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Midwifery 28 (2012) 366–373

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Midwifery
journal homepage: www.elsevier.com/midw

From hospital to home: The quality and safety of a postnatal discharge


system used for remote dwelling Aboriginal mothers and infants in the
top end of Australia
Sarah J. Bar-Zeev, RN, RM, MPH, MNSc (NH&MRC Doctoral Research Candidate)a,n, Lesley Barclay, RN,
RM, BA, MEd, PhD (Professor and Director)b, Cath Farrington, RN, BN, Cert Child Health, Grad Dip
Midwifery (NH&MRC Doctoral Research Candidate)a, Sue Kildea, RN, RM, BHSC (Hons), PhD (Professor
of Midwifery)c
a
Northern Rivers Department of Rural Health, School of Public Health, Faculty of Medicine, The University of Sydney, New South Wales 2480, Australia
b
Northern Rivers Department of Rural Health, The University of Sydney, New South Wales 2480, Australia
c
School of Nursing and Midwifery, Australian Catholic University and Mater Mothers’ Hospital Brisbane, Queensland 4101, Australia

a r t i c l e i n f o a b s t r a c t

Article history: Objective: to examine the transition of care in the postnatal period from a regional hospital to a remote
Received 26 August 2010 health service and describe the quality and safety implications for remote dwelling Aboriginal mothers
Received in revised form and infants.
30 March 2011
Design: a retrospective cohort study of maternal health service utilisation and birth outcomes, key
Accepted 27 April 2011
informant interviews with health service providers and participant observation in a hospital and two
remote health centres. Data were analysed using descriptive statistics and content analysis.
Keywords: Setting: a maternity unit in a regional public hospital and two remote health centres within large
Aboriginal Aboriginal communities in the Top End of the Northern Territory, Australia.
Postnatal
Findings: poor discharge documentation, communication and co-ordination between hospital and
Discharge process
remote health centre staff occurred. In addition, the lack of clinical governance and a specific position
Safety
holding responsibility for the postnatal discharge planning process in the hospital system were
identified as serious risks to the safety of the mother and infant.
Conclusions and implications for practice: the quality and safety of discharge practices for remote
dwelling mothers and their infants in the transition from hospital to their remote health service
following birth need to be improved. The discharge process and service delivery model must be
restructured to reduce the adverse effects of poor standards of care on mothers and infants.
& 2011 Elsevier Ltd. All rights reserved.

Introduction 2009). Discontinuities in communication and documentation


resulting from multiple handovers across the chain of care
During the early postpartum period, most mothers and infants in providers involved in transitions of care, increases risk of medical
Australia move from acute based maternity services to community errors and compromises patient safety (Moore et al., 2003). This
based services. These include general practitioner or child and risk is greatest at the time of hospital discharge when poor,
family health nursing care. The manner of this transition differs delayed or absent transfer of information may result in adverse
across the country but usually occurs in the first two weeks post patient outcomes (Kriplani et al., 2007; Callen et al., 2008; O’Leary
partum though may occur as late as two months. During this period, et al., 2009). This has been demonstrated in the Northern
where women move from one service to another, it is critical that Territory (NT) where poor communication led to the death of an
they are connected with services that support their transition into elderly Aboriginal man who was flown home from hospital and
the parenting process (Homer et al., 2009). left on the airstrip in his remote community. The breakdown in
Poor service co-ordination or communication among health communication with the remote health centre (HC) meant that
professionals can result in fragmentation of care (Homer et al., no-one collected him from the airstrip and he was subsequently
found dead (Chalmers, 2007).
n
The effectiveness of various mechanisms for the transfer of
Corresponding author.
E-mail addresses: sbarzeev@usyd.edu.au (S.J. Bar-Zeev),
care from maternity to community based services in Australia has
Lesley.barclay@sydney.edu.au (L. Barclay), not been assessed. It is unclear how services might best be
Cath.farrington@cdu.edu.au (C. Farrington), sue.kildea@acu.edu.au (S. Kildea). integrated to provide optimal care for mothers and their families

0266-6138/$ - see front matter & 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.midw.2011.04.010
S.J. Bar-Zeev et al. / Midwifery 28 (2012) 366–373 367

during the early postpartum period (Homer et al., 2009). There is 2006). This paper reports on baseline data examining the quality
a dearth of published evidence to guide policy makers in design- and safety of the postnatal transition of care from a regional
ing this transition across services, particularly in remote settings. hospital to remote health services.
Few studies have investigated the consequences of health service
design for remote dwelling Australian Aboriginal mothers and
their infants (Kildea, 1999; Watson et al., 2002; Ireland, 2009). Methods
The transitions of care across services for these mothers and
infants, specifically in the postpartum period have not been The research was conducted in two HCs located within
previously studied. purposively selected remote Aboriginal communities and in a
The NT spans one-sixth of Australia yet has only 1% of its 363 bed regional, public hospital, in the Top End of Australia’s NT.
population (Australian Bureau of Statistics, 2009). In stark contrast Ethical approval was obtained from the Human Research
to other regions of Australia, Aboriginal and Torres Strait Islander Ethics Committee of the Menzies School of Health Research and
Australians comprise 30% of the NT population with 80% living in the NT Department of Health and Families (DHF).
remote remote locations (ABS, 2006a, 2006b). The vast geographic A Continuum of Maternal and Infant Care Assessment Frame-
area and cultural diversity of the Aboriginal population, the work (COMIC) developed by the first author informed the data
multitude of service providers (Northern Territory Government, collection. This framework, based upon a situational analysis
Aboriginal Community Controlled and joint national funded ser- methodology (Miller et al., 1997), was used to assess the quality
vices), patient information systems and a high burden of maternal and utilisation of maternal and infant health services throughout
and infant morbidity, add to the complexity of providing an the antenatal, birth, postpartum period and during the infant’s
effective discharge system (Banscott Consulting, 2007). first year of life. Qualitative and quantitative data were collected
The prevalence of teenage pregnancy, late presentation for and analysed to inform health service improvements and report
antenatal care, smoking (Australian Government Department of the views of the range of staff involved in maternal and infant
Health and Ageing, 2008), anaemia (Panaretto et al., 2006) and care. Data collection occurred from January to August 2008. Only
gestational diabetes (Ishak and Petocz, 2003) in Aboriginal and selected data relevant to the discharge process will be reported
Torres Strait Islander women in Australia is higher than that here with other data reported elsewhere.
among non-Indigenous women. Rates of preterm birth, low
birthweight and infant mortality are twice that of non-Indigenous Retrospective cohort study
infants (Australian Institute for Health and Welfare, 2010). This
situation requires excellent and proactive postnatal care. Limited data exist about the pregnancy, birth and postpartum
The HCs provide the primary health-care service in most NT outcomes of remote dwelling Australian Aboriginal women from
remote communities. They generally operate from Monday to the NT and their utilisation of maternal health services. We
Friday during business hours with on call staff after hours and do conducted a retrospective cohort study of all Aboriginal mothers
not have inpatient beds. Antenatal and postnatal care in remote from these communities who gave birth from 2004 to 2006 and
communities is typically provided in HCs by local or outreach followed them up to six months post partum. All Aboriginal
services. Current practice in the NT is that remote dwelling women who gave birth to an infant at the regional hospital, in
women are transferred from their home community to a regional hostel accommodation, in transit to regional hospital or in the
centre at 38 weeks gestation to birth in a hospital (Banscott Health remote community from first January 2004 to 31 December 2006
Consulting, 2007). Transferred women reside in hostel accommo- with gestation of at least 20 weeks or birth weight of at least
dation until the onset of labour and then give birth at the hospital 400 g, were included. The study cohort was constructed through
with care providers with whom they are generally unfamiliar manual data linkage between community birth records from two
(Kildea, 1999). Women are frequently without personal supports government operated primary HCs and medical records at the
during this period as the cost of transporting family members is regional hospital.
not subsidised by government and prohibitive for families on some Data shown in Table 1 were collected using manual review of
of the lowest mean incomes in Australia (Australian Bureau of medical records at the hospital and HCs. Four hundred and twenty
Statistics, 2006a, 2006b). Following initial postnatal care in hospi- women were identified as eligible for the study. In total, 413 medical
tal, the transfer process to the HC occurs. records were available for review at the hospital and 400 at the HCs.
This model of care that is used by the majority of remote
dwelling mothers is logistically complex and fragmented, invol- Interview data
ving transfer of care among multiple organisations and sectors of
the health system (Steenkamp et al., 2010). Fragmented maternity Sixty semi-structured interviews were conducted by the first
care results in adverse outcomes (Homer et al., 2001; Homer et al., author with key health, management and administrative staff
2002). Remote health-care staff and Aboriginal women themselves employed in the HCs (n¼30), the regional hospital maternity,
have expressed major concerns about the lack of continuity of care neonatal and paediatric units (n ¼18) and other staff providing
and choice around the model of care, poor service co-ordination clinical, administrative or logistical support for remote dwelling
and communication across NT maternity services (Barclay and women during pregnancy, around the time of birth and during
Kildea, 2006; Kildea, 2006; Kruske et al., 2006; Ireland, 2009). the first year of their infant’s life (n ¼12) (see Table 2). Participant
The current study is nested within the National Health and selection for interviews was conducted as follows. Three of the
Medical Research Council (NH&MRC) funded ‘1 þ1¼A Healthy authors identified a list of 30 potential key informants and invited
Start to Life’ project. This five year project is designed to improve them to participate in the interviews. Of these, six declined and
maternal and infant health for remote dwelling Aboriginal two did not respond to the invitation. Twenty-two participants
families in two of the largest communities in the Top End of the were initially recruited and interviewed. Snowball sampling was
NT. It has a mixed method, action research design with baseline used to recruit a further 38 participants because we required
data informing interventions. The project was developed in expert staff who worked in very specific roles and locations for
response to long standing concerns voiced by Aboriginal women, the interviews and these staff were often unknown to the authors
policy makers and health providers about the quality of maternity and otherwise difficult to identify. Recruitment continued until
services and culturally unsafe practices (Barclay and Kildea, data saturation had been reached in the analysis. Interviews
368 S.J. Bar-Zeev et al. / Midwifery 28 (2012) 366–373

included questions about the participants’ role in the discharge Data analysis
process, their views about the current discharge process, and the
strengths and weaknesses of the discharge process in relation to Medical record data were entered into an Access (TMMicrosoft
remote dwelling Aboriginal mothers and infants. Corp.) database and analysed descriptively using STATA 10.1
(TMStatcorp, College Station, TX, USA). Interviews were tape
recorded with the participant’s consent and transcribed verbatim
Observational data along with observations and field notes. Pseudonyms were used
to protect anonymity. The transcribed material, which included
Eighty hours of participant observation was undertaken by the both qualitative and quantitative data, was analysed by the first
first author, a qualified midwife, within the antenatal and post- author, using content analysis in ATLAS T.I 5.4 (TMScientific
natal units of the regional hospital and in the women’s health Software Development GmBH, Berlin, Germany). The first author
rooms in the remote HCs. A structured observation checklist was examined the transcriptions to identify issues and themes in the
used to obtain the data shown in Table 3. Field notes were data, assigning codes to units of meaning apparent in each
recorded during and following interviews and observations to paragraph or sentence. The first and second author then discussed
assist in describing the setting, behaviours, body language and the codes until consensus was reached. Data were then consoli-
non-verbal communication of the care provider. dated into higher level categories and core themes identified.
Content analysis was then undertaken to ascertain frequencies
evident within the core themes. We used multiple sources of data
(interview, observational and retrospective cohort study data) to
Table 1
validate our findings around the issue of the quality of care
Maternal data collection.
received by women and babies in relation to the discharge
Category process.

Demographics Age, Aboriginal status, community,


Employment status
Partner status
Findings
Antenatal Gravida, parity, EDC
Past obstetric history
Eighty-nine per cent of the births took place at the regional
Utilisation of antenatal care (number and location of
antenatal visits, routine tests and hospital whereas the remaining births were in the remote com-
ultrasounds undertaken, outcomes and follow up munity (10%), in transit to hospital or at hostel accommodation
of certain routine pregnancy tests) within the regional centre (1%).
Medical and pregnancy complications
Antenatal hospital admissions

Birth Place of birth


Regional hospital cohort
Labour and birth outcomes
Birth complications
The mean age of the mothers who birthed at the regional
Post partum Length of hospital stay
Postpartum complications up to six months following birth
hospital was 23 years (range 13–41) and 55% were multiparas.
Postpartum hospital admissions Most mothers (63%) had an unassisted vaginal birth, 30% had a
First presentation to health service within caesarean section and the remaining women had an instrumental
six months following birth, (6%) or breech vaginal birth (1%). Postpartum haemorrhage
Postnatal check in remote health service
occurred in 25% of all births with 8% of these being over
Presence or absence of discharge summary at remote HC
1000 ml. Nineteen per cent of all hospital births were preterm.

Table 2
Interview participants.

Place of employment Health staff Administration Management

HC 1: Midwives (n¼ 3) HC HC managers


(n¼ 15) District medical officers (n¼ 2) Administration (n¼ 2)
Remote area nurses (n¼2) Staff
Child health nurses (n ¼2) (n¼ 2)
Aboriginal health workers (n¼ 2)

HC 2: Midwives (n¼ 2) HC HC managers


(n¼ 15) District medical officers (n¼ 2) Administration (n¼ 2)
Remote area nurses (n¼2) Staff
Child health nurses (n ¼3) (n¼ 1)
Aboriginal health workers (n¼ 3)

Regional hospital Midwives (n¼ 4) Ward clerk Hospital management


(n¼ 18) Doctors (n¼ 7) (n¼ 1) (n¼ 3)
Paediatricians n¼ 5, obstetricians n ¼1,
obstetric resident n¼1
Special care nursery/paediatric nurses (n¼ 2)
Aboriginal health worker (n¼ 1)

Other services Outreach midwives (n ¼4) Patient travel officer Health services management
(n¼ 12) Outreach child health nurses (n¼ 2) (n¼ 1) (n¼ 1)
Urban domiciliary midwife (n¼ 1) Aboriginal liaison officer Hostel managers
(n¼ 1) (n¼ 2)
S.J. Bar-Zeev et al. / Midwifery 28 (2012) 366–373 369

Table 3
Observational data collection.

Period Observation Location Individual observations (n)

Antenatal Number and role of staff present during visit Regional hospital and remote HCs n¼ 19
Location of visit
Woman’s gestation
Content of antenatal visit
Tests undertaken
Documentation used by staff
Number and type of care handovers
Length of time between care transfer or handover
Duration of visit and waiting time to be seen

Post partum Number and role of staff present each shift Regional hospital n¼ 22
Birth mode
Number and type of care handovers
Number and role of staff involved in discharge process
Documentation used by staff
Length of time between care transfer or handover
Number and role of staff during postnatal visit Remote HCs n¼ 6
Content of postnatal visit
Documentation used by care providers
Number and type of care handovers
Length of time between care transfer or handover
Duration of visit and waiting time to be seen by staff

Postnatal model of care and discharge systems postnatal visit sufficiently to make it worthwhile for them to
undertake.
Following birth in the Delivery Suite or theatre, early postnatal The majority of HC staff (n ¼21/30), around half (n¼10/18) of
care of the mother and infant was observed to be provided by regional hospital staff and most (n¼9/12) of the other staff
staff attending the birth. Mother and infant were then transferred identified significant problems with the postnatal discharge
to a shared or occasionally single room in a busy antenatal/ processes. The following case study illustrates these intersecting
postnatal unit and care handed over to different staff. In general, issues that have been identified in the study. Most commonly
the staff were unknown to the mother. The mean length of occurring problems identified in the analysis were poor written
hospital stay was three days (range: from four hours to 23 days). information transfer, poor verbal communication, lack of co-
During this period mothers and their infants were observed to ordination between the hospital and the remote health services,
receive direct patient care from two to 15 different individual lack of clinical governance and leadership and poor knowledge of
health-care providers (registered midwives, nurses, student mid- roles and work practices in HCs by hospital staff.
wives and doctors) with multiple care handovers, usually occur-
ring at every shift change. Over a three day admission, the average Case Study
number of different care providers observed per mother was nine.
Some mothers and infants also received additional care from
lactation consultants and physiotherapists. Tina, aged nineteen, gave birth to her first infant at the
Discharge information which comprised of a discharge sum- Regional Hospital. She had a caesarean section for ‘failure to
mary, birth summary and neonatal checklist were compiled and progress’ and a subsequent wound infection and mastitis
completed by two or three staff members, and their timely during her inpatient stay. Tina was commenced on antibiotics
completion delayed if test results or other information was on day five and discharged on day nine. She stayed with
pending. On other occasions, a fourth staff member was respon- relatives near the hospital until her flight back to her home
community on day 12.
sible for sending the discharge summary to the HC. This task was
not always completed at the time of discharge. As part of the
Tina presented to her HC centre upon her return; febrile
hospital discharge planning process, mothers are advised to
and feeling very unwell. She had asked to see the midwife as
return to their HC for a six week postnatal check or earlier if she had been told by a doctor in the hospital that ‘the midwife
needed and to take their infant for a visit upon their return home. would give her treatment at the health centre’ when she
Following discharge, remote dwelling mothers either returned returned to her community. The HC midwife was unaware
directly to their home community or to a temporary residence that Tina had been discharged from hospital and did not have
such as a friend or relative’s home or hostel in the regional centre any information about Tina’s inpatient stay.
while awaiting their flight home. One of the study communities
was serviced by an airline that instituted a policy restricting The discharge summary had not been sent to the HC. Tina
travel to infants under one week old, thus delaying their did not receive a copy of the summary when she was
return home. discharged. The midwife spoke with Tina in an attempt to
Some mothers received domiciliary postnatal care in their gain information about her birth and inpatient stay. English
was Tina’s second language and she did not understand the
temporary residence up to day 10 following discharge, although
reason for her caesarean section. She could only tell the
the provision of these visits was inconsistent. Reasons described midwife that the hospital doctor had said she needed
by health providers for inconsistency in service delivery in this ‘treatment’ for her painful breasts. The midwife was required
context included patient mobility following hospital discharge, to make numerous phone calls to the hospital to ascertain
miscommunication between the health providers and the information about the woman and spoke with five different
mothers about the timing and location of the postnatal visit and staff members (ward clerk, two midwives, a resident and a
the perception by health providers that mothers do not value the registrar) in order to obtain a complete history. This process
370 S.J. Bar-Zeev et al. / Midwifery 28 (2012) 366–373

took more than two hours of the midwife’s time. The midwife filing in reception and never get handed to us (midwives) by
was then required to contact the medical records department reception staffythere are lots of gaps in the system where
and fax through a request form to obtain the discharge important information seems to just vanish (HC Midwife)
summary. She waited a further 50 minutes for the summary
to be located and faxed back to the health centre. The consequences of absent or delayed discharge summaries
on mother and infant care described by HC participants were
The discharge summary was located by medical records numerous. The most frequently reported consequences were
staff in the mother’s history. It specified that Tina required missed opportunities by HC staff to follow up the mother and
daily caesarean wound care, support with breast-feeding
infant upon their return to the community and provide postnatal
attachment which had been difficult for Tina from birth,
continued antibiotics, blood tests and a medical review upon and newborn checks (n ¼26/30), parenting support (n¼26/30),
return to her community. The discharge summary had never ongoing management of postnatal complications (n ¼21/30) and
been sent from the hospital. Tina was reviewed again by the the failure to have medication regimes implemented or tests
midwife at home later that evening; she was becoming administered (n¼20/30) or pending test results followed up
increasingly unwell and subsequently evacuated back to the (n ¼12/30). Other mothers and infants were reported to have
hospital with sepsis and required a further seven day had missed outpatient appointments back at the regional centre
inpatient stay. due to the lack of information and communication.
The administrative burden and excess time wasted by staff
following up absent summaries was reported as substantial.
Incorrect, conflicting or missing discharge information such as
Information transfer and poor communication medication doses; birth complications and reasons for caesarean
section were observed multiple times in medical records and
Lengthy delays or outright absence of discharge summaries confirmed by participants:
sent from the hospital to the HC were described by HC partici-
yyou ring the (postnatal) ward and try to speak to a doc or
pants as the most serious problem:
midwife who was involved with the woman’s care in hospital
I saw a primipya shy young girly(she) came up to the health to piece together the missing informationyand invariably, the
centre a few weeks after having her babyyI didn’t have a doc is busy and doesn’t call you backyor is on days offy (HC
(discharge) summary from the hospital yshe was given Midwife)
medicine from the hospital to take at homeybut she didn’t I saw a woman whose discharge summary said she had a
know what fory.and I couldn’t tell her either because I didn’t vaginal birth with a 3rd degree tear ythen I asked her what
have any informationy it can be absolutely frustrating for us happened in her birth and she said ‘I had an operation in the
out here..It’s like we get just left out of the picture by the middle..A Caesarean’yso I don’t know where this other
hospitaly like we don’t county.’ (HC Midwife) information has come from. You begin to wonder if all the
other stuff you read is trueyor if they got the right lady to
The regional hospital policy is for discharge summaries to be start with!! (HC Midwife)
completed within 48 hours of discharge. Ideally this occurs prior
to discharge and the mother is given her own copy to take home, Lack of clinical governance and leadership
one copy is to be sent to her GP or HC if she is in a remote
community and a third copy to be filed in the hospital medical Hospital participants described a lack of clinical leadership in
record. addition to the high staff turnover and multiple staff engaged in
The practice of mothers being given their own summary upon the discharge process as reasons why discharge processes were
discharge was inconsistently performed. The most common often problematic:
reason given by staff for mothers not being provided their own
copy was that paperwork was not always complete at the time of We have known about the problems between here (at the
discharge, with staff citing competing priorities of managing busy hospital) and remote (HCs) for yearsythey are always hard to
and complex patient workloads. resolve unless you get someone to step up and specifically take
Other reasons reported included staff being unable to locate on the responsibility to see that the problem gets fixed..(this
the mother at the time of discharge and lack of trust by hospital is) always hard in such a frantic workplace (Hospital Midwife)
staff that mothers could reliably take their own summary back to Participants from both the HC and the hospital spoke of the
their HC. One hospital participant reported that if mothers were importance of improving the ‘links’, ‘connections’ and ‘associa-
given the summary they ‘wouldn’t read it anywayywho bothers tions’ between the two health systems as a means of improving
with those forms?’, ‘[they] would just lose them’ [or] ‘throw them in the continuity of care and the communication process. Designated
the bin on the way outyI see that happen all the time’. leadership positions including a discharge co-ordinator were seen
Health Centre participants reported receiving hospital sum- as the most effective way of achieving this:
maries ‘sometimes months after the mother has been discharged or
not at all’. Eleven per cent of maternal records reviewed at the We need more positive links between the hospital and health
HCs, did not have a discharge summary for the birth that occurred centresya midwife (at the hospital) who knows all the
during 2004–2006. women from the communitiesywho can update health cen-
Most HC participants described the hospital as the primary tres about how the women are going in hospital, what’s been
source of the discharge information transfer problem with a few happening with the baby and ring them when they are
acknowledging the role of their own HC for the discontinuities in planning on dischargey (Hospital Management - Midwifery).
the flow of information between administration staff and clinical
staff: Lack of knowledge and understanding of roles and work practices
in HCs
Well we can’t always go blaming the hospital systemyI know
they (the hospital) often send out the discharge summaries Health Centre participants expressed frustration at the lack of
y.but sometimes those summaries just sit in a big pile of understanding by hospital staff of their roles within a remote
S.J. Bar-Zeev et al. / Midwifery 28 (2012) 366–373 371

primary health-care service and felt that staff did not understand treatment that will end up happening out here in the com-
that the HC was not ‘an outback version of a busy city hospital’ munity with us.
(Remote HC Management). Participants described cases whereby (Remote District Medical Officer)
women had been discharged home from hospital with inadequate
supplies of medication, infant artificial milk or dressings that Further recommendations made by both HC and hospital staff
were not readily available in HCs or remote communities that do to improve the discharge planning process included the introduc-
not have pharmacies: tion of a comprehensive, multidisciplinary discharge planning
pathway or a ‘care map’ that would commence in pregnancy and
y I saw this ex-premmie out hereyher grandmum and mum be could be used by the HC and hospital staff, and a routine phone
brought her up to the clinic for a weigh and I got the summary made by postnatal staff to the HC midwife to inform them of the
out and it said ‘mother to breastfeed 2–3 hourly, express with woman’s birth outcomes and to discuss discharge plans.
pump and top up with a bottle’yI found out she (the mum)
had never used a pump let alone own oneyI rang the nurses What works well?
(at the hospital) and this young one said to me ‘Oh I thought Only one-fifth of all participants identified one or more
you would have them (the pumps) to hire to the mums out strengths with the current discharge process. Comprehensive
there’ .. we don’tyso I had to then spend the next few hours orientation to discharge process at the commencement of
trying to teach this young mum how to hand express and work employment and the presence of some senior staff who had
out how she was going to store milky we had to get bottles knowledge of both the hospital and HC health system were
and teats and formula and teach her how to use them and identified as the main strengths of the discharge process.
clean them ..They just expect it would just magically happen
for her out here (HC child health nurse)
Discussion
Staff interviewed from HCs also felt that hospital staff had
unrealistic expectations of the type of care that could be provided
In many Western countries, hospital based postnatal care is
in a remote HC such as requesting a midwife to visit a mother at
often a neglected area of maternity service delivery and ‘rarely
home multiple times per day for breast-feeding support. Health
viewed or planned as part of a continuum of planned, effective
Centres across the NT differ in their provision of maternal and
maternity care for individual women’ (Beake et al., 2010, p. 8).
child health services. One community had a midwifery service
This experience has been highlighted in this study with remote
available two days per week whereas the other had a full time
dwelling Aboriginal women.
service. Lack of time due to high workloads focused on the
The transfer of mother and infant care from the hospital to the
delivery of acute care and staff shortages within the HC as well
remote health service is fragmented with major discontinuities in
as a lack of transport for staff were cited as reasons that often
care. The inconsistent, ad hoc and chaotic nature of communication,
prevent home visits or indeed any postnatal care from being
at times entirely absent, can result in serious clinical consequences for
undertaken.
new mothers and their infants during an already vulnerable period.
Common problems reported by HC providers were missing
Joint discharge planning discharge summaries or summaries with inaccurate or incom-
plete information. These findings are consistent with a previously
Participants interviewed from HCs often claimed that hospital published study that also identified problems in accuracy, time-
staff did not fully understand the way HCs functioned ‘unless liness and completion of discharge paperwork and high rates
they’ve spent time out here on the ground themselves’ (Remote (18%) of missing summaries in HCs across the NT (Mackenzie and
District Medical Officer). They also stated that hospital staff did Currie, 1999). There appears to be little improvement over the
not know the consequences of the poor discharge practices on past decade.
patient outcomes and the implications for remote staff trying to The lack of co-ordination between the regional and remote
deliver effective postnatal care. health services was manifest in limited communication between
This lack of understanding and appreciation of the way the staff, lack of understanding of the role and capacity of HC staff and
‘other’ service functions was identified as a major contributing a lack of clear responsibility for discharge planning at the regional
factor in the breakdown of co-ordination between the remote and hospital. This compromised the quality and safety of mothers and
regional health services: infants in the transition of care across the services. Such problems
arising in the transition of care across health services are well
..The hospital doesn’t understand what’s achievable out here-
documented (D’Amour et al., 2003; Barclay and Kildea, 2006;
yit’s doing it their way and not recognising the expertise out
Van Walraevem et al., 2008; Homer et al., 2009) and are
here in the health centreyhow things work .. (HC nurse)
frequently due to breakdown in communication and co-ordina-
One third of HC and hospital participants suggested joint tion across services. These problems were further exacerbated by
discharge planning case conferences, which could be conducted the remote geography of the NT, the fact that many women speak
by phone, as a way of providing more effective discharge care and little English and often do not understand the treatment they
improving collaborative relationships. These case conferences have had and the complex social and health situation of Austra-
would involve multidisciplinary hospital and HC staff and focus lian Aboriginal women (Banscott Consulting, 2007).
on individualised discharge planning, particularly for women Multiple care givers are involved in the delivery of care during
requiring complex postnatal care in the community: the antenatal, birth and postnatal period as women transition
between health services in their remote home communities and
We (the remote doctors) absolutely need to be more involved regional hospital and then back to the community following birth.
in the discharge planning for these women and families when Evidence links a lack of continuity of care with increased inter-
they get sent into hospitalya case conference or something vention during labour, maternal dissatisfaction with care and
needs to happen so that we can fill the hospital doctors in increased costs per birth (Homer et al., 2001, 2002; Tracy and
about the best way to manage the family...and work together Tracy, 2003). Aboriginal women vulnerable to poorer perinatal
to make the right decisions especially about ongoing outcomes tend to be adolescent, have poor attendance at
372 S.J. Bar-Zeev et al. / Midwifery 28 (2012) 366–373

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