Midwife Aotearoa New Zealand

OUR HEROINES

TALES OF MIDWIFERY THROUGH EXTREME WEATHER EVENTS P.18

SGA AND FGR GUIDELINES P.24

HPV TESTING: THE NEW PRIMARY SCREENING PATHWAY FOR CERVICAL CANCER PREVENTION P.28

CLIMATE CHANGE, CLIMATE ACTION INTERVENTIONS, AND WHAT WE CAN DO P.32

ACC-registered midwives can lodge claims for specific injuries with us for the first time.

If you’re a midwife, check out our quick guide on how to do this successfully on our website.

FORUM

FROM THE PRESIDENT

4. HE ORA TE WHAKAPIRI

FROM THE CHIEF EXECUTIVE

5. CULTURAL REVIEW

8. BULLETIN

10. YOUR COLLEGE

12. YOUR UNION

14. YOUR MIDWIFERY BUSINESS FEATURES

16. NGĀ MAIA

17. PASIFIKA 18. OUR HEROINES 24. SGA GUIDELINES

28. HPV TESTING 32. CLIMATE CHANGE AND ACTION INTERVENTIONS 36. BREASTFEEDING CONNECTION 40. CONFERENCE

42. FROM BOTH SIDES DIRECTORY

EDITOR

Hayley McMurtrie

E: communications@nzcom.org.nz

ADVERTISING ENQUIRIES

Hayley McMurtrie

P: (03) 372 9741

MATERIAL & BOOKING

Deadlines for September 2023

Advertising Booking:

7 August 2023

Advertising Copy:

14 August 2023

ADVERTISING POLICY AND DISCLAIMER: The New Zealand College of Midwives maintains a schedule of guidelines to exclude advertisements for products or services that are not aligned with its principles and ethics. Every effort is made to ensure that advertising in the magazine falls within those guidelines. Where advertising is accepted, this does not imply endorsement by the College of the product or service being promoted Aotearoa New Zealand Midwife is published quarterly for the New Zealand College of Midwives. The articles and reports printed in this newsletter are the views of the authors and not necessarily those of the New Zealand College of Midwives, its publishers or printers. This publication is provided on the basis that New Zealand College of Midwives is not responsible for the results of any actions taken on the basis of information in these articles and reports, nor for any error or omission from these articles and reports and that the College is not hereby engaged in rendering advice or services. New Zealand College of Midwives expressly disclaims all and any liability and responsibility to any person in respect of anything and of the consequences of anything done, or omitted to be done, by any such a person in reliance, whether wholly or partially upon the whole or any part of the contents of this publication. The College acknowledges and respects diversity of identities through the language used in this publication. Te reo Māori is prioritised, in commitment to tāngata whenua and te Tiriti o Waitangi. To maintain narrative flow, the editorial style may use a variety of terms. Direct citation of others’ work maintains the original authors’ language, and contributing writers’ language preferences are respected. All advertising content is subject to the Advertising Standards Authority Codes of Practice and is the responsibility of the advertiser. Contents Copyright 2020 by New Zealand College of Midwives. All rights reserved. No article or advertisement may be reproduced without written permission. ISSN: 2703-4062.

Welcome to issue 109 of Midwife Aotearoa New Zealand

Kia ora, as the new editor of the College’s magazine Midwife Aotearoa NZ, I would like to begin with a thank you to my predecessors as I come full circle in my editorial journey. I began my role at the College 17 years ago working with the agency that published the magazine on the College’s behalf. Since then we have brought the magazine in house and it has gone from strength to strength under the guide of Maria Scott and more recently Amellia Kapa, who I am delighted to say is still writing for the magazine in a freelance capacity. Having been involved in the redesign of the magazine in 2020 I am proud to retake the reins in the position of editor. I would also like to introduce sub-editor Annie Oliver. Annie’s knowledge and passion for words and how they come together on the page is legendary in the College office and I am delighted to have her skills on the editorial team.

This issue features just a few of the midwife heroines that exist within our communities. It is the nature of midwifery as a profession that embodies those intrinsic instincts of doing what needs to be done and just getting on with it. We acknowledge the amazing efforts of many midwives throughout Aotearoa in times of crisis through the few stories we can publish here.

We also congratulate Heather Muriwai on her appointment as the first Chief Clinical Officer of Midwifery. We know Heather will be successful in improving outcomes for wāhine and whānau and wish her all the best in her role. The climate change article (p.32) provides a rare glimpse of what we are on track to achieve in the field of climate change, as well as practical tips on what we can all do to improve our world for future generations. Thank you to all those who have contributed to the magazine, we value your input and hope all te rito (p.7) enjoy the magazine. As always, we welcome your feedback.

Ngā mihi nui, Hayley square

HAYLEY MCMURTRIE EDITOR & PUBLICATIONS MANAGER Email: communications@nzcom.org.nz

Survival by sticking together, disaster in separation” – Source unknown

In today’s world, the word wānanga is often associated with higher institutions of learning, workshops, or seminars. But like many other reo Māori words, wānanga can’t be limited to a single definition; it is multidimensional in nature and points to te ao Māori values and philosophies.

Wānanga is just as much a verb as it is a noun. To be ‘in wānanga’ is to plug into the collective consciousness; to share, discuss, consider, and deliberate openly with others, through the heart, acknowledging that each individual has something unique and valuable to offer. Connecting in this way can be enriching and uplifting; as one individual’s passion or vision is ignited, the spark is passed around the room and the inspiration becomes contagious.

Although wānanga often unfolds in group settings, it can look like many things. It can be an individual process of going deep within to peel back layers and identify where healing needs to occur. It can be formal, or informal. And we are often in wānanga with others - whānau, friends and colleagues - without even being conscious of it. The process of wānanga naturally unfolds whenever we are in a mode of open enquiry.

So knowing this, how can we weave it into our modern-day working environment when we have deadlines to meet and plans to progress? It’s true, going into ‘wānanga mode’ may not be practical at every stage, however I do believe there’s a place for it, and that its value could be felt by the whole profession if it was implemented at all levels.

The possibility of the College moving to a co-governance model has been on the cards for some time now, as a way of ensuring our organisation is meeting its Tiriti obligations. And while this is still a relevant conversation, I wonder whether we might benefit from a shift in focus. Rather than talking about co-governance, perhaps our attention should be redirected toward how we can bring the concept of wānanga into our organisation.

One possible way of achieving this could be to have two College presidents in the future: one Māori/tangata whenua and one tauiwi/ tangata tiriti. This would not only create an opportunity for wānanga between the two, but would also ensure the responsibility of the role was shared.

Members will be given the opportunity to vote this idea in or out at a Special General Meeting in July and I would suggest that two minds, two hearts and two bodies of knowledge and experience will always be better than one. Much like having an LMC partner to reflect with, or a second midwife at a birth, the opportunity to utilise each other as soundboards and find solutions together is more beneficial for everyone involved, keeping whānau and midwives even safer.

In other words, wānanga might just hold the key to transforming co-governance from a tick-box, lack-lustre term into its more inspiring counterpart: co-creation. From here, anything is possible, including the bright future our unborn tūpuna deserve. square

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

“He ora te whakapiri, he mate te whakatākiri”

COLLEGE MEMBERS POSITIONED AS TE RITO

Historically, midwifery has based its understanding of cultural safety on the foundational work of Irihapeti Ramsden, as a process which relates to individual practice and the way in which midwifery care is provided.

The Midwifery Council’s statement on Cultural Competence sets out that: “Cultural safety is the effective midwifery care of women by midwives who have undertaken a process of self-reflection on their own cultural identity and recognise the impact of their own culture on their practice”. It further states “A midwife who is culturally safe recognises that power imbalances are often invisible within professional relationships and healthcare services and works to address inequality and inequities and to transfer power to women as the users of midwifery services. However, it is the woman and her family/whānau who determines whether her relationship with her midwife and the midwifery care she receives is safe for her.”

The concept of cultural safety has since been expanded to consider what influence and accountability organisations have in bringing this concept to life. One of the desired outcomes of cultural safety is achieving health equity, which is a system-level responsibility. A critically conscious, empathetic and culturally safe health professional workforce is key to ensuring services are accessible and acceptable. However, this is only one of the necessary factors in reducing inequities;

another is the health system environment in which practitioners work. Through the development of both a culturally safe health workforce and health care system, we move a step closer to eliminating inequities. A third major factor is one we have less direct influence over – the wider social policy settings which contribute to the social determinants of health – income, housing and education (among others).

With this in mind, at its November 2021 meeting, the College’s national board agreed to adopt the broad definition of cultural safety suggested by Curtis et al. – one which pertains not only to the practice of individual midwives but also to the College as an organisation.

The College has a role in leadership to champion the provision of high-quality health care that strives for equity of health outcomes, and to support midwives to provide care that meets the health care needs and aspirations of Māori. Although the College does not provide health care services directly, its role is central to the practice of midwives, just as the needs of women and their whānau are central to the midwife’s role.

from the chief executive, alison eddy

“Cultural safety requires healthcare professionals and their associated healthcare organisations to examine themselves and the potential impact of their own culture on clinical interactions and healthcare service delivery. This requires individual healthcare professionals and healthcare organisations to acknowledge and address their own biases, attitudes, assumptions, stereotypes, prejudices, structures and characteristics that may affect the quality of care provided. In doing so, cultural safety encompasses a critical consciousness where healthcare professionals and healthcare organisations engage in ongoing self-reflection and self-awareness and hold themselves accountable for providing culturally safe care, as defined by the patient and their communities, and as measured through progress towards achieving health equity. Cultural safety requires healthcare professionals and their associated healthcare organisations to influence healthcare to reduce bias and achieve equity within the workforce and working environment”. (Curtis et al. 2019)

It is against this background that the College took the decision to undertake a cultural review in 2022. The College acknowledges and thanks the many members who engaged with the external reviewers, Moe Milne, Linda Thompson and Koha Aperahama, in person through face-to-face interviews and focus groups, as well as those who completed the members’ survey. The reviewers completed their report in March 2023. The cultural review’s objectives, main findings and recommendations are summarised below. The six objectives of the review were:

• To identify improvements to the College structures and services which will help to build the development of a Māori cultural framework within the organisation and the establishment and appointment of a Māori midwifery advisor position

• Application of Te Tiriti o Waitangi and commitment to equitable outcomes for Māori through examining the College’s structures nationally and regionally to identify how they can be strengthened to drive equity

• To bring to life the expressions and application of Te Tiriti o Waitangi, as defined in Whakamaua, (Māori Health Action Plan) in College activity

- Mana tangata: Achieving equity in health and disability outcomes for Māori, enhancing the mana of people across their life course and contributing to the overall health and wellbeing of Māori

- Equity: Being committed to achieving equitable health outcomes for Māori

• To enable the College to be a culturally safe organisation that positively and effectively meets the professional support needs of Māori and non-Māori members

• To develop a Māori cultural framework that incorporates the following:

- Kawa Whakaruruhau - the continued development and promotion of cultural frameworks and infrastructures that ensure culturally safe practice

- Ngā Tāngata - upholding the integrity of Māori midwives and embracing the professional and cultural diversity that they bring to midwifery

- Mātauranga - Respecting the knowledge that has been given, celebrating successful Māori models of practice and integrating Kaupapa Māori into all aspects of midwifery

• To produce a high-quality report within the timeframes agreed that includes findings and recommendations for improvements

REVIEW OUTCOMES

The reviewers utilised Te Pā Harakeke (the flax bush) as a framework to present their findings. Māori have long utilised Te Pā Harakeke as a metaphor for whānau wellbeing and structure, it is made up of many parts.

• Te Rito - the new shoot or centre represents the baby or future potential within the plant.

• Awhi rito - outer leaves represent the mātua and tūpuna that provide the protection and support to ensure the rito is nurtured to grow strong and realise the potential held within.

The reviewers positioned the members of the College as te rito, or the centre of the

plant, with the College entity represented by the awhi rito (mātua) or outer leaves, providing the support and structure that nurtures the developing rito (members). The College in turn is supported by tūpuna leaves, which represent ancestral knowledge, Te Tiriti o Waitangi and the importance of equity. These tūpuna leaves provide the foundational support and hold the practical, tangible actions to uphold the articles of Te Tiriti o Waitangi, which supports equity for Māori in the first instance and equity for all. Whakataukī were also used by the reviewers to illustrate and bring to life the concepts underpinning their findings and recommendations.

Me ngaki te whenua kia tupu ora ai ngā hua. Till the soil so the harvest is plentiful. Through careful preparation and planning, great outcomes can be achieved.

Finding 1: There was a call for change and restructuring of the organisation.

Recommendation 1: That the College takes deliberate steps, in a phased approach, to implement changes to its structures and services to include dedicated Māori positions.

Tungia te ururua kia tupu whakaritorito te tupu o te harakeke. Clearing away the undergrowth to allow new growth to emerge and flourish. Addressing the gaps and identifying the areas for potential development ensures quality improvement.

Finding 2: The importance of Te Tiriti o Waitangi to the membership.

Recommendation 2: That the College applies Te Tiriti o Waitangi in commitment to achieving equitable outcomes for Māori and formalising a Te Tiriti partnership relationship with Ngā Maia.

I hāere mai koe I te āhuru mōwai ki tea o mārama tau ana. Transferring the safety of te whare tapu o te tangata – the womb – a to the world of light. From one safe space to another.

Findings 3 & 4: Creating environments that are culturally safe and affirming, an environment that nurtures its membership, recognising the importance of addressing racism across the organisation.

Recommendations 3 & 4: That the College initiates a pathways programme and programme of training and education to address institutional and interpersonal racism in the organisation.

Hūtia te rito o te harakeke, kei hea te kōmako e kō? Uia mai ki a au, he aha te mea nui o te ao? Māku e kii atu, He tangata he tangata he tangata. If you cut out the

centre of the flax bush, where will the Bellbird sing? Ask of me What is the most important thing in the world, I will reply it is people, it is people, it is people.

Finding 5: The importance to members of Te Tiriti and equity across the organisation.

Recommendation 5: That the College initiates a separate internal review of the cultural responsiveness of its Midwifery Standards Review process.

Te rito o te harakeke. The membership is the critical centre that ensures the success of the College and contributes greatly to the wider health and wellbeing of whānau.

The College has a key role in shaping and influencing midwifery practice and the profession as a whole.

Finding 6: The request is that the College applies a cultural framework to do this.

Recommendation 6: That the College adopt Turanga Kaupapa as the cultural framework for the organisation.

The full report has been presented to the College board and Ngā Maia board who are considering the recommendations and their response to them. The College’s board has been considering Te Tiriti and its role in supporting cultural safety in practice, its governance model and organisational capacity over recent times as the strategic plan was revised, so the cultural review recommendations presented no major surprises.

Some key decisions have already been made, which include changing the constitution to enable the election of tangata whenua and tangata tiriti co-presidents this year, as well as establishing two Māori midwifery advisor positions. The College is working to establish online Te Tiriti workshops (which we have been providing in person since 2018) to increase access and availability. Alongside this we are working to establish additional cultural education opportunities and embed elements of cultural safety throughout all of the College’s educational offerings. The board made a decision some time ago that it would develop a College cultural safety statement; however, it has been agreed that we await the outcome of the Midwifery Council’s Aotearoa Midwife Project and finalisation of the revised scope of practice before progressing the development of this statement. The way ahead for the College and its membership is exciting, as we work towards strengthening our organisation’s cultural responsiveness with a view to better-supporting midwifery practice and ensuring we meet the needs of wāhine, pēpi and their whānau. square

References available on request.

Te Rito College Members

Awhi rito (mātua) the College

Tūpuna College Support

CONGRATULATIONS HEATHER MURIWAI

Tēnā tātou katoa, Ngā Maia Trust and the College are delighted to announce and congratulate Heather Muriwai who has been confirmed as the first Chief Clinical Officer Midwifery, by Te Aka Whai Ora. Kahu Pōkai (registered midwife) of twenty-five years, Heather has worked in a variety of clinical settings as well as education, leadership and management.

Heather believes the importance she places on whanaungatanga is evident in her approach while in her role as the Principal Advisor, Family & Community Health for Te Whatu Ora, Heather guided three Crown entities (Health, Oranga Tamariki and NZ Police) to embrace a Te Tiriti o Waitangi framework and work in partnership with iwi Māori with the goal of creating iwi-led local agreements to ensure the safety of newborn pēpi, and whānau.

The emphasis of this work is on prevention - ensuring the aspirations of our tamariki mokopuna can be realised.

Heather is committed and passionate about achieving equity of hauora outcomes for tangata whenua through Kahu Taurima, one

of the priorities of Te Pae Tata, which lays the foundation to improve outcomes for pēpi, tamariki and whānau.

Heather believes the inaugural role of the Chief Clinical Officer Midwifery is pivotal to the ongoing development of Kahu Taurima.

The appointment will make up a full complement of sector leads to accompany the Chief Clinical Officer Nurse, Chief Clinical Officer Allied Health and Chief Clinical Officer Medicine.

Please join us in congratulating Heather on her successful appointment and achievements to date.

Tamara Karu Ngā Maia Trustee (Secretary) square

E te māreikura, e poho kererū ana mōu, nā whai anō e rere topa ana a tātou mihi kia koe.

Mai i te whiti, i te muri, i te tonga i ngā tōpito o te motu tae noa atu ki te mounga tītōhea mātou ka mihi, mōu i ngākau nui ki te hāpai i ngā moemoeā a rātou mā.

Tēnei mātou ngā huruhuru mo ō waewae e mihi ana e tautoko ana i a koe me tō whānau.

Nō reira e hika Whāia, Whāia i te urutapunui o Hine! Hine i ahu i te one, Hine i kauorohia, Hine i raukatauri, Hine te wānanga, ki a Hine te iwaiwa te whakaputa nei i a koe ki te whai ao ki te ao mārama.

Tū te ngana, Tū te maranga, Tu o whiti whakamaua ki a tina, haumi e, hui e, Taeki e!

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National maternity guidelines webinars

Over the last few months a number of new and updated national maternity guidelines have been developed. To support their implementation, Te Whatu Ora and ACC have commissioned a prerecorded webinar for each guideline:

• Small for Gestational Age and Fetal Growth Restriction

• Referral Guidelines

• Hypertension in Pregnancy

• Cord blood lactate testing

The webinars are available to watch or listen to on Te Whatu Ora website alongside the guideline documents. The webinars are intended as an introduction and overview of the guidance, and it is also necessary for midwives, obstetricians and other professionals involved in maternity care to familiarise themselves with the specific recommendations in the guideline documents. square

Women’s Refuge resource about family violence for health practitioners

Women’s Refuge has published a new resource about the role of health practitioners in responding to, and treating family violence. This document has facts and data about family violence, and it highlights how perpetrators of violence can misuse women’s private health information to the detriment of women’s health and wellbeing. There is also information about how health practitioners can respond - ‘hear it’, ‘check it out’ and ‘follow up’. Women’s Refuge conducted research in 2021 to explore how family violence impacted women’s access to healthcare and online health platforms. The responsiveness of health practitioners was found to have a significant influence on whether women could safely take care of their health. Women’s Refuge is interested in feedback from midwives about this resource. Feedback can be sent to Natalie@refuge.org.nz and the resource can be accessed here https://womensrefuge.org.nz/the-role-of-healthpractitioners-in-treating-family-violence/. square

your college

maternal immunisations

Immunisation is a key health protection activity. It has a strong evidence base as an effective public health strategy to protect individuals and communities from avoidable morbidity and mortality. While the Covid-19 immunisation campaign saved many lives in Aotearoa by achieving high levels of full vaccination, immunisation rates for other vaccine-preventable diseases have decreased, and pre-existing equity gaps have widened. In 2022 the College was represented on the National Immunisation Taskforce which made 54 recommendations on how to urgently and rapidly increase childhood and pregnancy immunisation rates.

The College continues to work with Te Whatu Ora and the districts on immunisation, advocating for clear and consistent messaging about immunisation during pregnancy, equitable access to services offering antenatal immunisations, and resourcing for midwives who wish to offer vaccinations as part of their antental care provision.

Key messages for midwives about vaccinations during pregnancy are:

• Pregnant women are strongly encouraged to be vaccinated against whooping cough (Tdap) from 16 weeks of pregnancy and influenza at any time in pregnancy, as early as possible in the flu season (April onwards).

• Covid-19 vaccination additional doses (boosters) are available six months after a previous dose or Covid-19 infection.

• Covid-19 additional doses are especially recommended for those people with health conditions that put them at higher risk of severe illness from Covid-19.

• Vaccines can be safely co-administered (given at the same time).

• All vaccines can be accessed in participating pharmacies. square

a ‘how to’ guide for developing, updating and reviewing college guidance

The College is committed to providing quality guidance to support optimal midwifery practice by its members. This takes three forms: consensus statements, guides for practice, and multidisciplinary guidelines. The ultimate goal is to support midwives to provide culturally and clinically safe care which leads to optimal outcomes for wāhine and their whānau. The College has developed a document which sets out the different types of guidance it produces and the

processes involved in developing, updating and reviewing each of the guidance documents. We are seeking feedback from members on the document which can be accessed through your College portal. square

new draft consensus statement: unassisted childbirth

Unassisted birth can be defined as intentionally birthing without an appropriately trained health professional in attendance. These situations can be complex. The intention of the statement is to articulate the need to respect an individual’s right to accept or decline treatment or care, and the implications of this for midwifery practice, including the responsibility to provide information about the potential risks associated with unassisted birth decisions. The College has developed a draft consensus statement to identify the profession’s position and to support midwives in this situation. We will soon be emailing members to seek feedback via the College portal on the draft consensus statement. square

national consensus statement for lactate testing of newborn babies in Aotearoa New Zealand

One of the of the ACC Neonatal Encephalopathy (NE) Taskforce initiatives has been investigating the utility of testing lactate levels in umbilical cord blood as a component of newborn assessment to assist in the detection of babies who are at risk of developing NE.

As there was insufficient evidence to develop a guideline, a consensus statement has been developed. College representation was included in the working group which developed the statement and members were consulted on the draft. Last year, the College was asked to endorse the final draft of the statement. The board initially declined to offer its endorsement as it noted concerns about accessibility of equipment and the equity issues that this raised as well as concerns about how the various clinical circumstances in which lactate testing was recommended were defined. The ACC working group accepted the College’s feedback and agreed to make amendments to the statement which addressed the concerns. As a result, the College agreed to endorse the statement at its March meeting.

The College will notify members when the consensus statement is published on the Te Whatu Ora website along with an explanatory webinar video. square

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CAROLINE CONROY MERAS CO-LEADER (MIDWIFERY)

a year of change

This year is certainly emerging as a year of change. At the end of April Jill Ovens retired from MERAS and we welcomed Sam Jones as the new MERAS Co-Leader (Industrial). In May Jessica Maxwell joined the MERAS team as an organiser for the Wellington, Hutt and Wairarapa areas. Sam and Jessica join the MERAS staff team of Karen Gray, the MERAS organiser based in Canterbury, Lisa Donkin membership secretary based at the College national office and myself, Caroline Conroy, MERAS Co-Leader (Midwifery).

SAM JONES

Sam brings two decades of union experience with him to the MERAS role. Sam has a good understanding of pay equity, having been involved in the original pay equity case for care and support workers, and is experienced in tri-partite negotiations. He has picked up the lead on the midwifery pay equity claim for MERAS, working closely

Over the years in his union work Sam has gained significant experience as an advocate and negotiator and was involved in the negotiations of several of E tū’s largest collective agreements, including their national agreements in the public hospitals.

For MERAS Membership merasmembership.co.nz

www.meras.midwife.org.nz

with Caroline and Karen who have been involved in this work with Jill since it began.

Over the years in his union work Sam has gained significant experience as an advocate and negotiator and was involved in the negotiations of several of E tū’s largest collective agreements, including their national agreements in the public hospitals. Bringing this experience with him to the MERAS role, Sam will be taking over the lead on the SECA negotiations, working closely with the rest of the MERAS negotiating team, which includes Caroline, Karen, Michelle Archer (NRC Chair), Kelly McConville (NRC member), Verity O’Connor (NRC member) and MERAS workplace representatives Charlotte Godbaz and Jo Barnfield, along with other MERAS workplace representatives who are part of the sounding board.

During his time with E tū Sam was involved in the Holiday’s Act Compliance Review which has been progressing over the last 4 years. Sam will continue that involvement for MERAS. This work should conclude this year with payments owing rolling out to MERAS members during the latter part of the year.

Based in Taranaki and of Ngāi Tahu and Pākehā descent, Sam has grown up around marae and is passionate about his Māori culture and looks forward to the

opportunities that could be presented by Te Aka Whai Ora – Māori Health Authority for MERAS members and the women and whānau for whom we care.

Sam is excited about his new role with MERAS and the opportunity to work with the rest of the MERAS team to advocate for improvements to the working lives of MERAS members.

JESSICA MAXWELL

Jessica is well known to MERAS members at Wellington Hospital, having been a MERAS workplace representative there for several years. Jessica has joined MERAS as an organiser for 16 hours a week whilst continuing to work as a midwife at Wellington Hospital. Jessica will be able to provide local support to MERAS members and represent MERAS at the various meetings and forums in the Wellington, Hutt and Wairarapa hospitals, as well as contributing to the national work that MERAS is involved in.

YVONNE MORGAN – A GREAT SUPPORTER OF MERAS

In this edition we’d like to acknowledge the recent retirement of Yvonne Morgan from her role as the midwife manager at Whangārei Hospital. Yvonne was one of the

early members of MERAS and a foundation member of the MERAS National Representative Council, assisting in building the strong foundations of MERAS that continue to hold it in good stead today. We wish Yvonne all the best for her retirement and thank her for the support she has given MERAS and Whangārei MERAS workplace representatives over the years.

CHANGES AT TE WHATU ORA

Te Whatu Ora and Te Aka Whai Ora were established in July 2022. Since April there has been an increasing number of consultation documents emerging. This reflects the proposed changes to many of the leadership and reporting structures within these entities as they dismantle and replace the 20 DHB management structures and reporting lines. So far, the changes have been focused on the departments that support frontline services, such as finance, data and digital, purchasing and procurement. This has impacted the jobs of thousands of people within the health sector, with some new roles being created and others disestablished. There will also be new roles for clinical leadership at a national level, but at the time of writing these had not been released for consultation.

Work has also started on Kahu Taurima (First 2000 days of life) which will influence maternity and child health services. I am involved in this work, along with Alison Eddy from the College and midwife representatives from Ngā Maia, the Midwifery Leaders Group and Schools of Midwifery. We will update members as information becomes available from this work.

The Midwifery Workforce Development Group has also commenced its meetings, and currently involves myself, Alison and midwife representatives from the College, Midwifery Leaders group, Ngā Maia, Schools of Midwifery and Te Aka Whai Ora. There are plans to establish working groups and it is expected there will be broader consultation with the midwifery sector. Although this national group has only recently been established, I have been working with MERAS workplace representatives and Directors of Midwifery to establish local “midwifery workforce meetings” and focus on local initiatives that support student midwives, new graduates and the retention of experienced midwives. Through this local work there have been some positive gains, including the establishment of a new AUT satellite campus at Rotorua, where they welcomed their first cohort of students at the beginning of this year. square

Changing Birth Culture One Birth At

Sam Jones brings two decades of union experience with him to the MERAS role.

Image: Angela Scott Photography

WAYNE ROBERTSON EXECUTIVE DIRECTOR, MMPO

greater autonomy and flexibility

Self-employment is an increasingly valued choice for midwives providing care in Aotearoa. It allows midwives (together with their group practices) to provide care with autonomy and flexibility, which has a number of benefits for midwives and the māmā, pēpi and whānau they care for.

Greater autonomy leads to a greater sense of purpose for midwives. When midwives have more control over their practice, they are able to provide care in a way that is not only meaningful but also fulfilling to them (through better alignment of personal beliefs, values and sense of purpose).

It also encourages the delivery of more personalised care with midwives being able to work to the full scope of their interests and strengths. This leads to improved communication and a greater understanding of each māmā’s unique needs, ultimately

Greater autonomy leads to a greater sense of purpose for midwives. When midwives have more control over their practice, they are able to provide care in a way that is not only meaningful but also fulfilling to them (through better alignment of personal beliefs, values and sense of purpose).

leading to better health outcomes for māmā, pēpi and whānau.

Greater flexibility also leads to improved access to care for māmā, as midwives can provide care in all settings (including the whānau home). This is particularly beneficial for those māmā who live in remote or under-served areas, have transportation challenges, or who may have difficulty accessing healthcare services.

Greater flexibility also allows the midwife to better balance work and life responsibilities. This is particularly important for midwives who have whānau or other caregiving responsibilities.

Self-employment with access to greater autonomy and flexibility helps to sustain the midwifery workforce in Aotearoa, by not only helping to sustain those actively working within the profession but also making midwifery a more attractive career option.

In expressing my comments, it is vital to acknowledge that community midwives who choose self-employment are not without need for equitable supports.

LOCUM SUPPORT FOR TIME OFF

One of the most valued workforce supports the MMPO provides is helping assure access for midwives to time off through the

provision and backing of flexible on-demand locum cover. Our current response includes access to the following locum cover choices for community midwives:

• Emergency (including illness and critical events) locum cover for those working in urban, rural and remote work settings

• Non-emergency locum cover for those midwives working in rural and remote work settings only

• COVID-19 locum cover for those midwives required to self-isolate and unable to work

The intrinsic value of community midwifery locum support is significant, including being able to access as required and at short notice.

Other key benefits include:

• Assuring continuity of access to midwifery care, especially in communities where there may be a shortage of midwives

• Maintaining the highest quality of midwifery care

• Helping assure the sustainability of the community midwife with support for:

- securing their ongoing self-employed income

- valuable time off (especially in emergency situations)

All of this occurs cost effectively, mainly achieved through the framework, systems and importantly the people at the MMPO.

Over the past year we have seen the value of midwifery locum support grow significantly not only in terms of the MMPO’s delivery of existing contracts but also in the way that our service and the wider midwifery workforce has been able to assist the entire midwifery workforce. This includes support for maternity facilities challenged with staffing and providing help to those localities and regions impacted by natural disaster, as we have seen recently in the North Island.

In respect of the latter situation, we have been humbled and inspired by the positive and proactive response that was clearly evident and received from midwives even before the MMPO immediate calls for help … a perfect example of this was both the initial and ongoing team of midwives who have been relocated from around Aotearoa into Hawke’s Bay.

It is, however, vital to note that this type of response (provided in different ways) is not unexpected and is occurring regularly around our motu … something that the profession should be proud of.

RIGHT NOW…

The recent response to workforce challenges and natural disasters in Hawke’s Bay is just one example and testament to the dedication and resilience of the wider midwifery profession.

Despite these positive aspects, equal access to support and incentives must be

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provided to guarantee sustainability and equity in the sector.

The MMPO and College are always actively advocating for greater investment to support midwives in their practice and professional development, and as I write, we are again doing this important work. Our immediate focus is on enhancing access to more comprehensive time off (for midwives providing care in both urban and rural work settings) and greater support and incentive for cultural and professional development.

Greater investment will not only help assure the sustainability of the entire midwifery workforce, it will also help ensure the promotion of equity in the sector, including

equal access to maternity care, time off, and more tailored support of midwives from diverse backgrounds. square

www.mmpo.org.nz

mmpo@mmpo.org.nz

03 377 2485

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TAWERA TRINDER (TE ATIAWA) NGĀ MAIA TRUST BOARD MEMBER, RURAL COMMUNITY MIDWIFE

Ngā Maia: honouring both ways of knowing

“Mātauranga Māori” can be described as “Māori knowledge originating from Māori ancestors, world views, values and perspectives”. This concept of Mātauranga Māori is foundational to our core principles and values. It enriches our practice as Māori midwives and students, and is reflected in our practice with whānau.

The western scientific academy of research is certainly a valuable source of learning, however it doesn’t validate Māori traditions or our knowledge of healing, and its validity is implied. It’s vital that we

also continue to acquire mātauranga from the same sources as our tūpuna, such as whakairo, oriori and ceremonial practices that kept us safe. Kaupapa Māori research is a unique methodolgy in which Māori seek, and undertake, research for Māori by Māori. Contributors to this academy are holding space to decolonise maternity systems, birth practice and even our bodies.

Honouring both ways of knowing, continuing to kōrero with your kaumātua, hapū and iwi, and absorbing the birthing stories of your tupuna, whilst also accessing

the abundance of academic research on traditional Māori birthing practices and mana wāhine, continue to broaden our scope as Māori midwives.

Looking ahead, our next hui-a-tau will be held 25-27 October. And while the programme is tentative at this time, our hosts Waiariki have the support of many members from the Kaupapa Māori research academy. Waiariki’s theme is ‘Kotahitanga’, a beautiful concept we can all aspire to, which calls on all of us to find and hold on to the common threads that bind us, regardless of our various midwifery work settings, or our differences in practice, beliefs or upbringings. During hui-a-tau, there are always opportunities to learn mātauranga Māori and enrich our birthing practices and knowledge, be it through guest speakers, knowledge-sharing or hands-on wānanga. These opportunities are a powerful way to find those common threads and focus our collective attention on them for the betterment of the whānau we care for.

The venue is located on the beautiful shores of Tauranga Moana at Maungatapu Marae. We encourage you all to register your interest and be immersed in an allinspiring environment where you will create connection through whakawhānaunga, gain valuable learnings and kōrero kanohi ki te kanohi with our Trustees.

If you do not attend the hui-a-tau in October, consider diving into the Kaupapa Māori research of Waimarie Onekawa, Aroha Harris, Kelly Tikao, Naomi Simmonds, Kirsten Gabel, Ngahuia Murphy and Nicky Barrett, to name a few.

Nau te rourou, Naku te rourou. Ka ora ai te iwi. square

Maungatapu Marae, the venue for the next Ngā Maia hui-a-tau, is located on the beautiful shores of Tauranga Moana.

NGATEPAERU MARSTERS

NATIONAL PASIFIKA MIDWIFERY CO-ORDINATOR

maternity care for Pacific non-residents

In March, Pasifika midwifery was invited to present at Moana Connect’s “Pacific Child Wellbeing” conference in Manukau, Tāmaki Makaurau. Moana Connect is an independent Pacific research group, committed to capturing the voices of Pasifika families and communities, for positive change. At the conference, they also released their 10-year action plan “Tamaiti ole Moana 2033”.

It was an empowering Pasifika space with panels of politicians, clinicians, researchers and consumers, all sharing their thoughts, findings, dreams and aspirations. Our breakout session was on “Protection and Autonomy”. It was a tall order to deliver an engaging, meaningful and thought-provoking 15-minute kōrero.

Elani Mafi, a proud Tongan LMC who works in South Auckland, was my copresenter and our presentation was titled “Midwifery - waters of protection”. We used an analogy between a midwife and amniotic fluid - both protective of the whakapapa of whānau. The reference to water also acknowledged our deep connectedness as Pasifika peoples to the moana.

I gave a whistle-stop tour of midwifery autonomy in Aotearoa - highlighting the opportunity of self-employment, and the real gem, continuity of care with a named carer - Elani’s true passion. The approach was a talanoa, defined as an open and informal discussion, and also an established Pacific research methodology.

Elani shared her love of whānaucentred care, and the moment became overwhelming. Her tears flowed as she recounted a collective story of non-resident pregnant wāhine, of predominantly Tongan and Samoan descent, whose journeys have

multiple barriers. They are not entitled to free maternity care and have difficulty finding a midwife, as many want payment upfront. They encounter stress when navigating a foreign system and the financial burden can lead to limiting costly investigations like scans and blood tests. Their care is being compromised due to fiscal pressures and the joy of having a baby is often overridden by anxiety, with the anticipation of an invoice from Te Whatu Ora.

Elani’s account was humble, considered and unrehearsed. She was emotional and whakama raising the topic and exposing herself and our people. She provides midwifery care at no cost, as many midwives do - a selfless act and one that Elani had wanted to remain hidden, yet having the intention to raise this plight.

The eligibility criteria for non-residents is presented in a 6-page document on Te Whatu Ora - Health New Zealand’s website. It reads in plain English, that belies the complexity, emotion and unfairness. Aotearoa’s Pacific neighbours fill workforce shortages that contribute to Aotearoa’s economy, and their mere presence embellish the fabric of the country’s society. A review of their eligibility status is warranted. Pacific workers’ responsibilities often go beyond these shores, to across Te Moana-Nui-a-Kiwa to whānau who are financially dependent on them.

Aotearoa taxpayers bear the financial burden of non-residents’ debt, with the largest being Tāmaki Makaurau based Te Whatu Ora. At the time of writing this, I was unable to find itemised costs and therefore could not distinguish actual debt for Women’s Health. Interestingly, the Cook Islands, Niue and Tokelau, known as New

Zealand Realm Nations, qualify to receive Aotearoa citizen entitlements under this jurisdiction. Citizens of these nations are transferred to Aotearoa for acute medical episodes.

At the conclusion of our presentation, the Q & A session drew out experts in the audience who shared their experiences of supporting non-residents within the industry and personally for whānau. Due to necessity, they had doggedly discovered alternative routes to satisfy authorities. Such is the richness of talanoa - an open and informal discussion. Kia manuia ~ malo aupito. square

Mana

When you flow through my body I know

I am caught in the current of a river Larger than the length of my own lifetime

It bends where we have all been before same rapids other waters our veins my blood I know

I am in the flow of something greater than my own self

The final slide of Elani Mafi’s and Ngatepaeru Marsters’ presentation at Moana Connect’s conference in March this year was a poem by Tongan, Pālagi, Samoan poet Karlo Mila.

AMELLIA KAPA REGISTERED MIDWIFE

OUR HEROINES: TALES OF MIDWIFERY THROUGH EXTREME WEATHER EVENTS AND CYCLONE GABRIELLE

Auckland Anniversary Weekend marked the beginning of a treacherous time for Aotearoa, with torrential downpours and atmospheric rivers causing chaos in Northland, Auckland and the Coromandel, followed by the wrath of Cyclone Gabrielle, which devastated the Hawke’s Bay and Tairāwhiti areas. Throughout it all, midwives continued to provide an acute 24/7 maternity service with limited resources, pulling together in their communities to keep whānau safe. Amellia Kapa caught up with a few midwives from some of the affected areas.

Linley Taylor had been working in the Napier area as an LMC until the end of 2022, when she wrapped up her caseload in preparation for working with Médecins Sans Frontières (Doctors Without Borders). In the early morning hours of 14 February, Linley observed howling winds and lashing rain over the city from her home on Napier Hill. Her power had switched off, but she still had cellphone service, so she called the maternity coordinator at Hawke’s Bay Hospital in Hastings, to check if they needed help.

Acting Director of Midwifery Catherine Overfield answered. “We didn’t really know how bad it was at that point,” Linley explains, “and some of it still hadn’t happened yet. Roads were still open, the hospital

still had power, so when I called and asked if they needed anything, they were ok at that point. But within about an hour and a half, all of the roads were suddenly shut and news was coming in saying the river banks were bursting, or had already burst.”

After messaging the local private LMC Whatsapp group and only getting one response, Linley, who is also the sub-regional College chairperson, knew the situation was serious. “That’s when I realised how bad things were. I did a couple of ring arounds and couldn’t get hold of anyone. I then called Catherine back to let her know people couldn’t even call their LMCs, so we had a major problem.”

“Catherine mentioned Julie Kinloch (LMC) was heading down to the Napier Health Centre to set up a temporary space for pregnant women,” Linley recalls. “That’s only a few minutes away from my house, so I went down there. A plan was made for Julie to stay at the health centre overnight and a paediatrician had agreed to stay too. There was no way in or out of Napier at that point, and no way to get hold of anybody either, so it was the best solution we could come up with.”

“By the next morning, a couple of other LMCs had trickled in,” she continues. “They would pop in to say they could help, but once they left, there was no way to get hold of them again. I realised the best use of my time was to get on my laptop and using my list of College members, find out where everybody lived, go around to all of their houses and put together a roster to take us through until Sunday.”

After visiting every Napier midwife on the list, a roster was produced. “I took a photo of the shift list, emailed it to Catherine so she knew what was happening in Napier, and then we were away. Everyone was amazing – it was like clockwork. We still had no communication lines, but everyone turned up. As the only

one with cellphone service, we made the decision that I wouldn’t be on the roster, but I’d be on call 24/7 as a second midwife for births or any other situations requiring another pair of hands.”

Pooling resources from across the region was key, as Linley explains. “We pulled an old CTG machine from our Midwifery Resource Centre in Napier, we had homebirth kits from LMCs at the ready, including oxygen. We managed to get a Neopuff over from Hastings hospital as well as PPH drugs – the extra drugs homebirth midwives wouldn’t normally carry. So along with triaging, we were ready to deal with birth, neonatal resus and PPH if need be.”

“An obstetric registrar who lived in Napier turned up as well, so it was like we had a mini maternity centre. The camaraderie was actually really cool. Everyone I spoke to was more than willing to help and in the end, they didn’t need to do much – some women did get transferred out, but no one birthed in Napier over that time.”

Even though she played a significant role, Linley is clear that the reason the temporary clinic was established so quickly was due to the foresight of widely known and respected LMC Julie Kinloch. “It was Julie who went down there to the Napier Health Centre, off her own bat, without waiting to be directed. She planted herself there, set things up and made it happen. And it was the core midwives and LMCs who turned up on cue.”

Over in Hastings at the Hawke’s Bay Hospital, Catherine Overfield, Acting Director of Midwifery - Te Whatu Ora Te Mata a Maui, was managing the secondary unit under the same challenging circumstances.

“The day of the cyclone I’d come to work in Hastings from my home in Napier and within a few hours the roads had closed, so it became clear that those of us who were from Napier couldn’t get back. Hastings itself was functioning reasonably normally – there’d been some interruptions to power but people could travel, so we didn’t really know the full scale of the emergency because we had no communications coming in from those places worst hit. There was no cellphone service or power in Napier, so we had no way of knowing who was even coming in to work their shifts,” Catherine says.

The only solution was to work with what they had. “There were a few of us midwives who just camped out at the hospital and worked back-to-back shifts.

We slept in the unit, got up, and went back to work again,” she explains.

The personal sacrifice for midwives and their maternity colleagues – particularly on the first day of the cyclone – was huge, as Catherine describes. “The biggest issue for staff on shift that day was having absolutely no idea whether their families at home were safe, knowing that their areas were being evacuated and having no way of communicating with them. Yet they continued to provide care and a sense of normality for women and whānau walking through the doors, even when they couldn’t contact their own families.”

And while the issue of Napier and Hastings being cut off from one another was problematic, she was also aware that the more remote areas were potentially in even deeper trouble. “Wairoa have a continuity model, and they were in a situation where the midwives who worked there not only didn’t live there, but couldn’t travel there either. So Wairoa was completely cut off. It took a day or so before we even knew whether the hospital there was still standing, or whether our colleagues were safe and well.”

Like Linley, Catherine also observed midwives supporting one another seamlessly throughout the Hawke’s Bay region, prioritising whānau care above all else. “Those of us from Napier who got home but then couldn’t get back to Hastings pitched in at the Napier Health Centre, and in turn, the LMCs in Hastings supported the hospital staff by picking up shifts. Everyone just pulled together and supported one another across primary and acute emergency services.”

Once the cyclone was over, much needed support was gratefully received from outside of the region, as Catherine recalls. “Those midwives who came to us through the locum service brought an energy that was so well received by midwives here. For those who were directly affected, we could tell them to just stay home and do what they needed to do.”

Catherine points out that the after-effects of the events lingered on well after the flood waters had receded, and may do for some time yet. “It’s been an emotional rollercoaster. Once the adrenaline wore off, we were all coming back down from that and starting to hear the stories trickling through. The drive to and from work was quite confronting for a while.”

“The biggest issue for staff on shift that (first) day was having absolutely no idea whether their families were safe, knowing that their areas were being evacuated and having no way of communicating with them. Yet they continued to provide care and a sense of normality for women and whānau even when they couldn’t contact their own families.”

As highlighted by Catherine, some midwives were more directly affected than others throughout the weather events.

Jacquelyn (Jax) Paki, an LMC based in West Auckland, is one such midwife, whose rental property in Glen Eden – which houses herself, her four children and her mother –was damaged by flood waters.

On the evening of 27 January, after a full day of postnatal visits, Jax found herself desperately sweeping water out of her house as it poured through the downstairs level “like a river”. On the phone to her landlords, explaining she couldn’t do anything more after being at it non-stop for hours, Jax had to give up trying to stop the water and change tack, rescuing as much furniture as she could from three downstairs bedrooms.

“We’re on a slope, so the water was coming straight through the gaps in the house and then just running straight off the tarp in the basement. None of it was being absorbed into the earth at all, which was the main issue in Auckland.”

“We’ve got a double garage, so we moved the three bedrooms in there,” she explains. “It all just got dumped. The lounge became our wardrobe and bedrooms – initially my older girl slept in there, while myself and the little ones slept on the floor in my clinic space and my mum took the master bedroom. I had to cancel clinic because I was too whakamā to have people over.”

The emotional and psychological toll was significant for Jax, who was juggling the needs of her own whānau with her caseload, including caring for her 10-month old pēpi and still adjusting to a new lifestyle after her older son was diagnosed with Type 1 diabetes just before Christmas in 2022.

“It took me 3-4 days to reach out to māmā because I wasn’t in the headspace and didn’t have the capacity to check on them in amongst everything else that was going on. Obviously they were being cared for by my locum, but I just wasn’t able to work for a few days. Then we had more warnings about the cyclone – so I contacted all of them to ask what their plans were, to make sure they were ready and had strategies in place if their houses were at risk of flooding.”

“Eventually we shuffled everything around so I could still do clinic and felt better about whānau coming into our space,” she explains. “But for quite a few weeks I just did home antenatal visits so that I could sort out my own whare while still giving whānau the care they needed.”

The reality of potentially being cut off from services meant Jax’s conversations with whānau evolved accordingly. “Especially for māmā who were nearly term, I went over what to do if baby birthed and I wasn’t there and they needed assistance. Going over the possibility of neonatal resus with their tāne or whānau became a necessary kōrero.”

Like others, Jax says it was community support that got her through. “I wouldn’t have been able to do it without the persistence of midwife friends like Mel Nicholson and Brigid Beehan. They were so supportive. Mel dropped off a giant tray of sandwiches and helped out financially so I could go and spend a day at the laundromat.

The reality of being cut off from services meant conversations with whānau evolved accordingly. “Especially for māmā who were nearly term, I went over what to do if baby birthed and I wasn’t there and they needed assistance. Going over the possibility of neonatal resus with their tāne or whānau became a necessary kōrero.”

LMC Julie Kinloch set things up and made it happen at the Napier Health Centre.

As one of the worst hit areas, Gisborne’s hospital resources were majorly affected, as Nerissa explains. “We have a hospital generator, but for a period of time it only covered essential power. A water pipe had also burst, so the whole hospital was on restricted water, which is never ideal in maternity, and it meant the labs weren’t fully functioning either."

and the heavy downpours were happening, I was cut off from going in to work my night shift. I’d tried to go down the road, but the water was too high to get through, so I had to call in about four hours before my shift to say I couldn’t make it. I had to ring on my landline because power and internet were both cut off.”

“The first night wasn’t too bad,” she continues, “because the hospital still had power, but as the rain got heavier, the biggest concern was that our communications were cut off and we had around 20 women due to birth in the area, with no way of them being able to call their LMCs or us at the hospital.”

ok and ask whether they were available to come in for birthing and how we could contact them.”

“The LMCs were great,” Nerissa says. “They came to the party and covered the LMCs living on the other side of the river. I stayed on-site the second night, so that my husband and I could be the runners. If someone came in to birth, we would go and get an LMC who lived on this side of the river. I was there to support our night staff to birth whoever turned up, and we also had our obstetrician, paediatrician and anaesthetist stay close to our unit.”

Brigid dropped off spaghetti bolognaise. Not having to worry about what to cook was such a huge help.”

In Gisborne, Nerissa Walters, Director of Midwifery - Te Whatu Ora Tairāwhiti was also juggling priorities as Cyclone Gabrielle hit her region and home. “On the first night when the cyclone was starting

Once the rain had slowed and the water levels had receded enough for Nerissa to get out of her road, she and her whānau evacuated and went into town. Many other midwives were still stuck, however. “The majority of LMCs lived across the bridge, but that was closed at night for safety, so we couldn’t get to them and vice versa. I went around and knocked on the doors of some of the LMCs who lived on this side of the bridge, to check they were

“The next day, the LMCs made a plan to do 8-hour shifts and created a roster. The LMC on that shift would be responsible for triaging, providing birth care, or any primary antenatal assessments. That happened for the remainder of the week and it was actually nice for our employed staff to have an extra midwife around too, especially at night.”

As one of the worst hit areas, Gisborne’s hospital resources were majorly affected, as Nerissa explains. “We have a hospital generator, but for a period of time it only

covered essential power. A water pipe had also burst, so the whole hospital was on restricted water, which is never ideal in maternity, and it meant the labs weren’t fully functioning either. We couldn’t order any tests online, so all requests had to be handwritten, and they would do batch processing, so if we needed PET labs done for example, they could only be collected and processed at certain times.”

“We’ve been on Badgernet here for years,” Nerissa continues, “which is what everyone’s used to, but then power and internet went out, so we had nobody’s records. Nothing. Our LMCs couldn’t access their records either, so it was an interesting time. Our staff were so amazing though – they just carried on.”

Finding solutions as issues arose became part of the daily routine and, in some cases, the answer was found through connections, or whakawhānaungatanga, as Nerissa explains.

“There was a woman in Ruatoria region who we knew we needed to keep an eye on, but of course without Google maps, we couldn’t figure out how to locate this woman’s whare. Then we realised another whānau staying with us at the time were from the same area, so we asked them if they knew the whānau, and of course they did! With their help, we were able to create a map and instructions for the retrieval team so they could go up and collect this woman and her whānau.”

Along with the other midwives featured in this article and many others throughout the motu whose stories haven’t been shared here, Nerissa found herself going above and beyond the call of duty. “With support from our amazing social worker, I went out and found women who were on our vulnerable list. My husband and I went to their homes to find out what they needed and mostly it was food, because eftpos was down everywhere, ATMs weren’t operational, and no one had cash.”

“I went to the supermarket and at that time we were only allowed one trolley, and to shop for one whānau, but I explained to staff who I was and what I was doing, and that the three households I was shopping for didn’t have any kai. At the end, once they had scanned the items through, they asked me to wait because people standing in line had heard what I’d said and donated. I ended up leaving with three trolleys full of kai and basic supplies for those whānau in need.”

Nerissa’s pride in the way her team and midwives of the region conducted themselves throughout the cyclone is evident. “We had women who birthed over that time and the feedback was exactly the same as usual; they didn’t want to go home. Even though everything else in our lives and region was displaced, the women felt safe here, and that’s what midwifery is about.” square

Along with the other midwives featured in this article and many others throughout the motu whose stories haven’t been shared here, Nerissa found herself going above and beyond the call of duty. “With support from our amazing social worker, I went out and found women who were on our vulnerable list."

MACDONALD MIDWIFERY ADVISOR

Small for Gestational Age and Fetal Growth Restriction in Aotearoa New Zealand: A clinical practice guideline He Aratohu Ritenga

After two and a half years of intensive work, the new national guideline on small for gestational age (SGA) and fetal growth restriction (FGR) is being published by Te Whatu Ora. A multidisciplinary panel, including College and Ngā Maia representatives, agreed research questions, reviewed the evidence, drafted recommendations and then consulted widely with maternity providers including midwives.

All College members were invited to provide feedback on the draft guideline and the College’s submission was developed from this consultation process. The College’s recommendations were incorporated into the guideline and the College’s national board endorsed the guideline after its recommended final amendments were accepted.

The SGA and FGR guideline will underpin the Aotearoa Growth Assessment Programme (GAP) education and inform the use of customised gestation-related optimal weight (GROW) charts. The new SGA and FGR definitions have also been incorporated into the Referral Guidelines (Te Whatu Ora, 2023).

The guideline is comprehensive, with 54 recommendations. To support ease of use, it is presented in two parts: a Summary of Recommendations, including the evidence level and rationale for each recommendation,

and the detailed Evidence Summary. Several tables and flow charts are included for quick reference. Where relevant, responsibilities of primary (including LMC) and secondary/ tertiary maternity services are specified. A video presentation about the guideline is also being made available to support implementation. Midwives are encouraged to familiarise themselves with the new guideline.

WHY DEVELOP A NATIONAL SGA AND FGR GUIDELINE?

The aim of the guideline is to “reduce rates of stillbirth and neonatal mortality and morbidity associated with fetal growth restriction (FGR) by standardising care across Aotearoa New Zealand.” As the Evidence Summary states, “FGR affects approximately 5 to 10% of all pregnancies. FGR is associated with several adverse pregnancy outcomes, including maternal and neonatal

morbidity, perinatal death and longer-term adverse health outcomes in childhood and beyond.” ACC funded the development of the guideline under its Neonatal Encephalopathy Taskforce work to support a reduction in newborn brain injury. The guideline articulates the value of screening for FGR and monitoring fetal growth and wellbeing when SGA or FGR is diagnosed. It also acknowledges the complexity of clinical judgement and recommendations inherent in this aspect of maternity care. Feedback from College members raised concern about the potential for false positive diagnoses of SGA through ultrasound, which could lead to unnecessary intervention, and this has been acknowledged in the guideline. “While antenatal identification of FGR fetuses is challenging, an approximate 60% reduction in the risk of stillbirth exists for

CLAIRE

RECOMMENDED SCREENING SCHEDULE OF GROWTH SCANS FOR PREGNANT WOMEN/PEOPLE WITH FGR RISK FACTORS OR UNRELIABLE FUNDAL HEIGHT MEASUREMENT (TABLE 4 IN THE GUIDELINES)

Three or more minor risk factors or unreliable fundal height Major

Consider two growth scans:

• at 30 to 32 weeks’ gestation and

• at 36 to 38 weeks’ gestation

(For example, one scan at 32 weeks’ gestation and one scan at 37 weeks’ gestation)

factor for SGA or FGR

Monthly growth scans starting from between 28 and 30 weeks’ gestation until birth

(For example, one scan at each of 30, 34 and 38 weeks’ gestation)

One or more risk factors for early-onset FGR

Monthly growth scans starting from between 24 and 26 weeks’ gestation until birth plus

Consider UtA Doppler study between 20 and 24 weeks’ gestation

(For example, one scan at each of 24, 28, 32, 36 and 40 weeks’ gestation)

DEFINITION FOR FGR IN THE NEONATE (TABLE 5 IN THE GUIDELINES)

• Customised birthweight <3rd centile

• Customised birthweight centile from ≥3 to <10 with two or more additional features:

- BMI z-score < -1.3

- length z-score < -1.3

- skin or body fat z-score < -1.3 (where equipment and expertise allow)

- antenatal diagnosis of FGR

- one or more major maternal risk factors for FGR

- evidence of placental insufficiency on histology

• Antenatal diagnosis of FGR and evidence of placental insufficiency (e.g., abnormal Doppler studies), even if the customised birthweight is ≥10th centile.

pregnant women/people when FGR is recognised antenatally. Health practitioners make difficult choices when trying to balance the risks and benefits of prolonging fetal development when evidence of FGR exists, compared with preterm birth and the associated adverse outcomes. Additionally, approximately 5% of pregnancies identified antenatally as SGA are not SGA at birth. It is important to consider the implications for whānau of pathologising a normal pregnancy due to a false positive diagnosis of FGR.”

Wāhine Māori and Indian women have higher rates of SGA and perinatal mortality than other ethnic groups. The guideline recognises that “These risks are disproportionately experienced by Māori due to the effects of colonisation such as unequal access to resources and the social determinants of health. This highlights the need for more to be done to address the health and socioeconomic inequities affecting wāhine Māori and which underlie higher

SGA rates.” Health system-based actions to improve health equity include appropriate screening, monitoring and birth planning when SGA or FGR are present.

To support the development of balanced and contextualised recommendations for Aotearoa, the guideline panel agreed a set of guiding principles.

FIVE PRINCIPLES UNDERPIN THE CLINICAL PRACTICE RECOMMENDATIONS:

• The pregnant woman/person is at the centre of all care decisions and shares decision-making with health practitioners within Aotearoa New Zealand’s model of continuity of midwifery care.

• The optimal pregnancy outcome is the birth of a healthy, well-grown baby and a well woman/person following spontaneous onset of labour at term.

• Where a pregnancy is identified as SGA or FGR, additional monitoring and judicious use of intervention is planned with informed decision-making between the pregnant woman/person and care provider with the aim of optimising outcomes for the pregnant woman/person and baby.

• Where possible, expectant management should be planned, supporting the safe prolonging of pregnancy and physiological birth.

• Potential resource limitations and access to care and equity are considered at each step, but these considerations do not change the best practice recommendations.

The recommendations are specifically focused on SGA and FGR, which are of course situated within the midwife’s holistic care, assessment and discussions to support informed decision-making for whānau. Some of the key points for midwives include:

• As part of the midwife’s detailed health assessment at the registration appointment (and reassessed throughout pregnancy), identify if the woman/person has any risk factors for FGR (Tables 1 and 2 in the guideline). Advise women/people to stop cigarette smoking and other recreational drug use (including cannabis) before pregnancy, or by 15 weeks of pregnancy. Offer low-dose aspirin to pregnant women/people who have had a previous FGR pregnancy or who have a major risk factor for pre-eclampsia (these recommendations align with the 2022 Hypertension in Pregnancy guideline).

• Recommended screening for pregnant women/people at low risk of FGR (that is, no major and two or fewer minor risk factors) is serial fundal height assessment at each antenatal visit, plotted on a customised fundal height chart, starting at 26 to 28 weeks’ gestation. Measurements should be at least two weeks apart. If the plotted fundal height is <10th centile or if fundal height declines >30 centiles, refer for ultrasound assessment of fetal growth.

• Growth scans are recommended in the third trimester for women and people with risk factors as per the table on previous page. Plot EFW on a customised GROW chart.

• If SGA (EFW or AC <10th customised centile) or FGR (definition in Table 1 of the guideline) is diagnosed, recommend referral to an obstetrician for monitoring and birth planning.

• Additional monitoring is recommended for neonates with FGR, with paediatric review in some circumstances.

• Midwives have a role in assessing newborns for FGR. Babies with a birthweight <3rd customised centile have FGR. For babies where FGR is suspected (e.g. birthweight 3rd to <10th customised centile or a decline in EFW >30 centiles during pregnancy), the midwife enters routinely taken measurements into an easy-to-use calculator which calculates BMI and provides ‘z-scores’ for BMI, weight and length. This enables midwives to diagnose FGR according to Table 5 in the guideline. Babies who are confirmed as SGA but not FGR do not need the same level of monitoring or investigations.

ACCESS TO ULTRASOUND

It is anticipated that the ultrasound recommendations will provide clarity on who should be offered third trimester ultrasound and who should not; for example, recommendation 14 states, “Do not offer routine ultrasound for fetal growth assessment to pregnant women/ people without ≥1 major or ≥3 minor risk factors for FGR.” The College has consistently raised concerns about access to pregnancy ultrasound with ACC and Te Whatu Ora to ensure this guideline is equitably implemented. Te Whatu Ora has issued the following statement:

“Te Whatu Ora acknowledges that there are barriers to accessing ultrasound scanning and anticipates that fully embedding this guideline may take some time. We are actively working towards solutions to improve access. It is expected that practitioners utilise this guideline to the best of their ability, ensuring clear documentation and rationale when there is an inability to do so”. square

References available on request.

HPV testing

the new primary screening pathway for cervical cancer prevention

Starting on 26 July 2023, a new screening process to prevent and detect cervical cancer will begin. The following article from Te Whatu Ora explains the new HPV screening process, including how midwives can become involved in offering screening as the phased implementation rolls out. The College will work with the National Screening Unit and Te Whatu Ora to advocate for the resources midwives need in order for the profession to offer testing, including specific funding, training to use the relevant systems and referral pathways into cytology and colposcopy.

Human Papilloma Virus (HPV) testing will become the primary cervical cancer screening test in Aotearoa New Zealand from late July 2023. HPV primary screening offers up to 60 to 70% greater protection against the development of invasive cervical cancer, compared to cytology-based screening alone (Ronco et al., 2014). Testing for the HPV virus is more sensitive and will lead to better detection of high-grade cervical changes which can cause cancer. Because the test involves a vaginal swab rather that a speculum examination, it is anticipated that more people will participate in regular screening.

The incidence and mortality rates from cervical cancer are expected to decline over time with HPV testing. However, initially the incidence of cervical cancer and demand for colposcopy services may increase due to the higher sensitivity of the HPV test. By 2035, the incidence and mortality rates from cervical cancer are expected to reduce by 32% and 25%, respectively, compared to 2018; this is equivalent to the prevention of 149 new diagnoses and 45 cervical-cancer related deaths in New Zealand.

Implementation of the HPV test, and in particular the option of self-testing, will empower participants with choice. The screening test is more acceptable to many people and is expected to increase uptake in those previously reluctant to screen. This will lead to more equitable outcomes.

The National Cervical Screening Programme (NCSP), one of the programmes within the National Screening Unit, is leading the implementation of the new test, clinical pathways, training, resources and NCSPRegister.

Midwives’ scope of practice already includes cervical screening and this will remain the case with the new screening clinical pathway. Here are the answers which we hope will give our midwives a better understanding of the issues.

Q: Has the current cervical screening programme been a success?

New Zealand’s National Cervical Screening Programme was established in 1990 following the 1988 Inquiry Into Allegations Concerning The Treatment Of Cervical Cancer At National Women’s Hospital (the Cartwright Inquiry).

The Cartwright Inquiry was a significant event for public health in Aotearoa, resulting in the establishment of the Health and Disability Commission and Commissioner, the

development of a legislated Code of Patients’ Rights and the establishment of independent national ethics committees. It also recommended the urgent implementation of a nationally planned, population-based cervical screening programme - now the NCSP.

Since the introduction of the NCSP, cervical cancer rates have reduced dramatically, and the gap in the incidence between Māori and “all women” has reduced. However, there remain persistent and unacceptable inequities in cervical cancer incidence and mortality between Māori, Pacific and non-Māori/non-Pacific (Fig. 1).

Q: Why change?

There is more work to be done. Around 180 women are diagnosed with cervical cancer every year in Aotearoa, and about 60 die. The overall decline in cancer incidence has stalled over the past few years. Furthermore, equitable outcomes are yet to be achieved, with lower rates of cervical cancer experienced by non-Māori/non-Pacific ethnic groups. Achieving equity will require the health system to improve the accessibility and acceptability of screening and treatment for Māori and Pacific people.

The World Health Organization’s goal to eliminate cervical cancer states that all countries must reach and maintain a cervical cancer incidence rate of below 4 per 100,000

women. New Zealand’s current rate is 6.3 per 100,000 and is expected to fall to 4.1 by 2032. Only increased vaccination against HPV will get us past the 4 per 100,000 threshold set by WHO.

HPV testing offers a new and better alternative as a primary screen, compared to the current test (previously known as a “smear test”). Increased uptake of screening, alongside higher rates of HPV vaccination, are essential to achieve equitable elimination of cervical cancer in New Zealand.

Q: What is HPV?

HPV is a virus that infects the skin and mucous membranes. It is passed on by intimate skin to skin contact during sexual activity.

There are over 150 types of HPV that can live on the body. Most are not of concern, present no symptoms and are dealt with naturally by the body’s immune system. About 90% of people clear the virus within 2 years of infection.

However, 14 types can cause cancer, and are the cause of over 95% of cervical cancers. HPV primary screening tests for all of these. Of the 14 oncogenic types, two types - 16 and 18 - account for over 70% of cervical cancers. While many people have HPV infections for a short time, it is persistent infection with oncogenic HPV that is the risk factor for cancer.

FIGURE 1. AGE-STANDARDISED CERVICAL CANCER INCIDENCE FOR MĀORI AND ALL WOMEN, 1985–2017

All Women Māori Women

Rate are per 100,000 women, age-standardised to the WHO Standard Population (all ages).

Q: What will the new test do, compared to the current test?

This new screening method will test for the presence of 14 strains of HPV which can lead to the development of cervical cancer.

The current speculum (cytology) test looks for abnormal cells or cell changes in the cervix that could lead to cervical cancer, so people at increased risk are identified only once changes have started.

The HPV test looks for the virus that subsequently could cause changes. So, it allows earlier intervention before cell changes occur. Results will show either: HPV not detected; HPV 16 or 18 detected; or HPV “Other” detected (a strain that is oncogenic but not 16 or 18).

This will determine if the participant needs a further follow-up test. The clinician who has taken/arranged the HPV swab will need to:

• refer people with HPV 16 or 18 detected (the highest risk types) to colposcopy

• undertake or arrange for a speculum examination for cytology for those who have HPV “other” detected.

Q: Are there any other differences between HPV and cervical cytology testing?

HPV testing is more sensitive than liquidbased cytology testing. It will lead to the detection of more high-grade abnormalities, via the initial detection of HPV. Among those women who have HPV testing, 10% will require further testing, either cytology in primary care or colposcopy.

The vaginal speculum-based test will remain important in the clinical pathway so it is important to explain to people having an HPV test that they may need to return for a vaginal speculum examination for cytology.

HPV testing will find more pre-cancers and prevent more cases of cervical cancer, supported by the speculum and colposcopy tests within the pathways.

Q: How do you take the HPV test?

It is a simple vaginal swab test. The swab is inserted into the vagina and gently rotated while touching the vaginal walls, so there is no need to find the cervix.

Q: Can the person do the swab themselves?

Yes. The test does not need a vaginal speculum exam and the participant can do

the swab test in private in a clinical setting or take the test kit home and do the swab there, if this option is supported by their health provider.

Health providers whose scope includes cervical screening will provide sufficient information to gain informed consent and explain how to self-take the test. The health provider will then be responsible for clinical oversight (i.e., sending the sample to the lab for testing and contacting the participant if any follow up is required). Central mailouts of kits is not within the initial scope of the Project. The Project team is actively working with midwives and the wider sector to support the transition to HPV screening for cervical cancer prevention.

A self-test is as accurate as a clinician-taken sample in determining the presence of HPV. Self-testing is not the only option available from late July 2023. If women or people prefer, they can opt to have a screen-taker do the swab test or do a vaginal speculum (cytology) test. If they choose to have a speculum-based test, the sample will first be tested for HPV. If the virus is found, the same sample will automatically be sent for a cytology test.

People with symptoms such as vaginal bleeding after sex (when they are not menstruating), and those who have had a high-grade change in the past who have not returned to the regular screening interval should not do a self-test. They need a clinical examination and cytology test.

Q: What is recommended if the screening due date comes up during pregnancy?

Both HPV self-testing and cytology testing are safe in pregnancy. Cervical screening, with the HPV test, or via liquid-based cytology, should be considered part of routine antenatal care for those who are due or overdue for their screening.

Midwives’ scope of practice already includes cervical screening. The NCSP will work with the New Zealand College of Midwives to ensure the changes to the test and the clinical pathways are well understood and that practical issues are addressed, in order that midwives feel confident and supported to offer screening.

All pregnant women who test positive for HPV 16 or 18, or who have high-grade cytology results, should be referred to colposcopy. This should not be delayed until

after giving birth. The colposcopy visit is important to exclude invasive cervical cancer which is associated with increased risk of maternal morbidity and poor pregnancy outcomes. Biopsy will only be done for suspected invasive disease. High-grade changes will be treated after giving birth.

Q: Will this improve screening rates?

Because the test is less invasive and the swab can be self-taken in privacy, more people at risk of cervical cancer are expected to engage with screening.

Q: What happens to the screening interval?

The screening interval will change from the current 3 years to 5 years for those who return a negative test because the HPV test is a more sensitive predictor of high-grade changes. The chance of having a high-grade change 5 years after a negative HPV test is lower than 3 years after a negative cytology test. The 5-year screening interval is the same as other countries that have introduced HPV screening, including Australia, the UK and the Netherlands

Q: What is changing with the NCSP-Register?

To enable HPV primary screening, a new NCSP-Register will be implemented. The new NCSP-Register will be a population-based Register sourced from NHI data and will now also include those who are eligible for cervical screening but have never had a test. There will be an opt-off option. The Register is currently set up to include those who are 25-69 years old and coded as ‘female’. This means that those who have a cervix but are not coded as ‘female’ (for example trans men) must be manually entered into the register. Midwives need to be aware of this data issue when providing care for trans people and support them to be added onto the NCSP-Register.

Q: Will there be any specific training in the new primary screening requirements for midwives?

Training in the form of e-modules is being developed for health professionals. These will provide information on the HPV virus, the HPV test and clinical pathways, and how to communicate effectively with participants about HPV primary screening including

conversations about results. Additional educational resources will be developed to support specific learning for the different roles involved in cervical screening.

Q: Where does immunisation fit in?

HPV vaccination combined with screening provides the best protection from cervical cancer. The first line of defence against cervical cancer is prevention by safe, effective and proven HPV immunisation which is free for all people from ages 9 to 26 years old. The second line is maintaining regular cervical screening.

Vaccination is vital for Aotearoa to achieve the World Health Organization’s goal to eliminate cervical cancer as a public health problem by 2030. The WHO target is for a 90% vaccination rate by the age of 15.

Those who are fully immunised against HPV still need to continue cervical screening, since the vaccine does not cover all oncogenic HPV types.

Q: How is equity factored into the project?

Our Te Tiriti o Waitangi obligations are fundamental to the design of the new programme, including achieving equity. Equity recognises different people with different levels of advantage require different approaches and resources to get equitable health outcomes. The strategy for notifying people that they are due for screening and follow-up will integrate more closely with community-based providers including screening support services. This includes improved resources and campaigns developed in collaboration with Māori and Pacific stakeholders.

Active protection must include prioritisation of access to screening services and follow-up for Māori, Pacific and other groups who face barriers to screening.

Our Te Tiriti o Waitangi and Equity strategy means reaching and supporting the approximately 40% of people who are not currently well-served by the NCSP programme. Supporting midwives to offer HPV screening will greatly assist in achieving equity.

For participants there will be a choice around the type of test they can do, and they can complete the initial HPV screen in a setting more comfortable for them. In order for participants’ beliefs and values to be understood and supported in primary and community care, training will include key cultural safety considerations, especially Māori and Pacific priority groups. Researchers in Aotearoa have established that the test itself will be equity-enhancing, as the embarrassment and discomfort of a speculum examination is a major barrier in the current cytology-based programme.

Q: How will HPV primary screening be rolled out?

The rollout will be achieved in three Phases. Phase one starts on 26 July 2023 when HPV testing becomes Aotearoa New Zealand’s primary screen for cervical cancer prevention.

The First Phase from late July to August will be called the Foundational Step, when all participants will be able to choose a self- or clinician-assisted HPV primary screening test, or a speculum test. New clinical pathways and the new NCSP-Register will be rolled out. There will be a particular focus on promoting the screening to Māori and Pacific

participants and increasing screening in the under- or unscreened populations.

Expanding Reach is the Second Phase (August to December) and will focus on getting more people onto the screening pathway through notifications, including under- and unscreened populations not enrolled in primary care.

Full Benefit, the Third Phase (December 2023 to March 2024), is when the full future vision of HPV primary screening will be achieved. A more complete pool of participants will be encouraged into screening, increasing our screening coverage. What we will achieve:

• HPV testing as the primary screening test for cervical cancer prevention - HPV testing will lead to increased and more equitable uptake of screening. It will find more pre-cancers and prevent more cases of cervical cancer, supported by the speculum and colposcopy tests within the pathways

• New NCSP-Register - A single source of truth for screening records and individual schedules

• New pathways - Embedding more choice and flexibility into screening, removing barriers to entry and better supporting and increasing equitable outcomes for Māori and Pacific people

• Additional workforce and trainingThe aim is to support an expanded and more diverse screening workforce. Accredited screen-takers/GPs/midwives can continue to do the speculumbased LBC test as well as the HPV test. Registered Nurses can oversee the HPV swab test with training. square

References available on request.

How do you take the HPV test?

LESLEY DIXON MIDWIFERY ADVISOR CAROL BARTLE POLICY ANALYST

climate change, climate action interventions, and what we can do

The IPCC roadmap towards a safer climate future shows us the path we can all take to reduce net emissions. There are a number of mitigation options that can be taken by climate change conscious citizens but the majority of mitigation actions will need to be taken by governments and industry. Focusing on what we can do as individuals can alleviate, to a small degree, the anxiety that many people are feeling and the sense of hopelessness that can become overwhelming.

When looking at IPCC reports it’s easy to become despondent, and as articulated by a high school student in Auckland recently, experience “a low grade panic at all times” which has been described as eco-anxiety (Mathias & McLean, 2023). This article looks at some positive actions nationally and globally, and also addresses some of the issues for midwives who have been asking what difference they can make in their personal and working lives. Change is urgent and we need to act now to ensure we can secure a liveable future for future generations.

Climate change is our new life-experience reality, and we are now living with a global surface temperature at 1.10C above pre-industrial levels (IPCC report, 2023). We see the reality of this in more frequent

Climate change is our new life-experience reality, and we are now living with a global surface temperature at 1.10C above pre-industrial levels.

and more intense weather events which have negative impacts on our environment and people throughout the world. The road to zero emissions is long and challenging but it’s still possible to get there.

NATIONAL AND INTERNATIONAL ACTION – SELECTED KEY INITIATIVES ENERGY SYSTEMS

Te Tari Tiaki Pūngao (Energy Efficiency and Conservation Authority) is working towards a sustainable energy system within Aotearoa. About 40% of New Zealand’s emissions come from burning fossil fuels for heating, for transport or for manufacturing. Becoming carbon neutral requires an urgent move away from this fossil fuel usage and an increase in the use of renewable energy systems such as solar, wind and small scale hydropower.

NATIONAL

• 40.7% of the primary energy in Aotearoa New Zealand was from renewable sources in 2021.

• The government has set a target of 50% of total final energy consumption to come from renewable sources by 2035 - it currently sits at 28.4%.

• Wind turbines generated enough electricity to power 360,000 homes and more windfarms have been established.

INTERNATIONAL

• About 30% of the world’s energy consumption comes from renewable sources.

• An Australian Energy Market Operator (AEMO) report found that Australia broke records for renewable energy activity and low energy demand. This created recordlow greenhouse gas emissions during the last three months of 2022.

INDUSTRY AND TRANSPORT

There is a need for both industry and transport businesses to move towards mitigating greenhouse gas emissions. This involves reviewing production processes, and the electrification of transportation systems such as electric and hybrid cars, trucks, railways, buses, and air transport.

NATIONAL

• Air New Zealand has signed a letter of intent to purchase 23 Alice electric planes. This is part of New Zealand’s plan to provide zero-emission flights by 2026. The country

LIST OF MITIGATION OPTIONS FROM THE LATEST IPCC REPORT

Wind energy

Solar energy

Bioelectricity

Hydropower

Geothermal energy

Nuclear energy

Carbon capture and storage (CCS)

Bioelectricity with CCS

Reduce CH4 emission from coal mining

Reduce CH4 emission from oil and gas

Carbon sequestration in agriculture

Reduce CH4 and N2O emission in agriculture

Reduced conversion of forests and other ecosystems

Ecosystem restoration, afforestation, reforestation

Improved sustainable forest management

Reduce food loss and food waste

Shift to balanced, sustainable healthy diets

Avoid demand for energy services

Efficient lighting, appliances and equipment

New buildings with high energy performance

Onsite renewable production and use

Improvement of existing building stock

Enhanced use of wood products

Fuel efficient light duty vehicles

Electric light duty vehicles

Shift to public transportation

Shift to bikes and e-bikes

Fuel efficient heavy duty vehicles

Electric heavy duty vehicles, incl. buses

Shipping - efficiency and optimisation

Aviation - energy efficiency

Biofuels

Energy efficiency

Material efficiency

Enhanced recycling

Fuel switching (electr, nat. gas, bio energy, H2)

Feedstock decarbonisation, process change

Carbon capture with utilisation (CCU) and CCS

Cementitious material substitution

Reduction of non-CO2 emissions

Reduce emission of fluorinated gas

Reduce CH4 emissions from solid waste

Reduce CH4 emissions from waste water

Net lifetime cost of options:

is partnering with four aircraft makers to develop zero-emission demonstrator flights using electric, green hydrogen, and hybrid technologies.

• Electric Trucks Reliance Transport has commissioned two battery-powered electric trucks that will take to the road in New Zealand. The vehicles are suitable for short to medium-haul trips and have a range of 180 kilometres. The trucks will cart containers and steel products around port and freight networks.

• The number of electric cars in New Zealand has been increasing with 41,203 vehicles with some form of electrification sold in 2022.

INTERNATIONAL

Continuing with the ‘business as usual’ transport approaches was described as not being able to accommodate the sharp demographic changes that are forecast, in a transport report by the United Nations Department of Economic and Social Affairs (2021). Sustainable transport is central to sustainable development, transport solutions do exist, and the right policies and investments will bring much needed change. These include:

• Subsidised transport initiatives, such as a project in India which provides free travel to women, supports sustainable transport and enables lower income women to achieve better safety and improved productivity (United Nations, 2021).

• China plans to expand its electric vehicle charging network by 50% and India is aiming to transform its rail system to net-zero emissions by 2030 (United Nations, 2021).

• The United States has a climate plan that promotes zero emission vehicles and increasing fuel economy standards (United Nations, 2021).

CITIES, SETTLEMENTS AND INFRASTRUCTURE

N2O = Nitrous Oxide; CH4 = Methane; AFOLU = Agriculture, Forestry & Other Land Use; H2 = Hydrogen; CO2 = Carbon Dioxide

Urban areas can make a major impact on emission reduction through consideration of land use – ensuring compact use, co-location of jobs and housing, supporting public emission-free transport and encouraging personal mobility (cycling & walking for those people able to do this). This will involve using efficient building designs, and low-emission materials for building. Another concept now being discussed as a way to mitigate heavy rainfall is the use of ‘Sponge

cities’. This concept incorporates the use of green roofs, rain gardens and permeable pavements. The idea being that these systems will absorb, capture and reuse rainwater. They include the need to have more green space and trees incorporated into urban design.

GREENING THE CITY AOTEAROA

• There is a growing awareness in Aotearoa of the importance of green cities, with individual cities undertaking various initiatives to improve urban greening, and increase green elements into city spaces. Unfortunately it has been reported recently that Auckland and Hamilton have lost up to a third of their green spaces in recent years (Cardwell, 2023). This demonstrates the tension between much needed housing development and the loss of private residential land. Accommodating population growth but also staying focused on the need to retain and/or create new urban green spaces is the way forward. Equal prioritisation of network infrastructure and green spaces was reported as a priority (Cardwell, 2023).

• The New Zealand Centre for Sustainable Cities is an interdisciplinary research centre which provides evidence-based solutions for urban development challenges, and their current focus is on maximising wellbeing from public housing (NZ Sustainable Cities). This organisation works with all New Zealand universities, and many other partners including ACC, Kāinga Ora, MBIE, and Stats NZ. The absence of Te Whatu Ora, Te Aka Whai Ora and the Ministry of Health from the list of partners may indicate a failure to take into account health as a key issue for sustainability and wellbeing.

GREENING THE CITY INTERNATIONAL

• Green Cities is a campaign running in 13 countries. It focuses on the importance of public green space in terms of the positive effects on biodiversity, climate, wellness and air quality to ensure cities are better places to live and work (Green Cities Europe). The initiative aims to encourage the greening of public spaces by providing information and ideas based on science, research and technical expertise. Green Cities helps professionals who have roles in city and landscape planning.

CITIZEN ACTION – WOMEN ARE KEY

• On International Women’s Day 2023 the United Nations sent out a media release about the importance of women and how

they play a vital role in tackling climate change (United Nations, 2023). They noted that women are often left out of climate change conversations despite being half the world’s population.

• Indigenous women are described as having invaluable knowledge and expertise that can help build resilience and help create a sustainable future (United Nations, 2023).

• Women are usually the first responders to natural disasters in communities and can contribute to the recovery needs of their families (United Nations, 2023).

• The first Gender Action Plan to support gender-responsive climate action calls for women’s full, equal, and meaningful participation in the international climate process and climate action (United Nations, 2019). This was developed because of the recognition that women commonly face higher risks in responding to disasters and bear a greater burden from climate change impacts.

WHAT CAN WE DO?

Looking at the list of mitigation options from the IPCC Report, there are a number of actions we can all take to help reduce net emissions. In terms of what we eat, taking more care with our food systems in terms of minimising food loss and waste, and making some incremental shifts to more balanced and sustainable diets that include increasing our plant based ingredients and reducing meat intakes, will help.

How we get around is another area where we can consider changes. Simple changes like reducing car trips, and petrol free days. When we purchase a car – we could consider moving to electric or hybrid vehicles, and if possible e-bikes, and bicycle use. The Call the Midwife TV series in the UK inspired a group of midwives working for NHS Grampian in Elgin, and now they have been given access to electric bikes supported by Sustrans, who are a charity working to make it easier for people to walk, wheel and cycle. Sustrans have supplied some of the midwives in the Elgin team with bikes with a large fixed carrier and two large panniers, helmets, high visibility jackets, and locks. Midwives have been enjoying the exercise as well as supporting sustainable travel (NHS Grampian, 2022).

Recycling is also important, as is looking at more efficient lighting, appliances and equipment. This can be in our own homes and we can also be advocates in our workplaces.

One further very important action we can do is to continue to put political pressure on our governments to take meaningful action.

CONCLUSION

The 2022 Lancet Countdown on Health and Climate Change (Romanello et al, 2022) described the world as being at a critical juncture, and that a health-centred response to the crisis would still provide an opportunity for a low carbon and resilient future, and avoid climate change health harms. As midwives we are all a part of that health-centred response. The Lancet Countdown report is described as showing “the direst findings yet”, with 1.1˚C of heating “increasingly undermining every pillar of good health and compounding the health impacts of the current Covid-19 pandemic and geopolitical conflicts.”

On a positive note, despite the false solutions to climate change which have been promoted, such as carbon trading and offsetting, and the underrepresentation of women at the discussion and decision making climate action tables, the first multilateral environmental agreement to include an explicit reference to the human right to a clean, healthy and sustainable environment was made at COP27 late last year (Bidga, 2022). The 2022 Lancet Countdown report also found some “glimmers of hope” with government engagement with health and climate change reaching record levels. As previously noted the largest and much needed gains to be made in the fight against global warming needs to come from industry and government actions; making a smaller but still important difference can be made by individual citizens – including midwivesand this can go some way towards supporting individual and collective wellbeing, and relieving the experience of eco-anxiety. To inspire us further it’s important to celebrate gains, and a report commissioned by The Jump (2022) showed that citizens have more agency than we think, and 25-27% of emissions saving by 2030 will be influenced by citizen action. Making dietary changes and giving up fast fashion were described as significant actions.

Fast climate change mitigation efforts by every country, every sector, and every citizen playing their part is the way forward. As The Jump report said, “There is no one silver bullet, and no one lead actor. We all need action, from all actors NOW.” square

References available on request.

CAROL BARTLE POLICY ANALYST

THE 2023 LANCET SERIES ON BREASTFEEDING

In 2016 the Lancet released a series on breastfeeding based on a growing body of evidence which highlighted the significant economic and health benefits, for both rich and poor countries alike, when governments support breastfeeding through meaningful investments and targeted programmes (Rollins et al, 2016; McFadden et al, 2016; Victora et al, 2016). The urgent need for breastfeeding support in terms of paid maternity leave, nursing breaks at work and commitment from governments and health authorities (Rollins et al, 2016) has not been fully realised in Aotearoa, and these issues have been barely addressed in some countries.

Another key issue addressed in the 2016 series was the need for coordinated global action on formula marketing (McFadden et al, 2016). The new Lancet Breastfeeding Series 2023 highlights the vast economic power of the commercial milk formula (CMF) industry, the continued underregulation of industry practice and marketing, and the chronic under-resourcing of breastfeeding support services.

INTERNATIONAL CODE BACKGROUND

The International Code of Marketing of Breast-milk Substitutes was adopted over forty years ago in 1981 (WHO, 1981) in recognition of declining breastfeeding rates globally, which in part are attributed to the unethical, misleading and aggressive marketing and advertising of breastmilk substitutes (Kent, 2015; Palmer, 2009; WHO / UNICEF / IBFAN, 2016). This Code is a set of recommendations from the collective membership of the World Health Assembly (WHA). The aim is to contribute to the provision of safe and adequate nutrition for infants through the protection and promotion of breastfeeding, and by ensuring the proper use of breastmilk

substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing and distribution (WHO, 1981). Subsequent, relevant WHA resolutions ensure the Code stays current and up to date, and together with the 1981 Code their aim is to raise awareness of policy issues on infant and young child feeding at international and national levels. In 2022, the WHO global status report on national implementation of the International Code provided data about country progress in aligning national laws with the Code. More countries had put into effect new legal measures so progress had been made, but many gaps were also noted, and the reasons for these gaps included the absence of highlevel political will, industry interference, poor accountability, and a lack of monitoring and enforcement mechanisms (WHO, 2022).

The only legal measures reported for Aotearoa New Zealand (and Australia) were the New Zealand 1991 Food Standards Australia and New Zealand Act 1991, Standard 2.9.1, 2015, Standard 1.2.1 and Standard 1.2.7, 2016. Australia has joined the World Breastfeeding Trends Initiative (WBTi), which is an initiative designed to support the breastfeeding rights of women by measuring

and monitoring policy progress using an assessment tool. The first WBTi assessment of Australia was undertaken in 2018 and the score was 25.5/150 which ranked Australia third last out of 98 countries. The Australian score for implementation of the International Code and resolutions was 1.5 out of 10.

Aotearoa NZ has not yet committed to the introduction of the WBTi initiative.

2023 LANCET SERIES

Targeted advertising of formula now dominates the marketing landscape on the internet and within social media platforms. Covid-19 concerns have also been exploited by the CMF industry to increase the sales of their products using tactics such as positioning themselves as public health sources, and recommending inappropriate measures which potentially undermine breastfeeding. Improved implementation and enforcement of the International Code with severe sanctions for violations in every country has been called for urgently (van Tulleken, 2020).

The 2023 series consists of three papers, an editorial and a comment. The editorial highlights the point that women’s decisions about infant feeding are based on the information they receive, the support available for breastfeeding, and the influence of the predatory marketing practices of the CMF industry. As Brown (2018) highlighted, many barriers to breastfeeding exist at the societal rather than the individual level, and because these influences are typically out of the control of many women, this creates serious inequities in infant feeding choices. The editorial also emphasises that systems should be in place to support all mothers with their feeding decisions, and criticism of the “predatory marketing practices" [of the commercial milk formula industry] should not be interpreted as a criticism of women.

The Lancet Comment (Doherty et al, 2023) identifies the “striking message” of this series, which is that the consumption of commercial milk formula by infants and young children has been normalised, and more children are consuming formula than ever before. The pervasive influences of social media on

families, and the control of the infant feeding discourse by industry, along with industry relationships with governments, academic institutions and health professionals, represent a significant threat at a time when global economic and climate crises disrupt formula supply chains, compromise infant health and potentially endanger the lives of infants and young children who are not breastfed. Disruptions that have threatened global stability and safe infant and young child feeding have included the Covid-19 pandemic, climate disasters such as flooding, and the war in Ukraine. The ability to make decisions about breastfeeding and infant feeding, free from commercial influences, is of significant importance, and elevating breastfeeding up to a public health priority is recommended to improve not only infant and child health but also women’s health.

In the first Lancet article, Pérez-Escamilla et al (2023), examine the structural barriers to breastfeeding in more depth, and also highlight scientific advances in knowledge around breastfeeding, breastmilk and lactation. Breastfeeding is described as a species-specific biopsychosocial system evolved to optimise the health and survival of mothers and their infants. Losing these evolutionary mammalian health benefits by undermining breastfeeding and failing to support breastfeeding women represents an irretrievable loss. The section about the complex biopsychosocial system of breastfeeding, which describes in detail how the nutritional, microbial, and bioactive components of breastmilk engage with

Targeted advertising of formula now dominates the marketing landscape on the internet and within social media platforms. Covid-19 concerns have also been exploited by the CMF industry to increase the sales of their products using tactics such as positioning themselves as public health sources, and recommending inappropriate measures which potentially undermine breastfeeding.

each other, the protective antibodies provided by breastfeeding, and the unique, beneficial features of breastfeeding startlingly demonstrates how impossible it is to ever replicate this unique complexity. Expected normal infant behaviours that mistakenly often lead to parents introducing commercial milk formula due to exploitation of parental concerns by industry are also addressed. Recommendations for policy and programmatic actions to support women who want to breastfeed, which are grounded in equity, human rights and public health principles, are made.

The marketing of commercial milk formula and the range of the capture of parents, communities, science and policies is the main focus of article 2 (Rollins et al, 2023) and the key messages include how the marketing of ultra-processed commercial milk formula for use in the first three years of life has altered the infant and young child ecosystem to the detriment of health. Misleading parents, and some health professionals, into thinking that common infant feeding challenges can be resolved by using commercial milk formula, and claiming that these ultra-processed products are linked to ‘benefits’ such as increased infant and young child IQ have been very successful industry marketing strategies. Rollins et al, provide a comprehensive description of the industry marketing playbook, the value of industry capture of health professionals, including midwives, the importance of the International Code of Marketing of Breastmilk Substitutes, and the erosion of legal and regulatory standards which are invariably underpowered, underused and unable to effectively counter industry power.

There is also a section which looks at how breastfeeding advocacy is framed by industry as a harmful moral judgement that causes women to feel guilty. The marketing messages obscure the root causes of breastfeeding challenges which, as previously mentioned, are exploited by industry to influence parents who are often looking for answers to common feeding issues. A key message of this article concerns government obligations to ensure citizens have access to impartial infant and young child feeding information which is free from commercial influences. The absence and/or erosion of legal and regulatory standards means that actions to prevent misleading marketing will remain “underpowered and underused”.

Article 3 continues the focus on the structural barriers to breastfeeding globally, and it also addresses how the commercial milk formula industry contributes to not only widening socioeconomic inequities but also to environmental harms on a large scale. The environmental harms have been obvious for many years and in Aotearoa NZ the contribution of dairy farming intensification which contributes significantly to environmental degradation has been highlighted regularly by concerned ecologists such as Foote & Joy (2014). Smith has suggested that the environmental and health harms of increased formula use, combined with economic evidence, highlight the need for a strong public health response (2019). Article 3 also includes a much needed focus on women, care and work which examines women’s access to the economic resources of time and money and how dependence on commercial milk formula is fostered. Recognising and valuing the contribution of breastfeeding and breast milk in terms of women’s care work, and how this is mostly unrecognised is discussed. This has been another ongoing issue for women and breastfeeding in terms of measures of productivity and economic performance. Marilyn Waring in 1988 wrote about the failure to include reproductive functions and breastfeeding in terms of their economic value, and Smith & Ingham highlighted how economic production is underestimated when GDP measurements exclude the value of unpaid work (2001). The ongoing failures of governments to enact any or sufficient maternity protection, recognise care work, value the contribution of women and breastfeeding, and address conflicts of interest in health systems are ongoing and long standing public health damaging issues.

CONCLUSION

In summary, it is not possible to cover all the issues addressed in this exceptionally important Lancet 2023 Series and accessing the full series is strongly recommended to all midwives. As the Lancet commentary highlights, “the consumption of commercial milk formula by infants and young children has been normalised”, and the infant and young child feeding ecosystem has been negatively altered (Rollins, et al 2023). Midwives know that breastfeeding makes a significant contribution to population health, and they are also well aware of the systemic barriers that women who intend to breastfeed have been faced with.

While all parents need support with their infant feeding decisions regardless of the reasons why they make them, the protection, promotion and support of breastfeeding, and the need for the International Code of Marketing of Breastmilk Substitutes need to remain uppermost and visible as health priorities. square

Key Points

The commercial milk formula industry has a vast economic power

Industry marketing practices remain chronically under-regulated

Breastfeeding support services, and support for women who wish to breastfeed, remain under-resourced

Targeted advertising of formula milks dominates the marketing landscape on the internet and social media platforms

The consumption of commercial milk formula has been normalised and more infants and children are consuming formula than ever before

Governments have an obligation to ensure citizens have access to impartial infant and young child feeding information free from commercial influence

The protection, promotion and support of breastfeeding and the International Code of Marketing of Breastmilk Substitutes need to be uppermost and visible as public health priorities

References available on request.

The marketing of commercial milk formula and the range of the capture of parents, communities, science and policies is the main focus of article 2 and the key messages include how the marketing of ultra-processed commercial milk formula has altered the infant and young child ecosystem to the detriment of health.

For excellence in online postgraduate midwifery education

Our fully online postgraduate courses are perfect for busy midwives who wish to study alongside their midwifery work.

10 July to 25 August

• Midwives and reproductive justice

• Political and practical challenges to breastfeeding

• Infant mental health

• New! Clinical teaching and learning in midwifery*

18 September to 3 November

• Applied anatomy and physiology for midwives

• Hypertension in pregnancy

• Global midwifery: practical steps

• New! Staying connected – digital technology in midwifery education*

For a full description of courses, visit www.op.ac.nz/study/midwifery-2/postgraduate/postgraduate-courses

For more information about any of our postgraduate courses, contact suzanne.miller@op.ac.nz

* available to those who have completed the ‘Principles of Midwifery Education’ course

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:

https://www nsu govt nz/healthprofessionals/antenatal-screening-down-syndromeand-other-conditions/procedures-guidelines

0800

op.ac.nz

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 information:

https://www nsu govt nz/healthprofessionals/newborn-metabolic-screeningprogramme/procedures-guidelines-and-reports

See you there!

02 - 04 NOVEMBER 2023

Book flights and accommodation early, to obtain the best pricing

Notification of Special General Meeting

The College will hold a Special General Meeting (SGM) on Wednesday 26 July in Auckland (venue to be confirmed) at 6pm.

The purpose of the SGM is to vote on a constitutional change to enable two co-presidents (one Māori and one non-Māori) to be nominated/elected this year when the current president’s term ceases in November at the College conference.

The following proposed Constitutional changes set out the remit for the SGM. The proposed changes are shown blelow as tracked changes in blue. We are planning to have a Zoom option available for members to attend the SGM virtually.

NATIONAL CONSTITUTION OF THE NEW ZEALAND COLLEGE OF MIDWIVES [INC]

Section 2: INTERPRETATION

Proposed addition of two clauses

“Māori members” means any members of the College who identify as Māori within the College’s membership database.

“Non-Māori members” means members of the College who do not identify as Māori within the College’s membership database.

Section 9. NATIONAL CO-PRESIDENTS

9.1 The two national co-presidents shall be full members and are elected for a term of two years with right of renewal.

9.1.1 One national co-president identifies as Māori and one national co-president identifies as non-Māori

9.2 Process for nominating co-president candidates

9.2.1 Process for nominating Māori co-president candidates

9.2.1 (a) Regions may submit nominations with a regional seconder to the Chief Executive three months prior to the AGM or SGM.

9.2.2 (b) Ngā Maia may submit nominations to the Chief Executive three months prior to the AGM or SGM

9.2.2 Process for nomination of non-Māori co-president candidates

9.2.2 (a) 9.1.1 Regions shall submit nominations with a regional seconder to the Chief Executive three months prior to the AGM or SGM

9.3 Election of co-presidents

9.3.1 9.1.2 The Chief Executive shall forward all valid seconded nominations to each region

9.3.2 9.1.3 In the event of a contested position (for either position), voting shall be an online ballot of members with results to National Board 14 days prior to AGM

9.3.3 Māori members can cast a vote for both the Māori co-president position and the non-Māori co-president position

9.3.4 Non Māori members can cast a vote for the non-Māori co-president

9.4 Functions of the co-presidents

9.4.1 The co-presidents shall be the national spokespersonpeople for the New Zealand College of Midwives

9.4.2 The co-presidents shall chair National Board meetings, AGM and National SGM

9.4.3 The co-presidents have the right to attend Regional meetings

9.4.4 In the absence of thea co-president, the National Board member will deputise square midwife.org.nz/conference-2023

For further information and to register go to

my postgraduate supervisor my postgraduate supervisee

After five years of full-time LMC practice, Waimarie Onekawa (Ngāti Kahungunu, Rongomaiwahine) was ready for a change of pace and eager to explore how she could contribute a Māori voice to the body of midwifery mātauranga (knowledge).

In 2020, Waimarie commenced study towards a Postgraduate Certificate in Health Science - Midwifery (Honours) through AUT; a pilot pathway that prepares exceptional undergraduate students with significant practice experience for doctoral or PhD qualification. Waimarie completed one research paper in the first semester, then dove straight into a dissertation, which she had a year to complete.

Entitled ‘I don’t know why I want a Māori midwife, I just do’, her dissertation was written in auto-ethnography style (a personal narrative), incorporating the stories of whānau she cared for as an LMC and exclusively utilising kaupapa Māori methodologies.

Waimarie’s motivation for sharing her story as a Māori midwife was both personal and professional. “I felt like it was going to give a stronger voice to Māori. I recognised a huge gap in published Māori ways of knowing and being, and I wondered whether having something recorded, something that’s peerreviewed and verified, would help to validate the voice of Māori - to give us a platform.”

The process of writing it turned out to be much more than an academic pursuit, as she discovered. “Because I don’t speak the reo and didn’t grow up steeped in mātauranga Māori, I had those doubts about whether I was Māori enough. But going through this process of writing down my experiences, analysing them and exploring deeper layers, I solidified the fact that what I know as a Māori midwife is actually valid.”

Waimarie was supervised by a team throughout, comprised of Professor Judith McAra-Couper, Annabel Farry, and cultural supervisors Beatrice Leatham and Paraone Tai Tin. The benefits of having a whole team were many, as Waimarie explains.

“One thing I really enjoyed was the diversity of worldviews within my team. Having two tauiwi supervisors and two Māori cultural supervisors meant I had access to a wide range of skills and knowledge. They were structured, helped me stay on task, and gave me ideas I never would have otherwise thought of.”

Annabel’s contribution in particular, was invaluable. “Annabel brought the esoteric element; te ao Māori wasn’t hard for her to grasp. When I would present a concept, Annabel would understand where I was coming from, so there was a meeting of minds. She was instrumental in helping translate what was in my head into research terms.”

Now enrolled to complete her doctorate, Waimarie is also part of a wider research project, funded by Health Research Council New Zealand, which will look at the sustainability of LMC midwifery. The project will, in turn, inform her doctoral thesis. square

Annabel Farry (Lebanese, Scottish) has been a midwifery lecturer at AUT since 2007 and played a key role as a member of Waimarie’s postgraduate supervisory team.

After gaining a Master of Health Science and publishing her thesis on place of birth in 2015, Annabel completed a research fellowship through i3 (Institute for Innovation and Improvement) in 2018 and is currently completing her doctorate by publication.

Her own postgraduate journey has, in part, been about fulfilling her responsibilities as an educator. “For a while I was content with learning and teaching, but then you need further qualifications to really be able to understand research and teach at a different level. So it’s been a journey of gaining qualifications on the job, as well as being an expectation of my role as a lecturer.”

Since Annabel is still in the process of gaining her own doctorate, she wasn’t Waimarie’s primary supervisor, but played a significant role within the team of four. “I was myself learning to supervise, and because it was a dissertation, I was able to do that. So I was being shown the ropes by senior supervisors and learning how to support someone in the post-graduate space.”

Acknowledging the tapu nature of Waimarie’s process and dissertation was integral for Annabel, who was constantly mindful of the different roles each member of the team was playing, and why. “The reason it worked was because of the presence of Paraone and Bea. They held the space in a way that allowed for the supervisory team - of which I was a part - to be advised. It’s a space in which deep care must be taken; when knowledge is coming from te ao Māori, it’s not for non-Māori supervisors to comment on it.”

The whole experience was a privilege, as Annabel explains. “To be supervisory of someone like Waimarie was utterly extraordinary, because she had so much depth of knowledge from the richness of her practice. The extent to which I could support her was only in clarifying thoughts she couldn’t quite capture.”

Holding a particular interest in te Tiriti as a basis for reshaping curriculum, Annabel was grateful for the opportunity to gain even more clarity through the experience. Playing her part in ensuring Māori voices are heard and valued was an honour - one she didn’t take lightly. “I learnt a lot about myself, about Aotearoa, about midwifery, about whakawhānaungatanga, and about working alongside Māori. I feel so fortunate, but at the same time I’m aware that it’s incredibly complex, and I’m a humble student taking part in a huge, important conversation.”

Annabel’s view on her own role, as well as the collective responsibility of all midwifery educators, is clear. “If we’re to uphold and strengthen those voices and understandings that have been historically suppressed, it’s an ‘all hands on deck’ moment. Reckoning with our colonial history is urgent, and part of that is supporting people brave enough to explore what successfully working with whānau Māori could look like.” square

New Zealand College of Midwives Directory

National Office

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

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

College Membership Enquiries

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

Chief Executive

Alison Eddy

President

Nicole Pihema Ph 021 609 011 nicolepihema@gmail.com

National Board Advisors

Kuia: Crete Cherrington

Elder: Sue Bree

Education Advisor: Tania Fleming

Regional Chairpersons

Auckland

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

Bay of Plenty/Tairāwhiti

Cara Kellet chairnzcomboptairawhiti@gmail.com

Canterbury West Coast Sheena Ross chairnzcom.cantwest@gmail.com

Central

Laura McClenaghan centralchair@nzcom.org.nz

Nelson Marlborough

Karen Hall tetauihunzcom@gmail.com

Northland

Shelley Tweedie 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 nzcomwellington@gmail.com

Regional Sub-Committees

Hawke's Bay Sub-Committee

Kerri Smith kerrijeansmith@aol.com

Horowhenua

Laura McClenaghan midwife.laura@hotmail.co.nz

Manawatu Sub-Committee

Jayne Waite j.waite70@gmail.com

Taranaki Sub-Committee

Ange Hill nzcom.taranaki@gmail.com

Wanganui Sub-Committee

Laura Deane laura.deane@wdhb.org.nz

Consumer Representatives

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

Royal New Zealand Plunket Society

Zoe Tipa zoe.tipa@plunket.org.nz

Student Representatives

Penny Martin pennymartin79@live.com

Ana Ngatai ana.olsen.ngatai@hotmail.com

Ngā Maia 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 0800 Midwife/643 9433 rural@mmpo.co.nz

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

You are kaitiaki for hapū māmā and pēpē

Maternal immunisation provides vital protection for pēpē and māmā before and during the most vulnerable first months of life. Your recommendation to immunise can save lives.

INFLUENZA

Pregnant people and their babies are at greater risk of serious influenza-related complications. Most young babies whose mothers were vaccinated during pregnancy are protected against influenza.

WHOOPING COUGH

Babies, particularly younger ones, can get very sick or even die from whooping cough. Most young babies whose mothers were vaccinated during pregnancy are protected against whooping cough.

COVID-19

COVID-19 vaccination in pregnancy protects against infection, severe disease, hospitalisation and death. Babies of immunised mothers receive some of that protection too.

Immunisation during pregnancy boosts disease-specific antibodies that not only protect hapū māmā, but also  travel across the placenta and protect pēpē until their first three immunisations at six weeks old.

Influenza vaccination is recommended at any stage of pregnancy and is free during the influenza season

COVID-19 vaccination is recommended and funded at any stage of pregnancy Tdap*

* Tdap is funded from the beginning of the 2nd trimester and is recommended from 16–26 weeks. † MMR post-delivery is recommended for those who haven’t had the MMR vaccine.

For more information, visit immune.org.nz

MMR post-delivery†