A midwife who gave her client a saline solution instead of pain relief because she believes in the placebo effect has been called disgraceful and dishonest by the Health and Disability Commissioner.

The findings, released today by Anthony Hill, related to an unnamed midwife who cared for the pregnant woman in 2017 and was present during the birth in 2018.

The client - Ms B - had told her midwife she wanted [Entonox] gas and pethidine prior to giving birth.

Photo: Supplied

However, when she asked for pethidine during labour, the midwife told a student midwife and another midwife at the hospital that she would instead give her saline solution and that the "placebo effect is awesome".

The other midwife said the woman appeared to be proud of the fact she had done this previously on several occasions, despite the other midwife having told her what she was doing was illegal.

This was backed up by a student midwife who told Mr Hill the woman received four 10ml syringes of saline - three of which were in half doses.

"The [midwife] and myself went to dispensary to get the pethidine. The [midwife] told me about the placebo effect ... I asked if she tells the woman afterwards, and she said no. Sometimes if the client is a good friend and can laugh about it afterwards she tells them," the student told Mr Hill.

Mr Hill said the midwife had breached the Code of Health and Disability Services Consumers' Rights.

"Ms B's birth plan included the use of pethidine, and [the midwife] told Ms B that she was being administered pethidine when in fact she was being administered saline. Ms B's pain continued, and by not providing her with the medication she had requested and agreed to receive, [the midwife] ignored the fundamental importance of consent."

Ms B was given the saline solution over two-and-a-half hours. The amount was not recorded but the midwife told the Commissioner it was less than what the student midwife recalled.

Ms B was eventually given pethidine about four hours after she had originally asked for it.

After the birth the midwife told Ms B what she had done and Ms B confirmed to the Commissioner she was glad she had not been given pethidine. The Commissioner said Ms B had therefore not been told she eventually had been given real pethidine.

The other midwife and the student midwife expressed their concerns to their colleague and told a manager.

A review was completed on 16 February 2018 and stated that because [the midwife] was an independent practitioner no internal formal investigation of her practice occurred.

It said the incident would be reported to the Midwifery Council of New Zealand.

The midwife of 23 years was confident of her decision at the time.

"I felt it was in the best interests of the baby not to give pethidine. However, in the best interests of Ms B, I was to give her a sense of support and help in a difficult time, therefore I administered normal saline, leading her to believe it was pethidine. I knew it would do no harm, and that pethidine could still be administered at any stage going forward, if required," she said.

However, she told the Commissioner she was "deeply regretful" and would not repeat the situation again.

She said she had not tried the placebo effect theory on a client in 10 years.

She has requested a special circumstances midwifery review.

The Commissioner has referred the midwife to the Director of Proceedings, for the purpose of deciding whether legal action should be taken.

The Midwifery Council will be sent a copy of the report and advised of the midwife's name.

The District Health Board would also be told.