Sharing obstetric care: barriers to integrated systems of care

Objectives To map the provision of shared obstetric care in Victoria, and i nvestigate the views of care providers about the ways in which current prac tice could be improved. Method: All Victorian public hospitals with greater than or equal to 300 bi rths per annum and a purposive sample of hospitals with <300 births per ann um were mailed a questionnaire seeking information about current practice. Interviews with key informants (n=32) were conducted at four case study sit es. Results The response rate to the hospital survey was 98% (42/43). Fourteen different models of shared care were identified. Two-thirds of hospitals wi th greater than or equal to 300 births per annum (16/28) had three or more different models of shared care. Six hospitals (15%) had written guidelines for all models of shared care offered; 13(32%) had written guidelines cove ring some models. Practice varied considerably in relation to: exclusion cr iteria, recommended schedule of visits and use of patient-held records. The re was little consensus about the content of visits and responsibility for covering particular aspects of care. Few hospitals (6/42) had written infor mation for women about shared care. Care providers expressed divergent view s regarding the question of where ultimate responsibility lies for individu al patient care and for the overall management of shared care. Conclusions Current funding arrangements provide strong incentives to expan d enrolment in shared obstetric care. Expansion of shared care has occurred without the development of formal, consultative and agreed arrangements be tween providers, or adequate provision for monitoring, evaluation and revie w. The variety, complexity and fluidity of models of shared care and lack o f agreed procedures contribute to difficulties experienced by both provider s and women participating in shared care. Implications: Detailed evidence-based agreed guidelines developed in consul tation with hospital and community providers, and provision of improved inf ormation to women about what to expect in shared care arrangements are urge ntly required.