Working Through Complexity: How Women Living in Areas of High Socioeconomic Deprivation in New Zealand Access and Engage With Midwives
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Women living in areas of high socioeconomic deprivation in Aotearoa/New Zealand experience significantly higher rates of stillbirth and neonatal death than women living in other areas. This is potentially related to access to, and/or engagement with, maternity services. Constructivist grounded theory methodology was used to explore the research question ‘How do women living in areas of high socioeconomic deprivation in New Zealand access and engage with midwives?’ In total, 24 individual interviews were undertaken with 11 women living in areas of high socioeconomic deprivation in three North Island cities, and 10 community Lead Maternity Carer midwives working in those areas. How women accessed midwifery care was complex and varied. Entering the maternity system exposed women to complexity additional to that they constantly navigated through their daily lives. Women navigated a shifting landscape to find a midwife, where midwife location and availability were inconsistent. The complexity of the women’s lives meant they were often prioritising their needs in a range of changing conditions, consequently risking missing midwifery care. The degree and nature of the support available through the maternity system to meet their complex requirements was limited, and shifted, depending on contexts. Midwives responded in a number of ways to a maternity system which was not working for women, aiming towards keeping women engaged with care, working towards an optimal pregnancy outcome. Building effective relationships enabled women and midwives to work together to effectively address the woman’s care requirements within a maternity system that did not readily meet their needs, and encouraged women to remain engaged with pregnancy care. If women missed an appointment with their midwife, following up was crucial, as midwives knew this was a group of women who traditionally fell through the gaps in the maternity system. Staying connected was dependent on the midwife’s knowledge of the woman’s connections, and took time, and energy. When a woman did not develop an effective relationship with her midwife, while midwives went to some lengths to remain connected to ensure she remained engaged with midwifery care, there were limits to their resources. Once a midwife was accessed, women relied on her support and advocacy to negotiate solutions that would facilitate an acceptable pathway for them through the maternity system. The effective relationships women had built with their midwives and the provision of continuity of midwifery care enabled negotiations. Elements influencing the negotiation included the facility resources of staffing and funding, and the resources women and midwives had available. When women developed complications, depending on the context and the conditions operating at particular times, they were caught between a maternity system which divided their one continuous pregnancy journey into care categories, and the midwifery model of care supporting continuity centred on the women. To sustain themselves in practice midwives negotiated solutions around how they worked.