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High Risk Maternal Foetal Outreach Clinic in Moree

Hunter New England Local Health District
Project Added:
29 July 2013
Last updated:
8 October 2014

High Risk Maternal Foetal Outreach Clinic in Moree

By Hunter New England Local Health District

Summary

The project to deliver a High Risk Maternal Foetal Medicine Service (MFMS) in Moree, is part of the Federal Government funded Medical Specialist Outreach Assistance Program (MSOAP).

MSOAP, as the name indicates, is an ‘assistance’ program which provides funding for travel, accommodation, clinic administration and clinician backfilling.  The funding does not cover all expenses associated with conducting the outreach service, with additional costs such as co-ordination or corporate on-costs being met by the Local Health District.

Moree is located in the Hunter New England Local Health District in the north west of NSW, approximately 650km and 9 hours from Sydney; 500km and 7 hours from Brisbane. The closest tertiary facility is 500km / 6.5 hours away in Newcastle.

Need and Project Scope

  • High risk obstetric population
  • Difficulty with equity of access due to geographical isolation
  • Lack specialist resources to supplement care for moderate to high-risk obstetric patients
  • Cost of long distance travel for low socio economic population
  • Large distances to tertiary centres
  • No direct air services to acute hospital (Tamworth) or tertiary hospital (John Hunter Hospital in Newcastle)

The Service

The service commenced 14 February 2012 with 1 day visits, every six weeks with 10 visits approved per annum.

  • Monthly, same day fly in/fly out (10 visits per year)
  • Newcastle (John Hunter Hospital) visiting team consists of:
    • Maternal Foetal Medicine Specialist
    • Obstetrics and Gynecology (O&G) Senior Registrar
    • Clinical Midwifery Consultant - High Risk
    • Neonatal ICU nurse specialist
    • Aboriginal Maternal and Infant Health Service (AMIHS) Manager
  • Supported by the local team members including:
    • Midwife
    • Aboriginal Health Education Officer
    • Ultrasound sonographer (private)
    • Social Worker

The original project scope was to establish an outreach clinic, supported by staff from John Hunter Hospital in Newcastle. However when the clinic commenced, not all of the health professionals were available given workforce constraints.  As an alternative, social work support was negotiated with the oncology social worker located in Moree. 

Due to concerns with transporting ultrasound equipment it was decided to use the local private service in Moree for the ultrasonography service. This proved beneficial for both the women and the visiting team as previous scans could be reviewed, women were also familiar with the local sonographer, and knowledge could be shared to ensure the best foetal and maternal views and outcome for women and their babies.

Support by the local AMIHS health care workers was also required to facilitate early access to antenatal services and ensure continuity of care for women during their pregnancy.  This support often includes the need to address transportation issues to/from Moree, Wee Waa and Narrabri.

  • Clients are consulted by Clinical Midwife Consultant and local midwife:
    • previous pregnancy and antenatal history
    • other medical history and medications
    • antenatal check
    • devise birth plan, which provides clear, concise and uniform approach to ante-natal, intrapartum and post natal care for the local women and their healthcare providers
    • co-ordinates appointments and referrals
  • Ultrasonographer performs scans

Women are then introduced to the Foetal Medicine Specialist, visiting O&G Registrar and the sonographer.

Results

  • 68 women seen
  • Women presenting aged 17-43 years (avg 28 years)
  • Aboriginal women presenting 25 (= 36.8%) 
  • Gestation on presentation ranged from 10-39 weeks (average 27.5 wks)
  • Utilisation of available technology to assist in the continuity of service provision. For one clinic the John Hunter Hospital team were unable to take their flight due to poor weather conditions. Rather than cancel the outreach clinic the local ultrasonographer and midwife performed the ante natal checks and scans for the women who attended the clinic. These results were then uploaded into our web based reporting tool so that the Newcastle based specialists could review which resulted in ensuring timely continuity of planning and care
  • The MFM clinic for rural women referred with a maternal or foetal issue in pregnancy equates to less economic and social stress
  • Enables most women in a rural setting to travel less distance to consult a specialist and to birth in their own local area.

Geographic Breakdown of Referrals

  • 50 women from Moree and surrounding area up to 50- 100kms
  • 11 Women from Narrabri and 3 from Wee Waa which are around 100kms south and south west of Moree
  • 1 from Collarenebri (over 100kms west of Moree)
  • 3 Not specified

Many women still travel some distance in order to access the high-risk outreach service. Providing the service closer to home means that partners can attend clinics with women, which was not always possible when travel to Newcastle was required.

Families also benefit with the mother not being away for days just for an antenatal visit. 

One husband was very happy that he was able to take a few hours off the farm at harvest time to accompany his wife to the clinic.  Previously this had been a huge issue for that couple as she was high risk and he had never been able to go with her due to farm and family commitments.

The Clinic has experienced excellent attendance rates and feedback from clients is extremely positive.  There were only two instances where women did not attend their appointments without cancellation, which were results of unexpected car breakdowns.

Presenting Conditions

Women were referred to the clinic for a range of conditions, including:

  • Gynaecological complications (cervical incompetence; CIN 1,2 or 3; Bicornate uterus; vaginal prolapse; previous caesarean (Lower Segment Caesarian Section); requesting vaginal birth after caesarean (VBAC)
  • Endocrine conditions (gestational Diabetes; Type 1 Diabetes; and hyperthyroid)
  • Haematological concerns (clotting disorder and spherocytosis)
  • Antibody identification
  • Neurological history (VP Shunt and Epilepsy)
  • Other conditions for which women were referred include autoimmune disease, musculoskeletal concerns, cardiac history, PET in previous pregnancies, psycho-social issues, mental health issues, drug and alcohol issues, and BMI over 38.

Presenting Conditions - Foetal Concerns

Foetal concerns that initiated the referrals to the clinic included:

  • Twins
  • Hydonephrosis
  • Interuterine growth restriction
  • FDIU - previous pregnancy
  • 4 or more miscarriages
  • Previous neonatal death
  • Previous premature birth
  • Abdominal cyst on foetus
  • Foetal Abdominal ascites
  • Abnormality identified on ultrasound scan
  • Foetal Pyelectasis
  • Previous pregnancy cardiac abnormality
  • Amniocentesis
  • Family congenital abnormality

Birth Outcomes

  • 39 (59%) of women attending the Maternal Foetal Medicine Clinic were able to birth at their local maternity unit (Moree or Narrabri) including one set of twins who birthed at Moree, and were able to remain until discharge
  • 28 (41%) referred to higher care facility for birth (including 1 premature birth in Collarenebri, retrieved by NETS)
  • 1 chose to birth elsewhere

Some positive outcomes have included: 

  • A woman referred for an epidural because she had a VP shunt.  An epidural was recommended for labour to reduce hypertension and cerebral effects, which enabled the woman to birth vaginally. This woman travelled 100kms rather than 250km which would have been required for a Rural Referral Hospital; or 450km to the closest tertiary facility
  • A local woman was able to birth vaginally after consultation with the team concerning possibilities of vaginal birth after caesarian
  • A local woman was able to birth locally after consultation for an antibody issue, and the Maternal Foetal Medicine team were content with pathology services and positive feedback to local GP Obstetricians with precise birth plan.

Benefits – Workforce

Workforce surveys continue to show that both rural GP obstetricians and midwives are aging. The specific challenge in rural settings is succession planning.

  • Support from speciality services, not only supports the contemporary workforce of rural GP Obstetricians and midwives working in rural areas, but may act as a recruitment tool, offering specialist hospital staff insight into opportunities available in rural settings
  • Through education and shared knowledge, confidence and skills can be acquired which in turn can provide a means to maintain some of our diminishing rural maternity services
  • Lunchtime meetings for health professionals, also teleconferenced to Narrabri. Sessions have included information on:
    • vaginal birth after caesarean
    • use of epidurals
    • evidence based support for types analgesia use in labour
    • malposition at birth
    • cephalic rotation
    • foetal growth monitoring in utero
    • maternal cervical length monitoring and treatment
    • autoimmune disease in pregnancy
    • education to local clinicians extremely valuable

Benefits – Cost, Travel and Time Savings

We receive every year just over $100,000 to run this service which equates to $10,000 per clinic. Although this appears an expensive service the benefits for the women, local health care providers and community are profound.

Previously approximately 25% women would have been treated at John Hunter Hospital in Newcastle, with the remaining 75% at Tamworth. The average number of visits to the Moree service was two, therefore the travel savings for the women and their families would be:

  • 136 trips (34 John Hunter at Newcastle, 102 Tamworth)
  • 90,100 km’s (1,000kms round trip to/from Newcastle from Moree; and 550kms round trip to/from Tamworth from Moree)
  • 1,190 hours spent driving (7 hours each way to/from Moree and Newcastle, 3.5 hr each way between Moree and Tamworth)
  • 306 days away from home and family (3 day visit for the Newcastle appointments and 2 days for Tamworth)

Conclusion

Importantly, delivery of the outreach High Risk Maternal Foetal Medicine Service for rural women with maternal or foetal issues in pregnancy results in better access to a specialist service closer to home, and less economic and social stress for these women and their families.

The Service supports both the local rural community and the local GP and maternity workforce. 

Contact


General Manager, Mehi Cluster
Alice Street, Moree, NSW, 2400
Hunter New England Local Health District
Tel 02 6757 0007

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