KEY POINTS:
The pregnancy test is positive. Your GP confirms the result and suggests a midwife to ring. She's booked solid so you reach for the Yellow Pages.
The following days and weeks become an increasingly frantic search for someone to look after you, and to deliver your precious baby.
"We get a number of phone calls from women every day looking desperately for a midwife," says Tony Mansfield, chief executive of Serious About Maternity Care, a South Auckland-based group which supports maternity practitioners, mainly midwives.
New Zealand's rapid increase in births and its static number of midwives have crunched into each other like opposing weather systems, making the search for an independent community midwife _ a lead maternity carer _ fruitless for some.
Burn-out from high workloads and being on-call 24 hours a day have driven many LMCs out of the job, compounding the problems for those who remain.
Add the intense public scrutiny of the profession after errors and baby deaths _ such as the alleged failure of a midwife to call in medical help for a breech birth in Porirua this year, one of several deaths which led the Government to set up a review of Wellington maternity services.
One of the issues under review is the agreement that gives private midwives and obstetricians access to hospitals. The contract was modified after being faulted by Health and Disability Commissioner Ron Paterson in a 2006 report in which he criticised a doctor and private midwife over the death of a baby following a traumatic birth at North Shore Hospital.
The degree of public criticism of midwifery, however, is not reflected in the quantity of breach-of-rights findings by the commissioner, five to 10 a year, or less than half the rate of GPs, although some sectors of midwifery acknowledge a lack of confidence _ but not competence _ among new graduates.
Some of the worst shortages of LMCs, and in some cases hospital midwives as well, are in Auckland and Wellington, but provincial areas like the West Coast, Wanganui and Invercargill are struggling too.
"We could usefully have another 10 independent midwives in south Auckland," says Mansfield. "Central Auckland the same, Wellington the same. The areas really hard hit are rural centres: Wanganui, New Plymouth, Tauranga."
Wellington's Capital and Coast District Health Board planned to give $100 supermarket vouchers to some mothers who left hospital within six hours of giving birth, but dropped the scheme after it was criticised.
A DHBs survey last year put the national shortage at around 200 hospital and private-sector midwives, although the Government insists _ against National Party claims of a crisis _ all health boards are able to "meet demand" for maternity services.
Associate Health Minister Steve Chadwick says there is a "distribution problem" _ a shortage in some areas and enough in others _ and much is being done to address the shortages, like the increase by 80 since 2005 in the number of trainee midwives, to 200. "New Zealand has a safe, effective, world class maternity system," she enthuses.
The Ministry of Health is more guarded, telling ministers in a report: "Our international rankings for a number of maternity benchmarks are satisfactory but not outstanding."
The number of practising midwives sits at around 2500 after crashing by more than 600 in 2005, when a new law governing health workers forced them to demonstrate ongoing competence. Those who gave up their claim to a midwifery practising certificate are thought to be mainly nurses who held dual qualifications and who decided to stick solely to nursing.
But while the number of midwives is now static, the number of births has spiked up sharply from around 55,000 annually in 2002 and 2003 to a 36-year high in the 12 months to March this year when it reached 63,250 live births. The births graph seems to follow the improvements in the economy this decade and one watcher of maternity trends believes the economic downturn may be contributing to fewer women becoming pregnant.
"This time last year we were getting a lot of calls from women trying to find a midwife," says Maternity Services Consumer Council co-ordinator Lynda Williams. But the trend, which lasted several years, seems to have tailed off.
COUNTIES Manukau is one of the worst affected areas. Its baby boom has been the highest. The number of babies born annually has increased 25 per cent since 2001, to around 8000.
Counties has 100 private LMCs and the health board has 139 full-time equivalent midwifery positions at its three primary birthing units (Botany, Papakura and Pukekohe) and Middlemore Hospital. There are 42 vacancies, but 15 are routinely covered by internal and external bureau midwives doing casual shifts. It copes with long-standing shortage by employing an extra 15 nurses or health-care assistants.
"We have a double whammy," says Counties general manager of women's health, Nettie Knetsch. "We have a higher birth rate, a similar midwifery shortage in hospital, but a much bigger shortage in the self-employed ranks."
She says the hospital-midwife shortage across the Auckland region is around 25 per cent.
Counties began paying juicy staff-retention packages to midwives last year, forcing the region's other two boards to follow suit. Counties even acknowledged paying $700 to one midwife for a casual shift.
The payments seem to have made little dent in its shortage, however.
Knetsch says the three boards have agreed on a new scheme. In a "special contribution allowance", a DHB's midwives are paid extra when its shortage is above a set level _ Counties remains above the trigger level _ and they will receive an additional top-up at holiday times for taking on "an awful lot of extra shifts".
Counties, unlike other health boards, continues to foster the involvement of GPs in maternity. GPs largely withdrew in the 1990s, feeling excluded by funding rules they considered unfavourable. But Counties has about 150 contracted GPs who share care of women with midwives during pregnancy, up to the start of labour. The delivery is managed by the hospital or a community birthing units.
The board promotes the community units as a safe option for women expected to have a straightforward delivery and has increased their use by more than 10 per cent, to over 1300 deliveries a year.
Some independent midwives are such enthusiastic supporters of the cause, says Knetsch, that they advise women to engage another provider if they insist on going to Middlemore.
Health boards such as Auckland DHB are urged by women's health groups to increase access to lower-tech birthing facilities like the Counties units and Birthcare's Parnell facility, but some women, wanting to minimise the risks of childbirth, feel they are not doing the best for their offspring unless they arrange to deliver in a high-tech hospital like Middlemore.
THE shortage of midwives can cause some to take on too many births. Bala Naidu, found guilty of professional misconduct in June for providing substandard care, had told the woman she was tired because she had had eight deliveries in one week. A range of penalties were imposed on her, including being limited to 50 births for a year.
The College of Midwives recommends a caseload of up to 60 patients a year, but many appear to have more than this, although Mansfield says the workload may be reducing following an increase in Government funding for LMCs last year.
"Two years ago I would be seeing caseloads between 8 and 14 a month. Now I'm seeing between five and nine a month for full-timers. Most people are around six or seven."
A study of 94 LMC midwives published in the college's journal last year found that 43 per cent had a caseload of 26-50 women; 33 per cent had 51-75; and 7 per cent had 76-110.
The findings, labelled "disturbing" by the authors, paint a picture of an over-worked workforce, most of whom were continuously on call for births and with little time for their own lives or their families.
"... the structure of LMC practice with long hours of call, along with increasing demands being placed on midwives are causing midwives to leave practice due to exhaustion.
"With 30 per cent of LMC midwives in this one urban region planning to leave within the next two years, there is some urgency required in attending to this problem."
The college's chief executive, Karen Guilliland, says that despite its recommended limit, some midwives, for example those who have no family ties, are able to take on more. The average actual caseload is 60.
Mansfield calculates that at a caseload of five second or subsequent births a month _ a woman's first birth attracts more state funding _ an independent midwife can earn $65,000 to $70,000 a year after expenses but before tax.
Rank-and-file midwives can earn up to $67,000 in a hospital job, including shift allowances, on the agreement negotiated by the Nurses Organisation; or a maximum $77,000 flat salary as a hospital "caseload" midwife.
The Midwifery Council is well aware of the fragility of the workforce, its heavy reliance on overseas-trained (mainly British and Australian) midwives and its average age (48). But it has a plan.
It aims progressively to double, to nearly 500, the number of students in the three-year midwifery degree programmes. The plan involves encouraging the five midwifery schools to allow students to study at satellite centres. Already AUT University has set up three _ in south Auckland, Taranaki and Northland _ and is planning more. The Otago and Christchurch polytechs plan to open four satellites next year and eventually up to 10, depending on demand, from Nelson to Invercargill.
Council chairwoman Sally Pairman says midwifery students are often aged from the late 20s on and have children. Potential students in rural areas have been put off by having to shift their families. But with the planned increased flexibility, they will have to travel to main cities to study only several times a year, doing the rest of their course nearer to home and on the internet.
The duration of the course is being extended, in effect, to four years, but will still be completed in three _ the holidays will be shortened.
Currently the required minimum clinical practice and theory are each 1500 hours, although Guilliland says most already do 4000, making up the extra 1000 hours in their own time and at their own expense.
Minimum practice hours will be increased to 2400 and theory to 1980, the rest of the total of 4800 hours being used for either as each school decides.
Pairman says the increased hours do not reflect any concerns about competence, but there were "worries in terms of the confidence of new practitioners." The degree programmes had not been comprehensively reviewed since their introduction in the early 1990s and so much has changed since: the average age of first birth has increased, pregnant women more often have multiple illnesses and obesity has become more common.
"There was a feeling from the profession that really experienced midwives had got their experience in a different climate and now the demands on the new graduates were really different; had we done the best we could to prepare them for that."
Another aid to new graduates is the Government's pilot mentoring programme, which Pairman understands will be made permanent.
She says the Christchurch and Otago polytechs are close to finalising their programmes under the council's new educational standards and it is expected all five schools will be operating under them by 2010.
The Tertiary Education Commission has not yet approved funding for the new qualifications, but will consider doing so as soon as possible, once each school's programme has been approved.
Those intending to become pregnant can only hope the council's plan works _ and there are signs many potential rural students are waiting to sign up. Those who are pregnant can only keep on phoning midwives _ and their district health board.
MIDWIVES IN NZ
* Workforce: Around 2500. Fell by more than 600 in 2005, when a new law governing health workers forced them to demonstrate their ongoing competence and many opted to return to nursing.
* Average age: 48
* Pay: $67,000 in a hospital job, including shift allowances, or a maximum $77,000 flat salary as a hospital "case-load" midwife. Such is the present shortage that one health board paid $700 for a casual shift by a midwife.
- The maternity page at www.moh.govt.nz provides information on how to find a midwife and a list of LMCs is available from 0800 MUM 2BE.
