As part of our series on the midwifery crisis, The Spinoff Parents editor Emily Writes asked midwives to share what’s gone wrong, and how they believe the crisis can be solved.
It’s coming up to a year since I interviewed dozens of midwives about their experiences working in one of the toughest, most under-paid and under-resourced jobs there is. Almost a year on, not only has nothing changed for the better for these incredible women, it has possibly become even worse. Back then, politicians were keen as to make a difference. Today, Stuff have begun an open-ended investigation into maternity care in New Zealand.
At The Spinoff Parents we have covered this issue for some time, beginning with Dr Jess Berentson-Shaw’s deep dive into the state of maternity care in New Zealand in October 2016. And we covered the dangers families face if rural maternity units like Lumsden Maternity Centre in rural Southland close. And yet here we are.
Midwives and families stood at Parliament last year and demanded change. We demanded a safe maternal health system that protects mothers, babies, and the wonderful women who care for them. When is that change coming?
The Ministry of Business, Innovation and Employment (MBIE) added midwives to the “immediate skill shortage list” in December. The question is – who would want the job? You have to be a saint to give up seeing your own children to deliver other people’s. And if anything goes wrong, you’re done. Be prepared to be attacked in Facebook groups and have your photo posted online. If you get a call at 4am and say the wrong thing because you’ve just woken up, be prepared for complaints and being dragged in mum groups. If you wake up sick, you have to pay someone else to cover for you. If your mother or child dies, you have no bereavement leave. If you want annual leave, book it up to nine months in advance, and you still won’t be guaranteed to get your time off. You hold the weight of life or death decisions in your hands every day of the week. All for an hourly wage sometimes as low as $7 an hour.
I wanted to hear from midwives about what is needed to turn this crisis around. I am grateful to all of the midwives, from all over New Zealand, who got in touch. All the responses below are anonymous and some have been edited for clarity. Almost every response to the first question (“What worries you the most about the state of midwifery in New Zealand today?”) centred pregnant people – midwives are incredibly worried birthing parents will not have adequate care.
One midwife begged me to tell pregnant people that midwives don’t blame them for the crisis they’re facing; this was echoed many times over.
“I don’t tell my women how very tired I am and how much work I and my colleagues do for free as it feels somehow crass to discuss it at this most wonderful and joyous (yet completely overwhelming) time in their lives. I don’t like speaking out publicly about this as our main concern and focus has always been the woman who we place right at the centre of care. However, this public campaign has risen out of sheer desperation and frustration. As a woman I 100% resent being taken for granted by our government and the Ministry of Health. I feel like I am nothing more than cheap labour to them and yet we save them so much money by keeping birth out of secondary/tertiary care wherever appropriate. We do this by being with women at their most vulnerable times and it takes so much out of us physically and emotionally.”
I thought in collecting possible solutions I would be inundated with different ideas. In fact, midwives know exactly what the solution is. Every midwife asked supported the New Zealand College of Midwives and Ministry of Health co-designed model. Midwives were firm in that the midwifery model of having a lead maternity carer and continuation of care was world-class and the best model for all parents.
I put a call-out to more than a dozen midwives to tell me about the day to day reality of their job, and what has gone wrong in the midwifery system in New Zealand. Here’s what they told me.
What worries you the most about the state of midwifery in New Zealand today?
What are the biggest problems?
The huge responsibility of being a midwife for a remuneration less than minimum wage – or similar to a junior administrator. We have two lives in our hands with each client we look after, Mum and baby. There is no payment that we can claim when we are called out for urgent check-ups, such as when someone calls at 10pm at night with an antepartum bleed, or reduced or no fetal movements. We leap straight out of bed and go and assess them. This is life or death stuff and any other profession would be very well remunerated for it.
When we’ve been attending a client in labour for over 12 hours and we want to call in our back up midwife to take over, we have to pay her out of our own pockets as there is no provision for an extra payment you can claim.
We are paid to look after a women for two hours after the baby has been born, but often end up staying three to four hours while waiting for a room to be available on the postnatal ward, which we are not remunerated for, and the delivery suite staff are unable to care for our women during that waiting time.
There is no payment for the call outs which happen in addition to the routine appointments. You’re paid the same amount for subsequent births, many are just as long as first births, still happen all hours, still require call outs for assessments before the woman is actually in established labour, still often take much longer than the minimum two hours allowed for postnatal care.
There is not enough funding of rural midwifery and poor structuring of the rural travel fee (this affects urban LMCs also). For example, I live and work in New Plymouth and get paid the same rural travel fee to travel to Inglewood postnatally (10min drive each way) and Tarata (30min drive each way).
There is a real misinterpretation of the 24/7 availability. It is for urgent matters. It is up to us to set boundaries early on in the partnership, but texts and non urgent phone calls at all hours still happen.
I have been an LMC for more than 15 years. Supporting my large family I have had to work 80 hour weeks for all of those 15 years just to pay bills. My greatest fear (and my truthful prediction) is that in five years there will be no lead maternity carer workforce in New Zealand. We will have a hospital-based system like Australia, where there is no continuity of care.
Midwives are having to take on more clients than they can handle to get paid, there is no new workforce as students lose heart and nobody applies for study, and women are being given bare minimum care at one of the most vulnerable times in their lives.
The pay disparity between midwives and all other health professionals is a huge problem. The annual practicing certificate for a nurse is $110; for a midwife it’s $445. Indemnity insurance for nurses including union fees is $345 (as part of your NZCOM membership); for core midwives and LMCs it’s $695. Yearly fees for a nurse are $428; yearly fees for a core midwife are $1100 and yearly fees for an LMC midwife are $1430. As a midwife working in sole charge in a birthing unit, responsible for all care in the unit and every patient there, supervising all LMCs and nurses, my salary is $66,755. A nurse practitioner with a similar skill set can expect to earn up to $120,000.
The biggest problem facing midwives is the increasing complexity of care that both community (LMC) and core (hospital) midwives are encountering. On top of already pressured workloads, this is adding to the stress and the burn out of the midwifery workforce. Complexities that were once “managed” in hospital clinics are increasingly being asked to be managed by the LMCs in the community. Not only is it beyond the scope of what Section 88 suggests is safe midwifery practice, but the LMCs are not being remunerated for an increased workload. For example, being asked to do weekly blood checks, or weekly fetal heart checks on women that you would normally be seeing every two weeks reduces the income that is provided for that trimester. But it also puts the onus on the LMC. What happens if the fetal heart is low, or the BP is high? The woman then needs to go to the secondary or tertiary hospital for review and often the LMC is expected to be there too. That means the LMC is forced to postpone clinics and post natal visits, and an already stressed workload is increased.
The flipside of this is that the more complex the woman’s care is, the more input she is likely to need postnatally. But there is no increase in hours allocated to her immediately post birth so she is sent home from the hospital/maternity unit not quite ready for the next stage of parenthood.
It’s a lose-lose for women, their whanau and the LMC, plus the core midwife who feels she has failed in her duty of care as she has sent a woman home too early.
Being an LMC is hard enough, and has historically been about providing care to well women and their families, knowing that when complex issues arose there were the specialty teams able to look after them. This is no longer the case – these women and their families, who need extra help, are being thrust back into the care of the LMC too soon.
In the hospital situation, a midwife’s patient load doesn’t cover the baby; only the mother is counted as a number. So although a midwife might have six postnatal women in her care for the shift, she actually has at least 12 people in her care (assuming none of those mothers has has twins/triplets.) Even looking after an antenatal woman, there are two individuals involved in your care plan, each as important as the other.
The biggest problem is a lack of fair remuneration for both core and LMC midwives. Core midwives are specialists who work autonomously, looking after the most complex birthing women. They literally hold two lives in their hands and are paid on an identical pay scale to nurses – this is not fair. The other big issue is the constant midwife-bashing in the media if there is a sad outcome. It portrays midwives as second class to doctors and does not mention the fact that we have some of the best outcomes in the world.
What do you think are the solutions?
The best solution I can see is for the government to fund the co-design model which was negotiated over two years of mediation between the NZ College of Midwives the Ministry of Health. A lot of money and time has been put into this negotiation and mediation, with a team of officials from the Ministry of Health and a team from the NZ College of Midwives, plus extensive research and expert advisers and consultation with midwives around the country. It is a model which would fund midwives fairly and allow them to work sustainably, it has been agreed on by all parties and is just waiting for the Minister of Health to sign it off for the 2018 Budget.
The Ministry of Health needs to listen to and implement the co-design funding model that was drawn up last year by midwives and the College of Midwives.
DHBs need to increase their full time employees to staff the wards adequately.
The solution is very simple – we already ‘co-designed’ a system which clearly lays out payment schedules. The work is done. The Ministry of Health simply needs to action it as they have promised. They have lied and lied and promised and promised and stalled and stalled and we are worn down. We are exhausted, we are defeated. We are DONE.
Implement the LMC co-design model. Create a new position description and pay scale for core midwives recognising them as specialists, separate to nurses, and increase staffing in hospitals and birthing units.
Midwives definitely need better pay for the hard work we all do. We need better staffed hospitals and we need to educate staff midwives on what constitutes primary and secondary care with clear handover guidelines to stop LMCs doing work that isn’t safe or work we are not paid to do.
I think the solutions are for the Ministry of Health to acknowledge the hard work the New Zealand College of Midwives has put into the co-design for payment for LMCs, and act appropriately and swiftly on increasing payments to the LMCs. The Ministry of Health needs to make provision for extra visits that LMCs undertake, to provide some sort of financial support for midwives to take time off, and to have legislation around the number of hours a LMC can expect to be awake for (much like truck drivers and their logs).
The system needs a massive cash influx. Midwives need an acceptable hourly pay rate. There needs to be regulations around resting after x hours and paid cover for the down time. Also midwives need annual leave, bereavement leave, and sick days.
We need a fair and equitable system that allows midwives to work a sustainable number of hours per month for a wage that reflects their vitally important role in ensuring mothers and babies health, safety, and general wellbeing before, during and after birth.
To end, here are the words of a midwife speaking directly to the New Zealand public:
“I am a registered nurse that has post graduate qualifications in both paediatric nursing and midwifery. I choose to work as a midwife, as that is where my passion lies and always has. I choose to work as a midwife in a primary unit as that is my special interest. I’m asking to be valued and validated as a health professional. I’m asking for my LMC colleagues to valued and validated.”
In the week leading up to International Midwives Day, midwives and their supporters will march on Parliament to share #DearDavidClark messages and deliver a petition calling for urgent action to fully fund the co-design developed between the New Zealand College of Midwives and the Government. They are hoping the public will join them in solidarity and support. More information here.