Culturally capable and culturally safe: Caseload care for Indigenous women by Indigenous midwifery students

The Continuity of Care Experience in Australian midwifery education - Where are we heading now?

PROBLEM OR BACKGROUND

The Continuity of Care Experience (CoCE) is a mandated practice-based learning model for all pre-registration midwifery students in Australia. Evidence confirming the value of the learning experience continues to grow, and recommendations for improving the learning model have yet to be addressed using a standardised approach.

AIM

This integrative review provides an updated synthesis of the literature detailing the outcomes of the CoCE as an educational model since a previous review published in 2017.

METHODS

This updated review replicated the methods used in the original review, including the search strategy, screening, extraction, and synthesis of newly identified studies. The results were synthesised to determine alignment with previous themes and identify emerging themes relevant to the midwifery student CoCE.

FINDINGS

Since the original search, 29 additional publications were identified. The themes were consistent with the original review, with the addition of two new themes with five sub-themes, including clarifying the value of CoCE and recommendations to optimise learning.

DISCUSSION

The CoCE's value is increasingly recognised as a critical inclusion in midwifery curricula. Adopting a coordinated approach to integrate the CoCE into core curriculum design, prioritising practice-based learning, and adopting standardised learning objectives and outcomes will overcome challenges and optimise the learning.

CONCLUSION

This updated review confirmed that the CoCE is a unique and valuable learning model that fosters woman-centred care. Implementing the key recommendations from internationally published research can significantly enhance midwifery education and prepare a future workforce capable of providing woman-centred care to improve women's outcomes.

A systematic review of key principles relating to decolonising interventions in midwifery education

PROBLEM

Midwifery education is predominantly influenced by Eurocentric models, contributing to systemic health inequalities for marginalised groups.

BACKGROUND

The health disparities for ethnically diverse maternity service users are well documented. There are various decolonising interventions such as cultural safety education, being implemented to address these disparities by challenging colonial legacies and power imbalances that perpetuate health inequity.

RESEARCH QUESTION

What are the key principles of decolonising interventions in midwifery education, that can be applied to midwifery education on a global scale?

METHODS

This study follows a systematic literature review based on the PRISMA guidelines. Data were sourced from six databases, evaluating peer-reviewed articles between February 2014 and February 2024. The PICO framework guided the research. A thematic synthesis approach was used for data analysis.

FINDINGS

Four major themes emerged: (1) centring Indigenous knowledge, (2) cultural safety, (3) transformative learning, and (4) systemic institutional support. Workshops, yarning circles, and experiential placements were identified as effective mechanisms for promoting cultural safety and addressing discomfort. However, educators often lacked the skills and confidence to implement these changes.

DISCUSSION

Decolonising midwifery education requires ongoing reflexivity, institutional support, and curricula co-design with Indigenous communities. Barriers such as discomfort from participants and inadequate institutional structures must be addressed to ensure long-term impact.

CONCLUSION

Decolonising interventions in midwifery education fosters culturally safe care. However, further research is needed to assess the long-term outcomes on health equity and the impact of such interventions on marginalised communities.

'Mob aren't staying when there's no support': Enablers and barriers of recruitment and retention of First Nations midwifery students - A qualitative study

BACKGROUND

Aboriginal and Torres Strait Islander (hereafter referred to as First Nations) childbearing women report negative experiences from a lack of culturally safe maternity care. Evidence supports improved health outcomes for First Nations women and infants when cared for by First Nations midwives. There are barriers to First Nations students accessing university, particularly nursing and midwifery students, with a lack of evidence exploring the experiences of First Nations midwifery students.

AIM

This study aims to understand the impact of the current strategies to improve recruitment and retention of First Nations midwifery students and identify further innovations.

METHODS

A semi-structured yarning circle was held with six Bachelor of Midwifery students at a university in Queensland, Australia.

FINDINGS

Three key categories emerged: student recruitment, student retention and student success. Enablers included culturally appropriate recruitment, partnerships with other First Nations peoples, incorporating First Nations ways of Knowing, Being, and Doing, culturally safe support, placements and mentorship, and identification and representation. Barriers included financial impacts, experiences of racism and lack of Cultural Safety and humility.

DISCUSSION

Overall, students felt the university provided a culturally safe environment and implemented strategies that supported students' recruitment, retention and success in the degree. They suggested improvements to current strategies and new ideas for implementation.

CONCLUSION

Strategies to improve recruitment and retention of First Nations midwifery students are imperative to close the gap in educational attainment and improve health outcomes for First Nations peoples. These strategies need to be multi-layered, culturally appropriate and implement a whole of university approach.

What are the experiences of Aboriginal and/or Torres Strait Islander midwifery students and midwives? A scoping review

BACKGROUND

Aboriginal and/or Torres Strait Islander midwives are underrepresented within the midwifery workforce and is likely compounded by lower graduate rates. This review is a part of the Midwifery Futures Project. It explores the experiences of Aboriginal and/or Torres Strait Islander midwives and midwifery students to illuminate issues impacting work and study and uncover successful strategies towards addressing current disparities.

METHODS

A scoping review was guided by the Joanna Briggs Institute framework. Literature searching identified 1311 papers. Eleven papers, four qualitative research studies, and seven grey papers met the inclusion criteria: published academic journals, book publishers or key professional organisations; focused on the professional experiences of Aboriginal and/or Torres Strait Islander midwives or the learning experiences; written in English; and published 2004 onwards (inclusive). The papers were analysed using inductive thematic analysis.

RESULTS

Three interconnected themes emerged: connection and kinship, racism and balancing responsibilities.

CONCLUSION

Culture, connection and kinship are foundational in providing experiences for Aboriginal and/or Torres Strait Islander midwives and midwifery students that are clinically and academically transformational, culturally safe and promote resilience for Aboriginal and/or Torres Strait Islander midwives and midwifery students. Midwives and midwifery students need to connect with each other and value working with Aboriginal and/or Torres Strait Islander women, clinicians and academics. Strategies that balance work, study and life responsibilities promote retention and resilience. Clinical, work and study contexts must be culturally safe by respecting and embracing Aboriginal and/or Torres Strait Islander cultures and actively opposing racism in the personal, Community and organisational interfaces.

Development of the essential learning outcomes for the midwifery student continuity of care learning model: A Delphi study

BACKGROUND

In Australia, midwifery students are required to undertake at least ten Continuity of Care Experiences (CoCE) during their education. The learning outcomes of this experience have never been explicit or standardised resulting in inconsistent assessment.

AIM

To develop and identify standardised learning outcomes for the CoCE.

METHODS

A modified Delphi survey was conducted with an expert panel. Intended learning outcome statements were developed, reflecting the learning objectives identified in a previous study. Bloom's taxonomy levels of thinking complexities guided the wording of the outcomes. Participants were asked to rank and rate their level of agreement with each statement over two survey rounds.

FINDINGS

Round one was completed by 32 participants, with 92.5% of the 40 statements reaching consensus. The second round was completed by 23 participants, with 70.7% of the 33 statements reaching consensus. Content analysis of participant comments from each round identified duplicates that were removed and informed refining the wording of some statements. A final set of 15 learning outcomes were agreed upon. The outcomes were broadly grouped within the themes of accountability, advocacy, and autonomy.

DISCUSSION

This study has identified agreed learning outcomes for midwifery students undertaking CoCE. The consensus agreement of experts reinforced the learning model enables the development of woman-centred practice that is underpinned by accountability, advocacy, and autonomy.

CONCLUSION

Purposeful learning outcomes for the CoCE have been developed, informing how the model can be embedded in curricula, guide student learning and assessment to standardise the pedagogy of the model to prepare future midwives.

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.

Advocacy, accountability and autonomy; the learning intention of the midwifery student continuity of care experience

PROBLEM

The Continuity of Care Experience is a mandated inclusion in midwifery education programs leading to registration as a midwife in Australia. The practice-based learning experience has evolved over time, yet there remains no standardised learning intentions, objectives, or outcomes for the model.

AIM

To identify the key learning intentions of the Continuity of Care Experience by an expert panel to support the development of learning outcomes.

METHODS

A descriptive qualitative study with two focus groups were conducted with an expert panel (n = 15). Participants were midwifery education subject matter experts on the Continuity of Care Experience with backgrounds in academia, policy development, curriculum design, accreditation, or clinical education. The discussions were transcribed and thematically analysed.

FINDINGS

Three main themes and six sub-themes describe the learning intentions of the Continuity of Care Experience. The main themes were: (1) advocacy for women; (2) accountability of care; and (3) autonomy in practice.

DISCUSSION

The education model of continuity of care enables students to develop midwifery practice that involves advocating for women, being accountable for their care and being autonomous in practice. We have established that during the experience students practice in partnership with women and are exposed to the full scope of midwifery care. Importantly students learn holistic woman-centred practice.

CONCLUSION

The learning intentions of the Continuity of Care Experience reflects woman-centred practice. Having identified a common understanding of the learning intention, these can now be used to design learning, and assessment, through the development of measurable learning outcomes.

Project20: Maternity care mechanisms that improve (or exacerbate) health inequalities. A realist evaluation

BACKGROUND

Women with low socioeconomic status and social risk factors are at a disproportionate risk of poor birth outcomes and experiences of maternity care. Specialist models of maternity care that offer continuity are known to improve outcomes but underlying mechanisms are not well understood.

AIM

To evaluate two UK specialist models of care that provide continuity to women with social risk factors and identify specific mechanisms that reduce, or exacerbate, health inequalities.

METHODS

Realist informed interviews were undertaken throughout pregnancy and the postnatal period with 20 women with social risk factors who experienced a specialist model of care.

FINDINGS

Experiences of stigma, discrimination and paternalistic care were reported when women were not in the presence of a known midwife during care episodes. Practical and emotional support, and evidence-based information offered by a known midwife improved disclosure of social risk factors, eased perceptions of surveillance and enabled active participation. Continuity of care offered reduced women's anxiety, enabled the development of a supportive network and improved women's ability to seek timely help. Women described how specialist model midwives knew their medical and social history and how this improved safety. Care set in the community by a team of six known midwives appeared to enhance these benefits.

CONCLUSION

The identification of specific maternity care mechanisms supports current policy initiatives to scale up continuity models and will be useful in future evaluation of services for marginalised groups. However, the specialist models of care cannot overcome all inequalities without improvements in the maternity system as a whole.

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.

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.

'Continuity of Care Experiences' within pre-registration midwifery education programs: A scoping review

BACKGROUND

Midwifery is based on the philosophy of woman-centred care. The continuity of care experience in pre-registration education programs exemplifies this philosophy. Wide variation in how education providers implement 'Continuity of Care Experiences' into their programs of study can challenge this valuable learning opportunity.

AIM

To provide a comprehensive analysis of the governance and empirical evidence of knowledge, practice and enablers to support continuity of care experiences within pre-registration midwifery education.

METHOD

A scoping review of research, policy and professional documents pertaining to the continuity of care experience in pre-registration education programs was conducted with 46 articles meeting the inclusion criteria.

FINDINGS

Several factors were identified that support the implementation, facilitation and evaluation of the continuity of care experience within pre-registration midwifery education. These include: a woman-centred model of maternity care; enabling midwifery students and women to develop 'relational continuity'; tripartite support models; optimising the sequencing of these experiences within the program and, woman-led evaluations of student performance. There was little consensus regarding the pedagogical intent and, therefore, an inability to clearly define and measure the learning outcomes of the continuity of care experience.

CONCLUSION

In countries where the predominant model of maternity care is fragmented and not woman-centred, further research is required to understand the pedagogical intent of the continuity of care experience.

The experiences of Aboriginal and Torres Strait Islander Bachelor of Midwifery students: An integrative literature review

ISSUE

There is an underrepresentation of Aboriginal and Torres Strait Islander midwives across Australia and an inadequate number of graduating midwives to redress this. A major pillar for the Birthing on Country Model is maternity care workforce development.

AIM

The purpose of this review is to examine the enablers and barriers that Aboriginal students experience while undertaking the Bachelor of Midwifery degree in Australia.

METHODS

A search of the literature was undertaken through electronic databases. When only three papers were found looking at the experiences of Aboriginal midwifery students the search was broadened to include Aboriginal undergraduate health students.

FINDINGS

The literature review reported a strong need for cultural safety in both the clinical and education systems. Students with access to cultural supports, relationships with Aboriginal mentors and academics and Aboriginal clinical placements felt empowered and were able to navigate the 'two worlds' in a meaningful way.

DISCUSSION

This review highlights a significant gap in the literature. Despite the expanded search terms to include Aboriginal health students, a relatively narrow range of papers were found. Interestingly, the combined search revealed similar themes: kinship, personal factors, and cultural issues.

CONCLUSION

Empowering and supporting Aboriginal Peoples to become midwives is essential. While systems and societies aim for cultural safety, this review shows there is still a way to go. Further research is essential to decolonise higher education and health care systems, and provide strong, well supported pathways for Aboriginal midwifery students.

Graduating midwifery students' preferred model of practice and first job decisions: A qualitative study

OBJECTIVES

To explore and describe the preferred model of practice and first job decisions of final stage midwifery students from three Western Australian universities.

DESIGN

Qualitative descriptive.

SETTING

Three Western Australian (WA) universities offering courses leading to registration as a midwife.

PARTICIPANTS

Twenty-seven midwifery students from undergraduate and postgraduate (pre-registration) courses.

METHODS

Data were collected from recorded interviews and focus groups. Thematic analysis of interview transcripts was used to identify commonalities. Data saturation guided when recruitment ceased and final sample size was achieved.

FINDINGS

Participants' preferred model of maternity care was influenced by learning about and witnessing both autonomous midwifery practice and collaborative care during their studies. The greatest influence was clinical experience, with most preferring a continuity of midwifery model (CoM) but first consolidating their practice in a public hospital. Most students reported that they would not choose a private hospital as their first option. Work/life balance was also considered, with some accepting that family commitments and a need to work close to home may prevent them from choosing a CoM model.

CONCLUSION AND IMPLICATIONS

Although many Australian midwifery students start their midwifery course with preconceived ideology of their eventual workplace, the influences of their educators, clinical placement environment, preceptors and continuity of care experience relationships with women helped determine their final direction. To provide students with the experiences to become woman-centred autonomous practitioners it is important for universities and all maternity care providers to carefully consider their responsibility in how they influence midwifery students in education and practice.

Evaluation of a student-led midwifery group practice: A woman's perspective

BACKGROUND

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OBJECTIVE

To evaluate women's experiences of a student-led midwifery group practice.

DESIGN

A mixed methods design was used to examine women's experiences and level of satisfaction about a student-led midwifery model of care. An on-line survey elucidated women's levels of satisfaction and experiences with the student-led midwifery group practice. The online survey was sent to all women (n = 25) who were receiving care from third year Bachelor of Midwifery students in 2018 via email up to 6 weeks postnatally. The online survey was distributed in the first instance to obtain baseline information about the importance of this student-led midwifery group practice and so the survey information was linked to the in-depth interview in the analysis for the purpose of identifying if the women were primiparous or multiparous. Women (n = 9) were invited to participate in an in-depth interview by self-opting on the survey and this extra data provided a richer understanding about the level of satisfaction about woman-centred care led by midwifery students. Retrospective data were also collected from the Maternity database - E-Maternity about birth outcomes.

SETTING

A tertiary teaching public hospital in New South Wales (NSW).

PARTICIPANTS

Fifteen women participated in an online survey. Five primiparous and four multiparous women opted to be involved in the in-depth interviews on the online survey.

MEASUREMENTS AND FINDINGS

Analysis in SPSS provided descriptive statistics including frequencies and percentages of data including birth outcomes. Simple correlations enabled associations to be established between levels of satisfaction, individualised care, quality of care, benefits and anxiety during pregnancy. The overarching themes from the qualitative findings identified the students' presence for the women as the most important component of the women's journey. The four main themes that emerged from the study included: familiarity of the caregiver, staying informed on the journey, feeling supported and reassured by their expertise, and control and decisions over birth events.

KEY CONCLUSIONS

For a variety of reasons, women valued the presence of the students throughout their childbearing journey, including valuing the woman's private space during labour and her time with her partner. This combination of pedagogical approaches provides an alternative to the current placement approach, which includes working shifts in all areas of maternity. This approach will better support midwifery students to achieve the skills necessary to provide a continuity of care experience (CoCE) amongst a small team by a student-led midwifery group practice that is supported by a registered midwife in the antenatal clinic. The midwifery student is able to develop a relationship with the woman as a component of the CoCE under the guidance of a registered midwife and this is an important underpinning of the philosophy of woman-centred care.

IMPLICATIONS FOR PRACTICE

This model of care provides evidence that women do value the students' support and presence throughout their experience and that the benefits of this model should be offered to all women as a normal component of their midwifery care.

Evaluating awareness of Cultural Safety in the Australian midwifery workforce: A snapshot

PROBLEM

There are no validated tools to measure midwives' awareness of Cultural Safety.

BACKGROUND

Cultural Safety is an important component of midwifery practice. Measurement can inform practice and evaluate professional development strategies.

AIM

To adapt and evaluate the Awareness of Cultural Safety Scale with the midwifery workforce.

METHODS

An online survey was distributed to members of Australian College of Midwives and Congress of Aboriginal and Torres Strait Islander Nurses and Midwives. Measures included the Awareness of Cultural Safety Scale - Revised, Self-assessment of Cultural Knowledge and Perceptions of Racism scales.

FINDINGS

The revised Awareness scale had a Cronbach's alpha of 0.87. Principal Component Analysis with varimax rotation produced a three-factor structure accounting for 67% of variance. Awareness scores correlated with Self-assessment of Cultural Knowledge (r=0.22 p<0.03) and Perceptions of Racism (r=0.62 p<0.001) scales. Educators scored significantly higher on awareness compared to clinicians (t (1,80)=-3.09, p=0.003). Perceptions of Racism predicted Awareness of Cultural Safety scores (F (2,87) 29.25, adjusted r square=0.39 p<0.001 95% Confidence Interval=1.09, 1.93).

DISCUSSION

The revised scale was a reliable and valid measure of Cultural Safety across a diverse sample of midwives. Midwives working in education settings have a higher awareness of Cultural Safety than clinical peers.

CONCLUSION

The Awareness of Cultural Safety Scale can be used with midwives across practice settings. Professional organisations and education providers need to promote the professional responsibilities of midwives towards Cultural Safety in clinical practice and education.

Cultural security in the perinatal period for Indigenous women in urban areas: a scoping review

BACKGROUND

Culturally secure care is considered foundational for good perinatal outcomes for Indigenous women. It is unknown what literature reports on whether Indigenous women giving birth in urban areas receives appropriate cultural care. The aim of this scoping review was to examine and summarise relevant evidence which reports on culturally secure care for Indigenous women using urban maternity services at any time during the perinatal period.

METHODS

Ten journal databases plus grey literature and theses databases were searched for relevant material dated 1986-2018. Articles were included if they were about Indigenous women from Australia, New Zealand, Canada or the USA; care was provided anytime during the perinatal period, in an urban area; and cultural security (or variations of this term) were used.

RESULTS

6856 titles and abstracts were screened, of these: 25 studies, 15 grey literature documents and 9 theses matched the search criteria. Studies were mostly qualitative (13/25) and from Australia (18/25). Studies showed women's access to and experiences of culturally secure maternity care in urban areas as variable. The grey literature originated from Australia (8/15); New Zealand (4/15); and Canada (3/15); while theses were from Canada (7/9) and Australia (2/9).

CONCLUSION

The scoping review results showed substantial qualitative evidence on Indigenous women's experience during the perinatal period in urban areas. In-depth analysis of these studies is required to inform future practice and policy on what works and what needs improvement. Culturally secure midwifery care shows promising results.

Implementing Birthing on Country services for Aboriginal and Torres Strait Islander families: RISE Framework

BACKGROUND

Birthing on Country is an international movement to return maternity services to First Nations communities and community control for improved health and wellbeing.

QUESTION

How can we implement Birthing on Country services for Aboriginal and/or Torres Strait Islander families across Australia?

METHODS

We have developed a framework from theoretical, policy and research literature on Birthing on Country; Aboriginal and Torres Strait Islander voices from across Australia; reviews exploring programs that have improved outcomes for Indigenous mothers and infants; and the retrospective synthesis of learnings from two empirical studies that have redesigned maternal infant health services and improved outcomes for Aboriginal and Torres Strait Islander families.

RESULTS

The RISE Framework has four pillars to drive important reform: (1) Redesign the health service; (2) Invest in the workforce; (3) Strengthen families; and, (4) Embed Aboriginal and/or Torres Strait Islander community governance and control. We present the evidence base for each pillar and practical examples of moving from the standard 'western' model of maternity care towards Birthing on Country services.

CONCLUSIONS

Application of the RISE framework to plan, develop and monitor Birthing on Country services is likely to result in short and long-term health gains for Aboriginal and Torres Strait Islander families.

Establishing teams aiming to provide culturally safe maternity care for Indigenous families

PROBLEM

It is not well known how to prepare new multidisciplinary teams aiming to provide culturally safe maternity care for Aboriginal and Torres Strait Islander families in an urban setting.

BACKGROUND

National policies recommend increasing the Aboriginal and Torres Strait Islander workforce and cultural competencies of the non-Indigenous workforce as key drivers of culturally safe care.

QUESTION

What are the key learnings from staff experiences establishing multidisciplinary teams aiming to provide culturally safe maternity care that aims to privilege Indigenous ways of knowing, being and doing?

METHODS

As part of a larger participatory action research project, semi-structured qualitative interviews were conducted December 2014-April 2015 with 21 Aboriginal and Torres Strait Islander and non-Indigenous healthcare staff. Thematic analysis was used to identify learnings for practice.

FINDINGS

Four key learnings were identified for forming new teams aiming to provide culturally safe care: (a) having a shared understanding of what characterises cultural safety in the local program context; (b) understanding and valuing different roles and knowledges people bring to the team; (c) acknowledging the influence of race and culture on staff behaviour; and (d) acting on individual and organisational responsibilities for continuous improvement towards cultural safety.

DISCUSSION

We present recommendations from our participatory action research approach to respond to these learnings in practice.

CONCLUSION

A deliberate workforce investment at the early stages of team development is crucial when aiming to provide culturally safe maternity care that can respond to the unique needs of Aboriginal and Torres Strait Islander women and families.

Beyond enrolments: a systematic review exploring the factors affecting the retention of Aboriginal and Torres Strait Islander health students in the tertiary education system

BACKGROUND

Indigenous Australians are under-represented in the health workforce, with large disparities between rates of Indigenous and non-Indigenous people in every health profession, including nurses, medical practitioners and all allied health professionals. Yet Indigenous people have long requested to have Indigenous practitioners involved in their health care, with this increasing the likelihood of culturally safe care. To address the shortage of Indigenous health professionals, it is important to not only recruit more Indigenous people into health courses, but also to support them throughout their studies so that they graduate as qualified health professionals. The aim of this systematic literature review was two-fold: to identify the factors affecting the retention of Indigenous students across all tertiary health disciplines, and to identify strategies that support Indigenous students to remain with, and successfully complete, their studies.

METHODS

Eight electronic databases were systematically searched between July and September 2018. Articles were screened for inclusion using pre-defined criteria and assessed for quality using the Mixed Methods Assessment Tool and the Joanna Briggs Institute Checklist for Text and Opinion.

RESULTS

Twenty-six articles met the criteria for inclusion. Key factors reported by students as affecting retention were: family and peer support; competing obligations; academic preparation and prior educational experiences; access to the Indigenous Student Support Centre; financial hardship; and racism and discrimination. The most successful strategies implemented by nursing, health and medical science faculties to improve retention were multi-layered and included: culturally appropriate recruitment and selection processes; comprehensive orientation and pre-entry programs; building a supportive and enabling school culture; appointing Indigenous academics; embedding Indigenous content throughout the curriculum; developing mentoring and tutoring programs; flexible delivery of content; partnerships with the Indigenous Student Support Centre; providing social and financial support; and 'leaving the university door open' for students who leave before graduation to return.

CONCLUSIONS

Universities have an important role to play in addressing inequities in the Indigenous health workforce. A suite of measures implemented concurrently to provide support, starting with recruitment and pre-entry preparation programs, then continuing throughout the student's time at university, can enable talented Indigenous people to overcome adversities and graduate as health professionals.

Participatory action research opens doors: Mentoring Indigenous researchers to improve midwifery in urban Australia

PROBLEM

There is increasing demand for capacity building among the Aboriginal and Torres Strait Islander (Indigenous) maternal and infant health workforce to improve health outcomes for mothers and babies; yet few studies describe the steps taken to mentor novice Indigenous researchers to contribute to creating a quality evidence-base in this space.

BACKGROUND

The Indigenous Birthing in an Urban Setting study is a partnership project aimed at improving maternity services for Indigenous families in South East Queensland.

AIM

To describe our experience setting up a Participatory Action Research team to mentor two young Indigenous women as research assistants on the Indigenous Birthing in an Urban Setting study.

METHODS

Case study reflecting on the first six months.

FINDINGS

Participatory Action Research was a very effective method to actively mentor and engage all team members in reflective, collaborative research practice, resulting in positive changes for the maternity care service. The research assistants describe learning to conduct interviews and infant assessments, as well as gaining confidence to build rapport with families in the study. Reflecting on the stories shared by the women participating in the study has opened up a whole new world and interest in studying midwifery and child health after learning the difficulties and strengths of families during pregnancy and beyond.

DISCUSSION

We encourage others to use Participatory Action Research to enable capacity building in the Aboriginal and Torres Strait Islander midwifery workforce and in health research more broadly.

Emotional labour and aboriginal maternal infant care workers: The invisible load

BACKGROUND

The term 'emotional labour' has been used to describe the competing demands on midwives to empathize with clients whilst maintaining a level of professional detachment. Previous research indicates that when individuals experience difficulty managing these emotions, burnout may result. Aboriginal health care workers often have roles with large emotional demands, as they are relied upon heavily to engage clients in care. However, the concept of emotional labour has received little attention in relation to this group.

AIM

To explore potential sources of emotional labour for Aboriginal Maternal Infant Care workers in a maternity care program for Aboriginal women in South Australia. The program involves these workers providing care for women in partnership with midwives.

METHODS

We employed a phenomenological approach. Thirty in-depth interviews were conducted with staff and clients of the program. Recorded interviews were transcribed and coded and emerging themes identified.

FINDINGS

This workforce undertakes extensive emotional labour. Key sources include the cultural and family obligations they have to clients, complex social needs of many clients, and potential for community backlash when poor perinatal outcomes occur. A lack of respect for the role within the workplace further contributes to these experiences.

CONCLUSION

This study found that the responsibilities inherent to the role as both cultural broker and carer create significant emotional labour for workers. Recommendations to address this and enhance the sustainability of this workforce include: recognition and valuing of emotional work by management and other staff, enhancing cultural awareness training, and building stress-relieving activities into the workplace.

Improving maternity services for Indigenous women in Australia: moving from policy to practice

The well established disparities in health outcomes between Indigenous and non-Indigenous Australians include a significant and concerning higher incidence of preterm birth, low birth weight and newborn mortality. Chronic diseases (eg, diabetes, hypertension, cardiovascular and renal disease) that are prevalent in Indigenous Australian adults have their genesis in utero and in early life. Applying interventions during pregnancy and early life that aim to improve maternal and infant health is likely to have long lasting consequences, as recognised by Australia's National Maternity Services Plan (NMSP), which set out a 5-year vision for 2010-2015 that was endorsed by all governments (federal and state and territory). We report on the actions targeting Indigenous women, and the progress that has been achieved in three priority areas: The Indigenous maternity workforce; Culturally competent maternity care; and; Developing dedicated programs for "Birthing on Country". The timeframe for the NMSP has expired without notable results in these priority areas. More urgent leadership is required from the Australian government. Funding needs to be allocated to the priority areas, including for scholarships and support to train and retain Indigenous midwives, greater commitment to culturally competent maternity care and the development and evaluation of Birthing on Country sites in urban, rural and particularly in remote and very remote communities. Tools such as the Australian Rural Birth Index and the National Maternity Services Capability Framework can help guide this work.