The Business Of Birth

Nine months from now the first baby will be born in the new primary birthing unit in the grounds of Hawke’s Bay Hospital. As yet unnamed, the unit is currently just a seed, germinating in a hole in the carpark. By the end of the summer it will be a fully-developed, seven-bed maternity space, the first of its type in New Zealand.

Of all babies conceived now and due in April, 97% will be born at the hospital; 3% will be born at home. To be allowed to birth in the new unit the mother must be healthy, carrying only one baby and must go into spontaneous labour. There’s no facility for epidural, forceps or ventouse.

Whether born at home or in the unit, wrapped around that baby will be a net of support that includes family and friends, but also a bevy of professionals in a range of roles depending on the mother’s wants and needs. Central to that care will be the midwife – the LMC (lead maternity carer) – who will care for mother and baby from conception to baby’s sixth week in a system that is world-class, and free.

There are around 40 midwives working in Hawke’s Bay as LMCs. There are another 50 midwives working shifts in the hospital. There are five midwives working for Choices, who predominantly care for Māori women. Some of the other services working in the birth community are Bay Babies and Home Birth Hawke’s Bay, who offer different perspectives on birth in the Bay.

New Zealand’s maternity care system is the envy of the world – known as the Rolls-Royce – in terms of continuity and quality of care. But while mothers birth around 2,000 babies a year in Hawke’s Bay, in a wide variety of circumstances and situations, the people who deliver them are quietly battling the challenges and complexities that come with being at the business end of birth.

Positive Birth

Ila Northe and Julie Kinloch are the longest serving midwives in Hawke’s Bay. Ila has been delivering babies since the 1970s. Julie was one of the first home birth midwives with an access agreement to the hospital. They call midwifery their business and their passion.

They operate out of an old bungalow in Napier, which has recently been given a new lease on life as a Maternity Resource Centre, thanks to a partnership with the DHB. They have three midwives working with them at 234 Kennedy Road at various stages of their midwifery careers. Bec Heyward has been practising for 13 years, Kimai Cure and Karen Maplesden are only just starting out with a couple of years under their belts.

With a case load of about 40-50 babies a year each and with a combined experience of nearly 100 years, the midwives at 234 have met a lot of mothers and attended lots of births. They also wear a number of hats: sitting on steering groups and committees, advocating for midwives and for mothers at a regional and national level.

The senior midwives at 234 have seen a big change in the mind set of many mothers over their time delivering babies.

They have no doubt that birth has changed because mothers have changed.

“There is an assumption now that we have a baby no matter what,” says Ila Northe. “So we are older and fatter and sicker, and there are people who have babies who should never have been pregnant.”

“There is more screening and more medicalisation of birth,” explains Bec Heyward.

This then changes the way the needs of a pregnant mother are met. Birth has been shifted from a normal part of life, where mothers deliver within their families, to a removed ‘specialist’ setting. Even the new birthing unit has been criticised by some midwives, Choices and the Home Birth community, for being too attached to the hospital.

Home birth advocate Rachel Pearson is concerned that medicalising birth is leading to greater rates of not only postnatal depression but post-traumatic stress disorder.

“That’s what people come back from war with!” she says. “How we birth is pivotal to how that family goes on to grow and develop.”
“Our culture turns women against the belief that their bodies are made to birth; that it is to be feared and surgically managed,” says Pearson, who resurrected Home Birth Hawke’s Bay in 2004 and carried the organisation through until recently when she stepped down from her leadership role.

Julie Kinloch wonders if women are becoming ‘overthinkers’ when it comes to birth.

“It’s such a new adventure for a family,” she says. “It’s a whole new university degree they know nothing about. Some people want people around them, some want to read everything there is!”

‘People’ may include a doula, an ante-natal coach, those offering complementary therapies. Bay Babies is a collective of practitioners who have a passion for ante- and postnatal wellbeing. It’s the love-child of Bronwyn Gardner, an ante-natal teacher, and Di Reefman, who comes from a massage and yoga background, and runs positive birthing classes.

Reefman believes women’s mind set around birth has changed partly because there is now too much knowledge available to them in terms of checks, scans and tests.

“Knowing is ‘head based’ information.  Not ‘feeling based’,” she explains. “This work is not just for the hippy dippies. I’ve worked with all kinds of people. The process is about shedding fear and all the other chatter that goes on in the head to get to ‘I am doing this’ with solid reliable tools to get you through.”

Jules Arthur is the Midwifery Director at the DHB. She has spearheaded the building of the new unit and is proud of what it means for birth in the Bay. “Low risk women are more likely to come away with positive births and stories. It’s about who owns the birth. My view is women own their birth, we’re just there to give them options and support. It’s about listening to women and their families, to what they’re saying, and hopefully we’ll see intervention rates fall.”

Where the need is

The experiences of those giving birth in Hawke’s Bay differ hugely. What is important, what’s a must have, where the gaps lie, what success looks like … are poles apart. At one end of the spectrum are births in poverty situations.

Of those 2,000 babies born here each year, 60% are born into decile 8-10 homes (here 8-10 represents the lowest socio-economic groups).

Beverly Te Huia has been a midwife for 15 years but has put practice to one side to concentrate on running Nga Maia and Choices as well as sitting on a number of boards, committees and steering groups, all on a volunteer basis.

“Midwifery was bestowed upon me, my Māori side has always been involved in delivering babies, both the men and women,” explains Te Huia. “The picture of Māori birth is whānau-centred. It is a shared responsibility of all the whanau members.”

The only increase in births in Hawke’s Bay, which has a falling birth rate, is in the Māori population. 40% of births each year are into families that identify as Māori. 98% of Choices clients are Māori; many of them living in high deprivation areas. Choices midwives delivered 400 babies in the past year; 6,000 since the service began 20 years ago.

Te Huia believes the knowledge held at Choices around birth should be better utilised by the DHB. There’s a disconnect between the guidelines set out by the hospital and the MoH, and what works on the ground for the women Choices cares for; there’s a gap between what is prescribed and what is needed.

“Caring for our women puts us out on a limb,” says Te Huia. “We’re left out on a ledge with no support so we come head to head in providing care for our Māori women. A big part of our Māori practice, is defending our practice!”

The line between what’s accepted and what is not can be a fine one, and can include everything from what’s suitable in breastfeeding, co-sleeping, treatment of the placenta, adhoc midwife check-ups at hui and on marae.

“When we make decisions, it’s not just the practical that needs to be considered, it’s emotional. It takes its toll. It’s hard to be Māori because you get tangled up in representing the whole of Māori.”

The key is for Māori midwifery knowledge to become central in DHB designing and planning.

“People have a distrust of kaupapa Māori. If the DHB came here and asked what would help, we would tell them,” Te Huia says.

She explains that there is a nervousness among Māori midwives to stick their heads up because often they are rubbing up against guidelines that don’t align with specific circumstances.

“Some of our work could be seen as clinically unsafe, but ethically and culturally it is right for whanau,” she says. “For us to go into a home to raise MoH concerns can seem ridiculous.”

Te Huia gives as an example smoking cessation, which is an MoH directive all midwives must follow.

“We can go into a home where there are six family members sleeping in the kitchen using the oven as the only heat source. Telling them to stop smoking seems irrelevant. Then the family will isolate themselves further, they won’t be home when we call around – they’re home, but they’re not answering the door.”

“The targets of health [MoH] seem so far away from what’s facing you at the time,” says Te Huia. “We’ve been working in the community; they’ve been sitting behind their desks.”

The cave woman within

Bay Babies provides a range of support for pregnant women at the other end of the spectrum. Their services have fees attached, so are predominantly used by higher socio-economic families.

Some of the paid services found at Bay Babies would traditionally have been done by a woman’s family, including her own mother. But in our middle-class communities, time, distance and perceptions of decency put up barriers for women wanting to access support during pregnancy.

“We don’t often live near our mothers, sisters and aunties, and we don’t have close relationships with women who we want to expose our bodies to, so the choice of paying someone to be with us at the birth who does that work professionally might be quite comfortable for us,” says Bronwyn Gardner who runs Bay Babies.

As much as birth has become something to fear and equate with pain, it has also become something we have little real knowledge of until we’re in the thick of it.

“We struggle with birth because we actually have a cruisy, easy life. We’re not out hunting, we’re not scrubbing floors every day, we’re not standing for hours making preserves, life is easy,” say Gardner.  “Birth can be the first experience of going past that threshold and meeting a person you don’t recognise, then that can be scary, and fear can set it. Some of what we do is about challenging women to meet the threshold before the birth, like meeting the cave woman inside yourself!”

As well as offering birth training and education, Bay Babies includes practitioners of everything from cranial sacral work to homeopathy. Modalities that can offer help to mothers at various times of their journey, but all unfunded.

Home birth champion Rachel Pearson advocates for the use of alternative practices alongside orthodox ones and would like to see the current funding model wrap in options for naturopaths, herbalists, acupuncturists, massage therapists.  “They’re all saying ‘we can help’, but they’re not getting funded.”

Midwifery as a business

A series of changes to Section 88 of the Health and Disability Act had the effect of ‘professionalising’ midwifery, meaning midwives could work as primary healthcare professionals paid by the Ministry of Health. Before that time, midwives worked in hospitals and were paid as specialist nurses.

As well as officially validating the role of midwives, for the midwives themselves the changes to the act meant they became self-employed sole-traders, with all the business responsibilities that entails. Midwifery as a calling remained, but as well as attending births, midwives had to do tax returns and GST, attend professional development courses, advertise their services, compete with others in the market place (a crowded one in Hawke’s Bay).

Today, what pregnant women, their families and society sees of midwives is a calm, reassuring, knowledgeable presence who cares for a woman from early pregnancy through to their baby’s sixth week. The reality for the midwife is that with a case load considered manageable of six women due every month they earn a similar wage to a primary school teacher but with all the costs of a small businesses. (The care of each woman is about 40 hours of work through the time of the pregnancy).

On top of that, Ministry of Health directives keep adding to their plates. Midwives are now screening for diabetes, dishing out diet and smoking cessation advice, doing checks on family violence – all prescribed by the MoH but with no added payment for the extra work.

“You are now getting a stressed work force, because we’re not funded as we once were. Hospital staff are stressed too, because the pressure flows on to them. The whole maternity health work force is stressed,” says Bec Heyward.

New directives and initiatives mean extra training, which is often paid for by the individual midwife who also pays for the person to cover them while they are away, travel to and from the course and accommodation. And if one of their babies is born while they are away and they’re not there to catch it, they miss out on the chunk of pay associated with that part of the process; the payment instead going to the midwife who covered for them.

Training student midwives is also an important part of our Hawke’s Bay midwives remit. Supervision of a student equates to 900 hours with a payment of about $1.25 an hour.

Sarah Glass has been working as a midwife for 13 years. Alongside her practice she is a vocal proponent for the rights of midwives to earn a fair living.

“I am astonished at the disgusting way we are treated,” she says.

Midwives are paid in sections; one payment for the first 28 weeks of the pregnancy, a second for the third trimester and the birth, and a third for aftercare.

Since the Section 88 changes 25 years ago there has been very little increase in pay, to such an extent that midwives are now being paid less than they were in 1990.

“When I started bringing it up, I felt resistance from midwives because we love our job,” Glass explains. “But the Ministry of Health is taking credit for this state of the art, world-class system, and we the midwives are paying for it.” Glass has calculated that at the end of the day, taking into account the money paid to midwives, the money paid out by them in tax and costs, as well as what would be a living wage, each LMC is donating $40,000 a year to the cause. Glass has calculated they are working for about $23 an hour for being on call 24/7; hospital midwives working shifts are on $32.

“It is an unrelenting workload,” says Glass. “What we provide has increased and increased.” The message from the MoH is if you want more money you need to take on more women.”

“Midwives do their job because they care, they don’t look at it as ‘what’s in it for me’,” says Glass. “But we’ve come to a crisis point because if we project these numbers into the future it will mean we are doing this for minimum wage, or cutting everything shorter to take on more clients.”

Because they are sole traders, midwives have no right to join a union, so there’s no collective bargaining. And if they band together to ask for more money they could be accused of colluding to price fix.

Glass is concerned that the future may not be as bright for the quality of midwifery care in New Zealand.

“Women will miss out because we could move to a place where woman queue up like cattle in a market place for their clinics and there’s no one there at the c-sections who’s known them through their pregnancy,” says Glass. “We need to work this out with the MoH or ten years in the future we’ll look back and say ‘Wow, look what we lost’.”

New DHB Unit

Due for delivery in the second quarter of 2016, the new DHB unit gets mixed reviews. The unit is the DHB’s response to consultation findings with input from interested parties in maternity health care.

It will link to the hospital’s existing ‘secondary’ care unit. If mothers need to use the facility it’s because they need a “managed” birth or they’re not “progressing”, or there’s “complications”.

Rachel Pearson was one of the people who submitted when the new unit was still a glint in the DHB’s eye. She feels she wasn’t listened to and the outcome is less than satisfactory.

“This is the worst case scenario for encouraging non-intervention birthing,” she explains. “They put it in a carpark, they dressed it as a hospital resource and they joined it by a corridor.”

For Julie Kinloch and Ila Northe, and the midwives who work with them, despite some details not being quite right – it would be nice to have the birthing unit in a refurbished home within a garden – the new facility is exciting.

“There is an expectation that everyone will have a family member staying the night, usually the father. And Hawke’s Bay is the only place that encourages this,” explains Julie Kinloch.  “Also it is midwifery led and midwifery supported so we are sitting in there as midwives running that unit without any secondary input, which is a wonderful thing for the women of Hawke’s Bay.”

Bec Heyward agrees: “It’s about supporting normal primary birth because all the research says that if you want a normal birth you need to be at home or in a primary unit – as soon as you go into secondary care there is a higher rate of epidural, vetouse, forceps and c-section.”

“Midwives want people to stay in the primary birth unit and not go to secondary, because the place of birth makes a difference,” says Kinloch. “Being in the primary care unit or being at home, the decision making is the same. The new unit is amazing and it’s a great opportunity to change Hawke’s Bay birth culture.”

The midwives at 234 believe the unit will become a model other DHBs look at to emulate.

Jules Arthur agrees that environment affects outcomes in birth and has advocated for the primary birthing unit for a number of years, spearheading the initiative through to fruition.

Two years ago after community consultation, including with ‘consumers’, Arthur put a paper to the District Health Board.

“We didn’t really get any opposition and we were commended by the board for our consultation,” explains Arthur. “It’s pretty amazing for a board to support that, in this climate. We’re one of the few DHBs who are in a position to do this and it’s a once in a lifetime opportunity.”

Beverly Te Huia, however, was disappointed by the process.  She sits on the steering group of the new unit.

“I wanted there to be an environment that reflected that lineage of Ngati Kahungunu and I have the balls to say I don’t think there will be,” she say. “I wanted it to be a story, and I was asked ‘how are you going to pay for that?’ but I felt that’s essential, I didn’t want it to be tokenism.”

“I signed it off but I’m disheartened. We’ll be asked about a name but we’re more than just a name. We spent more time talking about whether there should be toasters in the rooms than the integral stuff.”