Independent midwifery in New Zealand

Introduction
Independent Midwifery in New Zealand became an autonomous profession in 1990.The midwife is known as a Lead Maternity Carer (L.M.C.) and works under section 88 of the New Zealand Public Health and Disability Act, 2000. It is a partnership with women and we work under defined codes of conduct and scope of practice. Evidence of our standards of practice is reviewed every two years by an independent panel. Student Midwives are also trained to eventually become independent midwives.

Methods of Practice
Care is classed as either primary or secondary and this seems to cause difficulties with definition and overlapping, depending where one works. Primary care is all normal midwifery and applies to antenatal, intra partum and post partum care. Secondary care would include complications across the board as well as Epidurals and Syntocinon administration in labour, for which the hospital could have an input. Some Midwives can opt-out of caring for their women with Epidurals and Syntocinon and yet the code of practice clearly states that Midwives are required to make a declaration of competence when applying for an Annual Practising Certificate, and remain competent to practise across all the scopes and skills of practice. This also includes induction of labour where some places may expect you to start off the induction.

The midwife works independently and autonomously and our individual caseload is very variable. The average number would be 5-6 women a month although some midwives take up to ten a month. We usually work in a group partnership, but work in pairs. We have five midwives in our practice, and we find our own premises to work from. This is a business just like any other and we pay rent, taxes, G.S.T. web site promotion, signage etc. We are paid by the government in stage payments of the pregnancy and we are all paid the same regardless of experience. This is frustrating when we lose the majority of the birth payment if a woman has an Elective Caesarean i.e. breech presentation .We also have no holiday pay and have to pay for insurance cover and study days. We work in various ways with a partner to cover our practice when we have time off. This often means that we are on call 24 hours a day maybe seven days a week – you are free to work as you want. Some Midwives may work together, share the caseload and split the payment. When you are on annual leave your partner will cover your caseload and this has to be planned in advance and therefore most of us would not book women for delivery at that time.

Prescribing
Another difference from UK midwifery is that we are able to prescribe and this has been a learning curve for me. We can prescribe a variety of drugs within our scope of practice. Midwives from the UK now have to complete a pharmacology paper in order to practice in New Zealand. We are able to prescribe antibiotics and anything related to pregnancy. We are also able to prescribe nicotine patches and oral contraceptives.

Equipment
In order to practice independently each individual should have specific equipment available. An Ante-Natal box with B.P. cuff, Doppler, Urine testing sticks and all resource information for women leaflets etc; Post-Natal box with scales, stethoscope, ophthalmoscope, tape measure and again information about contraception etc in various languages. We also carry birth equipment in our car for home deliveries or emergency homebirths. We can hire oxygen for homebirths but we are not allowed to use Entonox at home! We are given an extra birth fee for home births.

Means of obtaining clients
Women can contact us from the early outset of pregnancy especially women whom we had delivered previously. They may ring us directly or some may have seen their G.P. first (if they have one). The G.P. may also refer and recommend Midwives as some practices work from Doctors rooms. Midwifery practices are in the local phone directory and also on the internet, with our own websites.

Some women wish to meet the Midwife first to ascertain if she is suitable for her needs and we also can refuse a client if we wish. Women have our mobile numbers and this can be a problem as some do not consider our private times and we are contacted evenings, weekends even in the night with all sorts of problems which then may have to be addressed. Sometimes women change Midwives at various stages of pregnancy and we also can ask them to find another midwife if the partnership does not work out. Some also move to another midwife; these changes do not help to maintain a stable salary. We are the first port of call regarding the pregnancy and have to be contacted first before sending into hospital.

Ante-natal
Midwifery care is from booking usually around 6-8 weeks and up to 4-6 weeks postnatally. We are able to organise blood tests and scans as necessary throughout the pregnancy. All women are offered a nuchal translucency scan and maternal serum screening integrated blood test between 11-13 weeks. We can refer for amniocentesis and chorionic villus sampling if required.

During the pregnancy we can arrange for a range of blood tests if we so wish and also can contact various Pathologists to discuss results. The Pathologists lab people are very helpful and willing to share their expertise. We refer to the Obstetricians at the hospital and also have access to an Obstetric Physician regarding medical problems. Some Midwives attend the hospital appointments with their women. For most women they may never have contact with a doctor during the entire pregnancy. We also have access to Social workers, Physiotherapists and other professionals.

Midwives work collaboratively with other health professionals when necessary to meet any additional, medical, health or social needs of mothers or babies (NZCOM).

Labour
The women contact us when they go into labour; we then can assess if they need to go to the hospital at that time. Some midwives may visit the women in their home at first to assess the labour before going into hospital. The women’s preferences would have already been discussed, with a care plan if she so wishes. The majority of Midwives would be happy to perform water births as well as home deliveries. If there are complications during the labour, Obstetricians are always available for advice and assistance. The Obstetricians are supportive of us and I am sure that this relationship has developed as the role of L.M.C. midwives has evolved.

Midwives, as in any profession, are variable in their experience and the obstetricians would recognise this. There is also help on hand if required from the hospital staff although the core staff does not intervene unless asked. We are mainly the sole carers of the women in labour and this can mean being with the woman for several hours. It also means that one midwife manages the labour, taking into account the woman’s requests and needs. The epidural rate is probably the same as any large hospital but I am aware of more N.V.D. even with the epidural. Some would argue that this is a direct result of one to one care and that the partnership with the women greatly improves the outcome.

The majority of women here would only see at the most two midwives during their pregnancy and I don’t know if they stay with the women throughout the labour. Before 1990 the midwifery care was just the same as private health care, whereby the obstetrician or G.P. would deliver your baby. These models of care are still an option for women as some G.P’S are still L.M.C’S with the core staff mainly doing the labour care. This does not seem the role of the G.P. anymore.

There is private obstetric care either completely or shared with the Midwife for ante-natal and post-natal care; the women pay for private Obstetric care. For some of the older population they may question independent practice of a midwife for their children and often ask questions around this subject; they do not always have confidence in our abilities!

Post natal care
The continuity of care postnatally, 4-6 weeks after birth is a great advantage to the women especially regarding Breast feeding, we have a higher number of women exclusively breast feeding at discharge especially primigravida. There is a higher rate of breast feeding in New Zealand especially in the younger age group. We have to update regularly as part of our registration and produce statistics on our Breast Feeding rates.

We are also responsible for the care of the newborn up to this period and we perform full baby checks at birth, one week and on discharge, any concerns that may arise we can refer to a Paediatrician or G.P accordingly.

Another learning curve for me in Independent Midwifery has been treating Mastitis and Breast Abscesses, this is all part of the length of time we continue with care and seems to be more common at certain times of the year.

My clientele range from European to Chinese, Koreans, Indians, Maori and Pacific Islanders.

There may be language problems and we can resource help for this. It is interesting to notice how various races cope and accept pregnancy and labour. There are of course still lots of myths which are handed down from generation to generation mainly in the Asian population.

Complications
In areas of low socio economic households there can be problems of obesity, diabetes, grandmultiparae also non attendingappointments and arriving in labour with no Ante-natal care. I have seen hardly any problems of Hypertensive disease of Pregnancy (P.E.T.) There are many private scanning places to choose from, some are free others charge about 12-15 on average. This is the woman’s preference.

This is also the case if we recommend women to see a Physiotherapist, Chiropractor, Osteopath or Acupuncturist. There are many other available options for women but they would have to pay for these services.

We care for women with medical problems as well. These problems are usually made aware at the booking visit and according to the problem would be seen by the obstetrician or obstetric physician at clinic. It is our responsibility to refer and make appointments for the women and some of us attend these appointments with the women.

The caesarean section rate is a problem here as anywhere else and many factors are involved. One comment many experienced Independent Midwives that I work with make is that we see inexperienced registrars unable to attempt forceps/ventouse deliveries and are more skilled with caesarean sections. Consultant backup is not always present to teach them. This for us as midwives can be frustrating and a challenge as we are the woman’s advocate.

I feel my skills have been extended and my thinking widened as we become more experienced with early pregnancy problems including screening and miscarriages, S.T.D.’s as well as managing medical issues affecting pregnancy. You develop the skills to think outside the box. The decision making is a huge learning curve. If a midwife was newly qualified it would be important to pair her with a more experienced midwife.

Students
It is our choice to take on student midwives and there are always vacancies although sometimes they experience difficulties in finding midwives. But because we have to have a practising review every two years, most of us need the points that come withtaking on a student. They are with us nearly every day for about 8 weeks, but their experience would depend on the midwives caseload at that time. As Midwives our role is also as a teacher and we should impart our knowledge to others. Student midwives are trained to practise as Independent

Practitioners and their training has been lengthened recently to include more practical hours, which is definitely necessary.

Once qualified they can do a mentoring system for 18 months in the hospital but this is only if there are vacancies as there are more midwives than jobs. Some choose to be Independent Midwives.

A.C.C.
We have a system whereby one can sue; it is ACC (Accident Compensation Corporation). I do not know enough about how the system works for compensation regarding birth, but the individual is not sued. As Midwives, our college fees cover us re: insurance.

This is also the system through which we can access physiotherapy treatment etc for an accidental injury this would include third and fourth degree tiers for future follow up and further surgery if necessary.

In order to survive as an Independent Midwife, I think you have to have lots of stamina, well organised flexible work practices, good work ethic and a supportive relationship/family. My personal view would be it would be very difficult to do this job with a young family as the work is unpredictable in its timing! One does have great job satisfaction though.

This is a very idealistic system of care for women a one to one relationship, but for midwives it can cause burn out. Midwives leave the system as they struggle to cope with the on calls, long hours and family commitments. This is not a job I feel one can do continuously for years; many midwives opt in and out of the system over their career span.

Independent Midwifery is a challenging, yet rewarding way of working.

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