Aust. J. Rural Health (2003) 11, 110–115

Blackwell Publishing Ltd.Oxford, UKAJRThe Australian Journal of Rural Health1038-52822003 Blackwell Science Asia Pty LtdJune 2003113Original Article ANTENATAL RECORD CARDSK. PATTERSON and P. LOGAN-SINCLAIR

CONTINUUM OF CARE AND THE ANTENATAL RECORD IN RURAL NEW SOUTH WALES

Karen Patterson1 and Patricia Logan-Sinclair2

1Department of Nursing, Faculty of Health and Behavioural Sciences, University of Wollongong and 2Orana Health Unit, Faculty of Health Studies, Charles Sturt University, Dubbo, New South Wales, Australia

ABSTRACT

Objective: The aim of the study was to determine the effect of the woman held antenatal record card (PNC2) onthe continuity of maternity care received when presenting to the acute rural setting for clinical assessment.Design: Qualitative, open-ended questionnaires.Setting: Rural New South Wales public hospital.Subjects: Maternity consumers, 50 women who were inpatients receiving antenatal or postnatal care betweenAugust and October 1998. A stratified sample of healthcare professionals employed by the service, 12 midwives and13 general practitioners.Main outcome measure: The self reported use of the antenatal card and the viewed effects of the card on the con-tinuity of healthcare received.Results: The study identified a significant difference between the responding professionals (93%) positive perceptionof the effect of the PNC2 on the women’s pregnancy continuum of care and the maternity consumer (36%), who feltit bore little impact on their care. The study findings suggested a lack of compliance and standardisation in usage ofthe antenatal card negated any flow on effects for the women.Conclusions: The intended purposes of the PNC2 were compromised in this rural setting. The study recommendsthat stakeholders in rural maternity care be accountable for examining the benefits and barriers of their antenatalpractices, that the rural community’s expectations of ‘continuity of maternity care’ are sought and that there shouldbe a review of the available models of rural antenatal care.

KEY WORDS: antenatal, continuum of care, maternity, questionnaire, rural.

INTRODUCTION

Nationally and internationally public hospital maternityservices have reviewed their models of care for pregnancyand childbirth. From these reviews, the woman, as theprimary consumer and the healthcare professionals,midwifery and medicine, have been identified as the key

stakeholders. Continuity of care, safety and sharing ofinformation are three of the most consistently raisedissues.1

It is well published that rural New South Walesmaternity services lack access to the specialist services ofurban public hospitals, and are dependent on the generalpractitioner obstetrician for maternity care.2 In 1996the National Health and Medical Research Council(NHMRC), recommended that shared care involving smallteams of general practitioners and midwives should beencouraged.2 The benefits of maternity care being pro-vided by a small group of health professionals through the

Correspondence: Karen Patterson, P.O. Box 305, Figtree2525, New South Wales. Email: karenpatterson@bigpond.com

Accepted for publication October 2002.

ANTENATAL RECORD CARDS 111

pregnancy continuum of care was also supported by theCochrane Pregnancy and Childbirth Group.3 To assistthe effectiveness of the small teams of professionals, theNHMRC also stated that they were ‘impressed with theweight of evidence that supports that all pregnant womenshould carry a maternity record’.2 As an intervention, thewoman held maternity record holds advantages for boththe woman and maternity care providers4 and NHMRC‘strongly support’2 the NSW Department of Health’s initi-ative in this area.

NSW health endorsed and supplied ‘free of charge’5

the antenatal record card PNC2 in 1994. The record wasdesigned in consultation with the Royal Australian Col-lege of Obstetricians & Gynaecologists and the RoyalAustralian College of General Practitioners.5 The purposewas to provide a woman held antenatal record thatimproved access of information. This approach althoughautocratic, would appear to be an effective approach toaddressing the aforementioned issues of concerns formaternity consumers of continuity, safety and informationsharing. In particular this approach would seem applica-ble to consumers in rural areas where the pregnant womanmay be isolated from her primary maternity care provider.

STUDY SETTING

The study was set in a rural NSW public hospital, in thecentral western region.

The eight-bed maternity unit had an average birth rateof 250 and a delineation role of low risk mothers andbabies greater than 36 weeks gestation. Models of mater-nity care included rotating on-call general practitionerobstetrician roster for antenatal /intrapartum/postnatalhospital care. Midwives provided hospital based maternitycare, there were no hospital antenatal clinic or shared care(general practitioner/midwife) teams within the service.

The maternity service attracted consumers from adiverse catchment area crossing three area health serviceboundaries. The outlying communities formed a radius ofapproximately 130-km. Due to the isolation and smallpopulation of these outlying communities the generalpractitioners had limited current obstetric experience.The ambulance service officers provided on-call serviceonly. It was likely therefore, that the pregnant woman’saccess to maternity services would be influenced by dis-tance and isolation and a significant proportion wouldcome in contact with multiple general practitioners duringtheir pregnancy.

These aspects of rural community life and the existingmaternity models of care would then have to exclude ruralwomen from the reported effects of improved outcomes

and satisfaction correlated with woman receiving carefrom small teams of professionals continuously throughouttheir pregnancy continuum of care.1–3,6 The reality ofrural healthcare reinforced the need for the appropriateusage of the antenatal record card (PNC2) as a means toprovide continuity of care in a fragmented environmentwhere there was no demonstrable continuity of carer.

IDENTIFIED PROBLEM

In 1996, guidelines were introduced within the maternityservice to standardise the usage of the recommendedPNC2.5 Stakeholders were identified and in-service edu-cation was provided for midwives. General practitionersreceived copies of the policy and the PNC2 Circular.5

Media campaigns to inform consumers were undertaken.However, 12 months later, it had become apparent to

the midwifery staff that the PNC2 guidelines were notbeing consistently implemented. The issue was raised anddiscussed with general practitioners on a local and arealevel. The midwives primary concern was that womenfrom 24 to 42 weeks gestation were presenting to thematernity unit without immediate access to a completewritten record of their medical, obstetric or currentpregnancy history.

The lack of compliance compromised the midwives oron-call general practitioners ability to treat acute mater-nity needs efficiently, a significant safety risk. The riskwas potentiated by a reduced probability within the exist-ing model of antenatal care that the woman would be‘known’ to the midwife or on-call general practitionertherefore effectively minimising any attempt at providingcontinuity of treatment and information.6 On a costdimension, limited resources were required to be divertedto source and access missing information.

What is already known: The woman held ante-natal record has been reported to be an effectiveapproach for enabling consumers to participatein their maternity care, whilst also address theconcerns of continuity, safety and informationsharing. This form of medical record has beenstrongly supported by the National Health andMedical Research Council and NSW Health as aprofessional and consumer friendly strategy. Theusage or the effects of the antenatal record in ruralNew South Wales settings have yet to be widelyevaluated.

112 K. PATTERSON and P. LOGAN-SINCLAIR

Consequently midwives, as the initial contact in theacute clinical setting, were faced with the situation ofintense questioning of labouring or ‘at risk’ women, orabandoning them in search of elusive yet critical informa-tion. The situation may have been averted if the pregnantwoman was carrying her completed PNC2.

The aim of the study was to determine the effect onthe continuity of care received in a rural maternity serviceby the woman carrying her completed PNC2 throughouther pregnancy and the healthcare professional havingaccess to the updated PNC2 when the woman presented tothe acute clinical setting for assessment.

THE LITERATURE

A search of the literature prior to 1997 identified theexistence of a division of alliances between medicalprofessionals in regard to patients holding their ownrecords.7–9 Doctors were perceived the main stakeholdersin ‘ownership’ of medical records and were dividedbetween embodying the paternalistic tradition of health7

and adopting practices that promote joint responsibility inachieving healthcare goals.8,9

Examples of the opposing views included medicalprofessionals expressing ‘doubt, criticism and hesitation’7

that health consumers needed or wanted to access theirrecords because, ‘all the patient wants to know is that bythe end everything was well’.7 While conversely, doctorsargued that confidence and trust8,9 should be central toprofessional relationships with patients. Doctors who pro-vide patients with access to their records expressedaccountability for their documentation8 and patients whoheld their own health records expressed feeling more in‘control’9 and generated ‘more trust’.9

Refining the search to the medical record being in theform of a woman held antenatal record, showed that therewere advantages considered for the professional and thewoman.4 A controlled trial of women’s views on carryingtheir record in comparison to women receiving traditionalantenatal care in Cambridge, found that overall womenperceived advantages in carrying their complete records.10

In this trial, women considered reading their own recordsadvantageous and half of the sample felt that carryingthe record gave them responsibility in their pregnancy.Women who found significant advantage in carrying theircomplete record were all either admitted to hospital orhad complications during the pregnancy.10

The Newbury Maternity Care Study,11 where 290women were randomly allocated to assess a policy ofwomen holding their own obstetric records, found thatwomen who held their full records were more likely to feel

in control of their antenatal care and perceived it easier totalk to doctors and midwives.11 There was no evidence ofnegative effects. Both studies did have commonality, infinding that women had more difficulty in understandingthe legibility of the notes rather then the content, and thatnotes being lost or not accessible at consultation was notstatistically significant for the woman held record.10,11

For the professional, women held antenatal recordshave been noted to positively influence the clinical envir-onment by improving access to records, reducing potentialadverse events through transcribing errors and segregatednotes, and also being cost effective.4 Reported influenceson maternal behaviours such as reduced smoking, improvedbreastfeeding rates and greater participation in care aresignificant health outcomes associated with the practice ofwomen held antenatal records.4

The published literature had also identified that themost consistent and important predictor of the quality ofessential maternity care was the use of printed forms.12

Provision of prompts within a printed form correlated withthe probability that the healthcare provider would performand document tasks.12 In antenatal care, one specificadvantage was the capacity to monitor and assess continu-ous fetal growth data by means of a woman held antenatalrecord.13 As a result, when women move from one facilityto another during the pregnancy, a form of continuity ofcare could be maintained that influenced the quality andsafety of maternity care.3,13

However, the integration of forms and standardisationof healthcare practices is not without barriers. Barrierscan present at varied levels, systemic, professional, com-munity and consumer, and require a multifacetedapproach if influencing clinician behaviour and practicesis an intended outcome.14 One approach requires activeparticipation of all key stakeholders in workshops, problem

What this study adds: The study’s questionnaireresponses identified that the antenatal record mayhave met the needs of rural health professionals,however, the maternity care consumers were una-ware of these benefits. The study suggests thatthe antenatal record was operationalised at thediscretion and for the convenience of the ruralhealth care professional. Identifying rural commu-nities perceptions of continuity of care and the needto explore models of care that promote continuityin rural areas, where significant findings of thestudy.

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based learning and group discussions14 and positiveoutcomes have been associated with including localconsensus in designing clinical assessment forms.15

The literature searched at the time of the study identi-fied a lack of studies including the use of the PNC2 orsimilar tools in Australia and did not provide evidence ofresearch in rural settings which have been demonstratedto be unique compared to the continuum of care receivedby their urban counterparts.16 Significantly, rural commu-nities were reported as being unique in their value systemin regard to health care. They wait longer to seek profes-sional care when they are sick and may resist assistancefrom an outsider whom they perceive to be a ‘stranger’.17

METHOD

Ethics approval for the study was obtained from theResearch Ethics Advisory Committee for Health WesternNSW. Separate open-ended questionnaires were designedby the researchers to elicit and enable collation of quali-tative information pertinent to the PNC2 for health careprofessionals (HPQ) and for maternity consumers (MCQ).Questionnaires were distributed using a cluster samplingtechnique. Study participants were informed that thequestionnaire was voluntary and individual participantswould not be identified.

The MCQ were distributed to 50 women attendingthe maternity service over three months commencing 1August 1998. The women were inpatients receiving ante-natal or postnatal care and completed the questionnaireduring their hospital stay. The MCQ was distributed priorto the HPQ so as to provide an accurate representation ofcurrent antenatal practices and not bias responses.

The 25 HPQ were distributed in November 1998 to astratified sample of medical and midwifery staff. Thirteen(13) questionnaires were distributed to general practitioners.

Four of these were posted to outlying general practitioners,who provided antenatal care, with a return envelopeattached. Nine were placed in the visiting medical officers(VMOs) designated correspondence pigeonholes and acollection box designated. The project was discussed atthe medical council meeting. Of the 22 midwives on staff,a random sample of 12 were given the questionnaire. Onemonth was allowed for completion of the questionnaires.

The qualitative information collated from the completedmaternity consumers and healthcare professionals ques-tionnaires were individually analysed utilising comparativefrequency distribution tables.

RESULTS

Maternity Consumer QuestionnaireA response rate of 84%, 42 of the 50 questionnaires werecompleted and returned. Only four of the responses indi-cated the woman had private health insurance giving arate of 91% Medicare insurance. The average age of therespondents was 26 years old, range 17–41 years. Theresponses came from women from five different postcodes.

The women’s first visit to a general practitioner inrelation to the pregnancy ranged from between 2 and 29weeks gestation, with the average being 9.3 weeks. Thewomen stated that they received their PNC2 between 6and 40 weeks gestation, with the average being 23 weeks.The purpose of the PNC2 was explained to 74% of thewomen. The most common explanations given for thePNC2 was to, ‘assist the hospital with information regard-ing the pregnancy’.

From the sample, 69% of women brought their PNC2with them when they presented to the hospital in regard totheir pregnancy. The PNC2 was updated at this time for55% of the women.

Of the women who responded, 60% indicated theirview of the PNC2 as having no effect on the care received.Two of the negative themes that emerged included thatthe doctor held the PNC2 throughout the whole pregnancyand the doctor refused to replace the PNC2 when it wasmisplaced stating, ‘the hospital had enough information’.

Healthcare Professional QuestionnaireAll 12 (100%) of the midwives and three of the 13 (23%)general practitioners responded. The responses con-sistently identified that the PNC2 had a vital role whenplanning maternity care for a woman presenting tohospital. Healthcare provider’s responses to ‘when apregnant woman presents to this hospital how do youaccess relevant antenatal information?’ are illustrated inFig. 1.

FIGURE 1: Continuum of care and the Antenatal Record in

Rural New South Wales.

114 K. PATTERSON and P. LOGAN-SINCLAIR

Thirteen of the 15 respondents identified the PNC2 asan effective way of improving communication betweencaregivers. Common themes in the comments accentu-ated the importance to the provider that each caregiverupdates the PNC2 and that the documentation is legibleand complete. Significantly, six respondents stated thatthey personally document each occasion of service on thePNC2, seven stated they sometimes document and oneprovider stated they never document.

Fourteen of the 15 respondents perceived thatwomen who carried their PNC2 throughout the pregnancyachieved a ‘positive effect’ on their continuity of care.Supportive comments included, the reduction in dupli-cation of information/questions and provides for con-tinuation of care, ‘even if it is your first meeting with thewoman’.

DISCUSSION

The high Medicare enrolment (91%) and 5 different post-codes from the consumer sample verifies the assumptionthat women in the rural setting have a greater probabilityof contact with multiple general practitioners throughoutthe pregnancy.2 Consequently, the probability of thewoman ‘knowing’ her midwife or general practitioner onpresentation to the hospital is minimised. The influence ofthe caregiver being a ‘stranger’17 to the woman impliesthat the woman may not be forthcoming with criticalinformation about her pregnancy, and may not have beenable to develop a feeling of ‘trust’8,9 for her caregiver. Thissupports the reported constraints to attaining a compre-hensive maternal /fetal history in the hospital setting if thePNC2 is absent or incomplete.

The commonest method of accessing relevant antena-tal information for the healthcare professional was thePNC2 (100%). This suggests the standardised format ofthe record when completed could impact positively on theaccess of information,10 with the benefit of avoidance ofclinical error, through transportability of the informationacross and within health care settings.4,13

The results of this study were consistent with themidwives observation that the majority of women were notreceiving their PNC2 on their first visit to their generalpractitioner and that the PNC2 was not being consistentlyupdated. The study identified that there was an average14 week delay from when the women first visited theirgeneral practitioner and when they received their antena-tal card. Six women received their PNC2 on their firstvisit, three women never received their record and threewomen were greater than 36 weeks gestation before theyreceived their record.

The women in the sample understood the purpose oftheir carrying the PNC2 as a method of providing infor-mation. They did not relate to the record as a method topromote communication between the professional andthemselves. Eleven women did not have the purpose ofcarrying the PNC2 explained at all.

There is, however, a comparison with the literature inthat women in the study who had complications during thepregnancy and their positive perception of carrying theirown record.10 Women in the sample who were havingtheir blood pressure monitored or had special needs,expressed that the PNC2 was ‘useful’ and was ‘easier thanexplaining or remember’ during the pregnancy.

Unlike previous studies, women did not identify carryingtheir record as facilitating feelings of control8 or jointresponsibility in healthcare.4,9 Women did not perceiveany ownership of the information on the record and thefindings suggest that the absence of a consensus approachin the design of the PNC2 by all stakeholders may be abarrier to the optimum usage of the antenatal card by con-sumers and professionals alike.14,15

The use of the PNC2 as a complete medical and obstetrichistory would require the assumption that the record wouldbe updated routinely by healthcare professionals.5 Theidentical responses by the professionals and the consumersthat the record is updated ‘sometimes’, suggests thisassumption does not reflect healthcare practices.

Unfortunately, the capacity to explore health profes-sional’s practices thoroughly has been marginalised in thisstudy due to the lack of responses by general practitioners,who were the primary rural maternity care provider andwho were responsible for the majority of documentationon the PNC2. Lack of response could imply the ruraldoctors alliance with the traditional paternalistic model ofmedicine.7 Blatant complacency towards recommendationsand hospital policies in favour of autocratic practices hasproven to be an effective strategy in delaying the intro-duction of models of maternity care that encroach onmedical autonomy in the rural setting.

The study identified a significant difference betweenthe professionals (93%) positive perception of the effect ofthe PNC2 on the women’s pregnancy continuum of careand the maternity consumer (36%), who felt it bore littleimpact on their care. This suggests that the professionals,predominately midwives, still identify with the PNC2 asan effective tool, even though it is incomplete, difficult todecipher and poorly implemented in clinical practice. Itis noteworthy, that the antenatal record for midwives mayhold a ‘halo effect’, in that it is the only medium that con-nects the midwives with the women antenatally. The infor-mation, though poor in quality, is better than nothing. The

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‘no effect’ of the PNC2 perceived by two thirds of thewomen implies a considerable need to identify with thewomen within the community and their expectations ofcontinuity of maternity care.

RECOMMENDATIONS

The study highlights that the intended purpose of thePNC2 as an effective tool to meet consumer issues ofcontinuity of maternity care, safety and sharing ofinformation1 in a rural community is compromised bybarriers that need to be addressed at multiple levels.14

A lack of compliance and standardisation adverselyinfluenced professional practice and negated any flow-onpositive effects for the maternity consumers. Implicationsof the study include the identification of professionalbarriers and an evaluation and review of the purpose ofthe PNC2 including all local stakeholders, that is thecommunity, general practitioners and midwives. Thestudy recommends that all stakeholders be provided withongoing education/support as to the potential benefits,risks and optimum usage of woman held antenatal cards.

A further recommendation is that there be a review ofthe models of rural antenatal care available and that therural community’s expectations of continuity of maternitycare is sought.

ACKNOWLEDGEMENTS

Contribution of Mudgee Maternity Unit Manager, RitaMcMaster, the support of Macquarie Area Health Service,Mudgee Health Service and RARHTU. Louise Lawler forproofing the original transcript.

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