To all concerned,
Aotearoa midwifery has, for a number of years now, been in a state of crisis. The impacts of this are far reaching, for maternity consumers and their families and babies, for maternity staff in our hospitals and birthing units, for independent midwives, and for our society at large - anything that negatively impacts the start of life has well researched impacts on later quality of life, and we are all well aware of the dire state of mental ill health among a very large portion of our community.
With a background in midwifery, I have been working in the field of birth trauma support and education for almost a decade. While birth has always inevitably entailed trauma for some, I am hearing growing numbers of stories of unnecessary trauma, trauma that could have been mitigated with better maternity support. The growing shortage of midwives and the inherent stresses (burn out, compassion fatigue, trauma) that this causes for many of those remaining maternity care providers, is having very real and devastating impacts on many maternity care consumers.
What follows are some of the more common experiences I am being told about in my work:
Pregnant women being unable to access an LMC midwife and therefore having no option but to have fragmented care from a team of core hospital midwives, and then having whoever is on duty as their midwife for their birth. This is problematic for a number of reasons - the well known benefits of ‘continuity of care’ are not accessible; the woman is required to birth in hospital irrespective of whether this is where they wish to birth or where they feel safest; the woman may have a poor relationship with her birth-care midwife, which commonly leads to trauma in the birth space; if the woman has a traumatic birth experience, she may not have the postnatal support (from a known, trusted midwife) that she needs in order to debrief and begin her healing journey.
When a woman is able to find an LMC midwife, oftentimes there is a mis-match of woman-midwife philosophies of birth care. Prior to the midwifery shortage, there was potential for women to interview a number of midwives and find one who felt to be a safe, trustworthy and aligned ‘fit’. These days ‘you have to take who you can get’ - a recipe for an unsatisfactory partnership, which in itself can lead to poor birth outcomes.
For people who desire to birth outside of the hospital, it is increasingly difficult (sometimes impossible) to find an LMC who will support them to birth at home or in a birth centre. My birth trauma support work has taught me that for many women who have experienced a traumatic hospital birth, hospital becomes a very unsafe place for them to birth subsequent babies. Many women who I work with as a result of their prior birth(s) being traumatic, often due to disempowering experiences in the hospital, including unconsented to procedures, unwarranted interventions, disrespectful care, lack of informed choice, coercion and bullying, are desperate to find an LMC who will support their autonomy in the birth space, and who will not intervene unnecessarily and without the their full informed consent. We are going to see increasing numbers of further traumatised people because they cannot access the safe birth care they need, and I believe we will see growing numbers of unassisted births taking place because some people will feel safer birthing at home without a midwife, than being forced to birth in the hospital with a care provider who they do not align with. This has become particularly pertinent and problematic since many midwives, supportive of autonomy in birth, including home birth, have been mandated out of their job.
Antenatal appointments are very short due to large midwife caseloads. This means there is little time to build rapport, to honour the importance of the midwife-woman partnership, and to allow for fully informed decision making.
Postnatal care is similarly rushed and inadequate for growing numbers of new mothers. I am frequently hearing stories of women whose wound healing has not been discussed or observed, for instance, and for some this is leading to ongoing physical recovery issues, such as pain, the need for corrective surgeries, incontinence issues, painful sex.
Many of the women I see have not been referred to Perinatal Mental Health services despite a clear need for mental health support. Of those who are referred, it is taking a number of months for them to hear back, and when they do, it is often to be told that their referral has been declined.
In the postnatal wards, call bells are not being answered in a timely manner, leading to dangerous, scary and upsetting experiences for fragile, exhausted new mothers, many of whom have just undergone major surgery and are very limited in their physical capacity to care for their newborn. When they do receive care, it is often very rushed and insensitive to the particular needs of the woman. I am hearing lots of stories of aggressive, insensitive and rushed breastfeeding support, too.
Understaffing of maternity wards means that the obligations of healthcare providers to comply with the HDC Code of Consumer Rights, are not always able to be met. For instance, there is often not enough time and/or human resources to support the birthing person’s rights to be fully informed, and to make an informed choice and give informed consent, before any desired or proposed medical procedures take place. In my birth trauma support role, a lot of the trauma I hear about is seated in the disempowerment that comes with lack of support to be able to make informed decisions and/or to give informed consent. Instead, many women are being manipulated or pressured into having procedures that they do not want. Staff shortages undoubtedly lead to more of this.
Many LMC midwives are taking on larger caseloads then they are comfortable with. A larger caseload leads to increased pressures, stress, burnout and compassion fatigue. It also increases the likelihood of being unavailable to attend their clients in labour (due to being at another birth), or of going from one birth to the next without sufficient rest in between. Apart from the obvious detrimental impacts on midwives and their own families, being overworked, under-funded, and under supported in terms of their own mental well-being, is also likely to negatively impact the families in those midwives' care.
Midwifery shortages were a concern prior to the Covid epidemic, but since then those shortfalls have been exacerbated by the mandated vaccination of healthcare workers. When the serious early strain of Covid met NZ shores and the vaccination was believed to be able to significantly decrease the spread of the disease, many may have been in support of the government’s action to mandate midwives. However, with the less serious strains now circulating, and with growing evidence that the vaccinations do little in the way of stopping people from contracting or spreading Covid, isn’t it time to review the risk-benefit analysis surrounding these mandates? We need to determine whether stopping unvaccinated midwives from working is causing more harm than the harm-reduction it was initially enforced for.
As a concerned birth worker who has heard evidence of the trauma that the midwife shortage is having on both women/whānau and midwives, it seems counterproductive to continue to stop competent and willing midwives from doing what they know and love - provide safe pregnancy, birth and postpartum care. What was purported to be a vital harm reduction strategy, has led to an escalating source of trauma within maternity care. An obvious first step to resolving this issue is to drop the mandates. We also need to provide more support and guidance for our budding new midwives, many of whom are currently being plunged into the deep end - big caseloads, minimal support, early burn out and fatigue, and we need to demonstrate more respect for the midwifery profession by paying them appropriately for the vital work that they do, and providing sustainable work conditions. Of course, more accessible and holistic mental health support services for new parents is also crucial. These requirements are well overdue. Midwives, women and whānau deserved better long ago!
Carla Sargent
Founder of Healing Birth - birth trauma support and education
BM, PG Dip Teach (secondary)
