employing more than 15,000 caregivers. We operate 27 hospitals and services comprising more than 3,500 hospital beds, welcoming more than 10,000 babies a year into the world. We have opportunities for Registered Midwives to join our highly skilled teams of healthcare professionals providing quality patient care in our hospitals located in Western Australia, New South Wales and Victoria. We can offer you: • Unique and competitive overseas relocation support including; - Assistance with work visas - Personalised support from a relocation specialist to assist with housing, schools, temporary accommodation, taxation, banking and settling in - Up to $10,000 financial assistance for eligible items such as visa fees, flights, quarantine or shipping • Highly competitive salary & conditions • Generous salary packaging options including up to $9010 on a range of benefits such as mortgage, rent, or everyday living expenses • A welcoming and supportive culture • Dynamic multidisciplinary team • Opportunities for post-graduate support • Professional development & qualification allowances Working at St John of God Health Care is more than just a job. You will play an integral part in providing some of the very best health care in Australia. Our culture is one of supported and empowered workplaces – with highly engaged and committed teams supporting our local communities and one another at work. Learn more about your future at www.sjog.org.au/workingwith-us Contact Carly Smith, Recruitment Manager on +61 8 6116 0533 or Carly.Smith@ sjog.org.au
YOUR UNION
CAROLINE CONROY MERAS CO-LEADER (MIDWIFERY) JILL OVENS MERAS CO-LEADER (INDUSTRIAL)
the impact of midwifery workforce shortages Midwifery workforce shortages within DHBs are a key area of focus for MERAS currently. These shortages are having a significant impact on many maternity units across the country; in some regions there is a shortage of DHB midwives but a sufficient number of LMC midwives, whilst in others there is a shortage of both. To compound the problem, a shortage of employed and LMC midwives usually requires DHBs to put additional midwifery services in place to support women who cannot find a local LMC, depleting in-patient services even further. The ongoing shortfall of staff on each shift takes its toll, with the pressure of working extra or longer shifts, difficulties obtaining annual leave, and ever-increasing workloads creating additional stress and causing more midwives to reduce their FTE or resign, resulting in even greater pressure for those who remain. It is important to seek support if you are feeling stressed or anxious about the situation in your unit. Talk to your midwife manager or director of midwifery, or discuss the situation at a staff meeting or shift handover.
It is important that the ward has a plan during midwifery staffing shortages. Here are some suggestions: • Reduce numbers of inductions of labour and elective caesarean sections to reflect available staffing. • Seek support from casual midwives and LMC colleagues to assist in covering shifts. • Consider additional HCA or clerical support so that midwives can focus on midwifery. • Establish a debrief process at the end of each shift. • Identify local registered but non-practising midwives - promote ‘return to practice’ opportunities to them. • Identify the minimum number of midwives needed each shift and try to roster accordingly. • Allow for flexible rostering that supports midwives to have time off when needed. • Ensure night and weekend shifts have sufficient midwives and pre-book casual midwives to assist with these shifts.
For MERAS Membership merasmembership.co.nz www.meras.midwife.org.nz 03 372 9738
12 | AOTEAROA NEW ZEALAND MIDWIFE
• Maximise the use of primary maternity units where available and transfer postnatal women and babies as early as safely possible to these units. • Advise LMCs of staffing situation and possible delays in handovers to secondary care.
• Plan annual leave to ensure staff can have regular breaks.
The midwifery shortage has not arisen overnight and has been 10-15 years in the making due to insufficient numbers of new graduate midwives emerging from midwifery education, over-reliance on overseas recruitment, poor retention of midwives within some workplaces and insufficient attention to health workforce planning at a national level. Pay rates have also failed to recognise the unique knowledge and skills midwives possess. Whilst some DHBs have experienced midwifery shortages for several years, for others who have historically had good staffing levels, the shortages have hit hard and fast. More recently, some secondary maternity units have been known - on occasion - to have only one midwife on duty. In many maternity units, the midwife manager and other senior midwives are often working clinically, to support midwives on duty. Our focus, along with the MERAS workplace representatives, has been working with members, midwife managers and directors of midwifery to develop midwifery workforce plans that make use of the opportunities from the Midwifery Accord, MERAS MECA, and CCDM to identify:
• ways to retain and value existing midwives • how shifts can be rostered and midwives supported in the short-term • how elective work can be managed according to available staffing • opportunities to attract midwives in to permanent roles • opportunities to promote ‘return to practice’ • support for new graduate midwives • ways to promote midwifery as a career and the support needed for local midwifery students • ways to maximise the opportunities from the Midwifery Accord • ways to gain support and assistance from local LMCs.
The challenge facing all DHB midwives at this time is not to give away the midwifery sphere or responsibilities to other professional groups or health workers. If we give away the care, responsibilities and decision-making normally provided by midwives, it will be hard to reclaim once midwifery workforce numbers start to increase. There is light at the end of the tunnel: midwifery education providers have seen an increase in student enrolments and the number of APCs issued by NZ Midwifery Council is increasing. Council advises around 140 new graduate midwives will join the workforce this year, along with over 40 internationally qualified midwives and a further 16 midwives registered via the Trans Tasman Mutual Recognition Act. There is more support available for ‘return to practice’ and new graduate midwives with the creation of the midwifery clinical coach role (outcome from Midwifery Accord), funding has increased for courses and conferences as a result of the continuing professional development funding (MERAS MECA), pay has increased (MERAS MECA), and work continues within the midwifery pay equity claim, which should be concluded this year. TRENDCARE AND VRM/VIS These CCDM tools are useful in demonstrating midwifery staffing shortages and it is vital that they are utilised, especially when staff are busy. Trendcare data highlights the workload and acuity on the ward, whilst the VRM tool demonstrates how well staffing levels match that workload. Key areas to pay attention to in the VRM:
• Skill mix: ensure you indicate that the skill mix is not appropriate when you have staffing levels below what should be rostered. • Staff mix: make sure you indicate where the staff mix is not what should be rostered, if there is no experienced midwife on the shift or if RNs are being used to fill midwife positions. • Professional judgement deems it unsafe: this is the most important indicator for a midwife to use when staff rostered is below par.
SUPPORT FOR MIDWIVES It is recognised that midwifery is a stressful role and it is important that support is available. From the latest MECA: “It was agreed the Midwifery Leaders Group will develop a national policy, in conjunction with the GMs HR, on support for midwives following sentinel and/or adverse events, including the ability to provide special leave if needed.” Until that policy is developed, it is vital that there are processes in place. Readily available support should include: • Clinical debriefs – this should be offered to a midwife prior to going home from her shift and contact made with her in the days after by her midwife manager or director of midwifery.
reason relating to Covid-19; or • you have been directed/required to stand down awaiting results of a Covid-19 test; or • you have confirmed Covid-19; or • you need to look after sick dependents who have Covid-19.
You will have to use annual leave or LWOP if you decide to stay at home to look after child(ren) despite your children’s school or early childhood centre being open and your children being well and able to attend. If you want to stay away from normal duties due to concern about a vulnerable household member, consideration will be given for working from home if possible, or accommodation support. The FAQs contain tips on how to ensure you don’t take Covid-19 home. There may be restrictions on taking annual leave at times depending on staffing levels. However, if you have approved annual leave, this cannot be withdrawn without your agreement. square
You can join MERAS if: •
• MERAS – midwives can contact their local MERAS workplace representative or MERAS co-leader (midwifery) to talk through situations that have arisen in the workplace.
COVID-RELATED SPECIAL LEAVE EXTENDED MERAS has been involved with other health sector unions, the DHBs and MoH in revising the DHBs’ employee-related FAQs and these are available on the MERAS website. The FAQs cover leave arrangements, redeployment, personal and business travel, working from home, transportation to and from work, vulnerable workers, childcare, accommodation, contractors, locums and casual workers.
• Missed meal breaks: make sure YES is chosen if you are the only midwife on duty, as you
• you are symptomatic and may have been
You are employed as a midwife by a DHB, Trust, community organisations,
• EAP – midwives should be able to access counselling support easily.
One improvement is that all leave in relation to Covid-19 will be paid as ‘special leave’ and will not be deducted from your sick leave balance. Special leave includes when:
will not be able to take an unrelieved break.
• you are required to self-isolate for any
or private maternity units •
You are employed by a midwifery education provider
•
You are a midwifery student
•
You are an LMC doing casual work for a DHB or other provider
•
You are an employed midwife also doing LMC work.
You may be eligible for the low income union sub if your gross income as an employed midwife is less than $30,000 a year (i.e. not including LMC income). This is 50% of the full sub and also applies to graduate midwives enrolled in the MFYP programme. Student midwives have free membership in MERAS, but must belong to the College of Midwives. All MERAS members must belong to the College of Midwives, and those who are employed by DHBs can apply for up to $345 of their College fees to be paid from the Continuing Professional Development Fund set up as a result of the last MECA for MERAS members only.
exposed to Covid-19; or
ISSUE 104 MARCH 2022 | 13
YOUR MIDWIFERY BUSINESS
WAYNE ROBERTSON EXECUTIVE DIRECTOR, MMPO
2022: reaffirming our purpose At the start of any new year, we take the opportunity to reflect and learn from what happened over the previous 12 months before planning for the year ahead. The purpose of the MMPO remains clear: to help and support community midwives in any way we can, a focus which is paramount during these challenging times. Over the course of 2021, we focused solely on what needed to remain, whilst also bedding in two significant digital projects: BadgerNet Global transition and the new Primary Maternity Services Notice 2021 (Notice 21) claiming and payments framework. We also continued to advocate with the Ministry of Health (the Ministry) for improvements to better support the community midwifery workforce and ensure its sustainability. WHAT WAS MOST IMPORTANT FOR THE MMPO TO RETAIN? • Being an accessible point of contact and help for community midwives • Supporting: - Graduates with their induction from student to community LMC midwife - Rural community LMC midwives with time off, emergency locum cover, mentoring, relocation, and practice establishment - Urban community LMC midwives with emergency locum cover - All community LMC midwives with Covid-19 locum cover - Community LMC midwives using the BadgerNet Global Suite of products and Tiaki
14 | AOTEAROA NEW ZEALAND MIDWIFE
- Community LMC midwives with Notice 21 claiming and payroll - All community LMC midwives with Xero accounting software and help with finding an accountant - Access for all community midwives to an effective and affordable midwifery and digital equipment insurance policy at $75 per annum • Advocacy work on behalf of the LMC community midwifery workforce, to improve work conditions and sustainability.
WHAT NEEDS TO IMPROVE FOR LMC COMMUNITY MIDWIVES? Throughout 2021, the MMPO (together with the College) proposed workforce requests and initiatives to the Ministry, in an attempt to create a more stable foundation for the existing workforce, to relieve stress, improve work satisfaction and ensure a sturdy base from which to build the workforce back up and promote sustainability. The proposals included: • Access to a greater and more equitable number of locum cover days for all community LMC midwives (both urban and rural). • An increase to the daily locum cover rate to not only include a long overdue cost-of-
living adjustment, but to also acknowledge the increased planning and handover requirements and impact of births on each locum cover. • Access to greater funding for graduates and a better way to transition from student, to graduate, to LMC community midwife. • A better way to transition/return to LMC community midwifery practice for existing midwives. • Better utilisation and acknowledgement of long-standing experienced community LMC midwives nearing retirement. • Strengthening and improving individual practice structures through systems, technology, and people (including administrators). • Strengthening inter-practice relationships within a locality to help ensure midwifery care (including on-call), sharing of skills, knowledge and experience, better support for time off, and quality, timely primary health/hospital interfaces and integration.
We also consulted on and provided data regarding the Notice 21 payment model, to ensure a clear understanding of LMC community midwives’ claiming patterns. Together with the College, we continue to
New Zealand Breastfeeding Alliance The MMPO, together with the College, has proposed workforce requests and initiatives to the Ministry, in an attempt to create a more stable foundation for the existing workforce.
ask the Ministry about available support for midwives during the Covid-19 Omicron stage, with cases increasing markedly at time of writing. Whilst we acknowledge the reasons provided by the Ministry for the lack of any real progress (regarding support during the Covid-19 pandemic and transition to a new health system structure), this is not good enough for a critical health workforce whose recruitment and retention are currently affected by: • An excessive demand for midwives in the face of critical workforce shortages • An ongoing failure by the Ministry to settle fair and reasonable pay • The ongoing impact of Covid-19 and more recently, vaccination
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mandates • A historical and systemic underinvestment by the government in community midwifery infrastructure and supports afforded to other health professionals.
A comprehensive but simple way forward was identified and proposed in partnership between the Ministry and College codesign team in 2017. Whilst some year-on-year improvement has been made to pay, (noting that there is still a way to go and at time of writing this may not be the case for all midwives with the implementation of Notice 21) little has improved in terms of more structural and systemic support. This stagnation has persisted despite the co-design review proposal of a national community midwifery structure that could deliver a national community midwifery contract.
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
ISSUE 104 MARCH 2022 | 15
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calmbirth.com.au
Image: Natural Focus Birth Photography
As we move forward into an Omicron-fuelled 2022 with a workforce supply crisis and LMC community midwifery-led court case looming, it is vital that the entire profession is united and that the voices of all midwives are heard - not only by each other, but most importantly, the Ministry and Government. square
Changing birth culture for future generations
NGĀ MĀIA
JAY WARETINI-BEAUMONT REGISTERED MIDWIFE, NGĀ MAIA TRUSTEE (NGĀTI RANGI, NGĀTI UENUKU, NGĀTI APA)
Ngā Māia: he waka eke noa Mana motuhake is one of those whakaaro Māori; I know exactly what it means, but struggle to articulate it beyond the common translation of self-determination. Mana, a supernatural force within human beings, is the essence of power, authority, and control inherited at birth from our tūpuna. Mana motuhake is that mana expressed through exercising control over one’s destiny. The western concept of self-determination
micro levels, but make no mistake, it is
teina creates opportunities for professional
is psychology-based and refers to one’s
not derived from these sources. The Māori
development, cohesion and the pursuit of
sense of control over their decisions and lives
response to Covid-19 has been an outward
mana motuhake. Collectivising, redistributing
(Cherry, 2021). But I believe mana motuhake
display of mana motuhake; evident in the
resources and exploring different leadership
encompasses so much more. To me, it derives
way Māori have gathered, opened dialogue,
styles allows for open dialogue and
from the unique relationship Māori have with
implemented rāhui and supported each other
the development of new infrastructure.
the whenua and te taiao (natural environment)
to protect the health and wellbeing of whānau.
Entrenching ourselves within te ao Māori
and is inherited through whakapapa. These
This response was in the context of crisis and
serves to re-imprint tikanga, kawa, and
connections between tāngata, taiao, ngā atua
urgency and I feel the same urgency regarding
wairuatanga into our lives, midwifery practices,
and wairua affirm our responsibility to protect
my colleagues and the environments they are
and the maternity system at large.
our environment and therefore our future.
now working in (if they are working at all).
Characterised by tikanga, encompassing all
My dedication to being a Māori midwife
Ngā Māia are moving forward purposefully, carving out space for Māori midwives to
that is valued within te ao Māori, it extends
is one of my contributions to the pursuit of
unapologetically be themselves, engage and
beyond individual determination and into
mana motuhake for this generation and the
collaborate. It is my hope that the outcome
the collective domain. It can revitalise our
next. I feel a responsibility to contribute
is a strengthening of mauri, the growing of
innate power and drive much needed change,
towards the sustainability of the midwifery
mātauranga and the reclamation of unique
initiated by Māori, for Māori, with Māori. We
profession and the recruitment and retention
skills. By knowing who we are, where we
need mana motuhake to burn brightly within
of Māori midwives. For me, midwifery without
come from and acknowledging the innate
us, so that we continue to strive for health,
the pursuit of mana motuhake makes for a
connections between ira tāngata, ira atua
wealth and happiness. When mana motuhake
dire future. Māori midwives are among those
and ira whenua, Ngā Māia are in hot pursuit of
is firmly established on an individual level, the
experiencing racism, isolation and burnout; the
mana motuhake. Like muka, it takes more than
result is strong, determined people who can
impact of the vaccine mandate is widely felt,
one strand to weave together something as
then share their expertise with their wider
but particularly for the Māori workforce, it has
beautiful and functional as mana motuhake, for
whānau and communities. It is therefore also
caused great loss and mamae (pain).
the collective. He waka eke noa: we are all in
the potential for enhancement and expansion. Mana motuhake can be found in political,
Nurturing mana motuhake amongst Māori midwives therefore, must be a priority.
economic, social, environmental and cultural
Utilising whakaaro Māori like whānaungatanga,
contexts and applied at macro, meso and
hui, wānanga, mātauranga and tuakana-
16 | AOTEAROA NEW ZEALAND MIDWIFE
this together. Me haere tonu tātou, let’s keep the momentum going. square References available on request.
LEGAL
CARLA HUMPHREY LEGAL ADVISOR
birth filming: your rights as a midwife The issue of midwives’ rights when whānau/
would therefore not be seen as a breach of the
support people film a birth without the
midwife’s privacy under the Privacy Act 2020.
midwife’s knowledge/consent is a common concern and is generally considered unfair;
SO WHAT ARE YOUR RIGHTS?
however, it is only in rare cases, such as the
The Privacy Act acknowledges that sometimes
criminal law, that the concept of unfairness is
people will collect and use information such
relevant. This article explores the issue further
as a video in a way which would be “highly
and outlines steps midwives can take. Some
offensive to a reasonable person”.
DHBs have published policies on this issue, but
Although this wording is general, there are
to my knowledge, most LMCs do not have a
some scenarios that, in my opinion, would
written policy. The wording of such policies
justify a complaint that the midwife’s privacy
varies. Examples are:
was being interfered with. This is particularly
No recording/videoing of staff: "Please do not record or video any conversations or procedures with staff, unless staff give you their consent to do so. Please be mindful in making any recording that you may be capturing the personal information of other people who have not consented to the recording and therefore you may be breaching their privacy in making and keeping any recording.” (CDHB)
the case where the midwife’s ability to carry out safe clinical care is compromised by the words, actions or intentions of the person filming. Clinical safety in such cases may justify the midwife calling security or taking other assertive and legal measures to stop the recording.
household” affairs; however, this does not
only after consultation with the clinical staff
mean that the midwife has no rights. Whilst
and express permission is given from the
a midwife is not legally or ethically bound to
patient.” (SDHB)
agree to being filmed, she will be open to
The CDHB example is in the nature of a
criticism if she has not previously raised this topic with the family. The midwife can
THE PRIVACY ACT 2020 Families gathering information for their own personal, domestic and household affairs are not regulated under the Privacy Act 2020. This is because only ‘agencies’ or businesses are required to follow this law. A private family individual filming a birth, in a normal situation,
have the same rights as any other citizen concerning their reputation, including defamation and harassment.
CONCLUSION Although a written policy may not override the general law allowing families to video the birth, a written policy does set a basis for the partnership; prompting a discussion and, potentially, a reason to withdraw from the partnership, or to add strength to the decision to request the person taking the video be removed from the clinical setting; particularly in cases of clinical safety. square
have the general right to film a birth as it pertains to their “personal, domestic and
for staff and LMCs?
If a video is published about a midwife, they
With the consent of the woman, families
"Photographs/video recordings can be taken
more prescriptive. What is the legal position
DO I HAVE ANY OTHER RIGHTS?
THE IMPORTANCE OF A POLICY ON VIDEO RECORDING
Photographs/video recordings:
request, while the SDHB example appears
with their managers.
consider her own comfort level and what is acceptable to her, but concerns must be communicated in advance and any formal policy regarding videoing should be communicated to consumers - preferably prior to registration and in writing. This may ensure the midwife is not criticised if issues arise as a result of being filmed without consent. Employed midwives will need to communicate any concerns on this issue via their union or
ISSUE 104 MARCH 2022 | 17
FEATURE
18 | AOTEAROA NEW ZEALAND MIDWIFE
FEATURE
AMELLIA KAPA COMMUNICATIONS ADVISOR, REGISTERED MIDWIFE
invisible wounds: how can midwives support women with a history of sexual abuse?
“If I’d known how much of an impact it would have on my labour and birth, I would have told you.” A painful but necessary truth for a midwife to hear. Three years after giving birth to her second child
time, Lucia had laboured spontaneously and birthed
under my care, my ex-client and I were catching up
her son vaginally: a VBAC victory! Learning that my
over coffee, soaking up the late afternoon sun and
version of events could not have been further from
enjoying a rare opportunity to chat uninterrupted
my friend’s truth was horrifying, to say the least. How
while her children were on a play-date. We had
could I have allowed this to happen?
become close friends, so when Lucia* told me she had started suffering nightmares and panic attacks, I was concerned about what could have triggered this change from the cool, calm Lucia I had come to know. What I would learn over the next few hours was that my friend had been raped as a teenager. Not once which is more than any human should ever have to bear - but twice. I also learned that when she was in the second stage of her labour three years earlier and I requested an obstetric consultation, she doesn’t remember much of the birth beyond the sound of the male registrar’s voice as he entered the room. Her surroundings turned pitch black at that point and although she could still hear the voices around her, she couldn’t see a thing. At the time, I noticed a shift in her behaviour, but put it down to overwhelm and sheer exhaustion, knowing she had been awake all night, in active
As we talked, Lucia explained that even though I had carried out family violence screening during her pregnancy, this wasn’t effective in identifying the abuse inflicted on her many years earlier. And because I wasn’t aware of it, I hadn’t explained the possible implications for her labour and birth. Lucia had received counselling therapy over the years and thought she had dealt with her trauma. She had not been suffering nightmares or flashbacks during her pregnancy. She did not feel as though the pregnancy was an invasion of her body. She did not feel unsafe in any way in her intimate or other close relationships. As far as she was concerned, her trauma was not present in her everyday life. She didn’t disclose the history, because she simply didn’t think there was a reason to. But as her midwife, I know how different her
labour for hours. In reality and unbeknownst to me,
experience could have been. With Lucia’s permission,
she had psychologically checked out of the unsafe
I’m sharing her story to increase awareness of
situation she found herself in. The involvement of a
these invisible wounds. As midwives, we are often
male obstetrician was a re-enactment of her abuse;
completely unaware that a woman we are caring for
the ventouse-assisted birth a further violation.
has been the victim of sexual abuse. The challenge
From my (evidently) limited perspective at the time,
then, is how to factor an undisclosed history into
I had considered Lucia’s birth to be a great success.
midwifery care, so that women who have survived it
Her eldest child was born via emergency caesarean
are more likely to tell us their stories and take control
section following augmentation of labour, but this
of their maternity experiences.
ISSUE 104 MARCH 2022 | 19
FEATURE
PREVALENCE OF SEXUAL VIOLENCE The World Health Organisation (WHO, 2021) estimates around 30% of women globally have been the victims of either physical and/or sexual violence in their lifetime. A survey of a representative sample of 2,855 New Zealand women was carried out as part of the WHO Multi-Country Study on Violence Against Women in 2003 and revealed 20% of participants experienced childhood sexual abuse, defined as being touched sexually, or made to perform a sexual act that they didn’t want to do, before the age of 15. University of Auckland researchers conducted a birth cohort study comparing these data with the results of the 2019 New Zealand Family Violence study which comprised a sample size of 1,464 women, to examine changes in the reported prevalence of adult and child sexual abuse in Aotearoa over a century. The 2021 report showed one in six New Zealand women have experienced sexual violence by an intimate partner – a rate that has remained unchanged since 1938 (Fanslow et al., 2021). The study also found rates of child sexual abuse and non-partner sexual assault appear to have declined over time, but remain high at one in five for child sexual abuse and 1 in 14 for non-partner sexual assault. In contrast to the apparent decline, New Zealand Police (2019) state the number of reported sexual assaults in Aotearoa increased by 9.06% from 2016-2018, with more than 6,000 sexual assaults reported in 2018. In their report, New Zealand Police also acknowledge sexual assault is underrecorded globally. RE-TRAUMATISATION: MATERNITY CARE AND BIRTH Montgomery, Pope & Rogers (2015a, 2015b) explored the maternity experiences of women who had been the victims of childhood sexual abuse through a qualitative feminist narrative lens. The authors highlight the fact that although anecdotal accounts indicate childbirth and maternity care can trigger distressing memories for victims of sexual abuse, research data on the subject are limited. Their study aimed to demonstrate ways in which maternity care can be reminiscent of abuse and highlights the resounding silence surrounding sexual abuse as a significant compounding factor; few women disclose this type of history, meaning those caring for them are often unaware of their trauma.
“They will not necessarily be distinguishable from other women accessing maternity services but they may find their experiences deeply traumatic. Silence is a challenge for those providing their care”
20 | AOTEAROA NEW ZEALAND MIDWIFE
“They will not necessarily be distinguishable from other women accessing maternity services but they may find their experiences deeply traumatic. Silence is a challenge for those providing their care” (Montgomery, Pope & Rogers, 2015a, p. 54). In a meta-synthesis of the maternity care needs of women who were sexually abused in childhood,
Montgomery (2013) analysed eight qualitative studies and identified the following recurring themes: •
control
•
remembering
•
vulnerability
•
dissociation
•
disclosure
•
healing
Unsurprisingly, control featured prominently across all eight studies. Retaining or achieving it allowed women to overcome feelings of powerlessness and counteract the effects of their abuse, whilst the lack of it acted as a distressing trigger, bringing back memories or causing flashbacks. Clinical procedures frequently triggered such events, leaving women feeling vulnerable and provoking a fight or flight response. Where physical flight was impossible, psychological flight occurred; dissociation, such as that experienced by Lucia, was common to all eight studies. Vaginal examinations in particular can be potential re-enactments of abuse for some women, but the authors explain that these procedures are not necessarily problematic in and of themselves; rather how they are conducted is of more significance. Some women, for example, stated care providers didn’t take them seriously when they indicated vaginal examinations were painful. Being told that examinations ‘shouldn’t be’ painful led to feelings of invalidation and disempowerment, the consequence of which was the women retreating into silence, just as they had during their episode/s of abuse (Montgomery, Pope & Rogers, 2015a, 2015b). WHAT CAN MIDWIVES DO? Montgomery, Pope & Rogers (2015a) state midwives are likely to encounter women who have been sexually abused on a regular, if not daily basis. Not only will the majority of these women choose not to disclose their history to a midwife, they are also unlikely to respond to a direct question about it. This poses a further barrier to developing individualised care plans in partnership with women that acknowledge their trauma history and address their specific needs. Furthermore, potential triggers are specific to individual wahine and are therefore unpredictable - for both the woman and midwife meaning they cannot necessarily be avoided, regardless of how sensitively care is provided. The Ministry of Health’s Family Violence Assessment and Intervention Guideline: Child abuse and intimate partner violence (Fanslow & Kelly, 2016) provides guidance for midwives, recommending the following question as a routine enquiry into physical, emotional and sexual abuse: ‘Within the past year has anyone forced you to have sex, or do anything sexual, in a way you did not want to? (If so, who did this to you? When did this happen (the last time?)’
Unfortunately, the recommended questioning is framed around abuse within the past year and fails to offer women the opportunity to disclose historical abuse, which, as demonstrated by Lucia’s experience, may be just as significant
FEATURE
as more recent abuse, in the context of labour and birth. Whilst guidelines such as these provide a framework for midwives, given the sensitive nature of the issue, the context, manner and approach surrounding the enquiry are key to ensuring women feel comfortable and confident to reveal their past or present experiences. Wales-based midwife Dionne Aldcroft published a guide to providing care for survivors of child sex abuse in 2001 and the advice still resonates 20 years on. She suggests that asking women questions such as ‘Have you ever been sexually abused?’, although direct, may not be the best way to ask, as many women will not recognise that they have ever been ‘abused’, or may not label it as such.
A potential alternative could be: ‘Have you ever had unwanted sexual experiences, either as a child or an adult?’ Although these questions are similar, Aldcroft points out that the latter option concentrates on how the woman herself perceives her experience (Seng and Petersen, 1995). Montgomery (2013) iterates that above all else, survivors of sexual abuse are striving to feel safe throughout their maternity experience. They will do anything to avoid re-enactment of their trauma, either by taking control, or employing avoidance strategies such as dissociation or denial. If the strategies are successful and women are able to develop positive and trusting relationships with health professionals, birth can be empowering and in some cases, a healing experience. But if they are unsuccessful, this can lead to powerlessness, vulnerability and feeling unsafe; the effects of which lead to an overall feeling of having been violated once again. As women frequently do not disclose their history, Montgomery acknowledges that the solutions to providing individualised care for these women are not clear. Whilst she points out a need for more high-quality research on the subject, she advises practitioners to examine their practice and explore how one might best create connections with women that engender a feeling of safety (Montgomery, 2013). Demonstrating respect, communicating openly, and being genuinely interested in women as individuals may help in achieving this. Listening for the unspoken messages women are trying to convey is also encouraged (Montgomery, Pope & Rogers, 2015b). Given women are more likely to cope with invasive procedures such as vaginal examinations if they trust those performing them and retain as much control as possible, revisiting the way this procedure is approached may be worthwhile for midwives in practice. Explaining the process of a vaginal examination before commencing and ensuring women understand that they can ask a midwife to stop at any time during the process may aid women in retaining a sense of control throughout what could otherwise be a disempowering procedure (Montgomery, Pope & Rogers, 2015b). Listening or watching for unspoken cues may also be more achievable if information is shared with women before
a potentially triggering event occurs. For example, informing a woman that a Listening or watching for male obstetrician is available unspoken cues may also be more to consult, and taking achievable if information is shared a moment to gauge her response before acting, may with women before a potentially assist midwives in detecting triggering event occurs. any changes in the woman’s behaviour. If a midwife picks up on any change, or even suspects that the woman feels uncomfortable, a discussion can then be initiated with the woman about what would feel safe, and arrangements made to meet those needs, wherever possible. Seng et al. (2002) state some women may not be aware of how their trauma history and consequent post-traumatic sequelae might affect their general health or pregnancy. This was true of Lucia and ultimately, she found herself wishing that she had disclosed her history, so that I could have worked more deliberately to protect her from exposure to events or procedures which had the potential to cause further harm. Clearly but sensitively sharing information with all women - whether they disclose a history of abuse or not - about the potential for this trauma to be triggered in labour and birth could be the deciding factor for some women, and certainly would have made a difference for Lucia. Explaining the benefit of disclosure in the context of safety throughout the maternity continuum may encourage more survivors to share their histories. If women do disclose a history of sexual abuse to their midwife, it may be advisable to encourage these women to seek out counselling therapy or other modalities that may support their healing process in preparation for labour and birth. Unfortunately these specialised services are not publicly funded; a factor that may further perpetuate current health inequities and prevent women from receiving the support they need and deserve. A FINAL MESSAGE FROM LUCIA "If I could go back and change one thing about the lead up to my son’s birth, it would be to inform my midwife of my history of sexual assault. I entered pregnancy and birth completely unaware of the implications my past could have on my birthing experience. I am certain that armed with that knowledge, my midwife would have been able to see me and advocate for me when I could no longer. By telling my story, I hope that conversation about past sexual trauma becomes commonplace between midwives and their clients. If survivors are made aware of potential triggers within labour and birth, they stand a chance to plan for this, regain control, and have their bodies be a place of healing rather than further trauma." square *Pseudonym used to protect the identity of the wahine and whānau involved. References available on request.
ISSUE 104 MARCH 2022 | 21
CLIMATE CHANGE
LESLEY DIXON MIDWIFERY ADVISOR
global heating:
a hazard for pregnant women and their babies “It is unequivocal that human influence has warmed the atmosphere, ocean and land” (IPPC 6th report, 2021). The planet is warming at an unprecedented rate, with an increasing frequency and severity of extreme weather events globally. More heatwaves, droughts, floods and tropical cyclones are all a result of human-induced climate change. It is predicted that temperatures will continue to rise until at least the mid-century with warming of 1.5-2°C exceeded, unless deep reductions in emissions are achieved.
in 18 of the 28 studies that reported this outcome, and eight studies found an increase in stillbirth rates (1.05, CI 1.011.08) for every 1°C increase in temperature. These risks were particularly increased for women in lower socio-economic groups or at age extremes.
Two more recent studies provide further evidence of this risk. The first, from Harris County in Texas, explored the links between extreme heat and the risk of spontaneous Climate change is affecting every country across the globe pre-term birth (Cushing, Morello-Frosch, & Hubbard, and we are now starting to see the impact of these changes 2022). The study concluded that the risk of pre-term on the health and wellbeing of women and their babies birth was 15% higher on extremely hot days (>40°C) and during pregnancy and following birth, with a growing this association was stronger earlier in pregnancy and in body of evidence linking air pollution and heat exposure to economically disadvantaged groups. The second study, set negative outcomes. in New South Wales, Australia, assessed the risk of heat EXTREME HEAT AND PRE-TERM BIRTH exposure and pre-term birth for women with different health and demographic characteristics (Jegasothy, Randall, We know that extreme heat compromises the woman’s Ford, Nippita, & Morgan, 2022). They found an increased ability to thermo-regulate which increases the risk of adverse risk of pre-term birth at mean daily temperatures of 25°C outcomes for the neonate. A meta(RR 1.14, CI 1.07, 1.21) and analysis of 70 studies set in 27 the increase was slightly higher countries explored the association among women with diabetes, between high environmental “This decade is make or break hypertension, chronic illness temperatures and stillbirth, preand women who smoked during for the planet. To stand a chance term birth and low birth weight pregnancy. (Chersich et al., 2020). This of limiting global warming to analysis found that pre-term birth WILDFIRE EXPOSURE AND 1.5°C, the science shows we now was more common at higher than AIR POLLUTION lower temperatures, with the odds have about eight years left to increasing by 5% per 1°C increase The warming global environment almost halve global greenhouse in temperature. During heatwaves has also led to an increase in gas emissions” (Minister of the odds of pre-term birth the frequency and severity of increased by 16% (1.16 CI 1.10wild/bush fires, which release Climate Change, James Shaw). 1.23). Higher temperatures were pollutants into the air, soil and also linked to lower birth weight groundwater. A Californian
22 | AOTEAROA NEW ZEALAND MIDWIFE
CLIMATE CHANGE
ISSUE 104 MARCH 2022 | 23
CLIMATE CHANGE
study explored the association between wildfire exposure and embryo development leading to gastroschisis (Park et al., 2022). Pregnancies were considered exposed to wildfire effects if the woman lived within 15 miles of the closest edge of the wildfire. The study was undertaken between 2007 and 2010 and included 844,348 births, of which 176,581 were exposed during the first trimester, and 15,963 (2%) exposed before pregnancy (within 30 days prior to the pregnancy). For women exposed to wildfire in the first trimester, there was a higher risk of gastroschisis (adjusted relative risk (aRR) 1.28, 95% confidence interval (CI) 1.07, 1.54). Those with wildfire exposure before pregnancy (within 30 days) demonstrated even higher risk (aRR 2.21, 95% CI 1.40, 3.48). In contrast, second and third trimester wildfire exposures were not associated with higher gastroschisis risk. Ambient air pollution from burning fossil fuels not only impacts the environment but has also been linked to pre-eclampsia and pregnancy-induced hypertensive disorders (Pedersen et al., 2017), low birth weight (Smith et al., 2017) and pre-term birth
(Costello, Steurer, Baer, Witte, & JelliffePawlowski, 2022).
significantly increased its contribution to the global effort to tackle climate change by aiming to reduce net greenhouse emissions by 50% by 2030.
WHAT IS AOTEAROA DOING? “Climate change is a priority for the Government because it’s a threat to our economy, our environment and our everyday
• An emissions reduction plan, which has been drafted and is currently being finalised.
lives” (Rt Hon Jacinda Ardern).
HOW IS NEW ZEALAND TRACKING?
Like many countries, politicians are working towards policies and programmes of work that will set out how we will reduce carbon emissions. In Aotearoa this work has involved:
The Global Climate Action Tracker (CAT) measures government action on climate change against the globally agreed Paris Agreement. This agreement aims to limit warming to 1.5°C. The CAT provides independent analysis and tracks 39 countries, covering 85% of global emissions. They track:
• Establishing a Climate Change Commission to provide advice on ways to mitigate and adapt to climate change, as well as
• Climate policies and actions on emissions
monitoring progress towards reduction
• The impact of pledges, tartes and NDCs
goals.
• The efforts of countries in comparison to others, to identify whether it is a ‘fair share’ of the effort to limit warming.
• The Zero Carbon Act, which was legislated in 2019, identifying a reduction target for greenhouse gas emissions to be achieved by 2050. • Adopting an international target known as a Nationally Determined Contribution (NDC) under the Paris Agreement. This sets out the contribution the country will make towards the agreement’s goals. New Zealand has
The CAT rates New Zealand’s efforts as “highly insufficient” and not stringent enough to limit warming to 1.5°C at present, with a need for substantial improvements. It is hoped that the emissions reduction plan will set more ambitious reduction targets and climate policies.
NEW ZEALAND - OVERALL RATING: HIGHLY INSUFFICIENT Policies & action HIGHLY INSUFFICIENT < 4OC WORLD Net zero target
year 2050
24 | AOTEAROA NEW ZEALAND MIDWIFE
Domestic target INSUFFICIENT < 3OC WORLD comprehensiveness rated as POOR
Fair share target CRITICALLY INSUFFICIENT 4OC+ WORLD Land use & forestry
Climate finance HIGHLY INSUFFICIENT
historically considered a SINK
WHAT IS THE COLLEGE DOING? The College and its members are committed to health-centred climate action and supporting national and global initiatives which reduce the negative impacts of climate change. The College is a member of Ora Taiao, the New Zealand Climate and Health Council, which is part of a worldwide movement of health professionals and organisations focusing on the health challenges relative to climate change and the opportunities therein. We strongly support the Ora Taiao mission statement and purpose which is: • To educate all New Zealanders on the threat of climate change and its effects on human health and survival. • To promote interventions that combine health and environmental benefits. • To encourage personal and organisational action on climate change. • To promote a rapid reduction in New Zealand’s greenhouse gas emissions. • To encourage societal responses to climate change, that promote equitable health and social outcomes and are consistent with Te Tiriti o Waitangi.
The College’s consensus statement Climate change, midwifery and environmental sustainability was ratified in November 2021, and in January 2022, a webpage dedicated to the topic was added to the College website. The webpage currently has three sections: About climate change, Take action, and Learn more. It will be updated regularly with useful information supporting midwives to develop ‘green’ practice, along with information they can share with whānau on ways to reduce their impact on the environment. We would welcome feedback and articles from midwives on what they are doing to reduce their carbon footprint. square
Student Midwifery Grants 2022 The College is offering grants to assist students at each midwifery school who are currently
ways to act on climate change: every action counts
undertaking a Bachelor of Midwifery programme. Grants are available for each school of midwifery
•
Support policies to reduce carbon emissions: keep the pressure on all political parties to ensure that climate change
•
and application forms www.midwife.org.nz
Buy less: every product we buy has a carbon footprint;
To apply, applicants must:
therefore reduce, reuse and recycle wherever possible.
1. be a College member
emissions. Adopt a more plant-based diet: animal agriculture is a large contributor to global emissions, so reducing consumption of meat and dairy products can help reduce emissions. • •
refer to the College website for further information
and carbon emission reduction remain priorities.
The fashion industry contributes to up to 10% of global •
for second, third and fourth year students. Please
2. intend to practise in New Zealand on graduation Please email your completed application forms to lynda.o@nzcom.org.nz
Reduce food waste: food scraps in landfill are broken down
The Grants Advisory Committee will award
by bacteria which produce methane.
the grants.
Fly less, drive less: travel is a large contributor to global carbon emissions.
References available on request.
ISSUE 104 MARCH 2022 | 25
Applications open until 15 July 2022
MATERNITY OUTCOMES
CLAIRE MACDONALD MIDWIFERY ADVISOR
maternity outcomes for 2019: key outcomes and trends since 2009 The Ministry of Health’s annual Report on Maternity data was published at the end of 2021 as an interactive web tool which enables users to see descriptive statistics and trends in maternity interventions and outcomes since 2009. The Maternity Clinical Indicators data for 2019 is yet to be published at time of writing. Indicators can be viewed by DHB, age group, ethnicity and deprivation, with graphs and tables presented as percentages or numbers. This article looks at some of the patterns and points of interest for 2019.
26 | AOTEAROA NEW ZEALAND MIDWIFE
MATERNITY OUTCOMES
BIRTH NUMBERS SLIGHTLY UP IN 2019
BIRTH RATE TRENDS DOWN SINCE 2009 Although there were more births in 2019 compared with recent years, the birth rate* was only slightly increased compared with 2018 and the overall pattern is a downward trend over the last decade. As illustrated in Figure 1, the most common age to give birth in 2019 was 30-34 (32.9% of all births). The number of births to wāhine under 20 years old has been trending down since 2009. In 2016 the proportion of births to people <20 and ≥40 equalised and since then more ≥40 year olds have given birth than <20 year olds. The Report on Maternity does not provide any indication of reasons for the statistical patterns, but New Zealand Family Planning Association (2019) points to the introduction of funded long-acting reversible contraception (LARC) in 2011 as one likely factor in the decreasing rate of births to younger women. Increasing overall maternal age may be one factor contributing to the increasing intervention rates seen in
50
37.5 % of births
The three DHBs with the most births were Counties Manukau (8,492), Waitematā (7,825) and Canterbury (6,464), while the three DHBs with the fewest births were West Coast (349), South Canterbury (627) and Tairāwhiti (688). The variation in birth numbers across the 20 DHBs reflects local population numbers, and represents different service delivery needs in areas with high urban density compared with rural populations dispersed across large geographic areas.
FIGURE 1. BIRTHS BY MATERNAL AGE
25
12.5
0 2007
2008
2009
2010
2011
2012
20-24
25-29
birth to 60,167 liveborn babies. This is the highest annual number of births in this dataset since 2015 (by a small margin), with 2010 continuing to hold the record of 64,869 babies.
2014
2015
2016
2017
2018
2019
30-34
35-39
40+
FIGURE 2. TYPE OF BIRTH BY MATERNAL AGE 2019
100
75
50
25
0 < 20
20-24
25-29
30-34
35-39
40+
Age group Elective caesarean
Emergency caesarean
Assisted vaginal
Aotearoa and other similar countries. Figure 2 illustrates type of birth by maternal age. MORE MĀMĀ ARE SMOKE-FREE
In 2019, 59,818 women gave
2013
Year < 20
% of births per aga group
In 2019, 59,818 women gave birth to 60,167 liveborn babies. This is the highest annual number of births in this dataset since 2015 (by a small margin), with 2010 continuing to hold the record of 64,869 babies.
Gains continue to be made in the proportion of birthing people who are smoke-free at two weeks postpartum, reaching 91.6% in 2019. MOST MATERNITY CARE PROVIDED BY MIDWIVES In 2019, 93% of all wāhine registered with a Lead Maternity Carer (LMC), of which 94.8% registered with a midwife LMC, continuing a trend of gradual increases since 2009. There has been a concurrent year-onyear decrease in the proportion of
Instrumental vaginal
Spontaneous vaginal
women registering with a GP (0.1%) or obstetrician (4.9%) LMC. After several years of significant decreases in people registered with a DHB for maternity care, this trend has stabilised since 2016 at approximately 3% over the last four reported years. First trimester registrations for antenatal care (with either an LMC or DHB) continue to climb, reaching 68.7% in 2019 compared with 48.4% in 2009. Early registration is most common among wāhine in their 30s (74.5%) and least common in those under 20 (45.6%). Deprivation level is also correlated with timing of registration – first trimester LMC registration is most common among the most well-resourced women (quintile 1) (79.9%), and decreases with each quintile to 53.3% among the least resourced people (quintile 5).
ISSUE 104 MARCH 2022 | 27
MATERNITY OUTCOMES
FIGURE 3. IOL BY DHB 2007-2019
% of births (excl elective C/S)
50
37.5
25
12.5
0 2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
First trimester registration remains largely unchanged between 2018 and 2019 among the broad ethnicity categories, with the highest rates among Pākehā/ European/Other (81.7%), followed by Asian (73.9%), Indian (66.8%), Māori (55.5%) and Pacific (39.7%) people. As we noted in the March 2021 issue of Midwife, facilitating equitable access to care and responding to our Tiriti responsibilities is a key focus for the College as it works with the Ministry and DHBs on how the health reforms (which will start being implemented this year) will support the diversity of Aotearoa’s maternity population.
Year Auckland
Counties/Manukau
Southern
Tairāwhiti
Nelson Marlborough
Northland
DHBs with the most births were Counties Manukau (8,492), Waitematā (7,825) and Canterbury (6,464), while DHBs with the fewest births were West Coast (349), South Canterbury (627) and Tairāwhiti (688).
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INDUCTION OF LABOUR Induction of labour (IOL) has seen a significant increase over the data reporting period, from 19.6% in 2009 to 27.3% in 2019 – a proportional increase of 39%. Conversely, there was a 29% decrease in the proportion of wāhine whose labour was augmented, from 28.7% in 2009 to 20.5% in 2019. IOL rates varied dramatically by DHB. Figure 3 illustrates the IOL rates from 2007 to 2019 for the three DHBs with the highest rates compared with the three DHBs with the lowest rates. The denominator for IOL data is all births excluding elective caesarean section.
MATERNITY OUTCOMES
FIGURE 4. IOL BY MATERNAL AGE
% of births (excl elective C/S)
50
37.5
Induction of labour (IOL) has seen a significant increase
25
over the data reporting period, from 19.6% in 2009 to 27.3% in
12.5
2019 – a proportional increase 0 2007
2008
2009
2010
2012
2011
2013
2014
2015
2016
2017
2018
2019
Year < 20
20-24
25-29
30-34
35-39
of 39%. Conversely, there was a 29% decrease in the proportion of wāhine whose labour was
40+
augmented, from 28.7% in 2009 to 20.5% in 2019. FIGURE 5. IOL BY PARITY
In 2019, 93% of all wāhine
% of births (excl elective C/S)
50
registered with a Lead Maternity Carer (LMC), of which 94.8%
37.5
registered with a midwife LMC, continuing a trend of gradual
25
increases since 2009.
12.5
0 2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
Year P0
P1
P2
P3+
ISSUE 104 MARCH 2022 | 29
MATERNITY OUTCOMES
FIGURE 6. IOL BY ETHNICITY
Caesarean section continued its upward trend, reaching 29.1% in 2019, from 23.8% in 2007; a proportional increase of 22% over the 13 years of reporting. Instrumental vaginal birth has remained relatively static at 9%, while ‘assisted birth’ was at 2% in 2019.
% of births (excl elective C/S)
50
37.5
25
12.5
0 2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
Year Pacific
Indian
Euro/Other
Asian
Māori
FIGURE 7. IOL BY DEPRIVATION QUINTILE
% of births (excl elective C/S)
50
37.5
25
12.5
0 2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
Some of the variation in IOL rates by DHB may be ascribed to demographic differences, and the Report on Maternity dataset unfortunately does not provide these data or any multivariable analyses or measures of association. Figures 4-7 demonstrate IOL rates by maternal age, parity, ethnicity and deprivation quintile, to provide insight into how the demographic variation of different regions may affect IOL rates. However, despite these demographic differences it is likely there is also regional variation in practice and threshold for IOL, which demonstrates the importance of national consensus guideline development such as the Induction of Labour in Aotearoa NZ Clinical Practice Guideline (MOH, 2019) and subsequent implementation in all DHBs.
Year Dep quintile 1
Dep quintile 2
Dep quintile 3
Dep quintile 4
TYPE OF BIRTH
Dep quintile 5
FIGURE 9. INTERNATIONAL COMPARISONS 2019
% of births per country
100
75
50
25
0 Spont. vaginal Caesarean
Instrumental Aotearoa
Assisted
Induction
England/Wales**
Hospital
Primary facility
Home
Australia
*Birth rate is the number of women or people giving birth per 1,000 women of reproductive age (females 15-44 years old). **Type of birth, induction of labour and low birth weight data are for England alone and includes data from 1 April 2019 to 31 March 2020 (NHS Digital, 2020), while home birth data is for England & Wales (Office for National Statistics, 2020).
30 | AOTEAROA NEW ZEALAND MIDWIFE
Due to recent clinical coding changes, there are now different categories for ‘instrumental birth’ and ‘assisted birth’. The former includes forceps, vacuum/ventouse or both, while ‘assisted birth’ includes vertex or breech vaginal births where additional assistance by the midwife or doctor was necessary, for example McRoberts manoeuvre, assisted breech or breech extraction. The explanatory notes indicate, “Some births previously categorised as spontaneous vaginal births are now categorised as assisted births. This means the data may show an increase in assisted births, but it may be due to the change in coding standards rather than a true increase” (Ministry of Health 2021, p. 3). It is unclear how much of the slight decrease in spontaneous vaginal birth in 2019 (59.84%) compared with 2018 (60.65%) may be due to these coding changes rather than an actual decrease.
MATERNITY OUTCOMES
FIGURE 8. TYPE OF BIRTH BY DHB IN 2019
Whanganui West Coast Waitemata Wairarapa Waikato Taranaki Tairawhiti Southern South Canterbury Northland Nelson/Marlborough MidCentral Lakes Hutt Valley Hawke's Bay Counties Manukau Capital Coast Canterbury Bay of Plenty Auckland 0 % of all births
Caesarean section continued its upward trend, reaching 29.1% in 2019, from 23.8% in 2007; a proportional increase of 22% over the 13 years of reporting. Instrumental vaginal birth has remained relatively static at 9%, while ‘assisted birth’ (coded as above) was at 2% in 2019. Figure 8 demonstrates the variation between DHBs in the proportions of each birth type in 2019. INTERNATIONAL COMPARISONS Aotearoa has seen year-on-year increases in several birth interventions, including IOL and caesarean section, with a corresponding
25
50 Elective caesarean
Emergency caesarean
100
75 Assisted vaginal
decrease in spontaneous vaginal birth. It is worth considering these data in the context of somewhat comparable populations and maternity systems, such as Australia and the UK. Figure 9 describes selected maternity indicators where data collection parameters were similar. The category of ‘assisted birth’ only appears in New Zealand and was included for completion of the birth cohort. Data on primary facility and hospital birth is collected together in England so this has been omitted and only home birth is reported in the chart. square
Instrumental vaginal
Spontaneous vaginal
Aotearoa has seen year-on-year increases in several birth interventions, including IOL and caesarean section, with a corresponding decrease in spontaneous vaginal birth.
References available on request.
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Recovery Abdominal Muscle Separation. C-Section Perineal Trauma
www.srchealth.com
ISSUE 104 MARCH 2022 | 31
FEATURE
FIONA GIRDWOOD REGISTERED MIDWIFE
ISOLATED CLEFT PALATE: CONSIDERATIONS FOR MIDWIVES IN PRACTICE
After her midwifery colleague’s baby was diagnosed with an isolated cleft palate, Fiona Girdwood was introduced to a technique proven to have improved early detection of this rare but often under-diagnosed anomaly. Her interest piqued, Fiona focused on the topic for a postgraduate assignment and generously shares what she has uncovered here, for other midwives throughout Aotearoa to consider in their own practice. Cleft palate occurring as an isolated anomaly without cleft lip is most often diagnosed after birth, and should be recognised by the midwife at the first full neonatal examination. In my combined eight years as a lead maternity carer (LMC) and employed midwife at Wellington Regional Hospital, I was never aware of, nor involved in the care of a newborn with a cleft palate. In the three years that I have been working in the Wairarapa, I have come across three babies born with cleft palates, two of whom have had an impact on my practice and midwifery knowledge. As an undergraduate student, I was taught to check for clefts by palpating the newborn’s palate with a gloved finger, but have never recognised one in this manner. Two years
32 | AOTEAROA NEW ZEALAND MIDWIFE
ago, I was taught how to use a torch and wooden tongue depressor by my colleague Birgit, when she returned from maternity leave after her third child was born with an isolated cleft palate. Birgit had breastfed her other two children without any problems, so was distressed when her third baby was having difficulty latching deeply, making clicking noses when feeding, and regurgitating milk through his nose. It was only at four days of age, when her little boy yawned, that her LMC noticed the presence of a soft palate cleft. Birgit shared the story of her journey with our team when she returned to work, along with the knowledge that she gained about checking the newborn palate from attending a conference on cleft palates in New Zealand.
ANATOMY & INCIDENCE Unique to primates, the palate is necessary for infant suckling, making it possible to breathe and take milk into the mouth simultaneously (Ritto et al., 2021). It comprises an anterior hard bony palate, which separates the pharynx from the nasal cavity, and a posterior soft fibromuscular palate, which closes off the nasal passages during swallowing (Perry & Zajac, 2016a). Cleft palate is a birth defect that occurs during pregnancy, where the roof of the baby’s mouth doesn’t completely join. It can be found together with cleft lip, as the same gene is associated with both, or each can be found in isolation (Alois & Ruotolo, 2020). Clefts are most commonly classified
FEATURE
ISOLATED CLEFT PALATE
CLEFT PALATE: WHERE THE ROOF OF THE BABY'S
UVULA
INCISIVE FORAMEN
PREMAXILLA
UPPER PALATE
NORMAL PALATE
according to their position and degree, and can be unilateral or bilateral (Burg et al., 2016; Perry & Zajac, 2016a). Globally, isolated cleft palate has an incidence between 1.3 and 25.3 in 10,000 births, being most common in Canada and in non-Hispanic Europeans, and least common in Africa (Burg et al., 2016). In New Zealand, 71 babies were born with isolated cleft palate in 2019, with an average of 76 per year over the last eight years. The only more common anomalies found in New Zealand during this time period were heart septal defects, undescended testes and hypospadias (New Zealand Congenital Anomalies Register, n.d). The incidence of isolated cleft palate was found to be double in the Māori population when compared to New Zealand Europeans (1.54 in 1,000 live births compared to 0.73 in 1,000 live births), with the New Zealand Pacific population having a rate about halfway between. Incidence related to ethnicity could imply a genetic component,
MOUTH DOES NOT COMPLETELY JO JOIN. IN. ITITCAN CANBE BEFOUND FOUND TOGETHER WITH CLEFT LIP, OR IN ISOLATION.
and with about half of these types of clefts being associated with other anomalies, such as congenital heart defects and genetic syndromes, this is not unlikely (Burg et al., 2016; Thompson et al., 2016). Environmental factors also play a part, with evidence showing increased rates are associated with maternal smoking, glucocorticoid exposure, pre-existing maternal diabetes and alcohol use. Clefts are also possibly linked with folic acid deficiency, low maternal zinc levels, and corticosteroid use, especially if the latter is topically applied for dermatitis (Burg et al., 2016). Some medications have also been associated with increased occurrence, specifically ondansetron, valproate and opiates, so these are best avoided in the first trimester if possible (Bateman et al., 2021; Huybrechts et al., 2018; Jackson et al., 2016). CHALLENGES When a baby is born with a cleft palate, the obvious first challenge is feeding. With intact lips and palate, a baby breastfeeds
by forming a seal around the breast with the lips, and closing the oral cavity at the back by raising the soft palate to make a seal with the pharyngeal wall. A vacuum is created when the baby lowers the tongue and jaw, enabling the baby to suck milk from the breast. Milk removal is also assisted by wave-like movements of the tongue (Boyce et al., 2019). Babies with cleft lips can often push the tongue against the breast tissue to create a seal and thus feed effectively. A cleft palate, however, causes difficulty in creating suction, potentially resulting in reflux, nasal regurgitation and insufficient milk transfer. These babies spend longer at the breast, take in excessive air, tire easily, have impaired nourishment and tend to struggle with growth (Boyce et al., 2019; Snyder & Ruscello, 2019). Zajac (2016) acknowledges that some babies with clefts can breastfeed, so breastfeeding should be encouraged and evaluated before assuming that all babies with cleft palates need to be bottle-fed. Different positions and techniques can be
ISSUE 104 MARCH 2022 | 33
FEATURE
employed to help the mother-baby dyad achieve effective milk transfer and avoid nasal regurgitation, or the mother can be helped to express milk and feed it to her baby via a syringe or spoon. Once feeds are larger in volume, cups or specialised bottles with oneway valves can be used, or bottles that work via compression action rather than suction can be introduced (Boyce et al., 2019). In a cohort of babies studied by Kaye et al. (2017) it was found that babies with cleft palates had consumed more formula, less breastmilk, and took 21 days on average to regain birth weight, compared to babies with cleft lips or both cleft lips and palates, who took an average of 14 days. Other challenges include hearing loss and speech difficulties. The production of stop consonants, like “b” and “p”, require oral pressure that cannot be produced with a cleft palate. Learning speech is also affected by hearing loss; muscles of the soft palate wrap around the eustachian tube, contracting to open the tube and equalise pressure, and allowing fluid to drain from the inner ear. These functions are lost if the palate remains unrepaired (Perry & Zajac, 2016b). Isolated cleft palate is known to be associated with smaller upper airways, sleep-disordered breathing, and obstructive sleep apnoea, so some experts recommend sleeping in a lateral position to prevent this (Davies et al., 2017). Evidence is not clear however, with a retrospective study of sleep investigations finding little evidence to support non-supine sleeping in infants with cleft palate, and advising caution in recommending such positions to parents due to increased SUDI risks (Greenlee et al.,
Some babies with clefts can breastfeed, so breastfeeding should be encouraged and evaluated before assuming that all babies with cleft palates need to be bottle-fed. Different positions and techniques can be employed to help the mother-baby dyad achieve effective milk transfer and avoid nasal regurgitation.
34 | AOTEAROA NEW ZEALAND MIDWIFE
2019). Currently in New Zealand, parents of babies with cleft palates are given a copy of “The Blue Book”, a handbook that hasn’t been updated since 2006, which advises that all babies with clefts sleep on their sides so that “reflux can drain away”, and also describes how a foam wedge can be used under the mattress to elevate the torso if a baby needs an elevated sleeping position (Cleft Lip and Palate Support Group, 2006). TREATMENT Treatment is the surgical repair of both hard and soft palates, with goals being to protect mid-face growth, separate nasal and pharyngeal cavities, and form a velopharyngeal valve to facilitate normal speech and swallowing (Burg et al., 2016). Initial surgery is usually performed in the first year of life, but issues with ear infections, hearing, speech and dentition can require ongoing management (Costa et al., 2019). In New Zealand, lip repairs are done at 3-5 months of age, and palates at 9-12 months, with exact timing depending on the health and size of the baby. The aim is to repair the defects in time for the child to be able to learn to speak. In the lower North Island, referral to the cleft co-ordinator at Hutt Hospital is made as soon as a baby is born, so that all aspects of care can be co-ordinated. Three other cleft centres serve the rest of the country: Auckland, Waikato, and Christchurch (Cleft Lip and Palate Support Group, 2006). DETECTION AND THE MIDWIFE’S ROLE New Zealand legislation requires that midwives perform a full examination of the newborn within the first 24 hours following birth, at seven days after birth (Ministry of Health, 2007), and also at 4-6 weeks, as set out in the Well Child Tamariki Ora health book (Ministry of Health, 2020). In this book, assessment of the mouth is part of the 24-48 hour assessment. In 2006, Habel et al. published a paper on the importance of visualisation of the posterior palate and the uvula, suggesting newborn palates were probably being examined digitally rather than visually, because it was less distressing for the newborn. In 2014, the Royal College of Paediatrics and Child Health (RCPCH) published a best practice guide, Palate examination: Identification of cleft palate in the newborn, recommending visual examination of the whole newborn palate, as palpation alone had been shown to be less effective.
The RCPCH recommended technique is to use a spatula to depress the baby’s tongue, pushing it down and out of the way, so that the back of the throat is visible with a torch. The practitioner should know how to recognise the normal palate, and the single conical uvula that confirms the whole palate has been sighted and is intact. Large defects should be obvious, but smaller clefts can be missed, and while a bifid uvula could be an isolated finding, it is suggestive of a submucosal cleft, and should be checked by an experienced paediatrician. In 2017, McElroy et al. reported that 2832% of cleft palates in the United Kingdom (UK) were being diagnosed after 24 hours of age, and some much later, potentially causing significant morbidity in the baby, and distress for the family. Since the RCPCH recommendations have been adopted, detection rates in the UK have improved, with a recent letter written by Maraka et al. (2020) reporting that only 12% of cleft palates were still being diagnosed after a week. The authors were concerned, however, that some feeding difficulties caused by clefts were being misdiagnosed as tonguetie, and so advocate for rechecking the palate, visually, whenever there are growth concerns attributed to poor feeding in the early weeks (Maraka et al., 2020). In the rural unit where I work, with an annual birth rate of 450-500, there may be a baby born with an isolated and previously undiagnosed cleft palate every one to two years, so most midwives have little experience in visually recognising a cleft. I am grateful to have seen one, but one doesn’t make me an expert; therefore, incorporating this technique into every full neonatal examination ensures I am repeatedly visualising normal palates, making it easier to recognise a cleft if I come across one. Initially, I felt uncomfortable using the spatula, as babies tend to push up against it with their tongues and often gag. However with practice, and as I have gained the confidence to ask parents to assist me with the torch, I am finding that I can do it more easily and cause less discomfort. Our unit has put individually wrapped wooden spatulas in all the birth rooms, and in the box containing the newborn examination kit; an effective reminder that it should be used in order to detect this anomaly for babies and their families as early as possible. square References available on request.
rural student midwifery grant Mary Garlick, a retired long standing rural midwife has generously granted a sum of money to the College to administer as an annual grant for midwifery students who intend to practise rurally on graduation. Applications will be accepted from students who are enrolled in the final year of a New Zealand Bachelor of Midwifery programme in 2022. Midwifery students are eligible to apply for the annual $2,000 grant if they meet the following criteria: •
Applicant must be a College member and enrolled as a final year student of an approved New Zealand Bachelor of Midwifery programme for 2022.
•
Applicant must intend to practise as a rural midwife in New Zealand on graduation. Preference may be given to those intending to practise as an LMC.
To apply, applicants must: •
demonstrate a commitment to rural midwifery practice on graduation
•
complete the application form and ask two referees to complete the relevant form. One referee must be a lecturer at the midwifery school in which the student is enrolled and the other, a midwife who the student has completed a clinical placement with.
Applications must be submitted via email to lynda.o@nzcom.org.nz by 15 July 2022, noting ‘Rural student grant application’ in the subject line. Further information and application forms are available on the College website www.midwife.org.nz NB: Only one grant will be awarded per annum. The Midwifery Student Rural Grants Advisory Committee will award the grant.
BREASTFEEDING CONNECTION
CAROL BARTLE POLICY ANALYST
CLEFT-AFFECTED BABIES AND BREASTFEEDING Babies who are born with oral clefts face a range of short and long-term difficulties with feeding. Effective attachment at the breast and removal of breastmilk from the breast requires the baby to latch at the breast, be positionally stable, and to be able to generate suction. Babies with a cleft lip and intact palate may manage an effective seal around the breast and also generate enough suction/negative pressure to effectively achieve milk transfer (Boyce et al, 2019). Creation of a seal at the site of the cleft lip is one of the critical factors for breastfeeding success and in most situations the mother’s breast will mould to the gap and cover the cleft lip area so the baby can create the suction and negative pressure needed to remove milk. For babies with a cleft palate and lip, or cleft palate and intact lip, breastfeeding is more complex, although the mother’s breast, to a degree, does conform to the shape of the baby’s oral cavity and may create a partial seal. The size and degree of the cleft, the maturity of the baby, the baby’s health, maternal milk supply, and the availability of good maternal support are all factors that contribute to the breastfeeding experience. The complexities of breastfeeding cleft-affected babies and the key issues involved are discussed in three sections: breastfeeding; milk supply; and why breastmilk plays an important role in alleviating common problems associated with cleft palate. As described by the Academy of Breastfeeding Medicine, literature describing breastfeeding outcomes in cleft-affected babies is limited, but there are some recommendations that can be made for clinical practice, and breastfeeding/
36 | AOTEAROA NEW ZEALAND MIDWIFE
provision of breastmilk is to be encouraged (Boyce et al, 2019). BREASTFEEDING Cleft lips are usually obvious from birth and if this is an unexpected event for the parents it is important to be sensitive and supportive. An infant’s orofacial defect can be stressful to observe, and parents are likely to experience feelings of shock, confusion, and distress due to the aesthetic and functional implications. Time spent supporting mother-
Cleft lips are usually obvious from birth and if this is an unexpected event for the parents it is important to be sensitive and supportive. An infant’s orofacial defect can be stressful to observe, and parents are likely to experience feelings of shock, confusion, and distress due to the aesthetic and functional implications.
baby skin-to-skin contact, while carefully discussing the issues that will arise is critical. There is no reason to avoid early skin-to-skin contact and support for mothers to initiate breastfeeding/lactation with cleft-affected babies. Breastfeeding, even if limited, is beneficial. When discussing breastfeeding it is important to present the options realistically. It is highly likely that some form of combination feeding will be necessary and this will involve expressing breastmilk and probably some adaptive feeding equipment such as a special squeezable bottle. Some clinicians use a palatal obturator that can be inserted into the baby’s mouth to help temporarily close the cleft and support feeding, but these devices have to be regularly checked and refitted as the baby grows, and this can be distressing for some babies when the mould is made and the obturator fitted (Tirupathi et al, 2020). When the cleft-affected baby is latched at the breast, positional stability is needed, and this includes both the position of the baby and the stabilisation of the breast in the baby’s mouth. An upright position for the baby can help reduce reflux and regurgitation, which can be distressing complications for these babies. Mothers can hold the baby’s chin during the feed with their free hand and this can help to stabilise the baby’s jaw and ensure the breast stays in the mouth and the baby maintains the latch (Boyce et al, 2019). This technique is often called the dancer hand hold and an image of this position can be found on page 9 of the breastfeeding protocol document developed by the Baby Friendly Initiative Ontario (2019). For babies with a cleft lip only, they should be held so that the cleft is orientated to the top of the breast, which may mean using a cross cradle hold for one breast and an underarm position for the other breast. Sometimes the mother can occlude the cleft lip with a finger or thumb to facilitate closure around the nipple (Boyce et al, 2019). A good flow of milk is essential when breastfeeding a baby who is cleft-affected, which means that maximising
BREASTFEEDING CONNECTION
Support for any amount of breastfeeding is uncontroversial, and having practical, skilled, realistic support available can be significant in terms of helping mothers come to terms with their baby’s condition and breastfeeding outcome.
milk production is usually a necessary part of the picture. Breast compression, while taking care not to dislodge the breast from the mouth, can support more effective removal of milk from the breast and increase the volume of milk ingested by the baby. Expressing breastmilk after a breastfeed is recommended to protect lactation, to increase supply and for supplementary feeds. Given the complexities involved with breastfeeding a cleft-affected baby, it is necessary to carefully monitor hydration and growth (Boyce et al, 2019). Supplementary feeds to support adequate growth and nutrition may be needed. These supplementary feeds will ideally be breastmilk – either from the mother or from a screened donor. Support for any amount of breastfeeding is uncontroversial, and having practical, skilled, realistic support available can be significant in terms of helping mothers come to terms with their baby’s condition and breastfeeding outcome. Women with strong beliefs about the importance of breastfeeding to their maternal role attainment may experience psychological distress if they stop breastfeeding in the first few months (Cooke, Schmied & Sheehan, 2007). Although there is likely to be some grief associated with the loss of the breastfeeding journey mothers may have hoped to have, supporting even limited breastfeeding can help alleviate distress and may feel empowering for some women. Surgery for cleft lips and cleft palates are usually undertaken between 3-12 months of age with cleft lip repairs being carried out at an earlier age than palate repairs. After a cleft lip surgical repair it is recommended that breastfeeding can recommence immediately and this may also be the case with a cleft palate repair although some clinicians may prefer to wait for 24 hours (Boyce et al, 2019).
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BREASTFEEDING CONNECTION
A baby needs to suck for comfort as well as nourishment, and breastfeeding supports a baby to spend time at the breast sucking for comfort, as well as for some milk transfer. Even a short time suckling at the breast with limited milk transfer is beneficial. BREASTMILK SUPPLY Expressing breastmilk is highly likely to be necessary to support feeding for a cleftaffected baby due to insufficient milk transfer and concerns about adequate growth and nutrition. Hand expression of breastmilk 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). Morton (2009) and Morton et al (2009) found that using a combination of hand expression, breast compression and pumping can maximise milk supply. The Morton technique was primarily developed for mothers of pre-term babies who were not feeding at the breast, but the principles are applicable to all women aiming to maximise milk supply. BREASTFEEDING/BREASTMILK AND PROTECTION Negative consequences for babies who are cleft-affected include fatigue, reflux, nasal
38 | AOTEAROA NEW ZEALAND MIDWIFE
regurgitation, insufficient milk transfer and problems with growth and nutrition (Boyce et al, 2019). Although regurgitation due to milk leakage into the nose is a common problem when there is an opening in the soft or hard palate, breastmilk does not irritate the baby’s mucous membranes so it is a better choice than formula milk. Defense factors in human milk include anti-inflammatory factors as well as direct antimicrobial agents (Hanson, 2004). There is some evidence that breastfeeding and breastmilk reduce the rate of otitis media in children who are cleft affected (Boyce et al, 2019). Breastfeeding has also been found to support better development of the oral facial musculature and speech development (Boyce et al, 2019). CONCLUSION AND KEY MESSAGES Although it is important to diagnose the existence of a cleft palate as soon as possible after birth, care should be taken when examining the oral cavity of any baby. Oral examinations should be as gentle as possible and should preferably not occur until after the mother and baby have had undisturbed skin-to-skin contact following birth. Delaying an intrusive oral examination until after the first breastfeed is also recommended.
As described earlier, breastfeeding mothers require good support, particularly when feeding babies with complications due to cleft lips and palates. square
key messages
1. Realistic support for breastfeeding and milk expression 2. Extensive maternal and family support is needed 3. Even a short time suckling at the breast with limited milk transfer is beneficial 4. Supplementary feeds – baby may require combination feeding / adaptive feeding equipment 5. Optimal milk expression strategy 6. Breastmilk is a better choice than formula – donor milk can be used if necessary and available 7. Breastfeeding / breastmilk – infection protection 8. Take care with oral examinations.
References available on request.
PASIFIKA
TISH TAIHIA CLINICAL CHARGE MIDWIFE MANAGER, NGĀ HAU MANGERE BIRTHING CENTRE
Mehikitanga Fine: our wise woman It has been nearly two years since midwife Fine Matoto retired from the maternity service at Middlemore Hospital, having served the South Auckland community for 20 years. It’s not only Fine’s long service that we recognise, but the long journey she embarked on many years ago as a Tongan woman in the islands, and the many hurdles she navigated along the way. Hailing from the village of Ha’ateiho, on
National Women’s Hospital and community
the island of Tongatapu, the fourth of eight
clinics in Glen Innes.
siblings, Fine first trained as a nurse in 1971. After completing her six-month midwifery qualification at Vaiola Hospital in 1986, she spent the next 11 years practising as a dual-registered professional at Tonga’s main hospital base. By 1997, married with three children, Fine
After gaining registration, Fine returned to Tonga to take up a senior midwifery role at Vaiola, relieving fellow Tongan-Māori midwife Ruth Chisholm, who was returning to Aotearoa. Asked whether her exposure to the New Zealand midwifery model influenced
gained a scholarship to complete her Midwifery
her practice back at Vaiola Hospital, she says
Diploma (later transitioning to degree) at
“change within the hierarchy is not easy”,
Auckland’s Institute of Technology. With her
acknowledging the strong Tongan societal
youngest child Ana (10) in tow, Fine arrived
values of rank and nobility, enacted under a
at her sister’s home in Devonport - a short
monarchical patriarchy.
commute to the Akoranga Campus. Imagine adjusting to a new culture, while
When asked about how she merged those entrenched cultural norms with Western values,
studying in a second language, separated
she cites negotiation, saying gender roles have
from one’s older children and husband, and
been clearly demarcated in recent history, but
unable to drive. Many less driven (excuse the
perspectives are changing due to educational
pun) individuals would have quit before they’d
and financial influences.
started. But for Fine, quitting was never an option, as she recounts the kindness of those who helped her through. Aside from family, she mentions midwifery tutor Judith McAra-Couper and then head of the midwifery school, Jackie Gunn, to whom she is grateful for being driven to her continuity-of-care visits. Moving across the city to another sister in
Fine’s wisdom has always been apparent. Recently, she opened a Pasifika Midwives Aotearoa meeting with a call to “keep midwifery alive”; a plea to midwives to hold onto their professional identity and autonomy. She understood the significance of cultural safety well before it was part of any curriculum, sharing this nugget at the same meeting: “I was told by a Tongan man visiting his wife that people knew about me in Tonga, so they would want to come to Middlemore to have my care. When I speak Tongan, it makes them feel more comfortable and they understand what is happening”. Pasifika Midwives Aotearoa are honoured to have Fine as our matua. These days, Fine is an active grandmother caring for a pre-schooler, doing the school pick-ups/drop-offs and of course, being a wise woman. square
In 2000, Fine emigrated back to Auckland with her family, joining the diaspora of Tongans living offshore. Extremely humble in nature, Fine has not been concerned with gaining recognition amongst her peers, but has been wholly committed to providing women and pepe with nurturing, safe care. Her appreciation of the New Zealand
Onehunga, this middle-aged ta’ahine would
midwifery model of care stems from the
become used to walking, catching the bus,
tikanga principles of equitable care for all,
and cycling to fulfil her clinical placements at
regardless of background.
ISSUE 104 MARCH 2022 | 39
FEATURE
introducing covid-19 mate korona e-resource The College is developing a range of e-resources to provide timely, convenient access to emerging evidence and practice guidance for midwives. Midwifery e-Resource: Covid-19/Mate Korona is the first to be published and collates information from multiple sources to support midwifery practice in relation to clinical care and public health responses for Covid-19/Mate Korona.
ELAINE GRAY MIDWIFERY ADVISOR
40 | AOTEAROA NEW ZEALAND MIDWIFE
FEATURE
THE E-RESOURCE INCLUDES INFORMATION REGARDING:
Information relating to Covid-19/Mate Korona
• The broader Covid-19 public health
advances; the e-resource will be updated as
responses relevant to midwifery and maternity services. • The pathophysiology of Covid-19 during pregnancy and post-partum; clinical care for Covid-19 during pregnancy and postpartum including roles and responsibilities of midwives; DHB maternity services; and community-based clinical and social support for individuals who are self-isolating with
is evolving as our understanding of the virus new evidence emerges and members will be
2 / Pathophysiology: Covid-19 during pregnancy is associated with increased rates of: • Pre-eclampsia
informed accordingly. It is hoped that along
• VTE (DVT or PE)
with other e-resources, this package will soon
• IUGR, prematurity, and stillbirth
be supported by a comprehensive online learning platform, e-Ako to be launched in April 2022. The platform will enable midwives to explore practice issues and refresh knowledge at their convenience, on a wide range of topics.
• Caesarean section • Admission to neonatal unit (three-fold increase). 3 / Planning midwifery care in response to screening questions will be guided by the
OVERVIEW: COVID-19/MATE KORONA E-RESOURCE
clinical needs of wāhine and pēpi and is a key
to support midwifery practice in the
Many aspects of providing midwifery care
We wish to acknowledge and sincerely thank all
community.
in the Covid-19 space are covered in the
midwives and other colleagues who contributed
e-resource - in particular, how to provide
to the development of this e-resource
midwifery care for Covid-19 positive wāhine in
package.
Covid-19. • Practical advice, information and resources
This interactive e-resource is divided into topics, each of which can be viewed and read separately; however, to gain the most from it we recommend midwives work through the information sequentially. In addition to videos from recent College webinars and links to
the community (see diagram below).
The College welcomes any feedback on the Covid-19/Mate Korona e-resource and the
PRACTICE TIPS FROM THE E-RESOURCE 1 / The College advises all community-
other resources, it also includes a section on
based midwives to request access to their
self-care and sustainability and can be viewed
local DHB Community Health Pathways portal
on any electronic device.
if they don’t already have access.
Covid-19 exposure: looking after yourself and colleagues
broader concept of sharing information via e-resources. Please email any questions or comments to nzcom@nzcom.org.nz. square
Screening for
Midwifery care for positive Covid-19 wãhine
Covid-19
Covid-19, equity and inclusiveness
Covid-19 Protection Frameworks and Pathways
Personal Protective Equipment (PPE) & Infection Prevention & Control (IPC)
role of the midwife.
Pyschological and social impacts of Covid-19
Covid-19 e-resource
Vaccination in pregnancy
ISSUE 104 MARCH 2022 | 41
FROM BOTH SIDES
my mentor my mentee Urunumia Tahana recently completed the MFYP programme under the mentorship of Jay Beaumont and is grateful to have been guided by someone who could anticipate her needs. As an 11-year-old, Urunumia (Ngāti Māhanga, Ngāti Pikiao, Tainui, Te Arawa) remembers her sister’s midwife visiting the family home. There was nothing mystical about her journey to midwifery, but a seed had obviously been planted, and she knew it was her path. “It wasn’t anything super spiritual, but something about it just always sat right with me,” she explains. Urunumia became hapū with her first baby in her final year of midwifery study through Ara Institute of
Unearthing what sustains Māori midwives is of particular interest to Jay Beaumont, and mentoring new graduate Urunumia Tahana over the past year has provided an opportunity to both learn and teach. After eight years of midwifery practice in both LMC and employed settings, and unofficially mentoring students and midwives along the way, Jay (Ngāti Rangi, Ngāti Uenuku, Ngāti Apa) decided to embark on formal training to become an MFYP mentor in 2020. “I had a really cool mentor myself. She was non-Māori, but the closest thing to a Māori midwife that I could find at the time, so it was my way of giving back to the profession once I felt I had consolidated my practice,” she says.
Technology and birthed her son the day after being signed off on her 40th facilitated birth. Transitioning to motherhood, combined with losing her unofficial mentor Diana (Di) Bates Keepahunuhunu in 2019 nearly saw Urunumia walk away from midwifery before her career had started.
Embarking on the mentoring training was about recognising her unique worth, and that of her Māori colleagues. “You can’t replace a Māori midwife,” she explains. “It’s a particular kind of worldview and there aren’t enough of us to go around.”
Urunumia’s middle name is Pam, and up until she met Di, this was what she called herself. “My whole life I’ve always been known as Pam - because it was easier for other people to say it,” she explains. Di would put an end to this, however, permanently altering Urunumia’s life trajectory. “Di wouldn’t let people call me Pam. She’d say ‘No, her name is Urunumia’. She was the first person to give me enough confidence to stop making myself small.”
Jay had a personal connection to her first mentee, Urunumia, and the decision to mentor her was an easy one. “She was often supported by our mutual friend Diana Bates Keepahunuhunu. Sadly, Di passed away suddenly and left a huge gap for Urunumia. “It became so obvious how important it was to ensure she felt heard and supported, in order for her to transition in to a confident Māori midwife, or we would lose her from the profession. She worked so hard to get
In 2021, Urunumia not only found the strength, but the right mentor to continue her midwifery journey. “I asked Jay to be my mentor because I really wanted to be with somebody who understood and saw the world from a Māori perspective. That was really important to me. I needed that safety of someone who knew me culturally,” she says. Jay continued what her friend Di had started, and Urunumia has not only completed the MFYP requirements, but is already strategising to futureproof the Māori workforce. “One of the most valuable things I’ve taken away from the mentor/mentee relationship is the importance of Māori stepping into leadership/tuakana roles, to ensure the sustainability of the Māori midwifery workforce,” Urunumia says. An internal fire has been stoked, she explains. “Jay has sparked inspiration inside of me and the desire to heed that call to tuakana; to pass the gift of mātauranga whakawhānau and awhi from a kaupapa Māori perspective on to Māori new graduate midwives.” Reducing the experience of the past year down to bite-size quotes is difficult for Urunumia, but she sums it up perfectly by circling back to a midwifery pillar. “Jay and I were able to form a partnership through exchange of mātauranga Māori and wānanga with each other, leading me on the journey from competent to confident practitioner. We achieved so much together over my graduate year, I couldn’t have asked for anything more in a mentor.” square
42 | AOTEAROA NEW ZEALAND MIDWIFE
through her degree and register; it wasn’t going to be on my conscience to see her walk away,” Jay explains. Jay’s insights and guidance as a Māori midwife have been invaluable for Urunumia in her first year of work. “I can understand where she’s coming from when she’s reflecting on what she’s seeing in practice, like whānau Māori being treated differently to other whānau. I can unpack that with her and problem-solve it,” she says. Through the process, Jay has gained even more clarity around where Māori midwives are needed. “I’m telling my Māori colleagues how important it is that we do the preceptor workshop, the MFYP mentoring workshop, and become standards reviewers - so that we can have more Māori representation across the board.” Recently taking on a new role as Māori liaison for Ara Institute of Technology’s midwifery school, Jay is also working toward her Master of Māori and Indigenous Leadership through Canterbury University, focusing on the topic of sustaining the Māori midwifery workforce in Te Waipounamu. But as is often the case, some of her most significant lessons have come from the partnership she developed with Urunumia. One of the most poignant can also be applied to midwifing women through labour and birth. “Let mentee midwives guide their own journeys,” Jay advises. “Be the sounding board that invokes reflection.”
square
DIRECTORY
New Zealand College of Midwives Directory President
Northland
Parents Centre New Zealand Ltd
Nicole Pihema
Christine Byrne
Liz Pearce
Ph 021 609 011
tetaitokerauchair@nzcom.org.nz
Ph 04 233 2022 extn: 8801
nicolepihema@gmail.com
e.pearce@parentscentre.org.nz Otago
National Office PO Box 21-106, Edgeware, Christchurch 8143 Ph 03 377 2732 Fax 03 377 5662
Jan Scherp, Charlie Ferris otagochair@nzcom.org.nz
nzcom@nzcom.org.nz
Southland
www.midwife.org.nz
Natasha Baillie
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 021 258 2701 merakimidwifery@gmail.com
Student Representatives Penny Martin pennymartin79@live.com Ngā Māia Representatives www.ngamaia.co.nz Sarah Wills
Waikato/Taranaki
Ph 021 02551963
Tracey Williams
sarahandcale@hotmail.com
chairwaikatonzcom@gmail.com Wellington Suzi Hume chair@wellingtonmidwives.com
Lisa Kelly lisakellyto@yahoo.co.nz Pasifika Representatives Talei Jackson
Regional Sub-Committees
Ph 021 907 588 taleivejackson@gmail.com
Ph 09 625 9764 Fax 09 625 0187
Hawkes Bay Sub-Committee
auckadmin@nzcom.org.nz
Sarah Nation
Nga Marsters
sarahnation.midwife@gmail.com
Ph 021 0269 3460
National Board Advisors
lesngararo@hotmail.com
Elder: Sue Bree
Manawatu Sub-Committee
Kuia: Crete Cherrington
Jayne Waite
MERAS
Education Advisor: Tania Fleming
j.waite70@gmail.com
PO Box 21-106, Edgeware
tania.fleming2016@gmail.com Regional Chairpersons
Taranaki Sub-Committee Isabel Bedford nzcom.taranaki@gmail.com
Auckland Sarah Ballard, Linda Burke
Wanganui Sub-Committee
auckchair@nzcom.org.nz
Jo Watson
Bay of Plenty/Tairawhiti chairnzcomboptairawhiti@gmail.com
Christchurch 8143 www.meras.co.nz General Enquiries & Membership Ph 03 372 9738 meras@meras.co.nz
Ph 021 158 6874
MMPO
jothemidwife@gmail.com
mmpo@mmpo.org.nz
Horowhenua
Ph 03 377 2485 PO Box 21-106, Edgeware, Christchurch 8143
Canterbury/West Coast
Jennie Ferguson
Bex Tidball
Ph 021 232 1980
chairnzcom.cantwest@gmail.com
thejensterrocks@gmail.com
Central
Consumer Representatives
Julie Kinloch
Royal New Zealand Plunket Society
Ph 06 835 7170
Carla Kamo
julie.kinloch.nz@gmail.com
Resources for midwives and women
carla.kamo@plunket.org.nz
The College has a range of midwifery-
Nelson/Marlborough
Home Birth Aotearoa
other resources available through our
Rose O’Connor
Eva Neely
website: www.midwife.org.nz/shop
roseocon@gmail.com
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Rural Recruitment & Retention Services Rural contact: 0800 Midwife/643 9433 rural@mmpo.co.nz
related books, leaflets, merchandise and
looking after you supporting your practice
Complete community midwifery support, including: • Care data and digital records (including Tiaki) • Notice 21 (Section 88) claiming • Business set up (including Xero) and day-to-day support • • Equipment insurance • Workforce and locum services
Call 03 377 2485 or visit www.mmpo.org.nz to find out more