He said Jennifer Rowan, who at the time had graduated as an independent lead maternity carer (LMC) just seven months earlier, sent Barlow home after administering the controlled drug pethidine, failed to recognise an abnormal labour and did not communicate any urgency to Waikato Hospital staff during transfer.
Matenga noted that though the doctor acknowledged her inexperience and accepted her responsibility in the case, Rowan did not.
Robert Barlow said the couple wanted changes to New Zealand's midwifery system to ensure mothers and babies were safe, a sentiment they reiterated in May when 20-year-old Casey Nathan died after giving birth at Huntly Birthcare.
The first-time mother's baby boy, Kymani Nathan-Tukiri, died several days later in Waikato Hospital's newborn intensive care unit. Both deaths have been referred to the coroner, who is awaiting final post-mortem findings.
It is understood that preliminary findings have been unable to answer whether the mother had an underlying medical condition and its role in the tragedy, or if something went awry in the birth-care.
Matenga's Barlow findings refer back to his Wellington colleague Garry Evans' 2005 findings on the death of newborn Saskia Marama Swagerman-Fugle.
Reporting on two deaths, Evans criticised the midwives for failures to perform vaginal examinations, which he said would have diagnosed the breech presentations in both cases.
His call for internship and supervision of new-graduate midwives was resisted at the time by the College of Midwives but later adopted and the Midwifery Council reviewed the profession's education, leading to big changes.
In 2006, the then-Health and Disability Commissioner Ron Paterson prompted Government changes to the agreement governing access of community midwives and obstetric doctors to public hospitals following the death of a newborn delivered at North Shore Hospital. He criticised the maternity service nationally for its lack of co-ordination and confusion over who was responsible for individual patients.
In 2010, the latest year for which figures are available, 704 babies and fetuses died between 20 weeks' gestation and 27 days following birth - "perinatal-related deaths".
New Zealand's perinatal-related mortality rate in 2009 was 11.3 deaths for every 1000 births. This was significantly higher than the average rate of 9.8 for most of Australia.
Looking at just the first weeks following birth in 2008, New Zealand's death rate sat alongside Australia's and slightly below both Britain's and the average of 40 countries in the Organisation for Economic Co-
operation and Development.
The graph for these first few weeks shows the New Zealand death rate has declined from more than four per 1000 live births in 1990, to around three in 2008.
This seems a marked reduction. But Jenn Hooper - a campaigner for improvements to maternity care after her daughter Charley was left with severe cerebral palsy from a troubled birth in Morrinsville in 2005, which also nearly killed Hooper - reads the trend as showing no reduction since the mid-1990s.
"When you think about other advances in medical technology you would think we would be getting it down further, like other countries have."
The committee appointed to investigate perinatal and maternal deaths found that 124 or 18 per cent of the "perinatal-related" deaths in 2010 were potentially avoidable.
In 21 of these cases, the failure of health workers to follow "recommended best practice" was identified as a contributory factor in the death.
But mothers bore some responsibility in 84 of the deaths, for reasons such as late booking for antenatal care, not attending ante-natal clinics and not complying with treatment.
In Adam's case, coroner Matenga said Rowan did not follow Health Ministry-approved referral guidelines which recommended consulting an obstetrician after one hour of making no progress in the second stage of labour.
"Even accepting that the time began to run at 11 [am on October 25, 2009], the call to the hospital was not made until 12.30 and Linda Barlow did not arrive at delivery suite until 1.15," Matenga said.
Adam was delivered by emergency caesarean section at 3pm. He died soon after, from sustained lack of oxygen linked to the difficult labour, his forward-facing position and the rupturing of his mother's uterus, which led to her bleeding profusely. She was taken to intensive care and survived.
Matenga said the Barlows were let down by Rowan, who qualified as a bachelor in midwifery in March 2009 from the Waikato Institute of Technology.
She had done clinical placements, while a student, at the practice of midwife Colleen Hugill, who had particular experience with difficult births. Rowan went to work there once qualified and Hugill became her mentor under the Midwifery First Year of Practice programme.
Barlow, whose first baby, Orry, had had a difficult birth, engaged Hugill as lead maternity carer. Rowan inherited Linda Barlow as a patient after Hugill went on long-term sick leave.
"Jennifer did not tell Linda that she was a new graduate or at least within the first year of graduation and qualification as a midwife," the coroner said.
Rowan declined an interview when approached by the Weekend Herald. She confirmed that she is employed by the Counties Manukau District Health Board and is on maternity leave.
Hugill could not be contacted. It is understood she has gone to Canada, where she qualified as a nurse in 1979 before passing a New Zealand midwifery course in 1982.
Both midwives have been through Midwifery Council competence reviews. Rowan has conditions on her practice.
Hugill was suspended from practice in the month before Adam's death, then again in 2010 and in April last year. The latest suspension, made under the law relating to competence reviews, remains in force.
Beyond that, the council refused to state why it had suspended Hugill and pointed out that details of individual competence reviews must be kept secret, by law.
Matenga concluded from the evidence before him and an earlier newborn-death inquest with similarities that there was a tolerance within midwifery for working outside the "safe harbour" of the referral guidelines - a document designed to manage safe transfer from community to hospital care - if mother and baby are thought to be coping. He sought to stamp out this tolerance.
He also expressed misgivings over midwifery education. He recommended a review, asked that the first-year programme Rowan had been on be made compulsory, and urged the role of mentor be beefed up to supervisor.
Matenga drew a distinction between midwifery and obstetrics: midwives believed birthcare was a natural process and aimed to help women to deliver naturally, without medical intervention; obstetricians aimed to identify and mitigate risks by medical intervention.
This characterisation riled the Midwifery Council, which feared it could undermine public confidence in midwives.
In fact, the council's lawyer told the coroner after seeing his draft report, the midwifery philosophy was "to assist the woman to birth normally, recognise deviations from normal and refer appropriately".
Council chief executive Sharron Cole told the Weekend Herald Matenga appeared to have misunderstood the profession's stance on the Referral Guidelines.
"We're absolutely clear. The Referral Guidelines are evidence-based and any good clinician will practise within the guidelines."
There were situations - such as in rural areas remote from a hospital - where it might be appropriate to depart from the guidelines. The guidelines themselves provided for this.
Dr John Tait, the head of New Zealand's branch of the Australasian college overseeing obstetricians, acknowledged midwifery and obstetrics have "contrasting philosophies" on maternity care, but said they had made good progress towards providing "seamless, collaborative care".
"... the basic aim for both colleges is to try to ensure safe delivery of maternity services. I do think the recent work that has been done through the ministry on quality and safety, and in particular the new referral guidelines, will go a long way to improve maternity care and overcoming some of those philosophical differences."
The Midwifery Council said there were no underlying problems with new-graduate midwives: from 2004 to 2011 it received only two "complaints of substance" against new graduates.
However, it has already strengthened midwifery education, from 2009, cramming a fourth academic year's work into the three-year programme, with a heavy emphasis on practical placements in the final year.
And, also before coroner Matenga's recommendations, it called for the first-year-of-practice scheme to be made compulsory - virtually all new graduates do it anyway - and to provide greater oversight of participants, although not direct observation of their practice.
Professor Des Gorman, chairman of Health Workforce NZ, which finances the first-year programme for midwives in either community or hospital practice, said that like a similar programme for new nurses, it would be converted into an internship with skill development, performance management, pastoral care and career advice.
He flagged the idea that new-graduate midwives' and nurses' registration could be made "provisional" during their internship, as is the case with first-year doctors, who must work in hospitals.
"That's yet to be resolved. The historical perspective has been that they graduate work-ready. There's a very big 'but'. Most of us have a view, I think, that all undergraduate health workers need to go into a year of transition and that transition year is called an internship."
Hooper, of the Action to Improve Maternity (AIM) group, said it was wrong to think inexperienced new-graduate midwives were the only problem area in maternity care.
AIM and Robert Barlow are calling for wider changes.
They want a thorough review of maternity services, better oversight of the Midwifery Council, and the creation of a perinatal database that will go beyond the work of the mortality committee and collect internationally comparable information on all New Zealand births.
Hooper, who has twice taken her concerns to Parliament's health select committee, is especially concerned about the Referral Guidelines, updated earlier this year. She considers them too weak on several points, including that they require only "consultation" with a specialist, rather than deeming it an "emergency", when:
* A mother, following delivery, loses more than half a litre of blood; and
* Moderate or thick meconium - a baby's first motion and potentially a sign of distress - discolours the amniotic fluid that surrounds the fetus in the uterus."You can have black waters coming out and it's still only 'consultation'. You don't know if a kid is going to walk away from that unscathed. It should always be treated very seriously."
College of Midwives' acting chief executive Norma Campbell, a member of the group that developed the guidelines, said the emergency category was kept for "life-and-death emergencies", such as cardiac arrest, amniotic-fluid embolism and umbilical cord prolapse. It was appropriate that meconium and post-delivery haemorrhage were listed for consultation.
The level of fetal distress when meconium was present had to be determined by other factors such as fetal growth and heart rate, Campbell said. And some women, if they had a good red blood cell level, could cope with losing 500ml of blood, because of the increased blood volume in pregnancy.
The Barlows are pushing for the rights of a full-term baby who dies during childbirth to be recognised, to allow coroners' inquests into the deaths.
"If we had not been able to provide evidence that Adam was alive after birth [he was initially recorded as stillborn], there would not have been an investigation and important information for the safety and protection of others would not have been learnt," Robert Barlow said.
"This is really important as currently how much information for the safety of others is being lost when a full-term baby dies during labour and the parents are told it is just one of those things?"
The couple say without an investigation by the coroner, parents won't know if their child's death was preventable.
"The information from these potential coroners' inquests would be extremely valuable to improve maternity services and the safety of the public."
Despite the depths of their tragedy, Robert and Linda Barlow have managed to find joy again in their new baby Flynn, although the 6-week-old is not a Barlow yet, not officially anyway.
Following Adam's death the couple explored the possibility of having another child using in-vitro fertilisation and a surrogate.
They underwent six months of the invasive treatment and finally, their surrogate a good friend fell pregnant.
The Barlows must legally adopt Flynn, even though genetically he is their baby a process they say is outdated and frustrating.
But Flynn's birth and first weeks of life have been a bright light for the family after so much grief and the newborn is doing everything he is supposed to be, including keeping his parents up at night.
"He's just amazing. We're really enjoying him. Even when he keeps us awake it's good," Barlow said.
Older brother Orry, 5, "adores" his sibling after much mourning for baby Adam.
Flynn was born on May 9 and though he looks just like his two older siblings, the Barlows are adamant he was never a "replacement" for Adam.
"He's a completely different person and our aim was to have three children.
"We've always said we've got three boys, it's just one has got wings."
