A Time of Travelling Hopefully: a Mixed Methods Study of Decision Making by Women and Midwives about Maternity Transfers in Rural Aotearoa, New Zealand

Abstract

<p>Making decisions about the reasons for, and the timing of transfer to specialist care from rural maternity care were examined in this study. This is a time when women and midwives 'travel hopefully' through labour and birth aware of their rural context. A Mixed Methods Research (MMR) approach was used to gather data from a national survey of rural maternity units together with individual and small group interviews of women and of midwives. A modified Concurrent Mixed Model Design was used to structure the research process with each data strand collated and discussed consistent with its paradigmatic roots. The findings were then drawn together in a metainference. A 17% rate of transfer during labour and up to 6 hours postpartum was found for the two year period examined. Slow progress in labour was the most common reason for transfer. Interviews with rural women and midwives revealed a similar range of decision making styles. The strategy of 'thinking ahead' emerged as a common theme which allowed for the distance and time involved in the transfer and in anticipation of critique from the secondary care system and local community.This thesis makes a significant contribution to the national and international understanding of the experience of maternity transfer in rural areas and finds that within a regionalised perinatal system, midwives make cautious and timely decisions about transfer in labour and birth. Further, that a rural birthing service contributes to the health and well being of the community and ought to be appropriately resourced to provide the optimal environment for safe decisions about transfer.</p>

Rural midwifery practice in Aotearoa/New Zealand: Strengths, vulnerabilities, opportunities and challenges

“…The appreciation of rural women and the commitment to rural communities have been found in other research into rural midwives in New Zealand (Crowther, 2016;Kyle & Aileone, 2013;Patterson 2009). A common thread in the survey was that midwives identified that working autonomously is an essential and central tenet of rural practice and most commented on this positively.…”

“…My biggest challenges are the isolation -the closest midwife lives 85km away, the numbers (it's financially unsustainable to call this a caseload), and time off -there is no time off to be able to do anything reliable with my family. (Kim, Forum) The issues related to the time associated with travel, isolation and maintaining a sustainable workload have been highlighted in other research on rural midwifery in New Zealand (Crowther, 2016;Kyle & Aileone, 2013;Patterson 2009). In addition, many participants wrote about the impact of adverse weather conditions.…”

“…Previous research in New Zealand has also identified that rural midwives need enhanced skills to deal with emergencies which include skills in decision-making and contingency planning (Crowther et al, 2018;Kyle & Aileone, 2013;Patterson 2009). The purpose of these skills is to enable rural women to have the benefit of birthing in their own communities, close to their families rather than in obstetric facilities far from home when this is not what they need:…”

“…Challenges include shortages of rural Lead Maternity Carer (LMC) midwives (Gibbons, Lancaster, Gosman, & Lawrenson, 2016;Kyle & Aileone, 2013) and the marginal economic feasibility of rural LMC midwifery practice due to the costs and time associated with travel distances and low caseload numbers (Crowther, 2016;Kyle & Aileone, 2013;Patterson, 2009). Several studies have found that rural midwives experience relative professional isolation which leads to "heightened vigilance" (Kyle & Aileone, 2013, p.39) and pervading feelings of vulnerability (Crowther, Smythe, & Spence, 2018) in needing to be prepared to manage unexpected and emergency events on their own.…”

“…Several studies have found that rural midwives experience relative professional isolation which leads to "heightened vigilance" (Kyle & Aileone, 2013, p.39) and pervading feelings of vulnerability (Crowther, Smythe, & Spence, 2018) in needing to be prepared to manage unexpected and emergency events on their own. This is exacerbated by the fear of being subjected to criticism from urban-based colleagues (Crowther et al, 2018;Patterson 2009;Patterson, Skinner, & Foureur, 2015).…”