Summary Report on Consumer, Carer, and Stakeholder

Summary Report on Consumer, Carer, and Stakeholder
Perspectives on Maternity Care in Regional, Rural and Remote
Queensland: June 2010
Written and submitted by:
Sue Kruske and Rachelle Jones
Queensland Centre for Mothers & Babies
prepared for:
Kerry Ann Ungerer
Manager, Maternity Unit
Primary, Community & Extended Care Branch
Queensland Health
6ummary 5eport RIFonsumer, Farer, Dnd Vtakeholder Serspectives on Maternity Care
in Regional, Rural and Remote Queensland
June 2010
Written and submitted by:
Sue Kruske and Rachelle Jones
Queensland Centre for Mothers & Babies
Introduction
As part of the Review of Maternity Services in Queensland, Hirst (2005) undertook a comprehensive
review of maternity services in Queensland, which led to a number of initiatives being implemented
by Queensland Health. This report builds on the culminating Re-Birthing report by ensuring
representation from previously under-represented groups including Indigenous consumers and their
care providers as well as rural and remote consumers and maternity care providers.
Between March and June 2010 representatives from the Queensland Centre for Mothers & Babies
travelled throughout regional, rural and remote Queensland to explore the maternity care
experiences of these groups.
The following is an overview of the consultations that were undertaken during this time, including
recommendations based on our findings.
Aim
The aim of the „Roadshow‟ was to seek representation from previously under-represented groups of
maternity care stakeholders in Queensland. In addition to this we sought to meet the following
objectives:

To promote the activities of the Queensland Centre for Mothers & Babies (QCMB)

To access and develop relationships with particular target audiences (i.e., rural, remote and
Indigenous consumers, maternity care providers and broader stakeholder representatives)

To encourage feedback on stakeholders needs and expectations of the QCMB

To enable a mapping of consumers‟ and clinicians‟ maternity care needs

To identify sites for future potential collaborative research projects and activities
Towns visited
A total of 31 towns and 37 facilities were visited, 27 of which offered birthing services.
Roadshow1:
Cairns
Innisfail
Mareeba
Tully
Georgetown
Hughenden
Atherton
Croydon
Richmond
Charters Towers
Townsville
1.
Roadshow2: 2.
Mt Isa
Cloncurry
3.
Barcaldine
4.
Woorabinda
Blackall
Biloela
Longreach
Emerald
Winton
Blackwater
Mackay Rockhampton Proserpine
5.
Roadshow3: 6.
Millmerran
Toowoomba Dalby
7.
St George
Goondiwindi
Roma
Miles
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Sample/Target groups
Representation from all maternity care consumers and providers were sought. These included:
 „Mainstream‟ pregnant, or recently pregnant, women

Indigenous pregnant, or recently pregnant, women

„Special-focus‟ women (e.g. culturally and linguistically diverse women, women who
experience perinatal loss, young women, women with low income, women with multiple
births)

Community and non-government organisations

Maternity care providers and managers

Community child and family health services

General Practitioners (GPs)

Retrieval and outreach health care professionals

Aboriginal Medical Services (where appropriate)
Resources used
Factsheets:

2010 Road show and overview of QCMB

Survey

Website

Birthplace
Pregnancy book
QCMB Consumer Leaflet
QCMB Introductory Brochure
HABIQ Book topic checklists
HABIQ Pilot Survey
QCMB Sign-up forms for consumers and carers/stakeholders
QCMB Thank you cards
Powerpoint presentation (electronic and via Flipchart)
Methodology
In response to local community needs, consultations occurred in a variety of different ways.
Attempts were made to identify a local consumer „champion‟ through consumer networks (e.g.,
Maternity Coalition, Australian Breastfeeding Association) or local organisations (e.g.,
Playgroups, Child Care Centres, Community Child Health). These groups proved invaluable in
the marketing of the consultations and advising on venue, caterers and other local
requirements.
In addition to conducting pre-organised consumer consultations, informal discussions were
held with women in parks, coffee shops and supermarkets. Having two to three „out of towners‟
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wearing „Queensland Centre for Mothers & Babies‟ t-shirts with „www.havingababy.org.au‟ on
the back prompted many interested responses and QCMB staff responded to this interest by
striking up conversations, explaining the purpose of being in town, and enquiring about their
own or their families experiences of maternity care. These impromptu consultations provided
us with a rich mix of information from consumers who may not traditionally present to preorganised consultations.
Consultations with maternity care providers were arranged through the local hospital,
community child and family health centre and local medical centre/s. Hospital consultations
were arranged to coincide with handovers between the morning and afternoon shift to
maximise access to clinical midwives. Lunchtime was identified as the best time to try to see
General Practitioners and Community Child health nurses, who either attended the hospital
session or nominated an additional time and venue that suited the staff. Consumer
consultations were held in a range of child friendly venues such as parks, to community halls,
churches and government or non-government buildings.
Information from the consultations were recorded by hand as field notes and transcribed onto a
computer at the end of each day. Individual reports from each consultation were sent back to
QCMB each evening to inform the development of activities such as the Having a Baby in
Queensland (HABIQ) Survey, Website and Book.
Data were analysed using thematic analysis and are presented under the following 12
categories.
Perceived benefits of Birthing in a rural facilities
Information sharing
Transfer and referral
Midwifery care
Pregnancy care
Labour and birth care
Postnatal care
Attitudes of staff
Care for Aboriginal and Torres Strait Islander women
Travelling away for birth
Collaboration and integration of care
Private facilities
Results
The following table provides a breakdown of consultations
Consumer/stakeholder consultations
Mainstream women
„Special-focus‟ women
Culturally & Linguistically Diverse
Indigenous
Young
Men (fathers)
Grandparents
Stakeholders (e.g. ABA, SANDS, Maternity Coalition, doulas)
Support Workers (including Indigenous)
Expos – Cairns, Millmerran
Shopping Centres – Mackay, Townsville
TOTAL
Carer consultations:
Midwives
Obstetricians:
General Practitioners
37
285
23
21
20
8
6
40
29
120
55
605
86
156
11
24
35
Child Health Nurses
Registered Nurses
Enrolled Nurses
Indigenous health workers
Managers
General health staff
Specialists
Allied Health
RFDS
Other (nurse educator etc)
TOTAL
45
25
8
26
34
11
2
5
3
3
353
TOTAL consultations events: 123
TOTAL individuals consulted: 958
Findings
Perceived benefits of birthing in a rural hospital
Women reported:
That they could often stay longer postnatally in rural and remote facilities
compared to regional or urban hospitals. Women considered the care in rural
facilities less “factory-like”.
The care is seen as much more informal – visiting hours more flexible, sometimes
husbands can stay over.
Staff are seen as more supportive of breastfeeding and promoting close contact
between the mother and her baby („they let me fall asleep with my baby‟)
The food is fresh, not prepacked!
More freedom to walk around with their babies, go outside, breath fresh air.
Women reported being surprised when they or their friends birthed in regional
facilities and told they were not „allowed‟ to take their baby outside or off the
ward.
In general, women reported that they felt supported by their community and care
providers and valued being able to share information about being pregnant
and caring for a newborn within their small community. However, other women
felt they lacked confidentiality and were uncomfortable sharing information
about themselves because they feared local gossip
Pregnant women are known in the community and there is a general feeling that
everyone helps new mothers– “they hand over baby stuff and say, come and
drop by, I‟ve got a bassinet for you”.
The reviewer reported:
There are some rural facilities with a very active maternity workforce and this is
evident in the experiences women have. The consultations in towns that had
continuity of midwifery care models were well attended and women reported
extremely high satisfaction with these services.
In other services where more traditional, fragmented models were offered
midwives appeared to be lack confidence and feared birth. Such attitudes in
staff were reported by women who either reported dissatisfaction with the
service in their home-town or had by-passed these systems and travelled away
to give birth.
There were some examples of models (e.g., Toowoomba) that provide support for
private midwifery and private midwives in the community more explicitly.
Toowoomba and Dalby both reported the existence of transfer policies and
collaborative case review processes between hospital staff and private
midwives. They were also actively preparing for the November rollout of MBS
access to midwifery care and its potential impact on public health services.
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Information Sharing
Information sharing across and within agencies is variable, though generally
limited. Women reported being frustrated when information was not shared
between facilities. Some women reported having to have bloods retaken and
commented on the waste of public money to do this (as well as the discomfort
of having unnecessary painful procedures) because one provider did not share
information (e.g., blood results) with another.
The hand-held antenatal record (HHR) is not being used consistently by health
care providers in rural or regional Queensland. One woman reported „the
hospital midwives gave me one (a HHR) and when I gave it to my GP to fill out
he tore it up in front of me!‟
Women who had access to the HHR highly valued it.
The reviewer reported:
The content of the discharge summaries is generally insufficient and could be
easily improved. Largely the information provided consists of key medical
information (e.g., mode of birth, date of birth, birth weight). Minimal information
is provided about the woman‟s psycho-social situation, including EPDS scores,
history of previous depression or other social risk factors.
Consistency in the provision of discharge summaries is also problematic. Most of
the public hospitals attempt to provide discharge summaries but this is
generally only provided to GPs or community child health services, and not to
non-government agencies (NGOs) such as Aboriginal Medical Services
(AMSs) or Family Support services. This is problematic as it is these agencies
that tend to provide care for some of the most socially disadvantaged women.
The universal postnatal contact has funded midwifery positions in some
communities. Many hospitals reported sending information through to the
midwife providing the universal postnatal contact, but not the local child health
service. This makes it difficult for child health services to continue care.
Many public facilities provided discharge summaries/referrals for „high risk‟ women
only. Child health services expressed a desire to have discharge summaries
on all women.
Private facilities provided no discharge summaries and were frequently criticised
by health staff for not providing any information to community health, GPs or
NGOs.
Many health providers in rural areas reported not being aware that their clients had
returned to their communities until they either drop in or they „see them at the
shops‟
There is minimal evidence of case conferencing across agencies to support
families with complex needs. Where case conferencing is implemented (e.g.
between Mareeba hospital and the AMS), staff report these discussions are
highly valuable and result in more women remaining engaged in the system
and fewer women „falling between the cracks‟.
The women reported
Women who have previously had a stillborn baby or miscarriage(s) reported
needing to re-tell each of their carers their maternity history because this
information was not recorded on their hand held record.
Not all women are being offered a copy of the hand held record when they
surrender the original when admitted in labour. Many women were not aware
that they were entitled to receive a copy. Furthermore, of those women who
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were aware and wished to receive a copy, some were refused a copy when
they requested it.
Recommendations:
Develop guidelines around comprehensive discharge summaries that are provided to all
Community child health centres, GPs (where appropriate) and AMSs (as appropriate) for all
women.
Discussions with private facilities will be required to facilitate this within the private sector.
Case conferencing should be established in all facilities and involve GPs, midwives, OBs child
health nurses, allied health, AMS staff (where appropriate).
All women should be offered a copy of their hand held records on discharge from maternity
services. This is mentioned in the HHR brochure and should result in women asking for a copy.
There needs to be a way of indicating previous perinatal loss on the hand held record eg use
of a tear drop sticker used previously
Transfer and Referral
Women and staff reported:
There are variations on what services use to guide referral of women to higher
level services: some use locally developed protocols, others use the Australian
College of Midwives Consultation and Referral Guidelines. For other women,
the nature of the referral process is at the discretion of the obstetrician at the
time.
Many public hospitals insist on a referral from the GP to „book in‟. For example, in
Hughenden women can self refer to the hospital for antenatal care. Women
are required to travel to Townsville to birth and generally „book in‟ to one of the
Townsville hospitals around 20 weeks. The Hughenden midwives are not able
to provide the referral nor can the women self refer. Instead the woman must
make an appointment to see the only GP in town, and pay a consultation fee to
get the required referral. This results in inefficiencies of time and money for
women and undermines the local midwifery staff. Palm Island women however,
can be referred for booking in by the Palm Island midwife, to the same hospital
in Townsville that the Hughenden women cannot.
In some rural towns, the midwives are not able to order blood tests or scans and
instead must refer the woman to the GP to do this. In other towns, midwives
can use request forms as standing orders or pre-signed by the doctors. Nurses
and midwives in some rural areas have reported resistance or refusal by GP‟s
to sign pathology or ultrasound request forms.
Facilities that did not have consistent medical backup appeared significantly
disruptive for women and many women reported avoiding the local facility
altogether because they could not rely on them being open if they needed
them.
Gestational age at booking in was inconsistent across facilities. Some facilities
(e.g., Innisfail, St George) encourage booking in early (by the end of the first
trimester) so that women could be offered psycho-social assessment (e.g., the
„Safe Start program‟) and access midwifery care. Other facilities (e.g., Cairns)
do not typically accept women until after 20 weeks gestation. In some cases,
variability in timing of booking in visit appeared to be attributable to the
preferences or practices of the local GP. Women and hospitals reported that
some GPs fail to inform women they can receive pregnancy care at the local
hospital. Rather women reporting being „told‟ to continue coming to the GP
until as late as 30 weeks gestation.
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There are resource implications if women book in early. For example, women who
book into the hospital before 18 weeks may choose to have ultrasound
scanning that would have otherwise been sought through the private sector.
Similarly, if the 18 week scan diagnoses a fetal abnormality, counselling
services would be provided through the public facility, again at additional cost.
In many towns, ultrasound and pathology services are only provided by private
services. This lack of publically funded services disadvantages women who
are unable to afford private services. Some of these women report not having
any tests or scans, while others report travelling (sometimes at their own
expense) to bigger cities to access these services.
There are also variations on how much women pay for maternity care. One
woman reported not presenting to her GP for pregnancy care until after 20
weeks because she couldn‟t afford the consultation fee. Some GPs bulk-billed
but most did not. Many women were not aware that they could receive
maternity care at the local hospital and paid for care at the local GP.
Some women reported high levels of dissatisfaction with processes when babies
are transferred for higher level care. For example, one woman we spoke with
birthed twins in a rural facility at 33 weeks gestation. Her babies were
transferred by RDFS but the mother reported not being „allowed‟ to accompany
them. Her husband reported being very stressed driving her to the regional
town a few hours after birth after neither had slept all night. When they arrived
at the referral hospital they were told the mother could not have a bed as she
was „not admitted‟. As she was initially meant to be a private patient she was
admitted to the private hospital but had to travel by taxi each day to the public
hospital to see her babies, as her husband had to take the car home to care
for his two other daughters and manage his cattle station.
Recommendations:
Support early booking in to hospitals to give women access to psycho-social assessment and
access to midwifery care.
Women should be able to self refer to hospitals
In rural areas nurses and midwives should be supported to order bloods, tests and scans AND
refer women directly to birthing facilities.
Develop strategies to ensure rural women are not financially disadvantaged for routine
components of care (blood tests and scans).
Standardise the use of Consultation and Referral Guidelines such as the ACM ones (though
new ones are being developed through NHMRC so maybe wait for those ones to be developed
before making a policy).
Midwifery care
The women and staff reported
Some facilities had not heard of the Rural Maternity Initiative (RMI) or thought that
was only for facilities that provided birthing services. There are many
opportunities for midwifery care to be strengthened during pregnancy and post
birth in non-birthing facilities
Resistance or a lack of interest from middle managers and DONs were often
reported to be barriers to the implementation of innovative midwifery models.
The most noted comment from people in these positions was that “midwives
are required for general nursing duties”.
In some rural/regional facilities doctors are called in to be present at all births, a
practice that differs from the practice in other rural or urban centres. Some
39
women/midwives/doctors raised concerns that this practice was unnecessary,
and was an inappropriate use of resources.
Private women also lack access to information around pain relief in labour etc.
Some private obstetricians employ midwives in their rooms, and women
receiving care in this way report it to be highly valuable. The trend towards
private obstetricians employing midwives can be expected to increase
following rollout of the MBS rebate for midwifery care from November 1st.
Some hospital staff reported that some GPs tend to act as the gatekeeper of
maternity care, and appear to have a lot of influence on women‟s access to
midwifery care and other services. Women frequently reported not being told
by GPs that they can access midwifery support at the local hospital, or that
there is a caseload model available at the next town. We were unable to
ascertain whether GPs lack knowledge themselves about these services, lack
time to share this information with women, or actively choose not to share this
information with women.
Early discharge programs are largely unavailable to women in rural and remote
areas. Women either stay in the hospital until four or five days post partum or
they are discharged home without any professional support. In the
communities that did not have well resourced child and family health services,
women reported this was particularly stressful, particularly women having their
first baby and women living out of town on stations.
Many facilities supported the implementation of midwifery and caseload models of
care but said they could not implement such models themselves within existing
budgets. This contrasts with other facilities (e.g., the Mater Hospital) who have
implemented such models without additional funding.
Services for women in rural and regional centres where continuity of midwifery
care was available were highly praised and highly valued. These women
reported getting the „Rolls Royce‟ treatment, in contrast to what they believed
was the lower quality, more fragmented models that most women experienced.
The reviewer reported
Rural and remote women are significantly disadvantaged with regards to a lack of
access to midwifery care and the social and emotional assessment and
support that usually accompanies that care.
In remote areas, the RFDS provides outreach services of doctors who provide
pregnancy care but this appeared to be very clinical in nature with only
physical checks offered. The RFDS also provides outreach child and family
health nursing services that provide some support in the postnatal period,
though this seems focused on the child and also limited to „baby weighs‟ and
immunisation services. The RFDS currently do not provide any midwifery
outreach service with the exception of Cairns but these midwives are provided
from the hospital, not RFDS.
Rural women are even more disadvantaged because they do not receive RFDS
services and may only have the option of one GP to provide all care through
pregnancy and the postnatal period.
There are some cases of innovative models of midwifery care. For example,
Hughenden Hospital have recently commenced offering women care from a
known midwife during pregnancy and in the postnatal period, regardless of
where they go to have their baby (e.g., public or private facilities).
.
Some facilities with RMI funding clearly did not have the infrastructure, leadership
or stability to implement new midwifery models effectively. Some project
officers did not have the necessary skills or experience to effectively implement
midwifery models.
40
Whilst it is important to acknowledge the difficulties managers have in filling
nursing positions, midwifery care will continue to be compromised when
midwives are rostered on as general nurses.
For many years midwives have been restricted to bio-physical care in the
antenatal, birth and immediate (2-5 days) postnatal period. Currently, service
planning does not appear to take full advantage of midwives‟ capacity to
effectively support women‟s broader social and emotional wellbeing across the
full perinatal period.
Many of the midwives who were not involved in birthing appeared to have negative
perceptions of birthing women – one midwife reported that „women need to
know that birth is dangerous‟. The confidence and knowledge of many of the
midwives in the rural facilities would benefit from further development.
Recommendations:
All women in Queensland should have access to midwifery care – this could be through the
local hospital, outreach services or telephone/video conferencing support.
Include continuity of care models for rural women who must travel away to birth (eg based on
the Hughenden model). This involves share-care with the regional hospital where local care is
provided by a known midwife and is then referred to either a private doctor or a known midwife
at the referral hospital. Postnatal care could then be continued through the same midwife back
at the local service.
Rural midwives should be offered professional development and up-skilling through programs
such as MIDUS through CRANAplus.
Senior midwives with experience in implementing midwifery models are necessary to assist
facilities funded through the RMI. This needs to be onsite initially (through RMI funding) but
also continued through „Clinical Midwifery Consultant‟ type positions who would be located in
regional centres such as Townsville or Mackay but offer clinical leadership and support across
the district.
Regional hospitals should become more involved in the support of rural midwives or the
provision of outreach midwifery care to rural and remote centres. Cairns currently provides this
service to some remote communities in Cape York, whereas most referral facilities do not.
Regional staff could also provide mentoring or telephone support to smaller facilities.
There is also the opportunity to offer women care by a known midwife when they travel into the
regional centre to await birth. This model is currently being offered in the Northern Territory for
remote Aboriginal women and is being positively evaluated.
Where midwifery care is available community marketing and promotion of the service (both
locally and state wide) would improve access for women in rural areas.
Develop guidelines to introduce caseload models within existing budgets.
It is timely for Queensland Health to consider the potential increase of demand on midwifery
st
care post Nov 1 , given the rollout of the MBS rebates for midwifery care at this time. It is
believed that private women currently accessing care from a private obstetrician because of
continuity may change to access private midwifery care – this care will result in an increase in
public hospital births, and will put increased demand on public facilities
Pregnancy care
The women and staff reported:
There is inconsistent ordering of antenatal tests based on individual doctors, with
women and midwives reporting that some GPs do not offer women all the tests
Queensland Health recommends. Similarly there is duplication of tests when
41
public facilities repeat blood tests when pathology results are not provided by
the private provider.
Very few rural and remote women have access to ultrasound scan for nuchal fold
measurement. This was mainly due to the lack of scanning services locally and
the costs incurred to travel to the regional facility to access it. Many women,
however, were not told about the test. There appeared to be an assumption on
behalf of care providers that difficulties for women in accessing the test
precluded providing information about the test.
There is a lack of consistency in the availability and quality of antenatal classes
across Queensland. Many women were not offered any form of structured
antenatal education. Others accessed education but complained they were „old
fashioned‟ and not useful.
Women who were offered a tour of the maternity ward highly valued this
opportunity to know where they would be having their baby.
Some of the practice nurses (who are not midwives) are providing pregnancy care
as per Medicare Item 16400 (“Antenatal Service Provided by a Nurse, Midwife
or a Registered Aboriginal Health Worker”). Many of these nurses expressed a
lack of confidence providing this service care due to lacking the skills and
knowledge to do so properly. The provision and promotion of local midwifery
services would go some way to addressing this.
The reviewer reported:
Women receive pregnancy care from a range of providers including: public
midwifery via the hospital; GP/RFDS doctor with travel to the regional facility
for scans and birth; shared care between the local GP and the local hospital;
and, shared care between the local GP/midwife and the private obstetrician at
the regional facility. Communication between these providers and facilities is
generally poor (though may improve following the distribution of the statewide
Pregnancy Health Record).
There is a lack of consistency in the use of psycho-social and depression
screening tools (including the EPDS) across rural areas. Some women are not
being offered the EPDS at all, and many women are being offered no social
and emotional assessment or support during pregnancy or early parenting.
Some sites are yet to implement the Safe Start Program. Other sites have
implemented the Safe Start Program but are not universally applying it as it is
designed to be used.
Recommendations:
Facilities should be supported to fully implement Safe Start and ensure all women are offered
psycho-social assessment.
Antenatal education guidelines should be developed to support evidenced based and effective
programs are available to all women.
Opportunities for outreach ultrasound facilities should be explored with private providers.
Labour and birth care
The women and staff reported:
There were many requests from women and midwives to have a large bath or pool
available for either labouring and/or birth. Very few rural facilities offer women
water immersion as a form of non-pharmacological pain relief, despite good
evidence to support its use. Concern among many doctors and some midwives
related to the use of water immersion during labour was due to beliefs that
42
offering water immersion for labour may lead women to want water immersion
for birth. Rockhampton is currently designing new birthing rooms and it was
reported that „the doctors are not allowing baths to be included‟.
Attitudes of midwifery staff, both positive and negative, was the most commonly
mentioned aspect of care in labour and birth mentioned by women (see
Section 8 below).
Most women accepted that there were limited services in rural and remote areas.
Where birthing services were provided, the inconsistencies in medical support
were problematic and many women (e.g., in towns like Charters Towers) were
unaware that the local hospital provided low risk birthing services.
Caseload midwifery models, such as Mareeba and Goondiwindi, were highly
valued by both women and midwives. Women who experienced care from a
primary midwife across the perinatal spectrum praised the dedication of the
midwives and reported high levels of satisfaction in all aspects of their care.
They reported the care was „individualized‟, „professional‟, „rewarding‟ and
„empowering‟.
Most facilities did not believe it would ever be possible to offer birthing services
based on midwifery care alone (ie without the presence of medical backup).
Staff reported that without medical backup and the capacity of the service to
deliver babies by caesarean sections, facilities could not allow women to birth
there. Lack of provision of VBAC in low risk facilities (where OT facilities are
available) is resulting in many women choosing to have an elective Caesarean
Section because this was available in their local facility, and negated the need
to travel to a regional hospital to attempt VBAC. The reason given to women is
lack of pathology services – however elective caesarean sections in the local
facilities are possible. (Reviewers comment: It could be argued that recurrent
uterine scarring through repeat c/sections carry a much greater risk to the
woman than providing VBAC services in low risk facilities).
Some facilities do routine CTGs on all new admissions, despite current evidence
and statewide policies to the contrary – midwives appeared to support this
practice and reported this was because they are „in the country, not the city‟.
Midwives reported that some doctors (both GPs and QHealth doctors) commonly
undermined their attempts to practice using evidence. For example one
midwife told of a local doctor who does not do fetal hearts in second stage of
labour – when the midwives try to (to listen to the fetal heart) he says to the
midwives, in front of the women, „don‟t do that‟ and says to the women „they
get that out of nursing textbooks‟. There were other reports of doctors rupturing
membranes in their rooms and sending the women to the hospital and other
doctors doing unnecessary interventions such as social inductions at 37
weeks.
Women reported being told a range of information around the „safe‟ number of
Caesarean sections they could have. One woman said her doctor told her she
couldn‟t have more than two Caesarean sections. Another woman was told
„none after 3‟ whilst a third woman was having her fourth caesarean section at
her local low risk facility and when asked what information she was provided
about her impending operation, she replied „none‟.
Many women reported their wish to have their partners stay with them in hospital.
This was the most important aspect of care. Most places did not allow partners
to stay over, with shared rooms being given as the most common reason. In
the facilities that could offer partners overnight accommodation, this was highly
valued by women and their partners.
The reviewer reported:
Some facilities do not practice evidence based care. For example in one facility,
midwives are doing second hourly Vaginal Examinations, and two midwives
43
must be on site for all women once they are 5cms dilated. The staff reported
that this was at the insistence of the local GPs in response to two adverse
events that occurred the year before. However there is no evidence that either
of these two policies will reduce the likelihood of another adverse event and
staff could not explain the rationale behind the practice other than to say the
„doctors were insisting‟.
Recommendations:
VBAC should be offered to appropriately assessed women in low risk facilities.
Birthing services should be offered/tested in primary care units (with no available surgical
services) supported by established transfer and referral pathways.
Water immersion should be offered to women in labour, particularly in new or renovated
facilities.
Facilities should be supported to develop protocols based on evidence. For example, two hour
Vaginal Examinations is not supported by the evidence.
Upskilling should be provided for rural midwives through short courses (eg CRANAplus
MIDUS, MaCRM, ALSO).
Postnatal care
The women and staff reported:
Rural facilities are generally much more flexible with how long women can stay in
hospital after birth compared to the larger regional facilities. Midwives reported
the women can stay „as long as they want‟ – they believe if a bed is empty it
costs the service no extra to have a postnatal woman occupy it.
Some of the postnatal beds were poorly positioned (eg close to the „nurses‟
station‟ or alongside mental health patients). In these instances women and
staff requested capital funding to provide more appropriate postnatal space for
women.
Women reported inconsistencies across facilities regarding the level of freedom
they had to take their babies out of the ward area. In regional facilities, staff did
not permit the women to walk around hospital gardens or take baby out of
hospital building.
Women who birth away at the regional facilities have the option of coming back to
the local hospital for postnatal care but most women do not take this option.
This is because many of the local facilities don‟t promote the service or women
prefer to go home. Unfortunately many women go home with minimal support
and then struggle with breastfeeding and parenting skills.
Many women reported that they did not have a 6-week check, with some women
saying that they did not know they should have had one. Others went to their
GPs but reported that sometimes this was not appropriate due to gender and
other issues. Of the women who went to the GP for postnatal support they
reported this was purely physical with no opportunity to discuss social or
emotional needs. Many women reported it was „not the doctors job‟ to listen to
their problems. When asked whose „job‟ it was, some replied their husbands,
and others reported their midwife or child health nurse filled this role.
Child health services are extremely variable across the state with some services
reporting that they see women „weekly for eight weeks‟ and other women
being told on discharge from the hospital to book in for their 8 week
immunisation as soon as they get home as the waiting list is eight weeks long.
44
These women therefore are not offered professional help around breastfeeding
or sleep and settling issues in the first weeks of parenting.
Many child health services report no increase in human resources in many years,
in spite of increasing population numbers and the greatly expanding role of the
child and family health nurse.
Parent/mothers groups that are offered are usually structured with „special‟ topics
each week. Women reported that often the topic is not relevant to them at that
time (eg introduction to solids when their baby is 2 months old) and requested
more flexible groups or topics that are more age appropriate.
Psycho-social assessment is not universally offered to women in the postnatal
period.
Immunisation services are provided by some child health services but not others.
In child health services where immunisations were offered, both the women
and the child health nurses spoke of the benefits of having one provider
provide immunisation as well as checking the infant‟s development and
supporting the parenting skills and social and emotional well being of the
mother and wider family.
Practice nurses in GP clinics frequently commented on the lack of postnatal
services for mothers, particularly in the Central West district. One nurse (who
was not a midwife or a child health nurse) reported „they come in very
distressed – I try to help them but I only really can do that as a mother myself,
not as a health professional‟. This nurse was not aware of resources such as
13Health or the Raising Children Website.
There is a common perception that rural towns are supposed to be friendly close
communities but many women and service providers reported some women
are very socially isolated. Women such as miners‟ wives and station-workers‟
(„ringers‟) wives had a lot of problems meeting other mothers and receiving
social support. Some of these women are quiet transitory due to their partners
work.
13Health was reported to be widely used by women and families. Some women
said it was very useful, others said the Brisbane based nurses did not
understand the issues for rural and remote women. Others said it was too
medically focus and they wanted to talk to someone about breastfeeding and
sleep and settling. Some women rang at night and said there were no child
health nurses available, only nurses wanting to know if the child was sick.
.
Women and health staff reported the widespread lack of breastfeeding support for
women in most rural areas. There are very few lactation consultants or
breastfeeding counsellors available. Women, midwives and child health nurses
believed that many women give up breastfeeding in the first few weeks and
months of life because they cannot access this type of support.
There was also no evidence of Family Support funding in many rural facilities. This
is in spite of high levels of disadvantage in some areas (eg Tara) where many
families live in rural blocks with no town water or electricity. Local child health
services reported they were not staffed adequately to offer support to these
vulnerable families, even though many of the families are known to child
protection agencies.
The reviewer reported:
Postnatal care is another area where rural and remote women are disadvantaged.
The mean discharge time at Townsville hospital is 1.6 days for women having
a vaginal birth and 2.3 days for women experiencing caesarean sections.
These women are sent home to their home towns or properties, often without
the local hospital or child health centre being informed.
45
Universal postnatal contact funding appears to be working very well in some areas
and not at all in others. In some places the funding has gone to the hospital
and the midwives provide the service, other places a midwife sits in the child
health facility and others again where midwives and child health nurses work in
collaborative models. In some consultations, child health nurses reported that
the midwives were supposed to be seeing women until 6 weeks but they didn‟t
have the time or the skills and the child health staff felt like they were being
excluded and found it hard to engage the women after 6 weeks
Parent/mothers groups are not universally available to rural or remote women and
are frequently requested by women who cannot access them (and highly
valued by women who could). The Child Health services who did offer them
tended to offer them after 2-3 months of age, despite good evidence that
women need support the most in the first few months of parenthood.
There appeared to be little opportunity for women to talk to other women in
postnatal wards across Queensland. In the larger regional hospitals women lie
in bed behind drawn curtains. Models to promote mobilization and peer
support could be encouraged by communal dining rooms. This is successfully
done in interstate maternity facilities such as the Royal Prince Alfred in
Sydney.
Developmental assessment checks are not standardized and the checklist used
on the QHealth forms is not known to be evidence-based (ie minimum
specificity and sensitivity of 70% as recommended by NHMRC). Very few of
the professional staff knew about developmental assessment tools that
incorporate parent-elicited concerns eg PEDS or Ages and Stages. These
tools are well known and used in all other states and territories in Australia
The quality of postnatal care varied – few mothers, child health nurses or midwives
reported discussing concepts such as infant attachment (using tools such as
Circle of Security etc), infant cues and communication methods. Rather, in
general the focus was on traditional weighing, measuring, and developmental
checks. Some of the child health nurses reported that they had not had the
opportunity to undertake professional development updates on child health
topics. Others believed the current child health courses available in
Queensland (graduate certificate in child and youth health) did not suitably
prepare nurses and midwives to practice effectively.
Recommendations:
A formula or index needs to be established to determine what is the appropriate level of
service per birthing population weighted by vulnerability and isolation.
Parenting groups such as the EarlyBird program currently offered to women in NSW should be
made available to women in Queensland. This program is offered to women from birth to 8
weeks, is unstructured and promotes peer support and knowledge sharing amongst women.
Psycho-social assessment (and the EPDS) should be offered to all women antenatally and at 6
weeks post-birth as per national (beyondblue) guidelines.
The educational preparation of child health nurses requires review.
Communal dining rooms should be provided in postnatal wards to encourage women to get out
of bed and talk to other women.
13Health should be staffed by qualified child health nurses 24/7
Support from Lactation Consultants via videoconferencing should be trialled
Child health and midwifery services should offer education around attachment, infant cues,
influences on stress on the developing fetus and infant etc.
46
Attitudes of staff
The women and staff reported:
Poor staff attitudes were mentioned in all consultations with women across all
towns. Women referred to the „lottery‟ of whether they would get one of the
„nice‟ or „good ones‟. In one small town we were told of the „dragon nurse who
bragged that people are scared of her‟. Another woman told us the midwife
made her feel so inadequate when she asked questions in early pregnancy
that she did not return, had no antenatal care and birthed in New South Wales
where she had family support. In another town women reported receiving a
very unsatisfactory level of service through the town‟s only GP who had been
there a long time and was very „old fashioned‟. One father described a midwife
who „went off her tits‟ when his labouring wife with 33 week twins presented at
the local facility. This facility provided low risk birthing services and was staffed
by midwives and had medical back up available.
Many women reported conflicting advice from the midwives. Some midwives were
considered helpful in providing information, others seemed to explicitly avoid
providing information/options/explanations or enforcing their own value
systems.
The reviewer reported:
Staff at the facilities who did not provide birthing services were very fearful of
labouring women „appearing‟ at their hospital. They showed no empathy for
women who either avoided transfer out for birth or who presented in premature
labour. These women reported being „treated like children‟, being shown no
respect or being victims of racism and prejudice (see Section 9 below).
Recommendations:
Strategies should be developed to address poor staff attitudes
Care for Aboriginal and Torres Strait Islander women and their families
The women and staff reported:
Lack of models where Aboriginal women can be cared for by AMS staff in labour
and birth
Indigenous specific Medicare items (eg children‟s checks, adult checks, antenatal
checks and postnatal checks) are perceived by some mainstream services to
be a „revenue raising activity‟ for Aboriginal medical services. Some hospital
staff believe that the AMS „keeps‟ women going to the AMS and not the
hospital because of this. This leads to women not being referred to the hospital
for booking in and reduced opportunities for Aboriginal women to access
midwifery care when this is not available at the AMS. There is also concern
that some women are being over serviced because of „double dipping‟ with
different services doing the same activity.
Most Aboriginal women do not appear to get offered the hand held records (HHR)
– AMS staff believed the hospital did not give Indigenous women the hand
held record– though one AMS midwife admitted she had a „drawer full of them‟
but did not give them out. None of the Aboriginal women we spoke to had
been offered the HHR.
Aboriginal women are commonly excluded from continuity of care or midwifery
models because of their risk status. This further excludes them from the
47
benefits of developing relationships and trust with providers and experiencing
intrapartum care from a known provider.
Women with medical complications during pregnancy must travel to the regional
centre for obstetric care. One obstetrician in Rockhampton highly valued his
previous role of travelling monthly to a remote Aboriginal community to provide
outreach care. He believed it provided better care to women but also gave him
the opportunity to learn from and understand the wider social and
environmental issues experienced by the women under his care.
There were many reports of Racism in QHealth facilities. There was a common
perception by Aboriginal people that mainstream health staff look down on the
Aboriginal women. The Aboriginal women recognise this and reported
dissatisfaction in going to the hospital. Similarly non-Indigenous families
described perceived inequities between what they were offered compared to
Aboriginal women and families. Several women and men reported „if we were
black we would have been flown out in a helicopter‟ or „the Aboriginal women
get five star hostel services, but we get don‟t get anything‟.
Aboriginal services and women reported that mainstream facilities just didn‟t
understand or respect the different ways Aboriginal people do things or the
environment to which they are being discharged. For example, in
Rockhampton Aboriginal women who live at Woorabinda can get discharged
on a Friday night with no transport arranged to take them home and no
communication with the Woorabinda health centre of their impending arrival
back at the community.
Aboriginal women repeatedly reported their distress of having to travel away to
give birth and their desire to birth in their local communities. Barriers to birthing
in poorly resourced rural and remote areas were noted by QCMB staff.
However, there are several sites in Queensland that would be appropriate
„test‟ sites for a „birthing on country‟ project.
Accommodation is a significant issue for Aboriginal women – there are some good
examples of Aboriginal hostels (eg Mookai Rosie‟s in Cairns) but in many other
regional centres the women are not well supported when waiting in the
regional towns to have their babies. This is not only an issue for Aboriginal
women but the Aboriginal population is more significantly affected. See
Section 10 below for more details.
Women who „hide‟ from the system and end up birthing at the local birth centre are
commonly still transferred in after birth, even in the absence of complications
or risk factors. This is perceived by the Aboriginal women as „punishment‟ for
not relocating to the regional centres when they were supposed to.
The reviewer reported:
Aboriginal women continue to be the most disadvantaged group of women
accessing maternity care. There are increasing opportunities for national
programs being made available and taken up by Aboriginal Medical Services
(AMSs) but this does not include care in labour or birth and there is little
communication between the services offering these nationally funded
programs and the local public health facility.
Nationally models exist where staff from Aboriginal medical services have
developed memorandum of understanding (MOUs) with the local hospital
where AMS midwives can accompany Aboriginal women into the hospital to
labour and birth. (eg Congress Alukura in Alice Springs). This model is not
currently available in any Queensland facility.
48
Recommendations:
Programs should be developed that provide continuity of midwifery care models that include
intrapartum care (eg Indigenous specific Midwifery Group Practices)
MOUs should be established between AMSs and public facilities to allow Aboriginal women to
receive intrapartum care from a known AMS-employed midwife.
Strategies should be developed that promote communication between AMS staff and QHealth
maternity services.
Racism in QHealth facilities should be addressed through Cultural Competence and Racism
awareness education programs (eg Dealing with Difference).
Services should explore opportunities to provide outreach care outside the hospital in venues
or facilities the women find more acceptable.
Services should explore avenues of federal funding to employ Aboriginal health workers, and
liaison officers to support Indigenous clients.
Opportunities should be explored to support Indigenous doulas.
Discharge planning should be done by people who understand where women are being
discharged to. More thoughtful discharge planning is required.
Case load models should include women of all risk levels. Continuity of care models should
also include dedicated medical staff on each team.
Birthing on Country projects should be tested and rigorously evaluated.
There should be a policy that women and babies born in small (non birthing) facilities who do
not have medical indications should not have to be transferred to the regional facility routinely.
Travelling away for birth
The women and staff reported:
Accommodation availability is rare and costs are high for rural women and their
families who are required to transfer to larger centres to have their babies.
These women are entitled to PATS (Patient Assisted Travel Scheme) funding
but the difference in the actual cost of travelling away to birth and the
reimbursement received is significant.
There were also variations on who could (or would) assist women to find and
secure accommodation. Some hospital midwives offered this service; at other
facilities women had to arrange their own accommodation. One woman
reported having to change motels six times in the four weeks she was in
Cairns because she could not find a place that had vacancies for the whole
time she needed it (and she didn‟t know how long she needed it and many
places wanted definite dates).
There were frequent requests for a government sponsored maternity specific
hostel in each of the larger regional and urban cities that women and their
families could stay for at a subsidised price.
Women resent when the staff “make you go to XXXX” and “get up you” if they
choose to stay at home or go home while at temporary accommodation.
The women also reported being legally threatened to travel away to have baby –
“I‟ve been told to go to Longreach at 37 weeks otherwise you get fined”.
Staff believe the women were being offered various „incentives‟ (seen by some
women as „punishment‟ if they don‟t take the incentive) to leave town. For
example, in Barcaldine, women are told if they go to Longreach (their local
referral facility that is only 110 kms away) by 37 weeks they get free
accommodation, if they go after 37 weeks they have to pay.
Many women are expected to move to the regional town at 36-37 weeks even
when the town was less than one hour away (particularly in Central District – ie
Blackwater to Emerald, 70kms).
49
The reviewer reported:
Women are being sent out of their home towns at varying times between 34 – 38
weeks gestation. The gestation point at which they are sent appears to be
provider-dependent with the most disadvantaged women being sent by
facilities who don‟t have midwifery staff (e.g. Richmond). The nursing staff
instruct women that they must go as early as 34 weeks when there are no
clinical indications for early transfer. These decisions appear to be driven by
fear. Nurses with no midwifery qualifications report being stressed and
frustrated when women refuse to leave town at 34 weeks gestation.
Evidenced based testing such as fetal fibronectin does not appear to be used in
rural facilities in Queensland. When used on women less than 37 weeks
gestation, a negative result is highly predictive that the woman will not go into
labour within the next seven days.
Recommendations:
Guidelines should be developed regarding what gestation women should routinely transfer to
the regional town (eg 38 weeks unless clinically indicated).
Non-midwives should be offered professional development programs such as the Maternity
Emergency Course for Non-Midwives offered through CRANAplus.
Fetal Fibronectin testing should be made more available to rural facilities.
Collaboration and integration of care for rural and remote women
The reviewer reported:
Relationships between the various agencies and workforces were extremely
variable. Generally speaking relationships between midwifery and medical staff
were good in the rural areas. However there were small isolated examples of
problems between midwives, GPs and other medical staff. Women are aware
of these conflicts, making comments like “[doctor x] is okay but the midwives
don‟t like him‟. Or „some of the doctors are so rude to the midwives, I felt really
humiliated for them‟.
One GP observed the main aspect of collaboration was the building of a
relationship with the midwives – „you can‟t trust someone who you don‟t know‟.
He believed all of the problems with his local hospital were with new midwives
who didn‟t know the GPs.
Another major problem that was perceived by the midwives is the inconsistency in
ideas, opinions and attitudes of different obstetricians working within the same
facility, and the blatant dismissal by some doctors of clinical guidelines.
Some rural towns providers and women reported positive working relationships
between GPs and midwives owing to a shared care model where each
workforce genuinely respected each other‟s contribution to the woman‟s care
and the right of woman to choose which model of care best suited her.
Private Facilities
The women and staff reported
Many of the private facilities reported activities that are not supported by evidence,
particularly around breastfeeding. Midwives in one private hospital midwives
reported that they were very „women centred‟ because they took the babies off
the women at night („they need all the rest they can get. They will learn soon
enough when they get home‟). They also offered to give their babies formula to
give the women a rest. These practices are not supported by state, national or
international guidelines.
50
There were reports by women of private facilities giving formula without consent.
One woman travelled to the Mater in Rockhampton to have her first baby (she
said her GP recommended this because of her age, which was 38). She
reported that her wishes as a mother were not respected - her baby was given
formula and pacifier without her consent, the first bath was done without her
knowledge, and she and other women were not woken to feed their babies
despite requesting that they would be. Other mothers reported midwives
„insisting‟ to remove baby from mother‟s room; or made woman feel
inadequate. One woman said „a midwife said “your baby has flaky skin
because your placenta was inadequate” and [to the baby after a breastfeed]
“that‟s all your mother has got for you”.
Many women in rural towns who were booked in to birth at the regional facility
reported not having access to information both antenatally and postnatally.
Access to information was generally insufficient for woman accessing both
private and public maternity care. However, for private women this was
reported to be a much bigger issue.
There was minimal use of hand held records by private health care providers.
Many private health staff said the women didn‟t want them, but most women
we spoke to did not know they could have them and when we discussed what
they were, they believed they would have been very useful.
Women who accessed private care by medical practitioners (GPs or private
obstetricians) reported the information they received was inconsistent or not
provided. Most were not satisfied with the information they received and they
often had to ask for more information or access it through other avenues such
as books or the internet. Most women reported that GPs did not provide any
information to women at their visits. When we asked GPs or their practice
nurses to show us what information they gave to women on the first visit, the
majority had nothing to show us, or they pulled out a folder with a collection of
very old brochures or typed A4 information sheets.
Some women reported that the GPs assumed the women did not need antenatal
support/information for subsequent births. As one woman said “the doctor said
„well, you‟ve had one before, you know what to do‟.
Other women spoke highly of their service and relationship with their GP. Some
women had known their GP for many years and valued the personal
relationship they had with them and the knowledge that they would continue to
care for their babies as they grew up.
Women told us they choose to go private for the following reasons:
Their GPs recommended it
Because they believed it would be better care
They had private health insurance and they may as well use it on something
because they don‟t use it for much else.
Because that is „what you do‟
Because they wanted to know the person who delivered their baby
Because they didn‟t trust the local public hospital
Because of confidentiality issues of being known in a small town and going
through the local hospital
Because they wanted control over induction/caesarean
Because they wanted to choose their care provider
Potential Future Collaborative Projects with QCMB
 Postnatal support

How information is shared between stakeholders/how to engage private providers.
51








How to implement midwifery models that build on resources already developed by
OCNO
How we can support the MANY women who have unresolved birth issues.
Explore or evaluate models where private obstetricians provide midwifery care such as
the NKC Obstetric Service in Cairns.
Developing capacity in consumers to fulfil their role as consumer representatives.
Determine a formula of staff to client ratio of child health services weighted by
vulnerability.
Test an Indigenous case-load model where AMS midwives take AMS women to the
hospital for labour and birth. Base this on the Alukura model in Alice Springs.
The Rural Birth Index.
Test a model of outreach midwifery support through video conferencing.
Potential consequences of improved access to services for women
Once private women are aware of the outcomes of midwifery care there could be
increased demand on already under-resourced midwifery models. This is
currently seen in the high demand on Birth Centre and other midwifery models
as “word spreads” of the women‟s‟ experiences of midwifery care.
This in turn will further disadvantage vulnerable women as caseload allocations
get booked out before 12 weeks and vulnerable women tend not to access
antenatal care early on in their pregnancy.
Summary
Women living in rural and remote areas continue to be significantly disadvantaged compared
to their urban counterparts in all aspects of maternity care. Women in these areas do
recognise and appreciate the benefits of birthing at rural facilities and some rural facilities are
balancing the provision of safe care with the provision of care that is aligned with women‟s
needs and preferences. In towns where women were able to access midwifery care there was
much greater satisfaction with the service. Women who were receiving postnatal care from the
child health nurses, GPs and/or local midwives were very grateful for the service and felt that
having access to these services made a significant difference for them in their transition to
parenthood (at all levels: physically, socially and emotionally). In response to this situation,
access to midwifery care and postnatal support (both professional and peer) are areas
requiring urgent attention at a facility and State-wide level.
The Queensland Centre for Mothers and Babies and many of the stakeholders we consulted
recognise the significant attempts Queensland Health has made to improve care for women in
rural and remote areas through initiatives such as the Universal Postnatal Contact Visit and the
Rural Maternity Initiative Funding. These initiatives can be further enhanced by engaging the
support of regional referral centres and the provision of clinical leadership positions such as
regional Clinical Midwifery Consultants.
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