MATERNITY STUDY
Quantitative Survey
Executive Summary
MATERNITY STUDY
Results of Quantitative Survey
Introduction
The impetus for this study was due to concerns expressed by the Dublin maternity hospitals about their ability to meet demands made by the increasing number of births among residents of their geographical catchment area and those women coming from areas with their own maternity services. It was appropriate to concentrate on the process of choosing maternity services of those mothers who opted for Dublin services, initially but in order to provide a more complete picture the process for those mothers who opted to avail of local maternity services – 90% of births to residents of the South Eastern Health Board – also needed to be included. The views and experiences of two groups - those who choose not to use a service and those who use a service – are both of importance when the focus is on improvements.
Aim
The aim of this study was to expand on the information obtained from the qualitative study, which explored why women who were residents of the South Eastern Health Board (SEHB) travelled to Dublin to avail of maternity services, by including mothers who opted for Eastern Health Board (EHB) maternity services and mothers who opted to remain in the South Eastern Health Board (SEHB).
The objectives were:-
· To explore mothers’ views, knowledge and beliefs of locally based services.
· To gain an understanding of factors, and their relative importance, which influence mothers’ choice of maternity services.
· To explore what are the motivating factors, and their relative importance, to a particular maternity service.
· To identify factors, and their relative importance, which cause mothers to leave maternity services.
Methods
Sampling
On a geographical basis the two Community Care Areas with the largest drift to Dublin maternity hospitals are Carlow-Kilkenny and Wexford. Within the former, Carlow has the largest exodus. Community Care Areas were chosen as the sampling unit for ease of checking with the Public Health Nurses on suitability of including a mother in the sample. In the period (01/04/97 – 31/03/98) the following births occurred:-
SEHB Maternity Unit /EHB Maternity Unit
/Total
Carlow/Kilkenny
/ 1020 (78.2%) St. Lukes / 285 (21.9%) / 1305Carlow
/ 328 (57.7%) St. Lukes / 240 (42.3%) / 568Kilkenny / 692 (93.9%) St. Lukes / 45 (6.1%) / 737
Wexford / 1254 (90.8%) WGH / 127 (9.2%) / 1381
For births in SEHB maternity units, to achieve adequate sample sizes for sub-analysis a minimum of 200 respondents for each Community Care Area (CCA) was deemed necessary. For Dublin births a minimum sample size of 100 for each CCA was deemed necessary.
A list of those born between 01/04/97 and the 31/03/98 whose mothers were residents of Carlow/Kilkenny or Wexford was obtained from birth records. These were then stratified by delivery in a Dublin Maternity Unit or South Eastern Maternity Unit (St Luke’s Kilkenny or Wexford General) and by Community Care Area (Carlow/Kilkenny and Wexford). For births in the two South Eastern Maternity Units every 5th birth was identified for each Carlow/Kilkenny (n=204) and every 6th for Wexford (n=208). For births in Dublin Maternity Units every alternative birth was identified from the Carlow/Kilkenny list (n=141) and all from Wexford (n=126). (The mothers of twins/triplets were included once only).
Public Health Nurses in the two Community Care Areas were asked to identify any mothers on the lists whom they thought should not be contacted for the study due to family bereavement, severe illness or other relevant family reasons. Out of the list 52 (7.7%) were excluded (incorrect address 46%, baby with severe health problems 12%, family tragedy 8%, severe social problems 4%, reason not specified 30%.). A sample of 625 remained (51% CW/KK; 49% Wx; 39% EHB births, 61% SEHB births).
Instrument
Based on the views of mothers who attended the focus groups – all of whom delivered outside the SEHB – a questionnaire (Appendix 1) was developed. This was piloted on mothers (8) who had delivered in a similar time period to the study population and adjustments made.
In view of the size of the sample a postal questionnaire was considered the most suitable. To encourage respondents a prepaid envelope was included with the questionnaire and an opportunity to enter a draw for £100.00.
368 (59%) responded to this. One reminder was sent which resulted in the return of an additional 63 (10.1%) questionnaires. Eight questionnaires were returned as address unknown, giving an adjusted response rate of 70%. An additional 30 questionnaires were returned too late for inclusion in the analysis (postal response rate = 75%).
Analysis
Data was entered on SPSS for analysis. Analysis was based on frequencies, with Chi-square and Fisher' exact test used to identify statistical significance controlling for confounders where appropriate.
Results
Socio-Demographic Profile
Half of the respondents (50.5%, 216) lived in Wexford with the remainder divided between Carlow (28%, 120) and Kilkenny (21.5%, 92). Over three-quarters (325, 77.0%) had lived in the SEHB when at secondary school. An additional 12.6% (53) had lived in the EHB when at secondary school.
One third of the respondents (33.6%) were aged less than 30 years. Over three-quarters (337, 78.4%) of the group were married. More than half (53.6%, 230) were in employment outside the home. Details of these three variables are shown in Table 1.
Table 1. Age, Marital Status, Employment Status.
Age Group N % / Relationship N % /Work Status N %
<20 years 7 1.6 / Married 337 78.4 / Full time homemaker 166 38.7
20-24 years 46 10.7 / Single, in
Relationship 36 8.4 / Working full time
outside home 127 29.6
25-29 years 92 21.3 / Single, not in
Relationship 29 6.7 / Working part time
outside home 101 23.5
30-34 year 155 36.0 / Cohabiting 16 3.7 / Unemployed 27 6.3
35-39 years 105 24.4 / Separated/
Divorced 12 2.8 / Student 8 1.9
40-49 years 26 6.0
Total 431 100
/ Total 430 100 / Total 429 100Apart from work status, other socio-economic variables included the number with medical cards (26%, 110), the number without medical insurance (49%, 205) and the number living in households without cars (14.1%, 60).
One third of the group (33.3%, 142) had completed third level education. At the other end of the scale 4.2% (18) had ended their education at primary school stage. The remaining 62.4% (266) had completed secondary school.
Those with medical cards were in the younger age group (p< 0.001), were more likely to be single (p< 0.001), unemployed (p< 0.001), not to have access to a car (p< 0.001) and were less likely to have gone on to secondary or 3rd level education (p< 0.001).
Obstetrics Knowledge and Experience
(a) General:
For over one third of the group (38.7%, 165) this had been their first baby. For less than 5% (4.9%, 21) this last baby had been a 5th (or more) baby. During this pregnancy 82.3% (353) had taken folic acid. Over one third had started folic acid (37.9%, 134) before the pregnancy with an additional 29.9% (106) starting it in the first month of pregnancy.
Those with medical cards were less likely to have taken folic acid during their pregnancy (p<0.001). For those who did take folic acid in this last pregnancy, those without medical cards were more likely than their counterparts to have started it prior to or in the first month of pregnancy (p<0.001). Whether this was a first or later baby, after controlling for medical card status, was not statistically significant with the mother taking or not taking folic acid early in pregnancy.
For 95% (94.2%, 403) of the respondents the hospital nearest to them during their last pregnancy was in the SEHB. When asked whether their nearest hospital had a maternity unit the responses were “yes” – 94.4% (403), “no” – 4.0% (17) and “don’t know” – 1.6% (7).
Respondents were then asked if this hospital’s maternity unit had the following facilities:- specialist baby unit, epidurals on demand, paediatricians, good hotel facilities and good visiting arrangements. Their responses are shown in Table 2.
Table 2. Facilities Available at Nearest Maternity Unit
Facilities Available
/ Yes / No / Don’t Know / TotalNo. % / No. % / No. %
Specialist Baby Unit / 141 35.6 / 123 31.1 / 132 33.3 / 396
Epidurals on Demand / 278 69.0 / 29 7.2 / 96 23.8 / 403
Paediatricians / 240 60.2 / 62 15.5 / 97 24.3 / 399
Good “hotel” facilities / 246 61.3 / 66 16.5 / 89 22.2 / 401
Good visiting arrangements / 306 75.0 / 25 6.1 / 77 18.9 / 408
Those with medical cards were more likely to be in the “don’t know” category for SCBU facilities (P<0.001) while those without medical cards were more likely to be in the “don’t know” or “no” categories for knowledge of local paediatric facilities (p<0.01), good “hotel” facilities (p<0.001) and good visiting arrangements (p<0.01).
Non medical card holders knowledge of local SCBU, epidural on demand, paediatric and hotel-type facilities differed at a statistically significant level (p< 0.01) between those who delivered in the SEHB and those who delivered in Dublin maternity units. Those who delivered in a Dublin Unit were less likely to know about their local services (table 2).
Table 2(b):Knowledge of Local Facilities by Chosen Maternity Unit (Non GMS Only)
Local Facility Available / Yes % / No % / Don’t Know % / PSCBU:SEHB
Dublin / 40.5
22.1 / 31.6
45.8 / 27.8
32.1 / 0.01
Epidurals: SEHB
Dublin / 87.7
41.7 / 3.1
14.4 / 9.3
43.9 / 0.001
Paediatrician: SEHB
Dublin / 70.4
37.2 / 22.8
13.2 / 6.8
49.6 / 0.001
Hotel Facilities: SEHB
Dublin / 74.7
33.3 / 20.4
15.2 / 4.9
51.5 / 0.001
For the listed facilities (maternity Unit, SCBU, paediatricians, epidurals on demand, and good ”hotel” facilities), residents of Carlow/Kilkenny at a statistical significant level (p<0.01) were more likely than their counterparts in Wexford to answer “no” or “don’t know”. The only factor which didn’t reach statistical significance was good visiting arrangements.
(b) Pregnancy – (01/04/97 – 31/03/98):
Almost 60% (59.7%, 255) of respondents had their most recent baby in SEHB hospitals. Table 3 shows the maternity units in greater detail. Over one third (34.9%, 137) had decided which maternity hospital to attend before they became pregnant with an additional 27.5% (108) deciding between conception and their first visit to their GP (Table 3).
Table 3. Maternity Unit, Decision Time to Attend Maternity Unit
Maternity Unit Attended / Decision Time to Attend Maternity UnitNo. / % / No. / %
St. Luke’s, Kilkenny / 117 / 27.4 / Before Pregnancy / 137 / 34.9
Wexford General Hospital / 137 / 32.1 / Pregnant, before attending GP / 108 / 27.5
Coombe,
Dublin / 80 / 18.7 / Pregnant, after attending GP / 115 / 29.3
Holles St.,
Dublin / 71 / 16.6 / Did not know I had choice / 26 / 6.6
Rotunda, Dublin / 18 / 4.2 / Other: Specified / 7 / 1.8
Mt Carmel, Dublin / 4 / 0.9
Total / 427 / Total / 393
Carlow mothers, at a statistically significant level, were more likely to have attended Dublin (p<0.001) than mothers living in Wexford or Kilkenny.
Those for whom this was a first baby were less likely than their counterparts to have made their decision about maternity services before they attended their GP (p<0.05).
Non medical card holders were more likely than their counterparts to have had their most recent baby in a Dublin Unit (p<0.001) and to have decided where to have the child either before the pregnancy or before they attended their GP (p<0.001). At a statistically significant level (p< 0.05) mothers with private medical insurance were more likely to opt for delivery in Dublin than in the SEHB. Mothers living in households with cars, regardless of their number of children, were more likely to deliver in Dublin Maternity Units than mothers without cars (p< 0.001).
Among medical card holders, the difference between those who delivered in Dublin and the SEHB was not statistically significant with regard to when they actually decided to attend their chosen maternity hospital. However, this was not the case for non medical card holders (p<0.003). Over three quarters (77.1%) of non medical card holders who opted for a Dublin delivery had made their decision before attending their GP compared with 70.8% of non medical card holders who opted for delivery in the SEHB. One fifth (20.5%) of the former made their decision after attending their GP compared with 28.9% of the latter.
Respondents had previously been asked what facilities were available in the maternity unit in their nearest hospital (table 2). This question was repeated in terms of the facilities available in the maternity unit which they had attended for their most recent pregnancy (table 4).
Table 4 – Maternity Unit Facilities in Chosen Unit
Facilities Available
/ Yes / No / Don’t Know / TotalNo. % / No. % / No. %
Specialist Baby Unit / 281 6.75 / 54 13.0 / 81 19.5 / 416
Epidurals on Demand / 382 91.8 / 8 1.9 / 26 6.3 / 416
Paediatricians / 366 88.0 / 29 7.0 / 21 5.0 / 416
Good “hotel” facilities / 351 84.4 / 52 12.5 / 13 3.1 / 416
Good visiting arrangements / 397 94.5 / 23 5.5 / ------/ 420
Medical card holders were more likely to be in the “don’t know” in terms of their knowledge of SCBU (p<0.001) and Paediatric facilities (p<0.01) available in their chosen maternity unit.