Do maternity services in New Zealand's public healthcare system deliver on equity? Findings from structural equation modelling of national maternal satisfaction survey data.

BACKGROUND: Birthing outcomes in New Zealand are demonstrably inequitable based on governmental reports and research. However, the last Ministry of Health maternal satisfaction survey in 2014 indicated that 77% of women were satisfied or very satisfied with care. This study used data from the maternal satisfaction survey to examine aspects of inequity in reported satisfaction with care. METHODS: Structural Equation Modelling (SEM) was used to infer latent variables of satisfaction with equity domains from responses to the satisfaction survey. Additional data (residential location and deprivation score), not used in the Ministry of Health primary analysis, were provided and included in this modelling. RESULTS: SEM showed that satisfaction was not equitably distributed. Younger women, those from areas of high socio-economic deprivation, and remote rural women were most likely to be affected by dissatisfaction associated with physical access, cultural care, information provided, and/or barriers to equity associated with additional costs (all p<0.05). Financial burden of additional costs was also unevenly distributed. CONCLUSION: While these findings are congruent with other research on the association between social determinants and maternal satisfaction, it is concerning that they remain sources of inequity in New Zealand twenty years after they were first identified as priorities to address. On the basis of this study, urgent attention needs to be paid to removing sources of inequity within the health system and maternity care in particular.

Barriers to equitable maternal health in Aotearoa New Zealand: an integrative review.

BACKGROUND: The purpose of this review was to examine the literature for themes of underlying social contributors to inequity in maternal health outcomes and experiences in the high resource setting of Aotearoa New Zealand. These 'causes of the causes' were explored and compared with the international context to identify similarities and New Zealand-specific differences. METHOD: A structured integrative review methodology was employed to enable a complex cross disciplinary analysis of data from a variety of published sources. This method enabled incorporation of diverse research methodologies and theoretical approaches found in the literature to form a unified overall of the topic. RESULTS: Six integrated factors - Physical Access, Political Context, Maternity Care System, Acceptability, Colonialism, and Cultural factors - were identified as barriers to equitable maternal health in Aotearoa New Zealand. The structure of the maternal health system in New Zealand, which includes free maternity care and a woman centred continuity of care structure, should help to ameliorate inequity in maternal health and yet does not appear to. A complex set of underlying structural and systemic factors, such as institutionalised racism, serve to act as barriers to equitable maternity outcomes and experiences. Initiatives that appear to be working are adapted to the local context and involve self-determination in research, clinical outreach and community programmes. CONCLUSIONS: The combination of six social determinants identified in this review that contribute to maternal health inequity is specific to New Zealand, although individually these factors can be identified elsewhere; this creates a unique set of challenges in addressing inequity. Due to the specific social determinants in Aotearoa New Zealand, localised solutions have potential to further maternal health equity.

General Practitioners providing obstetric care in New Zealand. What differentiates GPs who continue to deliver babies?

AIM To identify factors that have enabled some New Zealand general practitioner obstetricians (GPOs) to continue providing maternity care and factors implicated in decisions to withdraw from maternity care. METHOD Semi-structured interviews and one focus group (n = 3) were conducted with 23 current and former GPOs. Interviews were transcribed and analysed thematically. RESULTS Current and former GPOs practiced maternity care because they enjoyed being involved in the birth process and delivery suite environment. Their maternity practice was framed by a philosophy of lifelong continuity of care for patients. CONCLUSION GPOs still practicing in New Zealand do so because they find maternity care highly rewarding despite their perceptions that the current maternity care model is incompatible with general practice. They have often developed local solutions that support their practice, particularly around shared care arrangements.

Why do patients attend Dunedin's free clinic? An audit of general practice activity using the ICPC-2 classification system.

AIM: To describe the reasons for socially vulnerable patients at Dunedin's Free Clinic visiting their general practitioner, using the International Classification of Primary Care, Second Edition (ICPC-2). METHOD: An audit of electronic medical notes at Dunedin's Free Clinic for a 13-week period, to profile the health needs of patients and associated general practice activity RESULTS: There were 9.0 visits per patient over 12 months at the Free Clinic. An average of 1.2 presenting complaints or requests was made per visit. The most frequent "reasons for encounter" (RFE) at the Free Clinic were requests for prescriptions and Sickness Benefit medical certificates. An average of 1.9 diagnostic or therapeutic procedures was recorded per consultation at the Free Clinic. CONCLUSION: Patients at Dunedin's Free Clinic had a high rate of prescription and Sickness Benefit medical certificate requests. However, they brought on average fewer RFEs and received fewer than expected "processes of care" than patients in the NatMedCa study.

The use of nurses in community palliative care.

This qualitative study uses a phenomenological life world perspective to examine the utilization of nurses in community palliative care for people with noncancer conditions with a life expectancy of 2 years. Sited in Otago, New Zealand, while there was a number of health professionals involved in providing palliative care in the community for people with malignant conditions, none of the participants with nonmalignant disease were receiving specialist palliative care at the time of interview. Support services used a rehabilitative model of care that was not always appropriate in meeting the needs of the people who were dying and their families.

A qualitative comparative investigation of variation in general practitioners' prescribing patterns.

BACKGROUND: In New Zealand there is increasing interest in the variation in the prescribing behaviours of general practitioners (GPs). Research conducted to date hasfocused primarily on the quantifiable aspects of prescribing variation. AIM: To investigate the qualitative aspects that may help explain variations in prescribing behaviour between GPs. DESIGN OF STUDY: Qualitative and comparative interviews. SETTING: Thirty New Zealand GPs. METHOD: A sample of 60 GPs (comprising 20 low, 20 medium, and 20 high-cost prescribers) was selected. Half of this sample (10 GPs in each prescribing category) was recruited to the study. Responders participated in a 60-minute interview. RESULTS: Low-cost prescribers reported more experience in practice and appeared to have a more 'relaxed' attitude towards medicine. They were more comfortable with refusing patients and they responded to patient expectations with education and explanation. In addition, they viewed the prescription as a pragmatic means of delivering health care to patients. Low and medium-cost prescribers did moreformal counselling and emphasised the 'listening' aspects of general practice. High-cost prescribers appeared to be more highly motivated and to have a more 'serious' attitude toward medicine. They tended to view their obligations and responsibilities to the patient in terms of medical competence. They described their roles with patients in terms of service provision and suggested that patients viewed the prescription as a signifier of the GP's service to the patient. CONCLUSION: This study suggests that there are discernible, non-quantifiable differences between low, medium, and high-cost prescribers in the Otago and Southland areas of New Zealand.