Midwife Aotearoa New Zealand by Collegeofmidwives

Q&A: PELVIC ISSUEPHYSIOTHERAPYHEALTHP.26106SEPTEMBER2022I THE MAGAZINE OF THE NEW ZEALAND COLLEGE OF MIDWIVES BUNDLESOASIUNPACKINGCARE ARE THEY RIGHT FOR AOTEAROA? P.18 SUDI: MINISTRY REVIEW AFFIRMS POVERTY A MAJOR FACTOR P.28 CLIMATE CHANGE: CONSUMERISM & MIDWIFERY P.32 handsPoised? off?hands BirthPosition?Warmcompress?perinealmassage?Slowbirthofhead?TwoMidwivesatbirth?

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FROMFORUMTHE PRESIDENT 4. HE MAŪNU KAUKAU WAI FROM THE CHIEF EXECUTIVE 5. ARE WE FIT FOR THE FUTURE? 8. 14.12.10.BULLETINYOURCOLLEGEYOURUNIONYOURMIDWIFERY BUSINESS 16.FEATURES NGĀ MĀIA 17. ACC COVER: MATERNAL BIRTH INJURIES 18. OASI CARE BUNDLES 26. Q&A: PELVIC HEALTH PHYSIOTHERAPY 28. SUDI: MINISTRY REVIEW 32. CLIMATE CHANGE: CONSUMERISM AND MIDWIFERY 36. PASIFIKA: TAPU ORA KUA MUA, KA MURI 38. BREASTFEEDING CONNECTION 42. MY MIDWIFERY / MY MIDWIFE DIRECTORY ISSUE 106 SEPTEMBER 2022 EDITOR Amellia Kapa E: communications@nzcom.org.nz ADVERTISING ENQUIRIES Hayley McMurtrie, P: (03) 372 9741 E: Hayley.m@nzcom.org.nz MATERIAL & BOOKING Deadlines for September 2022 Advertising Booking: 7 November 2022 Advertising Copy: 14 November 2022

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Otago Polytechnic Principal Lecturer (Midwifery) Lorna Davies challenges us - both as individual practitioners and a profession - to explore a term very much entrenched in the midwifery psyche (pg. 32). Is it as benign as we might like to think it is?

The proposed legislative changes poised to extend ACC’s cover of maternal birth injuries have set the tone for this issue. A comprehensive analysis of OASI care bundles undertaken by the College’s own Elaine Gray and Research Midwife Specialist Dr Robin Cronin can be found on pg. 18. This deepdive into perineal care explores a number of international approaches and studies, providing much food for thought in the current climate of increasing intervention.

Recent history demonstrates those who have been in positions of influence within the old structures have not performed, so I struggle to see how a reshuffle of these same people into different positions, with refurbished job titles, will produce different results. As the whakatauki above alludes to, what have they achieved directly for whānau? Will they continue to swim around aimlessly, spouting big promises but achieving little? Let accountability start now.

If you are involved in webinars or waananga, ask questions and remember who said what. It’s not only Te Aka Whai Ora who are responsible for holding Te Whatu Ora

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

If so, by all means advocate for it and consult with our collective bodies - Ngā Māia and the College - for support. The course of our waka is about to change, but we need to make sure it’s being steered toward our whānau, so they can be picked up and asked what direction they want to go in.

accountable; we too are consumers of this system, alongside the whānau we care for. Many ideas are sure to emerge from the workstreams, so my advice is to remain connected to the whānau receiving our care. Do the ideas align with what whānau want?

“Āe, he maūnu kaukau wai”

Finally, From Both Sides (pg. 42) tells the story of two women whose similar childhood experiences made for an even more meaningful midwifery partnership.

The focus on the pelvic floor is continued on pg. 26, where Auckland-based women’s health pelvic physiotherapist Tania McLean offers her insights and experience to midwives in a Q&A. The proposed extended list of ACC-covered maternal birth injuries and further details can be found on pg. 17.

As the whakatauki above alludes to, what have they achieved directly for whānau? Will they continue to swim around aimlessly, spouting big promises but achieving little? Let accountability start now.

The (former) Ministry’s SUDI review, including the Expert Advisory Group’s (EAG) report and recommendations, are detailed on pg. 28. A sobering but necessary read for midwives, the EAG highlights the broader stressors foregrounding SUDI, reiterating the need for an overhaul of social policy and increased focus on achieving equity if this tragic event is ever to become a thing of the past.

Nau mai haere mai ki Aotearoa New Zealand Midwife

When I first learned of the proposed health system reforms and the creation of the Māori Health Authority, I tried hard to suppress my inner critic and believe that after so many years - of empty promises, heartfelt apologies, re-designs, and failures - our government might finally get it right.

In a previous issue I discussed my fears around who will hold power in these two new entities, now named Te Aka Whai Ora and Te Whatu Ora. As information comes to light about the individuals who will have the most influence determining the trajectory of women’s health, it can be likened to the reveal of each room on a home renovation series. A fresh lick of paint and an array of flash new appliances gives the impression that this is a completely fresh start, and our newest chief executives are playing the role well; fresh-faced, motivated and passionate about change. Peel back a few layers, however, and the developing strategy reveals old, rotting timber frames.

I want this new system to succeed. I want our whānau to feel safe. I want care to start in the home, on the marae, on the street corner. Wherever our whānau are, is where we need to be, and this approach should be applied across the board in healthcare, not only in midwifery. I will do my part to ensure positive health outcomes for whānau are at the centre of what we do; not personal agendas or flash job titles. Nothing is more important than whānau and whenua. square

from the president, new zealand college of midwives, nicole pihema

Yes, like a duckling that swims about in the water (Mead, 1891:16)

4 | NEW ZEALAND COLLEGE OF MIDWIVES MAGAZINE FROM THE EDITOR 4 | AOTEAROA NEW ZEALAND MIDWIFE FROM THE PRESIDENT

For the vast majority of midwives currently practising in Aotearoa, the College has always existed. Established 33 years ago, at a turbulent and formative time in our profession’s history and evolution, I have always considered our professional identity in this country to be intertwined with the College, to a greater or lesser extent. The re-establishment of midwifery autonomy and its important link to women’s autonomy over their childbirth choices is a fundamental part of our back story and professional identity.

ISSUE 106 SEPTEMBER 2022 | 5 FROM THE CEO

College’s objectives have been refreshed and updated over the years, our core function representing the collective

As a membership organisation, we exist to represent the views and conscience of our profession. At times this may mean we engage in healthy and respectful debate with each other and with various other agencies in the wider health sector.

ARE WE FIT FOR THE FUTURE?

Throughout these changes, the College’s unique role and purpose (as expressed by our constitutional objectives) has remained clear. In its early days, in the absence of a dedicated regulatory authority, the College defined many of the professional frameworks which were necessary to develop in order to ‘re-establish’ the profession. As other entities such as the Midwifery Council have evolved over time, the College’s role has changed to become complementary to that of the regulator. As a membership organisation, we exist to represent the views and conscience of our profession. At times this may mean we engage in healthy and respectful debate with each other and with various other agencies in the wider health sector, although for the most part, we all have the same end goal; improving care and outcomes for māmā, pēpi andAlthoughwhānau.the

ALISON

The College has experienced the various iterations of the health system and the different entities which have been established and disestablished along the way: Regional Health Authorities; Crown Health Enterprises; the Health Funding Authority and Health and Hospital Service; District Health Boards and now Te Aka Whai Ora (Māori Health Authority); and Te Whatu Ora (Health New Zealand).

EDDY CHIEF EXECUTIVE

voice and vision of the profession has remained steadfast. Our reason for existing is not one of self-interest for the profession, but rather the clear understanding that the protection and promotion of universal access to quality midwifery care supports equity and improves outcomes for birthing women and newborns. Over the years since the College’s establishment, the evidence base which demonstrates this has grown considerably, giving strength to our purpose as an organisation.

• To provide expert advice to government and other relevant agencies to strengthen and support the midwifery profession.

Te mahi: support a cohesive, sustainable and innovative workforce for the future Kāwanatanga: strengthening our organisational structure and capacity

The College’s responsibility to uphold the articles of te Tiriti O Waitangi have been a central feature of the board’s deliberations as the plan was developed. Instead of this responsibility being a stand alone focus area, it is intentionally woven throughout the entire plan, to provide more meaningful direction. Undergoing this process has stimulated further conversations about how we achieve our goals and what this means in terms of our organisational governance, leadership and wider capacity. The College has already taken positive steps toward honouring this commitment, with the cultural review we are about to embark on.

Built on a culture of commitment to the profession by its members, the College started as a grassroots feminist organisation. Our membership has grown over the last 33 years, as has our understanding of the health gains our profession has the potential to contribute to. Our way of working and organisational model has served us well. But if we are to remain successful, we must ask ourselves what we need to change, to ensure we are ready to take on the challenges we face in Aotearoa in 2022. square

• To advocate for, promote, and evaluate undergraduate and postgraduate education and provide continuing education for midwives.

COLLEGE’S OBJECTIVES

• To operate in an efficient and effective manner to the benefit of its members through the delivery of a comprehensive professional service to its members.

• To lead, promote and support partnershipbased midwifery practice that conforms to the Code of Ethics and the Standards for Midwifery Practice.

• To commit to upholding the articles of te Tiriti O Waitangi by recognising Māori as Tangata Whenua of Aotearoa.

6 | AOTEAROA NEW ZEALAND MIDWIFE FROM THE CEO College Annual General Meeting (AGM) Date: 23 November 2022 Venue: Novotel Hotel, Cathedral Square, RemitsTime:Christchurch6.00pmforconsideration: Social Media consensus statement. Members will be notified of any further AGM remits prior to the meeting, via email.

As a profession, we have a strong social mandate. We are accepted by the public as possessing particular knowledge and skills, which we are trusted to utilise in the interest of others. Essentially, the public trusts us to carry out our role as we have been educated to, adhering to the accepted professional standards. When we consider our social mandate,

• To build and maintain relationships with relevant national and international agencies to the benefit of midwifery in New Zealand, and to contribute to the global midwifery community.

• To purposefully and continuously develop and maintain a strong autonomous midwifery profession in New Zealand.

Although these are the result of issues such as intergenerational poverty, colonisation, institutional racism and the Crown’s failure to honour its te Tiriti commitments - all of which go well beyond the scope of what health professionals, let alone the entire health system, can solve - we cannot ignore these issues. Although the College is not a Crown entity, we must consider our responsibilities as an organisation, to address what we can within the context of maternity care.

2022–2026: Strategic plan focus areas Ōritetanga: equity, inclusion and belonging Rangatiratanga: leadership & advocacy

alongside our role to act as change agents for women’s reproductive rights, we must also consider our responsibility to address the well documented health inequities particular individuals and groups experience.

The College’s board has deliberated over our priorities as we have been updating our strategic plan. Through these discussions, four key areas have been identified to focus on over the next four years.

At a societal level midwifery has acted as a change agent to advocate for women’s reproductive rights, particularly in relation to choices over childbirth and challenging unnecessary medicalisation. Globally, midwifery also plays an important role in advocating against the discrimination women experience as a result of their unique biological reproductive capabilities. Although we may feel we have made significant progress, the recent US Supreme Court decision overturning Roe vs Wade demonstrates that our work is not yet over.

• To lead the development and maintenance of a quality assurance framework to improve maternity outcomes for women and families.

• To conduct, promote and disseminate relevant research which provides an evidence base for midwifery practice in New Zealand.

• To advocate for the development and provision of services, policies and programmes that support the improvement of maternity outcomes and health status of women and their whānau.

There’s no birth like a Calmbirth ®

The World’s Safes t Baby Wrap w w.safet sleep.com safely lasts two babies aged 0-2 yrs

• develop a new primary midwifery services contract;

The College remains committed to exploring all avenues for a durable solution that protects the interests of its members and resolves the systemic issues faced by the profession. This includes enforcing the commitments made by the Government to the profession and/or working constructively with Te Whatu Ora to secure a durable solution to the systemic issues faced by the profession. square

1992est

The Minister and Associate Minister expressed genuine concern about the Government’s failure to comply with its commitments to the profession. They have indicated an intention to take meaningful action to address our concerns, including setting in place a process to develop a new contract and consider the wider support services needed for primary midwifery services. Minister Little has committed to overseeing the work directly. This is a welcome and constructive response from the Minister and Associate Minister of However,Health.giventhe

SPACE IS LIMITED – To register for a class go to www.pepi.adhb.govt.nz

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ISSUE 106 SEPTEMBER 2022 | 7

• explore what support services (in the form of a midwifery provider organisation) would be required to sustain them.

The College has been working tirelessly on behalf of the profession to hold the Government to its commitments for several years now. Most recently, the College met with the Minister and Associate Minister of Health to ensure the Government fully understood the nature of the issues, why we were proposing to take legal action, and what our desired outcomes are.

PhotographyScottAngelaImage:

Government’s history of broken promises despite formally entering into settlement agreements on two occasions, the College considers that it is incumbent upon it to take steps to protect the legal position of its members. The College has therefore filed a legal claim on 31 August 2022. The purpose of the claim is to protect the legal position of the College’s members and the profession more generally, under the terms of the existing settlement agreement entered into with the Government.

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class action update

This level of response demonstrates the depth of concern and feeling amongst the profession about the manner in which the profession’s views have been disregarded, and the desire to hold the Government to account for repeated failures to honour commitments made to the College - and the profession more generally - in legally binding agreements.

· Live within the Te Toka Tumai catchment area

Calmbirth ® is partially funded by Te Whatu Ora Te Toka Tumai for pregnant couples who meet the following criteria:

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a g e d a p p r o x i m a t e l y 0 2 y r s

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Over 1,300 members have signed up to participate in the class action developed by the College to enforce the terms of the settlement agreement against the Government.

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Comfort and safety for babies newborn-2 years

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· Plan to birth at Auckland Hospital

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• fund primary midwifery services to a ‘fair and reasonable’ amount; and

· Plan to have a normal birth (ie a vaginal birth, not an elective Caesarean-Section)

Comfort and safety for babies newborn-2 years

Under the terms of the current settlement agreement, the Government agreed to:

DECLINICALLYPROVENSAFE•TRIALL•

The College congratulates Bev Pownall (Ngāti Apakura, Ngāti Kahungungu ki Wairarapa), who was recently made an Officer of the New Zealand Order of Merit for services to health - in particular breastfeeding.

Her contributions to national breastfeeding strategy have been recognised, including the integral role she played in the development of national tongue-tie in breastfeeding guidelines.

Bev Pownall

and co-ordinated by the World Alliance for Breastfeeding Action, was Step Up For Breastfeeding: Educate and Support. Target audiences for this message included governments, health systems, workplaces and WBWcommunities.hasbeenaligning with the United Nation’s Sustainable Development Goals since 2016 because of the strong links between breastfeeding and nutrition, food security for infants, and the ever-increasing issues of poverty and inequity globally.

Scope of practice

In July, the Midwifery Council reported on feedback received from the first consultation on the draft revised midwifery scope of practice. The feedback had been collated and analysed by an external organisation commissioned by the Council.

conditions, workload and staffing problems faced by midwives. square another midwife joins New Zealand Order of Merit

Bev qualified as a midwife in London in 1996 and certified as an International Board Certified Lactation Consultant (IBCLC) in 1997. Since then she has mentored many health professionals to become qualified IBCLCs, worked with both the New Zealand Breastfeeding Alliance and New Zealand Lactation Consultants Association serving on both organisations’ boards, and played a key role in the implementation of the Baby Friendly Hospital Initiative throughout Aotearoa’s maternity facilities.

8 | AOTEAROA NEW ZEALAND MIDWIFE BULLETIN

The College had provided a submission on the draft scope - informed by extensive member consultation - and the themes identified by the College were visible in the Council’s report. The Council has committed to developing a second draft in response to the 224 submissions it received, and consulting with the sector again on the next iteration. square

bulletin

Midwives play a key role in supporting breastfeeding women, and recognise the importance of breastfeeding to maternal, infant and child health, both short and long-term. The NZ government has expressed a commitment to increasing the number of mothers who breastfeed for longer (Verrall, 2021) but actions speak louder than words, and the time to actually step up, fund, resource and provide the structures to enable and support women to breastfeed is well overdue. This includes solutions to the

The theme for this year’s World Breastfeeding Week (WBW), held 1-7 August

World Breastfeeding Week 2022

GLOBAL GUIDELINE FOR MIDWIFERY LEADERSHIP

Whānau of the rapidly growing Selwyn district now have a modern alternative following the closing of Lincoln Maternity Hospital, with all staff from Lincoln transferring to Oromairaki.

The new facility - situated a 15-minute ambulance drive from Christchurch Women’s Hospital - contains two birth rooms, two assessment rooms and ten postnatal rooms.

This document was ratified, although discussion acknowledged the need for changes to further strengthen it.

www iblce org | +61 7 5529 8811 apaadmin@iblce org

Lactation Speciﬁc Education

IBCLC Examination Eligibility Criteria

ICM: reformsgovernanceandglobal guideline for midwifery leadership ratified

Oromairaki Community Maternity Unit, a new birthing facility located within Toka Hāpai/ Selwyn Health Hub in Rolleston, Canterbury, was officially opened at the end of May.

Turn your lactation knowledge and skills into an international qualification...•Registration/degree as a recognised health professional or 14 subject courses, AND • 95 hours of education on human lactation and breastfeeding, including 5 hours of education focused on communication skills, AND • Examination eligibility for midwives is Pathway 1: 1,000 hours in an appropriate supervised setting (All lactation speciﬁc education and clinical hours must be completed 5 years prior to application) ISSUE 106 SEPTEMBER 2022 | 9

Bev served 13 years as treasurer of the Auckland regional College branch and continues to represent the region on the Northern Breastfeeding Network. A founding and ongoing contributor to the Big Latch-On and World Breastfeeding Week in Aotearoa, Bev is also an active member of the Māori Women’s Welfare League.

The decision to reduce the number of ICM board members to one representative

The name Oromairaki means ‘resonating sounds of heaven’ and was gifted by Te Taumutu Rūnanga. It acknowledges Hinete-iwaiwa, the atua wahine (female deity) of childbirth, and represents the sighs of motherhood and cries of new life.

per ICM region, plus a treasurer, was agreed at last year’s Council meeting.

She continues to support whānau throughout their birthing and breastfeeding journeys at Ngā Hau Mangere Birthing Centre, where she enjoys working alongside South Auckland’s diverse communities. Ngā mihi nunui ki a koe e Bev. square

As a member of the International Confederation of Midwives (ICM), the College was represented at the annual ICM Council meeting, held virtually in June. Two significant remits were passed at this meeting, both of which provide ongoing guidance for the development of midwifery.

These revisions will be made and an updated version will be presented at next year’s Council meeting (to be held face-to-face in Bali next year, directly before the ICM congress). The document

square Oromairaki Community Maternity Unit

Health Sciences Education

GOVERNANCE REFORM

will be available on the ICM website shortly, alongside the recently published Enabling Environments policy brief. square

This decision does not impact New Zealand; as part of the Western Pacific region we have only ever had one representative for our region - currently Ann Kinnear from Australia.Thisyear, the Council agreed to ratify the Terms of Reference for an independent election committee, paving the way for ICM board members to be selected by appointment rather than being voted in by the regional membership associations. The rationale for this change is to strengthen the overall governance of ICM and ensure there is equity, diversity and inclusivity in the board’s composition.

opening of Oromairaki

Lactation-Speciﬁc Clinical Practice

10 | AOTEAROA NEW ZEALAND MIDWIFE YOUR COLLEGE

Midwives are encouraged to familiarise themselves with the Aotearoa New Zealand STI Management Guidelines for use in Primary Care. Go to sti.guidelines.org.nz for practice guidance for each STI, as well as great information on taking a sexual history, recommended tests when a sexual health check is needed, partner notification and contact tracing.Thewebinar recordings will be made available on the College’s new e-learning platform when it is launched this year. square

Researchers from the University of Auckland held a multidisciplinary symposium in July to present the findings from their HRC-funded research programme, with attendance by College representatives.

The webinars were very well attended and we have received positive feedback, including requests to offer future education updates via webinar.

• How do cultural values impact on reproductive health for women and men in A/EM communities?

• What are the implications of NZ’s 2020 abortion reform for A/EM communities?

Kate Clark, MFYP administrator finished at the end of July for a new career opportunity after eight years. Geri Nolan has commenced in this role as Kate's replacement.

Ngā mihi aroha ki a koutou katoa. square

STI WEBINAR SERIES AND GUIDELINE

Jacqui Anderson has retired and left the College at the end of August. A great loss to the College, Jacqui was a founding member and has held many roles in midwifery throughout her career. Her depth of knowledge and experience will be missed.

The purpose of the day was to initiate an in-depth conversation around reproductive and sexual health issues that impact particularly on Asian and Ethnic Minority (A/EM) women in New Zealand. Sessions were focused on community, policy and data, with presentations followed by group workshop discussions. The researchers framed the day around the following questions:

• A detailed meeting report and considerations for actions will be communicated to members in due course. square

We wish you all well in your future endeavours and thank you for many years of service and wonderful shared memories.

• What are the data needs, gaps and challenges in order to understand reproductive practices among A/EM women?

In June, the College hosted a three-part sexual health update webinar series on STI screening, diagnosis, treatment and referral in primary care.

Women, Reproductive Health and Cultural Diversity in Aotearoa NZ Symposium

Changes at national office

A new front office administrator, Fiona Ruddenklau, has been employed to replace Kerry Blackwood, who has also retired after 14 years at the College.

ISSUE 106 SEPTEMBER 2022 | 11

Terranova argued that the only comparison needed was that of the four male workers

The 1972 Equal Pay Act’s (EPA) 50th anniversary falls on 20 October this year. Whether midwives achieve pay equity by then or not, I relish the idea of hundreds of women picnicking on the grounds of Parliament wearing 1970s clothes. Many of us, myself included, were not yet born at the time.

My parents were married in September 1972 - one month before the EPA was passed into legislation. Being young and newly married, it’s likely my mother was thinking about other things, but I like to imagine she thought “this is great if I have daughters one day, they’ll be paid fairly”.

In 2003 the Labour government established

a Pay Equity Unit in the Ministry of Women’s Affairs and a Taskforce on Pay & Employed Equity in the Public Service was initiated. As the 2008 election loomed, all 39 public service departments had been assessed: undervaluation ranging between 3%-35%. However, citing job evaluations as “unaffordable in the current economic and fiscal environment”, the incoming National government abolished the Pay Equity Unit and the taskforce.

THE BARTLETT CASE

If my mother was alive, I wonder what she would think of the socio-political changes that have occurred since she was a newly married woman needing her husband’s permission to obtain the contraceptive pill. She died when I was 10 years old, but if she had held strong beliefs as to what she wished for my future, she might have mentioned something, even in passing. My parents were married in September 1972 - one month before the EPA was passed into legislation.

The claims remained unaddressed, however, when three months later the incoming National government threw out the legislation. Little changed throughout the 1990s, despite the Human Rights Act stating sex-based discrimination was unlawful.

ELIZABETH WINTERBEE MERAS WORKPLACE REPRESENTATIVE TE WHATU ORA NELSON MARLBOROUGH DISTRICT

The Labour government’s 1990 Employment Equity Act remedied this, allowing pay comparisons between different industries. Ten groups lodged claims and quickly established that their male counterparts were paid $100 more a week, for work of equal value.

In 2012, the Service Food Workers Union (SFWU) on behalf of Kristine Bartlett, filed a claim with the Employment Relationship Authority against her employer, Terranova Homes and Care Ltd. Citing a breach of the Employment Relations Act, Bartlett argued she was not being paid fairly based on her skills, experience and working conditions. Despite 20 years of experience, she was earning $14.46/hr as a caregiver, while the gardener earned $16.56/hr. Her case was forwarded to the Employment Court to consider whether the original intent of the EPA included pay equity.

12 | AOTEAROA NEW ZEALAND MIDWIFE YOUR UNION

Being young and newly married, it’s likely my mother was thinking about other things, but I like to imagine she thought “this is great – if I have daughters one day, they’ll be paidThefairly”.EPAensured pay equality (women and men doing the same job to be paid the same), but it remained unclear whether this extended to pay equity (equal pay for work of equal value). In 1986, the Clerical Workers Union tested this in the Arbitration Court, but the court lacked the authority to resolve the ambiguity of the EPA, closing the door on future claims.

fifty years in the making

Women have always had to fight five times harder to obtain the same rights as men, so I was not surprised to witness underhand tactics commonly used by the patriarchy when faced with potential loss of money and power. It was the blatancy however, beginning with the deliberate omission of GPs as a potential comparator, which left me stunned.Afterleaving school, my mother worked behind the counter at the local post office until she married my father. She had two children, cooked, cleaned, knitted and sewed us matching outfits. I will never know if she harboured other aspirations, but I do know that it is only due to decades of hard-won

In 2015, while Bartlett’s case was still making its way back to court, other organisations representing women-dominated professions, such as the College, began filing pay equity claims. In October, the Nationalled government announced it would seek to resolve the Bartlett case out of court. This was met with cynicism, given the government’s vested interest in employer rights and fiscal responsibilities.Nonetheless,a Joint Working Group formed in June 2016, developed universally applicable equal pay principles, and presented these to the government. Formally accepting these recommendations in November, the government enacted the 2017 Care and Support Worker (Pay Equity) Settlement Act, settling Bartlett’s case on 18 April 2017.

of new legislation to enable further pay equity claims. However, despite the 2013 court ruling and the working group’s recommendations, the bill limited comparators to those within the same workplace or industry. However, the only occupational group in the health sector that is not women-dominated are bio-medical technicians.Theincoming Labour government rejected the bill, instead drafting a revised EPA. MERAS presented our union’s submission at the Select Committee in February 2019. I had made a last-minute decision to attend and found myself addressing the Select Committee. “The (1972) Equal Pay Act was passed before I was born”, I began. “I shouldn’t be here - none of us should be herethis should have been sorted a long time ago.”

socio-political change that I had choices not socially acceptable in her era: two bachelor’s degrees, a master’s degree, earning my own income and buying a house with the mortgage in my own name. But I like to imagine it is the fact that I am a registered midwife who prescribes contraception for women - with no regard for their husband’s consent - that would have left her most proud. square

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

ISSUE 106 SEPTEMBER 2022 | 13

THE EMPLOYMENT (PAY EQUITY AND EQUAL PAY) BILL 2017

The Ministry for Business, Innovation and Employment consulted the Council of Trade Unions and others on its draft

Since 2017, the $2 billion settlement has seen 55,000 aged and disability residential care and home, community and support workers achieve pay rises of between 15% and 50%.

employed in the same role, stating it would be “too difficult” to make wider comparisons. In August 2013, the court ruled in Bartlett’s favour, stating “it would be illogical to use a small percentage of men as a comparator group if they are paid less because they are undertaking ‘women’s work’”. Terronova responded by heading to the Court of Appeal, and when that was rejected, to the Supreme Court, who threw out their appeal, declaring it premature.

A few months later, I was back in Wellington as a MERAS representative on the Bipartite Oversight Committee for the (employed) Midwifery Pay Equity claim lodged by MERAS in June 2018.

Left to right: Leila Sparrow, Karen Gray, Elizabeth Winterbee (all MERAS) and Sue McNabb (NZNO)

• Seeking better recognition for the increasing workload and care requirements for all locum midwives which has culminated in the new Planning and Handover and

• Negotiation of specific, focused funding to help with community midwives’ costs of relocation to areas negatively affected by Covid-19 vaccination mandate.

to access and add an experienced, expert, professional point of view.

communicate the expected timing of claiming and payments during the Christmas period to community midwives. Even though the subsequent Ministry communication was too late, the outcome was that future claiming payment terms improved from an average of 7-9 working days, down to three working days for all community midwives countrywide.

• Negotiating to widen the scope and extend the locum cover support available in situations where the community midwife is impacted by Covid-19, until 30 June 2023.

The MMPO has always been well placed to use our understanding to articulate the needs of community midwives and advocate for them with the Ministry of Health - now Te Whatu Ora (Health NZ). Over the past 12 months, this has become noticeably more challenging due to the health system reforms, staff changes within Health NZ, and the ongoing impacts of Covid-19, amongst other things.Restassured, every day MMPO staff ensure that your voice is heard. We do not always openly report this work, however, here are eight examples of what the MMPO has been doing over the past 12 months:

• Recent and ongoing communication, advocacy, and insistence about the long outstanding delays to Covid-19 care payments and UAC travel adjustments. The MMPO proposed an alternative payment system early in 2022, which could have been put in place easily and immediately. This was dismissed at the time by the Ministry of Health.

14 | AOTEAROA NEW ZEALAND MIDWIFE YOUR MIDWIFERY BUSINESS

But there is a critical - albeit less visibleadvocacy role the MMPO plays behind the scenes, especially now, as the health sector in Aotearoa undergoes significant structural change.Dueto the nature of the MMPO’s services, we take regular opportunities to interact with community midwives providing care across Aotearoa. The chance to talk to midwives and listen in this way allows a better connection to the heartbeat of the workforce, through all its ebbs and flows. With this connection comes a real life understanding of the lived experience of community midwives, which we can combine with data and information, to paint a coherent picture of the state of the workforce and what its needs are.

WAYNE ROBERTSON EXECUTIVE DIRECTOR, MMPO

Initially formed back in 1997 to support community midwives, the MMPO’s sense of purpose has never wavered over the past 25 years, however its role has most certainly evolved to become much more significant.

What started as a means of providing access to a manual wrap-around clinical and practice management system (which helped with claiming and being paid) has expanded over time, into an electronic platform which now offers a comprehensive service, including the provision of workforce supports, business assistance and much more.

• Dealing with ongoing Notice 21 direct claiming difficulties and the Christmas payment problems on behalf of all community midwives claiming through the MMPO. In respect of the latter, we had insisted from late November 2021 that the former Ministry of Health clearly

What helps even further is our close relationship with the College, ensuring that when an opportunity is identified to improve community midwifery supports, we are able

the critical but less visible importance of the MMPO

• Regularly reminding and reinforcing why community midwifery works well in Aotearoa, even during times of significant workforce stress, because it is purposedriven, offers choice and working flexibility and is underpinned by autonomy.

Due to the nature of the MMPO’s services, we take regular opportunities to interact with community midwives providing care across Aotearoa. The chance to talk to midwives and listen in this way allows a better connection to the heartbeat of the workforce, through all its ebbs and flows.

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• Ongoing advocacy for investment in new support systems to enable community midwives to engage in the reformed health system.

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

Whilst some community midwives may not directly use any of the services the MMPO currently provides, every community midwife in Aotearoa can receive a benefit because of the way that the MMPO is structured (100% owned by the College), its purpose, and the way it goes about its day-to-day business.

• Provision of comprehensive but intimate knowledge to help inform and focus the distribution of limited and fixed funding available in Notice 21 and out of Budget 22.

• Expanded access to funded education for rural midwives.

• Increased locum cover days (non-emergency and emergency) for all community midwives in Aotearoa irrespective of their locality setting (urban, rural, or remote).

Birth Acknowledgement Fees for each emergency (including Covid-19) locum cover.

With the pay equity class action building in the background, looking ahead to the next 12 months I continue to be optimistic that the value of this critical workforce will finally be acknowledged, appreciated, and supported in an equitable way. square

• Working with maternity facilities to provide shift or short-term locum and other local community midwifery supports.

• Funded professional and administrative support for community midwives, to mitigate the effects of stressful working environments.

Currently, the MMPO - together with the College - is advocating for community midwives with Te Whatu Ora (Health NZ), to increase existing workforce supports and introduce new initiatives as a matter of priority. This includes access to:

for the formation of Ngā Māia (Tupara & Tahere, 2020) and the organisation has therefore become our Hawaiki; an ecosystem of Māori guardians of traditional birth practice. Together, we harness a Māori worldview and beliefs, acting either directly or indirectly, as a collective voice for the benefit of tangata whenua.

The institutional racism tangata whenua must contend with during pregnancy, birth and motherhood are well documented. Recently, several investigations have highlighted the chronic failings of government sectors to enact authentic te Tiriti o Waitangi partnerships. The western maternity system is the product of imperialism; complicit in the exertion of hegemonic power over Māori and over women. Consequently, Māori midwives across Aotearoa have spent decades embedding whānau-centred values into practice, with tools such as Tūranga Kaupapa. One could say Māori midwives assumed the role of kaitiaki within the rigid dichotomy between midwifery and mātauranga Māori.

Throughout the history of Ngā Māia, an ongoing deficit of Māori midwives within the workforce and the absence of senior Māori midwives in leadership roles has persisted. Tupara and Tahere (2020) highlight that tapuhi have been under-represented across all levels in midwifery; especially leadership. The historical trend of systemic racism highlighted in recent reports clearly demonstrates that the maternity service in Aotearoa continually puts our whānau - and tapuhi - at risk of cultural unsafety. Midwifery

education providers have also failed to maintain initiatives that produce Māori graduates to meet the increasing birth rate and cultural requirements of tangata whenua inAsAotearoa.weusher

To awaken the lifeforce of one and all

16 | AOTEAROA NEW ZEALAND MIDWIFE NGĀ MĀIA

TAMARA KARU (NGĀTI TAMATERĀ) CLINICAL MIDWIFE SPECIALIST MĀORI HEALTH TE WHATŪ ORA WAIKATO, NGĀ MĀIA TRUST BOARD

in a new health systemTe Whatu Ora - let’s not talk about the discomfort of uncertainty and how we used to do things. Let’s instead examine our relationship with power and develop succession plans to include pathways for Māori in leadership, to effect systemic change. Let’s have honest conversations about racism and commit to policies and procedures which grow midwives into champions of anti-racism, both as a collective, and as individual practitioners. square

The dispossession of indigenous knowledge and traditions in Aotearoa is deeply rooted in the dispossession of our lands. In spite of this, we are witnessing a resurgence of traditional Māori birthing practices, which are time-honoured and significant to wāhine hapū. Tapuhi (midwives) are trusted sources of these practices and in partnership with wāhine hapū, must negotiate the dual spaces that conventional health care and law dictate we conform to. Māori are cognisant of the realities of colonisation and are willing to conquer barriers to practice their traditions (Gable 2013).

Currently, regional hubs meet regularly to provide a supportive space for tapuhi and tauira to discuss professional issues, including: the advancement of Te Aka Whai Ora | Māori Health Authority; the aspirations of Te Kahu Taurima First 2000 days; Te Ara ō Hine - an initiative in the tertiary education sector; the development of a kaupapa Māori Bachelor of Midwifery; promotion of a national Māori leadership program - Ngā Manukura o Apōpō; and the establishment of a kaunihera kaumātua within our governance structure.

Ngā Māia:

Ki te whakaohooho i te mauri o tēnā, o tēnā

Discrimination and institutional racism within the health sector were the catalysts

• Obstetric fistula (including vesicovaginal, colovaginal and ureterovaginal)

• Symphysis pubis capsule or ligament tear.

The amendment bill proposes an extended list of specific birth injuries to be categorised as accidents and therefore automatically eligible for ACC cover. The provisional list of birth injuries (still under consideration) include:

• Coccyx fracture or dislocation

• Obstetric haematoma of the pelvis

• Postpartum uterine inversion

• Anterior wall prolapse, posterior wall prolapse or uterine prolapse

clinicians, birthing women, parents and whānau across the motu with expertise or lived experience in this area, to better understand what services are needed.

Public submissions made to the select committee are also assisting in informing the completeness of the list of injuries which will be included in the final amendment bill. It is expected that this list will include all injuries resulting from what ACC defines as ‘forces of childbirth’.Theproposed changes will result in updated pathways for those who experience birth injuries and practitioners, so that appropriate care, treatment and support is available for Aotearoa’s diverse birthing population. If passed by Parliament, the changes in the Accident Compensation (Maternal Birth Injury and Other Matters) Amendment Bill are expected to come into effect from 1 October 2022. square

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• Levator avulsion

• Ruptured uterus during labour

• Pudendal neuropathy

Currently, ACC provides cover for injuries related to pregnancy and childbirth which have been proven to occur as a result of a ‘treatment injury’. This means the injury needs to have occured either as an unexpected result of treatment, or a lack of appropriate treatment during childbirth.

The 2021 Accident Compensation (Maternal Birth Injury and Other Matters) Amendment Bill proposes an expansion of ACC cover to include maternal birth injuries. A broader definition of the term ‘accident’ has evolved to include force or resistance internal to the body, from the start of labour to birth.

• Obstetric anal sphincter injury tears or tears to the perineum, labia, vagina, vulva, clitoris, cervix, rectum, anus or urethra

To prepare for the anticipated increase in ACC-funded services which will result from the legislative change, ACC has been engaging with health practitioners, sector groups (including the College), Māori

ACC COVER TO INCLUDE MATERNAL BIRTH INJURIES

• Pubic ramas fracture

Under the proposed legislation, mental injuries such as PTSD will continue to be included if they’re caused by a covered physical birthing injury. No changes are proposed for pēpi injured during birth; existing cover for these cases is still available.

18 | AOTEAROA NEW ZEALAND MIDWIFE PRACTICE handsPoised? off?hands

3rd degree 448 3.8 170 1.1

4th degree 29 0.2 12 0.1 41

Total 11,827 100 15,757 100 27,584* 100 *Excludes women who had an elective caesarean section (n=2,581) Episiotomy by parity Episiotomy Primiparous Multiparous All women n % n % n % Yes 2,357 19.9 573 3.6 2,930 10.6 No 9,470 80.1 15,184 96.4 24,654 89.4 Total 11,827 100 15,757 100 27,584* 100 *Excludes women who had an elective caesarean section (n=2,581). NB: Caution should be used when comparing to previous reports as the 2011 data reported episiotomies as a proportion of all births and did not exclude elective caesarean sections. 2018)(MMPO,

Perineal trauma and parity for all vaginal births Perineal Trauma Primiparous Multiparous All women n % n % n % Intact/Graze 5,625 47.6 10,219 64.9 15,844 57.4 1st degree 966 8.2 2,084 13.2

OASI care bundles: are they right for Aotearoa?

2nd degree 4,759 40.2 3,272 20.8

DR ROBIN CRONIN RESEARCH MIDWIFE SPECIALIST ELAINE GRAY MIDWIFERY ADVISOR

Perineal trauma is the most common complication of vaginal birth for wāhine. The most recent report from New Zealand’s Midwifery and Maternity Providers Organisation (MMPO, 2018), encompassing around half of all birthing women in Aotearoa, reports 53% of vaginally birthing women will sustain some degree of perineal trauma. This includes minor first-degree perineal skin tears, through to severe third and fourth-degree anal sphincter trauma (also known as obstetric anal sphincter injury or OASI), and episiotomy. Trauma to the perineum may be in addition to labial, clitoral, and vaginal grazes and tears. 3,050 11.1 8,031 29.1 618 2.2 0.1

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The official classification of perineal tears was developed by Abdul Sultan, a UK obstetrician, in 1999 (Table 1). This was adopted as the standard in UK health professional guidelines (National Collaborating Centre for Women's and Children's Health [NICE]; Royal College of Midwives [RCM]; Royal College of Obstetricians and Gynaecologists [RCOG]). The aim of the classifications is to support health practitioners in their assessment of perineal trauma and to support decisionmaking regarding management.

First-degree tears (over 10% of vaginal births in Aotearoa) are confined to perineal skin and subcutaneous tissue less than 1.0cm deep and are not routinely repaired, although may be sutured if edges are not well aligned. Second-degree perineal muscle tears are the most common, at around 30% of vaginal births, and all require repair. An episiotomy incision, performed for 11-17% of vaginal births in Aotearoa (Ministry of Health, 2022; MMPO, 2018) involves the same tissues as a second-degree tear and requires the same repair technique. Third and fourth-degree tears or OASI, involving the anal sphincter and anal epithelium are uncommon, at around 3% of spontaneous vaginal births, but up to 6% during instrumental vaginal births, and the repair of OASI remains the domain of obstetric specialists.

REFRESHER ON ANATOMY

WHAT ARE OBSTETRIC ANAL SPHINCTER INJURIES (OASI)?

It is important that midwives have a clear understanding of perineal anatomy and the changes that occur during pregnancy and childbirth.Themain functions of the female pelvic floor are to support the internal pelvic and abdominal organs and maintain the integrity of the bladder, uterus, vagina, and rectal function. The perineum encompasses a diamond-shaped area from the pubic arch to the coccyx and is subdivided into anterior (urogenital) and posterior (anal triangle) sections. Anterior perineal trauma includes injury to the anterior vagina, labia, urethra, and clitoral area, which usually heals well with minimal concerns. The posterior perineum is the area midwives are usually referring to when they talk about

‘the perineum’. Posterior perineal trauma is the cause of most perineal morbidity and includes injury to the posterior vaginal wall and perineal muscles, which may extend to involve the anal sphincter.

CLASSIFICATION OF PERINEAL TRAUMA

Illium Coccyx Ischial spine Anal UrethraVaginacanal Sacrum Coccygeus PubococcygeusIliococcygeus Urogenital diaphragm Symphysis pubis Levator ani Female Pelvic Diaphragm - Superior View 20 | AOTEAROA NEW ZEALAND MIDWIFE PRACTICE

The consequences of perineal trauma can be significant, affecting quality of life for some women in the short- and long-term. Physical impacts include: perineal pain; wound healing issues; infection; incontinence of urine, flatus and stool; faecal urgency; and painful sexual intercourse. The emotional, psychological, and social effects can also be extensive; therefore, recognising the extent of perineal trauma is important, with appropriate and timely surgical repair, analgesia, and physiotherapy increasing the likelihood of successful healing and restoration of normal function.

OASI are third and fourth-degree perineal tears, defined as any degree of injury to the anal sphincter muscle sustained during childbirth. Rates of OASI appear to have been rising, with several possible explanations. The increase may be a reflection of an increase in recognition and diagnosis due to improved education and experience in perineal assessment by health professionals. Alternatively, it may be related to changing demographics, maternal-fetal risk factors, or increasing induction of labour rates and the resultant cascade of intervention.

WHAT IS AN OASI CARE BUNDLE?

The identification and assessment of the degree of perineal trauma can be challenging. Second-degree tears may be as diverse as shallow splits in the superficial perineal muscle or deep forked tears, challenging the skills of even the most experienced health professional. Most wāhine find the hands-on examination required for perineal assessment uncomfortable at best. This may result in some women having an OASI missed or misidentified as a second-degree tear, which can have significant ongoing consequences.

The responsibility for identification and management of perineal trauma after a spontaneous vaginal birth in Aotearoa ordinarily rests with midwives, who have a key role in providing information to clients about how to support pelvic and perineal health.

Norway (Hals et al., 2010; Laine et al., 2008) was the first country to publish observational research on a bundle of perineal protection interventions (Table 3) that identified and

Awareness of risk factors for OASI (Table 2) can help midwives to identify women who have an increased chance of experiencing severe perineal trauma, to consider, discuss and implement protective factors in advance of the birth.

Non-modifiable

Potentially modifiable

Perineal skin, superficial perineal muscles, and perineal body

Anal sphincter complex (EAS and IAS) and anorectal mucosa

Asian ethnicity Shoulder Prolongeddystociasecond stage

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(Ministry of Health, 2022; MMPO, 2018)

Does NOT involve the anal sphincter (although some episiotomies can extend into OASI)

Table 2. Risk factors for OASI

Table 1. Classification of perineal tears

(Royal College of Obstetricians & Gynaecologists, 2015)

- 3c: both EAS and internal anal sphincter (IAS) torn

Epidural

Persistent occipito-posterior position

Perineal skin and subcutaneous tissue of anterior or posterior perineum and vaginal mucosa

Superficial tear

Anal sphincter

Depth around 1 cm; may not require repair if edges well aligned and not bleeding.

- 3a: less than 50% of external anal sphincter (EAS) thickness torn - 3b: more than 50% of EAS

Extremes of maternal age

Shorter perineal length

Degree of perineal trauma Tissues involved

Second-degree tear 29% (MMPO)

First-degree tear 11% (MMPO)

17%11%Episiotomy(MMPO)(Ministry of Health)

Muscular tear Requires repair within midwifery scope. Most common type of tear.

First vaginal birth (including VBAC) Induction

Instrumental birth (especially forceps)

Fourth-degree tear

Birth weight >4000gm Episiotomy

Third-degree tear 2-4% (MMPO)

Severe tears or obstetric anal sphincter injury (OASI) Requires repair by obstetric specialist.

Norway 1. Ask the woman not to push while the head is born.

3. Finnish version of manual perineal support (MPS) for the infant’s head and shoulders. Episiotomy when clinically indicated.

2. Spontaneous pushing; if possible, ask woman to breathe through the last contractions.

1. P = Position for birth.

PEACHES

2. E = Extra midwife present at birth.

6. E = Episiotomy if required.

7. Restrictive use of episiotomy (e.g., if suspected fetal asphyxia).

2. Coach to ensure excellent communication with the woman during the active second stage to promote more controlled and less expulsive pushing. Verbal encouragement to slow down expulsive efforts at crowning of the head.

Australia Warm perineal compress (38-44 degrees centigrade) during the second stage at the commencement of perineal stretching. Gentle verbal guidance to encourage slow controlled birth of the fetal head and shoulders: Support perineum with dominant hand holding warm compress. Apply counter-pressure on the fetal head with non-dominant hand. If shoulders do not birth spontaneously, use gentle traction to release the anterior shoulder. Allow posterior shoulder to be released following the curve of Carus. Episiotomy with a 60° mediolateral angle at crowning when clinically indicated. Perineal examination, including rectal examination, even with an intact perineum. Grading of trauma according to RCOG guidelines and confirmed by a second experienced clinician. & Smith, 2018; Basu et al., 2016; Bidwell et al., 2018; Edqvist et al., 2022; Frohlich, 2017; Women’s Healthcare Australasia, 2019)

7. S = S-L-O-W-L-Y birth head and shoulders.

4. C = Communication with woman.

(Basu

Table 3. Perineal protection interventions 22 | AOTEAROA NEW ZEALAND MIDWIFE PRACTICE

6. MPS during birth of the infant’s head and shoulders according to the birthing position and the midwife’s preferences.

Stop Traumatic OASIS Morbidity Project (STOMP)

2. MPS for vaginal births (especially forceps, vacuum) whenever possible, while communicating with the woman to encourage a slow and guided birth.

4. Perineal examination, including PR exam, after vaginal birth for all women, even with an intact perineum.

3. Giving birth in a position that allows good visualisation: all birth positions can be used depending on the situation. Avoid lithotomy position and sitting position as they are non-flexible sacrum positions. Side lying position or birth on all-fours is recommended to achieve a slow and controlled birth.

1. Antenatal information.

1. Position to avoid the semi-recumbent position, encourage upright non-flat positioning.

5. H = Hands-on technique.

2. Giving birth in a position that allows good visualisation. Semi-recumbent or lithotomy birth positions used unless the woman has a strong preference.

5. Warm compresses held at the perineum.

4. Two-step head-to-body birth, depending on the clinical situation.

3. A = Assess the perineum (identify risk factors, offer massage guidance beforehand and warm compress during birth).

Country of origin Interventions within each bundle

United Kingdom OASI1 and OASI2

3. Speed, using simple tactile control with one hand to slow down delivery of the head (not manual manipulation of vertex, pinching of fourchette or Ritgen manoeuvre). Aim for spontaneous delivery of shoulders, i.e., with no/minimal traction to shoulders.

Sweden 1. Good communication with the woman.

3. Episiotomy with a 60° mediolateral angle at crowning when clinically indicated.

The emotional, psychological, and social effects can also be extensive; therefore, recognising the extent of perineal trauma is important, with appropriate and timely surgical repair, analgesia, and physiotherapy increasing the likelihood of successful healing and restoration of normal function.

The exclusion of warm perineal compresses from the UK OASI Care Bundle was unexpected, given strong evidence from a Cochrane review (Aasheim et al., 2017) that warm compresses applied during late second stage may reduce the incidence of OASI by over 50%. In 2018, a similar perineal care bundle was introduced in Australia (Women’s Healthcare Australasia, 2019), although with the welcome addition of warm perineal compresses.

Warm perineal compresses: Strong evidence from a Cochrane systematic review (Aasheim et al., 2017) found that warm compresses applied during late second stage may reduce the incidence of OASI by over 50%. This finding has been supported by another systematic review (Magoga et al., 2019) which found that in addition to a reduction in OASI, warm compresses increased the likelihood of an intact perineum and lowered the risk of episiotomy.

The UK OASI Care Bundle wasn’t entirely new information for midwives, as there were commonalities between this and the PEACHES programme (Frohlich, 2017) developed at Guy’s and St Thomas' Hospital in London in 2015. However, unlike PEACHES, the UK OASI Care Bundle does not require an extra midwife at birth, nor recommend warm perineal compresses during second stage, but rather focuses on MPS and post-birth perineal and digital rectal examination.

a significant reduction in OASI rate from 4.7% to 2.2% at one UK hospital. STOMP differed considerably from the UK OASI Care Bundle. The key components of STOMP did not require MPS, and instead used three common midwifery perineal protective techniques: position (upright birthing positions, avoid supine); coach (verbal encouragement to slow down pushing); and speed (flat of hand to support baby’s vertex and judge speed).

inflatable silicone balloon designed to allow women to gradually stretch the vagina and perineum from 37 weeks gestation. A 2015 systematic review found that the Epi-No did not reduce episiotomy rates and had no influence on reducing perineal tears (Brito et al., 2015). Closer to home, an Australian multi-centred randomised controlled trial (Kamisan Atan et al., 2016) reported that the Epi-No is unlikely to prevent levator ani damage, or anal sphincter and perineal trauma.

Antenatal perineal massage: Antenatal perineal massage involves stretching perineal tissues by inserting lubricated fingers 3-4cm into the lower portion of the vagina and slowly massaging downward in a U-shaped movement. A Cochrane systematic review (Beckmann & Garrett, 2006) found antenatal perineal massage had no impact on the incidence of perineal tears and OASI, but there was a 16% reduction in episiotomy, although this was only significant in women without prior vaginal birth, who massaged from 35 weeks gestation as few as 1.5 times per week. However, women who had previously birthed vaginally experienced less perineal pain three months postpartum.

Manual perineal support (hands-on techniques or manual perineal protection): The same Cochrane systematic review (Aasheim et al., 2017) also reported that there was no evidence that controlling delivery of the fetal head through hands-on MPS made a difference in the incidence of OASI. This review included the HOOP (hands on or poised) trial (McCandlish et al., 1998), which found fewer episiotomies in the hands-poised group, but no other differences between the two groups.

Around the same time, a quality improvement initiative, the Stop Traumatic OASIS Morbidity Project (STOMP) (Basu & Smith, 2018; Basu et al., 2016), reported

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WHAT EVIDENCE SUPPORTS PERINEAL INTERVENTIONS?PROTECTION

Furthermore, a 2015 systematic review (Bulchandani et al.) did not show a beneficial effect of hands-on or hands-off techniques in regard to perineal trauma. This was supported by a midwifery-led systematic review published the same year (Petrocnik

reduced the incidence of OASI rates from 4–5% to 1–2%. The interventions included health professional education, and hands-on manual perineal support (MPS), including the ‘Finnish grip’, commonly practised during births in Finland (Pirhonen et al., 1998). These interventions were taken up in other European countries, including Sweden (Poulsen et al., 2015), Denmark (Leenskjold et al., 2015; Rasmussen et al., 2016), and Netherlands (De Meutter et al., 2018), and extended to some hospitals in England (Naidu et al., 2017) and as far as the USA (Yeung et al., 2018) and Palestine (Ali-Masri et al., Based2018).onthe Nordic research, despite the lack of any high-quality randomised controlled trials and no evidence that hands-on MPS does more good than harm, the UK OASI Care Bundle was introduced into 16 UK maternity units between 2017 and 2018 (Bidwell et al., 2018). The UK bundle was a joint initiative of the Royal College of Midwives and Royal College of Obstetrics & Gynaecology and includes MPS for vaginal births. The rollout of the bundle continues across the UK, with a multi-centre stepped-wedge design study demonstrating a reduction in OASI from 3.3% to 3.0% (Gurol-Urganci et al., 2021). However, it is still not clear which aspect(s) of the bundle have caused the improvement.

In Aotearoa the use of OASI care bundles has not been fully assessed, although they have been introduced in some areas. It is important to consider the evidence, the relevance to the Aotearoa context and implications, and proper processes for implementation.

Women and midwives would agree that reducing the incidence of OASI would be of great benefit. However, many wellintentioned maternity care interventions in the past have been found to be ineffective, and in some cases, harmful (e.g., routine enemas, perineal shaving, amniotomy, fetal movement monitoring bundles). Therefore, it is important that care is taken to fully understand the evidence and potential consequences before implementing any single or bundled perineal interventions. Sharing information on perineal protection with pregnant women is an important and valuable part of the midwifery role. To support women to make informed decisions, this information should include:

Inflatable devices for antenatal pelvic floor stretching: Inflatable pelvic floor ‘training’ devices such as Epi-No have entered the market in recent years. They consist of an

SUMMARY

following perineal repair is recommended to ensure sutures have not inadvertently gone through into the rectum (which would usually require re-suturing and antibiotics) and to administer perineal analgesia (Diclofenac 100mg PR as recommended best practice, plus Paracetamol 1gm PR if no contra-indications).

It has been suggested (Laine et al., 2013) that as the episiotomy rate has increased, the incidence of OASI has dropped, but there is limited evidence to support this claim, and none in the Aotearoa context. Research is currently being undertaken using the National Women’s Hospital database to explore outcomes following episiotomy.

A systematic review reported that mediolateral or lateral episiotomy for women giving birth for the first time via vacuum birth may reduce OASI (Lund et al., 2016). Another systematic review on assisted vaginal births found that OASI was more likely with a forceps delivery irrespective of whether an episiotomy had been performed (O'Mahony et al., 2010).

• Angle of episiotomy incision

24 | AOTEAROA NEW ZEALAND MIDWIFE PRACTICE

In 2021, a systematic review and metaanalysis of randomised controlled trials focused solely on the hands-on technique (Pierce-Williams et al., 2021) and found not only no beneficial effect of hands-on over hands-off regarding perineal trauma, but reported that hands-on resulted in an increased incidence of third-degree tears and episiotomy.

time, and that squatting and using a birth seat/stool was associated with an increase in OASI risk among multiparous women (Elvander et al., 2015).

Digital rectal examination

• During perineal assessment

• Selective versus routine use of episiotomy

Ethnicity: There is a higher rate of OASI among women of Asian ethnicity in European countries, however the reasons for this remain unclear. Despite commonly held beliefs that there are significant differences in perineal length between women of Asian and European ethnicities, a systematic review (Wheeler et al., 2012) and studies of women in Asian counties (Suto et al., 2015) have found that Asian ethnicity does not increase the risk of perineal trauma for Asian women living in Asia. It has been suggested that language barriers between health professionals and Asian women may be a contributing factor (Groutz et al., 2011). This theory is supported by an Australian observational study that found the need for an interpreter was significantly associated with OASI in women giving birth for the first time (Davies-Tuck et al., 2015).

It is widely recommended as best practice to perform a digital rectal examination during perineal assessment if there is vaginal and/or perineal trauma, to enable accurate and timely diagnosis and repair of the OASI. However, there is limited evidence to recommend routine rectal examination when a full vaginal and perineal examination has diagnosed an intact perineum (Women’s Healthcare Australasia, 2019).

Episiotomy

Two midwives present during the active second stage: The presence of a second midwife during the active second stage, specifically to provide support for OASI prevention, was found to reduce OASI for women giving birth for the first time in a multicentre, randomised controlled trial at five hospitals in Sweden (Edqvist et al., 2022). Almost all women in this trial also had MPS and warm compresses held at the perineum and nearly 40% also had perineal massage.

A prospective study reported that mediolateral episiotomy at a 60° angle reduced the risk of OASI (Kalis et al., 2011) and another found a 50% reduced risk of OASI with every six degrees that the episiotomy was from the perineal midline (Tincello et al., 2003).

• New Zealand research

Having reviewed the evidence, it is clear there are some inconsistencies. Much of the research has been undertaken overseas in different models, where there is little continuity-ofcare. It would be useful to understand the impact of continuity-of-care on perineal outcomes, particularly given the importance of communication during second stage highlighted in the section above, and further exploration and research within Aotearoa’s system is needed. The ‘practice points’ table collates the available evidence, along with practice knowledge and experience shared by midwives during College education workshops, for midwives to consider in their discussions with pregnant and labouring women. square References available upon request.

Birth position: There is limited evidence on birth position and OASI. However, a 2016 systematic review of birth positions and perineal trauma (Lodge & HaithCooper, 2016) reported an intact perineum was more likely in all-fours and kneeling birth positions. Evidence regarding water birth and the risk of OASI is contradictory, with one study reporting an increase in OASI at waterbirth (Cortes et al., 2011) and another a decrease (Geissbuehler et al., 2004). A cross-sectional study of midwife-led birth from Norway found kneeling birth position was associated with the lowest risk of OASI and supine birth position with increased risk (Tunestveit et al., 2018). A Western Australian cohort study (Hauck et al., 2015) and a population-based study from Sweden (Elvander et al., 2015) reported increased risk of OASI for women who gave birth in the lithotomy position. The Swedish study found that the lowest rates of OASI were found among women giving birth in standing position. It was also reported that compared with a sitting position, a lateral birth position had a slightly protective effect for OASI in women giving birth for the first

& Marshall, 2015) concluding there was no high quality evidence for or against MPS, and that the choice should be based on the clinical situation during birth. These reviews also reported a higher rate of episiotomy with the hands-on technique.

A Cochrane review of selective versus routine use of episiotomy for vaginal birth reported that selective use of episiotomy, compared to routine, for women where no instrumental delivery is intended, results in fewer women with OASI (Jiang et al., 2017). Furthermore, there were no benefits of routine episiotomy.

• Assisted vaginal birth

• Following perineal repair

A second digital rectal examination

• Advice that antenatal perineal massage may decrease the likelihood of episiotomy in women with first vaginal birth and does not reduce perineal tears or OASI.

• Discuss the recommendation for perineal and PR examination if women experience vaginal and/or perineal trauma to ensure all trauma is correctly diagnosed and OASI is not missed.

• Assist women into a position to enable thorough examination of the vagina and perineum (usually semi-sitting or supine with towels under the buttocks, or lithotomy)

• To reduce discomfort during the examination:

• Warm perineal compresses (38-44 degrees centigrade) applied at commencement of perineal stretching in the second stage. Ensure careful temperature check if applying to women with an epidural.

During pregnancy

- Women with vaginal and/or perineal trauma decline an examination.

• Information about second stage perineal protection techniques.

After perineal repair

- During PR examination, use plenty of water-based lubricant and advise women that it may relax their anus if they push down as if breaking wind as the examining finger is gently inserted.

a) Verbal midwifery encouragement to slow down pushing efforts at the crowning of the head.

Remind women about perineal protection techniques during second stage:

- Support women to keep baby skin-to-skin.

Offer women information about perineal protection, especially those at high risk of OASI:

• Visualise the perineum and the vagina up to the cervix:

• Always consult with midwifery colleagues and/or obstetric colleagues if:

• Position to avoid semi-recumbent birth position and encourage upright non-flat positioning (including left or right side and hands and knees).

Advise women of the benefit of a second PR examination following repair:

- If vaginal and/or perineal trauma is seen or suspected, recommend a PR examination to assess anal sphincter integrity and diagnose the degree of tear.

- Assessment of the trauma is too painful for the woman.

• Hands-on MPS or hands-off/hands-poised as the fetal head stretches the perineum as clinically indicated (note that hands-on may increase the likelihood of episiotomy and there is no evidence to recommended specific MPS techniques or fetal head flexion):

Evidence-basedpoints

- Complexity of the trauma is beyond your expertise to repair or your scope of practice (e.g.,if OASI).

During pregnancy

(Hedayati et al., 2003; Marín Gabriel et al., 2010; Metcalfe et al., 2002)

Practice

b) Spontaneous birth of shoulders or only minimal traction to shoulders.

practices to reduce the risk of OASI

• Two midwives present during active second stage of labour if possible.

- Any doubt about the severity of the trauma.

- Thoroughly assess both the length and depth of any trauma

• To insert PR analgesia. If not contraindicated, offer rectal non-steroidal anti-inflammatory drugs (NSAIDs) to reduce postnatal perineal discomfort (commonly PR Diclofenac 100mg and PR Paracetamol 1gm).

Perineal and digital rectal examination - also known as ‘per rectum’ or ‘PR’ examination

During labour

- Offer pain relief (Entonox, lignocaine, or existing epidural).

• Discussion about their risk factors for OASI.

• To ensure a suture has not inadvertently gone through into the rectum.

ISSUE 106 SEPTEMBER 2022 | PRACTICE25

Immediately after birth

c) Episiotomy ONLY if clinically indicated (e.g., fetal distress) and if required, cut mediolaterally at ≥60° angle. Ensure adequate pain relief before cutting.

By far the most common issues I see as a physiotherapist in pregnancy are pelvic girdle pain, back pain, and symphysis pubis pain, but these aren’t directly related to the pelvic floor. The most common pelvic floor issue

would be urinary incontinence; mainly stress incontinence, but occasionally urge. The next most common would be constipation, which overloads the pelvic floor, hence the need for pelvic health physiotherapy input in some of these cases.

Associated with prolonged pushing (traction on the nerves) and forceps births, it may cause initial inability to contract superficial pelvic floor muscles. This usually resolves between six weeks and six months.

Q&A: pelvic health physiotherapy perspective

• Perineal tears: unfortunately in the DHB setting we don’t have capacity to see all women who’ve sustained a perineal tear, so only those with 3rd and 4th degree tears are routinely seen on the ward before discharge. These women are followed up at 4-6 weeks postpartum to assess any associated pelvic floor dysfunction.

WHAT CAN MIDWIVES DO - BOTH ANTENATALLY AND POSTNATALLY - TO ASSIST WOMEN IN PREVENTING OR REDUCING THE EFFECTS OF THESE INJURIES?

I’d always worked in musculoskeletal/ sports therapy and found I enjoyed getting women back to activity postnatally. I completed formal training with WHAT (Women’s Health Training Associates Australia), which provided a learning platform of internal pelvic muscle assessment and specialist pelvic floor dysfunction education, including: stress urinary incontinence; overactive bladder; bowel dysfunction; prolapse; and pelvic pain. I felt I was able to connect the dots well between various pelvic dysfunctions women are often too embarrassed to talk about.

The most common birth-related pelvic floor injuries I see are:

Tania McLean is a pelvic health physiotherapist and works as both a private practitioner and for Te Whatu Ora Waitematā. With over 20 years of experience in the field, Tania has worked with countless women throughout her career and lends her expertise to midwives in this Q&A on pelvic floor health and assessment.

AMELLIA KAPA COMMUNICATIONS ADVISOR

WHAT ARE THE MOST COMMON PREGNANCY OR BIRTH-RELATED PELVIC FLOOR INJURIES/ISSUES YOU SEE IN YOUR PRACTICE?

26 | AOTEAROA NEW ZEALAND MIDWIFE FEATURE

WHY DID YOU CHOOSE TO SPECIALISE IN PELVIC HEALTH PHYSIOTHERAPY?

Obviously the care of the perineum during birth is paramount, but aside from this I believe the best thing a midwife can offer is education. Creating a safe space for women to disclose any existing pelvic floor dysfunction - including any issues following previous births - is vital. Bladder - and to a greater extent bowel - dysfunction is often taboo and not talked about, particularly in certain cultural groups. Midwives get to know women intimately and are positioned well to use this as a platform to ask about any issues and then refer for appropriate advice or treatment.

• Levator ani avulsion: the true incidence of this is debatable and reports vary throughout the literature, but rates could be up to 20%. Levator ani avulsion is often not diagnosed postpartum but detected 5-10 years down the line, when a woman presents with other pelvic floor dysfunction.

• Pudendal neuropraxia: transient pudendal neuropathy occurs in up to 70% of women

HOW EARLY IN PREGNANCY SHOULD WOMEN BE FOCUSING ON STRENGTHENING PELVIC FLOOR MUSCLES?

- so that women can cough, sneeze and lift comfortably. Then I move on to teach women how to relax and lengthen the pelvic floor.

Week 2: 10 x contractions, hold 2 seconds

Theearly.other thing midwives can do is ensure they are identifying issues and/or referring early in the presence of risk factors, regardless of whether the woman reports any pelvic floor dysfunction. Known risk factors for levator ani avulsion are: forceps birth, prolonged second stage of labour and birth weight of >4kg, so the presence of any of these warrants careful assessment and consideration of referral.

Week 3: 10 x contractions, hold 3 seconds

Week 1: 10 x contractions, hold 1 second

WHAT ARE THE KEY ASSESSMENTS

In any healthcare role we are given great insight into our clients’ lives. With pelvic health physiotherapy, we celebrate the little gains - like picking a baby up without leaking, coughing without fear and returning to activities like walking or running without needing to know in advance where every public toilet is en route. Leaking is never normal and showing our clients practical ways to prevent this and regain confidence gives me great pleasure. square

I think one of the most important checks a midwife can perform is assessment/ observation of a pelvic floor contraction after any perineal trauma has healed. This involves asking the woman to contract her pelvic floor muscles and observing whether there is an indrawing motion of the perineum and an anal wink. Often, women unconsciously bear down when asked to do this, which needs eliminating, but will not be obvious unless the perineum is actually observed during the contraction. If a woman is bearing down, try to teach her to lift her pelvic floor by providing verbal feedback and observing for change. If there is no visible motion during a contraction, it may be that there is either a transient pudendal neuropathy, or a more significant trauma. Flagging any of these signs for pelvic physiotherapy assessment is vital.

Whilst a certain degree of strength is important, it shouldn’t be the only focus of pelvic floor health. From initial stages of conception, a woman should be able to contract her pelvic floor effectively to brace for a cough and in my practice, I tend to focus on using the pelvic floor functionally

The postpartum period is where the strengthening begins. Initially post-birth, gentle, quick contractions of the pelvic floor to assist circulation and healing are optimal, rather than focusing on strength. From

WHAT IS THE MOST REWARDING PART OF YOUR JOB?

ISSUE 106 SEPTEMBER 2022 | FEATURE27

there, I like to make it easy for mums. Every time they sit to feed, I recommend doing 10 contractions, holding for as many seconds as the baby is old, in weeks:

All too commonly - even more so these days with the pressures of social media and so much focus on tensing core musclesa young woman will have a hypertonic/ hyperactive pelvic floor. But the pelvic floor doesn’t just need to be strong; it needs to be able to stretch beyond its resting length - up to 259% of its resting length in fact - in order to allow a baby safe passage during labour and birth. Total, optimal pelvic floor muscle function requires adequate relaxation to allow optimal lengthening. Personally, I believe the correlation between pelvic floor hypertonicity and levator ani avulsion is an area worthy of further research.

Midwives’ jobs are busy enough as it is, so we don’t expect them to be able to diagnose and treat pelvic floor dysfunction, but even just starting the conversation discussing with women what is and isn’t normal and providing appropriate channels of help can make all the difference. It’s never normal to leak urine or faeces, and this really needs to be emphasised to women if they are to seek help

MIDWIVES SHOULD BE CARRYING OUT POSTNATALLY TO ENSURE WOMEN’S PELVIC FLOOR HEALTH IS OPTIMAL PRIOR TO DISCHARGE FROM MIDWIFERY CARE?

The review was intended to identify how the Ministry-led National SUDI Prevention Programme (NSPP) - established in 2017 - could be improved. The NSPP evolved from the Sudden Infant Death Syndrome (SIDS) Prevention Programme of the 1990s, which saw an initial rapid decline of SUDI rates. Since then, rates have plateaued and there has been no substantial improvement since 2012.

AMELLIA KAPA

The first part of the Ministry’s review involved data analysis of the Coronial SUDI Liaison Reports of 64 infants who likely died of SUDI between September 2018 and June 2020. Professor Barry Taylor and midwife Anna Foaese found that previous correlations identified between

SUDI and maternal smoking, bedsharing and infant sleep position were reiterated by the analysis, however some new insights added further context, highlighting the complex whānau circumstances foregrounding SUDI.

More recently, since 2018, SUDI rates for whānau Māori have been rising and the review is a stark reminder of how inequitably the issue affects Aotearoa’s different populations. Despite the national programme and delivery of safe sleep devices such as wahakura and Pepi-Pod to whānau considered to be most at risk, pēpi Māori are currently nine times more likely, and Pasifika babies six times more likely to die of SUDI than non-Māori non-Pacific infants.

• Poverty and housing unaffordability are major contributing factors. Less than 20% of whānau from the dataset were living without considerable financial insecurity, meaning whānau of most SUDI cases were renting, boarding, living in shared accommodation, or squeezed into a single shared room, reducing capacity to create a separate/safe sleeping space for a baby.

• Extreme parental tiredness was the most significant theme to emerge from the data, with maternal or paternal exhaustion directly impacting the infant’s sleep place and position.

In 2020, the Ministry commissioned research to better understand the reasons behind the unacceptably high numbers of babies continuing to die from Sudden Unexpected Death in Infancy (SUDI) in Aotearoa. In May 2022, three reports detailing the findings were published.

• Drug and/or alcohol addiction, as well as family violence contributed to household and whānau dysfunction, ultimately affecting sleep space and position.

COMMUNICATIONS ADVISOR 28 | AOTEAROA NEW ZEALAND MIDWIFE FEATURE

The findings of Taylor and Foaese’s (2022) analysis show:

More recently, since 2018, SUDI rates for whānau Māori have been rising and the review is a stark reminder of how inequitably the issue affects Aotearoa’s different populations.

• A history of clinical unwellness and/or recent hospital admission was the second most common theme. Parental decisions to change their infant’s usual sleep place or co-sleep were due to concerns about baby’s wellbeing, unsettledness or irritability, and whānau reported wanting to “keep an eye on their breathing”. Pillows were another contributing factor, for the same reasons.

The quantitative data showed safe sleep messages were received and understood by whānau/carers, with 75% having good or very good knowledge of key risk factors. Similarly,

SUDI: REVIEWMINISTRYAFFIRMS POVERTY A MAJOR FACTOR

As a result of the analysis, the Expert Advisory Group (EAG) on SUDI Prevention was established and in their report, Sudden Unexpected Death in Infancy Prevention in New Zealand: The Case for Hauora – a wellbeing approach, the group extends on Taylor & Foaese’s findings and makes recommendations.TheEAGreiterate that in general, parents of SUDI infants are aware of risk factors, but for one reason or another, act in a fashion contrary to best advice. They go on to point out that this is merely another symptom of living in desperate circumstances; that all findings point toward the significance of poverty, along with other social determinants of health, and the broader associated stresses impacting on the wellbeing of the whānau unit. These constant stresses impact parents’ abilities to make healthy decisions either for themselves, or their children, and it is suggested that a significant improvement in financial security is likely to affect all of the above positively.

the risks of smoking during pregnancy were understood by mothers, but smoking cessation opportunities were not taken up, the reasons for which were not elicited by the research.

development of any SUDI prevention initiatives consider the broader systemic, community and whānau contexts within which SUDI occurs. They strongly advocate for the development of systems run by Māori and Pacific women, which engage whānau and communities through a Hauora-wellbeing approach and move away from the previous didactic format.

Finally, a kaupapa Māori evaluation of the NSPP was also commissioned as part of the Ministry’s review, and Kia Puawai, the final report, outlines key recommendations to transform the NSPP into a programme that can more effectively redress health inequity and improve outcomes for whānau Māori, ‘āiga Pasifika and other priority populations.Acomplete refresh of the NSPP programme, co-designed with Māori, Pasifika and health leadership is recommended, with emphasis placed on the overhaul being grounded in te Tiriti o Waitangi, kaupapa Māori, and Pasifika-based principles. Demonstration of meaningful partnership in the form of prioritising Māori and Pasifika leadership is recommended, alongside ensuring the SUDI-prevention workforce is culturally safe and therefore able to engage appropriately with priority groups.

ISSUE 106 SEPTEMBER 2022 | FEATURE29

WHAT DOES THIS MEAN FOR MIDWIVES IN PRACTICE?

The EAG also posits that the services/service providers are either failing to engage appropriately with whānau Māori, or simply do not suit the whānau in a socio-cultural sense. The distinct possibility that whānau are overly ill-equipped to recognise how they can take advantage of what is being

underperforming, but because long after the midwife has left, the systemic inequities and complexities remain.

determinants of health remain the most accurate predictors of outcomes for whānau, and events such as SUDI rarely occur in a Thisvacuum.isnotto say the findings are not worthy of ongoing reflection. The data show the breakdown for affected whānau has happened well before engagement with midwifery care; that the underlying issues are undoubtedly symptoms of colonisation and are clearly not resolved using a tickbox approach. Dropping off a wahakura, demonstrating how to position a baby face up and clear and hoping for the best is simply not working; not because midwives are

These constant stresses impact parents’ abilities to make healthy decisions either for themselves, or their children, and it is suggested that a significant improvement in financial security is likely to affect all of the above positively.

As well as ongoing advocacy work to address the deep-seated societal inequities impacting SUDI outcomes at political and systemic levels, the College’s role is also to support individual midwives through education provision, practice guidance and other professional development processes. An obvious example of this is our safe sleep consensus statement, which is currently being updated. Ensuring te Tiriti underpins our updated strategic plan and following the recommendations of the cultural review currently in progress will further strengthen the College’s ability to respond to the inequitable SUDI burden experienced by particular groups.

The dire circumstances many whānau are facing in the lead up to SUDI are multi-layered and stem from intergenerational mamae (pain/wounds). Midwives alone certainly cannot solve these issues, but engaging with whānau meaningfully, in ways that are culturally safe, may be more likely to lead to honest conversations about where and how babies are sleeping. Within safe partnerships, whānau may be more likely to open up about what stressors might be impacting their ability to make different choices, allowing midwives to see the fuller picture and offer safe solutions within that whānau’s capabilities.

square For excellence in distance midwifery education Our flexible, practice-focused courses are designed to meet the needs of midwives and the requirements of Te Tatau o te Whare Kahu Midwifery Council. It’s not too late to enroll for our September 2022 courses: Certificate Courses (15 Credits) 19 September 19 to 4 November • Applied Anatomy & Physiology for Midwives • Midwifery Practice in Rural and Primary Settings • Leadership and Change in Midwifery Ever wondered about becoming a midwifery educator? Coming in 2023 four new courses with a focus on education* • Principles of Midwifery Education: Honouring Ako and Mātauranga Māori • Learning Design & Assessment for Midwifery Education • Clinical learning and teaching in midwifery • Staying Connected: Digital Technology in Midwifery Education * subject to NZQA approval If you wish to complete the Complex Care Certificate in 2023, please register your interest with suzanne.miller@op.ac.nz 0800 762 786 · info@op.ac.nz 30 | AOTEAROA NEW ZEALAND MIDWIFE FEATURE

CONSUMERISM: THE GLOBAL CONSEQUENCES

32 | AOTEAROA NEW ZEALAND MIDWIFE CLIMATE CHANGE

LORNA DAVIES PRINCIPAL LECTURER (MIDWIFERY) – OTAGO POLYTECHNIC

DEFINING CONSUMERISM

a link between the seemingly innocuous word family of ‘consume’ with consequences like climate change, the loss of biodiversity, war, and food insecurity may be a stretch for some. However, an understanding of how consumerism operates within the context of our daily activities and indeed our sphere of practice, may help to shed light on the pervasive nature of the concept and how it influences our lives, both personally and professionally.

THE DEVELOPMENT OF CONSUMERISM

Our consumer habits are incontrovertibly driving climate change (Thøgersen 2021) and unbridled consumption in high-income countries is rapidly surpassing the availability of resources needed to satisfy demand. High-income countries driven primarily by the USA (27%) and EU countries (25%) are responsible for 74% of excess resource use, whilst low and middle-income countries including those in Latin America and the Caribbean, Africa, the Middle East, and Asia contribute only 8% (Hickel et al 2022). The principal producers are having the most impact per capita and as Figure 1 illustrates, the contribution of Aotearoa to greenhouse gas emissions is extremely concerning. It is contended that this figure reflects the fact that the emissions are attributed primarily to agriculture, where gases are created in the production of essential foodstuffs (Ministry of the Environment 2021). However, the food industry, like all other industries, is governed by consumer demand.

From a historical perspective, consumerism is closely aligned with the concept of capitalism, which in a modern sense took shape in the 17th century. Consumerism intensified throughout the ensuing centuries and spread globally as capitalism became the dominant economic system fuelled by the transformational might of The Enlightenment and the Industrial Revolution. Consumerism continued to develop at breakneck speed during the 20th and into the 21st century, as communications and technologies improved and globalisation escalated international free trade, converging cultural and economic systems. As a result, consumerism today extends way beyond economics, into an ideological, socio-political, transactional model that influences attitudes, values, beliefs and behaviours pervading and structuring our lives in a myriad of ways (Metcalf 2017).

Dictionary definitions of ‘consumer’ are generally focused around the purchasing of goods and services for personal use by an individual. ‘Consumerism’ is related more to protecting the interests of the consumer, which may feel like familiar territory within the professional midwifery context. However, from an etymological perspective the word ‘consume’ is rooted in the Latin cōnsūmere which means “to use up, devour, waste, destroy”, which may lead us to question any perception of the term ‘consumer’ as benign. It is this etymological interpretation of the word consume that has resulted in our consumerist driven western lifestyle, leading to overuse of precious natural resources which, if not curtailed, could ultimately annihilate the

Our consumer habits are incontrovertibly driving climate change and unbridled consumption in high-income countries is rapidly surpassing the availability of resources needed to satisfy demand.

andconsumerismmidwifery: transactional transformational?or

Envisioningplanet.

‘The human body performs to maximum trained and prepared Childbir th is no exception ’ Dr Wilhelm Hor kel Starnberg (EPI-NO inventor)

EPI-NO Patient Brochures can be requested for New Zealand via info@starnbergmed.co.nz

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EPI-NO is clinically proven to of an intact per ineum, reduce episiotomy, and is safe to use EPI-NO is a dual pur pose CE approved medical device designed muscles from ear ly in pregnancy, and again postpar tum The per ineal stretching exercises commence concur rently after Week 36.

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although the original reforms have weakened since, the language of marketisation appears to be deep-rooted (Barnett and Bagshaw 2020). Thus, patients become consumers, those working in healthcare become providers, and the healthcare system becomes an industry.

CONSUMERISM AND MIDWIFERY

The concept of consumerism is deeply embedded within the culture of healthcare in Aotearoa dating back to the 1980s, when neoliberal reforms introduced extensive economic restructuring that led to social and political change (Dawson 2019). Healthcare at this time was rationalised to mimic a private market in the public sector and

The resurgence of midwifery in Aotearoa in the late 1980s and early 1990s coincided with the introduction of these market reforms. A more consumer focused maternity service was viewed as a vehicle to overturn the patriarchy of medically dominated care and the replacement of ‘patient’ by ‘consumer’ was celebrated (Pairman & Guilliland 2010). As a result, we employ the term ‘consumer’, perhaps more than any other health profession. We refer to those accessing our services as consumers; have maternity consumer representatives on our committees; share information relating to consumer rights with those we care for; and elicit consumer feedback for our MSR process. Yet how much do we know about the origin and historical evolution of the word, or its socio-political significance? Do we ever consider the word in relation to its sibling concepts of consumerism and consumption, and how they may wield influence on our professional structural frameworks, models of care, and even how we practise?

MARKET REFORMS AND THE GROWTH OF CONSUMERISM IN HEALTHCARE

Figure 1. International comparison of greenhouse gas emissions 2520151050equivalentdioxidecarbonofTonnes Annex Countries Australia Japan New Zealand United Kingdom USA CO2 only per capita All gases per capita 34 | AOTEAROA NEW ZEALAND MIDWIFE CLIMATE CHANGE

If we take the example of the manufacturing of highly processed dried milk powder in Aotearoa shipped to feed infants in South East Asia, enabling their mothers to return to the workforce to produce goods to export to Aotearoa, we have a stark example of the reach of consumerism within a global context. Consumerism also explicitly feeds inequity both at local and global levels (Roach et al 2019). The richest 1% percent of the global population who are by default the greatest consumers, emit more than twice that of the poorest 50% (UNEP 2020). Yet the poorest world citizens are victim to the most injurious effects of climate change because for example, their housing is poorly structured, they do not have access to heating and cooling systems and they cannot afford insurance. Despite a decrease in greenhouse gas emissions from the economic slowdown resulting from the Covid-19 pandemic, a trajectory of temperature rise above 3°C is predicted this century, which is beyond the goals of the Paris Agreement (UNEP 2019).

Midwifery in Aotearoa is viewed by most as a caring profession without commercial bias, situated in a health system where maternity

care is universally available for citizens and residents and funded by the government. However, as we have already established, the concept of consumerism is set firmly within our professional line of vision, within the language our profession has adopted and perhaps even within the midwifery model designed for primary care. So how else does consumerism manifest in midwifery practice and how does it influence us as practitioners?

Midwifery is influenced by consumerism in a multitude of ways. Some of these are guided by the decisions we make about things such as what equipment to use, what vehicles we access and where we choose to support women to birth. We are directly and indirectly influenced by advertising in professional journals, or by being given free samples at conferences (Davies 2019). As midwives, we are also affected by the influence of consumerism on those we are supporting during their childbirth experience. This might include dealing with the fear of someone who cannot afford a handheld doppler to ensure the ‘safety and well-being’ of their baby, or feeling unsettled when the local radiology provider begins advertising 4D scans for screening at gender reveal parties. The unifying factor though - in relation to consumerism and midwifery care - is cloaked in the form of choice. Choice is fundamental to a market economy because it promotes and supports competition, which is the cornerstone of the free market ideology (Green 2022). As a result, the ‘right to choose’ has become an ideological watchword

in our consumerist society (Craven 2004) and choice is a word firmly embedded in maternity services (Davies 2017).

Gardening www.foodforestplants.co.nzwww.gogardening.co.nz

We are currently moving towards a Tiriti-led regulatory approach that aspires to improve the wellbeing of all wāhine and their whānau (Midwifery Council 2022). Perhaps, it is therefore time to turn to the principle of manaakitanga - which embraces the values of respect, generosity and care for the wāhine and whānau accessing our services - as an alternative concept to consumerism and its focus on using and devouring. Perhaps we could even utilise a word to replace ‘consumer’ in maternity care, that speaks less to transaction and more to transformation. square

ISSUE 106 SEPTEMBER 2022 | 35 CLIMATE CHANGE

Ethical fashion www.tearfund.org.nzwww.fairandgood.co.nz

Box 1. Ideas for becoming a more ethical consumer

The distraction of consumerism in midwifery care can lead us to turn away from the things that really matter; the things that perhaps brought us to midwifery, the things that will make a difference to the lives of the wāhine and whānau with whom we work, such as addressing gender inequity, fighting for social justice, working towards poverty reduction, respecting indigenous rights and restoring ecological balance.

By creating a constant need for immediate gratification, consumerism perpetuates inequality and promotes self-preoccupation at the cost of collective interests (Scribe 2014). By being social connectors (Davies & Crowther 2020), we can help to restore community engagement and a collective sense of belonging. Bringing together those in our caseloads, for example, to form walking or crafting groups, or becoming involved in a community garden may unexpectedly fulfil a deep longing to be part of something more profound than material acquisition.

References available upon request.

www.tradeaid.org.nzwww.sustaintrust.org.nz

The marketing strategy makes health claims that imply health risks are present without buying the product. Consumerist approaches promise freedom but can deliver anxiety and self-doubt about the consumer choices we make (Leonard 2010).

Refillable and bulk-buying www.theurbanlist.com

message by selling the idea of consumer culture itself. Advertising preys on our deepest vulnerabilities and can leave us feeling short-changed and dissatisfied with our lives. Annie Leonard, CE of Greenpeace US and the creator of The Story of Stuff, purports that consumerism and the desire to shop is almost always driven by negative emotions such as anxiety and unhappiness. Often, products aimed at expectant and new parents explicitly exploit the heightened anxiety and lack of confidence many people experience in becoming parents.

IN CONCLUSION

It has been proposed that both those providing and accessing maternity services are encouraged to adopt a consumerist approach by viewing interventions as sets of choices, in a manner bearing resemblance to a visit to the supermarket (Daellenbach & Pilley; Edwards, 2011; Davies 2017). Hewson (2004) suggests that the concept of informed choice within what is essentially a consumerist framework, is actually decreasing self-determination in decision making and is less about choice and more about social regulation. Kirkham (2017) addresses the commodification of maternity care as the process by which things become defined and measured according to their commercial value. So a checklist of an assessment - a concrete form of measurement - yields greater value than the less tangible actions of building relationships with and supporting women.

Never underestimate the power of walking the talk and leading by example. Positive psychologist Niki Harre (2012) advises that our brains are highly attuned to noticing others’ behaviours, because we are orientated to do so and neural activity merges the image of an activity with the activity itself. Therefore, if we cycle instead of driving whenever possible, others will follow. Becoming a more ethical consumer also changes how we view the world and that message is communicated to others we are with (see Box 1 for some ideas).

PREYING ON VULNERABILITY

Farmers’ markets www.organicexplorer.co.nz

Becoming familiar with the 17 Sustainable Development Goals set by the United Nations General Assembly in 2015, to be achieved by 2030, is another great starting point. Many of these provide a blueprint for social responsibility in midwifery practice

Crafts www.allyouneedle.co.nz

Ethical consumerism

An example of such commodification can be found in the support of breastfeeding, where policies framing infant feeding practices as optimal are used to benchmark success. When breastfeeding does not meet the criteria defined by such benchmarking, an ever-increasing array of breastfeedingrelated products and accessories - from lactation cookies to designer nipple shields, to digitalised executive breast pumps - are available to assist. However, in spite of the lotions, potions and mechanical aids, women’s confidence is undermined and the barriers become too high for them to ‘succeed’ at breastfeeding (Brown 2017). Additionally, many can ill afford to buy what is often expensive equipment, and are consequently left feeling as though they have failed to meet the needs of their baby.

BUT WHAT CAN WE DO?

The advertising of all manner of products and accessories for those in pregnancy and during the transition to parenting provides a lucrative and open playing field for manufacturers with a captive audience; desperate to do the right thing in order to be good parents. To be fair, part of the role of advertising is to inform consumers about the product being marketed. However, advertising is primarily designed to appeal to our emotional vulnerability, desires and fantasies, with our practical needs lagging well behind (Roach et al 2019). Advertisements - whether they are on a billboard, in a magazine, or part of a social media site - all share a powerful cultural

Gifts www.consumer.org.nz

Effecting a paradigm shift of any magnitude can be challenging and tackling the issues generated within such a powerful ideological context is potentially incapacitating. However, we have to start somewhere and as the old adage states, if we want change to happen – we must start with ourselves.

and encourage a public health perspective which can serve to make us more sustainably focused.

Foraging www.thisnzlife.co.nz

Upcycling www.thisnzlife.co.nz

students, as well as successful completion of the programme. However, the main purpose is to increase the Pasifika midwifery workforce, with equity at the heart of the initiative. Having a service that reflects, understands and improves outcomes for the Pasifika community is key. Many Pacific peoples reside in the most socially deprived areas in Aotearoa and experience the poorest health outcomes. Are in-roads being made towards making a real difference?

This brief reflection paints a colourful picture of Pasifika midwifery potential. A more robust and extensive review of Tapu Ora is expected in the future.

The three main objectives that underpin Tapu Ora māhi are recruitment and retention of Pasifika midwifery

What began as a humble collaborative proposal between AUT and Counties-Manukau DHB over a decade ago, provided the blueprint for Tapu Ora. It’s now a strategic reality to be rolled out across every midwifery school in Aotearoa. The main focus is a Pasifika liaison (PL) role, to provide wrap-around support including: pastoral care; academic support; clinical expertise; and connections to internal student services or external community-based ones. Students’ feedback states the Pasifika liaison role was more valuable than receiving putea; the PL was accessible and most importantly, understood Pasifika cultural nuances.

Tapu Ora is partnered with Te Ara Ō Hine, the Māori arm of the national workforce initiative. It’s been 15 months since the fanfare of its launch, so what has happened between then and now?

Complementary to the liaison role are peer mentors and a capped hardship fund available to all students, which has helped tauira with petrol, hospital parking and some living costs.

Since April 2021, PL roles within all five institutions have doubled to four, with two more appointments pending. The extensive consultative process has delayed appointments, and tertiary institutions have the same staffing tensions as clinical areas, with chronic midwifery workforce shortages. There are approximately 50 Pasifika students throughout Aotearoa. The irony is inescapable; we need midwives to support and educate student midwives, to help alleviate our current situation.

The Cook Island kama’atu, or whakatauki, ‘Kua mua, ka muri’ beckons a backward glance to inform the way forward. The Pasifika workforce initiative Tapu Ora is built on that premise; a reflection of what supported tauira to successfully complete their study and register as midwives.

Kia manuia. square

Fuimaono Dr Karl Pulotu-Endemann, esteemed Pasifika health advocate and activist, gifted the name Tapu Ora to acknowledge the sacredness of birth and bring the midwifery tauira journey into alignment with that sacredness.

NGATEPAERU

The five midwifery schools organised stakeholder meetings to hear the voices of tauira, midwives, educators and the community health sector before defining the liaison role. The feedback laid the foundation for a job description, and was unanimous in stipulating that the role be carried out by a midwife. Other valuable information was shared about recruitment strategies, student learning and connectedness between stakeholders, to strengthen the kaupapa of Tapu Ora

Now, with stakeholder meetings completed, job descriptions developed, and more Pasifika liaison roles nearing appointment, the real work begins. The goal is to retain and graduate all 50 students over the next three years and to keep the workforce pipeline filled and fuelled.

MARSTERS TAPU ORA NATIONAL CO-ORDINATOR

Tapu Ora: kua mua, ka muri

ISSUE 106 SEPTEMBER 20221 | PASIFIKA37

BIRTHAFTERBREASTFEEDINGCAESAREAN

also reported as being confused about infant night waking, which caused some women to have concerns about their milk supply. The researchers pointed out that publicised risks of caesarean birth do not necessarily include the potential disruption to breastfeeding, but the main breastfeeding problems which were identified in this study, including mobility issues, incision pain, maternal tiredness, mucousy infants, and latching difficulties can clearly be linked to mode of Womenbirth.who have given birth by caesarean are one of the priority populations in the Australian National Breastfeeding Strategy, which notes that breastfeeding needs extra support after caesarean birth, or when obstetric or childbirth complications are present (COAG, 2019). Targeted approaches are recommended for women with health or medical risk factors, those with lactation difficulties and those who give birth by caesarean. The Academy of Breastfeeding Medicine also suggests additional support may be necessary for women who have had a caesarean birth (Holmes et al, 2013).

TARGETED APPROACHES TO SUPPORT BREASTFEEDING INITIATION

Working with women who plan to breastfeed is a primary role for midwives, who support both the initiation and establishment of breastfeeding. Initiating breastfeeding after a caesarean birth can be challenging. In Aotearoa caesarean section rates increased to 29.1% of all births in 2019 - the highest ever recorded (Ministry of Health, 2021) - so challenges to breastfeeding continue to increase.

Once breastfeeding is established ongoing difficulties are reduced, so the importance of very early breastfeeding experiences cannot be overstated. The term ‘breastfeeding difficulties’ covers a range of influences including physical, psychological, social and environmental.

Breastfeeding obstacles after caesarean have been identified as including maternal mobility limitations, positioning difficulties, and frustration at the need for assistance to breastfeed (Tully & Ball, 2014). The women participants in the Tully & Ball research were

Caesareanassessments.birthislinked to delayed breastfeeding initiation and shorter breastfeeding durations (Chen et al, 2018; Hobbs, 2016). Women who have given birth

These are compounded further by the neglected state of support for midwifery and the maternity sector; primarily, issues with midwifery shortages, workload, recruitment and retention. Adding to these stressors is the continued catastrophe of the Covid-19 pandemic.Oncebreastfeeding is established ongoing difficulties are reduced, so the importance of very early breastfeeding experiences cannot be overstated. The term ‘breastfeeding difficulties’ covers a range of influences including physical, psychological (can be linked to previous experiences), social (support for breastfeeding) and environmental. Environmental factors include situations now regularly experienced on postnatal wards, which are understaffed and/or have a reduced number of midwives. Provision of optimal midwifery support for breastfeeding initiation is challenging despite the positive influence of the Ten Steps to Successful Breastfeeding and the Baby Friendly Hospital Initiative. Babies who are born by caesarean should realistically be considered additional to their mothers in midwifery workload calculations, otherwise they represent an invisible midwifery activity in acuity

via caesarean are less likely to breastfeed than those who have vaginal births (Arora et al, 2017; Zanardo et al, 2010) and there is an association with higher rates of non-exclusive breastfeeding (Sadkii et al, 2022). Hobbs et al (2016) also found that caesarean births are associated with more breastfeeding difficulties and a greater use of resources. Pain and lack of support negatively impact breastfeeding after caesarean birth (Fielder, 2016).

1 / Mother-infant skin-to-skin contact: Step 4 of the WHO Ten Steps to Successful Breastfeeding is about facilitation of immediate and uninterrupted skin-to-skin contact, as well as support for mothers to initiate breastfeeding as soon as possible after birth (WHO, 2018). Skin-to-skin contact after caesarean birth is an important part of Step 4 and the infant can be placed, with immediate and ongoing support, on the mother’s chest above the theatre

Ways to ameliorate the identified breastfeeding issues are already employed by midwives, who work with recently birthed women in caesarean theatre, women with post-op mobility issues, pain, difficulties with latching and mucousy infants. Further points for discussion are outlined below, including the importance of early skin-toskin in theatre.

38 | AOTEAROA NEW ZEALAND MIDWIFE BREASTFEEDING CONNECTION

CAROL BARTLE POLICY ANALYST

ISSUE 106 SEPTEMBER 2022 | 39 BREASTFEEDING CONNECTION

drape. On the mother’s chest the infant can progress through the nine instinctive, distinct, and observable stages including self-attachment and suckling (Brimdyr, et al, 2018). Mother-infant skin-to-skin contact has well-researched physiologic, social and psychological benefits for the infant and mother.Guala et al (2017) examined skin-to-skin after caesarean birth in a cohort of 252 women with a follow up study period of six months. Skin-to-skin contact with the mother (57.5%), with the father (17.5%), and no skin-to-skin contact (25%) was evaluated, and there was a statistically positive association between skin-to-skin contact with the mother and the exclusive breastfeeding rates on discharge. This effect was statistically significant at three and six months, as compared to the other two groups. A quality improvement project looking at skin-to-skin contact in the operating theatre to increase the success of breastfeeding initiation found lower rates of formula supplementation in infants who had skin-to-skin in theatre (Hung & Berg, 2011). Two midwives were employed to support skin-to-skin contact for women who were having planned elective caesarean births in a public hospital in New South Wales with 4,000 births per year, and a caesarean rate of 39% (57.8% elective C/S) (Sheedy et al, 2022). In this study, women who had skin-to-skin contact at elective caesarean births were more likely to breastfeed earlier, to be successfully breastfeeding on leaving the maternity facility, and to report a positive birthingKollmanexperience.etal(2017) conducted a randomised clinical pilot study looking at early skin-to-skin contact after caesarean and did not find any significant disadvantages for neonatal transition. A feasibility study found that immediate and uninterrupted skin-to-skin during medically uncomplicated caesarean surgery was a feasible and low-cost intervention that can safely begin during surgery and continue, uninterrupted for extended durations (Crenshaw et al, 2019). Early skin-to-skin contact immediately, or soon after a caesarean section, has been associated with physiological stability and the emotional wellbeing of mothers and their newborns, potential reduction in maternal pain, increase in parent and newborn communication, and an improvement in breastfeeding outcomes (Stevens et al, 2014).

/ Mobility: Infants being within easy reach of their mothers is an obvious consideration,

3 / Pain: Because maternal movement exacerbates the post-surgical pain after a caesarean, effective pain control plays a significant part in early breastfeeding establishment. A participant in the Tully & Ball study (2014) reported the pain as being restrictive. Women reported high levels of pain during the first 24 hours after caesarean birth (n = 60) and this pain negatively affected breastfeeding and infant care (Karlström et al, 2007).

experiences and using a feeding position that supports latching while avoiding pressure on the wound is important. The infant positioned under the mother’s arm (underarm/rugby hold), means that their legs are well away from any tender abdominal area. An adapted laid back/semi-reclined breastfeeding position or side lying position can also work well.

Baby CotAve 2 Birthing Bed

Women are likely to be anxious about how to position the infant for breastfeeding to avoid pressure on the wound area. Women who have had caesarean births are reported to have more problems with latching, positioning, and more pain when compared to those who birthed vaginally (Hobbs et al, 2016; Brown & Jordan, 2013). Regular analgesia will support more comfortable

In an observational (video) study (Tully & Ball, 2012), participants (n=35) described the side-car bassinet as permitting visual and physical access to their infants, enabling emotional closeness, facilitating breastfeeding, and minimising the need

and Tully & Ball (2014) highlight the difficulties women experience manoeuvring themselves to access their infants and to breastfeed. The caesarean incision wound can make picking up an infant painful and difficult. Ideally, postnatal units would have side-car cots attached to beds, which would not totally eliminate pain issues, but as mothers have expressed overwhelming enthusiasm for this option, maternal wellbeing is likely to be increased (Tully & Ball, 2012). It has been suggested that stand-alone cots may present an unnecessary breastfeeding obstacle and pose a hazard for infants after caesarean birth because of the compromised mobility of postoperative women during the early postpartum period.

BedandObstetricNeonatalSpecialists Request a complimentary trial of one or both beds and experience first hand the difference these beds make. activehealthcare.co.nz | 0800 336 339 | sales@activehealthcare.co.nz

Nipple pain can also be an issue if caesarean pain and positioning difficulties result in latching problems. A clinical reasoning model was developed by Amir et al (2015) and the complexity of pain was divided into three categories: local stimulation, external influences and central modulation. Tissue pathology, damage or inflammation leads to local stimulation of nociceptors (nerve cells capable of sensing pain and transmitting a pain signal). Pain modulation can be affected through central mechanisms including maternal illness, lack of support, exhaustion, anxiety and depression. These categories are useful to consider and address in situations where multiple factors such as anxiety and exhaustion can complicate painful experiences and breastfeeding difficulties.

/ Latching difficulties: As discussed in previous Breastfeeding Connection articles, infants who are having initial latching difficulties are at significant risk of shortened duration of breastfeeding and loss of breastfeeding exclusivity. When an infant is not latching on the breast, lactation is fragile and a multi-pronged strategy is needed: feeding the infant; provision of the right support for the infant to move closer towards latching; protecting lactation; and avoidance of further complications from any

Natural

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to request midwifery assistance. A more frequent breastfeeding trend and total breastfeeding effort, more mother-infant sleep overlap, and less midwifery presence in the side-car group was noted, but this was not statistically different compared to the stand-alone cot group (Tully & Ball, 2012). Discussing side-car cots may seem pointless given their current lack of availability in Aotearoa, but future maternity unit planning could give this some consideration because of the obvious Meanwhile,benefits.beingaware of where the infant’s cot is placed in relation to the bed, and facilitating family/visitor input to support women post-caesarean is the best option available. Tully & Ball (2014) found that night was the most difficult time for these breastfeeding mothers due to visitors not being permitted to stay in the unit. This situation compounded maternal tiredness.

5 / Newborn infants and mucous: There is limited research about this issue. Ingram et al (2013) collected information about factors during labour and around birth associated with excess mucous production in 160 breastfed infants (80 mucousy infants and 80 non-mucousy controls). Significant associated factors were induction, a long membrane rupture to birth interval, heavier birthweight, delay to the first breastfeed and skin-to-skin contact that was shorter than 30 minutes. Although caesarean birth was not directly associated with mucousy infants in the Ingram study, anecdotal reports indicate that infants in the first 24 hours after caesarean birth may be disinterested in feeding and vomit mucousy fluid. Infants do seem to clear mucous faster when colostrum feeding commences, so infants who are disinterested in feeding initially will likely benefit from early colostrum feeding, via breastfeeding wherever possible. Strategies for supporting the infant to feed include skin-to-skin contact as the first action.

• Mother-infant skin-to-skin contact is associated with positive breastfeeding outcomes

• Effective pain relief is protective of breastfeeding

• Initiation of, and early establishment of breastfeeding is linked to a reduction in ongoing breastfeeding difficulties

• Additional support for breastfeeding after caesarean birth is essential

intervention. Delayed lactation may be an issue for some women. Hand expression of breastmilk may remove larger volumes of colostrum than a breast pump in the first few days after birth, and gentle breast massage and hand compression may also increase the amounts of available milk (Academy of Breastfeeding Medicine, 2017).

• Caesarean births are increasing and are linked to breastfeeding challenges

• Mobility restriction needs to be addressed to enable women to access their infants for breastfeeding easily

• Providing targeted information and facilitating family/visitor support for the mother post-caesarean can support breastfeeding by reducing maternal tiredness and stress.

References available on request.

ISSUE 106 SEPTEMBER 2022 | 41 BREASTFEEDING CONNECTION

CONCLUSION AND KEY POINTS

New challenges cropped up in Kasanita’s third pregnancy, but she was reassured by Shweta’s thorough, compassionate care. “At one of my scans the sonographer mentioned something about the amount of fluid around my baby and when I told Shweta I was worried, she followed up, got all the information, and explained it to me in a way that I could understand. I’d never had a scare like that in any of my previous pregnancies, so I was quite concerned, but Shweta really put me at ease.”

Kasanita Kini hadn’t planned on registering with a new midwife for her third pregnancy, but finding common ground with Shweta Kumar made for a special connection and partnership.

Although Kasanita is Itaukei (indigenous Fijian) and Shweta is of Fijian Indian descent, both were born in Fiji and emigrated to Aotearoa with their families as children. “That was probably the pivotal moment - when I realised she had faced the same challenges as me; moving here from Fiji as a child, experiencing the same culture shock I went through. It’s not that common to meet other people who understand how difficult that adaptation was, so we instantly connected on that level,” Kasanita says.

When Kasanita went into labour, Shweta was off-call, so she was surprised - and touched - to see her walk into her hospital room later that day. “I had Kobe on Friday morning and she came to visit me after a meeting, even though she wasn’t on call. I knew she didn’t need to do that, but she popped in to congratulate us and check on how we were doing. I really appreciated her going above and beyond and I’ve never forgottenShweta’sit.”understanding and experience of Fijian culture was especially valuable to Kasanita, who says it helped her to feel more relaxed about home visits. “In Fijian culture, after giving birth women are supposed to just focus on healing and resting, which can come with its challenges. When Shweta came over to visit us, I knew she understood my situation and family without me having to explain or justify anything. It was such a relief - I felt like I could just be myself and be completely honest with her, without any fear of being judged or misunderstood.” square

Gaining an understanding of the role language plays throughout the maternity journey has been an eyeopener for Shweta. “At first I didn’t appreciate how much of a difference it made, but women’s feedback has made me realise how significant it is. Women have said they not only speak, but think in their mother tongue, meaning when they’re stressed, that’s what they default to and it’s the only way they can express what they’re feeling or thinking in those moments.”

mymymidwiferymidwife

Shweta Kumar’s family emigrated to Aotearoa from Fiji when she was five years old and now the West Auckland-based LMC personalises midwifery care for the diverse communities she serves.

Kasanita (below) was hopeful she’d reconnect with her first midwife for the birth of her third baby and was disappointed to discover she wouldn’t be available around her due date. Hesitantly, she accepted a recommendation for another West Auckland LMC and her partnership with Shweta was established in early 2020, amid nationwide Covid-19 lockdowns.

An early clinical placement sealed the deal for Shweta (above), who has been practising as an LMC in West Auckland since graduating in 2020. “On my first LMC placement I saw how appreciative the families were of the work midwives do and how much it meant to the midwives to be a part of their journeys. I knew I wanted to experience that unique connection.”

Of Fijian Indian descent, Shweta speaks both Hindi and Fijian Indian Hindi and is well sought after for her ability to traverse worlds. “I do care predominantly for Indian clients. They often approach me saying they’re specifically looking for a midwife who speaks Hindi because they feel more comfortable interacting in their mother tongue, with someone who understands their cultural beliefs and values.”

“Our first couple of appointments weren’t face-to-face, so I didn’t actually meet her properly until I was about 15 weeks,” Kasanita explains. “I’d been nervous about having to start again with a midwife I didn’t know, but as soon as we met in person and shared our stories, we just clicked, and as my pregnancy progressed my appointments felt more like catching up with a friend. It was so nice - Shweta just made me feel so comfortable.”

42 | AOTEAROA NEW ZEALAND MIDWIFE FROM BOTH SIDES

Shweta also cares for a diverse range of women from throughout the Pacific and although she might not speak their native languages, she enjoys searching for common cultural values and building partnerships from there. “I do think language plays an important part, but I’ve also found being able to relate culturally or at least find some common threads is hugely beneficial. I feel like I can personalise the midwifery care more when I understand the cultural values underpinning a woman’s wishes or Shweta’sdecisions.”naturalcuriosity means she is always keen to learn about cultures other than her own, so she relishes the opportunity to care for women of all backgrounds. “The most rewarding part of my job, without a doubt, is the connection with the women and their families. You become a part of them; they become your whānau and you don’t realise how much of an impact you make until they invite you to their family functions or their baby’s first birthday. I enjoy the experience of being part of another culture - another story. Each time I’m contacted by a new client I get excited, because it’s another opportunity to connect and learn.” square

Shweta’s younger brother arrived when she was 11 years old and from that point, she became fascinated with babies and their development. When researching different career options she decided midwifery ticked the most important boxes: “I found midwifery and I knew it would be a great balance. I wanted to help people through a significant life journey and I also wanted to work with babies”.

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Articles inside

BREASTFEEDING CONNECTION

PASIFIKA: TAPU ORA KUA MUA, KA MURI

SUDI: MINISTRY REVIEW

YOUR UNION

YOUR COLLEGE

BULLETIN

Q&A: PELVIC HEALTH PHYSIOTHERAPY

YOUR MIDWIFERY BUSINESS

ARE WE FIT FOR THE FUTURE?

HE MAŪNU KAUKAU WAI

ACC COVER: MATERNAL BIRTH INJURIES