Midwifery and maternity services in transition: An Examination of change following The Nurses Amendment Act 1990

Abstract

The Nurses Amendment Act 1990 enabled midwives in New Zealand/Aotearoa to care for women throughout normal childbirth on their own responsibility, without the supervision of a medical practitioner, as had previously been the case. The Act brought about significant changes to midwives' scope of practice, pay and status which had important implications for women's care, midwifery, the relationship between midwifery and medicine and the structure of maternity services. Three years after the passage of the Act, in July 1993, major restructuring of the health system along market principles began. From this time, consultation began for new maternity services arrangements, which fitted within the philosophy and structure of the new health system and which aimed to rectify some of the perceived problems resulting from the initial implementation of the 1990 Act. The consultation process was to take three years. This thesis describes and critically analyses changes to midwifery and maternity services, particularly in the greater Auckland region, in the six years from the passage of the Nurses Amendment Act in August 1990 until the official introduction of the new maternity structure in July 1996. This was a period in which midwifery was establishing itself in a medically-dominated domain while, simultaneously, a significant ideological shift was occurring in the philosophy and structure of the health system. Using an ethnographic approach, which included extensive key informant interviews and participant observation at a range of meetings over a period of three years I investigated in depth both the process of change and the relations of power between interest groups (consumer representatives, midwifery, medicine, hospital managers and regional health authorities) within local and national maternity services arenas. These findings were analysed using Foucault's later work on power and his concept of governmentality. A range of factors, including some of the trends occurring within the public sector, weakened the medical profession's control of normal childbirth and facilitated midwifery's entry as a competing provider of maternity care. Strategies used by midwifery representatives to maintain and develop the occupation's autonomous status were often effective, albeit constantly challenged. Despite ongoing conflict and some polarisation between medicine and midwifery, in general, relations of power between the various interest groups in both local and national settings were found to be complex and contestable with unstable alliances forming around particular issues. However, the fluidity of these power relations and the gains made by midwifery operated within constraints imposed by the influence of neo-liberal policies on the development of the new maternity structure. This gave the government's agents, the regional health authorities, the controlling influence on maternity services policy. Although the professed aim of the new structure was a more women-centred service, there were limits to consumer influence on maternity services policy and fiscal imperatives took precedence over some consumer interests. KEYWORDS: Midwifery; Maternity Services; Nurses Amendment Act 1990; Health Reforms; Power; Foucault; Professions; New Zealand; Aotearoa.