NEWSLETTER September 2012

CHAIRPERSON’S REPORT UPDATE

Welcome to the second addition of the New An organisation of organisations with a unified Zealand Rural Network. A lot is voice for cohesive social and population health for happening out there at the moment and we are rural NZ. This body has been recently established forever facing the challenges of the tightening to provide a framework whereby rural health can health dollar and expected to work harder, faster be represented in a unified manner. Its members and smarter. It is great to hear from so many of are wide ranging – RHN, NZ Institute of Rural you about the challenges you face and how you Health, Mobile Surgical Services, NZ Rural GP deal with them. Network, Rural Women NZ, College of Nurses and many others. We are currently seeking Work continues on the Executive Committee with membership from local government and have members having duel roles across varying recently had real interest from the rural and organisations. Once again I would like to take this provincial mayors throughout NZ. opportunity to thank the board who represent all of you. Even though they all have full time jobs they This body sees real benefits in getting unified and are committed to getting this network off the cohesive: ground and to ensure rural continue to  Provide a strong presence in the advisory and have a voice at a national level. policy development fields of rural health  Develop closer working relationships Remember to check out our website  A single point/conduit which strengthens the www.nzrhn.co.nz or join us for lively discussions activities of all the organizations involved. on our newly created facebook page.

RHAANZ will: If you would like to contribute a story about your  Develop a rural health strategy for NZ experience working in rural hospitals then please contact me at [email protected]  Develop a research agenda for the rural sector  Engage in planning for the future of rural health services

Although in its infancy this is an organization which we believe will have a strong, unifying presence in rural health. The Rural Hospital Jen Thomas Network has a representative on the interim Interim Chair executive committee of RHAANZ so there is direct Rural Hospital Network and critical involvement as this group grows. www.nzrhn.co.nz PROFILE Nikki Close

Nikki is the CEO of Te Aroha Community Hospital in the Waikato District. The Hospital is community owned and is predominately Aged Care with 9 Medical Beds for the community. They are currently looking at new contracts to assist the wider rural community to have better and quicker access to Healthcare Services.

Te Aroha is immensely proud of the service they provide and their service has recently been awarded 4 years Certification by the MoH. In her spare time Nikki is a volunteer Firefighter with the Te Aroha Brigade.

The Rural Hospital Network would like to welcome Nikki Close, CEO, Te Aroha Community Hospital to the Executive Committee.

The Rural Hospital Network is participating in the NEW ZEALAND RURAL planning of the 2013 New Zealand Rural General Practice Network conference to be held in GENERAL PRACTICE Rotorua. The conference is being organised in association with the RHN and will take place from NETWORK CONFERENCE 2013 March 14-17 at the Energy Events Centre, Rotorua. Pre-conference workshops will be held The interim executive members will update the on Thursday March 14, with the conference proper members on the status of the organisation and held on Friday and Saturday, March 15 and 16. seek nominations and elections of officers. The conference theme is “Let’s Get Connected”.

We invite all members of the RHN to join us at our The conference content will cater for a wide first AGM. number of health professionals working in rural areas including staff working in rural hospitals. Some examples of sessions include: rural The RHN is excited to be involved in the Rotorua maternity, impact of Information Technology on conference and hope that it will offer members rural hospitals and practices, use of Ultrasound both a learning and a networking opportunity. and CT technology in rural hospitals, electronic Please mark your calendar to join us at the prescribing, acute wound management, patient conference between March 14 and 17, 2013. The transport, and the use of technology in the conference details are being finalised and will be community. In addition there will be presentations accessible through the RHN website in due course on research papers. www.nzrhn.co.nz.

On March 14 during the pre-conference day, the RHN is planning a forum dedicated to staff working in rural hospitals to share ideas, discuss challenges and learn from each others’ achievements. We will be calling for papers from members of the RHN soon. The plan is to have the RHN forum from 1pm to 4pm on March 14. Also, on March 14 the RHN is planning its inaugural Annual General Meeting. We invite all members of the RHN to join us at our first AGM. MEMBER - TARARUA HEALTH GROUP

ABOUT TARARUA HEALTH GROUP Clinical excellence is the cornerstone of the service and staff from within the organization

network effectively on a district and regional-wide The Tararua Health Group was established in April 2009. This private company comprises two basis for clinical governance. A range of tertiary GP practice sites and a community hospital training institutes have agreements for the placement of students (GP’s, nurses, midwives) located in Southern Hawkes Bay with the sites within our rural teaching programme. based in Dannevirke and Pahiatua. Tararua Health Group provides services to the Tararua Tararua Health Group has been instrumental in district of New Zealand. The range of services launching an integrated family health centre provided by the group encompass GP primary (Tararua IFHC) which demonstrates integration of healthcare, practice nursing, community nursing, services across the geographical area. Through hospital, maternity and radiology services. The alliance contracting, clinical governance and input organization employs over 100 staff, including from a range of health/social services it is hoped GP’s, registered nurses (hospital and practice that this approach will deliver more flexible, based), radiographers, midwives and ancillary community focused services to our population. staff. There are a range of support staff providing business and quality systems to the overall organization.

This organization uses leading-edge technology to support the provision of their services. Tararua Health Group has invested in fiber optic cables to link the sites for the high speed transmission of digital x-rays. The software is a Medtech supported framework and patient records for up to 17,000 patients are integrated, thereby allowing a borderless sharing of information amongst health providers. RURAL MIDWIFERY After a little over a year of living in , the Maternity was invited to share the statistics and IN OAMARU - PART 1 how we work with Midwives at a conference entitled “Midwifery Practice: Lowering BY JENNIFER WRIGHT Our Caesarean Section Rate”. This was a great LMC Midwife at the Oamaru Maternity Centre opportunity to look at our statistics; our outcomes and our collaborative care with Dunedin midwives and Southern DHB and share our uniqueness with My journey to Oamaru Maternity has been one of others. opposites. I came from the 45 parallel North (Oregon USA) to the 45 parallel South. I left a We were nervous as to what the numbers would culture where 90% of pregnant women were show, yet determined to take a look. We analysed looked after by obstetricians to a culture where the care provided over the calendar year 2011 90% are looked after by midwives. In the States from January through December. Our Oamaru the physicians or large hospital organizations do Maternity team was delighted that our not support out-of-hospital-birth. It was a interpretation of how we think we work was complicated political choice if a woman wanted a reflected positively in our review of our statistics. birth outside the hospitals. In Oamaru it is a The reality of Oamaru Midwifery is reflected in the woman’s choice of where to birth: Oamaru numbers. Maternity Centre, home or at the larger facility Queen Mary in Dunedin Public Hospital. Rural This article will summarize the presentation from women in America are expected to travel great the conference in two parts. The first part will distances to seek health care during pregnancy. In describe Oamaru Maternity, who we are and how Oamaru, the midwife travels to the women, visiting we work. The second part of this article (in the next mothers and babies in their own homes. In the issue) will present the ambulance transfers of States health care is a business. In Oamaru women in labour, present our calculated midwives are paid to provide the service of caesarean rate and summarize our statistics and midwifery to the community. safety of our primary unit. Finally this two part series will explore future areas of study for rural There was a moment on the airplane with my midwifery practices. family seated beside me, where I had a flicker of doubt and questioning. “What am I doing, moving my family to the other side of the world? How will the reality of Oamaru Midwifery measure up to my fantasy New Zealand Midwifery?” I left the comfort of the known exhausting for-profit oriented American Medical system to explore the uncharted unknown-to-me publicly funded midwifery of New Zealand. Thankfully that was where the oppositions ended. The reality of Oamaru Maternity and the midwifery services offered here has far exceeded my fantasy. I made an assumption that all midwifery services were like Oamaru. I have learned that Oamaru Maternity is Oamaru Maternity Centre unique in New Zealand. 8 Steward St OAMARU, NEW ZEALAND OAMARU MATERNITY OVERVIEW We have three private postnatal rooms with ensuite bathrooms. These rooms are cosy and Oamaru Maternity is a part of the Oamaru warm. Our Centre Staff Enrolled Nurses have Hospital, which is located in the heart of the little rural town known for the Victorian extensive breastfeeding training and give Precinct, Blue Penguin Colony and the Steampunk individualized support to the new mums. A breastfeeding chair is in each room that has a movement. The hospital is a Local Authority Trade footstool attached to provide comfort. Prior to Enterprise (LATE) and is supported by a trust. The Maternity Centre MMPO claims and facility fees leaving the hospital our families watch a CPR DVD support the workings of the Centre. The majority of and are oriented to the safety information in the our low risk women birth in Oamaru, others travel Well Child Books. Our families can access the kitchen and lounge with tea, coffee and to Dunedin for birth due to pregnancy milkshakes available. There are toys and books complications, medical indications or less frequently by personal choice. available for older siblings and visiting children. Currently we have a side cot that attaches to the We share an entrance with the main hospital but bed on loan for a trial to help further promote have a small separate hospital wing to ourselves. breastfeeding and mother baby bonding in the Maternity. It is a primary unit, with a home-like atmosphere. There are two comfortable large birth rooms with spacious bathrooms. In January 2011 as part of a generous donation from the Lions Club our birth pool was installed in one of the rooms. This room is now our preferred birth room. Both rooms have roomy showers that are large enough for a woman to sit and rock on the birth ball while sitting under the flow of water. We encourage families to bring personal items to make the space theirs, photos, music or pillows from home.

HOW WE WORK All Oamaru Maternity Staff and Midwives are employed by the Waitaki District Health Services (WDHS). Our philosophy is strongly Woman focused and collaborative. We work as an interwoven team of Enrolled Nurses, Midwives and the Midwife Coordinator with the Women and new families as the focus. HOW WE WORK CONTINUED Typically each midwife sees 5-8 women from 9- 5pm Thursday, Friday and Monday and Tuesday. The Centre Staff Enrolled Nurses and the During the weekends the midwives schedule a few Coordinator are the foundation of the Maternity. postnatal visits or new bookings. The weekends The Enrolled Nurses work shifts seven days a are reserved primarily for paperwork, and to allow week. If there are no mothers and babies in the time to work on Maternity Centre projects such as unit the Enrolled Nurses are available by call from writing and reviewing policies, updating our midnight to 7am. emergency trolley and transfer packs, or writing The Centre Staff offer personalized care to our client information. All three midwives are on call families, they answer the phone, and they order the entire 24 hours each day they work. The supplies, clean and restock the rooms and assist midwives also rotate first-call amongst the the midwives in numerous other ways. The midwives to cover for A&E as well as for any Midwifery Coordinator works part-time miscarriages or unbooked women who come administratively. She is the liaison between the through our area and require urgent midwifery Enrolled Nurses, Midwives and the Hospital. When services. the midwives are fatigued due to births in the night The midwives earn an hourly wage guaranteed to or if two midwives are on an ambulance run to 64 hours in a fortnight (salary). They are paid Queen Mary, the midwife coordinator steps in to hourly for any additional hours worked above the help cover. 64 hours. There are seven midwives total: three teams of There are local relief midwives who cover and are two midwives and the midwife coordinator. There paid by WDHS or by Rural Recruitment. We are are always three midwives on at one time, one LMCs but the MMPO claims go to support the from each team. The three midwives that are on hospital, not to the individual midwives. together support each other when exhausted. Although caseloads are shared with another Individual practices of midwives are unique with midwife, the midwives only overlap on variations celebrated. As a whole the Oamaru birth Wednesdays when all midwives are on. Then one culture is of trust of the process of birth. The partner carries on for eight days and the other will midwives honour the natural rhythm of labour and have six days off. Wednesdays allow time for birth. The focus is on the woman and baby not the meetings and handing-over between the midwifery clock. The labour environment is protected with partners. The eight days on are full days. limited disruption to the families.

All the midwives in Oamaru are supportive of water use for comfort in labour and with water birth. Active labour is discussed at the antenatal visits and encouraged once the Woman is in labour.

Home visits are offered in early labour to assist the family in determining when it is time to go to the Centre. Care is tailored to each woman, family and the midwife providing the care.

Continued on next page... There are several interventions that can be done if The courses support the Maternity Centre by a labour is taking a detour: position changes, encouraging families with normal pregnancies and encouraging the woman to keep her bladder births to stay in Oamaru. empty, entonox, giving IV fluids, artificial rupture of membranes, obtaining a second opinion from a As supported in numerous studies, birthing colleague, distraction and conversely limiting outcomes are most favourable for healthy well distractions. CTGs, Pethidine use, cervical exams, Women (low risk) who stay within primary partograms, coached pushing and absolute maternity services provided by Midwives. I no timeframes are avoided on a routine basis. During longer need studies of far away places to show me second stage the midwives allow the women to be the benefits for women and babies for I have it in the guide, watching and waiting for spontaneous practice in Oamaru. It is important to be born in pushing. Cervical evaluation is done if indicated or your community, to have family and support requested, not routinely. The second midwife and networks around for those exhausting early days Enrolled Nurse are updated at this stage of labour of parenthood. Honouring the process of birth, and are on standby to come to the birth if needed. preparing women for motherhood in their own environment, supporting women in their choices The physicians at Queen Mary, Southern DHB are for birthplace and practices all lead to better easily available for consult and support in the rural outcomes. This is what I believed to be true while environment, for antenatal, labour and postnatal practicing in America, but had to come to Oamaru concerns. At times ambulance transfer is needed New Zealand to experience it for myself. The and usually acts as a distraction to the woman. reality is better than the fantasy. I am honoured to Often the women deliver soon after arrival at be a part of this type of care and system. Well Queen Mary. Times of consultation can be done Oamaru, well done New Zealand! stressful; this is when the full team approach to care at Oamaru Maternity is evident. The next part of this article will look at the Oamaru Maternity ambulance transfers in labour, which The entire team pulls together to care for not only lead to the calculation of our caesarean rate. It is a the woman and her family but also support the small study from 2011 with big implications and midwife involved. Time is taken to reflect and ideas for future study. process if needed after a transfer. Dr Hanna, an obstetrician from Southern DHB, holds a clinic in Oamaru once a month for our high-risk women. The team of A & E physicians in Oamaru are also supportive of the Maternity Centre and midwives. The local GPs are also very helpful in coordinating care of women and families. This is a rural practice, but it never feels lonely or isolated.

The Maternity Centre collaborates with the Parents Centre. The Parents Centre offer free antenatal and breastfeeding education courses to Oamaru families.

The course instructors have worked in the Maternity Centre and are very knowledgeable about how the Centre works.