Te Whatu Ora Counties Manukau (CM) Health (the new name for the region after July 2022) provides health services to a population of approximately 560,000 in South Auckland, New Zealand. The vibrant community of CM is home to the largest population of Pacific people and also has the second largest population of Māori, compared to other regions in New Zealand.[[1]] Thirty-six percent of its residents live in areas of the highest socio-economic deprivation (decile 9 & 10) compared to a national average of 20%.[[2]] Over 123,000 children live in CM, with one in two living in areas of the highest socio-economic deprivation. Obesity increases health risks in the CM population, with over 66% of the women birthing in this region in 2015 having an overweight body mass index (BMI) (25%) and having obesity (41%). The ethnic distribution for women with an overweight BMI for Māori, Pacific, European, Indian, Chinese/Other Asian was 29%, 20%, 30%, 25% and 17% respectively. The obesity BMI for Māori, Pacific, European, Indian, and Chinese/Other Asian was 50%, 68%, 26%, 15% and 7% respectively.[[1]] In addition, disparities in services and health outcomes for Pacific and Māori peoples in New Zealand have been well documented.[[3–6]]

More than 7,000 babies are birthed in the Te Whatu Ora CM Health district each year and the perinatal mortality is higher than elsewhere in New Zealand.[[7–8]] In this community, postnatal access to and engagement with maternal and child health services is important to ensure the ongoing health and wellbeing of mothers and babies.

An external review of maternity care in the CM Health district in 2012[[9]] highlighted the contribution of maternal obesity to increased pregnancy complications in the region. The review reported high rates of unplanned pregnancy and many barriers to accessing contraception. A number of recommendations were made, including that “urgent work needs to be undertaken to develop culturally appropriate nutritional and lifestyle interventions to optimise weight gain during pregnancy” and “immediate consideration needs to be given to ways of making contraception much more accessible, affordable and available to women in CM Health region”.

The Healthy Mums and Babies (HUMBA) trial of nutritional interventions in pregnant women with obesity was developed in response to the recommendations.[[10–11]] Participants in the HUMBA trial were followed up at 12 months after birth. A survey was administered with the aim to assess access to early childhood health care services, (Well Child Tamariki Ora programme [which included Plunket]) and primary healthcare,[[12]] as well as access to and uptake of family planning/contraception.[[13]]

Methods

The HUMBA study recruited a multi-ethnic sample of pregnant women (n=230) with a body mass index of >30kg/m[[2]] (12[[+0]] to 17[[+6]] weeks pregnant) from the Te Whatu Ora CM Health area, who participated in a randomised controlled trial to investigate the effect of a dietary intervention vs routine dietary advice and a daily probiotic capsule vs placebo on maternal and offspring health outcomes. Women were enrolled in the study and recruitment commenced from April 2015 to June 2017. The last birth was in January 2018, with the last 1 year of birth follow-up in February 2019. Detailed methods for the trial are described in the HUMBA protocol.[[14]] Ethics approval was obtained from the Southern Health and Disability Ethics Committee, New Zealand (14/STH/205). The HUMBA trial was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12615000400561). The results of the HUMBA trial showed that although our interventions did not impact our primary outcomes of excessive weight gain and infant birth weight, we were encouraged by the dietary intervention resulting in participants gaining fewer than 1.8kgs in total.

As part of the 12-month postpartum follow-up in the HUMBA study, participants were asked to complete maternal and child health surveys, which consisted of questions about their access to and use of 1) local primary health and child wellness services, and 2) family planning services postpartum.

The survey was designed by the clinical investigators specifically for the Te Whatu Ora CM Health population, to be suitable for a multi-ethnic sample of New Zealand women. Four five-point Likert scales were utilised for different questions: 1=very easy to 5=very hard; 1=strongly disagree to 5=strongly agree; 1=very likely to 5=very unlikely; 1=never to 5=always. Prior to finalisation, the survey was piloted among community midwives and community health workers with multi-ethnic backgrounds to check the suitability, clarity of the questions and ease of administration.

Socio-economic status was determined using the NZ Deprivation Index (NZDep)[[15]] and scored from 1 to 10, with 10 being most deprived and 1 being the least deprived. NZDep was used because it combines several variables including communication, income and employment, and applies the score to a geocode representing a specific region. Primary home addresses provided by participants at the time of study enrolment were used to obtain a Meshblock code via a Classification Coding System (CCS) developed by Statistics NZ.[[16]] Once each address had its assigned code, these Meshblock codes were assigned a deprivation score, which were later grouped into quintiles.

Family planning/contraception was defined as use of methods to prevent conception (classified as permanent, hormonal and other) from birth until the 12-month visit. Permanent methods (tubal ligation, vasectomy) and hormonal were used: either long-acting reversible contraception (LARC) namely Jadelle (implant), Mirena (Levonogestrel intrauterine contraceptive device [LNG_IUCD]), copper intrauterine contraceptive device (Cu_IUCD); or depo-provera injection or oral contraceptive pill. Other methods included: condoms, withdrawal method and natural family planning.

Data and statistical analyses were performed using SAS version 9.4 (SAS Institute Inc., Cary, NC, USA). Demographic characteristics were compared between women who completed the maternal health surveys at 12 months and those who did not. Continuous variables were compared using t-Test, and categorical variables were compared using Chi-squared test. A p-value of <0.05 (two-tailed) was considered statistically significant. Utilisation of healthcare and family planning/contraception and data on the use of different family planning/contraception methods were evaluated using frequency tables for those who completed the 12-month healthcare survey.

Results

Of the 230 pregnant women who consented and were randomised into the HUMBA Trial, 127 (55.2%) mothers completed the health and family planning/contraception surveys at 12 months following the birth of their HUMBA baby (Figure 1).

View Figure 1 & Tables 1–4.

The demographic details of those who did and did not complete the 12-month postpartum mother and baby surveys are outlined in Table 1. Those followed up at 12 months after birth were older, more likely to be European, had a planned pregnancy and were less likely to be in the highest New Zealand deprivation quintile. Allocation to the nutritional intervention, which included an additional four visits with a community health worker, did not differ between those who did and did not complete the survey.

The utilisation of healthcare services by the HUMBA mothers and babies is shown in Table 2. The mean (SD) age of the babies at the follow-up visit was 14.3 (1.9) months. All babies and 99% of the mothers were enrolled with a general practitioner (GP). Enrolment with the same GP as their babies was reported by 94% of the mothers. The GP practice was the preferred healthcare facility chosen if the baby was unwell (97%), although over 60% also used community and hospital emergency departments if needed.

Plunket was the main Well Child provider (88.2%). Only two babies were not enrolled with a Well Child provider. Most babies (88%) were seen in the previous 6 months with approximately half of the visits taking place in the home (Table 2).

Eight percent of the participants found it “hard or very hard” to see their Well Child provider. The three main barriers to accessing their provider were 1) too busy with work (23%), 2) provider was not available or appointments were cancelled (18%), and 3) too busy with household duties (14%). Specific feedback included the provider not keeping scheduled appointments or coming to the home without a booked appointment. Over 80% agreed that home visits would assist in accessing their provider and over two thirds agreed that after-hours/weekend clinics and having a clinic in their own community would also assist with access.

For the mothers, 7% found it “hard or very hard” to access their GP. The three main barriers were 1) the cost of GP visits (37%), 2) too busy with work (29%), and 3) too busy with household duties (24%). Women gave specific feedback on the unavailability of same-day appointments, the long waiting time at appointments, especially with a sick baby, and the higher cost for weekend appointments when it would be more convenient and less stressful for them to attend.

The family planning/contraception survey was completed by 127 women (Table 3).

A discussion on family planning/contraception, either during or after pregnancy occurred in 123/127 (96.9%) of the women (Table 3). Nearly 90% said they had this discussion with their lead maternity caregiver (LMC). Postpartum family planning/contraception was arranged for 74/127 (58.3%) of women and was most likely to be arranged by the LMC (42/74, 56.8%). Of the 74 women who had family planning/contraception arranged, the majority (61/74, 82%) did use it (Table 3).

Of the women who had no family planning arranged, 37.7% (20/53) chose not to use any form of contraception.

Twelve (9.4%) women were pregnant at the time of the 12-month visit with an average interpregnancy interval for these women of 19.8 months (median 20 months, range 14.7 to 26.5 months); of these, six had used some form of contraception, three did not believe in using contraception and three chose not to answer.

If family planning/contraception decisions are needed in the future, participants said they would most likely see their GP (91/106, 86%), followed by the GP practice nurse (56/105, 53%), a nurse at a Family Planning Clinic (35/105, 33%), a doctor at a Family Planning Clinic (34/105, 32%) and 8% (8/105) said they would see a pharmacist. Women reported various factors that would assist them to access family planning/contraception in the future, including after-hours/weekend clinics (58%); community clinics (55%); home visits (50%) and mobile clinics (49%).

Methods of family planning used by the HUMBA mothers during the previous 12 months since the birth of their baby are outlined in Table 4.

Discussion

This survey of mothers in the HUMBA randomised trial at 12 months after birth aimed to gain pertinent information on: enrolment in primary care and/or a Well Child health provider; utilisation of healthcare services; and discussions about access to family planning/contraception. The demographic characteristics of participants in this survey was broadly representative of the CM Health population in 2015.[[7]] In our sample, the highest quintile of deprivation was present in 58.3% of participants compared to 45.0% overall at CM Health, and Pacific people were over-represented (45.6% vs 30.2%) and Indian/Other Asian underrepresented (7.9% vs 16.9%) compared with the general birthing population. Our study population included whānau who face greater inequities in our health system, and it was therefore valuable to have their feedback.[[3–6]] Although our recruitment started in April 2015 and our last HUMBA baby 12-month follow-up was February 2019, our results are likely still relevant today.

1. Enrolment in primary care and Well Child health care provider.

In our sample of 127 participants in the HUMBA trial at 12 months postpartum, enrolment with a GP was reported for all the babies and all but one mother; 94% of the mother/baby pairs shared the same GP. New Zealand babies are recommended to enrol in with a GP soon after birth as per Ministry of Health (MoH) guidelines.[[17]] This policy was instituted in 2012, when it was realised that from October 2009 to September 2010 almost no new-borns in New Zealand were enrolled with a GP by 6 weeks and less than 50% were enrolled by 12 weeks of age. The move was to ensure that babies born in New Zealand were monitored to be safe, in good health and have immunisations up to date. The new-born GP registration can be activated through the National Immunisation registry notification process. GPs are also expected to develop their own inhouse guidelines to ensure that babies born to mothers in their practices are registered soon after birth.[[17]]

In this sample, 98% of babies were enrolled with a Well Child Tamariki Ora provider (mostly Plunket). The New Zealand Government is committed to supporting early childhood services to ensure optimal health of tamariki (children).[[12]] “Well Child/Tamariki Ora” is a comprehensive and well-funded programme to ensure that New Zealand children from birth to 5 years of age have an optimal start to life, to reach their full potential as adults. The Lancet series on “Advancing Early Childhood Development” reported that investing in the health of children resulted in improved intellectual abilities, better health and fewer psychological issues.[[18]] The Well Child/Tamariki Ora Programme Practitioners handbook is available for health professionals, as well as the Well Child Tamariki Ora My Health Book given to the mother at birth to record the child’s first 5 years of growth, milestones, health checks and immunisations.[[12]] The programme was designed to be equitable, accessible and improve the long-term productivity of New Zealand children. The New Zealand Government is seeking further improvement to this programme.[[19]] Similar programmes are also in place in many developed countries with some doing better than others.[[20–21]]

Plunket services were received by 88% of mothers, which is very similar to the overall rate in New Zealand.[[22]] Half of these Well Child Tamariki Ora visits took place in the home, which was identified as the strongest factor that assisted with accessing this service. HUMBA mothers were concerned (similar to a 2013 review), with appointments not being kept by the Well Child provider, and expressed a preference for home visits.[[22]]

Among the mothers, all but one was enrolled with a GP, usually the same one as their baby. The reported challenges in accessing primary care by the HUMBA participants are similar to those reported in a review of health equity for Pacific peoples in New Zealand around barriers to accessing primary care due to cost.[[4]] After-hours and weekend appointments were more costly, when it was more convenient for women to attend due to employment, childcare and transport issues. Their inability to get an appointment within 24 hours with an unwell baby was also concerning.

Although community and hospital emergency departments were used by 60% of the cohort when their babies became unwell, their preference was to use their GP. It is encouraging that this population was aware of the appropriate pathway to review their children to reduce pressure on emergency departments with already stretched services, as in a UK study.[[23]] The emergency department serving the CM region is often in crisis due to overcrowding, limited resources, short staffing and poor access to GP services.[[24]] Fortunately, New Zealand children have free healthcare, hence GP services are accessible.

2. Access to family planning/contraception.

The 2014/2015 New Zealand Health Survey found that 80% of women (16 to 49 years) who were sexually active had used at least one form of family planning/contraception.[[25]] Our findings were very similar, with 72% (92/127) reporting some form of family planning/contraception use in the previous 12 months. A study in Eastern Australia in a sample of women aged 18–39 years reported that 43.2% (n=1814/2854) were using hormonal family planning/contraception methods. The most common form was the combined oral contraceptive (COC) pill, and long-acting reversable contraception (LARCs) or injectables.[[26]]

In November 2019, the LNG-IUS (Mirena) became fully funded in New Zealand.[[27]] It was an important equity issue in New Zealand, as the device cost $340 NZD and only those able to afford it could access it. Women in New Zealand not only benefit from LARCs as an excellent form of contraception, it also reverses abnormalities in the lining of the uterus in women with obesity,[[28]] who are more likely to be from low socio-economic regions with high fertility rates[[2]] and are at increased risk of endometrial cancer.[[29]] The Australian Government in February 2020 added the LNG_IUCD (Kyleena) as another form of contraceptive choice for Australian women in addition to the already funded Mirena.[[30]] Australia does not fund copper IUCDs. LARCs have reduced the rates of abortions in New Zealand and are the preferred choice for contraception due to their “fit and forget” capability, effectiveness and reversibility once removed.[[31]] Contraception allows spacing of pregnancies, improved maternal and perinatal outcomes and reduces the risks of unwanted pregnancies.[[32]] There is strong evidence that instituting contraception (LARCs or injectables) soon after birth is effective, convenient and avoids the inconvenience of booking an appointment to discuss and obtain contraception.[[32]]

A limitation was that information from postnatal women was not collected on whether the discussion regarding family planning/contraception offered was adequate and understandable. Also, whether the offered information enabled them to make the appropriate choice that suited their needs.

In conclusion, it is encouraging that in this sample of pregnant women who participated in the HUMBA trial in the Te Whatu Ora CM Health region, almost all of the women registered themselves and their baby with a GP and/or a Well Child health provider by 12 months postpartum. It is important to continue providing suitable and engaging family planning/contraception information antenatally and postpartum to women. More imperative is ensuring the information is fully understood and there is unimpeded postnatal access to family planning/contraception, as women are more likely to use them if arranged.