A career that can go from daunting to delighting: The community midwife

• Community midwives are sole traders contracted directly to the Ministry of Health. They are paid through the Maternity Services Notice under Section 88 of the New Zealand Public Health and Disability Act 2000.
• Many midwives practise in small groups, so they can share equipment and clinic rent, and provide back-up to one another.
• The New Zealand College of Midwives has been calling for fair pay for midwives as well as a new contract. The college has been in discussions with the Ministry of Health since 2015.

Community midwifery is a com­plex business, where it can be challenging to get established and stay afloat, says New Zealand College of Midwives chief executive Alison Eddy.

From the moment they graduate, community midwives go it alone, Ms Eddy says.

Being a self-employed sole trader supporting women on a critical, in­tensely personal and sometimes risky journey might feel daunting.

But these midwives also work under a contracting arrangement that’s deemed out of date.

Midwifery and Maternity Providers Organisation executive director Wayne Robertson says the original notice gov­erning their work was most likely designed for straightforward cases in­volving well women.

“But over time, changes in complex­ity mean what was right then is now definitely not,” Mr Robertson says.

Community midwives are lead ma­ternity carers (LMCs) who contract directly with the Ministry of Health. They claim remuneration through the Maternity Services Notice under Sec­tion 88 of the New Zealand Public Health and Disability Act 2000.

Payment comes in automatic lump sums: at 28 weeks; after the labour and birth; and at discharge when the baby is a month old.

Looking after about 40 women a year will earn a midwife approximately $53,000 after expenses, according to the Careers website.

Typically, a heavy caseload consists of about five to six women birthing a month, or about 60 a year.

Ms Eddy says the contract model has both pros and cons.

Self-employment allows for autono­my and flexibility, but the associated costs are significant and current fund­ing is inadequate for the work midwives actually do, she says.

Lump-sum payments are also heavi­ly weighted towards labour and birth, which means most LMCs start working before actually receiving any income.

Midwives fresh from a three-to-four-year degree struggle to cope with this. Most have student debt. “They are not likely to have a lot of spare cash.”

Since 2015, the New Zealand College of Midwives has been in discussions with the ministry towards an updated contract arrangement that will recog­nise and reimburse extra work.

The Section 88 Notice is also under review and proposed changes include more timely payments, especially in the first trimester.

Mr Robinson says the consultation with the ministry needs to deal with the extra complexity of today’s mothers-to-be. “The funding needs to be flexible and follow the woman.”

The provider organisation, set up by the college in 1997, aims to make busi­ness processes as easy as possible, as well as providing LMCs with a support­ive practice management system.

West Auckland midwife Shweta Ku­mar says the lump sum payment at 28 weeks – $398.50 – fails to take into ac­count the work that goes into caring for the woman at this time, including any emergency assessments, or added emo­tional support.

“Your client might have recently lost a family member, or they’re struggling with work, or their partner has lost their job. They already have other young children and you’re trying to or­ganise food packages for them.

“You’re going to be doing frequent visits, because you don’t want any of your clients to fall off the cliff. Some­times us midwives are the only professional they may seek help from.”

South Auckland midwife Fateme Moloodi says LMCs incur significant costs getting ready to practice before payment arrives.

“You have to buy all of the clinical equipment, set up your caseload, pay rent for the clinic. So much of it comes from your own pocket.”

What keeps Ms Moloodi in her job is the privilege of sharing each individual birth experience.

Ms Kumar, who graduated a year ago, says she faced plenty of expenses and administrative tasks, including life in­surance, and her annual practising certificate.

“As a student, that takes a few thou­sand [dollars] off you. You’re always thinking, what next? What process do I have to complete now, like getting set up with Labtests or radiology?”

Aware of this reality while studying, Ms Kumar signed up to attend home births as a second midwife so she could prepare herself for the next steps.

Mr Robertson says a series of nation­al workshops in 2017 revealed that midwifery students were not being equipped with the business knowledge they needed.

Since then, Mr Robertson says, the providers’ organisation has helped set up numerous midwives with online ac­counting software Xero, cost-effective group equipment insurance schemes, and a new app, Tiaki. This provides practice management support and aims to replicate physical diaries.

In the app, midwives can send and receive digital referrals, set up their personalised calendar, send texts, and perform video consults, using a plat­form called Whereby, similar to Zoom.

A measure of success for community midwifery, Mr Robertson says, would be to see LMCs fairly and reasonably paid, as well as having easy access to both practice and business supports.

“If this was any other business, it wouldn’t exist or would be bankrupt. It’s the strong sense of purpose…and a large number of midwives have chil­dren. That personal experience is why it has sustained.”

Even though LMCs are individually contracted, Ms Eddy says their strength comes through teamwork.

Every LMC has a back-up, another midwife who can provide 24/7 cover to their caseload, in case they’re sick, on leave, or attending the birth of another client.

Usually a small group of midwives will form a practice together, and share clin­ic space and equipment.

Ms Eddy says strong professional relationships are probably the key ingre­dient to establishing a successful mid­wifery business.

Finding colleagues who share the same ethos and philosophy is crucial, she adds.

Christchurch-based midwife Violet Clapham says this tends to happen or­ganically, when student midwives go on clinical placements in their final year.

“They form relationships, which of­ten evolves into an offer to join that group.”

As a student, Ms Moloodi was placed with experienced mid­wife Anne Whyte at LMC Services in Papa­toetoe, Auckland. A fellow student who shared the same place­ment later became her back-up.

“Our philosophies all seemed to match; we could understand each other. So, I held on to them, and we’ve been practising together ever since.”

LMC Services is a group practice of about 22 midwives based in a clinic at Hunter’s Corner.

Chief executive Tony Mansfield says the company provides the clinical facilities for rent, as well as business and emotional support. When a team member goes on leave, the others swing in to share out the workload.

“It’s a supportive col­lective,” Mr Mansfield says. “We help them if they’re struggling with their paperwork, and there’s always someone to come to for a quiet confi­dential chat.

“We look after the midwives, so they can look after women and their babies.”

Ms Clapham emphasises that joining an established group, which already has a reputation and receives referrals, helps a midwife develop a caseload.

Personal recommendation is key to building a reputation, with social media playing a greater role in recent years.

“It takes time to build,” Ms Clapham says, “but then it snowballs, which can be challenging if you’re practising in an area where there is a shortage and there’s 100 women for one midwife.”

She points out that community mid­wives, unlike their peers in hospital, have no overt career pathway to follow.

“It’s more linear, there’s no hierarchy.

“All LMCs have the same in­come-earning ability. An LMC is an LMC whether they’ve been one for 20 years or one week.”

Midwives can, however, add more “feathers” to their caps by mentoring new graduates or completing a masters degree or doctorate.