A tiny kick reminds Anna Edlington that her life is about to change. Forever. Soon the 27-year-old West Aucklander will not only be a daughter, a wife or a teacher. She is becoming a mother - and learning just what that will mean. On the eve of a major review, Debrin Foxcroft investigates the midwife crisis, and the state of the baby business across Auckland.
Anna Edlington is one among thousands of Auckland women choosing to begin or enlarge their families this year. "It's a little nerve-racking," she says. "It's not really real yet."
In the year to March, 64,160 live births were registered in New Zealand, up one per cent on the previous year. At almost every one of those births, a health professional was on hand to help.
The ability to choose who delivers a baby sets New Zealanders apart internationally. Our maternity system is discussed, held up and analysed by other nations. This year, the hard-fought-for system is set for a shake-up with a new Ministry of Health Maternity Action Plan.
The ministry touts this as a plan to strengthen maternity services. Other parties argue it doesn't do enough to tackle the problems maternity professionals and mothers face every day.
It's a given that Auckland has very real problems in the baby business. The Aucklander reported more than two years ago that there are not nearly enough lead maternity carers (LMCs) for the population.
They take more clients to cope with demand. The College of Midwives recommends midwives care for four women a month, or 50 a year. Some midwives cannot say no to the voice on the phone, pleading: they are taking eight or more clients in a month because the women have no one else to turn to.
Healthy women are giving birth in hospital wards designed for the sick and, when a woman moves from one DHB to another, information can be lost.
To Mrs Edlington, the most important thing is the emphasis on choice. "The fact that Kiwis have the choice of who cares for them and where they give birth, that's really important."
But it's limited. "My husband and I were lucky. We were able to find a midwife late - I was eight weeks pregnant. I know it's not the same for others."
Mrs Edlington also counts her lucky stars her midwife takes only a limited number of clients - four a month.
"For her, it's never been an issue that she is at one birth when someone else goes into labour. It just doesn't happen," she says.
"In terms of personal care, it makes a huge difference. It's harder the more clients your midwife has."
IT'S A NUMBERS GAME. Emma Farmer, Waitemata District Health Board's associate director of midwifery, agrees the shortage of midwives is the biggest problem.
"AUT has increased the number in the midwifery course, so we will be getting more midwives. But we are also losing midwives. It's a hard job. It's hard to get up in the middle of the night and be available for women whenever they want you."
The average age for a midwife is 47, and the lifestyle takes a toll.
Another problem is the lack of primary birthing centres - specialist facilities in the suburbs where families live, offering the range of equipment and options that well-informed 21st century parents expect.
"Most of these babies born in Waitemata [West Auckland, North Shore and Rodney] are delivered in hospitals," says Ms Farmer.
"Only a handful are born in the primary birthing centres, like the ones in Helensville and Warkworth [others are Parnell's Birthcare and Pukekohe], which care for well women and well babies. We would like more women giving birth in primary units or at home."
But for all the challenges, Ms Farmer says we musn't forget "what an amazing system we have.
"We have had it for some time now and the new generation of Kiwis have nothing to compare it to. We have to remember that New Zealand is often referred to as the gold standard."
BEFORE 1990 a doctor had to supervise all births, which is still the case in other countries. The Nurses Amendment Act 1990 allowed midwife-led care for well women; in 1996 the Government enshrined choice for women by developing the Lead Maternity Care model. This meant women could choose who would look after them during pregnancy, birth and post-natal care.
It was a brave and socially challenging decision. It threatened the previously inviolate role of doctors in healthcare.
Even today: Counties Manukau District Health Board has more births than anywhere else in the country; its head of maternity was unwilling to be interviewed for this piece. The head of maternity services for the Auckland District Health Board, which includes the world-leading National Women's Hospital, was also unavailable.
Karen Gulliland, chief executive officer of the College of Midwives, agrees with Ms Farmer's assessment. "Auckland does have a problem with recruitment," she says.
"But I just spent two weeks at a conference in The Hague. I keep going over there and I wonder, why do we moan? New Zealand's maternity system is universal and, what's unique, it's universally accessed - 96 per cent of women have a lead maternity carer."
What our system does well is the partnership between carers and women, she says. There is also an awareness of women's consumer rights - "but this does fall down when the workforce isn't enough to meet the demand".
She is concerned there is no standard model for health boards to collect electronic data. The methods differ from area to area - crucial in Auckland where a woman from, say, Henderson may go to National Women's in Grafton if there's a problem.
Post-natal care is another issue. "Having primary care centres where mums and dads can get used to being parents would help. It's going back to what we had in the old days when women had a lie-in period."
There are six such centres between Pukekohe and Warkworth. Waikato has eight.
Kathy Fray, an independent midwife based on the North Shore, sees areas ''screaming out for improvement.
''Hospital shiftwork midwives earn minimal incomes, especially considering the enormous responsibilities of managing the care of a labouring woman and unborn foetus,'' she says. ''Self-employed midwives can earn a reasonable income but only with the cost to lifestyle by
being on call 24-7. Let's face it, that deserves an excellent income.''
She worries about public opinion after several high-profile cases. ''The other horrid area within the current environment is the hideous way the media revels in attacking midwifery.
Childbirth has never been so safe, yet midwives have never been so slammed with criticism. It's incredibly denigrating and disparaging to all of us who work with phenomenal dedication.''
For Denise Hynd, another independent midwife, the main concern is the high level of medical intervention, stemming in part from where most of the country's babies are born.
''Even with midwives it's still a very medicalised system,'' she says. ''All the evidence suggests that normal healthy women have best outcomes if they give birth at home or at birthing centres.''
But she praises our approach against other countries where she's worked - Australia and Britain.
MIDWIVES working in the hospital system list pay inequity against independent practitioners as a major gripe. But they see another side of the debate that's not often aired.
''We need to ask ourselves: in a small country, how do we prioritise where the health dollar goes? The public need to know that there is a very limited amount of health dollars. Whenever we bring in some new advance, something else has to give way,'' a senior midwivery professional told The Aucklander, speaking on condition of anonymity.
''We have many new treatments that save babies and mothers who weren't saved before. We can save younger babies - down to 24 weeks. They are likely to go on to have lifelong health
needs.
''Society has to ask whether those sexy new treatments you see on TV get the health dollars - or do we care for the vulnerable women, the poor, people challenged by drug, alcohol and social issues such as diabetes, obesity. There are considerably more of those women, andthose are social issues waiting to explode.
''And then there is the debate about caesareans. This is the only area of medicine in which people can demand surgery that is not recommended or medically indicated. You can't do it for a hip replacement.
''It is way more expensive and carries more risk than a normal birth. Yet it is taking up our maternity beds and services, and your health dollars.''
WHICH IS A good time to bring in the doctors. Dr Mark Peterson, the Medical Association's maternity spokesman, helped write the draft action plan but believes it needs refinement.
''Maternity care requires a team,'' he says. ''The potential problem of our system is we have lost the team philosophy. Care is concentrated on one person.
''Disasters tend to happen because of system errors, not because of people. But when you only have one person the system is not so robust. When you have a team you have more eyes.''
He is sceptical of the Government's push for more GPs to take on the LMC role: ''GPs got out [of maternity care] because the environment and funding were not conducive.''
He sees a hole in the system.
Sometimes GPs don't know a woman is pregnant until she brings her six-week-old infant to the clinic for a well-child check.
''But they have potentially useful information on the woman, medical histories and family histories that could affect the birth. We need to be placing more focus on integration,on teamwork.''
BACK IN WEST AUCKLAND, Mrs Edlington is not letting the debate get her down. She is focused on what's coming next. ''We've been offered really good choices,'' she says.
''I'm excited.''
WELCOME TO OUR WORLD
- Some 64,160 Kiwi babies were born in the year to March.
- An overwhelming 75 per cent of women chose a midwife as their lead
maternity carer; 6 per cent chose an obstetrician and another 6 per cent
went to their local GP. - The other 13 per cent? Believe it or not, most don't use ante-natal
services - they ''rock on up'' to hospital when the time comes. - In October the Ministry of Health released a draft Maternity Action Plan
for 2008-2012. It aims to strengthen present services and address
''perceived shortcomings''. Consultation closes on July 31. - It identifies seven main issues - leadership, integration and coordination,
quality and safety, information and data collection, inequalities across
regions, the state of the workforce (age and numbers), cooperation and
relationships between various disciplines (midwives, GPs, specialists, etc). - The draft suggests more funding, infrastructure, extra training for GPs,
recruitment and retention schemes for midwives.
WHAT ARE PEOPLE THINKING?
We asked a range of people what works in Auckland's
maternity services and where the challenges are ...
Anna Edlington (mother-to-be)
loves the choice for
women but believes the present system needs more
resources.
Emma Farmer (Waitemata District Health Board)
believes we need more lead maternity carers and birthing
centres - ''but we also need to remember the system is
good''.
Denise Hynd (independent midwife)
''The system is too
'medicalised' but it's OK. We need more birthing centres.''
Kathy Fray (independent midwife)
''The dedication of
lead maternity carers makes our system so successful.
But the people who work in the field need to be
recognised for their work.''
Karen Gulliland (NZ College of Midwives)
''The system is
sound but we need more lead maternity carers, a
standardised system across district health boards and
more birthing centres.''
Dr Mark Peterson (NZ Medical Association)
''We need
more teamwork and integration between GPs, specialists
and midwives.''