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WELL CHILD TAMARIKI ORA
working in collaboration:
referrals to Tamariki Ora Well Child services
CLAIRE MACDONALD MIDWIFERY ADVISOR
The Well Child Tamariki Ora (WCTO) programme is a universally offered, publicly funded child health and whānau support programme. The programme delivery begins with midwives, who undertake the first four health assessments: at birth to 24 hours, within 48 hours, up to one week, and at 2-6 weeks.
A WCTO provider follows on, with health assessments at 4-6 weeks, through to 2-3 years, and the programme is completed with the B4 School Check, at four years old. The GP team provides a six week check alongside immunisations.
A national review of the WCTO programme was undertaken in 2020, with a report pending. The College had a representative on the Review Advisory Rōpū, the members of which all shared a clear desire: for the programme to support equitable health outcomes and meet Tiriti o Waitangi responsibilities by flexing to meet the needs of whānau, so that they are supported to thrive. While the programme redesign is yet to begin, there are some clearly identifiable actions for improvement, which will be as relevant and necessary in future as they are now. For midwives, these include information-sharing with whānau about all provider options, and ensuring timely referral to the WCTO provider of choice.
Concepts like equity, access and te Tiritibased care are frequently discussed in the current health context, so what does this mean in practice when it comes to primary maternity and infant/child care services?
The Ministry of Health’s definition of equity is: “In Aotearoa New Zealand, people have differences in health that are not only avoidable but unfair and unjust. Equity recognises different people with different levels of advantage require different approaches and resources to get equitable health outcomes.”
It is estimated that health care is responsible for around 20-25% of health outcomes, while the social, environmental, cultural and commercial determinants of health contribute significantly more. Health services, including maternity, have a responsibility to support optimal health outcomes wherever they can.
Access, and related concepts like acceptability and engagement are about ensuring services are culturally safe, relevant, and available in locations and at times that work for whānau. In her presentation at the Perinatal and Maternal Mortality Review Committee’s 2021 webinar about Te Taitokerau-based antenatal education programme Ngā Wānanga o Hine Koopu, Raewyn Smith described the programme’s unique approach: “We don’t have DNAs [did not attend], we have DNIs [did not inspire]”. Viewing health care through this lens requires services to adapt to the needs of whānau, rather than using a one-size-fits-all approach that tends to be more focused on the needs of the service provider.
Te Tiriti-based health care uses te Tiriti o Waitangi as the guiding framework for health services. Te Tiriti is the document that guarantees tangata whenua the same rights and protections as tauiwi, including equal health outcomes, and is the document that enabled tauiwi to settle and call Aotearoa home.
HOW DO THESE CONCEPTS APPLY TO THE CONTINUUM OF CARE IN THE FIRST 1,000 DAYS? The WCTO programme review highlighted the need for transitions between services to be strengthened, so that all whānau receive the ongoing care they are entitled to. Currently, only 77% of non-Māori are referred to WCTO by 28 days, and there is a disparity for Māori and Pacific peoples, with even lower referral rates of 68% and 70% respectively. Prior to discharging whānau from midwifery care, midwives should be confident that the next service has received the referral, and that whānau have already engaged with the provider. Late referrals affect the likelihood of a whānau receiving their first visit before 50 days of age and contribute to further health inequities (50 days is the audit standard, but the first core contact should occur by six weeks according to the WCTO programme).
The data tell us what is happening, but not why, and there are likely to be a number of factors contributing to the referral rates and disparity by prioritised ethnicity.
CHOICE OF PROVIDER In many areas, Plunket is the majority WCTO provider available to all whānau and is contracted nationally. For whānau Māori in most areas, and Pasifika families in some areas, there is also the option of Tamariki Ora and/or Pasifika WCTO providers.
As My Māori Midwife has beautifully illustrated, and national workforce priorities have identified, kaupapa Māori services increase access and engagement for whānau Māori through home visiting, whakawhanaungatanga and the addition of wrap-around support; in other words they are more likely to inspire whānau to engage with services. Tamariki Ora providers are contracted locally, often within a Whānau Ora service and/or as part of an iwi rūnanga. They include health support through WCTO nurses, as well as breastfeeding support services, social and cultural support with the assistance of kaimahi, and many provide home visits to whānau for the duration of the programme. As local services, each has grown and developed to meet the specific needs of whānau within the rohe.
All options for WCTO service provision need to be offered to whānau. It is particularly important that whānau Māori and Pacific families are given the option of Māori or Pacific WCTO providers where available, as well as Plunket. It is important to note that GPs are not WCTO providers, and do not receive any funding to provide routine WCTO health assessments (apart from the six week check).
TIMING OF REFERRAL Contractually, midwives claiming from Section 88 are obliged to give a written referral to a WCTO provider by four weeks postpartum, or can request WCTO involvement as early as two weeks after birth if the baby or whānau needs further support. This also supports work planning by WCTO nurses who, like midwives, are driven by a clear purpose to provide personalised care to whānau, and as a predominantly women’s workforce, experience similar service delivery pressures.
Dianne Oakley, Team Leader for Tamariki Ora at Te Puawaitanga ki Ōtautahi, describes the prescriptive structure of the contract, explaining nurses are expected to see 100 new babies per year in addition to their pre-existing caseload. Each nurse has a caseload of about 500 whānau at any given time, all requiring home visits. If referrals for new pēpi are received late, it becomes near impossible to schedule the first visit by six weeks of age.
FIG 1. RESULT COMPARISON BETWEEN MĀORI AND NON-MĀORI
100
80
60 68% 77%
68% 78%
40
20
0
WCTO Referral by 28 Days WCTO Referral by 50 Days
Māori Non-Māori
FIG 2. RESULT COMPARISON BETWEEN PACIFIC AND NON-PACIFIC PEOPLES
100
80 70% 75%
70% 76%
60
40
20
0
WCTO Referral by 28 Days WCTO Referral by 50 Days
Māori Non-Māori
Although it’s a juggle, Dianne’s team is dedicated to the mahi. “We love the work because we love the women and the babies. You’ve got to be satisfied that you’ve done a good job. If it was about the money, you wouldn’t be there. It’s about the women.”
Michelle McGregor, Tamariki Ora Clinical Nurse Leader at Te Rūnanganui o Te Atiawa ki te Upoko o Te Ika a Maui in Waiwhetu, Lower Hutt, describes the importance of te ao Māori lens in developing relationships with both whānau and midwives in the area. “Our whānau like to kōrero. It’s an informal way of engaging and sharing information and you can obtain the required information necessary for an assessment and for care planning. That’s the difference - you don’t start off as clinical, but as manuhiri, gaining trust and developing positive relationships.”
When a referral is received, a kaimahi will visit the whānau to establish whakawhanaungatanga (connection), after which a nurse completes the health assessment. “Our kaimahi and nurses work equally together to support each other in our mahi and in care planning for the whānau. The clinical assessments are a part of the well child assessment; whānau engagement and support is just as important. Early referral, even if it is verbally in the antenatal stage, allows us to engage and build the relationships early and provide early intervention if required,” Michelle says.
DISCUSSIONS WITH WHĀNAU ABOUT WCTO
Michelle also points to the importance of knowing who the local Tamariki Ora services are and what they offer. She recommends picking up the phone to have a kōrero and develop a relationship with local services, or to discuss a specific whānau who may need extra tautoko and guidance.
Examples include safe sleeping devices, breastfeeding community support, and connecting with rūnanga and marae social services. Being able to describe the WCTO services to whānau when considering their options supports an informed decision.
In the early postnatal period, midwives are often providing intensive support for ‘in the moment’ issues like recovering from birth, infant feeding and settling, adapting to parenting a first baby or a growing family, or mental health. It is therefore ideal to introduce the continuum of primary care from midwifery to WCTO during antenatal discussions, so the whānau already has a preference when discussing which service to make a referral to once the baby is born. square
