By Frank Film
Our midwifery system is admired the world over - so why are so many midwives facing burnout?
"I'm always surprised at how famous New Zealand midwifery is everywhere else," says Karen Guilliland, "except in New Zealand."
For over three decades Guilliland, co-founder and former chief executive of the New Zealand College of Midwives, has been at the forefront of the movement to revive the midwifery profession and meet the needs of the 60,000 mothers giving birth every year.
"That's 60,000 mums and 60,000 babies that midwives look after," she tells Frank Film. "That's 120,000 humans a year. That's the start of life's journey for those babies."
New Zealand's midwifery-led maternity approach to the beginning of that journey is admired across the globe. Under the current system, the community midwife is the lead maternity carer (LMC), case managing the woman's maternity experience from pregnancy, through labour and birth and on until the baby is around four to six weeks old.
The success of this approach lies in the close partnership between midwife and new mother. As Guilliland says, by the time a woman gives birth, her midwife has spent "hours and hours and hours with that family - she is so well placed to understand what that family needs."
Globally it is unusual. In Christchurch, expectant mother Magali Caulier says in her home country of France it is uncommon for a community midwife to accompany the mother-to-be through the entire process of antenatal care and birth. "You just go to hospital and whoever is working on the day takes care of you and the delivery of your baby."
As a country, we've been there.
New Zealand was one of the first countries to register midwives in 1904. At that time, midwifery was an autonomous profession - most women gave birth in maternity homes run by midwives; male doctors, says Guilliland, "didn't really take much interest."
The advent of painkillers and antibiotics to stop the ever-present threat of infection saw an increase in hospitalised births.
The Nurses Act of 1971 removed the right of midwives to practice autonomously. New Zealand midwifery changed from a community-based profession into a hospital-based workforce. Maternity units were closed down. Women moved into the hospitals.
"The midwives became sort of obstetric nurses - the obstetrician looked after the woman and the nurses did as they were told. Medicine ruled".
With lobbying from the newly formed New Zealand College of Midwives, the Nurses Amendment Act in 1990 gave midwives the right to operate as fully independent providers of pregnancy and childbirth services without needing supervision by medical practitioners. It has been described as one of the most significant milestones in the evolution of the midwifery profession in New Zealand.
Midwifery now, says Guilliland, is "a fabulous job". But it is a challenging one. Christchurch community midwife Anne O'Connor describes a recent eight-day stint in which she had four births. Midnight call-outs are common, on call "means 24 hours a day, 7 days a week." An NZIER report from last year found midwives were working up to 26 percent more than expected from a full time equivalent role.
Unlike core midwives in maternity facilities, community midwives are paid a set fee for the first and second trimesters, then the third trimester, then the birth and around seven postnatal visits. There is no adjustment made if it is a 40-minute or 40-hour labour or if the woman is a two-minute or two-hour drive away, and no top ups for extra visits to those with additional needs.
Many midwives have taken on other part time work; some have left the industry altogether. As with other countries, New Zealand is facing a shortage of midwives. "Most midwives nowadays will work for about six years because the work is unsustainable. There's a lot of burnout."
There have been successes, but they have been hard fought-for. Last year the Government announced a $242 million boost for maternity services, including extra funding for rural care, spread over four years - about a quarter of this has gone directly to improve midwives' working conditions and pay. In March this year, $6m was earmarked to address the shortage of Māori and Pasifika midwives in the country.
These are all positive steps, but the straw still breaking the midwives' back, says Guilliland, is the absence of a contract structure that enables midwives to spend the time required, "because it is all about time."
"A plumber gets a call-out fee and a travel fee - that is recognised. Midwives treat haemorrhaging, they prevent haemorrhaging, they suture when things go wrong, they put in IV lines, they resuscitate babies. They do a lot of the stuff that a lot of GPs don't do but we get a bulk sum and are meant to do everything for that."
Midwives describe it as deflating.
"There is no explanation other than women's work is not valued in the same way as other work. Young women today don't want to do things for nothing - and rightly so.
"You'd think with this government, which prides itself on egalitarianism and equality, mothers and newborns would take precedence. But they don't, and they never have under any government. We want to be understood as a really prime life-saving health profession. Maternity can't fix everything, but we have had a real influence on the wellbeing of women and babies."