Maternity Services Survey

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The NCWNZ Maternity Services Survey was launched in the Beehive Foyer. The function was hosted by Steve Chadwick MP for Rotorua, Member of the Health Committee and a former midwife. JR McKenzie Trust funded the survey anaylsis and publication, and GlaxoSmithKline sponsored the delicious afternoon tea.

Guests attending the launch included representatives from the Ministry of Health, Ministry of Women's Affairs, NZ Medical Association, Kokiri Marae, Royal Australian & NZ College of Obstetricians and Gynaecologists, Royal NZ College of General Practitioners, Parents Centres NZ, Fed of Women's Health Councils, Council of Jewish Women, Royal NZ Plunket Society, MATPRO, Family Planning Association, Rural Women NZ, Zonta International, Catholic Women's League and representatives of NCWNZ Branches and Standing Committees.

Media coverage was excellent with Radio NZ filing a Morning Report and the Dominion Newspaper publishing an article on Friday 15 February.

NCWNZ President at the time, Barbara Glenie, spoke about the changes in Maternity Care, and Dr Heather Worth from the Centre for Research on Gender, University of Auckland presented an overview of the results of the survey, the summary of which follows:

Executive Summary

Background

In 1998 the first survey concerning the impact of new maternity services was developed and carried out by the National Council of Women of New Zealand (NCWNZ). Women with babies under six months of age were invited to participate. 1337 questionnaires were received and of these, 1245 containing complete demographic information were analysed. In 2001 NCWNZ decided to run a follow-up survey to gauge the current level of public satisfaction amongst mothers and to compare the results with those of the 1998 survey. The current survey questionnaire, like the 1998 one, was distributed via the NCWNZ membership, which includes 35 branches to which 150 societies are affiliated, and 43 nationally organised societies. Thus the sample is not randomly selected. However, comparison with the 1998 survey is possible. In total in 2001, 1020 useable survey forms were returned. Thirteen otherwise useable questionnaires had a page missing due to a photocopy error. This accounts for some missing data, as these forms have been included in the analysis.

The 2001 respondents had the following characteristics:

Maori women were slightly under-represented, and Pacific women were highly under-represented
Women under 20 years of age were under-represented
Women with high levels of education were over-represented.
The mean age of the women who responded to the questionnaire was between 30 and 34. This compares to the national average of 29 years.

There was a reasonably balanced representation from each of the four designated areas: major city, provincial city, provincial town, and rural area. There was less representation in the major cities.

All major New Zealand regions were represented.

It was intended that all women responding to this questionnaire would be recent mothers with babies of six months or younger.In practice, the distribution was:

90% of babies were 0 - 6 months
10% of babies were aged between 6 and 12 months

Forty one percent of the women responding had only one child (live birth), 31% had two children, and the remaining 28% had three or more children.

Choices of Lead Maternity Carer (LMC)

Lead maternity carer is defined as the General Practitioner, Midwife or Obstetric Specialist who has been selected by the women to provide their comprehensive maternity care including the management of their labour and birth.

Compared to the 1998 survey, women expressed fewer concerns about locating an LMC and deciding on who was appropriate, although many women expressed the importance of the ‘right' LMC.

Women did not appear to be confused about the maternity services available to them. However, some women found information such as how to choose between types of LMC, contact details for LMC's, and likely cost of LMC and other services, difficult to obtain, particularly from their GP.
The single most important advice mothers said that they would give to other women having a baby under the New Zealand system was the necessity of being informed and assertive; the importance of choosing their LMC carefully; and of using recommendations from others who have used their services.
Women do not appear to be as concerned as they were in the 1998 survey with the lack of choice, in particular with the reduced number of GPs available as LMCs.
A high percentage of those sampled (88%) felt that they had obtained sufficient information to make a decision about their LMC. Just under half the respondents (48%) found out about the available maternity services from their GP. The other major ways women found out were from midwives (16.2%) and from friends, family or even in the Yellow Pages. The concerns women felt in choosing an LMC centred around GPs giving them little information.
An independent midwife was the first choice LMC of 59% of the women, followed by a hospital midwife (9%). In the final selection of LMC, the number of women using independent midwives as LMCs rose to 86%.
Their own or another GP was the first choice of 11%.
Shared care was the first choice of 13%
Their choice was determined by availability, and whether they were likely to have complications during the pregnancy.
Choice was greater in major cities
Fourteen percent of women found their first choice of LMC was not available. For these women, finding an alternative was difficult with 50% having to approach three or more people.

Antenatal services

Once an LMC was chosen, women reported high levels of satisfaction with the care provided.

Ninety four percent of women said that they were either ‘very satisfied' or ‘satisfied' with the services they received before the baby was born. The level of satisfaction was mainly due to the good care provided by the LMC.
Satisfaction with antenatal services varied according to LMC. Those who were attended by a hospital team or hospital specialist recorded the highest levels of dissatisfaction.
Dissatisfaction with antenatal care also varied according to ethnicity. Maori women had higher levels of dissatisfaction than non-Maori.
Most women (79%) first saw the LMC at an early stage in the pregnancy (between 6 and 14 weeks pregnant). This is up from the 1998 survey. There appeared to be adequate access to other health professionals.
Half the women saw health professionals other than their LMC during the course of the pregnancy. The main reasons given for this were concerns over the mother's or baby's health, or as an extra precaution or to provide additional help.
Eighty percent of women had a care plan discussed with her before birth and 75% of these plans were in writing.

Antenatal classes

Approximately half the women attended antenatal classes ( 85% of women having their first baby).

The most popular antenatal class providers amongst the women were Parents Centre and Hospitals
Most women (87%) considered themselves either ‘very satisfied' or ‘satisfied' with the course, however amongst those there were comments regarding the need to have more practical post-natal ‘baby-care' advice, more information on alternatives to midwife only care, and information on the practicalities of both breast and bottle feeding.
29% of women had to pay to attend antenatal classes (down from 37% in 1998).

Delivery

The LMC was present and assisted in 84% of deliveries
Over two thirds (71%) of women had ‘normal' deliveries, while 17% had caesareans and 11% had complications of some type.
Over 90% of women delivered in a public maternity facility, 7% at home, and 3% at a private maternity facility or elsewhere.
For 88%, their place of delivery was their first choice.

Most women (88%) indicated that they would do things the same way if they were having another baby, while the rest would do things differently. This is higher than in 1998 (75%).

Of the 267 women who would do things differently the most common reasons given were desire for a home birth, private or satellite hospital postnatal care, and preferring to stay in hospital for a shorter or longer period.
Most of the women who said that they would stay a shorter time in hospital said this because they considered the hospital understaffed, noisy, crowded and in a few cases dirty.
Fifty eight percent of women were (also) attended by a health professional other than their LMC at the time of the birth for extra help or precaution, training, intervention, foetal distress and when caesarean section was performed.
Ninety five percent of women felt that they were included in the decision making regarding themselves or their baby's care during labour and delivery.

Ninety percent of women were either very satisfied (68%) or satisfied (25%) with the treatment their baby received after delivery. This level of satisfaction is up from the 1998 survey. Satisfaction rates were highest for those women who were attended by a GP (98%) and lowest for those who had a hospital team or specialist 79%).

Breastfeeding

When questioned about their intentions prior to their baby's birth, almost all (97%) of women intended to breastfeed. Those who did not intend to breastfeed made that decision primarily due to previous lack of success, preference for bottle feeding, or physical disability.

Seventy five percent of women were currently feeding when answering this questionnaire.
Of the women who had been breastfeeding, but were no longer breastfeeding, fifty four percent had stopped by six weeks.
The reasons for stopping are varied. They include pain or tiredness (12%), the baby not feeding properly (11%), or returning to work and needing to wean (7%).

Postnatal Services

A major area of concern raised by the women responding to the questionnaire was the level of postnatal ward care provided in public hospital wards. The main points identified were:

There is a considerable reduction in the length of hospital stays since the 1998 survey
There is pressure for some women to leave hospital quickly.
The quality of postnatal care provided was inconsistent between different women, and between different hospitals.
Women who have caesareans, multiple births and complications were very satisfied with postnatal care

The length of stay in hospital differed (as could be expected) between all women and women having ‘normal' births.

All births: Within 48 hours (2 days) of giving birth, just under a half (48%) of all women had left hospital with their babies.
Women having ‘normal' births: Within 48 hours of giving birth, sixty two percent of women had left hospital.

Most (79%) women said that they did have a choice about how long they would stay in hospital, however for some women there was either:

pressure to leave quickly, or
noisy, understaffed postnatal wards provided an incentive to leave

The average number of postnatal visits received at home in the first two weeks was approximately five (up from 4 in 1998). The number of visits varied considerably between women (ie: between 0 and 11).

35% of women received 3 or fewer home visits
30% received 4 or 5 visits
29% received more than 5 visits

Midwives accounted for almost all (95%) of home visits in the first two weeks. Mostly these are independent midwives.

Seventy seven percent of women did not have to travel to see a health professional during the first two weeks. Of those who did travel:

14% went to their own GP
17% to specialists
8% to their midwife
the rest to a variety of professionals. .

The average number of postnatal visits received at home in the first six weeks was approximately nine (up from 7 in 1998).

30% of women received between 0 and 5 visits during this time.
55% received between 6 and 10 visits.
17% received more than 10 home visits.
Eighty eight percent of mothers received home visits by independent midwives during the first six weeks.
A quarter (25%) said that Plunket had visited them during the first six weeks.
Women living in rural areas received similar numbers of postnatal home visits as mothers in other areas

Seven percent of women had to call a health professional to their home urgently because they were worried about their baby. Seventy percent of these called an independent midwife, but women also called their own GP or a hospital midwife. The reasons for the urgent callouts were mainly given as breastfeeding problems, illness such as rash or vomiting, and baby being very unsettled for an unknown reason.

Nine percent of babies had to go back to hospital within the first six weeks, paediatric checks, internal problems were the main reasons for these visits.

Almost all women (96%) reported that they had received all the information they needed after the baby was born. This information was received mostly from their midwives or Plunket nurse. While overwhelmingly the comments were positive, there were some comments recorded about it being difficult to obtain information.

Ninety six percent of women said that overall, they were either very satisfied (66%) or satisfied (30%) with the postnatal services they and their baby had received. This is due, from the numerous individual comments received from the care received from midwives and other providers such as Plunket.

Satisfaction varies, however. Higher rates of dissatisfaction were found amongst those in provincial cities (10%); those who had an obstetrician (16%); and those who had shared care (11%).
A sixth (16%) of the women had to pay for the services they or their baby received from the time they discovered they were pregnant until the birth. This is down from 25% in 1998.
Six percent of women had to pay for services received during delivery.
Fifteen percent of women had to pay for services received after birth until the baby was six weeks old.
Of those women who had to, or chose to pay, the mean amounts paid were : between $51 and $100 before birth, $500-$1000 during delivery and $51-100 after delivery.

General

Evaluation of women's answers and comments throughout the questionnaire indicate a general very high level of satisfaction with maternity services, overall. Both the quantitative data and the open-ended responses show that most staff including independent midwives, hospital midwives, GPs and private obstetricians are held in extremely high regard by the vast majority of women who use their services. However, there are inconsistencies in the type and quality of maternity services available to women. These often relate to hospital services, and hospital teams and specialists.

Women were asked what helpful advice they would give other women about having a baby in New Zealand. They could make as many comments as they wanted, but only three pieces of advice were recorded. The majority of responses centred around three issues:

There is a need to become well informed and assertive.
The importance in choosing an appropriate type of LMC, and the individual LMC within that type.
Recommendation to use an independent midwife.

The most frequently offered advice by over a half of the respondents was to become well informed about maternity services and to be assertive about what they wanted. This included asking questions, doing research and standing up for themselves. This included exploring LMC options available in their area, and also finding out about antenatal classes, where delivery would take place, what postnatal care was available etc.

A third of the women who responded to this question made reference to the great importance of choosing the best LMC that a woman could trust to support her during her pregnancy and after the birth. Women recommended that women should look around (and look early) for the right LMC. That LMC should be professional, caring, and open to the mother's suggestions. The choice should also be based on recommendations from others.

Twenty percent of women advised others to use an independent midwife.

Many other comments (rather than advice) were received. Amongst others, these revolved around making the most of the pregnancy, doing things differently next time, keeping healthy and fit, and NOT opting for a caesarean.

Copies of the NCWNZ 2001 Maternity Survey are available to order online, or from National Office PO Box 12-117, Wellington, fx: 04 499 5554 Cost $10.00 (includes postage)