Pregnant women in one town in Southland have lost the last remaining midwife and are now served by maternity care based 100km-160km away
Te Anau’s only midwife is the latest casualty of the beleaguered maternity system in the South and now it appears the town’s maternal and child hub is being downgraded before it is even fully up and running.
The Southern District Health Board told Newsroom the town and nearby area did “not have sufficient” pregnant women or baby numbers to sustain a maternal and child hub and a full-time midwife in the town.
Health professionals Newsroom spoke to were concerned that the health board was using inaccurate and outdated statistics to justify reducing maternity services further and for not funding a locum midwife.
It’s a bitter blow for the town’s families three years after losing a hard-fought battle to stop the downgrade of their closest birthing unit at Lumsden.
Southern DHB said Winton midwives were “perfectly positioned” to provide care for women and babies in the town and the surrounding area. The DHB will continue to lease a room at the community centre in town - used by the former lead maternity carer (LMC) - for visiting midwives.
Local pregnant women are now under the care of LMCs based in Tuatapere, Winton, Gore or Invercargill who live 100km-160km away from the town.
Fiordland Medical Practice Director Dr Paula King said it was heart-breaking the town had lost its last midwife, but that without collegial support the role was unsustainable.
The burden on Te Anau GPs would now be greater with no midwife living in town, said King.
“We are geared to deal with emergencies, and including maternity ones, but if someone has a rapid normal birth what you want is a midwife, not a doctor.”
King said the only sustainable model for the area would be to reopen the Lumsden Maternity Centre and employ a minimum of three midwives, including one dedicated to Te Anau and the surrounding basin.
Jo’s story
Jo Johns, Te Anau’s last midwife, left town in early April to take up a six-month LMC contract in Westport. The role has a more “sustainable package” such as six days off a month compared with the four days she had off in Te Anau covered by a Southern DHB-funded locum.
Johns closed her midwifery practice late last year but still provided some postnatal care and responded to emergency call-outs up until she left.
She loved her job, but it was relentless. She worked 24/7, 26 days a month with four days off, and in a bid to keep going last year she started to pay for another two days' midwife cover.
“I wanted to continue to do a good job and to be supportive of this beautiful community and its lovely whānau but I just got overwhelmed,” she said.
Johns said over the 13 years she poured her heart and soul into her Te Anau role, but it simply wasn’t enough.
In hindsight, she said, being the sole LMC in the town become unsustainable the day the Lumsden Maternity Centre was downgraded. Once the birthing unit closed, the 24/7 midwife support based at the centre went too.
It “severed” her back-up support so if she was away birthing a woman at Southland Hospital, in Invercargill, and another of her women in Te Anau went into labour or had complications, she could call on the Lumsden midwife any time of the day or night for support.
“I think there needs to be two midwives up here, they [Southern DHB] will say there is not the number of births for two, but there is too many for one. I would absolutely love it to be re-opened. It should never have closed.”
It was her own midwife who inspired Johns to take up the profession after a really hard labour with her first son. "I saw what my midwife sacrificed for me on that day," she said. "It was her son’s birthday. It evoked something in me that I wanted to do that for other women, I wanted to help them.”
Her disillusionment with the maternity system grew when she received a letter from the Southern DHB last year informing her that it was stopping the $300 per booking “sustainability funding” given to rural midwives when Lumsden was downgraded.
“I honestly didn’t have the energy to fight it. I think it [the extra funding] was just to appease us when they shut Lumsden,” said Johns.
Seeing her clients in active labour being redirected while en route to Southland Hospital because all the beds were full and then sent on a two-hour journey to Dunedin had been heart-breaking, said Johns.
Expectant mums
Michelle Crouchley lives in Te Anau and has three preschool children. She was 36 weeks pregnant with her youngest child, Luke, when Johns stopped working. She said it was a “head spin” experience so close to her due date but she never felt an ounce of anything but empathy for her midwife.
Johns was her midwife with her oldest son, Jonathan, and she had witnessed the toll the job had taken on her over the years, said Crouchley.
“How gutting it is that she got to the point where she had to change people’s midwives so close to giving birth. She obviously needed a break really quickly.”
Crouchley saw her new midwife once a week at a clinic in Te Anau but some of her friends in the later stages of pregnancy, or who needed to see their midwife more frequently, were sometimes having to travel to their midwife, said Crouchley.
It was also unsettling there was no midwife in town, especially if there was an emergency, she said.
“It just feels like everything with maternity services in the Southland area is just like, 'take, take, take away' and nothing is really given back.”
Te Anau yoga teacher Mariana Alvarino is due to give birth to her first child in under four weeks and is hoping she can have a home birth so her mum, who will arrive from Uruguay, can be at the birth. Covid restrictions mean that she would only be allowed one support person if she gave birth in hospital or a birthing unit.
Alvarino is grateful after she had to change midwives that her new Winton-based midwife has travelled to her. She was initially concerned she would have to juggle work and other commitments around the three-hour return trips to her midwife appointments.
Midwife view
Experienced midwife Nicky Pealing has worked as an LMC in Te Anau and has advocated for years to improve conditions for herself and fellow rural midwives.
She still lives in the area but works a couple of shifts a fortnight at Gore’s primary birthing unit where she has the support of two other midwives.
Pealing said she stopped LMC work in Te Anau several years ago because she felt it was unsafe for her.
“After Lumsden closed it was very ad hoc but at least the GPs could call Jo or me.” Midwife support for women in Te Anau and the surrounding area was “moving further and further away” she said.
Pealing fought hard to keep the Lumsden Maternity Centre open. She was part of a delegation that travelled to Wellington, which included Paula King, to ask the Health Select Committee to investigate the Southern DHB’s decision to downgrade the Lumsden birthing centre to a maternal hub.
The group argued that this was in breach of the Ministry of Health Service Coverage Schedule and would put mothers and babies at risk.
“My big fight for keeping Lumsden open was to keep that support in place for midwives because I knew you couldn’t do this on your own,” said Pealing.
Pealing said the personal toll on rural midwives was huge. “I would say most midwives who work rurally would have a phase in their careers where they feel overwhelmed and dread the phone ringing.”
Pealing said the toll on relationships for rural midwives was immense.
“I’m amazed my husband is still married to me. The amount of time they just have to pick it up, whatever is going … with the kids … your daily lives get put on hold … so many relationships get damaged.”
Jo was under a lot of pressure and Pealing said she had even tried to persuade her not to take on the lead maternity role when Lumsden was downgraded.
“We had many conversations. I said to her, ‘You are mad doing it, Jo, mad’, but she wasn’t at the same stage as I am in my career and she felt she needed to do that for the community, she needed to be there for her community.”
National midwife view
New Zealand College of Midwives Chief Executive Officer Alison Eddy said it was a concern that there were no midwives based in Te Anau, one of the most remote settings in New Zealand.
“I have been aware that it has been a really challenging environment for her to work in with the distance and all the challenges that go with rural midwifery.”
Eddy said the maternity system was not working well in remote rural areas such as Te Anau.
“If there is another midwife in Te Anau and she has a colleague to share the role with potentially the income is then halved and then it makes the role financially unsustainable.”
Pay conditions for the work was only one aspect, said Eddy. Another was the structure of support that sits around the practitioner that allows them to have regular time off call, so they can access professional development, something that can reduce midwives’ professional and geographical isolation and support their work.
Eddy said a point the college had been repeatedly making to DHBs was that rural primary maternity units not only provided a service to their community they also provided a recruitment and retention strategy for the rural midwifery workforce.
“So you know what happened at Lumsden? You took away the unit and what happened to the workforce? It all disappeared.”
The knock-on effect, said Eddy, was that midwives such as Jo found they had less support, which made it incredibly hard to sustain their roles.
The Ministry of Health will establish the Health New Zealand and the Māori Health Authority on July 1. Under the restructure all 20 DHBs are due to be abolished and replaced by the centralised health authorities.
Eddy said no one knew what the health system reform changes were going to bring but the college had been raising the sustainability issues around rural midwifery with the Ministry of Health for a long time. But she hoped that the health restructure would bring with it a better approach to rural maternity care.
Eddy said it was an equity issue. “It is a service for woman, run by women in the main and I don’t see other services necessary struggling in the same way as midwifery has to.”
Health board response
Southern DHB Planning, Funding and Population/Public Health executive director Andrew Lesperance said the Southern DHB “was saddened to hear that the Te Anau-based LMC was closing up her practice”.
When it found out she was stopping, the Southern DHB had reached out to the coordinator at the Maternal and Child Hub in Lumsden, as well as the Winton-based LMCs, to gauge their reaction and understand their ability to cover the region, said Lesperance.
“The departing LMC had already spoken with other LMCs in the area and a plan to cover had been put in place. There were no concerns raised in these conversations.”
Lesperance said the Winton LMCs were “perfectly positioned” to provide care for Te Anau women and babies and there was midwife support at the Lumsden hub.
“Our Winton LMCs will travel up to Te Anau or will meet women in Winton or Lumsden at our hub,” he said.
Lesperance said the LMCs were routinely advised to discuss any issues of concern with the DHB, and that it had not heard from any LMCs or any women considering birthing in the area who were struggling to find an LMC.
“Most of our rural areas can be anywhere from 45 to 90 minutes from their nearest hub or birthing unit, this is not abnormal given the geographical spread and decreasing number of births in our district,” he said.
Southern DHB has stopped the $300 rural sustainability payments but they were “always a short-term measure to encourage continuity of care and to pick up shortfall in Section 88 funding for LMCs who had to travel exceptionally far distances”, said Lesperance.
These payments were stopped when two other measures were brought into place such as the room being leased for the LMC, a locum service to allow for several days a month cover and the supply of emergency consumables through Fiordland Medical Centre, said Lesperance.
Hub mystery
In response to questions sent by Newsroom, the Southern DHB also cast doubt on the future of Te Anau’s maternal and child hub.
“Te Anau is primarily an emergency birthing hub, as the number of women pregnant at any given time in Te Anau is not sufficient to need a maternal and child hub,” said Lesperance.
Paula King said it was the first time she had heard that Te Anau was no longer considered to have a maternal and child hub and she had not received any correspondence from the Southern DHB to say otherwise.
It appeared the Southern DHB was deciding to downgrade support services in Te Anau and the surrounding basin as a result of a midwife shortage instead of looking at how it could recruit and retain maternity services close to mothers and babies, said King.
According to Southern DHB statistics, Te Anau and the nearby area had 14 to 25 births a year, a number that had been consistent for the past five to six years.
Johns said the statistics were incorrect because her caseload was 25 to 30 babies a year and another 40 percent had been covered by other midwives based locally, when there were some, or from outside of the area.
At the Fiordland Medical Centre, 50 newborns a year on average had been registered over the past five years and so far this year 12 babies have been registered.
King said you had to question why it was now that the Southern DHB considered the town did not have sufficient numbers to sustain a maternal and child hub when baby numbers have had a steady increase over the past two decades.
Her understanding was that plans were still in place to extend the Fiordland Medical Centre to create the maternal and child hub, a two-room extension for emergency births and another for midwife clinics.
The evidence of strong baby numbers over the past decade are all around the town.
Te Anau School is bursting at the seams. With classrooms full, this year the school hall became a classroom and in a matter of weeks the library will house a junior class. Mararoa School, up the road at The Key, also has healthy junior numbers.
The town has two preschools - the newest and largest opening in 2017 - a kindergarten, and home-based educators.
The building boom continues in the town, with roads and pathways and the first houses starting to take shape at the newest housing subdivisions and another mixed housing and commercial development recently went out for tender.
In the 2018 Census, Te Anau overtook Winton as the town with the largest population in the Southland District Council catchment.
Political comment
Southland MP Joseph Mooney said more needed to be done to support midwives so they stayed in their communities because they played such a crucial role for mothers and babies.
Mooney said he spoke with midwives across the Southern region “relatively frequently” and knew they were “under the pump” working long hours and often travelling long distances caring for the region’s women and babies.
“They have not been well-supported, that is the message I’m getting,” he said.
Mooney said it was critical for the region that the Lumsden Maternity Centre reopened.
While it wouldn’t be particularly difficult to do in the “funding sense”, the “human infrastructure” would be the more challenging factor in reopening the centre because those who worked there had since moved on, said Mooney.
* Vaneesa Bellew's son was one of 42 babies born in the Te Anau maternity system in 2017. She was Te Anau Plunket president between 2015-2017.
