When you're a professional working
woman, you don't always have the time to think and plan for your
first baby, as our Ask the Expert question First baby due, what
do I do? showed. This article on pregnancy care options is
intended as an introduction to the topic for you expectant, but
busy, women out there.
Satisfied Customers
As I began my research, a letter to the Herald editor caught my
eye. Written by a man who'd just become a new father, it finished
with the words, "…I cannot think of anywhere I would rather have a
child than in New Zealand." He and his wife had evidently felt very
well supported throughout pregnancy, during the birth, and on to
post-natal care.
I had similar positive experiences, but the letter made me
wonder what the process and options were nowadays for arranging
maternity care. The "system" changed in July 1996, shortly after my
daughter was born, and I didn't notice many differences when my son
came along in 1998, perhaps because I used the same combination of
health professionals.
The Current System - Overview
The objective of the changes seems to have been to improve the
continuity of care for a woman. Instead of being passed from GP
care during pregnancy to often-unknown hospital midwives (who
changed as their shifts changed) for labour and then to ward staff
for post-natal care, women now choose a Lead Maternity Carer
(LMC).
The system is also designed to provide "integrated" care, in
that LMCs can access any necessary additional services such as
obstetric or paediatric services for their clients.
Lead Maternity Carers (LMC)
The Ministry of Health defines the LMC
as a professional who "takes responsibility for the care provided
to the woman throughout her pregnancy and postpartum period,
including the management of labour and birth."
The LMC can be a midwife, a GP with obstetric qualifications, or
an obstetric specialist. In the case of 'shared care', combinations
of these professionals provide care. Note that depending on where
you live, not all these options may be available.
Section 88 Maternity Services Notice details the minimum service
specifications to which LMCs must work. For example, an LMC (or
their backup) must be available to you 24/7. All LMCs are paid the
same to provide the same level of service.
According to the most recently available Report
on Maternity from NZHIS, at first registration in 2003, 78%
women chose a midwife. About 7% never registered with one and the
rest were split between GPs and obstetricians. These proportions
partly reflect availability (see 'How Easy Is It To Find an LMC?'
below).
The Basics
The good news is that there is plenty of information out there.
A
booklet from the Ministry of Health explains about care options
and the role of the LMC as well as providing general pregnancy
information. Other good sites to read about care options (and much
more) include:
In essence, the steps you take are these:
- Establish if you're pregnant. Once you think you're pregnant,
visit your GP or a midwife. This person is responsible for
confirming pregnancy and for explaining the system and your options
re your LMC. They should also explain the different kinds of places
you can give birth, where you can attend antenatal classes and so
on.
- Choose an LMC. Your LMC does not have to be the person you went
to for your first visit. Even if you went to a midwife for your
initial consultation, you can still choose a different LMC for the
duration of your pregnancy.
- Develop your care plan with your LMC. The care plan covers such
issues as your preferences for birth location and attendees, your
attitudes to medical interventions, the backups to LMC and so
on
- Plan your move to free Wellchild care. Four to six weeks after
birth, your LMC care ends. You are then entitled to move to free
Wellchild care which can be provided by Plunket, your GP's team or
others.
Choosing an LMC
The Ministry of Health booklet on page 22 suggests a list of
questions to help you choose your LMC. Some of the other websites
mentioned above offer similar lists.
These are a help, but if this is your first pregnancy, and if
you haven't shared the experience of a pregnancy via a close
girlfriend you may actually find it hard to know what the right
answers for you are! For example, how many years of experience will
you expect your midwife to have? How many is a 'good' number?
In the absence of prior experience and the time to undertake lots
of research, we would suggest four ways to find a successful
match:
- get word of mouth referrals if you can. It's a method that
works for other professions like doctors and accountants, so why
not here?
- see how aligned you and your potential LMC are on any issues
that really do matter to you e.g. attitudes to pain relief, to home
births, to breastfeeding and to medical intervention
- talk to more than one potential LMC. Comparison is a great way
to get perspective and a sense of who you feel most comfortable
with
- consider how likely you may be to have medical complications
during your pregnancy and delivery. Do you have pre-existing
conditions? Do you have a history of complications?
How easy is it to find an LMC?
In the National Council of Women of New Zealand's second Maternity
Services Survey (2001), based on a sample of over a thousand
women, almost 85% reported no trouble securing their first choice
of LMC. However, 50% of the remainder had to approach three
potential LMCs. And that was over five years ago…
Consumer Magazine's 2005 report painted a grimmer picture,
pointing to the decline in delivering GPs from 600 in 1997 to a
mere 20 in 2005. In addition, I found that the number of midwives
applying for an Annual Practising Certificate (APC) has halved this
century from nearly 5000 in 2000/01, partly in response to the
rising cost of the APC and to increased professional competency
requirements.
During this same period, NZ's birth rate - as a proxy for demand
- has been fairly steady around 58,000. If the supply/demand
balance is tightening, then choice must be falling too.
About 60% of the current midwives work in hospitals and are not
available as LMCs. This leaves about 1000 midwives to care for the
80% or so of those 58,000 mums who choose midwives; that means a
caseload of 45-50 cases per midwife. Compared to the recommended
maximum load of 50-70, this looks fine at first glance. However,
even small regional imbalances can lead to a woman's LMC search
being frustrated.
The Cost of Maternity Care
If you're a New Zealand resident or citizen your maternity care
is free. Things you have to pay for, if you choose them, are:
- Private birthing hospital fees. Depending on the facility and
standard of room, charges can be around $300 per night for a room
and meals
- Obstetricians are permitted to charge on top of the LMC fee
they receive from the government. I paid $1200 ten years ago. The
going rate in Auckland for care from conception through to post
natal period is apparently now around $4000.
- Ultrasound scans that are not necessary from a medical
perspective. These cost about $120 each.
What Can I Expect At Birth?
No-one knows how things will go on the day but statistics from
the Report
on Maternity make interesting reading.
In terms of deliveries:
- Almost a fifth of deliveries were induced
- Almost a quarter of deliveries had epidurals. These were more
common in women aged 30-34 and in Asians
- About two thirds of deliveries were 'normal' which included
0.6% breech
- Of the 'non-normal' deliveries:
- 23% deliveries were by Caesarean (up from 11.7% 15 years
earlier) and of these, nearly two in five were elective
- 9% needed interventions like forceps or ventouse
- Almost all (>98%) deliveries were made in hospital, or mum
and babe were taken there shortly after delivery
And your baby?
The average New Zealand baby weighs 3.41kg.
- 51.4% of live births were male
- Under 1.5% were twins or other multiple birth - but, of course,
some families are prone to them!
- 7% were born 'preterm' ie before 37 weeks
After birth, you may feel the effects of the maternity funding
regime! Hospitals are funded for two days hospital stay for a
'normal' birth and up to five days for a caesarean. However, there
is no legal requirement for you to leave before you feel ready,
particularly if you are having issues, such as problems
establishing breastfeeding or the onset of post natal
depression.
Women's Experiences and Advice
Encouragingly, the National Council of Women's Maternity
Services Survey 2001reported that over 90% of women were
'satisfied' or 'very satisfied' with their care before the baby was
born, with the treatment their baby received after delivery, and
with post-natal care. The level of satisfaction was stated to be
mainly due to the good care provided by the LMC.
The women were invited to offer advice to other women having a
baby. The three most common themes were:
- To become well-informed about maternity services and be
assertive. This included exploring the LMC options available in
your area. They also recommended finding out about antenatal
classes, where delivery would take place and what postnatal care
would be available.
- The great importance of choosing the best LMC, one you can
trust to support you during your pregnancy and after the birth.
Respondents recommended that women should look around early for the
right individual within their preferred type of LMC. The LMC should
be professional, caring, and open to your suggestions. The choice
should also be based on recommendations from others.
- To use an independent midwife. This was the recommendation of a
fifth of respondents.
Whether a new survey would reveal greater frustrations with
finding an independent midwife is open to question!
Your Experience and Advice
This article has only scraped the surface of what is a very
large topic. Do you have anything to contribute - perhaps your own
path to choosing your LMC, or the advice you always share with
girlfriends who become pregnant? We'd love to hear from you. Get in
touch with us at: feedback@professionelle.co.nz
or post your comments on our newly-installed messageboard.
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