Remote access and care: A comparison of Queensland women's maternity care experience according to area of residence

Women and Birth 27 (2014) 281–291

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Remote access and care: A comparison of Queensland women’s maternity care experience according to area of residence Julie Hennegan a, Sue Kruske a, Maggie Redshaw a,b,* a b

Queensland Centre for Mothers & Babies, School of Psychology, The University of Queensland, Brisbane, Australia National Perinatal and Epidemiological Unit, University of Oxford, Oxford, United Kingdom

A R T I C L E I N F O

Article history: Received 12 March 2014 Received in revised form 28 June 2014 Accepted 29 June 2014 Keywords: Remote and rural Maternity care Pregnancy Childbirth Postnatal care

A B S T R A C T

Background: This study fills a gap in the literature with a quantitative comparison of the maternity care experiences of women in different geographic locations in Queensland, Australia. Method: Data from a large-scale survey were used to compare women’s care experiences according to Australian Standard Geographical Classification (major city, inner regional, outer regional, remote and very remote). Results: Compared to the other groups, women from remote or very remote areas were more likely to be younger, live in an area with poorer economic resources, identify as Aboriginal and/or Torres Strait Islander and give birth in a public facility. They were more likely to travel to another city, town or community for birth. In adjusted analyses women from remote areas were less likely to have interventions such as electronic fetal monitoring, but were more likely to give birth in an upright position and be able to move around during labour. Women from remote areas did not differ significantly from women from major cities in their satisfaction with interpersonal care. Antenatal and postpartum care was lacking for rural women. In adjusted analyses they were much less likely to have booked for maternity care by 18 weeks gestation, to be telephoned or visited by a care provider in the first 10 days after birth. Despite these differences, women from remote areas were more likely to be breastfeeding at 13 weeks and confident in caring for their baby at home. Conclusions: Findings support qualitative assertions that remote and rural women are disadvantaged in their access to antenatal and postnatal care by the need to travel for birth, however, other factors such as age were more likely to be significant barriers to high quality interpersonal care. Improvements to maternity services are needed in order to address inequalities in maternity care particularly in the postnatal period. ß 2014 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.

1. Introduction For many women, living in a rural or remote area has both benefits and challenges. Navigating maternity care is often much more difficult than for those in city or regional areas. Women face limited access to antenatal and postnatal care, the need to travel away from home and support networks to actually give birth, and the added emotional and financial costs associated with this travel.1,2 The facilities available in rural areas do not provide the same level of clinical services as tertiary facilities in major cities,

* Corresponding author at: Policy Research unit for Maternal Health and Care, National Perinatal Epidemiology Unit, University of Oxford, Old Road, Oxford OX3 7LF, United Kingdom. Tel.: +44 01865 289700; fax: +44 01865 289701. E-mail address: [email protected] (M. Redshaw).

and specialists such as obstetricians or anaesthetists may be less available. In addition, private hospitals, and newer models of care such as midwifery group practices may also be less available or at further distances from these women.3–5 Recent decline in the number of maternity services for rural and remote families in Australia and Canada due to closures in many states/provinces has been argued to further disadvantage this population, and received attention from advocacy groups.6,7 In response, attention to the needs and experiences of women in rural and remote areas has increased. The vision of the Australian National Maternity Service Plan8 is to achieve a service where ‘‘All Australian women will have access to high-quality, evidence-based, culturally competent maternity care in a range of settings close to where they live.’’ The plan prioritises improvements in care for Aboriginal and Torres Strait Islander (A&TSI) and women in rural and remote areas.

http://dx.doi.org/10.1016/j.wombi.2014.06.012 1871-5192/ß 2014 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.

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To achieve the goals of the Maternity Service Plan and elicit effective change, it is essential to adequately understand the issues facing women in remote areas, and how their experiences differ from those in urban areas. Furthermore, any positive changes evoked by the implementation of policies or programmes (such as the Maternity Service Plan) cannot be effectively evaluated without a baseline understanding of the differences in experience. Whilst population-level data exists on clinical differences between urban and rural mothers, and qualitative studies have described the experiences of women in these areas, there is a significant gap in the availability of quantitative data assessing the pregnancy and maternity care experiences of this population. Little evidence exists comparing rural and remote women’s experience with those with easier access to care, in Australia and other parts of the world, nor do current studies account for other demographic differences such as indigenous status, socioeconomic resources, or maternal age which may contribute to any differences observed.9,10 1.1. Rural and remote health Australian national health surveys have often identified poorer outcomes for those living in rural and remote areas.11 A review of urban–rural differences in health in high-income countries found considerable variation in differences across countries and health conditions.10 In Australia, overall perinatal death rates have been found to significantly increase with rurality, with much higher rates identified in very remote areas compared to major cities.11 However, much of this difference has been attributed to the much higher perinatal death rates for babies of Indigenous mothers.11,12 Indeed review of rural–urban health disparity has emphasised the role that other demographic disadvantages such as minority group status, lower socioeconomic status, and lower levels of education play in observed differences.10 Emerging literature on remote and rural health has advocated for further analysis to investigate: if rurality represents a unique risk factor, the way rurality may interact with other non-spatial health determinants, and the role that accessibility may play in exacerbating other disadvantages.1,9,10,13 A study seeking to address this question, compared babies born to Indigenous mothers in remote areas to those born in cities and found that even after adjustment for age, parity, smoking and diabetes or hypertension, babies born to mothers in remote areas were more likely to be of low birthweight and in poorer condition at birth.14 The study suggested that, at least for this group, rurality represents a unique risk factor for health outcomes. 1.2. Rural and remote experience of care Studies primarily conducted in Canada and Australia have documented the challenges that women from rural and remote areas face in accessing maternity care. Women encounter long travel times for check-ups, and must often relocate to a regional centre to give birth.6,15–17 This brings with it added expenses of accommodation and travel costs as well as needing to arrange care for other children and time off work.7,17 Themes from qualitative interviews and focus groups frequently reflect these issues with major themes being preferences for local care, concerns about accessing and travelling for care, and concerns about cost.1,2,17 Themes of isolation are discussed in studies of remote women’s health generally, as well as those specifically addressing maternity care.17–19 Women can feel isolated or alone at home, in travelling long distances to reach antenatal or postnatal care appointments, and in relocating to another city or town to give birth. Relocating to another location for birth can occur weeks before doing so;

resulting in many days spent in temporary accommodation alone.3,18 Qualitative studies have also revealed themes around women’s pride in their rural identity as well as some positive reports on the personal care provided by health care practitioners in smaller rural facilities.19,20 Few studies have investigated rural women’s intrapartum care experiences. Bourgeault and colleagues17 reported that rural and remote women described a poor quality of interpersonal care attributed to the busyness of care providers. Sutherns and Bourgeault1 echoed this message, finding women in rural Canada reported poor quality of care including a lack of appropriate care, culturally sensitivity, or continuity of care. However, it should be noted that these focused studies did not compare care in a rural context with that experienced in urban settings. Interviews with Aboriginal women in northern Australia identified care provider beliefs, attitudes and practices were identified as barriers to high quality antenatal care.21 Limited quantitative data is available on women’s experience of care. Parturient women travelling more than one hour to access services have been found to be more likely to experience moderate or severe stress than those with local access to care.22 Wellbeing, specifically depression, has been compared between rural and urban women in one Australian study which found no difference in the prevalence of postnatal depression between urban and rural women, but found antenatal depression was more common in the urban group.13 The study found demographic characteristics and past history of depression were both key in predicting postnatal depression with predictors slightly different for rural and urban mothers (with socio-economic status a significant predictor in rural, but not urban women). As discussed above there is increasing recognition of the role of other demographic factors in contributing to different clinical outcomes for rural women. Recent work on women’s experiences of maternity care also suggest that these factors significantly impact upon experiences of care and quality of care ratings,23–29 and thus these must be taken into account in any comparison of rural and urban women’s experiences. 1.3. The present study This study sought to address the lack of quantitative data on the way in which remoteness and rurality impacts upon women’s clinical experience and experience of care; whilst considering demographic differences that may exist amongst the groups. The study utilises four groups based on the Australian Standard Geographic Classification30 which measures remoteness in terms of the distance required to travel in order to access various levels of a range of services [see 31]; major city, inner regional, outer regional, remote and very remote. Those in major city areas face relatively unrestricted access to services, whilst, whereas those from remote and very remote areas have very little accessibility to services including any emergency medical services, and would need to travel for much more than an hour to access birthing facilities.22,31 In 2011, 61.3% of Queensland birthing mothers lived in major city areas, 19.0% in inner regional, 15.5% in outer regional and 2.3% and 1.9% in remote and very remote areas respectively.12 Each of these groups faces different environments and barriers to accessing antenatal, intrapartum and postpartum care. The study compares outcomes across the groups, but focusses on the experience of those from remote and very remote areas. The following research questions were addressed: (1) Are there demographic differences between the groups? (2) Were there reported differences in access and engagement with care at each stage of maternity care? and (3) Do women from different areas receive a different quality of care?

J. Hennegan et al. / Women and Birth 27 (2014) 281–291

2. Methods 2.1. Data collection and participants Secondary analysis was conducted on data collected in a statewide population based survey of women who gave birth between February and May 2010.32 Women who had a live singleton or multiple birth were sent a survey package approximately four to five months after birth by the Queensland Registry of Births, Deaths and Marriages using hospital notifications. A reminder postcard was mailed two weeks later. Women who had a stillbirth or neonatal death were excluded from the sample. Survey packages contained an introductory letter, information sheet, a Translating and Interpreting Services sheet, a reply paid envelope and a paper copy of the survey. Women could also complete the survey online or over the phone with a trained interviewer. Approval for the survey was received from the Behavioural and Social Sciences Ethical Review Committee of The University of Queensland. 2.2. Measures The survey measure included sections on antenatal care, labour and birth, interpersonal care, post-birth care, and demographic information. Women self-reported both clinical and interpersonal care experiences using items based on other national surveys in the UK and North America, and local user and care provider input.33–35 Rurality/geographical classification: Accessibility and Remoteness Index of Australia (ARIA) scores, the standard measure of remoteness endorsed by the Australian Bureau of Statistics (ABS), were derived from suburb/town and postcodes provided by respondents. From ARIA scores the ABS Australian Standard Geographical Classification30 groupings were used to define participants’ location as major city, inner regional, outer regional, remote or very remote. Demographics: Women indicated the highest level of qualification they had completed through a set of standard response options,36 and a dichotomous variable was created of women who had and had not completed secondary school education. Socioeconomic resources used the Socio-Economic Indexes for Areas’ (SEIFA) Economic Resources Index (ER) derived from Census variables related to income, housing expenditure and assets of households.37 Postcodes were used to determine SEIFA-ER quintiles. Women reported their type of birthing facility and insurance status. A three-category variable for birthing facility used public hospital, private hospital or public birth centre as categories in descriptive analyses. In multivariate analyses a dichotomous public facility/private facility variable was used. Clinical characteristics and experience: Multiparous women indicated if they had any complications in previous pregnancies, labours or births. For the most recent pregnancy, complications were assessed through a multiple-response option list. Structured selfreport items were completed on induction, foetal monitoring and pain relief, episiotomy, position and location for birth, perineal tears and repair. Women were coded as having perineal trauma (an episiotomy or tear), with or without stitches. Response options for birthing position were: standing, squatting or kneeling, propped up or sitting, lying on my side, lying flat on my back and other. For location, options were: on a bed, on the floor, on a birthing stool, in the shower, in water (a pool or bath) or other. Using a checklist, women reported the type and number of care providers caring for them during labour and birth. They reported the time from birth to first holding their baby in minutes and hours, and using structured response format indicated when their baby was first put to the breast. Access to care: Women indicated if they travelled to ‘another city, town or community’ for their birth and the reason for doing so. Women reported the number of check-ups they had with different

283

providers and indicated if they saw the same care provider for each check-up ‘every time’, ‘some of the time’ or never. Length of hospital stay was reported in days/hours, followed by ratings of satisfaction with the length of stay as ‘about right’ ‘too long’ or ‘too short.’ Women also indicated if their partner/support people had felt welcome at during labour, birth, after birth, and overnight after birth. A multiple-response item was used to describe the different types of contact with care providers in the first 10 days at home, and the number contacts with care providers until the time of survey completion (mean 21 weeks after birth). Quality of interpersonal care: Women reported on a 5-point Likert type scale how well they were looked after by care providers overall. Dichotomous variables were created to compare goldstandard care (looked after very well) to lower scores. Women rated different aspects of interpersonal care during labour and birth care on a 3-point scale of ‘not at all’, ‘some of the time’ and ‘all of the time’. Again a gold-standard response of ‘all of the time’ was compared with less than optimal care. Choice and postnatal well-being: A dichotomous variable was created to compare women who felt free to move around during labour ‘most of the time’ with those who indicated feeling free some or none of the time. Women indicated the extent to which they had experienced breastfeeding problems, and feeling depressed after birth with a dichotomous variable comparing those who experienced problems never or rarely, to those reporting problems sometimes or often. Women rated their confidence to care for their baby after returning home on a 5point scale from ‘‘extremely confident’’ to ‘‘not at all confident’’. 2.3. Analysis Univariate comparisons were used to describe the sample and compare access, clinical experience, and the quality of interpersonal care received amongst women living in the four geographical remoteness classifications. Binary logistic regressions were then undertaken to adjust for demographic differences between the groups. Adjustment was made for age, SEIFA-ER, identification as Aboriginal and/or Torres Strait Islander, and type of birthing facility (public or private). No significant differences were identified amongst the groups on mode of delivery after adjusting for demographic characteristics and thus no further adjustment was made for this variable. Analyses were conducted using SPSS Version 20 with significance set at p < 0.05. 3. Results 3.1. Respondents Of the invited sample of 20,365, a total of 7193 women completed the survey resulting in a response rate of 35.3. Of these 84% completed the paper survey, 16% completed the online survey and <1% completed the survey via telephone interview. Women from a major city area, primiparous women, and those birthing in private facilities were over-represented in the sample compared to the Queensland birthing population,38 whilst women younger than 20 and those identifying as Aboriginal and/or Torres Strait Islander were under-represented. A total of 138 women with missing postcode or suburb/town data were excluded from the present study resulting in a total study sample of 7055. 3.2. Demographic characteristics Comparison of demographic and maternal and infant characteristics (Table 1) between the groups showed that there were no differences in parity, previous caesarean section, history of

J. Hennegan et al. / Women and Birth 27 (2014) 281–291

284 Table 1 Characteristics of women by remoteness classification.

Demographic characteristics Parity (n 6995, p = 0.203) Age (n 6965, p < 0.001)

Education level; completed high school (year 12) (n 6952, p < 0.001) SEIFAa (n 7025, p < 0.001)

Aboriginal and/or Torres Strait Islander (n 6958, p < 0.001) Language spoken at home (n 6979, p < 0.001) Type of birthing facility (n 6921, p < 0.001)

Type of patient for birth (n 6894, p < 0.001) Clinical characteristics Previous caesareanb (n 3798, p = 0.160) Had complications with previous pregnancies/birthsb (3778, p = 0.121) Pregnancy complications (n 6780)

Infant characteristics Infant birth weight (n 6822, p = 0.823) Gestation at birth (n 6944, p = 0.736)

Major city % (n = 4523)

Inner regional % (n = 1365)

Outer regional % (n = 997)

Remote and very remote % (n = 170)

Primiparous Multiparous <25

46.1 53.9 11.5

43.4 56.6 17.8

43.9 56.1 15.6

48.5 51.5 22.8

25–29 30–34 35+

27.1 35.9 25.4 91.6

31.9 31.2 19.0 85.2

31.5 31.7 21.2 89.6

38.3 20.4 18.6 89.3

6.3 8.6 20.6 34.6 29.9 0.9

7.5 31.5 22.2 29.2 9.7 2.4

9.4 27.7 34.7 21.9 6.3 3.6

16.5 47.1 20.6 14.1 1.8 5.4

Only English English and/or other languages Public hospital Private hospital Public Birth Centre Public patient Private patient

90.0 10.0 51.6 46.1 2.3 52.6 47.4

97.3 2.7 65.8 33.3 0.8 61.0 39.0

94.3 5.7 63.3 34.0 2.7 59.7 40.3

95.3 4.7 70.7 28.7 0.6 58.9 41.1

No previous caesarean Previous caesarean

66.9 33.1 55.9

70.4 29.6 58.4

67.1 32.6 56.6

74.7 25.3 45.3

7.2 8.7 2.2

7.8 10.1 3.1

7.9 9.7 2.0

10.2 9.0 2.4

4.8 95.2 7.6 92.4

5.1 94.9 8.0 92.0

4.5 95.5 7.2 92.8

3.7 96.3 5.9 94.1

Quintile Quintile Quintile Quintile Quintile

1 (least resources) 2 3 4 5 (most resources)

Gestational diabetes (p = 0.423) High blood pressure (p = 0.389) Depression diagnosed by health professional (p = 0.222) <2500 g 2500 + g Preterm (<37) Full term (37+)

a SEIFA: Socio Economic Indexes for Areas: Economic Resources is derived from Australian Census variables related to economic resources such as income, housing expenditure and assets of households.37 b Multiparous women only.

pregnancy/birth complications, index birth pregnancy complications, low birthweight or preterm birth. However, compared to the other groups, women from remote or very remote areas were more likely to be younger than 25 years (x2(1) = 11.38, p = 0.001), to live in an area in the lowest quintile of economic resources (x2(1) = 20.78, p < 0.001), to identify as Aboriginal and/or Torres Strait Islander (x2(1) = 12.09, p < 0.001), and to give birth in a public facility (x2(1) = 10.89, p = 0.001). 3.3. Antenatal care Univariate and adjusted comparisons of the antenatal experience of women from each geographic area are shown in Table 2. Women in remote and very remote areas were very much less likely to have accessed maternity care by 18 weeks gestation and antenatal care was much more likely to involve check-ups with GPs than other care providers. While there was a significant difference amongst the groups in seeing the same care provider all or some of the time for pregnancy check-ups in the univariate comparison, these differences were no longer significant after adjustment for age, economic resources, A&TSI status and type of birthing facility (public/ private). Similarly, although women from remote areas were less likely to rate their overall interpersonal antenatal care very

positively in the raw comparisons, there was no difference after adjustment. 3.4. Travelling for birth As expected, women from remote and very remote areas were much more likely to travel to another city, town or community to give birth (x2(1) = 171.03, p < 0.001), and to have done so in order to use a facility providing birthing services (x2(1) = 20.22, p < 0.001) (Table 3). Significant differences were identified in the x2 comparing all four areas with the four category duration of hospital stay variable, however those from remote and very remote areas were no more likely to stay more than 24 hours in their birthing facility when compared to the other areas (x2(1) = 0.42, p = 0.516). There was no difference between women from remote areas on preferences for mode of birth (vaginal, CS, no preference) compared to the other areas combined (x2(2) = 0.82, p = 0.664, data not shown). 3.5. Clinical aspects of labour and birth There were a number of differences and similarities in the reported clinical aspects of labour and birth between women from the four remoteness classifications (Table 4). No significant

J. Hennegan et al. / Women and Birth 27 (2014) 281–291

285

Table 2 Comparison of antenatal care by remoteness classification.

Antenatal booking appointment (n 6261, p < 0.001)

Had 3 or more check-ups with care providers:

Major city % (n = 4523)

Inner regional % (n = 1365)

Outer regional % (n = 997)

Remote and very remote % (n = 170)

By 18 weeks

71.2

60.6

42.0

37.4

After 18 weeks ORadj (95%CI) (OR 1.00 = after 18 weeks)

28.8 1.00

GP (n 7022, p < 0.001)

37.6

39.4 0.54 (0.46–0.62) 44.5

58.0 0.25 (0.21–0.30) 49.9

62.6 0.19 (0.13–0.27) 60.6

1.14 (0.99–1.32) 48.3 1.09 (0.91–1.30) 50.6 1.38 (1.20–1.60) 67.5

1.44 (1.22–1.70) 46.0 0.86 (0.70–1.05) 44.3 1.08 (0.92–1.26) 72.5

2.45 (1.70–3.54) 40.6 0.73 (0.47–1.13) 45.3 0.95 (0.67–1.34) 68.0

0.88 (0.75–1.02) 61.3

1.15 (0.96–1.37) 65.5

0.99 (0.69–1.44) 53.3

1.00 (0.87–1.14)

1.19 (1.02–1.39)

0.80 (0.57–1.11)

ORadj (95%CI) (OR 1.00 = less than 3 check-ups)

1.00

OB/OBGYN (n 7019, p < 0.001) ORadj (95%CI) (OR 1.00 = less than 3 check-ups)

55.5 1.00

Midwife (n 7021, p < 0.001) ORadj (95%CI) (OR 1.00 = less than 3 check-ups)

38.4 1.00

Saw the same person for pregnancy check-ups ‘every time’/‘some of the time’ (n 6965, p < 0.001)

74.0

ORadj (95%CI) (OR 1.00 = ‘no’)

1.00

Overall looked after ‘very well’ during pregnancy (n 6996, p = 002)

64.9

ORadj (95%CI) (OR 1.00 = not ‘very well’)

1.00

ORadj: with adjustment for maternal age, SEIFA, A&TSI status, and facility (public/private).

differences were found amongst the groups on induction procedures, however, the odds of receiving constant electronic foetal monitoring became lower with rurality as did the use of epidural or spinal anaesthesia for pain relief in labour. The latter was consistent with the finding that the odds of having care provided by an anaesthetist reduced with rurality. Women from regional areas had higher odds of receiving pethidine or a similar pain killer than those in major cities. Although no significant difference was found for women from remote areas, odds ratios were similar to those found for regional areas, and the smaller sample size may have meant insufficient power to detect an effect. After adjustment there were no differences according to remoteness on mode of delivery. Odds of giving birth in a more upright position such as standing, squatting or kneeling increased with rurality.

3.6. Intrapartum care and care immediately post-birth Aspects of interpersonal care such as being treated with respect and as an individual differed amongst the areas in the univariate comparisons, however, differences between women from major cities and those from remote areas were no longer significant after adjustment for age, economic resources, A&TSI status and birth facility (Table 5). Similarly, despite a significant difference found in the univariate comparison, no differences in overall rating of quality of interpersonal labour and birth care were found after adjustment. When all predictors were included in the model (rurality, age, economic resources, A&TSI status and birthing facility) only maternal age, and type of birthing facility significantly predicted overall quality of interpersonal care rating. This

Table 3 Travelling for birth by remoteness classification.

Travel for birth to another city, town or community (n 7011, p < 0.001) Reason for travela (n 1638, p < 0.001)

Duration of hospital stay (n 6922, p < 0.001)

a

Only women who travelled.

Major city % (n = 4523)

Inner regional % (n = 1365)

Outer regional % (n = 997)

Remote and very remote % (n = 170)

13.8

40.0

37.8

65.9

Had to travel (to get to a facility or a facility with an appropriate level of care) Wanted to travel (due to hospital, care provider or model of care preference) <24 h

38.6

73.7

75.5

82.0

61.4

26.3

24.5

18.0

4.9

5.4

4.7

3.6

1–2 nights 3–4 nights 5+ nights

24.8 45.1 25.3

32.5 40.7 21.5

30.6 41.0 23.7

34.3 40.8 21.3

286

J. Hennegan et al. / Women and Birth 27 (2014) 281–291

Table 4 Comparison of clinical aspects of labour and birth by remoteness classification.

Membrane stretch & sweep (n 7009, p = 0.358) ARM to induce labour (regardless of success) (n 7009, p = 0.528) Medical induction (regardless of success)a (n 7009, p = 0.571) Electronic foetal monitoringc (n 5383, p < 0.001) Constantly with belt or clip Occasionally with belt No EFM ORadj (95%CI) (OR 1.00 = occasionally or no EFM) c Pain relief Gas and air (n 5260, p < 0.001) ORadj (95%CI)

Major city % (n = 4523)

Inner regional % (n = 1365)

Outer regional % (n = 997)

Remote and very remote % (n = 170)

12.2 14.8 20.7 57.0 22.5 20.5 1.00

14.1 16.4 21.6 46.1 32.6 21.4 0.66*** (0.57–0.77) 67.3 1.33*** (1.13–1.55) 32.9

12.9 14.7 22.6 45.9 31.4 22.7 0.66*** (0.56–0.78) 66.1 1.29** (1.08–1.54) 34.5

11.8 15.4 21.9 38.9 34.4 26.7 0.49*** (0.34–0.72) 70.0 1.46 (0.97–2.20) 37.1

1.49*** (1.24–1.79) 27.8 0.52*** (0.43–0.63) 58.4 8.8 19.4 13.4 1.01 (0.86–1.18) 43.1

1.41 (0.95–2.11) 26.2 0.49** (0.32–0.75) 55.7 12.6 19.2 12.6 0.98 (0.69–1.40) 38.6

56.9

61.4

59.2 1.00

Pethidine or similar (n 5094, p < 0.001) ORadj (95%CI)

23.5

Epidural (n 5197, p < 0.001) ORadj (95%CI)

43.6 1.00

Unassisted vaginal birth Assisted vaginal birth Planned caesarean section Unplanned caesarean section ORadj (95%CI) (OR 1.00 = Un/assisted vaginal birth) Lying on side or backy

52.5 12.3 22.3 12.8 1.00 48.0

1.41*** (1.20–1.66) 32.7 0.64*** (0.55–0.75) 59.4 9.3 17.5 13.8 0.95 (0.82–1.09) 43.7

Other (standing, squatting, sitting, kneeling) ORadj (95%CI)

52.0

56.3

Location when baby borne (n 4553, p = 0.021)

Bedy Other ORadj (95%CI)

87.7 12.3 1.00

Episiotomye (n 4536, p < 0.001)

20.0 ORadj (95%CI)

15.3 1.00

Trauma with stitches Trauma without stitches No trauma ORadj (95%CI) (OR 1.00 = Trauma without stitches or no trauma) Midwife (n 6958, p = 0.457) Obstetrician (n 6959, p < 001) ORadj (95%CI)

61.0 11.0 28.0 1.00

Anaesthetist (n 6959, p < 0.001) ORadj (95%CI)

54.1 1.00

GP (n 6958, p < 0.001) ORadj (95%CI)

11.9 1.00

Nurse (n 6958, p = 0.939)

22.8

Mode of birth (n 6997, p < 0.001)

Position when baby borne (n 4544, p = 0.011)

Perineal Traumae (n 4517, p < 0.001)

Care during labour and birth provided by:

1.00

1.00

87.8 69.7 1.00

**

*

1.24 (1.06–1.46) 86.6 13.4 1.15 (0.90–1.47) 14.7 0.80* (0.64–.996) 50.8 15.0 34.1 0.68*** (0.58–0.80)

1.27 (1.06–1.53) 83.2 16.8 1.41** (1.09–1.83) 21.9 0.75* (0.58–0.97) 57.5 14.6 28.0 0.94 (0.78–1.13)

1.68* (1.12–2.51) 85.1 14.9 1.24 (0.70–2.22)

89.0 60.3 0.84* (0.72–0.99) 42.4 0.70*** (0.61–0.80) 15.9 1.30** (1.08–1.57) 22.1

88.8 61.2 0.87 (0.73–1.05) 40.3 0.63*** (0.54–0.74) 20.7 1.75*** (1.45–2.12) 22.4

90.5 59.2 0.90 (0.62–1.32) 37.3 0.56*** (0.40–0.79) 29.0 2.75*** (1.91–3.94) 23.1

1.27 (0.78–2.07) 50.4 14.2 35.4 0.68 (0.46–1.02)

ORadj: with adjustment for maternal age, SEIFA, A&TSI status, and facility (public/private). y Denotes reference category for logistic regression. a Pessary/gel/tablet and/or hormone drip. b Of women had a medical induction or ARM procedure. c Of women who had a labour. d Of women who had a caesarean birth. e Of women who had a vaginal birth. * p < 0.05, ** p < 0.01, *** p < 0.001.

pattern was observed for most analysis of quality of interpersonal care variables. Consistent with the findings regarding position for birth, reporting feeling free to move around during labour ‘most of the time’ increased with rurality. As expected, women from remote areas had significantly lower odds of reporting they were able

to choose the gender of their care provider than women a major city. There were no differences in women’s satisfaction with the length of their hospital stay or how often they were checked on after birth. Early contact in the period immediately after birth and satisfaction with this contact did not differ by rurality.

J. Hennegan et al. / Women and Birth 27 (2014) 281–291

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Table 5 Comparison of labour and birth care by remoteness classification. Major city % (n = 4523)

Inner regional % (n = 1365)

Outer regional % (n = 997)

Remote and very remote % (n = 170)

Choice Felt free to move in labour most of the timea (n 5080, p = 0.002) ORadj (95%CI)

63.7 1.00

Could choose the gender of care provider (n 6992, p < 0.001) ORadj (95%CI)

18.6 1.00

Felt all medical procedures were necessaryb (n 5460, p = 0.312) Staff activity Had at least one carer through labour/birth (n 6875, p = 0.016) ORadj (95%CI)

84.1

69.1 1.32** (1.12–1.55) 15.1 0.91 (0.76–1.10) 81.8

67.9 1.24* (1.03–1.49) 15.9 0.99 (0.80–1.21) 84.2

72.4 1.69* (1.11–2.56) 8.8 0.45** (0.25–0.82) 82.1

73.2 0.92 (0.79–1.08) 9.0

74.1 0.94 (0.79–1.11) 8.4

74.7 1.06 (0.73–1.55) 9.8

84.4 0.73** (0.60–0.88) 85.5 0.83 (0.69–1.01) 82.9 0.85 (0.71–1.02) 83.8 0.89 (0.74–1.06) 85.5 0.79* (0.65–0.96) 86.3 0.79* (0.65–0.97) 81.2 0.86 (0.72–1.02)

88.0 0.98 (0.78–1.23) 88.0 1.02 (0.81–1.28) 85.7 1.02 (0.83–1.26) 86.2 1.06 (0.86–1.31) 87.1 0.88 (0.71–1.11) 87.7 0.89 (0.71–1.12) 82.5 0.92 (0.76–1.12)

83.4 0.80 (0.51–1.25) 87.0 0.98 (0.61–1.57) 86.4 1.21 (0.76–1.94) 89.3 1.54 (0.92–2.56) 87.0 1.06 (0.65–1.73) 87.0 0.95 (0.59–1.54) 81.7 0.94 (0.62–1.43)

77.1 1.00

Felt rushed or hurried by staff during labour1 (n 5508, p = 0.803) Staff behaviour and interaction ‘all of the time’ Talked to me in a way I could understand (n 6928, p < 0.001) ORadj (95%CI)

89.3 1.00

Treated me with respect (n 6933, p = 0.002) ORadj (95%CI)

89.3 1.00

Treated me with kindness and understanding (n 6929, p = 0.003) ORadj (95%CI)

86.9 1.00

Treated me as an individual (n 6922, p = 0.020) ORadj (95%CI)

86.9 1.00

Were open and honest (n 6923, p < 0.001) ORadj (95%CI)

89.5 1.00

Respected my privacy (n 6916, p = 0.002) ORadj (95%CI)

89.9 1.00

Respected my decisions (n 6909, p = 0.002) ORadj (95%CI)

85.1 1.00

Overall perspective Looked after ‘very well’ during labour/birth (n 6922, p = 0.002) ORadj (95%CI)

72.1 1.00

66.8 0.91 (0.79–1.06)

70.3 1.06 (0.90–1.24)

67.3 1.06 (0.75–1.50)

Support people welcome During laboura (n 5484, p = 0.526) During birth (n 6867, p = 0.008) ORadj (95%CI)

97.6 97.5 1.00

After the birth (n 6895, p < 0.001) ORadj (95%CI)

97.0 1.00

Overnight after the birthc (n 6214, p < 0.001) ORadj (95%CI)

68.4 1.00

97.2 96.6 0.92 (0.63–1.35) 95.0 0.75 (0.54–1.05) 60.6 0.91 (0.78–1.07)

96.8 95.6 0.67* (0.46–0.99) 94.6 0.63** (0.44–0.89) 64.1 1.03 (0.87–1.24)

96.2 97.0 1.08 (0.43–2.75) 97.6 1.72 (0.61–4.79) 60.5 0.97 (0.66–1.42)

80.4 69.6

81.3 74.3

77.4 76.9

1.13 (0.98–1.31) 76.1 0.96 (0.82–1.12)

1.46*** (1.23–1.73) 79.4 1.16 (0.97–1.40)

1.66* (1.13–2.44) 73.5 0.90 (0.62–1.31)

80.5 1.00 (0.84–1.18) 89.3 76.3

78.2 0.86 (0.72–1.03) 86.7 77.1

79.6 1.05 (0.70–1.57) 86.2 82.7

Facility stay Satisfied with duration of hospital stay (n 6860, p = 0.081) Visited by a labour/birth care provider after birth (even if just to say hello) (n 6894, p = 0.002) ORadj (95%CI)

9.5

78.1 68.9 1.00

Checked ‘about the right amount’ after birth (n 6858, p = 0.016) ORadj (95%CI)

79.6 1.00

Comfort and early contact Held baby within first 5 min (n 6926, p = 0.033) ORadj (95%CI)

82.1 1.00

Satisfied with early contact (n 6920, p = 0.055) Baby placed to breast within an hour (n 6944, p = 0.272)

89.5 76.3

ORadj: with adjustment for maternal age, SEIFA, A&TSI status, and facility (public/private). a Of women who had a labour. b Of women who felt they had a medical procedure. c Of women who stayed overnight. * p < 0.05, ** p < 0.01, *** p < 0.001.

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3.7. Postnatal experience Women from all areas reported having the contact details of a care provider they could contact if worried (82–83%). However, postnatal contact with care providers decreased with rurality (Table 6). Women from remote areas had much lower odds of being telephoned or visited by a care provider in the first 10 days after birth. Similarly from birth to the time of survey they were much less likely to have been visited by a care provider. Despite these marked differences, women from remote areas did not significantly differ from those from a major city in their satisfaction with postnatal contact after adjustment, nor did they report a poorer quality of interpersonal care.

Despite no significant differences in parity, confidence to care for the new baby when women first returned home increased with rurality, with women from remote and very remote areas having more than 2 times higher odds of feeling confident than women from a major city. The rate of breastfeeding at 13 weeks was also significantly higher for women from remote and very remote areas. After adjustment there were no differences in experiencing post-birth complications including breastfeeding problems, infections following CS or perineal trauma, or re-admission to hospital for either mother or baby. We found no significant difference in self-reported ‘feeling depressed’ at the time of survey according to area of residence.

Table 6 Comparison of postnatal experience by remoteness classification.

Contact in the first 10 days of being homea

Had contact with care providers since going home

Major city % (n = 4523)

Inner regional % (n = 1365)

Outer regional % (n = 997)

Remote and very remote % (n = 170)

Visited at home by midwife or nurse (n 6884, p < 0.001) ORadj (95%CI)

44.2

40.1

41.8

28.7

Telephoned by midwife or nurse (n 6884, p < 0.001) ORadj (95%CI)

38.2

1.21* (1.05–1.39) 46.7

1.02 (0.87–1.20) 43.4

0.78 (0.55–1.11) 37.1

Visited midwife, nurse or GP (n 6884, p < 0.001) ORadj (95%CI)

48.4

0.43*** (0.36–0.51) 54.8

0.50*** (0.42–0.60) 50.1

0.19*** (0.13–0.29) 38.3

No contact (n 6884, p < 0.001) ORadj (95%CI)

25.4 1.00

Telephoned by care provider (n 6909, p < 0.001) ORadj (95%CI)

47.9

1.13 (0.99–1.29) 15.6 0.71*** (0.58–0.86) 58.1

0.94 (0.81–1.09) 20.6 1.07 (0.86–1.33) 50.6

0.52*** (0.37–0.73) 31.1 3.46*** (2.23–5.36) 48.8

Visited by care provider (n 6911, p < 0.001) ORadj (95%CI)

43.4

1.34*** (1.16–1.54) 40.0

0.93 (0.80–1.09) 41.3

0.85 (0.61–1.20) 27.4

Visited a care provider (n 6909, p = 0.653)

87.6

0.51*** (0.44–0.60) 87.5

0.58*** (0.49–0.69) 86.4

0.22*** (0.15–0.33) 89.3

77.5

80.9

82.7

81.1

Satisfied with amount of contact with care providers since birth(n 6912, p = 0.001) ORadj (95%CI) Had contact details of a care provider could get in touch with if worried (n 6925, p = 0.597) Overall looked after ‘very well’ after birth (n 6942, p = 0.002) ORadj (95%CI) Confidence when first had new baby at home (n 6889, p < 0.001)

1.00

1.00

1.00

1.00

1.00

1.00 82.0

1.17 (0.99–1.38) 82.9

1.32 (1.09–1.59) 83.6

1.24 (0.82–1.87) 81.9

50.1

50.5

56.5

47.0

1.09 (0.96–1.24) 89.0

1.37*** (1.18–1.59) 89.7

1.01 (0.73–1.39) 92.9

11.0 1.40*** (1.14–1.72) 66.1 0.83** (0.72–0.95)

10.3 1.44** (1.14–1.82) 74.5 1.23* (1.04–1.45)

7.1 2.23** (1.22–4.08) 76.5 1.52* (1.04–2.23)

47.0 0.86* (0.75–0.98) 33.1 8.2 6.1 7.6

49.5 0.93 (0.81–1.08) 33.7 9.1 4.7 8.2

47.6 0.88 (0.64–1.21) 31.1 7.1 4.7 6.5

1.00

Confident (extremely/fairly)

86.1

Not confident ORadj (95%CI) (OR 1.00 = ‘not confident’)

13.9 1.00

Breastfeeding at 13 weeks (n 6871, p < 0.001) ORadj (95%CI)

72.4 1.00

ORadj (95%CI)

51.7 1.00

Experienced after birth Breastfeeding problems (n 6913, p = 0.021)

Feeling depressed (n 6900, p = 0.759) Infection to cut or wound from birth (n 6944, p = 0.348) Mother re-admitted to hospital (n 6976, p = 0.274) Baby re-admitted to hospital (n 6953, p = 0.538) ORadj: with adjustment for maternal age, SEIFA, A&TSI status, and facility (public/private). a Excluding women who indicated their baby had not yet come home at 10 weeks. * p < 0.05, ** p < 0.01, *** p < 0.001.

**

34.2 7.5 6.2 8.6

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4. Discussion The present study sought to provide a quantitative evaluation of the impact of rurality on women’s experience of maternity care in Queensland. As emphasised in review10 and suggested by national health comparisons,11,12 demographics systematically varied with rurality. In this study, women from remote and very remote areas were younger, poorer, less likely to have completed secondary schooling, and more likely to be Aboriginal and/or Torres Strait Islander. Women were much less likely to birth in a private hospital, reflecting the limited availability of these facilities outside of urban centres. By adjusting for these differences, the present study not only addressed a significant gap in the lack of quantitative data regarding women’s experience of maternity care, but also investigated the impact of rurality on this experience beyond pre-existing demographic differences between the groups. Generally, results found that at the birthing facility there were few differences accounted for by rurality, with some differences reflective of clinical service capabilities in rural facilities apparent. However, differences in access to a birthing facility and receiving antenatal and postnatal care were much more pronounced. Based on the respondent sample, the present study identified no differences by rurality on clinical outcomes including pregnancy complications, low birthweight or pre-term birth. There was also no difference in infection or hospital re-admission of mother or infant after birth. Contrary to expectations of a higher rate of caesarean rate or induction to manage the timing of birth, there was no difference according to rurality on mode of delivery or receiving induction procedures. The lack of variation in the rate of caesarean section according to remoteness is consistent with recent national perinatal statistics which noted no variation in primary caesarean across areas, suggesting the lack of variation may be attributable to the high caesarean rate nationwide which needs to be addressed more broadly.39 Constant electronic foetal monitoring was much less prevalent amongst women from remote areas and this may have contributed to women feeling more able to move around and choose the position that felt most comfortable for them during labour. They were also more likely to give birth in a more upright position, rather than lying on their back or side. This may reflect the lower prevalence of constant EFM and epidural use, as well as personal preferences and clinician practice. Large differences in the use of different types of pain relief were observed, with women from remote areas much less likely to receive an epidural or see an anaesthetist during labour or birth. The use of gas, and pethidine or similar pain-killers was more prevalent outside major cities, possibly due to the lower availability of epidurals for pain relief. Whilst it may be the case that women from more rural areas differ in their preferences for pain relief, these findings suggest that women from these areas have less choice in this regard. This is consistent with service capabilities and findings from qualitative research.2,40 For all women, ratings of interpersonal care were highest for the intrapartum period and lowest in the postnatal period. This is consistent with findings in a smaller survey or rural women’s experiences (see 41) and reinforces the marked need for policy development, associated changes in practice and improvements in care in this area. In contrast to the conclusions of some qualitative research studies1,17 coming from a more rural area did not impact upon the interpersonal and care experiences reported by women, after adjustment for other demographic differences. Age and birthing in a public facility were stronger predictors, accounting for much of the variance in observed differences in raw analyses. This is an important outcome and may serve to contextualise qualitative findings. As others have noted, future research must determine if rurality presents a unique risk factor or interacts with

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other non-spatial health determinants to contribute to disadvantage.1,9,10,13 The role of young age in a poorer experience of maternity care has been documented both quantitatively and qualitatively.23,27,29,42 Results of the present study suggest that programmes to address the care provided to young women (e.g., 43) may be particularly important in improving the experience of rural women. Further, although Aboriginal and Torres Strait Islander women were underrepresented in the survey sample,38 these women were much more likely to come from remote areas. Recent work documenting improvements in care for this group through the expansion of midwifery continuity care services suggests this may be an effective way to reduce disparities between rural and urban maternity care experiences (see 5). An encouraging message regarding the quality of interpersonal care can also be drawn from the present study. Findings positively reflect on the care provided to women from remote areas and the staff in rural facilities. Further, smaller facilities with fewer births may be associated with environments where women have a greater ability to choose their position in labour, to have a known care provider, and to be visited by a labour/birth care provider in the facility after birth. Nevertheless, despite the lack of differences in ratings of care, 29% of women state-wide did not report being cared for ‘very well’ during their labour and birth, 21% were dissatisfied with the amount of contact they had with care providers after birth and 49% reported they were not cared for ‘very well’ after birth. These figures are not consistent with a maternity service goal that ‘‘All Australian women will have access to high-quality, evidence-based, culturally competent maternity care in a range of settings close to where they live.’’8 and demonstrate the need for immediate and significant attention to be paid to the improvement of maternity services for all women throughout the state. Accessing a birthing facility, antenatal and postnatal care was an area of greater disparity between women from different areas. Women from remote areas were overwhelmingly more likely to need to travel to get to a birthing facility. Kornelsen and colleagues22 in Canada have found this can subject rural women to much high levels of stress with both financial issues and disruptions to continuity of care contributing. Qualitative research has also consistently reflected this issue2,7,16,44 and it is argued that future research studies should explore the feasibility of re-opening rural facilities as well as other strategies (including financial support) to improve the experience of relocation for birth. Beyond accessing the birthing facility, there were other differences by rurality in access to antenatal and postnatal care. Women from a remote or very remote area were much less likely to have had their antenatal booking appointment by 18 weeks (37% compared to 71% in major cities). Women from remote areas were much more likely to have had check-ups with a GP. Similarly, they were more likely to have had care provided by a GP: in rural facilities this is generally from a GP-Obstetrician with additional training,45 during labour/birth, reflecting the organisation and availability of maternity and health service provision more broadly. Although they were no less satisfied with the amount of contact with care providers after birth, women from remote areas were significantly disadvantaged in their contact from, and access to care providers for postnatal support. In the first 10 days after birth women from remote areas were much less likely to be visited by a midwife or nurse (although a lack of power meant this difference was not significant in adjusted analyses), and still much less likely to have been telephoned. They were less likely to have visited a care provider themselves and to have had 3.46 times higher odds of not having any contact with a care provider in the 10 days after facility discharge which is a cause for concern for policy makers and care providers, as well as families. In the period up until the time of survey women from remote areas were still much less

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likely to have been visited by a care provider. The finding that a lack of visitation was not compensated for by an increase in telephone contact was disappointing. As technology improves the use of internet and telephone services for health service provision to rural areas is one way that access issues for these women could be addressed,46,47 though access to these will not be universally available. Despite poorer access to support from care providers after birth, women from rural areas were more likely to be breastfeeding at 13 weeks after birth, and were much more likely to report being confident to care for their new baby at home. These differences existed both before and after adjustment for other demographic differences between the groups. It may be that women in remote areas have more community and family support in the immediate postpartum period and that expectations and working patterns are contributing here. 5. Strengths and limitations The size of the present study and ability to conduct quantitative analyses to compare the experience of rural and urban women was a strength and significantly contributed to work in the area, as did the use of data encompassing antenatal, intrapartum and postnatal care. Further, the ability to adjust for demographic differences allowed the investigation to better highlight differences due to rurality compared to other non-spatial determinants of health care, as has been called for in the literature.9,14 The underrepresentation of A&TSI and young women was a significant limitation of the study, as was the low response rate, although this rate was comparable to other published Australian studies. Whilst the use of a mainstream survey meant groups could be compared, questions were not specific to the experiences of rural women. A more focused survey addressing the experiences of rural women with questions regarding travel, costs, and decision making would add to the quantitative data available for this group. However, it is also acknowledged that other research methods may be more appropriate in research participation for different groups and in identifying what may be important to indigenous women in the context of maternity care. Whilst differences between public and private facilities and service capacity may be specific to Australia, the experience and needs of women in rural areas, and the role of other demographic factors has relevance for more diverse contexts including Canada, North America and Europe. Strengths and limitations of the area classification we used have been discussed,48 however for the present study the use of a standardised and nationally recognised classification of remoteness/rurality was a strength. It should also be noted that the present study focused on women who lived in remote and very remote areas, determined by their postcode. Some of these women likely travelled to regional centres or major cities for birth, dependent on their level of clinical risk and preferences. Whilst the experience of these women may have differed, the sample size would not have been sufficient to examine sub-group differences based on facility location. Further the study was not intended to compare the care provided by different birthing facilities. Rather the purpose of the present study was to compare the experiences of women according to their area of residence. 6. Conclusions The present study was the first to provide comprehensive quantitative data on the maternity care experience of women from remote and rural areas in Queensland. Findings demonstrate support for qualitative assertions that women in these areas are disadvantaged in their access to antenatal and postnatal care and

the need to travel for birth. Qualitative studies have provided insights about their experience, but have not directly made comparisons with women in other situations. This quantitative study found little difference between the interpersonal care experienced, finding that other demographic differences such as age were more likely to be significant barriers to quality interpersonal care. Findings support the goal of the National Maternity Service Plan8 to achieve a service in which women can access high-quality care close to where they live, and suggest that improving access through both distance to facility, but also other novel modes of support such as increased telephone or internet communication, may be central to improving equity in maternity service provision. Although there is a need for more quantitative work to be done, the present study provides a useful baseline for assessing improvements consequent on policy developments and any changes to maternity services and care. Study findings emphasise the need for maternity services to prioritise the needs of women from all areas and improve the quality of care and postnatal support provided to women. Acknowledgements The research on which this paper is based was conducted as part of the Having a Baby in Queensland Survey Program of the Queensland Centre for Mothers and Babies at the University of Queensland. We are grateful to the Queensland Government for funding and to the women who provided survey data. The Queensland Registry of Births, Deaths and Marriages contacted women to invite them to participate on behalf of of the Queensland Centre for Mothers and Babies to ensure women’s privacy was protected. References 1. Sutherns R, Bourgeault IL. Accessing maternity care in rural Canada: there’s more to the story than distance to a doctor. Health Care Women Int 2008;29:863–83. 2. Evans R, Veitch C, Hays R, Clark M, Larkins S. Rural maternity care and health policy: parents’ experiences. Aust J Rural Health 2011;19:306–11. 3. Kruske S, Jones R. Summary report on consumer, carer, and stakeholder perspectives on maternity care in regional, rural and remote Queensland: June 2010. Queensland: Queensland Centre for Mothers & Babies; 2010. 4. Hoang H, Le Q, Terry D. Women’s access needs in maternity care in rural Tasmania, Australia: a mixed methods study. Women Birth 2014;27(1):9–14. 5. Josif CM, Barclay L, Kruske S, Kildea S. ‘No more strangers’: investigating the experiences of women, midwives and others during the establishment of a new model of maternity care for remote dwelling aboriginal women in northern Australia. Midwifery 2014;30(3):317–23. 6. Department of Health and Ageing. Improving maternity services in Australia: the report . of the maternity services review. Department of Health and Ageing; 2009 7. Kornelsen J, Grzbowski S. The reality of resistance: the experiences of rural parturient women. J Midifery Womens Health 2006;51:260–5. 8. Australian Health Ministers’ Conference. National maternity services plan. Canberra: Department of Health and Ageing; 2011. 9. Wang F, Luo W. Assessing spatial and nonspatial factors for healthcare access: towards an integrated approach to defining health professional shortage areas. Health Place 2005;11:131–46. 10. Smith KB, Humphreys JS, Wilson MGA. Addressing the health disadvantage of rural populations: how does epidemiological evidence inform rural health policies and research? Aust J Rural Health 2008;16:56–66. 11. Australian Institute of Health and Welfare (AIHW). Rural, regional and remote health: indicators of health status and determinants of health. Rural health series no. 2 AIHW, cat. no. PHE 45. Canberra: AIHW; 2008. 12. Li Z, Zeki R, Hilder L, Sullivan EA. Australia’s mothers and babies 2011. Perinatal statistics series no. 28 cat no. PER 59. Canberra: AIHW National Perinatal Epidemiology and Statistics Unit; 2013. 13. Bilszta JLC, Gu YZ, Meyer D, Buist AE. A geographic comparison of the prevalence and risk factors for postnatal depression in an Australian population. Aust N Zeal J Public Health 2008;32(5):424–30. 14. Graham S, Pulver LRJ, Wang YA, Kelly PM, Laws PJ, Grayson N, et al. The urban– remote divide for indigenous perinatal outcomes. Med J Aust 2007;186(10):209. 15. Hirst C. Re-birthing. Report of the review of maternity services in Queensland. 2005. 16. Smith M, Askew DA. Choosing childbirth provider location – rural women’s perspective. Rural Remote Health 2006;6:510.

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