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Who pays the midwife? And why isn’t it enough?

In the third piece in our series on the midwifery crisis in New Zealand, Kimberley Davis writes about how – and how much – midwives are paid. 

We are often told that we’re lucky to have the midwifery-led maternity-care syst­­em we do here in Aotearoa, and indeed we are. It’s unique and it’s the envy of other countries – but it’s also becoming increasingly evident that we’ve still got it only thanks to the goodwill of the few midwives who remain working in it.

The cracks are starting to show. Every day, new stories emerge from all over the country, of communities who aren’t willing to see their maternity hospitals close without a fight, of midwives stretched to breaking point, of new mothers barely surviving the birth of their babies. Journalist Michelle Duff launched an ongoing investigation into the state of maternity care in New Zealand. This investigation is already highlighting the understaffing of maternity wards in hospitals, the barriers inhibiting access to basic maternity care, and the shortage of graduate midwives that’s driving our government to try to lure grads from Australia.

It’s at this point that you might be realising you’re a bit foggy about what, exactly, our maternity-care system is and how those midwives who work in it are paid. Consider this a primer.

For starters, maternity care is free to all eligible women resident here in Aotearoa, and it’s provided by what are called Lead Maternity Carers, or more commonly LMCs. All LMCs are contracted by the Ministry of Health to provide continuity of care throughout a woman’s pregnancy up until six weeks postnatally. An LMC can be a midwife, or an obstetrician or GP with a diploma in obstetrics – but, for the most part, LMCs are midwives, hence why it’s often referred to as a “midwifery-led” system (and you can find out what a midwife does here). While some GPs do still provide LMC care, they are few and far between. And, though obstetricians can provide LMC care, it’s not free – far from it – and a midwife is still required. Note that this means obstetricians, unlike midwives, can charge their clients specialist fees at the same time as also claiming fees from the Ministry of Health.

This midwifery-led system of maternity care was established in New Zealand in 1990, when midwives began to work again as autonomous practitioners in order to take, as the NZ College of Midwives puts it, “a proactive, woman-centred role in normal pregnancy and childbirth”. There are a number of studies that have shown the benefits of such a midwifery-led system of care, including in particular a 2016 Cochrane review comparing models of care, which concluded that “women who received midwife-led continuity models of care were less likely to experience intervention and more likely to be satisfied with their care”.

There are essentially two kinds of midwives here in New Zealand: core midwives and community midwives. Core midwives work in maternity facilities (such as a hospital or birthing unit), have rostered shifts and receive set pay, which in theory should account for their hours worked, but in understaffed wards this is rarely the case. Community midwives are  contractors to the Ministry of Health and provide LMC services. According to the 2016 Midwifery Workforce Survey conducted by the Midwifery Council, 50.7 % of those surveyed reported working as core midwives, while 36.6% reported working as “caseloading” (or community) midwives.

When it comes to gross pay for a midwife (whether core or community), the New Zealand Government’s careers websites make it look like it’s not such a bad deal. Careers.govt.nz says midwives “usually earn $49K–$115K per year”, while the Ministry of Business, Innovation and Employment’s site Occupation Outlook claims that a “steady increase in employment is expected and the income for midwives is high … The average annual income for midwives is estimated to be around $69,500.”

So, if that’s the case, what’s all the bloody fuss about?

This is where it’s useful to have a clearer idea of exactly how the Ministry of Health pays midwives. Remember that community midwives, who provide LMC services, are contractors to the Ministry. This means that they work on-call, around the clock, and they receive set fee payments for each woman they care for. The fees are paid per head, so to speak: a midwife is paid the same amount for each woman they care for, no matter where in the country they are (though there’s a difference between first and subsequent labour and birth payments). This, of course, ignores the fact that the care a pregnant woman in central Auckland needs from her LMC midwife is going to be vastly different from what a woman in a remote area of the South Island requires – but there’s no allowance in the existing fee system for the variation in service that midwives provide from one community to another.

In terms of when community midwives are actually paid, they receive fees per “module” of care that they provide to a woman – which is to say that pregnancy, birth and the postnatal period are sliced and diced to tier the fee stages. Midwives can only claim fees retrospectively, at the end of each module, after verifying that they have provided all the services within the module.

To give you a snapshot of how these modular payments currently work, a midwife receives no fee for registering a woman, and the fees for the first and second trimesters are not paid until the end of the second trimester. What this means is that the midwife will not receive any payment whatsoever for the care she has provided until the third trimester of a woman’s pregnancy starts – in other words, a midwife can have a woman under her care for as long as 26 weeks before she receives any payment at all. During those 26 weeks, the midwife is expected to cover any costs that providing the care might accrue.

That’s because, when you’re an independent midwife, you’re personally responsible for all your costs of business: rent, equipment, cover if you want to go on holiday, travel and vehicles, insurance, ACC, GST, income tax … The list goes on. You’ll most likely have student-loan payments to service as well – and the total fees for the four-year qualification to become a midwife can land somewhere in the vicinity of $20,000. You’re also not entitled to leave or sick pay; if you don’t work, you have to pay someone else to do it in your stead.

All of these costs come out of a community midwife’s total pay, and can add up to more than $20,000 a year, not to mention vary wildly depending on such factors as what the cost of living is like in the community where you’re operating, or how big the area is that you have to service (i.e. how much travel you do). So, even if you’re earning that average figure mentioned earlier of $69,500, what you can actually expect might be something closer to $49,000.

What’s more, midwives work notoriously uncivil hours – many say a 40-hour working week would be a dream come true. So, when you take into account all those business expenses then divide what’s left across the hours worked, it’s easy to see how midwives are going home with well under minimum wage.

And that, in a nutshell, is how we find ourselves where we are: with a maternity-care system that is the apparent envy of other countries, but that we seem determined to break because we won’t pay those providing it enough.

Of course, midwives’ pay is an issue that has been simmering away for quite some time; we’re only seeing the pot boil over at the moment because the midwifery workforce is at breaking point and it’s making national headlines. Back in May last year, the NZ College of Midwives, in response to a pay-equity court action they’d lodged, actually received a promise from the then-government of “a 6 per cent pay increase and a place at the table for community midwives to design their pay structure and working conditions” – a promise that seemed to evaporate as soon as it was uttered. Then, earlier this month, Radio New Zealand reported that the College was still “pleading with the government” to put into action the funding model for midwives they had co-designed with the Ministry of Health. A couple of days later, the College released a statement saying their Chief Executive, Karen Guilliland, had met with the Acting Director-General of Health, Stephen McKernan, to discuss the funding model – which they call “the co-design process” – and the Ministry of Health’s response.

It all starts to feel like a bit much talking and not very much doing, especially when you consider that every day babies are continuing to be born, and the remaining midwives’ caseloads are only getting heavier.

This is, at its very core, a funding issue and, since the Ministry of Health is the body providing that funding, they’re also responsible for fixing it. It’s seeming increasingly as though that’s going to require an overhaul of the entire fee system (which was, in fact, the aim of the co-design process in the first place) – one that takes into account the massive variation of needs between our country’s diverse communities, and how that affects the maternity-care they require. Whatever it takes, though, the starting point has to be paying midwives what they’re worth – and they’re worth an awful lot to us.

Read part one of this series: What is going on with New Zealand’s midwives? And part two: ‘We have two lives in our hands and we’re paid less than minimum wage’.

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