Maternity care embedded in a primary care service Monika Steinmetz, Sue Pullon and Ben Gray Department of Primary Health Care and General Practice University.

Dept PHC and GP Sue Pullon 1

Maternity care embedded in a primary care service

Monika Steinmetz, Sue Pullon and Ben GrayDepartment of Primary Health Care and General

PracticeUniversity of Otago Wellington

Sept 2011


Maternal and infant health

Sept 2011

Sept 2011 Sue Pullon Dept PHC and GP

Reproductive years

Sexually active years

Pregnancy, Birth

New babies

Birth Older ageChildhood Adolescent Younger adult Older Adult

child rearing

Youth rearing…

Sexual and reproductive health: a recurring and integral part of life

4

A measure of health system effectiveness

• Maternal, Perinatal and Infant mortality• Breastfeeding rates; 6 weeks, 3 and 6 months • Immunisation rates; 6 weeks, 3 and 5

months…• Consumer satisfaction

Sept 2011 Dept PHC and GP Sue Pullon


NZ’s usual model of maternity care• Case based midwifery services

– since 1991• Lead maternity carers (LMCs)

– funded as such since 1996• defining elements: continuity

of care, ready access to maternity services, multidisciplinary collaboration…

• Obstetric back up from secondary care

• Most often independent of primary care services

Sept 2011


Continuity of care

• The continuity of not only care but also carer throughout the childbirth experience a feature of the New Zealand system – most similar to the Netherlands, in contrast to Australia, Sweden and the UK.

• lead maternity carer (LMC) often remains the primary caregiver even when the pregnancy has become complicated.

Sept 2011


Reducing inequalities

• ethical and social inequalities lead to poorer outcomes and experiences for women (Raleigh, et al., 2010)

• Outcomes are improved by enabling all women equal and easy access to good quality maternal and child health services

Sept 2011


Multidisciplinary collaboration

• Internationally, – big differences in the scopes of practice which regulate

and guide midwifery practice.– collaboration with and from maternity services varies

extensively • But what we do know…where health needs of

patients are more complex, collaboration amongst health care professionals needs to happen to a greater extent - not only of medical but also social care, health promotion and illness prevention.

Sept 2011

The spectrum of collaboration

(Spectrum of Collaboration. Oandasan et al., 2006)


Newtown Union Health Service - NUHS

Sept 2011

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What does NUHS do?

• primary health care in the community for over twenty years • service delivery is holistic and based on whãnau / family-

based care within the community, ensuring continuity of care and building of mutual trust and respect

• emphasis on community participation at all levels of the service

• quality awards for excellence in service provision to the community

• the first primary health care service in New Zealand to be accredited by the Te Wana programme in New Zealand in 2002


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Who does NUHS serve?

• 62% of patients - quintiles 4 and 5 of New Zealand Deprivation index (1= least deprivation and 5= most deprivation)

• Mixed ethnicity - – Pacific Islanders (21.7%) – European (19.2%), – Middle Eastern (17.1%), – Maori (15.2%) – Asian (15.2%). – African 11.7%.

• accessible and appropriate services for people from lower socio-economic groups and from Maori and Pacific backgrounds



…the multidisciplinary team of health professionals

• GPs• Practice nurses• Receptionists• Practice managers• Mental health liaison• Community health

workers• …and the team of

midwives

Sept 2011


the NUHS team of midwives

Sept 2011


The 5 midwives…

• Successfully work in a collaborative service with other primary health professionals whilst remaining autonomous lead maternity carers working in partnership with women– registered patients - access midwifery services as conveniently as

any of the other primary care services– ‘casual patients’ - women registered with other primary care

providers - ‘maternity only’ care • integrated with child health and other primary care services

– midwives provide the lead maternity care; the clients’ other health care needs are met by the GP, Nurses and other associated health professionals.

– all midwives are employed and paid by salary - as are all the other staff employed by NUHS.

Sept 2011


…the midwives work a – a team-based ‘shared caseload’ – model

• all women receive intra-partum care from the midwife on duty on the day as opposed to each being allocated to an individual midwife.

• women get to meet all midwives throughout their antenatal care - a ‘known’ midwife is present at the time of labour and birth.

Sept 2011

The spectrum of collaboration

Teamwork


NUHS pregnancy care 2006-2010

1st January 2006 to 1st November 2010• 702 women/pregnancies (registered + casual)

– 441 (63%) normal vaginal birth – 70 (10%) instrumental delivery– 189 (27%) elective or emergency LSCS (national LSCS rate 24%)

• Half (49%) in quintiles 4 and 5 • 84% fully or partially breastfeeding at 6 wks (national 6wk rate 79%)• Immunisation rates at 6 weeks - registered patients = between 91

and 100% for every quartile of the study period (Newtown Union Health Service, 2010)

• Immunisation rates at 6 months - registered patients = between 96 and 100% in 2010

Sept 2011


“How do women rate the team-based midwifery care they receive at the Newtown Union Health Service?”

Sept 2011


Consumer satisfaction survey

• Written form - in English - given to women at discharge from service – SAE

• Based on generic questionnaire from Midwifery council

• A requirement of the service

Sept 2011


Survey details • 5-point Likert scale questions (1= unsatisfied…5= very satisfied)

asking about…– Satisfaction with midwifery support provided– Ease of contact with midwives– Amount and quality of information to make good choices about care– Feeling safe– Treated with courtesy and respect– Usefulness of discharge visit?

• And open ended questions asking about– Positive aspects of care– Possible improvements– What could change for the better – Other

Sept 2011


Responses

• About half the women cared for by the midwifery team are registered patients; the other half casual

• Overall low response rate – variable each year• Primiparous and NZ European women far

more likely to complete and return the discharge consumer satisfaction survey

Sept 2011

Findings

Qustion 1 a)

Question 1b)

Question 1 c)

Question 2

Question 3

Question 4

Question 5

Question 6

0%10%20%30%40%50%60%70%80%90%

score 1score 2score 3score 4score 5

Findings

Themes from open ended questions and comments :

STRENGTHS WEAKNESSES SUGGESTIONS- Having a team - not enough time at visits - clear PN

appts.- Experienced midwives - lack of clear PN appts. - more time at

visits- Good availability - level of antenatal info - more info

antenatally- Home visits - unclear discharge visit -better

communication- Postnatal support- Prompt response- Good level of info- Safe care- Good collaboration


At a glance…

• Quality of care well-comparable with national data

• Team based care works well for midwives• Additional casual patients make service viable • Consumer satisfaction with team based

midwifery care appears very good• High number of return pregnancies• But response rate too low to be confident

Sept 2011

Dept PHC and GP Sue Pullon 26Sept 2011


Discussion at NUHS…

• Keen for improvements• Redesign the questionnaire; collect more data;• Compare registered and casual patients • But also…– Real limitations of written questionnaires– English as a second or third language – Need for other feedback

Sept 2011


On going work at NUHS…

• Revised satisfaction questionnaire, data collection ongoing

• Focus groups to be held• With health professionals – midwives but also

others in service • With women who have had midwifery care at

NUHS; casual; registered• Attention to possible need for interpreters

Sept 2011


Key references• Birkbeck University of London. (2010, 16th December ). National Evaluation of Sure Start (NESS). Retrieved 31. December,

2010• Department of Health, U. K. (2009). Delivering high quality midwifery care: the priorities, opportunities and challenges for

midwives.• Health Care Aotearoa. (2010). Te Wana Transforming social inequalities through community inspired health services. • Health for the People Newtown Union Health Service -20 years on-. (2009). Wellington: Steele Roberts Publishers.• Kateman, H., & Herschderfer, K. (2005). Multidisciplinary Collaborative Primary Maternity Care Project Current Practice in

Europe and Australia. A descriptive study: International Confederation of Midwives.• Ministry of Health. (2002). Guidelines for consultation with obstetric and related specialist medical services.• Ministry of Health. (2010). Maternity Snapshot 2008.• New Zealand College of Midwives. (2010). Midwifery in New Zealand. 2010• New Zealand Ministry of Health. (2007a). Primary Health Care Strategy: Key directions the information environment • New Zealand Ministry of Health. (2007b). Primary maternity services notice. Retrieved 3rd January, 2011• New Zealand Ministry of Health. (2008). Maternity Action Plan 2008-2012: Draft for Consultation.• Newtown Union Health Service. (1st April 2009 - 31st Mar 2010). Annual Report. Wellington.• Oandasan, I., Baker, G., Barker, K., Bosco, C., D'Amour D., Jones, L., et al. (2006). Teamwork in health care: promoting

effective teamwork in Canada.• Poulton, B., & West, M. (1993). Effective multidisciplinary teamwork in primary health care. Journal of Advanced Nursing, 18,

pp. 918-925.• Raleigh, V., Hussey, D., Seccombe, E., & Hallt, K. (2010). Ethnic and social inequalitites in women's experience of maternity

care in England: results of a national survey. Journal of the Royal Society of Medicine, 103(5), pp.188-198.• Royal New Zealand Plunket Society. (2010). Breastfeeding data: Analysis of 2004 -2009 data.

Sept 2011


• Schneider, Z., Whitehead, D., Elliott, D., Lobiondo-Wood, G., & Haber, J. (2007). Nursing & midwifery research Methods And Appraisal For Evidence-Based Practice (3rd ed.). Sydney: Mosby Elsevier.

• Skinner, J., & Foureur, M. (2010). Consultation, Referral And Collaboration Between Midwives And Obstetricians: Lessons From New Zealand. Journal of Midwifery and Women's Health, 55(1), 28-37.

• Statistics New Zealand. (2006). Quick Stats about Culture and Identity 2006 Census • U.S. Department of Health and Human Services. (2010). Quality Early Head Start Services. Retrieved 31st

December, 2010• van Teijlingen, E., Wrede, S., Benoit, C., Sandall, J., & DeVries, R. (2009). Born in the USA: Exeptionalism in

Maternity Care Organisation Among High-Income Countries. Sociological Research online, 14(1), • Waldenstrom, U., & Turnbull, D. (1998). A systematic review comparing continuity of midwifery care with

standard maternity services. British Journal of Obstetrics and Gynaecology, 105, 1160 - 1170.• White, P., Gunston, J., Salmond, C., Atkinson, J., & Crampton, P. (2008). Atlas of Socioeconomic Deprivation in

New Zealand NZdep2006.• Williams, K., Lago, L., Lainchbury, A., & Eagar, K. (2010). Mother's views of caseload midwifery and the value

of continuity of care at an Australian regional hospital. Midwifery 26, 615-621.• Xyrichis, A., & Lowton, K. (2008). What fosters or prevents interprofessional teamworking in primary and

community care? A literature review. International Journal of Nursing Studies 45, 140-153.•

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Sept 2011

Maternity care embedded in a primary care service Monika Steinmetz, Sue Pullon and Ben Gray Department of Primary Health Care and General Practice University.

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