Reducing preterm birth amongst Aboriginal and Torres Strait Islander babies: A prospective cohort study, Brisbane, Australia

'Great in theory': Women's care experiences in relation to Australia's national maternity Strategy-Qualitative survey responses

BACKGROUND

The provision of woman-centred maternity care in Australia is guided by a national Strategy released in November 2019 titled Woman-centred care: Strategic directions for Australian maternity services (the Strategy). The Strategy upholds four values (safety, respect, choice, and access) that underpin twelve principles of woman-centred care.

AIM

To examine the maternity care experiences of women in Australia and explore how these align with the stated values and principles of the Strategy.

METHODS

A national online survey was undertaken between February and June 2023. Women who received all their maternity care in Australia since 1 January 2020 were invited to participate. The survey consisted of predominantly closed questions; however, six open-text questions were included to give participants the opportunity to provide in-depth responses about the Strategy and its values. This paper presents a qualitative content analysis of the free-text responses.

FINDINGS

A completed survey was submitted by 1750 eligible participants, of whom 1667 provided 3562 qualitative responses included in this analysis. These showed that while the definition of safety provided in the Strategy favours physically safe care, the survey participants preferred a definition that was more holistic, providing for emotional and psychological safety. Participants expressed the need for respectful relationships with their maternity care providers where they felt listened to and heard. They wanted to be made aware of their choices and to have their maternity care decisions supported without coercion. Participants also desired access to continuity of care, particularly with midwives, and greater access to mental health support across the maternity care episode.

CONCLUSION

The intent of the national Strategy has not yet been fully realised. A nationally coordinated response is required if the Strategy is to move from policy to practice, ensuring that women in Australia receive true woman-centred maternity care as intended.

'Every woman deserves that': A qualitative exploration of the impact of Australia's national maternity strategy

BACKGROUND

Since 2019, maternity care in Australia has been guided by the national maternity policy, Woman-centred care: Strategic directions for Australian maternity services (the Strategy). The Strategy has four core values (safety, respect, choice and access), which underpin 12 principles of woman-centred care.

AIM

To describe women's experiences of receiving maternity care in Australia and explore how their care aligned with the values and principles of the Strategy.

METHODS

A qualitative descriptive approach was used. Fifty women from across Australia, including women from each of the priority populations within the Strategy, were interviewed. Data analysis was conducted using Braun and Clarke's reflexive thematic analysis.

FINDINGS

Women described how their care aligned and misaligned with the Strategy. Workforce shortages impacted their sense of safety, and they frequently had to self-advocate for individualised care that made them feel safe. Women wanted a holistic approach to care provision where they were listened to, heard, and their choices were respected by maternity care providers, but they felt the need to arm themselves with information to achieve this. They also expressed a desire for better care in the postnatal period to 12 months that included appropriate and affordable mental health support.

CONCLUSION

Receiving care that aligns with the values and principles of the Strategy is on an ad hoc basis, and maternity care provision is not consistent across Australia. A greater commitment to the implementation and adoption of the Strategy is required at a national and service level if its intent is to be fully realised.

Factors associated with preeclampsia and the hypertensive disorders of pregnancy amongst Indigenous women of Canada, Australia, New Zealand, and the United States: A systematic review and meta-analysis

PURPOSE OF THE REVIEW

Preeclampsia and the Hypertensive Disorders of Pregnancy (HDP) occur more frequently amongst Indigenous women and can have short- and long-term impacts on maternal and infant health and wellbeing. To understand factors associated with increased risk for Indigenous women a systematic review and meta-analysis was conducted. The PRISMA guidelines were adhered to, and the review protocol was registered on PROSPERO (Registration CRD42023381847). EndNote, Covidence and Excel were used to screen and extract data, with studies assessed using JBI critical appraisal tools.

RECENT FINDINGS

Seven studies from Canada, Australia, and the United States (none from New Zealand) were included in this review. Meta-analysis showed women classified as overweight (OR 1.32, 95% CI: 1.09-1.60), obese (OR 1.88, 95% CI: 1.57-2.25), or having high mean BMI (MD 3.02 95% CI: 1.72-4.31), high mean systolic blood pressure (MD 15.19 95% CI: 12.83-17.541), or high mean diastolic blood pressure (MD 15.26 95% CI: 13.05-17.47), pre-pregnancy diabetes (OR 3.63, 95% CI: 1.66-17.94), or high microalbuminuria (OR 2.76, 95% CI: 1.40-5.43) were more likely to be diagnosed with preeclampsia. Smoking (OR 0.77, 95% CI: 0.58-1.03), alcohol consumption (OR 1.70, 95% CI: 0.76-3.81), and gestational diabetes (OR 1.74, 95% CI: 0.90-3.37) were not associated with preeclampsia. Understanding factors associated with increased preeclampsia/HDP risk amongst Indigenous women is important to minimising adverse perinatal events and future health complications. This review demonstrates current gaps in the evidence, specifically in relation to social, economic, and environmental factors.

Transformation to a Patient Centred Medical Home in an Urban Aboriginal Community Controlled Health Service: A Qualitative Study Using Normalisation Process Theory

RATIONALE

The Patient-Centred Medical Home (PCMH) is a model of team-based care that is patient centred, coordinated, accessible, and focused on quality and safety. To learn how this model of healthcare works in an Indigenous primary health care setting in Australia, we explored the experiences of health staff in an urban Aboriginal Community Controlled Health Service (ACCHS) transitioning to an adapted model of a PCMH. Normalisation Process Theory (NPT) was applied to better understand factors enabling and inhibiting implementation of the PCMH, and the work required to deliver it.

AIMS AND OBJECTIVES

Applying NPT, we aimed to examine enablers and barriers to implementing a PCMH in an ACCHS setting and identify practical strategies to strengthen its implementation and delivery.

METHODS

We employed semi-structured interviews with 19 health staff in an urban ACCHS to explore mechanisms that inhibit and promote the implementation and delivery of a PCMH in their setting. Interview data were analysed using thematic analysis that mapped codes against NPT constructs (Coherence, Cognitive Participation, Collective Action and Reflexive Appraisal) to generate themes.

RESULTS

Five key themes and 14 sub-themes related to NPT constructs were identified. Broadly, health staff found the model of the PCMH to be coherent, engaged with others to adapt their roles, and worked collectively to embed new practices. Characteristics and practice norms of the clinic already aligned with the PCMH model were key enablers. Barriers were related to inadequate resourcing and ill-defined roles. Stronger leadership and support, practical learning resources for staff, workforce mapping to better define staff roles, and training to address gaps in staff skills were strategies identified for strengthening implementation of a PCMH and sustaining its delivery in the ACCHS setting.

CONCLUSIONS

Applying NPT revealed the characteristics and practice norms of Indigenous community controlled health care as key enablers of implementing a PCMH in an urban ACCHS. Less than optimal resourcing and workforce development emerged as barriers needing to be resolved to strengthen implementation and delivery of a PCMH in this setting.

Perinatal mortality among term births: Informing decisions about singleton early term births in Western Australia

BACKGROUND

To minimise the risk of perinatal mortality, clinicians and expectant mothers must understand the risks and benefits associated with continuing the pregnancy.

OBJECTIVES

Report the gestation-specific risk of perinatal mortality at term.

METHODS

Population-based cohort study using linked health data to identify all singleton births at gestations 37-41 weeks, in Western Australia (WA) from 2009 to 2019. Lifetable analysis was used to combine the risk of each type of perinatal mortality and calculate the cumulative risk of perinatal mortality, termed the perinatal risk index (PRI). Rates of antepartum and intrapartum stillbirth and neonatal death, as well as the PRI, were examined for each gestational week at term by non-Aboriginal and Aboriginal ethnicity. For non-Aboriginal women, rates were also examined by time-period (pre- vs. post-WA Preterm Birth Prevention Initiative (the Initiative) rollout), primiparity, and obstetric risk.

RESULTS

There were 332,084 singleton term births, including 60 perinatal deaths to Aboriginal mothers (3.2 deaths per 1000 births to Aboriginal mothers) and 399 perinatal deaths to non-Aboriginal mothers (1.3 deaths per 1000 births to non-Aboriginal mothers). For non-Aboriginal women, the PRI was at its lowest (PRI 0.80, 95% CI 0.61, 1.00) at 39 weeks gestation. For Aboriginal women, it was at its lowest at 38 weeks (PRI 2.43, 95% CI 0.48, 4.39) with similar risk at 39 weeks (PRI 2.68, 95% CI 1.22, 4.14). The PRI increased steadily after 39 weeks gestation. The risk of perinatal mortality was higher among Aboriginal women. The gestation-specific perinatal mortality rates were similar by the time-period, primiparity and obstetric risk.

CONCLUSIONS

The gestational ages at term associated with the lowest risk of perinatal mortality reinforce that the recommendation not to deliver before 39 weeks without medical indication is applicable to both Aboriginal and non-Aboriginal women giving birth in WA. There was no increase in the perinatal mortality rate associated with the introduction of the Initiative.

Everyone should have their own midwife: Women's and staff experiences during the implementation of two midwifery continuity of care models in regional Australia

PROBLEM

Midwifery Continuity of Care (MCoC) remains inaccessible for most Australian women; this is especially true in rural and regional areas.

BACKGROUND

Strong evidence demonstrates MCoC models improve experiences for women and their babies and are also shown to improve midwifery workforce wellbeing. However, implementation and upscale remains limited.

AIM

To explore the views and experiences of implementing MCoC for both staff and women, understanding their experiences, concerns and solutions in a regional context.

METHODS

Qualitative data was collected via focus groups with women and healthcare staff, at six and twelve month post implementation. Data was thematically analysed using Braun and Clarke six step process.

FINDINGS

The findings support that 'women love it' and midwives working in the new MCoC model 'loved their job'. The major concern was that not all women could access the model and disconnected communication was problematic during implementation. 'Sharing stories' was a solution to overcoming these issues and promoting the positive impact of MCoC - in particular ways of working and adaption to an all-risk midwifery group practice.

DISCUSSION

This study supports widespread evidence that MCoC is valued by both women and staff. In a regional context it is important to recognise challenges faced during implementation and identifying solutions that other maternity services could consider when implementing MCoC.

CONCLUSION

The study offers strong recommendation for regional areas to consider MGP to maintain safe, quality local maternity services.

Global, regional, and national burden of preterm birth, 1990-2021: a systematic analysis from the global burden of disease study 2021

Background

Preterm birth and its complications are leading causes of mortality among children under five years of age. Given the increasing burden of preterm birth on neonatal mortality and long-term health outcomes worldwide, a comprehensive global analysis is essential to guide effective public health interventions and policies. This study aims to assess the burden of preterm birth at the global, regional, and national levels.

Methods

Using data from the Global Burden of Disease (GBD) 2021 database, this study analysed trends in age-standardized incidence rates (ASIR), age-standardized mortality rates (ASMR), and disability-adjusted life-years (DALYs) as primary outcomes for preterm birth from 1990 to 2021 at global, regional, and national levels. Data were assessed using joinpoint regression analysis, decomposition analysis, and the health inequality concentration index.

Findings

Globally, the incidence, mortality and DALYs due to preterm birth have shown a declining trend, but ASIR started to increase in 2016. Males were more commonly born preterm than females (12329075.82, 95% uncertainty interval [UI]: 12192632.55-12464605.4 vs. 9224694.94, 95% UI: 9113876.1-9330107.89). Changes in DALYs were primarily due to epidemiological change (111.97%) and population (-21.59%). Low Socio-demographic Index (SDI) regions increased in annual incidence cases (43.1%, 95% UI: 40.17-46.09), while high SDI regions decreased in annual incidence cases (-9.6%, 95% UI: -11.45 to -7.79). The highest annual mortality and DALYs respectively occurred in sub-Saharan Africa (295490.66, 95% UI: 241762.78-353624.41) and South Asia (32760273.93, 95% UI: 27295547.76-39070225.69). Western sub-Saharan Africa showed the largest increase in annual incidence (98.95%, 95% UI: 94.77 to 103.09), and Australasia had the lowest annual mortality (287.18, 95% UI: 244.26-339.42) and DALYs (61081.4, 95% UI: 50897.33-73069.96). Western sub-Saharan Africa also had the highest ASMR (21.57, 95% confidence interval [CI]: 17.9-25.89). The highest ASIR (543.78, 95% CI: 535.11-553.21) and age-standardized DALYs (2064.65, 95% CI: 1717.27-2473.36) both occurred in South Asia, while the lowest ASIR and age-standardized DALYs were seen in East Asia (147.31, 95% CI: 144.22-150.85) and High-income Asia Pacific (143.32, 95% CI: 117.9-167.25). India, Nigeria, and Pakistan ranked highest globally in terms of annual incidence cases, mortality, and DALYs, while the lowest annual incidence, mortality and DALYs respectively occurred in Tokelau (2.34, 95% UI: 2.12-2.56), San Marino (0.04, 95% UI: 0.02-0.07) and Tokelau (17.22, 95% UI: 11.11-24.95).

Interpretation

While the global burden of preterm birth has decreased, significant disparities persist, especially in low SDI regions. There is a need for more refined policies and preventive measures to effectively address preterm birth.

Funding

No funds, grants, or other support was received.

Indigenous maternal and infant outcomes and women's experiences of midwifery care: A mixed-methods systematic review

BACKGROUND

The impact of midwifery, and especially Indigenous midwifery, care for Indigenous women and communities has not been comprehensively reviewed. To address this knowledge gap, we conducted a mixed-methods systematic review to understand Indigenous maternal and infant outcomes and women's' experiences with midwifery care.

METHODS

We searched nine databases to identify primary studies reporting on midwifery and Indigenous maternal and infant birth outcomes and experiences, published in English since 2000. We synthesized quantitative and qualitative outcome data using a convergent segregated mixed-methods approach and used a mixed-methods appraisal tool (MMAT) to assess the methodological quality of included studies. The Aboriginal and Torres Strait Islander Quality Appraisal Tool (ATSI QAT) was used to appraise the inclusion of Indigenous perspectives in the evidence.

RESULTS

Out of 3044 records, we included 35 individual studies with 55% (19 studies) reporting on maternal and infant health outcomes. Comparative studies (n = 13) showed no significant differences in mortality rates but identified reduced preterm births, earlier prenatal care, and an increased number of prenatal visits for Indigenous women receiving midwifery care. Quality of care studies indicated a preference for midwifery care among Indigenous women. Sixteen qualitative studies highlighted three key findings - culturally safe care, holistic care, and improved access to care. The majority of studies were of high methodological quality (91% met ≥80% criteria), while only 14% of studies were considered to have appropriately included Indigenous perspectives.

CONCLUSION

This review demonstrates the value of midwifery care for Indigenous women, providing evidence to support policy recommendations promoting midwifery care as a physically and culturally safe model for Indigenous women and families.

Model of perinatal care but not prenatal stress exposure is associated with birthweight and gestational age at Birth: The Australian birth in the time of COVID (BITTOC) study

OBJECTIVE

The present study aimed to understand, relative to standard care, whether continuity of care models (private midwifery, continuity of care with a private doctor, continuity of care with a public midwife), and women's experience of maternity care provision, during the perinatal period buffered the association between prenatal maternal stress (PNMS) and infant birth outcomes (gestational age [GA], birth weight [BW] and birth weight for gestational age [BW for GA]).

METHODS

2207 women who were pregnant in Australia while COVID-19 restrictions were in place reported on their COVID-19 related objective hardship and subjective distress during pregnancy and provided information on their model of maternity care. Infant birth outcomes (BW, GA) were reported on at 2-months postpartum.

RESULTS

Multiple linear regressions showed no relationship between PNMS and infant BW, GA or BW for GA, and neither experienced continuity of care, nor model of maternity care moderated this relationship. However, compared with all other models of care, women enrolled in private midwifery care reported the highest levels of experienced continuity of care and birthed infants at higher GA. BW and BW for GA were higher in private midwifery care, relative to standard care.

CONCLUSION

Enrollment in continuous models of perinatal care may be a better predictor of infant birth outcomes than degree of PNMS exposure. These results highlight the possibility that increased, continuous support to women during pregnancy may play an important role in ensuring positive infant birth outcomes during future pandemics.

Aboriginal and Torres Strait Islander community members' experiences of care in an urban Aboriginal Community Controlled Health Service transforming to a Patient Centred Medical Home

Background Few studies have examined patient experiences of the Patient Centred Medical Home (PCMH). This qualitative study explores the experiences of patients of an urban Aboriginal Community Controlled Health Service during its transition to a model of a PCMH. Methods Twenty-eight community members who were registered as patients of an urban Aboriginal Community Controlled Health Service were purposively recruited to participate in yarning interviews. Yarns were conducted using a guide containing open-ended questions in the same domains as those used in patient satisfaction surveys at the participating clinic. Data from yarns were analysed by Aboriginal and non-Indigenous researchers using thematic analysis. The interpretations of Aboriginal and Torres Strait Islander researchers were privileged in the analysis. Results Key themes highlighted the importance of relationships, connectedness, and personal growth and empowerment to community members' health and wellbeing, which they described as a journey of healing and recovery. Delays in implementing a process to empanel patients in a care team meant that most community members were unaware a PCMH had been implemented. However, community members commonly reported a more welcoming environment, more contact with the same doctor and more involvement of Aboriginal Health Workers in their care. Conclusions Aboriginal and Torres Strait Islander community members' narratives of their experiences bear evidence of the acceptability of a PCMH model for delivery in Aboriginal Community Controlled Health Services to improve relational care between patients and health staff. A patient-directed empanelment process has been implemented to better connect patients to their care team in the clinic, and the role of the Aboriginal Health Worker reshaped to strengthen connections between patients and their care team in and outside the clinic.

Djäkamirr: Exploring principles used in piloting the training of First Nations doulas in a remote multilingual Northern Australian community setting

PROBLEM AND BACKGROUND

There is growing evidence in First Nations doula care as a strategy to address perinatal inequities and improve maternal care experiences. However, there is no evidence around the approach and principals required to successfully deliver First Nations doula (childbirth) training.

QUESTION/AIM

To explore and describe the approach and principles used in piloting the training of First Nations doulas in remote, multilingual Northern Australian community settings.

METHODS

Case study with participant interviews to identify principles underpinning our Decolonising Participatory Action Research (D-PAR) approach and training delivery.

FINDINGS

Reflections on our D-PAR research process identified enabling principles: 1) Use of metaphors for knowledge reflexivity, 2) Accommodate cultural constructions of time 3) Practice mental agility at the Cultural Interface, 4) Advocate and address inequities, 5) Prioritise meaningful curriculums and resources, 6) Establish cross-cultural recognition and validity; and 7) Ensure continuity of First Nations culture and language.

DISCUSSION

The success of our doula training pilot disrupts a pervasive colonial narrative of First Nation deficit and demonstrates that respectful, genuine, and authentic partnerships can power transformative individual and collective community change. Our D-PAR approach assumes mutual learning and expertise between community and researchers. It is well suited to collaborative design and delivery of First Nations reproductive health training.

Breaking the cycle: Effect of a multi-agency maternity service redesign on reducing the over-representation of Aboriginal and Torres Strait Islander newborns in out-of-home care: A prospective, non-randomised, intervention study in urban Australia

BACKGROUND

Strategies to reduce over-representation of Indigenous children in out-of-home care must start in pregnancy given Indigenous babies are 6 % of infants (<1 year), yet 43 % of infants in out-of-home care.

OBJECTIVE

To determine if an Indigenous-led, multi-agency, partnership redesign of maternity services decreases the likelihood of babies being removed at birth.

PARTICIPANTS AND SETTING

Women carrying an Indigenous baby/babies who gave birth at the Mater Mothers' Public Hospital, Brisbane (2013-2019).

METHODS

A prospective, non-randomised, intervention trial evaluated a multi-agency service redesign. Women pregnant with an Indigenous baby birthing at a tertiary hospital were offered standard care or Birthing in Our Community (BiOC) service. We compared likelihood of babies being removed by Child Protection Services (CPS) at birth by model of care. Inverse probability of treatment propensity score weighting controlled baseline confounders and calculated treatment effect. Standardized differences were calculated to assess balance of risk factors for each copy of multiple imputation. Australian New Zealand Clinical Trial Registry, ACTRN12618001365257.

RESULTS

In 2013-2019, 1988 women gave birth to 2044 Indigenous babies, with 40 women having babies removed at birth (9 BiOC, 31 standard care). Adjusted odds of baby removal were significantly lower for mothers in BiOC compared to standard care (AOR 0.37, 95 % CI 0.16, 0.84). In total, 2.0 % of Indigenous babies were removed by CPS; eight times higher than non-Indigenous babies at the same hospital (0.25 %).

CONCLUSIONS

BiOC reduced removals of newborn Indigenous babies likely disrupting generational cycles of CPS contact, trauma, and maltreatment, and contributing to short and long-term health and wellbeing benefits for mothers and babies.

A content analysis of women's experiences of different models of maternity care: the Birth Experience Study (BESt)

BACKGROUND

Pregnancy, birth, and early parenthood are significant life experiences impacting women and their families. Growing evidence suggests models of maternity care impact clinical outcomes and birth experiences. The aim of this study was to explore the strengths and limitations of different maternity models of care accessed by women in Australia who had given birth in the past 5 years.

METHODS

The data analysed and presented in this paper is from the Australian Birth Experience Study (BESt), an online national survey of 133 questions that received 8,804 completed responses. There were 2,909 open-ended comments in response to the question on health care provider/s. The data was analysed using content analysis and descriptive statistics.

RESULTS

In models of fragmented care, including standard public hospital care (SC), high-risk care (HRC), and GP Shared care (GPS), women reported feelings of frustration in being unknown and unheard by their health care providers (HCP) that included themes of exhaustion in having to repeat personal history and the difficulty in navigating conflicting medical advice. Women in continuity of care (CoC) models, including Midwifery Group Practice (MGP), Private Obstetric (POB), and Privately Practising Midwifery (PPM), reported positive experiences of healing past birth trauma and care extending for multiple births. Compared across models of care in private and public settings, comments in HRC contained the lowest percentage of strengths (11.94%) and the highest percentage of limitations (88.06%) while comments in PPM revealed the highest percentage of strengths (95.93%) and the lowest percentage of limitations (4.07%).

CONCLUSIONS

Women across models of care in public and private settings desire relational maternity care founded on their unique needs, wishes, and values. The strengths of continuity of care, specifically private midwifery, should be recognised and the limitations for women in high risk maternity care investigated and prioritised by policy makers and managers in health services.

TRIAL REGISTRATION

The study is part of a larger project that has been retrospectively registered with OSF Registries Registration DOI https://doi.org/10.17605/OSF.IO/4KQXP .

The Role of Genetics in Preterm Birth

Preterm birth (PTB), defined as the birth of a child before 37 completed weeks gestation, affects approximately 11% of live births and is the leading cause of death in children under 5 years. PTB is a complex disease with multiple risk factors including genetic variation. Much research has aimed to establish the biological mechanisms underlying PTB often through identification of genetic markers for PTB risk. The objective of this review is to present a comprehensive and updated summary of the published data relating to the field of PTB genetics. A literature search in PubMed was conducted and English studies related to PTB genetics were included. Genetic studies have identified genes within inflammatory, immunological, tissue remodeling, endocrine, metabolic, and vascular pathways that may be involved in PTB. However, a substantial proportion of published data have been largely inconclusive and multiple studies had limited power to detect associations. On the contrary, a few large hypothesis-free approaches have identified and replicated multiple novel variants associated with PTB in different cohorts. Overall, attempts to predict PTB using single "-omics" datasets including genomic, transcriptomic, and epigenomic biomarkers have been mostly unsuccessful and have failed to translate to the clinical setting. Integration of data from multiple "-omics" datasets has yielded the most promising results.

Prevalence and trends for Aboriginal and Torres Strait Islander children living with cerebral palsy: A birds-eye view

AIM

To provide a birds-eye view of the trends of cerebral palsy (CP) for Australian Aboriginal and Torres Strait Islander children and young adults.

METHOD

Data were obtained for this population-based observational study from the Australian Cerebral Palsy Register (ACPR), birth years 1995 to 2014. The Indigenous status of children was classified by maternal Aboriginal and Torres Strait Islander or non-Indigenous status. Descriptive statistics were calculated for socio-demographic and clinical characteristics. Prenatal/perinatal and post-neonatal birth prevalence was calculated per 1000 live births and per 10 000 live births respectively, and Poisson regression used to assess trends.

RESULTS

Data from the ACPR were available for 514 Aboriginal and Torres Strait Islander individuals with CP. Most children could walk independently (56%) and lived in urban or regional areas (72%). One in five children lived in socioeconomically disadvantaged remote/very remote areas. The birth prevalence of prenatal/perinatal CP declined after the mid-2000s from a high of 4.8 (95% confidence interval 3.2-7.0) to 1.9 per 1000 live births (95% confidence interval 1.1-3.2) (2013-2014), with marked declines observed for term births and teenage mothers.

INTERPRETATION

The birth prevalence of CP in Aboriginal and Torres Strait Islander children in Australia declined between the mid-2000s and 2013 to 2014. This birds-eye view provides key stakeholders with new knowledge to advocate for sustainable funding for accessible, culturally safe, antenatal and CP services.

WHAT THIS PAPER ADDS

Birth prevalence of cerebral palsy (CP) is beginning to decline for Aboriginal and Torres Strait Islanders. Recent CP birth prevalence for Aboriginal and Torres Strait Islanders is 1.9 per 1000 live births. Most children with CP live in more populated areas rather than remote or very remote areas. One in five Aboriginal and Torres Strait Islander children with CP live in socioeconomically disadvantaged remote areas.

"This has changed me to be a better mum": A qualitative study exploring how the Australian Nurse-Family Partnership Program contributes to the development of First Nations women's self-efficacy

BACKGROUND

The Australian Nurse-Family Partnership Program is based on the Nurse-Family Partnership program from the United States, which was designed to support first-time mothers experiencing social and economic disadvantage from early in pregnancy until their child's second birthday. International trials have demonstrated this program measurably improves family environment, maternal competencies, and child development. The Australian program has been tailored for mothers having a First Nations baby.

AIM

This study aimed to understand how the program impacts self-efficacy using a qualitative interpretive approach.

METHODS

The study took place in two sites within one Aboriginal Community Controlled Health Service in Meanjin (Brisbane), Australia. Twenty-nine participants were interviewed: first-time mothers having a First Nations baby who had accessed the program (n = 26), their family members (n = 1), and First Nations Elders (n = 2). Interviews were conducted either face-to-face or by telephone, using a yarning tool and method, to explore women's experiences and perceptions. Yarns were analysed using reflexive thematic analysis.

FINDINGS

Three main themes were generated: 1) sustaining connections and relationships; 2) developing self-belief and personal skills; and 3) achieving transformation and growth. We interpret that when the program facilitates the development of culturally safe relationships with staff and peers, it enables behaviour change, skill development, personal goal setting and achievement, leading to self-efficacy.

DISCUSSION

Located within a community-controlled health service, the program can foster cultural connection, peer support and access to health and social services; all contributing to self-efficacy.

CONCLUSION

We recommend the program indicators are strengthened to reflect these findings and enable monitoring and reporting of activities that facilitate self-efficacy, growth, and empowerment.

Comparing the views of caseload midwives working with First Nations families in an all-risk, culturally responsive model with midwives working in standard caseload models, using a cross-sectional survey design

PROBLEM

Little is known about midwives' views and wellbeing when working in an all-risk caseload model.

BACKGROUND

Between March 2017 and December 2020 three maternity services in Victoria, Australia implemented culturally responsive caseload models for women having a First Nations baby.

AIM

Explore the views, experiences and wellbeing of midwives working in an all-risk culturally responsive model for First Nations families compared to midwives in standard caseload models in the same services.

METHODS

A survey was sent to all midwives in the culturally responsive (CR) model six-months and two years after commencement (or on exit), and to standard caseload (SC) midwives two years after the culturally responsive model commenced. Measures used included the Midwifery Process Questionnaire and Copenhagen Burnout Inventory (CBI).

FINDINGS

35 caseload midwives (19 CR, 16 SC) participated. Both groups reported positive attitudes towards their professional role, trending towards higher median levels of satisfaction for the culturally responsive midwives. Midwives valued building close relationships with women and providing continuity of care. Around half reported difficulty maintaining work-life balance, however almost all preferred the flexible hours to shift work. All agreed that a reduced caseload is needed for an all-risk model and that supports around the model (e.g. nominated social workers, obstetricians) are important. Mean CBI scores showed no burnout in either group, with small numbers of individuals having burnout in both groups.

DISCUSSION AND CONCLUSION

Midwives were highly satisfied working in both caseload models, but decreased caseloads and more organisational supports are needed in all-risk models.

Psychosocial Support Provided to Parents of Infants in Neonatal Intensive Care Units: An International Survey

OBJECTIVE

To describe current psychosocial support practices and programs for parents with infants in level II nurseries and level III neonatal intensive care units (NICUs) across Australia and New Zealand.

STUDY DESIGN

A staff member from each level II and level III hospital completed an online survey about the psychosocial support services available for parents in Australia and New Zealand. Mixed methods (descriptive and statistical analysis; descriptive content analysis) were used to describe current services and practices.

RESULTS

Of 66 eligible units, 44 participated in the survey (67%). Hospital-based pediatricians (32%) and clinical directors (32%) were the most common respondents. Level III NICUs reported providing significantly more services for parents than level II nurseries (median [IQR]: level III, 7 [5.25-8.75]; level II, 4.5 [3.25-5]; P < .001), with variability in the type and number of services available (range, 4-13). Less than half of units (43%) reported using standardized screening tools to assess parents for mental health distress, and just 4 units (9%) provided staff-led parent mental health support programs. In qualitative feedback, respondents frequently reported a lack of resources (staffing, funding, and training) to support parents.

CONCLUSIONS

Despite the well-documented distress that parents with infants in neonatal units experience and the evidence-based practices known to reduce this distress, this study identifies significant gaps in parent support services in level II and level III NICUs across Australia and New Zealand.

Targeted health and social care interventions for women and infants who are disproportionately impacted by health inequalities in high-income countries: a systematic review

BACKGROUND

Disadvantaged populations (such as women from minority ethnic groups and those with social complexity) are at an increased risk of poor outcomes and experiences. Inequalities in health outcomes include preterm birth, maternal and perinatal morbidity and mortality, and poor-quality care. The impact of interventions is unclear for this population, in high-income countries (HIC). The review aimed to identify and evaluate the current evidence related to targeted health and social care service interventions in HICs which can improve health inequalities experienced by childbearing women and infants at disproportionate risk of poor outcomes and experiences.

METHODS

Twelve databases searched for studies across all HICs, from any methodological design. The search concluded on 8/11/22. The inclusion criteria included interventions that targeted disadvantaged populations which provided a component of clinical care that differed from standard maternity care.

RESULTS

Forty six index studies were included. Countries included Australia, Canada, Chile, Hong Kong, UK and USA. A narrative synthesis was undertaken, and results showed three intervention types: midwifery models of care, interdisciplinary care, and community-centred services. These intervention types have been delivered singularly but also in combination of each other demonstrating overlapping features. Overall, results show interventions had positive associations with primary (maternal, perinatal, and infant mortality) and secondary outcomes (experiences and satisfaction, antenatal care coverage, access to care, quality of care, mode of delivery, analgesia use in labour, preterm birth, low birth weight, breastfeeding, family planning, immunisations) however significance and impact vary. Midwifery models of care took an interpersonal and holistic approach as they focused on continuity of carer, home visiting, culturally and linguistically appropriate care and accessibility. Interdisciplinary care took a structural approach, to coordinate care for women requiring multi-agency health and social services. Community-centred services took a place-based approach with interventions that suited the need of its community and their norms.

CONCLUSION

Targeted interventions exist in HICs, but these vary according to the context and infrastructure of standard maternity care. Multi-interventional approaches could enhance a targeted approach for at risk populations, in particular combining midwifery models of care with community-centred approaches, to enhance accessibility, earlier engagement, and increased attendance.

TRIAL REGISTRATION

PROSPERO Registration number: CRD42020218357.

Ethnic minority women's experiences of accessing antenatal care in high income European countries: a systematic review

BACKGROUND

Women from ethnic minority backgrounds are at greater risk of adverse maternal outcomes. Antenatal care plays a crucial role in reducing risks of poor outcomes. The aim of this study was to identify, appraise, and synthesise the recent qualitative evidence on ethnic minority women's experiences of accessing antenatal care in high-income European countries, and to develop a novel conceptual framework for access based on women's perspectives.

METHODS

We conducted a comprehensive search of seven electronic databases in addition to manual searches to identify all qualitative studies published between January 2010 and May 2021. Identified articles were screened in two stages against the inclusion criteria with titles and abstracts screened first followed by full-text screening. Included studies were quality appraised using the Critical Appraisal Skills Programme checklist and extracted data were synthesised using a 'best fit' framework, based on an existing theoretical model of health care access.

RESULTS

A total of 30 studies were included in this review. Women's experiences covered two overarching themes: 'provision of antenatal care' and 'women's uptake of antenatal care'. The 'provision of antenatal care' theme included five sub-themes: promotion of antenatal care importance, making contact and getting to antenatal care, costs of antenatal care, interactions with antenatal care providers and models of antenatal care provision. The 'women's uptake of antenatal care' theme included seven sub-themes: delaying initiation of antenatal care, seeking antenatal care, help from others in accessing antenatal care, engaging with antenatal care, previous experiences of interacting with maternity services, ability to communicate, and immigration status. A novel conceptual model was developed from these themes.

CONCLUSION

The findings demonstrated the multifaceted and cyclical nature of initial and ongoing access to antenatal care for ethnic minority women. Structural and organisational factors played a significant role in women's ability to access antenatal care. Participants in majority of the included studies were women newly arrived in the host country, highlighting the need for research to be conducted across different generations of ethnic minority women taking into account the duration of stay in the host country where they accessed antenatal care.

PROTOCOL AND REGISTRATION

The review protocol was registered on PROSPERO (reference number CRD42021238115).

Health engagement: a systematic review of tools modifiable for use with vulnerable pregnant women

OBJECTIVE

To examine available health engagement tools suitable to, or modifiable for, vulnerable pregnant populations.

DESIGN

Systematic review.

ELIGIBILITY CRITERIA

Original studies of tool development and validation related to health engagement, with abstract available in English, published between 2000 and 2022, sampling people receiving outpatient healthcare including pregnant women.

DATA SOURCES

CINAHL Complete, Medline, EMBASE and PubMed were searched in April 2022.

RISK OF BIAS

Study quality was independently assessed by two reviewers using an adapted COSMIN risk of bias quality appraisal checklist. Tools were also mapped against the Synergistic Health Engagement model, which centres on women's buy-in to maternity care.

INCLUDED STUDIES

Nineteen studies were included from Canada, Germany, Italy, the Netherlands, Sweden, the UK and the USA. Four tools were used with pregnant populations, two tools with vulnerable non-pregnant populations, six tools measured patient-provider relationship, four measured patient activation, and three tools measured both relationship and activation.

RESULTS

Tools that measured engagement in maternity care assessed some of the following constructs: communication or information sharing, woman-centred care, health guidance, shared decision-making, sufficient time, availability, provider attributes, discriminatory or respectful care. None of the maternity engagement tools assessed the key construct of buy-in. While non-maternity health engagement tools measured some elements of buy-in (self-care, feeling hopeful about treatment), other elements (disclosing risks to healthcare providers and acting on health advice), which are significant for vulnerable populations, were rarely measured.

CONCLUSIONS AND IMPLICATIONS

Health engagement is hypothesised as the mechanism by which midwifery-led care reduces the risk of perinatal morbidity for vulnerable women. To test this hypothesis, a new assessment tool is required that addresses all the relevant constructs of the Synergistic Health Engagement model, developed for and psychometrically assessed in the target group.

PROSPERO REGISTRATION NUMBER

CRD42020214102.

Embracing the continuity of care experience: A new Australian graduate entry master of midwifery course with a student caseload of 15 women per year

BACKGROUND

Women receiving continuity of midwifery care have increased satisfaction and improved outcomes. Preparation of midwifery students to work in continuity models from the point of graduation may provide an ongoing midwifery workforce that meets rising demand from women for access to such care.

AIM OF THE PAPER

The aim of this paper is to describe an innovative midwifery course based on a continuity model, where students acquire more than 50 % of clinical hours through continuity of care experiences. Additional educational strategies incorporated in the course to enhance the CCE experience within the philosophy of midwifery care, include a virtual maternity centre, case-based learning and the Resources Activities Support Evaluation (RASE) pedagogical model of learning.

DISCUSSION

Australian accredited midwifery courses vary in structure, format and philosophy; this new course provides students with an alternative option of study for those who have a particular interest in continuity of midwifery care.

CONCLUSION

A midwifery course which provides the majority of clinical hours through continuity of care may prepare graduates for employment within midwifery group practice models by demonstrating the benefits of relationship building, improved outcomes and the reality of an on-call lifestyle.

Developing and evaluating Birthing on Country services for First Nations Australians: the Building On Our Strengths (BOOSt) prospective mixed methods birth cohort study protocol

BACKGROUND

With the impact of over two centuries of colonisation in Australia, First Nations families experience a disproportionate burden of adverse pregnancy and birthing outcomes. First Nations mothers are 3-5 times more likely than other mothers to experience maternal mortality; babies are 2-3 times more likely to be born preterm, low birth weight or not to survive their first year. 'Birthing on Country' incorporates a multiplicity of interpretations but conveys a resumption of maternity services in First Nations Communities with Community governance for the best start to life. Redesigned services offer women and families integrated, holistic care, including carer continuity from primary through tertiary services; services coordination and quality care including safe and supportive spaces. The overall aim of Building On Our Strengths (BOOSt) is to facilitate and assess Birthing on Country expansion into two settings - urban and rural; with scale-up to include First Nations-operated birth centres. This study will build on our team's earlier work - a Birthing on Country service established and evaluated in an urban setting, that reported significant perinatal (and organisational) benefits, including a 37% reduction in preterm births, among other improvements.

METHODS

Using community-based, participatory action research, we will collaborate to develop, implement and evaluate new Birthing on Country care models. We will conduct a mixed-methods, prospective birth cohort study in two settings, comparing outcomes for women having First Nations babies with historical controls. Our analysis of feasibility, acceptability, clinical and cultural safety, effectiveness and cost, will use data including (i) women's experiences collected through longitudinal surveys (three timepoints) and yarning interviews; (ii) clinical records; (iii) staff and stakeholder views and experiences; (iv) field notes and meeting minutes; and (v) costs data. The study includes a process, impact and outcome evaluation of this complex health services innovation.

DISCUSSION

Birthing on Country applies First Nations governance and cultural safety strategies to support optimum maternal, infant, and family health and wellbeing. Women's experiences, perinatal outcomes, costs and other operational implications will be reported for Communities, service providers, policy advisors, and for future scale-up.

TRIAL REGISTRATION

Australia & New Zealand Clinical Trial Registry # ACTRN12620000874910 (2 September 2020).

Perspectives of health service providers in delivering best-practice care for Aboriginal mothers and their babies during the postnatal period

BACKGROUND

Evidence suggests that Aboriginal babies in Western Australia are not receiving adequate primary health care in their first 3 months of life, leading to questions about enablers and constraints to delivering such care. This paper presents findings from a qualitative research project investigating health providers' perceptions and experiences of best and current practice in discharge planning, postnatal care and health education for Aboriginal mothers and their newborn babies.

METHODS

Constructivist grounded theory guided this research involving 58 semi-structured interviews conducted with health providers who deliver care to Aboriginal mothers and infants. Participants were recruited from hospital-based and primary health sites in metropolitan Perth, and regional and remote locations in Western Australia.

RESULTS

Structural factors enabling best practice in discharge planning, postnatal care, and health education for mothers included health providers following best practice guidelines and adequate staffing levels. Organisational enablers included continuity of care throughout pregnancy, birth and postnatally. In particular, good communication between services around discharge planning, birth notifications, and training in culturally respectful care. Structural and organisational constraints to delivering best practice and compromising continuity of care were identified as beyond individual control. These included poor communication between different health and social services, insufficient hospital staffing levels leading to early discharge, inadequate cultural training, delayed receipt of birth notifications and discharge summaries received by Aboriginal primary health services.

CONCLUSION

Findings highlight the importance of examining current policies and practices to promote best practice in postnatal care to improve health outcomes for mothers and their Aboriginal babies.

The Western Australian preterm birth prevention initiative: a whole of state singleton pregnancy cohort study showing the need to embrace alternative models of care for Aboriginal women

BACKGROUND

Preterm birth (PTB) is the greatest cause of mortality and morbidity in children up to five years of age globally. The Western Australian (WA) PTB Prevention Initiative, the world's first whole-of-population whole-of-state program aimed at PTB prevention, was implemented across WA in 2014.

METHODS

We conducted a prospective population-based cohort study using pregnancy data for singleton births in WA from 2009 to 2019. Logistic regression using the last full year before the Initiative (2013) as the reference, and run charts were used to examine changes in PTB rates compared to pre-Initiative levels, by gestational age group, hospital type, low and high risk of PTB in mid-pregnancy, and onset of labour (spontaneous/medically initiated). Analyses were stratified by Aboriginal and non-Aboriginal maternal ethnicity.

RESULTS

Amongst non-Aboriginal women, there was initially a reduction in the PTB rate across the state, and in recent years it returned to pre-Initiative levels. Amongst Aboriginal women there was a small, non- significant reduction in the state-wide PTB rate in the first three years of the Initiative, followed by a rise in recent years. For non-Aboriginal women, the reduction in the rate of PTB at the tertiary centre was sustained and improved further for women of all risk levels and onsets of labour. This reduction was not observed for Aboriginal women giving birth at the tertiary centre, amongst whom there was an increase in the PTB rate overall and in all subgroups, with the exception of medically initiated PTB. Amongst Aboriginal women the PTB rate has also increased across the state. At non-tertiary hospitals there was a large increase in PTB amongst both Aboriginal and non-Aboriginal women, largely driven by medically initiated late PTB. Maternal risk factors cannot account for this increase.

CONCLUSIONS

The reduction in PTB rates amongst non-Aboriginal women at the state's tertiary hospital demonstrates that with the right strategies, PTB can be reduced. A sustained collaborative model is required to realise this success in non-tertiary hospitals. The series of interventions was of limited use in Aboriginal women, and future efforts will need to be directed at strategies more likely to be successful, such as midwifery continuity of care models, with Aboriginal representation in the healthcare workforce.

A continuity of care programme for women at risk of preterm birth in the UK: Process evaluation of a hybrid randomised controlled pilot trial

BACKGROUND

The development and evaluation of specific maternity care packages designed to address preterm birth remains a public health priority. We aim to evaluate the implementation, context, and potential mechanisms of action, of a new care pathway that combined midwifery continuity of care with a specialist obstetric clinic for women at risk of preterm birth (POPPIE) in London (UK).

METHODS

We did a multiphase mixed method triangulation evaluation nested within a hybrid type 2, randomised controlled trial in London (United Kingdom). Pregnant women with identified risk factors for preterm birth were eligible for trial participation and randomly assigned (1:1) to either midwifery continuity of care linked to a specialist obstetric clinic (POPPIE group) or standard maternity care. The primary outcome was a composite of appropriate and timely interventions for the prevention and/or management of preterm labour and birth, analysed according to intention to treat. Clinical and process outcome data were abstracted from medical records and electronic data systems, and coded by study team members, who were masked to study group allocation. Implementation data were collected from meeting records and key documents, postnatal surveys (n = 164), semi-structured interviews with women (n = 30), healthcare providers and stakeholders (n = 24) pre-, mid and post implementation. Qualitative and quantitative data from meeting records and key documents were examined narratively. Qualitative data from interviews were analysed using three thematic frameworks: Proctor's (for implementation outcomes: appropriateness, adoption, feasibility, acceptability, fidelity, penetration, sustainability), the Consolidated Framework for Implementation Research (for determinants of implementation), and published program theories of continuity models (for potential mechanisms). Data triangulation followed a convergent parallel and pragmatic approach which brought quantitative and qualitative data together at the interpretation stage. We averaged individual implementation measures across all domains to give a single composite implementation strength score which was compared to the primary outcome.

RESULTS

Between May 9, 2017, and Sep 30, 2018, 553 women were assessed for eligibility and 334 were enrolled with less than 6% of loss to follow up (169 were assigned to the POPPIE group; 165 were to the standard group). There was no difference in the primary outcome (POPPIE group 83·3% versus standard group 84·7%; risk ratio 0·98 [95% CI 0·90 to 1·08]). Appropriateness and adoption: The introduction of the POPPIE model was perceived as a positive fundamental change for local maternity services. Partnership working and additional funding were crucial for adoption. Fidelity: More than 75% of antenatal and postnatal visits were provided by a named or partner midwife, and a POPPIE midwife was present in more than 80% of births. Acceptability: Nearly 98% of women who responded to the postnatal survey were very satisfied with POPPIE model. Quantitative fidelity and acceptability results were supported by the qualitative findings. Penetration and sustainability: Despite delays (likely associated with lack of existing continuity models at the hospital), the model was embedded within established services and a joint decision was made to sustain and adapt the model after the trial (strongly facilitated by national maternal policy on continuity pathways). Potential mechanisms of impact identified included e.g. access to care, advocacy and perceptions of safety and trust. There was no association between implementation measures and the primary outcome.

CONCLUSIONS

The POPPIE model of care was a feasible and acceptable model of care that was implemented with high fidelity and sustained in maternity services. Larger powered trials are feasible and needed in other settings, to evaluate the impact and implementation of continuity programmes in other communities affected by preterm birth and women who experience social disadvantage and vulnerability.

TRIAL REGISTRATION

UKCRN Portfolio Database (prospectively registered, 24 April 2017): 31951. ISRCTN registry (retrospectively registered, 21 August 2017): ISRCTN37733900.

Giving birth in rural Arctic Greenland results from an Eastern Greenlandic birth cohort

Eastern Greenland is one of the most remote areas in the world. Approximately 3,500 people lives in two small towns and five villages. There is limited information on birth outcomes in Eastern Greenland. A cohort of all birthing women from Eastern Greenland from 2000 to 2017 was established and pregnancy, birth, and neonatal outcomes were described. A total of 1,344 women and 1,355 children were included in the cohort where 14.5% of the women were 18 years or younger, and 36.2% were single parents. Most women, 84.8% gave birth in East Greenland and 92.9%, experienced a vaginal, non-instrumental birth. The overall caesarean section rate was 6.5%. The rate of premature births was 10.1% and 2.2% of the children were born with malformations. The rate of premature births was high, preventive initiatives such as midwifery-led continuity of care including a stronger focus on the pregnant woman's social and mental life situation may be recommended. Organisation of maternity services in East Greenland may benefit from a strong focus on public health, culture, and setting specific challenges, including the birth traditions of the society.

Midwifery continuity of care: A scoping review of where, how, by whom and for whom?

Systems of care that provide midwifery care and services through a continuity of care model have positive health outcomes for women and newborns. We conducted a scoping review to understand the global implementation of these models, asking the questions: where, how, by whom and for whom are midwifery continuity of care models implemented? Using a scoping review framework, we searched electronic and grey literature databases for reports in any language between January 2012 and January 2022, which described current and recent trials, implementation or scaling-up of midwifery continuity of care studies or initiatives in high-, middle- and low-income countries. After screening, 175 reports were included, the majority (157, 90%) from high-income countries (HICs) and fewer (18, 10%) from low- to middle-income countries (LMICs). There were 163 unique studies including eight (4.9%) randomised or quasi-randomised trials, 58 (38.5%) qualitative, 53 (32.7%) quantitative (cohort, cross sectional, descriptive, observational), 31 (19.0%) survey studies, and three (1.9%) health economics analyses. There were 10 practice-based accounts that did not include research. Midwives led almost all continuity of care models. In HICs, the most dominant model was where small groups of midwives provided care for designated women, across the antenatal, childbirth and postnatal care continuum. This was mostly known as caseload midwifery or midwifery group practice. There was more diversity of models in low- to middle-income countries. Of the 175 initiatives described, 31 (18%) were implemented for women, newborns and families from priority or vulnerable communities. With the exception of New Zealand, no countries have managed to scale-up continuity of midwifery care at a national level. Further implementation studies are needed to support countries planning to transition to midwifery continuity of care models in all countries to determine optimal model types and strategies to achieve sustainable scale-up at a national level.

Protecting the brain of the micropreemie

Advances in perinatal care have seen substantial improvements in survival without disability for extremely preterm infants. Protecting the developing brain and reducing neurodevelopmental sequelae of extremely preterm birth are strategic priorities for both research and clinical care. A number of evidence-based interventions exist for neuroprotection in micropreemies, inclusive of prevention of preterm birth and multiple births with implantation of only one embryo during in vitro fertilisation, as well as antenatal care to optimize fetal wellbeing, strategies for supporting neonatal transition, and neuroprotective developmental care. Avoidance of complications that trigger ischemia and inflammation is vital for minimizing brain dysmaturation and injury, particularly of the white matter. Neurodevelopmental surveillance, early diagnosis of cerebral palsy and early intervention are essential for optimizing long-term outcomes and quality of life. Research priorities include further evaluation of putative neuroprotective agents, and investigation of common neonatal interventions in trials adequately powered to assess neurodevelopmental outcome.

Early detection of Australian Aboriginal and Torres Strait Islander infants at high risk of adverse neurodevelopmental outcomes at 12 months corrected age: LEAP-CP prospective cohort study protocol

INTRODUCTION

Neurodevelopmental disorders (NDD), including cerebral palsy (CP), autism spectrum disorder (ASD) and foetal alcohol spectrum disorder (FASD), are characterised by impaired development of the early central nervous system, impacting cognitive and/or physical function. Early detection of NDD enables infants to be fast-tracked to early intervention services, optimising outcomes. Aboriginal and Torres Strait Islander infants may experience early life factors increasing their risk of neurodevelopmental vulnerability, which persist into later childhood, further compounding the health inequities experienced by First Nations peoples in Australia. The LEAP-CP prospective cohort study will investigate the efficacy of early screening programmes, implemented in Queensland, Australia to earlier identify Aboriginal and Torres Strait Islander infants who are 'at risk' of adverse neurodevelopmental outcomes (NDO) or NDD. Diagnostic accuracy and feasibility of early detection tools for identifying infants 'at risk' of a later diagnosis of adverse NDO or NDD will be determined.

METHODS AND ANALYSIS

Aboriginal and/or Torres Strait Islander infants born in Queensland, Australia (birth years 2020-2022) will be invited to participate. Infants aged <9 months corrected age (CA) will undergo screening using the (1) General Movements Assessment (GMA); (2) Hammersmith Infant Neurological Examination (HINE); (3) Rapid Neurodevelopmental Assessment (RNDA) and (4) Ages and Stages Questionnaire-Aboriginal adaptation (ASQ-TRAK). Developmental outcomes at 12 months CA will be determined for: (1) neurological (HINE); (2) motor (Peabody Developmental Motor Scales 2); (3) cognitive and communication (Bayley Scales of Infant Development III); (4) functional capabilities (Paediatric Evaluation of Disability Inventory-Computer Adaptive Test) and (5) behaviour (Infant Toddler Social and Emotional Assessment). Infants will be classified as typically developing or 'at risk' of an adverse NDO and/or specific NDD based on symptomology using developmental and diagnostic outcomes for (1) CP (2) ASD and (3) FASD. The effects of perinatal, social and environmental factors, caregiver mental health and clinical neuroimaging on NDOs will be investigated.

ETHICS AND DISSEMINATION

Ethics approval has been granted by appropriate Queensland ethics committees; Far North Queensland Health Research Ethics Committee (HREC/2019/QCH/50533 (Sep ver 2)-1370), the Townsville HHS Human Research Ethics Committee (HREC/QTHS/56008), the University of Queensland Medical Research Ethics Committee (2020000185/HREC/2019/QCH/50533) and the Children's Health Queensland HHS Human Research Ethics Committee (HREC/20/QCHQ/63906) with governance and support from local First Nations communities. Findings from this study will be disseminated via peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

ACTRN12619000969167.

Options for improving low birthweight and prematurity birth outcomes of indigenous and culturally and linguistically diverse infants: a systematic review of the literature using the social-ecological model

BACKGROUND

Prematurity and low birthweight are more prevalent among Indigenous and Culturally and Linguistically Diverse infants.

METHODS

To conduct a systematic review that used the social-ecological model to identify interventions for reducing low birthweight and prematurity among Indigenous or CALD infants. Scopus, PubMed, CINAHL, and Medline electronic databases were searched. Studies included those published in English between 2010 and 2021, conducted in high-income countries, and reported quantitative results from clinical trials, randomized controlled trials, case-control studies or cohort studies targeting a reduction in preterm birth or low birthweight among Indigenous or CALD infants. Studies were categorized according to the level of the social-ecological model they addressed.

FINDINGS

Nine studies were identified that met the inclusion criteria. Six of these studies reported interventions targeting the organizational level of the social-ecological model. Three studies targeted the policy, community, and interpersonal levels, respectively. Seven studies presented statistically significant reductions in preterm birth or low birthweight among Indigenous or CALD infants. These interventions targeted the policy (n = 1), community (n = 1), interpersonal (n = 1) and organizational (n = 4) levels of the social-ecological model.

INTERPRETATION

Few interventions across high-income countries target the improvement of low birthweight and prematurity birth outcomes among Indigenous or CALD infants. No level of the social-ecological model was found to be more effective than another for improving these outcomes.

Are Indigenous research principles incorporated into maternal health research? A scoping review of the global literature

BACKGROUND

Indigenous women world-wide are diverse and heterogenous, yet many have similar experiences of colonization, land dispossession, and discrimination. These experiences along with inequitable access to, and quality of, maternal healthcare increase adverse maternal health outcomes. To improve health outcomes for Indigenous women, studies must be conducted with Indigenous involvement and reflect Indigenous research principles. Objectives/Aim: The aim of this review was to explore the range, extent, and nature of Indigenous maternal health research and to assess the reporting of Indigenous research principles in the global Indigenous maternal health literature.

METHODS

Following a systematic scoping review protocol, four scholarly electronic databases were searched. Articles were included if they reported empirical research published between 2000 and 2019 and had a focus on Indigenous maternal health. Descriptive data were extracted from relevant articles and descriptive analysis was conducted. Included articles were also assessed for reporting of Indigenous research principles, including Indigenous involvement, context of colonization, Indigenous conceptualizations of health, community benefits, knowledge dissemination to participants or communities, and policy or intervention recommendations.

RESULTS

Four-hundred and forty-one articles met the inclusion criteria. While studies were conducted in all continents except Antarctica, less than 3% of articles described research in low-income countries. The most researched topics were access to and quality of maternity care (25%), pregnancy outcome and/or complications (18%), and smoking, alcohol and/or drug use during pregnancy (14%). The most common study design was cross-sectional (49%), and the majority of articles used quantitative methods only (68%). Less than 2% of articles described or reported all Indigenous research principles, and 71% of articles did not report on Indigenous People's involvement.

CONCLUSIONS

By summarizing the trends in published literature on Indigenous maternal health, we highlight the need for increased geographic representation of Indigenous women, expansion of research to include important but under-researched topics, and meaningful involvement of Indigenous Peoples.

Can birth outcome inequality be reduced using targeted caseload midwifery in a deprived diverse inner city population? A retrospective cohort study, London, UK

OBJECTIVES

(1) To report maternal and newborn outcomes of pregnant women in areas of social deprivation in inner city London. (2) To compare the effect of caseload midwifery with standard care on maternal and newborn outcomes in this cohort of women.

DESIGN

Retrospective observational cohort study.

SETTING

Four council wards (electoral districts) in inner city London, where over 90% of residents are in the two most deprived quintiles of the English Index of Multiple Deprivation (IMD) (2019) and the population is ethnically diverse.

PARTICIPANTS

All women booked for antenatal care under Guys and St Thomas' National Health Service Foundation Trust after 11 July 2018 (when the Lambeth Early Action Partnership (LEAP*) caseload midwifery team was implemented) until data collection 18 June 2020. This included 523 pregnancies in the LEAP area, of which 230 were allocated to caseload midwifery, and 8430 pregnancies from other areas.

MAIN OUTCOME MEASURES

To explore if targeted caseload midwifery (known to reduce preterm birth) will improve important measurable outcomes (preterm birth, mode of birth and newborn outcomes).

RESULTS

There was a significant reduction in preterm birth rate in women allocated to caseload midwifery, when compared with those who received traditional midwifery care (5.1% vs 11.2%; risk ratio: 0.41; p=0.02; 95% CI 0.18 to 0.86; number needed to treat: 11.9). Caesarean section births were significantly reduced in women allocated to caseload midwifery care, when compared with traditional midwifery care (24.3% vs 38.0%; risk ratio: 0.64: p=0.01; 95% CI 0.47 to 0.90; number needed to treat: 7.4) including emergency caesarean deliveries (15.2% vs 22.5%; risk ratio: 0.59; p=0.03; 95% CI 0.38 to 0.94; number needed to treat: 10) without increase in neonatal unit admission or stillbirth.

CONCLUSION

This study shows that a model of caseload midwifery care implemented in an inner city deprived community improves outcome by significantly reducing preterm birth and birth by caesarean section when compared with traditional care. This data trend suggests that when applied to targeted groups (women in higher IMD quintile and women of diverse ethnicity) that the impact of intervention is greater.

A realist review to explore how midwifery continuity of care may influence preterm birth in pregnant women

BACKGROUND

Midwifery continuity of care models are the only health system intervention associated with both a reduction in preterm birth (PTB) and an improvement in perinatal survival; however, questions remain about the mechanisms by which such positive outcomes are achieved. We aimed to uncover theories of change by which we can postulate how and why continuity of midwifery care models might affect PTB.

METHODS

We followed Pawson's guidance for conducting a realist review and performed a comprehensive search to identify existing literature exploring the impact of continuity models on PTB in all pregnant women. A realist methodology was used to uncover the context (C), mechanisms (M), and outcomes (O) and to develop a group of CMO configurations to illuminate middle-range theories.

RESULTS

Eleven papers were included from a wide variety of settings in the United Kingdom, Australia, and the United States. The majority of study participants had low socioeconomic status or social risk factors and received diverse models of midwifery continuity of care. Three themes-woman-midwife partnership, maternity pathways and processes, and system resources-encompassed ten CMO configurations. Building relationships, trust, confidence, and advocacy resulted in women feeling safer, less stressed, and more secure and respected, and encouraged them to access and engage in antenatal care with more opportunities for early prevention and diagnosis of complications, which facilitated effective management when compliance to guidelines was ensured. Organizational infrastructure, innovative partnerships, and robust community systems are crucial to overcome barriers, address women's complex needs, ensure quality of care, and reduce PTB risk.

CONCLUSIONS

Pregnant women living in different contexts in the United Kingdom, Australia, and the United States at low and mixed risk of complications and with low socioeconomic status or social risk factors experienced continuity models in similar ways, and similar underlying mechanisms may have influenced PTB outcomes. Further research is required to understand how continuity models may influence behavioral change, physiological stress levels, ethnic disparities in PTB and care coordination, and navigation of health services.

Caring for Mum On Country: Exploring the transferability of the Birthing On Country RISE framework in a remote multilingual Northern Australian context

BACKGROUND & PROBLEM

Birthing On Country (BOC) is an international movement for returning childbirth to First Nations peoples and their communities. The RISE Framework was developed to guide evidence-based BOC implementation but has not yet been tested in a remote Australian community setting.

AIM

To test the transferability and acceptability of the RISE Framework in a remote multilingual setting in a Yolŋu (First Nations) community in Northern Australia.

METHODS

Working in partnership with one remote Yolŋu community, we used a decolonising participatory action research (D-PAR) approach to begin co-designing services and test the acceptability of the RISE Framework. A three-phased transferability process was developed: Warming the ground; Co-Interpreting; and Acceptability Testing.

FINDINGS

The RISE Framework was customized to the local Yolŋu context and called 'Caring for Mum on Country'. It was articulated in two languages: Djambarrpuyŋu and English. We successfully used it to guide discussions at a community gathering privileging the voices of senior women to inform the design of local maternity services.

DISCUSSION

Using the D-PAR approach, the RISE Framework was readily adapatable to this complex, remote and multilingual setting. It resonated with the Yolŋu community and proved useful for identifying current limitations of existing maternity services and importantly facilitating the design of Yolŋu centred strength-based maternity services.

CONCLUSION

The RISE Framework, combined with our transformative methodology, offers a promising approach to guiding complex interventions for returning services to First Nations communities in diverse contexts. Testing in other settings will further contribute to growing an evidence-base for BOC service planning and implementation.

Gestational diabetes is associated with postpartum hemorrhage in Indigenous Australian women in the PANDORA study: A prospective cohort

OBJECTIVE

To assess associations of hyperglycemia in pregnancy with the risk of postpartum hemorrhage (PPH) in a prospective cohort of Indigenous and non-Indigenous women, compared with normoglycemia.

METHODS

Data were from 1102 (48% Indigenous) women of the Pregnancy And Neonatal Diabetes Outcomes in Remote Australia (PANDORA) Study. Age-adjusted associations of gestational diabetes mellitus (GDM) or pre-existing type 2 diabetes mellitus (T2DM), obstetric and demographic covariables with PPH (blood loss ≥500 ml) were assessed using logistic regression. Multivariable-adjusted models included Indigenous ethnicity, diabetes type and their interaction.

RESULTS

A higher proportion of Indigenous women developed PPH than non-Indigenous women (32% versus 22%; P < 0.001). Compared with non-Indigenous women with normoglycemia, risks of PPH for Indigenous women with GDM or T2DM were higher (odds ratio [OR] 1.83, 95% confidence intervals [CI] 1.11-3.02, and OR 1.72, 95% CI 0.99-3.00 after age adjustment, OR 1.84, 95% CI 1.06-3.19, and OR 1.33, 95% CI 0.70-2.54 after adjustment for school education and delivery mode, and OR 1.62, 95% CI 0.95-2.77, and OR 0.99, 95% CI 0.53-1.86 after adjustment for birth weight). Importantly, Indigenous women without hyperglycemia in pregnancy were not at increased risk of PPH.

CONCLUSION

The significantly higher rates of PPH experienced by Indigenous women compared with non-Indigenous women may be explained by a greater effect of GDM among Indigenous women that was only partly accounted for by birth weight.

Effect of a Birthing on Country service redesign on maternal and neonatal health outcomes for First Nations Australians: a prospective, non-randomised, interventional trial

BACKGROUND

There is an urgency to redress unacceptable maternal and infant health outcomes for First Nations families in Australia. A multi-agency partnership between two Aboriginal Community-controlled health services and a tertiary hospital in urban Australia designed, implemented, and evaluated the new Birthing in Our Community (BiOC) service. In this study, we aimed to assess and report the clinical effectiveness of the BiOC service on key maternal and infant health outcomes compared with that of standard care.

METHODS

Pregnant women attending the Mater Mothers Public Hospital (Brisbane, QLD, Australia) who were having a First Nations baby were invited to receive the BiOC service. In this prospective, non-randomised, interventional trial of the service, we specifically enrolled women who intended to birth at the study hospital, and had a referral from a family doctor or Aboriginal Medical Service. Participants were offered either standard care services or the BiOC service. Prespecified primary outcomes to test the effectiveness of the BiOC service versus standard care were the proportion of women attending five or more antenatal visits, smoking after 20 weeks of gestation, who had a preterm birth (<37 weeks), and who were exclusively breastfeeding at discharge from hospital. We used inverse probability of treatment weighting to balance confounders and calculate treatment effect. This trial is registered with the Australian New Zealand Clinical Trial Registry, ACTRN12618001365257.

FINDINGS

Between Jan 1, 2013, and June 30, 2019, 1867 First Nations babies were born at the Mater Mothers Public Hospital. After exclusions, 1422 women received either standard care (656 participants) or the BiOC service (766 participants) and were included in the analyses. Women receiving the BiOC service were more likely to attend five or more antenatal visits (adjusted odds ratio 1·54, 95% CI 1·13-2·09; p=0·0064), less likely to have an infant born preterm (0·62, 0·42-0·93; p=0·019), and more likely to exclusively breastfeed on discharge from hospital (1·34, 1·06-1·70; p=0·014). No difference was found between the two groups for smoking after 20 weeks of gestation, with both showing a reduction compared with smoking levels reported at their hospital booking visit.

INTERPRETATION

This study has shown the clinical effectiveness of the BiOC service, which was co-designed by stakeholders and underpinned by Birthing on Country principles. The widespread scale-up of this new service should be prioritised. Dedicated funding, knowledge translation, and implementation science are needed to ensure all First Nations families can access Birthing on Country services that are adapted for their specific contexts.

FUNDING

Australian National Health and Medical Research Council.

Perinatal care with a view to preventing cerebral palsy

Birth prevalence of cerebral palsy (CP) is declining in high-income countries, to as low as 1.4 per 1000 live births in the most recent international reports. This represents a 35% reduction in birth prevalence over a 15-year period. This reduction is underpinned by a heightened focus of attention towards all aspects of CP, including: increased awareness, better data collection, development of national networks and registries, an explosion of research in basic science, perinatal care, neonatal neurology, public health, early detection, and targeted early intervention. Quick uptake of evidence into practice has ensued and overall improvements in clinical care occurred concurrently. It is anticipated that with continued partnerships with families, ongoing research driving further clinical improvement and vice versa, birth prevalence and severity of CP will further decline and the focus will shift to prevention in low- and middle-income countries. WHAT THIS PAPER ADDS: Research in the field of perinatal care and cerebral palsy (CP) prevention has increased significantly. In high-income countries, increased awareness of CP and scientific advances have improved clinical care. Population-based registers have limitations but remain the best mechanism to quantify birth prevalence of CP and accurately track trends. There have been recent reductions in the birth prevalence of CP.

Improving antenatal engagement for Aboriginal women in Australia: A scoping review

BACKGROUND

Aboriginal women have an increased risk of poor antenatal engagement in pregnancy in comparison with Caucasian women, due to inequalities in health care provision. The Pregnancy Outcome in South Australia reports Aboriginal women having 10 times the risk of non-attendance of antenatal care throughout their pregnancy, 3 times the risk of attending the initial booking appointment later than recommended in their pregnancy, and Aboriginal women have an increased risk of attending significantly less antenatal appointments than Caucasian women.

OBJECTIVE

The primary purpose of the scoping review is to map the body of literature known about Aboriginal women engaging with antenatal care in Australia, and the factors that facilitate or cause barriers to this engagement. Secondary to this, the review will describe how culturally safe care influences antenatal engagement.

METHODS

Scoping reviews utilise a broad range of literature, encompassing all types of studies. An online search of 6 databases was conducted to identify and critically analyse sources discussing antenatal engagement for Aboriginal women in Australia. Using the JBI framework for Scoping Reviews, the researcher was able to strengthen the rigour of the methodology.

FINDINGS

The search produced 9 articles, relating to 6 studies addressing antenatal engagement for Aboriginal women in Australia. Several themes were prevalent in the research that impact antenatal engagement including: Smoking, Relocation, Continuity of Care, Aboriginal maternity infant care workers, home visits, birthing on country, age, family and culturally safe care.

CONCLUSION

Aboriginal women have identified continuity of care, Aboriginal workforce, home visits, family involvement, birthing on country and cultural safety as factors that improve antenatal engagement. Aboriginal women have reported smoking, rural and remote location, cultural incompetence and young age as factors that deter them from engaging with antenatal care. In order to improve antenatal engagement for Aboriginal women in South Australia, culturally safe care is essential. In order to determine the factors that facilitate and/or deter Aboriginal women from antenatal engagement, further research is required.

Parental mental health before and during pregnancy and offspring birth outcomes: A 20-year preconception cohort of maternal and paternal exposure

BACKGROUND

Preterm birth (PTB) and small for gestational age (SGA) are increasingly prevalent, with major consequences for health and development into later life. There is emerging evidence that some risk processes begin before pregnancy. We report on associations between maternal and paternal common mental disorders (CMD) before and during pregnancy and offspring PTB and SGA.

METHODS

398 women with 609 infants and 267 men with 421 infants were assessed repeatedly for CMD symptoms before pregnancy between age 14 and 29 and during pregnancy. Associations between preconception and antenatal CMD symptoms and offspring gestational age/PTB and size for gestational age/SGA were estimated using linear and Poisson regression.

FINDINGS

In men, persistent preconception CMD across adolescence and young adulthood predicted offspring PTB after adjustment for ethnicity, education, BMI and adolescent substance use (adjusted RR 7·0, 95% CI 1·8,26·8), corresponding to a population attributable fraction of 31% of preterm births. In women, antenatal CMD symptoms predicted offspring PTB (adjusted RR 4·4, 95% CI 1·4,14·1). There was little evidence of associations with SGA.

INTERPRETATION

This first report of an association between paternal preconception mental health and offspring gestational age, while requiring replication in larger samples, complements earlier work on stress in animals, and further strengthens the case for expanding preconception mental health care to both men and women.

FUNDING

National Health and Medical Research Council (Australia), Victorian Health Promotion Foundation, Australian Rotary Health, Colonial Foundation, Perpetual Trustees, Financial Markets Foundation for Children (Australia), Royal Children's Hospital Foundation, Murdoch Children's Research Institute, Australian Research Council.

Midwifery continuity of care versus standard maternity care for women at increased risk of preterm birth: A hybrid implementation-effectiveness, randomised controlled pilot trial in the UK

BACKGROUND

Midwifery continuity of care is the only health system intervention shown to reduce preterm birth (PTB) and improve perinatal survival, but no trial evidence exists for women with identified risk factors for PTB. We aimed to assess feasibility, fidelity, and clinical outcomes of a model of midwifery continuity of care linked with a specialist obstetric clinic for women considered at increased risk for PTB.

METHODS AND FINDINGS

We conducted a hybrid implementation-effectiveness, randomised, controlled, unblinded, parallel-group pilot trial at an inner-city maternity service in London (UK), in which pregnant women identified at increased risk of PTB were randomly assigned (1:1) to either midwifery continuity of antenatal, intrapartum, and postnatal care (Pilot study Of midwifery Practice in Preterm birth Including women's Experiences [POPPIE] group) or standard care group (maternity care by different midwives working in designated clinical areas). Pregnant women attending for antenatal care at less than 24 weeks' gestation were eligible if they fulfilled one or more of the following criteria: previous cervical surgery, cerclage, premature rupture of membranes, PTB, or late miscarriage; previous short cervix or short cervix this pregnancy; or uterine abnormality and/or current smoker of tobacco. Feasibility outcomes included eligibility, recruitment and attrition rates, and fidelity of the model. The primary outcome was a composite of appropriate and timely interventions for the prevention and/or management of preterm labour and birth. We analysed by intention to treat. Between 9 May 2017 and 30 September 2018, 334 women were recruited; 169 women were allocated to the POPPIE group and 165 to the standard group. Mean maternal age was 31 years; 32% of the women were from Black, Asian, and ethnic minority groups; 70% were in employment; and 46% had a university degree. Nearly 70% of women lived in areas of social deprivation. More than a quarter of women had at least one pre-existing medical condition and multiple risk factors for PTB. More than 75% of antenatal and postnatal visits were provided by a named/partner midwife, and a midwife from the POPPIE team was present at 80% of births. The incidence of the primary composite outcome showed no statistically significant difference between groups (POPPIE group 83.3% versus standard group 84.7%; risk ratio 0.98 [95% confidence interval (CI) 0.90 to 1.08]; p = 0.742). Infants in the POPPIE group were significantly more likely to have skin-to-skin contact after birth, to have it for a longer time, and to breastfeed immediately after birth and at hospital discharge. There were no differences in other secondary outcomes. The number of serious adverse events was similar in both groups and unrelated to the intervention (POPPIE group 6 versus standard group 5). Limitations of this study included the limited power and the nonmasking of group allocation; however, study assignment was masked to the statistician and researchers who analysed the data.

CONCLUSIONS

In this study, we found that it is feasible to set up and achieve fidelity of a model of midwifery continuity of care linked with specialist obstetric care for women at increased risk of PTB in an inner-city maternity service in London (UK), but there is no impact on most outcomes for this population group. Larger appropriately powered trials are needed, including in other settings, to evaluate the impact of relational continuity and hypothesised mechanisms of effect based on increased trust and engagement, improved care coordination, and earlier referral on disadvantaged communities, including women with complex social factors and social vulnerability.

TRIAL REGISTRATION

We prospectively registered the pilot trial on the UK Clinical Research Network Portfolio Database (ID number: 31951, 24 April 2017). We registered the trial on the International Standard Randomised Controlled Trial Number (ISRCTN) (Number: 37733900, 21 August 2017) and before trial recruitment was completed (30 September 2018) when informed that prospective registration for a pilot trial was also required in a primary clinical trial registry recognised by WHO and the International Committee of Medical Journal Editors (ICMJE). The protocol as registered and published has remained unchanged, and the analysis conforms to the original plan.

Community Perspectives of Complex Trauma Assessment for Aboriginal Parents: 'Its Important, but How These Discussions Are Held Is Critical'

Background and Purpose

Becoming a parent can be an exciting and also challenging transition, particularly for parents who have experienced significant hurt in their own childhoods, and may be experiencing ‘complex trauma.’ Aboriginal and Torres Strait Islander (Aboriginal) people also experience historical trauma. While the parenting transition is an important time to offer support for parents, it is essential to ensure that the benefits of identifying parents experiencing complex trauma outweigh any risks (e.g., stigmatization). This paper describes views of predominantly Aboriginal stakeholders regarding (1) the relative importance of domains proposed for complex trauma assessment, and (2) how to conduct these sensitive discussions with Aboriginal parents.

Setting and Methods

A co-design workshop was held in Alice Springs (Central Australia) as part of an Aboriginal-led community-based participatory action research project. Workshop participants were 57 predominantly Aboriginal stakeholders with expertise in community, clinical, policy and academic settings. Twelve domains of complex trauma-related distress had been identified in existing assessment tools and through community consultation. Using story-telling and strategies to create safety for discussing complex and sensitive issues, and delphi-style methods, stakeholders rated the level of importance of the 12 domains; and discussed why, by whom, where and how experiences of complex trauma should be explored.

Main Findings

The majority of stakeholders supported the importance of assessing each of the proposed complex trauma domains with Aboriginal parents. However, strong concerns were expressed regarding where, by whom and how this should occur. There was greater emphasis and consistency regarding ‘qualities’ (e.g., caring), rather than specific ‘attributes’ (e.g., clinician). Six critical overarching themes emerged: ensuring emotional and cultural safety; establishing relationships and trust; having capacity to respond appropriately and access support; incorporating less direct cultural communication methods (e.g., yarning, dadirri); using strengths-based approaches and offering choices to empower parents; and showing respect, caring and compassion.

Conclusion

Assessments to identify Aboriginal parents experiencing complex trauma should only be considered when the prerequisites of safety, trusting relationships, respect, compassion, adequate care, and capacity to respond are assured. Offering choices and cultural and strengths-based approaches are also critical. Without this assurance, there are serious concerns that harms may outweigh any benefits for Aboriginal parents.

Barriers and enablers for midwives to use the Nursing and Midwifery Board of Australia's Endorsement for scheduled medicines for midwives

BACKGROUND

In 2010, the Nursing and Midwifery Board of Australia introduced a new registration standard: Endorsement for scheduled medicines for midwives. The endorsement enables midwives to provide women with Medicare-rebatable care, prescribe relevant medications, and order relevant Medicare-rebatable diagnostics. Translating endorsement education into clinical midwifery practice has been slow, indicating the presence of barriers affecting midwives' ability to use this standard, despite it increasing their scope for service provision.

AIM

To discover the mechanisms affecting midwives' ability to work to full scope of practice after completing a programme of study leading to endorsement.

METHODS

An observational (non-experimental) design was used. Midwives who had completed an education programme leading to endorsement were invited to complete a survey. Descriptive statistics were used to analyse the quantitative questions and content analysis was conducted on the qualitative data.

FINDINGS

Results indicated that barriers - such as the limitations of Medicare provisions for endorsed midwives and a general lack of support for the role - restrict endorsed midwives' ability to provide quality maternity services. Having some form of support for the role may act as an enabler, in addition to midwives having personal determination and confidence in their ability to use the endorsement. Recommendations to strengthen the endorsed midwife's role include facilitating endorsement use in the public sector, relaxing Medicare Benefit Schedule and Pharmaceutical Benefit Scheme restrictions, raising awareness of the role and scope, and improving midwives' pre-endorsement preparation.

CONCLUSION

This study highlights the need for an all-of-system approach to support and develop the endorsed midwife's role.

The elements of success in a comprehensive state-wide program to safely reduce the rate of preterm birth

Background

In 2014, a whole-of-population and multi-faceted preterm birth prevention program was introduced in Western Australia with the single aim of safely lowering the rate of preterm birth. The program included new clinical guidelines, print and social media, and a dedicated new clinic. In the first full calendar year the rate of preterm birth fell by 7.6% and the reduction extended from the 28–31 week gestational age group upwards.

Objective

The objective of this study was to evaluate outcomes in greater depth and to also include the first three years of the program.

Study design

This was a prospective population-based cohort study of perinatal outcomes in singleton pregnancies before and after commencement of the program.

Results

There was a significant reduction in preterm birth in the tertiary center which extended from 28 weeks gestation onwards and was ongoing. In non-tertiary centers there was an initial reduction, but this was not sustained past the first year. The greatest reduction was observed in pregnancies classified at first attendance as low risk. No benefit was observed in the private sector, but a significant reduction was seen in the remote region of the Kimberley where the program was first launched and vaginal progesterone had been made free-of-charge.

Conclusion

Preterm birth rates can be safely reduced by a multi-faceted and whole-of-population program but the effectiveness requires continuing effort and will be greatest where the strategies are most targeted.