10 minute read
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In addition to these oversights, community midwifery lags behind the remainder of the health system, stuck with an out-of-date contract that has remained largely unchanged since it was written in 1996.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
Student midwifery and rural student midwifery grant applications close 15 July 2022. Midwifery post-graduate education Semester Two grants are open.
Refer to www.midwife.org.nz for further information.
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THE BEST PROTECTION FOR BABY 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.
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.
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.
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.
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.
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
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. square
