National Survey of Access to Public Antenatal Care Services 2012

Contents

Acknowledgements1

Glossary2

1Executive summary3

1.1The Access Survey3

1.2Scope of survey3

1.3Survey findings4

2Introduction6

2.1Background6

2.2Scope of project9

2.3Content of report10

3Access issues11

3.1Maternity Services Review and National Maternity Services Plan11

3.2Literature review12

3.3Summary18

4Design of the antenatal services access survey19

4.1Design process19

4.2Survey distribution21

4.3Survey support21

4.4Survey response and data cleansing22

4.5Commentary on future survey activity23

5Survey findings26

5.1Reading the survey results26

5.2Survey results29

6Concluding comments54

Appendix A – Survey questions55

Appendix B – Communications pack

Appendix C – Survey responses

Appendix D – Bibliography

1

Acknowledgements

The Maternity Services Inter-Jurisdictional Committee (MSIJC) would like to thank the Victorian Department of Health for its contribution to the National Survey of Access to Public Antenatal Care Services and KPMG for the design, distribution and analysis of the survey.

The MSIJC would also like to thank individuals and organisations that participated in the survey.

Glossary

1Executive summary

This executive summary and following sections comprise the final report for the National Survey of Access to Public Antenatal Care Services 2012 (the survey) project undertaken for the Victorian Department of Health acting under the auspice of the Maternity Services Inter-Jurisdictional Committee.

1.1The Access Survey

The National Maternity Services Plan (2010) (the Plan) was developed with the vision that ‘all Australian women will have access to high-quality, evidence-based, culturally competent maternity care in a range of settings close to where they live’. The Plan aims to improve, coordinate, and ensure greater access to maternity services in Australia and has the following priorities: access, service delivery, workforce and infrastructure.

The Plan is coordinated through the Standing Council on Health (SCOH) and auspiced by the Maternity Services Inter-Jurisdictional Committee (MSIJC) in consultation with government and non-government stakeholders who share responsibility for implementing components of the Plan.

Under this auspice, the Victorian Department of Health and the Tasmanian Department of Health and Human Services led inter-jurisdictional work to evaluate the availability of access to publicly funded antenatal care services across Australia. This included:

• consultation with representatives of state and territory antenatal health services and representatives from state and territory Divisions of General Practice or Medicare Locals regarding their perspectives on the dimensions of access and jurisdictional health models;

• an online and email based survey design and distribution; and
• survey analysis and report.

1.2Scope of survey

The survey, which was completed by antenatal service providers, focused on public antenatal services across Australia.

Survey questions were based on a high level literature review and input from members of the MSIJC. Areas covered included:

• access factors that reflect potential access, namely:

-demand drivers: local population and locational characteristics;

-supply factors: resourcing, workforce, infrastructure and service models;

• access factors that reflect realised access, namely:

-client preferences and response to costs;

-client usage rates;

• the types of service models available and networking arrangements (through referral practices);

• locational data to assist identification of the impact of misdistribution of service delivery; and
• population measures to assess differences in services to vulnerable population groups (Indigenous, CALD and lower socio-economic women).

The survey was run from 16 January 2012 to 2 March 2012. 234 valid survey responses were received.

1.3Survey findings

Overall, the survey findings indicated an antenatal service sector that is under some stresses, particularly in relation to workforce maintenance issues, however in general, is not at a point of failure.

The following key themes were also identified:

• The distributional nature of the acute service system is a key determinant of variance in the access patterns of women to antenatal services across Australia. These variations reflect the availability of service models at different geographical locations and should be acknowledged as a lower level of access choice rather than an access failure.

This is confirmed in more remote communities where lower levels of choice are not reflected in lower levels of client satisfaction (i.e. where the acute service system is not located).

The above theme may not apply for medium to high risk women who require acute services due to their risk level. Access for these women is more likely to mean access to services away from their home.

• It should be noted that where the survey drilled into small subsets of the survey population, the level of margin of error in the findings rapidly increases and hence should be treated with higher levels of caution. For this reason that are limitations to the survey outcomes in understanding the specific barriers to antenatal care for vulnerable population groups (Indigenous and CALD women).

Nine per cent of service providers reported that the number of Indigenous women attending antenatal care under-represents the population profile. Service providers caring for higher numbers of Indigenous clients were however found to offer a wider range and more targeted antenatal activities.

• Areas where higher barriers to access exist are not confined solely to rural and remote communities. Socio-economic variation and location appear to play a significant role in defining areas with greater challenges to access. Similarly, access barriers for Indigenous communities exist in metropolitan environments as well as remote areas.

Positive incidences of access variations due to location do occur in remote communities. In these cases the increased role of GP or community midwife models results in greater responsiveness and client satisfaction.

• Workforce maintenance is the defining issue for the continuing supply of antenatal care.

Midwife supply was a frequently noted issue. This has particular impact where midwife led care is playing an increasing role in antenatal service design. Models that depend on midwife participation are as critical to the supply of non-acute services in rural and remote areas as are GP services.

The survey also received fewer, but similar, comments regarding the availability of GP obstetricians.

• General health sector developments have seen all aspects of system access improve over the last five years. This likely reflects the ongoing government investment in health services and networks in recent years. However, resourcing (staff and other resources) has improved the least and any resource constraint issues may compromise the ability of services to continue investing in service model innovation. This is critical to effective service delivery for smaller communities, and possibly for lower socio-economic areas.

One area where continuing development appears to be required is the continuing promotion and acceptance of advanced midwife care and participation in collaborative models. Qualitative comments to the survey suggest that the cultural shift in health services associated with these models is not yet complete.

2Introduction

The National Maternity Services Plan (2010) (the Plan) provides a maternity service improvement framework for 2011 – 2015. Priorities for the Plan include: access, service delivery, workforce and infrastructure.

Implementation of the Plan is auspiced by the Maternity Services Inter-Jurisdictional Committee in consultation with government and non-government stakeholders who share responsibility for implementing components of the Plan. Under this auspice, the Victorian Department of Health and the Tasmanian Department of Health and Human Services led inter-jurisdictional work to evaluate the availability of access to publicly funded antenatal care services across Australia.

This report describes the approach and results from the National Survey of Access to Public Antenatal Care Services.

The remainder of this introductory section of the report sets out:

• the background and context of the access survey;
• the scope of work undertaken; and
• the structure of the following sections of the report.

2.1Background

Maternity services in Australia encompass antenatal, intrapartum and postnatal care and, by international standards, these forms of care are relatively safe and readily available to women and their babies.

Australian health and outcome indicators for pregnant women and the reach and diversity of antenatal care models describe a service system that generally meets the needs of the Australian community, and is based on international best practice. However, anecdotal evidence and submissions made to the Maternity Services Review (2009) identify challenges within the antenatal service system, encompassing:

• continuity of care – all women are not able to source their antenatal care from a single provider or team during their pregnancy;
• locational availability of antenatal care options – either excessive demand or locational factors mean that specific antenatal options are not available at particular locations.

Locational availability has been noted as an issue in both metropolitan and rural areas. Anecdotal evidence does however distinguish between breadth of supply issues in rural areas and excess demand issues in specific metropolitan areas;

• absence of choice – many women express a lack of empowerment regarding their choice of antenatal care and care provider;
• antenatal service model – services and local antenatal systems display varying ranges of service responses, whether under traditional medical and directive approaches or collaborative team based approaches; and
• Indigenous antenatal care – rates of maternal and perinatal health are markedly poorer than for those in the wider community, and some submissions to the Maternity Services Review had noted that culturally respectful antenatal care does not always occur consistently across the country.

It is acknowledged that Indigenous maternal health outcomes do reflect poorer general health measures in Indigenous communities. However in some cases attendance late in pregnancy and lower rates at which perinatal services are accessed (and hence resultant perinatal health) are noted as reflecting a narrower service system and cultural factors (for example the preference for ‘birth on country’).

In addition to the above, the Australian antenatal and wider perinatal systems are subject to a number of factors that place constraints on the system to deliver accessible and responsive services. In particular:

• workforce availability – like many sectors, the perinatal sector is confronted with significant workforce maintenance issues. In part these relate to the ageing perinatal workforce where the average age of midwives in Australia is 46 years old, and obstetricians and gynaecologists is 51 years old. Additionally, for some jurisdictions, midwifery education programs are predominantly only available in metropolitan areas, which may influence the availability of a midwife workforce for rural areas;
• capacity to be culturally responsive – demand for particular models of perinatal services arise from particular cultural and linguistically diverse (CALD) communities. These can vary from religious expectations regarding the role (or not) of male practitioners delivering perinatal services to preferences for practices such as cultural confinement. For example, the Royal Women’s Hospital in Melbourne has a cultural advocate system to help CALD women navigate the perinatal system and ensure perinatal services are delivered in a culturally appropriate manner; and
• Indigenous services – issues such as remoteness, cultural responsiveness, and disadvantage in Indigenous communities play a varying role in how effective antenatal services are at reaching women in those communities (this applies across all regions nationally as well as within the most remote communities).

Australian governments have recognised that Australia has a highly effective and safe perinatal system. However, there is scope for system improvement, with particular focus on problematic areas such as those described above. The National Maternity Services Plan (2010) has been developed within the context of broader changes to Australia’s health and hospital systems. The Plan’s vision is that ‘all Australian women will have access to high-quality, evidence-based, culturally competent maternity care in a range of settings close to where they live’[1].

The Plan aims to improve, coordinate, and ensure greater access to maternity services in Australia. The Australian Health Ministers’ Conference (AHMC)[2] endorsed the Plan on 12November 2010. Since its endorsement, the Standing Council on Health (SCOH) has taken carriage of the Plan, and state and territory governments now report to SCOH on progress against the Plan and benefits delivered to Australian women and their families over the period 2011 - 2015.

The Plan recognises that antenatal care (as well the subsequent phases of maternity care) can be provided in a range of settings under a range of models. The Plan draws a series of priorities to guide the delivery of those services recognising the importance of:

• access to information and models of care - maternity services in rural and remote communities are confronted with a specific range of issues that impact on how access is provided and resources required to ensure adequate access;
• service delivery - services should be high quality, evidence based, responsive to issues such as the need for cultural competency in services to Indigenous and CALD women, and responsive to vulnerability factors (for example social, welfare, socioeconomic or medical factors);
• workforce - training, development, and support of a quality workforce in a range of settings: general, rural and remote, and Indigenous services. Identification of workforce as a key priority focuses on collaboration between professionals as a key driver for the provision of quality maternity care; and
• infrastructure - the role of quality and a ‘women centred approach’ in ensuring a safe and responsive maternity care system.

The Maternity Services Inter-Jurisdictional Committee (MSIJC) is coordinating several elements of the Plan. The MSIJC tasked Victoria and Tasmania to lead inter-jurisdictional work to evaluate access to public antenatal care in a range of community settings as part of the Plan’s implementation schedule.

This project involved the development and distribution of a survey tool, data collation, evaluation, and analysis. The resultant survey findings will provide:

• information regarding the distribution or gaps in the delivery of antenatal services. In the absence of national information on access to public antenatal care, the information collated through the survey will provide a platform of service information for subsequent service development activities under the Plan’s implementation schedule and other general health system development; and
• information with the potential to illuminate instances of innovative or particularly effective models of antenatal care. This is especially relevant in those areas where delivery of care is particularly problematic (e.g. remote communities).

The survey tool also provides a mechanism for consistent collection and collation of antenatal service access information in future years, enabling: a longitudinal assessment of the efficacy of the implementation of the Plan; and description of the emergence of any new models of antenatal care[3].

2.2Scope of project

In September 2011, as part of its commissioning process for this project, the Victorian Department of Health (DH) under the auspice of the MSIJC noted that ‘…there is currently a lack of information regarding the availability of publicly funded antenatal care services across Australia..[4]’ and that the ‘…development of a standardised audit [survey] tool will support consistent data collection and enable jurisdictions to identify gaps in service delivery.’

The DH commissioned a project to develop and undertake a survey that would examine ‘…access to publicly funded antenatal care, ability to access care within the first trimester of pregnancy, location of primary service provider and total number of antenatal care visits received.’

The project was specifically required to:

• develop a survey tool which would: facilitate the collection of data and subsequent analysis of publicly funded antenatal care across Australia, and consider who the survey would target; and
• collate, analyse and report on the data collected through the distribution of the survey tool.

The project was intended to focus primarily on a data collection process to gather information to inform future access focussed activities under the Plan and to provide an initial data set under which potential longitudinal review works may be undertaken to assess the impact of actions under the Plan and of the general development of the antenatal service system.

It is noted that under the project scope, the required work excluded:

• any detailed literature review, regarding items such as research into national and international emerging models of care or best practice;
• review of the linkages between the antenatal service system, perinatal service systems, and post natal service systems;
• client outcomes in the antenatal service system, other than in relation to access; or
• cost and efficiency of different antenatal service models.

In addition, the project was to focus on surveying antenatal service providers. Any consultation activities with service providers were to be in relation to their views on the design and focus of the survey rather than for gathering evidence or submissions to guide the development of a wider review report.

The project scope also excluded any consultation or survey of antenatal clients.

The project was completed in a six month period from November 2011 to April 2012. The survey period ran from 16 January 2012 to 2 March 2012. The project methodology is described in greater detail in Section 4.