by Karen Guililland
Social change of the magnitude experienced by the New Zealand Maternity Service over the last eight years has not been without difficulties. The changes have challenged individual women and their families, midwives, general practitioners, obstetricians, politicians and institutions. Such challenges attract considerable excitement and enthusiasm but they also attract resistance and hostility. Now, some years down the track, New Zealand is starting to accrue some evidence on the effect of these changes on maternity services and overall health goals.
The midwifery profession’s first major change was the formation of the New Zealand College of Midwives (NZCOM) in 1989. Following quickly were the hard won changes to the Nurses Act in 1990 which gave midwives autonomy for practice. This autonomy in turn provided women an alternative maternity provider to the medical service, dominant since the sixties. However changing the legislation was the easy part. In New Zealand, like many other countries, midwifery autonomy is constantly challenged as society (via doctors, nurses and journalists) comes to terms with the ability of a woman dominant profession to provide a safe service without medical supervision. Mothers and grandmothers, from generations who didn’t experience choice or control in childbirth, also exhibit strong reservations about their daughters and grand-daughters choice of midwives as lead maternity practitioners. This inter-generational knowledge gap between women is often painful but more often revelational as daughters show mothers the unrealised possibilities a woman can experience in this now different transition to motherhood (Pairman, 1998 . Fersterer, 1993 .)
Imposed on these fundamental changes in service delivery were the health reforms or “deforms” as Joan Donley, our Elder Midwife, likes to say. The health reforms were a by-product of New Zealand’s economic turnaround from a welfare state to a market driven economy. Subsidies removed, taxes changed, import and export tariffs removed, government departments sold off to private enterprise all created a user pay, treasury led market. The health reforms followed the same market forces where the government withdrew and down-loaded fiscal and social responsibility to the individual providers, either hospital, agency or practitioner. In 1993 the hospitals became Crown Health Enterprises (CHEs), and were now required to make a profit. The emphasis was to establish competition between both health providers and purchasers. Initially the government was the only purchaser so the immediate focus was on CHEs to compete against each other and the private sector. This then was the environment in which midwives, general practitioners, obstetricians and maternity hospitals found themselves. Some three years after the Nurses Amendment Act the midwives, general practitioners and obstetricians became the “private sector” competing with each other and the hospitals for “cases”. Cooperation and teamwork struggles for survival in this atmosphere. As the newcomers, midwives have borne much of the blame for the changes when in fact they were as much victim to the economic reforms as everyone else. Midwives did, however, respond rapidly and effectively to the new market environment made possible by the reforms. Anti-competitive laws introduced some years previously enabled them to promote and sell their services in a way not previously countenanced by professionals.
The most overwhelming influential factor in the evolution of maternity services was the massive change to the way in which it was funded. The maternity service was the first health service to demand budget holding from its practitioners. Since July 1996 women have been required to nominate a lead maternity caregiver (LMC) from either a midwife, a general practitioner or an obstetrician. That provider then has a set budget claimed under modules of care throughout pregnancy, labour, birth and the postpartum period of up to four weeks. This budget is the same regardless of professional disciplines or whether an LMC is employed by a hospital or self employed. Only a private obstetrician can charge over and above this payment for their services. Hospitals which also provide acute and secondary maternity services are funded under a different budget. The effect of these changes was to identify, for the first time, the true cost of the maternity service to individual women. Money previously given in bulk to hospitals to divide up as they decided now came back into the community or primary health service.
This transparency caused the New Zealand Medical Association to claim midwives had caused a budget blow-out. This was not so as until midwives became able to provide the total service no-one had ever costed out the true price of a maternity service per woman. While general practitioners and obstetricians had provided antenatal care, the midwifery care in labour, birth and postpartum provided by hospital midwives was invisible and uncosted. Hospitals were of course vociferous in their resistance to this loss of control over the budget and having to compete with other providers. Even though they could still claim for primary service given by their midwives, it took some time for their respective managements to fully understand that it was a different payment mechanism rather than a reduced one. They were slow to rise to the challenge of giving their midwives autonomy and allowing them to take on LMC status and provide continuity of care. Some hospitals stopped providing primary care and concentrated on acute secondary services and providing facility only services to self employed midwives and general practitioners. (Rotorua Hospital, Tauranga Hospital, Wellington Women’s Hospital). Others have expanded their midwifery staff roles, and all teaching hospitals and the majority of provincial hospitals now provide midwife LMC services to women.
General practitioner-led organisations, known as Independent Practitioner Associations (IPAs), eventually realised they could also contract for services in primary maternity as well as the other primary health services. Their problem was that they couldn’t provide all the services required under the contract without the availability and support of midwives. Initially general practitioners had to negotiate with midwives, both self employed and employed, to agree on a price for the midwifery service their clients required. This caused considerable consternation for doctors as it became clear that midwives were not prepared to continue to pay general practitioners the historically high lump sum they had received regardless of the service they had provided. In the past a general practitioner could collect a delivery fee of over $300 even if he/she wasn’t present and the midwife provided the total service. Many general practitioners had become accustomed to hospital midwives providing virtually all the labour and postnatal care and only coming in when the midwife called. The hospitals bulk funding arrangements paid for that 24 hour midwifery service, regardless of the general practitioner involvement, and the general practitioner in turn was paid from a separate budget largely unknown to the hospital managers and midwives. There was no competition for funds as the general practitioners received their fee for service via the Maternity Benefit Schedule and the hospitals via bulk funding. Midwifery services were seen by the general practitioner as “free” to them and theirs by right. The lack of competition also extended into practice with most general practitioners happy for the non-competing midwife to provide the constant contact and support women required and them to provide the episodic interventions requested by the midwife. Duplication of services and double dipping were unknown expressions as no-one discussed or was accountable at that level for the funding or the allocation of resources. The Government, however, was clear that this level of funding was unsustainable. The LMC concept forced woman to choose their primary practitioners and that practitioner was funded to provide the total service. If more than one practitioner provided the service, the funds were to be shared.
On an individual level, many midwives and general practitioners slowly started to come to terms with this new environment of fee negotiation. True shared care with all roles valued and recognised was beginning to emerge. Politically however the NZMA continued to lobby for a return to their privileged past. They called for and got most of New Zealand’s general practitioners to boycott providing maternity care and increased pressure on politicians for more money. In March 1998 they succeeded and the Health Funding Agency changed the funding arrangements irrevocably by forcing the hospitals to provide general practitioners with midwifery “support” services for a set fee. This fee was low and could not be matched by self employed midwives, or by employed midwives providing continuity of care. This act fundamentally changed the nature of the service provision which had served women so well. It changed the LMC from the main provider of services to the coordinator of services. A general practitioner could once again provide women with midwifery care in a totally fragmented way. Pregnancy could be shared with the practice nurse and there were no longer any requirements for the woman to establish a relationship with her midwife antenatally as the hospital rostered midwife would automatically provide care when the woman was admitted to hospital. The general practitioner could also arrange for another midwife to provide postnatal care. The IPAs have heavily pushed this style of care on to women as the ideal. Some IPAs even threaten their own general practitioners who want to provide continuity of midwifery care with non payment if they don’t use the hospital midwifery service. This return to the old order has also unsettled the fragile midwifery unity and the divisions between rostered midwives and midwives providing continuity has stirred up again.
The world, however, is no longer the same. The majority of midwives have experienced autonomy and the rewards of knowing and beneficially influencing the woman’s experience of childbirth. Most are not willing to compromise that. Women too have very quickly come to expect their “own” midwife to attend them. Over 80% of women will know the midwife they have in labour and over 60% will have nominated the midwife as their lead maternity caregiver. (HBL, 1997) The general practitioners who boycotted obstetric care in 1996 remain outside the service either referring their patients who become pregnant on to midwives, obstetricians or hospital clinics. The money is still unattractive to general practitioners and the medico-legal environment further disenchants them. At present the NZMA estimates only 5-10% of general practitioners are willing to provide maternity services. The Health Funding Authority (HFA), after further numerous restructuring and with different leaders, has also backed away from entering into any new or different maternity contracts. No IPA has been able to produce any evidence to warrant additional funds for general practitioner care. It is likely therefore that all maternity contracts will return to an equal playing field. The IPAs who won more lucrative contracts in an effort to increase general practitioner shared care with midwives are all to have their contracts standardised to match the majority of maternity providers. If midwifery can weather these storms for a little longer it would appear women will eventually decide the issues of who provides care. As in the 1980s it was women who demanded change and it is women again who by choosing midwives as LMCs will ensure midwifery will remain autonomous.
So what have been the benefits or otherwise of this tumultuous change? The health reforms disintegrated the national data collection abilities of the Ministry of Health and did not replace them within the HFA. The data that is available comes from a variety of sources and has different collection methodologies, and it is therefore not particularly reliable. Data collection is evolving and becoming more reliable and the HFA hopes to have a dedicated Perinatal Database operational in late 1999. It is likely to be based on the NZCOM’s midwifery database. There are qualitative effects which are obvious however. There have been generally positive effects at individual social and institutional levels. The changes to the funding of the maternity system for example meant that practitioners had documented expectations that they must meet and that all women were entitled to similar access and services. The service specification framework was women rather than provider centred, it focused on health and normalness and it gave concrete form to a service which had previously been extremely variable in quality. It also recognised the bicultural nature of health services and recognised the multi dimensional partnership view of Maori. Significant numbers of Maori women have as a result been attracted to birth at home and to train as midwives. In 1998 20% of midwifery students were Maori.
As a result of a women centred service more women and their families are actively involved in choosing their LMC rather than having one appointed and choosing their place of birth. Homebirth is a valid and viable option with 6-10% of births at home. Most women now compile and take responsibility for their birth plan, making informed choices for themselves and their baby.
The process of a government funding agency defining childbirth as a life process rather then a medical event and giving midwives, general practitioners and obstetricians equal status in the provision of services around childbirth was a major triumph for women in general and the women dominant profession of midwifery. It has helped women become more responsible in relation to primary health and given weight to their choices. At the same time it clearly spells out to providers their responsibilities and holds them accountable contractually as well as professionally. This enables the tracking of the maternity service through one provider (the midwife) and costs that service reliably per birth. Recognition by government and society that the principle of equality for midwives enacted by the Nurses Amendment Act extended to equal pay for work of equal value was confirmed in 1993 by the Maternity Benefits Tribunal. This achievement was a world first for midwives and a New Zealand first for a women’s profession. Equality in the market place has given rise to midwives owning and operating their own birthing centres, establishing and operating individually owned service contracts for midwifery services and the formation of New Zealand’s first and only midwifery owned and operated commercial company contracting for midwifery services for an entire geographic region. This Midwifery Provider Organisation (MPO) is a parallel structure to the general practitioner owned IPAs. It was formed by the NZCOM to ensure midwives had the same contracting structure available to them as doctors. If midwives are to retain their market position, they must have a variety of ways in which to compete equally. These organisations can eventually contract with each other to provide both general practitioner and midwifery services. The MPO has recently tendered for, and won, the contract to provide rural midwifery services for a local hospital. All the midwives previously employed are now self-employed on a contract for service with the MPO — a totally midwifery run project and autonomy in action.
In spite of the resistance from general practitioners, the medical profession has moved from its position of ignore to inclusion in its response to midwifery autonomy. All medical colleges (obstetric, paediatric and general practitioner) have reached consensus with midwifery on referral guidelines for obstetric services. The College of Midwives and consumer groups had considerable influence in the evolution of this “risk list” and it remains a woman centred, consent required set of guidelines, despite early attempts by hospital management to make them strict protocols. Midwives were able to have influence in this way because they argued from an evidence base. As a result of this three year process to reach consensus, medicine has come to realise that obstetrics requires more evidence based practice. Responding to midwife challenges to current opinion based practice there is, as a consequence, more understanding of the interrelationships required not only between midwifery and medical practices but between education programmes. Medical students are now following the midwifery lead and gaining continuity of care experiences rather than just working hospital based shifts. Continuity of midwifery care has become an intrinsic part of all maternity education as women expect to know their midwife. The Bachelor of Midwifery (or Direct Entry) programmes have revolutionised midwifery education. They are a popular career choice for women and attract mature, dedicated students. The students themselves are valued and respected by the majority of the workforce as competent and challenging. All students must attend a minimum of 30 women throughout pregnancy, labour, birth and postpartum. All are apprenticed to an LMC midwife for this experience. Most attend many more births and all have gynaecology, paediatric/child health medical and surgical ward experience. They work in medical laboratories, community agencies and experience home and hospital, rural and provincial town practices.
Post graduate academic opportunities are still young. However, the last eight years have seen the establishment of Masters of Midwifery at two universities and Masters papers available at two polytechnics.
The physical outcome for women and babies would also appear to be beneficial. The following data gives some broad indication of trends over the last few years.
The perinatal mortality rate is the lowest in New Zealand’s history. The reasons for this are not quantified but it is clear midwifery autonomy has not increased the risk of perinatal mortality.
Figure 1: New Zealand Perinatal Mortality Rate (per 1000 live births) 1983-1995
In the annual Reports of 1994, 1995 and 1996 of National Women’s Hospital in Auckland, the Independent midwife has the lowest percentage of perinatal deaths than any other practitioner.
Figure Two illustrates the continuing decline in the infant death rate from all causes including birth related causes. Despite this evidence, general practitioners led a campaign for some months implying infant mortality was worsening because general practitioners were no longer involved at the birth.
Figure 2: New Zealand yearly average number of deaths per 100,000 infants during each five year period
In comparison to available Australian data, New Zealand’s perinatal figures indicate encouraging outcomes for maternity service where midwives are the majority of lead practitioners.
Figure 3: Perinatal data in New Zealand and Australia, 1995/1996[a]
(insert figure 3 Perinatal data in New Zealand and Australia, 1995/1996[a])
Another indicator used to illustrate safe and appropriate services is the transfer rate to specialist services. New Zealand has lower transfer rates than comparative studies but also a lower perinatal mortality. While not evidence of cause and effect, it does provide some substance to the safety of New Zealand midwifery.
Figure 4: Midwife Lead Maternity Caregiver LMC Transfer Rates
(insert figure 4: Midwife Lead Maternity Caregiver LMC Transfer Rates)
Figure 5 and 6
There is also evidence that breastfeeding rates overall are slowly increasing.
The following study and birth outcomes are provided here to demonstrate the potential of midwifery autonomy. They also provide a comparable database for further interpretation and research. The outcomes have strengths but their limitations in relation to survey data mean the results should be viewed as indicators rather than evidence. While this study gives an answer to the question “did the midwife led care in this study make a difference to women’s outcomes?” it does not answer the question as to why it did.
This study is the largest in-depth national study of midwifery or medical maternity practice conducted in New Zealand both prior to and following the 1990 Nurses Amendment Act and as such provides an invaluable record.
The birth outcomes are a self reported retrospective description of 2212 births attended by a total of 190 self employed midwives throughout New Zealand. The midwives can be considered largely representative of the total self employed population. The steps taken to minimise and control non sampling error were informal testing and pre-testing the questionnaire. There was a specific timeframe and midwife clients were restricted to a maximum of the last 15 clients in that period. The risk factors for each client were identified for risk status within the total client sample. The sample was similar to the maternity population in age, parity, ethnicity (excluding Maori) and range of risk factors present.
The Client Profile
The client profile is different to the majority of international studies of midwife led care and perhaps is a reflection of the partnership model of practice which has evolved in New Zealand under the influence of the women’s movement, the midwifery profession and the health agencies development of the LMC concept. The partnership model promotes continuity of midwifery care for all women, where all factors, including place of birth, focus on women’s informed choice. The high percentage of Maori women (17%) in this study with their concomitant socio-economic risk factors and increased morbidity and mortality over the predominant Pakeha or European population requires analysis. Maori women have their babies younger, closer together, exnuptially (77%) and with higher fertility rates than Pakeha women (Statistics New Zealand, 1996). Maori women/babies have higher rates of hospitalisation for caesarean section, hypertension, diabetes, intrauterine hypoxia/birth asphyxia, congenital abnormalities, perinatal jaundice and respiratory conditions of the foetus or newborn (Pomare, 1995). Despite these factors the Maori women in this study achieved similar outcomes to other women in the sample. Maori are also almost twice as likely to live in minor urban and rural areas (Census, 1991). The reliance on midwives in this study to provide maternity services in rural/town populations could be one explanation for the high Maori clientele. Further, however, is the expressed Maori need for whanau or family involvement in childbirth which the partnership model facilitates. Whatever the reasons it appears midwifery holds the potential to improve health outcomes for Maori.
Table 1: Antenatal Screening for Alerting or “Risk” Factors in Client Population
(insert Table 1: Antenatal Screening for Alerting or “Risk” Factors in Client Population)
The socio-economic mix of the client sample is also interesting in that almost 25% of the clientele are in the lower socio-economic bracket with a two child family income of under $28,000. The average income in New Zealand is approximately $34,000. Almost half the women in the study live in small towns or rurally without the proximity of level three or base hospital services.
Furthermore 14% of women have no partner. The mean age (28) is one year older than the national mean of 27 years with client age range of 14-45 also following national age range (Green, 1994). A quarter of clientele were between 14-24 years, similar to the survey. The national homebirth rate in 1996 was 6-10% according to the Ministry of Health (MOH, 1997). This survey included 18% at home, 70% in hospital and 7% in birthing units. This is quite a unique picture and indicates in my view that in New Zealand women and self employed midwives are cognisant of the evidence in relation to birth as a normal process and are beginning to place less emphasis on place of birth and more on birth where the woman chooses and feels safest. The majority of self employed midwives provide women with choice of all birth places.
Table 2: Client Characteristics of the Birth Outcome Survey
(insert Table 2: Client Characteristics of the Birth Outcome Survey)
Normal birth, caesarean section, forceps/ventouse, perineal status, augmentation, induction and breastfeeding rates are all similar to, and often better than, many midwife led studies including the meta analysis of the seven published randomised control trials (RCTs) on midwife care Waldenstrom, 1997). The number of antenatal and postnatal visits are consistent with other New Zealand studies. Transfer rates are not well described in many studies which makes comparisons difficult. However it would appear midwives in this study transfer care less often than the combined RCT meta analysis of Waldenstrom and Turnbull, 1997, which is yet unpublished.
The consultation rates antenatally and in labour and birth are high however, which may reflect a valuable working relationship with obstetricians/paediatricians where the midwife remains as primary care giver with specialist advice, thus reducing the need to transfer. The Section 51 service specifications encourage this way of working as it increases continuity of care and increases women’s satisfaction with the process of unexpected events (Advice Notice, Section 51, 1996).
Table 3: Selected Outcomes for Total Sample
(insert Table 3: Selected Outcomes for Total Sample)
When broken down further into provider groups, midwife LMC clients do considerably better than doctor LMC clients.
Table 4: Maternity Care Provider and Outcomes – 1996
Sample Size/Total Number of Births 2212
(insert Table 4: Maternity Care Provider and Outcomes – 1996
Sample Size/Total Number of Births 2212)
A study (in Press) by Virtue and McLauchlan, 1998, demonstrated again the differences in outcome between provider groups.
Table 5: Independent Midwifery Practice Outcomes compared with Shared Care Outcomes: A Retrospective Cohort Study 1994-1997[a]
(insert Table 5: Independent Midwifery Practice Outcomes compared with Shared Care Outcomes: A Retrospective Cohort Study 1994-1997[a])
Because of the varying methodologies it is difficult to compare midwifery outcomes internationally but Table 6 does give some reassurances that New Zealand midwifery is at least consistent with international practice.
Table 6: Birth Outcome and/or Intervention Comparisons with RCT Meta Analysis of Midwifery Care
(insert Table 6: Birth Outcome and/or Intervention Comparisons with RCT Meta Analysis of Midwifery Care)
New Zealand has seen the triumphant, if often difficult, re-emergence of a women’s profession on its own merits and provides a role model for other countries in their fight against gender inequities.
The institutionalisation of childbirth, however, remains a major technique in the suppression of midwifery practice and women’s choices. Many hospital institutions continue to deny the independence of both women and midwives. Protocols and rules rigidly applied are designed to reinforce women’s dependence. The medical power structures are increasing and many midwives despair at having to work within, or use, maternity facilities in this environment as some institutions require submission from midwives and women to their world view. As Joan Donley says, “If submission cannot be achieved through positive willingness to participate in hospital procedures it is usually achieved by veiled intimidation of the threat of dire consequences for non-conformists”. The ultimate threat to women is the withdrawal of medical services and the threat to midwives is to deny their access to hospital beds. We continue to fight against these tactics but it has been a repetitive and constant factor throughout the 23 hospitals over the last five years. NZCOM and the HFA are currently working on a national access agreement which may overcome some of the difficulties.
This power struggle has resulted in significant increases in intervention rates. All care providers, midwives included, have seen a jump since 1996 (and midwife LMC status) in induction, epidural and caesarean sections. The difference in dealing with the issues in this decade, however, is that funding and political agencies are aware of and understand the underlying power dynamics. They are no longer willing to view medicine as always having the definitive answer. Midwifery and women’s groups are consulted and listened to and their views modify the outcomes.
We’ll have to wait and watch the unfolding socio-political outcomes for some years yet before we can truly say we will remain the primary maternity caregivers in New Zealand.
- Pairman. S. The Midwifery Partnership: An exploration of the midwife/woman relationship. MA Thesis, Victoria University, Wellington, 1998
- Fersterer. T. Empowerment in Childbirth: Women’s home and hospital birth experiences. MA Thesis, University of Waikato, Hamilton, 1993
- The budget for a woman having a first baby is approximately $1700 per whole maternity episode and $1500 for a second and subsequent baby. The first trimester and specialist consultation fees are on a separate budget and are easily accessible.
- Health Benefits Ltd, Christchurch. Reports of LMC Claimants, 1997
- Christinson. J. Maternity Services Evaluation Research, NZCOM Newsletter, Issue 9, July 1998
- Guilliland. K. M. A Demographic Profile of Independent (Self Employed) Midwives in New Zealand, MA Thesis, Victoria University, Wellington, New Zealand. 1998
- Midland Health Authority Annual Report for 1996, Hamilton, 1997
- Health Funding Authority Guidelines for Referrals to Specialist Obstetric and Related Specialist Medical Services. Health Funding Authority, Auckland, July 1997.
- Guilliland. K. M. A Demographic Profile of Independent (Self Employed) Midwives in New Zealand, MA Thesis, Victoria University, Wellington, New Zealand. 1998
- Pomare. E, Keefe-Ormsby. V, Ormsby. C, Pearce. M, Reid. P, Robson. B and Watene-Haydon. N. Hauora Maori Standards of Health III. A study of the years 1970-1991. Wellington School of Medicine. Hauora Publishers, 1995.
- Waldenstrom. U, Turnbull. D, Nilsson. C. A. A systematic review of Alternative versus Standard Models of Maternity Care (in Press), 1997.
© Karen Guilliland, 1999 This paper was presented at the Future Birth: The Place to be Born Conference, Australia, February 1999 for Birth International, PO Box 366 Camperdown NSW 1450