Delivering change: midwives call for better treatment
A first-time mum writhes through the pulsating pain of a contraction.
She has been in active labour for 10 hours and with her head slumped against the rim of the cold, white bathtub, she screams that she wants to give up - she can't do it anymore. Her contractions are becoming more intense and more frequent.
But she has an ally by her side.
Glen Valentine holds her hand and breathes her through the misery. Deep breaths in and slowly exhale, he says. The baby is crowning and Valentine shares the observation with the mum.
The calmness in his voice and encouraging words are enough to get her through the last stage and she births a crying, healthy baby.
In that intimate moment, the pain is forgotten.
"After my first birth, I knew I wanted to be a midwife," Valentine says.
"It's such a surreal experience being at a birth and helping the women through that."
The 31-year-old is one of only seven male midwives registered in New Zealand.
At the birth of his second daughter five years ago, he had a midwife who made him feel included and not useless. That experience prompted him to ditch a future working in supermarkets for a career looking after pregnant women, mothers and babies.
But for all Valentine's enthusiasm and zeal for his profession, there are some who argue the sector is lurching toward crisis.
Stagnating pay rates, heavy workloads, and, at times, intense media scrutiny, are prompting increasing numbers of midwives to walk away.
According to the New Zealand College of Midwives, those in the profession only stick it out for six years before looking for the exit.
In the past, the average stint was 15 years.
The college fingers stressful working conditions as one of the main reasons behind the growing exodus.
In addition, there have been fewer midwives graduating in recent years and students struggle with clinical placements in hospitals, says New Zealand College of Midwives chief executive Karen Guilliland.
"There has been little to no priority given to community maternity services since midwives became the predominant care providers," Guilliland says.
"Despite providing the 24-hour service that all other health services do, midwives have received no recognition for this."
Christina Campbell, a midwife for 20 years, has helped more than 700 women through pregnancy and birth.
The rewards are immense, she says - they assist women through one of the most intimate and special times of their lives.
Campbell cites her great grandmother, who was a lay midwife in Central Otago, as one of her inspirations.
"She was a very resourceful, kind-hearted person and a tough woman, as they had to be back then. I come from a history of midwifery and have always had an interest in the health and well-being of mothers and babies."
And just like her pioneer great grandmother, Campbell says today's midwives are incredibly resourceful and compassionate.
And unlike her foremother, she's spent 4800 hours in study to obtain her bachelor of midwifery - the equivalent of a four-year degree.
Midwives are also on call 24-7 and, at a moment's notice, can be thrown into any number of unexpected situations.
But notwithstanding their obvious passion and dedication to the women in their care, more and more midwives are choosing to quit.
This year alone, Campbell has seen a host of midwives, both new and experienced, leave the profession.
Without urgent action, the hard-fought gains in New Zealand's maternity care system could be lost, she says.
"In the 20 years I've been practising, it's fantastic the changes that have happened. Midwives provide pregnant women with a continuity of care and ensure they are treated with dignity and respect.
"My concern is that if midwives' working conditions aren't addressed, then things might slip backward, and it's the women and the family unit that will suffer."
In the past decade, community midwives (who provide the lead maternity carer service) have seen their workloads increase significantly while at the same time receiving two pay increases.
Adding to midwives' frustration is the Health Ministry's method of payment, which doesn't take into account midwives' experience or hours worked.
"If a situation becomes complex and involves extended hours, it's not factored into the ministry's payment schedule," Campbell says.
"If a midwife brings in another midwife to support her, that cost is paid out of the set amount. There have been times when I've worked for less than the minimum wage."
The average yearly income for community midwives is estimated to be $53,000 before tax, once costs and business expenses are paid.
The midwife shortage is best illustrated at some of the country's biggest hospitals as health bosses look overseas to plug vacancies.
Waikato District Health Board are currently looking as far away as the United Kingdom to fill seven vacancies at its maternity unit.
Capital & Coast DHB, which runs Wellington Hospital, and Auckland and Counties Manukau DHBs are also battling to fill positions.
The New Zealand College of Midwives has described understaffed maternity levels at some larger hospitals as an emergency situation.
Waikato DHB Women's Health Commissioner Tanya Maloney says Waikato has a good supply of midwives, with 180 working as lead maternity carers in the community.
Waikato Hospital's maternity service employs 84 permanent midwives and 12 casual midwives, making up 58 fulltime equivalent positions.
Additionally, four positions are filled by registered nurses on a fixed-term basis.
That 180 figure is disputed by some in the industry who say not all of the region's registered midwives have active caseloads.
What is agreed, however, is DHBs have to do more to attract midwives to work at their hospitals.
Guilliland says making it compulsory for midwives to work in hospitals upon graduation would not fix the shortage.
"All midwives work in hospitals during their training ... it is not lack of exposure to Waikato Hospital - it is the conditions they see there that are being rejected: Inflexible rosters, poor staff-skill mix, enforced protocols that are not woman-centred [shows that] midwifery is not valued by the organisation."
In February, Maloney and Waikato DHB chief executive Dr Nigel Murray met with college representatives to discuss the staffing shortage.
Maloney says there is a variety of reasons why midwives opt not to work in large tertiary hospitals: midwives train with a focus on primary care so the medical high-risk environment is less attractive to many; and midwives may not be able to work at the top of their scope in a hospital environment.
To address this, the Waikato DHB has embarked on several initiatives, including a new Maternity Day Assessment Unit, which opened at Waikato Hospital on Monday.
The unit will cater for high-risk women who need support and monitoring during pregnancy.
Maloney says the new unit is another step on the journey to transform the Women's Health service at Waikato Hospital and improve maternity, obstetric and gynaecological services.
The unit will also provide midwives with an opportunity to use their full skill set.
DHB-employed midwives report lower levels of empowerment and professional recognition compared to self-employed midwives.
Another initiative aimed at attracting midwives to work at Waikato Hospital is a 12-hour shift trial.
Providing the option of working an extended shift responds to midwives' desire to be present for the early part of labour through to birth.
Guilliland says pay equality and better working hours and resources would be a start to making the profession more attractive.
"On-call rates for core midwives is $4 [per hour] all up and recently, doctors on call during the junior doctor strike [at Waikato Hospital] got in excess of $450 to $500 an hour.
"In general, this is a problem of priority. All women-dominated health services face the same issue.
"There is little value placed on the caring nature of midwifery, nursing, social work, mental health, rehabilitation and aged care."
For Campbell, the struggle to improve the working conditions of midwives reflects wider gender inequality issues.
"We are highly professional group ... and yet why is it that we haven't been able to advance our working conditions? My hope is that the Ministry of Health and the DHB can attend to the maternity workforce crisis and our world-class midwifery system, which New Zealand women fought so hard for, is not lost or compromised. Recognising midwives is recognising the value of women in New Zealand society."
And it's recognising that value which saw Valentine choose to become a midwife.
It may seem an unpopular choice for a man, but for Valentine, it was the only career he wanted.
He currently has 14 women booked with him.
"Sometimes the partners of the women aren't too sure about me but because I've been in that position before, I can relate," he says.
"At my first birth, I knew I had chosen the right path."
FACTBOX: Midwife workforce
From the 2016 workforce survey (as of August 2016) 3023 midwives with a current practising certificate
- Seven male midwives (Glen Valentine graduated in 2017)
- Average age of a midwife is 47
- NZ European and other European make up 88.2 per cent of the workforce
- 1591 midwives worked for a district health board
- The average caseload for a midwife is 40.3 women