Inequities in pre-pregnancy folic acid use in Central and South Auckland: secondary analysis from a postpartum contraception survey.

Introduction In Aotearoa New Zealand (NZ), there is inequity in rates of neural tube defects (NTDs). Among Maaori, NTD occur in 4.58/10 000 live births, and for Pacific peoples, it is 4.09/10 000 live births; this is compared to 2.81/10 000 live births for non-Maaori, non-Pacific peoples. Aim To describe self-reported pre-pregnancy folic acid supplementation and to determine the association between pregnancy intendedness, ethnicity, parity, maternal age, care provider and pre-pregnancy folic acid supplementation. Methods Secondary analysis of postpartum survey data collected at Te Whatu Ora Te Toka Tumai and Counties Manukau birthing facilities in 2020 was conducted. Descriptive analyses explored pregnancy intendedness and self-reported folic acid use by demographic variables. Multivariable logistic regression explored independent associations between demographic variables and folic acid use among intended pregnancies. Results In total, 398 participants completed the survey. The response rate was (140/149) 94% at Counties Manukau and (258/315) 82% at Te Toka Tumai. Pre-pregnancy supplementation was reported by 182 of 398 participants (46%). Use was higher among those who intended their pregnancy (151/262, 58%) compared to those who were 'pregnancy ambivalent' (9/33, 27%) or did not intend to become pregnant (22/103, 21%). Factors independently associated with supplementation among intended pregnancies included: 'Other ethnicity' (European, Middle Eastern, Latin American, African) compared to Maaori (aOR 5.3 (95% CI 1.3, 21.8)), age ≥30 years compared to Discussion Low rates of pre-pregnancy folic acid supplementation exist in Auckland with significant ethnic disparity. Mandatory fortification of non-organic wheat is important, but supplementation is still recommended to maximally reduce risk.

How well do we support whanau with postpartum contraception? Comparison of two Auckland maternity hospitals.

AIM: To compare the rates of recall of contraceptive discussion and provision of chosen contraceptive method before discharge among patients who recently birthed in two tertiary maternity units in Auckland, New Zealand. METHOD: A cross-sectional survey of recently postpartum patients at tertiary and associated primary birthing units aligned with Auckland and Counties Manukau maternity services was undertaken in 2019 and 2020. RESULTS: Five hundred and seventy-one patients took part in the survey. Overall recall around contraceptive discussions was low, as was the number of patients leaving hospital with their preferred method of contraception. Compared to Counties Manukau, almost twice as many patients at Auckland were unable to recall either an antenatal or postpartum discussion with a health professional about contraception (77% vs 39%, p<0.001). Those birthing at Counties Manukau were also more likely to recall seeing a hospital contraceptive brochure than those at Auckland (42% vs 20%, p<0.001). Twice as many patients at Counties Manukau left hospital with their chosen method compared to those at Auckland (31% vs 14%, p<0.001). In addition, long-acting reversible contraceptives (LARCs) were more often chosen for contraception at Counties Manukau (31% vs 22%, p=0.01) and more patients left hospital with their LARC compared to Auckland (13% vs 7%, p=0.03). CONCLUSION: These differences between two large tertiary maternity services suggests an opportunity for quality improvement around contraception provision.

Factors associated with postpartum contraceptive planning in New Zealand.

OBJECTIVE: To identify factors associated with contraceptive planning in the immediate postpartum period. STUDY DESIGN: Survey of those receiving inpatient postpartum care in two tertiary hospitals/associated birthing units (Auckland, New Zealand). Multivariable analyses using logistic regression examined independent predictors of contraceptive planning. RESULTS: Of 571 participants, those who recalled both antenatal and postpartum contraception discussions were more likely to have a contraceptive plan than those who recalled neither (aOR 5.6(2.8-11.5)). CONCLUSION: Both antenatal and postpartum contraceptive discussions are associated with postpartum contraceptive planning. IMPLICATIONS: Both antenatal and postpartum discussions around contraception were independently associated with increased rates of established contraceptive plan postpartum, however patients who recalled both were more likely to have made a plan. Clinicians should provide multiple opportunities for discussing contraception throughout pregnancy and post-pregnancy to facilitate informed decision making.

Pregnancy planning and barriers to accessing postnatal contraception in New Zealand.

OBJECTIVE: To estimate rates of pregnancy and contraceptive planning and to identify barriers and enablers to postnatal contraceptive use. STUDY DESIGN: Face-to-face survey of patients during their immediate postnatal stay at Middlemore Hospital, Auckland, or associated primary birthing units. Patients were approached by study investigators over designated 2-week study periods in 2019 and 2020. The primary outcome was the rate of pregnancy and contraceptive planning. The descriptive analysis explored differences between ethnicities. RESULTS: We were able to approach 332 of 497 eligible women (67%), and 313 of 332 (94%) of those who approached completed the survey. Fifty-three percent of pregnancies were reported to have been planned. Pregnancy was more often planned by European (72%), Indian (68%), and Other Asian patients (72%) compared with Maori (33%) and Pacific patients (39%) (p < 0.001). Thirty-seven percent of patients reported an antenatal contraceptive discussion, and these were more commonly reported by Maori and Pacific patients (p < 0.001). A quarter of patients reported never having a conversation about contraception during or immediately after pregnancy, a third of whom said they would have valued one. Fifty-nine percent of patients reported having made a contraceptive plan immediately after birth. Concern about the side effects of contraception was a barrier reported by 51% of patients. Cost, travel, finding time, and family views were less frequent barriers. CONCLUSION: Rates of pregnancy planning reported postnatally are consistent with previous NZ research at approximately 50%, and we also found ethnic differences. Concerns about side effects were the most significant barrier for patients accessing contraception and this needs to be addressed in a culturally useful format. IMPLICATIONS: Postpartum patients report low rates of pregnancy planning. A significant proportion of postpartum patients report having no conversations about contraception with clinicians, and concerns about side effects are their most common barrier to contraception.

The effect of the Shorter Stays in Emergency Departments health target on the quality of ED discharge summaries.

OBJECTIVE: Time targets for ED stays are used as a policy instrument to reduce ED crowding. There is debate whether such policies are helpful or harmful, as focus on a process target may divert attention from clinical care. The objective of this study is to investigate whether the Shorter Stays in Emergency Departments target in New Zealand was associated with a change in the quality of ED discharge information provided to primary care providers. METHODS: The quality of discharge summaries was assessed retrospectively over time using chart review. Logistic regression was used to account for secular trends with adequate or not as the dependent variable. Explanatory variables were: age, ethnicity, deprivation, triage category, year, the step at target introduction (2009) and the change in slope before and after the target. RESULTS: Of 500 randomly selected discharge summaries, 491 (98.2%) were included in the analysis. There was evidence of a decrease over time in the proportion of adequate discharge summaries before the introduction of the target (slope estimate (SE) -0.43 (0.20), p=0.02). A step at the target introduction could not be shown (p=0.47). There was evidence of an improvement over time from pre-target to post-target: slope afterwards 0.33, estimate of change in slope (SE) 0.76 (0.27), p=0.006. CONCLUSIONS: There was no reduction in the quality of discharge summaries following the introduction of the shorter stays in ED target and trends in quality improved. These findings deserve replication in other hospitals which may experience different challenges.

Review article: Components of a good quality discharge summary: a systematic review.

OBJECTIVE: The present study aims to inform the use of discharge summaries as a marker of the quality of communication between ED and primary care; this systematic review aims to identify a consensus on the key components of a high-quality discharge summary. METHOD: A systematic search of the major medical and allied health databases and Google Scholar was conducted, using predetermined criteria for inclusion. Two authors independently reviewed the full texts of potentially relevant studies to determine eligibility for inclusion. Data were extracted using a standard form, and the level of evidence was assessed using a predetermined scale. RESULTS: We screened 827 articles, and 84 articles underwent full-text review. Thirty-two studies were included, and 15 studies were level A or B studies. The agreement between authors for level of evidence was good: k = 0.62 (95% confidence interval [CI] 0.4-0.84) and for which components were included was 1011/1056, 95.7% (95% CI 94.3-96.8%). Thirty-four components were identified; however, only four were ranked as important by ≥80% of respondents or scored ≥80% on a scale of importance. These were: discharge diagnosis, treatment received, investigation results and follow-up plan. The quality of information contained in summaries was incompletely assessed in most studies. CONCLUSION: The key components to include in a discharge summary are the discharge diagnosis, treatment received, results of investigations and the follow up required. The limited evidence pertaining to ED discharges was consistent with this. The adequacy of the components rather than just their presence or absence should also be considered when assessing the quality of discharge summaries.