Rationale for my interest in the topic of decision making around rural maternity transfer Research questions Underlying assumptions Contribution to the rural community Ethics process The survey findings Decision theory The themes from the interviews with women and midwives Overall conclusions Current and future support for decision making around rural maternity transfers

Rationale for my interest in the topic of decision making around rural maternity transfer

Research questions

Underlying assumptions

Contribution to the rural community

Ethics process

The survey findings

Decision theory

The themes from the interviews with women and midwives

Overall conclusions

Current and future support for decision making around rural maternity transfers

Rural maternity facilities are places where normal birth can occur and for some women birthing in their ‘place’ is important Transfer is a disruptive and often stressful process which affects everyone involved If transfers occur too early or too late the reputation and the viability of the local service may be threatened

Rural maternity facilities are places where normal birth can occur and for some women birthing in their ‘place’ is important

Transfer is a disruptive and often stressful process which affects everyone involved

If transfers occur too early or too late the reputation and the viability of the local service may be threatened

How do women and midwives arrive at the decision to transfer, or, not to transfer, during labour or postnatally from primary/rural facilities to secondary/tertiary care? What are the rates of transfer from primary /rural maternity facilities to secondary / tertiary maternity facilities, and the primary reasons for the transfers over a two year period? What are the particular characteristics of the primary/ rural facilities with regard to their geographical, climatic features and local arrangements for service delivery?

How do women and midwives arrive at the decision to transfer, or, not to transfer, during labour or postnatally from primary/rural facilities to secondary/tertiary care?

What are the rates of transfer from primary /rural maternity facilities to secondary / tertiary maternity facilities, and the primary reasons for the transfers over a two year period?

What are the particular characteristics of the primary/ rural facilities with regard to their geographical, climatic features and local arrangements for service delivery?

That it is appropriate for well women near term to plan to birth in their local rural facility ( Maternity Report/s,2004, 2006; 2007 Rosenblatt, 1984 & 1985; Tracy et al., 2006). Skilled midwifery workforce is a valuable resource in rural areas (Canadian Medical Association, 1994; Nesbitt, Larson, Rosenblatt, & Hart, 1997; Nolan, 2002; Tew, 1995) Making the decision to transfer involves personal, social and logistical considerations (Jones, 2005; Marshall, 2005; Reason, 1994; Sch ö n, 1991; Siddiqui,2005) and adverse outcomes can affect the confidence of the women and practitioners involved (Creasy, 1997; Griew, 2003 Nolan, 2002; Walker, 2000) There are frequently tensions at the rural /urban interface (Baird, 2005; Davis 2006; Patterson, 2003; Skinner, 2005). Transfer events and rates can affect the long term viability of the facility ( Green et al,1990; Kornelsen & Grzybowski, 2005).

That it is appropriate for well women near term to plan to birth in their local rural facility ( Maternity Report/s,2004, 2006; 2007 Rosenblatt, 1984 & 1985; Tracy et al., 2006).

Skilled midwifery workforce is a valuable resource in rural areas (Canadian Medical Association, 1994; Nesbitt, Larson, Rosenblatt, & Hart, 1997; Nolan, 2002; Tew, 1995)

Making the decision to transfer involves personal, social and logistical considerations (Jones, 2005; Marshall, 2005; Reason, 1994; Sch ö n, 1991; Siddiqui,2005)

and adverse outcomes can affect the confidence of the women and practitioners involved (Creasy, 1997; Griew, 2003 Nolan, 2002; Walker, 2000)

There are frequently tensions at the rural /urban interface (Baird, 2005; Davis 2006; Patterson, 2003; Skinner, 2005).

Transfer events and rates can affect the long term viability of the facility ( Green et al,1990; Kornelsen & Grzybowski, 2005).

Mixed Methods Research Design informed by pragmatism A modified concurrent mixed model design for the conceptual framework Data sources : Survey of rural maternity facilities Interviews with women and midwives Analysis processes: Descriptive statistics and thematic analyses

Mixed Methods Research Design informed by pragmatism

A modified concurrent mixed model design for the conceptual framework

Data sources :

Survey of rural maternity facilities

Interviews with women and midwives

Analysis processes:

Descriptive statistics and thematic analyses

Quantitative strand Rural maternity Survey Qualitative strands . Women’s and Midwives’ Interviews Modified concurrent mixed model design (Tashakorri & Teddlie, 2006) Research Question Data Collection Data Analysis Inference Research Question Meta-Inference Data Collection Data Analysis Inference Research Question Data Collection Data Analysis Inference

19 South Is. 11 North Is. 13 completed LA 30 rural fac. Participated in the survey 3 – No rural mat. Fac. 21 DHBs 18 Approached for LA Process for survey distribution 45 rural 64 Primary Facilities

Total of 3901 births over a 2 year period (1 st July 2004 to 30 th June 2006) Number of rural facilities <10 4 10 - 50 5 51-100 7 101-200 8 201-300 2 301-400 2 > 400 2 30 rural facilities

Labour and birth transfer rate 16.60% (777/4678)

Total of neonatal transfers 123 from 3901 births

Topographical features and weather effects Areas affected Mountains 11 Road slips and subsidence 25 Snow and ice 17 Flooding 16

The women Deciding on the safest place to give birth Deciding on transfer in labour Looking back on the transfer decision The influence of the rural maternity arrangements on their decisions The midwives Helping women decide about birthplace Deciding about transfer in labour Reflecting on the transfer decision Local issues and the impact on decision making

The women

Deciding on the safest place to give birth

Deciding on transfer in labour

Looking back on the transfer decision

The influence of the rural maternity arrangements on their decisions

The midwives

Helping women decide about birthplace

Deciding about transfer in labour

Reflecting on the transfer decision

Local issues and the impact on decision making

‘ Nothing special’ Niggles of fear Travelling hopefully It is up to you Making the decision about transfer Future planning Uncertainty about the maternity service

‘ Nothing special’

Niggles of fear

Travelling hopefully

It is up to you

Making the decision about transfer

Future planning

Uncertainty about the maternity service

Guiding women and setting boundaries Making the mind shift from normal to abnormal Dealing with transport Ripples in the community Responses from secondary care staff Attracting women to birth locally and keeping facilities viable

Guiding women and setting boundaries

Making the mind shift from normal to abnormal

Dealing with transport

Ripples in the community

Responses from secondary care staff

Attracting women to birth locally and keeping facilities viable

Rural women and midwives making decisions about transfer in childbirth Personal history and beliefs Power issues Desires and dreams Recent experience Perception of risk Local Context Distance and time, terrain, weather Transport and logistical support Community response Anticipated Secondary care response Personal decision making Normative/ descriptive Heuristics of anchoring, representativeness and availability Styles of decision making Prescriptive/ paternalistic Informed Shared Hybrid or continuum

Personal habit of critical reflection Improved transport and logistical support from local rural areas and appreciation and support at the secondary tertiary interface Public acknowledgment of the contribution of rural maternity services with continued funding and logistical support from government agencies

Personal habit of critical reflection

Improved transport and logistical support from local rural areas and appreciation and support at the secondary tertiary interface

Public acknowledgment of the contribution of rural maternity services with continued funding and logistical support from government agencies

Within a regionalised perinatal system midwives make cautious and timely decisions about transfer in labour and birth For well women near term it is an appropriate choice to plan to birth in their local areas Logistical support for rural birthing services provides the optimal environment for safe decisions about transfer

Within a regionalised perinatal system midwives make cautious and timely decisions about transfer in labour and birth

For well women near term it is an appropriate choice to plan to birth in their local areas

Logistical support for rural birthing services provides the optimal environment for safe decisions about transfer

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