It’s said that true leaders represent the interests of the people who have invested in them moreso than they do themselves: a conduit, if you will. When Karen Guilliland, President of the New Zealand College of Midwives (NZCOM), speaks of women and midwives in New Zealand – praising their sheer passion, resilience and tenacity in the recently respawned battle for the sexual, reproductive and maternal health services – that characterisation makes perfect sense.
And, like all effective leaders, she is quick to shrug off any praise.
“I was never particularly ambitious,” she says, “But everything changed when I became pregnant. I realised what a horrendous experience [birth] could be for some women. I had my children in a birthing unit and I was quite sure about how I wanted the process to be, but I realised other women didn’t have these opportunities.”
It was 1978 when Karen, with her newborn in tow, began to advocate for patients’ rights. At the time, midwives were not intuitively political in New Zealand, but their engagement in the womens’ rights movement was a perfect fit in the debate for women to have bodily autonomy and access to contraception. Issues that now, Karen is quick to point out, are the same today as they were 40 years ago.
New Zealand is the home of one of the highest-quality midwifery services in the world, where a woman-centred community of maternity care model in primary health has enabled women to have continuous care from midwives within both community and medical settings. Evidence has found that this access empowers women to have the kind of birth they want, and mothers in New Zealand are rated amongst the most satisfied with their birth experiences in the world.
The implementation of this system over two decades ago was an uphill battle at times for midwives like Karen, who campaigned heavily alongside countless women who wanted this service. Acceptance was a triumph; implementation, a success. But the enabling environment around woman-centred midwifery care is becoming less pliable under a more right-wing government over the last 9 years. Midwives are working longer hours, underpaid, exhausted, and carrying unsustainable caseloads – all while challenged on their ability to provide care in the community and home. This has enormous ramifications not just for midwives themselves, but the mothers and newborns who rely on them. Karen sees this as an innately gendered issue.
“Though so much has changed, many people in the health sector still don’t believe a women’s profession is capable of being autonomous. Midwifery is a profession that other people feel needs to be supervised. We shouldn’t have to prove over and over again that midwives are capable and competent to practise wherever they’re needed.” 
The professional respect midwives are demanding should be commonplace, but is not consistent with either policy or pay. In 2016, NZCOM launched a high-profile court challenge to the New Zealand Government, citing a pay equity gap of somewhere between thirty and sixty percent. It was a David and Goliath battle that lead to an initial mediation agreement that could begin to bridge the equity gap. It came with an agreement from the Ministry of Health to work with NZCOM in co-designing a new funding model for midwives. That should have been the end of the battle but in 2017 – despite the Ministry being a co-designer – they failed to support or recommend the new funding model when providing its health briefing to the newly-elected Government. Accordingly, midwives have found themselves forced to reassert their value.
The movement was to encourage women to make their voices heard. Every single politician in New Zealand has been visited by at least one woman and her midwife to be educated on the importance of midwives in a functioning health system. The response from women was simple, grassroots and overwhelming: the ‘Dear David’ campaign, so named for Health Minister David Clark, began in March 2018 and joined in with the Colleges pay equity court and mediation work, Facebook and twitter campaign.
The Dear David letters capture the essence of midwifery – honest, human stories from midwives and mothers that reinforced the importance of this relationship. They detail the sacrifices of midwives in their professional practise – from the rural midwife who drove 600 kilometres in one week and earned only $7 an hour, to the midwife who is forced to work part time at a café to supplement her vocational salary, to the midwife who wet herself after 3 hours of waiting for a fellow hospital staff member to reprieve her during a complicated labour. And though all of the stories, it is clear that there is no bitterness nor resentment against the women – just frustration with working conditions that exploit their devotion to the people who need them most.
The media has been instrumental in providing a platform to midwives and women who are willing to stand up and be counted to share their stories openly. And the country is listening, in no small part, Karen believes, because of the intimate relationship between women and their midwives.
“We are hearing story after story from women saying: ‘My midwife saved my life’. The model of care is loved by both midwives and women, but it is neglected because successive Governments won’t establish structural support or income. This is why women’s voices are so important: they understand that advocating for women – from the highly-educated to the completely impoverished – is what a midwife does. Not every society has placed a value on that yet; there’s still a struggle to see a woman navigate a whole maternity episode and come out a strong woman and mother. But what keeps midwives going is that women do appreciate it, and they are saying so.”
Perhaps what makes midwives and women such a formidable pairing is their intuitive similarities: in many medical systems around the world, the capacity of midwives is dismissed despite incontrovertable evidence, and women are regarded as risk-laden incubators. The common thread, Karen believes, is gender.
“Midwifery is a feminist profession – it has to be if we are to keep women protected and in control of their experiences at such a vulnerable time in their life,” she says, “Our whole reason for being is to give women and their families the best maternity experience they can have, but we still fight the same gender discrimination. It’s not as overt, but it’s still there. Birth is a profound life event and has enormous consequences if you get it wrong. Many health professionals see childbirth as a medical crisis waiting to happen, but midwives believe in the ability for women to give birth. We want to protect that.”
The battle is not limited to just birthing centres and hospitals – it’s interweaved throughout the entire medical system. Midwives are a female-dominated and female-oriented profession, and accordingly suffer the expected – and sometimes unexpected – discrimination. In New Zealand in 2018, Karen believes that the issues continue to centre around autonomy: both the woman’s and the midwife’s.
“It’s quite a lesson in understanding the gendered nature of the profession, having it pointed out to you again in ten-year cycles and needing to keep fighting for it. The part we played 27 years ago is now being replayed, almost word-perfectly. It says to me that no matter what midwives achieve, if we can’t fix the gender inequality in society, we’ll never be able to achieve a sustainable midwifery workforce.”
Ultimately, it seems New Zealand’s midwifery crisis is an issue of perception versus reality: midwives are skilled and passionate, yes… but without an enabling environment, burnout is inevitable. But Karen says this new government is listening so she is confident that the situation can be turned around as long as fidelity to midwifery’s core philosophy continues.
“Leadership has to be woman-centred,” she says, “If the system doesn’t work and a woman doesn’t want to use a midwife’s service, there’s no way to persuade her otherwise. This campaign has made it clear that midwives in New Zealand offer a service that women want. Midwifery is a very successful model of care – it is reliable and competent. That’s what makes me proud.”
The mandate is ambitious, but when Karen says, “I’m not giving up”, history shows, she means it.
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