Centering Women and Newborns in Health Human Resources Planning: A Needs-Based Approach to Inform Innovative Care Delivery in Primary Maternity Health Care

Background: In the midst of a global health human resource crisis and with increasing health needs, decision-makers are seeking new ways of designing health care in all clinical settings, including primary health care. Evidence is mounting in support of creating collaborative service delivery models as effective and efficient health human resources (HHR) strategies. The intent is that new models of care delivery will ensure an adequate supply and appropriate mix of healthcare providers to meet health needs and to improve patient, provider and system outcomes. In maternity care, there is not only a shortage of maternity care providers, including nurses, internationally and within Canada there are also increasing maternal and neonatal health needs. Although new models of primary care delivery have begun to emerge to address both the shortage of care providers and to meet perinatal health needs, implementation of these models have been typically based on utilization patterns, supply of providers or costs. For primary care in general and maternity care, specifically, most of the planning for HHR has used age and gender standardized provider-to-population ratios that assume that the number of providers determines services and that levels of service are optimal or that health needs of populations will not change. Although some research has included needs-based planning for perinatal services as part of planning for specific provider groups or for health services in developing countries, no study has used needs-based health human resources planning to plan for human resources specifically for maternal and newborn care in Canada generally or in Nova Scotia specifically. Therefore, research to determine primary maternity health care needs is warranted to inform future maternity primary health care transformation. The purpose of this ongoing research is to identify the primary maternity health care needs of women and newborns in Nova Scotia. The purpose of this presentation is to describe the theoretical underpinnings, design, results and policy, practice and planning implications of a sequential quantitative-qualitative mixed methods study aimed at identifying the primary maternity health care needs of women and newborns.

Methodology: This sequential explanatory quantitative-qualitative study is informed by General Systems Theory, the Conceptual Framework for Needs-Based HHR and Health Systems Planning developed by Tomblin Murphy & O’Brien-Pallas and the related HHR Analytical Framework. The aim of the HHR Conceptual Framework is to guide the associations between relevant HHR and health system variables to determine the impact of those associations on system, health and provider outcomes.  The aim is to determine whether efficient and effective human and non-human resources are achieved within broader health and social systems taking into account multiple contextual and processual factors. This is in keeping with General Systems Theory that focuses on the interconnectedness and interdependence of multiple large and small systems that are embedded within and also influencing each other.

Methods: Informed by established HHR frameworks, data from two data sources, the Canadian Community Health Survey (CCHS) (n=288; randomized stratified sampling) and the NS Atlee Perinatal Database (NSAPD) (n=17,824; entire 2009-10 population) were analyzed using univariate and multiple regression techniques to determine the health needs of women and newborns based on various health needs indicators.  After data cleaning and imputation for missingness, the final sample from the NSAPD was n=10,812. Multi-level, backward stepwise regression was used to determine predictors of health needs based on age, income, area of residence, maternal education, parity, method of delivery and race/ethnicity using evidence-informed health needs indicators. Through purposive sampling and using email and poster recruitment techniques,  two focus groups and two interviews were conducted with women (n=22), 18 interviews with health care providers and 16 interviews with health leaders.  A comprehensive codebook was created first containing ‘a priori’ codes based upon relevant evidence, the research purpose and questions and the related theoretical and conceptual frameworks. Additional (emergent) codes were added once a random sampling of transcripts was coded.  Inter-coder reliability was completed with three research team members and minor changes to the codebook were incorporated. Qualitative data were analyzed using content analysis and an interpretive thematic analysis approach.  Prior to the study commencement, ethical approval was received from the appropriate ethics committees.

Results: Relationships between specific determinants of health and maternal and newborn health needs were identified in the initial quantitative analysis and used to inform data collection and discussions in the qualitative phase. In the advanced analysis, a number of predictors (rurality, maternal education, maternal race/ethnicity and income) associated with a broad definition of health were found to increase maternal and newborn health needs. The needs varied in each phase of perinatal care---prenatal, intrapartum and postpartum/postnatal.  Qualitative analysis identified that women, health leaders and providers recognize a lack of patient-centredness in our current system influenced by differing philosophical approaches, professionalization and health care funding models as well as a need for interprofessional and full scope practice. Qualitative findings contextualized and humanized the experiences of women, health care providers and health leaders while the quantitative analysis provided statistically significant and generalizable findings. Together, the integrated findings provided a comprehensive understanding of maternal and newborn health needs. 

Nurses in both public health and acute care as well as those in leadership positions were included as participants in this study.  Participants from all groups—health leaders, health care providers (nurses, midwives and physicians) and women provided examples of various ways in which nurses were and were not meeting the primary maternity health care needs of women and newborns in Nova Scotia.  Therefore, the findings from this study support the need for ongoing support for nursing practice that is patient/woman-centered and that considers all the factors and determinants that influence the health of women and newborns. Moreover, participants in the study shared strategies that can be used for enhanced perinatal nursing practice.

The methods used and the findings from this study also highlight the need for improvements in how we measure health and health needs to inform how we design health human resources and deliver primary maternity health care.

Conclusion: It is anticipated that the integrated findings from this research will inform health human resources and primary maternity health care planning in Nova Scotia by identifying the health needs of women and newborns and in turn, informing different maternal and newborn care delivery models.  From a nursing perspective, participants identified strategies to improve the care of women and newborns. Such strategies included recommendations to enhance relational and culturally competent and safe care as well as for collaborative practice models that support and/or expand nurses’ scope of practice. Practicing to full scope and being engaged with their health colleagues, increases nurses’ autonomy, improves nurses’ satisfaction with practice and has the potential to increase nursing recruitment and retention.