By Sian Hannagan

Our Editorial.
Mar 2015

Here in Aotearoa, we have the enviable situation of having a world class midwifery system that is often held up globally as a superb model of Continuity of Care in birth. The New Zealand maternity system has a robust framework of education, certification and regulation that has been developed with the Ministry of Health, Midwifery Council, New Zealand College of Midwives (NZCOM) and Midwifery Educators.  NCOM runs a full time course that meets international standards for birth care and results in a high level of graduate proficiency. International evidence, including the highly regarded Cochrane Database of Systematic Reviews and the Lancet medical journal, shows our model to be both successful and safe. Comparative data produced over a number of years by the Perinatal and Maternal Mortality Committee shows our outcomes are among the best in the world.  NZ Midwifery Council states: New Zealand and International evidence demonstrates that we have had safe and effective maternity services over the last twenty years, providing excellent outcomes for mothers and babies. (Dixon, Prileszky, Guilliland, Miller, & Anderson, 2014; Perinatal and Maternal Mortality Review Committee, 2014; Page, 2014; Rowland, McLeod, & Forese-Burns, 2012).

Our midwives often work in diverse and difficult situations bringing care to women in a wide range of cultural, economic and education backgrounds. In many cases, bringing the care to women who would not always seek care in a hospital setting. They do good work in sometimes very challenging situations. There are rural midwives who cover a very large area to support rurally placed women in their births. There are midwives who support women in at-risk environments or women with complex health issues. Largely these midwives all do very good jobs. In fact, birth outcomes in New Zealand have been steadily improving over the past eight years. Perhaps most importantly, our midwifery system allows women to build relationships with their lead maternity carer, it offers women true choice.

With all of this you might be surprised to hear that midwifery is under attack in New Zealand. There are advocacy groups who feel that we need to move birth back into a hospital setting, requiring midwives to complete their training in hospitals and placing primary midwifery care back into the hands of general practitioners rather than the robust specialist training our midwives get now.  It is easy to understand where this fear based reasoning is coming from. When people make decisions based on tragedies you get reactive reasoning. Our hearts go out to the women and families who have been harmed by a traumatic birth experience. However, the problem when your motivations are founded in fear is that you cannot make a balanced assessment of the relevant facts.

This is evidenced by the recommendations that are being pushed by Action to Improve Maternity (AIM), which is an advocacy group claiming to support all women for better birth outcomes. However, the recommendations that AIM makes are not founded in research, they do not serve birthing women and their babies. They serve an agenda that is riddled with confirmation bias, which is to say they cherry pick their evidence to suit their agenda. Not only this, but they seem to be basing their advocacy on a complete misunderstanding on how midwifery training works. For instance, in a recent radio interview, a representative for AIM continued to argue that midwifery is a part time course – when in fact it is a full time course as is clearly stated in the enrolment guidelines. They also believe student midwives need to get the primary bulk of their training in a hospital setting, working with hospital midwives. Not only is this impractical in terms of resources and curricula. It is also misguided. Hospital midwives do not follow a continuity of care model, by following midwives in hospital settings, student midwives would only be seeing fragmented elements of midwifery care. They would not be following women from early pregnancy to birth, through to aftercare. While these essential aspects of safe birth are dismissed by AIM, they are integral to better birthing and birth outcomes. Not only do they help midwives get a full picture of a mother’s health from early pregnancy, but they also facilitate early recognition of serious issues that might need referral. By dismissing the relationships built between women and midwives during continuity of care, AIM is not only dismissing our midwifery system, but they are also dismissing women.  However, by continuing to court the media, these erroneous views continue to get airtime. The risk in this is that we face policy change based on kneejerk reactions and populist opinion. To prevent this happening, we need to speak out for midwives and acknowledge that they are the backbone to our birth system. Without them we would be heading down a very different path, such as in America where increased medicalisation has resulted in increasing maternal mortality rates.

Another dissenting voice in this discourse has been Coroner Garry Evans, who whilst reviewing a recent case involving maternal and infant death in New Zealand has made strong recommendations to our Ministry of Health, that New Zealand College of Midwives make significant changes to how they educate and support midwives. He has made these recommendations in disregard to the growing body of evidence which points to midwifery led systems being best practice. This is despite being provided with several submissions which included citations to the large body of scientific evidence which supports our current maternity model.

The coroner used a very narrow view to inform his findings. All of the currentresearch shows that midwives improve outcomes and that further medicalisation of our birth space would increase interventions and iatrogenic outcomes without improving our rate of maternal or perinatal mortality.

This is not the first time that Garry Evans has made sweeping statements based on a very limited number of facts. His discussion on bedsharing in recent years has shown again and again that he disregards peer reviewedstudies on issues such as these and latches on to the one aspect that matches his agenda. In the cases he examined he chose to disregard a range of serious contributing factors, such as cigarettes, drugs and alcohol in favour of putting out an alarmist ‘all or nothing’ recommendation that families should not bedshare at all regardless of their situation, not only is this culturally insensitive, but it also completely disregards the lived reality for parents in New Zealand. For a more balanced approach you’d be best to seek out the actual research and follow the Safe Seven guidelines should you choose to bedshare.

When it comes to birth we need to stop listening to loud, polarising, or self-aggrandising voices that serve fear, or serve ego and start listening to each other. Listen to our communities. Birth is more than a risk assessment, it is a human experience. So, while our choices are supported by science, it is more important that our choices are ours.  Midwives are there for birthing women and their babies, so let’s support them so they may support us.

“If women lose the right to say where and how they birth their children, then they will have lost something that’s as dear to life as breathing.” Ami McKay

Sian Hannagan our Acting Editor


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Horsley T, et al 2007: Benefits and harms associated with the practice of bed sharing: a systematic review. Archives of Paediatrics and Adolescent Medicine. 161(3):237-45.

Sandall J, et al 2013: Midwife-led continuity models versus other models of care for childbearing women. Cochrane Reviews.

Homer C, et al 2003: Collaboration in maternity care: a randomised controlled trial comparing community-based continuity of care with standard hospital care. International Journal of Obstetrics and Gynaecology. 108(1):  16–22.