Transcript DA – challenges to delivering mat care in r and r settings

Providing Maternity Services in a
Rural Area
Sandra Harrington
Midwifery Development Officer, Highland Council
NHS Highland
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Largest and most sparsely populated part of the UK
Forms 41% of the land mass of Scotland
Covers 33,000 km2
Population of 310,500 residents
Mix of urban, remote and rural communities
Quarter of the population living in or around Inverness
Inverness is one of the fastest growing Cities in Europe
Planning, co-ordination and delivery of adult services across
NHS Highland is managed through the Highland Health and
Social Care Service. Children's services through Highland
Council (Care and Learning Service)
NHS Highland Maternity
Services
North & West Operational Unit
North
• Caithness & Sutherland Consultant
Unit – no SCBU or paediatric cover
West
• Skye and Lochalash, Lochaber CMUs
Mid & South Operational Unit
• Ross & Cromarty,
• Nairn, Badenoch &Strathspey
Raigmore Operational Unit
• Raigmore Consultant Unit
• Community midwifery team
Argyll & Bute CHP
• 5 CMUs
Total number of caseload approx. 2221 +
500 A&B
midwives – 273 (66% part time)
Challenge of delivering services in rural areas
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Increased costs in time & travel
Access to support services may limited
What is provided versus what is needed
Informal care networks such as family/friends can undermine
the impetus to provide services in first place
• Voice of rural community can be marginalised
Maternity Services
Outcomes
• Healthy mother
• Healthy baby
• Confidence to nurture and look after self and baby
Process
• Early booking – before 12 weeks with midwife (national HEAT
target)
• Extensive history taking and risk assessment (using SWHMR)
• Midwife as first point of contact – named midwife/named person
• National pathways for maternity care – core, additional, intensive
(green/amber/red)
• Continuous assessment of risk and need at each contact
• Early support & early intervention
• Maternity care team, community midwife providing most of the
care
Domestic Abuse and Pregnancy
• 1 in 4 women will experience domestic abuse from a
partner in her lifetime
• Domestic abuse can begin in pregnancy
• Existing abuse often intensifies during pregnancy
• Domestic abuse during pregnancy is more common
than pre-eclampsia, gestational diabetes and twin
pregnancies
• In 90 % of cases of domestic abuse, other children are
in the same or next room
• Double intended abuse
Indicators within Maternity Care:
Behavioural
• Late booking
• Missed appointments
• Frequent visits and recurring admissions with vague
complaints or symptoms
• Partner accompanies the woman, insists on staying close
& answers questions directed at her - may also
undermine, mock or belittle her
• Frightened, ashamed, evasive, embarrassed or reluctant
to speak or disagree in front of her partner
• Lack of independent transport, access to finances and
ability to communicate by telephone
Indicators within Maternity Care:
common injuries and symptoms
• Vague complaints or symptoms - usually for abdominal pain,
reduced fetal movements, possible urine infections
• Injuries that are untended & of several different ages,
especially to the head, neck, breasts, abdomen & genitals
• Repeated or chronic injuries, minimalisation of signs of
violence on her body
• Physical symptoms related to stress - anxiety disorders,
depression, panic attacks, feelings of isolation or inability to
cope, self harm or suicide attempts
Outcomes related to Domestic Abuse
• High incidence of miscarriage and termination of
pregnancy
• Stillbirth
• Pre-term labour/ prematurity
• Intrauterine growth restriction/ low birth weight
• Mental health issues
• drug or alcohol use
• Unplanned or unwanted pregnancy
• Secure positive attachments with baby may be difficult
How are we addressing
this?
• Guidelines
• Training
• Asking the question
Scottish Woman Held Maternity
Record (SWHMR)
Maternity Summary Record
Domestic Abuse/Routine Enquiry
Seen alone at booking?
Routine enquiry question asked?
(date in woman held section of
SWHMR)
If not asked, document reason why
Abuse disclosed?
Current /Past?
Revised Protocol Domestic Abuse: Pregnancy and the Early Years
Revised Protocol
Domestic Abuse:
Pregnancy and the Early Years
Protocol Reference: 10.04.13
Prepared by: Sandra Harrington Midwifery
Development Officer (HC) & Caroline Tolan
Policy Development Officer (NHSH)
Lead Reviewer: Sandra Harrington
Midwifery Development Officer
Ratified by: NMAHP Policy, Procedure
& Guideline Ratification Group
PFF: Yes
Date of Issue: April 2013
Date of Review: April 2015
Distribution:
 Board Nurse Director
 Director of Public Health
 Head of Midwifery
 Lead Midwives
 Midwives
 Supervisors of Midwives
 Lead Nurses
 Lead Allied Health Professionals
 Obstetricians
 NMAHP Leadership Group
 Child Protection Action Group
 Violence Against Women Delivery Group
 Paediatric Nurses
 SCBU
 Accident & Emergency Dept.
 GPs & GP Sub Group
Highland Council Health & Social Care
 Head of Health
 Principle Officer Nursing
 Principle Officer AHPs
 Principle Officer Social Work
 Principle Officer Early Education/ASL
 Public Health Nurses
 Allied Health Professionals
 Child Protection Advisors
 Team Managers for Children & Families
 Integrated Services Officers
 Fostering & Adoption Service
 Youth Action Teams
Northern & Strathclyde Police/
 Domestic Abuse Liaison Officers
Version: 3
Date Ratified: May 2013
Date PFF: October 2012
Voluntary Sector
 Women’s Aid Services/Action for
Children/Home Start/Family 1st/Children
1st / Barnados/CALA
Role of Maternity Services:
Domestic Abuse
• Routine enquiry about domestic abuse with all women
within a safe environment
• Obtaining disclosure is not the main purpose – but to let
her know the door is open and there is help available
should she require it
• Providing universal information (Ready Steady Baby),
posters
• Vigilant, well informed, well trained staff
Disclosure
• Listen carefully, do not judge
• Let her know she is believed
• Let her know that she is not to blame and does not deserve to
be treated like this
• Offer information about local support groups or agencies
• Assure her that what she says will remain confidential unless
there are any issues around child concern
• Aim to empower her to make informed choices
• Do not rush her into making decisions
Comments from midwives in rural areas
“Geographical challenges are huge. It can take two hours to
get to some of our most remote women. On the up side the
women get to know us really well and often see the same
midwife throughout pregnancy and the postnatal period.”
“We are able to spend a lot of time with our women because
caseloads are small and there is therefore a lot of opportunity
for disclosure.”
Comments from midwives in rural areas
“Because communities are so small domestic abuse is often suspected or even
known about but the woman still may not disclose. This is very frustrating for the
health care team.”
“Even when women have moved away from violent relationships abuse can still
continue in the form of harassment, invalid calls to social services. Members of
the community may side with the perpetrator leaving the victim no choice but to
move her family away form the area.”
“lt’s a long way to the nearest refuge or place of safety and this can entail leaving
friends and family and moving right out of the area.”
“Attitudes to domestic violence can be archaic even amongst high school children
which is very worrying and can make disclosure more difficult for women as their
expectations of being taken seriously can be lowered”.
Service considerations
• One size does not fit all. We need to allow variability and
flexibility to permit appropriate adaptation to local
circumstances of rurality
• There may be difficulties in managing confidentiality within
smaller communities – uncertainty may be a deterrent to
seeking help
• Lack of anonymity- movements and relationships are more
easily observed
• Awareness of isolation of women who may be fearful of
stigmatisation
• Training and supervision of staff working within stressful
situations
Improvements required
• Increase the number of midwives asking the question
• Ensure training is updated regularly - obstetricians, GPs,
hospital based staff
• If routine enquiry question has not been asked – other
opportunities: in-patient, attending hospital for
appointments, GP
• Provide support to staff who still feel unable to discuss it – 1:4
• Consider the implications of rural practice
• Early Years Collaborative (Scottish Government)recognises the
impact that Domestic Abuse can have on children and it is
seen as a key driver at all ages and stages