Care should be equitable and accessible

This principle espouses the notion of equity—resources should be distributed fairly according to need, with more directed at those who require it most. In 2010, even in comparatively rich countries there are still gaping inequities and social injustices between individuals, communities and states that leave large segments of the population without basic healthcare.

This principle is also about reaching groups who are denied equitable access to services. In some cases, services are available but for some reason are not accessed as often or as well as they might be. In others, some population groups live so far below the poverty line that they simply cannot pay for the services they need or pay for the transport they require to get there.

New Zealand’s maternity service is free and universally accessible, with every pregnant woman expected to have access to her own lead maternity carer (LMC) for the duration of her pregnancy, birth and puerperium regardless of her economic status. There is emerging evidence that this universal access has improved outcomes for women who are in the higher (most deprived) socioeconomic decile populations. The Perinatal and Maternal Mortality Report (2009) identifies that New Zealand’s perinatal mortality rates are low with no clear association between socioeconomic deprivation index and mortality outcomes (Perinatal and Maternal Mortality Review Committee 2009). This is the first reported major reduction in the equity gap between the wealthy and the poor since records have been kept.

Primary healthcare should include essential, appropriate activities

A common concern worldwide is the lack of communication between funding bodies, and consequent failure to coordinate programs. Vertical programs may be introduced to combat a particular problem, but often they are not integrated with other services. For example, immunisation programs have been introduced to reduce the number of deaths from childhood diseases. However, although this initiative has stopped infants dying from infectious diseases, in developing countries children still die of malaria or gastroenteritis from drinking contaminated water.

In New Zealand, midwives are the main providers responsible for referring mothers to the well child services for their babies to start their immunisation program at six weeks. Some 95% of babies receive their first vaccination, indicating an effective integration from maternity care into the next primary healthcare service, the well child service. Regrettably, this level of vaccination in infants is not maintained in the well child service, with coverage rates of between 65% at six months and 80% at 24 months reported. This is still short of the goal of full vaccination coverage of 95% of New Zealand children by the age of two years (National Immunisation Register, New Zealand 2009). Despite this drop in vaccination coverage in the well child service, the six-week example demonstrates that integration from service to service is a possible consequence of a well-organised one-on-one primary maternity healthcare service.

In Australia, except in the newly formed midwifery group practices, women are merely encouraged to visit their GP to take up the vaccination program recommended. The new caseload models of midwifery, however, are strengthening links between women and future healthcare providers by implementing formal follow-through procedures when women are discharged from postnatal care.

Care should be accessible and acceptable to everybody

In general, societies dominated by one social group create healthcare services to meet the cultural needs of that group. In Australia and New Zealand the dominant stakeholders are primarily urban-dwelling people from Anglo-European backgrounds. This means that some Australians and New Zealanders are alienated from these services because their specific cultural needs and values are not recognised. Feelings of alienation may lead to healthcare services not being used even if they are accessible.

Dr Lowitja O’Donoghue (1999), a prominent Australian Aboriginal activist, told her audience at a rural health conference that members of remote Aboriginal communities who are ill experience triple jeopardy. First, they are Aboriginal with all the socioeconomic disadvantages that go with that; second, many live far from

medical services. And finally, in rural and remote areas in particular, Indigenous people have little involvement in the healthcare services they can access; and even if they do, they feel alienated from mainstream facilities.

Although the distances are much smaller in New Zealand than in Australia, the principle of establishing services within communities rather than moving women out to access services is an important consideration. New Zealand’s maternity service aims to meet the needs of women and their families on a one-to-one basis as close to women’s homes as possible. Midwives visit women in their homes if necessary, and state support for home birth and primary maternity unit birthing means that women can generally access services in their local community.

Primary healthcare should be affordable

Unlike people in countries such as the United States, all Australians and New Zealanders have access to ‘free’ healthcare. However, in Australia in particular, differences in the quality and quantity of these services, especially with regard to community-based midwifery, hospital waiting times and outpatient services, mean that many must pay extra for services that are better able to meet their needs. For example, until very recently Western Australia was the only state to offer a publicly funded midwife-led home birth service. In other states, women who prefer this model of care are expected to pay for it, although some insurance companies will offset some of the costs associated with these services.

The picture is very different in New Zealand, where all maternity care is free. All women expect to have their own LMC and 78% choose a midwife LMC (Ministry of Health 2009a). Women can choose where they give birth, and home birth is also fully funded. Women who do not require referral to specialist care can still choose a private obstetrician to be their LMC instead of the public obstetric service, although the private obstetrician is likely to charge a fee.

Primary healthcare should contribute to the self-reliance and self-determination of communities

Health bureaucrats and funding bodies often pay lip-service to the ideal of community participation in decision-making. Although structures for consultation may exist, stakeholders are rarely delegated any serious power or decision-making authority. Hence the wishes and priorities of the community are often buried in many layers of the consultation process. Moreover, a token ‘consumer’ on a Board of Health usually has little say in proceedings. For example, the Western Australian government consistently invites the community to join it in the identification of priority issues and to have input into the creation and implementation of programs to solve them (Thorogood 2001). However, the wishes of the community are often overruled if they are not in alignment with the needs of the powerful medical lobby.

There is good evidence (Barnett et al 2005) that community-based initiatives aimed at lowering maternal and perinatal morbidity and mortality are effective, sustainable and more likely to achieve high coverage in the poorest communities than are secondary or tertiary hospital-based approaches. The Strong Women, Strong Babies, Strong Culture (SWSBSC) program (see Box1.1) is a good example of such an approach. The SWSBSC program provides health promotion through local women’s groups. This social intervention harnesses the creativity and self-organising skills of Indigenous women living in the Top End of Australia.

New Zealand has established Primary Health Organisations (PHOs) which are required to have strong community governance. However, most have struggled to overcome the dominance of GPs, and primary healthcare remains largely primary medical care. It is for this reason that the midwifery profession has recommended that maternity services remain outside PHO structures until they can demonstrate a more integrated, community-based, multidisciplinary approach.

Some non-government organisations (NGOs) and Māori provider organisations have succeeded in developing a more primary healthcare model, and midwives have been successfully incorporated into their services without any apparent loss of the midwifery/primary healthcare focus.

Primary healthcare should be integrated with other health programs and sectors

If it is to be successful, primary healthcare has to involve horizontal, symmetrical and participatory relationships and direct, active and effective participation of the population it serves. Primary healthcare is multi-pronged, interdisciplinary, participatory and decentralised. Change will inevitably be slow and it will never come about by the efforts of a single sector or institution, isolated programs or specific services. As O’Donoghue (1999) remarks, none of the factors that lead to ill-health, be they geographic, environmental or socioeconomic, can be treated in isolation from one another; nor can they be seen as problems of the here and now, divorced from their history.

Consumer voice

From the 1920s through the 1980s, women in consumer advocacy organisations voiced their concerns over maternity care. They did not like the impersonal, hospital-controlled birthing culture and they lobbied hard over many years for a more woman- and family-centred maternity service (Dobbie 1990). They identified a need for the midwife to be more visible, and demanded that she take a stronger role in providing maternity care (Strid 1987).

For most of these years the midwifery profession was submerged within the nursing profession and not well organised to use its collective voice. While some individual midwives, in particular the home-birth midwives, were very clear about what midwifery was and had solid links to the consumer movement, the profession overall was slow to align itself with women. However, as women’s organisations became stronger and more universal, midwives also became more organised, and by the late 1980s had become part of this women-led movement. Once politicised, women’s groups and the midwifery profession worked together to make birthing services a political issue that could not be ignored (Guilliland & Pairman 1995). Helen Clark, the then Minister of Health, not only understood the foundation of the women’s health movement but was also strongly focused on the essential role of primary healthcare. She was sympathetic to the view that birth was a normal life event that should be controlled by each woman and her family in their own community. She understood that in order for this to happen, women would need midwives who were educated and resourced in a way that would make this care available and effective (Guilliland & Pairman 2010).

Maternity choices pre-1990

Prior to 1990, maternity services were almost entirely hospital based. Fewer than 1% of women had their babies at home, and there was only a handful of domiciliary or home-birth midwives and general medical practitioners who provided services for these women. General practitioners were able to claim fees from the Maternity Benefit Schedule without any cap for every service they provided, at considerably higher rates than domiciliary midwives, who were funded separately. Domiciliary midwives received funding from the Department of Health for three antenatal visits, labour and birth care, and 12–14 postnatal visits in the first two weeks postpartum. As for all women and midwives at the time, they were required by law to be ‘supervised’ by a medical practitioner, but as home birth was frowned upon it took a brave doctor and a brave midwife to offer a home-birth service, as they continually faced hostility from other healthcare professionals.

Women accessed the maternity service mostly through the GPs, who confirmed pregnancy and then directed the care in a variety of ways. Some provided the care themselves, although (according to the Health Department’s submissions to the Maternity Benefit Tribunal in 1992) at best only about 20% ever offered a full maternity service (McKendry & Curtin 1992). A larger number offered antenatal services to 28 weeks gestation before referring the woman to the hospital clinic, private obstetric specialist or a GP colleague who did provide full care.

Medical ‘teams’ provided the hospital antenatal clinic service. An obstetrician, who delegated the majority of care to registrars or house surgeon trainees, led the teams; midwives provided support. There were very few instances of midwife-led clinics. Antenatal clinics were crowded and women waited hours to be seen. As was the case in most of the Western world, a woman could be seen by as many as 50 healthcare professionals during pregnancy, labour, birth and the postpartum period (Flint 1986). Fathers and other family members struggled to be involved, and the information provided was heavily risk averse and based on hospital and medical priorities. There was little reporting or analysis of maternity services or practitioner outcomes either regionally or nationally.

Care was also delegated when a woman was in labour. If women were ‘normal’, midwives conducted the births regardless of who the client was booked under, and this was considered the midwife’s role. Doctors could still claim the $300 ‘delivery’ fee even though they were not present. Prior to 1990, midwives, rather than GPs, medical trainees or obstetricians, conducted between 66% and 90% of normal births (NZCOM 1992). However, the rate and type of midwife-managed care depended on hospital protocols, the type of midwifery leadership, the number and availability of obstetricians and the influence that obstetrics had over service delivery. It seldom relied on women’s wishes.

All midwifery care, regardless of whether it was for well, compromised or seriously sick women, was organised on a nursing framework, with midwives on rostered shifts for labour and birth and postnatal inpatient care. There was no postpartum midwifery care for women once they left the hospital. Midwives were not known to women and women had no way to access a known midwife. The exception was home birth, but only in the few areas where there was a midwife willing to provide a home-based service. However, in rural or small towns with primary maternity hospitals the care was more personalised, as the community members were more likely to know each other. Women who wanted primary care from an obstetrician usually paid for that service and this remains the case today.

Secondary-level services—that is, services for complicated pregnancy, labour and birth or the postnatal period—were provided to women under the care of a hospital-based obstetrician. Although in all major cities and many provincial cities there was a parallel private obstetric system, once in the state-funded service a woman could not choose a known obstetrician, and in fact most women never saw the obstetrician who was deemed to be providing their care. Obstetric medical care was provided mostly by registrars and house surgeons in training. The obstetrician leading the ‘team’ was not routinely present in the hospital, but ‘on call’ for registrars to contact if required. This continues in many hospitals today, although it is changing.

Medical education

By the late 1980s, some GPs had a postgraduate diploma in obstetrics, although that was not a legal requirement at the time, and some had no specific education in relation to normal birth, obstetrics or maternity care. The Diploma of Obstetrics was then a six-month course at a tertiary (teaching or base) hospital that focused on acute obstetrics, neonatal care and gynaecological services.

As the medical specialty of obstetrics developed and grew during the 1970s and 1980s, obstetricians slowly displaced the GP in maternity care, particularly in urban hospitals. By 1990 most GPs referred to obstetricians for operative procedures such as forceps and other specialised interventions, as did midwives. Rural GPs kept their obstetric skills for longer but they too eventually dropped out of intrapartum care. A 1990 report to the Canterbury Area Health Board found that the GPs in Canterbury who did provide maternity care did so for an average of 10 women per year (Canterbury Area Health Board 1990). While the style and method of service delivery may have been different, the scope of practice of most GPs was essentially the same as that of midwives by 1990. General practitioners have been reluctant to acknowledge this. Furthermore, general practice struggled to attract new graduates to maternity service provision. From 1990 onwards there was a decrease in the number of GPs providing maternity services. This exit of GPs from providing intrapartum care was a worldwide phenomenon and had similar causes in each country. These causes included doctors being less willing to provide 24-hour care (also manifested in the establishment of arrangements to provide care outside of 9 a.m. to 5 p.m., such as after-hours clinics and sports clinics) and the perception that general practice was a low-income, lower-status choice than some of the highly specialised options in medicine.

Midwifery education

Midwives’ education prior to 1990 was based on a general and obstetric nursing qualification followed by the Advanced Diploma of Nursing (ADN) in which midwifery was a 12-week module. The ADN was theoretically focused on primary healthcare and midwifery philosophy but struggled to provide clinical experience outside the tertiary hospital system (Pairman 2002). Most midwives were unhappy with their training and in 1986 an overwhelming 88% trained overseas (Pairman 2002). Registered midwives were also disillusioned with their limited role, and increasing numbers left midwifery practice (Department of Education 1987). It had been clear to midwives for decades that midwifery education required a major review, and the 1990 Nurses Amendment Act paved the way for development of direct-entry degree-level midwifery education (Pairman 2002, 2005a).

The Nurses Amendment Act 1990

The environment in the late 1980s was therefore one of increasingly inappropriate education of the primary maternity healthcare providers (midwives and GPs), job dissatisfaction, hospitalisation or medicalisation of normal birth services, fragmented and impersonal care for the majority of women, and consumer dissatisfaction.

Government steps to improve the situation included strengthening the midwifery profession’s ability to provide continuity of care. The Nurses Amendment Act 1990 (NAA) enabled midwives to practise all the competencies within a midwifery scope of practice. Midwives could now offer women the full range of antenatal, labour, birth and postnatal services from conception to six weeks postpartum without the supervision of a doctor.

The NAA also gave midwives hospital admission rights for their clients, the ability to prescribe and the right to claim for their services from the same government-funded Maternity Benefit Schedule (MBS) that funded medical practitioners. Importantly, the NAA also established a pathway for an experimental education program to prepare midwives without first requiring them to undertake a nursing qualification.

Midwifery’s right to claim from the MBS was challenged by the New Zealand Medical Association in 1992. The Minister of Health convened the Maternity Benefits Tribunal, and after a week-long legal hearing the Tribunal confirmed that midwives provided the same or similar services and outcomes for pregnant and birthing women as GPs. The Tribunal accepted the principle that if the work was the same then it must be of equal value, and therefore midwives were entitled to claim the same payment as medical practitioners from the MBS (Maternity Benefit Tribunal 1993).

Professionalism

The NAA was the legislative vehicle for change, but importantly for midwifery its achievement enabled midwives to recognise that real change would only come if practice reflected the wish of consumers to have control over their birthing experiences. If the potential the NAA gave midwifery to develop as a profession was to be realised, fundamental change was required in the way midwifery education and practice was organised.

Midwifery had started to reclaim its identity from nursing in 1989 by separating from the Nurses Association and forming the New Zealand College of Midwives (NZCOM, the College). The College provided a specific focus for both midwives and women who wanted to influence the maternity services to be more woman-centred and less medicalised. The College’s foundation and its philosophy is that of partnership between midwives and the women for whom they provide services. Women consumers were welcomed as members of the College and were a part of all the College’s decision-making structures from the beginning. The aim of the College was to replicate this partnership model within the maternity services, and consequently it was to become a major player in the reformation of the maternity service.

The New Zealand healthcare system

It is important to understand how the maternity system fits into the overall healthcare services. Healthcare services for New Zealanders are the portfolio of the Minister of Health. The Minister is served by a Ministry of Health which sets strategy and makes policy and funding decisions, which are in turn implemented by the 21 District Health Boards (DHBs) spread throughout New Zealand. Each DHB is funded on a population basis—that is, its funding reflects the numbers and make-up of its community of people, and each DHB is responsible for ensuring that the population receives the best possible range, mix and types of services their funding allows.

Each DHB must have Primary Health Organisations (PHOs) to manage primary care and coordinate appropriate referrals to the hospital services. People enrol with a PHO in their area if they wish to take advantage of the benefits a PHO can offer, such as subsidised prescriptions and doctors’ fees, and coordinated care. Currently most PHOs are centred on GP and practice nurse services, but it is envisaged that eventually all primary medical and healthcare services, including maternity, will be coordinated through community-governed PHOs.

At the time of writing community (primary) maternity and well child services remain outside the management of the regional DHBs and the PHOs, and are funded nationally by the Ministry of Health. Other nationally operated services that affect maternity services in general include: the National Screening Unit which directs policy for all the national screening programs (such as cervical, breast, HIV and antenatal screening); the New Zealand Health Information Service, which manages the health data provided by hospitals and healthcare professionals (such as midwives and GPs); HealthPAC, the payment arm of the Ministry, which pays health providers for services; and the National Health Committee, which advises the Minister on policy issues.

The maternity service

The maternity service in New Zealand takes an integrated and woman-centred partnership approach. The service is placed within the primary healthcare arena in recognition that birth is a normal life event and that women and their families should direct the care. The service specifications are explicit and within a set budget per woman. Standardised referral guidelines give the framework for consultation and transfer of care to hospital specialists if necessary.

Figure 1.1 The structure of New Zealand’s health system, 2008

(based on Structure of the New Zealand health and disability sector, Ministry of Health, www.moh.govt.nz)

Vision for the maternity service

Following the reforms outlined above, the government’s initial vision for the maternity service was set out under Section 88 of the Public Health and Disability Act 2000:

Each woman, and her whānau, will have every opportunity to have a fulfilling outcome to her pregnancy and childbirth, through the provision of services that are safe and based on partnership, information and choice. Pregnancy and childbirth are a normal life-stage for most women, with appropriate additional care available to those women who require it. A Lead Maternity Carer chosen by the woman with responsibility for assessment of her needs, planning her care with her and the care of her baby and being responsible for ensuring provision of Maternity Services, is the cornerstone of maternity care in New Zealand. (Ministry of Health 2000, p 11)

The influence of New Zealand’s pioneering women and midwives is obvious in this statement. The health system, including maternity, is overseen by a strong code of patients’ rights and a culture of informed consent. In 2010 New Zealand has a free maternity service, with equity of access for women to all the levels of care required. These levels of care cover primary care in the community and hospital-based specialist or secondary and tertiary care. All levels of service cross the geographic boundaries of 21 different DHBs and numerous PHOs. See Figure 1.2 for the funding mechanisms of New Zealand’s maternity services.

Figure 1.2 Funding mechanisms for New Zealand’s maternity services

The majority of women can have an LMC to provide and coordinate their maternity care, develop a care plan with them and attend their labour, birth and postpartum period of up to six weeks. The LMC service is a primary healthcare one and therefore is provided mainly in the community. Most antenatal care is in women’s homes or in community clinics. If not birthing at home, the majority of women in the first 12–48 hours following birth have their postnatal care in the hospital or birthing unit but then receive visits at home for four to six weeks. This primary healthcare service is centrally funded by the Ministry of Health, and LMCs claim from the Ministry for their service fees. When a woman requires additional medical or hospital care her LMC can choose to provide the care herself, arrange additional medical or other specialist carers but continue to provide midwifery care, or transfer the care to a hospital team including obstetricians, midwives and paediatricians.

In 2009 the Ministry of Health consulted on a national maternity strategy as a result of disquiet in the sector regarding variances between DHBs and inequity of service provision as a result of workforce shortages. While the current draft circulating is a reframing and simplifying of the original vision, it does reaffirm the woman-centred LMC model of care which is based on childbirth as a normal life event (Ministry of Health 2009b).

Place of birth

New Zealand women have a variety of options as to where they can give birth. Although there are no universal booking criteria for place of birth, the national consultation and referral guidelines provide a screening tool to assist women to make appropriate choices. The maternity facilities or hospitals and their associated services are funded separately from the primary LMC budget and this funding is managed by the DHBs rather than the Ministry.

Birth at home is a mainstream government-supported and -funded option. The LMC is almost always a midwife. While many women are supported by consumer-led home-birth associations, the majority of women today who choose home birth do so as a natural matter of course and no longer view it as a ‘fringe’ option. Some 4%–6% of women have their babies at home.

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