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From the Chief Executive's Desk
				
		
		
				Talking with members up and down the country a number of common themes emerge. Amongst those are concerns about where the midwifery profession is headed. I’d like to share some of the comments I have received and invite you to give these some thought and let us know how you feel.
		
		
				There have been many comments about the midwife’s scope of practice. I have been told on many occasions by many people, including representatives of NZCOM, each midwife has a right and an obligation to set their own scope of practice, provided their women are fully informed of the individual’s scope of practice and provided the scope reaches the minimum levels effectively set by the Midwifery Council. This right and obligation seems a fundamentally important principle as it allows a midwife to acknowledge she is more competent in some areas than in others and to practice only to the extent she feels competent to do so. Yet, within the scope of this discussion, comes the question of primary and secondary care midwifery and what these may entail for an LMC midwife. In this context, I feel it is fair to state the new ection 88 Maternity notice is helpful and clearly only applies to primary care.  It also provides a mandatory service specification. If nothing else, the Notice sets a standard for the minimum scope of care which must be provided in primary care maternity services. The Ministry of Health also sets the service specification for facilities.
		
		
				 Some midwives have commented “ 
		
		
				
						if it can’t happen at a home birth, its not primary care” 
				
				and thus define their scope of practice as primary only. Others have commented they feel their relationship with their women is such, they stay with them and provide all the services they can, including secondary services right up to the point where medical or surgical intervention may be required and stay as support beyond that point. And there have been a huge range of comments between those two extremes.
		
		
				Some have commented they provide some secondary care services, even when they need to hand over care, as the facilities they use are short staffed and they want to support their facility based colleagues. They further point out handing over in such a situation aggravates what is already undoubtedly a tense situation inside a short staffed facility and may lead to less optimal care 
		
		for the woman. Others have stated they would like to help their facility based colleagues but, at the end of the day, the only the DHBs benefit as they save money on staffing while the LMC and facility based midwives just get more and more stressed by the demands upon them. There is no doubt a work load that is too heavy does generate stress and reduces the ability to perform as well as might be expected. In this context it is pleasing to hear of many LMC midwives either deliberately reducing their caseload or working in groups with scheduled time off so they can begin to maintain a balance in their lives. At the same time, facility based midwives do not have the same opportunity to reduce their workload and, one asks, has the ongoing shortage of staff in many facilities created a situation where more suffer burn out due to staff shortages so they leave, and without replacement staff being available, the remaining staff are under even more pressure and get even more stressed. 
		
				Some have suggested one way forward would be to have, effectively, two practice types. One is a primary care midwife working in the community, in the same way LMC midwives do currently but only providing primary care and, if a situation arises that requires any form of intervention, care is then handed over to the other type of midwife, secondary care. This midwife would focus on women who required additional support and intervention, in whatever form that may take. The counter argument to this idea is the independent midwife forms a special bond with her woman and wants to be able to be with her and support her, as far as is possible, right through the entire process, using their secondary care skills as appropriate. And the facility based midwife likes to be able to do normal deliveries as well. Further, there is a danger midwives who increasingly deal only with complex and high risk cases may become more and more medicalised. 
		
		
				Now we have a consultation document from the Midwifery Council in which they ask if it would be timely to develop a scope of practice for health care assistants working in maternity care, i.e. midwifery assistants. It seems there is a strong possibility the midwifery profession may, over time, evolve into three levels of scope of practice – midwifery assistant, primary care midwife, and secondary care or facility based midwife. I have to ask if this is a positive development. And all this in an environment where, increasingly, all health professionals are not judged by the standard of care they provide but by 
				
						standards imposed in courts of law (which may or may not be relevant), 
						where health professionals are often pilloried for innocent mistakes and unavoidable outcomes. And where the patient often does not accept responsibility for their own health and well being.
				
		
		
				
						Midwifes may only have limited ability to influence some of the factors that impact upon them. However, as a profession, they need to have confidence in themselves as professionals, and in the direction their profession is headed.
				
		
		
				
						So where do you feel the profession should be headed? 
				
		
		
				• Should midwives have the opportunity to specialise in areas of particular interest (e.g. lactation consultants, child birth educators, educators) 
		
		and define their scope of practice accordingly without needing to maintain disused basic skills? • Should it be mandatory for all LMC midwives to have skills they would only use in secondary care 
		
				
						(e.g. the management of epidurals)? 
				
				• 
		
		Should it be mandatory for new graduates to spend a minimum period in a secondary/tertiary facility to acquire additional skills, competencies and experience? • 
		Should it be mandatory for facility based midwives to spend a minimum period every three years working as an LMC or as part of a community team so as to broaden their experience? • 
		Should we accept primary care midwifes and facility based midwives need different skill sets and encourage the profession to develop two distinct types of midwife with different scopes of practice? If that happened, would t encourage or discourage better relationships between the two groups? • 
		
				If we encourage the facility based midwives to focus on the secondary care skills and competencies, do we risk increased medicalisation of maternity care? • And what about midwifery assistants? Is this a good idea? What are the possible benefits? The risks? Would the availability of midwifery assistants improve the services available by giving midwives the opportunity to delegate?
		
		
				
						
								Your views please – I’d really like to know.
						
				
				
						
								
										Tony Mansfield Chief Executive