At the beginning of the year Counties Manukau Health (CMH) released a report it had commissioned Pacific Perspectives Ltd to prepare on what is working well and where improvements can be made in the maternity care being provided at Middlemore Hospital. The project was specifically focused on the experiences of Māori and Pacific mothers, teen mothers and women of childbearing age who live in areas of high socio-economic deprivation.
The report is called Maternity Care Experiences of Teen, Young, Māori, Pacific and Vulnerable Mothers at Counties Manukau Health and follows the independent maternity review in 2012 which found that unborn and newborn babies were dying at higher rates in South Auckland than the national average. The 96-page document makes for grim and at times very emotional reading and it is painfully clear that Middlemore Hospital often gives their young Māori and Pacific mothers a very hard time. The mothers interviewed said they felt unwelcome and their needs and concerns were ignored by a system that is focused on trying to make them comply with their unreasonable expectations.
Five Key Themes
Counties Manukau Health identified five key themes that they wanted the views of mothers on. They were:
- Accessing and engaging early in pregnancy.
- Using the primary birthing units – Botany Downs, Pukekohe and Papakura.
- Accessing appropriate advice and affordable contraception in a timely manner.
- Developing strategies to reduce smoking in pregnant women.
- Developing culturally appropriate interventions to reduce pre-pregnancy obesity.
A number of focus groups and face to face interviews were held in a variety of settings with young, Māori and Pacific women, as well as women living in economically deprived areas who had given birth at Middlemore hospital. All groups expressed dissatisfaction with maternal care provided by Counties Manukau Health. The report states that the dissatisfaction relates to:
Labour, delivery and the period immediately after delivery were mentioned as times when young mothers felt they needed support and care of health professionals and their families. However the predominant CMH culture was focused on timeliness and efficiency. Mothers perceived they received a service, rather than nurturing and care. The service failed to utilise family support. We were told of many cases when births occurred at night, partners and families were sent home (or charged an unaffordable fee to stay the night). This left vulnerable young women alone in an unfamiliar environment with staff who could not or would not respond to their needs due to other work pressures. We noted that mothers who had also delivered at Auckland District Health Board (ADHB) facilities, described a marked contrast in their experience of the maternal care services provided at ADHB. In particular staff attitudes were different, including:
- welcoming families and going the “extra mile” to make them feel comfortable and provide care and support in the period immediately after delivery;
- women with English as a second language and/or with low health literacy were not able to access additional resources to meet their needs;
- interworkforce rivalry and patch protection were obvious to mothers and their families. Mothers described tensions between private LMCs and hospital staff, with LMCs acting as advocates for them against hospital staff who were perceived as focused on discharging mothers home early; and
- hospital staff who criticised the actions and competence of LMCs. This impacted on their confidence and trust in the services, and their willingness to engage for future needs.”
Women have been reporting on the problems with the Shared Care service since it was first established. Shared Care is unique to CMH and was developed in response to a shortage of private LMCs. Under the Shared Care service women receive most of their antenatal care from a GP, but are also entitled to three antenatal visits with a DHB-employed community midwife. Care during labour and birth is provided by a CMH-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 in Obstetrics and Gynaecology. This is and has always been totally unacceptable.
What is also unacceptable is that the women who go to Shared Care for their initial maternity visit are not told about their other options, i.e. they can choose a self-employed midwife as their LMC, “due to financial incentives” that CMH provides to the Shared Care GPs. The report states “although doctors were the first contact for young mothers to confirm their pregnancy and their main source of information regarding different antenatal care options, they provide very little information and guidance. Women were unsure about the different options of maternity care, how to make choices and how to access the different types of care.”
Shared Care was therefore not an informed choice made by the women. Their experience of Shared Care was one of long waiting times, rushed appointments, and a lack of continuity of care after discharge from hospital – some mothers had no follow-up care, others were seen many weeks after discharge and/or had an insufficient number of postnatal visits. The service was perceived by women to be medically focused and inflexible.
This helps to explain why on average 190 women in CMH per year do not have any antenatal care and just over a third of women book very late in pregnancy.
It Has All Been Said Before
The authors of the report also note that their desktop review of previous reports indicated that these views were already well documented. The MSCC can confirm this as we were receiving calls about many of the issues described in the report a decade and more ago, especially those related to Shared Care.
Factors Preventing Early Engagement
Many teens were scared of a positive result:
“I was three and a half months when I found out… I was in denial because I didn’t want to find out I was pregnant. I had no symptoms I just missed my period hoping it would come the next month.”
“I didn’t want to know, I just pretended it wasn’t happening, but deep down I knew.”
Older mothers said:
“I usually don’t. I just get me a midwife when I’m about six months.”
Then there is the story of a Pacific mother who was encouraged to attend prenatal sessions with her LMC. To get to her first check up she had to catch two buses, and it took her two hours with children in tow. Once there it took 15 minutes to complete the checks. The mother was told “you’re fine” and sent home. She did not attend subsequent checks.
Low Health Literacy
This was particularly an issue for Pacific mothers of all ages.
“She told me I had to find a midwife and I was like what is this word? I have never heard this word before.”
“I was told I have to go here and here and here and I was like, why do I have to go to all these places. In Raro I saw one person; it gave me a sore head to think of all these new things.”
Religious and Cultural Beliefs
Pacific women know very little about the symptoms of pregnancy even with subsequent pregnancies:
“There’s no way we would talk about anything like that in our family, no-one in my culture does, you have to find out from your friends.”
Interworkforce rivalry and patch protection were obvious to mothers and families:
“I had a show and bad cramps, I waited three days and the baby still didn’t come. I couldn’t sleep or anything. I rang the hospital and they kept saying don’t come, it’s not time. I finally rang my own midwife because I was scared, I was worried I would be too tired to push this baby out. My midwife met me at the hospital and she told them off. I heard them argue up in there.”
History of State/Government Intervention
Vulnerable mothers described difficulties with any mainstream service because of historical and on-going relationships with CYF, the Police, and Work and Income.
“When I told her my age she looked at me funny and I was a bit terrified because she asked me who’s my supporters and I was worried in case she was going to get CYF.”
“They (Social Service provider) sent someone to help me; it took them two years to get through my door.”
Barriers to Access
Mothers highlighted significant issues with the continuity of care.
“I never had a midwife, due to when I did have a midwife she was very judgemental because of my age being pregnant young … so I felt uncomfortable so I just basically looked after myself through the whole 9 months and gave birth in my own bath tub, I didn’t go to hospital … I just did it on my own.”
“The day I gave birth to my daughter my midwife didn’t come and didn’t see me until three weeks later. They gave me someone else when I was in labour and I was like “who the hell are you?’ ”
Staff Attitudes and Lack of Cultural Competency
The lack of compassion is incredible.
“So I had my baby at midnight and she told me I could stay until I went to the toilet. At 4am I went to the toilet and she told me to leave. It was the middle of winter and I am sitting in the foyer waiting for my mum to come back and pick me up with my new baby. My mum only just left two hours before because they said she can’t stay the night. I was thinking of her petrol.”
“I was looking out the hospital window in my room and I could see my mum sitting in the dark at Middlemore train station and we were both crying.”
The research also highlighted that the women they interviewed very rarely complain about the service they received even when it is very bad. Others issues discussed with the mothers included accessing affordable and appropriate contraception, reducing or stopping smoking during pregnancy, and developing culturally appropriate nutritional interventions to reduce pre-pregnancy obesity.
The report includes a number of recommendations on how to achieve quality in maternity care across culturally diverse populations, doing something urgently about the poor service to teen, young, Māori, Pacific and other vulnerable mothers, the need to consider the whole maternity care system when making changes, and reviewing the mechanisms used by CMH for patient and consumer input.
The MSCC considers that similar problems exist with the maternity services provided to these groups of mothers in West Auckland, and recommends that Waitemata DHB undertakes a similar survey of women who have given birth at Waitakere Hospital.