Table 5 Themes identified from modified ADAPTE questions
Themes | Evidence |
|---|---|
Identified constraints and limitations to implementing the recommendations | |
Limited service capacity | “Constraints on [antenatal clinic] appointments to have women seen in an appropriate timeframe” “Bed capacity to offer admission for all women electing for expectant management [of preterm rupture of membranes]” “Bed availability for inpatient insulin and blood sugar management [for women with diabetes]” “NICU cot availability at local tertiary hospital and need to transfer elsewhere” |
Culturally considered care | “Diabetes is over-represented in Māori and Pasifika populations who are also the demographics that suffer disproportionately from inequitable maternity care in NZ” |
Access • Geographical constraints • To tests and interventions • To specialist services | “For women in rural areas it may be harder for them to access care when they do start bleeding and therefore do not receive interventions until later “Availability of emergency transfer and retrieval services and neonatal services” “Access to specialist scanning and MFM specialists if required” “BP monitoring more difficult for women living rurally or with transport difficulties. LMCs may have limited ability to visit and perform frequent checks” “Access to ultrasound where demand is exceeding supply and cost [is a] barrier” “Ideally a pre-pregnancy health optimisation consultation would take place for high risk and obese women but the scope and funding for this is certainly not prioritized and more often than not is opportunistic rather than planned. Our highest risk patients are the least likely to present for such consultations secondary to financial social and educational constraints” “Many peripheral centres do not have the neonatal expertise to care for the extreme preterm and women need to be transferred” |
Funding | “LMCs not resourced to deliver [anti-D] in the community which may contribute to women not receiving prophylactic dosing” “Funding of LMCs to perform frequent BP monitoring” |
Staff shortages | “Maternity services all around New Zealand are facing critical shortages and this means that optimal care is not being provided to women. This is more so in the most unwell women” “National midwifery shortage makes it challenging to perform frequent outpatient BP monitoring as well as undertake staff intensive interventions such as MgSO4 or IV antihypertensive therapy” “There is a shortage of specialist Maternal Fetal Medicine doctors and midwives for the population and this may hinder the advice, support and management that is provided to women” |
Education and care coordination | “Consistent availability of treatment recommendations in all main centres” “Staff education around implementation of guideline” “Skill expertise, legislation and policy, and organisational barriers” |
Factors that had a positive impact on equity | |
Quality of guidelines | “Administration of steroids [following binational guideline] to improve outcomes for preterm babies. Universal administration would ideally reduce differences for all” “If recommendations [from binational Magnesium Sulphate guideline] are implemented across all areas, [it] has the potential to reduce differences in PTB outcomes across populations” |
Nationally consistent guidance | “The clear guidance for what to do for women who are less than 24 weeks - all women should get [the] same talk and options for their baby” “Good to have clear indications/parameters about when to consider delivery at different gestations [for women with antepartum haemorrhage]” “Good to have explicit information about lines of communication and responsibility plus clear information about funding and support for women and whanau” “Good to have [a] clear step by step guide of how to arrange transfers and who is responsible at each step to streamline this potentially stressful event” |
Culturally considered approach | “Good that Māori/Pacific Island ethnicity scores a point as an Amber warning score [on the sepsis guideline] to account for women of these ethnicities often presenting later and having worse outcomes” |
Factors that had a negative impact on equity | |
Quality of guidelines | “Very low quality guideline with no referencing” “Extremely brief guideline, no background, no references, no comment about management” |
Nationally consistent guidance | “Recommend more consistency in practice that is likely to vary by clinician and unit” |
Culturally considered approach | “There is a lack of cultural safety in how this guideline would apply to Māori and Pasifika patients. As a result, it may be less successful for Māori and Pasifika patients if there is an absence of a more holistic approach, as well as the absence of upstream approaches” “No culturally diverse information/advice provided” “Unless population specific (culturally appropriate) support available then differences between Māori and non-Māori smoking cessation rates are likely to increase” |
Feasibility of implementing recommendations | “Women of low SES or with transport difficulties may find it more difficult to access prophylactic dosing and therapeutic dosing of Anti-D due to having to present to hospital to receive this rather than being able to get directly from their LMC in the community” “Access and cost of ultrasound examinations which is more difficult for women who are rural, low SES or have transport difficulties” “Less access to early midwifery care in rural and low SES women. Need to be able to present for consultation and afford prescriptions” “The aim of this statement was to standardise care for peri-viable gestations nationally to reduce equity issues, which is a good step. However the tyranny of distance still applies” “BP monitoring more difficult for women living rurally or with transport difficulties. LMCs may have limited ability to visit and perform frequent checks” “Rural and low socioeconomic populations may face barriers to accessing timely/appropriate clinical care and screening” |
Enablers to improving equity | |
Culturally considered approach | “Prioritisation of culturally appropriate [smoking] cessation support” “Training more Māori and Pasifika midwives” “Whanau-based support rather than individual based given that smoking is often a social activity” “Māori model of quit smoking support” “Programmes to ensure vaccinations can be carried out in [least advantaged] communities by removing barriers to health care. Having Māori and Pasifika role models advocating for vaccinations during pregnancy” |
Targeted approach towards groups experiencing least advantage | “Target [preterm labour] guideline to Māori, Pasifika and Indian women who are more likely to suffer greater barriers to antenatal care. This will ensure the implementation of the guideline prioritises the most vulnerable” “Increased funding for sexual health care and treatment for priority (underprivileged/highest incidence) groups” “Consultation and collaboration with target users and population to effect implementation” “Targeted auditing of outcomes in priority groups to provide feedback to clinicians and policy makers as to whether the recommendations are being followed and having effect” |
Nationally consistent guidance | “Ensure DHBs use the national guideline with some contextual information only [to apply to local setting]” |
Funding to support implementation | “Ensuring reimbursement of travel costs and financial support if women are leaving family behind for many weeks” “Funding of continuous glucose monitoring” “Easier access to Anti-D in the community with protocol and funding for midwives to deliver this where women are” “Loan home BP monitors may help women be able to monitor this more independently” |