 our next speaker today. So we have Tammy Heap. Now she is a homebirth midwife in New Zealand and has been a midwife has been in midwifery practice for 10 years before that she was a registered nurse. Tammy has been a trustee board member on the National Homebirth Pretorio Association since 2014 and run the birthplace matters campaign international category in 2017 for homebirth midwife of the year. During her time as a midwife, Tammy has coordinated a group of pregnancy centers in her region and has a strong passion for women's rights in health as well as reducing birth intervention trends. So welcome to you Tammy. Everyone. Hello everyone. Welcome to the International Virtual Day of the Midwife. It's great to see you here. This is my first ever time presenting so yeah naturally the a little bit there. Can everyone hear me okay? Thanks. Thank you. Thanks. Okay so I'm a homebirth practicing midwife here in New Zealand and as Karen Gilliland was discussing earlier in New Zealand we practice generally under the Continuity Partnership Midwifery Model of Care which you know globally the Rhetoric Research supports that continuity of care model is the key to best health outcomes for women and women and babies across their lifespan. There's a thing about coming back to why we're talking about this too. There is a great New Zealand presenter Nathan Wallace on the brain development and he talks about how in the last 30 years of research and development on the human brain we have learned more than in the last 300 years and it is talking about he talks about how it's neurologically and biologically impossible to underestimate how much we've learned in the last 10 to 20 years of research and just the impact on what we can do for the human brain and women babies and people throughout their whole lifespan. Okay the mother midwife died. There's no tool for development more effective than the empowerment of women. A empowered woman who feels confident in birth will often call sorry will call for a midwife well into established labor. Postnatally challenges are often reduced including with breastfeeding. This equates to increased job satisfaction for the midwife and lower work related hours for each woman over the maternity period. Within New Zealand and our Continuity Model of Care we stay with women from the beginning of pregnancy right throughout labor and birth and in the postnatal period as a lead maternity caregiver. So we join up with a lady she choices us right at the beginning of pregnancy and we've got amazing opportunities the whole way through that care partnership with women and with babies and creating a really happy family and things like that afterwards. I love being a midwife and have never dread my phone ringing or feel like I want to leave midwifery. I feel a big reason for this is right from the start I've practiced as a start as a means to go on. Sustainability in midwifery is an issue worldwide with an average length of career of less than 10 years with burnout being the highest reason for leaving. In New Zealand our rate has gone from six years on average to many areas being on average as low as two years and that's quite concerning the last so 30 years ago the average midwifery length of career was 10 years and that is you know quite concerning how much it has dropped in that level of time. So what are the issues? Job satisfaction rates are significantly declining in midwifery and equality and pay increased excessive workloads, staff shortages and issues harassment both from external and workplace cultures have all been identified as causative factors for midwives leaving or contemplating leaving midwifery. The impact of midwives leaving midwifery practice has both short and long term significant repercussions. Fewer midwives mean larger workloads. Less time is available for midwives to support each other professionally, socially and emotionally. New graduate midwives may struggle to find varied mentorship and support during their first year of practice. Midwifery education, student midwives are increasingly both observing and feeling the workload extremes and negativity. Student midwifery retention and new applications are very much at risk. With the midwifery population aging, on-going replacement of the midwifery population is crucial. Women-centered care and physiological birth statistics are at risk of declining due to potential failure to weight pressures caused by high workloads. Intervention field, medicalized births and the related increased birth traumas are all genuine causes for concern. So I'll go a little bit more in-depth into this. Job satisfaction rates. When I first came out with into my midwifery practice there was a large amount of midwives that were talking to women as students, myself and also as a new graduate. A lot of people found that everything or all the good outweighed the few things bad in that time. As Karen as well herself discussed earlier, the prey, we do have a pay equity issues in New Zealand and that has been identified as a large current situation that is being addressed and we're looking forward towards the budget and how things are going to help in that aspect this year. Increased excessive workloads. Within New Zealand we have both current stresses within wards, particularly on hospital-based wards with very high acuity for core midwives. This entails a lot of midwives are looking up to up to nine women on postnatal wards at any one given time. This can equate to very concerns about postnatally up a woman getting that support and that with breastfeeding. We have such a high fantastic breastfeeding rate in the world for the initial leaving the hospital within that first 72 hours, as well as at the six week mark of continued breastfeeding and as the primary mode of feeding and even the six months statistics down the track we have quite good breastfeeding rates. A lot of midwives are voicing themselves that they feel that they are unable to give that woman that really dedicated support with each feed for ensuring that women are feeling confident with the breastfeeding and not subsequently having to deal with issues down the track of things like breastfeeding, tenderness, mastitis and the related issues that can sometimes go from not having that initial in-depth support in those first few days of life. Staffing shortages can also equate to ill health increased incidence of ill health in both staffing on the wards and women that are coming into the birthing unit as LMCs on many instances within New Zealand and around the world. It is reported that a lot of midwives, both poor hospital midwives and women out in the community working as midwives are often being asked to offer increasing amounts of overtime and some women are going up to less than one scheduled day off every pay period in some cases not receiving any days off at all. So we're looking at short eight-hour workdays being increased up to 10, 16 and sometimes double shifts with people coming back from immediately in the morning after finishing a nighttime shift and sometimes they're finishing after midnight. So there's less than that eight-hour sleep period per se. Within the rural community in New Zealand we have many pockets in New Zealand that now have no midwives within an area. This puts women at a lack of being able to choose midwives and are having to travel very very very long distances or there's actually no available access to midwives or even local birthing units that provide well the woman low risk care. Harassment is another one that is an ongoing issue and it is linked often to workload being high, shortages in midwifery in general, resources, there is the premises also that women sometimes are coming in with more co-bidities for their pregnancy, labour and postnatal needs requirements and care and sometimes the policies and things like that can be a preempt for frustrations, tired over workers and often it's not just from financial resources and things like that and that's a you know that there has been an increase in that and we can you know often as I'll discuss later how we can you know do things to minimise that also. The impact of midwives leaving practice does definitely have an impact on our current new graduates and our future students. A lot of midwives are when being asked by ladies out in the community who have an interest in midwifery you know and some students are actually being put off training at the expected time that they thought they were going to you know enter midwifery whether it be after they've completed their you know having their families so you know we are women are putting their midwifery careers back by up to 10-15 years as an example alone or there are incidences or the voice concerns that actually is this a sustainable career for myself and where do I see myself in 20 years after putting the the time the money that it costs and that you know into this. Women-centered care and physiological birth statistics we midwives are excellent in providing well-women care to both low risk and higher risk women but there is a decline in as we can see in the normal birth rates in many countries around the world the cesarean section rate is increasing induction rates are increasing there is a study there was a study in the UK on birth trauma birth trauma rates are on the increase in as much as up to 40 percent for women with first-time pregnancies and births and including in that study as well it also talks about the impact on midwives and birth trauma and that midwives are increasingly be exposed and experiencing the impact with birth traumas themselves and these are also a you know a genuine cause for concern in the rates that the first primary birth there are most important births that we want to make sure that we are not having subsequent women with issues like postnatal depression and all of the ramifications that come out of that mentally as well as the physical issues such as the increasing rate of placenta recruiters with cesarean sections and the comorbidities that can go along with these things and then there's the impact as well on the child development and brain and connections with you know their ongoing you know lifespan development as well too the here we say again midwifery self-care in the unit so I currently have you know chatted with some midwives around the world as to what they find quite good both within New Zealand and you know that works well overseas I haven't worked within the unit myself other than going in and as a midwife and I used to have a I come from a background of being a registered nurse and a high acuity ward so definitely understand that the pressures of the workloads and that again a lot of the midwives say that our continuity based care with midwifery does definitely have a positive impact on women within the unit even if they're coming in for things like induction under either the LMC's or whether they are indeed under admitted under the high risk unit based care so the research still shows that woman will still come out with better outcomes under our continuity continued sorry partnership continuity model model of care for hospital and birthing unit midwives there is a strong ideal to as much as we like to help relieve you know shortages sickness and ill ill illnesses the research does show that the more we do overtime over and above one shift per cycle that we indeed put ourselves as well as the units and other midwives and staff at risk of themselves becoming ill both physically and just exhaustion and that as well can lead to errors in practice so here you know avoid overtime more than once it is a big ask me though most units whether it be primary birthing units hospital units you know utilize your midwifery leaders your charge midwives your hospital coordinators as a valuable resource as well not just for again asking about things for what's happening on the unit you know roster issues there have often been times where you can actually call in your extra support and many a time within my own nursing life we often had you know charge midwives and team leaders coming off and they're coming off their home time and coming in to help relieve the the staffing shortages when the pool of casual staff weren't unfortunately available or you know an ill health themselves so utilize you know utilize them and that's the thing you know we all work together really well to help everyone feel satisfied and experience less illnesses which in turn helps you know provide that great care for women take regular scheduled annual leave at least six monthly of two weeks a lot of women will often only take a week annual leave and this research supports of at least two week blocks help to refresh recharge and revitalize both the physical and the mental social aspect of our enjoyment and our satisfaction within our workspace there's also a few other things that can be done just to make the daily the daily work life satisfying women have also said that they feel more confident and feel like that relationship bond with a new midwife is actually quite strong even than the presence of just the the midwife at the beginning of a shift coming in and introducing herself and saying what what is your goals for today hi my name is this and I've read your birth plan just those simple acts alone can already actually make the woman feel a lot more at ease and develop that immediate connection and relationship with that midwife for that eight hours and also already immediately relax some of those apprehensions and extra potentials for anxieties so extra ringing the bell and actually can and you know reduce the midwife's workload over that eight hours just by these simple things but the connection of coming in and personalizing with that woman straight away rather than coming in and to do a task as a first instance instance has a dramatic impact just for that eight hours just for that woman one woman alone and can already ease up that day midwifery group practices yes we don't really have the bedside handovers within our unit I can't speak for other units around the country I know that within nursing there we used to do it and I can't really say whether that is a current practice lindell midwifery group practices and self-employed midwives a lot of midwives when they first go out look at joining up practices there are a lot of structures numbers and you know ways of practicing that will each and you know suit that midwife group and area there's there is a lot of things to take into consideration sometimes such as traveling area of coverage is particularly within home birth midwifery as well just so in this instance two midwives might suit one group six eight yes so that so that you know is individualized for each and every person however going into a midwifery practice that has this where everyone shares that same philosophy has been one of the big keys to that group sustaining their group and the midwife sustaining their practice one common mistake that new graduates can sometimes fall into is the pressures of joining up a practice for the either gaining the case gaining the case or area wise again too sometimes that can work but in the long term it has shown that that for sustainability and job satisfaction that there are definitely negative sometimes outcomes with this and midwives will often be leaving the practices faster or let you know often changing their mode of midwifery practice whether it be from lmc care practice or into the hospital negotiating a time off system that best suits your practice a lot of midwives have found that having weak about four weekends off one evening a week suits them midwives that have lower case loads particularly home birth midwives because they have that continuity of practice a lot will find that they don't have that and don't or don't require the rigid every second or third full weekend off but negotiate days off that best suit their events life practices and also doing a system that still enables that there's this you know within New Zealand we have two midwives for births and you know at the time of home birth so again too this is going to vary quite differently for whether you're in a small a small rural practice that the midwives don't actually travel a great distance or a large rural area small but with a small number of midwives or even urban areas whether it is a small compact area or a large area particularly in other countries as well when you have policies and things that can dictate where women are or are not able to birth based on risk factors and things like that or even indemnity insurances so every country again has sometimes have has their benefits that can be incorporated into how the practice will work or their limitations so it's just finding that drive as to how that's going to go complimenting each other with opportunities for short term events has rarely shown to have a good collegial relationship with each other that it makes the job on a day-to-day basis a lot more satisfying a lot of women with families report that just the ability to be able to go on the spare of the moment to you know an evening out with their husband or to events with their children or just things that sometimes being a LMC midwife practicing can be limited by the spare of the moment things really has been voiced to really have a great impact on just the job satisfaction overall and the ability to maintain that sustainable balance between both personal and professional life and enjoyment and also too it helps relationships both within the work life and within personal home expectations from family and friends so it definitely has been shown to have really good impact and regular face-to-face meetings with your colleagues ideally at least two weekly if you can't do face-to-face two weekly even doing things like Skype or Zoom or even phone meetings the presence has always shown that it is a lot more calming soothing than the mode of emails, texts and that as to you know the being present and just the presence with somebody that you're you know familiar and enjoy a social comfortable situation as you know with your work colleagues kind of thing it is a great time as well to to discuss cases and things in a short and positive way but again in that aspect just limiting the amount of time that you actually spend on that in that time that you're together and there's other things that you can find that really works for you as well too. Strategies that I've incorporated into my practice to achieve the satisfaction and state sustainability probably the work and personal life balance case load satisfaction I think again too a start as a means to go on when I first went out as a new graduate midwife realizing what physically I needed financially for my own personal life and work life to maintain a keeping up to standards on my midwifery workload education practice side of things personal life being able to you know just have that work balance work life balance where there is the satisfaction and that not only myself loves my career but also my family particularly yeah so in the aspect I currently take two to three women per month while my children are young I have when I first started out I had a load of between four and six when I had it only one child and just have titrated that as I need and that's helped with other aspects of life and looking at financials I've probably become a lot more sensible in some aspects and I think we tend to find that we do better if we're looking over the whole aspects of our you know well-being and how each can complement each other and sometimes how some tweak tweaking of one thing can make it easier you know in some aspects and I do see myself as well later on when the children are older you know going back into to fall you know four to six and I am going back to again changing how I was working then as to you know how the sustainability will continue as well in those modes so you know and that is you know it does it works quite well that way I've noticed within my midwifery care of 10 years of practice that having international appointments of an hour plus or at least 45 minutes has shown that women often feel a lot more confident they know where they are themselves with their own health status a lot both in pregnancy birth and postnatally which means they're very empowered with themselves that they take a lot of the self-responsibility for their own care keeping themselves well and emotional and physical aspects and not exposing themselves to unnecessary risks you know risky behaviors or things you know things like that when it comes I believe that and it has shown that it's not just the birth experience itself that seems to show the satisfaction in both women the babies and myself it is you know women are going away from appointments without any questions unanswered and often for the birth themselves they know where they are they often know where they are themselves and labors for right from the beginning you know at that first day antenatal form and it's really you know setting up that self-responsibility of you know what are you going to learn over you know the time period of coping strategies to enable you to have the best birth you know the best birth the shortest birth the most comfortable birth and you know the subsequently as well you know afterwards how are you preparing yourself for making that you know next six weeks you know that the best it can be in the you know the less tiring the support systems having them in place and in that as well for birth I often find that women are ringing me much later in labour by the way they're feeling so and you know antinaturally we often discuss you know if you're feeling these sensations and feeling these waves of contractions kind of this often this is probably you're probably about this kind of amount of centimetres dilated you know you may be experienced in this you may be experiencing that and that can help to allay their anxieties which in turn enables the ladies to feel that they are doing quite well where they are at the moment and they often don't need immediate presence of midwives you know quite early in the birth and postnatally you just got about a few minutes yep so and postnatally breastfeeding and relationships both with their own partners and the babies definitely sets up a really good paradigm both you know immediately into the future again too there is the choice whether we go I give one all women at a low risk the choice between the National Institute of Clinical Insulin Excellency Antinatal Appointment Guidelines which does advocate for a reduced amount of visits than the current model the current schedule that is used a lot in both the New Zealand around the world of the four-weekly till 28 weeks then two and then one kind of thing it definitely helps quite a bit no text communications as well definitely reduces the immediate continuous expectation of some midwives and women in general that we are truly yes we are 24-hour care as continuity midwives but not for things that are non-emergency based text communications is that availability I've got free I've got free money free texas in that whereas phone calls as women are actually actively making that decision too in responsibility to ring you so and I find that it is only for genuine things that women are ringing and they often will self discover their own not needs and non issues of care kind of thing so yeah so again it helps with the empowerment as well so sorry I'm go I will rush through this so again you can't give the best care if you don't care for yourself so strategies I incorporate into my own personal self-care practices sustained sustainability and they include my mindfulness and meditation again this doesn't have to be sitting down in silence kind of thing and sitting to a 20 minute you know clearing your head of all my you know thoughts and that it's basically what you look to find your moment of peace whether it's with a glass of wine or a coffee and things like that but taking that time we're not going to worry about the days and things mindfulness again too is really you know really about being in the present moment it's a therapeutic technique on being conscious and aware and just knowing that you know we don't have to solve the world in the next five minutes and you can just have that you know moment in time and appreciating the little things emotional physical fitness again too that can grow for everybody minds probably still you know quite in the small going on a vibration trainer going for a bit of a walk bit of swim certainly not hard out marathons is not my thing emotional freedom technique is another therapeutic mode you know mode really where you can actually either use it yourself and I've actually utilised it in my midwifery practice for women quite often whether for general everyday life or anxieties and I found that really helpful and what it does is you can use it every day when you get up and in moments where you can find that I'm just you know need clarity or moment of reducing tension or stress and that incorporates a combined acupuncture in the form of acupressure and neurolinguistic programming and thought therapy and it can actually help stimulate the brain alpha waves as well too so it's really good for you know things before exams or having to you know present for example so yeah that's really helpful and you'll find your own things as well some midwifery and knitting and things like that helpful and there's lots of researches so that helps to reduce depression and that and you'll find your mode so midway of supporting students sustainability of the mid future midwifery population debrief often I can't emphasise this often enough so I know that whether really increased work loads we sometimes put this on the back burner but it's actually one of the most important things to do and do it on a regular basis so set up those meetings and just even you know it's a casual chat but it really gives that chance to reduce those stress levels and get that clarity and share ideas to be mindful we're giving a balanced view with midwifery exposure to a constant negative stream of comments about midwifery to midwifery students can have a profound impact comments from students exposed to a culture of high negativity of voice doubting their own abilities and beliefs of midwifery being a long-term career option for them and why you know I have seen this on a number of occasions and it has both in the short and long-term incidences had doubts and you know impacts on um by the students going into midwifery retaining their current status or actually staying in the career long term you know within that you know lifespan of what they thought they were going to do and yeah I mean so just being mindful of really having that balanced view a lot more positivity than the negative and the realism share your experiences of challenging times with realism and problem-solving so encouraging students to identify their own coping strategies and the things that they find help them through those tough moments and the positive things midwives first year of practice have a clear place plan in place on how you want to practice so ours caseload you know caseloads and that from independent midwives and rosters for midwives that are planning on going to hospitals and birthing units so you know the common thing is do a maximum eight shifts in two weeks for hospital midwives and really avoid saying yes to overtime particularly in those that first year for caseloading midwives it is quite common for midwives coming out taking in a higher number of women that are on the high risk side of it and again going in and starting as a means to go on getting a clear question question sheet and that when you ask women for the interviews when you're interviewing them and and vice versa really getting a picture of you know is how you you know is this the number of women that I can take for this month kind of thing based on acuity so if so you may be finding that you're actually not available for someone based on their needs because of the work life balance that you're needing to keep as well rather than the saying yes you know we need to say no more often sometimes and that includes to other midwifery colleagues and mentors that are often trying to help us get a case like but sometimes we're getting a bit too built up number wise and you know stresses can be increased in that so it's just bearing in mind that side of it again too creating a healthy self-care plan yourself for both professional and um and your personal schedule and again we discussed that earlier you know both sides you know by both sides of things your personal life how you're going to keep yourselves well and the professional side and the first year of practices mentorship in New Zealand we have so getting a mentor yourself or going on to a relevant program so yeah they're available in New Zealand and around many countries around the world sorry I'm not went to a bit slow um education institutions institutions um I find that it would be quite beneficial to do a lot more um on sustainability and our educational courses kind of thing and also including things like healthy financial planning um and uh our personal lives how we're going to sustain sustained workloads um living in particular areas you know high urban um cost of living can be a lot higher particularly if you're a lmc midwife and what that's really gonna entail and in relation to your workload in that again course modules on maintaining self-care and healthy coping multiple um platforms for support things like um facebook groups whether um with lecturers and also um you know alone and also two to suit the midwives we know that we sometimes have different learning abilities visual help some writing help some so really you know making it multi-dimensional to suit everyone activate activists every time a woman stands up for herself we are actually fighting for ourselves our woman and the whole community as a whole and by and by that too it is on a daily basis like Perrin was saying and it is not just leaving it up to the main spokespeople everybody needs to be part of it and the thing is keeping that momentum going so being part of policies you well-women research and everything like that midwifery is one of the most people-centered careers and we transform health so we can help reduce women's babies and everything's co-morbidities over their lifespan by simply sorry i've gone too far by helping you know build and sustain ourselves and helping empower women and babies to having the best life you know best life they can thank you thank you tammy that was very interesting so we did have a question yeah is there any research around there um about sex communications with clients because it is the culture certainly of young midwives and of many clients yes in new zealand our own midwifery council has quite a clear policy that it recommends or actually discusses that it is not a professional midwifery practice that we should be doing as midwives for various reasons that it can provide a platform where you can have miscommunication on both sides of things not just in the area of delays in receiving um texas but actually in the events that things can be read as a non-essential non-emergency case or vice versa um and that it is not a mode of proper assessment um because you're often getting a very narrow picture that there is a way to combat this as well some midwives find that they have um in place like a i-800 free call system for um women that don't have that money on their phone um again too there that works for some midwives it doesn't for others what you can also do is you can um say to women just keep a dollar or two available money on your phone at all times and if you can't afford ring me ring me for so many hang you know rings hang up ring again you know hang up and then i will ring you back and that's for women that you know that do have that financial deprivation again too it's about promoting that responsibility for midwives um two women that they are indeed parents from the day in conception and they do have that responsibility there and it does help their confidence in that as well so that hey you know you've got to have some money on your phone at all times um or have the access to a phone where you can ring because after the event you can have a baby that needs you know assistance you know in the same aspect and you know throughout their lifespan you know as a child you're going to have need to have money on your phone money on yourself at all time so it's a way of setting them up as well too you know yeah and saline was wondering whether that was a policy of the college of midwives i think it sounds like quite an interesting prospective research area um to what the communication is between um women and their midwives via via text um so yeah but was that a policy from the college of midwives it's actually um from the midwifery council of new zealand who um are our um governing bodies and provide our practicing certificates and keeping us safe and thank you any other questions out there so they strongly discourage it it definitely still is in practice but um yeah um there is a clearly boarded out thank you okay so the next session is starting in 10 minutes i'm just going to wrap up now i'll just go through the final um thanks thank you very much for tamie heat that was very interesting and a great overview of