How does homebirth work in Aotearoa/New Zealand? || Chatting with community midwife 'Renee'

This episode is a part of the homebirth around the World Series. 

In this episode, I chat with Renee, a community midwife or a ‘LMC’ on the North Island of Aotearoa  ‘New Zealand’. 

I was really excited to chat with Renee as New Zealand is often looked up to in terms of its midwifery care and homebirth access. Renee shares her journey to becoming a midwife and how the system works in Aotearoa. We cover homebirth rates and access, the challenges, risks and a bit about funding. 

• Homebirth Aotearoa 
• New Zealand College of Midwives - you can find a definition of an LMC here too 
  • https://www.tewhatuora.govt.nz/for-health-professionals/health-workforce-development/midwifery
• Referral Guidelines 

Transcript

0:03

Welcome to Birthing at Home, a podcast. I'm Elsie, host. I'm a birth mom of two little boys, a doula in Melbourne supporting birth at home. I'm a mental health nurse and the co-creator of Home Birth Victoria. If you want to learn more about me, the podcast, or my work, check out www.birthingathome.com.au. Before we begin, I would like to acknowledge the Wurundjeri people who are the traditional custodians of the land I'm recording on in Ngaam, Melbourne, Australia. I would also like to acknowledge the Aboriginal and Torres Strait Islander peoples have been birthing at home on country for tens of thousands of years prior to the British invasion and acknowledge that sovereignty has never been ceded. This episode is a part of the Home Birth Around the World series. In this episode, I chat with Renee, a community midwife or an LMC on the North Island of Aotearoa, New Zealand. I was really excited to chat with Renee as New Zealand is often looked up to in terms of its midwifery care and home birth access. Renee shares her journey to becoming a midwife and how the system works in Outer Roa. We cover home birth rates and access, the challenges, risks, and a bit about funding. If you know a home birth midwife in a country other than Australia who might be interested in sharing how home birth works in their country, please let me know on Instagram or send them my details. You can find those details in the episode description below. Enjoy. Welcome Renee to Birthing at Home, a podcast. Thank you so much for joining me today on Sunday. It's always a bit tricky to line up podcast times when I'm here in Australia and time differences and whatnot. So I really appreciate it. Thank you. um Yeah, so I guess you have agreed to come on and tell us a little bit about Home Birth Midwifery and Home Birth uh in New Zealand, which I'm very excited to hear about because, yeah, like we were just saying before we started recording, at least here in Australia, we look up to New Zealand and we kind of, you know, aim to have what we think New Zealand has. So I'm keen to hear what New Zealand actually has. Yeah, so I have been a midwife for this my seventh year of midwifery um and I had been doing home birth since the beginning. um So I came to midwifery after I had my kids so I've had four um and for me it was more around that continuity relationship that we have here so for those that aren't aware of how our maternity system structured here in New Zealand. But in general, what happens is you have a government-funded maternity sector. All midwives um that practice this way are paid for by the government. There is no private midwifery in New Zealand. So you find out you're pregnant, you ring a midwife, and then we look after you right through your pregnancy, through your labor and birth, and then for five to six weeks postnatal. um So that's literally how all of us work. m There are some private obstetricians and there are some centers that would have community midwifery based from their hospitals, but they usually are for people who, because we do have a shortage of community midwives like us, which are called LMCs, which is lead maternity care. m So the community teams that the hospital runs would only would look after women if they couldn't find their own. um LMC midwife. um that's pretty much how that continuity relationship though from finding out you're pregnant and registering with the midwife and then being with that same midwife throughout the whole pregnancy, labor and birth and that postnatal period. It was that relationship that you build with the midwife and that time that struck me and that's what pulled me into wanting to do midwifery. So I have never This is all I've I've only ever been the LMC community midwife. I've never worked in the hospital except for the odd shift here or there if I've done a casual one to kind of help our local unit out. Sometimes I've done that but in general I've not actually worked as a hospital midwife, just as a community one. Yeah. And so does it differ because we were just saying that you're based in the on the North Island. Is it the same across New Zealand? Yeah, so all New Zealanders, all New Zealand has the same rules. Yeah. And yeah, so the only as a midwife, the only way we get paid is per module from the government. So every antenatal birth postnatal is known as a module and we get paid from the government directly for those modules. So it's in general a pretty flat rate for us. um Yeah, the biggest takeaway from that is that it was so that birthing people shouldn't have to pay anything for their maternity care. should be equitable for everybody, regardless of your socioeconomic standing or what you can and can't afford. Then everyone should be entitled to the same. Yeah, right. That's the whole purpose of it. Yeah. Yeah. And so do you find that most people, know, when they pee on that stick or whatever that they like, does everybody approach like a midwife or can you just opt out of that avenue altogether or like? So we would prefer people read on that stick and rung us because we book out so quickly because there's quite a shortage. um Of course, often when it's people's first babies and they're not like they haven't really been talking about it with people either and they're not sure they often just go to their doctor like their GP. um In which case they go to the GP, they might get some blood tests done and then get given a prescription for their. folic acid and iodine or whatever supplements um they're going to be given and then they're told you need to go find a midwife. um Well, the GP, the GPs are like very on board with like, we're utilizing the midwives. There's, you had no other option to be honest. like you said, can you opt out of it? can't, you, I mean, opting out of it would mean having no maternity care because that's how you would access it. Again, unless I said, unless I, like I said, if people were trying to find a midwife and they couldn't, they were like, I've rung them all. In our town, we have about 12 of us who do the community midwifery. We're quite a small town. And if you can't book with one of us, then you have to go to the hospital team. and use the hospital's service, which essentially runs very similarly. You see there's one antenatal midwife and she does all the antenatal care, but then when you're in labour, you just have to go to the hospital when you're in labour and have whoever's on shift. And then they will try and find you a midwife for the postnatal portion. yeah, there's no, your option is to have a midwife really in this country. guess in some cities they'll have private obstetric care. but that's not as popular and common as it used to be. And there's not really that many of them around. Yeah, so that kind of works slightly differently, yeah, there's so few of them. And particularly in our region, we don't have any privately practicing obstetricians anyway, so it still wouldn't be an option to anyone here. Yep. Yep. And so as a um sorry, what did you call yourself a community midwife? So we called LNCs. LMC. Yeah. So as an LMC, are there like, uh exclusion criteria to your support? Like if somebody's having twins or breach or you know, they've had a C-section before? No, in short. Wow. So we um would then do what we'd call shared care in situations where it was high complex. for example, twins, theoretically, we have quite a robust referral guideline, which is when things come up and we would be expected to offer a referral to obstetrics. um So twins, for example, would be considered transfer of care. So we would have input from the obstetrics team, but we would still be the one that, they'd still be coming to our clinic. We'd be the one sending them for scans and um bloods and all that kind of stuff. And then as the pregnancy progressed, they would have clinics with the obstetricians as well, but there would be an expectation that we would be doing the behind the scenes admin stuff for that woman. um Yeah, and then for her birth the same thing, that ah we would be the one that would go and attend the birth, but we would call obstetrics if we needed to. they could steal birth at home. Oh yeah, they could choose that, So there's no real, like there's no law here, right? That tells people they can't do it. Obviously there's strong recommendations, but we're very much autonomous practitioners here and we don't have, particularly the way we work as well as LMCs, we are our own boss. don't have, we have the Midwifery Council that is the overall governing body that texts the public from us, that's their job, ah and deals with complaints and people, you know, we pay them for our practicing certificates every year and all that. ultimately, no one can say to me, you can't, you can't support that woman in that home birth for that reason. that would not If she's wanting and she is aware of like all of whatever, then you can support her on that. In fact, I would argue that our duty of care is that if I have somebody who's at home who even I feel that maybe she shouldn't be birthing at home, but if she called me up and said, I'm in labour, this baby's coming, I refuse to go to hospital, then my duty of care would be I have to go to her even if I don't agree with it because she's asked for my help and if I don't give it, then potentially I'm going to get in more trouble for not attending her than if I attended. Wow. See, I don't know if you know much about home birth midwifery in Australia, but women are getting dropped um constantly, especially from publicly funded home birth programs because they go over 42 weeks or they're risked out at like the 38 week appointment and then they're left with no midwifery care. They say the midwives aren't allowed to come and support you. So oh We couldn't do it. We couldn't do it. I just, I, that just hurts me so much because in this day and age, I always think who's truly low risk? You know, like, like everyone's, everyone tends to have something somewhere that would probably like raise a flag somewhere. It's so silly. And of course the different, different midwives will have different levels of comfortability. And there are plenty of midwives that don't support home birth. um It's not kind of like given here just because you're a LNC midwife here means that you'll support home birth because there's plenty that aren't and just like in every other country I'm sure you have some midwives who practice quite on the medical side and then those that swing completely the opposite direction. But um there's no like defining thing you have to do to be a home birth midwife here. we have very similar to Australia, I think it's the four year midwifery degree. So it's got your bachelor's degree. It was always four years, but condensed into three years. But this is the first year that all our midwifery schools have had to make it a four year degree. Like there is no option for a three year anymore. Which might help in keeping our students going through the program and becoming a midwife at the end because the problem is A four-year degree in three years just means that your semesters are longer and you're doing all the same work but in a short time. So heaps of midwifery students were burning out or they were finishing the degree and not working as midwives because they were already burnt out. But once you've done your degree and you've set your registration exam and if you've decided that you're going to be an LMC, then you get a contract with Tu Whatu Ora, which is our Ministry of Health. um As soon as you finish your Bachelor of Midwifery, you are eligible to become an LMC. Yeah, so we all register and then once you've registered and that's and get your practicing certificate, then you can decide, am I going to work at the hospital or am I going to be an LMC? We have a midwifery first year practice program here. So in your first year, you have to enroll with it. And basically it just means you have a mentor and you get paid to do extra education just to kind of take you from the competent to the confident midwife in that first year with. um extra money basically so that you have the ability to have more people helping you if you need it. essentially once you have chosen your workforce and you've decided to be an RNC, you can be off and running. There's no requirement that you have to work in a hospital for so long before you can go out and be independent. You can just go straight into it, which is the road that I took. I just went straight into it. the LMC Midwifery because that was what brought me to Midwifery so I didn't have any desire to be working in the hospital. Yeah, yeah. And so as a sort of backtracking a little bit as a student midwife, um in terms of placements and things, are you then like totally attending home births and stuff as a student along with the LMCs or? so that's always going to really depend on the placements you get and what midwives you get put with. you do throughout each year, it looks a little bit different, but generally by the time you've come, I know from in my degree when I did it, by the time you get to your last year, your last year is 90 % placement anyway, and you have a few different placements. So you've got a couple that are just within different hospitals um and they do like you to go to a usually a hospital not in your area. m So then you go to a different hospital for those placements and then you'll have other placements that one of the longest ones they have is a 14 week placement and that is with an LMC midwife. So you are just with her every day basically following her around so that you can see her job in and out. I Ideally, you would want to be with an LMC then, particularly if home birth is where your heart lies. You would want to be with one that's going to have home birth so you can go. um I didn't actually, in my studies, I really wanted to be able to go to home births, but I actually think I only went to two or three home births in my whole degree, just because that's how my placements worked out. And some of the midwives that I was placed with didn't offer home births. It was a little bit of a baptism of fire when I came out and that's what I wanted to do. you know, and then some students will luck out and be with a midwife who does heaps of home births. so they see lots of it as as a student. you kind of can't you can to some degree, you can kind of pick your midwife that you get to go with. um But because it will often be more students available than there are midwives that can take them. Sometimes you just have to have the midwife that's got the space and has the numbers. you need to be with a midwife who's busy because you've got numbers that you're getting, is terrible that it comes down to that at the end of it. But in the last year, that's what you're looking at. You're just trying to get yourself signed off. Yeah. Yeah. You remember what so here in Australia, at least when I was, I'm not a midwife, but I was a student midwife. We had to get like 100 postnatal visits, 100 antenatal visits. then, yeah, I think it maybe was like 20 vaginal births and like 10 comps. So we definitely have similar. I can't even remember the numbers of Antenatal and Postnatal because to be honest, you absolutely will get them in your four years because it's something like a hundred, but you'll easily get that. Here it's 40 facilitated births. And you can start getting them from year one. It doesn't have to all be in your last year. But the reality is that a lot of the time people aren't counting births until they get to the last year anyway. Also, the definition of facilitated is always a bit murky because if someone literally walked in the door and a baby dropped out of them, you can count that zero facilitation going on, but you can count it. But if you've been with a woman for 12, 14 hours and then she ends up with a Ventus or a Fawcett or a Caesarean, then you can't count that as facilitated, which always blew my mind. There's so much more decision making in those births. Yeah, so 40 is kind of the magic number, which can be quite hard. actually to get this. mean, especially if you're looking at a roughly 38 % cesarean rate, I think in the country, it's like a little bit difficult to be relying on. you can still have 38%. Do you say 38 %? ah Wild, though that you have like this amazing midwifery care. That's wild. Yeah, I'm just like blown away by that. I'm also just blown away by, you know, you, you finish uni and yet you can just start attending home births because yet here, at least at the moment, you have to do like 5,000 hours in basically a hospital and you have to get endorsed, which is like a whole other thing. That's like whole other post-grad. um And then only then can you become a midwife that attends home birth. Isn't that so crazy? uh like crazy because um like here, at least at the moment, I think the majority, well, I would say all of the Bachelor of Midwifery programs are three years. But I think depending on where you are in Australia, it is a bit uncommon to only have Bachelor of Midwifery. Often it's alongside um nursing as well. So then it does become four years. And that's what I did. um So then you have your four years, but like obviously nursing, you're learning like highly medical skills. It's very different. but yeah, it would be so interesting to see what the syllabuses look like because I just don't understand how, um, I mean, even when I was talking to Lucy, the independent, midwife in England, like, yeah, when she finishes her, finished her degree, she was allowed to just go out and, you know, be a home birth midwife. But here in Australia, it's very difficult. um And yeah, for me personally, I just saw that 5,000 hours and I was like, actually, I don't want to do that. And if that's the only way in, then I'm yeah, I'm not even going to bother. Yeah, that's quite, that just blows my mind. Like that's so long. Yeah. And especially because when you think about the majority of, you know, midwifery students are women. So you go in when you're like, I don't know, 18, 19, you know, there's a lot of young women I know I was, or at the other end, you know, moms with kids that are doing it. Yeah. The amount of time it takes, like you got like seven years basically before you can actually be, um you know, and that's if you're doing it full time as well. That's crazy, it's halfway to being a doctor. oh Exactly. Yeah. my goodness. And um so what I wanted to ask as well is about professional indemnity insurance. Like who covers that? So we also have the New Zealand College of Midwives. um So New Zealand College of Midwives is our professional body and we would all, we all have membership, like we sign up to membership for that and that gives us our indemnity insurance. So that covers us for all of that kind of stuff. And yeah, you would, there wouldn't be any practicing LMCs that don't have that. membership anyway with New Zealand College of Midwives. they are there for us, they are our support, they also have legal support. So that if we did have like an unexpected outcome or anything, then the first thing we would do is contact the lawyers for them as well through them. So yeah, that kind of covers us and it's really not that expensive at all. I mean, you can pay it off on a weekly basis and it's, you know, maybe like $20 or something a week. um But you know, like that, yeah, that has you covered for all of that kind of thing as well, which is obviously super important. And you do, and I will preface it by saying that even though we do come out and we can practice and do home birth straight away, you have to have, we still, there are requirements around practice partners. um So you have to be working with other midwives because you do need two midwives at a home birth. And you do, even if you're uh Even if you're birthing women at the hospital, in my area, we don't have primary units here. um Other parts of our country do, but not in our little town. So we've got a secondary hospital or we have home births. So even if we're birthing there, you still need to have practice partners because you need to be able to offer your clients 24-7 midwifery care. And of course, it's completely unreasonable to think I'm going to be on call 24-7-365. Yeah Sometimes I think it's what they want. So you do have to work and you do have to the partner and obviously you have the requirements because we're self-employed. The requirements of all the equipment and medications and stuff that you need obviously is on us as well. But we do get a little bit of extra funding for women who home birth to try and offset that cost of the stuff that we need. Yep. um But yeah, that's completely on us to have all that stuff, oxygen and all that kind of thing. We have to have arranged that and paid for that ourselves. So, you know, there's quite a lot still quite a lot of set up with that as well. And some people aren't comfortable doing Homeverse straight off the bat either. You know, they, we've got a couple of new grads working in our practice this year and they'll come and second us for our Homeverse. But the clients that are taking on for the share, have kind of said, we wouldn't make that comfortable offering home birth this year as their primary, as a primary midwife. Yeah. Yeah. So it's just, it's, it is a little bit, it's not really a definitive, you must tickle these boxes before you can do it. uh Almost like a bit of a comes out, a lot of it comes down to your comp, your personal confidence in Yeah. Yeah. Yeah. And when, because there's also, I guess you could call it like witch hunting of home birth midwives in Australia. When something, you know, when you need to transfer to hospital or something that was unexpected happens, what is, what is your experience, I guess, like with the culture around you know, that transfer and how you received in the hospital and what they think of. So we, um all home birth midwives, we have to have an access agreement to the local hospital as well. So there's no, like, you have to transfer, so you're at the door, see you later, handing them over. uh You can work in the hospital as well. So I haven't, and again, this is probably, it probably could be quite regional, and I'm sure there are absolutely midwives in different regions of our country who may have different experiences, but particularly in our area, um we have actually quite a good culture amongst the other midwives around home birthing. um I'm sure some of our, even our obstetric doctors are quite supportive, even though I'm sure that we've given them grey hair when they've found out in which situations we've home birthed. But yeah, I've never had anybody basically give me grief. over a reason to home birth. I think a lot of that too is because I am just very, very big on informed consent and information sharing. So at the end of the day, I personally will support women to birth at home in almost any situation. I have done home births in situations where I was like, this is probably not a good idea. ah But the woman was just... she had all the information and she was like, well, this is what I'm going to do and I'll sign something if I have to, but this is a choice I'm making and I either do it with you here or I do it by myself. So for me, as long as I've had all the information and they know essentially what they're kind of getting themselves in for and they're willing to take the issue of the responsibility, then I'm happy to support them. I also like to think that um particularly in the way we work here, is that because you are their midwife from the time they found out that they're pregnant all the way to them giving birth, in that time frame, you've been able to grow that relationship with them and you have a lot of mutual trust. And so I always like to think that because I'm very confident at home and I'm confident to manage quite a lot of emergencies at home, that if we're at home and I say to them, this is really not good and we need to go. then they trust that that's coming from uh a place of all seriousness and not that I have to go because I'm overreacting or because I think, this isn't good and someone's going to tell me off because we've stayed home. That's not that for me at all. If I genuinely think this is not OK and we really need to go. uh because of that as well, feel that if I did say that, then they would go if they knew I was doing it from a place of a true emergency. um But I haven't really, I mean, I've only really had one birth that would be probably go into that box. Most transfers haven't been really that, you know, it's usually for pain relief or, you know, a placenta that doesn't want to come out, you know, and then comes out as soon as we walk in the door. Yeah, yeah, yeah, yeah. And would you say um that even amongst like ambulance or paramedics, it's the same kind of reception that they're kind of on board with being a part of that support? Yeah, so I've never had any issues with any of our AMBO staff to me anyway, or in that situation, whether they say stuff to other people outside of that, I have no idea, but definitely the reception to us isn't negative. In general, if we're bringing ambulances anyway, we just are really using them as transfer service because in that In that role, when they turn up at one of our emergencies and we're there with them, they very much are expecting us to still remain clinically in charge because we know more than them in that regard and they do expect us to go on the bus with them. So, yeah, so that's kind of what we do. We really are just using them for transfer at that point. Yeah, yeah. Yeah. Wow. um That's just like, yeah, so incredible. It'd be great to speak to even more New Zealand. Yeah, really like a set like a, you know, that it's not just you because it's that's so different to here in Australia. It's like paramedics, at least that, you know, some of the moms that I've had on the podcast sharing their birth stories have actually had partners that have been paramedics or are paramedics and like hearing about how fearful they are of like going to births if you know even if it's meant to you know if it's a precipitous labor or something it wasn't actually meant to be a home birth how fearful paramedics often are but even like some of the reporting to like the regularly regular regulation, I can't say the word today. But like that comes from, know, ED staff and paramedics. And it's very, yeah, it's quite toxic, really. um And I think that pushes midwives then as well, because I imagine if you're fearful that you're going to get reported, which is definitely on the minds of private midwives here, um then you probably are either, you know, more likely to swing one way like to both ends of the spectrum either be too safe or actually push it too far because you're like, you know, and I also know that I don't know how, cause even here in Australia, like state to state, it varies, which is very annoying, but at least here in Melbourne, in Victoria, I know most private midwives do not, if they have to transfer, they do not follow the woman in. So they do say, you know, goodbye, whatever point, because, yeah, I mean, I don't fully understand that in a lot of detail, but to do with it, you know, they don't have that relationship with the hospital, which means that they might be able to go in as like a support person. And depending on like how much m of a relationship they might have with the hospital, they might, you know, um sort of be able to take that primary midwife role without officially it being the case. um But otherwise, yeah, it's expected that no, you've come to hospital and now we're going to take over, um which just must be horrible for somebody that's, you know, had to transfer. Like that whole. Absolutely. Absolutely. And now you're in an unfamiliar environment, completely detached from your plan. And now you don't even have the midwife that you've had this whole entire time. And admittedly, in the case of Australia, they've paid for. I mean, they haven't paid for us. But yeah, no, we don't. We don't. We just go in and, you know. to keep doing our job but in the hospital. That makes a lot of sense. That's like continuity, right? Like that makes sense. um Yeah. Wow. And like, I don't even know what else to ask. I just like, I'm so impressed, I guess. So what is the rate of home birth in New Zealand? You'd think it would be more than what it is, wouldn't you? It's about 4%. It's about 4 % and that's quite low, that's I feel. C-section rate is so high. So from your perspective, what are the challenges that New Zealand faces with home birth then? So I, for a start, think the caesarean rate's really indicative of higher rates of induction as well. ah Different policies come out and research comes out all over the world, right? And then it changes things. think COVID really had an impact on how much medical intervention people were having. So there's a bit of an off-run from that, but um I don't know. I just feel like over the years, that caesarean rate hasn't really changed that much. It's still set there. um Also, there was, I know in our region, was, for a time, there a pulling away from using, um having assisted births. And so there was more caesareans because they were, the doctors were doing less assisted births, um which is another thing. um actually don't know what people's problem is with home birth. um And I don't know whether it's just a society expectation or not. While the country's home birth rate is 4%, our region is around 7%. So still higher than the country, but still quite low. My practice home birth rate is very year to year, depending on obviously how many people want home birth. But it's probably the last couple years it sits around 35%. And then you'll get some midwives, and I mean, very few, but some of wives that really just offer home births, that's all they do. I don't, because of where I live, you wouldn't have enough clients that would just home birth to actually be able to make, pay your bills, because at the end of the day, that is what you have to think of. Also, I don't mind, I like the mix of it, because there's also a lot more, obviously, responsibility on you when you're home birthing versus when you're going into the hospital. So sometimes that pressure gets quite... heavy when you've got quite a lot of home births. Or if you've got someone who wants to home birth their breech baby, for example, that kind of thing, obviously that puts a bit more pressure on you. then, you know, mentally you can be quite thankful that's the only one you've got this month. So I think that's also some of the challenges with offering home births is that you need to have all the equipment for it, which is a cost outlay. um but you also have to have practice partners who will either A, be available to you to second or be able to do it for you if you're not on. Cause that's the other thing is that for a time I would have, I'd be able to find midwives in my area that would back me up if I had a home birth and they'd come. But then I'd find it hard to have find someone who'd be happy to do my home births for me if I was going to be off in which case then you don't go off because. just in case they birthed. So of course that can get quite hard. But for the most part, potentially we as midwives, I would say we as in all of us, probably don't advertise it or encourage it as much as we could. Because even though I love home births I do a lot of them, I have to say I probably don't, you know, oh hey, have you thought about birthing at home? conversation as much as what I have because most of the time women come to me from the word go saying I'm interested in home birth or I haven't made my mind up yet but I'm thinking about that or come straight I'm going I want a home birth. If I've got a client that's like oh from the word go I just want to be in the hospital I do find it a little bit trickier to say oh have you thought about home or you know just we can't we always have a conversation about home birth just in case we don't make it because you always have those ones. But yeah, in general, um to where I live, so our secondary care hospital, while we have 24-7 access to it, we don't have obstetricians and theater there 24-7. They're only there Monday to Friday, nine to five. So outside of those hours, they're all at home in bed. So I always talk to clients, particularly here in our region, is that there's not much difference between you birthing in the hospital then and birthing at home because If you actually had an emergency where we needed obstetrics or we needed theater, it's gonna take them at like, we can get an obstetrician to the hospital within 20 or 30 minutes, but theater takes an hour for them to all come in and get ready to go. So we would be picking up that there was something going on well before that hour. So we would always have time to transfer. Anything that we as midwives, because I think people freak out, what if I bleed after the birth? What if the baby needs resuscitation? But those are very fast emergencies. happen super fast. They also dealt with very fast. And all the equipment and medications that we as midwives are allowed to use, we bring with us to a home birth. If you needed something that I couldn't bring to the home birth, then I couldn't use it even if I was at the hospital, I would need the doctor to do it. So when I think when people understand that, then they're like, oh, okay. I never really thought about it. I didn't realize you brought oxygen in that. you you can resuscitate babies or if I, can, bring suturing stuff so you can, you can stitch me up if I, if I need it. You know, like I don't think, I think that there is a bit of this belief that home birthing means you're hippies and you're gonna do nothing. We're just all gonna sit there and sing songs and you know, smudge our sage everywhere while the baby's born, you know, like, you're bleeding and we'll sing it away. Like, I don't know. I don't think they think, I don't think they appreciate that we. we are medically trained and that we have all the drugs. Yeah, with us. So in general, in times where we've had to transfer if someone was bleeding afterwards, mean, they're stable by the time you've got them there, you know what I mean? So it's like that kind of thing does change a lot. And I think if more people understood that, then maybe more people would be inclined with home birth. The other thing is that, you know, they're like, I don't want the mess. you know, it's just so messy. I honestly, I have to sit there, I'm like, I'm telling you right now that hospital birth is so much more messy. Yeah. Then home birth. mean, we are lucky here because our management wants us to have more home births. They let us borrow linen. So we're allowed to go get a linen bag and we just fill up with towels and stuff from the unit. then I just drop that with them. And then when we're done with that, I just take it back and drop it back off at opportunity and it gets taken away. Same with all the rubbish and stuff. We just drop it back up there and it gets disposed off through the hospital. So I've always liked people like when we... when we leave two or three hours after your birth, there's like the only evidence that there's been a birth there is the baby in your arms. Like we take the mess with us. It's not really your problem. We, our practice, and this is not New Zealand wide, but just our practice in general, we had our own birth pools. um So we give those to women because we just think the higher fees of birth pools can be quite steep and not everyone can afford that. um like we pick. we drain the pool packet down, take it with us too, when we go. yeah, like there's nothing, it's really nothing that they have to do except for the setup part of it. And again, I don't think they appreciate that. I think they have this idea in their head like, no, I don't want to do it. So I think I don't actually, a lot of the time I don't really think there's, you know, a really good reason that people aren't thinking about home births. It's just almost a socially accepted like, no sex, I don't want a home birth, I'll just go to the hospital. Yeah. Yeah. Do you find that you have like a particular, I don't know, like demographic that seeks out home birth or like, do you find that you have more second time moms after home birth or more first time moms? So I think in general it would be people that have birth before ah because I think sometimes you do have those first time, I just want to see how it goes first and then if I birth well the first time then you know I'll probably feel more comfortable home birthing. I have to say probably this last year and this year we've had more first time months which has been quite cool. um There's nothing quite like having that first time mum birth at home and then all her babies are born at home after that you know and that's all they know is to birth at home. Yeah. Which is such a different vibe, you know, and I don't think people, that's what people don't appreciate. Like the whole vibe of home birth is just so different to hospital birth. I personally, I would say that most of my clientele too tends to be decline-ers. Okay. So if people are going to decline different certain screenings or whatnot, then they are more likely to reach out to me. Yeah. I'm gonna ask that because yeah, even in the publicly funded, which is the, you know, the free programs, you are not allowed to decline anything. If you decline like, the G, well, I actually don't know about GBS, but, um, the glucose, um, you're just nonskies. Like that's, you're out. You can be as informed as you want to be, but if you disagree with what the hospital says, Oh, yeah. out. With a private midwife, it is often quite different. you know, but again, back what you said before, it kind of depends on each midwife and their comfortableness. Like, some people, some midwives like you to have X amount of scans, some midwives like you to, you know, do this and do that, but some, yeah, don't really Yeah, yeah. um Yeah, I obviously don't have that. I'd say about 80 % of my clientele would decline gestational diabetes screening. Yeah. And obviously, things like GBS screening isn't actually recommended routinely in New Zealand anyway. But that doesn't mean that there's not heaps of midwives still unnecessarily doing it. But anyway, that's a whole other podcast on its own. So I have I've had two planned breach vaginal births at home. Wow. And one was three years ago, and that was her second baby. And she had her first baby at home with us as well. And she was one that basically was just like, will lock myself in the room by myself if I have to. I am not going to the hospital. So of course, like, you know, but I I feel like you shouldn't even have to do that. Like you shouldn't have to say that because for us, particularly to here, breach is very much in our scope of practice. So I, my, I'm just like, why are we all arguing about this? It's literally in the midwife scope of practice guys. Like it's not like it's something that we have to refer for. um And then I just had another one. was about five weeks ago and it was her first baby. Wow. I'll tell you what, so she was the first, actually she was the first time I've seen deliver her baby breach. And I was just like, that's so much easier than a head down baby. That's amazing. Yeah. It was so good. But again, it was kind of like, had, we, in situation like that where obviously the baby is malpositioned. So we, do offer them a referral to Obstetrics, which they did agree. So they did speak to Obstetrics about it and both of them did opt to try and have an ECV to get the baby turned, but it didn't work. And then at that point they were like, um you know, the doctors discussed with them the options about cesarean birth and they were like, I'm not going to do that. I'm going to have vaginal birth. And they were both, neither of them actually said in the hospital, I'm home birthing this baby, but they did say, I'm going to vaginally breach birth. And to be honest, we actually, I've not actually had too much run-ins with doctors about that. They were just like, okay, well, if you've had all the information, that's what you're happy with and your midwife's happy then. We wouldn't recommend it, but that's on you to make that choice. And then they were like, well, know, this one I just had last month was like, can I still go on birth though? And I was just like, I mean, you can just, you can't ask for permission. in these situations, you have to just tell me what you're doing. And then that's what you're doing. Like that you have to be confident in it and then just tell me what you are doing and what you expect from me and then we'll go from there. So, and in those situations, I always will make sure that I have another midwife with me. I actually had two midwives both times I had two extra midwives come. um And I've always seek out midwives who I know are comfortable in that. did in those occasions, I did ah get a midwife friend of mine to come who I don't normally work with, who's done quite a lot of breach vaginal births. Just so that you've got that backup. I've done home births for VBACs. Again, there's no, you're always gonna say, for low risk women, it's always safest to birth at home, is kind of the national information that's given out. And of course, most people wouldn't see VBAC as the low risk option, but. um you know, given that the actual risk rate of rupture is less than 1 % still, how risky are they? You know what I mean? Like that, I'm just like, are we really going to take this drastic action when you have a 99 point something percent chance that you won't rupture? It just blows my mind. Because I just thought like either you'll have a baby or you don't. If you don't have a baby, then we transfer in. You know what I mean? Like that's, that's... That's kind of my viewpoint on it. And it's really, it's kind of really hard to, but the reality is, that people are more likely to have successful VBACs and successful joiners if they are at home. And so that is all the information that, you know, that you share too, and hope that they don't get too scared about it. But generally, I find if people have changed their mind because they've got scared, it's usually family. So I think often when women quite want to home birth and that's kind of become their plan, if that plan changes, it's often because either their partner or someone in their family has oh not been comfortable with it. That's generally where people would change their mind. Yeah. It's just so fascinating because like, yeah, it's so much more accessible to have a home birth. But I mean, you're saying kind of like the same, yeah, like society, you know, perspectives, like that the same problems, um which is just, yes, wild. um Because realistically in the history, like the history of time, like we only started birthing in hospitals not that long ago. know. know. Like probably, I mean even if you think a hundred years ago, birthing at home was still more normal than birthing in hospital. Yeah. And then I've completely swung to the very other end of the um spectrum, if you could call it that. Yeah. And yeah, like you say, it's still only, I mean, here it's like less than 1%, but it's still in New Zealand only 4%. That's just, yeah. mean, women here dream of like, just, you know, being able to access a home birth and it not costing, you know, six, seven, eight, nine, $10,000. And then you've got to hire the birth pool. And then I don't even know how that works. If, the midwife feels that they need a second, like a third midwife. I don't really know how that works with payment. presume you're paying extra then because obviously you're paying for three midwives times. Like, who's going to, doesn't that make it more risky? Yeah. extra backup. So I would, mean, like, yeah, because I assume then if they're privately paying for a midwife in Australia and having a home birth, then the woman is also paying the second midwife. That part of the fee. Everybody works. Well, there's a couple of different ways that they do it. The ways that I know, like my two home births, I went with midwives that were a part of like a, you wouldn't really call it like a midwifery group practice, but like a midwife business. So you pay like an amount and then your second midwife is like included. Yeah, okay. Yeah, that makes sense. If you there are also more independent issue. mean, everybody still has to have two midwives, but they're more independent. And then they might have, you know, a couple of midwives that they usually work with. then they say, okay, well, these are your possible seconds. And they're available at your birth. Who do you want as your second or this is the second that I work with and their cost is this and sometimes You know, you might pay the bulk to the primary and then they split it up to whoever, or you might have to pay two different amounts. It's like quite inconsistent really. At the end of the day, it's just so expensive. But that's, I mean, in this country, we would have, I would hazard a guess, the 1 % if it came down to paying too. um So a couple of years ago, they put in what we call the second midwife fee in our fee schedule, because before what would happen is um the main midwife would be claiming for the birth from the Ministry of Health, but then out of that money that she's claimed, which really isn't that much money, And for a whole entire pregnancy birth postnatal care, you're probably looking at around$3,500 is what we would get paid. So then you would have to pay the second midwife out of your own money, which of course made it really difficult for midwives to one, offer a home birth or two, ring a second because it's a lot of, would be half their fee. the... So they bought him the second midwife fee. So now when you do a home birth, the second midwife can claim to the Ministry of Health herself and get her second midwife fee. And it's about $600 or something. So it's better than not getting paid anything. For my example, when I had got the thirds on, I paid them. So they can't do a second midwife fee, but I just paid out of my money them for that. It wasn't required. But that was just for me a backstop for making sure that we were just covering bases. Especially in situations like with the breach where obviously you do have a potential that the baby may be the one that actually needs more help than mum might. And so having two pairs of hands for the baby and then the other one can be with mum, you know, was kind of my reason on that. Anyway, it was never needed, but. you know, that's just the safety stop that I kind of had put in place that made me feel comfortable about being there in that position. yeah, so it's quite, um not everybody would probably do that. um I wouldn't even, I'd be interested to know, because I don't even know if there'd be any kind of stats here to know even how many of our LMC midwives in New Zealand even like routinely offer home birth either. That would be quite interesting to see because yeah, there's quite a large scope of that. Are you paid differently like if you are an LMC offering home birth births working in Oh, yeah. So if you work in the hospital, then you are just paid your salary by the hospital. Yeah. You know, so the Ministry of Health obviously gives all their money to the hospitals and each hospital. They do they have you that's unionized, I think. So they do have like a, you know, all midwives that work in hospitals in New Zealand will be paid on the same scale as each other. um And then goes, you know, every year they can get paid more money until I think the seventh year it kind of tops out. here for us as LMCs, the rates are really assigned to the woman you're looking after. um you're paid, essentially everyone's paid the same base rate for all of the care given to women. And there are just kind of extra little bits of money that you might get if the woman is, um for example, if she's Māori, descent, Indian, Yeah. Like Samoan, like if there's cities that typically have with it, come with it a little bit of extra risk sometimes with their birthing experiences. So you might get, you know, extra $90 for that woman if she ticks those boxes, or if you've had to do a lot of acute call outs, then you might get, you can record your acutes and you might get paid a little bit of extra money per acute. So you'll get extra money for that. um Home births, you'll get paid. I think it's an extra $580 on top of the birth fee um to cover the cost of your equipment. then you get paid a little bit extra for the postnatal period because obviously they've never been an inpatient. So when they're an inpatient, they're obviously cared for by the hospital until they go back home and then they're basically discharged back to our care again. But obviously when they're home, that's not the case. So you have to visit more often when they're at home because you've got to go back the next day or that same afternoon if they've birthed in the morning. So there is a little bit of extra money in there to make up for that part. But in general, there's no difference in pay between, for example, a new graduate midwife offering home birth and me seven years down the track offering home birth and the midwife that's been doing it for 30 years. They're going to get paid the same amount of money. There's no way to... Yeah. Earn more money. Take on more women. That's your... Yeah. how many women roughly do you support per month? So my group, we stick to around three to four per month. Okay. Yep. So that would be considered a small caseload. ah But that's mostly because it's really hard to have that really good, solid continuity relationship when you have heaps of women, because then you have short appointments and you're trying to see them all. So having three to four means you can have longer appointments and it means you're more available when you're to offer the home births and stuff. Typically our busier midwives here don't offer home births. And generally that's what you see. Actually the midwives that have the case loads of eight to 10 a month often aren't doing that many home births to be fair. So yeah, there's no actual legislation or regulation on how many women we can take either. The recommendation is that you have 40 a year. Plenty of midwives don't have 40 years, especially if the other breed wanted for their family, that's probably not going to be enough for them. yeah, definitely care starts becoming an issue when you're looking at, you know, double figures a month. That's just, I don't even know how people do it. Like, you don't know how they could mentally have the space for that much. Yeah. And so with the modules that you get paid for, do you only get paid for all of that, like at the end of your care of the woman, like, you know, after that six years of postnatal you get paid as you go along? Now they pay it as we go along. used to be that you'd get paid after first trimester and then you'd get paid at birth. Okay. Like that. But now they pay us after. So you get paid when you register them, you get paid when they're at first trimester, second trimester, and then you get third trimester and birth when they birth and then you get postnatal when you've discharged them. Yeah. But that's small amounts. I mean, you're talking like...$110 when you register them, $110 at the end of the first trimester. It's small amounts. Most of the money in our job is really weighted in the birth fee. Which is always hard too because you're kind of a little bit like, you understand it but sometimes where it's hard is that you're going to get paid the same amount whether you walked in the door and the baby was already out. So you haven't really had to do anything. to if you were with that woman for 24 hours, you know what mean? You've got to get paid the same amount of money. And if you transfer and end up being, you know, the primary midwife in the room, even though you're in a hospital setting, are you still getting paid the same amount? Yeah, we for here our birth fee, it's we call it the birth fee, but it's labor fee to be quite honest. So as long as somebody's gone into labor and you've done a labor assessment, whatever happens to her from there, you'll still get paid. So if they have an assisted birth or if you have a caesarean, it doesn't matter. She labored, you did an assessment, you're going to get paid for the labor. It would only be, we just get paid differently if someone has an elective. if they don't, or if they have an emergency without labor, then then you won't get paid the birth fee part. And there's certainly no punishment and stuff to transferring um either. I think often it's just probably how people are made to feel. um And I think you're always going to get some doctors here and there that have got something to say for it. I know one of my colleagues did have a doctor who was as they were being weltered there, and was listing off all these things that this woman had, that why on earth would anyone be agreeing to home birth someone with all these things? ah she hadn't been practicing for quite as long, and it really kind of, like, was hard, a hard pill for her to swallow. And I was like, you have to remember, though, that we don't, they don't get to make the choice for the woman, and we don't get to make the choice for the woman. We just present her with her options. and they then can choose what they like with it. Like if someone never has an option and all they say is, you don't have an option, your option's the hospital, then there was no Informed Consent. There's no Informed Consent if you aren't being given options. if someone's like, oh, all my midwife's got is the hospital, can't home birth, I'm out, well then you don't have Informed Consent because she doesn't offer it, that's fine. But without the offer, you can't make an Informed Choice because you have no choice. Essentially you're being coerced into birthing at the hospital. Even if you're happy with that, it's still coercion because there was no other option available. yeah, yeah, yeah, yeah. I was recently at a like they're looking into the maternity workforce here in Australia. And um it was like a forum thing. And so I went on behalf of Home Birth Victoria, and I ended up speaking to some doctors. And we were trying to ask them, you know, why, like, just, you know, in a friendly way, why did GPs not present home birth or even private midwives as an option. And they were like, well, it's just extra time that we don't have time. It's a 15 minute consult. And I was like, yeah, but you're giving private and public hospitals their, can't you just slot in there? Like, you know, one sentence about home birth or one sentence about private midwifery because yeah, quite like 1000%. If you're not actually giving somebody all of their options, that is not informed consent because they don't know, like they're not being given their options. They're just being told whatever the doctor in this particular case thinks, you know, they would like to do really is what you should. 100%. And my argument with that is the same though for midwives here because um at the end of the day, if someone's like, well, even if I wanted to home birth, my midwife doesn't do home birth, so it wasn't going to be presented to me. Well, the thing is, even if you don't offer home birth, you still have to tell them that that's an option for them. You still have, like part of your obligation to give someone the options is to say, Hey, you also have the option to home birth. Now I don't offer home birth, but I could probably, if that's what you wanted to do, then you're more than welcome to find a midwife who could support you in that. You know? Because it's the same with, you know, it's the same with anything. Same with breech births. Someone comes to you and says, Oh, I don't think I want a caesarean. And you're going to be like, well, I'm not going to support a breech birth. So then you have cold worse too, too, because you don't want to do it, but that's, that's not appropriate either. Even if the doctors don't want to support the breech birth, you can't just say to her, her only option is a caesarean. you have to present the option that she can choose to vaginally breach with, even if you don't recommend it, you still have to offer it as an option because it is an option. Same if someone's, mean, you could be in the life and death emergency and present surgery as a life-saving option, but you can't like, that's your only option because you can choose to still say no. Even if that option means that you potentially are putting yourself at harm, that's your... legal right to make that choice. And that's the argument that I have with just about anything that woman choose to do. was like, you guys, the medical profession likes to make out that woman are willfully choosing to put their children in harm's way because of some selfish desire to want to birth however she wants to birth. And I'm always like, number one, you do not love that baby more than she does. No matter what you say, you do not love that baby more than she does. So even implying that you do is utterly offensive. But two, it actually wouldn't even matter if the decision she was making was going to harm her. She still has the legal right to make that choice. Even if it was going to kill her, even if nobody agrees with it, she still has the legal right to do it and to force it upon her if she's saying no would be assault. So then why are we getting so worked up when women are choosing options for them that aren't even as bad as the risks are being made out to be. Sure, they might be more risky than somebody who doesn't have those things going on, but ultimately, when it comes to childbearing, the risks are so ridiculous. I remember going to the surgeon once about something completely random and they were like, oh, look, there's a 75 % chance it will work, 25 % chance it won't work, probably worth doing in that case. And I remember laughing at him and I've said, do you know what, if there was a 25 % chance in my job, Like that is absurd. We do not work with those numbers. We do not work with those numbers. We're thinking a 10 % chance of a baby being at risk is as like a, not. must have a cesarean. Because if you're thinking about. less than one percent, if there's uh a of it happening, then no. That's it. I mean, you have someone with a classical caesarean and their risk of rupture is about 10%. You would not find a doctor on this planet that would be willing to support a VBAC with someone with that. So when you're talking like a 1%, it's even more ridiculous. So I was just like, this is the thing in our job is that we just, we become so baby-centric. that we lose the woman and they're all together and we essentially are just viewed as incubators. And that's the one part that I find it really hard, particularly to like when the gestations will change about, you know, late term terminations and stuff like that. For example, like a woman can have a late term termination. So I'm like, so how come we are allowed to do that? But if a woman wants to choose an option that you as a medical professional are deeming too risky for that baby, she's not allowed to make that choice. Just like, this makes sense. Like none of it makes sense. And nobody's out there willfully making a decision to put their baby in harm's way. Nobody. And while I think that there are, the witch hunts and social medias can be quite unhelpful in these regards as well, because of course then free birth becomes a thing. I don't think free birth happens that much in this country. probably because there is a little bit more accessibility of midwives and being able to home birth and stuff. But, and you'll always have the group for free birth is right, that just will do it regardless, right? Because that's their whole philosophy. But in general, most women choose free birth because they have no other options. That's it. That comes up. If they had the option to have a midwife, support them in a home birth without over managing it and without putting all these requirements on it and you must reach this time. And I've worked with midwives here who did work in Australia and did do home births in Australia, under MGP situations and said, you know, so stupid because every two hours you have to ring the birth unit and be like, this is what's happening. If that senior met the birth unit said, no, I don't like it, you need to come in, you had to come in. And I'm just like blown away by that because I'm like, Nobody's telling me when I'm going into the hospital. Like no one's telling me this birth took too long. Yeah, I recently recorded a story. um I can't remember which episode it was only a couple of episodes ago with a mom who was in his first baby birthing at home in the publicly funded. And had a midwife. um I mean, there was there's a couple of things that could have played into why this happened. But um the midwife. you know, it got to nine hours and like nine hours of attendance meant that they had to basically be talking about transferring in because that's what the midwives in this program were like, that was their limit. And so the midwife ended up, um, giving an episiotomy so that she could still birth at home because of the time constraint. And I was just like, what the heck? What the heck? Very silly. That's so messed up. So messed up. Yeah, yeah, yeah. And even, you know, also a couple of stories ago, um you know, a mom that got told she could be in the publicly funded, her birth program, and then they told her she couldn't, and then they told her she could, and then she had a positive GBS uh result. And then um they, you know, they risked her out again. And then they said, actually, oh, no, then she went in and asked for an appointment with obstetricians to argue her case. And then they were like, okay. And then, and then I think it was literally like at 38 weeks, or maybe even later, like the midwives had dropped off the pool and oxygen everything, she got a call and said, oh, the obstetrician has been looking at your notes again and you're now no longer eligible and she was only 38 weeks. So she ended up free birthing because like... But that's what happens. the fact that an obstetrician would make that choice blows my mind. uh just for my, I had this client who um had gestational diabetes, honestly, only just. She just tipped over. So she was going to be diet controlled anyway. That's my head in this stuff. But regardless, she did the test. This is what she got. Anyway, she went and saw an obstetrician and she must have I think she was about 36 weeks, went to the obstetrician and was like, you know, she had perfect blood sugars the whole time and even needed any medication for all intents and purposes. If you looked at her blood sugars that whole time, you would have thought she was a normal person without GDM anyway. Normally grown baby, all that. She's to the obstetrician, you know, while I'm planning to home birth. And he was just like, absolutely not. Absolutely not. can't home birth. And she said, well, why can I not home birth? And he's, she's like, because you have gestational diabetes. And she's like, but what is the risk of the gestational diabetes? And then he's like, you know, the shoulder dystocia, the baby with with bad blood sugars. And she's like, please tell me if my blood sugars though have been normal this whole time, how have I now grown a baby that will have shoulder dystocia and have blood sugar issues after birth when literally my sugars have been perfect this whole time? It doesn't happen. That's not how that works. And so when she came back to me and said that to me, I was like, why on earth? Would you ask an obstetrician for his opinion on you home birthing? He has no say in the matter. I said, don't even worry about it. He literally has no say. You're the only person that has a say. You could argue that I have a say, but I don't have a say because at the end of the day, if someone said to me that they're staying home to birth their baby, then okay, cool, we're staying home to birth the baby. Because all you have to decide is if you want to home birth and if you feel comfortable home birthing. And she was like, well, I do. And I'm like, well, then cool, we'll have a baby at home. I was just so crazy. And you know, it's just, she birthed the baby, no shoulder dystocia. The baby's blood sugars were completely fine. She was even like, should I check the blood sugars? And I'm like, I mean, you can do what you want, but I wouldn't be recommending it. So it just blows your mind, that kind of stuff. It's just no common sense either. And I think that's what is hard. Everybody's looking. I feel like it's because everybody's viewing it with a viewpoint of liability and being sued. But the thing that cracks up about our country is you can't sue for, no one can be sued in our country for that. um We have ACC, which is like an accident compensation thing, service, whatever you want to call it. And so like we, as health professionals, could, you could technically be taken through like, the Health and Disability Commission if something serious happened and someone complained about you and they could strike you off or they could make you do extra courses or have supervision, can decide that. But no one, know, like none of us could be sued civilly. know, obviously, if you made a willful choice that knowingly caused the death of someone, then you could be done criminally for it. But you can't, my argument to is that they can't, if something bad happened though, they can't sue you. So I can't understand also why anyone would use that as a, understand in countries where you can be sued for it, that it is a big hindrance for people to make certain choices, but you can't have that here. So again, I'm not sure, you know, if you've got your ducks in the row and you've done solid documentation or in certain cases, you know, you're woman's happy to sign something to say, hey, this is the conversations we've had. This was the information I was given and this is the decision I made. um Then I'm not quite sure why we're worried about. what somebody else chooses to do with their body. Yeah, yeah, yeah. it's, um, I wanted to say, like, I feel like there's so much that, I mean, there's a policy and there's something written about literally everything. And I think because like, you know, that must play a role that because it's all written down somewhere, we have lost the ability to think outside the box, because that's what the health system, you know, at least in a, in a pathological, like medical sense, that's what they want. They want everybody to follow the same thing. So that, you know, that you have the same outcome. Like if you break a bone, you know, you want it dealt with in a, in like a standard way, I guess. Yeah, well, for populations, they have to have that, right? To keep everybody in control and to manage how many hundreds of thousands of millions of people they need to put strategies, policies, guidelines in place to give some people guidance. But it's not a rule book for the woman to follow. Yeah, exactly. But I think, know, in like, my hospital systems, especially like, um you know, you just like lose that ability to think outside the box and actually like zoom out and be like, Oh, actually, no, that doesn't actually make sense. Yeah, for sure. Yeah, for sure. Anyway, it's been fantastic to talk to you and learn about New Zealand's home birth situation. um Obviously, yeah, there's such a difference between Australia and New Zealand, even though we're neighbors. um It's just wild that yeah, it's kind of like the country lottery or the postcode lottery. just really depends. But yeah, it's fantastic. I hope people have really enjoyed hearing about how you know, from my perspective, how well it can be set up. maybe that, you know, obviously there's um issues everywhere, but I think, yeah, ultimately I hope it like gives people some hope that it could be different. is a way, there is somebody doing it differently that does seem to be working, um you know, at least better than we have it here in Australia. um Yeah. Thank you so much. Sure, no problem, thanks having me.