Today marks International Day of the Midwife 2022. To highlight this year's theme, ‘100 Years of Progress', we sat down with two of Northland's longest-serving midwives, Lynley McFarlane, now retired, and Northland DHB Director of Midwifery/Maternity Service Manager Sue Bree, to find out how midwifery has changed during their careers.
Both Lynley and Sue took up midwifery because of the opportunities it gave them overseas and agree that a life-long career as midwives has enriched their lives more than they are able to describe.
Sue said it seems obvious now that women have a say in how they give birth, but when they first began their studies, this wasn't the case.
"Women were pretty much powerless and relatively uninformed. Every woman who gave birth was required to be in a lithotomy position (on their back with feet put up). They were shaved and given enemas, and women felt they could not refuse. They were alone in labour, without the support of family members.
"As student midwives, we had to make sure that the sterile drapes were in place and, if necessary, tell a woman to stop pushing while we waited for the doctor to come along."
All mothers and babies were separated after birth, with babies put together in nurseries while mothers stayed on the ward. At regulated feeding times, the babies, who were mainly bottled fed, were placed on trollies, each carrying around 20 babies, and wheeled out to the ward to their mothers to be fed.
"I remember working at National Women's Hospital. Women would wait in the corridor antenatal clinic wearing only a hospital gown that often didn't meet at the back so that doctors had easy access to their bellies when the time came for their examination,” said Sue.
"What that did to women on a cultural basis, let alone as individuals, must have been profoundly bad.”
She said that the lack of rights for unmarried women was worse still, "They had to be called Mrs and were often treated very inhumanely. There were many more babies put up for adoption back in the 70s."
"Humane, loving and deeply caring attitudes were not typical words to describe many maternity wards, including midwives themselves, unfortunately.
This is possibly because they felt disempowered due to a lack of agency, as doctors were very much in charge. Most doctors back then were male, so it was a somewhat paternalistic system overall.”
However, Lynley and Sue said, on a personal level, they always felt well supported by Northland Doctors - Graham Parry and Peter Milsom are two that immediately come to mind for them during the 1980s.
Sue is proud of the quality of inter-professional relationships currently within the Te Taitokerau maternity service. Nowadays, midwives and doctors work collaboratively, with mutual respect and depend entirely on each other.
Lynley said that Midwifery in Northland has always been progressive. This was evident when she first undertook interviews in 1986 at hospitals in New Plymouth, Auckland, Waikato and Whangārei.
"Whangārei was hands down the best place to be a midwife in New Zealand. We were the first region in the area to have an Area Health Board, middle management was very active – and there was a lot of connection with the community."
She said a lot of work went into making changes to enable midwives to work autonomously. But, first, they had to prove that their profession outdid everyone else, so they scrutinised and educated themselves.
They researched whether techniques such as shaving, enemas and lithotomy made a difference in birthing outcomes and concluded that there was no basis for these practices. These learnings allowed them to have the power to make changes.
Self-reflection by individual midwives of their practice, including scrutiny of outcomes and feedback from women, arose out of the Home Birth Association in the 1970s. When initiated, this process called Midwifery Standards Review, was to demonstrate accountability by those midwives attending home births and it is still required of midwives today as part of their recertification requirements. While Lynley said she did not always enjoy this she believes taking the time to examine statistics and look at outcomes every two or three years is one of the most valuable midwifery processes and is quite unique.
"I used to say to myself, if my C-section rates go over 10 percent, there's something wrong with my practice as a midwife."
Another significant change has been the acceptance of home birthing becoming standard practice. Sue said in the 1970s and 80s it was severely frowned upon, and, in order for a midwife to attend a woman at home, she needed the permission of the Charge Public Health nurse – as well as the support of a brave GP. Home births now make up approximately 10 percent of all births in Northland.
In 1990, the law changed, enabling midwives to practice autonomously and work as Lead Maternity Carers (LMC) in the community with their own caseload.
Sue said this gave them the ability to provide the all-important continuity of care that has been proven to have a positive influence on maternity outcomes. Sue and Lynley acknowledged Julie Strid, Linda Williams, Joan Donley, Karen Guilliland and Sally Pairman for leading these changes that were a direct result of midwives and women working together.
Also, in 1990 Direct Entry education was reinstated which enables people who are not nurses to undertake education to become midwives. The changes included studying to be a midwife being extended from just a six-month post nursing programme to the four-year degree that it is now. Both Sue and Lynley are envious of the quality of education current student midwives now receive.
Self-regulation, with the establishment of a Midwifery Council of NZ in 2004 completed the professionalisation of midwifery in NZ as a distinct and separate profession from nursing.
New Zealand midwifery is held in high regard globally and midwives from other countries are hugely envious of the maternity service in New Zealand. Midwives here acknowledge that nothing would have changed if midwives and women had not partnered together and this is the advice our midwives offer to countries still developing their midwifery profession.
Sue agreed that Northland midwifery had always been highly regarded, thanks to people like Lynley and because of the collaborative way self-employed LMC midwives in the community, and hospital midwives work together. This is apparent in all areas of Northland
"We do see ourselves as one and acknowledge that we are entirely reliant on each other –Even though our interventions (inductions, caesarean sections etc.) rates are increasing, they're still mostly below the rates of the rest of the country. There is no one reason for this, but I am pretty sure the quality of relationships amongst midwives and with obstetricians is hugely influential.”
Lynley noted that every intervention has a risk, and in midwifery, it's about finding a balance between risk and benefits.
"The result of your care alters the outcome very often, which begins with the relationship you develop throughout the pregnancy."
Sue added that in Northland, we must respect the worldview of Māori in relation to childbirth and we all have a responsibility to do better with this. Māori women make up almost 50 percent of our birthing population.
"Although Māori have inequitable outcomes in health generally, this is not so apparent within our maternity setting here in Te Taitokerau. However, I still don't believe our maternity service has got it right for Māori. There is more to outcomes than just physical outcomes – it is also about the experience whānau have and an unintentional bad experience will be remembered for a very long time. Fortunately, we have an increasing Māori midwifery workforce providing care to Māori women."
Sue said it appears the health of women in our population is under pressure. "There is an increased incidence of diabetes and high blood pressure in our birthing population, which impacts directly on our birth outcomes.”
Both noted midwives face challenges matching current science with midwifery philosophy and social expectations – like increased consumerism and pressures from social media.
"Midwives believe that every woman should have a well-educated regulated midwife throughout her childbirth experience. It's the enabling environment that we're struggling with – these workforce issues and intervention issues."
All midwives do ongoing education as part of the requirements to sustain their practising certificate, and AUT has established a satellite programme for Northlanders to undertake their Midwifery degree here. This has been key to sustaining our midwifery workforce. Sue said although there are competing job opportunities for young women, a lot of student midwives enter the service after experiencing birth themselves.
However, both have concerns about midwifery's ongoing place in the maternity setting. Especially with national negotiations around pay being stalled and staff being drawn to Australia, where they are offered very generous packages.
Sue believes deliberate measures need to be made to retain and grow the midwifery workforce, "Like national recognition that we're in trouble as a workforce. We're in constant deficit."
"We need to take care of student fees, have incentives and a retention package to keep midwives in New Zealand."
"Up until recently, Te Kotuku was one of the best staffed secondary units in New Zealand. However, our midwife numbers have significantly reduced, and nationally our midwifery workforce is aging – so we've got to get more vibrant young midwives to replace us oldies."
She said these staffing deficits can mean midwives are not always getting a personal sense of fulfilment because they're unable to provide the care they want to provide, and that's a very diminishing position to be in for an ongoing length of time.
When discussing the highlights of their career, Lynley said hers was seeing women making their own decisions - even when they went against Lynley's advice, and in the end, they were right.
"It's a time in someone's life of incredible intimacy. And it's a great privilege to be part of that family's experience."
Sue agreed that there was nothing like the deep relationship that is formed with a woman and her whānau, irrespective of whether that is over the length of the entire childbirth experience or, for the length of a hospital stay
"That connection is created through this incredible primal act of having a baby.”