BEYOND THE NUMBERS
MIDWIFERY CHALLENGES IN
ADDRESSING PERINATAL
MORTALITY IN NEW
ZEALAND
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 care
2. 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 health
3. Lack of knowledge about options available
in choosing a midwife
4. Cultural expectation that all midwifery care
is hospital based
5. Belief that there is a fee attached to having a
midwife
6. 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 disrespectful
10.Language difficulties creating lack of
understanding
11.Childcare difficulties for large families
12.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 English
14. Doctor or midwife hard to understand
15. Lack of money and /or transport to attend
clinic and scans
16. 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
Perinatal mortality per 1000 births
16
14
12
10
8
6
4
2
0
PMMRC
NWH
CMDHB
MMPO
TMP
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
Community
Data 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 anxiety
Information 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.