I have had a long-term connection with New Zealand since the early 1990s when both England and New Zealand started to implement policies for woman-centred care and continuity of care. Our shared passion for the importance of the relationship between women and their midwives, the nature of that relationship and how it might work for both women and midwives have led to collaboration in academic work, service development methods and systems change. I have travelled there on a number of occasions as visiting professor and to the New Zealand College of Midwives (NZCOM).
Returning to New Zealand after 9 years I was struck by the progress. It is now a world leader in providing a well embedded system of care that delivers truly woman-centred care for the majority of women. In New Zealand, women have a choice of lead maternity carer (LMC), and LMC midwives are community-based and publicly funded, they are contracted by the Ministry of Health rather than being employed by the Health Services, but have access agreements with hospitals and birth centres. LMC midwives take a caseload and provide continuity of care.
The system also allows for midwives to choose their place of work; some decide to be an LMC and some work as core staff in hospitals or birth centres. There are a number of primary units and birth centres that provide the opportunity for free standing birth centre care for pregnancy, labour and the postnatal period.
Women may choose between family doctor, obstetrician or midwife as their LMC. However, over 85% choose a midwife. The LMC midwives work in ways they choose (to provide a 24 hour 7 days a week service) and provide continuity of care from pregnancy to labour and birth and up until 6 weeks after birth.
During my recent visit with NZCOM, speaking and attending at their national conference, I spent some time with midwives in the community and in hospitals. I saw the way their philosophy of midwifery was expressed and demonstrated in practice. Watching as information was given and consent gained, observing that lovely interaction of midwives and women who have got to know each other over time, the trust, understanding and reciprocity and the enjoyment, I saw the partnership model in practice. On an evening visit at the end of a busy day, I enjoyed a cup of tea and some cake with a family, where a new mother told me that ‘she got to know and trust her midwife’, and how much it meant to her.
After many years of reading and hearing the phrase ‘midwifery is the relationship’, I started to really understand what it means. The midwifery relationship actually becomes an instrument of safe sensitive effective care.
Over many years, through my friendships, and reading of the literature that has emerged from New Zealand about the partnership model, I knew of the nuanced and careful understanding of the way midwives work in a relationship that enables the woman to retain or regain power, and that makes the relationship sustainable, but above all enjoyable and rewarding for women and midwives.
What is the reason for the success of this highly effective approach to care that is deeply rooted and winds itself through policy and practice? As a midwife I observed in practice told me, her contract is with the woman. But crucially there is a structure of support, standards, regulation and validation that keeps women, babies, families and midwives safe. NZCOM has been a central driver in what has been a whole system change including legislation, regulation, health services structure and payment (Guilliland and Pairman, 2012). This is truly woman-centred care.
What can we all learn from New Zealand? For one we can learn from an example of transformative fundamental change over a whole system. For another, the dynamic and developing literature from New Zealand about the nature of the relationship and sustainability of continuity of care is relevant to anyone developing continuity and woman-centred care.
Could other countries create such a fundamental and wide-spread systems change? New Zealand is a small country with a low population base, a unique culture, and the possibility of close contact for all concerned with maternity care. This may have provided an advantage, but it has not by any means been easy, and has developed over years.
However, the principles of change are there for all of us to see. These include an integration of philosophy and policy that were supported by a systems-wide structural change in the maternity services. The change has been fundamental including all aspects of maternity. Above all there has been powerful, formidable, courageous leadership.
This change in New Zealand was a response to a virtual loss of midwifery as a profession. Many countries around the world are seeking to reinstate midwifery as a profession, or to increase the autonomy of midwives and have them practice to their full potential as part of a system of care that is effective and cost effective. New Zealand provides a unique example for us all to learn from.