Access to maternity services: Qualitative research
Summary of findings
Knowledge and awareness of healthcare and pregnancy • Women know little detail about healthcare in pregnancy before they are first pregnant and often don’t know who one ought to see and when: they rely firstly on friends and family for information, and then may consult magazines and online sources • There is widespread awareness that there is a scan ‘early on’ around 12 weeks, but this may not be expected till 16 weeks, based on hearsay and family experience. • Most assume the GP is the correct first port of call, partly to confirm pregnancy, although all will have done tests. Existing mothers know the midwife will be main point of contact but still usually start with the GP first as a medical authority figure • Many reported the GP simply told them to book with the midwife service (often based at same surgery) and this could lead to unnecessary delay (the GP appointment may have taken time to get, or created problems in combining with working hours, and rebooking can also result in further delays or even confusion), and for some a sense of being dismissed or let down by a GP who simply passes them on with a short consultation. A range of situations can lead to late booking • Key barriers to early booking could be categorised into the following groups: informational, logistical, personal and social. However there was often a combination of factors that encouraged late booking. • Certain types emerged in the research. ‘Late discoverers’ did not know they were pregnant, or were not willing to accept they were pregnant until after 12 weeks six days. ‘Disappointment avoiders’ were anxious about losing their baby and did not attend through fear of jinxing the pregnancy. ‘The undecided’ knew they were pregnant, but were not ready to accept it, or were considering termination and therefore delayed starting their pregnancy journey. ‘Social disapproval avoiders’ delayed due to concerns about what others may say to them or about them. Some women suffered ‘logistical problems’ at the point of booking such as not being offered appointments in time or were ‘unengaged and ill-informed’ about the appointment. Some ethnic women feared ‘Poor cultural understanding’ from midwives and GPs. • Some ethnic and at risk groups had low awareness of UK medical practice. Others felt distant from the system or looked down on, and language barriers and difficulty of arranging help also played a part in holding back booking • A key theme and barrier across all types was a lack of knowledge about the ideal time frame for the booking appointment and an appreciation of its importance which meant many were not being proactive. It was typically seen as an administrative bureaucratic process rather than something beneficial and helpful to them and baby. • Once the ideal timing of the booking appointment is appreciated and it is discussed as a planning meeting to help decide about care, ensure best care, provide up to date advice and support and drive the scan appointment, it becomes much more attractive and likely to be more actively sought out. • Both professionals and mothers agree that an early scan is a key draw: both as this is an exciting point that pregnant women focus on, and as a non-intrusive precaution in the case of Neucal Fold scan, for those interested in diagnostic scans. Addressing the barriers • As most women did not know exactly how the system worked or the ideal timeframes, and generally believed the GP started the pregnancy care and the midwife came in later, communicating key facts about the early pregnancy healthcare process and the booking appointment was considered important in increasing knowledge and driving engagement and pro-activity. • As women tend to have taken personal pregnancy tests before visiting GP, communications, such as a leaflet, with the test would be an easy win – explaining what to do next if the woman is happy, unhappy or unsure about the result. • More generally, strategies that communicate the behaviour (first meeting pre 12 weeks) and the benefit, such as up to date advice and support, care, early scan and better planning, would empower women to be active in seeking appointments rather than waiting for system. • The GP, as a medical authority figure, was seen as important in encouraging early booking by explaining clearly to women the ideal timeframes of the appointment, the benefits of attending and the role/profile of the midwife. GP support and the provision of counselling could also help in keeping those who are considering termination in the system, so that if they do decide to keep their baby they can attend the booking appointment within the ideal timeframe. • A simple piece of literature (e.g. leaflet, poster, flyer) about the booking appointment was welcomed, and if provided at the first GPs appointment could be read at the woman’s leisure when she may also be more balanced emotionally. • Placing simple communications in the local community was also felt to be a good way to increase knowledge and understanding, particularly amongst those from ethnic groups if placed in relevant locations. • Few knew where to go on the web / who to phone about pregnancy specific information, but many felt NHS Direct (or Choices) was too medical for this topic. The creation of a specific pregnancy destination and phone number that offered booking, advice and counselling is seen as a potential way to fast-track women into the system • The early booking leaflets from Yorks / Humber and Birmingham, and the Hackney Wheel all were seen as very positive and useful, and worthy of wider distribution. There was a clear demand for simple ‘how it works’ leaflets, as well as simple explanations of the benefits of early booking. The material targeted at problem groups (e.g. Hackney Wheel) was also seen as a sensitive way of raising difficult topics and providing routes to help. • There was support for out of hours clinics, provision of home visits, drop in and Sure Start based facilities, and of the general principle of making access easier for the working mother to be and the mother of young children. • Ethnic groups and teenage mothers were supportive of specialist midwives who had and demonstrated experience and understanding of specialist issues. The provision of translators and ensuring that cultural understanding was demonstrated were essential to ethnic groups, and word of mouth within communities felt important in creating good will and understanding. • Ways of maximising the value of word of mouth within ethnic communities, and involving the community in supporting each-other would be worth further consideration, as would using other professionals and stakeholders who already deal with and are trusted by specific communities as a bridge. • Health professionals with contact with ethnic hard to reach groups felt the notion of Bump Buddies where advocates in local community were recruited was a very strong idea. • Beyond this, health professionals felt that the wider publication of how the pregnancy care system works, promotion of contact routes and improvement in referral systems were all seen as effective approaches. There was a widespread acknowledgement that referral routes are currently often passive, and diverge even within practices, and that a standard and automated system would be a real benefit • One area of divergence among professionals was the notion of direct access to midwives. While some (and most midwives) were strongly supportive, others felt uncomfortable about loss of personal contact with patients at a positive time, and concerned about possible problems with lack of medical input, or with the loss of opportunity to counsel the uncertain mother about her options. All were supportive of the notion that access to midwives should be easier, however. Conclusions and Recommendations The evidence of this research suggests that much of the late booking today can be attributed to six key factors: 1. Late diagnosis of pregnancy (physical) 2. Late acceptance of pregnancy (emotional) 3. Systemic problems with referral leading to late arrival at midwife 4. Practical barriers to getting appointments 5. General lack of information about importance of early first appointment 6. Cultural and demographic barriers to early engagement with the midwifery system • The first two areas are difficult to tackle, although leaflets and communications highlighting the routes and the benefit of early access, for example in pregnancy tests, would help address the second. • Systemic problems are largely to do with liaison between GP’s, surgeries, hospitals, other care providers and midwives. There can be an assumption that once someone knows you are pregnant the system will take over. Reminding the care providers that this is the assumption will of itself help, and could make other care providers more pro-active. • Practical barriers reflect the difficulty of getting GP appointments for many, and the uncertainly about who and where one ought to go if not the doctor. Again, publication of how it works and contact routes will help ensure women are more pro-active. Out of hours appointments and drop in clinics would clearly help too. • The general lack of information about how the system works (and how it has changed in terms of when scans happen) and what the booking appointment is, can be tackled, at a high or low profile level. Broad scale advertising seems wasteful and untargeted, however, education of late teenage girls about the system, PR seeding of stories and simple posters and leaflets in GP surgeries / Sexual Health clinics /local communities would all help, as would a pregnancy test leaflet. • There is also a need for specifically targeted information and support for minority groups both to get information across and to communicate to these groups that they matter and are a priority for the health service. Community outreach, local language leaflets and other community based work (for example among teens, drug users or travelers) would all help to reassure vulnerable groups that, if pregnant, they will be welcomed and cared for. • For professionals, the notion that these targets are important, are being measured, and resources being found to drive early access and uptake of Neucal Fold scans (for example) may also create a more positive attitude toward delivering this care to the target audience. At the moment there is a general belief that earlier access is a good thing, coupled with some uncertainty as to what policy is being worked toward.
Formative stage • Conducted with 10 x women in long cooking-based session in children’s centre • Mix of discussion and practical in order to evaluate concept properly Pilot • Implementation targeting “group rejectors” • Launch area predom. S. Asian • Some challenges around launch • Interpreter issues and Ramadan • Plus swine flu • Leading to review of target and area: Dewsbury = White British Evaluation • Forms as record of the visits - 7 x forms returned • Tele-depths of participants/ non-participants - 5 x pilot participants, 5 x ‘similar’ non-participants • Tele-depths with pilot professionals - 3 x interviews: with programme leader, food tutor and HV (referrals)
• The quality and choice of maternity care a woman receives is improved by early access to a GP or midwife. The Department of Health’s policy objective (PSA 19: Indicator 4) is to encourage women to access maternity services as soon as they know they are pregnant for an assessment, commonly known as the ‘booking appointment’. ‘Early booking’ happens before 12 weeks, 6 days of pregnancy. • The Department of Health want to understand barriers to accessing the booking appointment ‘early’ and in particular, approaches that will work to raise the number of women making early booking appointments • COI have been tasked with developing an intervention toolkit (based on existing best practice, and ideas derived from new primary research) that can be shared with PCTs to help drive up early booking rates to 90% by end financial year 2011.
Research to help understand the barriers to women accessing maternity services at the beginning of their pregnancy (known as ‘early booking’) The research suggests that much of the late booking today can be attributed to six key factors: 1. Late diagnosis of pregnancy (physical) 2. Late acceptance of pregnancy (emotional) 3. Systemic problems with referral leading to late arrival at midwife 4. Practical barriers to getting appointments 5. General lack of information about importance of early first appointment 6. Cultural and demographic barriers to early engagement with the midwifery system
Mixed including women from minority ethnic communities - Bangladeshi, Pakistani, Traveller (Romany and Irish), Somalian and Black African
• 8 mini-groups and 6 depths with mainstream DE women; including late and early bookers but biased to late bookers; all pregnant or had a child in the last year • 10 depths interviews with Health Professionals (mix of midwives and GPs) across early and late access locations • Interviews with approximately 34 women from minority ethnic communities interviewed via depths and small friendship sessions using translators where appropriate. Communities included Bangladeshi, Pakistani, Traveller (Romany and Irish), Somalian and Black African communities. These included both late and early bookers. • 6 depth interviews with teenage mothers and 1 depth interview with a former drug user • Conducted in England
Data collection methodology
47 depth interviews and 8 mini-groups with pregnant and recently delivered women, 10 depths interviews with Health Professionals
Plymouth, Manchester, Oldham, Northamptonshire