Mobile Technologies for Midwifery Service Delivery

Mobile Technologies for Healthcare Service Delivery Additional Possibilities for Midwifery Service Delivery **

The case for exploring Mobile Technologies in this health setting

Three Elements

1. Midwives

2. Women using

Independent Midwifery Services

3. Technology

1. Midwives gardenofpraise.com/godseg35.htm

New Zealand Independent Midwives Already Use:

Mobile laptop computers.

Mobile phones.

A maternity practice management system which includes:

Electronic fee claiming system for payment from the NZ Ministry of Health.

Electronic clinical maternity notes.

Electronic data collection for clinical audit and professional standards review.

Shared clinical notes

( maternityplus from Solutions Plus)

New Zealand Independent Midwives Are:

Mobile.

Provide services to well-women.

Provide service for a group who are high users of mobile phones.

Midwives Are Educators

Timely trusted information empowers women and enables them to particpate and make decisions that promote their own, and their baby’s health.

Midwives

Midwives are in a unique position that enables them to follow a women during the whole pregnancy, and have the opportunity to build trust, educate and empower women.

The relationship is a partnership model, each contributing towards the desirable outcome.

Midwives scope of practice:

Is restricted to care for women thoughout normal pregnancy and childbirth. (Section 88 Maternity Notice, MOH).

Is one of taking responsibility for the care of a woman immediately prior to and throughout her pregnancy, childbirth and up to six weeks postpartum.

Midwives

Communicate,

Monitor vital signs,

Educate and empower women to take control of their own health,

Conduct tests,

Keep accurate records,

Plan and manage labour and delivery,

Refer and consult in a timely manner.

Midwives

Promote care that fosters normality during pregnancy and childbirth.

Midwifery Services

The partnership model of one Lead Maternity Carer following a woman thoughout her pregnancy, birth and for six weeks following birth is a safe model for women although “caution should be exercised in applying this advice to women with substantial medical or obstetric complication.” (Cochrane 2009)

Communication

Effective communication is at the core of the caring model.

Effectve communication can lead to security, trust and empowerment.*

*Battersby, S., Evans, M., Marsh, B., Walker, A. & Medforth, J. Oxford handbook of midwifery , Oxford University Press. P216

Pairman, S., Pincombe, J., Thorogood, C. & Tracy, S. (2006) Midwifery: preparation for practice Elsevier Australia. P251

2. Women using independent midwifery services

Pregnant women have specific educational and information needs.

WHO guidelines advise:

Natural childbirth for normal pregancies is desirable and possible in most cases. Rates should be 10 – 15% (WHO)*

Smoking is detrimental to unborn babies.

Pregnant women need excellent nutrition to enable their unborn baby to develop optimally (WHO).

Breast feeding for six months benefits babies (WHO).

Abstain from alcohol during pregnancy(WHO).

*Belizã¡n, J. M., Althabe, F. & Cafferata, M. A. L. (2007) Health Consequences of the Increasing Caesarean Section Rates. Epidemiology, 18 , 4, 485-486 10.1097/EDE.0b013e318068646a.

Reduced intervention. normal childbirth and caesarean birth rates

Normal Childbirth “ Normal” childbirth is a labour where a woman commences, continues and completes labour physiologically at at term.” (ICM 2006) The New Zealand College of Midwives is committed to “protecting, promoting and supporting normal birth.”

World Health Organisation

The world health organization recommends that the caesarean section rate should not be higher than 10% to 15%.*

NZ in 1989 was 12%.

NZ in 1995/6 was 15.9% (Guilliland)

NZ in 1999 was 20%.

NZ in 2004 and 2005 was approx 23.7%.

*World health organization. Appropriate technology for birth. Lancet. 1985;2:436–7.

Caesarean Section Rate:

Caesarean birth rate in New Zealand is approximately 25%.

In the United States, a third of births are by caesarean section.

Caesarean Births in New Zealand

“ Fear of childbirth is a powerful force implicated behind women’s reasons for choosing a caesarean in the absence of clinical indiations.”

Douche, J.R .,Caesarean section in the absence of clinical indications: Discourses constituting choice in childbirth. 2007 Unpublished thesis Massey University.

Childbirth Education

In 2000, 70% of first time mothers attended childbirth education prior to giving birth.

In 2005, 56% of first time mothers enrolled in childbirth education classes(US figures).*

*Declercq, E.R., Sakala, C., Corry, M.P., & Applebaum S. Listening to mothers 11: Report of the second national US survey of women’s childbearing experiences New York: Childbirth Connection (2006) p24.

Barriers

Time (many women work up until delivery)

Cost (travel is an added expense)

Disinterest (engagement could stimulate interest)

The Internet is a prime source of information.

But evaluation, trustworthiness and volume of information contribute to confusion.

There is a need to:

Reduce smoking,

Improve nutrition,

Increase the level of physical activity,

Reduce interpersonal violence,

Encourage breastfeeding,

Intervene less,

Educate women on the effects of alcohol on their unborn baby.

2. Smoking during pregnancy

Smoking is:

Detrimental to women and especially unborn babies.

“ 22% of pregnant New Zealand women who smoked were smoking around the time of conception.

The proportion of Māori women smoking at conception was twice this estimate (55%).

The MoH has an ambitious goal to reduce this figure to 30% or lower by 2008.”

“ Smoking in pregnancy is the single most preventable cause of pregnancy complications such as miscarriage, pre-term birth, and stillbirth” (Glover).

“ Smoking increases the risk of sudden infant death syndrome and has adverse effects on children’s physical and mental development.”

Glover, M., Paynter, J., Bullen, C. & Kristensen, K. (2008) Supporting pregnant women to quit smoking: postal survey of New Zealand general practitioners and midwives’ smoking cessation knowledge and practices. The New Zealand medical journal, 121 , 1270, 53.

3. Maternal nutrition

Maternal Nutrition

“ pregnancy and lactation are periods during which good nutrition is exceptionally important.”

Zeisel, S. H. (2009) Is maternal diet supplementation beneficial? Optimal development of infant depends on mother's diet. American Journal of Clinical Nutrition, 89 , 2, 685S.

Nutrition in Pregnancy

Pregnancy and lactation increase demands on a woman’s body.

Low levels of maternal folic acid in early pregnancy are linked to birth defects.

Anaemia in pregnancy is common in women whose nutritional needs are inadequate.

Calcium requirements in advanced pregancy and lacation are increased.

4. Exercise during Pregnancy

Exercise during Pregnancy

“ As well as following a healthy, balanced diet, staying physically active is also very important during pregnancy.”

Choi, H. M. (2008) Nutrition in pregnancy. Korean J Obstet Gynecol, 51 , 5, 481-491 .

5. Breastfeeding

Breastfeeding/Lactation Support

Mobile technologies allow increased frequency and ease of communication, enabling greater support, especially during the post-natal period for first time mothers.

Breastfeeding Rate in New Zealand (MOH 2002):

In the past four years, the rates for babies which are reported as being fully breastfed at six months old are:

19-21 percent of European and other babies

17-18 percent for Pacific babies

13-14 percent for Maori babies

In 2002 the Ministry of Health recommended the New Zealand breastfeeding targets as outlined below: to increase the breastfeeding (exclusive and fully) rate at 6 weeks to 74 percent by 2005, and 90 percent by 2010

6. Alcohol during pregnancy

A University of Otago survey reveals New Zealand women are not getting the message that no alcohol should be consumed during pregnancy. More than half the women surveyed believed some alcohol was safe to drink while pregnant. (2006)

Alcohol is one of the main causes of brain damage in the unborn baby.

Otago Survey

40 per cent were of the opinion that women should abstain altogether from drinking during pregnancy.

Half of the women surveyed were of the opinion that one drink or less was safe to be consumed on a typical drinking occasion in pregnancy.

20 per cent of the women binged at some time during their pregnancy.

Seventeen percent had done so before they realised they were pregnant.

Guidelines

Professor Elizabeth Elliott, Discipline of Paediatrics and Child Health, The University of Sydney,

“ no drinking is the safest option”.

Elliott, E. J. & Bower, C. (2008) Alcohol and pregnancy: The pivotal role of the obstetrician. Australian and New Zealand Journal of Obstetrics and Gynaecology, 48 , 3, 236-239.

Guidelines

"There is no known safe level of alcohol consumption at any stage during pregnancy. Therefore, the Ministry recommends that, to be on the safe side, it is best that women avoid drinking alcohol at all during pregnancy. *

*New Zealand MoH Guidelines 2006

7. Women with high needs

Support for Women With High Needs

Women who are single,

Have high demands place on them because of the family situation or,

Who are in an unsatisfactory relationship, need support during their pregnancy.

This group of women need increased support during pregnancy.

Women With High Needs

This group of women may also be higher-risk women with obesity, diabetes, high blood pressure, smoking, drinking, drug, emotional, cultural or other issues.

Women in this group require more time, education and communication with their midwife.

Using the Internet for communication, support, information and educational needs could be exploited.

3. Mobile Technologies

The Future

“ Within 5 years, the majority of Web usage worldwide will be mobile.”

Daniel K. Appelquist , Senior Technology Stratagist Vodafone Group Research and Development (2007)

Mobile Technolgies and Web2.0 Foster

Connecting,

Contributing (user generated content),

Sharing and

Collaborating with

the women’s own healthcare record.

Internet technologies, mobile devices and communication technologies are evolving, converging and becoming more widely used because costs have reduced.

Software Technologies

Microblogs (aggregator) (Twitter)

Desktop clients (Twhirl)

Social networking sites (Ning)

Weblogs (aggregator) (Tumblr)

Page readers (aggregator) (GoogleReader)

RSS feeds and Yahoo Pipes

Commenting tools (Disqus)

Possible Software Technologies

1. Microblogging Tool e.g. Twitter Text updates via SMS appear on the midwives desktop client and feed to a personal weblog.

Microblogging site: Twitter

2. Desktop Client

On the midwife’s laptop computer.

E.g. Twhirl

3. Social Networking websites

The ease with with social networking sites can be set up gives midwives the opportunity to enable mothers to form support groups.

E.g. Ning software

4. Ning social networking site

5. Weblog e.g. Tumblr http://www.tumblr.com/ Women can update this website by SMS, email or from their computer. Midwives can post links for education and reminders or support posts.

Tumblr Weblog http://babyandme.co.nz/

6. Page Reader (aggregator) e.g Google Page Reader http://googlereader.blogspot.com/ A page reader contains all the women’s weblogs for one midwife to readily access for review.

Google Page Reader

7. RSS feeds

RSS (Really Simple Syndication) technologies distribute and aggregate information.

Possible configurations

Data Entry From Woman

Midwife and Woman Feed to a Weblog

Midwife’s pagereader

Integration

This configuration would require integration with midwives’ maternity notes software* currently used for clinical notes, audit and fee claiming.

* SolutionsPlus Software, MaternityPlus

Hardware Devices

Mobile phone.

Laptop computer.

Personal computer.

Communication Technologies

2G 2 nd generation mobile phone standard used for text and voice messaging.

3G 3 rd generation standard used by Vodafone NZ.

Other Issues

Security and Privacy

Security and privacy are always important healthcare issues.

Privacy in this setting could be similar to text messages on a mobile phone. Therefore the information transferred in this setting should be related to this level.

Deployment

A web-enabled server-side database to allow accessability is envisaged.

User Uptake User uptake of new technology is a recognised challenge. Such a plan requires engagement of midwives and women. The present focus is on more accurate assessment of current use and user needs.

Possible Gains

Why there are growing incentives to use mobile technologies within healthcare delivery.

1. Educational gains There could be increased educational opportunities for delivering trusted, relevant, tailored information.

according to:

Gestational age of baby

Literacy level and requirements of women

Interests of women

Health status of women

Support needs of women.

Education and knowledge are tools to empower women.

Pairman, S., Pincombe, J., Thorogood, C. & Tracy, S. (2006) Midwifery: preparation for practice Elsevier Australia. P 253

Fahy, K. (2002) Reflecting on practice to theorise empowerment for women: Using Foucault's concepts. The Australian Journal of Midwifery, 15 , 1, 5-13.

2. Trust gain

Increased frequency of communication can increase the interpersonal trust in the midwife* with possible implications for improved health of the woman and baby.

*Sheppard, V. B., Zambrana, R. E. & O'malley, A. S. (2004) Providing health care to low-income women: a matter of trust. Family Practice, 21 , 5, 484-491 .

Trust Model (Shepherd 04)

Communication

Continuity

Caring

Competence

Sheppard, V. B., Zambrana, R. E. & O'malley, A. S. (2004) Providing health care to low-income women: a matter of trust. Fam. Pract., 21 , 5, 484-491.

Trust model (Shepherd 04)

Trust gain (Berg 96)

“ A trusting relationship can be obtained by good communication and proficient behaviour. By providing a sense of control the women can be supported and guided on their own terms.”

Berg, M., Lundgren, I., Hermansson, E. & Wahlberg, V. (1996) Women's experience of the encounter with the midwife during childbirth. Midwifery, 12 , 1, 11-15.

Improved communication could lead to:

3. Engagement gain

There may be increased engagment, participation and involvement with their pregnancy and unborn child.

4. Access gain Women could have easier access to midwives.

5. Economic gain?

The cost of healthcare is unable to be sustained and grow to the level that could provide the healthcare demanded by a growing proportion of elderly population.*

* Future health connected communities and regional services Campbell-Stokes Andrew, Manager Regional Clinical Services Programme (TAS), Presentation to NZIHM Meeting Wellington, 14 May 2009

*PricewaterhouseCoopers HealthCast 2020: Creating a Sustainable Future 2005.

6. Surveillance gain There could be increased surveillance of women during pregancy. The level of antenatal care affects pregancy outcomes. Low, P., Paterson, J., Wouldes, T., Carter, S., Williams, M. & Percival, T. (2005) Factors affecting antenatal care attendance by mothers of Pacific infants living in New Zealand. Journal of the New Zealand Medical Association, 118, 1216. Bloom, S., Lippeveld, T. & Wypij, D. (1999) Does antenatal care make a difference to safe delivery? A study in urban Uttar Pradesh, India. Health Policy and Planning, 14, 1, 38.

7. Increased support By providing a professional ambient intimacy using mobile technology, there could be an increase in the support currently offered.

8. Time efficiency gain? Time could be saved by midwives by reducing the number of home visits,

with gains for rural women.

9. Tailoring care to individual needs gain

A number of studies have found that tailored messages result in greater behavioural change than generic or non-tailored messages.*

*Nansel, T. R., Weaver, N., Donlin, M., Jacobsen, H., Kreuter, M. W. & Simons-Morton, B. (2002) Baby, Be Safe: the effect of tailored communications for pediatric injury prevention provided in a primary care setting. Patient education and counseling, 46 , 3, 175. Eysenbach, G. (2000) Consumer health informatics. British Medical Journal.

10. Consumer led care gain Mobile technologies offer increased opportunity for consumer led care during pregnancy. Consumer choice is integral to the New Zealand midwifery model.

11. Safety gain “There is an increasing number of complaints made about the care provided by midwives; 53 such complaints were made to HDC in the two years to 30 June 2007.” (Health & Disability Commission)

Themes from HDC complaints include:

• failure to conduct tests, examine/monitor vital signs

• failure to appropriately consult/refer to specialist in a timely manner

• failure to act on test results/abnormal symptoms in a timely manner

• failure to keep adequate/accurate records

• failure to adequately plan/manage labour and/or delivery

• failure to communicate

• failure to practise with reasonable care and skill, according to guidelines.

Why and How?

1. The mobile Internet has evolved to support new opportunities for increased participation, communication and sharing.

2. New Zealand is moving towards ubiquitous computing.

3. The afforability and increased speed of mobile communications have enabled greater uptake of mobile devices. 3G mobiles are increasingly more affordable in New Zealand.

4. There has been a convergence of mobile and Internet technolgies.

5. Well-women are able to participation and contribute to their own healthcare record.

6. Women in the childbearing age group are high users of mobile phones and have new consumer skills and behaviours.

7. Trending health costs and directions require that consumers:

Engage with their own health needs.

Participate actively in promoting their own good health.

Women as Healthcare Consumers

Are able to particpate in decisions relating to their healthcare.

Are able to make lifestyle choices.

Have a degree of health literacy or capacity to understand basic health information and there is the opportunity for improvement with tailored health information.

8. The Internet can: