Postnatal care is essential for maintaining the health and well-being of women and newborns

The importance of comprehensive postnatal care and support and the difficulties that can arise when certain aspects are lacking were underscored in a decision by Deputy Commissioner Rose Wall, who found a midwife breached the Code of Human Rights Consumers of Health and Disability Services (the Code).

In her decision, Ms Wall found that the midwife failed to provide a woman and her newborn child with reasonable care and skill. She also highlighted the importance of comprehensive record keeping and the role of handover at the end of service delivery in maintaining continuity of care.

A woman, living in a more rural locality, who was pregnant with her first child hired a licensed independent midwife as her primary childminder. There were particular challenges for the midwife as she was working beyond her normal geographic area.

This case concerned shortcomings in the postnatal care provided to the woman and her newborn by the midwife. Unfortunately, the midwife did not provide the planned number of postnatal consultations for the woman in the period following her Caesarean section. As a result, the relatively common issues that can arise in women and newborns under such circumstances have not been appropriately managed.

Ms Wall highlighted her significant concerns about certain aspects of midwifery care, including not keeping patient notes properly; provide the appropriate number of postnatal visits to the woman; assess and manage baby’s reflux and colic; adequately treating the woman’s mastitis and failing to refer the woman to the appropriate services at the end of the postnatal period.

Ms Wall recommended that the New Zealand Midwifery Council (NZCOM) consider whether a review of midwifery competence was warranted. She also recommended that the midwife issue a written apology to the woman, complete an NZCOM midwifery record keeping course and make a number of changes to her clinical practice in relation to the record keeping, communication and follow-up procedures.

“Complaints provide a valuable learning opportunity for healthcare professionals – they lead to positive change and better service delivery for future consumers. I am delighted to see the midwife making changes to her hands-on and has had additional training,” says Ms. Wall.


This case relates to a complaint filed with HDC in 2020. Our goal is to investigate complaints as quickly as possible, while ensuring natural justice and the interest of all parties involved in providing information and responding to evidence. presented by others.

The F full report of this case can be viewed on the HDC website – see HDC’s’ Latest decisions‘.

Names have been removed from the report to protect the privacy of those involved in this case.

We anticipate that the Commissioner will name providers found to be in breach of the Code, unless doing so is not in the public interest or unfairly compromises the privacy interests of an individual provider or consumer.

More information for HDC’s media and naming policy can be found on our website here.

HDC promotes and protects the rights of people using health and disability services, as set out in the Health Services and Disability Services Consumer Rights Code (the code).

HDC recognizes the significant pressure the health and disability system is currently under with limited ability to meet the demands placed on it. However, despite these challenges, the rights of individuals under the Code continue to apply.

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