Service provision
Accessing the clinic
Difficulties with internal referral pathways, and identification of Indigenous status, resulted in some women who were eligible to access the MC, being allocated to mainstream services. This was sometimes rectified after women heard about the clinic and negotiated a transfer. Significant delays were identified concerning referral processes, reiterated by interview data, with the average referral for MC women received at 16 weeks gestation (range 5–37 weeks) with a further eight weeks wait on average to attend a ‘booking’ visit which occurred at 24 weeks vs. 20 weeks (mean) for Indigenous women in SC. Indigenous women attending SC were statistically more likely to attend eight or more visits (51.0% vs. 38.4%), although the hand held record which we accessed for audit purposes, is usually only commenced at the first hospital booking visit with previous episodes of community based care rarely recorded. Hence, antenatal attendance for women accessing MC shared care is likely to be under-recorded.
Shared care
Women accessed the MC from a wide geographical region including outside the hospital catchment area. Routinely collected data provided limited information on GP shared care arrangements (MC:14% vs. SC:34%) with interview data suggesting the proportion of MC women receiving shared care was higher. We instigated a chart audit of 2009 data and identified a much higher proportion (68% vs. 14%) participated in shared care with a variety of providers including two AMSs (39% and 15%); and GPs (MC: 14%). Participants expressed a desire for greater collaboration and partnership across organizations, believing that a team approach would be more effective and efficient, and reduce the substantial amount of photocopying and faxing of patient records between services:
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Everyone’s got their own patch. […] Everyone seems to be doing something but nothing. (Staff)
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They’ll drop in every three weeks […] even though they don’t need antenatal care […] you know there is kind of a doubling up. (External stakeholder)
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Women mentioned needing to tell their story numerous times to different providers:
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All they do is ask you the same questions. (Participant)
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Interview data highlighted concerns from hospital staff and external stakeholders about the lack of co-ordinated care and duplication of services, for example due to different pathology providers, screening test results which were inaccessible for ‘after-hours’ admissions.
Continuity of carer
At the time the Evaluation was undertaken the MC operated one day a week; midwifery appointments were available all day with an obstetric clinic operating alongside in the afternoon. Continuity of carer (midwife and obstetrician) was a major attraction, with women reporting that this reduced the likelihood of being asked the same questions:
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It’s good coming here too because you know you’re going to see the same people all the time. It’s not a different doctor or a different midwife every time who’s going to ask you the same questions over and over again […] she (midwife) knows your full-on history from the first visit to, you know, your last visit. She knows everything about you, which is good. (Participant)
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Survey data confirmed that continuity of midwifery carer was very important to women attending the MC, with continuity of obstetrician and social worker slightly less so (61% vs. 47% vs. 42%). Clinic staff believed that the social worker provision, with minimal or no continuity, discouraged women’s frank and honest disclosures about their troubles. For their part, Social Workers reported being disappointed when their efforts to engage ‘hard to reach’ women were thwarted because they were unable to secure the level of continuity required to ensure culturally safe practice.
Staff were further concerned that lack of continuity in this area jeopardised the clinical management strategies in place for ‘high risk’ women; they were also concerned that this might be a factor in such women disengaging from all care provision. Although staff considered Indigeneity to be an important feature of the MC, their clients seemed less concerned about the Indigenous status of staff, stipulating that more important was access to the same care provider who was well qualified and experienced, with good listening skills:
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I’m more concerned about their qualifications and how much experience they’ve had […]. I’m not really worried about whether they’re Indigenous or not. (Participant)
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It’s someone that’s going to listen to you, then it don’t matter what they look like. (Participant)
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Operational issues
The limited clinic opening hours were considered insufficient to meet demand. Lack of flexibility with schedu-ling appointments was a particular problem which staff believed deterred some women from booking with the MC.
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Sometimes they don’t come to this clinic because […] we’re only on a Thursday and it doesn’t suit everyone […] maybe the family’s working […] studying, and they can’t get here on a Thursday and for that reason they’ll go through mainstream. (Staff)
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Limited provision increased pressures on staff as the clinic was extremely busy on the one day it was in operation; women reported that their appointments rarely ran to time. Staff agreed that delays were frequent and often substantial, commenting that scheduled appointments were also not in keeping with Indigenous cul-tural norms, which favoured ‘drop in’ arrangements. An important concern for staff was that if they did not accommodate women who dropped in to the clinic unannounced, and who were more likely to be at higher risk with poor attendance records, a crucial opportunity for antenatal care would be lost. At the risk of inconveniencing women who were punctual with appointments, staff adopted an opportunistic approach to these less regular clients:
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Like she had an appointment two hours ago and now she’s here and it’s like so, I’ll just see her […] Indigenous health as you know is opportunistic and if you don’t get them then, you might not get them again. (Staff)
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Women sometimes used the knowledge that they would be seen without an appointment to their advantage:
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I figured out how it (the clinic appointment system) was working. So I would go up there like (at) nine (am) […] women would be waiting after me that were probably meant to be before me. (I felt) bad at first but, you know, that’s the way they operate. (Participant)
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Strategies which assist patients to circumvent perceived organisational deficits may be important for survival in systems which are not designed to take account of their individual needs. The efforts expended by staff to balance opposing needs and professional responsibilities, however, are also acknowledged as considerable [
25,
26].
Location
Clinic staff and external stakeholders were of the opinion that the location of the clinic, within a tertiary maternity hospital setting, was problematic with some believing this hindered women’s attendance at clinic appointments. In particular, they cited long journeys, with perhaps multiple changes on public transport, travel-related costs including parking fees, and problems associated with travelling accompanied by small children and pushchairs. Women who contributed to the Evaluation, however, refuted these suggestions, stating that accessing the clinic was relatively easy. Women who drove to the clinic for their appointments reported that they frequently parked in side streets where parking was cheaper (or free) rather than using the (expensive) hospital car parks. Busways (i.e. dedicated roadways separating buses from general traffic), were a popular alternative for those travelling by public transport, not least because the bus stop was located directly in front of the hospital. When women were asked their preferences regarding the location of the clinic, some suggested community-based locations, closer to where they lived. However, the hospital was also favoured for the opportunity it provided partners and family members to become familiar with the surroundings in advance of labour and admission to birth suite:
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I could be in labour and he’d have to bring me here and not know where to go. (Participant)
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Physical space
Complaints about overcrowding and lack of privacy to discuss confidential matters were frequently articulated. One participant referred to the waiting area as a 'fishbowl’:
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It’s a very fishbowl kind of situation. We’re all in there looking at each other in a very small space and as soon as the woman comes in with her other two kids and they start playing in the middle of the space, we’re all part of it you know? It’s like the comfort zones might be pushed for some […] I think it definitely needs a better situation […] at least a more appropriate one. (Participant)
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Male partners in particular were reported as being loathe to spend time in the waiting room, opting instead to use mainstream facilities:
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Yeah they (male partners) wait outside […] (they) don’t feel comfortable. Like my partner didn’t feel comfortable sitting in there […] sometimes I’d see just fathers just stroll past […] because they don’t really want to go in there. (Participant)
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In addition to concerns about confidentiality, staff believed lack of space hindered their ability to properly engage with women and their families. This was problematic as building rapport and establishing trusting relationships was an essential prelude for staff attempting to address the complex, and often long-standing, health-related risk factors disrupting the lives of so many of their clients.
Culturally responsive care
Analysis of survey data found that the majority of women (92%) felt ‘mostly understood and respected’ by staff whilst attending the MC. Other hospital locations were less well rated, however, with only 47% of women feeling similarly about birth suite, 31% about the postnatal ward and the 31% about the Maternal Fetal Medicine unit. Relatively small percentages of women stated they felt ‘not at all understood’ or ‘respected’ in selected locations including; birth suite (14%), the Neonatal Intensive Care Unit (NICU) (6%), the postnatal ward (8%), the Maternal Fetal Medicine unit (8%), and the Home Care Program (6%). Women described their disappointment with the lack of continuity of carer they experienced in birth suite and postnatally. Being cared for by unfamiliar staff during labour was especially difficult for younger Indigenous women, some of whom reported feeling ‘scared’ and/or ‘shamed’ when staff they had not previously met entered their room unannounced. Their discomfort was heightened by intrusions that occurred when clinical assessments were taking place, with women of the opinion that the intimate nature of labour and birth called for a known carer and that all other staff should seek permission to attend:
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I was kind of like covering myself. (I felt) shame. […] was like, embarrassed. (Participant)
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I think it’s a very private time labour, and I think you should have a choice as to who is to be there. (Participant)
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Staff generated anxieties about labour progress and infant welfare when they failed to discuss with women in their care the need for consultation with medical colleagues:
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It makes you panic more when more people walk in because it makes you think that there’s something wrong […] staff walk in and you think, what the hell is going on? Something’s going wrong here, is it going to be all right? (Participant)
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