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.

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

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

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.