Pasifika women and barriers to the initiation of antenatal care at CMDHBDr Sarah CorbettDr Kara Okesene – GafaAlain Vandel - StatisticianPSRH Conference July 2013

Background – importance of antenatal care• Recommended that all women should commence maternity

care before 10 weeks. • Under attendance and non attendance at antenatal care linked

with poor pregnancy outcomes including low birth weight, fetal and neonatal death.

• Auckland Stillbirth Study found that regular utilization of antenatal care was protective.

• 2011 PMMRC report analyzed contributing factors for the first time. Most common found to be barriers to accessing or engaging with maternity and health services.

• PMMRC report also found that Māori and Pacific mothers, mothers from the most deprived socioeconomic quintile, and teenage mothers were more likely to have stillbirths and neonatal deaths.

• PMMRC Perinatal and maternal mortality in New Zealand 2011:Fifth report to the Minister of Health January to December 2009. Wellington: Ministry of Health 2011.

• Stacey T, Thompson J, Mitchell E et al. Antenatal care, identification of suboptimal fetal growth and risk of late stillbirth. Findings from the Auckland Stllbirth Study. ANZJOG 2012: June 3;52(242)

Importance of early antenatal visit. • Pregnancy location, dating, number of fetuses + chorionicity• Previous past obstetric issues may be managed/prevented (eg severe

PET, IUGR)• Detection and management of medical issues – undiagnosed RH

disease, diabetes, thyroid, epilepsy, anemia, thromboembolism. • Detection and management of psychiatric and social issues. (Suicide

leading cause of maternal death, and family violence increases in pregnancy)

• Detection and management of infections – HIV/Hep B/Syphilis• Early trimester intervention to prevent fetal abnormality –

Medication safety, alcohol, smoking, drugs, folic acid, iodine.• Early detection of fetal abnormality – Aneuploidy screening, 11 week

anatomy scan. Opportunity for genetic counseling and screening in high risk women

• Smoking Cessation

Background - CMDHB• Counties Manukau District Health Board (CMDHB) serves one of

the most economically deprived areas of New Zealand, with a high proportion of young mothers, and women of Māori and Pacific ethnicity.

• At least four out of five CMDHB women (6,075 women) that deliver each year are at increased risk of experiencing a perinatal death using PMMRC defined flags

- <20- >40- Obese- Multiple pregnancy- Living in Socioeconomic depravation- Maternal medical problems- Maternal mental health problems

• PMMRC Perinatal and maternal mortality in New Zealand 2011:Fifth report to the Minister of Health January to December 2009. Wellington: Ministry of Health 2011.

Background – Model of care• LMC (Self employed midwife, GP, private obstetrician) • CMDHB bulk funded primary maternity services. (Community

midwives, shared care) • Women identified as high risk are referred to Secondary Care,

which includes both the Obstetric Medical Clinic and Diabetes in Pregnancy Service.

• Shared Care is unique system that developed in response to a Private LMC shortage. Women who choose Shared Care receive most of their antenatal care from a GP that enters into a Shared Care arrangement with the DHB. In addition, these women are offered three antenatal visits with a DHB employed community midwife and are delivered at a CMDHB facility by a DHB employed midwife. GPs that provide Shared Care are not required to have specific training in antenatal care and are not required to have a postgraduate Diploma of Obstetrics and Gynaecology.

The problem• July 2011 5th annual PMMRC report showed CMDHB had

highest rate of stillbirth.

Rates of late booking at CMDHB• Anecdotally there is a high rate of late booking.• 2000 study of Pacific infants 26% after 15 weeks• 2011 report based on Healthware hospital registration data.

Shows average of 190 women a year unbooked in labour, and over a third booked after 18 weeks.

• Difficulty knowing true rates as data collection issues. Date of booking visit currently not routinely collected.

• Jackson C. Antenatal Care in Counties Manukau DHB: A focus on primary antenatal care. Auckland: Counties Manukau District Health Board; 2011

• Low P, Paterson J, Wouldes T, Carter S, Williams M, Percival T. Factors affecting antenatal care attendance by mothers of Pacific infants living in New Zealand. The New Zealand medical journal. 2005 Jun 3;118(1216):U1489.

Impetus for research• Maternity services review committee set up – Report

published October 2012.

• Number of reports were commissioned : - Catherine Jackson Public Health registrar- Adrienne Priday - LMC

• My project ran concurrently.

Aims• Aim of study was to identify significant barriers to the

initiation of antenatal care in pregnant women presenting to CMDHB maternity services.

Study Design• Convenience sample of unselected women seeking pregnancy

care at CMDHB maternity facilities from 8 July 2011 – 9 Sept 2011.

• Inclusions: - Women in labour, or up to 6 weeks postpartum delivering a

baby at 19+5/40 onwards- Antenatal women greater then 37/40 gestation • Exclusions: - Women residing outside Counties Manukau Area.

Study Design - Recruitment

- Consultants, registrars, SHO, DHB and independent midwives, breastfeeding educators were asked to recruit women.

- Interpreters provided for women who did not speak English- Eligible women who were identified after discharge as not

having completed a survey were posted a survey to their home address with a stamped prepaid envelope.

- Participants demographics were checked against population demographics after 100, 300, 500 and 800 responses to ensure a representative sample.

Study Design - Questionnaire- Patient demographics (age, ethnicity, education level, relationship status, NHI, and date questionnaire completed) - Self reported gestation at diagnosis of pregnancy and at booking. - Self reported number of antenatal visits- Initial point of contact- Series of questions on specific barriers to antenatal care.

(Barriers identified by mapping patient journey, literature search, maternity consumer survey)

- 2 free text boxes where comments could be added about the difficulties faced in getting antenatal care, and what would have made it easier.

- From computer records – EDD, date of delivery, gravidity, parity, eligibility for free care, model of care.

Study Design• Pilot study done first – questionnaire followed by interview to

ensure easy to understand and that it was sufficiently discerning.

• All patients gave informed consent to be in study. Study protocol was approved by Northern Y Regional Ethics Committee (NTY/11/EXP/026) and the Māori Research Review Committee.

Study Design• Late booking was defined as booking >18 weeks as reported by the woman.

• Sample size calculation - Based on an audit of all registration forms completed at CMDHB from August 2008 – August 2009. - To detect an OR or 1.75 with a power of 80%, sample size of 800 needed.

• Statistical plan- OR for each item on the questionnaire was assessed using logistic regression, adjusting for demographic and antenatal care data as appropriate, based on Akaike’s information Criterion (AIC). Using backwards selection based on AIC starting with a model including all questionnaire items , demographic data and antenatal information a model was produced which best accounts for late booking of antenatal care. Pairwise interactions from this reduced model were also considered.

Results: • 826 women completed a patient survey from a estimated

eligible population of 2099. (39% response rate)

• 136 women (16%) booked for antenatal care after 18 weeks gestation

• Study population representative of birthing population.

Ethnicity: Ethnicity

CMDHB Births 2009

Study Population Early Bookers Late Bookers

n=8038 n= 867 Maori 1785 (22.21%) 155 (17.88%) 115 (74%) 40 (26%)Pacific 3081 (38.33%) 359 (41.41%) 261 (73%) 98 (27%)Indian 599 (7.45%) 67 (7.72%) 65 (97%) 2 (3%)Asian 428 (5.32%) 21(2.42%) 20 (95%) 1 (5%)European 1955 (24.32%) 183 (21.10%) 164 (90%) 19 (10%)Other 190 (2.36%) 82 (9.46%) 76 (93%) 6 (7%)

Late Bookers

MaoriPacificIndianAsianEuropeanOther

Demographics - Age

<20 20-24 25-29 30-34 35-39 40+0

10

20

30

40

50

60

70

80

90

100

Early bookersLate BookersPacific Early Pacific Late

Age

%

Age of Pacifika late bookers.

20.21%

27.66%

19.15%

18.09%

10.64%

4.26%

Pacifika late bookers

<2020-2425-2930-3435-3940+

Demographics - Parity

0 1 2 3 4 5+0

10

20

30

40

50

60

70

80

90

100

Early BookersLate BookersPacific Early BookersPacific Late Bookers

Parity

%

Parity of Late booking Pacifika women.

36

1612

16

10

10

012345+

Partner Support

yes no0

10

20

30

40

50

60

70

80

90

100

Early bookersLate bookersPacific Early BookersPacific Late bookers

Do you live with your husband/partner?

%

Demographics – Education

No formal education Primary Secondary Tertiary0

20

40

60

80

100

120

Early BookerLate BookerPacific Early BookerPacific Late booker

Education level

%

Was it difficult for you to find an LMC to look after you this pregnancy?

Study population Pacific National survey0

20

40

60

80

100

120

16.6 19 19

76.3 70

81

7.1 11

Did not tryNoYes

If yes; Why was it difficult?

study popula-tion

Pacific women National Survey

0

5

10

15

20

25

30

35

40

45

50

Shortage of midwives in my areaWanted care with my GPWanted care with a private obstetricianThe midwives were too busyDidn’t know I had to find an LMCI didn’t know how to find an LMCOther

How did you go about finding care for this pregnancy:

Pacifika women

GP helped me to find pregnancy careUsed the internet to find contact detailsPhoned 0800 MUM 2BEFriend or family member told me about an LMCI came to hospital and the staff helped me find LMCI didn’t know how to find an LMCI called the hospital and they sent me an appointmentI had the same LMC as last pregnancy

Impact of eligibility for free care:

Eligibility for maternity services Study population OR Pacifika women

Yes 673 (97.1%)

No 20 (2.9%) 3.07 (1.23,7.68) 4.45(1.42-13.99)

0 5 10 15 20 25 30 35 40 450

5

10

15

20

25

30

35

40

45

Gestation at diagnosis of pregnancy vrs gestation at book-ing.

Series1

Gestation in weeks at diagnosis

gestation in weeks at booking

52 women – 6.3%

0 5 10 15 20 25 30 35 40 450

5

10

15

20

25

30

35

40

45

Gestation at diagnosis of pregnancy vrs gestation at booking.

Series1

Gestation in weeks at diagnosis

gestation in weeks at book-ing

191 women - 23%

Factors significantly associated with late booking - Knowledge• Not knowing it was important to get pregnancy care (OR

11.53; 95% CI 1.27, 104.55)• Not knowing that it was important to start getting care early in

pregnancy (OR 2.55; 95% CI 1.25,5.20).• Patients who thought that they could look after themselves

during their pregnancy (OR 0.57; 95% CI 0.30, 1.06).

• Not knowing of the need to book an LMC (OR 1.58; 95% CI 0.97, 2.59) (not significant but almost)

Factors significantly associated with late booking • Having difficulty with English (OR; 0.37 95% CI 0.16,0.85),• Not having enough money to get to clinic visits (OR 0.26; 95%

CI 0.12,0.57),• Having no transport (a car) to get to appointments (OR 0.39;

95% CI 0.22, 0.69),• Having problems getting childcare so they could attend clinic

appointments (OR 0.48, 95% CI 0.26, 0.88), • Being too busy to go to appointments(OR 0.47, 95%CI 0.24-

0.89)• Couldn’t get an appointment at a time suitable (OR 0.41,

95%CI 0.23, 0.73)• Scared that CYFS would get involved (OR 0.21. 95%CI 0.05,

0.90)

Key Findings: • Pacifika women have higher rates of late booking. • Particularly a problem for young women <25, and women in

their first pregnancy. • Lack of partner support is a risk factor. • Being ineligible for free maternity care is a significant barrier• This can be despite higher education and literacy. • Many women did not find out they were pregnant early. • 11% of Pacifika women did not try to get pregnancy care. • Lack of knowledge about getting pregnancy care and how to

go about getting pregnancy care is a factor. Not knowing the importance of getting care earlier is a factor.

Key Findings: • For most Pacifika women, the GP is the place they first go

when they find out they are pregnant. • Societal factors that are barriers to care include transport,

childcare, lack of money to get to appointments and being too busy to go to appointments.

• Difficulty with English, not having appointment times that suit and being scared of CYFS involvement were systems issues.

What can be done?1)Advocate for those living in poverty, and aim to reduce inequality.

2)Governmental level: Need to have a recommendation that ANC start before 10 weeks. Improve data systems: Collect and disseminate data about gestation at booking.

3) Diagnose pregnancy earlier. - public education about signs/symptoms of pregnancy- Education campaign about what is a normal period?- Freer access to pregnancy tests?- Emphasize confidentiality of services.

• 4) Improve knowledge around importance of early antenatal care, and how to go about getting care. Create a simpler system to understand for patients and GP’s.

• 5)Increased integration of antenatal care into patient's existing heathcare relationship/community/family. Ideally close to home or sometimes in the home.

• 6) Development of workforce – Enough midwifes, provide continuity of care model.

• 7)Be responsive to cultural needs: Importance of shared language, developing resources in different languages.

Changes at CMDHB• CMDHB external review of maternity care – Report published

2012. Specific recommendations: • Before 10 weeks all women should have a personalized

assessment of their specific needs and an individualized care plan developed. Done by suitably trained GPs or midwives, with an expanded assessment form.

- Develop multimedia educational material, Consider incentives for early assessment, prioritize funding. • Improve access to USS, especially if urgent.

• Identify and prioritize vulnerable and high needs women- Set up vulnerable woman's MDT. - Consider ways which these woman can be provided with

continuity of care. - Development of comprehensive social worker/community

health worker supports.

• Priority given to expanding DHB case-loading model, with emphasis on continuity of care, and reducing shared care model. Ensuring doctors in shared care model are suitably qualified.

• Consider extra payments to LMCs for women who are more complex.

• Workforce recruitment and support of new graduates. • Improving access to contraception and family planning

services. Postnatal, woman’s choice and contraceptive plan should be communicated with GP.

• Improve data collection

Acknowledgements• CCREP – Innovation fund grant

• Women’s Health management team

• All the LMC’s, DHB midwives, breastfeeding educators, maternity nurses, medical staff who helped recruit women.

I would like to encourage people to take up research! Don’t be scared just because you haven’t done it before.