BEYOND THE NUMBERS

MIDWIFERY CHALLENGES IN ADDRESSING PERINATAL MORTALITY IN NEWZEALAND

Perinatal related mortality rates•Our Perinatal Mortality rates similar to UK.•NZ rate not increased in past year.•Still birth rate has decreased from 6.3/1000 to 5.2/1000 total births. •Same factors in previous PMMRC reports and other New Zealand research: socioeconomic deprivation, ethnicity, smoking, drug and alcohol use, age (<20) and barriers to accessing and engaging with maternity services.

The Challenge The most complex challenge posed to midwives (and in fact to all providers of maternity services) by this report continues to be the contribution of the social determinants of health to perinatal mortality.

The Challenge… 2012 Report:

“The higher proportion of vulnerable mothers among the birthing population in the CMDHB region compared to other regions is responsible for the significantly higher crude perinatal related mortality rate in CMDHB” (PMMRC 2012)

The Challenge…

“Thus a reduction in crude perinatal related mortality rate might be achieved in the Counties Manukau region by addressing the social and health needs of Maori and Pacific and socioeconomically deprived mothers.” (PMMRC 2012).

The Challenge…

We have to address the social deteriminants of health that impact on perinatal mortality and maternal health and well being.

Contributing factors and potentially avoidable perinatal deaths

2012 PMMRC Report urges key stakeholders providing health and social services to women at risk to work together and identify: 1. Reasons for barriers to accessing and engaging with maternity care2. Interventions to address these barriers

NB: No progress in the last four years! (PMMRC 2012).

The Challenge… • Midwifery and

Medicine cannot meet this challenge on their own.

• Solutions require infrastructure of service provision and delivery.

• Address areas where women are most at risk.

A RESPONSE to the Challenge

•Snapshot from two different research projects in Counties Manukau within past 12 months.

•Both projects relate to the specific issue of an accessible and appropriate maternity service as identified in PMMRC report.

•Both projects present insights and solutions for accessing and engaging with maternity services.

Project carried out for the Ministry of Health in 2011: ‘A Successful Lead Maternity Care Midwifery Practice In Counties Manukau.’(Priday and McAra-Couper, 2011)

Response to The Challenge: Project Researching Midwifery Practice• Mixed method research project. • Qualitative data collected using narrative,

interviews and written feedback. • Quantitative data from reports, client

evaluations and statistical maternity reports, including Midwifery and Maternity Provider Organisation (MMPO) reports and Perinatal Maternal Mortality Review Report 2011.

Response to the Challenge… Research: “Barriers to Initiation of

Antenatal Care Amongst Pregnant Women at CMDHB”.

• Conducted by Drs Sara Corbett & Kara Okesene-Gafa (2012)

• Background: Fifth Annual PMMRC report (July 2011) for the first time analysed factors contributing to perinatal mortality. Common factor: barriers to accessing or engaging with maternity and health services.

Response to the Challenge… Aim of this Study:

To identify barriers to initiation of antenatal care and predictors of inadequate care for pregnant women presenting to CMDHB maternity services.

• Surveys were offered to all women presenting to the hospital and maternity units.

• 826 women were included in the analysis. 136 (16.5%) were classified as late bookers (> 18 weeks gestation) and 151 (18%) were determined to have received inadequate care (< 6 antenatal visits) during their pregnancy.

Response to the Challenge….

Some of the principal barriers for women who book late, or who receive fewer than six antenatal visits can be summed up in two words:

NOT KNOWING

(Corbett and Okesene-Gafa, 2012)

Response to the Challenge… .

NOT KNOWING:

•the need to choose and book with an LMC

•the importance of getting care early in the pregnancy

•that they needed any care at all, as they “could look after themselves”

•how the maternity service system worked(Corbett and Okesene-Gafa, 2012)

Practical Barriers to Accessing and Engaging in Maternity Services

1. Rigidity of time structures at some clinics 2. Cultural priority of family needs over women’s own health3. Lack of knowledge about options available in choosing a midwife4. Cultural expectation that all midwifery care is hospital based5. Belief that there is a fee attached to having a midwife6. Difficulty in contacting a midwife(Priday and McAra-Couper 2011) (Corbett and Okesene-Gafa, 2012)

More Barriers…

7. Shyness or discomfort phoning a stranger 8. Lack of landline or credit for cell phone 9. Belief that asking for a service is culturally inappropriate and disrespectful10.Language difficulties creating lack of understanding11.Childcare difficulties for large families12.No midwife on site at their health centre, creating fear of unknown service location and personnel

• (Priday and McAra-Couper 2011) (Corbett and Okesene-Gafa, 2012)

And More Barriers…

13. Lack of health knowledge and limited literacy in English14. Doctor or midwife hard to understand15. Lack of money and /or transport to attend clinic and scans16. No phone (or phone credit) to make appointments

(Priday and McAra-Couper 2011) (Corbett and Okesene-Gafa, 2012)

Further Research from “A Successful LMC Midwifery Practice in Counties Manakau”:

The Midwifery Practice (TMP)

Clientele of TMP:

• Pacific (62%) & Maori families (15%)

• High deprivation (75% of women from deprived

areas – decile 10).

• Large families

• Complex needs

• Significant co-morbidities

• Poor utilisation of health services

The Midwifery Practice (TMP): Perinatal Mortality 2009 - 2011

PMMRC NWH CMDHB MMPO TMP0

2

4

6

8

10

12

14

16

Perinatal mortality per 1000 births

The Midwifery Practice: (TMP)Response to the Challenge

• Continuity of Care• Informed Consent• The midwife acting as

navigator and advocate

• Midwife upholding the woman, her family and her culture

• (Priday and McAra-Couper 2011)

TMP Response to the Challenge: Continuity of Care…

Continuity of Care allows for greater knowing, develops trust, and encourages open communication...

Continuity of Care keeps women and babies safe.

(Priday and McAra-Couper 2011)

Response to the Challenge:Continuity of Care…

• Those who were most satisfied were women who had Continuity of Care.

• The women who had to see different midwives and different GPs at each antenatal visit were least satisfied.

• Women said they would rather have one person caring for them throughout the pregnancy and it would be ideal if they had the same midwife to look after them throughout subsequent pregnancies.

(Corbett and Okesene-Gafa, 2012)

TMP Response to the Challenge: Continuity of Care…

Feedback from a Samoan woman translated into English:

“This is my first baby in NZ. I had my doubts of what kind of midwife that would be looking after me. I never thought and could not believe how thorough... was right from when she first saw me up to the time I had my baby...it was all good work she did for me and my baby...words are not enough for me to express how grateful me and my family are, for the care that I received from the beginning of my pregnancy up until and after my baby was born. I didn’t believe this was how a Palangi would care for someone like me Samoan...thank you for your professionalism…”(Priday and McAra-Couper 2011)

TMP Response to the Challenge: Midwife as Navigator and Advocate

• Help navigate through the health system – appointments, referrals, triage.• Educate woman, family and community • Utilise other health services in area• Read hospital correspondence and

instructions for tests• Keep an eye on ‘big picture’ – whole family

health• Speak up on behalf of woman

TMP Response to the Challenge: Midwife as Navigator and Advocate

“On Good Friday I had a call from a very distressed woman who had found my number in the back of the Well Child book. I had looked after her daughter in her last pregnancy (1 year ago). She told me her daughter was away and she had the three children but had no food and no money and could I help her. I told her I would get back to her or get someone to contact her by midday. Luckily even on Good Friday the Salvation Army were able to assess the situation and within three hours had food to that very needy family. Often we find ourselves in the position of navigator of social services - way outside of the midwifery role in one sense.”

TMP Response to the Challenge: Midwifery a Service Integrated into the CommunityData from Receptionists at local Medical Centres:

• “…just having them [midwives] here in the clinic just to go and knock on the door [when we needed a midwife or midwifery advice] was really good.” • “…the LMCs have worked a long time in this practice with

Pacific women...the feedback we get from the women themselves is just fantastic....the midwives are considered part of the community…”• “…referrals back to the [GP’s] practice was really important;

you were assured of competent care and that is why it worked really well at our Practice…well recommended Rolls Royce care here, getting those letters back, getting those results back...we work together - good collegial relationships the midwives and GP’s.”

TMP Response to the Challenge: Informed Consent

Ensure all information is fully understood• Fear of the unknown is a barrier to access• Knowledge reduces anxietyInformation fully explained and translated if required

(Priday and McAra-Couper 2011)

“

TMP Response to the Challenge: Informed Consent

“What is about the woman is never without the woman.”

Feedback written in Tongan – translated:

“She’d never leave me unattended; she even explained all the details of treatment before doing anything, even she asked me questions so I fully can understand....so once I gave birth to my baby girl I decided to name her (after the midwife) for her appreciation and great thanks because I have nothing to repay you for your kindness and caring...”

TMP Response to the Challenge: Practical Steps Emerging from the Research

1. Replicate this successful model of Lead Maternity Care (LMC)

2. Actively recruit to increase significantly the number of LMC midwives in areas where women are most at risk

3. DHBs employ Clinical Mentors for Practices, to facilitate new graduates and new midwives to transition to working in highly complex communities.

4. Develop strong links with a range of community services and providers such as Maori and Pacific health teams.

5. Provide appropriate and effective referral systems to LMC midwives

6. Publish a leaflet in multiple languages to be given to every pregnant woman, encouraging her to access local LMCs

7. Provide community education to ensure that women are aware of their entitlement for maternity care, and ways to access this in a confidential and appropriate way.

More Practical Steps…8. Translate consumer feedback forms. Women who have English as a second language must have the opportunity to provide written feedback in their first language.

9. Develop a pilot project in area to establish a link midwife for pregnant teens, to enable them to access care that is acceptable to them, and is tailored to meet their specific needs.

10. Designate a link midwife whose cell phone number and website appears on posters at local school health clinics, bus stops, WINZ, Housing NZ, MacDonald’s, Family Health Centres, Family Planning clinics etc.

11. Develop antenatal and parenting education tailored to meet the needs of specific groups of women.

12. Create media campaign on early pregnancy care.

Response to the Challenge: Practical Steps Identified by Women.

•More up-to-date information from their GP on LMCs, for their GP to assist in finding an LMC, and for appointments to be arranged for them. •A midwife attached to the GP clinic. Many felt that being looked after by an independent midwife and being visited at home was the best type of care.•A website giving LMCs’ contacts, location, their experience / expertise / specialty•An 0800 number for finding an LMC, for making appointments, and for contacting their midwife.

More Practical Steps Identified by Women…

•Make home visits for antenatal care. Those who had been seen at home rated this highly. •Provide a pick-up and drop-off service, or mobile clinics that are easy to get to. •Give enough notice (at least 2 weeks) to organise a carer for other children.•Flexibility with bringing other children to appointments and having a sitter would be helpful.

Midwifery care can only be safe and meaningful if

it includes holistic attention to the

sociological frameworks of the woman and family.

Continuity of midwifery care for vulnerable

communities will see positive health gains far

beyond the current pregnancy.

Poverty is consistently found to be the most significant barrier to accessing and engaging in health care. A community based midwifery service reduces this barrier and increases the utilisation of health services, thus greatly improving health outcomes.

The challenge for midwifery and service providers is to ensure that every woman has access to such a model of maternity care: a model which is integrated in the community, is well accepted by the local population - both consumer and professional - and leads to good outcomes for women, babies and their families.

The Challenge is Clear!

The challenge to midwives and to all providers of maternity services is to ACT! We must not be sitting here in a year’s time with the contributing and avoidable factors once again clearly presented, having taken no steps to reduce barriers for women to access and engage with the maternity services.

The Challenge is Clear!

The Practical Steps are:•DO–ABLE!•NOT complicated •NOT expensive

They take us “Beyond the Numbers” and provide the challenge that service providers must meet if they are to make this vital difference to perinatal mortality and maternal health and wellbeing.