RESUMO
BACKGROUND: Australian rates of adverse obstetric outcomes have improved little despite guidelines recommending history-based screening and intervention. The first trimester provides a unique opportunity to predict and prevent complications, yet population-based screening has failed to be translated into broad clinical practice. AIMS: This study aimed to redesign antenatal care within an Australian public healthcare centre to align with evidence-based maternity care, including population-based first-trimester screening with early initiation of preventative strategies in high-risk pregnancies. METHODS: A five-phase action-process model, sharing key elements with implementation science theory, was used to explore barriers to change in antenatal care, co-design a novel service with consumers and establish a population-based antenatal pathway commencing with a multidisciplinary first-trimester screening, assessment and planning visit. RESULTS: The case for change and associated barriers were defined from the perspective of antenatal care stakeholders. Key needs of each group were established, and solutions were created using co-design methodology, allowing the team to create a novel approach to antenatal care which directly addressed identified barriers. Implementation of the service was associated with a fall in the median gestation at first specialist maternity care provider visit from 20 to 13 weeks. CONCLUSIONS: This study confirms the feasibility of establishing a comprehensive first-trimester screening program within a public Australian healthcare setting and highlights a co-design process which places individualised assessment at the forefront of antenatal care. This framework may be applicable to most public maternity settings in Australia, with expansion aimed at providing equity of care, including in rural and remote settings.
RESUMO
PROBLEM: Access block is an increasing problem in delivery suites due to the rising birth rates. As well as more labouring women, more women are presenting to delivery suite with pregnancy concerns (at 18 weeks gestation and over). Waiting times for women with pregnancy concerns were prolonged because, prior to the implementation of the present project, these women were required to be assessed by a midwife and then a medical officer. AIM: The aim of this project was to safely and effectively reduce the length of stay of pregnant women presenting with pregnancy concerns who were managed as outpatients in the delivery suite. PROJECT SETTING: The project was undertaken in the Delivery Suite of a major tertiary referral hospital, NSW, Australia. METHODS: The project team used clinical practice improvement methodology (clinical audit, outpatient flow mapping, flowcharting, cause and effect diagrams, brainstorming, multi-voting and Pareto charting) to investigate and propose recommendations to improve the clinical process for this group of women. SUBJECTS: Five hundred thirty two pregnant women who were not in labour. INTERVENTION: The interventions involved developing the new clinical midwifery pathways and standing orders for the categories of cases where the midwives were able to assess, order tests and make independent clinical decisions; selecting, training and accrediting the advanced practice midwives; implementing the new clinical pathways; and evaluating the effectiveness, cost and stakeholder satisfaction levels with the changes. FINDINGS: The average length of stay was reduced from 178.4 to 91.5min (49%) p<0.001. Approximately 8h a week of midwifery specialist time (AU$33.75 per hour) was estimated to have been saved each week during the project at a cost saving of about AU$270.00 per week. The yearly projected saving would be AU$14,040.00 per annum. CONCLUSION: The use of advanced practice midwives reduced the overall length of stay for women with pregnancy concerns. There were no adverse events or complaints. Women, midwives and doctors all evaluated the change positively. These findings provide evidence to support this advanced practice midwifery model in other similar maternity services.
