Promoting positive interactions between midwives and obstetricians at the primary/secondary interface

Background: Interprofessional communication is a critical component of safe maternity care. The literature reports circumstances in Aotearoa New Zealand and overseas when interprofessional collaboration works well between midwives and obstetricians, as well as descriptions of unsatisfactory communication between the two professions. Aim: To explore and define effective collaboration between midwives and obstetricians at the primary/secondary interface in maternity care, in order to generate suggestions to foster positive collaboration. Method: Eight primary care midwives, three obstetricians and two obstetric registrars from a single District Health Board in Aotearoa New Zealand were interviewed about their interactions at the primary/secondary interface and their understanding, and use, of the Referral Guidelines. The theoretical perspective was Appreciative Inquiry. Data were analysed using thematic analysis. Findings: Results indicate usually positive interprofessional interactions. Dominant emergent themes are the need to negotiate differing philosophies, to clarify blurred boundaries that sometimes lead to lack of clear lines of responsibility, and the importance of three-way conversations. Of the three themes, this article focuses on three-way communication between midwife, obstetrician/registrar and woman. Participants reported that, when effective three-way communication between woman, midwife and obstetrician occurred, philosophical difference could be negotiated, blurred boundaries clarified and understanding of the respective roles of the LMC midwife and the obstetric team promoted. Participants value the Referral Guidelines but report some limitations to their applicability. Conclusion: Effective three-way communication promotes good maternity care. This study has identified ways to support optimal communication.

Midwives’ experiences of caring for women with antenatal anxiety and depression: A qualitative study with midwifery acupuncturists

Background: Pregnant women seek help for a range of physical and emotional pregnancy symptoms from traditional acupuncturists. Whether midwifery acupuncturists in Aotearoa New Zealand (Aotearoa NZ) provide acupuncture for antenatal anxiety and depression (AAD) in practice is currently unknown. Aim: This qualitative arm of a mixed-methods study aimed to explore midwifery acupuncturist experiences of caring for pregnant women with AAD in Aotearoa NZ. The aim of the research was to examine the factors that influence midwifery acupuncturists' perceptions of acupuncture use for AAD. Method: This was a mixed-methods study involving an online survey and in-depth interviews from a convenience sample of Aotearoa NZ midwifery acupuncturists who had completed a Certificate of Midwifery Acupuncture. This paper describes the thematic analysis of the semi-structured interviews. Findings: The eight interviewees were mostly NZ European (n=6) and Lead Maternity Carers (LMCs; n=6) caring for pregnant women in rural and urban locations throughout Aotearoa NZ. The interviews revealed an overarching theme, “helping midwives to navigate the ocean of AAD”, which identified the lack of support participants experienced from current maternity health services for AAD in Aotearoa NZ. Subthemes “Missing the boat during pregnancy” expressed how participants felt no options were available for AAD prevention, while “keeping women afloat with no ship in sight” represented how interviewees tried to keep women in their care stable even though access to maternal mental health services was difficult. Participants felt acupuncture was a useful non-pharmaceutical tool that works; however, they had reservations about “adding acupuncture to the midwifery toolbox”. Conclusion: Aotearoa NZ midwifery acupuncturists were concerned about AAD and the limited conventional options available for women in their care. Acupuncture was viewed as a promising adjunct to usual treatment for AAD. Reservations included adding acupuncture to an already heavy midwifery workload, the cost of acupuncture, and the appropriateness of the treatment.

A weighty issue: The implications of an ultrasound prediction of a large baby in pregnancy

Introduction: The assessment of fetal growth in Aotearoa New Zealand is governed by a largely medical model of care which highly values the purported objectivity of sonographic assessment. Ultrasound scans are an increasingly normalised part of pregnancy care, and expectant parents may advocate strongly for access to them. It could be questioned whether the increasing number of scans is aligned with clinical need. This paper presents a literature review that explores the implications of an ultrasound diagnosis of a large baby during pregnancy. Method: Databases searched were CINAHL, PubMed, Proquest, and Google Scholar. Search terms used were “macrosomia”, “large for dates” and “large for gestational age”. This search was first undertaken in May 2019, and then repeated in November 2020. Findings: Sonographic assessment of fetal size can be inaccurate and the existence of a predicted fetal weight on scan increases the likelihood of birth interventions, regardless of the baby’s actual size. While there are potentially negative outcomes associated with a larger baby, it is unclear whether birth interventions will significantly reduce the occurrence of these outcomes. There is limited research that focuses on the parents’ experience of having a predicted large baby, offering contradictory insights, which suggests the influence of conflicting meanings applied to large babies and ignoring the experiences of women whose babies were predicted to be large but were born “normal” sized. Discussion: Midwives are encouraged to openly discuss with women the limitations in available evidence in this area. Midwives can consider the context of the woman and whānau (wider family), and how they may assess risk uniquely. Finally, midwives can honour the woman and whānau as the decision-makers in their own experience. There are further opportunities for research to provide a counter-narrative to medicalising discourses about large babies, grounded in a midwifery belief in normal birth. Conclusion: Midwives and women are drawn into a risk-centric paradigm that pathologises large babies for questionable benefit. To support informed decision-making within the midwifery partnership, midwives need to critically evaluate existing research and communicate its limitations and risk-centric orientation.

The microbiota of the vulva and vagina: Ways of washing to optimise the protective function of the vulvo-vaginal microbiota during pregnancy

Background: The microbiota of the vulva and vagina has a crucial protective function, which is important for all women and has particular significance in pregnancy. Yet this microbiota is part of a delicately balanced ecosystem, susceptible to extrinsic factors which include the simple matter of how women wash themselves. Clinical observation and anecdotal evidence indicate that women in Aotearoa New Zealand have washing practices that may compromise the naturally acidic vulvo-vaginal environment crucial to optimising the protective function of the microbiota. Aims: The aims of this review are: to determine if there is dissonance between how women are washing their vulva and vagina and recommended washing practices; and to raise awareness of the emerging significance of the vulvo-vaginal microbiota to women’s health, particularly in pregnancy. Method: A literature review was undertaken to discover what is reported (in the published literature) about the ways women wash themselves, products used, and their effect on the vulvo-vaginal microbiota. The evidence behind the “wash with water” recommendation was investigated. Findings: There is a lack of primary research on ways of vaginal washing used by women in Aotearoa New Zealand. Globally, women are routinely using a variety of products that include soap, anti-bacterial wipes, gels and baby wipes, and invasive vaginal washing practices such as douching, flannel scrubs and internal soap cleansing. All washing products, including gentle soap but excluding lactic-acid based gels, alter pH levels when used on either the vulva or the vagina. Washing practices that alter vaginal pH levels can cause a microbial shift into a sub-optimal state that compromises the protective function of the vulvo-vaginal microbiota and is more susceptible to bacterial vaginosis and group B streptococcus vaginal colonisation. The frequency and duration within suboptimal states may be predictors of risk. Conclusion: There is dissonance between the ways women wash their vulva and vagina, and evidence-based advice to just wash with water. The back-to-basics message “just wash with water” promotes a way of washing that optimises the protective function of the vulvo-vaginal microbiota, while also protecting the integrity of vulval skin, and supporting physiological self-cleaning of the vagina.

A daunting journey: A qualitative comparative study of women’s experiences of accessing midwifery care

Background: Early engagement with a maternity carer is recommended as a means of reducing stillbirth and neonatal mortality. This is especially important for women who live in high deprivation areas, as these areas have been associated with late access to maternity/midwifery care and significantly higher rates of stillbirth and neonatal mortality. Co-locating midwives at general practitioner (GP) clinics in such an area was established with the aim of facilitating women’s early access to midwifery care. Aim: To explore the experience of multiparous women who live in socio-economically deprived communities within the Counties Manukau Health region and who accessed the services of midwives at co-located clinics. Method: Interpretive descriptive methodology was used to explore the experiences of each woman before and after using a co-located midwifery clinic. One-to-one, semi-structured interviews were undertaken and data examined using thematic analysis. Findings: The eight women interviewed found accessing Lead Maternity Care (LMC) midwives during early pregnancy a daunting journey before being able to use a co-located clinic in the Counties Manukau Health region. Barriers identified were: a lack of knowledge about how to find a LMC midwife, limited finance and limited time. These impacted on women’s ability and confidence to find a suitable LMC midwife. The women expressed the need for help to circumvent the maternity care maze through receiving a recommendation for a LMC midwife and having access to a midwife co-located at their GP clinic. Conclusions: The participants encountered numerous barriers accessing early LMC midwifery care. Enablers to accessing early LMC midwifery care include receiving recommendations from GP clinic personnel, and midwives being co-located at GP clinics to make maternity care convenient and with a smooth transition from GP to LMC midwife care.

The role of Aotearoa New Zealand midwives as positive influencers on food literacy with Samoan families: Report on a small Auckland-based study

Background: Healthy eating is crucial for optimal development during all stages of life and most particularly during pregnancy. According to Stats NZ, Pasefika people make up 8.1% of the total Aotearoa New Zealand population. Information from the Ministry of Health suggests that Pasefika people have the highest level of food insecurity and the highest level of obesity. Women are more likely than men to be involved with food preparation; therefore, it is important to know to what extent women are aware of what healthy eating means for themselves and their families. Aim: This study aimed to explore an understanding of the levels of food literacy among representatives of three generations of women in five Samoan families; how each of the three generations ensured that their dietary intake contributed to their quality of health; and whether the extent of food literacy was influenced both within and between/across generations. Method: The study used a combined Delphi-Talanoa approach to interview 15 Samoan women about the levels of their understanding of food literacy. Findings: Midwives played an important role in helping pregnant Samoan women understand about healthy eating during pregnancy. Women shared with other female relatives what they had learned about healthy eating from their midwives. Learnings taken from midwives included the importance of choosing healthy foods, portion control and physical activity. Conclusion: All study participants who had received antenatal care in Aotearoa New Zealand mentioned the important role of midwives in increasing their understanding of healthy lifestyle choices. What the women learned from their midwives also informed their wider family or aiga.

Rural midwifery practice in Aotearoa/New Zealand: Strengths, vulnerabilities, opportunities and challenges

Background: The sustainability of rural maternity services is threatened by underfunding, insufficient resourcing and challenges with recruitment and retention of midwives. Aims: The broader aim of this study was to gain knowledge to inform the optimisation of equitable and sustainable maternity care for rural communities within New Zealand and Scotland, through eliciting the views of rural midwives about their working conditions and practice. This article focuses on the New Zealand midwives’ responses. Method: Invitations to participate in an online questionnaire were sent out to midwives working in rural areas. Subsequently, themes from the survey results were followed up for more in-depth discussion in confidential, online group forums. 145 New Zealand midwives responded to the survey and 12 took part in the forums. Findings: The New Zealand rural midwives who participated in this study outlined that they are attracted to, and sustained in, rural practice by their sense of connectedness to the countryside and rural communities, and that they need to be uniquely skilled for rural practice. Rural midwives, and the women they provide care to, frequently experience long travel times and distances which are economically costly. Adverse weather conditions, occasional lack of cell phone coverage and variable access to emergency transport are other factors that need to be taken into account in rural midwifery practice. Additionally, many participants noted challenges at the rural/urban interface in relation to referral or transfer of care of a woman and/or a baby. Strategies identified that support rural midwives in New Zealand include: locum and mentoring services, networking with other health professionals, support from social services and community service providers, developing supportive relationships with other rural midwives and providing rural placements for student midwives. Conclusion: Midwives face economic, topographic, meteorological and workforce challenges in providing a service for rural women. However, midwives draw strength through their respect of the women, and the support of their midwifery colleagues and other health professionals in their community.

Maternal socio-economic disadvantage in Aotearoa New Zealand and the impact on midwifery care

Background: Maternal socio-economic disadvantage affects the short- and long-term health of women and their babies, with pregnancy being a particularly vulnerable time. Aim: The aim of this study was to identify the key factors that relate to poverty for women during pregnancy and childbirth (as identified by midwives), the effects on women during maternity care and the subsequent impact on the midwives providing that care. Method: Survey methodology was used to identify Aotearoa New Zealand midwives’ experiences of working with women living with socio-economic disadvantage. Findings: A total of 436 midwives (16.3%) who were members of the New Zealand College of Midwives responded to the survey, with 55% working in the community as Lead Maternity Care midwives, or caseloading midwives, and the remainder mostly working in maternity facilities. The survey results found that 70% of the cohort of midwives had worked with women living with whānau (family) /friends; 69% with women who had moved house during pregnancy due to the unaffordability of housing; 66% with women who lived in overcrowded homes; and 56.6% with women who lived in emergency housing, in garages (31.6%), in cars (16.5%) or on the streets (11%). The cohort of midwives identified that women’s non-attendance of appointments was due to lack of transport and lack of money for phones, resulting in a limited ability to communicate. In these circumstances these midwives reported going to women’s homes to provide midwifery care to optimise the chances of making contact. The midwives reported needing to spend more time than usual referring and liaising with other services and agencies, to ensure that the woman and her baby/ family had the necessities of life and health. This cohort of midwives identified that women’s insufficient income meant that midwives needed to find ways to support them to access prescriptions and transport for hospital appointments. The midwives also indicated there was a range of social issues, such as family violence, drugs, alcohol, and care and protection concerns, that directly affected their work. Conclusion: Recognising the impact of socio-economic disadvantage on maternal health and wellbeing is important to improving both maternal and child health. This cohort of midwives identified that they are frequently working with women living with disadvantage; they see the reality of women’s lives and the difficulties and issues they may face in relation to accessing physical and social support during childbirth.

Editorial: A new direction for the College Journal

2020: the Year of the Midwife, and the year of Covid-19…what a year it has been for midwives in every role and every part of Aotearoa, and throughout the world. In Aotearoa, midwives have shown incredible dedication, innovation and flexibility to continue providing quality care for women and babies throughout the pandemic. Midwifery educators have continued to teach, midwifery researchers have continued to research – everything has needed to be adapted to virtual consultations, virtual teaching and virtual research. This is the 56th issue of the College Journal and, for 28 years, the Journal has continued to publish original research and other articles, and has been printed and posted to all College members, libraries and other organisations who have subscribed.