Working Through Complexity: How Women Living in Areas of High Socioeconomic Deprivation in New Zealand Access and Engage with Midwives
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Working through complexity: How women living in areas of high socioeconomic deprivation in New Zealand access and engage with midwives A thesis submitted to Auckland University of Technology in fulfilment of the requirements of the degree of Doctor of Philosophy (PhD) March 2019 Christine Rae Griffiths Faculty of Health and Environmental Sciences Abstract Women living in areas of high socioeconomic deprivation in Aotearoa/New Zealand experience significantly higher rates of stillbirth and neonatal death than women living in other areas. This is potentially related to access to, and/or engagement with, maternity services. Constructivist grounded theory methodology was used to explore the research question ‘How do women living in areas of high socioeconomic deprivation in New Zealand access and engage with midwives?’ In total, 24 individual interviews were undertaken with 11 women living in areas of high socioeconomic deprivation in three North Island cities, and 10 community Lead Maternity Carer midwives working in those areas. How women accessed midwifery care was complex and varied. Entering the maternity system exposed women to complexity additional to that they constantly navigated through their daily lives. Women navigated a shifting landscape to find a midwife, where midwife location and availability were inconsistent. The complexity of the women’s lives meant they were often prioritising their needs in a range of changing conditions, consequently risking missing midwifery care. The degree and nature of the support available through the maternity system to meet their complex requirements was limited, and shifted, depending on contexts. Midwives responded in a number of ways to a maternity system which was not working for women, aiming towards keeping women engaged with care, working towards an optimal pregnancy outcome. Building effective relationships enabled women and midwives to work together to effectively address the woman’s care requirements within a maternity system that did not readily meet their needs, and encouraged women to remain engaged with pregnancy care. If women missed an appointment with their midwife, following up was crucial, as midwives knew this was a group of women who traditionally fell through the gaps in the maternity system. Staying connected was dependent on the midwife’s knowledge of the woman’s connections, and took time, and energy. When a woman did not develop an effective relationship with her midwife, while midwives went to some lengths to remain connected to ensure she remained engaged with midwifery care, there were limits to their resources. Once a midwife was accessed, women relied on her support and advocacy to negotiate solutions that would facilitate an acceptable pathway for them through the maternity system. The effective relationships women had built with their midwives and the provision of continuity of midwifery care enabled negotiations. Elements i influencing the negotiation included the facility resources of staffing and funding, and the resources women and midwives had available. When women developed complications, depending on the context and the conditions operating at particular times, they were caught between a maternity system which divided their one continuous pregnancy journey into care categories, and the midwifery model of care supporting continuity centred on the women. To sustain themselves in practice midwives negotiated solutions around how they worked. ii Table of Contents Abstract .............................................................................................................................. i Table of Contents ............................................................................................................. iii List of Figures ................................................................................................................... x List of Tables.................................................................................................................... xi Attestation of Authorship ................................................................................................ xii Acknowledgments .......................................................................................................... xiii Explanatory Comments ................................................................................................... xv Chapter 1: Introduction ..................................................................................................... 1 1.1 Introduction to this Research ................................................................................... 1 1.2 Aim of this Research ............................................................................................... 2 1.3 Purpose of this Research ......................................................................................... 3 1.4 Significance of this Study ........................................................................................ 3 1.5 Being a Midwife ...................................................................................................... 5 1.6 Te Tiriti o Waitangi and Its Influence on the Midwifery Profession ...................... 5 1.7 The History of Midwifery in New Zealand ............................................................. 6 1.8 The New Zealand Health System, Maternity System, and Midwifery Model of Care ............................................................................................................................. 13 1.9 Midwives and Women Working in Partnership .................................................... 16 1.10 Subsequent Legislation and Its Impact ................................................................ 18 1.11 The Socio-Political Context ................................................................................ 20 1.12 Assumptions Underpinning the Research ........................................................... 21 1.13 Defining Socioeconomic Deprivation in New Zealand....................................... 24 1.14 Conclusion ........................................................................................................... 26 1.15 Structure of the Thesis ......................................................................................... 27 Chapter 2: Literature Review .......................................................................................... 29 2.1 The Place of the Literature Review in a Grounded Theory Study ........................ 29 2.2 Search Strategy ...................................................................................................... 31 2.3 Women Living in Areas of High Socioeconomic Deprivation: Access to, and/or Engagement with, Maternity Services ......................................................................... 32 2.3.1 The benefit of increased midwifery support .............................................................. 32 2.3.2 Facilitative models of midwifery care........................................................................ 34 2.3.3 Facilitators and barriers to women accessing maternity services .............................. 36 2.3.4 Facilitators and barriers to women engaging with maternity services ....................... 41 iii 2.4 The Effects of High Socioeconomic Deprivation on Birth Outcomes–Specifically Stillbirth and Neonatal Death ...................................................................................... 43 2.4.1 The association between stillbirth risk and living in areas of high deprivation ......... 43 2.4.2 The relationship between reduced antenatal care and risk of late stillbirth for women living in areas of high socioeconomic deprivation ............................................................. 46 2.4.3 Reporting socioeconomic deprivation as a contributory factor to potentially avoidable perinatal deaths ................................................................................................................... 48 2.5 The Benefits to Women and Babies of Continuity of Midwifery Care ................. 50 2.6 Conclusion ............................................................................................................. 53 Chapter 3: Research Methodology .................................................................................. 55 3.1 Introduction ........................................................................................................... 55 3.2 Grounded Theory Methodology Overview ........................................................... 55 3.3 Theoretical Assumptions ....................................................................................... 56 3.3.1 Pragmatism ................................................................................................................ 56 3.3.2 Symbolic interactionism ............................................................................................ 58 3.3.3 Constructionist verses constructivist approaches ....................................................... 61 3.3.3.1 Constructivist approach ....................................................................................... 61 3.3.3.2 Constructionist approach ..................................................................................... 62 3.3.3.3 Objectivist approach ........................................................................................... 64 3.4 Grounded Theory Development ...........................................................................