Pasifika women and
barriers to the
initiation of antenatal
care at CMDHB
Dr Sarah Corbett
Dr Kara Okesene – Gafa
Alain Vandel - Statistician
PSRH Conference July 2013
Background – importance of
antenatal care
• Recommended that all women should commence maternity
care before 10 weeks.
• Under attendance and non attendance at antenatal care
linked with poor pregnancy outcomes including low birth
weight, fetal and neonatal death.
• Auckland Stillbirth Study found that regular utilization of
antenatal care was protective.
• 2011 PMMRC report analyzed contributing factors for the first
time. Most common found to be barriers to accessing or
engaging with maternity and health services.
• PMMRC report also found that Māori and Pacific mothers,
mothers from the most deprived socioeconomic quintile, and
teenage mothers were more likely to have stillbirths and
neonatal deaths.
• PMMRC Perinatal and maternal mortality in New Zealand 2011:Fifth report to the Minister of Health January to December
2009. Wellington: Ministry of Health 2011.
• Stacey T, Thompson J, Mitchell E et al. Antenatal care, identification of suboptimal fetal growth and risk of late stillbirth.
Findings from the Auckland Stllbirth Study. ANZJOG 2012: June 3;52(242)
Importance of early antenatal
visit.
• Pregnancy location, dating, number of fetuses + chorionicity
• Previous past obstetric issues may be managed/prevented (eg
severe PET, IUGR)
• Detection and management of medical issues – undiagnosed RH
disease, diabetes, thyroid, epilepsy, anemia, thromboembolism.
• Detection and management of psychiatric and social issues. (Suicide
leading cause of maternal death, and family violence increases in
pregnancy)
• Detection and management of infections – HIV/Hep B/Syphilis
• Early trimester intervention to prevent fetal abnormality –
Medication safety, alcohol, smoking, drugs, folic acid, iodine.
• Early detection of fetal abnormality – Aneuploidy screening, 11
week anatomy scan. Opportunity for genetic counseling and
screening in high risk women
• Smoking Cessation
Background - CMDHB
• Counties Manukau District Health Board (CMDHB) serves one of the
most economically deprived areas of New Zealand, with a high
proportion of young mothers, and women of Māori and Pacific
ethnicity.
• At least four out of five CMDHB women (6,075 women) that deliver
each year are at increased risk of experiencing a perinatal death
using PMMRC defined flags
- <20
- >40
- Obese
- Multiple pregnancy
- Living in Socioeconomic depravation
- Maternal medical problems
- Maternal mental health problems
• PMMRC Perinatal and maternal mortality in New Zealand 2011:Fifth report to the Minister of Health January to
December 2009. Wellington: Ministry of Health 2011.
Background – Model of care
• LMC (Self employed midwife, GP, private obstetrician)
• CMDHB bulk funded primary maternity services. (Community
midwives, shared care)
• Women identified as high risk are referred to Secondary Care, which
includes both the Obstetric Medical Clinic and Diabetes in Pregnancy
Service.
• Shared Care is unique system that developed in response to a
Private LMC shortage. Women who choose Shared Care receive
most of their antenatal care from a GP that enters into a Shared
Care arrangement with the DHB. In addition, these women are
offered three antenatal visits with a DHB employed community
midwife and are delivered at a CMDHB facility by a DHB employed
midwife. GPs that provide Shared Care are not required to have
specific training in antenatal care and are not required to have a
postgraduate Diploma of Obstetrics and Gynaecology.
The problem
• July 2011 5th annual PMMRC report showed CMDHB had
highest rate of stillbirth.
Rates of late booking at
CMDHB
• Anecdotally there is a high rate of late booking.
• 2000 study of Pacific infants 26% after 15 weeks
• 2011 report based on Healthware hospital registration data.
Shows average of 190 women a year unbooked in labour, and
over a third booked after 18 weeks.
• Difficulty knowing true rates as data collection issues. Date of
booking visit currently not routinely collected.
• Jackson C. Antenatal Care in Counties Manukau DHB: A focus on primary antenatal care. Auckland: Counties Manukau
District Health Board; 2011
• Low P, Paterson J, Wouldes T, Carter S, Williams M, Percival T. Factors affecting antenatal care attendance by mothers of
Pacific infants living in New Zealand. The New Zealand medical journal. 2005 Jun 3;118(1216):U1489.
Impetus for research
• Maternity services review committee set up – Report
published October 2012.
• Number of reports were commissioned :
- Catherine Jackson Public Health registrar
- Adrienne Priday - LMC
• My project ran concurrently.
Aims
• Aim of study was to identify significant barriers to the
initiation of antenatal care in pregnant women presenting to
CMDHB maternity services.
Study Design
• Convenience sample of unselected women seeking pregnancy
care at CMDHB maternity facilities from 8 July 2011 – 9 Sept
2011.
• Inclusions:
- Women in labour, or up to 6 weeks postpartum delivering a
baby at 19+5/40 onwards
- Antenatal women greater then 37/40 gestation
• Exclusions:
- Women residing outside Counties Manukau Area.
Study Design - Recruitment
- Consultants, registrars, SHO, DHB and independent midwives,
breastfeeding educators were asked to recruit women.
- Interpreters provided for women who did not speak English
- Eligible women who were identified after discharge as not
having completed a survey were posted a survey to their
home address with a stamped prepaid envelope.
- Participants demographics were checked against population
demographics after 100, 300, 500 and 800 responses to
ensure a representative sample.
Study Design - Questionnaire
- Patient demographics (age, ethnicity, education level,
relationship status, NHI, and date questionnaire completed)
- Self reported gestation at diagnosis of pregnancy and at
booking.
- Self reported number of antenatal visits
- Initial point of contact
- Series of questions on specific barriers to antenatal care.
(Barriers identified by mapping patient journey, literature
search, maternity consumer survey)
- 2 free text boxes where comments could be added about the
difficulties faced in getting antenatal care, and what would
have made it easier.
- From computer records – EDD, date of delivery, gravidity,
parity, eligibility for free care, model of care.
Study Design
• Pilot study done first – questionnaire followed by interview to
ensure easy to understand and that it was sufficiently
discerning.
• All patients gave informed consent to be in study. Study
protocol was approved by Northern Y Regional Ethics
Committee (NTY/11/EXP/026) and the Māori Research Review
Committee.
Study Design
• Late booking was defined as booking >18 weeks as reported by the woman.
• Sample size calculation
- Based on an audit of all registration forms completed at CMDHB from August 2008
– August 2009.
- To detect an OR or 1.75 with a power of 80%, sample size of 800 needed.
• Statistical plan
- OR for each item on the questionnaire was assessed using logistic regression,
adjusting for demographic and antenatal care data as appropriate, based on Akaike’s
information Criterion (AIC). Using backwards selection based on AIC starting with a
model including all questionnaire items , demographic data and antenatal
information a model was produced which best accounts for late booking of antenatal
care. Pairwise interactions from this reduced model were also considered.
Results:
• 826 women completed a patient survey from a estimated
eligible population of 2099. (39% response rate)
• 136 women (16%) booked for antenatal care after 18 weeks
gestation
• Study population representative of birthing population.
Ethnicity:
Ethnicity
Maori
Pacific
Indian
Asian
European
Other
CMDHB Births
2009
n=8038
1785 (22.21%)
3081 (38.33%)
599 (7.45%)
428 (5.32%)
1955 (24.32%)
190 (2.36%)
Study
Population
n= 867
155 (17.88%)
359 (41.41%)
67 (7.72%)
21(2.42%)
183 (21.10%)
82 (9.46%)
Early Bookers
Late Bookers
115 (74%)
261 (73%)
65 (97%)
20 (95%)
164 (90%)
76 (93%)
40 (26%)
98 (27%)
2 (3%)
1 (5%)
19 (10%)
6 (7%)
Late Bookers
Maori
Pacific
Indian
Asian
European
Other
Demographics - Age
100
90
80
70
60
Early bookers
% 50
Late Bookers
40
Pacific Early
30
Pacific Late
20
10
0
<20
20-24
25-29 30-34
Age
35-39
40+
Age of Pacifika late bookers.
Pacifika late bookers
4.26%
10.64%
20.21%
<20
20-24
25-29
18.09%
30-34
35-39
40+
27.66%
19.15%
Demographics - Parity
100
90
80
70
60
Early Bookers
% 50
Late Bookers
Pacific Early Bookers
40
Pacific Late Bookers
30
20
10
0
0
1
2
3
Parity
4
5+
Parity of Late booking Pacifika
women.
10
10
36
0
1
2
3
16
4
5+
12
16
Partner Support
100
90
80
70
60
Early bookers
% 50
Late bookers
Pacific Early Bookers
40
Pacific Late bookers
30
20
10
0
yes
no
Do you live with your husband/partner?
Demographics – Education
120
100
80
Early Booker
% 60
Late Booker
Pacific Early Booker
Pacific Late booker
40
20
0
No formal education
Primary
Secondary
Education level
Tertiary
Was it difficult for you to find an LMC to
look after you this pregnancy?
120
100
7.1
11
80
Did not try
60
81
76.3
70
16.6
19
19
Study population
Pacific
National survey
No
Yes
40
20
0
If yes; Why was it difficult?
50
Shortage of midwives in
my area
45
40
Wanted care with my
GP
35
30
Wanted care with a
private obstetrician
25
The midwives were too
busy
20
15
Didn’t know I had to
find an LMC
10
5
I didn’t know how to
find an LMC
0
study
population
Pacific women
National
Survey
Other
How did you go about finding care for
this pregnancy:
Pacifika women
GP helped me to find pregnancy care
Used the internet to find contact details
Phoned 0800 MUM 2BE
Friend or family member told me about an
LMC
I came to hospital and the staff helped me
find LMC
I didn’t know how to find an LMC
I called the hospital and they sent me an
appointment
I had the same LMC as last pregnancy
Impact of eligibility for free
care:
Eligibility for
maternity services
Study population
Yes
673 (97.1%)
No
20 (2.9%)
OR
3.07 (1.23,7.68)
Pacifika women
4.45(1.42-13.99)
Gestation at diagnosis of pregnancy vrs gestation at
booking.
45
52 women – 6.3%
40
35
30
25
gestation in weeks at
booking
20
Series1
15
10
5
0
0
5
10
15
20
25
30
Gestation in weeks at diagnosis
35
40
45
Gestation at diagnosis of pregnancy vrs gestation at booking.
45
191 women - 23%
40
35
30
25
gestation in weeks at
booking
20
Series1
15
10
5
0
0
5
10
15
20
25
30
Gestation in weeks at diagnosis
35
40
45
Factors significantly associated
with late booking - Knowledge
• Not knowing it was important to get pregnancy care (OR
11.53; 95% CI 1.27, 104.55)
• Not knowing that it was important to start getting care early in
pregnancy (OR 2.55; 95% CI 1.25,5.20).
• Patients who thought that they could look after themselves
during their pregnancy (OR 0.57; 95% CI 0.30, 1.06).
• Not knowing of the need to book an LMC (OR 1.58; 95% CI
0.97, 2.59) (not significant but almost)
Factors significantly associated
with late booking
• Having difficulty with English (OR; 0.37 95% CI 0.16,0.85),
• Not having enough money to get to clinic visits (OR 0.26; 95%
CI 0.12,0.57),
• Having no transport (a car) to get to appointments (OR 0.39;
95% CI 0.22, 0.69),
• Having problems getting childcare so they could attend clinic
appointments (OR 0.48, 95% CI 0.26, 0.88),
• Being too busy to go to appointments(OR 0.47, 95%CI 0.240.89)
• Couldn’t get an appointment at a time suitable (OR 0.41,
95%CI 0.23, 0.73)
• Scared that CYFS would get involved (OR 0.21. 95%CI 0.05,
0.90)
Key Findings:
• Pacifika women have higher rates of late booking.
• Particularly a problem for young women <25, and women in
their first pregnancy.
• Lack of partner support is a risk factor.
• Being ineligible for free maternity care is a significant barrier
• This can be despite higher education and literacy.
• Many women did not find out they were pregnant early.
• 11% of Pacifika women did not try to get pregnancy care.
• Lack of knowledge about getting pregnancy care and how to
go about getting pregnancy care is a factor. Not knowing the
importance of getting care earlier is a factor.
Key Findings:
• For most Pacifika women, the GP is the place they first go
when they find out they are pregnant.
• Societal factors that are barriers to care include transport,
childcare, lack of money to get to appointments and being too
busy to go to appointments.
• Difficulty with English, not having appointment times that suit
and being scared of CYFS involvement were systems issues.
What can be done?
1)Advocate for those living in poverty, and aim to reduce inequality.
2)Governmental level:
Need to have a recommendation that ANC start before 10 weeks.
Improve data systems: Collect and disseminate data about gestation at
booking.
3) Diagnose pregnancy earlier.
- public education about signs/symptoms of pregnancy
- Education campaign about what is a normal period?
- Freer access to pregnancy tests?
- Emphasize confidentiality of services.
• 4) Improve knowledge around importance of early antenatal
care, and how to go about getting care. Create a simpler
system to understand for patients and GP’s.
• 5)Increased integration of antenatal care into patient's existing
heathcare relationship/community/family. Ideally close to
home or sometimes in the home.
• 6) Development of workforce – Enough midwifes, provide
continuity of care model.
• 7)Be responsive to cultural needs: Importance of shared
language, developing resources in different languages.
Changes at CMDHB
• CMDHB external review of maternity care – Report published
2012.
Specific recommendations:
• Before 10 weeks all women should have a personalized
assessment of their specific needs and an individualized care
plan developed. Done by suitably trained GPs or midwives,
with an expanded assessment form.
- Develop multimedia educational material, Consider incentives
for early assessment, prioritize funding.
• Improve access to USS, especially if urgent.
• Identify and prioritize vulnerable and high needs women
- Set up vulnerable woman's MDT.
- Consider ways which these woman can be provided with
continuity of care.
- Development of comprehensive social worker/community
health worker supports.
• Priority given to expanding DHB case-loading model, with
emphasis on continuity of care, and reducing shared care
model. Ensuring doctors in shared care model are suitably
qualified.
• Consider extra payments to LMCs for women who are more
complex.
• Workforce recruitment and support of new graduates.
• Improving access to contraception and family planning
services. Postnatal, woman’s choice and contraceptive plan
should be communicated with GP.
• Improve data collection
Acknowledgements
• CCREP – Innovation fund grant
• Women’s Health management team
• All the LMC’s, DHB midwives, breastfeeding educators,
maternity nurses, medical staff who helped recruit women.
I would like to encourage people to take up research! Don’t be
scared just because you haven’t done it before.