Midwifery

As in 2023, our midwifery workforce continues to experience high levels of demand.

Health NZ has added over 100FTE midwives to its workforce over the year to March 2024, which has contributed to a significantly lower vacancy rate than in 2023. While this does reflect a better outlook for our midwifery workforce compared to 2023, it likely overstates improvements in our midwifery workforce, particularly in the community (where vacancies are not easily measured).

Around half of New Zealand’s midwifery workforce is employed directly by Health NZ, providing care in hospitals, primary birthing facilities and communities. Most other midwives are self-employed working as Lead Maternity Carers (LMCs) in our communities.

Our LMC model is relatively unique across the globe and our scope of practice for midwives is broader than most other countries, allowing for autonomous practice and prescribing. The education our midwives reflects this broader scope – and so is longer than international comparators at 4 years for undergraduate programmes. It is relatively difficult for midwives from most other countries to be able to practice in New Zealand without retraining or significant supervision requirements (only 23% of midwives had an overseas qualification as their first qualification in 2022).

The long-term outlook for midwifery in New Zealand is relatively positive – and we do not expect significant new shortages by 2033. There are two main reasons for this:

• Our population is aging – which means that we are expecting to have relatively fewer pregnancies and births. However, the average complexity of births over the next decade is anticipated to rise.
• Our midwifery pipelines produce a good number of graduates: 187 in 2023. But attrition rates are too high at 38.4%; if we could correct these, our number of midwifery students would be relatively well matched to our future need. We believe that growth in midwifery assistant roles – offered to midwifery students – is starting to help with financial drivers of student attrition.

However, given our current gaps, we will need to train above replacement rates to achieve the growth we need – as well as using other levers to grow our midwifery workforce.

In the interim, we have employed nurses (many with specialist maternity skillsets, or who are overseas-trained midwives not yet able to practice here) to help manage maternity workload in our hospitals and to help our midwives work at the top of their scopes. We have also supported an emergent role for midwifery assistants – midwifery students who take on a supporting role for midwives alongside their studies.

Our midwives have a unique model globally, with an expansive scope of practice and the prerogative to practice autonomously. This is a tremendous opportunity for us if we can get our midwifery numbers right; it means getting our midwifery workforce sustainable will ensure our whānau, mums and babies can always access safe maternity care.

Given relatively good long-term sustainability, our overwhelming focus for midwifery is on closing the gap we have today.

Because our midwifery workforce is unique globally, growing it rapidly is challenging. Many of the approaches available to us to more rapidly grow workforces are tough in midwifery:

• We cannot readily create a large ‘bulge’ in domestic training volumes – because we need training numbers to be sustainable long-term for them to make sense for tertiary education providers.
• It is harder to bring in midwives from overseas than in other professions, because our midwives have a different scope of practice to other jurisdictions. While transfer and re-skilling is possible, it’s more complex and slower than for other workforces, and requires care to ensure internationally qualified midwives (IQMs) can practice autonomously.
• There are things we can do to improve retention, including offering greater flexibility to our midwives (who quite often have other whānau obligations). But these measures will only have a material impact over the medium-term, and involve some exchange as our midwives may reduce their hours.

Given this, we will need to take a multi-pronged approach, pulling all the levers available to us. Even then, we estimate that we will have midwifery shortages for at least the next five years. In the interim, we can focus on the things we can control, including:

• Targeting retention in training. Improving the number of midwifery students who complete training, including through hardship support where required, will make a difference to annual growth rates – particularly given high rates of Māori and Pacific attrition.
• Boosting graduate pathways. Particularly for nurses already working in maternity roles, we need to offer more graduate training pathways.
• Minimising midwives leaving our workforce. By supporting improved flexibility for our midwives – and by reviewing funding arrangements over time – we can improve retention of the midwives we have today.
• Growing support workforces. There are significant opportunities in establishing more midwifery assistant roles, to apply the skills of midwifery students while they’re training. This can also help improve completion by mitigating financial pressures in training; and our midwifery leaders tell us it contributes to training better new midwives.
• Streamline pathways for internationally-qualified midwives. Where we do have IQMs coming to New Zealand, we can work with the Midwifery Council to make their pathway to practice simpler and faster in some cases – without compromising safety.

Over the long-term, we think we will be in a relatively better position given our strengthened training pathways – but will need to continue to refine our maternity models of care to target whānau need, and ensure midwives are fairly supported and compensated for supporting whānau with (on average) more complex needs.