Law Library Stacks

Back to Index of Alternative Maternity Care Providers

New Zealand has a midwifery-led maternity services system, with four out of five births attended by midwives as the lead maternity carer (LMC). Primary maternity services are provided by self-employed, community-based midwives, as well as by hospital-employed midwives. Midwives are regulated under the Health Practitioners Competence and Assurance Act 2003, with the Midwifery Council establishing rules and processes related to education requirements, registration, recertification, and conduct.

Primary maternity services provided by midwives are funded by the government, with women paying no additional fees. Secondary and tertiary services provided by practitioners at public hospitals are also free. Women can choose to give birth at home, in a birthing unit, or in a hospital. Midwives also provide government-funded care to women and newborn babies for up to six weeks postpartum, including at least five home visits.

Issues related to payment levels and working conditions for midwives have been raised with the government during the past year and ongoing work is being conducted in relation to funding models and workforce shortages.

Doulas, who expressly provide nonmedical maternity support, are not regulated under the current system and do not receive any government funding. They may be subject to the code of consumer rights that applies to all providers of health services.

I. Maternity Services Model

New Zealand’s maternity services model is referred to as a midwife-led system. Midwives are a regulated part of New Zealand’s public health care system, with specific education and registration requirements applying and all midwifery services funded by the government.

Under this system, most pregnant women in New Zealand choose to use the services of a midwife, who are the lead maternity professionals (lead maternity carers, LMCs) in four out of five births in the country.[1] Women can instead choose a specialist doctor (i.e., an obstetrician or a specially-trained general practitioner (GP)) as their LMC. Obstetricians are able to charge fees on top of the standard government subsidy for maternity services; midwifery and GP care is always provided free of charge to eligible women, which includes all women who are eligible for public health services as well spouses and partners of New Zealand citizens, permanent visa holders, or other visa holders.[2] Regardless of who the LMC is, specialist care will be provided if needed at any stage. Such care is usually provided free of charge through local hospitals.[3]

LMC midwives “work with midwife partners (mostly in small group practices) and alongside midwives who are employed to work in maternity units.”[4] That is, LMC midwives are generally self-employed (i.e., community-based), rather than hospital-employed. District Health Boards (DHBs) also employ midwives (“core midwives”) to “provide 24-hour, rostered shift cover in a maternity facility,” or to provide continuity of care.[5] Self-employed LMCs access DHB maternity facilities under the Maternity Facility Access Agreement, which applies nationwide.[6] LMCs are

responsible for organising women’s maternity care. They may provide all of the care or share the care with one, or more, other practitioners. They also provide information to assist with decision-making during pregnancy, preparation of the birth and for parenting. Information will include a wide range of matters such as nutrition, exercise, the risks of smoking and drinking alcohol when pregnant, labour and the birth process, pain relief, breastfeeding, baby care, immunisation, community services, contraception and many other matters.[7]

Women can choose to give birth “at home, in a birthing centre or small maternity unit, or in a hospital.”[8] Most women give birth in a hospital, although the Ministry of Health expressly states that “[h]ome birth is a safe choice for many women.”[9] The Ministry states that

[i]f you chose a midwife as your main carer, she will usually be with you during labour and birth. She will have another midwife available to support you and her during and after the birth. They’ll work alongside other midwives or doctors if you need additional care. If a specialist doctor is your main carer, they will usually be involved at the time of the birth and you will have a midwife or midwives to care for you during your labour (ask your doctor about this).

Your midwife (or one working on behalf of your specialist doctor) will stay with you for at least 2 hours after the birth.

If you have pregnancy complications or need specialist support, you will be encouraged to give birth in hospital. In some cases, you may need to be under the care of a medical specialist.

Once your baby is born you can stay in hospital for a couple of days and receive care from the hospital-based midwives to assist you to breastfeed your baby and to recover from the birth. Your midwife (or specialist doctor) will visit you every day that you stay in hospital. Your midwife (or one working on behalf of your specialist doctor) will visit within 24 hours of your going home.[10]

As discussed below, LMCs receive funding to provide care for mothers for four to six weeks after the birth, including at least five home visits.[11]

Back to Top

II. Regulation of Midwives

Midwives are primarily regulated under the Health Practitioners Competence Assurance Act 2003 (HPCA Act),[12] which applies to all health practitioners.[13] The Act established separate regulatory authorities, including the Midwifery Council,[14] to regulate each health profession.

Practicing as a midwife requires registration with the Midwifery Council.[15] In order to be registered, “applicants must hold the prescribed midwifery qualification and meet other stringent requirements.”[16] Following registration, midwives must apply for an annual practicing certificate[17] at the start of each year and must “meet requirements to maintain and enhance competence and practise in accordance with the Code of Conduct.”[18]

In addition to the Code of Conduct, the Midwifery Council has established various policies and processes to regulate midwives, including an auditing process to assess midwives’ engagement in its Recertification Programme. Furthermore, in terms of professional standards and conduct, the Code of Conduct should be read in conjunction with a list of competencies and the New Zealand College of Midwives’ Philosophy and Code of Ethics.[19] Midwives are also subject to the complaint and disciplinary processes under the HPCA Act.[20]

The legal definition of midwifery is provided by the Midwifery Council’s Midwifery Scope of Practice.[21]

Back to Top

III. Funding of Midwives

A. Government Funding

Maternity services, like other parts of New Zealand’s health and disability system, are funded from general taxation through the annual appropriation process.[22] In Budget 2018, the total appropriation under Vote Health for National Maternity Services was around NZ$181 million (approx. US$119.6 million) (about 1% of the Vote).[23] In the previous fiscal year, around NZ$161.3 million of the total maternity services appropriation of around NZ$166.7 million was spent on funding midwives.[24] A government statement regarding the funding increase in Budget 2018 explained that

“[b]udget 2018 includes $103.6 million of new operating funding over the next four years to support community midwifery services, plus $9.0 million in 2017/18. About half of that funding will go towards an 8.9 per cent ‘catch-up’ increase in fees for over 1,400 lead maternity carers.

“There is no question that over the last decade the fees paid to community-based midwives have not kept pace with the pay increases of their colleagues employed by District Health Boards (DHBs). That is simply not fair, and the 8.9 per cent increase will address that gap,” says [Minister of Health] David Clark.

The increase has been calculated using a range of factors, including CPI and DHB collective agreement increases, and means that average annual increases over the last decade for community midwives are now in line with average increases for DHB midwives.

. . .

The funding will also provide $10.0 million over two years to recognise the self-employed nature of community midwifery and the costs associated with that model.

. . .

The remaining $27.6 million over four years recognises population and demand pressures.[25]

LMC midwives claim payments[26] from the government for maternity services under the Primary Maternity Services Notice 2007,[27] which was made pursuant to section 88 of the New Zealand Public Health and Disability Act 2000.[28] The Notice sets out the terms and conditions for payment of LMCs, as well as the fees for the various services provided during pregnancy, birth, and the postpartum period.[29] The fee schedule of the Notice was most recently amended in 2018.[30]

From July 1, 2018, community midwives can also claim for services provided to support LMC midwives in their provision of primary labor and birth services. The Second Midwife Support Supplement “is an interim measure while the Ministry of Health continues to review future primary maternity services.”[31]

In addition, under Budget 2018, the Ministry of Health is making a one-time payment, the Business Contribution payment, to eligible LMC midwives.[32] This payment is intended to contribute to the costs of being self-employed.[33]

Hospital-employed midwives who provide primary maternity care are paid through funding provided to DHBs. In addition,

[m]aternity facilities are funded by the Government for all women who use them. There is an additional budget for the secondary and tertiary level services they are required to provide for women who need them. The services that they are required to provide are described in the Secondary and Tertiary Maternity Services Specification.[34]

According to the government’s career website, midwives employed by DHBs earn between NZ$49,000 (approx. US$32,400) and NZ$115,000 (approx. US$76,000) per year, depending on their experience and roles.[35] Self-employed midwives, paid directly by the Ministry of Health, earn around NZ$53,000 (approx. US$35,000) per year after expenses, depending on the number of women they assist.

B. Current Issues and Discussions

In early 2018, media articles began reporting on a “midwifery crisis” in New Zealand, related to issues associated with pay and conditions and a consequent shortage of community-based midwives in various parts of the country.[36] The New Zealand College of Midwives released a statement titled “Midwifery in Crisis” in which it appealed to the government to deal with an unfolding crisis in the midwifery workforce.[37] According to the statement, the College began court action against the government in relation to pay equity for midwives three years prior, and this led to a settlement agreement between the College and the Ministry of Health that involved designing a new funding model for community-based midwives.[38]

The Ministry’s website contains information related to the process of developing a new funding model. An update provided in January 2019 stated that,

[w]hile the Co-design process proceeded as agreed, the Ministry did not prepare a Budget bid that reflected the findings of the Co-design process. Accordingly, the Ministry acknowledges that it breached the May 2017 agreement that it had reached with the College.

Representatives of the Ministry and the College met in mediation on 14 December 2018. As a result of that mediation, the Ministry and the College have reached further agreement. Some, but not all, of the matters agreed are recorded in this statement.

. . .

The Ministry has reaffirmed its commitment to the Co-design principles, including a Blended Payment Model for LMC midwives.[[39]] The Ministry has also reiterated its support for the continuity of midwifery model of care as central to maternity services in New Zealand.

The Ministry has agreed to a process to ensure a ‘fair and reasonable’ service price for LMC midwives. The College and the Ministry will work on this together throughout 2019.

The Ministry and the College have agreed to work together in early 2019 on structural changes to the way LMC midwives are funded and contracted.[40]

In October 2018, the Ministry and the College agreed to the following principles applying in the development of any new maternity system:

  • Primary maternity care will continue to be free to all eligible women.
  • The midwifery led model of continuity of care will be maintained.
  • The right for community midwives to choose self-employment will remain under any new contract arrangements.
  • A National Community Midwifery Organisation will be developed.
  • A national primary midwifery contract will be developed as an alternative to Section 88.
  • The new contract will protect, strengthen and integrate the existing model of care, and will include a regular review clause, thus affording community midwives the right to regular renegotiation of the terms and conditions of the contract.
  • The on call and ‘self-employed’ nature of community midwifery will be accounted for in the new funding framework to enable flexible service delivery based on individual need.[41]

In addition to the funding issues concerning community-based midwives, DHB-employed midwives conducted strike actions in November 2018 and again February 2019, following failed negotiations over pay.[42] In April 2019, the midwives’ union, DHBs, and the Ministry of Health agreed a joint accord “to help ensure safe and sustainable staffing levels” in public hospitals.[43] This followed DHB midwives voting to accept a new Multi-Employer Collective Agreement. Under the terms of the accord the parties will

  • Explore options to support and encourage new midwifery graduates to choose DHB employment,
  • Develop a strategy for retention of the existing midwifery workforce, and workforce development,
  • Develop a strategy to better support midwives in training, with a particular focus on Māori and Pacific midwives,
  • Agree to progress the implementation of the safe staffing tool ‘Care Capacity Demand Management’ (CCDM) in maternity services.[44] 

Back to Top

IV. Postpartum and Newborn Care

As noted above, LMCs provide care to the mother for four to six weeks postpartum. This includes at least five home visits during this period.[45] During such visits, the midwife will also check on the baby’s development “and arrange for extra support if this is needed.”[46] After this period, women will be returned to the care of their family doctor, the baby’s care will be transferred to a Well Child/Tamariki Ora nurse, and the child will also need to be enrolled with a general practice.[47]

An organization called Plunket is the leading provider contracted by the Ministry of Health to deliver certain services under the Well Child/Tamariki Ora program;[48] more than 90% of newborn babies are seen by Plunket nurses each year.[49] Plunket nurses provide free home and clinic visits, provide mobile clinics, and operate PlunketLine, “a free telephone advice service for parents.”[50] In addition to Plunket, there are a number of Māori health providers contracted to deliver the program,[51] as well as other practitioners who provide certain services, such as hearing screeners, pediatricians, and nurses.[52] Various services are provided free of charge under the Well Child/Tamariki Ora program between the child’s birth up to five years of age.[53]

Back to Top

V. Doulas

The use of pregnancy, childbirth, and postpartum doulas appears to be increasing in popularity in New Zealand. Doulas expressly provide nonmedical services and are not regulated under the HPCA Act. There is no government funding for doula-provided services.

One article on the role and use of doulas in New Zealand states that the role is “a fairly new phenomenon in New Zealand” and that “[a]s yet there are no mandatory qualifications required to practise as a doula.”[54] It further clarifies that childbirth doulas support women throughout childbirth—“not with clinical or medical tasks, but with things such as massage, positioning, breathing exercises and aromatherapy.”[55] It also outlines the role of postpartum doulas and states that “[d]oulas will work alongside (but not replace) the work of your midwife or doctor.”[56]

Any nonregulated provider of health services in New Zealand (i.e., professions to which the HPCA Act does not apply) must still comply with a Code of Consumers’ Rights set out in regulations made under the Health and Disability Commissioner Act 1994.[57] This Code, and the related complaint procedures,[58] would apply to doulas if they “provide, or hold [themselves] out as providing, health services to the public or any section of the public, whether or not any charge is made for those services.”[59] “Health services” under the Act includes services to promote or protect health.[60]  

In November 2009, the New Zealand College of Midwives (NZCOM) adopted a “consensus statement” on the role of nonregulated support people in maternity services.[61] The document states that

NZCOM encourage every pregnant woman to have the birth support people of her choice.

Physical, emotional and psychological support during labour is an important part of intrapartum care and can be provided by a partner and/or close family/ whanau members depending on the woman’s relationships. Midwives provide continuous support during labour and facilitate the involvement of the partner/supporters as appropriate and as discussed in the care plan (NZCOM Handbook for Practice 2008).

NZCOM believes that doulas, health care assistants and maternity assistants are not a substitute for midwives or an appropriate alternative for midwifery workforce shortages.

. . .

. . . It is not appropriate for health authorities to replace a proven, regulated, fully funded midwifery workforce that enjoys the confidence and support of consumers with an inferior service provided by a less educated, non funded maternity workforce. 

The statement further notes that the role of doulas in other countries has developed in the context of obstetric services often excluding support people from attending the woman during childbirth, whereas, in New Zealand, the “midwifery model of partnership” “assumes and encourages discussions prior to labour with partners and support people with the woman around the role the support person will have.”[62]

Back to Top

Kelly Buchanan
Foreign Law Specialist
May 2019

[1] Ellie Wernham et al., A Comparison of Midwife-Led and Medical-Led Models of Care and Their Relationship to Adverse Fetal and Neonatal Outcomes: A Retrospective Cohort Study in New Zealand, 13(9) PLoS Med. (Sept. 2016), available at, archived at

[3] Choosing a Midwife or Specialist Doctor, Ministry of Health, pregnancy-and-kids/services-and-support-during-pregnancy/choosing-midwife-or-specialist-doctor (last updated July 24, 2015), archived at

[4] About Lead Maternity Carer (LMC) Services, New Zealand College of Midwives (NZCOM), https://www. (last visited May 1, 2019), archived at

[5] New Zealand Midwifery, NZCOM, (last visited May 1, 2019), archived at

[6] Primary Maternity Services, Ministry of Health, maternity-services/primary-maternity-services (last updated June 29, 2018), archived at

[7] Pregnancy Services, supra note 2.

[9] Id.

[10] Id.

[13] Understanding the Legislation, Midwifery Council, (last visited May 1, 2019), archived at

[14] Health Practitioners Competence Act 2003 s 114(3).

[15] Becoming Registered to Practise, Midwifery Council, becoming-registered-practise (last visited May 1, 2019), archived at

[16] Why Are Midwives Regulated?, Midwifery Council, (last visited May 1, 2019), archived at See also How to Become a Midwife, NZCOM, (last visited May 6, 2019), archived at

[17] Practising Certificates, Midwifery Council, (last visited May 1, 2019), archived at See also What Are the Ongoing Practice Requirements?, Midwifery Council, (last visited May 1, 2019), archived at

[18] Why Are Midwives Regulated?, supra note 16. See also Midwifery Council of New Zealand, Code of Conduct (Dec. 2010), code of conduct feb 2011.pdf, archived at

[19] What Is the Conduct Expected of Midwives?, Midwifery Council, professional-standards/what-conduct-expected-midwives (last visited May 1, 2019), archived at; Midwifery Council, Competencies for Entry to the Register of Midwives, for Entry to the register of Midwives 2007 new form.pdf (last visited May 1, 2019), archived at; Philosophy and Code of Ethics, NZCOM, (last visited May 1, 2019), archived at

[20] See What to Expect if a Complaint Is Made About You, Midwifery Council, https://www.midwiferycouncil. (last visited May 1, 2019), archived at

[21] Keeping Women and Babies Safe, Midwifery Council, (last visited May 1, 2019), archived at

[22] Funding, Ministry of Health, (last updated July 11, 2016), archived at

[23] Vote Health – Health Sector – Estimates 2019/2019, The Treasury, estimates/vote-health-health-sector-estimates-2018-2019-html#section-44 (last updated May 17, 2018), archived at; New Zealand Government, Vote Health: The Estimates of Appropriations 2018/19 – Health Sector 2 (B.5 Vol. 6, 2018), estimates/v6/est18-v6-health.pdf, archived at

[24] Id.

[25] Press Release, David Clark & Julie Anne Genter, Government Acts to Support Midwives (May 17, 2018),, archived at

[26] Primary Maternity Services, supra note 6.

[27] Primary Maternity Services Notice 2007, New Zealand Gazette, No. 41 (Apr. 13, 2007), https://www., archived at

[28] New Zealand Public Health and Disability Act 2000 s 88, 72.0/whole.html, archived at

[29] Primary Maternity Services Notice 2007, Ministry of Health, primary-maternity-services-notice-2007 (last updated Aug. 23, 2018), archived at

[30] Primary Maternity Services Amendment Notice 2018, New Zealand Gazette (June 28, 2018), https://, archived at

[31] Second Midwife Support, Ministry of Health, (last visited Sept. 13, 2018), archived at

[32] Lead Maternity Care Midwives: Business Contribution Payment,Ministry of Health, (last updated Feb. 20, 2019), archived at

[34] New Zealand Midwifery, supra note 5. See also Maternity Service Specifications, Nationwide Service Framework Library, Ministry of Health, cations/maternity-service-specifications (last updated May 11, 2015), archived at

[36] Kimberley Davis, What Is Going On with New Zealand’s Midwives, The Spinoff (Mar. 14, 2018), https://the, archived at; Emily Writes, ‘We Have Two Lives in Our Hands and We’re Paid Less Than Minimum Wage,’ The Spinoff (Mar. 19, 2018),, archived at; Kimberley Davis, Who Pays the Midwife? And Why Isn’t It Enough?, The Spinoff (Apr. 9, 2018), https://the­­­­/, archived at; Te Ahua Maitland, ‘The Midwife Crisis is Real’: Pleas for Help to Stop Burn-outs, Shortages and Pay Problems,Stuff (Mar. 3, 2018), midwife-shortage-highlighted-by-facebook-campaign, archived at

[37] Press Release, NZCOM, Midwifery in Crisis (Feb. 16, 2018), S00174/midwifery-in-crisis.htm, archived at

[38] Id.

[39] See NZCOM, Co-design Recommendations: What is the Blended Payment Model, https://www.midwife. (last visited May 1, 2019), archived at

[40] Updates on Work with the Maternity Services Sector, Ministry of Health, (last updated Jan. 14, 2019), archived at

[41] Id.

[42] Kiri Gillespie, Striking Midwives Say Profession at ‘Crisis Point’, NZ Herald (Nov. 21, 2018),, archived at; Hannah Martin & Hamish McNeilly, More Than Two Thousand Midwives Kick Off Two Weeks of Strike Action, Stuff (Nov. 22, 2018), more-than-a-thousand-midwives-kick-off-two-weeks-of-strike-action, archived at; Press Release, Midwifery Employee Representation & Advisory Service, DHB-Employed Midwives to Strike Again, (last visited May 1, 2019), archived at

[43] Press Release, David Clark, Midwifery Workforce Accord Welcomed (Apr. 14, 2019), https://www.beehive., archived at

[44] Id.

[45] Maternity Care after the Birth, supra note 11.

[46] Health Checks – The First Six Weeks, Ministry of Health, pregnancy-and-kids/first-year/first-6-weeks/health-checks-first-6-weeks (last updated May 17, 2018), archived at

[47] Id.

[48] The Well Child Tamariki Ora Programme,Connectus, (last visited May 1, 2019), archived at

[49] What We Offer, Plunket, (last visited May 1, 2019), archived at

[50] Id.

[51] Well Child Tamariki Ora Programme, KidsHealth, (last updated Aug. 13, 2018), archived at

[52] What Is the Well Child Programme?, Connectus, (last visited May 2, 2019), archived at

[53] See Plunket Visits, Plunket, (last visited May 2, 2019), archived at; Well Child/Tamariki Ora Programme Practitioner Handbook 2013 (Revised 2014), Ministry of Health, (last updated Mar. 31, 2017), archived at

[54] Kimberley Paterson, Doula, Kiwi Families, (last visited May 2, 2019), archived at

[55] Id.

[56] Id. See also Samantha Thurlby-Brooks, What Is a Birth Doula?, OHbaby! (Issue 12, Summer 2011),

[57] Health and Disability Commissioner (Code of Health and Disability Services Consumers’ Rights) Regulations 1996,, archived at; Non-Regulated Health Professions, Ministry of Health, (last updated Apr. 22, 2014), archived at

[58] Health and Disability Commissioner Act 1994 pt 4, 0088/latest/whole.html, archived at

[59] Id. s 3(k).

[60] Id. s 2 (definition of “health services”).

[61] NZCOM, Consensus Statement: The Role of Non-Regulated Support People in Maternity Services (Nov. 5, 2009),, archived at

[62] Id.

Back to Top

Last Updated: 12/30/2020