Updating the Pregnancy
and Parenting Education
Service
Consultation Document
May 2013
Contents
1. Introduction
3
2. Key Themes from Service Reviews
4
2.1 Access to Services
4
2.2 Acceptability of Services
4
2.3 Quality of Services
5
3. Proposed Changes
6
3.1 Service Definition
7
3.2 Service Objectives
8
3.3 Service Users
8
3.4 Access to Services
9
3.5 Service Components
10
3.6 Service Linkages
12
3.7 Quality and Reporting Requirements
13
3.8 Service Planning
14
4. Consultation Process
15
2
1.
Introduction
Pregnancy and Parenting Information and Education (the Service) is an essential
and valued component of maternity services delivered to pregnant women,
expectant fathers/partners and whānau. The Service is intended to reflect and build
on the information, support and advice received through Lead Maternity Carers
(LMCs), Secondary and Tertiary Maternity services, primary health care and other
formal and informal support accessed throughout pregnancy.
The objective of the Service is to give expectant women, fathers/partners and
whānau the opportunity to acknowledge their own experience, to increase their
knowledge and skills, to empower them to trust themselves and gain the confidence
to access additional information and support when they need it1.
Education courses in most district health boards (DHBs) are currently delivered
through a mix of DHB-funded providers, non-government organisation (NGO)/private
providers and providers funded from other agencies. The minimum requirements for
DHB-funded services are specified in the national service specification published on
the National Service Framework Library.
The current national service specification was last reviewed in July 2002. Since then
the accessibility and quality of services has been assessed as part of two service
reviews2,3 and information collected through the Maternity Consumer Satisfaction
Surveys4,5. There have also been changes to national health policies that need to be
reflected in the content of services and service linkages.
The Ministry of Health is reviewing the DHB-funded Service and associated national
service specification and seeks stakeholder feedback on the proposed changes.
This consultation document sets out the proposed changes to the Service, rationale
for changes and supporting evidence.
1
Ministry of Health, 2002. Pregnancy and Parenting Education National Service Specification.
Families Commission Research Fund - Childbirth education: Antenatal Education and Transitions of Maternity
Care in New Zealand (Dwyer, 2009).
3
Ministry of Health - Review of Pregnancy and Parenting Education Services (Litmus, 2012).
4
Ministry of Health (2012). Maternity Consumer Surveys 2011. Wellington: Ministry of Health
5
Health Services Consumer Research for the Ministry of Health. 2008. Maternity Services Consumer Satisfaction
Survey 2007. Wellington: Ministry of Health.
2
3
2.
Key themes from Service Reviews
The service reviews recommended a range of changes to improve access to
services, acceptability of services and quality of service content and delivery.
2.1 Access to Services
Almost three quarters of first-time expectant parents access pregnancy and
parenting education courses (both DHB-funded and private courses)6. Research
shows that services are more likely to be accessed by New Zealand Europeans who
are tertiary educated and from middle to high income households 7. Barriers to
access for other groups of prospective parents include:
-
-
inadequate booking systems and follow up,
confusion over which course to select,
late presentation to primary care and/or LMC and therefore late referral,
insufficient or inaccessible (free) courses in some areas,
timing or format of services isn’t suitable for families circumstances or
preferences,
concern about whether other parents attending will be in similar situations,
especially for groups like teen parents, single women, parents where
language is a barrier etc, and
education courses may be less of a priority for parents with other challenges
in their daily lives.
The recommendations relating to access included clarifying the target population for
the Service, improving the registration process and management of waiting lists and
improving the fit between the needs and preferences of the target population and the
timing, format and style of services.
2.2 Acceptability of Services
The acceptability to different groups of consumers impacts on both their initial and
ongoing engagement. Factors that were seen by consumers and providers to
improve the acceptability of services included:
-
considering the specific information and support needs of fathers/partners and
other support people,
tailoring education format, timing and content to meet the needs of individual
groups of consumers rather than delivering set education classes,
scheduling education for parents at similar stages of pregnancy and where
possible with similar life circumstances e.g. young parents, single parents,
different ethnic groups etc, and
6
Ministry of Health (2012). Maternity Consumer Surveys 2011. Wellington: Ministry of Health
Families Commission Research Fund - Childbirth education: Antenatal Education and Transitions of Maternity
Care in New Zealand (Dwyer, 2009).
7
4
-
delivering services from community settings that are accessed by and
comfortable for consumers including youth hubs, social service hubs, marae,
churches, community clinics or halls etc.
2.3 Quality of Services
Both service reviews considered the quality of services. Overall, the content of the
current services was generally well endorsed. Recommendations for improving the
content included:
-
more time spent on early parenting and postnatal adjustment,
more practical content on the first weeks with a baby,
introducing content on different aspects of pregnancy and parenting at
appropriate stages of pregnancy and/or postnatally,
ensuring all resources remain up to date both in terms of content and
technologically, and
ensuring messages are consistent with the advice being given by other health
professionals.
The majority of feedback and recommendations received on service quality were in
relation to the skills and competence of the facilitator/educator. A high-quality course
facilitator is seen as more important than any other factor in ensuring successful
education, as well as access to and acceptability of services.
The ‘ideal educator’ uses adult education principles and a collaborative parentcentred approach. Key characteristics include approachability, friendly and positive
attitude, inclusive, knowledgeable, non-judgemental, flexible to encourage balanced
discussion, up to date with information, resources and technology, empowering and
understanding of community needs.
Recommendations for improving the quality and consistency of educators included:
-
developing competencies or standards of practice for course facilitators,
introducing a quality improvement process into the service specification, and
improving access to professional development for educators/facilitators.
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3.
Proposed Changes
The Ministry is proposing shifting away from the single service delivery model of
formal education classes, which appear to have variable access criteria, capacity
and reach across DHBs.
The Ministry proposes a layered Service that provides various information, education
and support depending on the needs of the Service Users. The Service will also be
a key reference point for other health, education and social services that require
evidence-based and consistent information on pregnancy and parenting to provide to
their clients.
The key components of the proposed Service are:


Information Component
- National Information – The Ministry of Health will publish and maintain a list of
endorsed resources and web links for Service providers to encourage Service
Users to access and other health, education and social service providers to
refer their clients to.
- DHB/Regional Information - Regional or DHB-level information on pregnancy
and parenting related services in their area. At the discretion of each
DHB/Region, this may include web information, telephone and electronic/text
message services, information available through community hubs, family
centres etc.
Education Component
- Group Education - Delivery of group-based education sessions on pregnancy,
childbirth and early parenting for Service Users with high or complex support
needs.
- Individual Education - As considered necessary, delivery of individual and/or
drop-in education sessions for Service Users with high or complex support
needs who would otherwise not access the group-based sessions.
Any changes to DHB-funded Services must be affordable within current DHB funding
for these services. The proposed changes aim to introduce improvements by
altering the structure and targeting within the Education Component to prioritise high
needs Service Users, who are most likely to benefit from the Service.
The Information Component aims to enhance coverage and access to information
and advice for all pregnant women, expectant fathers/partners, parents and their
whānau.
The main focus for the proposed Education Component is Service Users who have
high and/or complex support needs or are experiencing multiple disadvantages. It is
important, however, that this change in focus does not result in a shift towards a
deficit model for service delivery. The shift in focus is not about identifying and
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responding to risk. It is about acknowledging that these groups have the most to
benefit from accessing the Service.
The Ministry acknowledges that there is not a single service delivery model that will
meet the varied and diverse needs of these groups of parents. The proposed
changes attempt to strike a balance between ensuring national consistency in
access and quality of services, while providing DHBs and their contracted providers
with flexibility to structure services in a way that responds to the needs of their local
population groups.
The DHB/Regional Information Service described above does not attempt to
prescribe the way in which this information should be delivered or made accessible
to populations. There are a number of excellent local initiatives already underway
aimed at improving coordination and integration across maternity, primary care and
child health services. The intention is not to create a separate service or hub for
information, but that DHBs or Regions consider the best place within existing
community services and/or web-based information for parents and providers to have
access to DHB or Regional information on pregnancy, childbirth and parenting
related services.
3.1 Service Definition
The current service definition is that “Pregnancy and Parenting Education is a course
on pregnancy, childbirth and early parenting provided to a group of pregnant women
and their whānau/families.”
This definition restricts funders and service providers to only provide Services in the
form of courses or classes. Feedback suggests this is not the most inviting way to
frame the Service to encourage access and participation by high need Service
Users. This definition also lacks specific mention of fathers/partners who are a
target population for the Service.
Consumers reported in service reviews that they valued the support, empowering
and confidence-building aspects of the current service and a greater emphasis on
this in a service definition is required. Best-practice for delivery of education
services is via group settings to enable parents to share the experience and journey
of pregnancy, childbirth and parenting. This concept has been retained in the
proposed Service definition. The proposed Service definition also highlights that this
Service is part of wider maternity and other parenting services available to Service
Users and the need for consistency with these other services.
The proposed changes attempt to address these issues along with providing a high
level outline of the new service structure and the targeting of priority groups within
the Education Component of the Service.
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3.2 Service Objectives
Service Objectives are split into General and Maori Health Objectives.
General Objectives
The current General Objective is “…to give expectant women and their whānau the
opportunity to acknowledge their own experience, knowledge and skills, empowering
them to trust themselves and to know how to seek additional maternity information
and support when they need it.”
Knowledge and empowerment were the two common benefits that consumers
described as having come from attending a pregnancy and parenting education
course. The current Service objectives provide most of these key messages.
However, the programme logic for current services is not immediately clear from the
way it is presently written.
The proposed changes outline knowledge, support and empowerment as the
intended outputs of the Service. The intended outcomes that these outputs
contribute to are listed; access to support and services, making informed choices,
developing parenting skills and building confidence. Reducing inequalities through
layering the intensity of the Service and targeting high need populations is also listed
as a key objective. These changes to the objectives will make it easier to review
Services and assess effectiveness in the future.
Māori Health
The current objective for Māori Health captures the concept of cultural sensitivity in
delivery of services but doesn’t acknowledge the need to make specific
considerations to ensure services meet the health, cultural and support needs of
Maori and participation of Maori in planning and delivery of services.
The Maternity Services – DHB Funded tier one service specification captures these
concepts well. The Ministry proposes including specific considerations Service
providers must make for Maori in designing the course content and facilitation.
3.3 Service Users
The current specification defines Service Users as “one pregnant woman (or
prospective adoptive mother), and, where relevant, her partner or support person or
whānau.”
Participants from the service reviews commented that pregnancy and parenting
education services are the one service that was available during pregnancy for both
parents, whereas other maternity services were more focussed on responding to the
needs of the pregnant women. However, the use of the term “where relevant” in the
8
definition of Service Users appeared for many to be dismissive of the involvement of
fathers/partners. The proposed changes include fathers/partners as a key Service
User group.
Current DHB-funded Services also appear to have variable capacity to deliver
services to their populations. The definition of Service Users does not clarify the
target groups who Services should be prioritised. This appears to have led to DHBfunded Services being filled by those who register early enough in their pregnancy or
are proactive in accessing services, with many of the highest need Service Users
missing out on Services as they tend to register later or are less likely to follow up
after making initial contact. The proposed changes include defining a high need
target population groups for the Education Component.
3.4 Access to Services
Entry, registration and exit criteria
The current entry and exit criteria are that “each eligible pregnant woman is entitled
to receive one Pregnancy and Parenting Education programme during the duration
of each pregnancy.”
The Service Reviews have highlighted that no DHB is funding sufficient places to
meet this requirement and that there are different local expectations relating to who
is eligible or included in the target population for Services. The current registration
process in many areas of a “first-in-first-served” answerphone service was also
highlighted by consumers and other health providers as a barrier for many high need
families enrolling in and receiving services.
The proposed entry criteria have been purposefully left flexible around who is eligible
or not for the Education Component of the Services. It is intended that the DHB and
Service provider will clarify this on the basis of a local area needs assessment in the
Service Plan. The Ministry’s expectations on the types of Service Users who should
be considered in the high need population are detailed under the Service Users
clause.
Specific mention is now made to the need for a registration process and for the
responsibility to follow up referrals and enrol people in Services to be on the Service
provider, rather than the Service User. Under the new Service structure and high
need Service User criteria, the Service provider will also be required to provide
Service Users with details of how to access the Information Component and other
pregnancy and parenting education services in the area to those who do not meet
the high need Service User criteria.
The exit criteria section notes that Services will be delivered until around six weeks
after birth. However, the section also allows for providers to deliver postnatal
9
Services beyond this if this is considered necessary and appropriate by the funder
and provider when planning the Service.
Time
Feedback from the service reviews suggested that the timing considerations from the
current service specification remain appropriate.
However, some additional
information about the new Components of the Service is proposed. The new clause
includes details about when the Information Component of the Service should be
available and when the registration process for the Education Component should be
available.
The proposed changes include specifying that weekends and nights may be the
most appropriate time for delivery of the Education Component. However, the exact
nature of the days, times and timing throughout pregnancy/postnatally for the
Education Component will remain flexible for Service providers and funders to agree
based on the needs assessment and Service Plan.
3.5 Service Components
Programme
The current specification outlines the range of topics to be covered during pregnancy
and parenting education in the areas of access to maternity services, pregnancy
care, labour and birth care and care following the birth.
Given the overarching changes to the structure of the Service that are being
proposed, this section has been split into an overview of the Service (Key
Components), the Key Messages for all Components, the Information Service
Component and the Education Service Component.
Through the service reviews consumers commented that they wanted more detail on
early parenting and postnatal adjustment, more practical content on the first weeks
with a baby and for information to be delivered at appropriate stages of their
pregnancy. The content also needed to be updated to reflect changes in various
health policies and guidelines.
The proposed Key Messages section expands on the existing topics with the
inclusion of more detail to guide Service providers in designing the Education
Component. The proposed specification also notes that while the Key Messages are
the minimum content to be covered, timing and emphasis will be guided by the
needs of individuals or groups of Service Users. This is in response to feedback
from consumers and current evidence that the acceptability of the Service will be
improved when consumers are treated as partners in planning the Service rather
than solely as service recipients.
10
The proposed Information Component section outlines the roles and responsibilities
of the Ministry, DHBs/regions and the Education Component Service provider in
relation to the Information Component. The specification is left open regarding how
the Information Component will be delivered to allow DHBs/regions to determine the
best way to reach their population within existing or new service structures.
The proposed Education Component outlines the key points for consideration when
designing the Service, being; coordination of groups, format and timing, Key
Messages, delivery style and aims, and individual services. Accepted best practice
for adult education is to deliver services over a number of sessions rather than in
intensive blocks. This is also a requirement for the proposed Education Component.
The proposed specification is not prescriptive about how the Education Component
is set up. The Ministry acknowledges that in order to reach the highest need groups
of Service Users, the Services will need to be adapted to meet their access,
information and support needs. There is no “one-size-fits-all” model for how the
Education Component should be designed. This can only be specified at a local
area in response to a needs assessment and consultation with Service Users. The
specification is designed to ensure there are consistent messages being delivered
and consistent quality is achieved across all areas, whilst allowing funders and
Education Component Service providers the flexibility needed to decide how best to
deliver Services to high needs Service Users.
Setting
Evidence and feedback from consumers and providers indicated that using an
appropriate venue for education services will improve access to and acceptability of
services.
The current specification defines settings for services as “community rooms, marae,
hospitals, private homes, practice rooms or other appropriate places. Venues may
vary according to the needs of the women attending. Settings should be safe and
accessible.”
The proposed new setting clause builds on this with further considerations that
should guide selecting suitable venues, being:
-
accessibility, familiarity and comfort for Service Users
colocation or linkages with other related services to both attract referrals and
improve the Service Users navigation of other services, and
consultation with Service Users during service planning.
The feedback from consumers in the service reviews supports these changes as
ways of improving the acceptability of and likelihood to access services. High need
Service Users who are navigating a number of service providers alongside chaotic or
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stressful lifestyles may not see the need to prioritise this Service. Access therefore
needs to be made as easy as possible to support enrolment and participation.
Equipment/resources
Currently, the specification requires Service providers to develop resources,
reference lists and provide printed material for service users to take home. It also
requires resources to be available in a range of formats and up to date.
Consumers reported in the service reviews that they generally appreciated the
resources received through the Service. However, where these resources offered
conflicting advice to that of other professionals or were seen to be out-of-date, this
significantly reduced the consumer’s confidence in the whole of the Service.
The new roles and responsibilities relating to the Information Component propose
establishing a hub of information for consumers and health, education and social
service providers on pregnancy and parenting. Where other resources are used, the
specification requires the Education Component Service providers to review the
authenticity and appropriateness of these resources.
Educators/facilitators
The current specification requires that each programme is coordinated by one
person and provides a list of qualifications and professions that programme
coordinators will preferably hold or be.
The majority of feedback received through the service reviews was in relation to
different education or facilitation styles encountered by consumers and a lack of
standards or professional development framework for educators/facilitators. The
effectiveness of the educators/facilitators is seen by consumers, providers and
funders as a fundamental requirement for the success of services.
The proposed changes to the specification move away from specifying the
qualifications of the individual who can deliver education to specifying the
competencies that must be met and maintained by educators/facilitators. The list of
competencies has been adapted from the Australian National Association of
Childbirth Educators (NACE) Competency Standards for Childbirth and Early
Parenting Educators – Australia (2011).
The specification also proposes
requirements for quality improvement including the training, peer review and
professional development required to continue to meet the competencies.
3.6 Service Linkages
The Service is seen to be a key source of information for Service Users on the other
services available to them throughout pregnancy and once their baby is born.
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The current specification requires service providers to establish and maintain
linkages with organisations and providers that may refer women to the Service.
Maintaining relationships with these services is an important service linkage for
providers to improve access to the Service. With the proposed changes to the
Service structure, it is especially important that referring services are made aware of
the entry criteria for the Education Component and how to access support their
clients to utilise the Information Component.
Ensuring consistency of messages with other service providers and providing
information on other pregnancy and parenting services available to parents are two
of the key quality requirements of the Service. Therefore, it is important that Service
providers also establish and maintain linkages with other services that Service Users
are accessing or that the Service provider may refer Service Users onto.
The new Service Linkages section of the specification proposes the various
providers, services and organisations that Service providers will be required to have
formal protocols and/or relationships with.
3.7 Quality and Reporting Requirements
The Quality Requirements in the current specification cover the key areas that
should be addressed by the Service. However, the Service Reviews have
highlighted that despite these requirements, there is variable Service quality across
different providers/areas and many areas are not achieving these requirements.
The new Quality Requirements section of the specification attempts to capture the
recommendations from the Service Reviews in relation to improving service access
and acceptability for high need Service Users. More detail is proposed for each
requirement to ensure funders and providers are clear on the expectations for
Service quality and the target population for Services.
The educator/facilitator quality requirements proposed reflect the measures required
to meet and maintain the new competencies. The competencies and quality
requirements cover the key aspects that are considered important to ensuring a
consistently high standard of delivery for the Education Component across DHBs.
The importance of undertaking and using consumer surveys across to inform service
delivery models was highlighted in the Service Reviews. The new specification
proposes to formalise this requirement across all quality measures.
Changes are also proposed to the unit level data that is reported to the Ministry of
Health to make this data more useable in analysis and future policy development.
The main change proposed is the removal of prescriptive reporting against the
specific quality measures. The service reviews revealed that in some areas
providers had been providing the same, unchanged report every quarter against the
specification requirement. This indicates that the previous requirements were not
13
providing useful information for Service providers and DHBs in reviewing and
planning Services. The proposed specification is more flexible on the types of
service delivery model that may be delivered and therefore the reporting
requirements must reflect this. The specification proposes a single narrative report
on risks, trends and issues. DHBs are also able to specify further requirements at a
local level to reflect the delivery models agreed between the Service provider and
funder and other information that will be useful to both in reviewing and planning
Service improvements.
The specification proposes the introduction of two purchase units, one to count the
Information Component (block), and one to count the Education Component, per
service user.
The Ministry proposes setting up mandatory reporting of the Education Component
purchase unit to the National Non-admitted Patient Collection (by Service User NHI
Number). The detail of this will be confirmed following this consultation and in
discussion with DHBs.
3.8 Service Planning
With the changes to the Service structure, targeting and flexibility of delivery models,
the Service Planning section of the specification has become increasingly important.
The proposed Service relies on funders and Service providers working together to
identify the target groups within their populations that will benefit from Services, and
the Service formats, timing, setting and delivery models that will best meet the needs
of these Service Users.
The revised Service Planning section of the specification requires Service providers
to undertake a local area needs assessment annually to inform the plan for
delivering Services. The key considerations that Service providers must make when
planning Services are proposed.
These considerations reflect the key
recommendations from the service reviews in relation to access, acceptability and
educators/facilitators.
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4.
Consultation Process
The Ministry of Health is inviting stakeholder feedback on the proposed Service and
associated specification. The closing date for feedback on the revised Service and
specification is 28 June 2013.
Feedback may be emailed (maternity@moh.govt.nz) or posted to:
Karen Davis
Child and Family Programmes, SCI
Ministry of Health
PO Box 5013
Wellington 6145
A template for feedback has been provided. To assist us in analysing the feedback
received, it would be useful if you are able to organise your feedback using this
template.
PPIE feedback
template.docx
Feedback will be analysed and a summary of feedback produced. This feedback,
along with the input of key DHB content advisors will be used to amend the
specification prior to submission to the Service Specification Programme Executive
for their consideration.
Thank you for your time.
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