First StepsTowards an: Integrated.

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FrameworkWorking Papers for the Report

Regional Health AuthoritiesMaternity Services Project

First StepsTowards an IntegratedMaternity- ServicesFrameworkI

November 1993

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Information Ccn reMinistry of HealthWellington

The Regional Health Authorities have recently received thisreport from their consultants on the review of maternity services.The policy issues and recommendations are subject to furtherconsideration by the RHAs.

ISBN 0-478-04754-1

CONTENTS

Page

INTRODUCTION 1Project Approach 3Format and Content of this Report 7

CURRENT CONTEXT FOR MATERNITY SERVICES 9Background

9Current Basis For Services 10Current Environment 10Government Objectives for Maori Health 14The Treaty of Waitangi

15A Framework For Developing Approaches to Care For Maori 17Problems with the Current System 17

KEY CHARACTERISTICS OF INTEGRATED MATERNITY SERVICES 21Individualised Services 21Services To Meet The Needs Of Specific Consumer Groups 22Continuity of Care 27Consumer Feedback About Quality 29Peer Review 30Perinatal Database 30

AN INTEGRATED MATERNITY SERVICES FRAMEWORK 33Introduction 33Education 34Informed Choice About Birth and Care 35Pregnancy Services 39Labour and Birth Services 43Services Following Birth for Mother and Infant 45Conclusion 49

MATERNITY SERVICES REQUIREMENTS 51Perinatal Database Implementation: A Proposed Framework 51

BENEFITS OF THE INTEGRATED MATERNITY SERVICES FRAMEWORK53Women and their babies 53Maori 54Maori providers 54Providers in general 55Regional Health Authorities 56

I

WHERE TO FROM HERE 57• Changes from Current Services 57

Implementation Risks 59Further Work Required 60

Appendix A

Participants 63

Appendix B

Terms of Reference 73

Appendix C

Perinatal Database Implementation79

Appendix D

Issues Paper 95

Appendix E

Bibliography 107

Appendix F

Selected References From Participants 115

Appendix G

Glossary of Terms 123

1

INTRODUCTION

1.1 Maternity services are a large and important part of New Zealand's health careprovision. The National Advisory Committee on Core Health and Disability SupportServices has found that normal delivery for childbirth is by far the most commonly usedhospital service and it is also the health service on which we spend the most publicmoney in total.

1.2 Maternity services have also proved effective. There have been significantreductions in mortality and morbidity rates for mothers and their babies over the past 30years. Medical advances, increased public awareness of factors likely to contribute tosuccessful and unsuccessful outcomes, and commitment on the part of those working inmaternity services have all contributed to this achievement.

1.3 The principal aim of maternity services is to ensure a healthy mother and baby.This is most likely under an holistic approach to health care which provides "voice,choice and safe prospect" for the consumer of the services'.

1.4 On 1 July 1993, four Regional Health Authorities (RHAs) assumed responsibilityfor purchasing health and disability support services for their members. Services are tobe delivered by providers under the terms of contracts agreed with the RHAs. A keypurpose of these contracts is to ensure that the populations served by the RHAs haveaccess to an appropriate range of quality services which meet their health and disabilitysupport needs. Each RHA is required to work within a budget fixed by the Government,and act to ensure its members are able to exercise choice to obtain services which areequitable, effective, accessible and affordable. In order to achieve this, the RHAs areexpected to explore a range of purchasing options for their regions.

1.5 The four RHAs have initiated a joint maternity services project. The object of theproject is to improve the quality of these services and the management of public fundswhich are used to purchase them. This is to be achieved by addressing issues relatingto quality, access, information and resource allocation.

1.6The RHAs' project is being conducted in three phases:

(i) Development of an integrated services framework covering good care inmaternity services and incorporation of the requirements of this frameworkinto a number of service delivery options.

(ii) Preparation of indicative costing s for possible service options.

1 Royal Commission on Social Policy, April 1988

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(iii) Development of a national communication strategy for consumers andproviders which will assist informed decision making by ensuring that anyimplications for future service delivery are adequately explained andunderstood.

1.7 A steering group has been established to oversee the entire project. This groupcomprises representatives from the four Regional Health Authorities and a Maori HealthResearcher. It is supported by representatives from the Ministry of Health. ReferAppendix A. 1 for members of this group).

1.8Coopers & Lybrand has been commissioned to undertake the first phase of thisproject. In doing so, we were required to:

•define the minimum requirements for care in pregnancy and childbirth;

•define quality standards associated with the components of care;

• describe possible options for the delivery of care that allow consumers toexercise choice in the type or mix of provider(s) they use, the philosophyof care that is adopted and, where appropriate, the style of serviceprovision; and

• determine factors which should be taken into account when purchasing orproviding care, including consumer variables (such as ethnicity,geographical isolation, socio-economic status and specified medical needs)as well as service issues (such as the point at which service is deemed tostart and finish, and factors which might indicate specialist care).

Details of our terms of reference are set out in Appendix B.

1.9 The term "care in pregnancy and childbirth" was used in our original terms ofreference. It was subsequently agreed to adopt the term "maternity services" toencompass all services which are associated or might be associated with pregnancy,childbirth and parenting in the immediate postnatal period.

1.10 As we progressed through phase one of the project it became clear that it wouldbe neither possible nor appropriate, in the time available, to develop a single protocolwhich defined minimum requirements and quality standards for good care in pregnancyand childbirth. In particular:

• the consumers whom we met, together with groups representing differentconsumer groups wished to see further development of diversity in thedesign and delivery of services to meet individual needs;

• our literature review revealed differing conclusions from overseas researchand an inadequate body of research findings relating specifically to theNew Zealand environment;

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• existing providers of maternity services have differing ideas on principlesand practices and there is currently insufficient information to permit anobjective evaluation of their claims and counter-claims;

• current quality standards are defined, to a large extent, to reflect theconcerns and priorities of specific provider groups and, as a result, thereis no all-embracing set of quality standards which can be used to makecomparisons among different types of provider.

1.11 In addition, the lack of a national database covering services and outcomes duringthe perinatal period is a further major obstacle to the objective evaluation of services.

1.12 Rather than specifying a single protocol to define the requirements for maternityservices, we have instead developed a recommended "integrated maternity servicesframework". This framework is illustrated overleaf. It includes a process for assessingthe individual needs of women and their babies and allows for flexibility in meeting thoseneeds. The options encompassed by the integrated maternity services framework areintended to reflect the views of providers, professional bodies, teaching institutions andconsumers about the requirements of care for maternity services. The project steeringgroup agreed to this modified approach.

1.13 An essential component of the framework is a perinatal database. This would beimplemented to cover those inputs, outputs and outcomes which are encompassed by theintegrated maternity services framework. Appendix C provides more details of such adatabase and outlines how it could be implemented.

1. 14 It should be noted that the integrated maternity services framework is a way ofimproving services within the current maternity services funding levels. For there to beimprovements, however, reallocation of those resources is likely to be necessary. Forexample, discussions with providers and consumers made it clear that some women arebelieved to receive more antenatal services than they need. The money spent on thoseservices may be diverted to provide more or better postnatal services. Similarly,resources may need to be transferred from women who are receiving more services thanthey need to isolated women, women with special needs and/or other women whosemedical or social history indicates need for an enhanced level of service to achieve aquality birth outcome.

Project Approach

1.15 Our role in the initial phase of the RHAs project has been to review, assimilateand report on the views of interested parties about current and possible future services.The prime aim of this phase is to bring together opinions and findings from a variety ofsources and produce a synthesis of current thinking.

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Pregnancy, Childbirth and ParentingIntegrated Maternity Services Framework

EDUCATION

"(Role of Schools, Public Health Commission/DSW)/\• Parenting

• Nutrition/good health habitsV• Understanding birth/sex -

Informed Choice about Birth and Care

• Preconception counselling• Confirmation of conception• Balanced information about birthing and outcomes,

care options*• Assessment of the women's psycho-social and medical

requirements*

Pregnancy Services

• Personal care which meets the individual needs ofwomen and babies

• Diagnostic services*• Antenatal education programmes*• Development of birth care plan and services required*

Labour and Birth Services

• Provision of services in response to women's and babies'needs as defined by birth care plans

• Specification of birthcare indicators and access tospecialist providers if required**

• Clarity of respective roles, responsibilities andaccountabilities

• Individualisedservice

• Continuity of care• Consumer feedback

about quality• Peer review• Perinatal database

* Further workrequired betweenRHA consumersand providers toagree basicparameters

** Work requiredbased on perinataldatabase

Services Following Birth for Mother and Infant

• Hospital-based services• Assessed maternity care though to six weeks• Emotional care• Breastfeeding advice & support• Parenting/family/whanau care• Home-based services• Effective transfer to providers of early childhood care

and general health services

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1. 16 Our work during phase one was broken into three stages. These were:

(i) reviewing information and preparing a draft issues taper;

(ii) obtaining input from interested parties; and

(iii) preparing this final report.

1.17 It is important to note that phase one explicitly excluded consideration of fundingand contracting issues. Clearly, however, these are both issues of some importance. Ourliterature review and discussions with interested parties confirmed this fact. For the timebeing, though, we are concerned to clarify what services the RHAs should purchase toensure quality birth outcomes. Consideration of how (in contractual terms) such servicesshould be purchased, and the amounts to be spent on them are beyond the scope of thisphase of the project.

Information Review

1.18 This project is being carried out against a background of considerable change inthe health sector. Furthermore, maternity services have been subject to numerous,reviews in the past. To ensure that these factors were properly reflected in our work weconducted a review of relevant New Zealand and overseas literature, met with the CoreHealth Services Secretariat and studied material produced by various earlier reviews ofthe services (including Maternity Benefits Tribunal submissions and findings).

Issues Paper

1.19 Prior to commencing our programme of discussions with interested parties weprepared an issues paper which summarised the findings of our initial information review.This paper, together with a discussion format based around ten key questions, providedthe agenda for our meetings (refer Appendix D).

Obtaining Input From Interested Parties

1.20 The second stage of phase one of the project was aimed at canvassing as broada range of views as possible and understanding the nature of the consensus about thepoints raised in our issues paper. To do this we conducted an extensive programme ofmeetings with:

providers of maternity services;

professional bodies representing practitioners in the areas of maternityservices;

teaching institutions; and

•consumer groups, individuals and agencies who represent their views.

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1.21 Copies of the issues paper were distributed prior to the meetings. Those who•received the paper were encouraged to circulate the paper further and compile comments

before the meeting took place.

1.22 Participants were also invited to return an annotated copy of the issues paper tous in order to clarify issues, suggest others or even delete any which they judged to beunimportant. We received around 40 annotated copies of the issues paper and at least asmany submissions from those we met. In addition a considerable amount of additionalcomment was made by means of follow-up correspondence from those we met as wellas unsolicited contributions from other groups and individuals. All such material,whatever its source and means of communication, was taken into consideration in ourwork.

1.23 We did not undertake a full process of consumer consultation. We were able tomake use of submissions from previous consumer consultation exercises. Also, theRHAs intend to consult with consumers in their regions over ;a longer timeframe.

1.24 During a six week period we attended over 120 meetings and talked to severalpeople at each meeting, some of whom were representing or networking for much largergroups. Lists of participants can be found in Appendices A.2 and A.3.

1.25 To obtain best use of our time, each RHA was allocated two days to organisemeetings for us with selected individual providers, consumers, Maori and special needsconsumers. In addition to the RHA organised days, we organised meetings with nationalrepresentatives of both consumers and providers.

Report Preparation

1.26 This report represents the final stage of phase one. It conveys our understandingof the key issues identified, highlights where thereare differences in opinion, andidentifies and recommends a specific approach to purchasing maternity services.

1.27 This approach is defined in terms of an integrated maternity services framework.This, if adopted, would enable RHAs to develop services consistent with requirementsfor good care in pregnancy and childbirth, based on the views expressed during ourmeetings with interested parties and our literature review.

1.28 We assume that the results of the RHAs' early purchasing decisions will besubjected to detailed and comprehensive evaluation. This will allow services to bespecified more precisely in later purchasing rounds and should provide the foundation fora programme of continuous improvement with significant benefits for all consumers.

Acknowledgement

1.29 During the course of our work in connection with phase one of the RHAs'maternity services project we have received considerable support and assistance frommany groups and individuals. We wish to thank all the providers, individual consumers,consumer groups/representatives, health professional organisations and others who wemet or who contacted us for their contributions. Special thanks are also due to membersof the Steering Group for their guidance.

Format and Content of this Report

1.30 The remainder of this report is structured as follows:

2Current Context for Maternity Services - this section describes thecurrent system and the major problems highlighted to us from our

- literature review and meetings with interested parties.

3 Key Characteristics of Integrated Maternity Services -this section..details the key characteristics which providers and consumers agree should.be common to all maternity services.

4 An Integrated Maternity Services Framework - this section discusses theintegrated maternity services framework by reference to the types andquality of services which we recommend RHAs should purchase.

5Maternity Services Requirements - this section introduces an analysis ofinputs, outputs, outcomes and quality indicators for maternity services

- based on work undertaken to specify a perinatal database.

6 Benefits of the Integrated Maternity Services Framework - this sectionoutlines some of the benefits of the integrated maternity servicesframework for women and their babies, Maori, providers and the RI-lAs.

7 Where to From Here - this section summarises a number of keydifferences between the proposed framework and services currentlyoffered, considers implementation risks and highlights areas where furtherwork is required.

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2

CURRENT CONTEXT FOR MATERNITY SERVICES

Background

2.1The Department of Health's vision for maternity services, as set out in its April1991 Service Statement, is:

Each woman (and her and her partner/whanau/family) has a safe and fulfillingoutcome to her pregnancy and childbirth, through provision of programmes andservices that are based on partnership, information and choice.

Pregnancy and childbirth are a normal life stage for most women, withappropriate additional care available to those women who require it.

2.2 Currently maternity services are delivered by a variety of providers. The initialpurchasing arrangements between RHAs and Crown Health Enterprises (CHEs) togetherwith the Health and Disability Services Act (1993) Section 51 Advice Notice allow thecontinuation of this arrangement. The diversity of providers which this permits hasresulted in a wide range of possible "models" of service delivery and has undoubtedlyfacilitated consumer choice and flexibility. It is also believed to have led to poorco-ordination of services in some areas, cost-shifting among providers and inequities interms of quality and access.

2.3 There has also been much debate in recent years concerning the nature ofmaternity services. Some women we met and some providers considered that serviceshave become unduly "medical" in character. Hospitals, in particular, were criticised forviewing birth as an "illness" to be tackled using high-tech interventions, rather than asa natural life event.

2.4 Counter-arguments, voiced by other providers, women and the medicalestablishment focused on issues of quality and safety. They emphasised the value ofmodern diagnostic techniques during the antenatal period, as well as the importance ofspeedy access to hospital facilities and other medical intervention if required by the

Vmother and/or the baby.

Current Basis For Services

2.5The provision of maternity services is currently governed by six main pieces oflegislation. These are:

•Health & Disability Services Act (1993);

Nurses Act (1977, amended 1990);

•Misuse of Drugs Act 1975 and Regulations (and amendments);

•Medicines Act 1981 and Regulations (and amendments);

•Obstetric Regulations (1986, amended 1990); and

•Privacy Act (1993)

2.6In addition, service delivery is also influenced by the following key documents:

•RHA policy guidelines and funding agreements;

•RHA service specifications and/or service requirements definitions;

•standards and procedures documents produced by health professionalorganisations;

•Crown Health Enterprise (CHE) access agreements/contracts withindividual providers; and

•CHE policy and procedure documents.

2.7 The principal aim of these statutes and other documents is to provide guidelineswhich ensure a holistic approach to health care and provide "voice, choice and safeprospect" for the consumer of the services.

Current Environment

2.8 For many years, only doctors could be legally responsible for the clinical care ofwomen before, during and after birth. Midwives attended mothers during labour andparticipated in care during delivery but only with the agreement, and under thesupervision, of a doctor.

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2.9 The passing of the Nurses Amendiñent Act in August 1990, allowed midwives totake the same scope and level of responsibility as was previously reserved for doctors.This development has given women more choice of where and how they access theservices they require during pregnancy, birth and the postnatal period. Depending ontheir preferences and their geographic location they can have the following professionalsprovide care:

•general practitioner;

•rostered hospital team;

independent midwife;

•private specialist; or

•any combination of the above.

2.10 In addition, diagnostic testing services, physiotherapy, social work and a varietyof other services are among the maternity services which are currently available towomen.

2.11 Full or partial subsidies or patient benefits are available for services provided byall of the above. No account is taken of the consumer's assets or income, or the actualcosts of the services provided to the mother and her baby. In the case of privatespecialists the Government, via the RHAs, pays a subsidy but co-payments are generallysought from those who use the service. The levels at which co-payments are charged areset by the individual specialist.

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2.12 Figure 2.1 below presents data on numbers of live births recorded in NewZealand between 1986 and 1992. These show a 13.8 percent increase in live birthsbetween 1986 and 1990. This trend has reversed in recent years, hOwever, with a

reduction to 59,266 live births in 1992 2. Home births accounted for an estimated 1.8%(some 1,130) 3 of these.

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61-

60-

59

58-

51 1986198719881989199019911992

2.13 Of the babies born in 1991, 11.6% were Maori, 8.4% were Pacific Islanders, andthe remaining 80% belonged to other ethnic groups. Figure 2.2 shows the breakdown ofbirths in 1991 by age of mother, ethnicity and Regional Health Authority.

2 1993 Year Book, Department of Statistics

3 Home Birth Statistics 1992 (Preliminary Analysis)

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Figure 2.2 Numbers of Live Births'

RHA/AGEMaori PacificOtherTotal

Islanders

North Health10-14 2 1 4 715-19 419 254 9671,64020-24 815 1,1032,9134,83125-29 6991,1365,1626,99730-34 346 6724,4185,43635-39 117 3191,5211,95740-44 26 65 20129245+ 0 6 8 14

Total 2,4243,55615,19421,174

Midland RHA10-14 5 0 7 1215-19 466 19 7761,26120-24 908 812,3713,36025-29 710 713,5884,36930-34 381 432,4452,86935-39 118 18 70183740-44 22 1 10512845+ 1 0 4 5

Total 2,611 2339,99712,841

Central RHA 0 0 6 610-14 223 51 62089415-19 382 2121,7982,39220-24 300 2283,1883,71625-29 167 155 2,6122,93430-34 51 53 87998335-39 10 14 13015440-44 1 0 4 545+

Total 1,134 7139,23711,084

Southern RHA10-14 0 0 5 515-19 58 23 66674720-24 126 672,1802,37325-29 84 753,8614,02030-34 54 482,9993,10135-39 22 16 85489240-44 1 7 10711545+ 0 0 2 2

Total 345 23610,67411,255

Grand Total 6,5144,73845,10256,354

Source - NZHIS. We note that according to the Department of Statistics 1993 Year Book,the number of live births in 1991 was 60,001. We have been unable to reconcile thedifference between these two figures.

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Government Objectives for Maori Health'

2.14 The Government requires that both purchasers and providers are to be guided bythe following general and specific objective(s) to meet the special needs of Maori in thedevelopment of their statements of intent, purchasing strategies and funding agreements.

"The Crown will seek to improve Maori Health Status so in the futureMaori will have the same opportunity to enjoy at least the same level ofhealth as non-Maori."

2.15 This objective should be considered in conjunction with:

• the overall purpose of and objectives for RHAs as outlined in the Healthand Disability Services Act 1993, and in particular Section 8, whichprovides for meeting the special needs of Maori as one of the Crown'ssocial objectives;

• the need to recognise Maori aspirations and structures such as those basedaround whanau, hapu and iwi, and the desire of Maori to takeresponsibility for their own health care;

•the need to purchase health services and encourage initiatives whichpromote positive health for Maori; and

• the need to encourage greater participation of Maori in order to develophealth solutions which are effective, affordable, accessible and culturallyappropriate.

2.16 The Government's Maori Health Policy Directions guide the development ofpurchasing strategies, together with provider development and change across all healthservice areas. The main policy directions for Maori health are:

greater participation of Maori at all levels of the health sector;

•resource allocation priorities which take account of Maori health needs andperspectives; and

the development of culturally appropriate practices and procedures asintegral requirements in the purchase and provision of health services.

This section, and the two which follow it ("The Treaty of Waitangi" and "A Framework for developingApproaches to care for Maori') were written by members of the Steering Committee and are basedon material originally published in North Health Strategic Direction: Maori Health (June 1993) andGovernment Objectives for Maori Health. We are grateful for these contributions.

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2.17 These objectives build on and begin the process of implementing theGovernment's public statement contained in Policy guidelines to Regional HealthAuthorities (November 1992) and recapitulated: in "Whaia Te Ora Mo . e Iwi (1993)".This public statement outlines Maori health policy direction and states that Governmentwill address Maori health needs through legislative, regulatory and contractualmechanisms developed by the reform process.

The Treaty of Waitangi

2.18 The Treaty of Waitangi affirms the values and norms inherent in Maori health andwell-being and provides a fundamental framework for approaching the Crown's objectivesfor Maori Health.

Treaty Provisions

2.19 Each article of the Treaty contains a significant provision that relates to health asfollows:

Kawangatanga

Article 1 provides for the Government to govern, though not in isolationof other provisions of the Treaty of Waitangi. The right to govern isqualified by an obligation to protect Maori interests. The role of RegionalHealth Authorities is defined by virtue of the fact that they are CrownAgencies.

Tino Rangatiratanga

Article 2 provides for tribes to exercise authority in respect of their ownaffairs. The extent of that authority and its relationship to the authorityof the Crown is a matter which will become clearer as opportunities areprovided for the appropriate parties to debate the matter. To a greater orlesser extent, Tino Rangatiratanga denotes the prerogatives of iwi/hapu incontrolling their own affairs including their own physical, social andcultural resources, within a tribal development context.

Sometimes the term is loosely applied to Maori people generally, in thepursuit of greater Maori autonomy. However it is at its strongest whenit refers to the position of iwi/hapu as tangata whenua in a particular areaor region. A characteristic of Tino Rangitiratanga is iwi autonomy. It isfor iwi to determine the role they may wish to play in their owndevelopment and having decided on that role they might then reasonablyexpect a significant relationship with the Crown or its agencies.

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Ore itetanga

Article 3 contains a provision which guarantees equality and equitybetween Maori individuals and other New Zealanders. As long associo-economic disparities remain the provision is un-ratified.

Treaty Principles

2.20 The Waitangi Tribunal, the Court of Appeal and the Crown itself have definedseveral principles arising from the Treaty. The Royal Commission on Social Policy("RCSP") April 1988 also formulated principles of particular importance to social policiesincluding health. The following principles are drawn from those sources:

Partnership

Partnership has been defined in several reports (Waitangi tribunal, Courtof Appeal, RCSP) as a key Treaty principle. In those contexts it refers toan ongoing relationship between the Crown, or its agencies and iwi.

A partnership with one iwi does not exclude a partnership with others, norshould it be presumed that one iwi can speak for another.

Iwi may organise as Maori Trust Boards, Runanga, or IncorporatedSocieties. Within a single iwi there may be more than one constitutedauthority. A prerequisite for the implementation of any partnership is theprior identification of the appropriate authority for an iwi as well as theidentification of iwi in the area/region who are tangata whenua.

Participation

Participation is a principle which emphasises positive Maori involvementin all aspects of New Zealand's society.

There are at least three levels of Maori participation:

-individual and group participation;

-participation in the decision making process; and

-participation in the delivery of social services.

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•Active Protection

In more than one of its reports, the Waitangi Tribunal has identified activeprotection as a key principle of the Treaty of Waitangi. They haverecommended that the Crown or its agencies adopt a pro-active approachto ensure that Maori well being is enhanced wherever possible. In healthterms active protection is essentially about health promotion andpreventative strategies and it implies that an RHA will, on its owninitiative, seek opportunities for the enhancement of Maori health.

A Framework For Developing Approaches to Care For Maori

2.12 A combination of Treaty provisions and Treaty principles can be used as the basisfor a framework in which the Crown's objectives for Maori health are realised. Inparticular, this dual focused framework' (provisions and principles) provides anencompassing template for the development of goals and strategies for ensuringcomprehensive and integrated approaches to care for Maori.

2.21 Provisions relate more directly and literally to the articles of the Treaty; thoughnot always specific, they can be regarded as the terms of the Treaty. Principles on theother hand are derived from the Treaty but reflect the spirit of the Treaty and its originalaims. Principles enable contemporary applications of the Treaty.

Problems with the Current System

2.22 Our literature review and meetings with interested parties highlighted a numberof problems with the current system. The major problems noted were:

fragmentation of funding;

fragmentation of care;

•differing philosophies;

•inequity of access;

•lack of balanced information; and

lack of statistical data.

6 Ref: Dune/Doherty North Health Strategic Directions: Maori Health, June 1993.

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Fragmentation of Funding

2.23 Maternity services currently receive government funding from RHAs by meansof two main mechanisms:

•Health and Disability Services Act (1993) Section 51 Advice Notice; and

CUE contracts.

2.24 On 1 July 1993, when RHAs assumed responsibility for purchasing health anddisability support services for their members, The Health and Disability Services Act(1993) Section 51 Advice Notice replaced the previous Maternity Benefits Schedule underwhich the majority of non-hospital providers of maternity services received payment.The fee structure was, however, unchanged and providers simply continue to claim fromthe relevant RHA the same benefits they previously received from the Department ofHealth.

2.25 The Maternity Benefits Schedule was established in 1939, as a means to paygeneral practitioners, on behalf of their clients, for the provision of maternity services.It was based on a global, one-off fee for all childbirth services. During the followingdecade, however, the Department of Health introduced specific fees for antenatal,perinatal and postnatal services. The passing of the Nurses Amendment Act in 1990enabled midwives to claim equivalent benefits under the Schedule on behalf of theirclients.

2.26 In addition to payments to individual medical and midwifery practitioners, RHAsalso purchase maternity services from CUEs and a number of private providerorganisations.

2.27 This fragmentation of funding can contribute to problems of poor access,inappropriate allocation of resources, cost shifting and problems of poor patientmanagement. For example:

cost-shifting can occur when consumers are referred to services funded ona fee-for-service basis in preference to those with a fixed (capped) budget;

•women often undergo the same physical examination by more than oneprovider.

Fragmentation of Care

2.28 Recently, in New Zealand, various components of health care have developed inisolation from each other. This is seen as having led to fragmentation of care.

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2.29 In the particular case of maternity services, several different types , of providers• currently offer services; and one woman may sometimes access several providers, eachof whom may be, an independent practitioner or may be employed by a differentorganisation. GPs and independent/domiciliary midwives are generally self-employedwhereas most hospital midwives are employed by CHEs and practice nurses work forGPs. Antenatal educators may be self-employed, or be employees of CHEs.

2.30 We noted widespread concern that fragmentation of care can result in duplicationof care for some women and their babies while other women and their babies may missout altogether. Problems can also arise as a result of inadequate communication amongdifferent care providers, and women themselves may receive conflicting opinions oradvice.

Differing Philosophies

2.31 We found from our meetings and literature review that major professional groupsinvolved in maternity services are often guided by different philosophies in theirapproaches to service delivery.

2.32 Many obstetricians, GPs and paediatricians whom we met appeared to follow whatis sometimes referred to as a medical model of service. They stated that birth outcomeshave improved because of medical advances and this supports the view that interventionis necessary for some conditions. In contrast, some providers we met put more emphasison the view that birth is a normal life event and should be as natural an experience aspossible, with little or no intervention.

Inequity of Access

2.33 Equity is an implicit or explicit goal of all four RHAs' purchasing policies. Keyaspects of equity are that health care resources should be fairly distributed and thateveryone who requires a particular service should be able to access that service.

2.34 It was evident from our meetings that the current system is geared towardsfunding providers to deliver services and pays little heed to the appropriateness oraccessibility of those services. The current benefit system has few, if any, safeguardsMagainst services being delivered when they are not needed; and it is also unable to ensurethat every woman and/or baby who requires a particular service receives it.

2.35 We were told that there are women, or groups of women, whose needs are notadequately met by the system as it currently exists. Women who are isolated or from alow socio-economic background are often unable to access the services they need, whilewomen from higher income groups may sometimes receive more services than are strictlynecessary to ensure a healthy outcome for mother and baby.

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Lack of Balanced Information

2.36 The diversity and fragmentation of service providers noted above is mirrored byan absence of accessible, comprehensive and balanced information from , a single source.Women may have established contacts with health care providers before they need toaccess maternity services, and none of those providers may be able to advise on the rangeof services available. Furthermore, many maternity service providers are onlyknowledgeable about the strengths and weaknesses of their own services and are lesswilling or able to advise on the services of other providers. As a result some women donot know the range of services available to them and are unaware of the choices they canmake.

Lack of Statistical Data

2.37 New Zealand's health system is characterised by a lack of accurate and relevantstatistical data. Maternity services are no exception.

2.38 There is currently no single information system (or a collection of independentsystems) which can record, analyse and report reliable and comprehensive informationon the types and volumes of maternity services provided for women and their babies, andthe outcomes of those services. As a result, it is impossible to undertake an objectiveevaluation of the effectiveness of services, or to investigate issues of access and equity.

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3

KEY CHARACTERISTICS OF INTEGRATEDMATERNITY SERVICES

3.1 In this section we describe a number of key characteristics, which consumers andproviders agree should underpin all aspects of services for pregnancy, childbirth andparenting. These are characteristics which must be common to all services, regardlessof how they are purchased, where and by whom they are delivered, and what theyencompass. We consider these key characteristics before we describe the integratedmaternity services framework in full (Section 4) since they define the essential practicaland philosophical basis on which services should be developed.

3.2The main characteristics which consumers and providers 'proposed are:

individualised services;

•services to meet the needs of specific consumer groups;

•continuity of care;

•consumer feedback about quality;

•peer review; and

•use of a perinatal database.

3.3 Many of these elements are already present, to varying degrees, in the existingsystem. Nevertheless, they are all areas where participants in general felt that there isa need for a more uniform adherence to higher standards than are currentlycommonplace.

Individualised Services

3.4 Participants told us that the conditions of pregnancy were unique to each womanand her baby. There was support for the development of flexibility so that services werebetter designed to meet the individual needs of the woman, her baby, her partner and herwhanau/family.

3.5 An enhanced focus on individual needs would help to address many of thosethings which lead to inequities in the way maternity services are delivered. For example,meeting the individual needs of isolated women would require account to be taken oftravelling time and costs.

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3.6Similarly, meeting the individual needs of Maori women would mean that they• would have access to services which take into account issues of cultural safety and service

location. For example, some Maori we met felt provision of antenatal services andeducation on a marae to be more relevant to their needs than mainstream antenatalservices.

3.7 The majority of the consumers and providers we met suggested that servicesshould be shaped around the individual needs of women and babies. Each woman wouldhave access to a more comprehensive and independent assessment of her particular needsand would herself play a more significant role in matching services to those needs andher preferred options for delivery. Such an assessment process does not exist at presentand will need to be developed. So too will independent information resources to assist inthe decision making process. The next section discusses how when combined withassessment, education and the provision of balanced information make up a process ofinformed choice.

3.8 We recommend that RHAs collaborate with maternity service practitioners todevelop an independent process for assessing women's and babies' psycho-social andmedical needs.

Services To Meet The Needs Of Specific Consumer Groups

3.9 As well as emphasising the importance of individualised services, providers andconsumers also highlighted the importance of ensuring that all aspects of services weredeveloped in ways which reflected and respected the needs and priorities of severalspecific consumer groups. The groups most commonly mentioned were:

•Maori women;

Pacific Island women;

geographically isolated women; and

•women with special needs.

Maori Women

3.10 Maternity services are purchased by the RITAs in keeping with the Government'sobjective for Maori health and its desire to seek an improvement in Maori health status.The adoption of an integrated maternity services framework is likely to lead to servicesbeing more appropriate to Maori than they are under the current system.

3.11 The focus on meeting the assessed needs of women and their babies would be thesame for Maori women as women generally. The difference is that currently providersare funded to provide a set package of services to each woman. The integrated maternityservices framework would entitle women and their whanau to seek services appropriateto their assessed needs.'

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3. 12 Maori researchers are observing the conditions of Maori women and their babies- to discover what components of care andservices are specifically related to Maori need.In the meantime, RHA purchasing of maternity care will be focused on meeting the needsof three broad categories of Maori women:

•Maori women who are well integrated into mainstream Maori society andactive participants in Maori institutions;

•Maori women who participate comfortably in mainstream New Zealandand are able to access its key institutions; and

•Maori women who are alienated from both Maori and Pakeha society andhave no ready access to health services of any kind.

3.13 As discussed by Dune and Doherty in North Health Strategies Direction (June1993):

"Gains in Maori health will require a multi-faceted approach. There is nosingle method which will satisfactorily address the complexitiessurrounding the maintenance of well-being, the avoidance of illness andthe recovery of good health."

3.14 For most Maori, Dune and Doherty note, there are three general goals thatwill be important:

an improvement in Maori socio-economic standing and particularlyimprovements to standards of housing, levels of employment,educational achievement and security of income - all of which are bothdirectly and indirectly critical for equitable outcomes for Maori;

• a greater measure of self-determination so that Maori themselves might bebetter placed to define their own realities and manage their own health;and

•an enhancement of the capacity of mainstream health agencies to addressMaori health needs.

3.15 We recommend that the RHAs should purchase services with the objective ofmaximising health care for Maori women across all sectors by: -

•promoting policies which allow for positive health impact;

•encouraging the development of compatible policies and complementaryprogrammes;

•ensuring programmes are better coordinated to secure continuity of care;

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•enabling Maori to define minimum requirements for good care inpregnancy and childbirth for Maori; and

•enabling Maori to define quality standards associated with each componentof care.

3.16 We also recommend that the RHAs should establish partnerships with iwi/haputo provide opportunities for:

•shared decision making;

long term development;

•information sharing;

•specific health related activities such as:

-joint ventures

-co-purchasing

-health services provision;

input into policy planning, purchasing and monitoring; and

the development of innovative approaches to securing health gains.

3.17 The terms of each RHA/Maori partnership established pursuant to thisrecommendation should be negotiated with iwi/hapu. Although partnerships may notalways lead on to specific programmes, they provide an opportunity for a sharing ofinformation and some discussion on broad aims and general directions.

3.18 We also recommend that RHAs ensure that maternity services for Maori aredelivered in the most appropriate and effective manner by purchasing from:

•Maori providers with access to Maori networks who can provide thespecified range of services appropriate to this network; and

Maori providers who are either part of an iwi/hapu initiative or whorepresent other communities of interest.

3.19 We also recommend that RHAs develop and implement strategies to enhance thecapacity of mainstream health services to meet the needs of Maori women and hence toensure that maternity services and their providers are:

•culturally acceptable;

•culturally safe;

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•accessible;

• based on comprehensive information;

developed in consultation with Maori;

accountable; and

•able to provide Maori specific information.

Pacific Island Women

3.20 The consumers and providers we met noted that delivery of maternity servicescurrently does not meet the cultural needs of Pacific Island women.

3.21 The existing system does not give balanced information to Pacific Island womenin ways that enable them to make informed choices about the care options available. Theinformation is often in a form that is culturally inappropriate and difficult to understandfor women for whom English is not their first language.

3.22 Pacific Island women told us that the most effective way to get information toPacific Island people is to train their people and use each community's networks.

3.23 The medical professions need to be sensitive to the importance of the extendedfamily as an integral part of the Pacific Island culture.

3.24 We recommend that RHAs enable Pacific Island people to develop their ownminimum requirements for good care in pregnancy and childbirth.

3.25 We also recommend that RHAs develop and implement strategies to enhancematernity services to meet the needs of Pacific Island women by ensuring that servicesare:

aligned to their own requirements;

culturally acceptable;

use appropriate languages and interpreters;

culturally safe;

accessible;

•based on information about Pacific Island needs;

•developed in consultation with Pacific Island women; and

•delivered by trained Pacific Island providers with access to Pacific Islandnetworks wherever possible.

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Geographically Isolated Women

3.26 We met a number of women who lived in geographically isolated areas. Theytold us that the distances that must be travelled in order to access services is currently amajor barrier.

3.27 We were told by participants that:

•mobile facilities should be made available;

a 24 hour telephone service would be beneficial so the women would havesomeone to talk to about her concerns; and

•the free exchange of information among health professionals must continueparticularly to those practitioners practising in rural areas.

3.28 When purchasing services, the RHA need to consider the cost of transport andaccommodation for geographically isolated women. Assessment should also take accountof the fact that time and travel costs can be significant and should endeavour to scheduleaccess to services in ways which reduce these burdens.

3.29 We recommend that the RHAs should pay particular attention to the needs foraccess to services and information among women who live in isolated communities andshould reflect these needs in their purchasing decisions.

Women with Special Needs

3.30 We met a number of women who, for a variety of reasons, were deemed to havespecial needs which impacted on their requirements for maternity services. We believethat the integrated maternity services framework, through its focus on assessment andindividualised packages of care, offers better opportunities to meet the needs of thisgroup.

3.31 Equally, women from other ethnic minority backgrounds and those whose firstlanguage is not English will have their own special needs. The integrated maternityservices framework should be capable of addressing those needs which, in many waysmay be similar to those identified earlier in respect of Pacific Island women.

3.32 We therefore recommend that RHAs take steps to ensure that assessmentprocesses take account of women with special needs. Services could then be planned anddelivered to take account of needs identified in the assessment process.

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Continuity of Care

3.33 The people with whom we met were unanimous in their support for the conceptof continuity of care. The actual definition of the concept of continuity differed,however.

For women, continuity of care was having the same provider throughpregnancy care, at birth and after birth. The same provider meant ageneral practitioner to some women and an independent midwife to others.The current system already provides for both options. In some parts ofthe country, it is also possible for a woman to receive continuous servicethrough her local CHE (although in some cases, personnel change and inothers, the woman may have the same midwife throughout).

• For midwives, continuity of care means the availability of midwiferyservices, probably by the same person, through pregnancy care to birthand until care is transferred to other appropriate providers following birth.

For general practitioners, continuity of care relates to family care, starting,_with routine GP practice, moving into maternity services (provided freeto the woman) from pregnancy care until six weeks after birth and thencontinuing with family care.

For CHEs, continuity of care may mean a number of different things:

service with the CHE through pregnancy to the period after birth,but with different people;

-service with the CHE through pregnancy to the period after birth,but with a team of the same people; and

the same CHE-based midwife attends the woman - the startingpoint for this could be from early pregnancy or up to three monthsbefore the expected delivery date.

3.34 Central to the concept of continuity of care is the role of a woman's "principalpractitioner". We noted differences in the way this role is defined, and we believe thatthese may lead to confusion if not resolved. For the purposes of this report, we haveadopted the following definitions:

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The contracted principal practitioner is the individual who conducts thefirst long consultation which will include an assessment of the parents'health and medical history and the current health of the woman and baby.The contracted principal practitioner is then responsible for ensuring thatappropriate services are delivered either by delivering them him/herself,or by arranging with other providers to do so. The identity of thecontracted principal practitioner may change as the pregnancy progressesbut all such changes should be formally agreed and recorded, withappropriate "hand-over" arrangements being observed. The contractedprincipal practitioner may be an independent individual or an employee (ofa CHE or a private/voluntary group).

• We use the term sub-contracted provider(s) to refer to those individualsor teams who, at any time, may be responsible for delivering a particularcomponent of service at the request of the contracted principalpractitioner. Some components of service may (and probably will) bedelivered by the contracted principal practitioner. The role of the sub-contracted provider(s) is to complement the core skills and professionalcompetencies of the contracted principal practitioner. One woman mayuse a number of different sub-contracted providers, working individuallyor in teams, during the course of her pregnancy, birth and immediatelythereafter. At all times, however, their involvement will be co-ordinatedby the contracted principal practitioner, to whom they will be accountable.

3.35 The final determination as to whether maternity services provide continuity to theconsumer rests with the consumer. Nevertheless, the following points are commonindicators that a service has provided continuity from a woman's point of view:

• the woman feels that neither she nor her baby nor herpartner/whanau/family have "fallen through the cracks of the system"during the pregnancy, labour and birth, and postnatal phases, especiallyduring emergency complications;

•she has a written care management plan and all those involved in the careare aware of their roles in its implementation;

•she receives consistent, accurate and unbiased information from all thoseinvolved;

•she and all those involved in her care know at all times who is hercontracted principal practitioner;

• she knows, in advance where possible, who her next contracted principalpractitioner will be if a handover of responsibility is sought or required;and

•she has access to appropriate telephone advice at all times.

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3.36 The existence of different types of continuity of care adds to choice. Where theoptions exist in the same locality, the woman can make an informed decision about whichtype of care is most suitable to the individual needs of her and her baby.

3.37 We recommend that RHA purchase from providers who specify the way in whichtheir services meet the requirements of continuity of care.

Consumer Feedback About Quality

3.38 Another area where there was unanimous agreement from those we met was thatthere should be consumer feedback about the quality of provider services. A number ofmethods for this were suggested including the following:

• There should be a meeting between the new mother, herpartner/whanau/family and her contracted principal practitioner before sheis discharged from hospital (or in the case of a home birth, about threedays after the birth) to discuss the events that occurred during labour and,--delivery. The management of the pregnancy and the birth would bediscussed in relation to the physical, mental and emotional health status ofthe mother and baby. The contracted principal practitioner would alsohave a responsibility to meet with others who attended the birth (midwife,GP, specialist, nursing staff etc) to discuss issues which arose.

Peer review with consumers joining professionals as members of the panelundertaking the review can be a method of gaining consumer feedback.Consumers' judgement of professional skills requires more informationthan simply their perceptions of service.

• Consumer research is another way to obtain feedback, but it was generallyfelt that the response would be more valuable if the information wasgained by interviewing the mother rather than surveying her. The timingof the interviews could change the nature of the results. Many thoughtthat it was best to interview the mother soon after the birth and before shebecame busy with infant care to obtain her earliest impressions. Evidencewas quoted, however, which showed the results of surveys taken shortlyafter birth differed from those taken later (the explanation being thatwomen tended to be optimistic shortly after birth because of hormonalchanges) and the results of later surveys were more reliable.

• Consumers views should be part of the input to the development ofservices. Hence it was thought consumers should not just be involved inmonitoring services, but also in ensuring that the information gained frommonitoring is applied to the planning and development of services.

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3.39 We recommend that RHAs purchase from those providers' who document•appropriate mechanisms for receiving consumer feedback as part of their service.Consumers need to be involved in planning as well as monitoring services. RHAsshould also require providers to implement procedures for informed consent andappropriate handling of complaints.

Peer Review

3.40 There was considerable support for the concept of peer review. Most providersclaimed that they were already doing it. However, most providers were also critical ofthe type of peer reviews which were 'undertaken by other providers. Consumersgenerally thought that the current system lacked good peer review processes.

3.41 The elements of peer review that were widely considered to be missing included:

•consumer representation on the panel undertaking the review;

standards for appropriate feedback of results to the consumers involved;

•transparency of the peer review process, even where it is appropriate thatthe actual review hearing be closed;

• cooperation among different health professionals in carrying out peerreviews; for example, even though some providers have their own reviewprocesses, review by other providers involved in the birth may also beappropriate; and

•clearer standards for ascertaining what qualifications are basicrequirements for professionals providing maternity services.

3.42 We recommend that RHAs should purchase services only from those providerswho have a peer review process, including a provision for evaluating and developing theirreview processes and for facilitating consumer participation.

Perinatal Database

3.43 A common theme in the New Zealand literature and in discussions with those whoparticipated in this project was that a perinatal database is required. The Second Reportof the National Advisory Committee on Core Health and Disability Support Services,titled Core Services for 1994195 (August 1993) recommends that "a perinatal database bedeveloped and used for monitoring and comparative analysis of outcomes for mothers andbabies." Without such a database it is not possible to monitor birth outcomes in relationto inputs of service and care.

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3.44 The information from a perinatal database could be used objectively to assess theservices of various provider groups and, to advance research which will in turn benefitconsumers. Differences in practices dearly exist, despite the strong consensus which isapparent about many aspects of maternity care. For example, many home birth midwivesconsider that the early identification of risk factors can lead to unnecessary interventionswhile GPs and obstetricians are concerned that because of the late identification of riskfactors, women and their babies may become unnecessarily sick and require greaterintervention than they would otherwise.

3.45 Although overseas evidence was referred to by providers to support both of theseviews, an equivalent analysis of the issue in New Zealand cannot be conducted becausethere is inadequate data on care through pregnancy. Such information could, however,be compiled via a comprehensive and co-ordinated perinatal database.

3.46 Every participant in the phase one meetings expressed a strong view in favour ofa perinatal database. This reflects the recommendation made in a number of officialreports since the mid-1980s that such a database should be established.

3.47 Given 'the importance of the postnatal period in establishing conditions for childhealth and growth, as well as the requirement of linking the quality of outcomes achievedwith inputs provided, any database should continue collecting information for at least thefirst six weeks after birth.

3.48 We recommend that RFIAs purchase from providers who collect data aboutservices and their outcomes in a format which is consistent with the requirements of aperinatal database, or who plan to collect data in such a manner. Key characteristicsrequired of the database would clearly need to be made known by the RHAs and shouldinclude:

• a framework for choosing the data to be collected which is based on aholistic view about birth, including socio-economic variables as well asvariables relating to the medical condition of the mother and baby;

•ability to link some elements to a national database for analysis andcomparison;

• that the operation of the database involve researchers and that the RHAs,providers and through them consumers, have access to the aggregated data(subject to appropriate safeguards on provider and consumerconfidentiality);

•the establishment of clear guidelines about the techniques for comparingthe outcomes of different services;

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that the database would not be a "medical records" system (the generalpreference is that women have the option to keep their own records) andthat data would be stored in a manner which would maintain theanonymity of contributors'; and

• that the collection of data continue into the postnatal period so that therecan be greater understanding of the linkage between antenatal conditionsand services and birth outcomes.

3.49 We also recommend that prerequisite additional work be undertaken by the RI-lAsto:

•complete the development of a data dictionary for the data elements to beincluded in the perinatal database providing explanations for inclusion;

•validate minimum requirements for good care in pregnancy, childbirth andrelated services against the data dictionary; and

design and publish specifications for a distributed database whichfacilitates the integration of perinatal data at individual, group, regionaland national levels, taking account of the requirements of women, infants,clinicians, health managers, health policy analysts and planners, qualitycontrol specialists auditors and health researchers in accordance with theprovisions of the Privacy Act 1993.

The Privacy Act 1993, Health Information Privacy Code 1993 (Temporary) issued by the Privac)iCommissioner, "provides specific guidance for agencies in the health sector on how they should complywith the Privacy Act .. with respect to health information collected, used, held and disclosed by healthagencies".

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El

AN INTEGRATED MATERNITY SERVICESFRAMEWORK

4.1 In Section 3 we discussed a number of key considerations which our work to datehas suggested should be common to all elements of maternity services. In this sectionwe focus in greater detail on the scope of the services which RHAs should purchase. Wealso consider some of the main quality criteria which should be met in respect of eachmain component of service. In Section 5 we provide additional detail of the services tobe purchased by RHAs.

Introduction

4.2 Our literature review was extensive in scope and our discussions covered a varietyof consumers and providers from all over New Zealand. We encountered a high levelof consensus on key components of services and we believe that it is both useful andappropriate to describe the key aspects of service which can be linked to form a packagewhich we have termed an "integrated maternity services framework":

4.3 An essential feature of the package of services described in this section is that itis integrated, with clear linkages between the different components. The package ofservices also offers continuity of care for the woman and her baby based on theirindividually assessed needs.

4.4 Many different views were expressed by those whom we met regarding particularelements of maternity services. In the absence of New Zealand based perinatal ' data itis not possible to assess those views. The integrated maternity services frameworkenvisages that, despite those differences of perspective, the various providers will be ableto co-operate.

4.5 Our recommendations envisage that providers will be responsible for showing howthey will provide elements of the service. They will also be expected to put in placemechanisms to monitor the services they provide, and to evaluate their outcomes againstdefined quality standards.

4.6 Most of the elements of this framework exist in some form as part of currentmaternity services. The main differences between current services and those envisagedby the integrated maternity services framework are as follows:

services are defined to match the assessed needs of the woman, her babyand her partner/whanau/family rather than being limited to servicescovered by specific schedules and approaches;

services are designed to focus on the achievement of quality outcomesrather than solely the process of service delivery; -

•the focus is on purchasing services rather than funding providers;

• there is greater provision of information to inform consumer choice (theobjective being to link service choice to quality birth outcomes) rather thanrelying on health professionals to make choices;

consumers, being better informed, play a greater role in service choice;

•the framework offers greater continuity of care; and

•progress will be made towards improving the match between assessedmaternity service needs and the services actually received.

4.7 To build informed choice into the framework, the, RHAs' purchasing approachwill include consumers and providers in the development of a process for assessing theindividual needs of women so that they can be matched to the appropriate antenatal,labour, birth and postnatal services. The integrated maternity services framework relieson assessment at different stages to determine the individual needs and choices of womenand their babies. While there are existing assessment procedures, many of these wouldneed refinement over time to evolve a system in which there is informed choice.

4.8The diagram on Page 4 illustrates the integrated services framework. Its basiccomponents, or modules, are:

(i) education;

(ii) informed choice about birth and care;

(iii) pregnancy services;

(iv) labour and birth; and

(v) services following birth for mother and infant.

4.9We discuss each of these components in greater detail in the remainder of thissection.

Education

4.10 Currently, the maternity services purchased by RHAs do not begin untilconception is confirmed. We asked providers and consumers when maternity servicesshould begin. The most common answer was that they should begin at school.

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4.11 Many participants expressed a belief that poor birth outcomes are often a result-of occurrences before conception. -Comments included the following:

•Teenage mothers are high risk, both in terms of their birth experience andin terms of their ongoing relationship to their babies.

• Parents' nutrition is known to affect the health, weight and possibly eventhe intelligence of the baby. By learning this in school, prospectiveparents would be better informed to make choices that result in better birthoutcomes.

• Smoking has been shown to result in low birth weight babies. Educationabout good health habits is likely to have a positive effect of improvingbirth outcomes, but also in reducing the costs which come about becauseof the long term effects of smoking on the health of the infant and itsmother.

•The development of parenting skills will help the ongoing health of theinfant and its family/whanau.

4.12 Better peer group education about birth/sex and parenting in high school was citedas a method of preparing women and their partners to make more informed (and moreresponsible) choices. Also, young Maori may find peer group education moreappropriate to their needs and interests. Education of this nature will require co-operation between health and non-health agencies.

4.13 In this context, the RHAs have expressed their support for the work carried outby the Ministry of Health and presented in its report, Reproductive Health Policy:Proposals to Reduce Unintended Pregnancy (1993).

4.14 We recommend that RHAs encourage the Public Health Commission, theMinistry of Education, the Department of Social Welfare and other relevant organisationsin the development of education programmes since these will have a significant influenceon birth outcomes. An appropriate education programme needs to enhance teenagers'understanding about parenting, nutrition, good health habits, birth and sex so that theycan make better choices about preparation for parenting.

Informed Choice About Birth and Care

4.15 Services which can ensure that informed choices are made about birth and carewhich are appropriate to a quality birth outcome for a woman and herpartner/whanau/family include (see diagram on page 4):

preconception counselling;

the confirmation of the pregnancy;

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•balanced information about birthing, care options and outcomes; and

•assessment of the woman's psycho-social and medical requirements.

4.16 Though a considerable range of services relating to birth and the care of themother and baby already exists in the current system, the lack of balanced informationis a barrier to access.

4.17 Consumers participating in the project felt that balanced information was not madeavailable to help pregnant women to make choices appropriate to their individual needsand that women are often not made aware of the choices available to them until they haveconsulted a health professional for confirmation of pregnancy. Providers felt equallystrongly about this and many noted that the birth experience was much better for thosewomen and their partners who had access to balanced information about different optionscovering all aspects of their care.

Preconception Counselling

4.18 A large proportion of participants saw advantage in preconception counselling asa way of reinforcing the messages of the education programme described above. Forexample, preconception counselling, especially if both parents were involved, wouldprovide an opportunity to:

inform prospective parents about the danger of smoking and too muchalcohol;

•discuss nutrition and the effects of good eating on both the mother's andthe baby's development;

•discover possible genetic or health conditions which should be managedduring the pregnancy;

•receive information about sources of social and/or financial support;

provide folic acid to the mother as a means of avoiding some forms offoetal abnormality;

provide positive parenting education;

•undertake infertility counselling; and

•discuss family planning.

4.19 Currently, most preconception counselling is outside the scope of the maternityservices. However these services may be purchased by RIIAs as part of other servicegroupings.

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4.20 We recommend that the RHAs investigate the links between quality birthoutcomes and the education, health and social conditions of parents prior to conception.For practical reasons, this information will need to be collected during the consultationwhere there is a full physical examination of the mother, and details of the woman'shistory and background are obtained.

Confirmation of Conception

4.21 Confirmation of conception is presently within the scope of maternity servicespurchased by the RHAs. The consultation which takes place when conception isconfirmed affords an opportunity for providers to discuss options for maternity care withthe woman.

4.22 Participants suggested that this first consultation should be used to provide moreinformation as women and their partners/whanau/families are generally very receptive.There was agreement, though, that the information about maternity services needed tocover the full range of services and providers, including a balanced assessment of theapproaches of different providers.

4.23 We recommend that the RHAs should require providers to use the consultationwhen pregnancy is confirmed to discuss the management of future maternity care with,the woman. As part of this discussion, the provider should also be required to outline.to the woman the various components of the integrated maternity services framework andto provide details of where she should go to obtain more detailed, and balanced,information on birthing and the care options available to her.

Balanced Information About Birthing, Care Options and Outcomes

4.24 Information about the range of choice in services available to the woman and herpartner/whanau/family, including those services available in her area and those servicesoffered on a centralised basis, is an input which will assist the achievement of a qualitybirth outcome. At present an information gap exists because providers are accountableonly for information about the strengths and weaknesses of their own services. They areless able to advise on the services of other providers.

4.25 There is less opportunity to learn about childbirth by experience than for mostother life events. A considerable amount of the learning is through the eyes of othersbut, since everyone's experiences of pregnancy and childbirth are likely to be different,the challenge is to provide balanced information based on the experiences of others thatenables the woman and her partner/whanau/family to make the best choices forthemselves.

4.26 No component of current maternity services appears to meet the principles ofbalanced information about birthing, care options and outcomes. A major aspect of sucha service is that it is information driven, rather than driven by the providers of maternityservices. The RHAs will need to initiate a process for developing this service.

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4.27 The information should cover all the different providers and offer a descriptionof their services, a specification of Who can help solve particular problems and on whereto get other practical support and further information.

4.28 The preparation of balanced information needs to be followed through in thedevelopment of the medium for presenting the information to the woman and herpartner/whanau/family. An important part of the service purchased by the RHA shouldbe follow up to see if the information was provided in a way that was understood andenabled informed choice to be made.

4.29 Although the presentation of the information is a vital part of the way in whichit is understood, informed choice puts the accountability on the consumer as well as theprovider. The presentation of information should, therefore, be regarded as an active,rather than a passive process.

• 4.30 An active process should have as one of its goals the empowerment of the womanto assert her individual needs and those of her baby. The woman, and her partner, willplay a major role in their child's health and development. The most effective healthsystem will be one where parents are empowered and know that they have the right toinsist on the best choices being made, based on the best information that is available.

4.31 In support of these findings, we recommend that RHAs purchase a service whichprovides balanced information. Since it is likely to take some months for such a serviceto be developed RHAs should, in the meantime, purchase from those existing providerswho specify an active process of providing balanced, understandable and objectiveinformation as part of their services. One of the objectives of providing such informationis empowerment so that the pregnant woman and her partner/whanau/family are preparedto make the right choices for their needs and those of their baby.

Assessment of the Woman's Psycho-Social and Medical Requirements

4.32 Having received balanced information about services, the next step is for thewoman to make a commitment to obtaining the services she needs. For the woman tomake an informed commitment, there are some factors about her health and socialconditions which need to be assessed, measured and understood so that the birth outcomeis optimal.

4.33 A key feature of an integrated maternity services framework is that pregnantwomen have access to maternity services which are appropriate to their needs - no more,no less. RHAs should purchase services which include a provision for assessment ofneed and identification of appropriate diagnostic and other services.

4.34 An informed choice will require the woman's assessed needs to be matched withthe services of health professionals. Following completion of the assessment, therefore,the woman should choose her contracted principal practitioner who will be responsiblefor her ongoing care.

4.35 A common criticism of the current system is that when women choose to havemore than one contracted principal practitioner, it is not always clear who is reallyaccountable. A woman needs to feel that she is the one making the decisions. Beingbetter informed about the criteria for choosing a contracted principal practitioner shouldassist in this. It is to the advantage of everyone involved in each episode of maternitycare to have the accountabilities of the sub-contracted provider(s) clearly specified andthe contracted principal practitioner identified.

4.36 It is important that the needs of women with special needs and those from lowsocio-economic backgrounds are equally well matched to services. Participants suggestedthat, because of the relationship that exists between low income and poor health, theassessed needs of women from low income groups are likely to be greater than those ofwomen from higher income groups. This may mean that more maternity services arerequired by the former.

4.37 Assessment will lead to different packages of service for different women. Forexample, there was general agreement that the number of antenatal visits for care duringpregnancy would differ.

4.38 Cohsumers we met noted that the achievement of quality birth outcomes forwomen from Maori, Pacific Island, Asian or other cultural backgrounds might requirethat they have their assessed needs met by culturally appropriate services such as:

services organised by their own people;

information delivered in their own community by their own people; and/or

assessments carried out by their own trained people.

4.39 We recommend that RHAs purchase from providers who are able to specify theiraccountability and assessment criteria so that it is possible to move to a system where thewoman's and baby's assessed needs are matched with required services. To ensure thatthe needs of all women are met, the services that the RHAs purchase may need addresshealth needs in the broadest sense of the term and must be culturally appropriate.

Pregnancy Services

4.40 A key element of the integrated maternity services framework is personal carewhich meets the individual needs of women and their babies. There is also a need forregular monitoring of the health of the pregnant woman and her baby. Antenatalprogramme should empower the woman and her partner/whanau/family to takeresponsibility for health care especially in areas such as smoking cessation and cot-deathprevention. Pregnancy is also the time for the woman and her sub-contracted provider(s)to develop a birth care plan for care and services required.

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Personal Care Which Meets the Individual Needs of Women and Babies

4.41 Personal care covers regular visits to or from a nominated health professional(maternity practitioner) to:

•check the health of mother and baby;

provide advice on important issues contributing to maintaining orimproving the health and development of the baby;

listening to, and checking, on the mother's/parents' concerns regardingpregnancy, birth and parenting; and

•other needs of the partner and whanau/family.

4.42 This is an area where present funding arrangements are significant since patiententitlements are defined which apply to specific providers and fund discrete elements ofservice rather than the full service.

4.43 We recommend that RHAs purchase personal care services from providers whoare able to demonstrate that their services are appropriate to a range of women's andbabies' needs.

Diagnostic Services

4.44 Diagnostic services include specific screening services and tests to monitor thehealth of mother and baby. Included are laboratory services, amniocentesis, ultrasoundand any other services applied to diagnose different conditions of the pregnancy.

4.45 A function of the assessment after the confirmation of the woman's pregnancy isto offer an initial indication of the amount and type of diagnostic services likely to berequired. These requirements are constantly reviewed as the pregnancy progresses.There was general agreement from those we met that healthy women probably do notneed as many diagnostic services as they currently receive. On the other hand, there aresome women whose health or whose babies' health requires access to more or differentdiagnostic services than those which are currently made available.

4.46 Participants were keen to discuss the pros and cons of ultrasound scans. Thegeneral consensus amongst consumers and providers was that all women should beentitled to the option of one scan at 18 weeks, with those in favour of scans notingdiagnostic, emotional and bonding advantages.

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4.47 There needs to be specialist training for the provision of diagnostic services. Thiswill ensure that the mother and her partner and whanau/family receive the best serviceand will also ensure that the most effective use is made of expensive equipment. Healthprofessionals who offer diagnostic services also need to be skilled providers of emotionaladvice in those cases where unexpected conditions such as multiple births or perhaps anabnormality are detected. The contracted principal practitioner should also be involvedin such circumstances.

4.48 We recommend that R1IAs purchase diagnostic services from a range of trainedproviders and that diagnostic tools continue to be regarded as services which can beprovided to meet assessed needs on referral from the woman's contracted principalpractitioner.

Antenatal Education Programmes

4.49 Antenatal education programmes focus on those aspects of pregnancy, birth andparenting that are common to all women. Many programmes include sessions designedto assist with stopping smoking, preventing cot deaths etc. Many also help to developsupport networks which continue to operate after the birth of the baby (eg coffeemornings for new mothers).

4.50 There was strong agreement that antenatal programmes, appropriate to the needsof the mother and baby, can make a substantial difference to birth outcomes. Some ofthe issues cited included:

• One of the most significant determinants of low birth weight babies andpoor quality birth outcomes is smoking. Any antenatal programme shouldinclude information about the risks of smoking and the means of giving itUP.

• The antenatal programmes currently provided are of variable quality andcontent so women in different geographical locations do not always havethe choice of a good antenatal programme free of charge.

• A considerable amount of antenatal education could be covered by thecontracted principal practitioner, if the consultation periods were longer(but if the programme meets the assessed needs of the mother, fewer shortconsultations might be appropriate).

•Community-based antenatal classes may be more appropriate in somelocations.

•Involvement of partners/whanau/family of pregnant women is a means ofreinforcing the responsibilities of parenting.

•All women should be provided with a tour of their chosen hospital as ofright, even if their preferred option is a home birth.

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4.51 Large groups work well for some women and are appropriate for some parts ofthe antenatal programme. On the other hand, some programmes work better when basedaround small groups. Some Maori women would prefer marae based antenatal education.

4.52 We recommend that R1IAs continue to purchase antenatal programmes whichinclude education about both home and hospital based services that are accessible to allpregnant women. Further, the RHAs should purchase from those who provide anantenatal programme which is geared to the individual needs of the woman, and whichincludes basic education relevant to quality birth outcomes, smoking cessation education,education about the services of different providers during birth and labour and about childhealth services that are available following the birth.

Development of Birth Care Plan for Care and Services Required

4.53 Consumers and providers who participated in our discussions felt that, as the timeof birth approaches, the parents generally become more focused on the actual birthingprocesses. As in other stages of the pregnancy, it is hard to predict exactly what thebirth will be like and a key component of any birth management will be preparing for theunexpected.

4.54 The experience of maternity service providers can assist the woman and herpartner in making choices. In time, a perinatal database would provide data which wouldenhance the quality of providers' advice by linking information about service inputs andquality outcomes.

4.55 The experience of a first birth is dramatic. Parts of the experience are likely tobe unexpected. An unexpected condition which is also painful can undermine thestrongest determination by a woman to maintain control of events.

4.56 Birth care plans recognise this aspect of birth but also provide a means for thewoman to understand what might happen and determine her response to different events.With good advice, much of what is unexpected can be discussed, at least in generalterms, among the woman, her partner, her whanau/family and her birthing team prior tothe birth. Then, if the woman finds her focus on labour too intense to make decisionsat that moment, those with her during that time will have guidance as to what herpreferences are for different services.

4.57 There is a continuum of birth experiences ranging from the full control of eventsby the woman to the condition where the woman and/or baby require(s) specialistintervention and decision making with informed consent. It is how this continuum ismanaged in practice which may causes problems. An effective birth care plan shouldinclude planning for the probable eventualities of the birth experience.

4.58 Another key purpose of the birth care plan is to enable providers to forward planand incorporate all the services that may be required, including those from midwives,CHEs, GPs, specialists and so on.

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4.59 We recommend that RHAs should require providers to work with women toprepare individual birth care plans. In the longer term, a perinatal database could yieldinformation to provide the RHAs, women, and their sub-contracted provider(s) withinformation about the outcomes achieved by different methods of birthing.

Labour and Birth Services

4.60 It was clear from all participants in this project (and from the literature) that agreat deal of effort goes into ensuring that the experience of labour and birth is as goodas possible.

4.61 The components of labour and birth services include:

provision of services in response to women's and babies' needs as definedby birth care plans;

specification of birth care indicators and access to specialist providers if,required; and

clarity of respective roles, responsibilities and accountabilities.

Provision of Services in Response and Women's and Babies' Needs as Defined by BirthCare Plans

4.62 Having set out a birth care plan, the provider's role is to match the services to theplan. Woman undergoing labour and birth may need the services of anaesthetists,obstetricians, paediatricians and/or neonatal, services. The interfaces between theseservices is critical as these are areas where there is known medical risk of poor birthoutcomes if appropriate services are not provided.

4.63 Comments from those we met include:

inadequate preparation and education of women about different types ofanaesthetics;

•poor transition from primary care to secondary care because primary caregiver did not refer soon enough; and

secondary caregiver disregarded woman's preferences.

4.64 Under the integrated maternity services framework, the contracted principalpractitioner will be responsible for ensuring that women have adequate preparation forthe birth and that the transition from primary to secondary care proceeds smoothly.

I'll

4.65 We recommend that RHAs monitor the assessed needs of women and their• babies, and the birth care plans which are developed to meet those needs. In this way

RHAs will be better able to forecast demands and purchase services which match therange of assessed needs of women and their babies.

4.66 We also recommend that the RHAs purchase from those contracted providers whospecify the criteria for transfer to secondary services and who provide guidelines toclarify accountabilities when such transfers take place.

Specification of Birth Care Indicators and Access to Specialist Providers if Required

4.67 There was disagreement among providers about the usefulness of risk lists. Theyare used by some providers to identify vulnerable groups. Other providers whom we metwere critical of the concept of risk, seeing it as predetermining interventions which mightlead to specific outcomes.

4.68 There was, however, some support for criteria for specialist referral. GPs,obstetricians and other medical specialists were strongly in support of the Guidelines forConsultation with an Obstetric Specialist published by the Royal New Zealand Collegeof Obstetricians and Gynaecologists in May 1993. Others we met told us that theybelieved these guidelines may lead to unnecessary intervention in some cases.

4.69 The 1989 working party paper on Care for Pregnancy and Childbirth' is anational discussion document which defines normal care. All those participants who wereasked were supportive and wondered why the guidelines have never been formallyimplemented. A perceived strength of the working party paper is that it starts with anidentification of what is normal in birth.

4.70 The current system has a number of barriers to receipt of specialist servicesduring birth. Those mentioned by participants include:

•women in high risk situations (and without a known primary careprovider) are frequently supported by inexperienced hospital midwives

•a reluctance by some providers to call in specialists when required

•barriers which come about because of the ways in which hospital maternityservices teams and independent specialists are funded.

4.71 Women who self-refer to specialist maternity services are required to pay. Thisis not in itself a barrier to access, however, since such services can also be subsidised bythe RHAs. Specifically, referral by a primary caregiver or through a CHE entitles thewoman and her baby to specialist services without charge.

8 Discussion Paper on Care for Pregnancy and Childbirth by the Working Group on Safe Options forLow Risk Pregnancy

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4.72 We recommend that the RHAs adopt the 1989 Working Party Report, Care forPregnancy and Childbirth, as! setting out some basic birth care! indicators. We alsorecommend that RHAs purchase from providers who specify guidelines, for consultationand referral to specialists that are consistent with the principles established in the workingparty report.

4.73 We recommend that RHAs purchase from some providers who have anappropriate level and mix of staff experienced in managing challenging births. Allproviders should also be required by the RHA to specify an appropriate policy on criteriafor referral to specialist services.

Clarity of Respective Roles, Responsibilities and Accountabilities

4.74 The description of current birthing that emerged from discussion with someparticipants (especially consumers) was of a battleground with providers fighting for theirparticular way of doing things. We believe that this stems, in part at least, from a lackof clarity regarding roles, responsibilities and accountabilities. There may also be inter-professional conflicts and tensions between CHEs and independent providers when theyare both involved in a woman's care.

4.75 CHEs have dealt with these problems by developing guidelines, in conjunctionwith independent providers and consumers, that clarify the roles of providers while thoseproviders are working in CHE facilities.

4.76 We recommend that RHAs support the establishment of an environment whereproviders can work together. Also, that RHAs purchase services which include protocolsand guidelines covering the periods both before and following birth. which ensure thatwomen, babies and their sub-contracted provider(s) have access to appropriate servicesand facilities.

Services Following Birth for Mother and Infant

4.77 These services have recently been a subject of a Core Health Services consensusworkshop. Participants felt that services following birth for mother and infant shouldinclude, on the basis of need:

hospital-based services;

•assessed maternity care through to six weeks;

•emotional care;

•breastfeeding advice;

•parenting/whanau/family care;

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•home-based services; and

•effective transfer to providers of early childhood care and general healthservices.

4.78 A significant majority of participants expressed views that current servicesfollowing birth are inadequate. Specifically:

•many of the current services were believed to be of poor quality - forexample, breastfeeding advice is often inconsistent and insufficient;

• current services often did not meet women's needs - for example, there isa gap in current services because there is one final check-up at six weeksrather than maternity services throughout the six weeks following birth.

• the scope of existing maternity services following birth is too narrowlydefined to ensure quality outcomes - for example, more practical home-based support was required by some women with special needs and thosewe met felt that many mothers and their partners required emotional andparenting/whanau/family care.

Hospital-based services

4.79 There was considerable feedback which suggested that, in some areas, hospitalservices following birth are not meeting consumers' needs. Provision of breastfeedingadvice and access to appropriate nursing and other support staff were particular aspectswhich consumers and providers highlighted as being poor. This may be one of thereasons why women choose to go home shortly after the birth.

4.80 We recommend that RI-lAs purchase hospital-based services in sufficient quantityand of adequate quality to meet the assessed needs of women following the birth of theirbabies.

Assessed Maternity Need Through to Six Weeks

4.81 Most participants felt that women and their babies should be entitled to maternityservices to meet assessed needs for a period of up to six weeks after the birth. Theseassessed needs relate to the normal consequences of birth with some additional medicalneeds for specific conditions.

4.82 Families with new babies may also require education about things such as cotdeath prevention, ways of settling babies, the right ways to dress babies, breastfeedingadvice, meeting the needs of the mother for rest and sustenance, contraception etc.

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4.83 Community support encompasses services such as visits as required from a trainedhealth professional who provides care and support in the form of practical advice on babycare, breastfeeding advice and other baby care similar to that provided when women hadlonger stays in hospital. Current provision of community-based support was generallyseen as good, though it is variable among regions and providers, and between urban andrural areas.

4.84 An opportunity should be provided for parents to discuss the care duringpregnancy, labour and childbirth with the contracted principal practitioner.

4.85 We recommend that RHAs purchase from contracted providers who are able toprovide a range of services to meet assessed needs through to six weeks. These servicesmay include practical housekeeping support, a continuity of medical support, midwiferysupport, emotional support, breastfeeding advice, parenting/whanau/family care andinformation about access to early childhood care services.

Emotional Care

4.86 The consumer groups we met noted that new mothers, in neighbourhoods wheremany of the women work, can be increasingly isolated. An important part of the support.needed for the first six weeks is emotional support. Some key comments from thosewhom we met were as follows:

• contracted principal practitioners should recognise this need andconsultations should be long enough to incorporate emotional care whenthere is assessed need;

•emotional support may sometimes require home visits;

continuity of service assists in providing the new mother with emotionalsupport from the contracted principal practitioner; and

•better identification of postnatal depression and provision of appropriatecare for mothers with emotional or mental health needs are required.

4.87 We recommend that RHAs purchase services from providers who includeappropriate emotional support as part of their care for new mothers and their babies withassessed needs for such support.

Breastfeeding Advice and Support

4.88 New Zealanders have been very successful in establishing a high level ofbreastfeeding on discharge from hospital. This is explained in part by the strongconsensus among women and providers about the positive health outcomes for the babyof breastfeeding.

4.89 There are a number of challenges, though, if the level of breastfeeding is to staythe same or improve. The most common complaint was that women received too muchdiffering advice about breastfeeding.

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4.90 We recommend that RHAs require contracted providers to provide informationand advice about breastfeeding in line with World Health Organisation recormnendationsand to be specific about the methods employed to delver such information and advice.

Parenting! WhanaulFamily Care

4.91 As with emotional support, there is general agreement that parenting/whanau/family care should be part of the service available to meet assessed needs following birth;but also agreement that current services do not meet these needs very well.

4.92 In this context, we note the observation by the National Collective of IndependentWomen's Refuges that;

"Women coming into refuge often talk of hearing other women's storiesthat parallel their own. Stories of their partner being wonderful, loving,warm and gentle until 'the wedding night' or their first pregnancy. Fromthere, his violence escalates ..."

4.93 We recommend that RHAs should purchase services for the six week periodfollowing birth which include parenting support and whanau/family care where needed.Such services should also facilitate transfer to other providers (or continue to bepurchased by the RHAs as part of a service other than maternity) at the end of the sixweek period as appropriate. Note that parenting support services are not part of currentpublicly-funded maternity services and would need to be funded by transferring resourcesfrom existing maternity services, or reallocating funds from other services.

Home-Based Services

4.94 Reductions in hospital lengths of stay in recent years and the requirements for careof women who choose home birth imply that resources should be made available tosupport women in their own homes.

: 4.95 A key difference between care in hospital and care in the community is thatgenerally hospitals will provide home-based services including meals, changes of bedlinen and changes of babies' nappies and clothes. The provision of these services fornew mothers was thought by many participants, both consumers and providers, toimprove their chances of establishing breastfeeding and bonding, and the quality of theirongoing relationships to babies and partners. Practical support is also thought to providean opportunity for mothers who require it to seek emotional support from partners andthose outside the home.

4.96 This was an area where the needs of women vary greatly. Part of the assessmentwhich RHAs should purchase will be to determine the likely extent of a new mother'sneed for practical home-based services in the period after birth.

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4.97 We recommend that RHAs monitor the postnatal period to determine therelationship between provision of home-based support to meet assessed needs and thequality of outcomes achieved for mother and baby. In the meantime, the RHAs shouldseek to purchase from providers who can provide community-based support for motherson the basis of need, whether they choose to have their babies at home or in hospital.

Effective Transfer to Providers of Early Childhood Care & General Health Services

4.98 There is a considerable amount of community-based support which, while not partof maternity services, is often available, at little or no charge, to mothers, their babiesand their partners/whanau/families after the initial six week postnatal period. Thissupport includes the services provided by Plunket, new mothers support groups, LaLeche, lactation consultants etc. Many of the consumers and providers whom we metnoted that mothers appeared not to be making use of these services.

4.99 The transfer of care from maternity services to child health and general healthservices was described as inadequate by a number of the providers and consumers whomwe met.

4.100 We recommend that RHAs purchase services from providers who include, as partof their services, guidelines for transfer to family and child health services. The sub-contracted provider(s) would be. accountable for providing new mothers with informationabout the range of child health services available, recommended immunisations and childsafety services.

Conclusion

4. 101 In this section, we have sought to apply our analysis of the literature andcomments from participants to the design of an integrated maternity services framework.Our aim has been to identify areas where there is agreement about principles andpractices and areas where there is not. There were many valuable additional commentsabout specific services from those whom we met and we have attempted to synthesisethem in a way which balances the various views of those we met.

4.102 The current focus, in the health sector, on funding provider inputs and discreteelements of service creates a situation where items of service which are available becomea minimum expectation for all women and their babies, whether they need thoseparticular service or not. The integrated maternity services framework which we haveproposed provides a way of planning and delivering services so that each woman canreceive the services that are right for her and her baby.

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5

MATERNITY SERVICES REQUIREMENTS

5.1 In Sections 3 and 4 we outlined an integrated maternity services framework. Werecommend that RHAs require providers to show how they will deliver services withinthe framework.

5.2 The framework will enable women to identify a contracted principal practitioner,choose sub-contracted provider(s) and access services to meet their assessed needs. Theinformation about assessed needs will determine which services are part of the packageof care made available to a particular woman and her baby.

5.3 The design of the framework in outline form in Section 3 is deliberate. It is clearfrom the literature that providers and consumers support the delivery of the range ofservices outlined by the framework. It is not so clear that there is agreement on theprecise components of the services and in the absence of a perinatal database, it is notpossible objectively to assess what precisely should be a minimum for all women.

5.4 Perhaps more importantly, a system which is designed to meet the needs ofwomen and their babies, assessed on an individual basis, will not result in the sameservices for all. Some providers told us that the focus on meeting the needs of a defined"normal" or "average" birth has led to over-servicing in some areas and under-servicingin others as well as fragmentation, lack of continuity of service and a poor match betweenneed and service for some women.

5.5 It is thus important to emphasise that, given the individual nature of pregnancy,labour, birth and infancy, any protocol or set of guidelines must build in flexibility. Onthe other hand, the RHAs as purchasers will expect a certain minimum level of servicesfrom providers, and those providers need to know what those expectations are.

Perinatal Database Implementation: A Proposed Framework

5.6 As part of their work towards specification of a perinatal database, TerranovaPacific Services Ltd (Terranova) have worked with health professionals to attempt todefine "a possible framework for contract management and maternity benefits". Theirwork also offers some valuable insights into the elements of service that might be offeredby providers to meet the minimum requirements for maternity services within theintegrated maternity services framework.

5.7 The concepts involved in the implementation of a perinatal database are outlinedin Terranova's draft document of 24 September 1993 titled "Perinatal DatabaseImplementation: A proposed framework for contract management and maternity benefits ".This is reproduced verbatim at Appendix C.

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5.8 Terranova's draft report outlines inputs, outputs, outcomes and quality standardsfor those components of the integrated services framework which, fall within the scopeof maternity services purchased by RHAs. These are:

•informed choice about birth and care';

•pregnancy services;

•labour and birth services; and

services following birth for mother and infant".

5.9 A strength of Terranova's work is that it is based on the knowledge of healthprofessionals and also reflects experience gained from association with some of theproviders who already use a perinatal database. Since other service providers may be'involved with other databases, however, they may define the detail of,-"the services slightlydifferently.

5.10 To specify a database, Terranova have been obliged to define services in detail.It is important to note, however, that Terranova's work was not, in itself, intendedcomprehensively to define requirements for good care in pregnancy and childbirth; nordid it seek to define quality standards associated with components of care. Equally, itshould be emphasised that the services which are needed by each woman and her babywill differ depending on their health needs and circumstances.

5.11 , The inputs, outputs, outcomes and quality standards discussed in Terranova's draftreport are illustrative only and, in practice, will vary among consumers. As part of theirpurchasing process, the RHAs will ask providers to specify their own plans to provideservices for women with different assessed needs. The services and quality standardsspecified will need to be consistent with the component of service concerned and with theassessment processes for maternity services which are adopted.

This component is referred to' as "Maternity Assessment Service" in Terranova's draft report

"Postnatal Services" in Terranova's draft report.

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6

BENEFITS OF THE INTEGRATED MATERNITYSERVICES FRAMEWORK

6.1The integrated maternity services framework provides a means to improvematernity services and ensure that they are accessible to all women who require them.

6.2This section outlines some of the benefits of the integrated maternity servicesframework for:

•women and their babies;

•Maori;

•Maori providers;

•providers in general; and

•Regional Health Authorities.

6.3Possible implementation risks are considered in Section 7.

Women and their babies

6.4 It was evident from our meetings that the structure of the current system does notempower women or provide them with good information for making choices in theirmaternity care.

6.5 The integrated maternity services framework envisages that services and processeswill be specified that are designed to ensure the woman is informed about the choicesshe has in services throughout pregnancy, childbirth and thereafter.

6.6Benefits for mothers and their babies include:

•better access to health and other services which are tailored towards eachwoman's needs and those of her baby;

•better advice and support in areas such as parenting and breastfeeding;

•more social and emotional support;

•more balanced information;

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•empowerment and control of decisions which affect them;

•continuity of care;

•better access to appropriate services for isolated women and women withspecial needs;

•information (from the perinatal database) about aspects of care that leadto better outcomes; and

•less conflict among service providers.

Maori

6.7 Dr Mason Dune at the Hui Hauora Mokopuna (1990) spoke of the importance ofiwi in developing health programmes where they have the advantage of their own whanaunetworks, appropriate tikanga and knowledge of their people's socio-economic conditions.

6.8The integrated services framework gives the base for Maori to develop a systemwhich is more appropriate to their needs than the current system.

6.9Benefits for Maori are:

•opportunities to have a say over the services they need;

•access to culturally-sensitive and appropriate services;

•a database to analyse services which would lead to better quality birthoutcomes;

•longer-term, a greater measure of self-determination; and

•an enhancement of the capacity of mainstream health agencies to addressMaori health needs.

Maori providers

6.10 Benefits for Maori providers of maternity services are:

•the opportunity for Maori to develop their own services where they havethe advantage of using their own whanau networks, appropriate tikangaand knowledge of their people's socio-economic conditions; I

•the opportunity to become part of teams of service providers;

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•statistical data to help improve services and the health status of Maori overtime;

opportunities to establish enterprises which provide for their own people;and

opportunities for Maori to work as co-purchasers with other serviceproviders.

Providers in general

6.11 The RHAs are the Government's purchasing agents for all publicly-fundedmaternity services. The integrated maternity services framework is based around theconcept of individually assessed need, so the services sought by individual women andtheir babies will vary.

6.12 Our recommendations envisage that RHAs will purchase from providers whointend to provide for a range of assessed needs. The women who choose the service ofa provider could include some who require only a limited range of services and otherswho require a much wider range of services.

6.13 RHAs are likely to prefer to purchase from groups of providers rather than fromsingle providers. Consistent with the integrated maternity services framework, someproviders are likely to want to group themselves into teams of providers of differentservices. Others may prefer to establish groups of providers who deliver the sameservice and set up arrangements for women to access other required services. Forexample, to meet the assessed needs of a woman and her baby in full, a team couldinclude those with skills in midwifery, medical care, counselling, radiology, antenataleducation and physiotherapy.

6.14 Benefits for providers are:

opportunities to improve birth outcomes;

•service improvements based on consumer feedback;

•opportunities to establish or join teams of maternity services providers,and to set up new provider entities;

• statistical data linking service inputs to outputs, outcomes and qualityindicators to help improve the quality and effectiveness of services overtime; and

•opportunities to work as co-purchasers with other service providers.

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Regional Health Authorities

6.15 The challenge for the RHAs is to reallocate resources among providers in amanner which better meets the assessed needs of women and their babies, while at thesame time providing an environment where providers can plan and invest in the futureso that they can remain flexible and viable.

6.16 Benefits of the integrated services framework for RHAs are:

•opportunities to obtain improved birth outcomes for mothers and theirbabies;

•less fragmentation of funding;

•processes for resolving differing philosophies of service;

•improved equity of access; and

•availability of statistical data which links inputs to outputs, outcomes andquality indicators to inform service purchasers over time.

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7

WHERE TO FROM HERE

7.1 A strength of the integrated maternity services framework is that it can evolveover time. The successful development of this approach will require the involvement ofpurchasers, providers and consumers.

7.2 In this final section of our report we summarise the main features of the integratedmaternity services framework, focussing on key areas of difference from current services.We also consider how the framework addresses some of the main risks surroundingimplementation and highlight a number of areas where further work is required.

Changes from Current Services

7.3The main differences between services delivered under the integrated maternityservices framework and those currently provided include:

•stronger consumer focus;

individualised services;

enhanced continuity of care;

•clearer accountabilites;

improved quality and consumer satisfaction; and

•more and better information.

Stronger Consumer Focus

7.4 The integrated maternity services framework places the woman, her baby and herpartner/whanau/family at the centre of service delivery. Unlike the current system whereservices can generally only be obtained under specific circumstances from specificproviders (and in accordance with specific conditions), the framework offers opportunitiesfor purchasers and providers to develop innovative approaches to the planning anddelivery of services. These will have to reflect the informed choices of women and, assuch, will be more varied and responsive than services offered under current models canbe.

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Individualised Services

7.5 By introducing a formal assessment process, the framework provides anopportunity for each individual woman to access an individual and comprehensivepackage of services which are tailored to her particular needs, as well as those of herpartner and whanau/family. This approach should enable women to access serviceswhich more closely match not only their medical and psycho-social needs, but also theirpersonal preferences in terms of service providers, the style of service and theenvironment in which services are delivered.

7.6 The integrated maternity services framework should prove to be particularlyappropriate as a means to meet the needs of Maori and Pacific Island women, womenwith special needs and those who live in geographically isolated areas.

Clearer Accountabilities

7.7 RHAs will purchase from those providers who deliver a clearly specified rangeof services, to meet defined quality standards and to comply with requirements to recordand report key data items regarding their clients and services. This will improveaccountability.

7.8 Also, the strengthening of the concept of contracted principal practitioner whichis central to the framework will ensure that women know, at every stage of theirpregnancy, labour and birth, and for six weeks after the birth, which individual personis ultimately responsible for their care. This will be the case even if that care is beingdelivered by a team of sub-contracted providers.

Enhanced Continuity of Care

7.9 By requiring all women who use maternity sertices to have a defined contractedprincipal practitioner at all times, continuity of care will also be enhanced. The principalpractitioner may change, but such changes must be explicit and there must be effective"hand-over" arrangements. Similarly, when different sub-contracted providers are usedfor different components of care, the existence of a single contracted principalpractitioner will ensure continuity and improve communication.

7.10 We were told by many consumers and providers that shortcomings in continuityof care are a significant weakness in current services.

Improved Quality and Consumer Satisfaction

7.11 The integrated maternity services framework envisages specific provisions toensure that consumer feedback and peer review mechanisms are in place and operatingeffectively. Furthermore, the development of a perinatal database will ensure thatinformation on services and their impacts is recorded, and is readily accessible to guidepurchasers, providers and consumers in their decision making.

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7.12 These aspects will all ensure that women have a meaningful role in making theirviews about services known and shaping the quality of the services they receive. Thiscontrasts with the current situation where many providers receive payments for services"as of right" with few opportunities for purchasers or consumers to influence the waythey operate.

More and Better Information

7.13 The development of a national or regional perinatal database, coupled with clearlyspecified procedures required to develop and document both contracts and individualassessments will greatly enhance the scope and usefulness of information about maternityservices. This contrasts with the current situation where individual providers are largelyresponsible for maintaining their own records in their own preferred format, and thereare few requirements for reporting on clients, services or outcomes. Better informationwill be better used, and will become a key resource to all parties as services develop.

Implementation Risks

7.14 Initially, most providers will continue to deliver the same services, in the sameways, that they do now. However, no system is without its problems when firstintroduced and there will be risks associated with the implementation of the integratedmaternity services framework.

7.15 A strength of the framework is that it relies on a system of monitoring, evaluationand informed choice. It also envisages that RHAs, providers and consumers will workas a network, which communicates needs and gaps in service, and that this will bebalanced by a willingness to reallocate resources to meet such needs and fill the gaps.In this way, the framework can be largely self-regulating, and implementation risksshould be minimised.

7.16 Particular strengths of this framework from an implementation perspective arethat:

RHAs purchase from providers who describe services they want to deliver;

•the framework can sustain different provider philosophies;

providers help implement the framework by doing what they do well;

•consumers can assist the improvement of services by making their needsknown; and

• the perinatal database will, over time, provide information that can bemade available to purchasers, providers and consumers of maternityservices to assist their decision making and support further developmentsin the purchasing and provision of maternity services.

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Further Work Required

7.17 Our discussions with providers and consumers have highlighted a number of areaswhere further work is required to develop specific aspects of the integrated maternityservices framework. These include:

•further consultation and research to identify and define Maori servicerequirements;

•detailed investigation of criteria for transfer to specialist services,including the use of "risk lists"; and

•more rigorous specification of minimum service requirements and qualitystandards for each component of the integrated maternity services model.

7.18 In addition, as indicated in our terms of reference, theRITAs will also bepreparing indicative costings for possible service options, and developing a nationalcommunications strategy for consumers and providers.

ZE

Appendix A

Participants

63

A.!

RHA STEERING GROUP

North Health

Sam DennyAwerangi Dune

Midland RHA

Patsi DaviesJane Hudson

Central RHA

Gillian BishopJackie Lay

Southern RHA

Kathryn CannanBill O'Brien

Te Manawa Hauora Ki, ManawatuDr Keri RatimaMaori Health Research UnitMassey University

Ministry of Health

Carolyn Boyd (to October 1993)Sandra Davies (from October 1993)Anne Hayes

65

A.2

PARTICIPANTS

Interested Parties Who Were Met

Representatives of Consumers

Catholic Support ServicesDPB ActionFederation of Women's Health Councils Aotearoa - New ZealandMaori Caucus, Ministry of HealthMaori Women's Welfare LeagueMaternity Services Consumer CouncilMinistry of Women's AffairsMothers AloneNeonatal Support Group (Hamilton)New Mothers Support GroupPost and Antenatal Depression Support GroupResearcher from Auckland University Project on Young MothersTe Puni KokiriUnion Health Clinic, WellingtonWomen's Division of Federated Farmers

Representatives of Health Sector Providers

Australasian College of Radiologists New ZealandCore Services Committee, Ministry of HealthChristchurch School of MedicineDepartment of Nursing and Midwifery - AlT AucklandDomino Midwives AssociationHome Birth AssociationHome Birth Midwives Collective - HamiltonAn Independent Midwife, HamiltonMaori Caucus, Ministry of HealthMaori Midwife Services, ChristchurchMaori Women's Homebirth, Support GroupMultiple Births AssociationNew Zealand College of MidwivesNew Zealand Family Planning AssociationNew Zealand Medical AssociationNew Zealand Obstetricians & Gynaecologists Society IncRoyal New Zealand Plunket SocietyOtago Medical School

67

Parent Centre National OfficePart Care MidwivesRoyal New Zealand College of General PractitionersSocial Workers AssociationTe Pum KokiriWaikato Home Birth AssociationWellington School of Medicine

CHEs

Auckland HealthcareCanterbury HealthCapital Coast HealthCoast Health CareEastbay HealthGood Health WanganuiHealth Care Hawkes BayHealth South CanterburyHealth WaikatoHealthcare OtagoHutt Valley HealthLakeland HealthMidCentral HealthNelson Marlborough HealthNorthland HealthSouth Auckland HealthSouthern HealthWaitemata HealthWestern Bay Health

Maori

At a national level Maori groups met with include:

Maori Caucus, Ministry of HealthMaori Midwife Services, ChristchurchMaori WomenMaori Women's Homebirth Support GroupMaori Women's Welfare LeagueTe Puni Kokiri

Each RHA in conjunction with their own Maori staff organised hui involving Maoriwithin their respective areas.

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Individual Consumers

Mother with a disabilityMother with a disabled childRural mother with eight childrenRural mother with one child

Participants Unable to be Met

Acorn ProjectChild Birth EducationsNew Zealand Maori Nurses CouncilTe Kohanga ReoTe Puawai Tapu

zu

A.3

CONSUMERS WITH SPECIAL NEEDS

Babies born with disabilitiesFirst time mothersImmigrant womenMother of Downs Syndrome babyNeonatal Support GroupPolynesian/Pacific Island womenRefugee womenRural/isolated womenSexual abuse victimsSingle parentsVery young womenWomen aged over 38Women at risk, eg history of babies born with congenital diseaseWomen having difficulty establishing breastfeeding or experiencing breast infectionsWomen who are in high stress jobsWomen who experienced difficulty with a previous birthWomen who have a medical problem, eg urinary tract infection, cancer, heart disease,diabetes etcWomen who have babies in neonatal unitsWomen who have no support at homeWomen who lose babies after birth, eg cot death etcWomen who put babies up for adoptionWomen whose health is at risk in relation to:-nutrition-illicit drug and alcohol users-smokers-psychiatric disordersWomen with a history of miscarriages/terminationsWomen with fertility problemsWomen with large families alreadyWomen with low socio-economic statusWomen with unemployed husbands/partners

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Appendix B

Terms of Reference

73

APPENDIX C

PERINATAL DATABASE IMPLEMENTATIONA PROPOSED FRAMEWORK FOR CONTRACT MANAGEMENT AND

MATERNITY BENEFITS

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PERINATAL DATABASE IMPLEMENTATION

1 Introduction

1.1 As part of their work towards specification of a perinatal database, TerranovaPacific Services have worked with health professionals to draft a possibleframework for contract management and maternity benefits. Terranova haveagreed for their work to be appended to this document.

1.2 The following work however was not, in itself, intended to comprehensivelydefine minimum requirements for good care in pregnancy and childbirth; nor didit seek to define quality standards associated with components of care.

1.3 The term 'database', 'perinatal database' and 'viability' are defined by Terranovaand included in the Glossary. Whilst the term 'perinatal' strictly refers to thetime frame between viability and seven day following birth, for practical datacollection purposes, data is collected from confirmation of pregnancy up to andincluding the six weed check. The term 'perinatal database' is usedinternationally. In New Zealand all data recorded on a perinatal database mustconform to the requirements of the Privacy Act 1993 and the Health InformationPrivacy Code 1993 (Temporary) as issued by the Privacy Commissioner.

2 Assumptions

2.1 The Minimum Perinatal Dataset was agreed by a national working party,including consumer representatives of Parent Centre, as well as midwives, GPs,obstetricians and paediatricians in 1989. It is the basis for the implementation ofperinatal data collection. The quality and type of maternity service can be definedusing the discrete data elements that form the Minimum Perinatal Dataset. Somequality measurements and indicators can be defined quantitatively.

2.2 The Minimum Perinatal Dataset is designed to collect quantitative data. TheRHAs may choose to enforce the collection of related qualitative data subject tothe conditions of the Health Information Privacy Code 1993. Qualitative narrativewill continue to be collated as part of medical notes and will be recordedmanually. It is acknowledged that, given current technology, computerisedanalysis of narrative script is not practical. In the meantime, it may be possibleto expand the minimum dataset to encode qualitative aspects of care. Interestedgroups should submit their specific requirements as choice lists, in tabular format.

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3 Objectives

The objectives of Perinatal Dataset Collection are:

3.1 To systematically record information on women and their infants (WHO)receive maternity care of a defined type and amount (WHAT andMERE) from a provider (from WHOM) over time (WHEN), and withwhat desired outcome (WHY).

3.2 To measure the type and quantity of goods and services produced(Outputs) and their impact on - or the consequences for - the community(Outcomes) REF.: Public Finance Act 1988.

3.3To provide data for the calculation of output costs

3.4To audit the payments of maternity services.

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4 Implementation Framework

4.1A Perinatal Database Collection Process:

4.1.1 The Perinatal database computer applications implemented inhospitals and with individual practitioners must record inputs,outputs and outcomes of the process; specifically who receiveswhat care from whom, when, where and why, with whatoutcome. Where a computerised solution is not in place, anequivalent manual process of data collection using forms will beimplemented.

4.1.2 Contracted providers (see below) are accountable for the completeand accurate recording of the perinatal dataset associated with eachservice module. The minimum perinatal dataset (or a negotiatedsubset thereof) for each woman and infant is made available to theRHA by Health Care User ID but without personal identificationdata on submission of maternity benefit claims.

4.2Perinatal Database

4.2.1 The minimum perinatal dataset is used to manager the quality ofmaternity services (inputs, outputs and outcomes) and, whereappropriate, to measure the quantity of the service elementsprovided within each service module.

4.3 Service Module Concept

4.3.1 A woman has the right to choose a provider who is accountable forthe delivery of a quality service, ideally, for the duration of herpregnancy, birth and postnatal care. The chosen provider contractswith the REIA or its agents to provide this care and is remuneratedthrough global fees for completed modules of care.

4.3.2 The contracted individual provider is responsible for the deliveryof comprehensive maternity care but may subcontract otherpractitioners (eg a subcontracted independent midwife or CHEmidwifery services) or other service organisations (eglaboratories).

4.3.3 The scope of service provided in each module is specified in termsof components (See "Service Module Components" below). TheRHA will set global fees for each module based on an averageexpected quantity of each care component

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4.4 Primary and Secondary Service Modules

4.4.1 The care is provided as a set of "primary service" or "secondary"service modules. Midwives, general practitioners and familyplanning clinics may contract to provide various primary servicemodules. Obstetric specialists and hospitals may contract toprovide primary and secondary service modules.

4.4.2The four service modules consist of minimum target inputs andoutputs. They are:

•Maternity Assessment: preferable 1st trimester

• Pregnancy Services: 2nd & 3rd trimester services,Antenatal education receives special emphasis withinthe Pregnancy Services module.

•Labour & Birth Services: including immediatepostnatal period (4 hours)

•Postnatal Services: up to and including 6 weekcheckup.

5 Service Module Components

A systematic and comprehensive definition of the Service Module Components isbased on the following framework:

1. Inputs (resources, processes and plans - with defined start and endpoints)

2. Outputs (goods and services delivered - scope of average servicemodule on which to determine global fees)

3. Outcomes (impact or consequences)

4. Quality Indicators (minimum requirements)

5. Applicable Perinatal Dataset Data Elements.See previous draft documentation by Terranova =

6. Costs of Outputs (by individual component; average cost).To be determined for all modules once average outputs have been agreed.

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The following comprises an initial (partial) analysis using this framework for eachof the four Service Modules:

Maternity Assessment

•Pregnancy Services

•Labour & Birth Services

•Postnatal Services

For each module (aside from the Maternity Assessment) there would be primaryand secondary service components, the transfer between primary and secondarycontracted providers is discussed later. The following outline of service modulecomponents is also intended as a basis for calculating average costs of outputs foreither primary or secondary providers.

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5.1Maternity Assessment Service

Objectives

To confirm pregnancy, assess maternal & (likely) fetal welfare, and refer for further pregnancyservices if necessary.

InputsStart: 1st consultation

Initial and subsequent ConsultationsReview History and options and Examination if appropriate.Investigations - Lab Tests - Bloods, Swabs, Urine, Smear, Scan (option)Education on care options/ choices explained/recorded preferenceAssess/feedback lab test results. Identify/discuss potential risk factors and risk avoidancemeasures to be undertakenReview choice of providers and further management of pregnancyPlan availability of, refer to culturally safe facilities for pregnancy servicesif TOP/miscarriage, assess outcome of failure, provide contraceptive advice and managecomplications

End: Min Dataset recording - register, medical/maternity history, current pregnancy details,incl. results of investigations & provider details (if TOP/miscarriage/ectopic complications,treatment, contraception) and Management/Care plan documented (Copy for woman).

Outputs

Baseline measurements, test results, diagnoses (including Gestation)TreatmentsProceduresProvision of culturally safe facilitiesIncreased awareness by womanJudicious referrals to secondary (incl for TOP), and other referralsPerinatal Dataset (Patient Record and Audit Trail on the above)Copy of minimum dataset record for womanContract with provider for Pregnancy service module:

Primary (Midwife, GP, Obstetrician) or Secondary (Obstetrician).

Outcomes

Woman is satisfied with standard of care provided (Discretion with TOP/Misc.)

Woman is referred to secondary specialist services for specialist assessments or treatmentson detection of complications

Woman is aware of options (informed consent) and understands the pregnancy and birthprocess to her satisfaction.

Pregnancy Diagnosis and Gestational Age confirmed as prerequisite for start of PregnancyServices module through a contracted provider and on the basis of a care plan and informedconsent.

Quality Indicators

Quantitative Standards/Guideline compliance: As determined by RHA and agreed withcontracted provider

Qualitative assessment by independent, randomised quality audit and consumer surveys:Choices explained satisfactorily.

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5.2Pregnancy Services

Objectives

To ensure provision of appropriate care during pregnancy so that early diagnosis of complicatingfactors can occur

InputsStart: Appointment for 1st consultation under the contracted provider:

ConsultationsHistory & Examinations (physical, psychosocial etc), review progress,Appropriate Investigations (Bloods, Swabs, Urine, Smear, Scan) with monthly visits from20-34 weeksEducation/Psych, Social Welfare referralsAssess/feedback lab test results and referalsDrug Prescriptions and Procedures

Referrals to Obstetric Specialist or Hospital as requiredIdentify/discuss potential risk factors and risk avoidance measures to be undertaken(including during labour and postnatally)Provision of Antenatal Education and if appropriate: Antenatal ClassesMin.Dataset recording - Antenatal details, medical/maternity complications, investigations,procedures, testsAssessment/Care Plan for Labour, Birth and Postnatal Service requirements

End: Professional judgement of onset of labour as determined by contracting provider ofLabour and Birth Services

Outputs

Measurements, test results, diagnoses (mci Gestation)Treatments and ProceduresProvision of culturally safe facilitiesIncreased awareness by womanJudicious referrals to secondary and other referralsPerinatal Dataset (Patient Record and Audit Trail on the above)Copy of minimum dataset record for womanContract with provider for Labour/Birth service module:

Outcomes (Second and Third Trimester)

Woman is aware of and follows individualised recommendations for good nutritionwell-being and safety

Woman is satisfied with standard of care provided

Woman is referred or transferred to secondary specialist services for specialist assessmentsor treatments on detection of complications

Woman is aware of options (informed consent) and understands the pregnancy and birth- process to her satisfaction.

Woman is in optimum health status at onset of labour

Quality IndicatorsQuantitative Standards/Guideline compliance: As determined by RHA and agreed withcontracted provider

Qualitative assessment by independent, randomised quality audit and consumer surveys:Choices explained satisfactorily.

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5.3Labour and Birth Services

Objectives

To ensure provision of appropriate service and care during labour and birth

Inputs.Start: Professional judgement of onset of labour

Review and revise care planManagement (monitoring) and support of labouring woman & support persons through 1st,2nd and 3rd Stage of LabourAssistance during birth by midwifery and medical staffImmediate postnatal assessments:

Initial examination of Infant(s)Examination of woman

Minimum Dataset recording - labour/birth details for woman and infant(s), initial examsPlan and arrange postnatal care

End: 4 hours post delivery.

Outputs

Measurements, test results, diagnoses (mci Gestation)Treatments and ProceduresProvision of culturally safe facilitiesInôreased awareness by womanJudicious referrals to secondary and other referralsPerinatal Dataset (Patient Record and Audit Trail on the above)Copy of minimum dataset record for womanContract with provider for Postnatal service module.

Outcomes

Woman is aware of and follows individualised recommendations for well-being and safety

Woman is satisfied with standard of care provided

Woman is referred to secondary specialist services for specialist assessments or treatmentson detection of complications

Woman is aware of options of care and understands the labour and birth process to hersatisfaction

Woman achieves best possible health status following birth under given conditions.

Quality Indicators

Quantitative Standards/Guideline compliance: As determined by RHA and agreed withcontracted provider

Qualitative assessment by independent, randomised quality audit and consumer surveys:Choices explained satisfactorily

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5.4Postnatal Services

Objectives

To ensure provision of appropriate postnatal care.

InputsStart: 4 hours post delivery.

Review and implement care planDiscuss contraception and prescribe if requestedAction Management Plan for postnatal care

Equivalent Postnatal Ward 3 day averageMonitor postnatal progress for woman and infant(s)Provide domiciliary care and support6 week check/exams and referralsMinimum Dataset recording - postnatal and referrals details

End: 6 week check completed

Outputs

Measurements, test results incl PKU, vaccinationsTreatments & ProceduresProvision of culturally safe facilitiesIncreased awareness by womanJudicious referrals to secondary and other referralsPerinatal Dataset (Patient Record and Audit Trail on the above)Copy of minimum dataset record for woman

Outcomes

Referrals to Child Health services and other postnatal services

Woman is aware of and follows individualised recommendations for wellbeing and safety

Woman is satisfied with standard of care provided

Woman and/or Infant referred to secondary specialist services for specialist assessments ortreatments on detection of complications

Woman is aware of options of postnatal care

Woman and Infant achieve best possible health status following birth under given conditions

Quality Indicators

Quantitative Standards/Guideline compliance: As determined by RHA and agreed withcontracted provider

Qualitative assessment by independent, randomised quality audit and consumer surveys:Choices explained satisfactorily.

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6 Quality and Audit

6.1 Qualitative standards may be formulated to formally supplement thequantitative measurements recorded on the database. Current professionalquality control processes will continue to determine breaches of professionalpractice.

6.2 Independent, random quality audits of contracted provider claims willsupplement the quantitative measurements recorded on the perinatal datasetsthat can be requested by the RHA.

6.3The quality management process would include financial measures, increasedreporting responsibilities or cancellation of the provider contract.

Kc

7 Perinatal Database Application Systems

7.1Information on the scope and content of the Perinatal Dataset has beenpreviously submitted to the RHAs by Terranova.

7.2The application systems for the collection of the perinatal dataset will consistof two versions:

A perinatal care system for hospitals, including provision for PatientManagement System Interfaces (ADT, RUS, DRGs, NZHIS etc.)

A perinatal care system for non-hospital providers

7.3The two systems enable the free interchange/transfer of data subject to astringent set of security and data validation prerequisites.

7.4 Each system includes audit program based on an agreed set of obstetricguidelines that are designed to identify potential breaches of standards. Forexample, such programs would be based on: "Standards and Guidelines forMidwifery and Obstetric Practice" published by the WellHealth ObstetricStandards and Review Committee.

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7.5Systems Implementation

Hospitals Providing Perinatal Services

Two locally developed and supported Minimum Perinatal Dataset ApplicationSystem are currently installed in New Zealand. One is marketed andsupported by Dr Neil Pattison and the Postgraduate School of Obstetrics andGynaecology, Auckland, the other is marketed and supported by TerranovaPacific Services Ltd.

Commercial processes apply to the choice of vendor but key functionalrequirements must be met. The application must:

1. Collates the Minimum Perinatal Dataset as defined in a DataDictionary to be published as part of the Joint RHA Project in a laterphase.

2. Allow identification of contracted providers and subcontracted caregivers, as well as investigations, diagnoses and procedures within eachservice module.

3. Allow automated production of maternity guideline compliancereports as specified by the RITA

4. Be capable of providing an interface that allows transfer of contractrelated information to the RHAs

5. Be capable of providing an interface to other systems processing theMinimum Perinatal Dataset.

Primary Maternity Practitioners Providing Perinatal Services

Commercial processes apply to the choice of vendor but key functionalrequirements must be met. The application must:

1. Collate the Minimum Perinatal Dataset as defined in the DataDictionary to be published as part of the Joint RHA Project in a laterphase.

2. Allow identification of contracted providers and subcontracted caregivers, as well as investigations, diagnoses and procedures within eachservice module

3. Allow automated production of maternity standard compliancereports as specified by the RITA

4. Be capable of providing an interface that allows transfer of contractrelated information to the RHAs

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5. Be capable of providing an interface to other systems processing theMinimum Perinatal Dataset.

8 Recommendations

8.1We recommend that RIIAs purchase from providers who maintain a perinataldatabase.

8.2We also recommend that prerequisite additional work be undertaken by theRHAs to:

8.2.1 complete the development of a data dictionary for the data elements tobe included in the perinatal database providing explanations forinclusion.

8.2.2 review and validate the input, outputs and desired outcomes forminimum requirements for good care in pregnancy, childbirth andrelated services.

8.2.3 develop agreed quality indicators and quality survey processes formaternity and related services.

8.2.4 develop a purchasing strategy for maternity and related services usinginformation held on the perinatal database.

8.2.5 validate the minimum requirements for good care in pregnancy,childbirth and related services against the data dictionary.

8.2.6 design and publish specifications for a distributed database whichfacilitates the integration of perinatal data at individual, group, regionaland national levels, taking account of the requirements of women,infants, clinicians, health managers, health policy analysts andplanners, quality control specialists, auditors and health researchers inaccordance with the provisions of the Privacy Act 1993.

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Appendix D

Issues Paper

95

ISSUES PAPER

The objective of our literature review was to prepare a preliminary "scoping" of currentissues. The issues paper then becomes the framework throughout our meeting processto provoke discussion and to channel the discussions into fruitful outcomes. Thisappendix represents the "Issues" chapter of our Issues Paper. The issues have purposelybeen written as bullet points rather than a descriptive analysis as we wanted to get peopleto think about the issues and provide us with their opinions.

The issues listed in this paper are not intended to be complete. The purpose of theconsultation is to discover the extent of the consensus about whether these constitute themain issues relevant to the current provision of maternity and related services.

We have broken the issues into seven sections, being:

•needs for services

•consumers

service delivery - antenatal

•service delivery - perinatal

•service delivery - postnatal

•quality standards & monitoring

•resources

-physical-human-financial

The issues have been numbered for reference purposes only and in no way representpriorities.

Need For Service

(1) What are the implications on current service levels of an increasing numberof women having babies?

(2) What implications are there on the current service delivery on the increase inolder women having babies?

(3) What implications are there on the current service delivery on the increase invery young women having babies?

(4) What impact does the current service delivery have on rates of maternalmorbidity?

(5) What impact does the current service delivery have on rates of neonatal andpostnatal morbidity' and mortality?

Consumers

(6) How does the RHA ensure through its purchasing that there will be acontinuous improvement in services from the perspective of consumerexpectations?

(7) Maternity & related services programmes need to have special considerationfor:

•Maori

•other ethnic groups

•vulnerable socio-economic groups

•mother's age

•community needs

•women with special needs

•women with disabilities.

(8) What impact does increasing ethnic variation within the population, have oncurrent service delivery?

(9) What additional or unique services do vulnerable groups require?

(10) What impact does demographic variation have on current service delivery?

(11) How can the preference of women for natural and alternative medicines becatered for?

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Service Delivery - Antenatal

(12) What standards/measures can be applied to determine high risk pregnancy?

(13) What constitutes quality antenatal care, and how does it impact on birthoutcomes?

(14) How is technology monitored to establish the extent to which it contributes togood outcomes?

(15) What are the guidelines for deciding use of advanced technology to ensure itseffectiveness and safety?

(16) How are the outcomes of social, financial and psychological support assessedin relation to technological support?

(17) Is the point at which maternity services commence at conception orpreconception? If it is preconception, what services are included, and fromwhat point?

(18) Should maternity services encompass health promotion and health protectioncampaigns and if so, what are the minimum components of promotion andprotection?

(19) How can potential barriers in access be appropriately provided for? Forexample:

•cultural and attitudinal factors

•transportation

inability to take time off work

•distance required to travel to service

availability of relevant providers

•childcare facilities.

(20) Should women carry their own pregnancy records?

(21) In attempting to instil a positive attitude towards labour and delivery, howshould topics such as forceps, caesarian section and neonatal care be portrayedas part of antenatal preparation?

I

(22) What are the basic components of antenatal classes in areas such as:

preparation of women for the deviations from the courses of normallabour (such as slow progress or operative delivery)

Upreparation of women to cope with their babies' needs

Upreparation of women to cope with their own needs in-the postnatalperiod?

Uparenting skills

whanau (family).

(23) What guidelines are required to cover cultural sensitivity during antenatal care?

(24) What information is available to women to enable them to make informeddecisions away from any bias a provider may have?

(25) How is the best balance achieved between professionals using advancedtechnology to diagnose conditions and other methods?

Service Delivery - Perinatal

(26) At what stage should a consumer be expected to have made a choice ofprovider?

(27) What should be the minimum requirements for information sharing wheremultiple providers are involved?

(28) Booking in to hospital: should this occur at a specified period - what shouldoccur at this stage?

(29) Should a "primary care giver" be identified for the care where multipleproviders are involved? Who should specify who this might be? What wouldtheir responsibilities be?

(30) Antenatal education as distinct from antenatal care. Should a provider ensurea choice in sources of education to meet social/ethnic/health needs ofconsumers?

(31) What are the criteria for determining the appropriate place of birth in termsof safety and preference?

(32) Number of people and levels of training/qualification needed to attend mothersduring delivery?

(33) Under what circumstances should there be intervention and how does itcontribute to outcomes?

IEsII

(34) Who is ultimately responsible under shared care? Do guidelines need to beestablished?

(35) What constitutes an appropriate environment for the delivery of babies to takeplace?

(36) What constitutes appropriate perinatal support for breast feeding/lactation?

(37) How, when and by whom should decisions to refer to obstetric specialists bemade?

(38) What standards/measures can be applied to determine high risk deliveries?

Service Delivery - Postnatal

(39) What levels, types and the location of support and guidance are appropriate,particularly for vulnerable consumers (see Appendix A), during the postnatalperiod?

(40) How can the needs and wishes of the whanau/family be encompassed bypostnatal services?

(41) What, if any, extra services are required by women who have undergonedelivery by caesarian section?

(42) What counselling and other services are required after a traumatic perinatalperiod both during the immediate postnatal period, and after the conclusion offormal postnatal care?

(43) Should early discharge be entirely the mother's choice or should an assessmentbe made of whether adequate home support services are available?

(44) To what extent do different caregivers provide conflicting advice to mothersand what impact can this have on their confidence in themselves and theirability to care for their baby.

(45) What constitutes appropriate postnatal support for breast feeding/lactation?

(46) What is the desirable duration of postnatal care, and how are the number ofvisits required within that period to be determined?

(47) What measures are required to ensure the safety and security of babies andmother while in hospital?

(48) For a normal birth, what is a reasonable hospital length of stay, given thatcommunity support is available?

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Quality Standards and Monitoring

(49) What quality measures are required to ensure services meet consumersexpectations?

(50) Are quality assurance and peer review processes sufficient to ensure womenobtain a quality service?

(51) What are the appropriate standards for professional bodies and the mechanismsto ensure adherence to standards?

(52) What are the appropriate national and locally developed protocols andmechanisms to ensure adherence to the protocols?

(53) Do processes, as currently legislated for Nursing Council of NZ, MedicalPractitioners Disciplinary Committee and Medical Council, adequately addresscomplaints and problems arising from complaints?

(54) What are the appropriate processes required to ensure that the service isadequate for Maori?

(55) What is the appropriate data to enable adequate planning and monitoring forMaori women?

(56) Does continuity of care achieve better outcomes?

(57) How can protocols be defined so that midwives, GPs and obstetricians areable to provide care appropriate to the mother's requirements without conflict?

(58) How can protocols be defined to ensure that the consumer can make the mostinformed choice between services?

(59) To what extent would a perinatal database capture data to enable analysis tobe undertaken which assists in providing resolution of the key issues?

(60) What guidelines should cover access agreements of independent providers tohospital facilities?

(61) How can the service delivery across primary and secondary care be optimised?

(62) What standards of cultural sensitivity should be set for health professionalsand what training should they receive?

(63) Who/which organisation should be responsible for determining andmaintaining provider competence?

(64) What arrangements should be made to ensure access to a reasonable level ofappropriate practical experience especially for those providers who may beworking in isolation from supervision?

ItIN

Resources

Physical

(65) What are the guidelines to ensure equity of access in rural settings to qualityservices?

Human

(66) Should training programmes include a balance between knowledge of newtechnology, western medicine and traditional knowledge and techniques?

(67) How do providers secure the appropriate staffing levels? What factors makethis difficult?

(68) What are acceptable training components of providers? Who should validateand evaluate the standards?

(69) What evaluation is required to ensure sufficient postgraduate and continuingeducation of maternity practitioners?

(70) How should those undergoing training (all professionals) gain practicalexperience in both normal and specialist aspects of care?

Purchasing

(71) How could purchasing arrangements be improved to enhance birth outcomes?

(72) How can purchasing arrangements ensure the appropriate services areprovided by the appropriate provider at the appropriate time?

(73) Vote:Health funding - is the money currently allocated in ways that achievethe best outcomes for birth mothers and their babies?

(74) What are the key steps for resolving uncertainty as to what constitutes the"core" of maternity and related services?

(75) How can new ways of purchasing alleviate problems such as:

multiple providers who aren't coordinating their care

over-servicing and duplication of services by providers.

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D.2

QUESTIONS FOR PROVIDER GROUPS

1.(a)When do maternity services commence and when does the handoverto child health services take place?

(b)In what circumstances does the answer differ (ie due to ethnicity,young or old mother etc)?

2.What do you see as the weaknesses in current service delivery for periodscovering:

(a) conception to six months(b) six months to nine months (including antenatal classes)(c) labour and birth(d) postnatal.

How would you overcome these weaknesses? What vulnerable groups are notbeing covered?

3.What information should the mother and partner receive? How and whenshould it be delivered and who delivers it?

4.What activities/interventions/resources are or should be offered to improve thehealth and well being of mothers and babies? Why are they used?

5.What are the barriers to women obtaining/accessing maternity services?Working within the existing budget how would you reduce these barriers?

6.What do you see as the benefit of having a perinatal database?

7.What are the inequities among providers in the current servicefunding/delivery arrangements and how do these impact on consumers?

8.What are the factors that indicate where specialist care is required duringphases?

(a) antenatal(b) labour and birth(c) postnatal.

9.What quality measures are required to ensure services meet the need ofconsumers?

10.If you had unlimited funding how would you extend/change the currentmaternity services to better service women and babies?

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APPENDIX E

BIBLIOGRAPHY

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E

BIBLIOGRAPHY

A Consensus Workshop Report to The National Advisory Committee on Core health andDisability Support Services, April 1993, Care of Mother and Baby After NormalDelivery, (Wellington: Department of Health).

A Consensus Workshop Report to The National Advisory Committee on Core Health andDisability Support Services, April 1993, The Baby Under 1000 Grams, (Wellington:Department of Health).

A Consensus Workshop Report to The National Advisory Committee on Core Health and- Disability Support Services, April 1993, Tamariki Ora, (Wellington: Department of

Health).

Albers L & Katz V, (1991) Birth Settings for Low Risk Pregnancies - An Analysis of theCurrent Literature, Journal of Nurse Midwifery, Vol 36, 1991, No.4 July/August 1991,pp 215-220.

Albers L & Savitz D, (1991) Hospital Setting for Birth and Use of Medical Proceduresin Low Risk Women, Journal of Nursing and Midwifery, Vol 36, No 6 Nov/Dec 1991,pp 327-333.

Auckland Area Health Board (1991) The Needs of Maori Women in Maternity ServicesWhakatupu, (Management Training Programme, Auckland Area Health Board).

Barber-Madden R, Kotch J (1990) Maternity Care Financing: Universal Access orUniversal Care, Journal of Health Politics, Policy and Law, Vol 15 No 4, Winter 1990,pp 797-814.

Bennet S (1990) A Quantitative Analysis of Responses to Draft Principles Proposed in theBrochure "Your Change to Help Plan Aucklands Maternity Service ", (Auckland AreaHealth Board).

Block B (April 1990) Evaluating the Quality of Perinatal Health Care, American Journalof Perinatology Vol 7 April 1990, pp 146-153.

Buekens P, Boutsen M, Kittel F, Vandenbussche P, Dramaix M (1993) Does Awarenessof Rates of Obstetric Interventions Change Practice?, BMJ, Vol 306, March 1993, pp623-625.

Buescher D, Roth M, Williams D, Goforth C (1991) An Evaluation of the Impact ofMaternity Care Coordination on Medicaid Birth Outcomes in North Carolina, AmericanJournal of Public Health, Vol 81 No 12, December 1991, pp 1625-1629.

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Campbell R, MacFarlene A (1986) Place of Delivery - A Review, British Journal ofObstetrics and Gynaecology, Vol 93, No 7, July 1986, pp 675-685.

Cardale P (1992) Springing the Poverty Trap, RCM Conference Nursing Supplement,Nursing Times, Vol 88 No 29, 15 July 1992, pp 66-67.

Carey T, Weis K & Homer C, (1991) Prepaid Versus Traditional Medicaid Plan: Lackof Effect on Pregnancy Outcomes and Prenatal Care, Health Services Research, June1991, Vol 26 No.2, pp 165-181.

Cavero CM, Fullerton JT, Bartlome JA, (1991) Assessment of the Process and Outcomesof the First 1000 Births of a Nurse Midwifery Service, Journal of Nurse Midwifery, Vol36, 1991, No.2 March/April 1991, pp 104-110.

Chalmers I,Oakley A,MacFarlane A (1980) Perinatal Health Services: an ImmodestProposal, BMJ, 1980, March 1980, Vol 1 pp 842-845.

Davidson E, Fukushima T (1985) Age Extremes for Reproduction: Current Implicationsfor Policy Change, American Journal of Obstetrics and Gynaecology, Vol 152, 1985, pp467-473.

Department of Health (1991) Service Statement: Pregnancy and Childbirth, (Wellington:Department of Health).

Department of Health (1992) Pregnancy and Childbirth Standards, Protocols and AccessAgreements, (Wellington: Department of Health).

Department of Health (1992), Future Regulations of Pregnancy and Childbirth Services,(Wellington: Department of Health).

Department of Health (1993) Changing Childbirth: Part 1, Report of the ExpertMaternity Group, (United Kingdom: Department of Health, London, HMSO).

Duff B (1992) Place of Ultrasound Imaging in Pregnancy, NZMJ No 936 Vol 105, 24June 1992, pp 236-237.

Enkin M, Keirse M & Chalmers I (1989) A Guide to Effective Care in Pregnancy andChildbirth, (London: Oxford University Press).

Evans C (1991) Description of a Home Follow Up Programme for Childbearing Families,Journal of Obstetric, Gynaecologic and Neonatal Nursing, Vol 20 No 2, March/April1991 pp 113-118.

Ford C, Iliffe S, Franklin, 0 (1991) Outcome of Planned Home Births in an Inner CityPractice, BMJ, Vol 303, 14 December 1991, pp 1517-1519.

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Fordham R, Field D, Hodges S, Normand C, Mason E, Burton P, Yates J, Male S(1992) Cost of Neonatal Care Across a Regional Health Authority, Journal of PublicMedicine, Vol 14 No 2, June 1992, pp 127-130.

Gravely E, Littlefield J (1992) A Cost Effectiveness Analysis of Three Staffing Models forthe Delivery of Low risk Prenatal Care, American Journal of Public Health, Vol 82 No2, February 1992, pp 180-184.

Hillan E (1992) Issues in the Delivery of Midwifery Care, Journal of Advanced Nursing,1992, Vol 17 No.3, March 1992, pp 274-278.

Insler V, Larholt K, Hagay Z, Baly R, Bar-David G, Meizner I, Karplus M, Stone D(1986) The Impact of Prenatal Care on the Outcome of Pregnancy, European Journal ofObstetrics, Gynaecology, Reproductive Biology, Vol 23, 1986, pp 211-223.

Kay B, Share D, Jones K, Smith M, Garcia D, & Yeo 5, (1991) Process, Costs andOutcomes of Community Based Prenatal Care for Adolescents, Medical Care Volume 29,No 6 pp 531-542.

Kilgour R (1990) Early Discharge After Childbirth - A Review of the 1980's Literature,(DOH Health Research Service, Wellington).

Knox A, Sadler L, Pattison N, Mantel! C & Mulimo P (1993) An Obstetric ScoringSystem: Its Development and Application in Obstetric Management, National WomensHospital, Auckland, Vol 81 February 1993.

Lennart Köhler (1991), Infant Mortality - The Swedish Experience, Annual Review ofPublic Health, 1991, Volume 12, pp 177-193.

Maternity Services Committee (1982) Special Care Services for the Newborn in NewZealand. Board of Health, Report Series No. 29.

Maternity Services Task Force (1990) Auckland Maternity Services Strategic Direction.(Auckland Area Health Board).

Maternity Services Task Force (1989) Report of Working Party on Education andTraining. (Auckland Area Health Board).

Maternity Services Task Force (1989) Roles, Responsibilities and Relationships in theMaternity Services. (Auckland Area Health Board).

McDonald T & Cobham (1988) Predictors of Prenatal Care Utilisation, Social ScienceMedicine, Vol 27 No 2, 1988, pp 167-172.

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Melia R, Morgan M, Wolfe C, Swan A (1991) Consumers' Views of the MaternityServices. Implications for Change and Quality Assurance, Journal of Public HealthMedicine, Vol 13 No 2, May 1991, pp 120-126.

Morrell V (1990) Preventing Low Birth Weight and Preterm Birth, a Review of SelectedLiterature, (DOH Health Research Services, Wellington).

National Advisory Committee on Core Health and Disability Support Services (1994)Core Services for 1994195, (Wellington: National Advisory Committee on Core Healthand Disability Support Services).

National Advisory Committee on Core Health and Disability Support Services (1993) TheBest of Health 2, (Wellington: National Advisory Committee on Core Health andDisability Support Services).

Notzon F (1990) International Differences in the Use of Obstetric Interventions, JAMA,Vol 263 No 24, 27 June 1990, pp 3286-3291.

Obstetrics & Neonatal Services (1986) Hospital Board Service Planning Guidelines.(DOH Wellington).

O'Sullivan A, Jacobsen B (1992), A Randomised Trial of a Health Care Programme forFirst Time Adolescent Mothers and their Infants, Nursing Research Journal, Vol 41 No4, July/August 1992, pp 210-215.

Parsons L, Day 5 (1992) Improving Obstetric Outcomes in Ethnic Minorities: anEvaluation of the Health Advocacy Service in Hackney, Journal of Public HealthMedicine, Vol 14, No 2, June 1992, pp 183-191.

Patterson C M, Chapple J C, Beard R W, Joffe M, Steer P J, Wright CSW (1991)Evaluating the Quality of Maternity Services - A Discussion Paper, British Journal ofObstetrics and Gynaecology, Vol 98 No 11, November 1991, pp 1073-1078.

Petitti D, Hiatt R, Chin V, Croughan M (1991) An Outcome Evaluation of the Contentand Quality of Prenatal Care, Birth No 18 March 1991.

Rosenblatt R, Reinken J, Shoemack P (1985) Is Obstetrics Safe in Small Hospitals?, TheLancet (Vol 2 pp Index - 738) August 1985, pp 429-431.

Scherjon S (1986) A Comparison Between the Organisation of Obstetrics in Denmark andthe Netherlands, British Journal of Obstetrics and Gynaecology, Vol 93 No 7, July 1986,pp 684-689

St Clair P, Smerglu V, Alexander C, Connel F, Niebyl J (1988) Situational andFinancial Barriers to Prenatal Care in a Sample of Low Income Inner City Women,Public Health Report Volume 105 May/June 1990.

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Street P, Gannon M, Holt E (1990) Community Obstetric Care in West Berkshire, BMJ,Vol 302, March 1990, pp 698-699.

Sutton F (1993) Proposed Contractual Agreements for the Domino Midwives Initiative(Wellington: Frances Sutton Economic Services).

Tew M & Damstra-Wijmenga 5 (1991) Safest Birth Attendants: Recent Dutch Evidence,Midwifery 1991, June 1991, Vol 7 No.2, pp 55-64.

Weddel S (1992) High Charis and Children, (Rotorua: Words Work).

Wellington Area Health Board, Standards & Guidelines for Midwifery & ObstetricsPractice, (Wellington Area Health Board).

Willis W & Fullerton J (1991) Prevention of Infant Mortality - An Agenda for NurseMidwifery, Journal of Nurse Midwifery November/December 1991, Vol 36 No.6, pp343-354.

Witner M (1990) Prenatal Care in the US: Reports Call for Improvements in Quality andAccessibility, Vol 22 No 1, February 1990.

Working Group on Safe Options for Low Risk Pregnancy (December 1989) DiscussionPaper on Care for Pregnancy and Childbirth, (Wellington: Department of Health).

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APPENDIX F

SELECTED REFERENCES FROM PARTICIPANTS

N

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F.!

SELECTED REFERENCES FROM PARTICIPANTS

A National Working Party (April 1988), A National Perinatal Information System: ABasis for Improving Child Health, Department of Health, Wellington, 8 April 1988.

An ad hoc national meeting (September 1991), Special and Intensive Care Services forthe New Born in New Zealand, collated by R N Howie, National Womens Hospital,September 1991.

Clinical Standards Advisory Group, (March 1993), Neonatal Intensive Care - Access toand Availability of Specialist Services, Report of a CSAG working group. Chaired byProfessor Sir David Hull.

Gardiner S, James S, Butterfield J, Quello R and Ryan G, (1977), Toward Improving theOutcome of Pregnancy - Recommendations for the Regional Development of Maternal andPerinatal Health Services, Committee on Perinatal Health, The National Foundation -March of Dimes.

Maternity Services Committee, (1982), Special Care Services for the New Born in NewZealand, Board of Health, Report Series No. 29.

Reed P, Puratapu, Book on Maori birthing practices

Ropiha D, Middleton L, (June 1993), An Evaluation of the Papakura Initiative: Te HunHauora, Ministry of Health, New Zealand Health Information Service, 1993.

Te Runanga o Toa Rangatira Inc (November 1992), Research into the AntenatalInformation Needs of the Ngati Toa Women, Ora Toa Health Unit, Takapuwahia, 1992.

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F.2

REFERENCES FROM PAEDIATRICS SOCIETY OF NEWZEALAND

1. Maternity Services Committee. Maternity Services in New Zealand.Board of Health Report Series No. 26. Wellington, 1976.

2. Committee on Perinatal Health. Toward improving the outcome ofpregnancy: recommendations for the regional development of maternal andperinatal services. White Plains (New York): The National Foundation -March of Dimes, 1976.

3. Maternity Services Committee. Special care services for the newborn inNew Zealand. Board of Health Report series No. 29. Wellington, 1982.

4. Maternity Services Committee. The mother and baby at home: the earlydays, Board of Health Report series No. 30. Wellington, 1982.

5. Level III newborn services in New Zealand, 1985. Report of an ad hocnational meeting held at the Memorial Hospital, Hastings, on 10 October1985.

6. Report of Working Party on Obstetric and Neonatal Service PlanningGuidelines. Wellington: Department of Health, 1985.

7. Royal College of Physicians of London. Medical care of the newborn inEngland and Wales. London, 1988.

8. A national perinatal information system: a basis for improving childhealth. Proposal to the Department of health from a national workingparty, April 1988.

9. Australian Health Ministers' Advisory Council. Guidelines for level threeneonatal intensive care. Australian Institute of Health, Canberra, 1990.

10. Special and intensive care for the newborn in New Zealand, 1991. Reportof an ad hoc national meeting held in Auckland on 2 September 1991.

11. Service statement: Child Health Services. Department of Health, April1991.

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12. Maskill C. A review of New Zealand newborn intensive care services1992. Health Research Services, Department of Health.

13. Darlow BA. Neonatal care in New Zealand 1991. Submitted forpublication.

14. Swyer PR. Organisation of perinatal/neonatal care. Acta PaediatricSupply. 1993, 385 1-18.

15. CSAG Working Group. Neonatal intensive care: access to and availabilityof specialist services. London: HMSO 1993.

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Appendix G

Glossary of Terms

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Glossary of Terms

Antenatal

Period from conception to birth - period of pregnancy

Balanced InformationInformation about the experience of pregnancy,About Birth and Care childbirth and parenting which describes care options

available in an objective manner rather than from theperspective of one provider.

Birth Care IndicatorsMeasures used to assess the needs of a woman and/orher baby for specific types of care.

CHE

Crown Health Enterprise - the main provider ofpublicly funded hospital care in a region.

Consumer (of maternityPregnant women and/or new mothers and theirservices) partner/whanau/family plus those who may become

pregnant in the future; also, agencies who representconsumers.

Continuity of CareThe practice of continuity of care differs forconsumers and providers but the concept refers to anintegrated service throughout pregnancy, childbirthand to six weeks afterbirth. This service may beprovided by a single caregiver (contracted principalpractitioner) who may contract other providers forsome maternity services or a team of providers wherethe accountabilities of each member are clearlyspecified.

Contracted PrincipalThe individual who conducts the first longPractitioner consultation which will include an assessment of the

parents' health and medical history and the currenthealth of the woman and baby. The contractedprincipal practitioner is then responsible for ensuringthat appropriate services are delivered either bydelivering them him/herself, or by arrangement withother providers to do so. The identity of thecontracted principal practitioner may change as thepregnancy progresses but all such changes should beformally agreed and recorded, with appropriate"hand-over" arrangements being observed. Thecontracted principal practitioner may be anindependent individual or an employee (of a CHE ora private/voluntary group).

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Database A set of logically related information recorded in aformat that is intended to be processed, or isprocessed, by a computer. This definition couldextend to a structured set of data on paper formswhich is intended to be entered onto a disk via akeyboard or other encoding device for furtherprocessing. A database is specified in terms of a setof data elements and their relationships, and isnormally documented in a data dictionary.(Definition supplied by Terranova Pacific ServicesLtd)

Home-Based MaternityAny maternity service which takes place in the homeServices of the woman.

Informed Choice Choice of maternity service options based on balancedinformation and assessment processes.

Informed Consent Freely given agreement to a proposed course ofaction based on a clear understanding of the proposal.(Ministry of Women's Affairs (1989) Women's Health,What needs to change: a summary of therecommendations of the cervical cancer inquiry and apractical guide to action. p31)

Integrated MaternityServices from conception through pregnancy,Services childbirth and the period following birth linked to

meet the holistic needs of the woman and baby.

Parenting Support Advice and practical support to women and theirpartners/whanau/family about the role andresponsibility of parenting.

Perinatal For the purposes of this report the term "perinatal"has been used to define the period extending from theconfirmation of pregnancy to six weeks after thebirth. Other definitions have been proposed whichsuggest that the perinatal period should be consideredto end seven days after the birth.

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Perinatal DatabaseA perinatal database for women and their infantssystematically records information in the form ofinputs, outputs and outcomes. The perinatal timeframe for the purposes of data collation normallystarts at diagnosis of pregnancy and ends at six weeksfollowing birth. It records information on antenatal,labour, birth and postnatal services. Such data maybe held at individual, group, regional and nationallevel. Appropriate data extract processes at eachlevel result in purpose-built databases which can beutilised for health management, review, audit,planning and research. (Definition supplied byTerranova Pacific Services Ltd)

Postnatal Referring to or associated with the time frame whichbegins at birth and normally ends six weeks followingbirth.

Pre-conception Time period (which varies for each person) prior toconception when there is focus on conceiving a baby,including an understanding of the impact of the healthof mother and father on the birth outcome.

Provider In the context of this report, any provider ofmaternity services including doctors, midwives,obstetricians, radiologists, paediatricians, nurses,social workers, physiotherapist, community workersetc.

Public Health An independent unit within the Ministry of HealthCommission responsible for funding public health strategies,

including health protection, health promotion anddisease prevention programmes. Public health isconcerned with the care of populations rather than thecare of individuals.

RHA Regional Health Authority which is responsible forpurchasing health and disability support services forpeople living in its region (sometimes referred to asits members) in accordance with purchasingguidelines laid down by Government.

Risk List A set of guidelines or clinical or other indicators thatidentify those women and babies who are considered

•-by health professionals to be at increased risk ofpossible morbidity and mortality either before or after

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delivery. Such guidelines and indicators are used torefer "at risk" women to an obstetric specialist.

Statement of RightsIn the absence of a formal New Zealand statement ofrights, such as the British Patient's Charter, manymaternity hospitals and practitioners already use apatient's code of rights based on the recommendationsof the Cartwright Inquiry of 1988

Sub-Contracted ProviderRefers to those individuals or teams who, at any time,may be responsible for delivering a particularcomponent of service at the request of the contractedprincipal practitioner. Some components of servicemay (and probably will) be delivered by thecontracted principal practitioner. The role of the sub-contracted provider(s) is to complement the core skillsand professional competencies of the contractedprincipal practitioner. One woman may use a numberof different sub-contracted providers, workingindividually or in teams, during the course of herpregnancy, birth-and immediately thereafter. At alltimes, however, their involvement will be co-ordinated by the contracted principal practitioner, towhom they will be accountable.

Viable Capable of living (Babies sometimes initially requireintensive life support systems and services to sustainlife.)

1.Morbidity in this context relates to illness.

Information Ccn reMinistry of HealthWellington

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