r h ca orao Ac 1982 the continuum of care. · r h ca orao Ac 1982 the continuum of care. RECOMMENDATIONS a. b. Actively encourage women who are healthy and have a normal pregnancy

Workforce Development: Increases in the midwifery workforce have been steady due to the effectiveness of workforce initiatives to recruit, retain and develop new midwives. Those increases are reflected in a reduction in the employed midwifery vacancy rate in 07/08 of 35.22% of the budgeted FTE to 15.23% in the 2011/12 year. In partnership with AUT, the student numbers trained within CMDHB have increased from 4 in 2007 to an intake of 30 in 2013. In 2007 the Midwifery Development and Education Service was commenced enabling an increase in student placements and a Satellite School to operate within CMDHB facilities. This school is now based in Ko Awatea.

CM Health Graduate Midwifery Programme anecdotally is known to be the best in New Zealand and the Women’s Health Division recognises that this is utilized by graduates who plan to work within the provider service and also for those to consolidate their training prior to LMC practice. The number of placements on this programme is determined by the number of new graduates the

Women’s Health Division can support within the available budget. On average 12 new graduates are employed from each intake.

Issues

Counties Manukau is committed to meeting national policy directions where self-employed LMCs are primary providers of maternity care. For Counties Manukau this requires a significant investment in supporting self-employed LMCs into practice and resource to support the complexities of our population health issues. There remain an insufficient number of employed and self-employed midwives; a lack of experienced midwives in comparison to graduate midwives and very low numbers of Maaori and Pacific midwives

Maternity health professionals have insufficient resources to meet the challenging population health issues. CMDHB has a higher proportion of women who could be deemed as vulnerable, clinically and socially, requiring a more intensive provision of care. Also, there

is an absence of a Maternity acuity tool to quantify the safe capacity of care that can be responsive to the unpredictable variation of demand particularly in the secondary care services.

The communication and clinical interface between the CM Health provider and self-employed midwives requires greater clarity and reflect a genuine intent to work in partnership. For primary maternity care, women are able to choose where they would like to birth – this has resulted in a higher proportion of low risk births at Middlemore and under-utilisation of the primary maternity units in the community.

The workforce development strategy will be reviewed in light of the current workforce issues to identify actions that may accelerate workforce growth. The workforce development model is being scoped and will include Allied Health, medical and other support services as well as Midwifery along the continuum of care.

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RECOMMENDATIONS

Actively encourage women who are healthy and have a normal pregnancy to receive midwifery led care and to birth at a primary birthing unit.

Improve the availability of LMC care throughout the district by increasing self-employed midwifery numbers and expanding "case- loading midwifery" services (DHB employed midwives) through the DHB.

Identify consumer preferences to location of labour and birthing through "Maaori, Pacific and Vulnerable Women Consumer" voice.

1. Interview LMCs/DHB primary staff and gather independent qualitative._ information about consumer birthing preferences, on what influences women's choices on birthing location and how an LMC's advice influence those choices.

2. Assess the appropriateness of women presenting to primary maternity birthing units both in the community and at MMH to address how low risk births can be diverted from MMH site.

Maternity and Midwifery Workforce Action Plan

Establish a "Maternity and Midwifery Workfor~e--Development" Project Group tasked to develop a workforce action plan pipeline toJQcrease the supply of t he maternity and midwifery workforce.

• Complete workforce projection and 'funding implications of increasing the supply for CM Health.

• Scope capacity requirement f~r tertiary services to manage expanding volumes.

• Identify actions (this may include modifying existing workforce initiatives) to increase the suppl'( of the Maternity and Midwifery Workforce to provide a fit for purpos~o'ff M"Health.

• Ko Awate~artnership with Women's Health Division to t ranslate this Plan into action working with Joint Venture partners.

Links to ~qmmendation 2(c), 5 (e, g) and 7 (c).

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Service Manager, Primary Maternity

Key Stakeholders: Consumers, LMCs.

Lead:

Director, Midwifery

Key Stakeholders: Service Manager, Primary Maternity; Ko Awatea; Portfolio Manager, Women's Health; Community midwives; Self-employed LMCs; GPs.

MILESTONE

31 December 2013

RECOMMENDATIONS

Seek an urgent review by the Ministry of Health of the Primary Maternity Notice funding mechanism for LMCs nationally, in order to create incentives to provide care for women who have clinical or social risk factors. This may include the introduction of an additional "high needs" or deprivation" payment to ensure the actual costs associated with providing care to women with risk factors and social constraints are adequately covers (e.g. home visits for women without transport, extra visit for those who requires additional monitoring or support at various stages of pregnancy).

Depending on the outcome of a review of Primary Maternity Notice funding by the Ministry, the DHB should consider supplementing the Primary Maternity Notice fu nding to create incentives to provide care for women who have clinical or social risk factors .

1 ... :AD/KEY SPECIFIC ACTIONS 1 STAKEHOLDERS

Review of the Primary Maternity Notice

Approach The Ministry of Health are not able to review the Primary Matern t-{Notice funding mechanism. The Ministry of Health will, however, review the funding allocation models nationally. In parallel, CM Health will review the allocation Primary Maternity Notice funding mechanisms to be more flexi bly 'applied to reflect a higher proportion of high need or vulnerable women in th~istrict. Work on vulnerable women criteria and the service responses from Recommendation 4 will inform this consideration.

Lead: Senior Portfolio Manager, Child, Youth & Maternity

Key Stakeholders: General Manager, Women's Health; Service Manager, Primary Maternity; Ministry of Health Self-employed LMCs.

MILESTONE

31 December 2013

RECOMMENDATIONS

e. Encourage midwives to work as self-employed practitioners in the CMDH B region to increase the number of LMCs available to provide care to women in the district. More support could potentially be provided to LMCs through the provision of ancillary clinical and non-clinical support services by the DHB and/or other incentives to make this an attractive option.

f. Re-establish the dedicated midwifery coaches/educators to support new graduate midwives and identify other measures that could be introduced to better support newly qualified midwives in both the community and DHB setting.

g. Externally benchmark the current FTE numbers and the composition of Counties Manukau midwifery, nursing and medical (Senior Medical Officer, Registrar and House Officer) staff in the community, Assessment Labour and Birthing Unit and Maternity ward at Middlemore Hospital and satellite CMDHB birthing units against other national and international providers. The purpose of such benchmarking is to determine the appropriate level and mix of safe staffing in such units. Notwithstanding the significant midwifery and medical workforce constrains with CMDH B, it is essential that objective safe staffing levels are identified as a matter of priority. The benchmarking should take into account the num ber of self- employed LMC providers practising in t he district and their caseloads.

SPECIFIC ACTIONS

Links to Recommendation 5 (b, f, g) and 7 (c). Lead:

Actioned in Recommendation 5 (b).

Approach In 2008 and 2010 benchmarking of FTE's was completed in comparison to Auckland and Waite mata DHBs. However, the issues for CMOHB are not just the budgeted FTE but the ongoing supply and skill mix of particularly midwifery staff (DH B and self- employed).

In addition to existing local, regional and national workforce planning, Ko Awatea will assist in leading a practical workforce development plan building on existing initiatives (e.g. Grow Our Own) to assess whether an accelerated growth intervention

Director, Midwifery Practice

Key Stakeholders: ~Ps; Auckland University of Technology; Service Manager, Primary Maternity.

MILESTONE

31 December 2013

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RECOMMENDATIONS

h. Ensure that experienced senior midwives are available 24 hours per day in both the labour and postnatal wards and that there are sufficient numbers of midwives

to provide one-to-one care for women in labour.

L.M. Review policy for handover of care in DU and suggest that needing an epidural or syntocinon should be managed by LMC at least short term until DHB staff can assist. May involve extra training for primary care LMCs.

Ensure that appropriate antenatal care is provided to those women not booked with a self- employed LMC.

SPECIFIC ACTIONS

Actioned in Recommendation 5 (b).

l inks to Recommendation 5 (g).

Approach

Identify gaps and solutions to ensure experienced senior midwives are available 24 hours per day through midwifery focus group.

1. Review CMDHB RN and RM escalation plan.

2. Agree a draft to enable coverage including resources requi~~· 3. Identify resource required to trial an on-call systerf

Pilot over a period of 3 months may include ~a(th'Care improvement methodology to support im~leme~qtion. Determine implications for funding stru~m~~·

Evaluate findings and publish.

Agree modifications or changes to existing resource and models of care. (_" Aim to integrate into existing ~siness.

Approach

Community Midwives Model of Care has been reviewed to ensure that full midwifery care can be provided to women who are not booked with a Self-employed LMC.

1. New Model of Care established.

2. ldentify>forecasted resource required for full implementation.

3. Evaluate findings and publish.

4 Ensure alignment to Recommendation 7 (c) within evaluation process.

5 . Agree modifications or changes to existing resource and models of care.

6. Aim to integrate into existing business.

7. Develop strategies to acknowledge and value existing staff members.

General ~aiiager, Women's Health

Ke.y ~taunolders:

~)condary Facilities and Core ~1dwives; Self-employed midwives; Community midwives; Ko Awatea.

Lead: General Manager, Women's Health

Key Stakeholders: Service Manager, Primary Maternity; Director, Midwifery; Community Midwives; GPs; Ko Awatea; Consumers.

MILESTONE

31 March 2014

31 December 2013

Commenced December 2012

RECOMMENDATIONS

Ensure that adequate numbers of clinics and suitably qualified multidisciplinary staff are avai lable to provide care to women with high medical needs, e.g. those women with diabetes and underlying health problems.

Ensure that when "Shared Care" arrangements are necessary these are provided:

• by a specific nominated general practitioner who has an on-going relationship with the individual pregnant woman; and

• in co-operation with experienced midwives; and

• by GPs and midwives who work closely together in a coordinated manner to ensure continuity of care and consistency of care contact with the pregnant woman.

The long-term goal should be that all general practitioners providing shared care wil l have appropriate qualifications. CMDHB should explore ways to support this occurring.

SPECIFIC ACTIONS

Actioned by Recommendation 4 and S(g).

Actioned by Recommendation 2 (band c) and 7 (c).

Th e Project Board are working closely with Primary Care o determine the support required for those GPs who

would like to provide a Shared Care model of care for their women within the agreed Vision for Maternity care for the d istrict.

General Man~er, Women's Health

Key Stakeho~~ers: Obstetric & Gyna ology Physicians; Community Midwives; Specia lty Midwives or l'Vlidwjfe Specialists; Self-employed LMCs.

Lead: Service Manager, Primary Maternity Portfolio Manager, Women's Health -Nettie, Debra

Key Stakeholders: Director, Midwifery; GPs; Ko Awatea; To remove- Nettie, Debra Community DHB Midwives; Self-employed LMCs; Consumers.

Lead : Chief Medical Advisor, Primary Care

Key Stakeholders: General Manager, Women's Health; Director, Midwifery; Service Manager, Primary Maternity; GPs; Ko Awatea.

MILESTONE

31 December 2013

Commenced December 2012

31 December 2013

Current Situation

Family Planning, Contraception and Sexual Health - There are only 3 Family Planning clinics in the CMDHB area – Manukau, Papakura and Highland Park.

Some schools also provide youth an access point for services. Family Planning provide a range of sexual and reproductive services including clinical services, health promotion, professional training, resources, personal products and cultural services. Funding is provided by the Ministry of Health for the delivery of services to Family Planning. Midwives currently provide contraceptive advice and can prescribe non-invasive methods as per their scope of practice.

Termination Services - Epsom Day Unit, Greenlane is the regional termination of pregnancy service for the Greater Auckland

area. This service is for first trimester pregnancies only. As this is the only service in the Auckland region, women must travel to Greenlane to access this service.

Vasectomy Services - Currently vasectomy services in CMDHB are accessed privately and incur a charge by the consumer There are three facilities currently providing this service and provider information can be accessed through Healthpoint. Family Planning provides low cost vasectomy services. This is less popular, particularly among Pacific males, as a form of contraception.

Issues

Due to the limited number of Family Planning clinics in CMDHB, services are restricted in the ability to provide the appropriate coverage and accessibility in relation to the needs of the district. Also, services accessed through schools are unable to provide continuity of care during the school term breaks. In addition, not all schools provide the same level of access. As termination services are centralised in Greenlane, there are obvious access issues for those women who live out of the area. Some women do find this a barrier for access especially as the current requirement is to attend twice. Anecdotally, the location of termination services outside the District may provide some anonymity for women, however, transport becomes an issue for many. The fee for vasectomy services is a major barrier for men to access this service. Some DHBs provide a subsidised fee for vasectomy services, which will be explored by this project.

6. FAMILY PLANNING

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RECOMMENDATIONS SPECIFIC ACTIONS LEAD/KEY STAKEHOLDERS MILESTONE

a. Review, as a matter of urgency, the current delivery of funding of family planning services in the CMDHB district. This issue needs immediate attention from both the Ministry of Health and CMDHB. The Panel recommends that a full review be undertaken of the services currently offered in the region, with consideration given to the accessibility of these services, particularly for your and “at-risk” women. It is essential that all women are able to access appropriate advice and affordable contraception in a timely manner.

Working with Ministry of Health as national funder, Identify gaps in the delivery of services for consumers:

Actions

1. Establish a “Family Planning, Contraception and Sexual Health” Project group to oversee the improved delivery of family planning services.

2. Commission work to comprise:• review current delivery of services and funding• identify gaps in services through consumer focus groups• agree a draft for improved service delivery

3. Identify solutions through consumer focus groups which may include modifications or changes to existing structures.

4. Pilot new service delivery packages (that may include attachment to existing mobile women’s health services)

5. Determine implications on current funding structures.

6. Evaluate effectiveness.

7. Agree modifications of new changes to be implemented and integrated as business as usual practice.

Consumer Perspectives

To be incorporated in Actions under Recommendation 2(a).

Lead:Clinical Director, Women’s Health

Key Stakeholders: Ministry of Health; Family Planning Services; Obstetrics & Gynaecology, Physicians; Director, Midwifery; Senior Portfolio Manager, Child, Youth & Maternity;Portfolio Manager, Women’s Health; GPs; Community Midwives; Self- employed LMCs; Consumers.

31 December2013

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RECOMMENDATIONS

A plan for postnatal/ subsequent contraception should be documented on the maternity antenatal care plan for all women, and should be further documented prior to d ischarge.

All women who leave CMDHB birthing facilities should ideally either be provided with contraception before discharge, or if needing to return for a long- acting reversible or permanent contraceptive method, have an appointment provided within 3-6 weeks of birth. The woman's choice and the plan should be documented in the clinical record and communicated to her GP.

Identify gaps in the delivery and planning of contraception for women

1. Through the "Family Planning, Contraception and Sexual Health" Projec,t group conduct and audit the consistency in contraception administration arr y lan ning by LMCs/Community midwives. This will include: <.J

• plan for postnatal contraception and antenatal care for al l ':'J'~'"\n ; • documentation pre-discharge confirming provision of ar prnp(iate

contraception;

• prescribing of contraception and administratio\ docurnented or an appointment made within 3-6 weeks of birth for procedural contraceptive devices. E.g. IUCD, Merena, Jardelle, diaphragm;

• woman's choice and plan documented ih c~ cal notes and her GP informed;

• train nurses, midwives, doctors i~ d~i~ery suite and postnatal wards to administer LARC such that a trajned,Jta ff member is available every shift;

• barriers that staff perceive may affect their ability to provide postnatal contraception care.

Determine issues and ide.Q:tifY solutions.

Pilot changes in prac ·ce. Evaluate effectiveness.

Agree modifications tO'new education material to be implemented and integrate

into existingJ>ust~ess.

Clinical Director, Women's Health

MILESTONE

Actions 1-3 31 December 2013

Action 4 30 June 2014

RECOMMENDATIONS

Urgent ly consider additional ways of providing contraceptive advice and long-acting contraceptives for women in Counties Manukau. This should include t he following:

introducing expert family planning midwifery/nursing roles in CMDHB;

training more health professionals to provide quality contraceptive advice and contraceptive services (such as inserting IUDs and Jadelle) and prescribing contraception, so that women can leave hospital after birth with a long-acting contraceptive method if desi red;

providing mobile contraceptive services and "afterhours" and "drop-in" contraception clinics; and

providing more coordinated and comprehensive schoolbased services including standing orders for emergency contraception and condoms.

Provide additional funding to extend Family Planning Association services in South Auckland to enable provision of:

• a drop-in clinic so that services can be provided when they are needed;

• extra after-hours clinics; and additional resources to train nurses, midwives, etc. to administer long-acting reversible contraception.

SPECIFIC ACTIONS

Identify improvement opportunities in the delivery of contraception advice and service delivery

1. Through the "Family Planning, Contracepp bn and Sexual Health" Project Group gove.rnanGe group to assess innovative methods f<\._aMress cont raception advice and servic~e)iv~y.

2. Dete rmine issues and identity solutions (including community education).

3. Pilot changes in prae>ti r,:~ Evaluate effectiveness.

4. Agree modifi catmr:is to changes in service delivery to be ·~p~ented and integrate into existing bLJAlile_.S~

Identify potential solutions to improve the delivery of contraception advice and service delivery

1. Through the "Family Planning, Contraception and Sexual Health" Project Group to assess innovative methods to address contraception advice and service delivery.

2. Determine issues and identify solutions including targeted approaches e.g. school based clinics, drop in family planning clinics

3. Pilot changes in practice. Evaluate effectiveness.

4. Agree modifications to changes in service delivery to beimplemented and integrate into existing business.

• • • LEAD/~.tY

s~."l{t.:Ll'JLDERS

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I •

Key Stakeholders: Ministry of Health; Family Planning Services; Obstetrics & Gynaecology, Physicians; Director, Midwifery; Senior Portfolio Manager, Child, Youth & Maternity; Portfolio Manager, Women's Heal th; GPs; Community Midwives; Self- employed LMCs; Consumers.

MILESTONE

Actions 1-3 31 December 2013

Actions 4 30 June 2014

RECOMMENDATIONS SPECIFIC ACTIONS LEAD/KEY STAKEHOLDERS MILESTONE

f. Counties Manukau women who require termination of pregnancy experience difficulties accessing this services given the need to travel to Greenlane Hospital. This issues needs further exploration by the DHB, perhaps in the first instance by considering the establishment of local non-surgical termination service.

1. Prioritise access issues for women requiring termination of pregnancy consultation and service.

2. Identify improvement opportunities address this issue that may include how and where access to Termination of Pregnancy consultations are accessed for vulnerable and young women in particular. This may also include the social support for women that needs to be considered alongside termination services (e.g. social worker, counselling).

3. Pilot changes in practice/services. Evaluate effectiveness.

4. Agree modifications to proposed changes to be implemented and integrate into existing business.

Lead:Clinical DirectorWomen’s Health

Key Stakeholders: Ministry of Health; Family Planning Services; Epsom Day Unit; Obstetrics &Gynaecology, Physicians; Director, Midwifery; Senior Portfolio Manager, Child, Youth & Maternity; Portfolio Manager, Women’s Health; GPs; Community Midwives; Self- employed LMCs;

Actions 1-331 December2013

Action 430 June 2014

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Current Situation

The maternity care sector is made up of multiple providers. The activity of different providers is guided by multiple policy and contract settings that do not necessarily align:

• Self employed LMC care is funded by section 88 Primary Maternity Notice that is managed centrally by the Ministry of Health;

• Secondary maternity care is funded by DHBs as part of their share of Population Based Funding for provider arm services. National service specifications define what is to be provided by DHBs including access to birthing and postnatal stay facilities, secondary care for high need women

• Some services are funded nationally by the Ministry of Health e.g. sexual and reproductive health promotion, antenatal and pregnancy education

• Diagnostic services in maternity are funded and provided by a combination of Ministry of Health (through section 88 claiming), DHBs and private providers

• Many services, while delivered in the District, are set by national policies and delivered through national agreements including primary care and Well Child

• Professional organisations e.g. Colleges also have a significant influence on what is provided by whom.

Issues

The consequence is that the incentives for services and health professionals to work together can be limited if funding and contracting incentives are not aligned. This can manifest in women experiencing multiple referrals and, sometimes, care that is not joined up. It is important that, locally, we make it easy for our health professionals to practice in a way that shares information and responsibility for a woman’s total experience

– sometimes despite the funding and contracting settings.

Counties Manukau Health will consider the clinical and managerial reporting lines and structure in context of what will help our maternity care sector:

• Join up care across the system so that women experience consistent care. Information sharing systems is a major enabler of joining up care;

• Take a whole of system approach to sharing information on population demand, clinical quality and issues of practice among all our colleagues both employed and self employed;

• Support flexible resource allocation to enable our maternity care system sustain itself while also being able to meet demand and manage complexity through an appropriately skilled workforce in all parts of the sector.

7. CLINICAL GOVERNANCE AND MANAGEMENT

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RECOMMENDATIONS SPECIFIC ACTIONS BY WHOM/KEY STAKEHOLDERS MILESTONE

a&b. Review current managerial and clinical reporting lines and structure within CMDHB Women’s Health Services as part of the review process.

The reporting lines and structure of Women’s Health requires a Whole Systems approach to Maternity Care. The Vision and Strategy work will assist in how the structure may be re-organized as the service re-shapes to respond to the needs of the community. The view is to align the integration of Maternity Care Services into the overall healthcare continuum.

Lead:Director, StrategicDevelopment

31 December 2014

c. With key stakeholders, agree a vision and strategy for maternity services that is articulated by all the Senior Leadership Team of Women’s Health as well as the CMDHB Planning and Funding division.

Approach

Form vision and strategy for Maternity Services in Counties Manukau Health.

1. Agree a method and process for strategy formation with Maternity stakeholders including consumers.

2. Complete detailed health needs analysis forecasting future births growth rate, likely workforce supply increase, p ojected socioeconomic need.

3. Develop options for consideration that include models of care, policy commitments to national settings and investments in Maternity services for CM Health.

4. Agree preferred options and draft, consult on draft and finalise strategy and implementation plan.

5. Agree implementation pathway that includes folding residual work from Maternity Review recommendations into ongoing work programme for strategy implementation.

Lead:Senior Portfolio Manager, Child, Youth & Maternity

Key Stakeholders: DHB Maternity and Women’s Health staff, LMCs – self employed and DHB employed, GPs; Obstetrics & Gynaecology Physicians; Maternity Nurses.

31 December2013

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RECOMMENDATIONS

d. Establish an overarching Maternity Clinical Governance Groups, chaired by a senior clinical, that is accountable for overseeing maternity services across the Counties Manukau population. This group should include representation from all of the providers of maternity services for the CMDH B population. It should include representation from the CMDH B Planning and Funding division but have a governance reporting line separate from the Child Youth and Maternity Clinical Governance Group will be to provide assurance to the Senior Leadership Team of Women's Health, the Executive Leadership Team of CMDHB, and the Board in relation to the safety of maternity services.

At the time of the Maternity Review's report was released the overarching Maternity Clinical Governance Group was the Maternity Expert Advisory Group (MEAG) which reported directly to the Child Youth and Maternity Strategic Forum. Th's was established in March 2011. The MEAG was chaired by the Clinical Director Women's Health and the membership included the whole of maternity system including general practice, LMCs (self-employed and DHB employed) and medical specialists.

Since this time there have been a number of new and/or additio nal drivers that would indicate a timely review of structure. Some of these drivers include:

• The Maternity Quality and Safety Programme;

• The External Review of Maternity Care in Counties Manukau, and subsequent recommendations and action plan, with di rect reporting expecations to ELT and the Board;

• The implementation of the Maternity Clinical Information System; and

• The Prime Minister's Youth Mental Health Initiative.

The agreed change in Women's Health in response to these drivers are:

•

The External Maternity Review Project Board becomes the MEAG and reports directly through to ELT.

Three n~ groups established which report to the new MEAG:

1. Maternity Data Governance

2. ~as Clinical Reference Group

3 Maternity Quality and Safety Programme Governance Group

These changes have commenced from June 2013.

Director, Midwifery Practice

MILESTONE

Completed June 2013

Current Situation

Maaori and Pacific women make up more than half the births in Counties Manukau, are disproportionately represented in clinically and socially vulnerable families requiring specific attention to ensure that services are accessible to them. Half of the Pacific population speak languages other than English and are likely to have larger families.

Maaori women on the other hand have a high incidence of teen pregnancies with higher rates of smoking during pregnancy than other ethnic groups. Due to the poverty experienced by many Maaori families, access to services are limited. Ensuring an LMC and supporting Maternity services can deliver services within a Maaori model of care is of utmost importance to many Maaori women and their whaanau.

Issues

Maaori and Pacific populations are increasingly diverse and assumptions about what is appropriate for those groups requires constant re-examination.

It is important that services and health professionals keep their knowledge and information current on what approaches are appropriate for Maaori and Pacific women. Updating Tikanga Best Practice and Pacific cultural competency training programmes are important sources of advice to ensure that health professionals are well informed about the barriers that exist for Maaori and Pacific women, and how their own clinical professional practice must adapt to be effective and responsive to their needs.

8. MAAORI AND PACIFIC WOMEN

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RECOMMENDATIONS

Improve the access to and quality (including cultural appropriateness) of maternity services for Maaori and Pacific women who are more likely to experience perinatal death. This includes ensuring that educational material and information is provided in a variety of languages that the maternity workforce better reflects the wider community, and that maternity care is provided in a manner that more appropriately meets the needs and requirements of different cultural group.

Reinforce strategies to reduce the number of pregnant women who smoke. This may include the development of a KPI to measure smoking rates and smoking cessation rates amongst pregnant mothers at 15 weeks' gestation. Smoking cessation should be specifically monitored by further collection of data around outcomes in women referred to smoking cessati0n services during pregnanf y

. KEY

SPECIFIC ACTIONS STJ'.l\Et'.'JLDERS

Establish Project Group comprising consumers and clinical experts to oversee project "Maaori, Pacific and Vulnerable Women Consumer Engagement"

The'e •ciioo. "e detoiled in Reoommend•tion 2 {•). ~ 0 <$-qf

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A target to increase the num~r of pregnant women who's smoking status is recorded (Ask) then offered brief interention (Brief) and offered cessation (Cessation) is In place for the 13/14 year. The ter~t 1s, however, in the early stages of development and wil l require information sy~tem developments to ensure that data is being captured and referrals to s'o~ree support are in place. This work links to the DHBs overall population healt~pr'ority to be a Smokefree DHB by 2025:

1. Establis.b with- maternity services and workforce plan to establish baseline data for smok~g'status among pregnant women.

2. lm~ment capacity building plan to enhance information capture, assess access to ~mokefree specialist support and available capacity.

Agree implementation plan to increase recording of smokefree status and access to smokefree services.

Link to birth outcomes to measure efficacy.

Lead: Director, Strategic Development

Lead: Smokefree DHB 2025 Sponsor

Key Stakeholders: Maaori and Pacific women; Maaori Health Team; Selfemployed LMCs; Community Midwives; Obstetric and Gynaecology Physicians; GPs.

MILESTONE

31 December 2013

Action 1 30 September 2013

Action 2-4 31 December 2013

RECOMMENDATIONS SPECIFIC ACTIONS KEY STAKEHOLDERS MILESTONE

c. Develop culturally appropriate nutritional interventions to reduce pre-pregnancy obesity and optimise weight gain during pregnancy, especially for Pacific women. This could include training community health workers to provide nutritional advice to at-risk pregnant women.

The DHB will work with specialist and community based maternity services to build on existing research and trial nutritional interventions.

Lead:Director, StrategicDevelopment

Key Stakeholders: Consumers, Maaori Health Team; Self- employed LMCs; Community Midwives; Obstetric and Gynaecology Physicians; GPs

31 December 2014

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Current Situation

Information: At the time the Review’s report was released, self employed LMCs did not have access to clinical information held by the hospital on their patients. In addition, the clinical record for pregnant women had been held by multiple health professionals with limited connectivity. Counties Manukau Health has approved capital funding in addition to regional Information Investment funding to develop the Maternity Clinical Information System. The purpose of the Maternity Clinical Information System is to provide a shared record of women accessible to those health professionals involved in her care (with consent).

Communication: Clearer channels of communication will be established to share and provide a way of gathering feedback from multiple stakeholders. Those channels include regular forums for communication among maternity health professionals involved in providing care, public updates on progress in implementing the maternity review recommendations and ensuring consumers have access to appropriate information wherever they a e accessing care.

Issues

The current maternity clinical information system has limitations and compromises the delivery of safe care due to the inability of information to be shared easily between maternity care providers, particularly between self-employed LMCs and the hospital databases. This reflects the general limitation of interface between DHB systems and general practice information systems. Consequently, women are often seen for care in the DHB with very little information available from the community and vice versa. This has obvious negative effects on continuity of care and sound clinical judgement when information about a woman and her baby are not easily accessible.

Communication pathways are also loose and require a solid structure for ensuring that health professionals and the public have the most up to date information and a feedback system that will assist in improving the delivery of our services. This is essential for engagement across the health sectors and especially the community.

9. COMMUNICATION AND INFORMATION

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RECOMMENDATIONS

Implement, as a matter of urgency, a comprehensive and integrated maternity information system.

Implement a means of communicating effectively with self-employed LMCs, particularly in relation to key information about care provided by CMDHB to women booked with the LMC.

Approved and endorsed to proceed with implementation from March 2014

This is to be overseen by the Women's Health Information System Steering Group who report monthly on progress to the Maternity Review Project Board.

LMC access to information about the women in their care will b ~ned through Recommendation 9 (a).

The following communication channels are in place:

1. New forums with self-employed LMCs to com)!{ment existing forums e.g. Access Holders meeting

A Healthpoint re-design pilot has been £ll.E.'} ssful. This has focused on the information accessed through HealtQpoint and is now transitioning into implementation phase. As a <t:ommunication portal, Healthpoint has profiled all LMCs and Maternf~services available to women in the Counties Manukau district e .g. Smokin8\~ssation, Diabetes clinics, and provide key information for LMCs to ass ist in service del ivery.

VPN access has bee~ctivated for a ll self-employed midwives that have accepted this offe r to enable connectivity to hospital information systems. Further progres~ tQ connect self-employed midwives to relevant applications continues.

4. A sta~eholder engagement and communication plan is in development with Comm~ications Team that includes web based information, newsletter and'~ublication inserts provid ing regular updates on the programme

V1plementation.

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General Manager, Women's Health

Lead: Senior Selfemployed LMC

Key Stakeholders: Communications team, CMH; Self-employed LMCs; Community Midwives; Facilities and Core Midwives; Obstetricians.

MILESTONE

Implementation March 2014

Action 1-3 Completed July 2013

Action 4 30 September 2013

APPENDIX 1- Maternity Review Recommendations Summary, O~er 2012

~tf • 1. Implementation and Monitoring

(a) Appoint a dedicated Project Manager to ensure that the recommendations in this report are implemented and that progress is closely monitored at Executive Management and Board level.

2. Early Pregnancy Assessment and Planning

(a) Develop multi-media educational material, with input from Pacific and Maaori communitfes, which emphasizes why early access to maternity care, including pregnancy assessment and planning, is important.

(b) Consider ways to incentivise women to attend a full pregnancy assessment appoint ment, with a midwife or general practitioner, before 10 weeks of pregnancy.

(c) Prioritise funding to enable this early pregnancy assessment/booking visit to be accessible to all women. This may include employment of midwives who have a special interest in early pregnancy care.

(d) Urgently review the current Pregnancy Booking Form to update screening and identification of clinical and social risk factors.

3. Ultrasound Scanning

(a) Undertake a detailed review of the provision of ult ra s0uq,d scanning services across the CMDHB district and develop a plan to enable adequate access to scans for pregnant women, especially when a prac ·tioner requests an urgent scan.

4. Prioritisation of Vulnerable and "High Needs" Women

(a) Establish a set of criteria to define and identify the most socially and medically vulnerable pregnant women.

(b) Establish a vulnerable women's multi-disciplinary group as soon as possible to which those women who are identified as most vulnerable can be referred.

(c) Consider ways in which those identified as most vulnerable can be provided with continuity of care - e.g. through LMC or case loading DHB midwives and/or specialty teams with dedicated additional social work/community with a single, consistent care provider, is particularly important for these women.

(d) Urgently consider the development of comprehensive social worker and/or community health worker support services, to assist pregnant women to address the social factors that may impact on their health status sand their ability to access and receive appropriate maternity care.

5. Models of Care and Workforce

(a)

(b)

(c)

(d)

(e)

(f)

(g)

(h)

(i)

(j)

(k)

(I)

Actively encourage women who are healthy and have a normal pregnancy to receive midwifery led care and to birth at a P{imary birthing unit.

Improve the availability of LMC care throughout the district by increasing self- employed midwifery numbers and expa~ding "case-loading midwifery" services through the DHB.

Seek an urgent review by the Ministry of Health of the section 88 funding mechanism for LMCs nationally, in orde r to create incentives to provide care for women who have clinical or social risk factors. This may include the introduction of an additional "high needs" or deprivation" payment to ensure the actual costs associated with providing care to women with risk factors and social constraints are adequate ly covers (e.g. home visits for women without transport, extra visit for those who require additional monitoring or support at various stages of pregnancy).

Depending on the outcome of a review of section 88 funding by the Ministry, the DHB should cons 'der supplementing section 88 funding to create incentives to provide care for women who have clinical or social risk factors .

Encourage midwives to work as self-employed practitioners in the CMDHB region to inarease the number of LMCs avai lable to provide care to women in the district. More support could potentially be provided to LMCs through the provislo of ancil lary clinical and non-clinical support services by the DHB and/or other incentives to make this an attractive option.

Re-establish the dedicated midwifery coaches/educators to support new gratlu~idwives and identify other measures that could be introduced to better support newly qualified midwives in both the community and DHB i>etting.

Externally benchmark the current Full Time Equivalent (FTE) numbers a~ the composition of Counties Manukau midwifery, nursing and medical (Senior Medical Officer, Registrar and House Officer) staff in the co~tm1ty, Assessment Labour and Birthing Unit and Maternity ward at Middlemore Hospital and satellite CMDHB birthing units against other nation~ ~n~ international providers. The purpose of such benchmarking is to determine the appropriate level and mix of safe staffing in such units. Notwithst~ding the s ignificant midwifery and medical workforce constrains with CMDHB, it is essential that objective safe staffing levels are identified as'a.m.atter of priority. The benchmarking should take into account the number of self-employed LMC providers practicing in the district and their caseloads.

Ensure that experienced senior midwives are ava'llable'J/hours per day in both the labour and postnatal wards and that there are sufficient numbers of midwives to provide one-to-one care for women 1~abour.

Ensure that appropriate antenatal care is p rov·ded to those women not booked with a self-employed LMC.

Ensure that adequate numbers of clinjc-s ~d suitably qualified multidisciplinary staff are avai lable to provide care to women with high medical needs, e.g. those women with diabetes anct uncierlying health problems.

Ensure that when "Shared Car(_~rangements are necessary these are provided: • by a specific nominated general practitioner who has an ongoing relationship with the individual pregnant woman; and • in co-operation with experienced midwives; and • by GPs and midwives who work closely together in a coordinated manner to ensure continuity of care and consistency of care contact with the

pregnant woman.

The long-term gbal should be that all general practitioners providing Shard Care will have appropriate and up-to-date postgraduate qual ifications in women'~tf\ and/or obstetrics and gynaecology. CMDHB should explore ways to support this occurring.

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6. Family Planning

(a) Review, as a matter of urgency, the current delivery of funding of family planning services in the CMDHB district. This issue needs immediate attention from both the Ministry of Health and CMDHB. The Panel recommends that a full review be undertaken of the services currently offered in the region, with consideration given to the accessibility of these services, particularly for young and "at-risk" women It is essential that all women are able to access appropriate advice and affordable contraception in a timely manner.

(b) A plan for postnatal/subsequent contraception should be documented on the maternity antenatal care plan for all women, and should be further documented prior to discharge.

(c) All women who leave CMDHB birthing facilities should ideally either be provided with cont ace ption before discharge, or if needing to return for a longacting reversible or permanent contraceptive method, have an appointment provided within 3-6 weeks of birth. The woman's choice and the plan should be documented in the clinical record and communicated to her GP.

(d) Urgently consider additional ways of providing contraceptive advice and long-acting contraceptives for women in Counties Manukau. This should include the following:

• introducing expert family planning midwifery/nursing roles in CMDHB

• training more health professionals to provide quality contraceptive advice and contraceptive services (such as inserting IUDs and Jadelle) and prescribing contraception, so that women can leave hospital after birth with a long-acting contraceptive method if desired;

• providing mobile contraceptive services and "after-hours and "drop-in" contraception clinics; and

• providing more coordinated and comprehensive school-based services including standing orders for emergency contraception and condoms.

(e) Provide additional funding to extend Family Planning Association services in South Auckland to enable provision of:

• a drop-in clinic so that services can be provided when they are needed;

• extra after-hours clinics; and

• additional resources to train nurses, midwives, etc. to administer long-acting reversible contraception.

(f) Counties Manukau women who require termination of pregnancy experience difficulties accessing this service given the need to travel to Greenlane Hospital. This issue needs furthe r exploration by the DHB, perhaps in the first instance by considering the establishment of local non-surgical termination service.

7. Clinical Governance and Management

(a&b) Review current managerial and clinical reporting lines and structure wit hin CMDHB Women's Health Services as parfof t he review process.

(c)

(d)

With key stakeholders, agree a vision and strategy for maternity services that is articulated by all the Senior Lea~rship Team of Women's Health as well as the CMDHB Planning and Funding division.

Establish an overarching Maternity Clinical Governance Groups, chaired by a senior clinician that is acc;au_Qtable for overseeing maternity services across the Counties Manukau population. This group should include representation from al l of t he provide~lmatern i ty services for the CMDHB population. It should include representation from the CMDHB Planning and Funding division but have a go er ance reporting line separate from the Child Youth and Maternity Clinical Governance Group will be to provide assurance to the Senior Leadersh ip[~m of Women's Health, the Executive Leadership Team of CMDHB, and t he Board in relation to t he safety of maternity services.

8. Maaori and Pacific Women

(a) Improve the access to and quality (including cultural appropriateness) of maternity services for Maaori and Pacific women who are more likely to experience perinatal death. This includes ensuring that educational material and information is provided in a variety of languages, that the maternity workforce better reflects the wider community, and that maternity care is provided in a manner that more appropriately meets the needs and requirements of different cultural group.

(b) Reinforce strategies to reduce the number of pregnant women who smoke. This may include the development of a KPI to measure smoking rates and smoking cessation rates amongst pregnant mothers at 15 weeks' gestation. Smoking cessation should be specifically monitored by further collection of data around outcomes in women referred to smoking cessation services during pregnancy.

(c) Develop culturally appropriate nutritional interventions to reduce pre-pregnancy obesity and optimise weight gain during pregnancy, especially for Pacific women. This could include training community health workers to provide nutritional advice to at-risk pregnant women.

9. Communication and Information

(a) Implement, as a matter of urgency, a rnmpre!iensive and integrated maternity information system.

(b) Implement a means of communicatillg'~ffectively with self-employed LMCs, particularly in relation to key information about care provided by CMDHB to women booked with the LMC.

APPENDIX 2 - Terms Of Reference

TERMS OF REFERENCE

Chair:

Project Executive:

Membership includes:

Objectives:

MATERNITY REVIEW IMPLEMENTATION PROJECT BOARD

Margie Apa - Director, Strategic Development

Pauline Sanders-Telfer - Project Manager, Strategic Programme Management Office

Nettie Knetsch - General Manager, Kidz First & Women's Health

Carmel Ellis - Senior Portfolio Manager, Child, Youth & Maternify

Thelma Thompson - Director, Midwifery Practice

Sarah Tout - Clinical Director, Women's Health

Adrienne Priday - lead Maternity Carer (Self-empl oye/ Midwife)

Philippa Andersen - Public Health Physician

Debra Fenton - Service Manager, Primary Maternity

Jennifer Njenga - General Practitioner

Gwynette Ahmu - Portfolio Manager, w"6rnen's Health

Pauline Sanders-Telfer - Project Man~er, Strategic Programme Management Office

The objective of this Project Board is to govern and direct the implementation of the recommendations outlined in the External Review of Maternity Care in the Counties Manukau District, October 2012. The Project Board will ensure the recommended actions are delivered, provide clinical guidance and quality assurance.

The Project Board will work to deliver the following activities: • Clear cl inical governance and managerial structure and processes. • Clear identification and management of high risk women. • Improved antenatal care. • Improved access to family planning services.

Improved access to diagnostic test especially urgent requests. • A clear workforce development strategy and action plan. • Improved communication systems and quality of information provided. • Reduced inequality of access to maternity care.

Scope:

Governance:

Programme Reporting:

Meetings:

Review Date:

This Project Board will ensure the recommendations of the Maternity Review lmp lementa_ti~ Project are del ivered.

The following is considered out of scope of this project:

• Any activity within the scope of other programmes or projects, which is be ingJTianaged in its total ity by a project

• Other DHBs

The Project Board is chaired by the Director of Strategic Management and will run on consensual lines however ultimate decision-making responsibility rests with the Chair. The meeting w ill be quorate providing the Chair or a person nominated in their absence is present and at least half of the members are in attendance.

The Project Manager will prepare an overall proj~t high;£:t report following every project board meeting and will go to the ELT via the Project Board Chair.

The Project Board will be responsible to th)DHB Board via the Project Board Chair.

The minutes and any collateral will be filed in th e W: Drive/ SPMO folder/ Proj Maternity Review Action Plan/ Project Board Documents folder.

The Project Board will meet monthly.

Six monthly.

Next due: 1 Jul;el l..>

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APPENDIX 3 - Project Groups

RECOMMENDATION LEAD

(2) Early Pregnancy and Assessment Portfolio Manager, Women's Health

(4) Prioritisation of Vulnerable and "High Public Health Physician Needs" women

(5) Models of Care & Workforce Director, Midwifery Practice

(6) Family Planning Clinical Director, Women's Health

"Maaori, Pa~ViO'nd ~ulnerab le Women Consumer Engagement"

i. Col1{~er Groups: Maaori, Pacific, Vulnerable

ii Cl i f"! ical Expert Group

" Vulnerable Pregnant Women Criteria"

i. Consumer Governance Group

ii. Clinical Expert Group

Maternity & M idwifery Workforce Development

"Family Planning, Contraception and Sexual Health"

i. Consumer Group

ii. Clinical Expert Group

APPENDIX 4 - Primary Maternity Notice 2007(excerpts related to LMC’s and Ultrasounds)

Part D

Specific requirements for each primary maternity service (including service specifications and payment rules)

Subpart DA—Lead maternity careGeneral information about lead maternity care

DA1 Aim of lead maternity care

(1) The aim of lead maternity care is to provide a woman with continuity of care throughout pregnancy, labour and birth, and the postnatal period.

(2) Lead maternity care is available to women, and their newborn babies.

Defined in this notice: labour and birth, lead maternity care

DA2 Registration

(1) In order to receive lead maternity care a woman who is eligible for primary maternity services must register with a LMC of her choice.

(2) By registering with a LMC, the woman is also registering with a maternity provider.

(3) Registration may occur at any time from the diagnosis of pregnancy until 6 weeks after birth, but no claim for payment may be made for lead maternity care that is provided before the date of registration.

(4) The woman and her LMC must properly complete a registration form in the format specified by the Ministry of Health.

(5) The woman must sign a registration form. Each form must be dated with the date on which the form was signed by the woman (date of registration).

(6) The woman may, at any time, change the LMC with whom she is registered by signing a registration form with the new LMC.

(7) The woman may be registered with only 1 LMC at a time.

(8) If a registration form needs to be re-submitted it is sufficient to have a photocopy of the original registration form containing the signature of the woman.

(9) A maternity provider must submit to HealthPAC the woman’s registration or a change of registration no more than 20 working days after the date of registration.

Defined in this notice: claim, HealthPAC, lead maternity care, LMC, maternity provider, working day

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DA3 Charging for lead maternity care

(1) Lead maternity care provided by a midwife or general practitioner is to be provided free of charge to persons who are eligible to receive it under this notice.

(2) A part charge may be charged to persons who are eligible for lead maternity care provided by an obstetrician.

Defined in this notice: general practitioner, lead maternity care, midwife, obstetrician

DA4 Where lead maternity care may be provided

Lead maternity care may be provided in a range of places, including the following places:

(a) a woman’s home:

(a) a baby’s home (if it is different from the mother’s home):

(a) the LMC’s rooms or practice:

(b) a maternity facility:

(a) a birthing unit.

Defined in this notice: birthing unit, labour and birth, lead maternity care, LMC, maternity facility

LMCs

DA5 Lead maternity carer (LMC)

(1) A LMC provides lead maternity care.

(2) A LMC who cares for a woman in a maternity facility must support the maternity facility in implementing the Baby Friendly Hospital Initiative (BFHI).

Defined in this notice: lead maternity care, lead maternity carer (LMC), maternity facility, BFHI

DA6 General responsibilities of LMCs

(1) The LMC is responsible for—

(a) assessing the woman’s and baby’s needs; and

(b) p anning the woman’s care with her and the care of the baby; and

(i) the management of labour and birth; and

(ii) ensuring that all the applicable primary maternity services are provided; and

(iii) ensuring all the applicable well child Tamariki/Ora

services are provided to the baby.

(2) The LMC or a backup LMC will be available 24 hours a day, 7 days a week to provide phone advice to the woman and community or hospital based assessment for urgent problems, other than acute emergencies.

Defined in this notice: back-up LMC, labour and birth, LMC, primary maternity services

DA7 Continuity of care

(1) From the time of registration of a woman, a LMC is responsible for coordinating for the woman all of the modules of lead maternity care in order to achieve continuity of care.

(2) Subject to sub clause (6), if a LMC is unavailable to provide an entire module of lead maternity care because of holiday leave, sick leave, bereavement leave, continuing professional education requirements or other exceptional circ*mstances, a back-up LMC may provide those services.

(3) Subject to sub clause (6), the LMC for a woman may, with the woman’s consent, delegate to another midwife,

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general practitioner, or obstetrician the provision of part of a module, but not the entire module.

(4) However, the responsibility for meeting the requirements of the module remain with the LMC.

(5) The respective responsibilities of the LMC and the practitioner to whom aspects of a module have been delegated will be clearly documented in the care plan.

(6) Despite subclasses (2) and (3), if, because of exceptional reasons, the LMC is unable to be responsible for the ongoing provision of lead maternity care to a woman, the maternity provider must ensure that the woman is registered with another LMC.

(7) A LMC is responsible for ensuring that handover to primary care and well child services takes place.

Defined in this notice: back-up LMC, general practitioner, LMC, maternity provider, midwife, obstetrician

DA8 Transfer of care to secondary maternity services, tertiary maternity services, and specialist neonatal services

(1) If there is a transfer of care to secondary maternity services, tertiary maternity services, or specialist neonatal service, clinical responsibility for the woman and baby transfers, until there is a transfer of care back to the LMC.

(2) Every transfer of care must be documented in the clinical notes, including the date and time of transfer

(3) If responsibility for a woman’s care transfers to a secondary maternity service or tertiary maternity service after established labour, the woman’s LMC may continue to support the woman.

Defined in this notice: es ablished labour, LMC, secondary maternity tertiary maternity, specialist neonatal services

Module: First trimester and second trimester

DA19 Service specifications for first and second trimester

(1) For a woman in the first trimester of pregnancy, the LMC must provide the following services as required:

(a) informing the woman regarding—

(i) the role of the LMC, which includes confirming that

the LMC will meet the requirements in clauses DA5, DA6, DA7; and

(ii) the contact details of the LMC and back-up LMC; and

(iii) the standards of care to be expected:

(b) providing appropriate information and education about screening, and offering referral for the appropriate screening tests that the Ministry of Health may, from time to time, notify maternity providers about:

(i) confirmation of pregnancy; and

(ii) ensuring that the woman has a copy of the Ministry of Health’s consumer information on primary maternity services; and

(iii) all appropriate assessment and care of a woman:

(d) care and advice if there is a real and imminent risk of miscarriage, the woman is experiencing a

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miscarriage or a miscarriage has occurred, including—

(i) all appropriate assessment and care of a woman; and

(ii) referral for diagnostic tests and treatment, if necessary:

(e) assessment, care, and advice provided in relation to a termination of pregnancy, including—

(i) referral for diagnostic tests, if necessary; and

(ii) referral for a termination of pregnancy.

(2) For a woman in the second trimester of pregnancy, the LMC must provide all of the following services:

(a) inform the woman regarding—

(i) the availability of pregnancy and parenting education; and

(ii) the availability of paid parental leave, if applicable; and

(iii) if necessary, any of the items of information listed in clause (1)(a) above:

(b) at the start of the second trimester or at the time of registration—

(i) conduct a comprehensive pregnancy assessment of the woman including, an assessment of her general health, family and obstetric history; a physical examination; and

(ii) commence and document a care plan to be used and updated throughout all modules including post natal that meets the guidelines agreed with the relevant professional bodies; and

(iii) arrange for the woman to hold a copy of her care plan and her clinical notes (or, if the woman prefers, to be given a copy of her clinical notes following the completion of each module):

(i) monitor progress of pregnancy for the woman and baby, including early detection and management of any problems; and

(ii) update the care plan; and

(iii) provide appropriate information and education; and

(iv) offer referral for the appropriate screening tests that the Ministry of Health may, from time to time, notify maternity providers about:

(d) book in to an appropriate maternity facility or birthing unit (unless a homebirth is planned):

(e) if a general practitioner or obstetrician LMC plans to use hospital midwifery services, make a prior agreement with a maternity facility on the use of its hospital midwifery services.

Defined in this notice: back-up LMC, birthing unit, care plan, first trimester, general practitioner, homebirth, hospital midwifery services, LMC, maternity facility, maternity provider, module, obstetrician, pregnancy and parenting education, primary maternity services, second trimester

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Module: Third trimester

DA21 Service specification: third trimester

In addition to the requirements set out under the service specifications for the first and second trimester, the LMC must—

(a) organise appropriate arrangements for care during labour and birth and following birth, including, if possible, organising for the woman to meet any other practitioners who are likely to be involved in her care; and

(b) discuss and confirm a plan of care for the baby or babies; and

Defined in this notice: labour and birth, LMC, module, NIR, practitioner, second trimester, third trimester

Module: Labour and birth

DA23 Service specification: labour and birth

(1) The LMC is responsible for ensuring that all of the following services are provided:

(a) all primary maternity services from the time of established labour, including initial assessment of the woman at her home or at a maternity facility and regular monitoring of the progress of the woman and baby:

(b) management of the birth:

(c) all primary maternity care until 2 hour after delivery of the placenta, including updating the care plan, attending the birth and delivery of the placenta, suturing of the perineum (if required), initial examination and identification of the baby at birth, initiation of breast feeding (or feeding), care of the placenta, and attending to any legislative requirements regarding birth notification by health professionals:

(d) the LMC must make every effort to attend, as necessary, during labour

and to attend the birth, including making every effort to attend a woman as soon as practicable —

(i) after the woman’s arrival at the maternity facility or birthing unit where she will give birth; or

(ii) when requested by the woman, for a homebirth:

(e) if a LMC is unable to attend the birth because of holiday leave, sick leave, bereavement leave, continuing professional education requirements or other exceptional circ*mstances, the LMC must make appropriate other arrangements with a back-up LMC:

(2) For a homebirth, in addition to clause (1), the LMC must—

(a) arrange for another midwife, general practitioner, or obstetrician to be available to attend the birth; and

(b) maintain equipment (including neonatal resuscitation equipment) and provide the delivery pack and consumable supplies; and

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practitioner, or obstetrician remains with the woman for at least 2 hours following the birth.

(3) For a birthing unit, in addition to clause (1), the LMC must—

(a) arrange for a midwife, general practitioner, or obstetrician to be available to attend the birth; and

(b) ensure that a midwife, general practitioner, or obstetrician remains with the woman until she is discharged.

(4) A general practitioner or obstetrician LMC who uses hospital midwifery services in order to provide the full service required during labour and birth must—

(a) ensure that the respective responsibilities of the LMC and the hospital midwifery services are clearly documented in the care plan, and that a copy of the care plan is given to the hospital midwifery services and to the woman; and

(b) monitor progress of labour; and

required at any time during the labour; and

(d) attend the birth and the delivery of the placenta.

Defined in this notice: back-up LMC, birth, birthing unit, care plan, established labour, general practitioner, homebirth, hospital midwifery services, labour and birth, LMC, maternity facility midwife, obstetrician, primary maternity services

SUBPART DC – Specialist medical maternity services

General information about s ecialist medical maternity services

DC4 Referral criteria

Specialist medical maternity services may only be provided to women and babies on referral from another practitioner or a family planning practitioner if the specialist who provides the specialist medical maternity services is not the practitioner or family planning practitioner making the referral, and—

(a) for ultrasound scans, there is a written referral signed by a midwife, general practitioner, obstetrician, or family planning practitioner specifying a clinical reason for the referral that is in

accordance with clause DC11; or

(b) for consulting obstetrician services, there is a written referral from a general practitioner or midwife and the referral specifies a clinical reason for the referral that is in accordance with the Referral Guidelines; or

(i) the referral specifies a clinical reason for the referral that is in accordance with referral guidelines; and

(ii) if a back-up LMC makes a referral, the referral should be identified as being signed by the back-up LMC on behalf of the LMC.

Defined in this notice: back-up LMC, family planning practitioner, general practitioner, LMC, midwife, obstetrician, paediatrician, practitioner, referral guidelines, specialist, specialist medical maternity services

DC5 Quality of service requirements

(1) A nuchal translucency ultrasound scan must be undertaken by a practitioner with the appropriate training and

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access to risk estimation software, and appropriate quality of equipment.

(2) Practitioners performing or supervising nuchal translucency ultrasound scans must have obtained the appropriate accreditation recognised by the Royal Australian and New Zealand

College of Obstetricians and Gynaecologists and the Royal Australian and New Zealand College of Radiologists.

Defined in this notice: maternity provider, practitioner

DC6 Service linkages

Providers of specialist medical maternity services will also maintain linkages with local providers of the following services:

(a) primary health services

(b) lead maternity care

Defined in this notice: lead maternity care, prima y health services, secondary maternity, specialist medical maternity services

DC7 Exclusions

Specialist medical maternity services do not include the following:

(a) lead maternity care

(b) ultrasound scanning except for reasons listed in clause DC11(3)

(d) any services provided by a practitioner if—

(i) the practitioner is an employee of a DHB provider arm; and

(ii) the practitioner provides the maternity service in their capacity as an employee of a DHB provider arm.

Defined in this notice: DHB provider arm, lead maternity care, practitioner, specialist medical maternity services

DC10 Service specification: ultrasound scan

A maternity provider who provides an ultrasound scan must provide the following services if a payment for services is claimed:

(a) conduct an ultrasound scan according to quality standards recognised by the Royal Australian and New Zealand College of Obstetricians

and Gynaecologists and the Royal Australian and New Zealand College of Radiologists:

(b) ensure that a radiologist or an obstetrician with a Diploma of Diagnostic Ultrasound (or equivalent as determined by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists) is available to tailor the radiological examination to the clinical situation by—

(i) being physically present at the place where the examination is being performed; or

(ii) when using teleradiology, being available to review the transmitted diagnostic images before the woman’s departure from the place where the scan is conducted:

(d) provide the referring general practitioner, midwife, obstetrician, or family planning practitioner with a written interpretation of the scan by a radiologist or an obstetrician with a Diploma of Diagnostic Ultrasound (or equivalent as determined by the Royal Australian and New Zealand College

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of Obstetricians and Gynaecologists) in a timely manner.

CLINICAL INDICATION

TA Threatened abortion Defined in this notice: claim, family planning practitioner, general practitioner, maternity provider, midwife, obstetrician, radiologist

EP Suspected ectopic pregnancy

PM Pelvic mass in pregnancy

DC11 Payment rules: ultrasound scan

(1) This fee may be claimed only if an appropriate referral has been received in accordance with clause DC4(a).

(2) A code corresponding to the relevant indication in sub clause (3) must be stated on both the referral form and on the claim.

(3) The following list identifies the approved clinical indications for ultrasound in

pregnancy. The listed conditions are mandatory indications and must be included on the referral form :

(4) A maternity provider may claim only 1

ultrasound scan fee per woman per date ~L

of service. )... eJ AH

(5) A claim for a subsequent scan requires a U new referral in accordance w ith DC4~~

Defined ;n th;, nodcec cJo;m, motemUy o}.)' ~0

0'l> «:-~

Uterus not equal to dates

Prior to booking CVS or amniocentesis

or Nuchal Translucency

Consideration of termination

Dating and early evaluation (?r chromosomal abnormality .. ~

Early evaluation for chromosomal abnormality follow u,,.P_,,.. __

Anatomy follow up

CJ>-UGR or macrosomia)

Suspected growth abnormality

(IUGR or macrosomia) follow up

Check placenta

Antepartum haemorhage

Abdominal pain

Malpresentation

Suspected foeta l compromise

Suspected intrauterine foetal death

M aternal post partum

COMMENT

Scan at time of bleeding. Seria l scans may be necessary if bleeding

persists.

e.g. Previous tubal surgery, PIO or ectopic.

Suggestive symptoms (e.g. abdominal pain).

Nuchal t ranslucency assessment at 11-13+6 weeks, assessment for gestational age, diagnosis of multiple pregnancy.

In cases where the first scan was technically unsuccessful.

Scan to confirm dates, assess foetal anatomy and placental position. Performed at 18-20 weeks ideal ly.

In cases where the first scan was technically

unsuccessful.

Cl inical suspicion of abnormal growth of foetus (IUGR or macrosomia)

or abnormal volume of amniotic flu id.

To assess growth t rend (2 weeks after GR scan).

To check placental site at around 36 weeks.

Bleeding in pregnancy. If serial scans are required refer to secondary

maternity services.

Abdominal pain in pregnancy.

To assess fetal position and size, after 36 weeks.

Signifi cant reduction in foeta l movements.

For suspected retained products or postpartum bleeding.

Maternity Review Action Plan I 2013 - 2014

Elective caesarean sections

DHB of residence I 37 2009

38 39 All I 37 2010

38 39 All I 37 2011

38 39 All I 37 All I 37 2012

38 39

Number of women giving birth by electi_ve caesarean section at 37, 38, 39 and total weeks' gestation by DHB of residence, 2009-2016

Northland 7 21 50 103 3 30 46 111 8 29 58 116 8 30 46 109 Waitemata 62 296 380 936 89 245 388 930 67 247 429 931 85 298 444 1047 Auckland 69 299 256 790 84 333 306 892 68 243 400 854 96 265 400 957 Counties Manukau 49 179 239 596 54 215 287 695 63 212 313 693 52 245 343 779 Waikato 47 134 161 451 42 138 158 436 41 113 184 461 43 107 235 497 Lakes 20 58 52 164 8 56 68 167 12 66 56 171 22 61 56 177 Bay of Plenty 23 121 86 278 39 105 60 294 36 83 80 273 33 104 120 316 Tairawhiti 14 24 27 90 8 30 14 68 6 22 19 62 7 18 22 64 Hawke's Bay 20 64 96 244 17 75 83 233 40 58 78 223 19 76 80 241 Taranaki 10 51 47 162 12 46 61 179 10 52 60 161 21 42 91 205 MidCentral 17 90 63 224 13 79 85 230 21 73 101 242 18 83 95 254 Whanganui 6 28 26 75 10 28 28 84 5 22 29 65 1 21 42 84 Capftal & Coast 48 150 171 468 65 188 130 493 55 149 164 457 49 144 184 485 Hutt Valley 31 107 105 299 22 72 109 250 19 80 110 268 23 73 93 228 Walrarapa 2 16 42 76 5 15 36 70 2 25 33 74 6 13 29 61 Nelson Marlborough 12 55 88 206 11 51 90 202 15 56 95 235 20 61 81 211 West Coast o 20 15 45 2 6 22 39 2 7 20 37 5 10 31 58 Canterbury 69 171 492 874 79 203 494 931 80 174 478 904 73 171 431 798 South Canterbury 4 25 26 70 9 25 24 77 5 17 24 57 9 22 26 79 Southern 48 130 204 505 40 154 178 476 33 135 189 490 40 124 216 491 Unknown 1 0 2 4 1 2 0 3 0 0 0 0 0 1 2 3 Total 559 2039 2628 6660 613 2096 2667 6860 588 1863 2920 6774 630 1969 3067 7144

Proportion (%)of women giving birth by elective caesarean section at 37, 38, 39 and total weeks' gestation by DHB of residence. 200

Northland Waitemata Auckland Counties Manukau Waikato Lakes Bay of Plenty Tairawhiti Hawke's Bay Taranakl MidCentral W hanganui Capital & Coast Hutt Valley Wairarapa Nelson Marlborough West Coast Canterbury South Canterbury Southern Unknown Total

7 15 17 10 15 20 15 27 14 13 13 16 21 26 9

17 0

19 11 24

8 25 26 13 19 23 28 21 18 25 28 20 25 30 23 24 31 21 27 27

10 19 15 11 14 13 12 15 19 13 13 13 17 17 32 22 19 27 17 23

4 12 12 7 8

10 9

12 10 10 10 8

12 13 14 12 11 13 11 13

3 20 22 10 15 10 22 14 14 18 10 20 22 18 19 18

7 21 19 23

10 20 29 16 18 23 24 26 21 22 24 22 29 23 21 22 14 21 25 29

9 19 19 12 13 16

9 7

17 17 15 13 14 19 30 21 19 28 15 21

4 8 9 11 5 12 16 21 20 12 13 17 22 23 13 8 13 14 13 8 8 13 17 16 9

10 11 24 14 11 10 21 23 12 10 9 13 22 9 8

10 24 18 16 10 11 13 24 17 10 10 15 23 17 ~ 9 11 21 14 ~8

12 22 25 17 ~· tz

~~ H ~; ~~ H 10 13 1~\.J 8 9 14 21 ~ 28 15 11 16 ""'"~~ 17 10 13 ~ "2~ 2: 13

11 ({JrJ 20 18 11

(l).Cj ~0

17 21 19

11 11 9

11 13 12 10 13 11 12 14 14 13 12 14

8 88 71 71 34 15 19 5

30 19 20 5

44 18 0

20 0

7 19 17 15 12 19 12 12 22 19 15

8 19 16 0

23 0

17 11 25

2013 38 39 All I 37

19 58 116 7 297 457 1026 94 261 362 849 73 265 345 817 66 126 204 472 33 70 66 193 12

104 107 284 27 14 25 59 7 75 80 236 3 42 85 183 If'!' 63 112 250 ~~_g) 14 38 67

155 174 478 0 64 102 ./i2Q 25 19 3~~9 5 65 •5~v,31 16

8 X19\ 35 4 153 l">l§ft 845 90

:V25 60 4 4{ 214 512 54

4 2 9 1 0 3060 7001 629

7 23 23 19 17 29 24 12 20 24 20 12 25 23 26 29 13 19 26 27

10 21 20 16 17 17 15 13 17 23 21 18 20 19 23 21 20 29 16 24

5 13 14 10 9

14 10 8

11 12 12 8

13 11 12 15 9

15 9

6 19 17 11 11 11 18 17 24 18 15

7 16 19 19 22 20 23 11 28

2014 38 39 All I 37

26 39 87 304 514 1100

288 3~838 239 ~7 15 9~ i! 426 62 7'6 177

tto7 133 313 ' 22 45 90

69 70 236 41 106 194 48 111 238 22 24 57

114 202 443 58 110 232 13 21 52 57 94 210

7 26 44 187 452 899

21 34 77 147 185 511

5 2 9 1929 3166 7048

8 23 24 16 12 25 24 21 20 19 17 18 20 20 17 30 17 22 24 28

8 22 20 16 16 19 17 22 14 28 20 12 22 21 17 24 29 26 18 20

4 14 13 10 8

13 11 13 11 13 11 7

13 13 11 15 13 15 12 16

4 88 82 72 34 9

30 8

19 18 15

8 37 15

7 21 4

69 5

39 1

585

4 19 20 12 12 9

17 31 14 21 11 17 17 13 29 23 24 18 12 22

2015 38 39

19 243 268 262

90 44

103 19 67 42 52 19

100 72 24 73 8

178 23

122 3

1831

6 19 24 17 13 19 23 16 21 19 18 15 18 21 26 33 14 20 26 23

49 515 372 327 233

73 117 22 86 94

122 26

211 100 16 96 15

495 39

214 1

3223

9 24 22 15 18 16 17 10 18 25 19 12 22 19 13 26 14 28 20 22

All I 37

93 998 868 780 446 156 302 67

217 186 227

61 424 221 59

223 39

916 79

505 6

6873

4 13 15 10 8

10 11 9

11 12 11

7 12 11 13 16 11 15 12 15

8 97 73

100 38 22 31

3 23 20 21 11 42 24

2 12

6 70

3 34 0

640

7 19 17 17 13 19 20 8

16 18 14 22 18 16 9

15 38 19 11 18

2016 38 39

38 268 299 294

96 65

114 17 56 52 74 15

112 49 16 58 11

199 26

134 1

1994

11 18 24 18 13 20 24 13 16 27 21 12 20 16 26 24 19 20 28 24

46 521 343 345 231

82 134

31 98 70

122 29

237 106 26 91 16

477 20

216 2

3243

8 22 20 15 18 19 18 14 19 20 20 14 24 19 21 21 19 25 12 24

All I

119 1069 851 875 466 198 340

76 210 182 258

70 493 226

60 188

41 877

66 500

5 7170

5 13 14 11 9

13 12 10 10 13 12 9

14 11 13 12 13 14 10 15

Inductions

DHB of residence I 37 2009

38 39 All I 37 2010

38 39 All I 37 2011

38 39 All I 37 2012

38 39 All I 37

Number of women who had an induction and gave birth at 37, 38, 39 and total weeks' gestation by DHB of residence, 2009-2016 Northland Waitemata Auckland Counties Manukau Waikato Lakes Bay of Plenty Tairawhiti Hawke's Bay Taranaki MidCentral Whanganui Capital & Coast Hutt Valley Wairarapa Nelson Marlborough West Coast Canterbury South Canterbury Southern Unknown Total

14 102 128 100 82 16 40

8 40 18 21

4 77 25

2 14

3 83

5 45

0 827

50 235 266 252 154 38 69

9 62 24 37 19

117 68 10 40 11

145 9

81 1

1697

42 349 251 1477 300 1591 193 1234 176 1080 28 225 70 493 18 98 49 371 27 283 44 301 17 129

111 924 80 403 10 84 36 260 18 91

124 922 13 100 97 716

1 2 1705 11133

21 101 117 125

75 13 28 10 25 15 15 13 73 25 9

13 4

95 3

38 0

818

81 264 292 277 191 43 67 14 70 35 35 23

148 52 12 37

4 218

10 110

0 1983

40 274 273 234 167 25 63 19 40 31 44 18

123 56 11 50 14

142 11

109 0

1744

410 1485 1511 1422 1062 195 449 115 362 262 275 150 870 363 95

304 64

1075 87

777 5

11338

17 94

130 108 94 22 35 10 47 19 29 9

70 21

1 19 2

98 8

58 2

893

63 286 335 352 192

61 60 17 84 42 52 21

140 56

6 41

7 232

10 114

2 2173

33 273 352 284 189

40 52 28 59 48 69 18

158 69

6 33 10

159 9

131 1

2021

349 1593 1660 1537 1143 237 443 122 418 307 361 141 862 389 82

253 67

1057 90

855 7

11973

19 114 157 130 102 26 36

4 46 16 29 12 76 38

4 16

3 137

4 52

0 1021

62 316 329 382 206

46 79 28 77 30 52 19

127 56

7 28 5

225 13

102 1

2190

39 372 390 305 212

51 81 21 67 44 57 12

127 66

3 27 10

211 14

141 0

2250

343 1659 1779 1771 1143 250 508 121 409 258 333 118 846 388

72 206 55

1154 105 752

5 12275

36 133 156 139

95 25 27 11 42 24 30 15 76 30 2

16 6

156 8

55 0

<: Proportion(%) of women who had an induction and gave birth at 37, 38, 39 and total weeks' gestation by DHB of residence, 2009-~\

Northland 14 18 8 15 18 28 8 17 17 20 6 15 16 20 7 '-. 15 32 Waitemata 25 20 13 19 22 22 13 19 23 24 13 20 25 24 .11~'i1 29 Auckland 31 23 17 23 30 25 17 22 33 30 20 25 39 29 ~i. V 27 37 Counties Manukau 21 18 9 14 24 20 10 16 23 24 12 18 25 26 1'"' 20 29 Waikato 27 22 15 19 27 25 14 19 31 29 16 21 33 '31t~ 21 33 Lakes 16 15 7 13 16 18 6 12 21 22 10 15 23 'lf8 12 16 32 Bay of Plenty 25 16 10 17 16 15 10 15 20 17 8 16 21 12 17 18 Tairawhiti 15 8 10 13 18 12 9 15 21 17 13 17 11 11 17 26 Hawke's Bay 28 18 10 15 21 20 8 15 28 26 12 19 ~ 14 18 30 Taranaki 24 12 8 17 22 17 9 16 24 19 13 20 ?J 11 17 24 MidCentral 16 11 9 14 11 11 8 12 20 16 12 t~ ~ 11 15 22 Whanganui 11 14 8 14 27 18 9 17 20 20 9 ~· 29 17 6 14 25 Capital&Coast 33 20 11 23 25 23 13 22 28 24 16 ./ 22 31 23 13 22 32 Hutt Valley 21 19 13 18 21 17 10 17 24 19 12 ~' 19 32 17 13 19 27 Wairarapa 9 14 8 15 35 17 9 18 6 8 ~ 16 13 12 3 14 14 Nelson Marlborough 19 18 9 15 22 16 12 18 24 18 15 22 13 7 13 19 West Coast 16 17 23 21 15 10 12 16 13 1~ 17 13 9 9 13 35 Canterbury 23 18 7 14 25 22 8 16 25 ¢_ 9 17 35 26 13 19 37 South Canterbury 14 10 8 15 6 10 7 13 25 ~ 1~ 7 16 11 13 8 16 21 Southern 23 17 11 19 22 20 13 21_ o~ 15 23 25 19 15 21 27 Unknown Total 24 18 11 17 23 21 11 18 0 24 13 19 28 23 14 20 30

(l).Cj ~0

2013 38 39 All I 37

2014 38 39 All I 37

69 33 317 24 79 37 328 346 379 1711 126 285 383 1620 374 385 1795 152 407 3i~738 417 334 1828 186 438 362 01 212 168 1055 93 23~7 ~ 1104 56 56 280 39 7 '41' 292 88 72 467 37 ilJ.8 00 518 18 25 103 6 ' Th 19 89

108 60 423 34k 85 61 346 37 52 323 10•~ 60 52 340 61 65 337 ~v 46 83 385 26 22 144 17 17 117

136 117 723 124 115 704 56 57 ./iffl. 38 69 83 418 13 170~1 5 14 15 78 32 ·~, 48 14 31 40 213 19 ~~ 92 4 4 17 75

216 ~~ 1227 124 247 274 1321 ~()11 102 10 7 10 90 '!:i ' 161 802 63 123 170 791

24 26 32 29 28 23 20 16 29 21 19 23 22 21 18 14 30 27 13 25

2 10 2 4 0 16 2307 12456 1111 2480 2432 12484

6 17 22 15 14 14 10 13 13 14 12 10 13 11 13 11 14 14

7 18

15 22 29 22 20 20 17 15 20 21 16 17 20 20 18 16 25 21 16 23

21 26 35 32 32 37 25 14 26 31 31 16 30 29 19 19 20 32 29 32

24 21 33 29 31 28 27 15 24 28 17 14 22 24 18 16 10 28 8

8 17 20 16 16 12 13 9

12 14 15

9 12 16 12 10 19 16

5 19

16 21 28 23 21 21 19 13 17 22 18 14 20 23 16 15 22 22 14 24

21 144 146 203

71 38 35

3 42 25 41 12 58 32

4 13 5

133 7

57 1

1091

19 31 36 34 25 38 20 12 31 29 31 26 26 27 17 14 29 34 17 32

2015 38 39

95 320 343 484 190 60

100 18 73 62 65 23

131 62 12 34 14

240 16

105 1

2448

28 24 31 32 27 25 22 15 23 28 22 18 24 18 13 15 25 26 18 20

44 330 320 423 164

51 109 27 50 61

108 21

126 98 15 23 12

247 29

175 5

2438

8 15 19 19 13 12 16 13 11 16 17 10 13 18 13 6

12 14 15 18

All I 37

320 1582 1567 2085 966 286 535 111 336 377 422 127 702 429

86 195

61 1255 119 748

20 12329

15 21 27 25 18 19 19 15 17 25 20 16 20 22 19 14 17 20 18 22

14 137 164 188

95 31 34

6 49 36 50 10 67 45

3 15 5

112 6

58 1

1126

12 26 37 32 32 27 22 17 34 32 34 20 28 30 13 19 31 31 21 31

2016 38 39

81 383 420 494 209 87

105 24

110 41 94 20

123 62 10 36 15

247 14

155 2

2732

24 26 34 31 27 26 22 19 31 21 27 16 22 20 16 15 26 25 15 28

44 351 363 42.2 170 54

112 20 57 53

107 29

129 83 22 49 9

286 23

168 0

2551

8 15 22 18 13 13 15 9

11 15 18 14 13 15 18 11 11 15 14 19

All I

346 1631 1666 2050 969 303 549 113 411 339 482 124 666 381 84

229 59

1272 105 811

9 12599

15 21 28 25 18 20 19 15 20 24 23 15 19 19 18 15 18 20 16 24

All births

I 2009 I 2010 l 2011 I 2012 I 2013 I 2014 I 2015 I 2016 I DHB of residence 37 38 39 All 37 38 39 All 37 38 39 All 37 38 39 All 37 38 39 All 37 38 39 All 37 38 39 All 37 38 39 All

Number of women giving birth at 37, 38, 39 and total weeks' gestation by DHB of residence, 2009-2016 Northland 98 276 514 2308 119 291 500 2475 101 314 528 2302 116 311 558 2301 112 287 557 2125 114 326 492 2104 111 336 540 2136 119 334 576 2264 Waitemata 405 1179 1973 7832 451 1202 2040 7914 413 1190 2110 7879 454 1335 2142 7973 460 1317 2180 7650 484 1342 2297 7846 469 1312 2190 7559 517 1449 2400 7936 Auckland 407 1142 1736 6819 390 1161 1651 6743 400 1130 1770 6531 405 1120 1796 6698 419 1158 1769 6247 431 1219 1681' 6302 410 1118 1670 5900 442 1241 1685 5909 Counties Manukau 471 1372 2220 8580 526 1380 2319 8752 475 1480 2366 8734 511 1497 2300 8767 484 1418 2194 8177 577 1490 2260 288 604 1523 2252 8196 593 1615 2377 8247 Waikato 309 714 1171 5547 278 773 1186 5615 305 662 1187 5367 309 669 1312 5481 286 751 1186 5218 294 755 1~ 5247 286 712 1281 5275 297 763 1262 5353 Lakes 101 249 386 1680 81 242 418 1610 106 279 411 1586 111 250 421 1557 79 242 389 1419 106 24( 1393 101 236 443 1508 115 332 428 1545 Bay of Plenty 158 438 718 2979 175 442 659 3013 172 363 689 2856 170 425 703 2972 153 442 691 2753 151 ~1 765 278! 178 452 694 2788 157 472 748 2890 Tairawhlti 52 116 181 762 56 114 203 762 47 101 217 738 36 99 200 733 42 116 191 707 42 10 203 685 26 120 215 737 36 129 216 777 Hawke's Bay 143 350 497 2429 119 355 503 2344 170 322 474 2255 132 355 488 2257 139 378 480 2154 129 353 500 2068 134 324 472 1994 144 358 506 2057 Taranaki 76 201 351 1630 67 207 357 1591 78 217 360 1570 72 194 398 1557 100 175 366 1520

~(; 215 380 1516 87 222 370 1515 113 191 348 1435

Mid Central 129 323 497 2207 133 331 575 2341 142 323 600 2297 125 333 507 2151 134 322 543 2121 277 563 2091 132 295 628 2109 148 346 600 2079 Whanganui 38 139 208 924 49 130 211 892 46 106 203 829 42 111 205 874 61 115 212 826 41--S 121 196 815 47 126 214 814 50 125 214 801 Capital & Coast 233 596 997 4041 297 648 934 3971 254 593 984 3857 246 554 985 3867 235 616 874 3627 53 558 929 3529 224 542 963 3533 238 562 997 3454 Hutt Valley 119 353 606 2221 120 311 569 2153 87 290 584 2052 119 326 516 2006 113 273 526 ~ 130 287 519 1854 120 344 531 1966 150 315 563 1967 Wairarapa 22 70 133 542 26 71 119 542 18 76 112 529 30 59 115 508 14 73 128a o 26 76 125 473 24 91 120 462 23 61 121 459 Nelson Marlborough 72 228 398 1691 60 228 419 1700 80 233 374 1649 72 218 384 1528 86 227 ~ 1 47 73 188 398 1418 91 221 370 1416 81 245 427 1548 West Coast 19 65 78 425 27 42 118 409 16 44 114 405 23 55 107 408 17 64 373 20 42 90 348 17 56 104 357 16 58 85 319 Canterbury 362 805 1802 6541 380 979 1752 6667 388 888 1684 6061 394 874 1660 5984 421 805 v3~ 5825 383 869 1759 5995 393 909 1781 6205 366 1006 1894 6305 South Canterbury 35 94 153 660 48 99 157 670 32 81 138 570 37 98 167 648 38

~ 54 638 35 86 189 651 41 87 193 659 28 94 168 650

Southern 200 473 881 3753 174 539 831 3676 195 484 893 3672 208 537 922 3595 202 904 3448 196 529 907 3283 180 530 952 3417 189 556 902 3317 Unknown 36 62 130 662 23 63 114 616 24 58 94 552 17 41 91 478 15 52 80 448 14 66 80 486 13 36 62 369 17 32 87 426 Total 3485 9245 15630 64233 3599 9608 15635 64456 3549 9234 15892 62.291 3629 9461 15977 62343 3610 434 15565 59239 3729 9592 16035 59179 3688 9592 16045 58915 3839 10284 16604 59738

BRIEFING REPORT NUMBER: MMWG-007

To: Sue Belgrave, Chair Perinatal and Maternal Mortality Review Committee

Title: Maternal Morbidity Working Group Report

From: Dr John Tait and Arawhetu Gray; Co-chairs Maternal Morbidity Working Group

CC: Kiri Rikihana, Group Manager, Mortality Review Committees National Maternity Monitoring Group

Date: 1 May 2018 Purpose 1. This report updates the Perinatal and Maternal Mortality Review Committee (PMMRC) on

the Maternal Morbidity Working Group’s (MMWG) achievements for the period January – March 2018.

Recommendations 2. It is recommended that the PMMRC note the progress made by the MMWG.

HQSC contacts

Name: Kiri Rikihana Name: Dr Leona Dann

Title: Manager, Mortality Review Committees

Title: Maternity Specialist

Phone: (04) 913 1742 Phone: (04) 913 1741

Mobile: Mobile: MMWG co chairs Name: Dr John Tait Name: Arawhetu Gray

Title: Co-chair MMWG Title: Co-chair MMWG Discussion Meetings 3. The MMWG met 27 March 2018, which was the first of three meetings this year. The

group agreed that work would continue between meetings via electronic means to save financial resource with one less meeting.

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Regional review panels

4. The first panel for 2018 was convened in February. This panel reviewed three peripartum hysterectomy and four hypertension cases.

5. Ensuring all disciplines are represented at the panels continues to be a challenge. This has been more apparent in the last six months of panels and may represent the challenges with resources in the DHBs.

6. The MMWG agreed at the recent meeting to address this by ensuring the Service Manager (for employed members) is included in the final email of confirmation with the panel member. We hope this will ensure that staff are released to attend.

7. Five more panels will be convened throughout 2018 after which reviews will cease

8. A poster on the establishment of national maternal morbidity review within a unique model of maternity care will be presented at the International Forum on Quality & Safety in Health Care conference, in May 2018.

ICU/HDU notifications 9. The MMWG continues to receive notifications of maternal morbidity (based on

admissions to high dependency (HDU) and intensive care units). The maternity specialist following up with two secondary care DHBs, as the MMWG had not received any notifications. One DHB has since provided three retrospective notifications and is being supported to provide future notifications.

10. Canterbury DHB is currently reviewing cases of women admitted to their acute assessment unit (similar to an HDU) and will provide retrospective notifications. They are reviewing admission criteria to these beds to support prospective notifications in the future.

The woman’s story 11. Women continue to be offered the opportunity to share their stories, unless their lead

maternity care midwife suggests otherwise.

12. At the Northern Panel in February, three out the seven cases reviewed had women’s stories included. The presenter read the story or excerpts of the story to the rest of the panel. The panel members felt that the stories added significant value to the review. Indeed, some chose to read the stories in entirety during their break.

13. Panel members asked the MMWG to consider changing their process, to include a copy of the woman’s story in their pre-pack to read in advance of the panel. MMWG agreed to change their process to send the story to all panel members. This change in process does not contradict the information brochures already produced for women.

14. A poster on the inclusion of women’s stories in national case review will be presented at the International Forum on Quality & Safety in Health Care conference in May 2018.

Maternal Morbidity Review Toolkit for Maternity Services 15. In April 2017, the MMWG chose to develop a toolkit for local maternity morbidity review.

The MMWG developed the toolkit in response to the identified need for a review process that provided consistency and structure.

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16. Five DHBs agreed to test the toolkit. One was unable to do so due to a lack of support from the executive team. Three DHBs have provided feedback.

17. The MMWG considered the feedback and believe that resource should be invested in refining the toolkit to meet the needs to the maternity service and promote local reviews. The self-appointed deadline for release on the website by end of May 2018 should be extended until the toolkit is fit for purpose.

18. The maternity specialist will speak to the DHBs individually regarding what is required to make the toolkit fit for purpose. Changes will then be made, circulated to the DHBs that tested for feedback and presented to the MMWG in July.

19. An essential principle of this work is that the national maternity monitoring group will take the opportunity of monitoring the implementation of this toolkit to promote local reviews of serious maternal morbidity. The MMWG is awaiting confirmation from the NMMG that they agree to this in principle, following correspondence sent to NMMG in October 2017.

20. The toolkit will need to be reviewed and updated in 2021. The MMWG has agreed to transfer the responsibility for the review and update to the PMMRC The PMMRC will review and may choose to update the toolkit in conjunction with the Adverse Events Learning Programme team at the Health Quality & Safety Commission. The MMWG agreed to write and handover this responsibility to PMMRC before launching the toolkit on the Commission website later in 2018.

Maternity early warning system 21. The clinical leads for the Maternity Early Warning System (MEWS) have been confirmed

(Matthew Drake, Anaesthetist and Craig Skidmore, Obstetrician). The Maternity Specialist will fulfil the role of midwifery lead along with midwifery advice from Fiona Coffey, a midwife recommended by NZCOM.

22. The MMWG will perform the role of an Expert Advisory Group.

23. A workshop was convened in December with 71 attendees representing key maternity stakeholders. The aim of the day was to introduce the sector to the concept of a system approach wider than the development of a vital signs chart alone (inclusion of governance, response, escalation, evaluation/measure and education) and to reach consensus on:

a) the type of track & trigger tool best suited for NZ maternity services

b) parameters indicating deterioration for maternity inpatients.

24 The clinical leads and the Deteriorating Patient Specialist met in January 2018 to develop the first draft of a vital signs tool.

25. The tool was sent to the sector for consultation in March. We received over 40 responses, some collated and representing multidiscipline teams and services as well as responses from key professional colleges and individuals. Overall the responses were positive to the vital signs chart and the development of a national maternity early warning system.

26. The clinical leads for the project, together with the midwife from NZCOM, considered the feedback with the MMWG, including specific feedback from the professional colleges.

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27. The MMWG are committed to developing a maternity vital signs chart and early warning system that is responsive, fit for purpose and that provides value to both the women and to the clinicians alike. Therefore, we have chosen to reply to the sector regarding the key themes and the responses taken. The letter will be sent in April. The MMWG believes that keeping the sector engaged throughout the project is essential to future success.

Annual report 28. The MMWG has consulted with the following groups on the recommendations in the

annual report:

a) The Ministry of Health

b) district health board directors of nursing and directors of midwifery

c) The National Maternity Monitoring Group

29. The draft MMWG report is with the Board for their review and approval.

Once the Board approves the report, it will proceed to editing and design before being published on the Commission’s website. It will be published on 26 June, alongside the PMMRC report. AMOSS 30. At the December meeting the MMWG considered the re-quote by AMOSS for the portal

development at . The MMWG agreed this was not feasible and suggested asking AMOSS to consider an option for the original one off cost. If this is declined, the MMWG suggests that no further action is taken.

31. To date there has been no further response from AMOSS.

Stakeholder engagement 32. The Maternity Specialist continues to actively engage with stakeholders such as

midwifery leaders and clinical directors.

33. The MMWG secretariat has continued to work with the team at the Ministry of Health regarding the national maternity record and the maternity early warning system.

34. Regular contact with the secretariat of National Maternity Monitoring Group (NMMG) has been maintained through email and letter correspondence and a face-to-face meeting in February 2018.

Detailed project plan and evaluation

35. The evaluation of the MMWG is underway. This is due to be completed before June 2019, when the MMWG completes tenure. Kiri Rikihana is working with internal staff to arrange the appropriate resources for the evaluation.

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National Maternity Monitoring Group

From: Janese Roche s 9(2)(a)

Sent: Wednesday, 4 April 2018 7:43 PM To: National Maternity Monitoring Group Subjed: Northern Southland Health Company ltd - Lumsden Maternity - SDHB Attachments: NSHCL submission to SDHB 3.04.18.pdf; Primary Maternity Report SDHB March

2018.pdf ~

Oeac Sfr!M..J..., '?)co I am one of the directors of Northern Southland Health Company Limited which operates the Lumsden Maternity ~tre. ~ou may be aware of the proposed downgrade of our services by the SDHB and I have attached a copy of our submi!fib~'to the SDHB regarding this for your information. .'-/

The directors believe that it may be of interest to the National Maternity Monitoring Group given its su . use of rural primary maternity facilities as we believe the SDHB's proposal is inconsistent with that aim

I have also attached a copy of the SDHB's proposed plan for the sake of completeness. Q Myself, or one of my co-directors would be happy to discuss with any of the NMMG me ~ i desired.

Kind regards,

Janese Priergaard-Petersen Director Northern Southland Health Company Limited Phon ; s 9(2)(a)

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National Maternity Monitoring Group

From: Janese Roche s 9(2)(a)

2018.pdf ~

I have also attached a copy of the SDHB's proposed plan for the sake of completeness. Q Myself, or one of my co-directors would be happy to discuss with any of the NMMG me ~ i desired.

Kind regards,

Janese Priergaard-Petersen Director Northern Southland Health Company Limited Phon •s 9(2)(a)

NATIONAL MATERNITY MONITORING GROUP

2017-18 WORK PROGRAMME

BACKGROUND

The National Maternity Monitoring Group (the NMMG) provides strategic advice to the Ministry

of Health on priorities for improvement to the maternity system and the implementation of the

New Zealand Maternity Standards.

This document outlines the NMMG’s work programme for an 18-month period: July 2017 –

December 2018. To deliver this work programme, we expect to meet quarterly (August,

November, February and May).

STRATEGIC CONTEXT

The NMMG’s work is guided by the priorities set out in the New Zealand Health Strategy1, the

accompanying Roadmap of Actions2, the New Zealand Maternity Standards and the Maternity

Quality Initiative (MQI).

The New Zealand Maternity Standards3 consist of three high-level strategic statements to guide

the planning, funding, provision and monitoring of maternity services:

1. Standard 1: Maternity services provide safe, high-quality services that are nationally

consistent and achieve optimal health outcomes for mothers and babies.

2. Standard 2: Maternity services ensure a woman-centred approach that acknowledges

pregnancy and childbirth as a normal life stage.

3. Standard 3: All women have access to a nationally consistent, comprehensive range of

maternity services that are funded and provided appropriately to ensure there are no

financial barriers to access for eligible women.

The MQI, refocused in 2015, contains four key priorities:

1. Strengthening maternity services including more timely access and more equitable access

to community-based primary maternity care and services

2. Better support for women and families that need it most, including better health and social

support for young mothers and for maternal mental health and support for improving

health literacy among vulnerable populations

3. Embedding maternity quality and safety including further support for local clinical

leadership and review, and meeting the Ministry’s obligations under the New Zealand

Maternity Standards, and

4. Improving integration of maternity and child health services including improving

transitions between health services through improved communication, coordination and

use of information technology.

1 Minister of Health. 2016. New Zealand Health Strategy. Wellington: Ministry of Health. 2 Minister of Health. 2016. New Zealand Health Strategy: Roadmap of actions 2016. Wellington: Ministry of Health. 3 Ministry of Health. 2011. New Zealand Maternity Standards. Wellington: Ministry of Health.

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SUMMARY

Our work programme for 2017-18 aligns to the priorities set out in the New Zealand Health Strategy and Roadmap of Actions as well as continuing previous

workstreams where further work is required. A summary of our work programme is provided below.

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INVESTIGATIVE PRIORITIES

There are four investigative priorities for 2017-18:

1. Maternal mental health

2- Place of birth

3. Workforce, and

4. Equity of access.

Maternal mental health

Why?

Women need access to appropriate mental health services during pregnancy a1 gost-partum. Women with existing mental health issues are at risk of escalation duri g e.:pregnancy and postnatal period. For some women, access to and provision of menta1f1Xlill services during and after pregnancy is essential to their safety and the wellbeing of thei liaOies. In the eleventh Perinatal and Maternal Morbidity Review Committee (PMMRC) r o~ the PMMRC noted that the suicide "continues to be the leadin9 sin9/e cause of maternf;,'1!11 in New Zealand". Women remain vulnerable to poorer mental health outcomes (in · ucijpg post-natal depression and suicide) up to one-year post-partum. Maori women ~~~r-represented in the number of maternal suicides and experience an increased risl~,f su~itle. New Zealand's rate of maternal suicide is seven times higher than of the United Ki gcto.,m. Improving access to primary mental health services as well as ensuring that servic: a~available for serious and acute episodic mental illness is an important way to supR@~'07 mothers to build wellbeing and live healthy lives for themselves, their babies and th~, f~ily /whanau.

In2017/ 18,we will: U'"' •

• •

•

work with the PMMRC t~prove awareness of the importance of supporting women's mental health for~ne-year post-partum and champion the establishment of the permanent Suicide MtJrtality Review Committee

champion th~blishment of the Maternal and Infant Mental Health Network, and

monito!fI{BBs"to determine if there are capacity issues that affect access to primary and secon~mental health care in DHBs

main in awareness of the Ministry of Health work programme 2017-2018 and link e;to ny emerging work on maternal mental health.

Approximately ten percent of New Zealand women birth at primary maternity facilities, with many of these maternity units located in rural areas. Rates of birth at primary facilities are decreasing: the number of women birthing at primary birthing units declined from 15.1 percent (2006) to 9.9 percent (2015). Evidence shows that, for a healthy woman and baby with no complications and low risk, birthing at primary birthing units is a safe and can result in fewer interventions (eg, the National Institute for Health and Care Excellence, 2014).

The NMMG supports strengthening primary maternity services including timely, equitable access to community-based primary maternity care. In 2017 /18, we will:

• encourage the Ministry of Health to promote physiological birth and to better understand women's preferences about place of birth, and

• explore influencers on women's preferences regarding place of birth. location of n . primary birthing facilities, staffing levels, and use/occupancy rates, access to primary °"" V maternity facilities in rural and remote areas, the integration of primary birthing!"'\ii. "V facilities into DHB management and quality frameworks. data gaps (for example, i -~ J labour and post-natal transfer rates between type of facility, number of LMCs working in remote and rural primary birthing facilities, etc.), and the guidance DHBs re'i!"1~ to maintain and manage primary birthing units within the MQSP framework. ~V

Workforce ~ Why? ~ There are concerns that inadequacies in maternity staffing may u~~e ability to always deliver high-quality maternity services both at a community leveka~m secondary and tertiary facilities. External reviews of D HBs identified staffing is jl_ ft~al success factor but most reviews made recommendations about reviewing staffinKf~better consider the acuity and complexity of birthing women. To address concerns a o ~ttnidwifery staffing, the Ministry of Health has established the Midwifery Strategic Advi50fY Group to provide advice to the Ministry on a sustainable midwifery workforce. • fN,

In2017/18, wewill: 1G~U • engage with the Midwifery UStr:al{~ Advisory Group to support delivery of its work

programme (as required)

• engage with the Minis~1Health on the working groups for the National Maternity Record, and remai~~a on workforce-led discussions

Equity of Access e, \ Why? ~o-The NMMG i c ncerned about equity issues that some consumers may face when trying to reach hif -guality, timely maternity services. This includes (but is not limited to) access to materi}-1:: u trasounds, first trimester care, maternal mental health services and long-acting reversible contraception (LARC).

~~eventh PMMRC report highlights the need to focus on outcomes for Maori mothers and '-. ~ :F.fants, as the inequity between Maori and non-Maori continues. There is a significantly higher, r>~ almost double. maternal mortality ratio among Maori mothers than New Zealand European

/)__V mothers. Maori women are over-represented among maternal suicides and the loss of babies to '~ very preterm labour. The PMMRC note that the main contributory factors amongst these deaths

continue to be barriers to access and/or engagement with care.

In 2017 /18: we will:

• monitor improvements in DHBs' efforts to engage with and ensure equity of access to services for ALL consumers (particularly Maori, Pasifika. Asian, Middle Eastern. Latin American and African women, women with disabilities and young women).

•

investigate equity of access to LARC by requesting and reviewing information from DHBs about availability and funding of LARC, exploring and promoting examples of good practice where DHBs ensure equity of access to LARC for all consumers, including groups of women with poorer maternity outcomes and monitoring the Ministry's progress towards introducing postnatal contraception is on its future work programme

m aintain awareness of the Ministry of Health work programme and link into any 0..-.~ emerging work on equity of access to maternity services. Cb-U

CONNECTING SECTOR LEADERSHIP

Connect with government maternity sector advisory groups to suppo

cohesive quality improvement advice to the maternity sector

Why?

A range of groups provide advice to government agencies on maternity is}uj: . This includes the PMMRC and its subcommittees, the Neonatal Encephalopathy (NE) Ta8K4L~ee, and the Maternity Strateg~c Advi:ory Gr~up (MSAG). :o improve maternity seeices~ . decision-ma.kers and matermty service providers need consistent and coherent reconny-e)li:lations and advice on the relative priority of implementation. The NMMG is well-place t o.€onnect between and support coordination of groups with responsibilities for provia ing maternity advice and service providers like lead maternity carers. DHBs, consumer: ~ an<hprofessional colleges .

• In 2017-18, the NMMG will provide strategic le~ e:Eship to the maternity sector, to drive and create change and improve maternity outl~~e will:

• work with the Ministry's Mat~n~~Tuld and Youth Health Leadership Group to progress

•

the Ministry's consideratio of ny maternity advisory groups' recommendations (includ~ng supporting i '> imp ementation of all recommendations made by the Matermty Ultrasoun~d~ry Group)

m eet with DHB chre~-xecutives at least annually to strengthen visibility of maternity services with DH executive leadership teams

monitor ~(~HBs respond to recommendations made by the PMMRC and its subcom!l1i~:es, the Neonatal Encephalopathy Taskforce and MSAG within Maternity Qual~l\P Safety Programmes (MQSPs)

r ~ive regular updates on work programmes and recommendations made (if any) from ~MMRC, the MSAG and the NE Taskforce

en courage government maternity advisory groups to coordinate information requests to DHBs and professional colleges, and

consider, in collaboration with other groups, if a maternity target is appropriate, and if so, what the target( s) could be.

Investigate culture of DHBs workplaces to ensure maternity staff are working

in safe and supportive environments

I Why?

A common theme from the five external reviews of DHBs' maternity/women's health services was that DHBs should be providing a positive and supportive working environment for maternity staff that is free from blame, bullying and harassment Positive, just cultures are likely to improve retention and recruitment rates for staff.

In2017/18, wewill: n . • request and review information from DHBs to about what processes (not policies) they~ 'b V

have in a place to manage bullying and harassment, what positive steps they have in ~J place to create better working environments, how many complaints have been made in the last year and if the DHB does regular staff surveys or exit surveys, and ~

~ • share our findings with DHB executive leadership teams as appropriate .

MONITORING ACTIVITIES

Review key sector reports

Why?

Reviewing key maternity sector publications is one of thee_MMG's responsibilities under its terms of reference. This includes reviewing publications lik~e Ministry of Health's Report on Maternity and each New Zealand Maternity Clinical I di' at0rs report. both of which provide data about mothers and babies' outcomes in our mat~nity;system. Reviewing and commenting on these publications supports independent ov;rsigh~f the performance of the New Zealand maternity sector and enables the timely id~nti[J£~on of areas for further action.

The NMMG will continue to monitor key s~~~ublications . In 2017 /18, we will:

• review the 2016 New Zeala"Qaternity Clinical Indicators and the 2015 Report on Maternity to: (lJ_ - consider the p ff&~ance of the maternity system overall

share our fi~'figs with and seek advice from each DHB on any identified significa<'-il:ld consistent variations from the national average and the DHBs' res po es.t! these (including where D HBs are performing well), and

a vise the Ministry of Health, DHBs and other government maternity sector aCl~sory groups on national and local priorities for action

• evi w the PMMRC's annual report, provide advice to the Ministry about any notable 0 n aings or recommendations (NB also see the maternal mental health investigative g priority).

-~xpect DHBs to also review these reports and consider how presented data applies to the ~~~~es provided in their areas. We would like DHBs to use their MQSP annual reports to describe «:--<lJ how they respond to any recommendations made in these key sector reports.

Monitor the implementation of DHBs' Maternity Quality and Safety

Programmes

I Why?

Each DHB produces an annual report describing maternity service delivery and work to improve maternity services in its area. Under its terms of r eference, the NMMG reviews these r eports to develop its understanding of how DHBs are identifying and responding to challenges in maternity and how they are responding to recommendations by key sector advisory groups. Occasionally, external reviews of maternity and/or women's health services are completed. Together. these two groups of reports provide rich information to support the NMMG's n . monitoring role by describing service delivery and potential areas for further improvement. ~ V

The NMMG will continue to support the Ministry of Health to monitor the implementation Rf"?) DHBs' MQSPs. In 2017 / 18, we will: . '

• review each DHB's MQSP 2016 and 2017 Annual Report to determine how each DHB:

•

articulated its priorities for maternity services and its progress toward lliese

responded to recommendations made by key maternity sector ad' · sory groups

published its report online 'i;:::. Q implemented changes to align processes and procedu~to the hypertension guideline released by the Ministry of Health ~ monitored rates of women diagnosed with eclamJl~ Cfuring birth admission and, if an increase was identified, investigated pos~ ·01~easons for the rise4, and

- undertaken continued efforts to ensur~~1~cfive caesareans are not completed prior to 39 weeks gestation. ~'

engage with DHB management and lead'~Hip teams to discuss DHBs' maternity service performance by: • (j

concentra ting our monit--ariQg efforts on "establishing" DHBs to support advancement to more con ected and integrated local MQSPs (West Coast and Southern DHBs ), includ1 · g-visiting both DHBs. and

encouraging "e ta lishing" and "excelling" DHBs to further embed existing programmes ·nt~ long-term, organisation-wide quality frameworks while retaining stffong clinical leadership and management support, and

suppo ~the Ministry to review the DHB MQSP Crown Funding Agreements and im l~ t any changes if required.

• review aRy external reviews of DHB maternity and women's health services to d'ete~ne key themes, sha re findings with DHBs and other key sector stakeholders, and

o >itor the DHB's implementation plan to address recommendations made in an ~xternalreview

g monitor how Counties Manukau, MidCentral/ Whanganui, Waikato and South Canterbury D HBs have responded to and implemented the recommendations set in their external reviews.

4 Eclampsia is a serious condition that is largely preventable through the detection and effective ma nagement of pre-eclampsia. Rates of eclampsia at birth admission have increased since 2010. It is important for DHBs to identify a nd investigate the reasons for eclampsia at birth admission.

Support ratification of national maternity clinical guidelines

Why?

National maternity clinical guidelines ar e a key component of the maternity sector. They set standards based on the latest clinical evidence or best practice and enable consistency in n . clinical maternity practice nationally. Once these have been developed, it is important that they °"" V are implemented in DHBs so that best practice is consistently delivered in our materni:._ r\..-U services. f"'l ~J

In 2017 / 18, we expect to ensure that national evidence-informed clinical guidance is ap~~Jsed

and ratified using the AGREE II Instrument and algorithm. We will: V • consider draft material fo r ratification as national guidelines (as required) ,~ • write to DHBs requesting information about how they have implement~e 'Diagnosis

•

and treatment of hypertension and pre-eclampsia in pregnancy in ~,~a/and: A clinical practice guideline', and ~

champion the development of a guideline on the indu~-h. '°1'-labour (as per the PMMRC's 2017 recommendation to develop a national cli:ni~l~ractice interdisciplinary on the indications and timing of induction oflabourJ . Q

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Literature Scan – Planned Place of Birth 1

HOW DO EXPECTANT PARENTS DETERMINE PLANNED PLACE OF BIRTH? A LITERATURE SCAN FOR THE NMMG, MAY 2018

Background

There is abundant literature that includes statistical data about how many women give birth in

primary, secondary and tertiary facilities; and these data inform the view that there are women

delivering in secondary and tertiary facilities whose medical risk indicators suggest that they

could deliver at a primary facility. However, there is a considerably smaller body of literature

about how women (and often also their partners) decide where they plan to give birth. The NMMG

is considering approaching schools of midwifery to encourage academic research into this topic.

Prior to doing so, the NMMG decided to conduct a literature scan to ascertain what research has

already been conducted in this vein, starting with theses produced through schools of midwifery

in New Zealand.

Scope of the Literature Scan

A desktop search resulted in two relevant theses and eight academic articles, including some

authored by or relating to New Zealand. Ministry of Health librarians were approached for

assistance with accessing full-text copies. The Ministry Library also ran three additional searches:

• one of the university libraries that had been inaccessible from the desktop;

• one that specifically searched the content of the Journal of the New Zealand College of

Midwives; and

• one that specifically searched the UK journal Midwifery, which had been the source of

several articles in the original desktop search.

The search criteria provided to the Ministry library was: ‘place of birth’ AND (women’s

perceptions’ OR patient perceptions ), with articles published since 2010, and theses dating back

to 2007.

Additionally, six references were provided by Judith McAra-Couper.

After eliminating multiple reports about the same study; a small number that addressed birth

‘outside the system’i; and those that did not pertain to the topic despite including the key phrases,

there were 19 items broken down as follows:

• Three theses, all for Master of Midwifery, all from New Zealand universities (theses from

universities outside of New Zealand were not sought)

• 16 journal articles from the following jurisdictions:

o New Zealand (3)

o UK (3)

o North America (3)

o Australia (2)

o Finland (2),

o Netherlands (2), and

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o one, authored in Cyprus, was a multi-national synthesis, including 21 research

papers from seven countries (USA (3), UK (9), Sweden (2), Australia (3), Greece

(2), Finland (2), and the Netherlands (1)) focussing on women’s perceptions of

their right to choose the pace of childbirth.

Of the 19 items, four were published prior to 2010, including one thesis and three articles that

had been cited in numerous later material.

Much of the literature draws on relatively small samples, usually using techniques such as in-

depth interviewing or focus groups, followed by thematic analysis. This is to be expected with

research exploring questions of this nature. There is also some use of surveying. Some studies

focused on one particular place of birth – often home birth but sometimes primary facilities,

whilst other studies compared perceptions and expectations across a range of settings

Major findings from the Literature Scan

Personal beliefs guide decisions concerning planned place of birth

The most prevalent point emerging in this body of literature is that the personal beliefs of the

woman are extremely important to her decision about where to birth. There is an important

caveat here: if her partner has strongly-held beliefs the beliefs of the woman may become

secondary, with talk of ‘compromise’ that in every case reported in this literature resulted in the

couple planning a tertiary facility delivery. Putting this caveat aside, it is evident in this literature

that women who choose home or a primary facility as the planned place of birth are very

commonly described as having ‘personal beliefs’ such as knowing their body to be capable of

giving birth, succinctly expressed as “an innate confidence in the ability of their body to give birth”

(Catling, Dahlen, & Homer, 2014).

There is a need to feel safe, but there are multiple understandings of safety

Regardless of where they plan to give birth, women aim to feel safe. But feeling safe comes about

in different ways, which the authors across this body of literature frequently align with the ‘beliefs’

of the woman (and/or her partner). For women possessing the ‘innate confidence’ described by

Catling et.al, it is possible to feel safe giving birth in a primary birthing facility or at home. But for

women (and/or their partners) who do not have that innate confidence, feeling safe can require

having immediate access to whatever medical interventions may be necessary to resolve

whatever complications may arise: mother and baby are ‘believed’ to have the best chance of an

optimal outcome, encapsulated by the birth announcement summation that ‘both mother and

baby are safe and well’.

Further, there are contrasting views regarding safety. Planned place of birth decisions of some

expectant parents are influenced by a desire to be ‘safe’ from interventions that they associate

with hospital-based maternity services. For example:

The participants who planned to birth at home or at a birthing centre aim

to avoid as much as possible obstetric interventions during labour, (Howie,

2007).

Comments from women about what they wanted to avoid included negative

interactions with staff, strangers coming into their room, hospital visiting

times that restricted partner access, travelling to hospital, not having access

to a waterbirth, having epidurals and other medical interventions,

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Literature Scan – Planned Place of Birth 3

restrictive protocols, feeling unable to resist pain relief medication, the

‘cascade of intervention’, infection, and separation from their infant,

(Catling et al., 2014).

[One homebirth mother felt it was] better to birth in the privacy of her own

home, outside of the influence the patriarchal hospital system where she felt

it was better “to keep away from it, otherwise I will get overtaken by it”

which is “why it’s so difficult to have a normal birth in a hospital” (Ozturk,

2010).

Contrastingly, other expectant parents whose views are expressed via this body of literature

would not consider giving birth outside of the hospital environment, because home birth is

considered “risky” (Murray-Davis, McDonald, Rietsma, Coubrough, & Hutt n, 2014),

“irresponsible or dangerous” (Murray-Davis et al., 2012), “dangerous or forbidden” (Viisainen,

2000). For such expectant parents, birth taking place outside the hospital constitutes an

emergency.

Making an informed decision

The literature frequently noted that women felt they were given incomplete information by health

professionals about their options for place of birth. Seven studies noted that women, especially

those exploring the possibility of or already planning a home birth, relied considerably on their

own research, ‘educating oneself’, firstly to discover the array of possibilities, and then to explore

the pros and cons of various options.

Whether the women found books, CD’s, antenatal classes or positive birth

stories most effective, they all engaged actively in seeking information

before choosing a homebirth and then in the preparation for that

homebirth, (Ozturk, 2010)

The timing of receiving information and of making a decision was highlighted in three studies.

Some women expressed a preference for receiving information early in their pregnancy but

delaying decision-making until there has been time to reflect. Comments suggest there is an

assumption that the place of birth decision is straightforward and does not warrant considered

exploration. (This is reflected in comments throughout the literature to the effect that it is ‘normal’

to give birth in hospital, and ‘abnormal’ to give birth elsewhere.) There seems to be an assumption

that the decision about birth place can (and should) be made spontaneously and immediately after

being provided with information.

Birth experiences of family and friends

Eight studies highlighted the influence upon planned place of birth decisions of others’ birth

stories. But it is also clear that people are not uniformly influenced by a particular birth story. For

example, where the story of a dramatic birth might make some people more inclined toward

hospital birth, others interpret the hospital environment as contributing to the drama and

therefore strengthen their resolve to deliver elsewhere.

Annotated Bibliography

The following bibliography includes a summary of the study findings pertaining to how women

(and sometimes their partners) decided where they planned to give birth – regardless of the

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eventual delivery location. Also included are summary points concerning the study methods and

the characteristics of the study participants. New Zealand studies are prefaced with an aster.

Barber, T., Rogers, J., & Marsh, S. (2013). The Birth Place Choices Project: Phase one. British Journal of Midwifery, 14(10). https://doi.org/10.12968/bjom.2006.14.10.21935

Jurisdiction: Southhampton University Hospitals NHS Trust and the Portsmith Hospitals NHS

Trust, England

Methods: Literature review, statistical analysis, cross-sectional survey of local women, focus group

with local women and with midwives

Cohort characteristics: Focus groups were attended by 20 women at 30+ weeks gestation; 398

survey respondents, with a mean age of 29 years, mostly 29 – 40 weeks gestation

Summary of findings: The focus groups revealed a preference to receive information about place

of birth option early, but not to be expected to make an immediate decision. This was about having

the space to make an informed and considered choice. Midwives were the health professionals

found to have most influence over planned place of birth choices; and it is suggested that midwives

could be doing more to ensure women were fully aware of the place of birth options available.

Catling, C., Dahlen, H. G., & Homer, C. S. E. (2014). The influences on women who choose publicly-funded home birth in Australia. Midwifery, 30, 892–898. https://doi.org/dx.doi.org/10.1016/j.midw.2014.03.003

Jurisdiction: New South Wales, Australia

Methods: semi-structured interviews followed by thematic analysis

Cohort characteristics: Data were collected though semi-structured interviews with 17 women

who chose to have a publicly-funded home birth.

Summary of findings: Four categories emerged from the data pertaining to place of birth choice:

feeling independent, strong and confident; doing it my way; protection from hospital-related

activities; and having a safety net (through the possibility of transfer to hospital, made acceptable

by home birth being publicly funded.)

The core category was having faith in normal. This linked all the categories

and was an overriding attitude towards themselves as women and the

process of childbirth, (Catling et al., 2014, p. 892).

Dahlen, H. G., Barclay, L. M., & Homer, C. S. E. (2010). The novice birthing: theorising first-time mothers’ experiences of birth at home and in hospital in Australia. Midwifery, 26, 53–63. https://doi.org/10.1016/j.midw.2008.01.012

Jurisdiction: Sydney, Australia

Methods: In-depth interviews, followed by thematic analysis

Cohort characteristics: Seven women who gave in a public hospital and seven women who gave

birth for the first time at home were interviewed and their experiences were contrasted with two

mothers who gave birth for the first time in a birth centre, one mother who gave birth for the first

time in a private hospital and two women who had given birth more than once (n=19).

Summary of findings: Planning the place of birth (which was a minor theme for this study

compared to other themes addressed in the article) was influenced by “beliefs, convenience,

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Literature Scan – Planned Place of Birth 5

finances, reputation, imagination, education and knowledge, birth stories and what was termed

‘life’s baggage’, or ‘previous life experiences’”, (Dahlen, Barclay, & Homer, 2010, p. 55)

*Dawson, P. G. (2015). Travel Patterns of Women Giving Birth in the Southern District Health Board (Master of Midwifery). Victoria University of Wellington, Wellington. Retrieved from http://researcharchive.vuw.ac.nz/bitstream/handle/10063/4755/thesis.pdf?sequence=1

Jurisdiction: Southern District Health Board, New Zealand

Methods: Paper-based survey, spatial modelling, more to go here…’small sample of women…

Cohort characteristics: The 165 women surveyed had all given birth in the region in three months

from April until June 2014. More than half lived in Dunedin, and roughly quarter lived in

Invercargill with the remaining quarter distributed across the Southern DHB region. Almost half

of the respondents had their first child, with one third having their second child in this time.

Summary of findings: Survey findings highlighted the dual desire to be in a safe place whilst being

as close as possible to home, with safety prioritised over distance from home Women who chose

to deliver in a primary unit are quoted as doing so for three reasons: partner able to stay too,

avoiding travel, and co-sleeping. For women who chose to deliver at home, the following three

reasons are provided: home environment, economics, and the desire to ensure availability of a

birthing pool.

*Grigg, C., Tracy, S., Schmied, V., Daellenbach, R., & Kensington, M. (2015). Women’s birthplace decision-making, the role of confidence: Part of the Evaluating Maternity Units study, New Zealand. Midwifery, 31, 597–605. https://doi.org/10.1016/j.midw.2015.02.006

Jurisdiction: Christchurch, New Zealand

Methods: Focus groups (eight groups, with a total of 37 participants), survey (six weeks

postpartum n=571)

Cohort characteristics: participants were assessed, during their pregnancies, as having a low-risk

of developing complications; and were booked to give birth in one of the four primary birthing

units or in the tertiary unit between 2010 and 2012.

Summary of findings:

Women who planned a primary maternity unit birth expressed confidence

in the birth process, their ability to give birth, their midwife, the maternity

system and/or the primary unit itself. The women planning to give birth in

a tertiary hospital did not express confidence in the birth process, their

ability to give birth, the system for transfers and/or the primary unit as a

birthplace, although they did express confidence in their midwife, (Grigg,

Tracy, Schmied, Daellenbach, & Kensington, 2015, p. 597)

The authors conclude that “a multiplicity of factors needs to converge in order for all those

involved to gain confidence required to plan what, in this context, might be considered a

‘countercultural’ decision to give birth at a midwife-led primary maternity unit,” (Grigg et al.,

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Hadjigeorgiou, E., Kouta, C., Papastavrou, E., Papadopoulos, I., & Mårtensson, L. B. (2012). Women’s perceptions of their right to choose the place of childbirth: an integrative review. Midwifery, 28(3), 380–390. https://doi.org/10.1016/j.midw.2011.05.006

Jurisdiction: International: Australia, The Netherlands, Scotland, Greece, UK, USA, Finland, Sweden

Methods: integrated literature review, with quantitative, qualitative, and mixed methods studies

Cohort characteristics: research literature focusing on women’s perceptions for their birthplace

choices; with data collected during pregnancy, at birth and postpartum; published in English,

between 1997 and 2009.

Summary of findings: Samples sizes varied from 8 to over 4,500 people. Most studies focused

exclusively on mothers, with some including health professionals and/or fathers. There was a

wide range of sampling strategies; and a range of data collection techniques, including one-on-one

interviews, focus groups, questionnaires, participants observation, reflective journals.

The following extract is from the section about the dominant theme identified through the review:

Choice of Birthplace and Medicalisation of Childbirth:

Twelve of the 21 studies from all countries except the Netherlands agreed

that women’s right to choose where to give birth protects them from the

medicalisation of childbirth. … Some of the studies sustained that women’s

choice of where to give birth is mainly limited by the general belief that birth

is only safe in hospital. … The dominant model of birth has a major influence

on women’s decisions, and is based on the assumption that birth is

considered to be a potentially pathological condition in which something

could go wrong at any time. … The legacy of the medical model appeared to

be culturally ingrained in women’s own accounts, and is one of the most

powerful influences on women’s choices. … [Another study] reported that

women… decided to give birth at home in order to avoid the involvement of

the medical model. They stressed that in their previous births in hospital,

they experienced numerous interventions as one intervention led to another.

This finding was further verified by [another study]: women give birth at

home in an effort to avoid unnecessary interventions. This is a system-

challenging praxis, as women reject the disciplinary power of obstetrics. …

Women’s power to give birth at home as ‘embodied knowledge’ and

‘women’s inner wisdom’, whereas according to the women’s narratives in

[another study] … giving birth in hospital was an experience of alienation

and disempowerment. [Conversely,] some studies contradict these findings,

as women … reported that they would feel safer if the consultant-led

maternity hospital was reestablished in their town.(Hadjigeorgiou, Kouta,

Papastavrou, Papadopoulos, & Mårtensson, 2012, pp. 8–9)

The following extract is about a second major theme relevant to this current literature scan, and

arising in the literature review: Informed Choices and Women’s Autonomy:

Without informed choice, there is no autonomy; and without autonomy,

there can be no informed decision-making, (Hadjigeorgiou et al., 2012, pp.

9–10)

In order for each woman to be truly autonomous, she needed to be respected,

valued and honoured for the authoritative knowledge that she possessed:

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Literature Scan – Planned Place of Birth 7

knowledge of her body, her values and beliefs, and what is important to her,

(Hadjigeorgiou et al., 2012, p. 9)

Houghton, G., Bedwell, C., Forsey, M., Baker, L., & Lavender, T. (2008). Factors influencing choice in birth place – an exploration of the views of women, their partners and professionals. Evidence Based Midwifery, 6(2), 59–64.

Jurisdiction: North-west of England

Methods: Questionnaires, non-participant observation (participants recruited at 12-weeks

partum) gestation and followed up at 34 weeks and post-, in-depth interviews.

Cohort characteristics: 50 pregnant women and their partners; 12 midwives, 15 GP’s, and 9

obstetricians

Summary of findings: Women and health professionals alike assumed that birth would take place

in hospital, which was perceived by both as a safer environment. “There was a fatalistic attitude

towards the birth process and an acceptance of the use of intervention around the time of birth

that strongly influenced women’s decisions to give birth in a hospital setting,” (Houghton,

Bedwell, Forsey, Baker, & Lavender, 2008, p. 59)

*Howie, J. (2007). Choosing the place of birth: How primigravida women experiencing a low-risk pregnancy choose the place in which they plan to give birth in New Zealand (Master of Midwifery). Otago Polytechnic, Dunedin.

Jurisdiction: New Zealand

Methods: Interviews

Cohort characteristics: Primigravida women experiencing a low-risk pregnancy

Summary of findings: Factors influencing the decision to deliver at a birthing centre included

proximity to medical assistance and ease of transfer to hospital (which is suggested to be

negatively value-laden for women transferring to hospital from home); ‘technology’ is out-of-sight

unless it is needed; a warm, attractive atmosphere, compared to a ‘sterile’ (refers to the

pleasantness rather than cleanliness) hospital room; and privacy.

Home birth mothers sought “to avoid as much as possible obstetric interventions during labour.

Their focus is on an environment which has comfortable and relaxing features,” (Howie, 2007, p.

49). For one woman there was a desire to have her mother present to karakia during the baby’s

delivery.

Amongst women who chose to deliver in a tertiary hospital, one wanted ready access to an

obstetrician. Her feelings were so strong on this point that she changed her original plan when

she realised the limitations of the birthing centre. For another, the idea of being transferred during

labour was “sickening” and so she opted to go directly to the tertiary unit. Finally, one woman who

wanted to explore the home birth option was faced with extreme opposition from her partner,

who insisted that “Home is not the place to birth,” (Howie, 2007, p. 53).

Jouhki, M.-R., Suominen, T., & Astedt-Kurki, P. (2017). Giving birth on our own terms - Women’s experience of childbirth at home. Midwifery, 53, 35–41. https://doi.org/10.1016/j.midw.2017.07.008

Jurisdiction: Finland

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Methods: Interviews

Cohort characteristics: 14 women who had given birth at home 28 times collectively over the

previous five years

Summary of findings:

Women described how giving birth at home enabled them to control the

birth, giving them autonomy and the ability to make decisions for

themselves regarding the birth. For example, it was important to them to

avoid medical interventions and to ensure there was a calming atmosphere

for the infant at the moment of birth and afterwards. A cosy home

environment enabled them to feel relaxed and calm, and to cope with pain.

It also made them feel strong, energised and capable of managing the

process, (Jouhki, Suominen, & Astedt-Kurki, 2017, p. 38).

Longworth, L., Ratcliffe, J., & Boulton, M. (2001). Investigating women’s preferences for intrapartum care: home versus hospital births. Health and Social Care, 9(6), 404–413. https://doi.org/10.1046/j.1365-2524.2001.00319.x

Jurisdiction: UK

Methods: Conjoint analysis (An economic technique applied in this instance to assess the relative

value attached to several main characteristics associated with maternity care). Compares

characteristic valued by women who have home births with those who planned hospital births.

Cohort characteristics: Two focus groups: one with 10 women who had booked for a home birth

in the previous 12 months; and another with 10 women who had booked for a hospital birth in

the previous 12 months.

Summary of findings: Women who had chosen home birth valued continuity of carer, a homely

environment and the ability to make their own decisions about what happens during labour and

delivery. Contrastingly, women who chose hospital birth placed a higher value on access to

epidural and the removal of a possibility of transfer during labour.

*McAra-Couper, J., Jones, M., & Smythe, L. (2011). Caesarean-section, my body, my choice: The construction of ‘informed choice’ in relation to intervention in childbirth. Feminism & Psychology, 22(1), 81–97 https://doi.org/10.1177/0959353511424369

Jurisdiction: Auckland, New Zealand

Methods: focus groups; critical interpretive analysis

Cohort characteristics: 33 women, aged mid-20s to mid-40s who had given birth in the previous

five years white, middleclass – purposively recruited to include the characteristics of women

considered to be increasingly undergoing elective caesarean-section.

Summary of findings: The choice of elective caesarean-section is critiqued as evidence of the

increasing socialisation of birth as a medical event, legitimised through a notion of ‘choice’ that

are heavily influenced by perceptions of pain coupled with a general increase in reliance on

technology in everyday life.

Murray-Davis, B., McNiven, P., McDonald, H., Malott, A., Elarar, L., & Hutton, E. (2012). Why home birth? A qualitative study exploring women’s decision making about place of birth in

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Literature Scan – Planned Place of Birth 9

two Canadian provinces. Midwifery, 28(5), 576–581. https://doi.org/10.1016/j.midw.2012.01.013

Jurisdiction: Two provinces of Canada

Methods: semi-structured interviews

Cohort characteristics: purposive sample: 34 women who were pregnant and planned to give birth

at home, or had given birth at home in the previous two years.

Summary of findings:

[Participants described that they wanted to] optimise choice, comfort and

control, and to have family involved in the birth. All of the women felt that

labouring at home gave them more choice of options to manage pain and

cope during labour. … they wanted the privacy and intimacy of their home.

They felt that being relaxed at home would facilitate labor progress. The

women said they felt safer in a familiar and comforting space and they

anticipated having an easier recovery at home,” (Murray-Davis et al., 2012,

p. 578)

Women felt they would have more control over decision-making in their own homes, including

thing such as lighting, music, temperature of the room, and who was going to be with them at the

time. They also want to avoid medications and interventions: “the perceived cascade to

intervention associated with hospital birth,” (Murray-Davis et al., 2012, p. 578).

Murray-Davis, B., McDonald, H., Rietsma, A., Coubrough, M., & Hutton, E. (2014). Deciding on home or hospital birth: Results of the Ontario choice of birthplace survey. Midwifery, 30, 869–876. https://doi org/10.1016/j.midw.2014.01.008

Jurisdiction: Ontario, Canada

Methods: self-administered questionnaire, including questions about sources of information used

to decide where to plan to give birth. 214 completed surveys analysed.

Cohort characteristics: aged 16+ years (slightly more than half being in the 30 – 34 age group), 24

weeks + gestation (mean gestation: 32 weeks), low-risk pregnancy, with equal opportunity to

deliver at home or in hospital (home = 78; hospital = 123, undecided: 13).

Summary of findings: Decisions about place of birth tend to be made prior to pregnancy or in the

first trimester, informed by books and research. “Women who planned home birth wanted to

avoid interventions and felt most comfortable at home. Those who planned hospital birth wanted

access to pain medication and found the idea of home birth stressful,” (Murray-Davis et al., 2014,

p. 869). Questions about the safety of home birth were a critical barrier for women who are

undecided about where to give birth. The authors conclude that “beliefs and values about birth

and the desire for pain relief options play significant roles in women’s decisions but are balanced

with views of safety and risk,” (Murray-Davis et al., 2014, p. 869).

*Ozturk, K. J. L. (2010). Becoming a homebirther…smooth sailing or rocky road? An exploration of Pakeha women’s experiences on the path to homebirth (Master of Midwifery). Victoria University of Wellington, Wellington. Retrieved from http://researcharchive.vuw.ac.nz/bitstream/handle/10063/1455/thesis.pdf?sequence=2

Jurisdiction: New Zealand

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Methods: Narrative Inquiry, using semi-structured interviews followed by thematic analysis

Cohort characteristics: five participants, all Pakeha, all of whom had a planned home birth

Summary of findings: For Ozturk, the most surprising finding was that four of the five participants

were a considerable way into their decision-making process about place of birth BEFORE they

conceived. Each had been influenced in various ways by experiences of friends and family

members – sometimes participating in these experiences as a birth support person. Oztruk

explains that through these prior experiences and the knowledge and understandings gained,

home birth became a genuine possibility for these women. For the fifth woman, a confluence of

three factors made home birth a realistic possibility from early in the pregnancy. Firstly, the

woman’s sister who is a midwife - a midwife who is supportive of home birth – and the expectant

parents received information from her, Secondly, the midwife with whom she booked was

supportive of home birth and openly expressed her belief in the woman’s ability to deliver at

home. Thirdly, the family of the woman’s partner had a history of home birth and was very

supportive.

*Patterson, J., Foureur, M., & Skinner, J. (2017). Remote rural women’s choice of birthplace and transfer experiences in rural Otago and Southland New Zealand Midwifery, 52, 49–56. https://doi.org/10.1016/j.midw.2017.05.014

Jurisdiction: Southland, New Zealand

Methods: Retrospective study of birth place choices

Cohort characteristics: 13 women, all living in remote locations, who had given birth in the

previous 18 months – nine with first babies and four with second babies. All were considered low

risk and anticipated normal births.

Summary of findings: Distance from a base hospital influenced some women’s decisions about

where to plan to deliver, reflecting their concern for safety and anxiety about the possibilities of

needing to transfer in labour. Reasons for planning to deliver at local, rural birthing centres

including proximity to family, avoidance of interventions associated with a hospital delivery, and

the desire for a ‘natural’ experience. The fear of a long trip to hospital (transfer) in the midst of a

difficult labour was a barrier for others, especially those for whom such transfers would take two

to three hours due to their remoteness. One woman reported that her midwife ‘preferred’ first

babies to be born in hospital, discouraging her from planning to birth at a primary facility.

van Haaren-ten Haken, T., Hendrix, M., Nieuwenhuijze, M., Budé, L., de Vries, R., & Nijhuis, J. (2012). Preferred place of birth: Characteristics and motives of low-risk nulliparous women in the Netherlands. Midwifery, 28(5), 609–618. https://doi.org/10.1016/j.midw.2012.07.010

Jurisdiction: Netherlands

Methods: self-administered questionnaire

Cohort characteristics: 550 first-time parents, early in pregnancy, accessed across 100 midwifery

practices and 14 hospitals, between 2007 and 2011.

Summary of findings: Older, wealthier women, who were more likely to have had reproductive

assistance, tended to prefer an obstetric-led pregnancy compared to others who preferred a

midwife-led pregnancy. The choice for home birth was driven by a sense of self-autonomy;

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Literature Scan – Planned Place of Birth 11

whereas those choosing hospital birth were “driven by a desire to feel safe and control risks,” (van

Haaren-ten Haken et al., 2012, p. 1)

Key conclusions: the characteristics of women who prefer a hospital birth

are different than the characteristics of women who prefer a home birth. It

appears that for women preferring a hospital birth, the assumed safety of

the hospital is more important than type of care provider. This brings up the

question whether women are fully aware of the possibilities of maternity

care services. Women might need concrete information about the

availability and the characteristics of the services within the maternity care

system and the risks and benefits associated with either setting, in order to

make an informed choice where to give birth. (van Haaren-ten Haken et al.,

2012 p. 1)

van Haaren-ten Haken, T., Pavlova, M., Hendrix, M., Nieuwenhuijze, M., de Vries, R., & Nijhuis, J. (2014). Eliciting Preferences for Key Attributes of Intrapartum Care in The Netherlands. Birth, 41(2), 185–194. https://doi.org/10.1111/birt.12081

Jurisdiction: Netherlands

Methods: questionnaires

Cohort characteristics: as above

Summary of findings:

Women with an intended home birth preferred a home-like birth setting

with the assistance of a midwife and transport during birth in case of

complications. Type of birth setting and transport during birth were not

considered important to women with an intended midwifery- or obstetric-

led hospital birth, (van Haaren ten Haken et al., 2014, p. 185).

Viisainen, K. (2000). The moral dangers of home birth: parents’ perceptions of risks in home birth in Finland. Sociology of Health & Illness, 22(6), 792–814. https://doi.org/10.1111/1467-9566.00231

Jurisdiction: Finland

Methods: Interviews

Cohort characteristics: home birth parents: 21 women plus 12 of their partners, who had planned

a home birth in the previous three years.

Summary of findings: This article, which was published considerably earlier than the guideline for

this literature scan, was accessed due to it frequently being cited in the more recent literature.

The pertinent point is that:

Parents considered three types of risks in their decision-making: medical

risks of pregnancy and birth, iatrogenic risks of medical practice and moral

risks of going against medical authoritative knowledge, (Viisainen, 2000, p.

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Wood, R. J., Mignone, J., Heaman, M. I., Robinson, K. J., & Stieber Roger. (2016). Choosing an out-of-hospital birth centre: Exploring women’s decision-making experiences. Midwifery, 39, 12–19. https://doi.org/10.1016/j.midw.2016.04.003

Jurisdiction: Winnipeg, Canada

Methods: qualitative, feminist perspective, phenomenological analysis

Cohort characteristics: 17 postpartum women from a diverse range of socioeconomic

circ*mstances, all of whom had planned to deliver at an out-of-hospital birthing centre

Summary of findings: The women’s sense of safety was influenced by six factors: the context of the

decision-making, where both the life partner and the midwife were highly influential; personal

agency; self-belief in one’s ability to achieve physiological delivery; carefully weighing up options,

and the pros and cons; meeting the criteria (risk profile); and the psychology of the space: feeling

comfortable and empowered.

The birth centre decision-making experience has many similarities to the

homebirth decision-making process. The visceral impact of the physical

design of the facility plays an important role and differentiates the birth

centre decision from other birth setting options. The concept of relational

autonomy was emphasised in this study, in that women make the decision

in the context of their relationships with their midwives and partners,

(Wood, Mignone, Heaman, Robinson, & Stieber Roger, 2016, p. 12)

i Births ‘outside the system’ are those where birth takes place in an unsanctioned place (such as a home birth in a jurisdiction where home birth is not permitted), sometimes with the assistance of a trained medical professional who is also acting outside the system, and sometimes without the assistance of a trained health professional.

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NATIONAL MATERNITY MONITORING GROUP

AGENDA

M eeting 23 on 30 August 2018

Venue: GN.8, M inistry of Healt h, 133 Molesworth Street

(On arrival, collect your pre-printed name tag f rom the reception desk) 'bf),. Q)

Also in Attendance: F~ NMMG Attendees:

John Tait (Chair)

Judith McAra-Couper

Jeanine Tamati-Elli ffe

Kass Jane, M inistry of Health (on behat Bconwen Pelvin)

Mary Matagi

Rose Swindells

Rachael McEwing

Deb Pittam

Carolyn Hooper, Allen + Clarke ~ Jack;e Ha•dson, Allen + C~

(lj. Guests: 1~n;str{ of Health

Frank Bloomfield

Sue Tutty

Leoni~or.viack, M inistry of Health

·~ ~~

0 Apologies:

Bronwen Pelvin (ex-officio)

0 Light refreshments available on arr;~ 9.30am

9.30 am

0'l>

Meeting begins

AdminiS rctt ion ~ inutes from 17 May 2018 for approval - [Annex 1 - Pg 3 U -Register of directorships and ro les

€'.orrespondence & other business

•

Summary of responses received from DHBs in regards to competence in cu ltural responsiveness - l4nnex 2 - (Pg 28)

Letter from Leonie McCormack, M inistry of Hea lth re schedu ling a meeting with the Maternity Oversight Group dated 15 June 2018 -

l4nnex 3 - (Pg 34)

• Letter from Dr Sue Belgrave, Chair PMMRC re acknow ledgement of input into the 12t h Annua l Report dated 18 June 2018 - ~nnex - (Pg 35

• Letter from M ichelle Wise, Chair, Guideline Development Group on Induction of Labour re status of the development of a nationa l guideline dated 30 June 2018 - l4nnex 5 - (Pg 36)

• MMWG Quarterly Report to PMMRC dated 17 July 2018 (for noting) -l4nnex B - (Pg 37)

Responsibility to lead discussion

Chair

10.00 am ue - Dr Ashley Bloomfield, Director-General Health Discuss priority issues from the NMMG 2017 / 18 work programme (Annex 7) and development of the 2019 work programme - (Pg 41)

10.45 am Morning Tea

11.00 am uest - Leonie M cCormack, Manager, Child and Family Programmes, Ministry of Health

Updates from the Ministry of Health

• Materal Health Improvement Programme work (Leonie/Kass)

• MQSP (Leonie)

• Growth Assessment Protocol (Kass)

• M idwifery Strategic Advisory Group (Kass)

• • • •

Chair/ Dr Bloomfield

Leonie McCormack/

11.30 am Discussion on query from Maternity Service Clinical Gover an e roup at Chair MidCentral DHB regarding access to Anti-D -~nnex fRg ~9)

12.00 pm Lunch

12.30 pm 2019 Work programme ~ ~ Chair Session t o discuss work programme to confir i , vest igat ive and monitoring

2.00 pm

2.45 pm

3.00 pm

priorit ies for 2019 (informed by Mini t'l~rnity Whole of Sector Workshop

- 19July). -...~

• • PMM RC 12t h Annual Repoff Execut ive Summary - ~nnex 1Q - Pg 60

r>~

Discussion on key the e and recommendations for inclusion in the 2017 / 18

Annual Report.q_.

Afternoon Tea

Genei I . usiness

Appointment of NMMG Chair - ~nnex 11 - (Pg 80) ZI • Any other business.

~' Confirm Next Meeting - possible date Thursday, 22 November 2018

3.30 pm Meeting ends

Chair

~For Information: PHARMAC - Information on Mirena® (action item from February 18 meeting) ~ttachment 1 - (Pg 82)

NMMG Draft Minutes 17 May 2018 Page 1 of 25

NATIONAL MATERNITY MONITORING GROUP

DRAFT MINUTES

MEETING 22 HELD ON 17 MAY 2018

VENUE: GC.2, MINISTRY OF HEALTH, WELLINGTON

Present: Also in Attendance:

NMMG:

John Tait (Chair)

Judith McAra-Couper (Vice-Chair)

Jeanine Tamati-Elliffe

Mary Matagi

Rachael McEwing

Deb Pittam

Frank Bloomfield

Sue Tutty

Bronwen Pelvin (ex-officio)

Carolyn Hooper, Allen + Clarke

Jackie Harrison, Allen + Clarke

Leonie McCormack, Ministry of Health

Josette McAllister, Ministry of Health

Andrew Simpson, Ministry of Health

Jill Lane, Ministry of Health

Keriana Brooking, Ministry of Health

Rachel Haggerty, Capital & Coast DHB

Apologies:

Rose Swindells

Sue Belgrave (ex-officio)

The meeting opened at 9.08 am

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NMMG Draft Minutes 17 May 2018 Page 2 of 25

1. MINUTES OF 22 FEBRUARY 2018

The National Maternity Monitoring Group (NMMG) reviewed the minutes from

22 February 2018. No changes were made, and the minutes were confirmed.

1.1. Register of Directorships and Roles

Professor Frank Bloomfield requested that the following disclosures be deleted:

• Perinatal Society of Australia and New Zealand – Member, Local Organising Committee,

2018 Congress,

• National Intestinal Failure Service – Member of the Clinical Governance Board, and

• Perinatal Research Society (USA) – Council Member.

1.2. Action Points

Open action items were discussed:

Item 1

Ministry of Health: Calendar invites for NMMG Consumer Representatives to attend

monthly teleconferences with the DHB MQSP Coordinators: Item deferred pending

MQSP funding confirmation.

Item 4 Secretariat: Draft letter to Ministry outlining the benefits of funding MQSP should a

decision be made to no longer fund he MQSP: Draft complete but pending the

outcome of funding before actioning further.

Item 6 Ministry of Health: Write to NMMG formally requesting advice on how to address the

research finding relating to new graduate midwives caring for higher risk women,

and the finding concerning low caseloads. Remains open.

Item 7 Ministry of Health Liaise with PHARMAC to obtain further information on Mirena

and report back to NMMG: Remains open.

Item 15 Ministry of Health: Request DHBs provide evidence of their efforts to engage with,

and ensure equity of access to services of all consumers: Remains open.

Item 21 Secretariat/Ministry of Health: Reprint of NMMG Annual Report: Updated report has

been reprinted and will be circulated when the PDF version is available on the

Ministry of Health website.

1.3 Government Inquiry into Mental Health and Addiction

The NMMG has not yet received a response to its letter to the Chair of the Government Inquiry

into Mental Health and Addiction (the Inquiry) dated 3 April 2018 highlighting the importance of

including maternal mental health in the Inquiry. The Chair advised he had presented to the

Inquiry in his role as Chief Medical Officer, Capital & Coast DHB, and will raise this issue at the

Wellington region DHB Chief Executives meeting on 22 May 2018.

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NMMG Draft Minutes 17 May 2018 Page 3 of 25

The NMMG agreed to provide a formal submission to the Inquiry noting:

• that maternal mental health is a public health issue

• the Government’s focus on ensuring people obtain wellbeing

• the Perinatal and Maternal Mortality Review Committee’s (PMMRC) recommendation

and background/justification for the inclusion of maternal mental health in the Inquiry,

and that is strongly supported by NMMG

• 20 percent of pregnant women will have some degree of mental health issue and include

a reference to suicides and terminations being included in maternal mortality

• the impact of illegal substance abuse on mothers and babies

• the UK study Maternal Mental Health – Women’s Voices undertaken by the Royal College

of Obstetricians and Gynaecologists in February 2017 highlighted the cost to women as

being 20%, however the real cost was the 80% cost to the children

• the NMMG’s commitment to mental health and the implementation of the pathways to

DHBs and the work undertaken by NMMG since its development in 2012

• the introduction of an integrated locality-based service in Counties-Manukau which co-

locates mental health teams and general practices to improve access to assistance for

mild/moderate mental health patients

• the importance of an integrated system whereby women come into the maternity service

well supported in their mental health. (or ‘well supported by their mental health

services’)

• current resourcing is inadequate, and

• DHB Maternity Quality and Safety Programme (MQSP) Coordinators are preparing a

submission to the Inquiry.

Submissions close on Tuesday 5 June 2018.

Action point/s: Secretariat – Prepare a draft submission to the Government Inquiry into

Men al Health and Addiction and circulate to members for review by

28 May 2018.

2. CORRESPONDENCE AND OTHER BUSINESS

2.1. Letter from Dr Sue Belgrave, Chair PMMRC re recommendations from the PMMRC

12th Annual Report

The PMMRC has requested the NMMG’s feedback on the recommendations in its 11th Annual

Report in relation to investigating why there has been no reduction in neonatal mortality in New

Zealand. Feedback received from Mary Matagi and Frank Bloomfield was provided to Carlene

McLean, PMMRC Secretariat on 30 April 2018.

The NMMG discussed the recommendation that regulatory bodies require cultural competency

training for all individuals working across all areas of the maternity and neonatal workforce,

noting the importance of addressing the issue and the need for it to be standardised in practice

and in systems. From a consumer perspective, this is a fundamental pillar of what is wrong with

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NMMG Draft Minutes 17 May 2018 Page 4 of 25

the current system. It has an impact on how services are accessed and women’s ability to access

information, knowledge and support. It would be beneficial to elevate the issue to support

practitioners and a whole system change approach to embracing bicultural development in

service provision.

Jeanine Tamati-Elliffe referenced information from the Māori Futures Collective called ‘Tokona

te Raki’ about income equity for Māori and rewiring the system for Māori success, and undertook

to circulate the link to the information.

Sue Tutty asked that the PMMRC consider the inclusion of long acting reversible contraception

(LARCs) as part of its recommendations.

Action point/s: Jeanine Tamati-Elliffe – Circulate a link to information from the Māori

Futures Collective called ‘Tokona te Raki’ about income equity for Māori and

rewiring the system for Māori success.

Secretariat – Provide additional feedback on the recommendations in the

11th PMMRC Annual Report to investigate why there has been no reduction

in neonatal mortality in New Zealand to PMMRC.

Secretariat – Highlight the issue of culturally appropriate services and the

engagement of women focusing on service provision in the 2018 NMMG

Annual Report.

2.2. Letter from The Maternal Morbidity Working Group (MMWG) re recommendations

from the MMWG Annual Report

The MMWG wrote to NMMG requesting feedback on the recommendations contained in its

second Annual Report. The NMMG discussed the recommendations, which highlighted the

requirement for an agreed process for prioritising the development of national guidelines.

The NMMG:

1. agreed the two national investigative priorities are maternal mental health and preterm

birth with an overarching view of equity

2. noted an opportunity to liaise with Australia in relation to the initiatives undertaken in

Western Australia which has shown significant decreases in preterm birth, and

3. noted support that DHBs ensure local protocols for the management of sepsis in

pregnancy are aligned with evidence-based guidance and promulgated at a DHB level.

Action point/s: Secretariat – Prepare a response to the MMWG outlining the NMMG’s

national investigative priorities and noting support for DHBs to ensure

protocols for the management of sepsis in pregnancy are in place.

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2.3. Acknowledgment of other correspondence

The NMMG acknowledged the following correspondence:

• a letter received from the Ministry in response to a request that the Ministry consider

convening national meetings from across the sector to discuss what could be done to

support maternal mental health and place of birth

• the MMWG’s letter dated 7 November 2017 (not previously tabled to NMMG) providing

an update on a national programme on the recognition and response to the deteriorating

maternity inpatient, and the testing of the Maternity Services toolkit for maternal

morbidity review

• the Waikato DHB’s response to a request by the NMMG for a detailed progress report on

how Waikato DHB was tracking towards implementation of the recommendations made

in the external review of maternity services

• MidCentral DHB’s project report provided in response to a request by the NMMG for a

detailed progress report on how MidCentral DHB was tracking towards implementation

of the recommendations made in the external review of maternity services

• Counties-Manukau DHB’s response to a request by the NMMG for a detailed progress

report on how it is tracking towards implementation of the recommendations made in

the external review of maternity services

• DHB data provided by the Ministry of Health on elective caesarean section and induction

following a request from NMMG to undertake an analysis on how many DHBs had

reported efforts to move elective caesarean sections to 39 weeks rather than 38 weeks

• the written update from the Maternal Morbidity Working Group regarding the status of

its current work programme

• Canterbury DHB’s response to a request by NMMG for clarification on processes that

DHBs have in place to ensure registered practitioners are competent in cultural

responsiveness

• Whanganui DHB’s response to a request by NMMG for clarification on processes that

DHBs have in place to ensure registered practitioners are competent in cultural

responsiveness

• Auckland DHB response to a request by NMMG for clarification on processes that DHBs

have in place to ensure registered practitioners are competent in cultural

responsiveness

• the written update from the Midwifery Strategic Advisory Group regarding their work

programme, and

• a letter from New Zealand Newborn Clinical Network and the Periviability Consensus

Group requesting feedback on the NZ Consensus Statement on the Care of Mother and

Baby(ies) at Periviable Gestations.

Action point/s: Secretariat – Collate NMMG feedback on the NZ Consensus Statement on the

Care of Mother and Baby(ies) at Periviable Gestations and provide to the

Steering Group for review.

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3. UPDATES FROM THE MINISTRY OF HEALTH

Leonie McCormack and Josette McAllister (Ministry of Health) joined the meeting.

3.1. DHB MQSP Crown Funding Agreements

The Ministry advised that MQSP funding has been approved for a further year. Over this period

consideration will be given on how MQSP can evolve as part of the broader maternity service

improvement approach.

3.2. DHB MQSP Annual Reports

The Ministry advised that DHB MQSP Annual Reports are due on 30 September 2018 and noted

that the reports are expected to be more compact than in previous years.

The NMMG noted the benefit in providing DHBs with a summary of MQSP annual reporting

requirements including DHB-specific information on the clinical indicators they should focus on.

Action point/s: Secretariat – Develop a list summarising DHB MQSP annual reporting

requirements (including DHB specific information on clinical indicators) and

forward to the Chair for review.

3.3. Growth Assessment Protocol (GAP)

The Ministry advised that a subgroup of the Neonatal Encephalopathy Working Group was

meeting with ACC on 21 May 2018 to discuss the national roll out of GAP. Work is continuing in

the national maternity record to embed GAP into the system. The NMMG noted preliminary

feedback has raised concern regarding the content of the Perinatal Institute’s education package

and how appropriate it was for the New Zealand environment.

3.4. Midwifery Strategic Advisory Group

The Ministry spoke to the update provided by Helen Pocknall, Chair, Midwifery Strategic Advisory

Group highlighting the development of the following four programme workstreams:

1. Workstream 1: Development of the Midwifery Pipeline

2. Workstream 2: Leadership

3 Workstream 3: Stablilise the workforce through recruitment and retention, and

4. Workstream 4: Midwifery Workforce Strategic Plan

The NMMG discussed the significant gaps in the midwifery workforce in many parts of the

country and the initiative of providing support to Australian new graduate midwives employed

by DHBs. A proposal is being submitted to the Health Workforce New Zealand Board in June 2018

making recommendations in terms of supporting Australian new graduates to work in the New

Zealand context. The Ministry advised that the proposal includes recognition of the costs involved

in supporting the new graduates to participate in the overseas competence programme and

Midwifery First Year Practice (MYFP).

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The NMMG debated the decision to support Australian new graduates to work in New Zealand as

opposed to supporting competent experienced midwives from Australia and the United Kingdom.

3.5. Maternity Ultrasound Advisory Group recommendations

The Ministry advised that a joint working group with representation from Integrated Service

Design and the National Screening Unit has been formed. Work to develop guidelines for primary

maternity ultrasounds is expected to be complete by the end of December 2018. It was noted a

clinical working group will be formed and engaged by the end of May 2018. The NMMG discussed

funding eligibility for people who have a national health index (NHI) number and inaccuracies in

the Primary Maternity Services Notice (Section 88).

3.6. Hypertension and pre-eclampsia guideline

The Ministry advised that a professional edit of the hypertension and pre-eclampsia guideline is

being undertaken prior to the guideline being published on the Ministry website.

3.7. New Zealand Maternal Fetal Medicine (MFM) Network

The Ministry advised that an application for a national service improvement project is

progressing, and ongoing liaison with DHB Chief Executives continues regarding sustainability of

the service in the interim. DHBs have been asked to consider funding those functions that the

Ministry no longer funds including maintenance of the MFM website and ensuring there are

appropriate referral pathways. The Ministry advised that it is highly likely that there would be an

item on Newsroom relating to shortages of MFM specialists following the receipt of an official

information request.

3.8. Neonatal Intensive Care Units (NICU)

The Ministry advised that the Newborn Clinical Network will lead a review into NICU occupancy

which will take approximately three months.

Leonie McCormack and Josette McAllister departed the meeting.

4. MINISTRY OF HEALTH CHIEF MEDICAL OFFICER UPDATE

Andrew Simpson, Chief Medical Officer (Ministry of Health) joined the meeting.

Andrew discussed priority issues from the NMMG 2017/18 work programme, specifically the two

significant investigative priorities of maternal mental health and place of birth as detailed in the

NMMG letter to the Ministry dated 30 January 2018, and the Ministry’s subsequent response

dated 29 March 2018.

Andrew advised the Maternal Child and Youth Leadership Group was established in 2017 to

define a clear decision-making process to ensure the coordination of work being undertaken in

the different business units within the Ministry. The Group has since been superseded by the

Maternity Oversight Group and a Child Wellbeing Design Authority, which is in its formative

stages. These groups were formed to align with the new direction in priorities with the change in

government, and the forthcoming change in the Director-General of Health.

Membership of the Maternity Oversight Group includes senior representation across the

Ministry, and Health Workforce NZ. It will provide a broad view across the maternity sector. The

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recommended future engagement approach between the NMMG and the Ministry is presenting

recommendations to the Maternity Oversight Group as the decision-making body.

The Chair spoke to the priorities of the NMMG work programme including equity, place of birth

and maternal mental health. He highlighted the importance of developing ways to obtain a

national view and share examples of great initiatives across the 20 DHBs. For example, innovative

work being carried out in maternal mental health pathways in some DHBs; however, there was

also no evidence of how many women were unable to access these pathways due to resourcing

issues. It was suggested that a stocktake of the national maternal pathway network may be

appropriate.

The Chair highlighted earlier discussion at the meeting of the multi-disciplinary work being

undertaken in Western Australia which has shown significant decreases in preterm birth, and

sought guidance from the Ministry on how a coordinated whole of service approach could be

implemented nationally in New Zealand.

The NMMG discussed the role of NMMG in providing comment to the Ministry on the

recommendations made in PMMRC’s 11th Annual Report and liaison with DHBs regarding the

implementation of recommendations. The Chair noted Annual Reports are peer reviewed and

recommendations widely disseminated prior to being published and suggested that the NMMG

write to DHBs six months following the publication of the report requesting progress on the

implementation of the PMMRC recommendations.

Andrew advised that there is potential for the NMMG to request that the Ministry consider the

inclusion of specific recommendations (of significant value or impact) in DHB work plans during

the annual planning process.

Action point/s: Secretariat – Write to the Maternity Oversight Group requesting an

opportunity for a subgroup of NMMG to meet with the Maternity Oversight

Group to discuss the possibility of national oversight of the NMMG priorities

of maternal mental health and preterm birth. Background information

including National Health System maternal health material and the Western

Australian preterm birth prevention initiative ‘The Whole Nine Months’ will

be provided.

Andrew left the meeting.

5. OVERVIEW OF MATTERS DISCUSSED AT MINISTERS’ MEETINGS

The NMMG discussed matters raised with Hon Julie Anne Genter on 8 May 2018, which focused

on the priorities of maternal mental health, equity, and interaction with the Ministry. Other

matters discussed were the maternity system from a consumer perspective, and interaction with

DHBs. An overview of matters discussed when the Chair met with Hon Dr David Clark on

19 March 2018 was circulated to NMMG via email. A further meeting will be scheduled in six

months.

Bronwen Pelvin advised the Ministry is planning a Maternity Sector Workshop in July 2018 to

bring representatives from the sector together to collectively develop a sector wide maternity

work programme.

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At 1.00 pm the Chair departed the meeting and Judith McAra-Couper assumed the role of Chair for

the remainder of the meeting.

6. NORTHERN SOUTHLAND HEALTH COMPANY LTD SUBMISSION TO

SOUTHERN DHB

The NMMG discussed the Northern Southland Health Company Ltd submission to Southern DHB

re the proposed downgrade of Lumsden maternity services.

Action point/s: Secretariat – Write to Northern Southland Health Company Ltd reaffirming

support for the submission noting place of birth as a priority in the NMMG

work plan, and the issue as being of great concern for mothers and babies in

terms of their wellbeing.

Secretariat – Write to Southland DHB in support of the submission, noting

NMMG priorities of place of birth and equity, and their responsibility of

providing a service to the community.

7. 2017/18 WORK PROGRAMME

The NMMG reviewed the work programme requesting the following updates:

Investigative Priorities

• Add Preterm birth as a priority

• Maternal mental health:

o Reference to family whānau in the descriptor box to be amended to remove the

word family.

o First bullet point to be amended to read ‘work with the PMMRC to improve

awareness of the importance of supporting women’s mental health from early

pregnancy to one-year post-partum and champion the establishment of the

permanent Suicide Mortality Review Committee.

• Place of birth: update descriptor box to match National Institute for Health and Care

Excellence (NICE) guidelines.

• Equity of Access: add a bullet point that aligns with the PMMRC recommendation that

regulatory bodies require competency training for all individuals working across all areas

of maternity and neonatal workforce.

Connecting Sector Leadership

• Clarification is required from Maternity Sector Advisory Groups regarding NMMG’s

responsibility for monitoring how DHBs respond to recommendations made by the

PMMRC and its subcommittees. Item to be placed on the agenda for discussion at the

Maternity Sector Advisory Group Secretariat meeting in June 2018.

• A mechanism is required for the prioritisation of recommendations to DHBs.

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General

• The work programme will be reviewed to ensure connection with the kaupapa NMMG

wants to provide leadership on, and to acknowledge the primary relationship with

tangata whenua.

• Reference to pacific people will be amended to read Tangata Pasifika.

Action point/s: Secretariat – Update the NMMG Work Programme to reflect discussion and

circulate with draft minutes.

8. MINISTRY OF HEALTH SERVICE COMMISSIONING DISCUSSION

Jill Lane, Director, Service Commissioning, Keriana Brooking, Deputy Director, Service

Commissioning (Ministry of Health), and Rachel Haggerty, representative from DHB Planning and

Funding Subgroup joined the meeting.

The Ministry reported on the outcome of Budget 18 (which was released earlier in the afternoon)

and its response to immediate pressures, workforce and funding, and developing with the sector

a maternal health improvement programme to support a sustainable maternity service. The

following was noted during discussion:

• Health priorities identified by the Government are primary care, mental health, equity

and child wellbeing.

• Five additional priorities for the Ministry are maternity, DHB performance, water quality,

capital assessment management and elective services.

• The Ministry’s primary focus is to deliver on the Minister of Health’s priorities for Budget

18, in particular community midwifery services and the development of a collaborative

programme of work to embed a clear pathway for the future.

• Budget 18 includes new operating funding over the next four years to support community

midwifery services, noting half of the funding will go towards an increase in fees for lead

maternity carers.

• The Ministry would like to include areas of interest from maternity sector groups,

including NMMG, in a maternity work programme.

• Strategic commissioning conversations have commenced with DHBs including:

o retirement of the Section 88 notice

o primary maternity top slice that goes into DHBs, and

o community services in a primary health care setting including other community

and health professionals that work in primary health care.

• The Minister of Health has yet to decide on the scope for a primary health care review.

• NMMG will be invited to participate in a Maternity Sector Workshop on 4 July 2018 to

develop a work programme. The workshop will include broad representation from the

community.

• Regular progress updates will be provided to NMMG.

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The Chair advised that the NMMG would welcome the development of a maternity sector work

plan, noting discussion earlier in the meeting regarding the requirement for a mechanism for

liaising with DHBs that would ensure a coordinated approach for the prioritisation and

implementation of recommendations from maternity sector groups. Also noted were the NMMG

(i.e., maternal mental health and preterm birth, underpinned by equity).

Rachel Haggerty advised it was a privilege to represent DHB General Managers Planning and

Funding in the maternal health area and signaled an opportunity for DHBs to work collectively to

respond to requirements and monitor performance.

The Ministry noted the importance of obtaining an understanding of the differing priorities of

communities across the country, to contribute to the national oversight of advances in maternal

health and child wellbeing. It was also noted the Government has indicated that Budget 19 will

be a budget of wellbeing, and the intention of redesigning the criteria for Gross Domestic Product

(GDP) over the course of 2018/19.

9. CONFIRMATION OF NEXT MEETING

The NMMG confirmed the next meeting date as being Thursday, 30 August 2018.

Calendar invites will be sent to NMMG as a placeholder for the Ministry Maternity Sector

Workshop planned for 4 July 2018.

Action point/s: Secretariat – Write a summary report to the Director-General of Health,

advising key points discussed at the meeting.

Secretariat – Send calendar invites to NMMG as a place holder for the

Ministry Matern ty Sector Workshop planned for 4 July.

Meeting Ends – 3.35 pm

The minutes were confirmed:

(Chair) Date

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NATIONAL MATERNITY MONITORING GROUP

INTERESTS, MATTERS ARISING AND CORRESPONDENCE REGISTER

As at May 2018

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NMMG - REGISTER OF DIRECTORSHIPS & ROLES................................................................................................................ ...... .. ........................... 13

NMMG MAY 2018 MEETING ACTION POINTS .................................................................................................................. ............................................. 18

CORRESPONDENCE SUMMARY –RECEIVED FROM 23 FEBRUARY 2018 – 17 MAY 2018 ...................... .. ..... ............................................... 22

CORRESPONDENCE SUMMARY – SENT FROM 23 FEBRUARY 2018 – 17 MAY 2018 ....................... .. .. ......................................................... 24

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R>rv Q) NMMG - REGISTER OF DIRECTORSHIPS AND ROLES ~"' This register ensures transparency by identifying NMMG members' other roles and responsibilities within org~Jons that have a mandate that could align, overlap or conflict with the NMMG, regardless of whether they are Directorships or otherwise. \

1. Bronwen Pelvin (ex-officio)

2. Deb Pittam

3 . Prof Frank Bloomfield

Ministry of Health

New Zealand College of Midwives

Northland DHB

ACC

Manager and Midwifery leader

President

New Zealand delegate, Internat ional Confederation of Midwives

Taskforce looking at measures to reduce neonatal encephalopathy in New Zealand

Member

Professor

Director

Consultant Neonatal Paediat rician

National Pulse Oximetry Screening Programme for Critical Chair, Steering Committee Congenital Heart Disease Feasibility study

Page 14 of 25

.... No. NMMG member Name of Organisation Position held / Role

4. Jeanine Tamat i-Ellif fe

5. Dr John Tait {Chair)

6. Dr Judith McAra-Couper (V Chair)

Maori 4 Kids Inc

Brainwave Trust Aotearoa

Manawa Titl Ltd

Royal Austral ian and New Zealand College of Obst etricians

and Gynaecologist s

Capit al and Coast DHB

ACC

• Trust ee

Chief Medical Officer

Private Obstetrician and Gynaecologist

Taskforce looking at measures to reduce neonat al encephalopathy in New Zealand

Co-Chair

Member

Severe Morbidity Preventable Review Co-invest igator

Head of Midwifery School

New Zealand College of M idwives Member

Page 15 of 25

M idwifery Council Chair

7. Mary Matagi New Zealand College of M idw ives

AN IVA Pan-Pacific Nurses Association of New Zealand

8. Rachael McEwing Christ church Women's Hospital

Christ church Radiologist Group Specialist obstet r ic and gynaecology rad iologist

Member

Examiner

9 . Rosemary Swindells Capit al and Coast District Consumer Representative on MQSP group

Birthw ise Facilit at or

10. Dr Sue Belgrave (ex-officio) Chair

Clinical Director of Obstetrics

Obstet r ician and Gynaecologist

Auckland DHB Obstet r ician and Gynaecologist in Ult rasound

Page 16 of 25

... No. NMMG member Name of Organisation Position held / Role

11. Sue Tutty

ACC

Royal College of Obst etricians and Gynaecologist s

Royal New Zealand College of General Practit ioners

Royal New Zealand College of General

Auckland faculty board

East Tamaki Hea lt hcare

Mat ernal Mortality Review Working G:..:.~.-...r ,_

Counties Manukau DHB

• Taskforce looking a measures to reduce neonat al encephalopath in New Zealand

Genera l Practit ioner

Member

GP Liaison

Page 17 of 25

NMMG MAY 2018 MEETING ACTION POINTS

Shaded items are completed

Post-meeting actions

2 Draft a letter to the M inistry outlining the benefits of funding MQSP(Jhould a 22/02/18

decision be made to no longer fund the MQSP.

3 Write to the NMMG formally requesting advice on how to address the research 22/02/18 finding relating to new graduate midwives caring for higher r isk women; and the

finding concerning low caseloads.

4 Liaise with PHARMAC to obtain further info maticfn on Mirena® and report back to 22/02/18

NMMG.

v 5 Request DHBs to provide evi enile of their efforts to engage with and ensure equity

of access to services fo C°Oonsumers (particularly Maori, Pasifika, Asian, Middle

22/02/ 18

8/12/ 17 Ministry of

Health

Secretariat

Ministry

Bronwyn to liaise with

Laura .

No longer required -

funding has been

approved. Complete

No longer required -

to be included in

maternity work

programme.

Complete.

Information provided with 30 Aug 18

meeting papers.

Bronwyn to liaise with

Laura

Page 18 of 25

Eastern, Lat in American and African women, women with disabilities and young

women) in t heir next MQSP reports.

Prepare a draft submission to the Government Inquiry into Mental Health and 17 /05/18 Addiction and circulate to members for review by 28 May 2018. 0 Circulate a link to information from the Maori Futures Collective called "Tokona te 17/05/ 18 Ra ki" about income equity for Maori and rewiring the system for Maori success.

Provide addit ional feed back relating to the recommendations in the 11 PMM RC 17 /05/18

Annual Report to investigate why there has been no reduction in neonatal mortality in New Zealand to PMMRC.

Prepare a response to the MMWG requesting feedback ~ll t heir second Annual 17 /05/18 Report, outlining NMMG national investigative priof'ties and noting support for

DHBs to ensure protocols for t he management of sepsis in pregnancy are in place.

Collate NMMG feedback on the NZ Consensus-.S atement on the Care of Mother and 17 /05/18

Baby(ies) at Periviable Gestations and provide to t he Steering Group for review.

Develop a list summarising DHB MQS annual report ing requirements (including 17 /05/18 DHB specific information on cl inical indicators) and forward to t he Chair for review.

Secretariat

Jeanine

Tamati-Elliffe

Secretariat

Complete.

List provided by

M inistry. Complete.

Page 19 of 25

Write to the Maternity Oversight Group requesting an opportunity for a subgroup

of NMMG to meet with the Maternity Oversight Group to discuss the possibility of national oversight of the NMMG priorities of maternal mental health and preterm

birth. Background information incl uding National Health System maternal health

material and the Western Australian preterm birth prevention initiative The Whole Nine Months' will be provided.

Write to Northern Southland Health Company Ltd reaffirming support for t eir 17/05/18 submission to Southern DHB re t he proposed downgrade of Lumsden maternity

services, noting place of birth as a priority in the NMMG work plan, and the jssueias being of great concern for mothers and babies in terms of their wellbelng

Write to Southland DHB in support of Northern Southland H~alth Company Ltd's 17/05/18 submission, noting NMMG priorities of place of birth and equity, and their responsibility of providing a service to the community.

Update the NMMG Work Programme to reflect discussion. 17/ 05/ 18

Write a summary report to the Director--General of Hea lth advising key points 17 /05/18 discussed at the meeting.

NMMG Draft M inutes

Secretariat

15/06/18 Secretariat

Complete.

Complete. Updated version attached to

draft minutes

Complete.

Page 20 of 25

r h ca orao Ac 1982 the continuum of care. · r h ca orao Ac 1982 the continuum of care. RECOMMENDATIONS a. b. Actively encourage women who are healthy and have a normal pregnancy - [PDF Document] (2024)