Tag Archive | rural

My experiences transitioning from UK maternity system to New Zealand system

My rural New Zealand midwifery office and home

My rural New Zealand midwifery office and home

I moved to NZ from the UK 9 years ago. My husband of 18  years is a New Zealander (a Kiwi) so it was fair that I give NZ ago! It has been a time of much transformation, delight, home sickness, isolation and many joys.

In this blog I want to share my transition to working as a practising midwife in a totally different system from the NHS and independent midwifery roles in the UK. I had worked extensively both in the NHS and independently as a midwife. My passion is and always will be family centred primary focussed continuity of care. I love it, thrive on it, inspired and energised by that model of care. Long before all the evidence started stacking up in favour of continuity and primary birthing I was hooked, convinced and intuitively just knew it is how I must work.

After working at Queen Charlottes Hospital in West London with its massive rates of epidurals, feeling downtrodden by a system that continually frustrated me, I moved to a group practice with the newly established Chelsea & Westminster maternity services under the management of Paul Lewis in the mid 90s. The seminal moment at QCH came when I chose to follow a mother from the antenatal induction of labour area to the labour ward. She was scared and had come to trust me throughout my shift. I went upstairs and provided continuity until after her birth. I was reprimanded for leaving the AN ward despite getting a colleague to take my place for the shift. Going into a group practice at Chelsea and Westminsiter was super exciting. Changing childbirth was a real possibility for change. Yet I still craved the continuity 1:1 relationship. So I went independent in and

around London and Surrey. Loved it but didn’t like having to ask for payment. I then worked as a midwife in France (long story for another blog!). Returning to the UK I continued in a community Group Practice in south London before going to Cambridge to be the first consultant midwife at Addenbrookes. That was a whole adventure (I’ll save that for another blog!)

Then to NZ. In midwifery terms I had died and gone to heaven! I spent a short time locuming in a Auckland hospital. Then swiftly moved rurally and within weeks was booking women for full childbirth care. No need to speak about money, no need to speak about insurance, (New Zealand has a no fault compensation system called ACC), no need to speak about who is in charge of my days on or days off! I was self-employed booking as many women as I wanted and being paid for the midwifery work I did.

In NZ women ask around, look in papers, yellow pages, look on notice boards and ring around to find the midwife they want to work with. They can even find a midwife online:



For my part I advertised and got known. I was in the local press, interviewed on a local rural radio station and attended several women’s support groups in the area. In one month I was busy. One month I was dashing to three births in one night! That was very unusual. Most months I had 4-6 births due. After the first year word of mouth is the most powerful way to gain more mothers for care.

Once a woman has decided to book with me we both sign a contract. This contracts me to provide full midwifery services. This then gets sent to the Ministry of health (DoH in the UK). The ministry then pays me. Such a great system. In New Zealand about 50% of midwives work as self employed caseload midwives 50% as employed working mainly in facilities. All midwives from qualifying and being certified to practice choose which area she practices. Some midwives spend time in both areas in the course of their careers.

I was living pretty rurally at the time so needed to ensure I had back up and good networks. This is vital in rural caseload midwifery. I got to know everyone as you can imagine. Sometimes I could be super busy others more calm. But what is always beautiful is the depth of connection forged with women and their families from 1st trimester booking to 6 week postnatal discharge. The collaboration, working together and guardianship of that precious time is warming and ackowledging of the human capacity to be together in health care. I felt the childbirth process unfolded more safely due to that relationship, knowing women over time allowed for red flags to become easily visible.

Knowing women allows for the felt experience to be magnified. The spirit of childbirth over the extended rapport with women and families comes alive. I have been at births when 4 generations are present…magic. I am so often moved to tears and feel the hairs on the back of my neck stand up on end in the sheer joy of those Kairos moments. Yes I am tired at times but knowing woman when they call me in labour is far less exhausting and stressful than shift work and fragmented care. Being woken up at 3am to attend a birth of someone you know well is so different to waking for an early shift at the hospital.

As a Lead Maternity Carer (LMC as named in NZ) midwife I am able to get full access agreements with local hospitals to ensure continuity is safeguarded. At these times I honour and respect my hospital based core midwifery colleagues. With them higher risk women get the midwifery expertise required in addition to the primary focus I provide as the LMC. The interface of primary and secondary service misunderstandings and differences fades. Women are in the centre of care.

NZ midwifery is a truly integrated service. I said to a group of student midwives in the UK before I came to NZ how working in 1:1 ways with women over the childbearing year  brings the felt experience of being a midwife to a whole different level. I now work with student midwives who have this embedded as the infrastructure of NZ maternity models of midwifery. Partnership, collaboration, protection and continuity lie at the centre of the philosophy of midwifery  in NZ.

Watching a women grow into her breastfeeding confidence over 6 weeks knowing you have provided consistent advice from AN, immediate postnatal when she first meets her baby and then ongoing support…pure magic. To work with a woman who is terrified of labour and birth and to watch her roar with delight as her baby emerges in water at home and see the power and rawness of a new being unfold infront of me, to have the elder children that I helped into the world watch on as I return to the family each year to see a new sibling come join the party, magic. Yes sometimes things do not go to plan. But with well formed relationships so many things are possible, even when outcomes are not positive. The relationship helps, heals and restores.

I was invited to the funeral of a neonatal death due to fetal abnormalities. It was a traditional ceremony in a Maori Marae (meeting house), I was invited to speak and sing for the baby. The whole ceremony was nourishing and healing. The eye to eye contact, the hugs the authentic being together in human pain was healing and freeing. Relationships and partnership are key to midwifery; birth is always significant whatever the outcomes requiring tact and sensitivity – connectedness.

Continuity of care is evidenced based, many midwives experience working this way, we are learning how continuity is sustainable, how continuity can be the very aspect of midwifery that maintains passion and joy of practice. It is not a gold standard, it is a minimum standard for all mothers, regardless of risk, place of birth. Yet we all all need to ensure that a philosophy of childbirth and midwifery is deeply grounded in trust and appreciation of physiology, a way of attuning that honours the invisible qualities of childbirth, the spirit, heart and hold what is most  sacred. Only then does continuity truly rise above the technocracy and fear surrounding childbirth. Fear can be moved to joy allowing all possibilities to arise!

Do you want to work in New Zealand? Working in NZ requires adjustment and further study. NZ midwives on qualifying are able to prescribe for childbirth related things (UTIs, mastitis, thrush for example). NZ midwives on qualifying need to be proficient in neonatal examinations and be confident providing care from early 1st trimester including miscarriage care, intepret scans, blood results and make referrals. I remember being professionally challenged ordering serial blood tests to measure HCG levels for a mother with threatened miscarriage shortly after arriving in NZ. With help from practice partners I learnt what I needed to do and say to provide support to this mother. Post natal care extends to 6 weeks; after my UK postnatal 28 days experience there was much to learn here also! The learning curve at the start can be steep and also includes gaining appreciation of a bi-cultural society  and the history of colonisation on indigenous Maori. Transitioning from UK midwifery to New Zealand midwifery can be challenging yet that challenge depends on what you have done previously, what you want to do and how adaptable and open you are.

That is a taster of my own felt experience. Hope it adds to your thinking about the myriad potentials in midwifery.

Here is some useful links to explore more….






Embracing the Dionysian Apollonian paradox in maternity care research

“Rachel was born at home, unplanned. In the lounge of course, right in the middle of winter. She came on hard and fast. I just woke up about 9.30 with feeling uncomfortable again nothing really, just niggles. Went back to bed I rang Sam [midwife] at about 10.30, said “I’ve had a couple of contractions, nothing regular”. She said “Do you want me to come around”. We’d just had a snowfall that weekend the roads were quite dodgy so needed to make the decision to travel or not. It can take a good hour and a half, two hours to the rural unit depending on conditions and up to 4 hours to the hospital. So it was a bit scarier especially at night time. The gorge passes can be quite treacherous with ice and snow on the roads. I cracked on – the road trip was not happening, they’d all decided for me but the decision had to be mine. I wasn’t frightening at all. It was horrible outside, cold and the roads were really bad. I had visions of getting stuck on top of the gorge and having the baby out side with my bare bum out in the middle of the snow. I was not leaving even if others wanted me to, not with that length of time travelling and the terrible weather conditions. I was comfortable here at home, it was really lovely. The fire was roaring, put the jug on, and had a cup of tea. Sam called her second midwife and popped home and got her home birth bag. We had a cup of tea and settled in basically, parked up, and let things progress – just did what I needed to do”

Things are certainly not as straight forward as we would often believe them to be as Lynn’s story narrates. I am now dwelling amongst pages upon pages of post doc gathered data. The data is brimming with stories of maternity care lived experienced descriptions from a wonderful host of participants as the one above. I am always bemused and delighted when I come to the part of qualitative research that involves ‘letting arrive what needs to arrive’ from the data. Amidst the seemingly overwhelming complexity of life rendered in these gifted stories are the shared meanings that gesture towards our together humanness! In this is the possibility of transformative understandings and how to go forward. At the end of day I’m a swirling energy of interpretive images and words punctuated by my exclamations of “yes”, “perhaps”, “oh I feel that”,” I see what that means”, “where is my note pad and pen” “oh wait there is more”. No-one warns one of the insomnia that can plague a qualitative researcher once immersed in stories about life.complx

To be fully engrossed in the process is to be witness to the Dionysian possibility of ceaseless convergence and divergence. It is to find oneself in Kairos time when fixed notions of the “final answers, solutions and conclusions” find no resting place. There never seems a ‘right’ time to stop for the day – nor is there a moment when interpretation is complete! I find it liberating and freeing not to have it wrapped up and formulaic. To be released from the need to have the final word on any phenomenon is absurd yet funded research demands the ‘output’.


Apollo directs into reason, systems and defined predictable processes

The often spoken secret between us Hermeneutic phenomenologists is knowing there never will be one definitive conclusion; there will always be ‘on-the-way’ findings ‘that satisfies’ the funding agency and those that accept your work for publication. I say secret because however many times I say that this type of ontological work bellies any finality I’m repeatedly asked “so what was your final conclusion?” – I smile, “There simply is no ending to the process of life”.

Maternity care provision in the remote regions of New Zealand is a tale of paradoxical tensions. This tension is between the need to let go into the uncharted yet inspiring territory of what may lay beyond the imagination of our own experiences while taking heed to the Apollonian structured world of the modern maternity systems when ‘things’ are made controllable, timed, charted, documented, where protocols and guidelines dominate and attempt to construct and hold that world together. There is the nearness of being home and feeling safe and fear when one is far from the highly structured world of medical help when needed.

Rural living tells a story of being on the edge and outside of that controlled environment of the 21st century maternity hospital. I see and ‘feel’ hard working down-to-earth pioneer types living frontier lives in these remote regions. People dealing with the challenges of isolation and close community; of scenic places that are often holiday destinations for many of us yet are the homes and birth places of many.

I will not speak in this blog entry further on the findings for that will come later, I promise! For now I am intrigued about the paradox as stated above.

dionysusDionysus eats the intoxicating fruits

This research, like maternity care in rural areas and birth itself requires an openness, receptivity and trust. These unfolding emergent processes epitomize the Dionysian approach. As researcher and midwife I find myself being reminded on this journey that responding to what emerges is about attuning with wonder to what surfaces in a kind of creative evolutionary flow. To be immersed in research that seeks to reveal meaning is to drink of the intoxicating Dionysian wine that releases me to go beyond constraints; it can make me dizzy! In my research on Joy at Birth I wrote:
The birth experience uncovers a drawing near of divinity that puts us face to face with Otto’s holy-other as Dionysus the ecstatic liberator from worldly concerns “… something that captivates and transports … with a strange ravishment, rising often enough to the pitch of dizzy intoxication…” (Otto, 1917/1923, p. 31). I am reminded of the lovely madness just after many births when everyone is intoxicated, fascinated and enchanted. Something enchanting is experienced that can be a moment of transformation; a moment in which we find ourselves able to go forward into new understandings.

I then wrote in my field notes at the time:

As soon as baby came the father held his son up to the night sky offering an Islamic prayer, all the hairs on the back of my neck stood up. This was a holy moment, I continued to attend to the mother yet there was such a presence that touched and thrilled me to tears. [Field notes 2011].

The mood of the Apollonian thinking that comprises systems, measures and to do lists would appear at odds with this intoxicating freedom. Yet that is not what I argue. Both the Apollonian and Dionysian ways of attuning speak to us as humans. Actions in the remote regions to secure safety and positive outcomes require planned actions, sharpened clinical decision making and critical thinking.

A recent heated discussion on social media concerning midwives and promotion of normal birth provoked condemnation from some quarters. Again the splitting of ways in the normal vs abnormal debate bears no useful long term fruit. What is important is acknowledging and appreciating that we are always somehow in the dance of the Dionysian and Apollonian paradox. Statistics at times can be used as weapons to prove “being right” and held up to be the sole voice of reason. Conversely an emotional charged flow of words can imply “rightness” – yet this ‘feeling’ contribution to the debate can be accused of being chaotic, unreasoned and therefore less valued. Both however can come at us like arrows of righteousness and strike us wherever we are situated.
As Rumi, a sufi mystic poet said in the 13th Century:

“Out beyond ideas of wrongdoing and rightdoing, there is a field. I’ll meet you there”

To dichotomise appears to be the domain of inflexible thinking that seeks rightness and disregard of the other. Likewise I am finding once again that the research project (whatever it may be) requires a Dionysian openness and flexibility. At the same time I need to pay attention to the more Apollonian disciplined processes such as the ethics procedures, funding applications, attention to literature (yes -quantitative and qualitative) and the academic restraint on styles of writing. It is in a sense a dance in Rumi’s field. It is neither this nor that, not a wrong way or a right way it is always dialectic, constantly both, one within the other…that is the tension.

Lynn had planned on a facility birth yet had her baby at home by the warmth of her own fire after a cup of tea with her husband and the local rural midwives. The snow storm and the worrisome distance from hospitals and secondary services lie beyond this tender scene. The story reveals qualities of relationships, trust, surrender and feeling safe. Life is always far more than we can predict and order.
For me it is about letting go of being right OR wrong and enjoying the fun of being finite in a universe of infinite possibilities that confound us! Befriend your Dionysian and Apollonian qualities.