A CLASH OF VALUES

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 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 square

“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).

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 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