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• A woman criticised the delay in the investigation after her baby was stillborn at home.
• The Health and Disability Commission found the midwife at fault for leaving her during labour.
• The midwife underwent supervision and changes to practice; complaints to the commission have risen 52%.

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A pregnant woman whose midwife left her during labour in her tiny rural home without power, internet, or phone coverage, says she still deals with pain and anger from her loss, and that the investigation has taken too long.

The Health and Disability Commission criticised the midwife in a report released in March, more than four years after the baby was stillborn.

The woman had not realised that by the time she was in labour at more than 43 weeks of pregnancy, her baby was already in danger and they should have been in hospital.

She told RNZ that though she believed her baby was in heaven, the loss was immensely deep and had impacted every part of her life.

“It hurts so deeply seeing our other children reaching special milestones and birthdays and wondering how our precious baby will be, how they will talk, how their personality will be and in what ways will they be similar or different from our other children,” she said.

Since she lost her baby more than four years ago, she has had two more children. The couple already had an older child and are raising all three in the same off-the-grid home that’s just 36sq m.

It had been hard dealing with the investigation into what went wrong over all these years, she said.

At times it had made her question whether it was worth making the complaint.

On the day her baby was born at home, more than two weeks after her waters broke, her contractions had slowed and her midwife left to go to town to get some lunch, telling the back-up midwife to leave too.

The midwife had spoken briefly to her husband outside as she left – he had been outside feeding chickens.

“By the time he came in to see me, I was sitting on our one little armchair, and I was in so much pain,” the woman said.

Not long afterwards, her baby was born not breathing. The umbilical cord was no longer attached.

The couple were panicking and praying and wondering what to do, she said.

The midwife arrived moments after the baby was born and helped her father to try to resuscitate her, the woman said.

“It was very, very traumatic,” she said.

“It kind of seems unreal now but it actually happened. And, I mean, time does help to heal but still when you think about it, it’s very, very painful,” she said.

The midwife told the commission she arrived just before the baby was born.

The commission’s report said the case had been very difficult to investigate because of the differing accounts of the mother and the midwife, and because of poor clinical documentation.

Despite that, it found that the mother should never have been left without care while in labour.

It also found the midwife at fault regarding the woman’s request to have an ultrasound scan 13 days after her waters broke.

The mother, who favoured a natural, home birth, had not wanted routine scans but asked about having one then because she had become worried and a nurse friend advised her to have one.

Again, both women’s accounts differed, with the midwife saying the woman did not want a scan, but the commission found the midwife missed an opportunity.

“By telling [the mother] that a scan would not tell them anything they did not already know, [the midwife] inferred that a scan was not clinically necessary,” the report said.

“In the context of [the midwife] knowing [the mother’s] reluctance to have medical interventions and her concerns about being forced to have treatments if she went to hospital, I consider that effectively, [the midwife] discouraged [the mother].”

The woman said she was haunted by that decision.

Advice to other mothers

The woman said for her next baby, she needed to go to hospital but the experience was a very positive one and her new midwife helped with that.

“A good midwife would say ‘I know you don’t want to go, but I will support you when you’re there. And I will make sure you are advocated for,’” she said.

She was personally now an advocate of shared care, where more than one midwife cared for the mother during pregnancy, so both knew them well when it came to labour.

She wanted women to know it was okay to seek a second opinion or even change midwives if they felt unsure.

“If you feel uncomfortable about anything, knowing that you can change, and it’s okay. It might be the best thing that you do,” she said.

She has had counselling through True Colours, a service that helps parents whose children have died or who have children with serious health conditions.

The commission’s report said the midwife in this case had undergone a year’s supervision as directed by the Midwifery Council and undertaken many changes to her practice.

Among them was consulting with obstetric teams if women declined recommendations in a complex case, taking better clinical notes, and undergoing education.

HDC delays

The mother said it had been hard to get answers, and she was critical that it took four years for the Health and Disability report to be released.

Health and Disability Commissioner Morag McDowell apologised for the delay and any distress caused, extending her sympathies to the woman and her family for their loss.

“We absolutely accept that the delays are unacceptable and we are absolutely committed to making sure we are reducing those delays going forward,” she said.

Complaints to the service have increased by 52% in the past five years – and that could be because of increased delays and pressures on the health system, she said.

Seventy per cent of all complaints were resolved within six months.

Only 7% to 8% went to the full, quasi-judicial investigation like this one, she said.

The commission had a target to try to complete those in an average of 18 months to two years – and is making progress, she said.

It has a particular focus on clearing its longest cases.