Historical and enduring maternal health inequities and injustices continue to grow in Aotearoa New Zealand, despite attempts to address the problem. Pregnancy increases vulnerability to poverty through a variety of mechanisms. This project qualitatively analysed an open survey response from midwives about their experiences of providing maternity care to women living with social disadvantage. We used a structural violence lens to examine the effects of social disadvantage on pregnant women. The analysis of midwives’ narratives exposed three mechanisms by which women were exposed to structural violence, these included structural disempowerment, inequitable risk and the neoliberal system. Women were structurally disempowered through reduced access to agency, lack of opportunities and inadequate meeting of basic human needs. Disadvantage exacerbated risks inequitably by increasing barriers to care, exacerbating the impact of adverse life circumstances and causing chronic stress. Lastly, the neoliberal system emphasised individual responsibility that perpetuated inequities. Despite the stated aim of equitable access to health care for all in policy documents, the current system and social structure continues to perpetuate systemic disadvantage.

Background: Increasingly, pregnant women in Aotearoa/New Zealand (Aotearoa) are unable to achieve the dietary intakes recommended by the Ministry of Health (MOH). While health professionals express frustration at "being the ambulance at the bottom of the cliff", the continued government response to this public health concern is to "educate women", as per the current mantra of personal responsibility and choice-based rhetoric. Aim: Using critical discourse analysis (CDA), this study examined the discourses regarding nutrition in pregnant women in Aotearoa. Pregnant women's nutrition is further considered within the contexts of food security and empowerment. Method: In July 2017, using 30 documents from three different platforms-media, government and academia-with a focus on Aotearoa, the first author undertook a CDA. Findings: Three key messages were identified: firstly, pregnant women, in not being viewed holistically or relationally, are isolated as being solely responsible for nutrition; secondly, women are positioned as naïve recipients, and achieving a healthy pregnancy requires women to be educated and to adhere to complex food guidelines; and lastly, there is an authoritarian use of fear and monitoring to motivate adherence to guidelines. Thus, women are personally responsible for achieving complex, unrealistic and often unaffordable nutritional targets. Conclusion: The most dominant discourse is one whereby malnutrition is seen as deficit behaviour and thinking by women, and one of self-responsibility, regardless of context. This is very much in keeping with the modus operandi of public health and neo-liberal discourse. We argue, however, this renders silent the fact that malnutrition for some women results more from food insecurity and disempowerment. Midwives need to make audible other less dominant narratives, alongside advocating for woman-centred, policy-based approaches towards nutrition, whereby the underlying drivers of poverty are actively addressed.

Background: Maternal socio-economic disadvantage affects the short- and long-term health of women and their babies, with pregnancy being a particularly vulnerable time. Aim: The aim of this study was to identify the key factors that relate to poverty for women during pregnancy and childbirth (as identified by midwives), the effects on women during maternity care and the subsequent impact on the midwives providing that care. Method: Survey methodology was used to identify Aotearoa New Zealand midwives’ experiences of working with women living with socio-economic disadvantage. Findings: A total of 436 midwives (16.3%) who were members of the New Zealand College of Midwives responded to the survey, with 55% working in the community as Lead Maternity Care midwives, or caseloading midwives, and the remainder mostly working in maternity facilities. The survey results found that 70% of the cohort of midwives had worked with women living with whānau (family) /friends; 69% with women who had moved house during pregnancy due to the unaffordability of housing; 66% with women who lived in overcrowded homes; and 56.6% with women who lived in emergency housing, in garages (31.6%), in cars (16.5%) or on the streets (11%). The cohort of midwives identified that women’s non-attendance of appointments was due to lack of transport and lack of money for phones, resulting in a limited ability to communicate. In these circumstances these midwives reported going to women’s homes to provide midwifery care to optimise the chances of making contact. The midwives reported needing to spend more time than usual referring and liaising with other services and agencies, to ensure that the woman and her baby/ family had the necessities of life and health. This cohort of midwives identified that women’s insufficient income meant that midwives needed to find ways to support them to access prescriptions and transport for hospital appointments. The midwives also indicated there was a range of social issues, such as family violence, drugs, alcohol, and care and protection concerns, that directly affected their work. Conclusion: Recognising the impact of socio-economic disadvantage on maternal health and wellbeing is important to improving both maternal and child health. This cohort of midwives identified that they are frequently working with women living with disadvantage; they see the reality of women’s lives and the difficulties and issues they may face in relation to accessing physical and social support during childbirth.

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