Midwife Aotearoa New Zealand

THE

OF FREEBIRTH IN AOTEAROA

If you’re a registered midwife, our fully online postgraduate courses are perfect for you to study alongside your midwifery practice.

Courses offered in 2024

Jul 8 - Aug 23

Complexities, Culture and Research around Safe Sleep for Pēpi

Diabetes in Pregnancy

Sexual Health in Pregnancy

Sep 16 - Nov 1

Applied Anatomy and Physiology for Midwives

Leadership and Change in Midwifery

Midwifery Practice in Rural and Primary Settings

Courses will run with a minimum of five enrolments. We also offer Postgraduate Diploma, Master of Midwifery, Complex Care and Midwifery Educator courses. Please email all enquiries to suzanne.miller@op.ac.nz

op.ac.nz/midwifery

FORUM

4.

16. YOUR UNION

18. YOUR MIDWIFERY BUSINESS FEATURES

20. NGĀ MAIA

21. PASIFIKA

22. THE RISE OF FREEBIRTH IN AOTEAROA

28. KURAWAKA: WAIPAPA OPENS ITS DOORS

32. HEPATITIS B VIRUS AND MANAGEMENT FOR PREGNANCY

36. KAUPAPA MĀORI

38. BREASTFEEDING CONNECTION

42. TAKU WĀHI MAHI / MY MIDWIFERY PLACE DIRECTORY

EDITOR

Hayley McMurtrie

E: communications@nzcom.org.nz

ADVERTISING ENQUIRIES

Hayley McMurtrie

P: (03) 372 9741

MATERIAL & BOOKING

Deadlines for September 2024

Advertising Booking: 1 August 2024

Advertising Copy: 12 August 2024

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 Midwife Aotearoa New Zealand 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 2024 by New Zealand College of Midwives. All rights reserved. No article or advertisement may be reproduced without written permission. ISSN: 2703-4546.

Welcome to Issue 113 of Midwife Aotearoa New Zealand

The complex topic of freebirth is a feature in this issue. Hopefully, the personal stories provide midwives with some insight into why some women appear to be choosing planned unassisted birth as an option, both in Aotearoa and in many other Western countries. The full complexities of the topic cannot be covered here but the article on p. 22, together with the CE’s piece, provides a basis for much deeper discussion both within the profession and with whānau choosing this option.

Page 36 introduces the maramataka antenatal wheel and challenges our concept of time in the first of an exciting new series celebrating te ao Māori. We have many interesting articles planned for this section over the coming publications.

This issue also acknowledges Norma Campbell’s decades of service to midwifery throughout her career and the positive and significant change she has achieved in her role at Te Whatu Ora Waitaha. Thank you Norma, we are privileged to have worked alongside you.

Practice Guidance looks at screening and the Heelprick test and highlights a change to the optimal time for testing, p. 12, and Breastfeeding Connection considers painful nipples through a clinical lens.

Page 15 features a save the date for the Joan Donley forum, 24 & 25 October in New Plymouth. Registrations will be open soon and we look forward to seeing many of you there as we celebrate the high quality of research being produced in Aotearoa.

As always, if you have any feedback or suggestions, please contact communications@nzcom.org.nz

CORRECTION

The publishers would like to apologise for the incorrect employment details of Sian Burgess published alongside her reflection in the previous issue (112 March 2024). The reflection was a personal one and was in no way related to her previous employer, added in error during the editorial process. We apologise to Sian for this error and to her previous employer for any inconvenience caused. square

HAYLEY MCMURTRIE EDITOR & PUBLICATIONS MANAGER

Email: communications@nzcom.org.nz

from the co-presidents

BEA LEATHAM

He kākano i ruia mai i Rangiātea e kore ai e ngaro - I am a seed sown from Rangiātea that will never be lost

It’s Anzac Day as I write this - a day of reflection and remembrance. And while I acknowledge our tīpuna - mine and yourswho were willing to sacrifice their lives for someone else’s war, I’m also thinking about those who stayed behind: the wāhine who kept the ahi kaa burning.

Those wāhine held everything down at home while their tāne were away - birthing babies, raising children, running households and becoming the protectors of their whānau.

As our tīpuna fought overseas, whenever they looked to the night sky and recognised particular whetū, not only could they draw on that te taiao for comfort and guidance, but they were reconnecting back home, to their whānau and whenua. And in Aotearoa, those left behind were looking at the same stars, reading the tohu, aligning their mahi and mauri with the maramataka to provide for their whānau.

Of course, many of our soldiers never returned home, so the link between Anzac Day and Matariki is real. By the time this issue of Midwife is in your hands, Matariki will be upon us, so it feels fitting to share this kōrero as we connect to Pōhutukawa, honouring those who have passed.

As we adjust to the reality of living out this next cycle under the current government, it occurs to me that tangata whenua have always embodied the concept of partnership. Our willingness to send soldiers overseas to fight a foreign war was demonstrative of our generosity as tangata whenua and te Tiriti partners; we’ve consistently been prepared to play our part and share our wisdom. Unfortunately, this has not always been reciprocal, as I reflect upon our tīpuna, who bravely fought for a government that has yet to show the same courage in honouring their side of the partnership. However, there’s no doubt we are a resilient people, and alongside this resilience there is also hope.

Ngākau nui, ngākau whakaiti  square

DEBBIE FISHER

Tēnā koutou, Hello, Mālō e lelei, Talofa lava, Taloha ni, Kia orana, Fakaalofa lahi atu, Namaste, Ni sa bula

It's exciting to see recent developments across midwifery, such as the partnership between the College and Ngā Maia in the Graduate Midwife Programme Re-Design project, which will see our new graduate midwives further uplifted and nurtured.

The highly dedicated and skilled pay equity team have reached a historical achievement in addressing sexism and discrimination in our workplaces and health system. This, together with the latest SECA settlement, addresses the chronic undervaluing of midwifery and internationally is making New Zealand a desired place to work again. The Midwifery Council has gazetted the new Midwifery Scope of Practice and work is underway on the new competencies to underpin this.

Recently, there have been many opportunities to present and attend events, including PSANZ, GOLD Lactation and Midwifery online, Big Latch On and the impressive Te Tiriti-based futures and antiracism programme. There was also the opportunity to challenge our workplace’s environmental footprint during International Day of the Midwife. The theme resonated well in New Zealand and it was very inspiring to hear our colleagues on the international stage! I hope all regions had a special day, celebrating and reflecting together.

Looking forward, advocating for what supports the best outcomes for whānau and what enables midwives to practise in the most optimal ways needs each one of us to pull together as a midwifery team. The ingredients of a strong team include drawing on what works well in our regions to lift morale, create a collective, achieve equity or simply ensure that no matter what our work is, midwifery is recognised and valued everywhere.

Let’s share our positivity and supportive feedback. Tell each other, go along to regional meetings, write to the board, # on social media. Be the change you are seeking - your voice, reflections, skills and energy are critical, so say what matters and why. A loud voice pulling together, sharing the stories - this is what we do well and what will support a better tomorrow for midwifery. square

DIVIDED SOCIETIES AND THE WIDER WORLD

Recently, within hours on the same day, I found myself dealing or engaging with two very different topics which illustrated the contradictory nature of our increasingly divided societies and the wider world.

The first topic was reading about the desperate and inhumane conditions pregnant and birthing women in Gaza are facing, giving birth on hospital floors, sharing cramped and unhygienic facilities, lacking access to basic supplies, medicines or even privacy. Also, the personal situations of Palestinian midwives and other healthcare workers are becoming so dire that some are no longer able to continue to practise, leaving women and their babies unable to access midwifery care. Famine is becoming more widespread, with many pregnant women and new mothers suffering from hunger. Shelters and informal settlements are overcrowded and lack clean water and hygiene facilities. Midwifery care during childbirth should be accessible for every woman

and yet in so many parts of the world, including Gaza at present, many women are being denied this (and other) fundamental and potentially life-saving human rights.

The second topic was while participating in a meeting with midwives from different regions and contexts around Aotearoa who had experiences of working with women who had chosen to “freebirth” or intentionally give birth unassisted by a midwife. This complex topic is explored in some detail in Amellia Kapa’s article in this edition of the magazine. These women are not a homogenous group and the reasons they are making this choice are multifaceted and nuanced. Regardless of individual reasons for making the choice to have an unassisted birth, at the core of their decision can be

Over the past 18 months the College has been considering how it can best support midwives who are dealing with planned unassisted birth in practice, and we have recently consulted on our draft Consensus statement on this topic. Thank you to members who engaged with this consultation; your feedback is highly valued, and helps us to refine and finalise the statement.

a rejection of our healthcare system and, by implication, a rejection of midwifery care too.

Over the past 18 months the College has been considering how it can best support midwives who are dealing with planned unassisted birth in practice, and we have recently consulted on our draft Consensus statement on this topic. Thank you to members who engaged with this consultation; your feedback is highly valued, and helps us to refine and finalise the statement.

The paradoxical nature of these two issues was hard to reconcile. In Palestine, women and babies are dying and suffering from lack of access to necessary care which they are being denied, due to the ideological, religious and geopolitical forces which have led to the war. In Aotearoa (a well-resourced country) our universal model of women-centred maternity care is widely accessible, yet some women are choosing to reject it outright, at the time that access to midwifery care could

potentially save their and/or their baby’s lives. The freebirth phenomenon has been influenced, at least in part, by women’s desire to maintain autonomy in decision making and to avoid disruption to the physiological process of birth. Midwifery care should enable and support these desires; however, our profession can become influenced by the predominant narrative around birth as “risky”, especially within the increasingly riskaverse and protocol-driven environment in which we practise. We work within a system which privileges medicine over midwifery and intervention over physiology. Fear of medico-legal consequences also place us in an invidious position. At times midwives can act as “guardians” of a normal process, shielding women from the negative influences and effects of a risk-averse healthcare system and society. Yet, concurrently, we have a critical role identifying deviations from the normal and mitigating risk through observations, assessments and timely advice or interventions. Midwives are educated, regulated health professionals and our role is to support women and whānau to have autonomy in decisions about their care, to avoid unnecessary disruption to physiological processes of birth, and also to recognise that birth comes with a level of risk, even when straightforward or uncomplicated.

Previous negative experiences of maternity care, as well as social media and international influences, are also undoubtedly impacting the increase of unassisted birth, and there is a reported rise in other high-income regions, such as the UK, USA, Australia and Europe. Some of the factors driving its rise are beyond the sphere of influence of midwifery alone; however, there is an opportunity for our profession to “pause and reflect” on why some women and whānau are rejecting midwifery care.

Although our maternity system and midwifery-led model of care was envisioned and enacted as one which places the woman and her whānau at its centre, the way some experience care is at odds with how it was intended. Manatū Hauora | the Ministry of Health’s recently published maternity consumer satisfaction survey report shows that satisfaction with maternity care remains consistently high, with nearly 80% of all respondents being satisfied or very satisfied with their experience, despite the survey being undertaken during the pandemic era when there were significant constraints in the system. Of all the various elements of care respondents were asked about, care

from LMC midwives rated very positively. However, there were differences in some categories, with those who experience inequitable access to care (and in some cases inequitable outcomes, including Pasifika, Māori, young and tangata whaikaha | disabled women) reporting somewhat less satisfaction compared with the overall cohort who responded.

Qualitative data gathered from both the Ministry’s survey and recent New Zealand research (Daellenbach et al., 2024) confirmed that when women have positive relationships with midwives, connection, trust and confidence is built. When there is trust between the woman and midwife, it could be reasonably assumed by extension that they and their whānau will be more likely to engage with maternity care and the healthcare system. Many midwives will be able to recall examples of acting as a bridge to the wider health system when whānau have been reluctant or unwilling to engage with it for a multitude of reasons, including past experiences which have been disempowering, frightening, traumatising or stigmatising.

Partnership-based, relational care is therefore a critical component of our maternity and midwifery model of care, and an important tool in our kete. It provides a means to support equitable engagement with maternity care, and thus more equitable outcomes.

With possible changes on the horizon to the way in which midwifery and maternity care is going to be organised, funded and contracted, how can we ensure that any new models will support and strengthen midwives’ ability to provide partnershipbased, relational care, within a continuity of care framework?

The New Zealand Health Plan, Te Pae Tata, (published in October 2022) set out a vision for Kahu Taurima that it “will drive the integration of maternity and early years services for a child’s first 2,000 days, from conception to five years old, across Aotearoa”. Included in the specific actions which were to be completed were:

“Redesign the universal model of care, working with LMCs and Well Child Tamariki Ora providers to implement a more flexible and responsive model.”

“Design and commission Te Ao Māori whānau-centred and Pacific whānau-centred integrated maternity and early years services.”

We have heard and read the promise that there will be an updated contracting model;

however, progress has been frustratingly slow, particularly when considering that midwives have been waiting since 2017, when the promise of a new funding model for primary midwifery services was first put on the table by the Ministry of Health.

The subsequent co-design process specifically considered what changes needed to be made to enable and support midwives to meet the varying needs of women and whānau, with the concept of additional modules of care, differentiated levels of service to address equity and investment in structures to support and enable midwives to make their integration with other services and the wider health system easier, more visible and accessible. Funnily enough, these sound like exactly the sort of things the government would want from an updated funding model for primary maternity services.

Some work is finally beginning this year, with Te Whatu Ora | Health New Zealand contracting a “Maternity Components of Care” report, which as we go to print is due to be finalised shortly. The College has been invited to provide feedback and input into this early work. Unsurprisingly, it appears that enhancing and strengthening continuity of care will be one its key recommendations. The College understands that the final report from this project will inform further work which will commence later this year to update the universal service contracting model for primary midwifery services.

This current work underway has left me with a sense of irony, which reminded me of the feeling I experienced when thinking about the contradictory nature of the plight of Palestinian women and the rise in planned unassisted birth within New Zealand. The work undertaken through the co-design and subsequent work to develop an updated contract under the second Settlement Agreement has been put on a shelf or been forgotten by some, even though it actively considered and addressed many of the challenges which the health reform is seeking to find answers to. On one hand we have some of the solutions, on the other, we seem to need to keep reinventing the wheel, repackaging the same solutions in the hope that people will finally listen to them. square

Reference available on request.

your college

class action update

In May 2017, under the requirements of the College’s first Settlement Agreement with the Ministry of Health, the process of developing an updated funding and contracting model for community midwifery services began, through the co-design process. The Ministry failed to meet its obligations under this agreement and subsequently apologised to the College and its members. In December 2018, the College and the Ministry reached another Settlement Agreement, which the College alleges the Ministry failed to deliver on, leading the College to file the Class Action in August 2022 against the Crown. Almost 1,500 midwives are participating in the Action, and the legal and expert fees for the case are being funded by an international funder.  This case is set down to be heard over a six-week period in the High Court at Wellington commencing on 5 August 2024. square

notice of annual general meeting 2024

The New Zealand College of Midwives | Te Kāreti o ngā Kaiwhakawhānau ki Aotearoa annual general meeting will be held on Wednesday 24 July 2024 at the Holiday Inn Auckland Airport, 2 Ascot Road, Airport Oaks at 6.30pm. If you would like to give notice of a remit or raise an issue for discussion at the AGM please email Lynda Overton lynda.o@nzcom.org.nz, all members are welcome to attend. square

midwifery standards review consultation

The College’s midwifery advisors, Te Paea Bradshaw and Brigid Beehan, are embarking on a consultation process centred on reviewing and redesigning the quality assurance programme for midwives, currently known as the Midwifery Standards Review. There will be various ways to participate in the consultation including virtual and face to face hui. The College values the voices of all midwives, whānau and stakeholders. Midwives are encouraged to participate in this process, providing valuable insights and perspectives to ensure that the revised Standards Review will effectively address midwives' needs. More information will be emailed to members over the coming months. square

midwifery first year of practice

It has been a great start for MFYP in 2024 with 157 new graduate midwives entering the programme in four cohorts so far. It is always such a rich time consolidating knowledge and competence to move towards confident midwives.

With excitement, MFYP is undergoing an exploration and re-design project in partnership between the College and Ngā Maia with support from Pasifika Midwives Aotearoa. The project is being led by Victoria Roper and calls in research expertise from Te Rau Ora and Moana Connect. Victoria shares more information about the project on p.14of this issue. Thank you to the midwives and mentors who have participated in the many focus groups, surveys and interviews so far. square

goodbye katie, welcome samantha

Welcome Samantha Humphreys who joins us as MFYP Administrator. Katie has passed the MFYP reins on as she moves to a new challenge in Christchurch, we wish Katie all the best. Samantha, originally from Wales, has lived in Canterbury for 17 years. Mum to two busy preschoolers, Samantha is pleased to be part of the team and looks forward to answering your MFYP queries. square

eLearning contracts

The College’s education offerings will be expanded under two Te Whatu Ora contracts to develop eLearning modules. The first is about Midwifery Care for Former Refugee Whānau, and the second is about Syphilis and other Sexually Transmitted Infections.

Stakeholder engagement with refugee communities is currently underway, led by midwifery subject matter experts who bring lived experience and extensive knowledge of working with refugee communities. Both modules will be designed and built on the College’s new eLearning platform and will be promoted to the membership when they are ready towards the end of the year. square

Are you a skilled midwife looking to make a meaningful impact in the lives of whānau? We’ve got exciting opportunities in our midwifery-led, stand-alone birth unit, and postnatal facility in Parnell, Auckland. At Birthcare we provide a supportive environment where your expertise is valued, and quality care is our focus. Take the next step in your career with us.

More restful, safer sleep limb and hip movement

Ensures swaddling, sleepwear, Sleepingbag use is safer and cosier

restful, safer sleep and helps prevent flat head Goes over any type of swaddling, sleeping bag or sleepwear, for a snug and more restful sleep Natural, flexible body, limb and hip movement

or

bulletin

st john payment/ invoicing update

The College has had recent communication with Hato Hone St John regarding ambulance services for maternity. Ambulance services required for maternity related transfers from home or primary maternity facilities to secondary or tertiary hospitals should come at no cost to the whānau (i.e. the co-payment is waived), if the ambulance was requested by a health professional (as outlined in the national Service Coverage schedule). Any invoices sent to whānau (in error) can be rectified when the midwife makes contact with Hato Hone St John with details of the ambulance service and APC number. square

gestational diabetes guideline consultation

Thank you to members for providing feedback on the College’s member consultation about the draft national gestational diabetes guideline. The guideline is extensive and detailed, requiring considerable time to read and digest in order to provide feedback. Given the importance of national clinical guidance on midwifery practice in Aotearoa, we really appreciate members engaging in this professional activity. Project manager

Allen + Clarke will collate the consultation feedback, revise the draft and discuss with the steering group, which includes two College representatives. square

national badgernet rollout

Te Whatu Ora has convened the Maternal and Neonatal Data & Digital Steering Group (MNDDSG) to oversee the implementation of BadgerNet in all Te Whatu Ora district hospitals over the coming years.

Expert Advisory Groups (EAG) for Midwifery & Obstetrics, Neonatal, and Anaesthetics have also been established, to provide clinical leadership on the utilisation of BadgerNet and potential improvements to the system. Several midwives have been appointed to the MNDDSG and EAG, with College support. square

kahu taurima maternity components of care

Last year, Te Whatu Ora contracted Ernst and Young, who are working in partneship with Ngāti Hine Health Trust and Taikura Trust to develop advice in the “key components” of care for a national maternity system that is suitable for all whānau. It is understood that the report generated from this work will

inform the next steps of redesigning maternity services under Kahu Taurima. College representatives, along with stakeholders from across the health sector including whānau/ consumers, were invited to participate in a series of wānanga on a Literature Scan and a Whānau Insights Report between March to May. The College will provide a copy of the report to members when it is published. square

take the pelvic floor challenge - world continence week 17-23 june

This year Continence NZ are encouraging you to Take the Pelvic Floor Challenge by doing your pelvic floor exercises daily from 17 to 23 June - find out more about the Pelvic Floor Challenge by visiting the website www. continence.org.nz. If you are worried or need advice, Continence NZ can help - visit the website or call them on 0800 650 659.

Continence NZ are also launching The World Continence Week Edition of the Pelvic Health Guide available as a free digital download. This guide answers common questions regarding pelvic health. You will find advice on pelvic floor muscle basics including simple explanations, practical tips and demonstrations, and where else to find help. The guide will be available shortly via www.continence.org.nz square

hdc launches consultation on review of the act and code

HDC has launched public consultation on its review of the Code of Health and Disability Services Consumers’ Rights (the Code) and the Health and Disability Commissioner Act 1994 (the Act).

HDC has published full and summary consultation documents seeking feedback on five topics. These documents are available in many accessible formats and in English and te reo Māori on the HDC website: review.hdc.org.nz.

Submissions can be made online or by one of the alternative submission options noted on the website. Submissions are due by 5pm Wednesday 31 July 2024. square

two organisations working to eradicate obstetric fistula

Obstetric fistula is an internal injury in the form of a hole between the birth canal and the bladder and/or rectum. It leaves women leaking urine or faeces, and sometimes both. Obstetric fistula is caused by a prolonged, obstructed childbirth, when a woman lacks access to emergency medical care. Tragically, 93% of women who suffer an obstetric fistula will give birth to a stillborn baby, often after an agonising obstructed labour that has lasted several days.

Although the condition is almost entirely preventable, it is still a huge public health issue in less developed countries. Without an understanding of the complication and its causes, a woman is frequently blamed for her condition, leaving her trapped in a life of pain, shame, and isolation.

The Catherine Hamlin Fistula Foundation and CBM (Christian Blind Mission) are working hard in Ethiopia and Nigeria to raise awareness and provide the very simple surgery that these women need.

For more information and the opportunity to donate visit www. hamlinfistula.org.nz/ or www.cbmnz.org.nz/ square

VIOLET CLAPHAM MIDWIFERY ADVISOR

MIDWIFERY PRACTICE GUIDANCE:

NEWBORN METABOLIC SCREENING (HEELPRICK TEST)

Midwives play a vital role in ensuring that whānau are informed about, and have equitable access to, the Newborn Metabolic Screening Programme. This screening programme is highly successful and almost all babies born in Aotearoa are screened for over 20 metabolic disorders, some of which

For effective newborn blood spot screening, baby must have been independent from the placental circulation long enough for many of the indicator markers to show an abnormality. The earliest optimal window of opportunity is now understood to be between 24 and 48 hours of age.

can be life-threatening if not detected and treated quickly.

Severe forms of some of the disorders screened for can be fatal within seven to ten days of age and babies may not show any signs or symptoms until irreversible damage has occurred.

For effective newborn blood spot screening, baby must have been independent from the placental circulation long enough for many of the indicator markers to show an abnormality. The earliest optimal window of opportunity is now understood to be between 24 and 48 hours of age.

Milk feeding, stool colour and antibiotic use do not affect results and must not delay sample-taking.

CHANGE TO TIMING OF SAMPLE COLLECTION

• The newborn blood spot samples should now be taken from 24 hours of baby’s age.

• The optimal time for newborn blood spot collection is between 24 and 48 hours of baby’s age and before 72 hours. This is a

change from between 48 and 72 hours of baby’s age.

• It is recommended that blood spot samples be collected while babies are still in the hospital or birth facility where possible.

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

• Monitoring of the samples that have already been collected from 24 hours indicated that there is no impact on the quality of samples collected.

PRACTICE REMINDERS

• Ensure the date/time of sampling is recorded on all blood spot cards.

• Send each blood spot sample when collected and dried - don’t hold onto samples to send them in batches.

• Record the courier tracking number before blood spot sample cards are sent to the laboratory. Take a photo or note down the number from the courier bag and add this to the baby’s healthcare records.

• Expect to receive a result in 7-10 days of the sample being taken; if not, check that the laboratory has the sample using the courier tracking number and call 0800 LABLINK to enquire about the sample/ result. Remember to let the parents/ guardians know the results.

• Record the test result in the baby’s clinical notes.

• There is a best practice eLearning module available at LearnOnline (learnonline. health.nz) “Best Practice - Newborn Metabolic Blood Spot Collection”. Midwives can use this e-learning as elective education hours.

• Results are no longer being sent by fax, so please contact the laboratory ASAP to update your preferred contact details. Fill out the form at nsu.govt.nz and email to LabLink@adhb.govt.nz

• There has been a change of card colour from buff to white. Keep using buff cards until the old stock is used up. For the new cards, new information is required regarding the location where the sample was taken (community, birthing unit, home or hospital).

• Resources: lancets, cards and courier bags can be ordered, free of charge, via newbornscreeningresources@adhb.govt.nz

• NMSP information resources for both midwives and whānau are available to download on the NSU website (nsu.govt.nz)

• When whānau/parents/guardians decline, if appropriate, please ask them if they agree to a blood spot card being filled out with their demographic information to monitor participation in the programme. If they consent, fill the sample card in as much detail as possible including a note that screening was declined, and courier it to the laboratory.

There are also changes to the Preterm Metabolic Bloodspot Screening protocol coming into effect on 1 July, visit www.nsu. govt.nz for details. square

VICTORIA ROPER MFYP REDESIGN PROJECT LEAD

redesigning the graduate midwife programme

Ngā Maia, the College of Midwives, Te Rau Ora and Moana Connect are collaborating on an exciting project to redesign the Graduate Midwife Programme. This initiative, commissioned by Te Whatu Ora, aims to create a more effective support system for new graduate and early career midwives within a tight 8-month timeframe.

The existing programme's strengths, including mentoring, professional development, and clinical support, will form the foundation of the new model. Importantly, cultural support will be added as a key element. The redesign will also focus on integrating undergraduate supports, like Te Ara ō Hine - Tapu Ora, for a seamless experience.

The first phase, Discovery, has been a meticulous process. We've conducted a national stocktake, gathering invaluable insights from over 200 individuals through surveys and focus groups. Graduate midwives, mentors, Te Tatau o te Kahu / Midwifery Council and other stakeholders have generously shared their experiences and perspectives. We're deeply grateful for this feedback, which will shape the programme's future.

As we transition into the Design phase, an advisory group and a reference group of graduate midwives will help us create a programme

that is accessible, beneficial, and supportive for all, with a particular focus on Māori, Pacific, and disabled midwives.

We want to thank everyone who has contributed to this process so far. Your voices are crucial in building a better programme. Please look out for more opportunities to share your thoughts and reach out if you have any questions.

While the implementation timeline for the new programme is still being determined, midwives graduating in late 2024 and 2025 can rest assured that a dedicated support programme will be available, offering at least all the elements of the current programme.

Ngā mihi nui for your ongoing support and participation in this important work.

Please feel free to contact the Project Lead Victoria Roper on mfypprojectlead@ngamaiatrust.org square

Thursday

CAROLINE CONROY MERAS CO-LEADER (MIDWIFERY)

the quality leadership programme (QLP)

should you be completing an application?

The Quality Leadership Programme (QLP) is well established in Health NZ | Te Whatu Ora workplaces, as well as being available in some of the birthing centres outside of Health NZ. The intention of QLP is to recognise core midwives, employed community midwives and caseloading midwives working at a confident and leadership level in their workplaces and the ‘value added’ contribution that they make.

The number of midwives who have completed QLP applications is variable across workplaces, with some workplaces having a very high uptake, whilst others have a low uptake. New graduate midwives are usually very prompt at applying for QLP Confident domain on completion of the new graduate programme.

However, many of our more experienced midwives, who are undertaking many activities in their workplace to support new staff, ensuring the smooth running of their workplace and demonstrating leadership in everyday practice have not made applications. MERAS is particularly keen to see more of the experienced midwives in the workplace completing QLP Leadership applications.

WHAT IS INVOLVED IN THE APPLICATION?

The QLP application process is structured in a way that should allow midwives to use material they have already produced for another purpose, such as Midwifery Standards Review, Midwifery Council portfolio or projects they are undertaking

in the workplace. The intention is to acknowledge work the midwife is already doing, not to create additional work.

There are some misconceptions about what is involved in applying for a QLP domain but the criteria are clearly outlined in the application process.

THE DOMAINS

There are two domains that midwives can apply for: Confident and Leadership. There is an expectation that all eligible midwives in a workplace should be able to achieve the Confident domain within two years of commencing work as a midwife.

MAKING AN APPLICATION

All the information about QLP is available on the MERAS website and should also be available on your workplace intranet.

• Discuss your plans to make a QLP application with your midwife manager at your performance appraisal.

• Get support from a midwife who has QLP Leadership or is a QLP assessor or a midwife educator.

• Print off the application form and domain criteria and gather the material needed.

• Send completed application to your midwife educator or QLP coordinator (these are usually midwife educators).

• You should be advised of the outcome within 6-8 weeks.

BENEFITS OF A SUCCESSFUL QLP APPLICATION

Following a successful application a midwife will receive the following allowance:

• Confident domain: $3000 pro-rated per annum

• Leadership domain: $4500 pro-rated per annum

In addition, a midwife has access to the following leave to assist in maintaining the requirements for the domain:

• Confident domain: 1 day per annum

• Leadership domain: 2 days per annum

The intention to use this leave should be discussed with your manager prior to taking it.

ANSWERS TO FREQUENTLY ASKED QUESTIONS:

• QLP is transferrable between districts

• Midwives employed on casual contracts can apply

• QLP is retained on return from parental leave

WHY ARE MIDWIVES ON THE SENIOR PAY SCALE NOT ELIGIBLE FOR QLP?

A midwife working in a senior midwifery role is by default in a leadership role. QLP was designed to recognise confidence and leadership in core, community and caseload midwives. QLP is seen as a way of preparing midwives for senior midwifery roles or recognising midwives where there are limited opportunities for senior midwifery roles.

IS THERE AN APPEAL PROCESS?

If a midwife submits a QLP application and is not happy with the feedback they have received, they can appeal. For more details on this, contact MERAS.

WHEN CAN A QLP APPLICATION BE SUBMITTED?

A QLP application can be submitted at any time. Good times to do this are:

• After an MSR as the exemplars prepared for that can be used to support the QLP criteria

• After you have completed a performance appraisal

• Now, as you have read this article!

HOW DO I BECOME A QLP ASSESSOR?

If you have achieved QLP Leadership domain, you can become a QLP assessor. Talk to your midwife manager and midwife educator to gain their support, then contact the MERAS Co-Leader (Midwifery) for the next QLP Assessor training dates.

For any further questions about QLP please contact: Caroline Conroy MERAS Co-Leader (Midwifery): caroline.conroy@meras.co.nz or phone 0276 888372 For MERAS Membership merasmembership.co.nz www.meras.co.nz

CRITERIA

Summary of the criteria for Confident and Leadership domains:

Confident domain Leadership domain

Midwifery Council APC printout to show you are up to date with recertification requirements

Copy of performance appraisal showing that QLP application is supported by midwife manager

Minimum of 12 months midwifery experience

Reflection on current midwifery practice to show autonomous evidence practice and confidence in current role (can use material from MSR)

Significant midwifery experience and able to communicate this to colleagues and demonstrate clinically

Reflection on:

• Midwifery practice

• Code of Conduct, Code of Ethics and contractual framework

• How education undertaken supports leadership in your role

• Leadership style

Confident handling complex clinical situations

REVALIDATION OF DOMAIN STATUS

• Peer review by 3 colleagues

• Project/resource role/champion and leadership activity report

Once a midwife has achieved a QLP domain there is a revalidation process to ensure that criteria for that domain continues to be met. The revalidation process for each domain is:

Confident

Leadership

Via performance appraisal process. Midwife manager will be aware of Midwifery Council and MSR status and will know if the midwife remains confident in her practice.

There may be a discussion encouraging the midwife to apply for the Leadership domain.

At the performance appraisal the midwife will discuss her leadership activity plans and have these signed off by the midwife manager. The midwife will need to resubmit a QLP application every three years.

Copy of MSR certificate of attendance

WAYNE ROBERTSON EXECUTIVE DIRECTOR, MMPO

empowering midwives through expert Section 94 claims and payment support

The Midwifery and Maternity Provider Organisation (MMPO) has always offered pivotal support to community midwives across New Zealand, enhancing their ability to manage Section 94 claims and payments effectively and efficiently. This support, described in more detail below, not only offers midwife personalisation but streamlines financial processes to help strengthen the sustainability of midwifery practices.

DUAL SUPPORT: BRIDGING PAPER AND DIGITAL DATA COLLECTION

The MMPO approach encompasses both traditional paper records and modern digital inputs, providing a comprehensive support system that caters to the diverse preferences of midwives. For those using paper records, MMPO assists in the review and digital entry of data, ensuring accuracy and integration into the digital system. This method guarantees that valuable historical data is protected and is systematically aligned with new digital records.

Similarly, midwives who prefer to directly input data into MMPO digital systems also benefit from MMPO's real-time support and training, which enhances efficiency and reduces the likelihood of errors.

Our commitment to a dual support system allows the MMPO to accommodate philosophical as well as varying levels of technological choice, ensuring that all midwives have equitable access to our organisation's resources. This hybrid model not only increases the flexibility and accessibility of data entry but also reinforces data integrity and reliability across the board. By supporting both methods, MMPO effectively bridges the gap between traditional and digital practices, enhancing service

delivery and ensuring robust and complete data collection for clinical and regulatory purposes.

ACCESS TO AN INTEGRATED CLAIMS SUPPORT SYSTEM

At the core of MMPO's services is an integrated digital and support system designed to manage both automated and manual claim submissions. Utilising our Tiaki application, MMPO facilitates the analysis and processing of data to meet specific and complex claim requirements, ensuring accurate and timely submissions to Te Whatu Ora | Health NZ. The system operates under a stringent ruleset and is complemented by the MMPO's comprehensive understanding of claim guidelines, which helps prevent discrepancies and delays in payment.

SUPPORT OF MORE COMPLEX CLAIMS

Whilst most claims under Section 94 are standard and automated, there are some that require careful consideration before a claim can be submitted and approved. These are:

• Additional Care Supplement (ACS) claims: These are known for their complexity and require careful attention to detail and documentation. The MMPO helps

support accurate claims submission by pre-populating Additional Clinical Services (ACS) claims with essential data from clinical records, such as visit details and demographic information. Midwives need only add specific details like acute visits or multidisciplinary meetings. We also clarify the thresholds for additional payments across various stages of care, including partial claims if care ends early antenatally or postnatally and distinguish how acute and after-hours visits are counted differently in antenatal versus postnatal periods. By providing the total value of the claim at completion, MMPO enables midwives to verify accuracy and understand the expected payment before submission to Te Whatu Ora.

• Manual and Single Service Claims: Despite the sophistication of automation, some scenarios require manual input, particularly for single service claims which arise from unique, one-off events. These claims lack a standard rule set and are highly dependent on the accuracy of the manually entered data by the midwife.

• Second Midwife Claims: These claims are particularly complex as they involve care provided by a second midwife at the request of the primary Lead Maternity

Carer (LMC). The claiming process requires detailed documentation, including the date of service and the identifying details of the LMC who requested the additional support. MMPO has implemented measures to ensure that all necessary information, like the reasons for the second midwife's attendance and the exact time spent at the service, are accurately recorded and easily retrievable in case of audits.

MMPO and our Tiaki application provide specialised support to midwives navigating these more intricate claims, ensuring all necessary data is accurately captured and submitted. This helps prevent common errors that could lead to claim rejections or audits, thus securing rightful compensation for the midwives.

RESOLVING REJECTED CLAIMS WITH MMPO SUPPORT

When claims submitted by midwives are rejected by Te Whatu Ora | Health New Zealand, MMPO plays a critical role in addressing and resolving these issues. MMPO provides essential support by carefully reviewing rejected claims to identify the reasons for denial, whether due to data inaccuracies, incomplete documentation or non-compliance with specific claim criteria. Following this analysis, MMPO assists midwives in gathering the necessary additional information or correcting any discrepancies. They also offer direct assistance in resubmitting the claims, ensuring that all requirements are thoroughly met. This not only helps in securing approval upon resubmission but also educates and empowers midwives to enhance their future claim submissions, reducing the likelihood of recurrent rejections.

Through this dedicated support, MMPO ensures that midwives receive the reimbursements they deserve, thereby minimising financial disruptions and maintaining the stability of midwifery services.

DATA INTEGRITY, AUDIT SUPPORT AND SAFE CLAIMING PRACTICES

MMPO is committed to maintaining the highest standards of data integrity and provides robust support to ensure the accuracy and safety of claim submissions. Through regular spot audits, MMPO verifies that claims generated by Tiaki accurately reflect the services provided. These audits are essential for maintaining the accuracy and integrity of claims data, and they help to identify and rectify any discrepancies promptly.

To aid midwives in managing their claims effectively, the MMPO also provides access to a variety of detailed reports. These include listings of outstanding claims, schedules of claims per record, and comprehensive data checkers that ensure every aspect of a claim is correct and complete.

We believe that our independent support is instrumental in navigating the complexities of the claims process, significantly reducing the risk of any Health NZ claims audit. By offering expert guidance and real-time assistance, MMPO ensures that all claims are submitted with complete and verifiable data, thereby securing timely and correct payments. Midwives are thus empowered to maintain high standards of claim integrity.

CONTINUOUS TRAINING AND SUPPORT

MMPO is committed to the continuous development of midwives. Through extensive training sessions and ongoing support, midwives claiming with the MMPO are kept abreast of the latest in claim management and are well-equipped to manage the complexities of the claims process.

ENHANCING AND SUSTAINING MIDWIFERY PRACTICE

By partnering with MMPO for claim and payment management, midwives ensure smooth operational workflows through the provision of seamless, efficient and safe claims processing, complemented by robust support, comprehensive training and the MMPO’s commitment to the highest professional standards.

These vital services all help contribute to improving midwifery practice and maternity services across Aotearoa, allowing midwives to concentrate on continuing to deliver exceptional care for māmā and pēpē. square

MMPO provides self employed community midwives with a supportive practice management system.

www.mmpo.org.nz

mmpo@mmpo.org.nz

03 377 2485

TAMARA KARU NGĀ MAIA GENERAL MANAGER

Tūranga Kaupapa Education Programme 2024-2027: embarking on an activation journey

A Tūranga Kaupapa Education Programme 2024-2027 is being offered by Ngā Maia from 1 July 2024. This investment represents a commitment from the Trust to Hauora Māori solutions. Tūranga Kaupapa are an unapologetic expression of a Māori values system much like our marae. The long-held aspirations of Ngā Maia to embed Tūranga Kaupapa into practice are a testament to the resilience, reclamation, and response of AI, ancestral intelligence.

The values of Tūranga Kaupapa are the signposts, the definitions signal toward safe and dignified care of whānau Māori. If you have ever visited multiple marae, you may have noticed that many roads leading to them lack tar seal and even street lamps. Marae or Māori communities often lack this critical infrastructure. It is no coincidence that, like our marae roads the pathway to harnessing the true potential of Tūranga Kaupapa has lacked professional infrastructure that offers durable protection and visibility. Ngā Maia, the kaitiaki of this values system, have been paving the long road forward regardless, and in 2024 the Trust seek to honour the legacy of its authors as well as the many contributors, most of whom are Ngā Maia founding members. The original change agents of our time.

This behaviour puts Māori at risk. Also, Cultural Competence was obtained upon entry to the register of Midwives, thus Midwives are, by their own professional standards, already culturally competent.

Let us quickly recap on what cultural competence and cultural safety means in the context of midwifery. Cultural competence focuses on understanding and interacting with people from all cultures different to yourself, while cultural safety emphasises ensuring that care is respectful and free from offence or denial of identity, again of all cultures. While these concepts are essential in healthcare, the minor and sometimes temporary attitude adjustments fail to significantly reduce prejudice that lead to actions such as withholding critical infrastructure that enhances the care of Māori. Hauora Māori initiatives to address the impact of colonisation on Māori birth givers, is where the predecessors fall short of Tūranga Kaupapa competencies. Māori, under Te Tiriti, are entitled to be recognised as Tangata Whenua and not grouped into an “all of minority culture” approach.

Tūranga Kaupapa competencies and corresponding Competencies Framework are being prepared for wider consultation with our membership. It is important to note Tangata Tiriti are the intended audience for these documents. You would think the learning journey begins with learning about Māori. This would certainly meet the definition of cultural competence, however experts such as Dr Elena Curtis warn health professionals to resist the temptation of observing, exoticising and ‘othering’ indigenous peoples.

The Tūranga Kaupapa Education Programme Competencies weave the whāriki, the foundational grounding within which the cultural competence, cultural safety and Te Tiriti honouring actions are expressed. The Tūranga Kaupapa Competencies Framework will place emphasis on progressing the learner through a journey beginning with Mōhio - a state of profound understanding and awareness, moving to Mātau - the phase nurturing whānau-centred reflective practice and service improvement change cycles commonplace for Kahu Pōkai/ Kaiwhakawhānau. Once here the learner can then progress into a transformative activator, the Mārama phase, which will facilitate measured and intentional actions that will reshape midwifery practice and potentially influence the healthcare system as a whole.

Ngā Maia envisions the Tūranga Kaupapa Education Programme as a transformative initiative that will be a catalyst for collaborative learning among midwives, ultimately enhancing their ability to better serve whānau Māori. We eagerly anticipate the Midwifery Council's decision regarding formal recognition of the programme in recertification pathways. As Ngā Maia invests in the critical infrastructure necessary to enrich durable and visible education in Hauora Māori for the sector, we encourage midwives to affirm the rights of Tangata Whenua through the expression of Tūranga Kaupapa, regardless of the Midwifery Council's decision. square

TALEI JACKSON COLLEGE OF MIDWIVES PASIFIKA MIDWIFE REPRESENTATIVE ROSE LEAUGA AOTEAROA PASIFIKA MIDWIFE

15th Pacific Society of Reproductive Health

Sexual reproductive health and rights in the Pacific: a changing climate, a resilient Pacific people

The Pacific Society for Reproductive Health (PSRH) encourages professional development of medical and nursing/midwifery professionals in obstetrics and gynaecology in the wider Pacific region. Midwives hold dual registrations due to their context and are often sole charge in remote areas.

It was great to welcome and host PSRH in Aotearoa. Many thanks to the organisation and co-host Moana Connect. The attendees’ presence brought the warmth, vibrancy of colour, music, dance and creativity that is synonymous with the Pacific.

The leadership workshop attendees came from the Solomon Islands, Fiji, Tonga, Vanuatu, Aotearoa, Samoa and Papua New Guinea. The two days were facilitated by Alison Eddy (NZCOM CE) and Professor Caroline Homer (midwifery researcher) and Rachel Smith (midwifery educator), both from the Burnet Institute, Melbourne.

Aotearoa Pasifika midwife Rose Leauga shares her experience of attending the workshop.

The workshop began with a prayer about gratitude that set the tone as the next two days unfolded. I learnt I was amongst very skilled, knowledgeable and humble midwives with many years of experience.

I spoke with a charge midwife, who talked fondly of her 15 colleagues - nurses, midwives and nurse aids. They did their best to manage their unit, which averaged 1400 births annually, had high acuity, limited resources and staffing issues. She was passionate about her people and the driver to attend this conference was to upskill and apply a train-the-trainer perspective. It prompted me to wonder what brought others here and their stories.

It was calculated the midwives sitting around our table collectively had approximately 200 years’ midwifery experience. I heard of the many disparities between the midwifery I am privileged to learn and practise in Aotearoa and the experiences of my fellow Pacific sisters and elders from across the Pacific region.

Over the two days of the workshop, I sat with my ears and heart open to all the stories I heard. When I reflected back on my overall experience, I was taken back to how we opened the workshop on the very first day - with gratitude. Gratitude for the wealth of knowledge

and skill our Pacific sisters freely shared. Gratitude for Aotearoa's model of care that enables midwives to be autonomous practitioners. But most importantly, gratitude in the knowing that if I have the opportunity to travel to any of the Pacific Islands, welcoming open arms will greet me due to bonds formed with these like-minded Pacific sisters.

The workshop was about leadership and that was truly evident in the intentional service these amazing Pasifika midwives spoke about in their daily lives. The variety of presentations to strengthen midwifery covered curriculum development, organisational leadership models, student-centred education approaches, ICM Pacific region support, Pasifika Midwives Aotearoa’s Aunties, which was warmly received, and lots of exciting research happening.

The Pacific region is fertile ground to plant homegrown ideas. Often due to a lack of resources and desperation to make a difference to save lives, true creativity springs and can flourish, e.g. PNG 2023 pop. 9,501,006, Maternal Mortality ratio/100,000 LB (2010-2023) 215. Neonatal Mortality rate/1000 LB (2010-2023) 20.

Check out the ICM’s or Burnet Institute’s website for PNG’s ‘Safe delivery’ app.

O le ala ile pule o le tautua.

The pathway to leadership is through service. square

THE RISE OF FREEBIRTH IN AOTEAROA

More whānau are choosing to have a planned unassisted birth, also known as freebirth (or wild birth) in Aotearoa, reflecting a growing international movement. Multi-layered and complex to address, Amellia Kapa explores it from different perspectives, speaking to both midwives and birthing whānau about their experiences, concerns, hopes and regrets. Aku mihi whakawhētai ki ngā wāhine kua tukuna mai ō rātou wheako hei tūwheratia tēnei wānanga / My gratitude to the women who’ve gifted their experiences to open this dialogue.

By its very nature, the prevalence of freebirth is impossible to quantify. Saying it’s on the rise, therefore, feels misleading. After all, how do we really know? The answer is, technically, we don’t. Or at least, we don’t have access to concrete data confirming how many whānau are choosing this option in Aotearoa. But the College can confirm it’s hearing from both midwives and whānau wanting to discuss freebirth and its implications.

College Midwifery Advisor Claire MacDonald says the numbers seem to be rising. “Advisors have received increasing volumes of calls over the last couple of years from midwives about clients - or prospective clients - indicating some level of planned unassisted birth. Calls have also been received from women experiencing difficulty accessing midwifery care that supports their birth preferences, particularly for planned homebirth.”

“We’re seeing a spectrum of scenarios,” Claire continues. “Some whānau are still wanting antenatal visits so they can ask the midwife questions, but are declining blood tests, scans, fetal monitoring, or abdominal palpation. Others are intending not to call the midwife in labour unless they need something, or they may want the midwife to be present for labour, but only to undertake very limited aspects of care; not listening to the fetal heart, not doing any routine maternal observations, but being in the house in case the baby needs resuscitation.”

Claire notes there are a myriad of reasons why increasing numbers of people might be choosing to explore the option of freebirth, and that College advisors and midwifery colleagues in Australia have noticed some overlapping themes underpinning people’s motivations.

One is a wish to avoid services where previous trauma was experienced, such as perineal injury, operative birth, racism or cultural unsafety. These experiences can lead whānau to feel that an unassisted birth within their existing support structures may be safer for them. Lack of access to homebirth midwifery care has been identified as another reason, where whānau wish to engage

AMELLIA KAPA REGISTERED MIDWIFE

"Obviously freebirth is largely hidden from mainstream maternity care, because they don’t want us, so we don’t usually know about them. But I’m increasingly aware of whānau who are opting for homebirth in the face of more and more complexity, and then opting for freebirth when they’re unable to find care that meets their needs.”

about them. But I’m increasingly aware of whānau who are opting for homebirth in the face of more and more complexity, and then opting for freebirth when they’re unable to find care that meets their needs.”

And while Bronwyn is respectful of the fact that many whānau choosing freebirth are motivated by something deeper, she also points to another group being influenced on a more superficial level. “I don’t say this to be dismissive of the choices whānau are making, but I also believe there’s a ‘vibe’ or buzz around freebirth at the moment. There are a number of Instagram accounts and Facebook pages filled with beautiful photos of people birthing unassisted and lots of lovely stories. I think there’s an element of romanticism about it that’s capturing a particular mood around slowing down the pace of life and returning to more of a natural way of living, and all of that’s feeding into a group who are deciding based on an image of something, which I think for us as midwives is a little bit scary.”

see whānau making an active choice not to engage with publicly-funded care that’s designed to support their needs, then we need to look at what we are offering and ask why, and ensure our services are accessible,” Claire says.

As Claire points out, at its core, our maternity system is designed to be protective. “Our system is set up to enable whānau to have individualised care that meets their needs. It’s also highly integrated, so for those who want a homebirth but need to transfer, their midwife can continue with them into a hospital setting. Their care plans can be maintained. And if they don’t feel the care provider is meeting their needs, they have the right to change.”

with midwifery care but either cannot find a homebirth midwife due to geographical isolation or the workforce shortage, or the existing care relationship is ended due to lack of agreement between the midwife and family about a birth plan.

A philosophical approach to freebirth or ‘wild birth’ is another reason, associated with the wellness movement and a sense of selfresponsibility and self-actualisation. An antigovernment/anti-system sentiment has grown in some communities since the Covid-19 pandemic response, including a rejection of midwives as part of the system. Perhaps lesser known are sovereignty movements, where people aren’t engaging with health services at all, because they don’t want their babies registered as part of the citizenry. This has been seen around the world and is understood to be happening in both indigenous and non-indigenous settings.

Bronwyn Fleet, a Rotorua-based LMC, has practised in the region for the last eight years. She confirms an increasing number of birthing whānau are approaching her for unofficial advice, or piecemeal maternity care, and acknowledges the same underlying motivations for women seeking to opt out.

"Obviously freebirth is largely hidden from mainstream maternity care, because they don’t want us, so we don’t usually know

The issue made headlines in Australia earlier this year, when twins born prematurely in an alleged ‘wild birth’ in Byron Bay both died. This was the latest in a string of mainstream media explorations regarding the increase of freebirth, including several news reports of perinatal deaths and at least one maternal death associated with planned freebirths in Australia. The College is also aware of some tragic outcomes associated with planned freebirth in Aotearoa, and CE Alison Eddy was recently interviewed on RNZ’s Nine to Noon about the phenomenon. Midwifery academics like Australia’s Professor Hannah Dahlen and the United Kingdom’s Professor Mavis Kirkham have also been writing and talking about the topic for a few years now, acknowledging the same underlying motivations as we are seeing here.

In countries like Australia and the UK, it appears the increase in freebirth is greater than in Aotearoa. This is perhaps not surprising given continuity-of-care is not the norm and homebirth services are not universally funded or available in other countries. But there are enough reports in Aotearoa that we need to ask what’s going on, when our maternity system is midwifery-led, fully funded, and based on a foundation of partnership and being whānau-centred. The undeniable truth is, not all whānau are experiencing maternity care in the way the model was intended to offer. “I would say when we see this happening, when we

In some cases, however, care provision does not meet women’s needs and, as Tania’s* story illustrates, it can be challenging to navigate the maternity system, particularly as a first-time mum. Currently preparing to freebirth her fourth baby, Tania is full-term at time of writing. Her decision to plan an unassisted birth is the direct result of trauma she experienced in her first and second births, in addition to being treated “like a number” while receiving treatment for a cervical ectopic pregnancy.

Like many first-time mums, Tania navigated the process of finding a midwife in her first pregnancy with no experience, not knowing what she didn’t know. She admits she didn’t ever feel she really “gelled” with her midwife, and notes her husband stated he didn’t like her, but as many first-time parents do, they continued, not really knowing they could change care provider and not realising the implications of continuing with an LMC who wasn’t a good fit for them. They went along with her recommendations, like a postdates ultrasound at 41 weeks’ gestation and, once in labour, agreed to an ARM at home to “speed things up”.

On discovering meconium-stained liquor following the ARM, Tania agreed to transfer to hospital, had her labour augmented, and ultimately, birthed her first baby via an emergency caesarean section. Postnatal depression followed and Tania planned a HBAC (homebirth after caesarean) for her second baby, again engaging midwifery services. Her second labour progressed well at home, but after pushing for two hours and sensing her midwife’s increasing anxiety, an exhausted Tania agreed to be transferred into hospital and was once again told she would be prepared for theatre, only to feel rectal pressure once her epidural had been

sited. Her second baby was born vaginally, following an episiotomy and ventouse. Again, postnatal depression crept in and Tania found herself feeling like a failure.

The road to healing got even harder for Tania, who then suffered three miscarriages in one year. “In that year I did a lot of processing and worked through a lot of my trauma. I had always thought the first birth went badly because I didn’t have the right support, but in actual fact, I realised I had been looking for someone to save me. I’ve now worked out that I don’t like being watched when I’m in labour. Not at all. Not even by someone I like. Looking back, I feel being observed was a huge hindrance.”

Together with her husband, they made some choices. “We figured out what had gone wrong was I’d handed my power over to the midwife. So for our third, we decided we weren’t going to get a midwife at all; we weren’t going to have any antenatal care, or any scans. It was the most cruisy, lovely, stress-free pregnancy.”

Tania’s third child arrived in the wee hours of the morning, following a six-hour labour. “I got to transition and I begged the baby for a break. I remember everything stopped, I went above my body and everything became crystal clear. Then I got this massive contraction, the ejection reflex kicked in and in three contractions, she was out. My husband caught her, our older girls watched, and it was the most amazing, healing experience. I did it; I grew that baby and birthed her all by myself. The post-partum was calm and even, and I experienced no depression or low mood at all.”

And while one can’t help but be overjoyed for Tania - who finally got the birth she’d always been entitled to - as a midwife, there’s a heartbreaking realisation that although we pride ourselves on our maternity system, some whānau out there are not experiencing what the model was established to provide.

Bronwyn reflects on how whānau experience could potentially be improved. “I think the first thing we need to do as midwives - and it’s probably the hardest - is to look at the way we engage with women. I think we need to look at the way we present recommendations and revitalise our understanding of - and belief in - women’s autonomy and rights to determine their own circumstances. And I hope that we can be a bit braver in supporting women in what they need, rather than what we think they need, or what we as midwives need. So, I do

think there are things we can do, but it’s not necessarily easy and I don’t know that there’s a great will among the midwifery workforce to do that, for multiple reasons.”

Claire suggests revisiting our foundations is a great place to start. “I think it’s really important that midwives explain what our role actually is. It’s a great reminder for us to go back to the basics of who we are, what we can offer, and what the benefits can be.”

Furthermore, taking the time to really explore what matters to whānau usually leads to feelings of mutual respect and trust, as Claire elaborates. “This involves very skilled communication on the part of the midwife and it’s not just about finding a midwife willing to support the woman to birth at home, but teasing out what’s important to the whānau and what their concerns are.

Sharing information to support informed choice is a cornerstone of our practice, however in the context of freebirth, this needs to be a very nuanced and sensitively conducted discussion, so that whānau both understand the skills that midwives bring to birth, and the reason why midwife attended births are recommended. At the same time, it’s important that communication is not perceived as coercive or persuasive. It’s a delicate balance, and building trust and rapport must be front and centre.”

“When there are significant risk factors and women are reluctant to give birth in a hospital setting,” Claire continues, “getting to the bottom of what’s important for the woman and her whānau during birth, and considering how these needs can be met within a facility setting can make a difference. Midwives have always had a role

in advocating for women’s choices in birth through communication and three-way conversations with obstetricians and other healthcare providers. We need to take time to listen and understand what’s important, so we can identify and advocate for the things that matter to women, people and whānau in any setting.”

Eliminating judgment from these conversations is another critical factor, Tania explains. “Most of the women I know who choose freebirth are educated people who want to make intuitive, intelligent decisions and take responsibility for their bodies and babies. We’re often painted as naïve; a bit stupid and irresponsible, and as if we don’t care about our babies, but that’s not at all true. It would be really nice if that stigma could be addressed.”

Having now had two births in hospital and one freebirth, Tania has no regrets surrounding her decision to freebirth her last baby, nor any doubts surrounding her

upcoming freebirth. “I feel that if I have someone in my birth space who is there to be a health professional, I’ve handed my power over, therefore I wouldn’t be listening to my own intuition. We know a midwife who would tick those boxes of being respectful and hands off, but I still don’t want anyone else there. I relied on other people in the past and it didn’t work for us.”

While Tania’s choices are the result of previous trauma, freebirthers are not a homogenous group, and in some cases, decisions are being driven by workforce shortage. Hana Tapiata grew up in Rotorua, immersed in te ao Māori and deeply connected to her whakapapa. In 2021, when she and her partner discovered they were hapū, Hana went for a scan, revealing she was due on the 23 December - a date synonymous with struggle for any whānau hoping to find a midwife available over the festive season. Unsurprisingly, Hana’s six phone calls to prospective

midwives were unfruitful and a journey of exploration began.

“I was born at home, so I wanted to birth my own babies at home,” Hana explains. “But there were no midwives available, and the hospital was an absolute last resort for me; my association with hospitals is it’s where you go when you’re unwell, so I didn’t want to bring new life into that – it conflicted for me. I didn’t know what to do and I was telling a friend of mine, and she suggested freebirthing.”

Looking into other options is understandable when choice is limited, as Claire illustrates. “When there is a workforce shortage and whānau can’t find a midwife to support a homebirth, it can feel like they have a binary choice – either have the birth they want but without assistance, or put their birth plans aside to be able to access maternity care in a hospital setting. There should be enough midwives in the community so whānau can find a homebirth midwife to support them.”

“I started to investigate more and fortunately there was a wahine on Instagram sharing her process who was about three or four months ahead of me,” Hana continues. “I did more research, and it felt like it was a good thing to do. And I have a long history of doing things that feel right,” she laughs.

“I started to buy books, read, watch, and fortify my mind, to trust in the process,” she explains. “That same friend gave me Bronwyn’s number, because she’d heard Bronwyn was a midwife who supported māmā choosing to freebirth and could potentially come around afterwards to check that we were both ok. I reached out to Bronwyn and she said she’d be available and to call if we had any questions, so that was another factor, especially for my partner and mum, who really weren’t sure whether it was a good idea.”

One December night in 2021, Hana’s labour started and after around 19 hours, she birthed her daughter in a pool at home with her mum and partner present. Both Hana and pēpi were well and around an hour and a half after pēpi had arrived, Hana called Bronwyn as her whenua hadn’t birthed yet. Bronwyn visited the whānau, talking through Hana’s options of either receiving an oxytocic, or waiting. Hana’s preference was to wait, so Bronwyn went back around the following morning, at which point she worked with Hana to guide the whenua out.

Hana has no regrets about freebirthing her first baby, yet when she discovered she was hapū with her second baby, she contacted Bronwyn, seeking midwifery care. “I went into it wanting the full experience. Even though I didn’t need to, because I’d already done it without the regular checks and monitoring, I wanted to experience something else along that birth continuum.”

Knowing Bronwyn’s capacity to provide respectful care was a huge factor for Hana. “Bronwyn engaged with me as though I had made good decisions and I could be trusted. When she shared information or asked questions, it was always respectful of my mana, or mauri, and never felt as though it was dismissive. She never spoke down to me,” Hana explains.

“Her ability to do that, I believe, comes from her knowing she has a wealth of knowledge to give, but also understanding she doesn’t need to impose it on others. I always got the sense that she trusted me to make good decisions for myself, my baby, and my whānau. Her approach was like ‘I have more information if you want it, and if you don’t, that’s ok too’.”

Hana also appreciated having some gaps filled in the second time around, laughing about what she calls the state of “blissful ignorance” she and her partner were in for the birth of their first pēpi. “I’m glad we had Bronwyn and that she was available when we found out we were hapū again. There were so many things we didn’t know the first time. It was great to have a comparison with our second baby and with Bronwyn as our midwife, who was so clear that we were leading everything and she was only there to guide or offer counsel if there were decisions we needed to make.”

No stranger to the development of mental agility, Hana’s experiences years earlier as a top-level rugby player led her down a path of self-discovery; a path which has served her well in her transition to motherhood. “In 2015, I injured my shoulder. I was this rugby player wearing the black jersey and then all of a sudden I couldn’t play, so I had this identity crisis. I really leaned into our kōrero and tūpuna mātauranga to build myself back up, and one of the things I discovered about myself was I’d been conditioned to be independent; so hyper-independent that I didn’t think I needed anyone.”

“Even though it may be true to a certain degree - that you don’t technically need anyone,” she continues, “when you do things by yourself, alone, you can miss out on so many amazing things. You can still retain your mana and ask for help, and if anything, it enriches you. That’s one of the key things I’ve learned from my birth experiences.”

And in a world where increasing references are being made to freebirth as a means of embodying mana motuhake, or returning to the ways of our tūpuna, Hana, who hosts a podcast called The Whakapapa Effect, and has written a self-help book based on tūpuna knowledge, encourages whānau to exercise caution. “In all spheres of te ao Māori, there seems to be an interpretation creeping in, of mana motuhake meaning all by myself, rather than accepting support. If you’re going to refer to our mātauranga, you can’t rule out things that don’t suit your interpretation. We had tapu surrounding birth, and we had birth keepers,” she clarifies.

And while Hana has no desire to actively promote freebirth, saying the decision is a very personal one, she acknowledges the broad range of circumstances out there and how fortunate she was to have had positive experiences both times. “It’s about being sensitive to others. I have friends who have had traumatic births and for all intents and purposes, my freebirth was a dream run. But that’s not the case for everybody.”

Asked if she felt any less empowered during the birth of her second baby with Bronwyn present, Hana is clear midwifery care was in no way obstructive to her process. “I had recorded an affirmation track for myself, so I was listening to that during contractions, to reaffirm that trust in myself. When I went in with Bronwyn second time around, that trust was still there and what she and the student midwife, Sandy, provided was complementary to that. It wasn’t that I needed them to guide me through the process, I could do that myself. They were joining me for the ride.” square

*A pseudonym has been used to protect the anonymity of this māmā.

what does this mean for midwives?

Midwives know undisturbed labour and birth is likely to result in a physiological birth and a positive experience for the whānau (if this is what they want), so freebirth will often go well, but we also know there are risks associated with birth; if this wasn’t the case, there would be no need for midwives or obstetricians. We also know planned homebirth with care from a midwife is a safe option for many whānau, which is different to planned unassisted birth.

Midwifery is described as both an art and a science, and this is particularly the case for conversations around supporting informed decision-making for pregnancy and birth. Putting the partnership model of midwifery care into practice requires time and skilled communication, and our professional frameworks (Standards of Practice, Philosophy, Code of Ethics, Tūranga Kaupapa) can support us in practice. This includes sharing information when risk is increased and making recommendations for evidence-informed care in line with our clinical guidance. Sharing recommendations does not oblige whānau to accept them - they have a right to decline recommended care and to be supported in their informed decisions, with dignity and respect.

With the apparent increase in freebirth, the National Board has decided a new College consensus statement on planned unassisted birth should be a priority. The statement has just undergone member consultation and the Board will consider feedback at its next meeting. The statement articulates the importance of midwifery care, advocates for maternity services to ensure whānau have access to homebirth care, and offers information to support midwives in their practice. square

With the apparent increase in freebirth, the National Board has decided a new College consensus statement on planned unassisted birth should be a priority. The statement has just undergone member consultation and the Board will consider feedback at its next meeting.

Midwife manager Kelly Kara (left) and midwifery student Kerianne Harmon-Becks (right) help Minister of Health Hon Dr Shane Reti cut the ribbon at the opening of the birthing unit.

kurawaka: waipapa opens its doors

The long-awaited opening of Kurawaka: Waipapa in April marked the end of a 13-year journey and the beginning of a new era for birthing whānau in Ōtautahi and the wider Waitaha region. Executive Director of Midwifery Canterbury and West Coast, Norma Campbell, acknowledges that the need for a primary birth unit in central Christchurch was first identified back in 2010, when Burwood Hospital’s primary birth unit closed after the Canterbury earthquake. Since then, the St. George’s primary birth unit has shut its doors, limiting choice even further for birthing whānau in Christchurch city. Further afield, the Christchurch area is well supplied with community birthing units in Rangiora to the north and Oromairaki in Rolleston to the southwest (replacing Lincoln Maternity).

AMELLIA KAPA REGISTERED MIDWIFE

“Our communities have been telling us very clearly for some time - not just tāngata whenua but also our Pasifika, Indian, refugee and LGBT communities - that we needed to change how we delivered maternity services, reiterating the need for a community birthing unit in the central city, and one that was whānaufocused,” Norma says.

Located less than five-minutes’ drive from Christchurch Women’s Hospital, Kurawaka: Waipapa is a community birthing centre comprising four birth rooms, 20 postnatal rooms, six clinic rooms and an education room. Ten of the postnatal rooms boast double

beds, with the other 10 containing single beds to accommodate recovery following caesarean sections. Norma describes the road to the centre’s opening as long and challenging but, much like labour, well worth the wait. She points to the model underpinning its establishment - a te ao Māori influenced modelas its best feature. “If you work at Kurawaka: Waipapa, you work within a te ao Māori-influenced model of care; you’re part of something bigger. And everyonestaff and birthing whānau alike - can exercise their own tino rangatiratanga. It’s part of the fabric at Kurawaka: Waipapa.”

College Māori Midwifery Advisor and Chair of Māori Midwives ki Tahu, Jay WaretiniBeaumont, is clear on what Kurawaka: Waipapa represents for the local Māori birthing population. “For whānau Māori in Christchurch it means we now have an accessible unit, built on the principles of te ao Māori. When they enter the space, they’ll be able to see a reflection of themselves imprinted into almost every aspect of the building - from the artwork, to the furnishings, through to the model of care itself. Māori

Midwives ki Tahu have been involved in every step of its development and we’ve come full circle to be alongside mana whenua for the whakamoemiti (blessing) and opening.”

Ngāi Tūāhuriri of Tuahiwi gifted the centre its name; Kurawaka refers to the tapu region of Papatūānuku from where the first human, a woman named Hine-ahu-one, was formed. And Waipapa acknowledges the braided rivers running throughout Waitaha. True to te ao Māori principles, the name acknowledges

the connection between whakapapa, whānau and whenua and the way mauri (life force) flows through and between all of them.

Jay acknowledges the privileged position she and other Māori Midwives ki Tahu members found themselves in at the opening of Kurawaka: Waipapa. “The majority of Māori midwives working and living in Waitaha don’t whakapapa here, so connecting with mana whenua has required more effort, but we were welcomed whole-heartedly, with open arms by Ngāi Tūāhuriri so that we could stand alongside them as the building was blessed and officially opened. It was an absolute honour for us.”

Having been involved since the beginning, Jay is not only proud of what’s been achieved thus far, but equally optimistic about what the future holds.

“The completion and opening of Kurawaka: Waipapa speaks to what we can achieve. We now have whānau cared for within a model that positions aroha and manaakitanga firmly at the forefront, because Māori Midwives ki Tahu have been involved every step of the way. We’ve imprinted our whakaaro into every aspect, including admission criteria, to ensure everyone is aware of their responsibilities and we’ve been able to bridge that gap between what whānau need and modern maternity services.”

Norma highlights the significance of Kurawaka Voice, a report produced in 2023 following extensive community consultation and which outlines the values Kurawaka: Waipapa staff are required to embody and guides the recruitment process. “Recruitment

“Our communities have been telling us very clearly for some time – not just tāngata whenua but also our Pasifika, Indian, refugee and LGBT communities – that we needed to change how we delivered maternity services, reiterating the need for a community birthing unit in the central city, and one that was whānaufocused,” Norma says.

Rooms at the new Kurawaka: Waipapa Birthing Centre.

a legacy of leadership and change: norma campbell, remarkable midwife and renowned midwifery leader steps down from full time work

After 43 years of service to midwifery in New Zealand, Norma Campbell is looking forward to stepping back and spending more time with her husband, children, and ten-month-old grandson Theo.

Norma’s wealth of knowledge and experience with all aspects of the profession paved the way to leadership roles. She trained originally as a nurse at Christchurch’s Princess Margaret Hospital before deciding to specialise in midwifery and training at the Royal Maternity Hospital, Glasgow. One of the initial wave of midwives to work as a self-employed community midwife after the law changed in 1990, Norma went on to become midwife manager of the Burwood Birthing Unit in Christchurch.

Norma joined the College as a Midwifery Advisor in 2000, providing advice and support for members, managing the College’s quality assurance processes, representing the midwifery profession in national forums and deputising for the Chief Executive. Norma has held several national leadership roles during that time and since, including being the inaugural chair of the National Maternity Monitoring Group in 2012 and Chair of the National Breastfeeding committee.

In 2017, after 17 years at the College, Norma took up the role of Director of Midwifery for Canterbury and West Coast district health boards. Norma knew when she moved to the role that reducing the pressure on the tertiary unit and supporting normal birth would be her challenge, one that she accepted with her usual tenacity and passion. Norma has much to be proud of throughout her stellar career, including the establishment of the Midwifery Assessment Unit (MAU) at Christchurch Women’s Hospital, as well as the network of community maternity units and the newly opened Kurawaka: Waipapa unit which is tribute to her vision, perseverance, and leadership.

Norma has proven that when leadership and decision making holds the birthing whānau at its core much can be achieved. It was this philosophy that earned Norma the MNZM for her contribution to women’s health and maternity in 2009.

We are privileged to have worked with you Norma and on behalf of College members we thank you for your service and wish you the very best in your transition from full time work. We know you still have much more to contribute to midwifery over the coming years. square

is based on an expectation that staff have a pepeha, some basic te reo Māori and are understanding of, and working in, a bicultural way,” she explains. “That ensures staff will be receptive to what whānau might need and, in turn, will treat each other with the same respect and consideration they’re extending to whānau walking through the doors.”

Norma is also quick to acknowledge the substantial mahi done by staff at the tertiary unit over this past decade during Kurawaka: Waipapa’s long gestation. “The team at Christchurch Women’s Hospital have done a remarkable job as a tertiary centre, providing care for mothers and babies as best they can. They have been running over capacity with a couple of thousand more births per year than they were built to cater for,” she explains.

But with Kurawaka: Waipapa now operational, its purpose is clear, and overburdening the hospital is set to become a thing of the past. “The vision is that all women without risk factors no longer go to Christchurch Women’s Hospital at all. And even for those women who might require an antenatal obstetric consultation, Kurawaka: Waipapa isn’t necessarily ruled out. Our obstetric team have reviewed the Referral Guidelines and agreed to a specific set of situations where they’ll see women for their consultation as required, but then recommend birth at Kurawaka: Waipapa because of its proximity to the hospital.”

Providing whānau with another option should ensure hospital staff are in an even better position to provide secondary or tertiary-level care if or when it’s required, Norma continues. “We’re asking women to come to Kurawaka: Waipapa first and, if they want or need an epidural, their car is parked right outside the door, so if they need to transfer, they jump in their car and five minutes later they’re at Christchurch Women’s, where the team will be waiting and able to care for them.”

Opening a new birth centre is no small feat, especially considering the constrained fiscal environment in recent years, which speaks volumes about Norma’s visionary and tenacious leadership to get the project across the line. But Norma insists this project was a collective one, from inception to completion. “You can’t do things like this without tāngata whenua, the wider community, or your entire workforce, which includes hospital midwives, LMC midwives, obstetricians, anaesthetists, neonatologists and everyone in between.”

Her approach, as the centre embeds itself into the community, is one we can all appreciate. “We all need to be in the same waka; this is a journey we travel together and it’s not without its challenges, which means we need to get even better at truly listening to one another.” square

Norma Campbell shows Hon Dr Shane Reti through the unit at the opening ceremony.

Central Destruction Unit (CDU)

A leading-edge system designed to collect and decompose large volumes of N2O.

• Accommodates several treatment rooms simultaneously

• Contributes to a healthy working environment for personnel

• Eliminates more than 99% of N2O entering the unit

• Low noise level and no vibrations

• Low energy consumption

M Mobile D Destruction Unit (MDU) Designed with the mobility needs of healthcare professionals in mind.

• Easy maneuvered between treatment rooms

• Contributed to a healthy working environment for the personnel

• Eliminates more than 99% of N2O entering the unit

• Low noise level and no vibrations

• Low energy consumption

Healthcare Goes Green: Innovative Technology Tackles Nitrous Oxide Emissions

Nitrous oxide (N2O), often called Entonox, Equinox, or laughing gas, offers pain relief benefits to patients undergoing labour or other procedures. It's particularly valued for its self-administration capabilities and rapid onset of action. Internationally, nitrous oxide is favoured because it allows patients to manage their pain while remaining mobile and without constant monitoring. However, nitrous oxide is a greenhouse gas so responsible use is crucial for both workplace safety and environmental protection.

SHAPING A GREEN FUTURE IN HEALTHCARE

As previously discussed in our earlier revisions (December, 2023 & March, 2024), to achieve New Zealand's net-zero goal and create a safe environment for health practitioners and New Zealand's wider community, we must explore safe and responsible ways to utilise nitrous oxide. Pioneering solutions for N2O since 2013, Medclair has reduced emissions and created a safer and healthier environment for healthcare professionals through technical innovation. As Medclair’s exclusive partner, Keyport delivers advanced N2O technology, optimising healthcare experiences throughout New Zealand.

INNOVATIVE TECHNOLOGY SOLUTIONS FOR TACKLING N2O

Medclair has developed innovative technology solutions for collecting and decomposing the N2O. When a patient that is using nitrous oxide exhales, the air enters the device and through a catalytic process breaks down the N2O into harmless oxygen and nitrogen - the main constituents of regular air. This purified air is then safely released into the atmosphere. The technology comes in two variants, each designed to address different client needs.

A FLEXIBLE SOLUTION FOR SMALL CLINICS

Already trialled and proven in many New Zealand hospitals, the Mobile Destruction Unit (MDU) has been designed with the mobility needs of healthcare professionals in mind. This mobile device represents an intelligent solution that can be effortlessly relocated between labour rooms. The MDU effectively collects residual nitrous oxide from the patient’s exhaled air and decomposes it in a self-supporting system with minimal energy consumption and low noise output. Over 99% of the nitrous oxide entering the system is purified by the MDU, creating a safer work environment for healthcare professionals, and significantly reducing the climate impact.

EFFECTIVE MULTI-ROOM SOLUTION

The Central Destruction Unit (CDU) is a leading-edge system designed to collect and decompose large volumes of nitrous oxide. This is the

most efficient method for destruction of N2O in healthcare settings that administer nitrous oxide to several patients simultaneously, such as larger maternity wards. The CDU is integrated with a fan system that connects evacuation points from each labour room. Exhaled N2O is then evacuated into the CDU, where more than 99% of the N2O entering the unit is broken down into oxygen and nitrogen. The CDU system features an impressive combination of low energy consumption and user-friendly design, with a virtually noiseless and vibration-free operation.

Regardless of the facility's airflow and inspiration technology, we offer tailor-made solutions to meet the unique needs of every client.

BUILDING A GREEN FUTURE IN HEALTHCARE

Committed to creating a sustainable future for healthcare in New Zealand, Keyport offers Medclair’s smart technology to significantly reduce N2O emissions in maternity units. This not only protects healthcare professionals from potential health risks but also safeguards the environment from this potent greenhouse gas.

THE CLIMATE CRISIS DEMANDS IMMEDIATE ACTION

We urge you to take a step toward a greener and safer work environment. Create a healthier work environment for your staff and revolutionise your healthcare facility. Contact Keyport today to schedule a free consultation and discuss how Medclair’s technology can transform your maternity unit.

KEYPORT, is a 100% New Zealand-owned family business dedicated to serving the needs of the New Zealand Healthcare Industry and maintaining its reputation for market-leading and innovative products that break the norms of the industry. Keyport is dedicated to providing delivery suites and birth centres with a safe and green work environment and has produced reports and datasets that drive the need for change to nitrous oxide control measures. To learn more about Keyport and how you can help reduce your carbon footprint please contact us. www.keyport.co.nz www.medclair.com

DR CHRIS MOYES MEDICAL DIRECTOR HEPATITIS FOUNDATION

NICOLA CAINE NURSE PRACTITIONER HEPATITIS FOUNDATION

HEPATITIS B VIRUS AND MANAGEMENT FOR PREGNANCY

An estimated 240 million people worldwide have chronic hepatitis B. More than one million people die from it every year. The disease is a global health burden with significant morbidity and mortality. Up to 40 per cent of people with the virus will develop chronic hepatitis B (CHB) and face possible liver-related complications such as cirrhosis, liver failure and hepatocellular carcinoma (HCC).

In 2018, an estimated 93,604 New Zealanders were living with CHB - nearly two percent of the population. In November 2019, 17,784 New Zealanders with CHB were registered on the national monitoring programme, representing just 19 percent of the country’s estimated total hepatitis B population. In 2024 there are now almost 20,000 people enrolled. New Zealand data has shown nearly 40 percent of patients who presented with advanced hepatitis B-related HCC were not aware of their condition at the time. This suggests there are a lot of people living with undiagnosed hepatitis B virus (HBV) in New Zealand.

WHAT IS HEPATITIS B?

HBV is transmitted through exposure to infected blood, semen and other bodily fluids. It may be acute <6 months or chronic >6 months. Hepatitis B has an incubation period of 30-180 days. It is a DNA virus that is more resilient than RNA viruses such as hepatitis C and HIV; it can live outside the body on any surface for at least seven days. HBV is the world’s most common serious liver infection and the leading cause of liver cancer. A vaccine is available.

VERTICAL TRANSMISSION

HBV doesn’t usually cause problems for pregnant women and their unborn babies. However, for a baby born to an HBV-positive woman, there is a risk of mother-to-baby transmission as high as 90 percent if no prophylaxis is given.

• Vertical transmission predominantly occurs during labour, but can also happen with threatened abortion or amniocentesis (low risk)

• The risk of transmission increases with higher virus levels (HBV DNA viral load) and for those who are e-Antigen positive.

HBV MANAGEMENT IN PREGNANCY

Women may come into pregnancy knowing they are living with HBV, while others may have HBV diagnosed for the first time during pregnancy. Hepatitis B Surface antigen (HBsAg) testing is routinely offered in early pregnancy as part of the first antenatal screen for each pregnancy, even if previously tested or vaccinated. If testing is done by a GP, the LMC or antenatal midwife should ensure HBsAg has been tested for.

HEPATITIS B SURFACE ANTIGEN - HBsAg

HEPATITIS B E-ANTIGEN - HBeAg

Determines whether there is continued viral infection. Everyone with positive HBsAg should be referred to The Hepatitis Foundation.

This checks the status of infection. A positive result indicates the virus is in the more active form and means HBV DNA is more likely to be at much higher levels.

ALPHA-FETOPROTEIN - AFP Is a biomarker for liver cancer but is also elevated in pregnancy.

LIVER FUNCTION TESTS - LFTS

HBV DNA

Midwives should familiarise themselves with local referral pathways for those with a positive result; in most cases this will be by obstetric referral for triage to the relevant service (in some regions this will be the hepatitis/gastro service). For all women who are HBsAg-positive, full HBV serology testing - HBeAg, liver function tests (LFTs) and HBV DNA (viral load)(explained in Table 1) should be offered in early pregnancy – this may be done by the LMC/caseloading midwife or the service receiving the referral. The Referral Guidelines indicate three levels of referral:

• Acute: consultation

• Chronic Active: consultation

• Active chronic on immunosuppressants: transfer

Testing undertaken after initial referral to the obstetric service will help determine which category the woman fits within, and what recommended follow-up should be. Those with high viral loads (>log 7 copies per ml or >200,000 IU/ml) or abnormal liver functions (high ALT) need referral to a service able to care for high-risk pregnancies alongside specialist hepatitis services. If indicated, the woman will be offered Tenofovir (antiviral medication) in the third trimester and continue for 3-4 months postnatally. Postnatal flares can occur (ALT>x5) and need to be monitored, so discontinuing anti-viral treatment postnatally needs careful monitoring in collaboration with the initiator/prescriber of this medication.

For those women who do not require ongoing care from secondary services (those with chronic, non-active HBV), midwives are recommended to refer to the Hepatitis

Checks for active liver inflammation. HBV can be present in the absence of abnormal liver tests. Elevations in ALT can indicate the need for anti-viral treatment for the mother’s own health.

A measure of viral replication and must be requested once HBsAg confirms HBV infection. This result determines the need or not of anti-viral treatment in pregnancy.

Foundation of New Zealand (HFNZ) for education and lifelong monitoring and care. Referrals to this service are also appropriate for all women who have tested positive for HBV, either during or after completion of care from secondary maternity services.

PREVENT VERTICAL TRANSMISSION FROM MOTHER TO BABY

Offer screening for HBsAg to those who are pregnant, early in each and every pregnancy. This is usually included in initial antenatal blood panel.

• Ensure screening is undertaken for HBsAgpositive women in pregnancy for HBV DNA level >200,000 IU/L - it is appropriate for midwives to lodge an obstetric referral for triage and testing advice. The risk of perinatal transmission is greatest for mothers with high viral load.

• Offer referral to HFNZ to all who have HBsAg positive result to enable ongoing monitoring.

• As part of a consultation or transfer of clinical responsibility, women with levels >200,000 IU/ml should be offered Tenofovir at 24-28 weeks gestation until puerperium 12 weeks to reduce the risk of perinatal transmission.

• Babies of HBV positive mothers should receive Hepatitis B Immunoglobulin (HBIG) for immunoprophylaxis and HB vaccine within 12 hours of being born. It is within the midwifery scope of practice to prescribe and administer these medications. All babies should go on to have three further HB vaccines as per the New Zealand Immunisation Schedule (midwives should ensure that maternal

HBV status and the need for newborn/ infant vaccinations is communicated on handover to GP and Well Child Tamariki Ora services.)

• Failure of immunoprophylaxis can occur in babies of women with HBV DNA >200,000 IU/L and increased risk with higher titres eg >100 million IU/L.

• It is therefore important for baby to be reviewed by a GP or Nurse Practitioner at around 9 months to assess for HBV.

WHAT ARE CURRENT TREATMENTS FOR ADULTS?

Recommended medications for most patients in NZ are either Entecavir 0.5mg daily or Tenofovir disoproxil, both of which can be prescribed by GPs or Nurse Practitioners, though it must be remembered, that not everyone living with CHB will require treatment. Both are extremely effective at suppressing HBV and reduce liver damage and HCC risk with very few side effects and no interaction with other medications, but they need to be continued long-term.

Tenofovir is considered to be safest for pregnancy and is the first choice in women of reproductive age. Tenofovir suppresses HBV multiplication, thereby stopping the virus crossing the placenta to infect the baby. Tenofovir is safe for mother and baby. Women can breastfeed while taking it. It can aggravate renal failure and very occasionally causes renal tubular problems so creatinine, calcium, and phosphorus should be monitored along with periodic liver function and viral load. square

References available on request.

in summary

CHB causes liver disease, liver failure and liver cancer

It is preventable by vaccination and risks are reduced with treatment

Six monthly bloods recommended for everyone with CHB - these can be undertaken by HFNZ

Antenatal bloods sAg +ve ► obstetric referral ► also refer HFNZ ► LMC or secondary services to arrange HBV DNA testing if required

Midwife to prescribe and administer HBIG and birth dose vaccine within 12 hours for baby of HBV-positive mother

Midwife to ensure HBV status communicated to GP and Well Child Tamariki Ora provider in postnatal referrals

Midwives are recommended to refer all HBV-positive women and people to the HFNZ, which offers patient surveillance and advice for patients and professionals. By referring your client we offer free:

- Confidential national follow-up programme for people with CHB

- Regular monitoring of HBV (vital in detecting early liver cancer)

- Six-monthly follow-up of CHB patients to help reduce the risk of liver disease

- Education and support to people living with or impacted by CHB

- Information on lifestyle and treatment, contact with a community hepatitis nurse and referral to secondary care (if required after maternity care is finished)

- Advocacy for clients living with CHB.

To refer your client or for more information contact The Hepatitis Foundation by calling 0800 33 20 10, email hepteam@hfnz.nz or visit hepatitisfoundation.org.nz, HFNZ have a number of resources in multiple languages. square

Midwives invited for study on bullying

Are you a midwife (registered/enrolled) who:

• Has experienced bullying in the last 5 years? OR

• Witnessed bullying in the last 5 years?

Then we want to hear from you. We invite you to take a 10-minute survey on your experiences/witnessed experiences of bullying.

Workplace bullying is a recurring issue. Research shows that it is part of midwifery culture across the world and has adverse effects on the individuals involved, the organisations, as well as on patient care. These include impacts on physical and mental health, absenteeism, burnout and turnover at an individual level, and staff shortages at an organisational and professional level. We are a team of researchers from Massey University exploring bullying in the midwifery profession, including the prevalence, experiences, and outcomes of bullying. We are seeking participants to complete an anonymous survey focussing on their experiences of bullying. Your participation will enable a deeper understanding of bullying of midwives in New Zealand and be valuable for researchers, practitioners, and organisations in addressing the issue.

Survey link: https://massey.au1.qualtrics.com/ jfe/form/SV_a2ESuAVrh1RCZUy

opportunities available!

Are you looking for a new adventure? Would you like to join an enthusiastic and supportive team and community with a lifestyle second to none? We are a small secondary rural hospital focused on providing equitable women centred care with the opportunity to provide midwifery care across the scope.

If you are a Registered Midwife and want to be part of a dynamic and committed team of health workers providing an innovative approach to healthcare in a rural setting, and you are seeking a new challenge or to broaden your midwifery experience we may have the role for you!

We are interested in what hours of work may suit you. We are happy to accommodate a range of options including full or part-time, permanent

An attractive relocation package including accommodation and travel assistance is available for both domestic and international successful

with further education and learning opportunities.

To learn more about the role, or for a friendly informal conversation please contact: Laura Ashwell, Interim Clinical Midwife Manager on Laura.Ashwell@wairarapa.dhb.org.nz +64 (6) 946-9800 ext. 4111

To apply or for a copy of the job description, please visit www.tewhatuora-wairarapa-careers.co.nz Vacancy Ref # 5473865

TE PAEA BRADSHAW MĀORI MIDWIFERY ADVISOR

re-claiming time and indigenising antenatal care a Maramataka antenatal wheel

Beverly Te Huia, of Ngāti Kahungunu and Ngāi Tahu descent, is a midwife whose career over the last 20+ years has been a mixture of clinical practice as an LMC in the Hawke’s Bay and as a researcher. I was fortunate to sit with her to discuss her latest research project. One of the research goals was ‘’to come up with a tool that enables the integration of our values, of our mātauranga within maternity care provision’’.

A Te Ao Māori (Māori world) lens is founded on whakapapa (genealogy) born from the celestial parents, Ranginui (Sky Father) and Papatūānuku (Earth Mother) - a whakapapa that connects Māori to the land, the water sources, all its inhabitants, the stars, the sun and the moon. It is this deep sense of interconnectedness that shapes our reo (language), our tikanga (ways of doing things) and our mātauranga (Māori knowledge base).

However, in Beverly’s experience as a Māori midwife and a Māori woman she explains,

It has always been assumed Western-based medical science trumps all other knowledge, but for Māori, clinical knowledge is just one aspect of our understanding, it is part of how we see something, not everything.

‘’there has always been this tension at the juncture where our values as Māori and our tikanga clash with the clinical stuff’’. She further clarifies, ”it has always been assumed, and largely still is, that clinical knowledge, Western-based medical science trumps all other knowledge … but for Māori, clinical knowledge is just one aspect of our understanding, and it doesn’t get priority, it is part of how we see something, not everything”.

It was this tension that she wanted to investigate further and that prompted her to apply for a Health Research Grant three years ago. She was successful in her application and gathered her interdisciplinary team. This consisted of Dr Anthony Cole (who has a background in accountancy), Niwa Brightwell (who has a background in weaving and also holds a business and teaching degree) and their supervisor, Dr Fiona Cram (a well-known Kaupapa Māori researcher, with a background in social and developmental psychology).

This team set out on an important journey to explore the maternity system as it is for Māori. Beverly wanted to know:

“If it was possible to integrate our mātauranga and tikanga within clinical practice. I didn’t want to write about

colonisation or be part of the obsession of describing the ‘other’, nor why our knowledge is seen as an additive, an attachment, which is frustrating and profoundly dissatisfies me. I felt as though I had written about this stuff for the last decade and I didn’t want to do that anymore”.

She says that as a team, “we decided our research would take place in Kahungunu. We felt there were enough people and participants who could contribute to the history of Māori birthing, both men and women of all ages. We did wānanga with wāhine, clinicians, kaumātua and kuia, as well as some individual interviews. Altogether we had 72 participants over the course of 3 or 4 wānanga. We never knew how this was going to land”.

As the research progressed, a strong theme emerged of water birth within Kahungunu. Whānau spoke of their elders who birthed along the many streams and awa that surround Heretaunga; there were many “birthing pools” mentioned. Another interesting story, says Beverly, “was with a kuia who explained how herself and her 14 siblings were named by their father, after the various fishing spots he was at during the time of their birth”. This sparked Beverly’s curiosity:

“How did we talk about time as Māori, how did he know when she gave birth?”.

Coincidentally, at the same time Beverly was doing this research, her daughter Maia was learning about traditional navigational studies at school. “As part of her project and my mahi, we decided to build a Māori star compass in our front paddock. From here I began to understand the profound deep, deep knowledge that our tipuna had of their environment, their place and wāhine place within it”.

“This is when my obsession with time started. I realised that everything we do in midwifery is framed around time. It’s important, it’s a clinical tool, scans, bloods, how and when we do our checks. But how did we as Māori understand our pregnancy, our babies, our body; how did we tell time pre-Gregorian Calendar?”

Generations of our ancestors have survived due to their meticulous observation, recordings and understanding of stars, lunar phases (maramataka), seasons, and the subsequent impact on tides, migration, plants, and when to hunt or fish. The maramataka, along with various tohu (signs), were known and believed to have the potential to influence not only nature but also physical performance.

Beverly’s curiosity meant “that I ended up taking a gestation wheel and updated it, integrating the maramataka. We have developed Version 1. It has had a trial in an antenatal clinic over a week, and we believe it is clinically accurate, now we can make it pretty”.

She explains that this tool “has the Gregorian Calendar/dates on it, and the gestational wheel we can turn as usual. But it also has the maramataka according to Takitimu Waka”. It is understood there are many different maramataka. “I know of at least 15 but the Takitimu maramataka was chosen as it aligns with the research, given it was conducted in Kahungunu, it aligns with the researcher and with the seasons on the East Coast”.

The colour-coded areas around the edge of the wheel are a depiction of the six seasons according to Takitimu maramataka, not four. “This is an example of Māori time.”

What does this mean for midwifery care provision? Beverly suggests that “whilst it’s just a calendar, it is also a framework, and we can now start having different discussions about hapūtanga (pregnancy), oranga (wellbeing), wahine (woman) and whānau (family). It enables our Māori midwives to have different discussions because it frames it in a different way, not just the clinical stuff. Whilst

the clinical aspect is important, it’s in the background, not at the front. It allows us to have conversations about the Māori ways of picking names, how we plan, how we predict”.

It is obvious this is just the beginning; the potential of this new Māori midwifery tool is not yet realised. In contrast, learning the Western values, ideas of medicine, science and midwifery allows Māori midwives to be registered and work within a pre-defined scope, “but it shouldn’t limit us and our ability to learn, explore and understand pūrakau and mātauranga that our ancestors had”. Beverly encourages all Māori, especially midwives, “to go out into that space, because within that space are some really amazing treasures that are yet to be discovered”.

When asked where we can see this being utilised in practice, Beverly says that it’s still early days as it was only unveiled at the Indigenous Midwives Hui on her home marae in January this year. She has been invited to present this tool at a forum in Canada in June, at which point she is hoping to take a completed ”prettier version”. Otherwise, the plan is that it will be trialled in 10 Māori midwifery clinics across the motu, before becoming readily available. square

The Maramataka antenatal wheel. Inset: Beverly Te Huia, daughter Te Iwa and friend Māhina

CLINICAL FOCUS: PAINFUL AND TRAUMATISED NIPPLES

Breastfeeding is a public health priority because it is a major determinant of short and long-term infant health, as well as being significantly important for maternal health. Prevention of clinical breastfeeding issues that may affect breastfeeding negatively is an important part of midwifery care. When there is a breastfeeding challenge, an assessment and management pathway is initiated by the midwife in collaboration with the breastfeeding woman.

In all clinical breastfeeding scenarios, there are some ‘always necessary’ actions that need to be immediately considered and addressed. The first ‘rule’ when it comes to any form of infant feeding is to (1) ‘feed the baby’, and feeding plans need to address this first while considering (2) how to protect lactation and (3) cause the least disruption to continued breastfeeding and avoid complications for the mother and the baby from any introduced intervention.

The aim of this three-pronged approach is to provide the best possible support for the mother to continue breastfeeding. Early support for challenges is essential to protect breastfeeding, and full breastfeeding assessments to diagnose breastfeeding challenges and identify contributing variables are necessary (Stuebe, 2014). Maternal stress, fatigue, despondency and pain may compromise oxytocin responses which will exacerbate the primary breastfeeding challenge – whatever that may be. In this

sense, the need to create oxytocin-releasing conditions as much as possible for mothers and their babies could be viewed as the underpinning strategy that supports all three prongs. Human touch, support and reassurance can facilitate oxytocin-mediated reduction of fear, stress and pain, as well as the promotion of joy and empowerment (Olza et al., 2020). Midwives’ support for mothers can provide this necessary empathy, empowerment and reassurance, as well as observation and evaluation. Midwives also support and facilitate mother-baby contact –including mother-baby skin-to-skin, which promotes oxytocin responses.

Painful and damaged nipples can make breastfeeding continuance very challenging, so prevention is always preferable to cure.

PAIN

Pain is one of the main reasons for discontinuation of breastfeeding. In a study of 58 postpartum day two mothers

the prevalence of nipple soreness was 97% (Jiménez Gómez et al., 2021). Seventy nine percent of women in a Melbourne study, which included 340 primiparous women, experienced nipple pain and 58% sustained some nipple damage (Amir et al., 2015). Early nipple soreness without nipple damage may be related to the new experience of a baby suckling frequently at the breast, but incorrect latching at the breast should always be considered when pain is experienced, and observation of a breastfeed/latch is essential. Tenderness can be expected at the beginning of a breastfeed up until about days seven to ten post-birth. Peak tenderness has been reported between days three and six but this is pain at the initial latch and not pain extending into the breastfeed which is not normal. Continued nipple pain indicates further evaluation is necessary.

A model was developed to evaluate local, external and central factors that contribute to the new mother’s pain experience (Amir et al., 2015) because the experience of pain is highly variable between individuals. This is a neurophysiological model which incorporates local stimulation, external influences and central modulation.

External influences such as creams and breast pumps, as well as factors related to the mother, the infant, and maternal–infant interaction, are described as potentially exacerbating the experience of pain. Amir et al. (2015) also looked at a range of factors that can modulate pain through central mechanisms, which include maternal illness, exhaustion, lack of support, anxiety, depression or a history of abuse. Emotional state, degree of anxiety, attention and distraction, past experiences, memories and other factors can either enhance or diminish the pain experience (Ossipov et al., 2010) and pain can be significantly modulated by cognitive, emotional and environmental factors (Keller, 2023). Previous traumatic breastfeeding experiences should be recognised. As previously mentioned, incorrect latching at the breast is the most common reason for nipple pain and damage, and this needs attention regardless of other influences.

CAROL BARTLE POLICY ANALYST

Early nipple soreness without nipple damage may be related to the new experience of a baby suckling frequently at the breast, but incorrect latching at the breast should always be considered when pain is experienced, and observation of a breastfeed/ latch is essential.

Amir in a breastfeeding seminar (2010) suggested some questions about nipple pain which can be asked to assist with a diagnosis of the cause of pain:

1. When does it occur - when the baby latches, during the feed, all of the feed or part of the feed? After the feed?

2. Where is the pain?

3. How would you describe the nipple or breast pain?

4. What makes it worse or better?

Answers to these questions, along with observation of full breastfeeds can support diagnosis, reduction of pain and, hopefully, resolution of the issues. Observing the actual latch, how the baby is breastfeeding, and observing the nipple when released at the end of a feed provides useful information. Other causes of painful and damaged nipples, such as nipple anatomy, infections such as thrush, milk blisters, dermatitis and Raynaud’s phenomenon, need to be considered when making a clinical diagnosis and treated accordingly when necessary (Kent et al., 2015).

MANAGEMENT STRATEGIES

Amir et al. (2015) divide nipple pain management strategies into local stimulation, external influences and central modulation.

Local stimulation – is underpinned by actions to improve healing of damage, such as dealing with a local infection on the nipple, hydrogel dressings and purified lanolin applied before and after breastfeeding.

External influences – the most important action is to improve the baby’s attachment to the breast. Also, it is important to reduce the

source of trauma such as checking a breast pump if being used and making sure it is effective and being used correctly, reducing pump friction by using a lubricant such as sunflower oil or purified lanolin, making sure the pump flange is the correct size, and reducing the strength of the pump setting. Potential irritants such as soaps should be considered as factors. In a small

There’s nothing like a common problem to spawn a whole industry of products offering solutions. If you are a breastfeeding woman who’s feeling sore, should you part with your money for glycerine gel dressings, ointments, or breast shells with lanolin? How do you know if you should trust the claims?

EVIDENTLY COCHRANESHARING HEALTH EVIDENCE YOU CAN TRUST

painful nipples in breastfeeding woman: what helps? take home points

Nipple pain is a common reason for stopping breastfeeding.

There are many products for sale to treat painful nipples, but there is evidence that putting nothing, or expressed milk, on sore nipples may be as good or better than using an ointment, for both pain and healing.

For most women in the research studies, nipple pain reduced to mild levels around a week to ten days after birth, whatever treatment they used.

Support with breastfeeding can help women avoid nipple trauma due to poor positioning and to breastfeed successfully.

number of babies, a tongue-tie may be interfering with the latch and this should be carefully evaluated.

• Observation of a tongue-tie does not necessarily mean this is the cause of nipple pain and trauma, and support with latching and positioning may resolve the issues. It is important to carefully select babies who may benefit from a referral for a frenulum release as there are many uncertainties with diagnosis, and unnecessary surgery should be avoided (Dixon et al., 2018). The release of a tongue-tie does not consistently improve sustained breastfeeding but has been found likely to improve maternal nipple pain (O’Shea et al., 2017).

Central modulation – managing pain with analgesia, improving maternal rest and sleep as much as possible, maximising the comfort of the position used for breastfeeding (the laid-back position for breastfeeding has been shown to support effective latching at the breast compared to traditional positions and may also reduce the incidence of nipple pain and nipple trauma – Wang et al., 2021), and avoiding airing the nipples if cold is a factor in the discomfort.

OVER THE COUNTER TREATMENTSWHAT HELPS?

Evidently Cochrane produced a very useful article about painful nipples in breastfeeding women and asked the question what helps? This article was updated in 2022 so reflects evidence up until that point (Chapman, 2022). Chapman in the Evidently Cochrane publication looked for evidence about over-the-counter treatments for painful nipples and whether they were worth spending money on. As she pointed out,

There’s nothing like a common problem to spawn a whole industry of products offering solutions. If you are a breastfeeding woman who’s feeling sore, should you part with your money for glycerine gel dressings, ointments, or breast shells with lanolin? How do you know if you should trust the claims?

A Cochrane Review from 2014 was referenced in this article – this has not yet had an updated review (Dennis et al., 2014). The review looked at four studies focused on glycerine pads, lanolin breast shells, lanolin, expressed breast milk and an all-purpose nipple ointment. Breastfeeding latch and positioning was also addressed as part of routine care. Chapman

reports the results in her article. Evidence indicates that applying nothing to the nipples or applying expressed breast milk may be as good as, or better than, an ointment for nipple pain and healing.

Nipple pain reduced to mild levels around seven to ten days after birth regardless of the type of treatment. This fits with a long-held hypothesis I have.

Using nipple creams from the beginning of early nipple tenderness means that when tenderness naturally resolves around seven to ten days, the nipple cream treatment is seen as the reason for resolution. Good press that may not be deserved. This is not to say that women should not use purified lanolin as some women do report experiencing some soothing relief after use.

Chapman concludes her review by saying, It can be hard to do nothing, when doing ‘something’ can make us feel more in control, but sometimes it may be the best thing of all. square

References available on request.

key points

Nipple pain is a significant cause of breastfeeding cessation.

Feed the baby - there may be situations where breastfeeding is very painful and the mother is expressing breastmilk to give to the baby for some feeds.

Protect lactation if any breastfeeds are being missed for the reason above.

Avoid complications for the mother and the baby from any introduced intervention.

Breastfeeding observation is key to diagnosing clinical issues.

Incorrect latching at the breast is the most common reason for nipple pain and damage.

Support oxytocin releasing environments for the mother and baby.

Experience of pain is highly variable.

Maternal stress, fatigue, despondency and pain may compromise oxytocin responses which will exacerbate the original issue.

Do not underestimate the power of support, empathy, empowerment and reassurance.

Applying expressed breastmilk may be as good as, or better than, an ointment for nipple pain and healing.

Check out the A-Z of Breastfeeding & Infant Feeding: Resources for midwives and their clients page on the College website for more information about nipple pain, causes and treatment.

Support services nationally for breastfeeding women, including breastfeeding groups, can be accessed at “Find your breastfeeding support” where there is a NZ map and listings. www.womens-health.org.nz/find-your-breastfeeding-support/

Midwifery Postgraduate Education Grants

Midwives who are engaged in formal postgraduate education (at Level 8 or above on the NZQA framework) may apply for a grant towards the cost of their postgraduate study. These grants are funded by Te Whatu Ora - Health New Zealand and administered by the College to subsidise the costs of fees, some travel, and accommodation. Applications are prioritised on a first come first served basis.

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

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taku wāhi mahi my midwifery place

Adele McBride is midwife manager of Queen Mary Maternity Centre, Dunedin Hospital’s tertiary maternity unit. Having worked in the region for three decades, she shares her evolution as a leader and the unique dynamics of Queen Mary’s wider team with Amellia Kapa.

Adele McBride feels the fear and does it anyway.

As part of the inaugural intake for direct entry midwifery education. Adele began her midwifery journey under an experimental clause, not knowing whether the government of the day would ultimately grant the programme approval. But her desire to become a midwife was so strong, she was willing to take the risk.

“I had my own children here in the old Queen Mary and that’s one of the reasons I wanted to become a midwife. It was my experience as a consumer; I felt so strongly that I wanted to make a difference and it was so compelling, I just couldn’t put it down.”

Of course, we now know direct entry midwifery education was here to stay, and upon graduation Adele went straight into LMC practice in Dunedin, working in a shared-care model with GPs and obstetricians. Over the years, the landscape has changed and Adele has moved in and out of Queen Mary, working in the caseloading team and as a staff midwife, before becoming the associate charge midwife.

“I think that’s part of the reason why I am where I am,” Adele explains. “I’ve formed very strong bonds here over time and I’ve been able to develop and maintain twodirectional relationships of trust and clinical credibility.”

Although Adele knew she possessed leadership qualities in her associate charge role, being willing to grow has been integral to her promotion, as was the mentorship from her midwife manager at the time, Fiona Thompson.

“I had to learn to modify my style,” Adele concedes. “I was very clipped and demanding, and Fiona softened me. She moulded me in a gentler way, so that I learned how

to be open. So when conflict came through my door, for example, I would open my body language as a way of indicating I was receptive to what this person had to say. She reflected her style back to me and I don’t know that I would be as effective as I am now without that.”

Clearly, the respect is mutual, as Fiona Thompson illustrates. “Adele learned from me, but I also learned from her equally; it wasn’t all one way. Adele’s very levelheaded; she stands by her word and has integrity. She was never someone who gossiped, she came to work, did a really good job and had great leadership potential. Midwives respected her as both a clinician and a leader. You need to have the trust of your team, which Adele undoubtedly has.”

Now midwife manager herself, Adele recognises the power of allowing her own humanness to be seen by her team. “I’m not shy to show my vulnerability and say: ‘I don’t know, but I’ll try to find out’. I believe I own up to my mistakes; I’ll say sorry and find out how I can fix it. You learn to be open, honest and humble. You have to be able to stand in front of your team, look them in the eye and let them know you understand. I think as leaders, we have to be brave.”

Being aware and inclusive of the wider team and not just focusing on midwives is another crucial part of Adele’s role, as she explains. “I work really hard to include and acknowledge our administrative staff, HCAs, doctors, students, patients, everybody. Everybody has a place here and I think that’s what keeps it all together. We’re like a huge family and we all care about each other. Every morning, everybody greets each other and it’s sincere.” square

Fiona Thompson and Adele McBride.

AMELLIA KAPA REGISTERED MIDWIFE

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

PO Box 24487, Royal Oak, Auckland 1345 Ph 09 625 9764 Fax 09 625 0187 auckadmin@nzcom.org.nz

College Membership Enquiries

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

Chief Executive

Alison Eddy

Co-Presidents

Beatrice Leatham bea.tangatawhenua.copres@nzcom.org.nz

Debbie Fisher

debbieF.tangatatiriti.copres@nzcom.org.nz

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

Emma Neal 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

Linley Taylor midwife.linley@gmail.com

Horowhenua Sub-Committee

Laura McClenaghan midwife.laura@hotmail.co.nz

Manawatu Sub-Committee

Megan Hooper-Smith megan.scott@live.com

Emma LeLievre emma@LMCmidwife.com

Taranaki Sub-Committee

Ange Hill nzcom.taranaki@gmail.com

Whanganui 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

Nicola Eccleton n.eccleton@parentscentre.org.nz

Royal New Zealand Plunket Society

Zoe Tipa zoe.tipa@plunket.org.nz

Student Representatives

Paytra Buckrell paytra_browne@windowslive.com

Te Rina Apelu tee_apelu@hotmail.com

Ngā Maia Representatives www.ngamaiatrust.org

Dani Gibbs dani.midwife.maori@gmail.com

Lisa Kelly lisakellyto@yahoo.co.nz

Pasifika Midwives Representatives

Talei Jackson Ph 021 907 588 taleivejackson@gmail.com

Ngatepaeru Marsters Ph 021 0269 3460 lesngararo@hotmail.com

MERAS

PO Box 21-106, Christchurch 8140

Ph 03 372 9738 meras@meras.co.nz www.meras.co.nz

MMPO

PO Box 21-106, Christchurch 8140 Ph 03 377 2485 mmpo@mmpo.org.nz

Rural Recruitment & Retention Services

0800 Midwife/643 9433 rmrr@mmpo.org.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

So many great digital tools saving you time and $ including: • Clinical documentation • Claiming and payments • Healthlink • • A Midwifery Practice Calendar • Quickly sending personalised referrals • • Staying connected • Getting tasks done • Sending group (Caseload) SMS • • Completing a video consultation • Taking notes on the go • • PLUS realtime access to extensive personalised support •