Midwife Aotearoa New Zealand

MORAL DISTRESS

WHAT ARE THE PROTECTIVE FACTORS? P.20 UPDATED MOH GUIDELINES

DISCONNECTION FROM MANAWA

WHAT MIDWIVES NEED TO KNOW P.16

MORAL DISTRESS THROUGH A MĀORI LENS P.26

ISSUE 105 JUNE 2022 I THE MAGAZINE OF THE NEW ZEALAND COLLEGE OF MIDWIVES

WHAT ARE WE GOING TO DO ABOUT NITROUS OXIDE? P.36

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YOUR COLLEGE COVER ILLUSTRATION: Ajun Abraham, Publica.

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ISSUE 105 JUNE 2022

FORUM

16

FROM THE PRESIDENT 4. A CLASH OF VALUES FROM THE CHIEF EXECUTIVE 5. MOVING FORWARD BOLDLY AS ONE 8. BULLETIN 10. YOUR COLLEGE 12. YOUR UNION

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14. YOUR MIDWIFERY BUSINESS FEATURES 16. UPDATED NATIONAL MATERNITY CLINICAL GUIDELINES 20. MORAL DISTRESS AND MIDWIFERY 26. DISCONNECTION FROM MANAWA 30. CLIMATE CHANGE: KEEPING UP THE PRESSURE

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34. PASIFIKA: NEW MOTHERHOOD AND STUDY 36. WHAT TO DO ABOUT NITROUS OXIDE 38. BREASTFEEDING CONNECTION 41. NGĀ MĀIA 42. MY COACH / MY COACHEE DIRECTORY

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EDITOR Amellia Kapa E: communications@nzcom.org.nz

ADVERTISING POLICY AND DISCLAIMER: The New Zealand College of Midwives maintains a schedule of guidelines to exclude advertisements for products or services that are not aligned with its principles and ethics. Every effort is made to ensure that advertising in the magazine falls within those guidelines.

ADVERTISING ENQUIRIES Hayley McMurtrie, P: (03) 372 9741 E: Hayley.m@nzcom.org.nz

Where advertising is accepted, this does not imply endorsement by the College of the product or service being promoted.

MATERIAL & BOOKING Deadlines for September 2022 Advertising Booking: 15 August 2022 Advertising Copy: 22 August 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 105 JUNE 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 This issue sheds light on the anguish many midwives may feel, but might not be able

“Ka ora pea i a koe, ka ora koe i au” Perhaps I survive because of you, and you survive because of me (Mead, 1981).

to name. Moral distress, its origins, and the protective factors against it, are all discussed on p.20. The same issue is then explored through a te ao Māori lens on p.26, where the concept of the three manawa (hearts) is revealed.

Climate challenges are surveyed in depth this issue, with an overview of the changes currently being implemented to reduce carbon emissions in the health sector on p.30. A robust conversation starter follows on p.36, where Middlemore-based anaesthetist Dr Rob Burrell highlights the environmental impacts of the extensive use of nitrous oxide throughout maternity facilities.

Tyra Fitisemanu’s balancing act of navigating new motherhood whilst studying midwifery is shared on p.34 and Breastfeeding Connection (p.38) reveals the terrifying truth about how the marketing of formula milk influences decisions about infant feeding.

From Both Sides demonstrates how pivotal the recently created clinical coach roles are for midwives joining DHB facilities or returning to them (p.42), and key updates to three of the Ministry’s national maternity guidelines are detailed on p.16.

We hope the discussion surrounding moral distress signifies to members that the College is acutely aware of the realities midwives are currently facing around the motu. We continue to advocate on your behalf and encourage all eligible members to join the class action lawsuit, as we hold the Ministry to account for promises made and broken (see From the CEO, p.5).

Mā te wā, Amellia Kapa, Editor/Communications Advisor Email: communications@nzcom.org.nz

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4 | NEW ZEALAND COLLEGE OF MIDWIVES MAGAZINE

The potential triggers for moral distress will be different for each midwife, and my experience of it is less to do with workload or a lack of support; relating instead to a clash of values.

I’m fortunate enough to have been raised in an environment that nurtured my Māoritanga; I’m deeply connected to my whānau, whenua and whakapapa, and this is evident in the way I practise as a midwife. Concepts like manaakitanga and whānaungatanga are not mechanisms I switch on and off; they are a default way of being, no less automatic than breathing, and I would argue most Māori midwives operate in the same way.

The article on p.26 describes moral distress through a te ao Māori lens and how for many, it can be triggered by a disconnection from any one of our manawa. My own moral dilemmas, however, are not related to shutting the pūmanawa down; after all, Māori models of care don’t lend themselves to this approach.

The pūmanawa does not know about fixed start or end points of care, nor is it concerned with professional boundaries, or restricted by which members of a whānau are technically included in the care, and which are not.

When we are led by pūmanawa, we are no longer constrained by such details, nor scope of practice, for that matter. We simply do what needs to be done. The source of my moral distress, therefore, is not disconnection from manawa; it occurs when the values of the system I am working within are diametrically opposed to my Māoritanga.

The proposed revision of our midwifery scope of practice has sparked much debate within the profession, as midwives have sought clarity. But I would argue that in this case, less is more. Less restriction equates to an

4 | AOTEAROA NEW ZEALAND MIDWIFE

increased ability to provide care for whānau in a way that truly honours the word (w)holistic.

It acknowledges the fact that for some whānau - who inherently mistrust the conventional health system and the professionals working within it - the midwife may be the first care provider the whānau has engaged with in a meaningful way, perhaps ever.

Recently, I attended an unplanned homebirth and when I asked a whānau member to bring more towels to dry and cover their new pēpi, it became clear that there were no more towels to bring. A whānau of four had a total of three towels between them; a scenario I was reminded may be commonplace for many whānau. So when I’m asked about moral distress, these are the memories my mind conjures up; my pūmanawa tells me to go and buy new towels for this whānau, but professional regulations tell me I’m crossing a line.

When I discharge whānau from my care, a lack of confidence in the services I’m handing over to becomes another source of distress.

Not knowing what awaits whānau or how safe they will feel to engage causes pūmanawa to kick in again, as I wonder whether I’m effectively handing over to thin air.

We can only hope that leaders within the new Māori Health Authority are connected to their own manawa, and more equitable solutions are on the way. Three towels for an entire whānau is simply not good enough, and in my view, this is precisely why manawa is so vital in the provision of care. To be connected to manawa - to feel this inequity on every level, and to act from that place, is to be human. Indeed, this is what it means to be a midwife. square

FROM THE CEO

MOVING FORWARD BOLDLY AS ONE Our new health system is slowly taking shape, with recent announcements about the proposed Health NZ and Māori Health Authority structures revealing glimpses of what the changes might mean for midwives and maternity services. Further details will be revealed when the Interim Health plan is published in June, but at time of writing, the future is unclear.

What we do know is, hospital and community services will be funded separately, with community services organised around localities, enabling residents of those localities to determine their own health care needs and how they are met. Nine locality ‘prototypes’ have been identified, to be connected through a provider network, which will support each service and encourage providers to work together.

Whilst community needs should undoubtedly drive any proposed changes, practitioners - who have the lived experience

of working within these communities and are equally invested in improving outcomes - are ideally placed to contribute to the solutions these health reforms seek. Concerningly, in almost every case, midwifery has not had the opportunity to be meaningfully involved in the planning stages, at either local or national levels, and continues to be viewed as an add-on, rather than a core service which should be consulted.

Unsurprisingly, midwifery has also been overlooked in the clinical leadership roles within Health NZ and the Māori Health Authority (see pg. 10).

In addition to these oversights, community midwifery lags behind the remainder of the health system, stuck with an out-of-date contract that has remained largely unchanged since it was written in 1996. The health system reforms provide an opportunity for contracting and employment models to evolve, and whilst Section 88

Whilst community needs should undoubtedly drive any proposed changes, practitioners - who have the lived experience of working within these communities and are equally invested in improving outcomes - are ideally placed to contribute to the solutions these health reforms seek.

ALISON EDDY CHIEF EXECUTIVE

ISSUE 105 JUNE 2022 | 5

FROM THE CEO

has been a strong enabler of midwifery practice autonomy and continuity-ofcare, it lacks the flexibility required to evolve into a modern, fit-for-purpose funding agreement and is in urgent need of review.

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Midwifery has no such support system.

In fact, I cannot think of any other primary health service required to provide a 24/7 acute emergency response service 365 days of the year, which has been left entirely to self-manage, without any funding or organisational support.

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Section 88 service specifications require a 24/7 acute emergency response service and in order to deliver this, midwives have developed formal (or informal) practice arrangements, displaying an extraordinarily high level of commitment and dedication, given the models of care provision have been entirely self-designed and implemented.

For many midwives, the autonomy Section 88 has provided has also contained the key to longevity in the profession - allowing them to selfmanage their practice and workload. But this autonomy should not come at the exclusion of structural supports which could assist midwives to manage practice issues such as leave allocation and cover, or the significant 24/7 on-call expectations. Not only is there no financial acknowledgement of this on-call burden, but the time and energy expended negotiating the necessary collegial arrangements have never been recognised.

This brings us to the chronic ‘Christmas issue’. Being able to spend time with whānau over the holiday season is an important cultural tradition in Aotearoa and historically, LMC midwives have arranged to cover each other for time off over this period. But the long-standing unresolved issues over pay and conditions, together with workforce shortages and recent Covid-related stressors have seen the psyche change over the past few years.

This is leading some LMC midwifery practices to reduce their service over the Christmas period, meaning already severely stretched hospital services must absorb the required care. This results in hospital-based midwives - whose working conditions are already untenable - being denied leave over this time, and women receiving fragmented care through a variety of hotchpotch arrangements.

Whilst it is easy to blame the recurring difficulty of securing LMC care over summer on the repeated failure by the Ministry to deliver on its promise of fair and reasonable working conditions, some self-reflection is also in order.

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Furthermore, the lack of a formal, funded national structure to support LMC midwives – as was proposed in the co-design – contributes to the increasing invisibility of midwifery within the health system, and the misconception that it is an ‘isolated’ workforce, disconnected from other health services. We all know this is grossly inaccurate; midwives are embedded in their communities and work closely with other providers, both community and hospital-based, every day. The missing puzzle pieces are the systemic support structures which would enable these connections to occur seamlessly, and had the Ministry honoured process, these structures could have been in place by now.

THE BEST PROTECTION FOR BABY

It could be considered that the same autonomy LMCs possess to determine caseload size, practice arrangements, back-up, and planned time off, come with professional and ethical responsibilities. By this, I mean not only the responsibility to the individual women and whānau LMCs care for, but also to the communities they serve. All midwives, regardless of where they work, are part of the wider maternity and healthcare system. Not unlike our old adage, “women need midwives need women”, it’s equally true that “hospital midwives need community-based midwives need hospital midwives”. When a large portion of LMC midwives are unavailable to provide birth care over the summer period, the knock-on effect leaves hospital-based midwives unable to manage the workload.

The counter-argument is that everyone is entitled to a holiday; that the responsibilities of on-call LMC work are burdensome to manage, particularly when practice partners are on leave, as the remaining midwives have to absorb the absent colleague’s caseload. There is no financial incentive for

LMCs to work through this period; other community services - such as general practice - have systems in place to manage these scenarios, including ‘after-hours’ clinics to support individual practitioners to take leave without compromising service provision.

Midwifery has no such support system. In fact, I cannot think of any other primary health service required to provide a 24/7 acute emergency response service 365 days of the year, which has been left entirely to self-manage, without any funding or organisational support. It’s little wonder some midwives are fed up and reluctant to work through the holiday season when there are no support measures, let alone incentives, to speak of.

Whatever your individual perspective on this issue, it has gained political attention. Each year, politicians seek information about the additional workload DHBs are carrying. Unfortunately, the reduction in LMC midwife capacity over summer sends a signal that the LMC midwifery workforce doesn’t see themselves as part of the wider maternity system and are acting in isolation of it.

There is now a significant risk that the solution to fix this issue – which will be unpalatable to much of the profession – is to simply employ all midwives. If this occurs, any advantages conferred by self-employment will be lost, alongside continuity-of-care. The College, as the default organisation that has been advocating, lobbying, bargaining and negotiating for fair pay and recognition for LMC midwives, has ‘hung its hat’ on the importance of midwives having self-determination in how they meet the demands of LMC midwifery care. We have stood by the fact that when this model is properly resourced, this self-determination is an enabler of high-quality care, as midwifery autonomy and continuity-of-care both support better outcomes for women.

However, we are now at the point where we have been waiting far too long for the resources needed to fix the ‘Christmas issue’, which is merely a symptom of a much wider and deeper failure to provide structural support for the midwifery profession. I often reflect on the fact that if we had achieved all that the co-design had set out to, we would be in a different situation now. We desperately and urgently need a new contract model to replace Section 88; one which provides sufficient resources and support to: manage the demands of primary maternity care; sustain our workforce; and enable the necessary integration between maternity and other communitybased services.

As I have previously written, the College is pursuing legal action against the Ministry for their breach of the second Settlement Agreement. By now, all members would have received communication informing them that this case is being lodged as a class action lawsuit and inviting them to join.

As I write this column, we are not long past celebrating International Day of the Midwives on May 5. Although you will be reading this some weeks later, it’s timely to reflect and consider why we celebrate this day every year.

college cultural review The College’s board has identified the need to demonstrate our commitment to upholding the articles of te Tiriti o Waitangi, and has been exploring alternative governance models over the past year.

In order to support this aim, the College has committed to undertaking an independent review of the cultural responsiveness of the organisation in terms of its governance, national and regional structures and administration, as well as its policies, strategies, services, and programmes.

This will provide a sound foundation for achieving positive experiences for its membership; particularly its Māori/Tangata Whenua membership, and the best possible outcomes for its professional relationship with Ngā Māia Māori Midwives Aotearoa.

The ability to respond to the professional needs of its Māori membership, maintain strong, positive relationships, and strengthen culturally safe midwifery practice for all members is also critical to ensure the profession meets the expectations and needs of māmā, pēpi and their whānau.

The overall objective for this review is to build the organisation’s cultural safety and responsiveness through the development of a Māori cultural framework to be implemented within the organisation.

The review terms of reference are being finalised at present, and the completed review report will be due in December.

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The (College's) ability to respond to the professional needs of its Māori membership, maintain

In Aotearoa, the midwifery profession has experienced significant gains, such as securing midwifery autonomy, direct-entry education, regulation through a dedicated midwifery council, and establishment as the primary maternity provider for most pregnant women. But we have also suffered the common fates of female-led professions: lack of pay equity; unfair working conditions; and the inability to be recognised fairly at a political level.

strong, positive relationships,

The women, whānau and midwives who walked before us achieved these gains by forming a strong collective movement, and we now find ourselves in need - once again - of a clear, unified voice to demand much needed change. I invite all midwife members who have claimed any module under Section 88 since March 2017, to join the College’s class action lawsuit to send this powerfully unified message to the government. We will stand together. We will stand up for what we believe in. We will move forward boldly into a sustainable future, as one. square

profession meets the expectations

ISSUE 105 JUNE 2022 | 7

and strengthen culturally safe midwifery practice for all members is also critical to ensure the and needs of māmā, pēpi and their whānau.

BULLETIN

bulletin International Day of the Midwives 2022: 100 years of progress

• supplies and functional facilities (33% of

International Day of the Midwives (IDM)

The survey, led by White Ribbon Alliance in collaboration with ICM, followed on from the What Women Want campaign, launched in 2019, which advocated for improvement of quality maternal and reproductive healthcare for women and girls globally. Among the top five requests from women and girls in 114 countries was “increased, competent and better supported midwives and nurses”.

2022 was celebrated worldwide on May 5, marking a century since ICM’s forerunner the International Midwives Union (IMU) - was established in Belgium.

This year, IDM served as a platform for the release of a global report detailing the requests of over 56,000 health providers in 101 countries, in response to the open-ended question: “What do you want most in your role as a midwife?”

What Women Want: Midwives’ Voices, Midwives’ Demands reports the responses, with the top two requests being: • more and better supported personnel (33% of respondents), with the most often cited sub-demand being proper remuneration.

8 | AOTEAROA NEW ZEALAND MIDWIFE

Rata midwives gain 30k+ signatures in bid to save St. George’s maternity In response to the proposed closure of St. George’s primary maternity service in Christchurch (see p.12 for background), LMC group practice Rata Midwives launched an online petition in April, gaining more than

respondents), which included access to

30,000 signatures in support of the service’s

basics such as clean water, equipment and

continuation.

medications for women under their care.

Midwives worldwide have felt the added pressures of the Covid-19 pandemic and although midwifery challenges are different for each continent, it is clear midwives are needed and wanted by women, and midwives everywhere feel undervalued and underrecognised.

St. George’s, a private hospital contracted by Canterbury DHB to provide maternity services, is the only central primary birthing unit available to wāhine and whānau in Ōtautahi, meaning its closure would limit birthing people’s options to Christchurch Women’s Hospital, or primary birth units situated more than 30 kms out of the city.

Rata midwife Hayley Gimblett explains the petition was needed to raise awareness about what the community could lose if the closure goes ahead. “If St. George’s maternity service closes, there will be even less choice for women in Christchurch. We need to have choices about where we birth. Primary birth options are an absolutely key part of a

The College hopes all midwives here in Aotearoa felt appreciated on May 5, 2022 and continues to advocate for increased

woman’s birth choices and in fact we need far

recognition from the government.

and MERAS on the publicity campaign, to

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more primary birthing options, not fewer.”

The College collaborated with Rata Midwives

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increase visibility of the issue on a national scale. At time of writing, the future of St. George’s maternity is unknown, with a decision expected end of May.

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STI webinar series The New Zealand Sexual Health Society has updated its STI Management Guidelines for use in Primary Care. The College will be hosting a series of three practice update webinars in June, to provide midwives with practical information and tips on screening, testing, treatment and referral for people who experience STIs during pregnancy. Invitations to register will be emailed to members in June. Here are the dates, subjects and speakers (as confirmed so far):

WEBINAR 1: SYPHILIS Thursday 16 June, 11.30am – 12.15pm Presenters: Dr Sunita Azariah, Sexual Health Physician, Auckland DHB; Dr David Hou, Neonatologist, Counties Manukau DHB.

WEBINAR 2: HERPES AND GENITAL WARTS Wednesday 22 June, 11.30am – 12.15pm Presenters: Dr Susan Bray, Sexual Health Physician, Waikato DHB; Wendy Girling, Sexual Health Nurse Specialist, Waikato DHB.

WEBINAR 3: CHLAMYDIA, GONORRHOEA AND TRICHOMONAS Tuesday 28 June, 1.30-2.30pm Presenters: Dr Edward Coughlin, Sexual Health Physician, Canterbury DHB; Linda Burke, Pasifika midwife, South Auckland; Claire Stewart, Sexual Health Nurse Specialist, Counties Manukau Health.

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ISSUE 105 JUNE 2022 | 9

Image: Natural Focus Birth Photography

Rata Midwives before delivering the 30K+ strong petition

YOUR COLLEGE

scope of practice submission

health system reforms

The College undertook an extensive process of engagement with

The proposed operating model and high level structure for both

members in order to prepare a submission to Te Tatau o te Whare

Health NZ | Hauora Aotearoa and the Māori Health Authority was

Kahu | The Midwifery Council of Aotearoa New Zealand on the

released in early May. Although there is much detail to be worked

draft Revised Scope of Practice Statement.

out, the Health NZ | Hauora Aotearoa structure proposes a clinical

There was extremely strong support for the integration of

leadership team comprising four national director positions,

te Tiriti o Waitangi into the revised scope statement, and the

covering:

elevation of cultural safety to a level of equal importance as

• Medical

clinical safety.

A large amount of feedback expressed confusion about the boundaries of practice and a request for more clarity around the

• Nursing/midwifery • Allied health, scientific and technical professions

clinical parameters of the scope and people for whom a midwife

• Primary and community.

can provide clinical care. The College’s approach of maintaining

The College (along with MERAS and the DHB Midwifery Leaders

the integrity of the revised scope wording, but adding text to

Group) have written to Health NZ | Hauora Aotearoa Chief

clarify areas where multiple interpretations have arisen, was

Executive Margie Apa, expressing our concern at the proposed

strongly supported by members.

combined nursing and midwifery leadership position, indicating

The College also identified the need for Council to promote

it is inappropriate for midwifery to be represented in this

te Tiriti o Waitangi education and opportunities for midwives to

way and advocating for midwifery to have its own, separate

explore the deeper meanings of the word whānau, in order to

leadership position.

support understanding and implementation in practice.

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HAUORA TAIWHENUA

TE REO MĀORI STRATEGY Te reo rangatira, te reo Māori is the first language of Aotearoa and a taonga which must be protected, promoted, spoken and respected.

The College board has agreed to establish a maternity chapter of the newly created multi-disciplinary rural health advocacy organisation Hauora Taiwhenua. This follows the College’s longstanding involvement with Rural Health Alliance

The College board has approved a strategy to increase

Aotearoa NZ (RHAANZ). Rural midwives Tawera Trinder (Taranaki)

and promote the use of te reo Māori in its documents and

and Kendra Short (South Canterbury) have been ratified by

communications, as part of the College’s wider commitment

the College board as co-chairs for the chapter. The chapter is

to te Tiriti o Waitangi. The strategy was developed with the

now seeking rural midwifery representatives from the College’s

support of tāngata whenua board members.

membership across the motu, so the breadth of issues facing

The inclusion of kupu Māori has increased within this magazine, with common kupu such as whānau, wahine and pēpi being used

rural midwives and maternity services can be included in the chapter’s work.

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routinely without English translations. Less common words are increasingly being introduced.

College kuia Crete Cherrington notes the new scope of

SGA guideline consultation

practice and recertification requirements from the Midwifery

A new national SGA and FGR guideline has been in development

Council should also provide more opportunity (and requirement)

over the last 18 months and will shortly be consulted with the

to engage with te Tiriti and te reo Māori.

maternity sector. The guideline includes a comprehensive review

10 | AOTEAROA NEW ZEALAND MIDWIFE

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of the evidence and international guidance, with recommendations for the Aotearoa maternity context.

The guideline covers antenatal screening, monitoring and birth planning for women with SGA or FGR pregnancies, and neonatal care for babies born SGA or FGR. The guideline was put together by a multi-disciplinary working group, including: midwifery, obstetrics, fetal medicine, neonatology and radiology.

Midwifery representatives were from the College, Ngā Māia Māori Midwives and the Pasifika Midwives Group. An invitation will be emailed to College members to participate in the consultation in June or July.

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REVIEW OF MORTALITY REVIEW FUNCTIONS In response to a request from the Minister of Health, in 2021 the Health Quality and Safety Commission (HQSC) commissioned a review of the mortality review function in Aotearoa, including the five current Mortality Review Committees (MRC) which are dedicated to reviewing: deaths of children and young people; babies and mothers where death is caused by pregnancy or childbirth; deaths resulting from family violence; deaths associated with surgery; and deaths by suicide.

The College’s representatives on several of these committees and sub-committees provided verbal feedback during the review process, as did the College Chief Executive when initial findings were presented to the professional associations. The College has advocated for the continuation of these committees and supports the vision of a te Tiriti-based mortality review system. The College has requested that the HQSC provide key stakeholders with the opportunity to provide formal feedback on the written report and proposed changes once they are published, so that our experience and perspective can be considered in the decision-making process about future mortality review functions.

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College kuia Crete Cherrington notes the new scope of practice and recertification requirements from the Midwifery Council should also provide more opportunity (and requirement) to engage with te Tiriti and te reo Māori.

ISSUE 105 JUNE 2022 | 11

YOUR UNION

JILL OVENS MERAS CO-LEADER (INDUSTRIAL)

St George’s midwives shocked at proposed closure Midwives were left stunned after a meeting in mid-March between maternity staff and St George’s Hospital Chief Executive, Blair Roxborough. Much to the staff’s surprise, a ‘change proposal’ presented by the CE outlined four options for the future of the hospital’s maternity service, including closure.

The 22 midwives, all but one of whom are MERAS members, were left in no doubt that closing the maternity unit was St George’s preference. Two other options involved scaling the maternity service back.

In a submission detailing our response, MERAS made it clear members’ preferred option was to continue the full maternity service.

St George’s midwife Noemi Gulliver has emphasised that women must have choices about where they have their babies, and the support they receive postnatally. She told the CE of St George's the midwives’ main concern was for the women of Christchurch.

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St George’s has been providing maternity care to Christchurch women since the 1940s. A new maternity ward opened in late 2020 included three purpose-built birthing rooms (two with birthing pools), and a 12-bed postnatal facility. The service is well supported, with more than 500 births and around 1,000 postnatal stays each year (including transfers from Christchurch Women’s Hospital).

Although St George’s is a private hospital, the maternity service is very reliant on its contract with the Canterbury DHB. Two rooms set aside for women paying privately were not well publicised, were rarely used, and the private service has since been discontinued.

Members were told that a drop in postnatal transfers from Christchurch Women’s Hospital over the past six months had affected financial viability. The trend towards early discharge, partly because of restrictive visiting policies due to Covid-19, resulted in fewer postnatal transfers to the unit.

St George’s was also concerned about the impact of a new DHB primary unit due to open next year in the central city. After years of lobbying from the midwifery community, the DHB announced that a new central city unit with 20 beds and four birthing suites would open in early 2023. It has since revised the opening time to mid-2023.

MERAS argued that closure of St George’s would leave a huge gap in primary birthing options in the meantime, and that there would still be an ongoing need for the service St George’s provides after the new DHB unit opens. Until 2016 there were two primary units in Christchurch – St George’s and one operated by the DHB at Burwood – both meeting the demand for primary birthing options and postnatal stays.

In the MERAS submission, we said birthing centres have different styles and ambience, and this is likely to occur in the Christchurch context with each unit appealing to different women, but increasing the overall number of women who birth in a primary setting.

L-R: James Gough and his second baby, who recieved postnatal care at St.Georges and St. Georges Maternity Unit staff

In an email to the CE, St George’s midwife Noemi Gulliver emphasised that women must have choices about where they have their babies, and the support they receive postnatally. She told the CE the midwives’ main concern was for the women of Christchurch.

“Having a choice and confidence in that choice play a key role in positive outcomes.

I worked at CWH for 10 years and know that the closure of the St George's maternity unit would put much more pressure on CWH.” St George’s midwives were encouraged by the support they received through media coverage of a petition started by Rata Midwives (see Bulletin, p. 8). Celebrities, consumers, the College of Midwives, LMCs and politicians publicly backed the petition, which quickly gained 31,000 signatures.

Christchurch city councillor and Canterbury District Health Board member, James Gough, whose wife and babies received postnatal care at St George’s, told Stuff he learned of the proposal for change through the media and was taken aback.

“I was surprised we didn’t have more visibility over it, and that is a concern. The approval of a new DHB primary birthing unit in the central city was never intended to replace the service contracted at St George’s, as it was recognised both would be needed to meet demand,” he said. “There’s a desperate need for a primary birthing unit

in Christchurch in addition to the existing service at St George’s.”

It is clear that the St George’s maternity unit has been under considerable pressure since November 2021. Staffing shortages exacerbated by the vaccine mandate and staff off work due to Omicron-related issues, led St George’s to reduce the number of available beds from 10 to five. They closed their maternity service for several weeks over Christmas for the same reason.

The hospital claimed this was despite extensive recruitment efforts. However, as MERAS workplace representative at St George’s Pene Marshall explains, this is not supported by the experiences of several applicants.

“Some midwives who applied at the end of last year were shortlisted, but by January and February they still hadn't been interviewed.

So from the end of last year to March, those midwives were left in the dark, while we were short staffed.”

However, in the MERAS submission Caroline Conroy pointed out that midwives generally enjoy working at primary maternity units and it is usually easier to fill midwifery vacancies there than in some larger services.

With borders re-opening, it should become easier to attract midwives from overseas.

“We are aware of other maternity units successfully recruiting midwives from the UK and Australia, and more midwives participating in return to practice

“I was surprised we didn’t have more visibility over it, and that is a concern. The approval of a new DHB primary birthing unit was never intended to replace the service contracted at St George’s, as it was recognised both would be needed to meet demand."

- James Gough, Christchurch City Councillor

programmes. Additionally, last year’s cohort of new graduate midwives are coming to the end of their first year and may also be looking for new midwifery workplace opportunities.”

The future of the St George’s maternity service remains uncertain at time of writing, with a decision expected at the end of May. square

For MERAS Membership merasmembership.co.nz www.meras.midwife.org.nz

ISSUE 105 JUNE 2022 | 13

YOUR MIDWIFERY BUSINESS

SHANTI DAELLENBACH LOCUM SUPPORT CO-ORDINATOR

community midwife locum support The past year has continued to see ongoing challenges for the midwifery workforce in Aotearoa which have been amplified even more by the effect of Covid-19 and the changing government response and related requirements.

The MMPO has continued to respond to these challenges through ongoing advocacy work, and negotiation with the Ministry to have community midwife locums acknowledged for the vital work that they continue to do. Furthermore, we have asked for fair and reasonable funding increases to support both the existing types of locum support services we provide, and for payments to recognise the extra work being carried out to support the midwifery workforce across the motu with locuming as we negotiate our way together, through this unprecedented pandemic.

COVID-19 LOCUM SUPPORT In early 2020, the MMPO (together with the College) secured funding from the Ministry to support Covid-19 emergency locum cover for all LMC midwives.

Throughout 2020 and 2021 this funding was only used during Covid Alert Levels 3 and 4 and the funding was limited by criteria and for a set period.

In advance of the outbreak of Omicron and based on the expectation of greater locum cover demand for Covid-19 emergencies, the MMPO and College were able to negotiate the continuation of this funding, at the same time widening the criteria required for community midwives to access this support and payment.

Importantly, the Covid-19 contract negotiation also allowed us the opportunity to negotiate more funding and payments for locums, recognising the extra work they are required to perform when planning

14 | AOTEAROA NEW ZEALAND MIDWIFE

and handing over cover. The negotiations also recognised the significant impact labour and birth care has on a midwife providing locum cover.

Since the start of March 2022 and with the impact of Covid-19 Omicron, there has been an unprecedented increase in locum support, with the MMPO workforce team managing and administering cover for over 620 community midwives who accessed more than 2,670 days of Covid emergency cover in that period alone.

We expect that the need for this type of locum cover will continue to remain high throughout the winter.

The MMPO would like to reassure midwives that Covid emergency locum funding has been agreed upon and extended with the Ministry until at least June 2023.

NEW PAYMENTS FOR COMMUNITY MIDWIFE LOCUMS FOR ALL EMERGENCY COMMUNITY MIDWIFERY LOCUM COVERS (INCLUDING COVID-19 URBAN AND RURAL NON-COVID EMERGENCY SITUATIONS)

Over the past six months, the MMPO (together with the College) successfully advocated for and negotiated new payments that better recognise and remunerate locum midwives for the work they do, including: • A Birth Acknowledgement Payment of $550 (exc GST), paid to locums where they undertake birth care during an emergency locum cover. This fee is in addition to the daily rate and can be claimed up to two times per locum cover.

• An additional Planning and Handover Payment, based on the daily rate and pro-rated to the cover duration. This payment recognises the work done by the locum prior to and following the locum cover, such as receiving a handover from the midwife, planning the cover, and handing back to the midwife at the end.

• Support to any locum community midwife who relocates for at least eight weeks to another region (that is affected by shortages of fully vaccinated LMCs in line with the Covid-19 Vaccination Order) with a payment of relocation costs up to $3,000 (exc GST) per midwife to cover travel, accommodation, and other start-up costs.

LOOKING FORWARD The stabilisation and future sustainability of the community midwifery workforce continues to face strong headwinds.

The passing of the Vaccination Order for Health Workers into law in November 2021, saw the entire community midwifery workforce abruptly contract. This government requirement, whilst affecting all, has had a significant impact on rural communities who are supported by only a small number of community midwives, where even the loss of one midwife is significant. Furthermore, some remote rural communities lost all access to primary maternity care from a midwife at this time, leaving them reliant on DHB hospital services hours away from where they lived.

To help with the current situation the MMPO locum service has expanded its role

Since the start of March 2022 and with the impact of Covid-19 Omicron, there has been an unprecedented increase in locum support, with the MMPO workforce team managing and administering cover for over 620 community midwives who accessed more than 2,670 days of Covid emergency cover in that period alone.

and scope to support some of the most affected communities across the motu. The MMPO did this primarily by working together with DHBs in the worst affected areas to find interim workforce solutions and facilitate DHB funded support packages, to support the sustainability of community midwives in those areas of crisis.

The start of July 2022 will see the establishment of Health NZ and the Māori Health Authority; national entities that will replace the DHB system across Aotearoa. For the MMPO locum service this means a shift of our workforce contracts (as they currently stand) from the Ministry to these new entities until at least 30 June 2023.

At time of writing, our negotiations with the Ministry continue, for both improvements to existing services and additional funding for new workforce and locum initiatives.

Some critical requests have been ongoing for a long time, such as increases to the current daily rate (which have not been changed for over a decade) and are still outstanding. Some are new workforce and locum initiatives and requests, including: • Introducing professional development leave locum cover for all community midwives • Introducing cultural leave locum cover (for kaupapa Māori professional development including te reo Māori) • Increasing emergency locum leave cover (including sick leave) to be more equitable considering the recent changes to employed sick leave entitlements • Increasing non-emergency leave and locum support for all community midwives • Expanding the new locum payments detailed above to include non-emergency locum covers.

At time of writing we wait patiently, but intently, for the announcement of Budget 2022. square

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

ISSUE 105 JUNE 2022 | 15

CLINICAL

CLAIRE MACDONALD MIDWIFERY ADVISOR

NATIONAL MATERNITY CLINICAL GUIDELINE UPDATES Three important national maternity guidelines have now been updated and are being published by te Manatū Hauora | the Ministry of Health. This article outlines the guideline review process, key changes and practice points.

The national maternity guidelines that have

nominate Māori midwifery representatives,

Sussex University Hospitals approach of using

been updated are:

but unfortunately nobody was available.

both gendered and gender neutral terms

The steering group was co-chaired in a Tiriti

together.

•

Guidelines for Consultation with Obstetric and Related Medical Services (Referral Guidelines) | Aratohu Kimi Āwhina ki te Ratonga Whakawhānau Pēpi, Ratonga Rata (Ngā Aratohu Tuku Atu)

•

National Consensus Guideline for Treatment of Postpartum Haemorrhage | Aratohu Tūtohu ā-Motu mō te Tumahu Ikura Whakawhānau Pēpi

•

Diagnosis and Treatment of Hypertension and Pre-eclampsia in Pregnancy in Aotearoa New Zealand A clinical practice guideline | Te Tautohu, Te Tumahu i te Toto Pōrutu me te Pēhanga Toto Kaha i te Hapūtanga ki Aotearoa.

The Ministry contracted consultancy company Allen + Clarke to project manage the update of five Manatū Hauora maternity guidelines in 2021, and a technical advisory group and steering group were established to provide oversight. Midwifery representation was provided by College advisors Dr Lesley Dixon and Claire MacDonald, Te Tai Tokerau Director of Midwifery and College Elder Sue

partnership model by tauiwi midwife Sue Bree and Māori obstetrician Dr Angela Beard.

College members were consulted on

Definitions and phrasing have been updated to ensure consistency with legislation passed since 2012 and references to other

proposed changes to ensure midwives’

key documents such as Ngā Paerewa Health

views were considered in the development

and Disability Services Standard and the

process and the College board endorsed the

Health and Disability Services Code of

final versions.

Consumer Rights.

WHAT HAS CHANGED? New content has been added to all three guidelines to include introductory statements on the application of te Tiriti o Waitangi to maternity care provision, cultural safety and equity. The Tiriti section was provided by the Ministry. These sections are an important

Clinical practice recommendations are listed at the start of the PPH and hypertension guidelines, followed by the evidence statements for those who wish to delve more deeply into the rationale for the recommendations. Flow charts provide visual tools for quick reference to key practice points.

support Tiriti-based midwifery care which will

GUIDELINES FOR CONSULTATION WITH OBSTETRIC AND RELATED MEDICAL SERVICES (REFERRAL GUIDELINES) I ARATOHU KIMI ĀWHINA KI TE RATONGA WHAKAWHĀNAU PĒPI, RATONGA RATA (NGĀ ARATOHU TUKU ATU)

be launched later this year.

The Referral Guidelines are used daily by LMC

acknowledgement that in order to be clinically safe, practitioners must be culturally safe.

Of course, bringing te Tiriti o Waitangi to life in our midwifery practice involves more than reading a document, and the College is currently working on an e-learning course to

At the College’s recommendation,

midwives and directly influence care provision

Bree, and Canterbury Director of Midwifery

gender inclusive language has been used

by DHBs and employed midwives. The four

Norma Campbell. Ngā Māia was invited to

in accordance with the Brighton and

different levels of referral have been retained:

16 | AOTEAROA NEW ZEALAND MIDWIFE

CLINICAL

•

Primary refers to a condition for which the referrer will discuss with the woman/person or parents that referral to another primary care, allied health or kaupapa Māori service provider may be warranted.

•

Consultation refers to a condition for which the referrer must recommend to the woman/person or parents that a consultation with a specialist is warranted.

•

Transfer refers to a condition for which the referrer must recommend to the woman/ person or parents that there is a transfer of clinical responsibility for care to a specialist.

•

Emergency refers to a condition for which there must be immediate transfer of clinical responsibility for care from the referrer to the most appropriate available health practitioner (where possible).

The process maps and flow charts have been updated for these referral categories, as well

recommended care, including the evidence for

as Emergency transport and When a woman/

that care") to:

person declines a referral, consultation,

•

ensure that appropriate conversations

transfer of clinical responsibility for care,

about the situation, options, risks and

emergency treatment or emergency transport.

benefits have occurred

Significant changes to the pathways are outlined here.

•

The recognition that some women previously didn’t reach the threshold of a transfer of clinical responsibility when they had multiple

clarify with the woman/person (or parents)

of carboprost and misoprostol, and adding a table of drug action timeframes •

additional advice on testing and laboratory services if transfusion is needed

•

content about multidisciplinary education.

when it may be appropriate to revisit

TRANEXAMIC ACID (TXA)

this decision (eg, a change in the clinical

The updated guideline notes: “tranexamic acid

circumstances).

increases overall survival from primary PPH and decreases the likelihood of hysterectomy. Early

consultation-level conditions has been

CONDITIONS AND REFERRALS

recognised in the consultation pathway: “If the

In addition to a small number of changes to

because effectiveness decreases over time

condition increases in severity, or if there are

the conditions and recommended levels of

following the PPH event. No benefit is gained

multiple conditions warranting consultation

referral, timeframes for referral have been

if administration is delayed beyond three hours

with a specialist, the LMC/referrer may

included for some conditions where obstetric

after the onset of the PPH event.”

request that transfer of the clinical

review and interventions need to occur by

responsibility for care to the specialist occurs.”

a certain gestation. Please see the guideline

Communication is key and a transfer of

for all of these timeframes. Table 1 sets out

clinical responsibility is negotiated in a three-

new conditions which have been added, and

way conversation between the specialist,

amendments to existing conditions.

woman and LMC, with the LMC midwife often

administration of tranexamic acid is advised

Tranexamic acid has been used in practice in Aotearoa for several years now, but regional practice has varied, with its use often limited to hospital settings or by medical practitioners.

In the 2022 guideline, consideration of the use

NATIONAL CONSENSUS GUIDELINE FOR TREATMENT OF POSTPARTUM HAEMORRHAGE I ARATOHU TŪTOHU Ā-MOTU MŌ TE TUMAHU IKURA WHAKAWHĀNAU PĒPI

of TXA has been brought forward, to the first

When a woman/person declines a referral,

The guideline consists of two documents:

(College Consensus Statement: Midwife

consultation, transfer of clinical responsibility

a clinical guideline and a poster for quick

Prescribing) so they are confident with

for care, emergency treatment or emergency

reference in an emergency situation.

prescribing and administration of TXA. This

transport. This pathway has stood the

The updated guideline has retained the

may also be appropriate in some home and

test of time and midwives are strongly

three different sections of the poster (green,

primary birthing unit settings. It is important to

recommended to familiarise themselves with

orange and red) but is now set out as a

note that first-line management is prioritised,

it, in order to support the woman’s right

series of three sheets, which should all be

including fundal massage, delivering the

to make an informed decision for her care,

displayed together: Green – Initial early

placenta, administering uterotonics, emptying

and for midwives to be assured that their

recognition and action; Orange – Ongoing

the bladder, siting IV luers and commencing IV

professional practice will be supported in

significant bleeding; Red – Ongoing

fluid, before the administration of TXA.

these circumstances.

uncontrolled bleeding. Other changes include:

remaining involved to provide midwifery care.

When midwives contact the College for advice on supporting a woman who feels the guideline recommendations are not right for her, College advisors refer to the pathway:

The first action point has been changed (previously "advise the woman of the

•

pathway of Initial early recognition and action.

Midwives are therefore encouraged to seek education to develop “knowledge regarding the effects, side effects, interactions and contra-indications of the drugs prescribed”

TXA does not replace the use of

amendments to drug information including

uterotonics but is used in addition, as they

adding tranexamic acid, clarifying the role

have different actions.

ISSUE 105 JUNE 2022 | 17

CLINICAL

Table 1. New conditions (marked *) and amendments Code

Condition

Referral category

1002

Malignant hyperthermia, neuromuscular disease, suxamethonium apnoea

Consultation

1043

Bariatric surgery (history of)*

Consultation in the second trimester

1074

Complex mental health needs*

Consultation

1075

Epilepsy: new diagnosis

Transfer

1066

Acute respiratory condition*

Primary

1069

COPD*

Consultation

3008 and 3004

Hypertensive disease (previous history)

3014

Previous spontaneous preterm birth 16–31+6 weeks of gestation

Consultation before 26 weeks of gestation

3006

Previous spontaneous preterm birth 32–6+6 weeks of gestation

Consultation before 26 weeks of gestation

4017

Class II obesity: Body mass index (BMI) 35-40 m2/kg

Consultation

4034

Class III obesity: BMI 40-49 m2/kg

4035

Class IV obesity: BMI ≥50 m2/kg; *

Transfer; include an anaesthetic consultation

4014

Contraceptive device in-situ*

Consultation in first trimester

4030 and 4036

Covid-19*

Consultation

4018

Multiple pregnancy: dichorionic twins

Transfer

4037

Multiple pregnancy: monochorionic twins and higher order multiples

Transfer at diagnosis

4038

Parvovirus B19 infection*

Consultation

4039

Polycystic kidneys: maternal not fetal finding*

Consultation

4021

Polyhydramnios: mild (deepest pocket measurement 9-11 cm)

Consultation

Polyhydramnios: moderate (deepest pocket measurement 12-15 cm) or severe (deepest

Transfer

Woman/Person

4040

Commence aspirin between 12-16 weeks of gestation; consultation before 16 weeks

Consultation; include an anaesthetic consultation

pocket measurement >16 cm)

4041

Short cervix: finding on ultrasound of a cervix <25 mm prior to 24 weeks of gestation

Consultation before 16 weeks of gestation

4042

Thromboembolism: deep vein thrombosis, pulmonary embolism

Emergency

4044

Investigated for possible DVT or PE (negative result)*

Consultation

4043

Velamentous cord insertion*

Consultation

6008

PPH: ongoing uncontrolled bleeding

Emergency

7009

Vaginal or perianal prolapse (postpartum)*

Consultation

7010

Suspected epidural abscess or haematoma. May overlap with 7003

Emergency

7011

Suspected post-dural puncture headache

Consultation

7012

Recall or awareness under general anaesthesia

Consultation

Code

Condition

Referral category

8012

Abnormal pulse oximetry screen result: persistent oxygen saturation 90-94% on third test*

Consultation

8020

Abnormal red eye reflex: as per the Red Reflex Screening Assessment*

Consultation

Baby

18 | AOTEAROA NEW ZEALAND MIDWIFE

CLINICAL

Baby cont.

8059

Hypoxaemia: <90% oxygen saturation*

Consultation

8060

Persistent tachycardia*

Consultation

8062

Ambiguous genitalia*

Consultation

8063 8064 8065

Antenatal genitorenal renal dilation: anterior-posterior renal pelvic diameter (AP RPD) <15 mm with no peripheral dilatation or additional findings* Antenatal genitorenal renal dilation: AP RPD ≥15 mm or with no peripheral dilatation or additional findings OR AP RPD <15 mm with peripheral dilatation* Antenatal genitorenal renal dilation: AP RPD >7mm or postnatal AP RPD ≥15 mm with peripheral dilatation or additional findings or any AR RPD with additional findings*

Primary Consultation Consultation

8014

Dehydration or >10-< 12.5% weight loss since birth

Consultation

8061

Weight loss of >12.5% since birth

Transfer

Neonatal subgaleal haemorrhage: normal vital signs and head circumference stable with no

Consultation

8066

8067

signs of ongoing bleeding* Neonatal subgaleal haemorrhage: any concern about baby’s vital signs OR signs of ongoing bleeding OR head circumference increasing*

Emergency

8044

Infant of woman/person with diabetes: hypoglycaemia (blood sugar<2.0 mM)

Transfer

8068

Infant of woman/person with diabetes: hypoglycaemia (blood sugar 2.0-2.5 mM)

Consultation

Infant of woman/person with diabetes: apparently normal infant or with abnormal findings

Consultation

8045 8047 8050

other than hypoglycaemia Maternal Lithium-based medications* Stridor, nasal obstruction, or respiratory symptoms not specified elsewhere: with low O2 saturation (<90%)

DIAGNOSIS AND TREATMENT OF HYPERTENSION AND PRE-ECLAMPSIA IN PREGNANCY IN AOTEAROA NEW ZEALAND A CLINICAL PRACTICE GUIDELINE I TE TAUTOHU, TE TUMAHU I TE TOTO PŌRUTU ME TE PĒHANGA TOTO KAHA I TE HAPŪTANGA KI AOTEAROA This clinical practice guideline was first published in 2018 and was reviewed in 2021.

The guideline commences with the definitions and classifications of hypertensive disorders and is followed by a list of clinical practice recommendations. The recommendations have not changed substantially, with most amendments made to increase clarity for the clinician.

Changes specific to antenatal care include: 1 / Aspirin: specific guidance is given on

Emergency

oral elemental calcium) supplementation

5 / Ongoing blood pressure medication:

should be given to women with major risk

The guideline also now advises: The hospital

factors for pre-eclampsia.

to send woman/person’s GP and LMC a

3 / A table of the monitoring requirements

comprehensive discharge summary. This is

for each of the hypertensive disorders has

expected to provide further clarity by setting

been re-orientated to make it easier to read

out the expectations for the individual woman

and understand.

related to her blood pressure medication

Changes specific to postnatal care include: 4 / Postpartum blood pressure monitoring: The frequency of postpartum blood pressure monitoring has been changed from daily for seven days to: BP at home 24-hour post discharge, then at one week, then

over time.

6 / A table listing indications for expediting the birth for women with pre-eclampsia based on the SOMANZ guideline has been added to support clarity and consistency.

Midwives are encouraged to familiarise

approximately weekly thereafter (in line with

themselves with the new guideline. It is

case-by-case planning according to severity).

expected that they will be implemented

The reason for this change was that peak postpartum blood pressure occurs between

by all DHBs (and future entities under the health reforms).

square

days three and six. The guideline recommends that women remain in hospital for at least

when to commence (between 12 and 16

72 hours (three days) with BP monitored 4-6

weeks), when to take (daily in the evening or

hourly. A further BP check within 24 hours

bedtime) and when to discontinue low-dose

of discharge ensures that the BP has been

aspirin (around 36 weeks gestation) for women

monitored for between four and five days.

with major risk factors for pre-eclampsia.

If the BP is labile or of concern, further BP

2 / Calcium: clearer guidance is given on

Consultation

assessments will be required. This can be

when (from first antenatal assessment to birth

identified by the midwife and a plan of care

is recommended) and how much (1.5 - 2.0g

and further monitoring developed as needed.

College members were consulted on proposed changes to ensure midwives’ views were considered in the development process and the College board endorsed the final versions.

ISSUE 105 JUNE 2022 | 19

FEATURE

20 | AOTEAROA NEW ZEALAND MIDWIFE

FEATURE

moral distress and midwifery "From the beginning of our education, it’s ingrained in us that we’re with women; in partnership, promoting physiological birth and all of the normal, wonderful parts of pregnancy and the early postnatal period. That’s entrenched in us as midwives and when we don’t have the time to really be with women, it feels like we’re not doing our jobs properly" (Midwife Manager).

Midwifery is both an art and a science and often midwives feel a great sense of pride, joy and satisfaction when they are able to practise it true to their values, ethics and morals. Whilst these will vary somewhat from midwife to midwife, a common minimum standard of professional midwifery care prevails and all midwives can surely agree that our role in protecting and promoting physiological pregnancy, labour, birth, postnatal recovery and transition is vital, as is providing positive birth care for women who require medical intervention.

(Oelhafen & Cignacco, 2020; Kälvemark et al., 2004), which Foster et al. (2021) suggest is the cumulative effect of repeated exposure to situations which precipitate moral compromise. Foster et al.

(2021) define it as:

Midwives are attracted to the profession for a variety of reasons, but it is certainly not a vocation one happens to fall into. For many, there is a drive to work with women, babies and whānau through a momentous life event.

Current staffing issues within our maternity facilities, combined with high-acuity, increasingly complex clinical situations, and subsequently over-stretched work environments can lead to this phenomenon becoming a daily reality for midwives.

Due to the symbiotic nature of the professional relationship between both community and employed midwifery workforces, this distress can have profound effects for both groups. Institutional constraints such as short staffing readily result in ethical dilemmas for all midwives, as they struggle to provide the quality of care that they are educated, or desire, to provide. When it is impossible to pursue a desired course of action, moral distress ensues.

While many aspiring midwives feel affirmed by their undergraduate experiences, students may also have reality-grounding insights as they progress through their education. For many, these experiences strengthen their determination and resolve to continue, whilst for others, the reality could not be further from their expectations, and they make the difficult decision to walk away.

As midwives enter the profession, the journey can be challenging, causing some to question their decision to become a midwife. Present day workforce shortages mean many midwives may grapple with disillusionment as they try to provide the standard of care they were educated to. This state of inner conflict, which many midwives have come to experience daily in their work, is known as moral distress.

A widespread phenomenon in healthcare settings, moral distress is stress caused by ethical dilemmas

“…a psychological suffering following singular or repeated moral compromise, which result in an experience of personal powerlessness and a significant negative psychological impact where the midwife perceives an inability to preserve all competing moral responsibilities” (p. 9).

Kälvemark et al., (2004) propose another definition of moral distress midwives may identify with: “Traditional negative stress symptoms, such as feelings of frustration, anger and anxiety, which might lead to depressions, nightmares, headaches and feelings of worthlessness, that occur due to a conviction of what is ethically correct but institutional and structural constraints prevent the desired course of action” (p. 1077).

ISSUE 105 JUNE 2022 | 21

FEATURE

These ethical dilemmas or morally compromising situations can be insidious, particularly for those midwives working in high-risk, high-acuity maternity units; moral distress can run undetected, as highly resilient midwives adapt to their environments over time. A classic example of this can be found on busy postnatal wards. As midwives, we are educated in the importance of observing a full breastfeed and encouraged to be as hands-off as possible when assisting. Ideally, mother and baby are gently guided to learn and practise together, and the woman is left feeling empowered. But we all know this doesn’t often happen in reality. A midwife’s caseload on a shift in a high-acuity postnatal ward includes babies on regimented feeding plans requiring blood sugar monitoring, breastfeeding and top-up feeds, whilst their mothers’ needs relate to recovery from a cascade of intervention, which has set them up for delayed lactogenesis and reduced levels of oxytocin.

Under these circumstances, the dream of enabling a wahine and her pēpi to learn to breastfeed together is often reduced to just that: a fantasy. Instead, midwives find themselves entering rooms, testing a baby’s blood sugar and latching them to the breast as efficiently as possible (usually by doing, rather than teaching) in order to attend the room next door, where the same routine is already 15 minutes overdue.

The next shift is simply a rinse and repeat, and before long, midwives have adapted to a new normal; what was once a distressing experience of not being able to provide the ‘caring’ aspect of the care, becomes background noise as midwives adopt various unconscious strategies to avoid or ignore their distress.

One midwife illustrates the inner conflict as she describes her distressing adjustment to work as an employed midwife in a busy tertiary unit, having come from a predominantly primary background as an LMC: “I’ve always been really patient when it comes to breastfeeding and I loved it as an LMC. But in this environment I’ve become precisely the kind of midwife I swore I’d never be; walking into rooms, hurriedly latching babies on to breasts and running to the next thing. It’s heartbreaking” (Midwife).

A survey of College members published in 2017 found that levels of stress and feelings of depression were high for all midwives, but the group of midwives providing continuity of care had "Being task-orientated isn’t part of higher average emotional health scores than the group the midwifery psyche, but that’s working in the hospital (employed) environment. what you have to become in

order to survive. You have to learn to prioritise the observations and the medications, and what falls to the wayside is the nurturing.

You physically don’t have the time to do that without someone else missing out, or being put at risk" (Midwife Manager).

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The study identified a correlation between inadequate resources to support midwives’ work, and burnout. Resource adequacy involved having enough midwives to provide quality care, enough time and opportunity for midwives to spend time with wāhine, and the ability to discuss care concerns with other midwives.

THE IMPACTS OF COVID-19 The College acknowledges that working within a global pandemic compounds these issues further. It’s not news to midwives that we, along with many other health practitioners, have been experiencing increased levels of work stress and burnout during the Covid-19 pandemic. The intensity of midwifery care provision during the pandemic has been exacerbated by existing workforce issues, concerns about clients with Covid-19 infection, anxiety about personal/family safety and wellness, alongside feelings of being undervalued and overlooked by the government.

The College undertook a survey of midwives in 2020 to ascertain the impact of the Covid-19 pandemic on midwives and midwifery care, and found that the majority of the 781 midwife respondents (26.8% of practising members at that time) agreed that Alert Levels 3 and 4 had impacted their work environment, and that this had been a major influence on their workload (Dixon, 2020). The New Zealand media has published many articles about the midwifery shortage and burnout, and highlighted the potential risk to mothers (Henry, 2021; Corlett, 2021; Wilson, 2022), which MERAS co-leader Caroline Conroy describes as a factor creating more stress for midwives (Quinn, 2021).

“Knowing that we were already beyond breaking point, running on skeletal staffing every day; the fear of how we would survive with further staff absences felt debilitating at times, not to mention the possibility of providing care for Covid-positive patients. That was complete overwhelm and I struggled to see a way through” (Midwife Manager).

Research by Foster at al. (2021) looking at why Australian midwives were leaving their profession found reports of psychological trauma, primary and secondary traumatic stress, burnout, anxiety, and depression, suggesting that moral distress may be a contributing factor.

Findings in the Foster et al. study (2021) identified three key themes: • experiencing moral compromise • experiencing moral constraints, dilemmas and uncertainties • professional and personal consequences.

Midwives also indicated that they were unable to adequately advocate for themselves, their profession, and the women in their care within the hierarchical and oppressive systems in which they were working (Foster et al., 2021).

Harvie et al. (2019), analysed data collected as part of the Australian arm of the Work, Health and Emotional Life of Midwives (WHELM) project (1,037 midwives) and examined the incidence of, and the reasons why Australian midwives were considering leaving the profession. They found that midwives felt their ability to provide quality maternity care was constrained by a fragmented medicalised system that did not work for women in their care, or themselves.

Themes identified in the work by Harvie et al., included “I cannot be the midwife I want to be”, where midwives described being rushed, pressured, constrained and restricted.

Another theme was “I am at breaking point”, where midwives described feeling overwhelmed, stressed, anxious and burnt out all the time. Profound levels of hopelessness were

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experienced and midwives felt that their passion for midwifery had been eroded.

The College 2020 survey included questions about the impact of the Covid-19 health response on the work of employed midwives and community midwives (Dixon, 2020). Hospital-employed midwives experienced a range of issues including increased time pressures due to screening procedures, as well as providing the majority of labour and birth care for women who were Covid-positive or suspected of being positive. Community midwives’ administrative and non-clinical workloads increased and they faced additional challenges of negotiating both telehealth and shorter in-person assessments.

The emotional, psychological and spiritual needs of new mothers and their whānau as they navigate a transition which is just as much a cultural, spiritual or emotional experience as it is physical, needs to be acknowledged.

Midwives are acutely aware of these needs, but in the face of short-staffing and high acuity, are forced to prioritise physical or clinical care, leaving whānau at a loss as they try to steer through an inherently emotional journey in busy, overwhelmed institutions. Women and their whānau aren’t the only ones who feel this disconnection; midwives feel it too, to varying degrees, contributing further to moral distress and feelings of despair.

In order to manage the detrimental effects of moral distress, midwives may choose to reduce their working hours, or at

worst, leave the profession altogether. These drastic actions can leave individual midwives feeling further defeated or disempowered, and the workforce even less sustainable in the long-term.

In spite of the stressors associated with the pandemic, some midwives have felt increased pride throughout it, knowing their contributions as essential front-line health workers - during an anxiety-inducing time - has been valued immensely by whānau receiving their care, particularly as other health providers reduced their services. The schools of midwifery have all reported a surge in applications since the onset of the pandemic, as the value of essential workers has become more visible.

WHAT PROTECTS AND SUSTAINS MIDWIVES? What can help mitigate or prevent the experience of moral distress, so that midwives can continue to experience the pride, joy and satisfaction the work offers? Although there are some factors within one’s individual control, midwives work within a much wider professional and systemic context. Therefore it is worth considering the contributing factors at personal, professional, environmental and structural levels, as these same factors may also reveal some protective measures.

This concept is perhaps best illustrated by way of an ecological model, demonstrating the ways in which these layers - and their relationship to one another - contribute to a midwife’s sense of moral integrity and professional fulfilment.

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Personal: what is within the midwife’s individual control, e.g. personal health and wellbeing, lifestyle, sleep, mindfulness, level/years of midwifery practice experience, family and social connections, permission to do the best job one can under the circumstances.

Professional: relationships with clients and colleagues, professional support mechanisms, mentoring/clinical coaches, education and professional development, professional organisation membership e.g. the College.

Environmental: workplace culture, collegiality, teamwork, clinical leadership which promotes autonomy, sustainable working conditions.

Structural: access to resources and education, safe staffing, CCDM, career pathways, workforce retention initiatives, improved working conditions in employment contracts, community practice support.

WHAT IS WITHIN OUR PERSONAL POWER? Harvie et al. (2019) found that midwives described they were happiest when they could “just be a midwife”. They commented on their love and passion for their profession and how “privileged” they felt providing care for women and their families. However, in order to experience this joy, midwives need to be emotionally present for women and whānau, in all contexts and settings (from busy tertiary units to community practice). We owe it to those we care for to be fully present with them, at a point in their lives which is of momentous significance – such as birth and becoming new parents.

But of course midwives cannot begin to be present for others until they are first present with themselves. Care providers are also in need of care, and acknowledging one’s own need for compassion and support is an essential part of this. Accepting that a midwife can only do what they can do on any given day or shift is integral to self-care. Berating oneself for the things that weren’t achieved is counter-productive; a kinder approach would be to grant oneself permission to do one’s best, knowing that it is enough.

"As a manager, that fear of something going wrong, or something being missed because of how chronically understaffed we are is ever-present.

And then on top of that, you’re worried your staff are unhappy and not feeling fulfilled. You’re constantly trying to fill the void of understaffing, shuffling things around to make it as doable as possible, so that your staff come back the next day" (Midwife Manager)

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Using mindfulness techniques, developing a meditative practice or simply taking the time to connect to one’s own emotions without judgment all have the potential to bring more presence to life. Finding a sense of calm or joy looks different for every individual and could range from jujitsu to gardening, listening to podcasts, sharing kai with family and friends, going to the gym, launching DIY home projects, practising yoga, walking or running in nature, reading, volunteering, and everything in between. Taking time to

centre ourselves and set an intention before starting a shift, clinic, or birth can help us to bring our midwifery hearts and expertise to the people we care for. Processing difficult and frustrating situations by debriefing with a colleague, or journaling, can help us gain useful insights from these experiences rather than carry them as burdens.

These acts of self-love and compassion are all about connecting to and taking personal responsibility for one’s inner environment. Taking personal responsibility should not be conflated with culpability, or taking blame for the working conditions midwives find themselves in. Nor should it be confused with condoning oppressive behaviours or structures.

This approach is not suggested at the exclusion of continued advocacy work to improve working conditions and increase recognition of the value of women’s health and the vital role midwives play within it.

Instead, these approaches simply serve to remind midwives of the personal power, or mana, they possess at all times. Ultimately, the only thing anybody truly has control over, is their inner landscape, and to wait for external circumstances to improve in order to feel calm, happy or fulfilled is to give away one’s personal power, keeping those more desirable states eternally out of reach. There are numerous approaches offering techniques to experience inner peace or calm more frequently, most of which originate in Eastern philosophies. Whilst these hold immense value, closer to home, te ao Māori also contains keys, which are explored further on pg.26.

PROFESSIONAL CONNECTIONS Midwives internalise the profession’s values and practices, demonstrating commitment and dedication to providing skilled, knowledgeable care. Hunter and Warren (2013), in their study on midwives’ sustainability, found that when midwives feel a sense of professional belonging and identity, this supported their resilience.

Collectivisation as midwives can be grounding and protective; College and MERAS meetings provide professional spaces to engage with colleagues about regional midwifery and support collective action on local and national issues affecting our work. Team or practice meetings and other midwifery gatherings can also bring collegiality and perspective to our practice.

Education, regulation and an effective midwifery professional association are important to ensure midwives have access to the support systems and structures necessary for them to be the midwives they want to be. Each of these frameworks supports quality of midwifery care through the setting of professional standards, the maintenance of those standards and ongoing education (New Zealand College of Midwives, 2018).

There are a variety of professional mechanisms to support midwives’ sustainability and professional practice. These include mentoring, reflective processes such as midwifery standards review, peer review, ongoing education, and professional development. These all aim to provide midwives with opportunities to explore various aspects of care and

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recognise their own value as health professionals, by allocating dedicated time and space for midwives to receive collegial support.

The quality of professional relationships with clients and colleagues relies on, among other things, individuals working together in agreement, communicating clearly, listening and being available to one another, and where possible, meeting each other’s needs. These are common goals of health professionals and are supported by the profession through a number of mechanisms, some of which are identified above.

THE ENVIRONMENT MATTERS Never has there been a more important time to address workplace culture, especially within the current climate.

When facilities invest in an environmental culture which promotes trust and supports autonomous practice, midwives are much more likely to feel valued and safe at work.

Effective teamwork directly affects midwives’ experiences of workplace culture and builds capacity to give quality safe care to mother and baby (Hastie & Barclay, 2021; Nash, 2021).

Unsurprisingly, when midwives have access to approachable colleagues, they are more likely to thrive and develop further confidence in their midwifery skills and ability to work autonomously (Matthews et al., 2021).

Working within a supportive environment has the potential to transform stress triggers into challenges, rather than stressors. Hammond et al. (2013) found workplaces with cultures of increased trust, reduction in stress, and empathetic colleagues triggered the release of oxytocin, increasing job satisfaction and provision of quality care.

A culture of trust can also aid in sustaining and retaining midwives by providing increased stability, allowing for healthy collegial relationships to develop. In such an environment, especially after an emergency event, feelings of isolation are dispelled and midwives feel reassured and emotionally cared for. Positive initiatives such as the newly developed clinical coach roles contain the potential to address midwifery workforce issues and reduce stress levels for midwives.

The real and reported issues facing midwives strongly suggest a current midwifery workforce emergency state, which will extend long into the future without strategic and radical action now. Acknowledging and addressing the factors that have led to the current shortage of midwives, and the potential future midwife shortage, alongside providing better support for midwifery educators and institutions offering midwifery degree programmes, is vital. The Covid-19 pandemic has certainly seriously hampered the already overdue need to address the issues facing midwifery and this has contributed to an increase in workplace tension and strain.

STRUCTURAL SUPPORTS Although personal, professional and environmental factors can be protective, the wider system in which midwives work plays an integral role in ensuring midwives are sufficiently supported to mitigate the effects of moral distress.

As Purser (2019) points out, “…anything that offers success in our unjust society without trying to change it is not revolutionary…”, reinforcing the need to continue to push

for radical action addressing the political and economic frameworks currently shaping “You come back to work because the external midwifery you want to support your team, landscape. MERAS and as hard as it is. Having colleagues the College have been collectively focused on who understand makes the world continuously advocating of difference and if you get an for the changes needed to opportunity - in between racing improve systemic resourcing and recognition of midwifery around - to share a laugh, it as a distinct profession with makes it easier to get through" unique needs. This advocacy (Midwife Manager). occurs nationally, regionally and of course politically and is aimed at seeking short, medium and long-term solutions to address retention and recruitment.

Many of the successes already achieved have been celebrated within the pages of this magazine, including: the establishment of clinical coach roles; CCDM outcomes; Trendcare calculations; career pathways for DHB employed midwives; pay equity claims and continual advocacy for improving working conditions in employment contracts. Other wins include improvements to Section 88 payments, successful advocacy for the establishment of DHB midwifery leadership positions, establishment and retention of primary maternity facilities, along with community practice supports, such as funding for locum relief.

These structural supports are an essential layer in the matrix surrounding midwives, however they need to be continually built upon and strengthened. Within an inadequately resourced health system, midwifery’s voice must continue to be loud and present, in all decision-making forums, so that our working environments become places where midwives are nurtured to flourish and thrive.

CONCLUSION “You come back to work because you want to support your team, as hard as it is. Having colleagues who understand makes the world of difference and if you get an opportunity - in between racing around - to share a laugh, it makes it easier to get through. Positive feedback from whānau when you’ve made a difference to their care; that’s another thing that keeps me coming back - being able to provide clear guidance at a crucial time in their lives when they’re surrounded by so many different opinions and influences. Despite it all, I just can’t imagine myself doing anything else” (Midwife Manager).

Not all midwives will necessarily be suffering from moral distress, but for those who can now name their experience, it is hoped that this article has shed light on some of the contributing factors, including those within our individual control. Whilst these are not a fix-all, they can be empowering tools for midwives, alongside the continuous advocacy work being undertaken by the College and MERAS. Most importantly, this article has aimed to acknowledge midwives all over the motu, across all work settings, who may be feeling this distress, to remind them that they are not alone. square References available upon request.

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AMELLIA KAPA COMMUNICATIONS ADVISOR, REGISTERED MIDWIFE

DISCONNECTION FROM MANAWA:

MORAL DISTRESS THROUGH A MĀORI LENS The concept of moral distress is complex and can be explored through a myriad of different lenses. Te ao Māori offers another perspective, which Amellia Kapa gets to the heart(s) of with Ruatau Perez and Hannah Livingston, of Te Whare Wānanga o Te Ara Teatea.

Ruatau Perez (Ngāpuhi, Tūhoe) spent 10 years immersed in the teachings of worldrenowned tōhunga (traditional Māori healer) Hohepa Delamere, or ‘Papa Hohepa/Joe’ as he was more commonly known. Since Papa Hohepa’s passing, Ruatau has continued to share the esoteric mātauranga, along with partner Hannah (Ngāpuhi), through wānanga and traditional Māori healing at their whare hauora (clinic) in Ōtautahi.

Their perspective on why midwives may be experiencing such high levels of distress is unique, and cannot be separated from the historical events that drastically reshaped how women would birth in Aotearoa. “The Midwives Act of 1904 and the subsequent Tohunga Suppression Act had a huge impact.

They took the mātauranga and power away from whānau, who had always birthed their babies at home, according to traditional Māori lore,” Ruatau explains.

As the tapu sphere surrounding pregnancy and birth was systematically broken down by colonisation and medicalisation, Ruatau explains the natural order was disturbed.

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“Historically in te ao Māori, birth wasn’t just a physical process. Takutaku (incantations) were used to protect wāhine and pēpi; waiata and oriori were performed to bring babies through in the highest vibration possible, in connection with te taha wairua (the spiritual dimension).”

“Grandfathers or koroua (male elders) were the birth attendants, who acted as pou, holding space for labour and birth to unfold.

Kuia were also there and played an important role, but typically grandfathers protected the space and called babies into te ao mārama (the world of light),” he explains.

This traditional division of roles may seem irrelevant, but this approach - steeped in ancient wisdom - maintained equilibrium between masculine and feminine energies.

Hannah explains present day challenges are, in part, due to the fact that this delicate balance has been lost.

“Birthkeeping has become women’s work, but it never used to be that way. The koroua kept the balance; there was synergy between the feminine and masculine energies and our

tūpuna understood the importance of that.

Part of the solution lies in regaining that balance - empowering our tāne to step back into their traditional role of holding space,” she says.

“Because our whānau have been so disempowered over time by the loss of our mātauranga, the responsibility of holding space for hapūtanga, labour, and birth has fallen almost entirely on midwives. So midwives are holding space for entire whānau and communities, but who’s holding space for midwives?” she asks.

Clearly, imbalance is a significant contributing factor. Disconnection is another, but before wading into this, a foundational concept must be understood. According to the esoteric mātauranga, human beings were gifted three hearts by the atua (gods), which can be thought of as heart spaces and likened to chakras or energy centres.

The three hearts each hold equal but unique significance, relating to different aspects of our being, and can be defined as follows:

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centre, connected to all aspects of our being.

If we are disconnected from any one of these heart spaces (whatumanawa, manawa, or pūmanawa) or they are not in alignment with each other, we find ourselves in a state of imbalance, which can affect us on every level and limit our potential.

The whatumanawa is the seeing or spiritual heart (whatu = eyes, manawa = heart), which our third eye is nestled within. This heart space connects us to deeper ways of knowing, intuition, as well as our atua and other nonphysical realms or dimensions.

The manawa is our physical heart and true

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The pūmanawa, situated below the pito (umbilicus) is our feeling heart or emotional centre, where we not only experience and express emotions, but store them up when we aren’t able to acknowledge them or become overwhelmed.

If we are disconnected from any one of these heart spaces or they are not in alignment with each other, we find ourselves in a state of imbalance, which can affect us on every level and limit our potential.

So what is happening relative to these three hearts when midwives are experiencing moral distress? Hannah explains the distress is a direct result of disconnection from the whatumanawa, pūmanawa, or both.

“Midwives enter the profession because they want to empower our wāhine, but they themselves can be disempowered by the colonised biomedical model, which doesn’t allow for - let alone nurture - intuitive abilities. Many midwives have that deep

longing to be birthkeepers, but may find themselves constrained by a system that forces them to disconnect. Over time, that can become a source of distress.”

“Being prevented from developing deep emotional connections with whānau can also be debilitating. If the pūmanawa is being activated, but then midwives are shutting it down, either as a coping mechanism, or because it’s seen as inappropriate in the work environment, it results in disconnection.

And not only are they disconnecting from pūmanawa, but across the board - including from the whānau they’re caring for.”

Ruatau explains why this is so painful if it occurs; disconnection of this kind is a violation of our wairua (spirit). “When we’re cut off from any of our manawa, it goes against our core values. All three hearts need to be activated or we’re not honouring the whole process (of life) and we’re going against our wairua, which is why we end up in a state of inner conflict and turmoil.”

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The solution, therefore, is a radical shift to heart(s)-centred care, which is within every individual’s control. “In an emergency or a busy shift, it’s challenging, but a moment needs to be found to whakatau (settle) our energy and connect. Turning inward is the key - paying attention to and connecting to our breath, to re-centre and reground ourselves before we connect with whānau.”

Rather than waiting for the systemic changes that are undoubtedly needed, Ruatau suggests small adjustments to individual practice. “It’s about the little things, like remembering to make the connection with pēpi in te whare tangata (in utero), and not just their mothers. Asking for a baby’s consent before laying hands on their māmā’s puku might not seem like a big deal, but it has the power to completely change the way we connect.”

In his own work with wāhine hapū, Ruatau asks pēpi for permission before massaging their mothers. “These pēpi are rangatira and need to be revered as such. Sometimes I’m

waiting for 10 minutes for the consent to come through,” he explains. “But I wait for as long as it takes.”

Both Ruatau and Hannah also highlight the importance of any health practitioner being attentive to their own healing if they wish to help others. “It’s about turning inward before looking outward,” Ruatau explains. “We’re always reminding tauira in wānanga – you’re not here to learn how to heal others. You’re here to heal yourself first.”

Attending wānanga isn’t the only way to achieve this, as Hannah points out. “This mātauranga is emerging in different spaces. It could look like attending wānanga for some, and for others it might be about returning to their papakainga or learning about their whakapapa as a first step.”

Both are clear about the fact that all is not lost, and everyone has access to the tools, which are simultaneously inside of, and all around us. “Connecting with the elements and nature to whakatau (settle) the mauri (life force/energy) during times of stress can

be really helpful. Going for a walk in the ngahere - noticing the sounds and vibrations of the manu, or connecting to the moana and its constant flow of waves and tides are just a couple of ways to do this. Even just knowing that there are three hearts can spark new awareness and potentially a journey of discovery.” square

Rather than waiting for the systemic changes that are undoubtedly needed, Ruatau suggests small adjustments to individual practice. “It’s about the little things, like remembering to make the connection with pēpi in te whare tangata (in utero), and not just their mothers."

For copies of this poster and breastfeeding information contact NZBA at info@nzba.co.nz

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CLIMATE CHANGE

LESLEY DIXON MIDWIFERY ADVISOR

keeping up the pressure to enable change In recent months, severe flooding has affected various regions of New Zealand, headlining the news. Personal stories of loss, fear and economic hardship have accompanied each headline and although flood waters may have receded, the distress for whānau is ongoing, taking much longer to overcome.

There is little doubt our climate is changing and if current trends continue, the impacts will be far-reaching, affecting us all. This makes for a depressing future, with the magnitude of the issue requiring a concerted international effort, but also individual change and support. For most of us, knowing what to do is challenging personally, professionally and politically. This article explores the changes currently being implemented both politically and within the health sector, to reduce carbon emissions.

THE GLOBAL PICTURE The Intergovernmental Panel on Climate Change (IPCC) Working Group has delivered the third part of the Sixth Assessment Report to world governments. The report examines climate change impacts, adaptation and vulnerability.

The report explains that we are in a critical time period if we are to limit warming, with the window of opportunity rapidly closing. The picture is grim. Without concerted global action, emissions could potentially rise and lead to a median warming of 3.2°C by the year 2100. It is expected that flooding, heat waves, extreme weather and drought will become more frequent and severe, and the impact on

“We are at a crossroads. The decisions we make now can secure a liveable future.

We have the tools and know-how required to limit warming” - IPCC Chair Hoesung Lee

vulnerable populations more pronounced. For children born now, the likelihood that they will be exposed to deadly heat stress is projected to increase from today's 30% to 48-76% by the end of the century (depending on future warming levels and location). Climate change will affect every part of our lives including the economy, the environment, where we live and how we work.

THERE IS HOPE: WE HAVE THE SOLUTIONS The good news is that the impact of climate change can be reduced to within limits, if humans and nature adapt to the changing conditions. This involves reducing greenhouse emissions, protecting and conserving ecosystems and taking action to change the way we live our lives.

THE FIRST STEP: REDUCING GREENHOUSE GAS EMISSIONS Greenhouse gas emissions can be reduced through a combination of government policy, infrastructural change and technological improvements, along with individual lifestyle and behavioural adaptations. Solutions involve clean energy generation, circular economies, healthy diets from sustainable farming, appropriate urban planning and transport, universal health coverage and social protection, training and education, as well as water and energy access for everyone, to help reduce poverty.

“We now know that a healthy planet is fundamental to secure a liveable future for people on Earth and that’s why we say that the needs of climate, nature and local communities have to be considered together and prioritized in decision making and planning - every day and in every region of our world” (IPPCC sixth assessment report).

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CLIMATE CHANGE

Many countries are adopting a range of policies and laws to enhance energy efficiency, reduce rates of deforestation and accelerate the deployment of renewable energy. However, limiting global warming will require major transitions in the energy sector (from coal and oil to renewable energy sources) as well as improved energy efficiency, and use of alternative fuels (such as hydrogen).

“To successfully secure our own future and the future of the coming generations, climate risks must be factored into each decision and planning. We have the knowledge and the tools. Now it is our choice to make” (IPPC sixth assessment report).

We need our governments to make transformational change if we, and our children, are to have a sustainable future.

POLITICAL PRESSURE In 2018, Ora Taiao, the NZ Climate and Health Council (of which the College is a member) called for “a rapid whole of society approach to a net-zero GHG-emitting nation, which is based in Te Tiriti o Waitangi and designed to make the most of opportunities for health and creating a fairer society”. Ora Taiao also outlined the need for robust interim targets and emissions budgets, in order to monitor progress. In May, the government published its first emissions budget, setting the pathway for lowering emissions. An emissions budget identifies the total quantity of emissions allowed over a five year period.

These budgets will act as stepping stones to keep Aotearoa on track to meet its long-term targets (Box 1).

Box 1. Political solutions Every political party needs to recognise the importance of climate change and ensure ongoing and concerted action to reduce carbon emissions.

These involve: •

Clean energy generation (renewables)

•

Supporting circular economies (using regenerative industrial processes and economic activities)

•

Sustainable farming whilst reducing emissions

•

Improved urban planning - to reduce travel

•

Increased public transport - to reduce reliance on cars.

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CLIMATE CHANGE

Many people consider that the government is not acting quickly enough, whilst others are concerned some sectors are being targeted more than others. There are always differences of opinion within society, although it is now clear - reducing emissions is urgent and non-negotiable. Climate change requires all political parties to work together and respond decisively.

A CALL TO ACTION FOR HEALTH On World Health Day (7 April) Ora Taiao published a letter to the Health Minister Hon Andrew Little asking for the healthcare system to be made climate-ready and climate-friendly as part of the health reforms.

They provided a series of critical actions needed within the health sector (Box 2), for inclusion within the health care reforms.

The letter was endorsed by 11 organisations representing midwives, nurses, doctors and other health professionals. The College was one of the signatories on this letter calling for a healthy climate response.

Box 2. Solutions for the health system Identified by Ora Taiao, the NZ Climate and Health Council as critical actions: •

which will oversee decarbonisation within the sector and be supported by practising health professionals.

•

The next step measures progress, including the need to identify the organisation’s greenhouse gasses using the accepted international standard for carbon accounting.

Equity remains a vital focus within health and the guide recommends that this remain a priority because climate change disproportionately affects disadvantaged populations.

Increase intersectionality between the health sector and other public agencies in order to ensure that a healthy climate response becomes a central factor for decision making in transport, housing, welfare, food systems, and other core government work.

•

Mandate that adequate funding, resourcing and agency is given to the Māori Health Authority so that it can be a central player in our health sector’s response to climate change. Too often lip-service is paid to the need to have te ao Māori at the heart of our climate response; this is an opportunity

SUPPORT FOR DISTRICT HEALTH BOARD (DHB) SUSTAINABILITY In 2019, the Ministry released a five-step guide to sustainability for the health sector, identifying the need to take an active role in sustainability, starting with organisational commitment and the whole hierarchy of the organisation being aware and supportive of the concept.

Establish a dedicated sustainability unit,

to actually achieve that.

•

Effectively incorporate primary care into the wider health sector climate response.

•

Outline the immediate climate gains that will be achieved in the initial

A further step is raising awareness with education campaigns to develop a sustainability culture within the organisation.

The final step is to build networks with other organisations with similar goals to share information and initiatives that may be helpful (Fig.1).

OUR DHBS ARE STEPPING UP AND SOME ARE LEADING THE WAY Over the last few years, many DHBs have been working to reduce their emissions, with others starting more recently. Many have joined the Global Green and Healthy Hospitals network (GGHH). This is an international network of hospitals, facilities and health organisations who have all agreed to work towards reducing their environmental footprint. They identify 10 goals for systems to consider (Box 3).

In 2021 GGHH published a list of Health Care Climate Champions who are “stepping up in transforming to a sustainable climate smart health sector by setting ambitious targets to mitigate their emissions”.

The list includes: Counties Manukau Health Board Counties Manukau have been measuring their carbon emissions for the past 10 years and were the winner of the Toitū Brighter

two-year Health Plan. For example: ongoing repurposing of coal boilers; and equipment procurement decisions

Box 3. 10 goals for Global Green and Healthy Hospitals

to have greenhouse gas emissions as a

1. Leadership – prioritise environmental

a ban on new gas boilers; all medicine

key decision factor; an immediate stop on international business-class flights for staff; plant-based hospital catering; and an urgent switch from metered-dose to dry powder asthma inhalers.

health 2. Chemicals – substitute harmful chemicals with safer alternatives 3. Waste – reduce, treat and safely dispose of health care waste 4. Energy – implement energy efficiency and clean renewable energy generation 5. Water – reduce hospital water consumption and supply portable water 6. Transportation – improve transportation strategies for patients and staff 7. Food – purchase and serve sustainably grown healthy food 8. Pharmaceuticals – safely manage and dispose of pharmaceuticals 9. Buildings – support green and healthy hospital design and construction 10. Purchasing – buy safer and more sustainable products and materials.

New Zealanders have been struggling in recent months with rising flood waters

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Future Award for Climate Action (large

Figure 1. Actions for successful sustainability programmes (MOH, 2019)

organisation). They have reduced carbon emissions by 42% since 2012 (certified

by Toitū).

Auckland District Health Board Auckland DHB have reduced carbon

Organisational Committment

emissions by 28% since 2015 and were also

Measuring Progress

Equity

Raising Awareness

Building Networks

a finalist for the Toitū Brighter Future Award for Climate Action (large organisation).

Northland District Health Board Northland DHB have reduced their carbon emissions by 21% since 2015 although emissions increased by 4% last year (2021). They remain committed to sustainability with a target to halve their

Table 1. DHB commitment to carbon reduction*

On 2 December, 2020 central government issued a directive that all public sector organisations will be carbon neutral from 2025. This means that all DHBs will need to work urgently to reduce emissions further. Individual DHB websites were searched for information on their sustainability planning (Table 1) with many just beginning this work, whilst others have set out their plans on reducing emissions.

North Island

emissions by 2030.

Auckland

28% reduction since 2015

Bay of Plenty

17% reduction on the baseline year

Capital and Coast

In second year of reporting with Toitū

Counties Manukau

42% reduction since 2012 Registered with Toitū and will set targets and initiatives in place to reduce carbon footprint.

Hutt Valley

No information on website

Lakes District

No information on website

Mid Central

No information on website

Northland

21% reduction since 2016

Tairãwhiti

No information on website

Taranaki

Registered with Toitū and will set targets and initiatives to reduce carbon footprint.

Waikato

No information on website

Wairarapa

No information on website

Waitematã South Island

As a member of Ora Taiao, the College is committed to being part of the solution, with the 2021 ratification of the Climate change, midwifery and environmental sustainability consensus statement and the progressive development of other resources for midwives and families on a variety of subjects aimed at helping to support systemic and individual change. Reducing emissions and becoming emission-free is the future goal; one which will require all of us working together to achieve. square

Progress on carbon reduction

Hawkes Bay

CONCLUSION There is little argument that climate change is having a detrimental effect on our weather and health. Action is urgently required, but many of us feel powerless when faced with the huge amount of work to make the major changes that are necessary. It is reassuring to see that the government is leading change and that DHBs are identifying their carbon emissions and looking at steps to reduce them. Midwives can be part of the solution by holding their DHBs to account for their actions and considering how they can contribute by raising awareness of the issues and initiatives in their workplaces.

DHB

Waitakere Hospital and North Shore Hospital are Toitū enviromark Gold certified.

Have set up the Transalpine Environmental Sustainability Group

Canterbury

and starting to reduce emissions. Working on other initiatives to support sustainability.

Nelson Marlborough South Canterbury

No information on website Business case for the maternity unit and energy change (away from coal) awaiting sign-off from Minister.

Southern

No information on website

West Coast

As per Canterbury

*This information has been identified by visiting individual DHB websites. Plans for sustainability may have been made, but not shared, on public facing websites. Please ask your local DHB to find out what they are doing.

ISSUE 105 JUNE 2022 | 33

PASIFIKA

TALEI JACKSON (FIJI/ENGLAND), AUT MIDWIFERY LECTURER/PASIFIKA LIAISON, COLLEGE PASIFIKA REPRESENTATIVE

navigating new motherhood and study Tyra Fitisemanu (Samoa/Niue), an AUT midwifery student in her final year of the degree, added new motherhood to an already full-time schedule last year. Talei Jackson catches up with her about the joys and challenges of her journey.

Why do you want to be a midwife?

My dream of becoming a midwife stemmed from my upbringing. I come from a family of seven children and have a large extended family. Seeing my hapū aunties and cousins growing up always fascinated me and it was empowering to witness them grow and nurture their pēpi. Once I knew about the scope of a midwife, I never had a Plan B. Many of my peers chose midwifery because their own midwife or midwifery experience inspired them and initially I couldn’t relate. But since having my daughter in 2021, I now understand. I had an inspiring Pasifika midwife, who supported my wish of birthing in a primary unit, and the experience only strengthened my passion further.

After having your first baby last year, you continued with your studies. How was that?

It was hard, but I would do it all over again! Growing up, I saw my mum work full-time, study part-time and care for seven kids, so I felt like I was born to do this. I’m not sugar coating it - having a baby during the degree, or having kids prior to starting, is tough. I remind myself that studying is temporary and the reward at the end will not only benefit myself, but my family and wider community.

I have great family support. Like the saying goes, ‘it takes a village to raise a child’ and I’m so grateful for the village

mama, as they embark on a life changing event. Another recent highlight has been working alongside a Pasifika LMC in a primary unit. Prior to this, much of my clinical experience has been in a hospital setting. Having the opportunity to work in a primary setting, facilitating physiological birth, has made the journey more special.

What have been your challenges through the degree?

Navigating the balance of being a mum with placement, assessments and social life has been challenging. Covid has also been a significant challenge and disrupted placements - it’s impacted the midwifery workforce and it can be hard working in such a stressful environment at times.

Do you have any advice for Pasifika students studying midwifery?

Find a group of like-minded peers; they will be your shoulder to cry on when you feel like you’re drowning, but also your motivators. Reach out for extra support from your Pasifika educators too – they’re there to help you, and no question is a dumb question. One mistake I’ve made is being too scared to apply for scholarships. I encourage my Pasifika peers to apply and take advantage of that extra support.

Lastly, recognise the importance of networking. It’s helpful

that helps me raise mine. My transition into my final year,

to meet midwives and know who you might like to work with

as a mother, has also been more manageable due to the

on placement or after you qualify.

support I receive from my lecturers, especially our Pasifika liaisons. My peers, who have become my sisters, have also

What are your plans following graduation?

been my back bone.

I plan to complete the new graduate programme at

What have been your highlights through the degree?

Midwifery Scholarship. Once I’ve gained more experience,

Working in partnership with wāhine, especially Pasifika

34 | AOTEAROA NEW ZEALAND MIDWIFE

ADHB, as I’m a recipient of an A+ Trust ADHB Pacific I’d love to work as an LMC. square

PASIFIKA

Tyra and daughter Alayah-Marie

ISSUE 105 JUNE 2022 | 35

FEATURE

WHAT ARE WE GOING TO DO ABOUT NITROUS OXIDE? Nitrous oxide, commonly used by labouring wāhine across all maternity facilities in Aotearoa, provides a safe pain-relief solution for women wanting something to take the edge off labour pain, whilst remaining mobile and in control. Dr Rob Burrell, anaesthetist at Middlemore Hospital and Chair of the Australian and New Zealand College of Anaesthetists Sustainability Group discusses the utility of Entonox, its environmental impacts, and suggests solutions midwives can advocate for in their respective work settings.

DR ROB BURRELL ANAESTHETIST MIDDLEMORE HOSPITAL

36 | AOTEAROA NEW ZEALAND MIDWIFE

FEATURE

Nitrous oxide is a great drug, and combined with 50% oxygen as Entonox, it is a very useful pain-reliever in maternity care.

Midwives have access to a safe, predictable, at least moderately effective agent, under the control of the labouring woman. With its quick onset and offset, it is almost ideal for childbirth. Nitrous oxide is a valuable asset; we need to ensure we continue to have it available.

The pharmacological effects - euphoria, analgesia, and anxiolysis - fit well with the need for economical and immediately available pain relief in childbirth, and maternal safety is ensured because the user must be conscious. Giving a woman control of her own pain relief is safe, consumercentric, and frees the hands of health providers to manage other aspects of care.

Once a mainstay of anaesthesia, nitrous oxide has been used since 1844. Hospitals pipe nitrous oxide, and all anaesthetic machines to this day are fitted with the ability to administer precise concentrations of the drug, but times have now changed.

Anaesthetists hardly use nitrous oxide anymore, and it is no longer carried on ambulances for painful emergencies. Dentists (especially paediatric dentists) use nitrous oxide, but it should be noted in lower concentrations than obstetrics; 20-30%, rather than 50%. Whilst this fabulous agent meets the needs of New Zealand parturients, its place amongst the rest of healthcare is fading. In fact, the birthing units in our hospitals and communities are now the biggest users. Midwives are the professional group with the most recent experience, and the greatest exposure. There are two problems with nitrous oxide: industrial exposure, and its contribution to climate change.

Industrial exposure is insidious. With almost no metabolism by the patient (anaesthesia) or the mother (childbirth), exhaled nitrous oxide mixes into the room air, breathed by the nearby healthcare staff.

Operating rooms have sophisticated systems for scavenging gases away from staff, and the standards for theatre air-conditioning are extremely high, with a complete air change every three minutes. Birthing suites are not required to meet the same levels; as a result staff will be breathing at least some nitrous oxide, when Entonox is in use. The chronic effects of nitrous oxide include DNA alteration, disrupted vitamin B12 metabolism with subsequent neuropathy, and adverse effects on a developing fetus. In my own hospital, Middlemore, the birthing unit is a converted ward, with air changes half that of the New Zealand standard for a labour ward.

The only time we attempted to measure midwife exposure, the levels were considered to be safe, but there is certain exposure for those caring for labouring women using Entonox analgesia.

Nitrous oxide is measurable in the atmosphere, rising inexorably over the past 200 years, just like CO2. About 60% is from natural sources, the remaining 40% from human activity. Most of that 40% is from agriculture; nitrogen fertilisers and animal urine get broken down by soil bacteria releasing nitrous oxide. Nitrous oxide is a potent greenhouse gas, with heat-trapping ability 265 times greater than carbon dioxide.

Nitrous oxide is also an ozone-depleting substance. Consequently, tackling climate change, particularly in New Zealand, will mean reducing nitrous oxide emissions from all sources, not just farming. While not (yet) in our emissions trading scheme, its footprint will require offsetting from healthcare under the Carbon Neutral Government Program.

Nitrous oxide as Entonox is a valuable choice for New Zealand’s labouring women.

For mothers, it is safe, effective, and meets their needs. It is critical that we continue to keep nitrous oxide available, but there are concerns for those healthcare professionals with prolonged exposure, and there are environmental implications we will be forced to consider.

Using the global warming potential of CO2 as a unit, the warming impacts of greenhouse gases are measured in kgCO2 equivalents.

The carbon footprint of Entonox analgesia for childbirth in my hospital is 287kgCO2eq per birth. Waitākere DHB numbers are possibly twice that, while CDHB is possibly lower (other sites are currently doing their own calculations). For perspective, 287kgCO2 is the equivalent of driving a small car over 2,000km, or burning 125 litres of petrol, for every baby born. The carbon footprint of nitrous oxide from childbirth is very significant. If my hospital is about average, with 60,000 births per annum in Aotearoa, the carbon footprint of Entonox across maternity facilities is 18,000 tonnes (the estimated carbon footprint of a labour epidural is a couple of kg, and of a caesarean section probably some tens of kg). Perhaps counter-intuitively, hospital-based vaginal births may not be as high carbon, on average, as those in community facilities, where fewer analgesic options are available.

The great news is that technology may come to our rescue, to reduce occupational exposure and climate change. Technical solutions akin to centralised vacuum cleaning systems are now available to scavenge and

Once a mainstay of anaesthesia, nitrous oxide has been used since 1844. Hospitals pipe nitrous oxide, and all anaesthetic machines to this day are fitted with the ability to administer precise concentrations of the drug, but times have now changed.

destroy exhaled nitrous oxide either as portable units, at the bedside, or amenable to reticulated systems as part of new facility builds. There are at least two companies in Sweden which make this type of equipment, and we can expect to take a look at the technology sometime this year.

As usual, there are some questions for which we will have to find answers: •

What does it cost and who will pay?

•

How portable is portable?

•

What fraction of nitrous oxide is captured?

•

How would we manage the more complicated mouthpiece and tubing?

•

Do we need training, and how do we ensure we are maximising effectiveness?

•

Will the extra costs involved be less than the anticipated carbon offsetting fees required by 2025?

The view of the Sustainability Network of the New Zealand Society of Anaesthetists, is that there is potential to protect our people, and our environment, while maintaining access to effective, safe analgesia under maternal control. We believe that where safe technical solutions exist to such problems, we should adopt them. Any new birth facility builds should incorporate a reticulated nitrous oxide destruction system, and portable units need to become available in existing units. We also believe that none of this will happen unless healthcare professionals demand it, and we ask for your support as individuals, and collectively as members of your professional organisations.

The next step is to assess the technology, in our local settings. If it is what we need, we will all have to speak up, and advocate for healthcare institutions to provide it. We must keep ourselves safe, protect our environment, and let our mothers do what they need to do: give birth safely, and make their own choices, with help from high quality maternal care. square

ISSUE 105 JUNE 2022 | 37

BREASTFEEDING CONNECTION

CAROL BARTLE POLICY ANALYST

WORLD HEALTH ORGANISATION REPORT:

HOW THE MARKETING OF FORMULA MILK INFLUENCES DECISIONS ABOUT INFANT FEEDING The International Code of Marketing of Breast-milk Substitutes (the Code), and the regular updates in the form of the World Health Assembly resolutions, are designed to not only protect breastfeeding by stopping inappropriate and misleading marketing of breastmilk substitutes, bottles and teats, but to also protect infants fed on breastmilk substitutes. All parents should have access to unbiased, commercial-free information about infant feeding, and health professionals also need a source of unbiased, scientific and factual information which is not provided, or influenced by, industry.

In 2020 the WHO and UNICEF published a national implementation of the Code status report which presented the legal status of the Code, including the extent of the provisions incorporated into national legal measures in member states (WHO, 2020). Of 194 WHO Member States (countries), 136 (70%) had enacted legal measures with provisions to implement the Code.

Of these, 25 countries had measures substantially aligned with the Code, 42 had measures which were moderately aligned, 69 had included some provisions, and 58 had no legal measures at all. Only 31 countries had legal measures that covered the full breadth of breastmilk substitutes, which includes milk products targeted for use up to at least 36 months of age. In this report, Aotearoa was identified as having no legal measures in place. Although infant formula products are regulated by the Australia New Zealand Food Standards Code, which covers quality issues

38 | AOTEAROA NEW ZEALAND MIDWIFE

such as composition, safety requirements and nutrient content, it does not apply to marketing or advertising practices.

Due to the absence of legal measures, the positive aspects of Code implementation in

Of the 8,528 pregnant and postnatal women surveyed, 51% reported exposure to formula marketing in the preceding year. It was reported that companies were seeking engagement with younger newly pregnant women, referred to as the “holy grail” for sales.

Aotearoa’s maternity system, such as the Baby Friendly Hospital Initiative and Ten Steps to Successful Breastfeeding, were not considered in this Code status report.

The 2022 report by the WHO and UNICEF about infant formula marketing summarises the findings from a multicountry research study and presents opportunities for action. The Code was adopted by the World Health Assembly in 1981 but now, over 40 years later, the marketing of formula milk is described as “one of the most underappreciated risks to infants’ and children’s health” (WHO/ UNICEF, 2022).

The countries involved in the 2022 study were Bangladesh, Mexico, Morocco, Nigeria, South Africa, Vietnam, the United Kingdom of Great Britain and Northern Ireland. The study aimed to capture the experiences of women, and those who influence them, such as health professionals, partners, family members and friends, and their exposure to, and experience of formula marketing. Over 8,500 pregnant women/mothers of young children, and 300 health professionals were surveyed. There were 80 in-depth interviews and 100 focus groups conducted.

Of the 8,528 pregnant and postnatal women surveyed, 51% reported exposure to formula marketing in the preceding year. It was reported that companies were seeking engagement with younger newly pregnant women, referred to as the “holy grail” for sales, and data-driven algorithms were used to target digital advertising to women whose online behaviour indicated that they may be pregnant. Multiple channels, including television, digital marketing, digital influencers with large social media followings, celebrity and paediatrician endorsements were identified as being significant.

Marketing messages were misleading and expansion of the portfolio of products, into follow-on, toddler and growing up milks to circumvent the Code, was found to be a common strategy. Marketing using sciencebased messages was impactful despite the incomplete evidence and unsupported health outcome claims.

BREASTFEEDING CONNECTION

The report also noted that companies have been active during the Covid-19 pandemic to create further anxiety and increase sales. A survey of 1,360 breastfeeding women in the UK during the Covid-19 national lockdown found that 80% of these mothers reported contact from formula companies.

In terms of breastfeeding intentions, pregnant women expressed a strong desire to breastfeed but they were exposed to breastfeeding and breastmilk mythology including misinformation about the adequacy and quality of breastmilk.

Exposure to formula marketing increased favourable attitudes to formula milks, and also convinced some women of the need for a wide range of products including unnecessary follow-on, toddler milks and specialised formulas.

The report is described as the “most complete picture to date of mothers’ and health professionals’ experiences of formula milk marketing” – and the executive summary of the report described the situation as “deeply troubling”.

Key findings in the report were: •

Formula milk marketing is pervasive, personal and powerful.

•

Companies use sophisticated techniques and manipulative marketing tactics, such as claims about products solving common infant problems that exploit parents’ anxieties and aspirations.

•

Companies distort science and medicine to legitimise claims and push products.

•

False and incomplete claims are made to position formula as close to, equivalent to, or superior to, breastmilk.

•

Industry systematically targets health professionals using sponsorship, incentives and training incentives.

•

Marketing undermines parents’ confidence in breastfeeding.

•

Governments, health professionals and their associations, civil society and many other actors can immediately take meaningful actions to end unethical marketing.

ISSUE 105 JUNE 2022 | 39

BREASTFEEDING CONNECTION

(Ministry of Health, 2009), the Code of Practice for the marketing of infant formula in New Zealand (a voluntary and self-regulated industry code), the Code for Advertising of Food and the Food Standards Code. Industry written codes of conduct do not fully represent the Code, and also ignore Code updates in the form of World Health Assembly resolutions. The Food Standards Code - which consists of a range of provisions including labelling, composition, nutrition and health claims, uses and storage information - is covered under legislation.

There is a complaints-based process for the reporting of Code marketing violations, which relies on public and health worker knowledge of the Code, and complainants having the time to submit the complaint and be involved with industry responses to the complaint process (Ministry of Health, 2020). There is no formal, active, or systematic monitoring of formula marketing in Aotearoa.

The report also noted that companies have been active during the Covid-19 pandemic to create further anxiety and increase sales.

A survey of 1,360 breastfeeding women in the UK during the Covid-19 national lockdown found that 80% of these mothers reported contact from formula companies (van Tulleken et al., 2020). Concerns were expressed that the formula industry was violating the Code and actively exploiting Covid-19 concerns about breastfeeding to increase sales by inappropriately and unethically positioning themselves as sources of public health expertise (van Tulleken et al., 2020).

urgency of the problem, to legislate, regulate and enforce the Code and subsequent relevant World Health Assembly resolutions, and to protect the integrity of science and medicine. Investing in training and building the skills of health professionals to enable provision of accurate impartial information, and active countering of the commerciallydriven messages about infant feeding was also recommended. Health professionals were reported as being the main source of infant feeding education in the survey, highlighting their need for accessible, accurate, up-to-date and unbiased information. Strong conflict of interest policies were suggested for health professionals and their organisations.

Opportunities for action suggested in the WHO report included the urgent need for governments to recognise the scale and

Aotearoa’s interpretation of the Code includes a Code of Practice for Health Workers (recommending best practice)

40 | AOTEAROA NEW ZEALAND MIDWIFE

Helen Clark (former Prime Minister of New Zealand) and Tedros Adhanom Ghebreyesus (WHO Director General) discuss the WHO report in the British Medical Journal (2022). They describe how the “cynical marketing tactics used to push milk formula drives over-consumption, discourages breastfeeding, undermines mothers’ confidence, and exploits parents’ instincts to do the best for their children”.

Clark and Ghebreyesus call on governments to enact and enforce legislation aligned with the Code, for ethical business practices, for protection of the integrity of science, with endorsements only for public good to be given by health professional associations, and for social media platforms to reject practices that undermine children’s health. They end their article by saying that now is the time to stop prioritising corporate profits over child health.

As the WHO report points out, it is the marketing of the products and not the products themselves that disrupt informed decision-making and undermine breastfeeding and infant and child health.

With the aggressive and misleading marketing of breastmilk substitutes continuing largely unabated, reported global sales revenue of US$57.12 billion in 2019, and an anticipated rise to US$110.26 billion by 2026 (Global Newswire, 2021), the WHO report highlights the need for urgent action by governments now. square References available on request.

NGĀ MĀIA

KATARINA KOMENE (NGĀPUHI, TE ARAWA), DEPUTY CHAIR NGĀ MĀIA TRUST BOARD

Ngā Māia: kawepūrongo mai ngā hau e whā The newly elected trustees of Ngā Māia Trust Board are excited to share the mahi that we have been undertaking since our Hui-a-Tau in October 2021.

We have been working alongside the Ministry

appropriate support not only for each roopu,

on expert panels reviewing practice policies,

of Health on two significant contracts:

but also for trust board members.

abounds. A big mihi to our chairperson Lisa

•

Mokopuna Ora - pregnancy and parenting website review

•

Health and disability system reforms.

A sub-committee has worked alongside

High on our priority list is a review of the new scope of practice document, which has been developed by the Aotearoa Midwives

Kelly, who is taking the lead on some very challenging kaupapa at the moment.

We are acutely aware of the need to better

roopu, including our own long-standing and

and more frequently communicate with our

respected members Heather Muriwai and

members regarding the mahi we have been

board members, providing input into the mahi

Beatrice Leatham. Initial feedback has been

involved in on your behalf. To this end, we are in

surrounding the health and disability system

sent to Midwifery Council, but we have also

the process of establishing a new Ngā Māia Trust

reforms and Pae Ora Healthy Futures Bill. On

requested a deadline extension so that we

website which will enable us to communicate

the recommendation of this sub-committee,

can send our draft feedback to members for

more efficiently with members and allow new

we will continue to challenge the processes

consultation.

members to register with Ngā Māia.

of the Transition Unit and ensure member engagement moving forward.

We have also worked with AUT to establish a position description for the role of Te Ara Ō Hine National Co-ordinator and determine how we, in partnership with AUT, will best meet the

Other mahi your board members have been involved in as Ngā Māia representatives include: •

midwifery •

The Māori midwifery school kaupapa is back Wānanga o Awanuiārangi and members will be

• •

consulted for feedback after the next hui. Our current trust deed is also under review and at time of writing, plans to wānanga about this have been set for the end of May. We are currently working with each Ngā Māia roopu around the motu to establish a Kaumatua Board, to ensure access to

Ministry of Health - Transition Unit and Mokopuna Ora

ongoing needs of tauira Māori nationally. on the table following a promising hui with Te

Tauira Māori hui advocacy - in all schools of

•

As a board, we have decided not to fill the CEO role with a permanent replacement at this time, but at time of writing we would like to hear from anyone willing to fill the role in a temporary capacity, until it is redefined. The person would in essence be the face of Ngā Māia Trust and the media spokesperson. Please

Te Ara Ō Hine (AUT) - administration of

contact either myself, Tamara Karu or Lisa Kelly

Māori mentor funds

to discuss further.

College governance restructure (more

Lastly, the board would like to congratulate

Māori representatives vs. Treaty partnership

Ngarangi Pritchard on her position as tangata

model)

whenua co-chair of Te Tatau o te Whare Kahu,

ACC legislation for maternal birth injuries.

and Beatrice Leatham as the new Minister of

Administrative changes and communication with varying organisations and individuals seeking advice/consultation with Ngā Māia on a variety of kaupapa, including representation

Health appointed member. It is always great to have our own representing whānau Māori in these very important roles.

Ngā manaakitanga ki a tātou katoa. square

ISSUE 105 JUNE 2022 | 41

FROM BOTH SIDES

my coach my coaching Midwife Ali Woodhouse received invaluable tautoko (support) from clinical

Māori midwife Dani Gibbs works as a clinical coach at Christchurch

coach Dani Gibbs throughout her new graduate year at Christchurch

Women’s Hospital (CWH) and sheds light on what the recently

Women’s Hospital (CWH) and considers the role indispensable.

created role entails.

Ali attributes her interest in midwifery to growing up on a farm in

Dani applied for the new clinical coach role in 2021, excited by the idea

Aotearoa’s deep south, where lambing season provided her earliest

of creating something from scratch. “I really like teaching and I’ve always

experiences of birth attendance. But despite figuring out her path

enjoyed working with students,” she explains. “Having been both a core

relatively early, the road to midwifery registration has been a long and

midwife and an LMC recently, I felt like I could see where the gaps in

challenging one.

support were and how we could best retain our new staff.”

“I started on a pre-health pathway with the goal of becoming a midwife

The Ministry funds the 1.5 FTE role, which Dani (Ngāi Tahu, Ngāti Māmoe,

when I was 18 years old, but stepped away to raise

Ngāti Apa, Te Āti Awa ki Te Tau Ihu, Te Āti Awa ki

children,” she explains. “I had already adopted my

Taranaki) shares with colleague Catherine. Collectively,

eldest son and couldn’t maintain studying while

the pair has designed the role to be flexible, staggering

raising a baby. I went on to birth three biological sons, one of whom was a second trimester loss eight years ago - which delayed my midwifery journey further - and a foster daughter also joined our whānau permanently.”

Over 20 years later, Ali stepped back on to the midwifery path, and this time, her five children - who are all Māori, with connections to Ngāpuhi and Ngai Tahu - would be her driving force. Her desire to honour their whakapapa as tāngata whenua is carried into her work as a midwife, where she aims to uphold equity through te Tiriti.

their start times so that support is on-hand for midwives from 8am-6.30pm, Monday-Friday.

“I work my day around new graduate midwives, so I look up their rosters and catch them on shift to see what they might need support with. It might be clinical, for example if it’s the first time they’re attending a very pre-term birth, or if they need help with IV cannulation. At other times it’s answering questions about guidelines and policies. It’s not exclusive to new graduate midwives either; if a senior midwife wants support refreshing perineal suturing skills, that’s also part of my role.”

As a new graduate midwife at CWH, her first interaction with clinical coach Dani provided the cultural safety she was looking for in her workplace.

“We were in a workshop and there was a discussion around perinatal mortality. Because Dani was involved, we were able to safely engage in a really robust conversation about te ao Māori and beliefs

At other times, the role is more pastoral. “A lot of what we do is actually whanaungatanga, like making cups of tea for our new staff who are working in the DHB at a really stressful time, coping with understaffing and the added challenges of Covid-19.”

Part of Dani’s motivation to become a clinical coach

surrounding the concepts of tapu (sacred/restricted)

was rooted in her own mixed whakapapa and the role

and noa (free from tapu/unrestricted).”

she plays within her local collective of Māori midwives.

The coaching relationship flourished from there.

“Dani would seek me out when I started a shift, checking in to see if there was anything I was unsure of, or that she could help me with.”

The manaaki she received was instrumental. “If Dani hadn’t been there providing those moments of pastoral care, allowing me to cry, offload, and receive support, I don’t think I would have survived as intact or confident as I am now. She became my training wheels for those first few weeks, but without making me reliant on her. She empowered me, and I wonder what retention would have been like for other cohorts, had the role existed previously.”

Also a Homebirth Association trustee, Ali has been so well supported at CWH that she perceives opportunity where others might see irreconcilable

“I also saw this role as an opportunity to build more collegiality within the DHB. I have a lot to do with Māori midwives ki Tahu, so I thought I’d be in a good position to engage with leadership while supporting minority groups like tāngata whenua by working within te Tiriti.”

Knowing that her role provides increased support for midwives returning to practice is another plus for Dani. “We’re now the Midwifery Council-appointed supervisors for midwives returning to practice, so midwives aren’t having to pay for supervision out of their own pockets anymore. DHB clinical coaches now perform that role, which is a great incentive for midwives who might be weighing up whether to come back.”

Dani also supports midwives with career progression and hopes her own

difference. “I feel like I straddle both worlds, having a homebirth

role will continue to expand as more midwives reap the benefits. “We

philosophy and working in a tertiary environment. But I enjoy the dynamic

have goals of being able to offer more group teaching sessions, run SIMS,

fast-paced nature of it and as I lean into the role more, I see how my values

and create individual career development plans with midwives who have

fit in. I can still promote normal physiology and protect birth. I see a lot of

specific goals like becoming a flight midwife, for example. We really want

good happening, as much as it’s challenging.”

to see midwives thriving.”

42 | AOTEAROA NEW ZEALAND MIDWIFE

square

square

DIRECTORY

New Zealand College of Midwives Directory President Nicole Pihema Ph 021 609 011 nicolepihema@gmail.com National Office PO Box 21-106, Edgeware, Christchurch 8143 Ph 03 377 2732 Fax 03 377 5662 nzcom@nzcom.org.nz www.midwife.org.nz College Membership Enquiries Contact Lisa Donkin membership@nzcom.org.nz 03 372 9738 Chief Executive

Northland

Student Representatives

Christine Byrne

Penny Martin

tetaitokerauchair@nzcom.org.nz Otago

Ana Ngatai

Jan Scherp, Charlie Ferris

ana.olsen.ngatai@hotmail.com

otagochair@nzcom.org.nz Southland Natasha Baillie Ph 021 258 2701 merakimidwifery@gmail.com Waikato/Taranaki Jenny Baty-Myles chairwaikatonzcom@gmail.com

www.ngamaia.co.nz Sarah Wills Ph 021 02551963 sarahandcale@hotmail.com Lisa Kelly lisakellyto@yahoo.co.nz Pasifika Representatives

Suzi Hume

Talei Jackson

chair@wellingtonmidwives.com Regional Sub-Committees Hawkes Bay Sub-Committee

Delia Sang, Administrator

Sarah Nation

Yarnton House, 14 Erson Avenue

sarahnation.midwife@gmail.com

PO Box 24487, Royal Oak, Auckland 1345

Ngā Māia Representatives

Wellington

Alison Eddy Auckland Office and Resource Centre

pennymartin79@live.com

Ph 021 907 588 taleivejackson@gmail.com Nga Marsters Ph 021 0269 3460 lesngararo@hotmail.com

Manawatu Sub-Committee

MERAS

auckadmin@nzcom.org.nz

Jayne Waite

PO Box 21-106, Edgeware

j.waite70@gmail.com

Christchurch 8143

National Board Advisors

Taranaki Sub-Committee

Elder: Sue Bree

Ange Hill

Kuia: Crete Cherrington

nzcom.taranaki@gmail.com

Ph 09 625 9764 Fax 09 625 0187

Education Advisor: Tania Fleming tania.fleming2016@gmail.com Regional Chairpersons Auckland Sarah Ballard, Linda Burke auckchair@nzcom.org.nz Bay of Plenty/Tairawhiti

Wanganui Sub-Committee

chairnzcom.cantwest@gmail.com Central Julie Kinloch

Ph 021 158 6874 jothemidwife@gmail.com Horowhenua Jennie Ferguson thejensterrocks@gmail.com

meras@meras.co.nz MMPO mmpo@mmpo.org.nz Ph 03 377 2485 PO Box 21-106, Edgeware, Christchurch 8143 Rural Recruitment & Retention Services Rural contact: 0800 Midwife/643 9433

Consumer Representatives

rural@mmpo.co.nz

Royal New Zealand Plunket Society Carla Kamo

Resources for midwives and women

carla.kamo@plunket.org.nz

The College has a range of midwifery-

Home Birth Aotearoa

julie.kinloch.nz@gmail.com

Eva Neely

tetauihunzcom@gmail.com

Ph 03 372 9738

Ph 021 232 1980

Ph 06 835 7170

Nelson/Marlborough

General Enquiries & Membership

Jo Watson

chairnzcomboptairawhiti@gmail.com Canterbury/West Coast

www.meras.co.nz

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

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