Pasifika women and barriers to the initiation of antenatal care at CMDHB Dr Sarah Corbett Dr Kara Okesene – Gafa Alain Vandel - Statistician PSRH 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 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 Wellington: Ministry of Health 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 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 th 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 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 Jun 3;118(1216):U1489.

Impetus for research Maternity services review committee set up – Report published October 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 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 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 (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 PopulationEarly BookersLate Bookers n=8038n= 867 Maori1785 (22.21%)155 (17.88%)115 (74%)40 (26%) Pacific3081 (38.33%)359 (41.41%)261 (73%)98 (27%) Indian599 (7.45%)67 (7.72%)65 (97%)2 (3%) Asian428 (5.32%)21(2.42%)20 (95%)1 (5%) European1955 (24.32%)183 (21.10%)164 (90%)19 (10%) Other190 (2.36%)82 (9.46%)76 (93%)6 (7%)

Demographics - Age

Age of Pacifika late bookers.

Demographics - Parity

Parity of Late booking Pacifika women.

Partner Support

Demographics – Education

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

If yes; Why was it difficult?

How did you go about finding care for this pregnancy:

Impact of eligibility for free care: Eligibility for maternity servicesStudy populationORPacifika women Yes673 (97.1%) No20 (2.9%)3.07 (1.23,7.68)4.45( )

Factors significantly associated with late booking - Knowledge Not knowing it was important to get pregnancy care (OR 11.53; 95% CI 1.27, ) 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; % 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 ) 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 %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 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.