Childbirth after 1990
The number of independent midwives increased from just 50 in 1991 to 350 in 1993. General practitioners (GPs) continued to offer maternity care after 1990, sometimes in partnership with midwives. Both were paid the same hourly rate.
Providing free maternity care using GPs and midwives was expensive. As a result, from 1996 women had to choose a single practitioner (known as a lead maternity carer, or LMC) who offered support during pregnancy and birth, and provided post-natal care for six weeks. LMCs received a lump sum for these maternity services. Additional health professionals were paid out of this amount. If doctors were the LMC, they had to pay for midwifery services (such as care during birth and breastfeeding support) out of the lump sum. Midwives could undertake maternity care alone or pay for the services of other health professionals out of the amount allocated for each normal birth.
As a result of these changes, GPs abandoned maternity care – an estimated 2,000 stopped delivering babies between 1996 and 2006. Private specialists were less affected because they could charge fees for their services to private patients, although they continued to offer free specialist care in public hospitals when there were complications during a pregnancy or a birth. This reduced the choices for women with normal pregnancies who wanted GP care or a combination of GP and midwifery. Many found it difficult to get midwifery care because demand outstripped supply.
Cascade of intervention
Some commentators talked about a ‘cascade of intervention’ related to hospital settings – a series of later medical interventions prompted by an initial one. Epidurals (local anaesthetic administered to the spinal cord) were widely available in New Zealand from the 1980s for pain relief. Studies showed that when labours were induced and epidurals used, the rate of unassisted vaginal births fell – the use of instruments like forceps, and deliveries by Caesarean section, were more likely.
Some commentators expected the number of home births to increase significantly after 1990, but this did not happen. A large majority of women continued to give birth in hospitals. Planned home births increased from 0.04% of all births in 1973 to 2% in 1993 and 3.4% in 2014. Almost one in four births were induced in the latter year.
The dominance of midwives in maternity care did not reverse an increasing rate of medical interventions by specialist obstetricians. Caesarean sections increased from 11.7% of births in 1988 to 25.9% in 2014 – a trend seen in many developed countries. The World Health Organisation stated that no health benefits were associated with a Caesarean rate above 10–15%.
Some commentators argued that midwifery care and home births would make birth less safe. However, maternal and neonatal mortality rates remained low between the 1990s and the early 21st century. A 1997 study concluded that home births were safe in New Zealand – infant death rates were comparable to those for low-risk women at National Women’s Hospital in Auckland during the same period. However, data on the number of home births has not been routinely collected on a nationwide scale, so it is not possible to determine annual death and injury rates.
In the 21st century midwives provided care and support for women and their families during most normal pregnancies and births. They also visited women during the post-natal period and provided advice and support for breastfeeding and baby-care. Women with complications during pregnancy or birth were referred to specialist obstetricians working in public hospitals.
Midwifery care as opposed to maternity care by general practitioners and specialist obstetricians continued to be controversial. A 2016 review of birthing data indicated that babies were less at risk during birth if their mothers' lead maternity carer was a doctor (81.5%) rather than a midwife (91.5%). The reasons for the difference included levels of funding for maternity care, collaboration between midwives, and doctors and training.
The College of Midwives responded to these findings by arguing that the findings indicated that the private hospitals where most obstetricians delivered babies were better resourced than public hospitals. They also highlighted the need for more obstetricians to be available round the clock in public hospitals to provide specialist care when complications occurred during births.
Overall, the risks of damage to babies at birth are very low in New Zealand, and most babies are delivered by midwives.
Payment for midwifery services
Independent midwives work as LMCs in small midwifery practices in the community. They are not paid by the hour, but through the lump sum for the care they provide over several months to pregnant, birthing and post-partum women, the babies and their families. 'Core' midwives work shifts in maternity units in hospitals and are paid by District Health Boards.
The long and irregular hours worked by independent midwives has resulted in a shortage of qualified professionals to do this work. In September 2015 the New Zealand College of Midwives filed a pay equity claim in the High Court asserting that the round the clock hours of LMCs mean that they earn less per hour than those on the minimum wage. At that time the average yearly taxable income for an independent midwife was $53,728. The College of Midwives claimed that midwives 'who are predominantly women' earn considerably less than those with similar qualifications and experience in male-dominated professions. They argued that this was a breach of the New Zealand Bill of Rights Act 1990 since it directly or indirectly discriminated against midwives on the basis of gender. In May 2017 the College of Midwives reached an agreement with the Ministry of Health to work collaboratively on a funding model that will pay community LMC midwives equitably for their work. This model will be in place by August 2018. The Ministry also agreed to interim fee increases for LMC midwives, some of them backdated. These increases constitute a 10.82% increase in fees from July 2015.
After reaching this agreement in 2017 the College of Midwives continued to negotiate with the Ministry of Health about a new co-design funding model for independent midwives that would provide better income certainty, recognise the business operating costs of independent midwives, and include compensation payments for being on-call. The Midwifery Employee Representation and Advisory Service (MERAS) has also been negotiating on behalf of midwives employed by District Health Boards for better base pay rates as well as penal rates for unsociable hours and on-call allowances. In September 2018 the Minister of Health, Dr David Clark, indicated that it would take some time to address issues relating to pay, turnover and sustainability in the provision of midwifery care.