Midwife Aotearoa New Zealand by Collegeofmidwives

VEGETARIAN & VEGAN PREGNANCY

P.24

RONGOĀ MĀORI P.18

CLIMATE: PREPARING FOR DISASTER AND EMERGENICES P.20

MIDWIFERY WORKFORCE CHALLENGES PART II P.30

ISSUE 108 MARCH 2023 I THE MAGAZINE OF THE NEW ZEALAND COLLEGE OF MIDWIVES

Antenatal and Newborn Screening Updates

Antenatal Screening for Down Syndrome and Other Conditions reporting changes:

The laboratory report will no longer include serum analyte levels and risk of neural tube defects from 1 March 2023.

Serum analytes will still be part of the risk calculation algorithm.

Link to more detailed information:

www.nsu.govt.nz/health-professionals/antenatalscreening-down-syndrome-and-other-conditions/ procedures-guidelines

Newborn Metabolic Screening Programme changes:

The optimal time for collection has been updated to between 24 and 48 hours and should be before 72 hours.

The earlier collection will help ensure early diagnosis and can prevent irreversible damage and life-threatening illnesses caused by delays in access to treatment.

Link to more detailed information:

www.nsu.govt.nz/health-professionals/newbornmetabolic-screening-programme/proceduresguidelines-and-reports

There are cu rrently opportu nities for midwives to work in our health district at the Royal Hospital for Women, St George Hospital and Sutherland Hospital . Ou r health d istrict is one of the most desi rable i n Australia – stretchi ng from the vi brant city of S yd ney, the iconic beaches from Bond i to Cronu lla, down to the breathtaki ng Royal National Park We pride ou rselves on providi ng exceptional health care to ou r patients and commu nity Ou r midwives can expect to work i n modern and world class faci lities, withi n a dynamic and i nnovative team with opportu nities to conti nue thei r professional development NO W IS TH E TIM E T O JOIN A TEAM TH AT YO U CAN BE PROUD OF ! South Eastern Sydney Local Health District ww w.seslhd.health.nsw. gov.au seslhd-nursingandmidwifer y@health.nsw. gov.au

ISSUE 108 MARCH 2023

FORUM

FROM THE PRESIDENT

4. KIA HOROIA TĀKU POROKAKĪ FROM THE CHIEF EXECUTIVE

5. EMERGENCY RESPONSE

8. BULLETIN

10. YOUR COLLEGE

12. YOUR UNION

14. YOUR MIDWIFERY BUSINESS

FEATURES

16. NGĀ MĀIA

17. MY EDITORSHIP / MY EDITOR

18. RONGOĀ MĀORI

20. CLIMATE: PREPARING FOR DISASTER AND EMERGENICES

24. VEGAN AND VEGETARIAN PREGNANCY

30. MIDWIFERY WORKFORCE CHALLENGES PART II

34. PASIFIKA

36. BREASTFEEDING CONNECTION

Nau mai haere mai ki Aotearoa New Zealand Midwife

In my final issue as editor, I reflect on my time in the role on pg. 17, alongside the musings of our College President, Nicole Pihema. The cover story this issue focuses on vegetarian and vegan pregnancy and the extra considerations midwives may need to take when caring for these whānau. Given people in Aotearoa are increasingly switching to plant-based diets, or at least reducing their meat consumption, the information shared in this article on pg. 24 is timely, relevant, and practical.

This issue’s Climate change article on pg. 20 is also pertinent. Given the devastating weather events that have wreaked havoc throughout the North Island of late, the importance of informationsharing with whānau regarding grab bags, breastfeeding, and safe infant feeding practices in emergencies have never felt more appropriate.

A follow-up to the workforce article featured in the December 2022 issue is presented on pg. 30, with a focus on student midwives as the key to ensuring midwifery has a workforce to speak of in the future. Particular attention is paid to what ensures a positive and enriching clinical placement for student midwives.

Given midwives can now lodge maternal birth injury claims with ACC, the article on pg. 18 explaining the modality of rongoā Māori (traditional Māori healing) aims to inform midwives who may not be familiar with the practices. An overview is provided, as well as an indication of what whānau can expect during a treatment.

Mauri ora, Amellia Kapa, Editor/Communications Advisor

Email: communications@nzcom.org.nz square

from the president, new zealand college of midwives, nicole pihema (Ngāpuhi, Te Rarawa)

Let my neck be washed by the waters of my own land.

Recent weather events have reminded us all of who’s really in charge, and our unmet responsibilities. As midwives, we are in constant relationship with whenua and acknowledge its significance; throughout a pregnancy, we value knowing the position of the whenua and whether its blood supply is sufficient or restricted. As we all know, if a whenua is compromised, the growth and wellbeing of pēpi are compromised, and māmā can also be at risk. After its birth, we inspect the whenua, assessing what condition it’s in and handling it carefully, following tikanga and treating it, rightfully, as tapu.

Reflecting on the word whenua in its other context, as land, I can’t help thinking that if we treated the land with the same reverence as we do each individual placenta; acknowledging it as our collective placenta - through which we are all sustained and nourished - our planet would look and feel entirely different.

The unfortunate reality is, we haven’t done this, and now we are being reminded of our accountabilities and responsibilities as kaitiaki. We have been - and continue to be - takers from the land, but collectively, we have given back very little. Through a te ao Māori lens, what we are experiencing now is not ‘revenge’ from Papatūānuku. Rather, it is a natural consequence of a lack of care and respect.

Te taiao, or the natural environment and the elements at play, have a fascinating way of teaching us. After reading a Stuff article recently, written by Karanama Ruru,

I discovered the true irony of Auckland’s recent battering by an ‘atmospheric river’. As it turns out, below the concrete jungle of Queen St runs an ancient awa (river/stream) called Waihorotiu. This awa, a significant food and water source pre-colonisation for Ngāti Whatua, was respected as the domain of a taniwha called Horotiu. Considered kaitiaki (guardians), taniwha were revered and the relationship worked something like this: we respected taniwha, and taniwha protected the natural environments they inhabited, therefore ensuring our ability to survive. In 1860, however, the Waihorotiu was covered over, to create a sewer.

Without minimising the very real trauma experienced by whānau in Tāmaki Makaurau and other hard-hit rohe, there are lessons to be gleaned from this. As midwives, we have collectively agreed to revere the whenua (placenta), but it’s high time we reassessed our role as kaitiaki of whenua in all its forms.

In November, my presidency comes to an end, so the responsibility of leading our profession to remember how we honour whenua as whānau within our revised scope of practice, will lie with your future president. What attributes will this person need to possess? For those of you considering throwing your hat in the ring, think about what initiatives you can get involved in between now and then. Familiarise yourself with governance processes; get involved in local groups or community organisations, make yourself visible, and start thinking about whenua as whānau - deserving of our attention and care. square

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

“Kia horoia tāku porokakī ki ngā wai o tōku ake whenua”

(Stowell in Mead & Grove, 2003)

EMERGENCY RESPONSE

As I put pen to paper to write this column, media reports of the devastating impacts of weather events in Auckland, Northland, and more recently, the Hawke's Bay and Gisborne are permeating the airwaves. Cyclones Hale, Gabrielle, and unprecendented rains have provoked five states of emergency so far this year, and it's only mid-February.

As highlighted in this edition of the magazine’s series on climate change (pg. 20), we need to prepare for a new normal; one in which there will be more frequent and severe weather-related events causing damage to infrastructure and property, and disruption to transportation or other essential services, including midwifery and maternity.

In addition to dealing with their own personal circumstances (damage to property and possessions, displacement from homes or housing), midwives have had another challenge to manage. As the predominant workforce in maternity care (an acute 24/7 primary, secondary and tertiary service), our profession holds the responsibility for

maintaining maternity service continuity and accessibility during such events. Just as we saw during the Covid-19 response, the essential and acute nature of the maternity service is a secret, hidden in plain sight. Midwives are so adept at ‘managing’ their caseloadsworking with colleagues to ensure ongoing services by rearranging and re-prioritising care, or stepping up to fill roster gaps to cover colleagues who are unable to get to work - that the additional resources needed to enable the midwifery and maternity service to continue in the face of adversity is often invisible. The College has heard examples of midwives inadvertently finding themselves in precarious situations as they braved the

Our profession holds the responsibility for maintaining maternity service continuity and accessibility during such events. Just as we saw during the Covid-19 response, the essential and acute nature of the maternity service is a secret, hidden in plain sight.

ALISON EDDY CHIEF EXECUTIVE

ISSUE 108 MARCH 2023 | 5

weather and flooded roads to make their way to rostered shifts or attend emergency call-outs during the peak of the January and February events. Given our workforce shortages, midwives are acutely aware that there is no ‘fat in the system’ and if they don’t turn up, there are real risks that services will not be provided, women will miss out on essential care, or colleagues will be further stretched and stressed due to staff absences. The College’s role is to represent and advocate for midwives at this time, as we

did throughout the Covid-19 response. At our request, Te Whatu Ora quickly agreed to apply exemptions to some Section 88 payment rules, and MERAS has negotiated ‘force majeure’ provisions for midwives who were unable to make it to work, providing some short-term financial relief. The College regions have been providing pastoral and practical support for affected members, but like any natural disaster of this scale, the road to full recovery - both physically and mentally - will be long. The reality of ongoing disruption to many aspects of life which typically occurs in the aftermath of such events is a slow burn, which can insidiously lead to chronic stress. In the words of our previous prime minister, being kind at this time is a seemingly small, yet important antidote that we can all embrace.

FUTURE GOVERNANCE AND STRATEGY FOR THE COLLEGE

During the process of developing our strategic plan, the College’s board identified four focus areas (below). The plan is in final editing stages and te reo translation, and will shortly be published on the College’s website. An overarching theme of how the College enacts its obligations to Te Tiriti o Waitangi

College strategic plan priority areas 2022 - 2026 Ōritetanga

and how our work supports equity to be achieved, is threaded throughout the plan. As we turned the spotlight on our organisation throughout the development process, the board identified the need for a cultural review; the final draft report of which is being considered at present. In addition to this, the need to consider our present governance model became apparent.

The College has always understood the importance of maintaining a sense of collectivism. As a small profession, it is unhelpful to have a variety of separate organisations representing the various midwifery interests or issues. As well as reflecting the founding principle of partnership (expressed by having consumer representation in governance and other College processes, e.g. MSR and Resolutions Committees), the College’s governance model also reflects collectivisation, through the broad and diverse composition of our governance body; the national board. This model has always been highly consultative and consensus-based, to ensure members’ views are represented and involved in decision-making processes. Since the establishment of the College in 1989, the governance structure has undergone a

Equity, inclusion & belonging Rangatiratanga

Leadership & advocacy Te mahi

Strengthening our organisational structure & capacity

6 | AOTEAROA NEW ZEALAND MIDWIFE FROM THE CEO

Support a cohesive, sustainable & innovative workforce for the future

Kāwanatanga

Te Kāreti o ngā Kaiwhakawhānau ki Aotearoa

The College regions have been providing pastoral and practical support for affected members, but like any natural disaster of this scale, the road to full recovery - both physically and mentally - will be long.

number of changes; as the diversity of the profession has grown, so too has the number of members on the board, to ensure its representative nature remains relevant.

This model means that the board is large, currently containing the following representatives:

• Kuia and elder

• Elected president

• 11 elected regional chairs; one for each College region (two for Auckland)

• Two Ngā Maia Māori Midwives representatives

• Two Pasifika Midwives Aotearoa representatives

• Up to four consumers

• Two student representatives (rotated around the schools of midwifery)

• Chief Executive (CE)

This makes a total of 25 individual board members. There are additional participants in attendance at board meetings, including an ex-officio education consultant, the independent member of the finance committee and some College staff. Frequently, subregional chairs also attend the board meetings as observers, and both incoming and outgoing chairs may also attend as part of the handover process. It is not uncommon to have in excess of 30 participants at any given board meeting. In latter years, a finance committee (a sub-committee of the board, including an independent member) has been established; its specific terms of reference requiring it to provide: strategic direction; financial oversight and advice; consideration of emerging issues; review of risks and mitigation strategies; support and mentoring for the CE; and coordination of the CE performance review. This smaller group reports to the board in an advisory capacity, ensuring overall accountability for the College.

The board has identified that although some aspects of our current governance model are highly valued - including its broad representative nature which brings a diversity of perspectives and range of skills, valuable networking, and relationships (and the support these offer) - there are some aspects that don’t work so well.

With a large board size, meetings are fulsome, with at times robust debate to build consensus on complex practice, strategic, political and governance issues. The model is highly democratic and consultative, however, it can be slow to move issues along. As well as the relatively infrequent timing of face-to-face meetings, regional chair roles are for two-year terms (albeit some with the right of renewal), so board member turnover can be high. Responsibility is somewhat diluted with such a large group, and communication can be challenging.

The need to increase Māori representation within governance and throughout the capability and capacity of our organisation was identified by the board as a key goal. Since finalising the strategic plan, the board has reviewed the governance models of organisations with similar purposes to ours, considering the principles and values that are important for us to reflect and maintain, as well as what other structures or forums could be established to ensure necessary functions and activities are not lost, but instead strengthened through any changes that eventuate. These are early days, but however we proceed, it is essential we remain true to our principles as a consensusbased organisation grounded in collectivism, and members must be able to have a say in whatever the future looks like. square

ISSUE 108 MARCH 2023 | 7

Midwifery workforce group

At last, following many months of deliberations, Te Whatu Ora have established a Midwifery Workforce Steering Group, to oversee the strategic work needed to address our workforce crisis. It is anticipated that working groups will be set up under the steering group, which will oversee initiatives focused on: enhancing workforce attraction; recruitment; supply; equity; development; workforce and workplace culture; and the overall resilience of the midwifery workforce. square

Community Midwifery Infrastructure Working Group meeting

Te Whatu Ora has established a working group to provide advice on the development or expansion of infrastructural supports for self-employed midwives working under

the Section 88 Notice. The group has broad representation, from practising LMC midwives working in a range of contexts, to College representatives, whānau/consumer representation, Ngā Māia and Pasifika midwives, as well as employed midwives working in caseload or community models. square

Congratulations Priscilla Baken, MNZM

Priscilla Baken is the latest midwife to become a Member of the New Zealand Order of Merit for services to midwifery, having worked in the profession for 41 years in New Zealand, the United Kingdom and Niger, Africa.

Over those years, Priscilla has worked as a homebirth midwife, helped to establish the Community Birth Services Trust, lectured in undergraduate midwifery education, and been part of the MidCentral community midwifery team.

One of the founding members of the College, Priscilla has also served as a midwifery standards reviewer, midwife consultant, expert witness, and a midwifery practice mentor. She has presented research both nationally and internationally on the effectiveness of homebirth, the impact of labour and birth on breastfeeding, and community birth services as a model of community-led maternity service provision. The College congratulates Priscilla and acknowledges the significant influence her work and contribution has had on the whānau she has cared for, as well as the many midwives she has mentored and guided throughout her career.

Ngā mihi nunui ki a koe e Priscilla. square

Changes to cervical screening programme planned from July 2023

From July 2023, the cervical screening programme will look different. The primary test for cervical screening (known as the smear test) will change to a human papillomavirus (HPV) test with the option available for self-testing. The primary aim of the change is to identify people at higher risk of developing cervical cancer for further

bulletin

8 | AOTEAROA NEW ZEALAND MIDWIFE BULLETIN

Priscilla Baken, MNZM

investigation. About four out of five people have HPV infection at some stage in life. The new screening method will test for the presence of HPV, making screening for cervical cancer more accessible and identifying those who need further testing at an earlier stage than the current cervical smear test.

For midwives and women, this means:

• Testing can be offered during pregnancy by the midwife or as a selftest, alongside other health screening.

• If the HPV test is negative, women can be reassured that there is a low risk of developing abnormal cells that may lead to cervical cancer within the next five years. In these cases, the screening will only be required five yearly, as opposed to the current three yearly programme.

• In the case of a positive test, referral for further testing can be made. square

Covid-19 vaccine approved for children at high risk of adverse outcomes

In December 2022, Ministers approved use of the paediatric Pfizer Covid-19 vaccine for children aged six months to four years

Changing Birth Culture

One Birth At A Time

at higher risk of severe disease as a result of Covid-19 infection. The vaccine became available from 9 February at nominated vaccination clinics. Vaccine appointments for babies and children in this group can be booked online or by calling Healthline on 0800 28 29 26.

• The vaccine contains a lower dose of mRNA that has been specially formulated for this age group.

• The vaccine is a three-dose course. The second dose is given three weeks after the first dose, followed by a third dose at least eight weeks after the second dose.

• The vaccine is available to those with the following health conditions (co-morbidities):

- chronic lung disease including bronchiectasis, cystic fibrosis, BiPAP for OSA

- complex congenital heart disease, acquired heart disease or congestive heart failure

- diabetes (insulin-dependent)

- chronic kidney disease (GFR <15 ml/ min/1.73m2)

- severe cerebral palsy (or severe neurodisability including neuromuscular disorders)

- complex genetic, metabolic disease or multiple congenital anomalies, e.g. Trisomy 21/Down Syndrome

- primary or acquired immunodeficiency

- haematologic malignancy and/or post-transplant (solid organ or HSCT in last 24 months)

- on immunosuppressive treatment including chemotherapy, high-dose corticosteroids (Prednisone 2 mg/ kg/day for more than 1 week, or 1 mg/kg/day for more than 1 month), biologics or DMARDS.

Children aged six months to four years who are not in these risk categories have a very low likelihood of developing severe illness following Covid-19 infection and do not need the vaccine (and are not therefore eligible to receive it). square

Image: Angela Scott Photography

ISSUE 108 MARCH 2023 | 9 BULLETIN

Apply now to become a Calmbirth® Educator in Aotearoa New Zealand.

calmbirth.nz

Book early for your MSR

The Midwifery Council requires mdiwives to undertake a Midwifery Standards Review (MSR) at least every three years, and it can be a long time for midwives to remember when their next review is due. Our administrator, Saili Tuitape, works hard to accommodate midwives’ booking requests; however, it can be stressful for midwives to realise their MSR is due imminently and find that there are no available slots, as they are usually booked up months in advance. If you think this could be you, check your MSR due date on your Midwifery Council portal. If it is due in 2023, book it in now to give yourself the time to prepare.

To help keep up with the demand, the College is recruiting more midwives and consumers into the MSR and MFYP reviewer roles earlier than the usual bi-annual ballot. This will only apply to certain geographical areas that are short of reviewers and will also look to increase the number of Māori reviewers, as more of our Māori members are requesting to be reviewed by Māori. square

Scope of practice submission

The College provided a submission to the Midwifery Council in December on the second version of the revised scope of practice statement. A member consultation of the draft submission was undertaken, and member feedback was incorporated into the final version. Key aspects of the submission were unequivocal support for the elevation of cultural safety, prioritisation of te ao Māori worldviews and honouring Te Tiriti o Waitangi partnership within the scope.

The College accepts and welcomes the transition to explicitly name whānau-centred care in the scope. A clear definition of whānau is needed to ensure health professionals, the public, the legal system, and relevant professional accountability forums have a consistent interpretation of who the midwife is authorised to provide clinical care to. The College sought further assurance that the Council will provide clear and transparent information to the profession about its intended process for socialising and implementing the new scope in a culturally safe way, and ensuring education is widely available to midwives. square

Te Whatu Ora pre-employment vaccination policy submission

When the prime minister announced the end of the legal mandate for Covid-19 vaccination in September 2022, health districts were advised to return to their regional vaccination policies for new staff until a national policy was confirmed.

When a draft policy was released for internal Te Whatu Ora consultation in January, the College requested to circulate the draft to its members and provide a representative submission, which was subsequently undertaken. Respondents broadly agreed with the College’s position, that vaccination is recommended and important for health care workers, but should not be mandatory, particularly given the public health risk of health workforce shortages.

The College also recommended that serology testing for immunity and the offer of vaccination to students and prospective staff should be made free of charge. A final version of the policy is expected in the coming months. square

Recent submission provided by the College

Sale and Supply of Alcohol (Community Participation) Amendment Bill

This consultation closed on 10 February. In its submission, the College continued to advocate for the regulation of alcohol promotion, advertising, and sponsorship, alongside the proposed legislation to increase participation of communities in decision-making processes. This bill will unfortunately only partially address the issues of alcoholrelated harm. square

Midwifery First Year of Practice Aotearoa National Programme

The College welcomes all graduate midwives to the profession in 2023 and also acknowledges the 2022 graduates as they move into their second year of practice.

Each year brings changes within the MFYP, which enables us to continue to strengthen the programme and support graduates over their transitional year. In 2023, the significant changes reflect the timing of entry to midwifery, as graduates nationally sit their Midwifery Council exam and enter the profession from November through to June.

We have already welcomed a large group of graduates from AUT, Ara, Otago Polytech and Wintec, and look forward to welcoming the first group of graduates from Victoria University’s School of Midwifery in November 2023. We anticipate there will be approximately 140-150 graduate midwives who will join the profession this year and work in their chosen practice setting.

Thank you to all of the midwives who have once again chosen to be a mentor midwife for graduates over 2023. We appreciate all of the support from professionals, graduates, mentors and the heads of schools as we navigate these new changes. square

10 | AOTEAROA NEW ZEALAND MIDWIFE YOUR COLLEGE

Continuing education update

It is with great pleasure that we inform members planning for the College’s national education calendar is well underway. It feels positive that we can now plan for the next couple of years with the challenges of Covid-19 hopefully well behind us all.

The College education team met at the end of 2022 and planned a varied and exciting education calendar for 2023-2024. Multiple modes of educational platforms will be utilised with the aim of supporting members’ access to education more easily: face-to-face workshops; webinars; e-Ako (e-learning); and hybrid models (e-Ako and zoom). New topics, as well as updated popular workshops will be available.

We welcome new members of our team - Annmarie Taiapa, Priya Pillar and Debbie MacGregor. We look forward to seeing you soon, either in person or online. square

Rural Student Midwifery Grant

Mary Garlick, a retired long standing rural midwife has generously granted a sum of money to the College to administer as an annual grant for midwifery students who intend to practise rurally on graduation. Applications will be accepted from students who are enrolled in the final year of a New Zealand Bachelor of Midwifery programme in 2023.

Applications must be submitted via email to lynda.o@nzcom.org.nz by 1 May 2023, noting ‘Rural student grant application’ in the subject line. Further information and application forms are available on the College website www.midwife.org.nz

Midwifery students are eligible to apply for the annual $2,000 grant if they meet the following criteria:

Applicant must be a College member and enrolled as a final year student of an approved New Zealand Bachelor of Midwifery programme for 2023.

Applicant must intend to practise as a rural midwife in New Zealand on graduation. Preference may be given to those intending to practise as an LMC.

To apply, applicants must:

Demonstrate a commitment to rural midwifery practice on graduation

Complete the application form and ask two referees to complete the relevant form. One referee must be a lecturer at the midwifery school in which the student is enrolled and the other, a midwife who the student has completed a clinical placement.

Top: Auckland graduate MFYP workshop. Bottom: College education team NB: Only one grant will be awarded per annum. The Midwifery Student Rural Grants Advisory Committee will award the grant.

ISSUE 108 MARCH 2023 | 11

AMELLIA KAPA COMMUNICATIONS ADVISOR

Honouring Jill as she prepares for retirement

MERAS Co-Leader Jill Ovens announced her retirement at the national MERAS conference in November 2022. As her five-year term comes to an end, she reflects on her journey with Amellia Kapa.

Jill’s extensive union history began at State Coal Mines in Huntly in 1987 when she was Information Officer. The then Labour government was laying off hundreds of miners, and Jill spearheaded a campaign highlighting the plight of State Coal apprentices and State Coal housing tenants.

Jill and her husband were both laid off and found themselves with a 22% mortgage

“It was immediately apparent that Jill was the best candidate for the job. The thing that really stood out was her understanding of the fact that this role required someone to be an advocate for women’s rights. She really grasped the importance of achieving equity for a female workforce and she very quickly joined the dots between the issue of discrimination against women, and what was happening to midwives.” - Alison Eddy

and three young children. She got a job as editor of the Waikato Weekender and later with Presbyterian Support Services in the Waikato, where she and her colleagues joined the Community Services Union (CSU). She became the CSU journalist, a role she continued when the CSU joined the Service Workers Union, and Jill continued to do parttime after she joined then Auckland Institute of Technology as a PR lecturer in 1992.

AIT became AUT, and Jill moved into the journalism stream where she became a senior lecturer and Branch Chair of the Association of Staff in Tertiary Education (ASTE). She was elected as ASTE President in 1999, a full-time job, and was subsequently headhunted by the Service and Food Workers’ Union. Representing kitchen staff, cleaners, and orderlies in this role - most of whom were women - gave Jill insight into the unique industrial challenges women faced.

By the time Jill saw the advertisement for the MERAS co-leader role in 2018, she had also gained notoriety in the world of politics, first as Alliance President and Co-Leader –where she first met Caroline Conroy – and later, as a Labour Party Council member. These experiences had armed Jill with even more feminist conviction and she jumped at the chance to apply.

College CE Alison Eddy was part of Jill’s interview panel and remembers the day well.

Over the years, this has held true, as Alison explains. “Jill’s extensive experience in union work and involvement with the Labour party, combined with her many years of experience in negotiations meant she was the obvious choice. It’s become even more apparent since she’s been in the role - seeing the significant gains for MERAS and the tangible results for midwives. She’ll be a huge loss for the union. Alongside Caroline Conroy, Midwifery Co-Leader, they’ve created a very effective leadership model.”

What some may not be privy to, is Jill’s previous connection to birth activism and the personal significance of landing the job. Jill birthed her second and third sons in Kansas in the late 70s, but not at home as she would have liked. At that time, midwifery was unlawful in Kansas and her maternity carer - a female GP - told Jill she couldn’t support her to birth at home, for fear of being reported to the authorities by her medical

12 | AOTEAROA NEW ZEALAND MIDWIFE YOUR UNION

colleagues and losing access to the hospital as a birthing facility.

Jill got involved in the homebirth movement, going on to be present at friends’ homebirths, attended by Oklahoma-based midwives who crossed the border in to Kansas to support women’s choices. Jill was a La Leche League leader, which she remained involved in for some time after the births of her sons. Her alignment with the midwifery cause, therefore, was a natural one. “I was really thrilled to get the job; it took me back full circle to working with women. The struggle for women is so much greater than for men in an industrial sense, which had been reaffirmed for me many times.”

Five years later, Jill is frank when describing her observations of how the maternity care landscape has changed over her term. “I think the position for midwives has deteriorated significantly, particularly in the last year or so, but at the same time, MERAS has changed dramatically.”

The gains for MERAS have been many, and Jill is proud to have been part of the transformation of the organisation. “I think that my biggest contribution as a co-leader was to turn MERAS into a proper union. The name says it all; Midwifery Employee Representation and Advisory Service. It was seen to be a service, whereas unions have long since moved on to being more focused on organising: activating the membership; growing leadership at all levels; educating members and our leaders to be more actionoriented. We can confidently say MERAS is doing all of that now.”

MERAS is now a force to be reckoned with and taken seriously as a union, she says. “I think we’ve really stepped up. We’re a very powerful voice within the Council of Trade Unions, particularly given our size. We’re a much more powerful voice for midwives now than we’ve ever been in the past. We’ve got over 100 workplace reps, who’ve all been trained within six months of starting.”

Jill has also witnessed a shift in the mindset of members, which puts the power firmly back in midwives’ hands. “Historically, there was an expectation that the union would step in and resolve all issues and solve everybody’s problems for them. But the model we’ve moved to now is more of an empowerment model, which fits much better with midwives and their ethos. They totally get it; they know they’re best placed to find effective solutions to any problems that arise.”

Member feedback also proves midwives were ready and willing to take real action during the rolling strikes, despite limitations. “I know from our members that taking industrial action was very empowering. Even though most of our members who were rostered on at the time couldn’t actually take industrial action because they needed to provide life preserving services, we still managed to get a lot of media attention and our members were more than ready for it.” Looking forward, Jill is adamant further progress can be made with the right approach. “I think it would be good for us to recognise and express the power that we have. I think there is hope that we can make changes, but the only way to do that is by refusing to accept what’s being dished out and taking action to ensure we exercise our power.”

The key, she believes, is to remember the whānau we serve and the part they are more than willing to play. “I think women out there in the community - along with their partners - are hugely supportive. We saw that at St. George’s. There is enormous potential

to mobilise the support that’s out there.”

The final word goes to Caroline Conroy, who has worked alongside Jill for the past five years. “It has been great working with Jill since she joined MERAS in 2018. I have admired Jill’s determination to get the best deal possible for MERAS members when we have negotiated Collective Agreements and her tenacity in ensuring progress continues in the Midwifery Pay equity claim. During her time with MERAS Jill has made a significant contribution in bringing recognition to the work that employed midwives do around the country.”

Ngā mihi nunui ki a koe e Jill, kia pai tō haerenga. square

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

ISSUE 108 MARCH 2023 | 13 YOUR UNION

WAYNE ROBERTSON EXECUTIVE DIRECTOR, MMPO

managing finances proactively

2023 is predicted to be tough financially for a lot of people in Aotearoa. Recent historically low interest rates, together with easier access to finance helped push asset (particularly house) prices and consumer demand (and inflation) to historical highs. But this set of circumstances, influenced strongly by the temporary global financial response to Covid-19, was never going to be sustainable.

Now, going into 2023, we are left with the remnants of a good time - albeit short-lived - and the start of a financial hangover in the form of:

• higher cost of living and pressure on wage inflation

• declining asset (house) prices

• expectation of rising unemployment

• rising interest rates.

Many financial commentators expect that the current economic situation will start to moderate sometime during 2024, but this statement comes with uncertainty. In challenging circumstances such as those expected this year, it’s worth spending time considering how to proactively manage your financial situation.

WHAT CAN I DO?

Acknowledging that everyone’s financial circumstances will be different, some practical options/actions that can be taken to manage the changing financial pressures that will be facing us all in the coming year include:

Updating and reviewing your whānau budget: reassessing, or re-prioritising spending for necessities, trimming spending

on discretionary items, and avoiding use of credit cards which incur high interest and can enable impulse buying.

Identify ways to improve your revenue. The current workforce shortages mean that for those who are working less than 1.0 FTE, there are a number of potential additional sources of income including second midwife care, locum work, postnatal modules, or additional shifts.

Talk to your bank about maximising your savings and cashflow and/or minimising the impact of debt, including:

• Reviewing the schedule of necessary regular payments so they are manageable (e.g. smaller, more regular payments may be more manageable when cashflow is tight).

• Managing your debt by reorganising and consolidating your accounts, and avoiding credit card debt.

• Assessing your interest rate situation and what is best for your whānau in the shortand medium-term (i.e., fixed, or floating rates).

• If you have surplus cash, investigating how it can best be invested, and for how long, in order to maximise your return.

One of the many challenging decisions you need to make is how to balance the tension between ensuring you have enough money to meet priorities (such as the need to maintain a minimum level of spending on necessities) and the need to save money for the longer term. Recent events in Auckland and the wider North Island demonstrate that a minimum level of insurance cover for valuable assets such as homes, contents and cars, is a necessity. For self-employed midwives specifically, kit insurance and income protection insurance are also in the mix. When considering longer term savings, the MMPO is receiving an increasing number of questions about KiwiSaver and

14 | AOTEAROA NEW ZEALAND MIDWIFE YOUR MIDWIFERY BUSINESS

One of the many challenging decisions you need to make is how to balance the tension between ensuring that you have enough money to meet priorities and the need to save money for the longer term.

whether or not self-employed community midwives should be signed up to it.

WHAT IS KIWISAVER AND WHY SHOULD I JOIN UP?

When you join KiwiSaver (which is recommended), you choose a contribution rate of your before-tax pay that is affordable and maximises your long-term savings potential. The amount of this contribution can be changed depending on your circumstances. For employed core midwives, their employers are also required to contribute at least 3% of before-tax pay.

The government provides incentives to encourage people to save for their retirement through KiwiSaver. These include an annual member tax credit of up to $521.43, as well as a first-home deposit subsidy for eligible first-home buyers.

Self-employed community midwife KiwiSaver members are eligible for the $521 government contribution if a minimum of $1042.86 per annum is added to their KiwiSaver account (effectively giving members a 50% return on investment). This is why we recommend everyone should sign up as one of the tools in their long-term savings plan.

As community midwives are also technically their own employer, they are able to determine the amount or percentage of income they invest in KiwiSaver. Depending on individual personal circumstances, investing more than the minimum of $1042.86 required to access the annual tax credit each year may not be worth it. If you are carrying debt in the current environment of high interest rates any surplus money (over and above the minimum $1042.86

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contribution) would be better used to reduce this debt down before investing in retirement savings. If you are in the fortunate position of being debt free and saving, increasing KiwiSaver contributions is a sensible option.

FINALLY …

If needed, you should prioritise time to ‘see the wood from the trees’, by sitting down together with your trusted financial advisor (accountant, tax advisor, and/or bank) with the purpose of gaining better understanding of your current cashflow and financial position, your medium to longer-term financial outlook,

and to test different scenarios so that you understand and are prepared to act to your benefit as the future unfolds. square

MMPO, the Midwifery and Maternity Providers Organisation provides self employed community midwives with a supportive practice management system.

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Ngā Māia: looking ahead

Tēnā koutou ngā māreikura o te motu nei

Ngā kahu pōkai

Nā wai te whare nei e?

Nā tuhi mareikura te whare nei e Nāu e hine i karanga

Nāu e hine i koingo

Ko koe

Ngā Māia came together in November 2022 for our long awaited hui-a-tau, held in Ōtautahi at the Tai Tapu Community Centre and hosted by our amazing whānau and regional roopu Ngā Māia Māori Midwives Ki Tahu. An opportunity for our kahu pōkai across the motu to come together and celebrate our achievements and successes, deliberate over our plans for the future and commit to reclaiming our birthing traditions for the wellbeing of our whānau. Since its

inception, Ngā Māia has maintained its philosophy to protect whānau, hapū, and iwi values and aspirations towards Māori birthing practices and provide a voice for whānau Māori to participate in maintaining and developing our traditions. Nāu te whatu Māori - through the eye of Māori.

Our theme for hui-a-tau was Mana whenua, mana whānau, mana motuhake; a beautiful theme incorporated throughout the hui with guest speakers and knowledge holders such as: Ruatau Perez - kairongoā and former tauira of Papa Jo Delamere (tohunga of Ngā Māia past); Mahina-Ina Kingi-Kaui - taonga pūoro practitioner; and our own Annmarie Taiapa-Johnson - sharing kaupapa Māori models of care through Matariki. We also had the pleasure of hearing from poet Raina Kingsley, young duet The Twins, who shared their experience of domestic violence through waiata, and Project Miere, a collaborative musical duo. And of course, our amazing tuahine and MC, Kelly Tikao.

We said haere rā to dedicated trustees Sarah Wills and Joyce Croft and welcomed

into our trustee whānau Tawera TrinderTaranaki, and Dani Gibbs - Te Waipounamu. The mauri of Ngā Māia - held by Waikato since 2020 - was returned, and a tono put forward by regional roopu Ngā Māia Ki Waiāriki, our newly established roopu, in a very emotional ceremony upheld by Papa Rob and Whaea Crete. The mamae of the past were left in the past, to now focus on the future of Māori midwifery.

Looking to this new chapter of Ngā Māia, the karanga has been set to take up those positions you have always thought about, step outside your comfort zone, be unapologetic in your decision-making, and go forward as the mareikura that you are, noble at birth, a supernatural being that carries the mana and authority of your whānau, hapū and iwi.

This year we will welcome Ngā Māiaendorsed kahu pōkai Māori in newly established roles, such as Chief Clinical Advisor - Midwifery within Te Aka Whai Ora, midwifery workforce programme advisors to Te Whatu Ora, community workforce advisors, Kahu Taurima advisors, Māori midwifery educators and researcher roles and many more work streams, as we navigate our newly structured health system.

If you would like to know more about up-and-coming positions or roles, please contact us at ngamaia@gmail.com. We look forward to our new year beginning at the rising of Matariki with a bright future for iwi Māori. He aha te kai a te rangatira? He kōrero, he kōrero, he kōrero. What is the food of leaders? It is communication. Kōrero mai. square

16 | AOTEAROA NEW ZEALAND MIDWIFE NGĀ

MĀIA

my editorship my editor

As her journey comes to an end, Amellia Kapa (Ngāpuhi, Te Aupouri) reflects on her time as editor of Midwife magazine. I’m often asked how the change came about. What inspired me to switch from journalism to midwifery? Well, somewhere along the way, I realised I wanted to do something that helped enrich other people’s lives. I just hadn’t quite figured out how. As a 26-year-old, I met a midwife in Melbourne and when I told her I had been present at the births of all three of my brothers (two homebirths and one hospital birth) a lightbulb came on and I realised what a beautiful gift my māmā had given me all those years before.

The journey to become a midwife began and I thought my writing skillset, although useful, would become background noise. But five years after gaining registration, I stumbled across the College’s ad for the communications advisor role and it seemed like the perfect combination of my skillsets and experience. I have relished the opportunity to tell the stories of midwives and whānau each quarter and produce a tangible product from what starts off as a single page of ideas.

A couple of articles in particular stand out for me as significant achievements over my editorship; Lucia’s story in the March 2022 issue, about sexual abuse and how we can be more mindful of it as midwives, was both pertinent and personal. The breakdown of moral distress in the June 2022 issue and how it affects our workforce also felt like an important conversation; one which struck a chord with many midwives.

One of my main goals as editor has been to normalise use of te reo Māori throughout the magazine, slowly but surely increasing the use of kupu Māori without English translations. Telling more Māori stories and pulling in threads of mātauranga Māori has also been intentional. A perfect example of this can be found in the June 2022 issue, where I shared the mātauranga of the three hearts, gifted to humans by the atua.

Working for the College has been a wonderful experience; I have gained insights into the invisible, constant nature of the mahi occurring behindthe-scenes to ensure our collective voice as midwives is heard at every table. The home fires, or ahi kaa, must never be allowed to extinguish, and this is how I perceive the College’s role; each advisor and staff member stokes the ahi kaa, so that midwives can continue to do the vital mahi we have all signed up to do.

My time as editor now comes to an end, as I dive deeper on a journey of returning to rongoā Māori (traditional Māori healing) and the wisdom of my tūpuna. It has been my honour to share the stories of those I have met along the way, to work alongside the wāhine pūmau of the College, and to be of service to midwives throughout Aotearoa.

Nei rā aku mihi whakawhetai ki a koutou. Mauri ora ki a tātou katoa! square

College President Nicole Pihema (Ngāpuhi, Te Rarawa) reflects on working with Amellia through her time as editor.

Each time I’m asked to write an article or provide insight into events, I seem to face this enormous stumbling block. The block usually presents itself whenever I’m questioning whether I should (or could) write about something I’m truly passionate about, or how I can word it to offend as few people as possible. I often wonder whether that was what members wanted; a President who wrote from their heart, or wrote from their head. But I have to be sincere to myself and to members. I need to be transparent; I cannot be hiding behind a thesaurus of words that do not show the real me - the me who writes what I think, rather than what you want to hear. My evolution - from my first contributions as College President, to now - has been a journey in itself and I have Amellia Kapa to thank for that.

I don’t even remember the exact year I first met her, as a student midwife who had come to Te Tai Tokerau for a rural placement. Looking back now, it feels like so long ago. Over the years, I’ve been privy to her midwifery practice through social links and the casual catch-up at events, if or when we both happened to attend.

There’s something about being in the company of other Māori that settles the soul: the whakawhānaungatanga that occurs; the connections that are made; the familial ties that are found. It’s a unique kind of connection that can’t be found anywhere else; I can’t quite describe it. It’s like our tūpuna set us all on paths to reconnect and discover how our tūpuna knew one another, so that we could reweave and strengthen the ties that bind us. All I know is, these reconnections are definitely no accident. I remember one phone call in particular, that started out business-as-usual, but somehow evolved into a tikanga wānanga, around how our current mindset is disrupted and challenged by mātauranga which confronts ingrained education intended to mould our minds into obedience. How does a phone call go from ‘What do you want to talk about this edition?’ to an entire wānanga on the de-construction of a colonised mind?

This journey has been profound, and having Amellia understand me, without having to detail every aspect of my upbringing and why I think this way and that way, has been a blessing. Therefore, hopefully a tohu for you all. Amellia has helped me to understand how to process my thoughts into words and when I am stuck, she literally - like an artisthelps me to express those whakaaro cleanly.

Tūpuna connections do not end when Amellia pursues her calling to rongoā. In fact, they only get stronger. Thank you Amellia, for sharing your mātauranga and being a part of my journey.

He waimarie mō tō haerenga e whai ake nei, mō āke tonu atu. square

ISSUE 108 MARCH 2023 | 17 FROM BOTH SIDES

RONGOĀ MĀORI: WHAT IS IT AND HOW CAN WHĀNAU BENEFIT FROM IT?

Rongoā Māori is an umbrella term describing all aspects of traditional Māori healing.

The 1907 Tohunga Suppression Act drove these practices underground and although much of the mātauranga - particularly in relation to hapūtanga, birth and postnatal care - has been lost, a significant amount has been retained and is being shared and practiced across the motu. Amellia Kapa sheds light on rongoā Māori and how wāhine hapū or māmā who have sustained birth injuries might benefit from treatment.

The word rongoā encompasses a range of practices, including - but not limited toromiromi, mirimiri and wai rākau. It describes a holistic system which acknowledges our inter-dimensional nature as humans. Through this lens, the wellbeing of our wairua (spirit) and state of our mauri (lifeforce/energy) is not separate from that of our physical body, and any emotional or psychological trauma we may have suffered can manifest as physical symptoms or disease.

In our modern world, some of the kupu describing different aspects of traditional Māori healing are being used interchangeably and this breakdown is intended to illuminate what the different terms mean and what whānau can expect during a treatment.

Mirimiri is often translated as ‘massage’, but in fact, it refers to energetic forms of healing practised through kōrero (talking/ counselling), takutaku (incantations), waiata

(songs), taonga pūoro (traditional musical instruments), breathwork, and connection to tūpuna (ancestors). Put simply, mirimiri is everything that occurs energetically, in synergy with the physical bodywork.

Romiromi is the physical aspect of treatment and is based on a system of pressure points located throughout the body, known as haemata. Pressure is applied to these haemata either with hands, elbows, forearms, or rākau, to stimulate and release stored/blocked trauma, tension or energy, and allow for the restoration of flow. Specific haemata are associated with different emotions, or aspects of our whakapapa (genealogy), so depending on where discomfort or tension is present, this can be an indication to both kairongoā (practitioner) and tangata whaiora (one seeking wellness) of where healing is needed. Other massage and stretching techniques

also assist in realigning and readjusting the body, allowing for further release. Although physical, romiromi is still holistic in nature and works in conjunction with mirimiri

In the context of a rongoā Māori treatment for maternal birth injury, for example, mirimiri is happening from the moment whānau engage with a practitioner, or practice, to begin their healing journey. The first session may not involve any bodywork at all and may simply serve as an opportunity for a woman to tell her story uninterrupted; perhaps for the first time. Before beginning, a takutaku (incantation), may be recited by the practitioner as a source of energy and protection for both tangata whaiora and kairongoā. Wai tai (sea water) may be sprayed over both, as another layer of protection. All of this mahi is considered to be mirimiri, until the point when the practitioner’s hands make physical contact

18 | AOTEAROA NEW ZEALAND MIDWIFE FEATURE

AMELLIA

KAPA COMMUNICATIONS ADVISOR

with the woman’s body. Once this occurs, the work has moved into the realm of romiromi

It's important to understand that through this lens, just as we humans have whakapapa (genealogy, bloodlines), so too, does trauma. Whether it can be traced back to childhood, or previous generations, the concept of trauma/grief being carried down through bloodlines is foundational to rongoā Māori, hence why physical treatment alone is not enough, and mirimiri is also required to enable shifts.

Wai rākau are plant medicines, the preparation of which follow tikanga, in line with any other aspect of rongoā Māori. These can either be ingested or used topically - through bathing or applying ointments/ balms directly. Wai rākau, if used, are complementary to mirimiri and romiromi

RONGOĀ MĀORI FOR CONCEPTION

In all aspects of pre-colonial life, takutaku (ancient incantations pre-dating karakia by thousands of years) were recited for specific purposes. If a couple was suffering with infertility issues, for example, potentially both partners would be treated, to remove blocks and allow a clear path for conception to occur. Through this lens, fertility issues are not necessarily related to the physical body and can be the result of historical hara (transgressions) that have not been addressed. Once the hara is resolved through mirimiri and romiromi, conception often occurs without issue.

Following baby loss, wāhine would have received rongoā Māori to clear the whare tangata (womb) of grief or trauma and return it to a noa, or non-tapu state. Whare tangata clearing practices such as steaming were regularly performed following live births, for the same purpose.

RONGOĀ MĀORI DURING HAPŪTANGA

Pre-colonisation, wāhine hapū regularly received romiromi and mirimiri throughout their pregnancies, not only to help keep their physical bodies supple and pain-free, but as a way of deepening the connection between māmā, pēpi and tūpuna, as well as preparing spiritually, emotionally, and psychologically for labour and birth.

Pregnancy romiromi and mirimiri are offered by a handful of practitioners throughout the motu. These treatments will often include massage of the legs, back,

shoulders, arms and puku, using oil/balm, therefore it would be within normal limits for the practitioner to ask the woman to remove her clothing down to underwear, with towels used to cover breasts and/or the parts of the body not being worked on.

A Māori midwife who recently received treatment while hapū with her first pēpi shares her experience. “Rongoā Māori helped me to connect with my wairua in a way I didn’t know I needed to. I had a straightforward physical experience of hapūtanga so to speak, but I did experience some emotional challenges. It’s not easy for a hapū māmā/midwife to be working in a tertiary birthing environment and not carry fear or trauma, unwittingly.

“Rongoā Māori, in the form of mirimiri, romiromi and takutaku, helped me to explore those emotional experiences and feel tau (settled) about moving into māmā-hood.

Rongoā Māori reminded me that my tūpuna were with me and that I wasn’t alone on this journey. I felt more connected to myself, my whānau, and my pēpi - before I’d even laid eyes on her.”

ACC-REGISTERED PRACTITIONERS

Rongoā Māori is an ACC-approved modality for the treatment of maternal birth injury. Like treatment for any other condition or injury, it will involve a combination of mirimiri and romiromi and the specifics of the treatment will vary between practitioners. Women can expect that they will not only have an opportunity to release trauma surrounding the birth in which they

sustained the injury, but potentially trauma related to previous births, baby loss, or sexual abuse.

Wāhine can be reassured that during treatment for maternal birth injury, they will remain fully clothed and will never be examined internally, through either vaginal or rectal examinations.

A list of ACC-registered rongoā Māori practitioners can be found on the ACC website, although not all of these practitioners will be providing treatment for maternal birth injury. Enquiries will need to be made with individual practitioners as to whether maternal birth injury work is part of their practice.

The mātauranga shared in this article is Whare Wānanga lore, handed down by tohunga Papa Hohepa Delamere (Papa Joe – Te Whānau a Apanui), gratefully received by Amellia Kapa through the teachings of Ruatau Perez (Te Ara Teatea Traditional Māori Healing). square

ISSUE 108 MARCH 2023 | 19 FEATURE

LESLEY DIXON MIDWIFERY ADVISOR CAROL BARTLE POLICY ANALYST

preparing for disaster and emergencies

Climate change is a public health issue, and health-protecting policiesboth global and national - are critical, overdue and urgent. Midwives engage in public health practice and play an essential role as primary and secondary health care providers. This article discusses midwifery care and emergency preparedness in the context of pregnancy, birth and breastfeeding/infant feeding.

Health-centred climate action means focusing not only on how the health system can take action and pay attention to sustainable health care practices, but also on the importance of promoting health in climate policy development as a top priority focus. The ability of health systems to deliver care will be disrupted, and public health gains will be undermined due to climate change. The health and economic benefits from cleaner air, healthier diets, and more active communities are clear, but these benefits are not yet being embraced in many climate policies.

Catastrophic weather events linked to climate change have been increasing across the globe and climate-related risks to health, livelihoods, food security, water supply, and human security are projected to continue to rise. Health effects of climate change vary considerably between different populations, and this is influenced by geographic location, demographics, background burden of climate-related

health conditions, and health system capability and capacity (Jones et al, 2014).

In climate emergencies, pregnant women, infants and young children are among the most vulnerable of populations, and women are already at risk of marginalisation in many environments. Displacement during humanitarian crises has a profound impact on maternal and child health, with significant consequences across the life course (Palmquist & Gribble, 2018). Climate emergencies are considered one of the biggest threats to achieving global targets for maternal health (Rylander et al., 2013).

In Aotearoa, we are now experiencing regular extreme weather events - predominantly related to flooding - which have the potential to cut communities off from support, health services, food supplies, and safe water supplies. The start of 2023 saw a state of emergency declared as Cyclone Hale hit Te Tai Tokerau, Bay of Plenty/Tairāwhiti and the Thames/Coromandel regions. This was followed by severe flooding in parts of Tāmaki Makaurau and then a national state of emergency due to Cyclone Gabrielle, with the most devastating impact on the Hawke's Bay/Gisborne regions.

BEING PREPARED FOR EMERGENCIES AND DISASTERS

During a state of emergency, pregnant or post-partum women and their whānau may be advised by Civil Defence to stay at home. Power, water and sewage may be disrupted, and this may last for up to three days or longer. Families will need to know how to turn off their water, power and gas if they are instructed to do so by the local authorities. It is important for pregnant women to stay connected to their whānau, and

20 | AOTEAROA NEW ZEALAND MIDWIFE CLIMATE CHANGE

ISSUE 108 MARCH 2023 | 21 CLIMATE CHANGE

Civil Defence advice

Have enough bottled water for three days - generally aim for three litres per person, per day, as a minimum (nine litres for every person).

Have long lasting food that doesn’t need cooking - unless you have a gas barbecue or camp stove. For example pre-washed fruit and vegetables that can be eaten raw, bread, crackers, hard cheese, long life milk, cereal etc.

Consider any special dietary needs and ensure you have enough food stock for up to three days.

Have a large plastic bucket that can be used as an emergency toilet.

Plastic or work gloves to protect hands, and N95 mask.

Have first-aid and medical supplies (paracetamol, plasters, bandages etc).

Have a grab bag ready to go - in case of evacuation.

midwife, and to inform the midwife of any concerns they may have related to their pregnancy. Families will be advised to stay connected to the local community and radio station/websites to get the latest news and alerts.

In some emergencies, families may be advised to evacuate to another region. Pregnant women will need to have a grab bag prepared for themselves and each member of the family. Post-partum women will need to have a grab bag ready to go for themselves and their baby. They will also need to have a baby seat for the car and ensure a safe sleeping space for the baby (wahakura/pēpi pod may be useful) at their destination. Again, it is important that the midwife knows if they are leaving the region, and where they are going. The midwife will be able to help access ongoing midwifery care until their return home.

In each person’s grab bag, they will need:

• Walking shoes, warm clothes, water proof jacket, hat, sun screen

• Water, snack food

• Hand sanitiser

• Portable phone charger

• Cash

• Copies of important documents - for pregnant women this includes their pregnancy records and results

• Medications (folic acid, iodine)

• First aid kit

• Torch

• Radio and batteries

• Maternity pads for post-partum women

Additional items for the baby

• Nappies

• Cleaning cloths

• Baby clothes

• Blankets

• Hat

• Baby sling/wrap

BREASTFEEDING AND INFANT FEEDING IN EMERGENCIES

The Ministry of Health published a range of resources to support infant feeding in emergencies in 2015. These include a position statement, a guide for District Health Board (DHB) emergency management staff, an outline of the roles and responsibilities of organisations and groups with key roles in helping make sure babies aged 0-12 months are fed safely in an emergency, and information for parents and caregivers (Ministry of Health, 2015). The College developed a consensus statement about infant feeding in emergencies and disasters, which recognises the importance of the midwifery role in supporting breastfeeding and safe infant feeding (NZ College of Midwives, 2016).

The DHB guide discusses planning and addressing infant feeding needs in their emergency response plans. An essential part of the planning is consideration of the workforce needed to assure ongoing service provision, including employed health staff and community based providers (such as lead maternity carers).

The Ministry of Health documents, including the one for parents, clearly support breastfeeding, and breastfeeding continuance with guidance for breastfeeding women in the parent guide about how to restart breastfeeding if recently stopped, what to do if expressed breast milk is being used, and addressing mythology such as loss of milk

supply due to stress. It also addresses what to do if stress is affecting the oxytocin response and milk flow. The guidance for parents and carers also includes information about the use of infant formula and how to make this as safe as possible. Unfortunately, the advice does not include one of the key issues in formula feeding safety which is the use of boiled water to reconstitute powdered formula (which is unsterile). Instead, it suggests parents use the instructions on formula tins. Powdered infant formula products in Aotearoa do not provide optimal reconstitution instructions, which should be to use boiled water, which has been allowed to cool slightly, but not below 70°C (WHO, 2012; Better Health Start & Baby Friendly Initiative UK, 2022).

Advice in the Ministry of Health ‘get ready, preparing for an emergency’ section of the parent and carer guidance information, suggests in the list of emergency supplies (for 3-5 days) for all babies who are formula fed, one 900g tin of unopened formula and five litres of commercially non-carbonated bottled water for preparing the feeds. Access to clean water may be compromised in an emergency, and if so, the bottled water will be necessary, and will still need to be boiled for young babies. Cups may be used for feeding if cleaning bottles and teats is an issue. The advice also includes instructions for sterilising bottles and teats, and maintaining hygienic conditions. Families who are using formula will need ongoing regular support to help with management of the complications potentially associated with bottle-feeding in disaster situations.

The Ministry of Health guidance for infant feeding in emergencies is easy to access from the internet – if people are aware that the information exists. In an emergency, it may be unlikely to occur to parents to look for guidance from this source, so midwives can support parents to access the information they need. Midwives and maternity units are listed as contacts for help and support in the MOH parent guideline. Te Whatu Ora, Health New Zealand regional websites do not appear to have infant feeding in emergencies information that is accessible by searching for key words, or by easily viewable and visible links.

The NZ Government Get Ready website has a section about getting households ready for an emergency, and in that section there is a link to “tailor your plan” which provides caring for babies and young children information, including a link to the Ministry of Health guidance (NZ Government, Get

22 | AOTEAROA NEW ZEALAND MIDWIFE CLIMATE CHANGE

Ready, 2023). Midwives can refer families to this useful website.

Midwives provide critical support systems for breastfeeding and infant feeding in emergencies and can support breastfeeding continuance and relactation if this is a realistic option. Midwives and other health practitioners are expected to decline and not seek donations of formula, as unsolicited donations of infant formula are discouraged during emergency and disaster situations. Formula distributed to families who need it is arranged by the relevant Civil Defence Controller after an assessment of the specific emergency situation. Gribble et al, (2019) carried out an audit of infant and young child feeding in emergency plans in Australia and found that there was a lack of planning at all levels of government for the needs of infants and children. Sourcing information easily and quickly about birth, breastfeeding and infant feeding in an emergency is also difficult in Aotearoa. Integration of plans across government organisations, and ensuring that information is regularly updated and easily accessible needs to be a priority.

MIDWIFERY CARE IN A STATE OF EMERGENCY

A state of emergency is a response to a situation in which there is a threat to the safety of the public or property in any part of Aotearoa. It can be invoked for any explosion, earthquake, eruption, tsunami, land movement, flood, storm, tornado, cyclone, serious fire and various other hazards. A state of emergency requires significant and co-ordinated response under the Civil Defence Emergency Management Act 2002. In both 2021 and 2022 respectively, there were seven states of emergency declared each year for severe weather, coastal hazards (severe sea swell) and flooding throughout Aotearoa (National Emergency Management Agency).

Most emergencies are unpredictable. In the best case scenarios, there may be some warning of an expected adverse weather event such as heavy rain leading to flooding. In these situations, planning to evacuate if and when necessary is usually possible, but unexpected and unpredictable disasters require families to be prepared for emergency events.

During a state of emergency, midwives will need to ensure their own safety - and that of their families – first, followed by consideration of how to ensure their clients are able to continue to access maternity care.

Midwives can support families to prepare, while at the same time considering plans for their midwifery practices in terms of communication, transportation to work in the event of landslides or flooding, how to manage their caseload, home visiting, supporting birthing plans and provision of ongoing support for families and each other. They will need to be prepared to support birth in any location and should carry basic equipment to support birth outside of a hospital setting. This is because women may opt to stay at home for birth during an emergency situation, or may be unable to reach the nearest hospital.

There has been an example in the media of how disaster can affect midwives in Aotearoa (Nickisson, 2021). Severe flooding in July 2021 caused devastation to Marlborough Sounds, and multiple road slips. A Marlborough midwife, Suzie Edmonds, was forced to drive from her home to a safe spot to park her car, then with head torch and gumboots she navigated on foot what was left of the road to another car parked in a safe place in the road, then continued on to work in Blenheim. On the day of the storm when Suzie left for work she was unaware of how serious the damage to the road had been; slips were happening in front of her, the road was slumping, there were trees down on the road, and she had to get through flood waters. After that drive, Suzie was stranded in Blenheim for four days. After driving alone on the day of the flooding, Suzie’s husband began to accompany her on the walk - which was next to a terrifying drop – but at times Suzie also navigated this route alone, in the dead of night, in the rain. Suzie did this for over seven weeks. As the media headline stated, this “muddy slog was not for the faint-hearted”. We talked to Corrina Parata, a remote rural midwife working in the Tairāwhiti region about her experiences during the recent state of emergency following Cyclone Hale. Corrina is the only midwife in a large geographical area. She was providing labour care to a client just before the cyclone was due to hit and identified the need to transfer to the local base hospital. Corrina explains that it is always better to facilitate a transfer earlier rather than later when signs of concern emerge. She called for the helicopter to facilitate the transfer and the helicopter was able to land, but unable to take off again due to the cyclone. In these situations she explains, “my level of expertise has to move from primary care to acute emergency, to tertiary care”, and there is a lot of risk

management and facilitating other staff whilst maintaining calm for the family. They were able to transport the client eventually and Corrina was relieved once she had heard that both mother and baby were fine.

Corrina lost communications during this time, as the cellular network went down during the storm. There were concerns about power and landline availability meaning women potentially had no way of contacting her. Sometimes during storms the lack of power and/or cell phone outages may only be for a few hours, but this time it was a few days. Corrina always discusses signs of concern with her clients and emphasises the need to contact her immediately. She finds that women are resilient and often manage to get messages to her by other means.

The need for effective communications with Civil Defence and regular updates was vital during that time. The Civil Defence in Gisborne communicated regularly with each rural community, updating them on the latest issues and road closures. Corrina sometimes needed hourly updates when trying to get to rural clients with fallen trees obstructing roads and workers using chainsaws to clear debris so that she could get through to families. There was also a strong communication network between the hospital, maternity unit, local council and health staff in the region. Corrina has a good relationship with the obstetrician at the base hospital, who she speaks to regularly by phone, and who also phones her to check how she is going and provide advice on clinical situations. There is a desperate need for long-term solutions to the road issues in the region, but in the meantime they are all becoming used to preparing for floods and other emergencies.

CONCLUSION

Midwives and midwifery are critical components of maternal, newborn and child health in disasters and emergencies, with midwives in a unique position to support women and their families, protect breastfeeding, and ensure safe infant feeding (ICM, 2014). The College has a consensus statement on climate change which recognises midwives as having unique insights into climate emergencies (NZ College of Midwives, 2021). Midwifery representation on strategic planning/ emergency management committees in Aotearoa could help ensure the needs of pregnant and birthing women, and their babies, are included in any priority population group response. square

References available on request.

ISSUE 108 MARCH 2023 | 23 CLIMATE CHANGE

24 | AOTEAROA NEW ZEALAND MIDWIFE FEATURE

VEGETARIAN & VEGAN PREGNANCY

Midwifery care involves discussion about healthy nutrition during pregnancy and breastfeeding. With the number of people moving to more plant-based nutrition on the rise, this article takes a look at the latest information and resources to support midwifery care for those who follow a vegetarian or vegan diet.

THE RISE IN PLANT-BASED EATING

According to a recent Colmar-Brunton poll, a third of all Kiwis now eat no meat, or are reducing meat intake. Vegan was the most googled diet in Aotearoa in 2019, and demand in supermarkets for plant-based food options has increased by 36% (Stuff, 2019).

The Auckland region boasts the highest vegan population in the country, and Wellington is home to the highest percentage of vegetarians. Northland and Waikato have the highest proportion of meat-reducers. Globally, there is a higher percentage of vegetarianism in the younger population and in people of colour. The number of people adopting plant-based diets is expected to continue rising.

IMPORTANCE OF HEALTHY DIET AND LIFESTYLE

What we eat and how active we are plays an important part in our overall health and wellbeing.

Many factors contribute to people’s food and physical activity choices, and ultimately their health.

These include social, cultural, economic, practical and personal factors and it is important to acknowledge that many are outside people’s direct control.

Differences in these underlying factors contribute significantly to inequities related to diet, physical activity and health in Aotearoa.

Healthy eating patterns are particularly important before conception, during pregnancy and while breastfeeding, because pregnant and breastfeeding women require extra nutrients. Healthy eating patterns can lower the risk of hypertensive disorders of pregnancy and gestational diabetes, as well as improve birth outcomes (USDA, 2019) and the long-term health of the baby (Horta and Victora 2013; Horta et al 2015; Koletzko et al 2019).

He Korowai Oranga (the Ministry of Health’s Māori Health Strategy) incorporates the concept of pae ora - healthy futures for Māori, as its overall aim. Pae ora is a holistic concept that includes three interconnected elements – mauri ora (healthy individuals), whānau ora (healthy families) and wai ora (healthy environments). Pae ora is a tool to help health practitioners think beyond narrow definitions of health, to consider the individual, the whānau, and the environment. As such, it is a useful model to draw on when considering the wider determinants of health and wellbeing. Mauri ora focuses on providing the individual with what they need to live with good health. Whānau ora considers the wider family group and acknowledges that for many Māori, whānau is the principal source of strength, support, security and identity. Wai ora acknowledges the importance of Māori connections to whenua as part of the environments in which we live and belong – and the

VIOLET CLAPHAM LMC MIDWIFE ISSUE 108 MARCH 2023 | 25 FEATURE

Did you know?

The World Health Organisation has classed processed meat (bacon, ham, salami etc) as a group 1 carcinogen, the same category as cigarettes, alcohol and asbestos (WHO, 2015).

Plant based diets are associated with an overall lower incidence of colorectal cancer, prostate cancer, and postmenopausal breast cancer (Orlich, M.J., et al (2015); Loeb, S., et al (2022); Watling, C.Z. et al (2022)).

82% of starving children live in countries where plant-based food is fed to animals, and the animals are eaten by people living in wealthy countries (University of Colorado, 2022).

Animal agriculture’s detrimental environmental impacts include animal gas emissions, nitrous oxide from animal waste, deforestation for farmland and stock feed. Nearly half of New Zealand’s greenhouse gas emissions are from agriculture (Ministry for the Environment, 2022).

significant impact this has on the health and wellbeing of individuals, whānau, hapū, iwi, and Māori communities.

Globally, people are increasingly focusing on the way food is produced and consumed, and the negative impacts intensive animal agriculture is having on the environment. With some additional attention to certain nutrients (such as iron, B12, calcium, and Vit D) vegetarian and vegan diets can be a healthy option during pregnancy.

WHAT IS A ‘PLANT-BASED’ DIET?

It may seem that there is a never-ending list of terms to describe various plant-based diets, however these can primarily be summarised into two main categories.

Vegetarian diets typically comprise of plant foods such as grains, legumes, nuts, seeds, vegetables, and fruit, and exclude all kinds of animal food including meat (pork, beef, mutton, lamb, poultry, game, and fowl), meat products (sausages, salami, and pâté), fish, molluscs, and crustaceans.

A standard vegetarian diet is often referred to as lacto-ovo-vegetarianism and

includes dairy products, eggs, and honey, together with a wide variety of plant foods. Subcategories are lacto-vegetarianism (excludes eggs), ovo-vegetarianism (excludes dairy products but includes eggs) and pescovegetarianism (includes consumption of fish).

Vegan diets include the same wide variety of plant foods and exclude meat, dairy products, eggs, honey, and any other food derived from animals (i.e. gelatine).

‘Flexitarians’ generally eat a mostly plantbased diet, but occasionally eat meat.

REASONS FOR GOING MEAT-FREE

The most common reasons for adopting a plant-based diet include health benefits, environmental consciousness, animal welfare concerns, religion/spirituality, and cost. Health is the strongest motivator for older people to adopt a plant-based diet and environmental impact is top of mind for the younger generation (Sebastiani et al, 2019).

PLANT-BASED DIET IN PREGNANCY

Current evidence highlights that wellbalanced vegetarian and vegan diets should be considered safe for the mother’s health and for babies during pregnancy and lactation (Sebastiani et al, 2019). Whilst it is important to monitor for nutritional deficiencies during a vegan or vegetarian pregnancy, if an adequate intake of nutrients is maintained, pregnancy outcomes are similar to those reported in the general population. Exclusively plant-based nutrition during pregnancy is not associated with pre-term birth or fetal growth restriction, and there are data demonstrating a protective effect of plant-based nutrition on anthropometric fetal development (explained by the high content of vitamins in such diets). A plant-based diet may also be protective against development of gestational diabetes (Sebastiani et al, 2019). Some nutritional requirements will increase as pregnancy progresses.

MOH EATING AND ACTIVITY GUIDELINES 2020

In November 2020, the Ministry of Health published an updated version of Eating and Activity Guidelines for New Zealand Adults (MoH 2020). The guidelines provide evidence-based recommendations on healthy eating and physical activity for all New Zealand adults (including recommendations and information for pregnant and

breastfeeding women) and represent a shift away from meat-focused diets.

The Eating and Activity Guidelines (MoH 2020) describe an eating pattern that is largely plant-based, and allows for moderate amounts of animal-based foods (eggs, dairy, poultry, seafood) and small amounts of red meat. The guidelines recommend:

• Exclusive breastfeeding until six months of age, and continued breastfeeding until two years and beyond

• Eating ‘whole and less processed’ nutrientdense foods

• Limiting highly processed foods with saturated fats, added sugar and salt

• Not overeating, and balancing intake with activity to achieve and maintain a healthy weight

• Choosing, preparing, cooking and storing food in a way that optimises food safety and minimises wastage

• Allowing for cultural preferences and different eating patterns, including those ranging from totally plant-based to a mixed intake of animal and plant-based foods. The Ministry guidelines state that other than the supplements which are universally recommended pre-conceptually, in pregnancy and post-partum, most people do not need to take additional dietary supplements. The only supplementations recommended by the Ministry are:

Universal supplements (for every women pre-conceptually, during pregnancy and breastfeeding):

• Folic acid from at least four weeks before pregnancy and throughout the first trimester (800 mcg/day for most women, 5mg/day for those at increased risk of NTD, and those taking anti-epileptic medications or insulin)

• Iodine 150mcg/day during pregnancy and breastfeeding

Additional targeted supplements (for those who require them):

• Vitamin D for those at risk of deficiency (guideline currently under review)

• Iron for those with iron deficiency anaemia

• B12 supplementation for those following a vegan diet

NEW VEGAN PREGNANCY RESOURCE

The Vegan Society of Aotearoa New Zealand have just published a new resource to help

26 | AOTEAROA NEW ZEALAND MIDWIFE FEATURE

guide healthy eating during pregnancy. The Vegan Pregnancy resource (above) is informed by the Ministry of Health Eating and Activity Guidelines (2020), and aligns closely with those recommendations.

The College encourages midwives to use the Vegan Pregnancy resource and refer to the Vegan Society website, which provides further information about plant-based diets, including recipes and other resources.

SPECIFIC NUTRIENT CONSIDERATIONS

When supporting vegan whānau during hapūtanga, it is important to provide information and support, to ensure they are meeting their protein, iron, vitamin B12, vitamin D, and calcium requirements. Including iron-fortified foods and plantbased milk alternatives fortified with vitamin B12, vitamin D and calcium (ideally soy milk, as it is higher in energy and protein) can help to boost nutritional intake. Most commercial plant-based milk alternatives are fortified with calcium, but only some are fortified with vitamin B12. Some plant-based milk alternatives may be low in protein and contain added sugar, so check the ingredients list and the nutrition information panel. Manatū Hauora recommends soy milk rather than rice, oat or nut milk because it is higher in protein than these other milk alternatives.

Eating plenty of vegetables during

pregnancy and when breastfeeding helps to provide important nutrients like folate, as well as vitamin C, which helps in absorbing iron. It can also help to establish healthy taste preferences in the infant. When a woman eats bitter vegetables (e.g. broccoli, rocket, watercress, pūhā, and taro leaf) during pregnancy and while breastfeeding, it can improve a child’s acceptance of vegetables in early childhood (Gerritsen and Wall 2017).

Vitamin C is found in a range of fruits and vegetables (e.g. kiwifruit, oranges, broccoli, red capsicum, berries, kūmara, tomato and silverbeet) and can help the body to absorb non-haem iron found in plant-based foods when eaten at the same time. This is especially important for vegetarian and vegan mothers.

IRON

The demand for iron during pregnancy is greater, to compensate for a higher maternal blood volume and support healthy fetal development. Iron requirements increase as pregnancy progresses and iron deficiency is common during pregnancy, causing symptoms such as fatigue, poor concentration and increased risk of infection. Anaemia increases the risk of symptomatic PPH, infection, mortality, and cardiovascular stress (Scholl & Reilly 2000).

Severe maternal iron deficiency can result in a sub-optimal iron supply to the baby,

with associated increased risks of perinatal mortality, pre-term birth, and lower birthweight (Scholl & Reilly 2000). Maternal iron deficiency in pregnancy can lead to longterm consequences for the baby, including effects on cognition, behaviour, motor development, activity and physical capacity, and may not be reversible. Iron deficiency during breastfeeding leads to increased risk of maternal illness, tiredness and breast infection. For a comprehensive overview of anaemia in pregnancy, see the June 2021 issue of Midwife.

The recommended daily intake (RDI) of iron for pregnant women aged 14–50 years is 27mg per day. About 40 percent of women aged 15–44 years in New Zealand have an inadequate intake of iron and the highest prevalence of low iron stores, iron deficiency and iron-deficiency anaemia is among Māori women (especially those aged 15–24) (Russell et al 1999; Ministry of Health 2020).

The main sources of iron for women aged 25–44 years in the New Zealand diet are bread (13%), red meat (11%), breakfast cereals (9%), and vegetables (8%) (Russell et al 1999). VITAMIN

Vitamin B12 is essential for normal blood and nerve function in the body. Pregnant women need enough B12 to

B12

from each of the following food groups/ngā whakarōpūtanga kai. 2 –3DAIRYALTERNATIVES 2 x F R U I T 5 xVEGETABLES 8+ GRAINS, CEREALS,STARCHYVEG 3– 4PROTEIN 2 –3DAIRYALTERNATIVES Grains, Cereals & Starchy Veg (cooked) Pata, Huapata, Māngaro 8+ servings a day Dairy Alternatives Ngā momo miraka anō 2-3 servings (fortified) a day Plant Protein Pūmua tipu 3-4 servings a day Vegetables Ngā huawhenua At least 5 servings a day Ngā Momo Inu Fluids 8+ cups or at least 2 L a day Fruit Ngā huarākau At least 2 servings a day FORTIFIED ISSUE 108 MARCH 2023 | 27

Did you know?

The PREFORM study in Toronto (2016) found prevalence of B12 deficiency in pregnancy to be 17% in the second trimester and 38% at full term (across the whole pregnant population).

Metformin (an antihyperglycemic agent used as first-line treatment for prediabetes and diabetes) may reduce the absorption of vitamin B12 and significantly reduce serum vitamin B12 concentrations.

meet their own needs and to ensure healthy fetal development. Low maternal serum concentration of B12 during the first trimester is a risk factor for neural tube defect and poor maternal outcomes such as pre-eclampsia, macrocytic anaemia, and neurological impairment. Evidence is now emerging that there is a strong association between maternal B12 deficiency during the third trimester and infant deficiency at birth. Infant tolerance to deficiency of vitamin B12 is much lower than adult tolerance and breastfed infants may suffer serious consequences even if their mothers are not showing clinical signs of deficiency. There are some recent reports from European newborn screening programmes who have recently begun looking for vitamin B12 deficiency on heel prick cards, and found that it is unexpectedly common. Maternal serum B12 levels of <394 pmol/L at 18/40 are a powerful predictor of B12 deficiency in infants.

Breastfeeding women are also providing a supply of B12 for their babies via breast milk.

As B12 is primarily found in animal foods and fortified foods, pregnant or breastfeeding women who follow a vegan diet will likely require B12 supplementation even if they are showing no signs of deficiency. If women have received treatment for B12 deficiency during the pregnancy, B12 levels should be reassessed two months post-partum to confirm whether levels have returned to normal.

The RDI of B12 for pregnant women aged 14–50 years is 2.6mcg per day. The RDI for breastfeeding women aged 14–50 years is 2.8mcg per day.

Vitamin B12 is synthesised by bacteria and found primarily in animal products (e.g. meat, eggs, milk and milk products).

Plant sources (such as nori seaweed) often contain vitamin B12 analogues, which have not been shown to have vitamin B12

Screening during pregnancy for vegetarians and vegans

First antenatal blood tests

Ideally undertaken in the first trimester of pregnancy (or pre-conception), screen for iron and B12 deficiency by including:

• Routine 1st antenatal bloods

• Ferritin (+ CRP)

• B12

• Folate

Subsequent antenatal blood tests

At 28/40, include:

• CBC and antibody screen

• Ferritin (+CRP)

• B12

• Folate

Postnatal blood tests

For those who have had deficiencies during pregnancy, re-check levels 4-8 weeks postpartum to allow for discussion and ongoing treatment planning. Some may require follow-up tests if deficiencies persist.

activity in the human body. Bacteria in the human intestine synthesise B12, but the bio-availability of this B12 is uncertain (Martens et al 2002). The main dietary sources of vitamin B12 for New Zealand women aged 35–44 years are milk (18%), red meat (17%), seafood (16%), and egg dishes (6%) (LINZ Research Unit 1999). For vegetarians, milk and milk products are a potential source of vitamin B12. The only dietary sources for vegans are plant foods exposed to vitamin B12 producing bacteria; plant foods contaminated with soil, insects or other substances containing B12; or foods fortified with vitamin B12 (such as nutritional yeast, soy milk, and textured vegetable protein (TVP)). Vegans often need to take vitamin B12 supplements or eat foods that have been fortified with vitamin B12 during pregnancy.

CALCIUM

Calcium is required for the normal development and maintenance of the

skeleton. It is present in the bones and teeth to provide structure and strength. Calcium status is affected by vitamin D status, so it’s important to consider possible vitamin D deficiency as well. Fetal requirements for calcium during pregnancy are significant but can be met by increased maternal calcium absorption, turnover and retention in early pregnancy. Most of the calcium required by the baby is transferred during the third trimester (Institute of Medicine, 1997).

Calcium supplementation during pregnancy is not generally necessary, however is recommended for women with inadequate dietary intake or at risk of developing hypertensive disorders of pregnancy. A vegan diet is likely to be low in calcium, so supplementation is recommended.

The recommended daily intake (RDI) for pregnant and breastfeeding women aged 19 years and over is 1,000mg per day, and the RDI for pregnant and breastfeeding women aged 14–18 years is 1,300mg per day. Adolescent pregnant and breastfeeding women have an increased requirement because their own bones are still growing (NHMRC, 2006).

The principal dietary sources of calcium for New Zealand women aged 25-44 years are milk (38%), cheese (11%), bread (6%), non-alcoholic beverages (6%), dairy products (5%), and vegetables (5%) (Russell et al., 1999). Foods vary greatly in their calcium content; milk has a particularly high calcium content, but other excellent sources include cheeses, yoghurt and calcium-fortified soy beverages. Other good sources include nuts, canned fish with bones, green leafy vegetables and dried fruit (Goulding, 2002).

VITAMIN D

Vitamin D deficiency during pregnancy may increase the risk of pre-eclampsia, gestational diabetes, fetal growth restriction, pre-term birth and hypocalcaemia. In infants, it is related to an inadequate immune system, eczema, wheezing, and respiratory infections.

In Aotearoa it is difficult to achieve an adequate intake of vitamin D through diet alone, as only a few foods contain vitamin D or are fortified with it. The primary dietary sources are seafood, dairy products, eggs, and fortified foods, therefore a vegan diet may require extra supplementation. Further information on risk based screening can be found on the Manatū Hauora (MoH) website. square

References available on request.

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Midwifery Postgraduate Education Grants

Midwives who are engaged in formal postgraduate education (at Level 8 or above on the NZQA framework) may apply for a grant towards the cost of their postgraduate study.

These grants are funded by Te Whatu Ora - Health New Zealand and administered by the College to subsidise the cost of fees and some travel and accommodation costs. Applications are prioritised on a first come first served basis.

For more information and to apply visit: www.midwife.org.nz.

Student Midwifery Grants 2022

The College is offering grants to assist students at each midwifery school who are currently undertaking a Bachelor of Midwifery programme. Grants are available for each school of midwifery. Please refer to the College website for further information and application forms: www.midwife.org.nz

To apply, applicants must:

1. Be a College member

2. Intend to practise in New Zealand on graduation Please email your completed application forms to lynda.o@nzcom.org.nz. The Grants Advisory Committee will award the grants.

Funded by:

Applications open on 1 May 2023

CLAIRE MACDONALD MIDWIFERY ADVISOR

Midwifery workforce part II: supporting midwives of the future

In the December 2022 edition of Midwife, we looked at current and upcoming initiatives to support the midwifery workforce, acknowledging what a tough few years we've had. This article reflects on supporting students as future midwives, specifically focusing on what makes a good clinical placement - how midwives who take on the crucial role of preceptors enable and enhance students’ learning experiences.

It's been said that we can’t make more midwives overnight to solve the workforce crisis. But we can support students over their Bachelor of Midwifery degree and welcome them to the profession as graduates. Successful completion of the degree relies on the student’s tenacity as well as support from their whānau, tutors, academic staff, midwifery preceptors, and of course the whānau at the centre of their care. It is a collective investment that surrounds the student to ensure the continuity and longevity of our profession – a team effort.

A snapshot of our student population in 2023 shows some exciting statistics for midwifery as we better represent the communities we serve, particularly for tāngata whenua and Pasifika. Across the five midwifery schools (AUT, Te Pūkenga Wintec, Victoria University of Wellington, Te Pūkenga Ara, Te Pūkenga Otago Polytechnic), students are heeding the call of Lisa Kelly, Chair of Ngā Māia Māori Midwives. “Midwifery is something to aspire to – go home and work for your iwi and look after your people.”

Māori students make up 20-25% of students at Otago Polytechnic, Ara and AUT, with much higher proportions in Te Tai Tokerau

and Lakes satellite programmes. A further 3-15% of students identify as Pasifika across the schools.

Clinical practice is often the highlight of the degree; the opportunity for students to step into the reality of the profession they have been drawn to. However, stepping into the workplace can also be stressful if students experience the impacts of severe workforce shortages. They may also witness or be subject to unprofessional behaviour, powerlessness, culturally unsafe situations and for some, outright discrimination or racism. So what can we do to support them?

Ngatepaeru Marsters, National Pasifika Midwifery Co-ordinator of Tapu Ora points to our Standards of Practice. “I believe in Standard 10”, she says, which states the midwife: gives special recognition to student midwives and shares her expertise with them in a supportive manner as a preceptor, and considers their role as a mentor for colleagues. Ngatepaeru acknowledges the current situation but challenges us as well. “The stress and strain on our workforce – the trickle-down, our students are really feeling it. I accept that it’s hard out there, but we have to look after each other.”

Supporting students is about looking after our next generation and can be very satisfying, says Suzi Hume, LMC midwife and chair of the Wellington region. “I always look forward to the academic year rolling around, to be working together in collaboration with students and sharing that relationship again.”

So what makes a great placement? We looked at the literature and asked current students, preceptors and midwifery heads of school to collate some top tips for preceptor midwives.

RELATIONSHIPS ARE KEY

Relationship-building as a preceptor supports the student’s learning and grows the student’s ongoing midwifery network. Once you have been a preceptor, you remain a familiar face to the student. Corridor chats and check-ins about how things are going let the student know they are valued in the profession.

Talei Jackson, Midwifery Lecturer at AUT and Pasifika Liaison Lead, undertook her Masters study about what supports Pasifika students to succeed. She highlights the centrality of connectedness and reciprocity within a Pasifika worldview. “It always comes down to relationships,” she explains.

ISSUE 108 MARCH 2023 | 31 FEATURE

In community group practice, close working relationships can be developed with several midwives. Suzi Hume finds it works well to have a student working across the practice, “to give lots of clinical opportunities and share the responsibility of ensuring the student gets the best out of their placement by experiencing differing perspectives”. It also gives each midwife ‘down time’ to process or reset.

KAWA WHAKARURUHAU | CULTURAL SAFETY APPLIES TO WORKING WITH STUDENTS

Kawa whakaruruhau | cultural safety is the bedrock of midwifery relationships with whānau, and our organisational values and processes (Curtis et al. 2019). Cultural safety requires that health professionals “acknowledge and address their own biases, attitudes, assumptions, stereotypes, prejudices, structures and characteristics that may affect the quality of care provided” (p. 14). While kawa whakaruruhau is undeniably essential for midwifery care provision, it also applies to our professional and interprofessional relationships; how we interact with and provide professional care to one another as midwives and student midwives.

Joyce Croft, National Māori Midwifery Co-ordinator of Te Ara o Hine, likens the

Kawa whakaruruhau

Gifted by Irihapeti Ramsden in the 1990s and grounded in Te Tiriti o Waitangi, kawa whakaruruhau marked a profound paradigm shift from providing care regardless of who the person was (“I treat everyone the same”), to being regardful of that person’s wholeness (“tell me who you are”) - it celebrates our uniqueness and demands that we turn the mirror to ourselves as health care providers. Who am I? Where do I come from?

What is my culture and world view? How does this shape what I bring to my role as a health worker? And how might that differ from who is in front of me? This process of introspection reveals how aspects of culture (in its broad sense)socio-economic status, age, gender, sexual orientation, ethnic origin, migrant/ refugee status, religious belief or disability (Ramsden 1997) - are important facets of identity but also loci of power.

needs of tauira to wāhine and their whānau during hapūtanga. "You want them in an environment where they feel respected and good about themselves. Like with wāhinerespected for the knowledge they come with. We have tauira who've come through kura kaupapa, so their worldview is different to someone who has gone through kura aoraki (mainstream), or who don't have a lot of connections to te ao Māori. Tāngata whenua are on their journey about being Māori themselves, as well as being tauira."

AT THE BEGINNING OF A PLACEMENT, TAKE TIME TO WELCOME AND GET TO KNOW THE STUDENT MIDWIFE

Anahera Ngatai (Ngāti Porou, Tainui) is a final year midwifery student at Victoria University of Wellington and a student representative on the College’s national board. Anahera remembers her earliest experiences of the degree. “It’s super intimidating to come into hospital. Stepping into handover on that first shift, I was shaking in my boots.” A friendly welcome from the co-ordinating midwife made all the difference – this included being expected and greeted, introduced to the midwifery team on shift, and being assigned to work with a specific midwife.

In her qualitative Masters study on student experiences of hospital clinical placements in Aotearoa, Rountree (2016) noted the negative impact on students’ learning when they were given the impression they were a burden to the midwife. Like most things, preparation is key - managerial communication with midwives in advance that students will be present (Rountree, 2016) and having a midwife pre-assigned for the student to work with supports them to feel valued and part of the team.

In hospitals and birthing units, midwives are highly skilled at building rapport quickly. Applying this to relationships with students means that even if it has to be brief, greeting and connecting goes a long way in building their confidence to get involved.

In community practice, it is valuable to meet with the student before commencing clinical work together. This provides time for the student to share goals and learning outcomes, setting up a professional relationship where information can be shared. For many students, long after their clinical placement is completed, these relationships continue as support structures and friendships.

Family and culture are central to many students’ identities and personal lives, and are

often part of why they want to be midwives, so checking in about important events (e.g. religious observance, children’s activities, exercise classes) can help students balance commitments, where possible.

PRE-BRIEFING

Starting each hospital shift or community day by pre-briefing the student on the caseload or appointments gives the student an opportunity to mentally prepare. At the beginning of a community placement, go through the caseload, who is due each week, some details about them, and where they plan to give birth.

At the beginning of the day or shift:

• In community practice: discuss the day, who is scheduled to be seen and how you are prioritising care to allow for acute calls. Understanding your thought process is invaluable for students.

• In hospital: involve the student in handover discussions and talk through how the midwife plans the shift.

FAMILIARISE YOURSELF WITH THE STUDENT’S LEVEL AND THE CLINICAL SKILLS THEY ARE READY TO PRACTISE

Preceptor midwives are encouraged to familiarise themselves with the different expectations of first, second, third and fourth year students by checking in regularly with the student and liaising with their tutor.

Initially, reflects Anahera, “it can seem a little bit fragmented – you’re learning all of these individual skills [first years] and you’re strengthening and developing those and becoming really confident [throughout the degree] but it’s not until you’re putting it all together and doing an entire care plan that it really consolidates itself [towards final year]. And when you start to do that it’s just the best feeling”.

SUPPORT STUDENTS TO CONSULT WITH OTHER HEALTH PROFESSIONALS

Patterson et al. (2021) identify “hierarchical and cultural practices in institutions” which can “inhibit engagement in interprofessional conversations” (p. 105), so it is essential that students have the opportunity to practise consulting as undergraduates. Schools prepare students with the theory and knowledge about the midwifery scope; having opportunities to lead a consultation in practice supports the consolidation of those skills.

32 | AOTEAROA NEW ZEALAND MIDWIFE FEATURE

Back the student – consultations can be nerve-wracking! Preparation is key – agree before the interaction that the student will lead the consultation, offer to practise or roleplay together and use the tools the student has learned, such as ISBAR. When a student has been with someone who has experienced a long labour, for example, who has been taken for a caesarean section, they are wellplaced to speak in theatre as they know the whole story.

Anahera is clear about being kept safe. “When the midwife asks you to do the consultation, it’s important for the midwife to be right there with you to tautoko you.”

FEEDBACK AND OPEN DIALOGUE –KŌRERO WITH YOUR STUDENT

Feedback, debriefing and reflection are crucial elements of students’ learning journeys and future practice. Te Pūkenga Otago Polytechnic’s online preceptorship course (2022) points to the three main types of feedback identified in the literature: affirming/positive, corrective, and reviewing/ reflecting. All three are important and require skilled communication and consideration of the appropriate timing. While some things need correcting at the time they occur (e.g. a medication dose calculation), it is vital to make opportunities for reflection outside the situation.

Anahera recalls “those golden moments in the car”, when the midwife and student have a chance to kōrero while travelling between appointments. The value of students travelling in the midwife’s car can’t be overstated; it supports the student’s financial situation and is a great opportunity for discussion and learning.

During a hospital shift, shared lunch and tea breaks offer similar opportunities for reflective conversations.

It’s important that these conversations involve open dialogue, for example “can you tell me why you did it that way?” Conversely, closed (yes/no) questions make it harder for the student to reflect. Corrections can be made with empathy, understanding the well-meaning intention behind a student midwife’s action that may not have come across well to the woman and whānau (for example, apologising a lot). Offering opportunities for students to consider the midwife’s actions is also valuable – “when I did [action], what did you think?”

REASSURANCE

Students need three times more positive feedback than corrective feedback to flourish (Otago Polytechnic, 2022).

The sensitive nature of midwifery and the inherent power dynamic of the preceptorstudent relationship mean that students can often worry they are not doing things right. Letting students know how they are valued by the midwife can go a long way in supporting their confidence.

Suzi Hume notes, “it’s just so helpful having students at the birth. It adds another level of knowledge and insight, not to mention the physical support. You end up with women having optimal birth care – the real essence of whānau having support for a normal physiological birth, and also for complex decision-making and births”.

ROLE MODEL SELF-CARE

Anahera points out that students observe everything, including how midwives care for themselves to ensure longevity in the profession. “We often only see their mahi but we don’t see their lives and the things they do to keep themselves safe. This is so important.” On one of Anahera’s placements, the midwives shared how they shape their practice arrangements to achieve work-life balance, giving her a sense of how she could make community midwifery work in her own life.

Anahera felt valued as a person and not just a student when precepting midwives checked in with her about her wellbeing – simple things like a reminder to drink enough water during a long labour. Seeing midwives take breaks, and being able to take a break herself, was extremely important.

INCLUDE THE STUDENT IN ‘BEHINDTHE-SCENES’ ASPECTS OF MIDWIFERY

A lot of midwifery happens away from direct contact with whānau, and students need to be exposed to the administrative aspects of the job to be ready for practice. Employed midwives explaining how they approach a shift before commencing inperson care supports students to organise and prioritise. Small things are useful early on in the programme, like asking students to send lab tests and look up results, while later, it is about putting the whole picture together.

Inviting students to group practice meetings builds relationships, includes them in the team and supports their understanding

of how community midwives engage in professional peer-to-peer conversations.

Involving students in the office work of LMC practice highlights the realities of managing a caseload, including following up results, claiming for payments, keeping accounts and paying taxes.

TAKE THE OPPORTUNITY TO DO A PRECEPTORSHIP COURSE

The Midwifery Council strongly encourages preceptor midwives to undertake a course in preceptorship at least once. There are several options for midwives, including the College’s mentoring workshop The Practicalities of being a Mentor Midwife. Otago Polytechnic offers an online preceptorship course on Moodle, which midwives can access with the same login they used for online abortion education. An in-person study day is also available at Ara in Ōtautahi.

REMEMBER WHAT IT’S LIKE TO BE A STUDENT!

Every midwife has been a student midwife, and knows the journey is a major commitment and a life-changing experience, not only for themselves but also their whānau. Being a midwifery student is challenging, rewarding, eye-opening, humbling, exciting and sometimes overwhelming. And while students’ knowledge expands rapidly, it can be easy for experienced midwives to forget that study still continues after students have left workplaces. Empathy goes a long way in making students feel validated, welcomed and confident to practise what they have learned.

Finally, as our students graduate and move into the profession, AUT head of school and College board education representative Tania Fleming’s key message is simple. “These are beginning practitioners; hold on to that thought. They have an amazing, broad range of foundational, contemporary knowledge. So wrap your arms around them.”

Talei Jackson acknowledges the significant challenges students have overcome. “The students have been super-resilient through the last three years with what they have had to sustain themselves through – I think wow, this group of soon-to-be graduates … they’re amazing.”

And as Anahera enters her final year she reflects, “being a student midwife is probably the proudest thing I’ve ever done. I love midwifery, I love the midwives that I’ve worked with, I love the whānau that I’m involved with and I love my peers”. square

ISSUE 108 MARCH 2023 | 33 FEATURE

34 | AOTEAROA NEW ZEALAND MIDWIFE FEATURE

NAMULAU’ULU LETITIA TAIHIA CLINICAL MIDWIFE MANAGER, NGĀ HAU MANGERE BIRTHING CENTRE

serving with loyalty

In 2015, a short article in the College’s Midwifery News by Pasifika Midwives Aotearoa featured the journey of Māori-Samoan midwife Horiana Thompson; sharing her life story through to obtaining her midwifery registration. It was truly an inspiration for others and definitely for her parents Jocelyn Whatuira (Ngāti Kahungunu) and Nu’ualofa Perese (Magiagi village).

As we revisit Horiana, we take a glimpse at the events that have sustained her professionally.

According to Midwifery Council records, the Counties Manukau region has seen a steady decline in LMC practitioners in recent years, compared to numbers in other areas of Tāmaki Makaurau. Meanwhile, eight years on, Horiana has continued to work in South Auckland, out of the same midwifery group that she commenced with as a new graduate - LMC Services.

Horiana credits its directors, midwife Anne Whyte and manager Tony Mansfield, who have given her unwavering support through her early years as a novice self-employed practitioner. In 2019, Horiana was voted in as chairperson of LMC Services and appointed a director given her extensive skills as a previous clerical administrator in the Women’s Health Service at Middlemore Hospital.

The continuity model has worked well for Horiana, who was Wellington-born but raised in the area of South Auckland from the age of two. She has been fortunate to have practice partners of similar ethnicity, who are also reflective of their clientele. Horiana communicates with her clients through language that is familiar and offers cultural nuances that put whānau at ease, paving the way for relationships that are honest and non-judgmental. This then opens up channels for exchanging vital information to keep themselves and their pēpi well. Her lived experience as a young mum and now a grandmother with mokopuna, opens up huge empathy as required.

During the peak of Covid-19, around labour and birth care especially, Horiana was

honoured to be present for women who were impacted by the limited support allowed in the hospital setting. She felt she was able to assist those experiencing anxiety due to the fact they would ordinarily have been immersed in extended family networks but were limited by restrictions.

Practising in a region with the highest Pacific birth numbers in the country, it seems logical that a drive to increase that particular workforce would go a long way to addressing systemic cultural and inequity concerns in maternity care.

Horiana has a vision to promote Māori and Pasifika holistic midwifery care and it has begun by her support of many students who have successfully graduated. She herself was a founding ‘niece’ of PMWA’s ‘aunties’ programme and her insight into what challenges students faced in the world of clinical environments and workplace culture urged her to help others negotiate their learning pathways.

In her own whānau, Horiana proudly states that she is considered their tohunga around childbirth, as she has “walked the amazing journeys of 30 whānau members” including two mokopuna (one on her lounge floor and one in hospital).

Horiana feels that she is “role modelling for our community”. What does that look like? She replies, “I’m action”.

Fa’afetai lava Horiana, for your loyalty and service to your community and ours.

PASIFIKA

Horiana Thompson with her mokopuna, Mahina Whatuira Kepa and Kikorangi Rivers Mehico

ISSUE 108 MARCH 2023 | 35

Left: Mahina Whatuira Kepa and Kikorangi Rivers Mehico CAROL BARTLE POLICY ANALYST

PREGNANCY, BIRTH, BREASTFEEDING, AND DISABILITY

The vision of the New Zealand Disability Strategy 2016-2026 is: “New Zealand is a non-disabling society – a place where disabled people have an equal opportunity to achieve their goals and aspirations, and all of New Zealand works together to make this happen”.

Non-disabling is a term used deliberately in the strategy, as it recognises the importance of removing the barriers in society for disabled people who have impairments. Using this term is considered to be a stronger and more meaningful message than talking about ‘enabling’. Enabling suggests support to help disabled people navigate around barriers, rather than a focus on removing barriers. Removing barriers to maternity care experienced by disabled women will be of interest to midwives who are already providing care to disabled women, and nondisabling aspects of care are interesting to explore. Stats New Zealand (2013) reported that one in four New Zealanders were limited by a physical, sensory, learning, mental health, or other impairment, and women were more likely to experience physical disability than men (20% compared to 15%). Disabled people, in particular women, were also more likely to experience violence than non-disabled people.

There has been some research looking at disabled women and their needs when pregnant, birthing, breastfeeding and parenting. More understanding of the issues affecting disabled women and their families would be valuable in terms of aiding not only the development of services to meet their specific needs where necessary, but also in removing barriers, rather than merely providing support to navigate barriers - this being the ultimate goal expressed in the Disability Strategy.

SELECTED RESEARCH SUMMARY –A FOCUS ON BREASTFEEDING

Guerin et al (2017), in a New Zealand study, found that disabled women encountered a range of economic, attitudinal, and knowledge barriers in relation to becoming mothers. A shortage of evidence in regards to the issues disabled women have to confront when accessing maternity services was also noted. Health professionals also reported difficulties in providing maternity-related services to disabled women. There may be a number of issues affecting pregnant women, and breastfeeding mothers with disabilities, which include concerns about medications that may affect the infant, access to existing services including childbirth education, and

specific issues for wheelchair users. Stigma still exists towards disabled women becoming mothers, but becoming a mother has been reported as affirming for disabled women (Guerin et al, 2017). Lezzoni (2017) found that for women with mobility disability, there was a degree of fear about whether childbirth could be successful, and a lack of trustworthy information was also reported.

A recent study in the Lancet (Brown et al, 2023) looked at disability and in-hospital breastfeeding practices in Ontario, Canada. The population-based cohort included 634,111 women of whom 54,476 (8.6%) had a physical disability, 19,227 (3.0%) had a sensory disability, 1,048 (0.2%) had an intellectual or developmental disability, 4,050 (0.6%) had multiple disabilities, and 555,310 (87.6%) had no disability. Disparities in breastfeeding outcomes between those without a disability, and those with intellectual, developmental, or multiple disabilities was found. The researchers looked at practices and supports for breastfeeding based on the WHO/UNICEF Baby Friendly Hospital Initiative guidelines, which included early initiation of breastfeeding, motherbaby skin-to-skin contact and assistance with breastfeeding. The study conclusion was that more could be done to increase breastfeeding rates, particularly for women with intellectual or developmental disabilities, or multiple disabilities. One weakness of this study was the lack of knowledge about the women’s breastfeeding intentions.

Twenty-five mothers with physical disabilities in the US were interviewed about their experiences related to the facilitators and barriers to breastfeeding (Powell et al, 2018). The participants reported a range of disabilities including multiple sclerosis, spina bifida, cerebral palsy, stroke and muscular dystrophy. Facilitators for breastfeeding included adaptations and equipment –the importance of finding a position for breastfeeding that worked, the need for pillows, the need for a breast pump for some women who could not find a position that worked for breastfeeding and /or did not have the physical strength to hold their

More understanding of the issues affecting disabled women and their families would be valuable in terms of aiding not only the development of services to meet their specific needs where necessary, but also in removing barriers, rather than merely providing support to navigate barrier.

36 | AOTEAROA NEW ZEALAND MIDWIFE BREASTFEEDING CONNECTION

babies for a full breastfeed, receiving physical assistance from others to support the baby during feeds, and support from peers who had similar experiences.

Barriers included: lack of support for breastfeeding; lack of information about medication and the potential interactions with breastfeeding-which caused concerns for some mothers who then did not breastfeed; limited information about breastfeeding among mothers with physical disabilities; disability-related difficulties with milk supply which were related to delayed breastfeeding initiation in some cases; and difficulties with latching the baby at the breast, which were mostly related to disability and positioning problems. Recommendations from this work were to address the facilitators and barriers, and to develop resources for breastfeeding women who have a disability, as well as resources for health care providers. Warkentin et al (2019) found that the most commonly reported breastfeeding challenge for women with physical disabilities was positioning the baby. Pillows and physical support from a partner were the most reported techniques used to facilitate breastfeeding, and the underarm (football) hold was described as the least beneficial position by women. A need for optimisation in the support and care provided to women with physical disabilities was recommended by König-Bachmann et al (2019).

Women with learning disabilities face different challenges. Johnson et al (2021), in a scoping review, found that tailored support for infant feeding was necessary along with accessible resources. There was a high level of agreement in the papers identified about the importance of using easily read visual images within resources. Some women wanted healthcare providers to give practical demonstrations. The importance of healthcare providers checking understanding was emphasised as important.

REMOVING BARRIERS –NON-DISABLING ENVIRONMENTS

Staying independent and in control during pregnancy and birth, sharing decisionmaking, and finding a maternity provider who was respectful of autonomy and the rights to make decisions, were identified as important for disabled women in an Australian study (Blair et al, 2022).

Midwifery care in Aotearoa takes place in partnership with women and is provided in a way that is intended to be flexible, creative, empowering and supportive. Midwives

ISSUE 108 MARCH 2023 | 37 BREASTFEEDING CONNECTION

Midwives also accept the rights of women to control their pregnancy and birthing experiences, and they uphold the right to informed decision-making and consent throughout the childbirth experience.

also accept the rights of women to control their pregnancy and birthing experiences, and they uphold the right to informed decision-making and consent throughout the childbirth experience. This philosophy is entirely consistent with the expressed desire for autonomy, communication, and individualised care by the participants in the Blair study. The majority of disabled women in this study also wanted “to just fit in” and to receive care in a similar or identical manner to those without disabilities. They resented an ‘at risk’ label on account of their disabilities when it was not medically indicated.

The creation of enabling environments by the reduction of physical access barriers was also discussed. Adjustable height examination tables, accessible weighing scales, and accessible baby cots were identified as ways to reduce anxiety and increase independence. Inaccessible weighing scales resulted in women not being weighed regularly, or at all, which caused anxiety in women concerned about their weight gain (Blair et al, 2020). Women valued providers who considered their feelings and needs, and appreciated a flexibility of approach. One woman suggested that health providers needed to listen to what women tell them about what they want and not request that women do things, but rather ask them if they can do things, and to not tell women about policies without explaining how they can be adapted, and/or why they are recommended in that way (Blair et al, 2022).

The development of accessible resources is important. In the UK, Best Beginnings provide information for parents with disabilities and parents with learning disabilities. The UK Best Beginnings Baby Buddy app has an option for speech to be read aloud, using simple and clear language, pictures and videos. In Aotearoa, the

BreastFed NZ and Mama Aroha apps have useful images and simple diagrams that can be used to aid discussion. Aotearoa also has the Baby Friendly Hospital Initiative and the Ten Steps to Successful Breastfeeding which can support early initiation of breastfeeding, mother-baby skin-to-skin contact and tailored support for breastfeeding.

CONCLUSION

The Convention on the Rights of Persons with Disabilities (2006) is a human rights instrument aimed at changing attitudes and approaches to disabled people. Aotearoa signed the Convention in 2007 and ratified it in 2008. Principles of the Convention include respect, freedom to make choices, full and active participation in society, equality and accessibility. Article 6 of the Convention is specific to women with disabilities and part of a future vision includes removing the barriers to sexual and reproductive health services for disabled women. The UN Committee on the Rights of Persons with Disabilities released a list of issues for Aotearoa in March 2018. Four main themes of the complaints from disabled women were related to IVF, postnatal depression, the effects of mental health perceptions of the ability to care for children, and workrelated problems related to women’s health, including endometriosis (Beard, 2019).

Whaikaha – a new Ministry of Disabled People, has been set up in partnership with the community, and Māori, to help transform the lives of disabled people. Supporting disabled people will be guided by using the Enabling Good Lives approach, and giving disabled people greater choice and control over their lives is an expressed aim.

Protecting birth physiology and supporting a positive childbirth experience has been a cornerstone of midwifery practice, with the aim of improving the health and wellbeing of all mothers and infants. More information about the issues that may affect pregnancy, breastfeeding, and parenting for disabled people would be significantly valuable. Redshaw et al, reported in 2013 that women with disabilities had to some extent been an invisible population within maternity. Stats NZ are conducting a new survey about disability this year, but the results of this may have limited relevance to midwives and midwifery care as questions about pregnancy are unfortunately not included, and midwives are not on the list of health professionals seen in the last 12 months. A question about unmet needs will be included, which could potentially generate some information, although the focus seems to be more on difficulties accessing a health care provider, rather than barriers experienced in health care systems (Stats NZ, 2023).

An Australian study investigating how disabled women were identified within maternity services was described as being the first to explore this issue in Australia (Benzie et al, 2022). A large variation in disability identification practices was found in the maternity systems and a recommendation was made to develop national guidelines and ensure routine collection of this information to support service development. Exploring these issues of relevance to disabled women and maternity stakeholders in Aotearoa could be transformational – and non-disabling. square

References available on request.

38 | AOTEAROA NEW ZEALAND MIDWIFE BREASTFEEDING CONNECTION

New Zealand College of Midwives Directory

President

Nicole Pihema Ph 021 609 011 nicolepihema@gmail.com

National Office

PO Box 21-106, Christchurch 8140 Ph 03 377 2732 Fax 03 377 5662 nzcom@nzcom.org.nz www.midwife.org.nz

College Membership Enquiries

Contact Lisa Donkin membership@nzcom.org.nz 03 372 9738

Chief Executive

Alison Eddy

Auckland Office and Resource Centre

Delia Sang, Administrator Yarnton House, 14 Erson Avenue PO Box 24487, Royal Oak, Auckland 1345 Ph 09 625 9764 Fax 09 625 0187 auckadmin@nzcom.org.nz

National Board Advisors

Elder: Sue Bree

Kuia: Crete Cherrington

Education Advisor: Tania Fleming tania.fleming2016@gmail.com

Regional Chairpersons

Auckland Jacquelyn Paki, Mel Nicholson auckchair@nzcom.org.nz

Bay of Plenty/Tairawhiti Cara Kellet chairnzcomboptairawhiti@gmail.com

Canterbury/West Coast

Sheena Ross chairnzcom.cantwest@gmail.com

Central

Julie Kinloch Ph 06 835 7170 julie.kinloch.nz@gmail.com

Nelson/Marlborough

Karen Hall tetauihunzcom@gmail.com

Northland

Christine Byrne tetaitokerauchair@nzcom.org.nz

Otago

Jan Scherp, Charlie Ferris otagochair@nzcom.org.nz

Southland

Liz Whyte liz.whyte@netspeed.net.nz

Waikato/Taranaki

Jenny Baty-Myles chairwaikatonzcom@gmail.com

Wellington Suzi Hume chair@wellingtonmidwives.com

Regional Sub-Committees

Hawkes Bay Sub-Committee Linley Taylor midwife.linley@gmail.com

Manawatu Sub-Committee Jayne Waite j.waite70@gmail.com

Taranaki Sub-Committee Ange Hill nzcom.taranaki@gmail.com

Wanganui Sub-Committee Susan O'Connell susan.cleland@hotmail.com

Horowhenua Laura McClenaghan midwife.laura@hotmail.co.nz

Consumer Representatives

Royal New Zealand Plunket Society Zoe Tipa zoe.tipa@plunket.org.nz

Home Birth Aotearoa

Bobbie-Jane Cooke bobbiejane.homebirth@gmail.com

Parents Centre New Zealand Ltd

Liz Pearce Ph 04 233 2022 extn: 8801

e.pearce@parentscentre.org.nz

Student Representatives

Penny Martin pennymartin79@live.com

Ana Ngatai ana.olsen.ngatai@hotmail.com

Resources for midwives and women

The College has a range of midwiferyrelated books, leaflets, merchandise and other resources available through our website: www.midwife.org.nz/shop

Ngā Māia Representatives www.ngamaia.co.nz

Jay Waretini-Beaumont midwifejay@gmail.com

Lisa Kelly lisakellyto@yahoo.co.nz

Pasifika Representatives

Talei Jackson Ph 021 907 588 taleivejackson@gmail.com

Nga Marsters Ph 021 0269 3460 lesngararo@hotmail.com

MERAS / General Enquiries & Membership

PO Box 21-106, Christchurch 8140 www.meras.co.nz

Ph 03 372 9738 meras@meras.co.nz

MMPO mmpo@mmpo.org.nz

Ph 03 377 2485 PO Box 21-106, Christchurch 8140

Rural Recruitment & Retention Services

Rural contact: 0800 Midwife/643 9433 rural@mmpo.co.nz

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CLINICALLYPROV E N EFAS DELLAIRT • CLINICALLYPROVEN

Call for Abstract submissions are open now!

02 - 04 NOVEMBER 2023

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Submissions closing on 24 March 2023

For further information and submission guidelines go to

midwife.org.nz/conference-2023

Midwife Aotearoa New Zealand

VEGETARIAN & VEGAN PREGNANCY

Antenatal and Newborn Screening Updates

Nau mai haere mai ki Aotearoa New Zealand Midwife

from the president, new zealand college of midwives, nicole pihema (Ngāpuhi, Te Rarawa)

EMERGENCY RESPONSE

FUTURE GOVERNANCE AND STRATEGY FOR THE COLLEGE

Midwifery workforce group

Community Midwifery Infrastructure Working Group meeting

Congratulations Priscilla Baken, MNZM

Changes to cervical screening programme planned from July 2023

Covid-19 vaccine approved for children at high risk of adverse outcomes

Changing Birth Culture

One Birth At A Time

Book early for your MSR

Scope of practice submission

Te Whatu Ora pre-employment vaccination policy submission

Recent submission provided by the College

Midwifery First Year of Practice Aotearoa National Programme

Continuing education update

Rural Student Midwifery Grant

Honouring Jill as she prepares for retirement

managing finances proactively

WHAT CAN I DO?

WHAT IS KIWISAVER AND WHY SHOULD I JOIN UP?

Obstetric and Neonatal Bed Specialists

FINALLY …

Ngā Māia: looking ahead

my editorship my editor

RONGOĀ MĀORI: WHAT IS IT AND HOW CAN WHĀNAU BENEFIT FROM IT?

RONGOĀ MĀORI FOR CONCEPTION

RONGOĀ MĀORI DURING HAPŪTANGA

ACC-REGISTERED PRACTITIONERS

preparing for disaster and emergencies

BEING PREPARED FOR EMERGENCIES AND DISASTERS

Civil Defence advice

BREASTFEEDING AND INFANT FEEDING IN EMERGENCIES

MIDWIFERY CARE IN A STATE OF EMERGENCY

CONCLUSION

VEGETARIAN & VEGAN PREGNANCY

THE RISE IN PLANT-BASED EATING

IMPORTANCE OF HEALTHY DIET AND LIFESTYLE

Did you know?

WHAT IS A ‘PLANT-BASED’ DIET?

REASONS FOR GOING MEAT-FREE

PLANT-BASED DIET IN PREGNANCY

MOH EATING AND ACTIVITY GUIDELINES 2020

NEW VEGAN PREGNANCY RESOURCE

SPECIFIC NUTRIENT CONSIDERATIONS

IRON

Did you know?

Screening during pregnancy for vegetarians and vegans

CALCIUM

VITAMIN D

Midwifery Postgraduate Education Grants

Student Midwifery Grants 2022

Midwifery workforce part II: supporting midwives of the future

RELATIONSHIPS ARE KEY

KAWA WHAKARURUHAU | CULTURAL SAFETY APPLIES TO WORKING WITH STUDENTS

Kawa whakaruruhau

AT THE BEGINNING OF A PLACEMENT, TAKE TIME TO WELCOME AND GET TO KNOW THE STUDENT MIDWIFE

PRE-BRIEFING

SUPPORT STUDENTS TO CONSULT WITH OTHER HEALTH PROFESSIONALS

FEEDBACK AND OPEN DIALOGUE –KŌRERO WITH YOUR STUDENT

REASSURANCE

ROLE MODEL SELF-CARE

INCLUDE THE STUDENT IN ‘BEHINDTHE-SCENES’ ASPECTS OF MIDWIFERY

TAKE THE OPPORTUNITY TO DO A PRECEPTORSHIP COURSE

REMEMBER WHAT IT’S LIKE TO BE A STUDENT!

serving with loyalty

PREGNANCY, BIRTH, BREASTFEEDING, AND DISABILITY

SELECTED RESEARCH SUMMARY –A FOCUS ON BREASTFEEDING

REMOVING BARRIERS –NON-DISABLING ENVIRONMENTS

CONCLUSION

New Zealand College of Midwives Directory

Articles inside

PREGNANCY, BIRTH, BREASTFEEDING, AND DISABILITY

serving with loyalty

Midwifery workforce part II: supporting midwives of the future

VEGETARIAN & VEGAN PREGNANCY