28 April, 2022
Members of Te Tatau o te Whare Kahu
Email:
[email address]
Dear Council members,
Thank you for the opportunity to provide feedback on the proposed revised Scope of Practice. This
feedback is provided by members of the midwifery leadership team at Northland DHB.
We acknowledge the extensive work and debate that has been invested thus far in the process of
revision of the Scope. We also acknowledge and appreciate the information shared on the webinar
hosted by the Midwifery Council on 14 April 2022 and 28 April 2022; however we are disappointed
in the delayed staging of the webinar. Considerable confusion, misunderstanding and feeling of
disconnect may well have been reduced if the intentions which lay behind the words within the
proposed scope had been clarified at an earlier stage of the consultation process.
Te Tiriti o Waitangi
As Aotearoa/NZ citizens and as midwives providing a health service in this country, we
wholeheartedly support the inclusion of Te Tiriti and matauranga Maori; the elevation of the
necessity of cultural safety to align with clinical safety; and recognition of Te Reo in the proposed
scope. We agree with the sentiments expressed in the webinars that this may go some way to assist
the profession of midwifery taking its place within a reformed health environment, however regard
this is as secondary compared to our obligations as Te Tiriti partners and the quest for equitable
health outcomes. We believe that considerable education is required in order to give life to these
words and aspirations within a midwifery context. We are therefore hopeful that cultural aspects
will be compulsory components of every Recertification programme going forward.
As you are aware, the use of the word whanau in the proposed Scope has generated much debate.
We acknowledge whanau to be those people, identified by a woman/wahine, who comprise her key
influence and support. We are aware that these people may not necessarily be direct family
members. We understand that it is crucial that these people should be included in care planning and
information sharing if that is the wish of the woman / wahine. We know that a professional
relationship with a hapu mama must also incorporate a relationship with her identified whanau.
These needs relate to both Maori and non-Maori people and we believe meeting these needs is
indeed possible within the current Scope and competencies. We see this in action on a daily basis,
notwithstanding that there are always opportunities to further develop this aspect of our work to
more wholly meet the needs of Maori women in particular. This is learning and subsequent
implementation we are each accountable for, both on individual and service levels.
What we did not know, nor do we believe is commonly understood and interpreted by members of
the midwifery profession or indeed the public general y, is that whānau also means an individual – in
this case a woman. As you know, the use of the word whānau to wholly replace the word
woman in
a midwifery context has not only generated huge confusion but also disquiet.
We are equally aware of the perception in relation to the proposed Scope that a) the woman as
fundamentally being central to our care is diminished and b) the requirement to provide some
degree of care to non-pregnant people within the whanau. While assurance was provided to those
who were able to attend the webinars hosted by Council on these matters, we believe,
at this time
of transition, that the word woman / wahine / person should be retained in addition to the word
whanau in order to better clarify to whom clinical care is provided. This should include the ability to
prescribe to the partners of women / wahine who have a sexually transmitted infection yet also
clarify that clinical care to other whanau members is not within Scope.
Scope of Practice
It is our understanding that the Scope of Practice is a gazetted, therefore legal document, which
serves as a foundation document of the profession of midwifery in NZ. From this, additional aspects
support the Scope such as competencies for entry to the register; pre-registration education
standards and the Code of Conduct. These, along with standards of practice and philosophy etc.
collectively form a professional framework.
In the context of midwifery, the Scope should describe what a midwife
does. It should differentiate
between what a midwife
does in a maternity environment as opposed to what other regulated
health professionals may
do. This information is therefore vital in informing the public and other
health professionals of the parameter of the practice and associated accountability of midwives.
How midwives practice is contained in the specifics of the competencies. In the proposed revision
we submit that the Scope is not adequately concise and confuses what midwives
do with
how
midwives may practice in some, but not all, areas of their work. We suggest that several paragraphs
are indeed more aligned with competencies and/or professional development e.g. paragraphs
3,6,7,8,9,10 and overal , the proposed Scope is more reflective of a philosophy of practice.
While we appreciate that one intention of the revised scope is to make it more enabling, we are
concerned that the revised breadth of the Scope results in lack of clarity. Subsequently, in a
disciplinary setting, it will be lawyers who may ultimately decide the interpretation of the Scope.
This is not their job but one they will not shirk away from in the interest of their client.
In an environment of profound workforce shortages, we are fearful that the current work of
midwives focussing on antenatal, labour & birth and postnatal areas of practice will be undermined
by the extension of the Scope into wider aspects of sexual, reproductive and infant health. The
impact of even a relatively small number of midwives opting to work in these other areas will
negatively impact on the available midwifery workforce to provide core midwifery practice
comprising antenatal, labour and birth and postnatal care by both employed and self-employed
midwives. We have already experienced this as a result of vaccination mandates and respectfully
suggest that the Scope remain relatively tight until the workforce challenges currently being
experienced are rectified.
We propose that an alternative approach be adopted to enable additional education leading to
specific new areas of practice which are deemed necessary e.g provision of abortion services; rural
midwifery; removal of LARCs; specific aspects of complex care. These could be regarded as ‘add on’
scopes whilst also maintaining a focus on those areas historically considered being the domain of
midwifery as outlined above. We suggest midwives should by and large “stick to their knitting” in the
first instance to assure the public of high quality midwifery care and for this not to be unintentional y
‘watered down’.
We are also concerned that key aspects of the previous Scope have been omitted in the revised
version:
• In the first webinar, the necessity to include what midwives do
on their own authority was
described as “old fashioned”. This is disingenuous and bears no reflection of the history of
midwifery in NZ when midwives have been stripped of any element of autonomous practice.
Regaining autonomy has been a hard won battle for midwives in NZ and is a significant
component in the description of our current Scope. Furthermore, we see the need for the
retention of autonomy in our Scope as being one way of ameliorating the relative invisibility
of midwifery in the Health Reforms to date. Without the description of autonomy, midwifery
could potential y be much easier consumed by nursing or medicine.
• History also dictates that home birth is a vulnerable component of where midwives may
practice. While the midwifery sector regards homebirth as an unquestionable option for
women / wahine / whānau, other professions do not. Home birth must be protected as a
place of work for midwives and a place of birth for whanau – inclusion in the Scope is an
overt way of achieving this.
• Reassurance was given on the webinars that, by and large, the timeframe surrounding the
involvement of a midwife with a women/whānau will remain unchanged. This verbal
explanation is inadequate given the legal status of a Scope of Practice. Six weeks postpartum
in the previous Scope was based on physiology and not on the funding model as some
purport. The inclusion of the word infant (one year) and the lack of a clear end point are
contributing to significant confusion and uncertainty. We urge Council to maintain the
current parameter of six weeks postpartum.
• A key feature of midwifery practice is the ability to detect complications through all stages of
the pregnancy and childbirth experience and to initiate emergency measures as required.
The capacity to do this is underpinned in appropriate undergraduate education yet there is
no assurance that midwives will be adequately prepared for this if it is absent in the Scope.
In addition, sometimes midwives (especially those working in rural areas) are required to
work beyond their commonly understood day to day Scope for a limited period of time
whilst providing emergency care. These midwives providing life-saving interventions will be
unprotected by the proposed Scope.
Conclusion
1. We applaud the inclusion of Te Tiriti, matauranga Maori and cultural safety in the proposed
Scope of Practice and look forward to on-going educational opportunities for all midwives to
better embed these in our mahi as midwives.
2. We are concerned that some components of the proposed Scope read more as a philosophy
of practice and that it does not fully describe the parameters of midwifery practice.
3. We ask for reassurance that the proposed Scope wil fulfil the legislative requirements of a
Scope of Practice as outlined in the Health Practitioners Competence Assurance Act (2003).
4. We feel strongly that the absence of autonomous practice may have unintended
consequences of diminishing the status of midwifery as a profession in its own right leading to
other health professionals encroaching on the domain of midwifery and midwives returning to a
role more akin to obstetric nurses.
5. We ask that other omissions identified above in the proposed Scope be retained.
6. We are aware that the proposed increase in the breadth of midwifery practice is leading to
significant confusion within the profession and may potential y have an adverse impact on
workforce capacity.
7. In order to ensure public safety we urge you ‘not to throw the baby out with the bath water’!
