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Sharing obstetric care: barriers to integrated systems of care
1Centre for the Study of Mothers' and Children's Health, School of Public Health, La Trobe University, Victoria.
Objectives:
To map the provision of shared obstetric care in Victoria, and investigate the views of care providers about the ways in which current practice could be improved.
Method:
All Victorian public hospitals with > or = 300 births per annum and a purposive sample of hospitals with < 300 births per annum were mailed a questionnaire seeking information about current practice. Interviews with key informants (n = 32) were conducted at four case study sites.
Results:
The response rate to the hospital survey was 98% (42/43). Fourteen different models of shared care were identified. Two-thirds of hospitals with > or = 300 births per annum (16/28) had three or more different models of shared care. Six hospitals (15%) had written guidelines for all models of shared care offered; 13 (32%) had written guidelines covering some models. Practice varied considerably in relation to: exclusion criteria, recommended schedule of visits and use of patient-held records. There was little consensus about the content of visits and responsibility for covering particular aspects of care. Few hospitals (6/42) had written information for women about shared care. Care providers expressed divergent views regarding the question of where ultimate responsibility lies for individual patient care and for the overall management of shared care.
Conclusions:
Current funding arrangements provide strong incentives to expand enrollment in shared obstetric care. Expansion of shared care has occurred without the development of formal, consultative and agreed arrangements between providers, or adequate provision for monitoring, evaluation and review. The variety, complexity and fluidity of models of shared care and lack of agreed procedures contribute to difficulties experienced by both providers and women participating in shared care.
Implications:
Detailed evidence-based agreed guidelines developed in consultation with hospital and community providers, and provision of improved information to women about what to expect in shared care arrangements are urgently required.