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

Lifestyle and sociodemographic risk factors for stillbirth by region of residence in South Australia: a retrospective cohort study

BACKGROUND

Stillbirth rates remain a global priority and in Australia, progress has been slow. Risk factors of stillbirth are unique in Australia due to large areas of remoteness, and limited resource availability affecting the ability to identify areas of need and prevalence of factors associated with stillbirth. This retrospective cohort study describes lifestyle and sociodemographic factors associated with stillbirth in South Australia (SA), between 1998 and 2016.

METHODS

All restigered births in SA between 1998 ad 2016 are included. The primary outcome was stillbirth (birth with no signs of life ≥ 20 weeks gestation or ≥ 400 g if gestational age was not reported). Associations between stillbirth and lifestyle and sociodemographic factors were evaluated using multivariable logistic regression and described using adjusted odds ratios (aORs).

RESULTS

A total of 363,959 births (including 1767 stillbirths) were included. Inadequate antenatal care access (assessed against the Australian Pregnancy Care Guidelines) was associated with the highest odds of stillbirth (aOR 3.93, 95% confidence interval (CI) 3.41-4.52). Other factors with important associations with stillbirth were plant/machine operation (aOR, 1.99; 95% CI, 1.16-2.45), birthing person age ≥ 40 years (aOR, 1.92; 95% CI, 1.50-2.45), partner reported as a pensioner (aOR, 1.83; 95% CI, 1.12-2.99), Asian country of birth (aOR, 1.58; 95% CI, 1.19-2.10) and Aboriginal/Torres Strait Islander status (aOR, 1.50; 95% CI, 1.20-1.88). The odds of stillbirth were increased in regional/remote areas in association with inadequate antenatal care (aOR, 4.64; 95% CI, 2.98-7.23), birthing age 35-40 years (aOR, 1.92; 95% CI, 1.02-3.64), Aboriginal and/or Torres Strait Islander status (aOR, 1.90; 95% CI, 1.12-3.21), paternal occupations: tradesperson (aOR, 1.69; 95% CI, 1.17-6.16) and unemployment (aOR, 4.06; 95% CI, 1.41-11.73).

CONCLUSION

Factors identified as independently associated with stillbirth odds include factors that could be addressed through timely access to adequate antenatal care and are likely relevant throughout Australia. The identified factors should be the target of stillbirth prevention strategies/efforts. SThe stillbirth rate in Australia is a national concern. Reducing preventable stillbirths remains a global priority.

"Safe, connected, supported in a complex system." Exploring the views of women who had a First Nations baby at one of three maternity services offering culturally tailored continuity of midwife care in Victoria, Australia. A qualitative analysis of free-text survey responses

BACKGROUND

In Australia, continuity of midwife care is recommended for First Nations women to address the burden of inequitable perinatal outcomes experienced by First Nations women and newborns.

AIMS

This study aimed to explore the experiences of women having a First Nations baby who received care at one of three maternity services in Naarm (Melbourne), Victoria, where culturally tailored midwife continuity models had been implemented.

METHODS

Women having a First Nations baby who were booked for care at one of three study sites were invited to participate in an evaluation of care. Thematic analysis was used to analyse qualitative data from responses to free-text, open ended questions that were included in a follow-up questionnaire at 3-6 months after the birth.

RESULTS

In total, 213 women (of whom 186 had continuity of midwife care) participated. The global theme for what women liked about their care was 'Safe, connected, supported' including emotional and clinical safety, having a known midwife and being supported 'my way'. The global theme for what women did not like about their care was 'A complex, fragmented and unsupportive system' including not being listened to, things not being explained, and a lack of cultural safety.

CONCLUSIONS

Culturally tailored caseload midwifery models appear to make maternity care feel safer for women having a First Nations baby, however, the mainstream maternity care system remained challenging for some. These models should be implemented for First Nations women, and evidence-based frameworks, such as the RISE framework, should be used to facilitate change.

Looking after bubba for all our mob: Aboriginal and Torres Strait Islander community experiences and perceptions of stillbirth

The stillbirth rate among Aboriginal and Torres Strait Islander women and communities in Australia is around double that of non-Indigenous women. While the development of effective prevention strategies during pregnancy and improving care following stillbirth for women and families in communities has become a national priority, there has been limited progress in stillbirth disparities. With community permission, this study aimed to gain a better understanding of community experiences, perceptions, and priorities around stillbirth. We undertook an Indigenous researcher-led, qualitative study, with community consultations guided by a cultural protection protocol and within an unstructured research framework. A total of 18 communities were consulted face-to-face through yarning interviews, focus groups and workshops. This included 54 community member and 159 health professional participants across remote, regional, and urban areas of Queensland, Western Australia, Victoria, South Australia, and Northern Territory. Thematic analysis of consultation data identified common themes across five focus/priority areas to address stillbirth: Stillbirth or Sorry Business Baby care needs to be family-centered; using Indigenous "ways of knowing, being, and doing" to ensure cultural safety; application of Birthing on Country principles to maternal and perinatal care; and yarning approaches to improve communication and learning or education. The results underscore the critical need to co-design evidence-based, culturally appropriate, and community-acceptable resources to help reduce existing disparities in stillbirth rates.

Enabling the context for Aboriginal and Torres Strait Islander Community Controlled Birthing on Country services: Participatory action research

PROBLEM

Establishment of Birthing on Country services owned and governed by Aboriginal and Torres Strait Islander Community Controlled Health Services has been slow.

BACKGROUND

Birthing on Country services have demonstrated health and cost benefits and require redesign of maternity care. During the Building On Our Strengths feasibility study, use of endorsed midwives and licensing of birth centres has proven difficult.

QUESTION

What prevents Community Controlled Health Services from implementing Birthing on Country services in Queensland and New South Wales?

METHODS

Participatory action research identified implementation barriers. We conducted iterative document analysis of instruments to inform government lobbying through synthesis of policy, economic, social, technological, legal, and environmental factors.

FINDINGS

Through cycles of participatory action research, we analysed 17 documents: 1) policy barriers prevent Community Controlled Health Services from employing endorsed midwives to provide intrapartum care in public hospitals; 2) economic barriers include lack of sustainable funding stream and inadequate Medicare-billing for endorsed midwives; and 3) legal barriers require a medical practitioner in a birth centre. While social barriers (e.g., colonisation, medicalisation) underpin regulations, these were beyond the scope; technological and environmental barriers were not identified.

DISCUSSION

Findings are consistent with the literature on barriers to midwifery practice. Recommendations include a national audit of barriers to Birthing on Country services including healthcare practice insurance, and development of a funding stream. Additionally, private maternity facility regulation must align with evidence on safe birth centre operation.

CONCLUSION

Government can address barriers to scale-up of Aboriginal and Torres Strait Islander Community Controlled Birthing on Country services.

Exploring satisfaction among women having a First Nations baby at one of three maternity hospitals offering culturally specific continuity of midwife care in Victoria, Australia: A cross-sectional survey

BACKGROUND

Continuity of midwife care is recommended to redress the inequitable perinatal outcomes experienced by Aboriginal and Torres Strait Islander (First Nations) mothers and babies, however more evidence is needed about First Nations women's views and experiences of their care.

AIMS

This study aimed to explore levels of satisfaction among women having a First Nations baby, who received maternity care at one of three maternity services, where new culturally specific midwife continuity models had been recently implemented.

METHODS

Women having a First Nations baby who were booked for care at one of three study sites in Naarm (Melbourne), Victoria, were invited to complete one questionnaire during pregnancy and then a follow up questionnaire, 3 months after the birth.

RESULTS

Follow up questionnaires were completed by 213 women, of whom 186 had received continuity of midwife care. Most women rated their pregnancy (80 %) and labour and birth care (81 %) highly ('6 or '7' on a scale of 1-7). Women felt informed, that they had an active say in decisions, that their concerns were taken seriously, and that the midwives were kind, understanding and there when needed. Ratings of inpatient postnatal care were lower (62 %), than care at home (87 %).

CONCLUSIONS

Women having a First Nations baby at one of three maternity services, where culturally specific, continuity of midwife care models were implemented reported high levels of satisfaction with care. It is recommended that these programs are upscaled, implemented and sustained.

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.

Culturally Safe Neonatal Care: Talking With Health Practitioners Identified as Champions by Indigenous Families

The burden of health inequities borne by Indigenous peoples can be overwhelming, especially when mothers and newborns' lives are at stake and health services seem slow to invest in responsiveness. In Aotearoa (New Zealand), urgent action is required to eliminate persistent systemic inequities for Māori (Indigenous) whānau (family collectives that extend beyond the household). This Kaupapa Māori (by Māori, for Māori) qualitative study aimed to explore the views of health practitioners identified as champions by whānau of preterm Māori infants. Ten health practitioners were interviewed and asked about their involvement with the whānau, their role in explanations and communication, and their thoughts on whānau coping. Interview data were analysed using interpretative phenomenological analysis. Three superordinate themes were identified: working together in partnership, a problem shared is a problem halved, and sacred space. Collaboration between health practitioners and with whānau was important to the champions and central to their goal of enabling whānau autonomy. This was built on a foundation of connectivity, relationships, and a full appreciation that childbirth is a sacred time that is potentially disrupted when an infant is born prematurely. The values- and relationship-based practices of these champions protected and uplifted whānau. They showed that health practitioners have important roles in both the elimination of inequities and the sustaining of Māori self-determination. This championship is an exemplar of what culturally safe care looks like in day-to-day practice with Māori and is a standard that other health practitioners should be held to.

Factors influencing infant feeding for Aboriginal and Torres Strait Islander women and their families: a systematic review of qualitative evidence

BACKGROUND

Breastfeeding provides all the necessary energy and nutrients for an infant and provides many benefits for mothers and babies. The effects of colonisation have contributed to reduced prevalence and duration of breastfeeding among Australian Aboriginal women and widespread use of infant formula as a substitute for breastmilk. This review aimed to synthesise qualitative evidence about the factors that influence breastfeeding and infant feeding practices of Aboriginal and Torres Strait Islander women and their families.

METHODS

MEDLINE, CINAHL, Informit and Google Scholar were systematically searched for qualitative studies that included the perspective of Aboriginal and Torres Strait Islander women and their families about the factors influencing infant feeding decisions. Included studies were appraised using an Indigenous quality assessment tool and were synthesised via inductive thematic analysis informed by an ecological framework.

RESULTS

The search identified 968 studies with 7 meeting the inclusion criteria. Key factors influencing breastfeeding and infant feeding practices of Aboriginal women included cultural practices, normalisation of bottle feeding, shame associated with breastfeeding in public, access to culturally safe nutrition education, support services and health professionals, family/partner support, knowledge of the benefits of breastfeeding, experiences with previous babies and concern that the baby was not getting enough milk.

CONCLUSION

The perspectives of Aboriginal and Torres Strait Islander women must be considered when providing breastfeeding and infant feeding advice. This can be achieved through Aboriginal and Torres Strait Islander people designing, implementing, and leading the delivery of education and information regarding breastfeeding and health infant feeding practices that have been influenced by the priorities of Aboriginal and Torres Strait Islander communities.

Trust, privacy, community, and culture: Important elements of maternity care for Aboriginal and Torres Strait Islander women giving birth in Victoria

BACKGROUND

The Australian maternity system must enhance its capacity to meet the needs of Aboriginal and Torres Strait Islander (First Nations) mothers and babies, however evidence regarding what is important to women is limited.

AIMS

The aim of this study was to explore what women having a First Nations baby rate as important for their maternity care as well as what life stressors they may be experiencing.

METHODS

Women having a First Nations baby who booked for care at one of three urban Victorian maternity services were invited to complete a questionnaire.

RESULTS

343 women from 76 different language groups across Australia. Almost one third of women reported high levels of psychological distress, mental illness and/or were dealing with serious illness or death of relatives or friends. Almost one quarter reported three or more coinciding life stressors. Factors rated as most important were privacy and confidentiality (98 %), feeling that staff were trustworthy (97 %), unrestricted access to support people during pregnancy appointments, (87 %) birth (66 %) and postnatally (75 %), midwife home visits (78 %), female carers (66 %), culturally appropriate artwork, brochures (68 %) and access to Elders (65 %).

CONCLUSIONS

This study provides important information about what matters to women who are having a First Nations baby in Victoria, Australia, bringing to the forefront social and cultural complexities experienced by many women that need to be considered in programme planning. It is paramount that maternity services partner with First Nations communities to implement culturally secure programmes that respond to the needs of local communities.

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).

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.

First Nations doulas: Training needs and industry support in the Top End, Northern Territory, Australia

PROBLEM AND BACKGROUND

First Nations doulas offer an innovative approach for strengthening capacity and increasing the Australian First Nations maternity workforce to improve access to services that produce optimal outcomes. Currently, there is no published evidence on the training needs and health sector industry support for developing a First Nations doula workforce.

QUESTION/AIM

In the context of the 'Top End,' Northern Territory, Australia, the aim of this article is to document Industry feedback on the training needs and support for developing a First Nations doula workforce.

METHODS

Ten purposively recruited Industry representatives participated in a facilitated workshop using the Kaospiolit Vision Backcasting education design tool.

FINDINGS

Participants identified and reached consensus on almost all the underpinning skills, knowledge, mindset, and attitudes required to work as a First Nations doula. Overall participants indicated strong Industry appetite and support for formally developing the doula role.

DISCUSSION

There was participant consensus that accredited doula training would be a 'game-changer', addressing inadequacies and inequities in NT's reproductive and maternal health services for remote-living First Nations women.

CONCLUSION

More research is required to explore First Nations doula practice in addressing perinatal inequities and workforce issues. Investigation is required to identify funding and appropriate workforce models.

Nursing in a different world: Remote area nursing as a specialist-generalist practice area

OBJECTIVE

Remote area nurses provide primary health care services to isolated communities across Australia. They manage acute health issues, chronic illness, health promotion and emergency responses. This article discusses why their generalist scope of practice should be formally recognised as a specialist nursing practice area.

DESIGN

Constructivist grounded theory, using telephone interviews (n = 24) with registered nurses and nurse practitioners.

SETTING

Primary health care clinics, in communities of 150-1500 residents across Australia.

PARTICIPANTS

A total of 24 nurses participated in this study.

RESULTS

Nurses' perceived their clinical knowledge and skill as insufficient for the advanced, generalist, scope of practice in the remote context, especially when working alone. Experience in other settings was inadequate preparation for working in remote areas. Knowledge and skill developed on the job, with formal learning, such as nurse practitioner studies, extending the individual nurse's scope of practice to meet the expectations of the role, including health promotion.

CONCLUSION

Remote area nursing requires different knowledge and skills from those found in any other nursing practice setting. This study supports the claim that remote area nursing is a specialist-generalist role and presents a compelling case for further examination of the generalist education and support needs of these nurses. Combined with multidisciplinary collaboration, developing clinical knowledge and skill across the primary health care spectrum increased the availability of health resources and subsequently improved access to care for remote communities. Further research is required to articulate the contemporary scope of practice of remote area nurses to differentiate their role from that of nurse practitioners.

Study protocol: primary healthcare transformation through patient-centred medical homes-improving access, relational care and outcomes in an urban Aboriginal and Torres Strait Islander population, a mixed methods prospective cohort study

INTRODUCTION

For over 40 years, Aboriginal and Torres Strait Islander Community-Controlled Health Services (ACCHS) in Australia have led strategic responses to address the specific needs of Aboriginal and Torres Strait Islander populations. Globally, there has been rapid growth in urban Indigenous populations requiring an adaptive primary healthcare response. Patient-centred medical homes (PCMH) are an evidenced-based model of primary healthcare suited to this challenge, underpinned by principles aligned with the ACCHS sector-relational care responsive to patient identified healthcare priorities. Evidence is lacking on the implementation and effectiveness of the PCMH model of care governed by, and delivered for, Aboriginal and Torres Strait Islander populations in large urban settings.

METHOD AND ANALYSIS

Our multiphased mixed-methods prospective cohort study will compare standard care provided by a network of ACCHS to an adapted PCMH model of care. Phase 1 using qualitative interviews with staff and patients and quantitative analysis of routine primary care health record data will examine the implementation, feasibility and acceptability of the PCMH. Phase 2 using linked survey, primary care and hospitalisation data will examine the impact of our adapted PCMH on access to care, relational and quality of care, health and wellbeing outcomes and economic costs. Phase 3 will synthesise evidence on mechanisms for change and discuss their implications for sustainability and transferability of PCMHs to the broader primary healthcare system ETHICS AND DISSEMINATION: This study has received approval from the University of Queensland Human Research Ethics Committee (2021/HE00529). This research represents an Aboriginal led and governed partnership in response to identified community priorities. The findings will contribute new knowledge on how key mechanisms underpinning the success and implementation of the model can be introduced into policy and practice. Study findings will be disseminated to service providers, researchers, policymakers and, most importantly, the communities themselves.

Respectful Maternity Care in South Asia: What Does the Evidence Say? Experiences of Care and Neglect, Associated Vulnerabilities and Social Complexities

Background

Respectful maternity care encompasses the right to continuity of care and dignified support for women during the reproductive period, enabling informed choice. However, the evidence is limited in the context of South Asia region where maternal, perinatal and newborn mortality is still a critical challenge to health systems. Evidence is required to better understand the context of respectful maternity care to inform directions for appropriate policy and practice.

Objective

The objective of this scoping review was to explore facilitators and barriers of respectful maternity care practice in South Asia.

Design

CINAHL, EMBASE, PubMed, Medline, SCOPUS and Cochrane databases were used to identify related studies. Data were systematically synthesized and analysed thematically.

Findings

There was considerable heterogeneity in the 61 included studies from seven South Asian countries, with most of the research conducted in Nepal and India. While the experience of abuse and neglect was common, 10 critical themes emerged related to neglected choices and compromised quality of care (particularly where there were health inequities) in the context of institutional care experiences; and the imperative for improved investment in training and significant policy and legislative change to enforce equitable and respectful maternity care practice.

Conclusions and Implications for Practice

Evidence about respectful maternity care in South Asia indicates that women accessing professional and facility-based services experienced high levels of disrespect, abuse and maltreatment. Women from vulnerable, socially disadvantaged and economically poor backgrounds were more likely to experience higher level abuse and receive poor quality of care. There is an urgent need for a well-resourced, sustained commitment to mandate and support the provision of respectful and equitable maternity care practice in South Asia.

Supporting Aboriginal and Torres Strait Islander Families to Stay Together from the Start (SAFeST Start): Urgent call to action to address crisis in infant removals

Reducing the rate of over-representation of Aboriginal and Torres Strait Islander children in out-of-home care (OOHC) is a key Closing the Gap target committed to by all Australian governments. Current strategies are failing. The "gap" is widening, with the rate of Aboriginal and Torres Strait Islander children in OOHC at 30 June 2020 being 11 times that of non-Indigenous children. Approximately, one in five Aboriginal and Torres Strait Islander children entering OOHC each year are younger than one year. These figures represent compounding intergenerational trauma and institutional harm to Aboriginal and Torres Strait Islander families and communities. This article outlines systemic failures to address the needs of Aboriginal and Torres Strait Islander parents during pregnancy and following birth, causing cumulative harm and trauma to families, communities and cultures. Major reform to child and family notification and service systems, and significant investment to address this crisis, is urgently needed. The Family Matters Building Blocks and five elements of the Aboriginal and Torres Strait Islander Child Placement Principle (Prevention, Participation, Partnership, Placement and Connection) provide a transformative foundation to address historical, institutional, well-being and socioeconomic drivers of current catastrophic trajectories. The time for action is now.

Translating evidence into practice: Implementing culturally safe continuity of midwifery care for First Nations women in three maternity services in Victoria, Australia

BACKGROUND

Strategies to improve outcomes for Australian First Nations mothers and babies are urgently needed. Caseload midwifery, where women have midwife-led continuity throughout pregnancy, labour, birth and the early postnatal period, is associated with substantially better perinatal health outcomes, but few First Nations women receive it. We assessed the capacity of four maternity services in Victoria, Australia, to implement, embed, and sustain a culturally responsive caseload midwifery service.

METHODS

A prospective, non-randomised research translational study design was used. Site specific culturally responsive caseload models were developed by site working groups in partnership with their First Nations health units and the Victorian Aboriginal Community Controlled Health Organisation. The primary outcome was to increase the proportion of women having a First Nations baby proactively offered and receiving caseload midwifery as measured before and after programme implementation. The study was conducted in Melbourne, Australia. Data collection commenced at the Royal Women's Hospital on 06/03/2017, Joan Kirner Women's and Children's Hospital 01/10/2017 and Mercy Hospital for Women 16/04/2018, with data collection completed at all sites on 31/12/2020.

FINDINGS

The model was successfully implemented in three major metropolitan maternity services between 2017 and 2020. Prior to this, over a similar timeframe, only 5.8% of First Nations women (n = 34) had ever received caseload midwifery at the three sites combined. Of 844 women offered the model, 90% (n = 758) accepted it, of whom 89% (n = 663) received it. Another 40 women received standard caseload. Factors including ongoing staffing crises, prevented the fourth site, in regional Victoria, implementing the model.

INTERPRETATION

Key enablers included co-design of the study and programme implementation with First Nations people, staff cultural competency training, identification of First Nations women (and babies), and regular engagement between caseload midwives and First Nations hospital and community teams. Further work should include a focus on addressing cultural and workforce barriers to implementation of culturally responsive caseload midwifery in regional areas.

FUNDING

Partnership Grant (# 1110640), Australian National Health and Medical Research Council and La Trobe University.

Using participatory action research to co-design perinatal support strategies for Aboriginal and Torres Strait Islander parents experiencing complex trauma

PROBLEM & BACKGROUND

Support is important for all parents but critical for those experiencing complex trauma. The The Healing the Past by Nurturing the Future project uses participatory action research to co-design effective perinatal support for Aboriginal and Torres Strait Islander parents.

AIM

This research aims to identify and refine culturally appropriate support strategies for Aboriginal and Torres Strait Islander parents experiencing complex trauma.

DESIGN

We presented our synthesised eight parent support goals and 60 strategies, collated from Elder and parent focus groups, previous participatory workshops, and evidence reviews, for discussion at a stakeholder workshop. Stakeholder perspectives were captured using a three-point agreement activity and, self- and scribe-recorded comments. Aboriginal and non-Aboriginal researchers analysised the qualitative data, to identify core factors which might facilitate or help enact the parenting related goals.

FINDINGS

Overall, stakeholders (n = 37) strongly endorsed all eight goals. Workshop attendees (57% Aboriginal) represented multiple stakeholder roles including Elder, parent and service provider. Four core factors were identified as crucial for supporting parents to heal from complex trauma: Culture (cultural traditions, practices and strengths), Relationality (family, individual, community and services), Safety (frameworks, choice and control) and Timing (the right time socio-emotionally and stage of parenting).

DISCUSSION

Context-specific support tailored to the Culture, Relationality, Safety, and Timing needs of parents is essential. These four factors are important elements to help enact or facilitate parenting support strategies.

CONCLUSION

Further work is now required to develop practical resources for parents, and to implement and evaluate these strategies in perinatal care to address cumulative and compounding cycles of intergenerational trauma.

He Tamariki Kokoti Tau: Families of Indigenous Infants Talk about Their Experiences of Preterm Birth and Neonatal Intensive Care

Māori (Indigenous peoples of Aotearoa New Zealand) bear an unequal burden of poor perinatal health outcomes, including preterm birth. An infant arriving preterm disrupts the birth imaginary of whānau (family collectives) and situates them in a foreign health environment that may not be culturally safe and nurturing. A cross-sectional interpretative phenomenological analysis of first interviews with 19 whānau participating in a Kaupapa Māori (by, with, for Māori) qualitative longitudinal study of preterm birth identified themes from their experiences and the meanings they attributed to them. Preterm birth was an emotional roller coaster, with the birth imaginary and anticipated roles disrupted as health practitioners took over the care of their infants. Whānau expressed the desire to be close to their infants, holding them, loving them, nurturing them, and emplacing them within whakapapa (genealogy, continual layering of foundations) networks. When health practitioners or hospital policies inhibited this intimacy by isolating, excluding, or discriminating, whānau were frustrated. Being familiar with hospital routines, staff, peers, infant cares, and being wrapped in wider whānau support were key for whānau coping. Whakawhanaungatanga (processes of establishing relationships) create safe spaces for whānau to be themselves. This quietens the 'storm' and returns whānau to a sense of calm, through the reclamation of their environment.

Project20: Does continuity of care and community-based antenatal care improve maternal and neonatal birth outcomes for women with social risk factors? A prospective, observational study

Background

Social factors associated with poor childbirth outcomes and experiences of maternity care include minority ethnicity, poverty, young motherhood, homelessness, difficulty speaking or understanding English, migrant or refugee status, domestic violence, mental illness and substance abuse. It is not known what specific aspects of maternity care work to improve the maternal and neonatal outcomes for these under-served, complex populations.

Methods

This study aimed to compare maternal and neonatal clinical birth outcomes for women with social risk factors accessing different models of maternity care. Quantitative data on pregnancy and birth outcome measures for 1000 women accessing standard care, group practice and specialist models of care at two large, inner-city maternity services were prospectively collected and analysed using multinominal regression. The level of continuity of care and place of antenatal care were used as independent variables to explore these potentially influential aspects of care. Outcomes adjusted for women’s social and medical risk factors and the service attended.

Results

Women who received standard maternity care were significantly less likely to use water for pain relief in labour (RR 0.11, CI 0.02–0.62) and have skin to skin contact with their baby shortly after birth (RR 0.34, CI 0.14–0.80) compared to the specialist model of care. Antenatal care based in the hospital setting was associated with a significant increase in preterm birth (RR 2.38, CI 1.32–4.27) and low birth weight (RR 2.31, CI 1.24–4.32), and a decrease in induction of labour (RR 0.65, CI 0.45–0.95) compared to community-based antenatal care, this was despite women’s medical risk factors. A subgroup analysis found that preterm birth was increased further for women with the highest level of social risk accessing hospital-based antenatal care (RR 3.11, CI1.49–6.50), demonstrating the protective nature of community-based antenatal care.

Conclusions

This research highlights how community-based antenatal care, with a focus on continuity of carer reduced health inequalities and improved maternal and neonatal clinical outcomes for women with social risk factors. The findings support the current policy drive to increase continuity of midwife-led care, whilst adding that community-based care may further improve outcomes for women at increased risk of health inequalities. The relationship between community-based models of care and neonatal outcomes require further testing in future research. The identification of specific mechanisms such as help-seeking and reduced anxiety, to explain these findings are explored in a wider evaluation.

A call for action that cannot go to voicemail: Research activism to urgently improve Indigenous perinatal health and wellbeing

In this call to action, a coalition of Indigenous and non-Indigenous researchers from Australia, Aotearoa New Zealand, United States and Canada argue for the urgent need for adequately funded Indigenous-led solutions to perinatal health inequities for Indigenous families in well-resourced settler-colonial countries. Authors describe examples of successful community-driven programs making a difference and call on all peoples to support and resource Indigenous-led perinatal health services by providing practical actions for individuals and different groups.

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.

Building an Indigenous-Led Evidence Base for Smoking Cessation Care among Aboriginal and Torres Strait Islander Women during Pregnancy and Beyond: Research Protocol for the Which Way? Project

Strong and healthy futures for Aboriginal and Torres Strait Islander people requires engagement in meaningful decision making which is supported by evidence-based approaches. While a significant number of research publications state the research is co-designed, few describe the research process in relation to Indigenous ethical values. Improving the health and wellbeing of Aboriginal and Torres Strait Islander mothers and babies is crucial to the continuation of the oldest living culture in the world. Developing meaningful supports to empower Aboriginal and Torres Strait Islander mothers to quit smoking during pregnancy is paramount to addressing a range of health and wellbeing outcomes. Aboriginal and Torres Strait Islander women have called for non-pharmacological approaches to smoking cessation during pregnancy. We describe a culturally responsive research protocol that has been co-designed and is co-owned with urban and regional Aboriginal communities in New South Wales. The project has been developed in line with the AH&MRC's (Aboriginal Health & Medical Research Council) updated guidelines for ethical research with Aboriginal and Torres Strait Islander communities. Ethics approvals have been granted by AH&MRC #14541662 University of Newcastle HREC H-2020-0092 and the Local Health District ethics committee 2020/ETH02095. Results will be disseminated through peer reviewed articles, community reports, infographics, and online social media content.

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.

Identifying preventable risk factors for hospitalised asthma in young Aboriginal children: a whole-population cohort study

BACKGROUND

Australia has one of the highest rates of asthma worldwide. Indigenous children have a particularly high burden of risk determinants for asthma, yet little is known about the asthma risk profile in this population.

AIM

To identify and quantify potentially preventable risk factors for hospitalised asthma in Australian Aboriginal children (1-4 years of age).

METHODS

Birth, hospital and emergency data for all Aboriginal children born 2003-2012 in Western Australia were linked (n=32 333). Asthma was identified from hospitalisation codes. ORs and population attributable fractions were calculated for maternal age at birth, remoteness, area-level disadvantage, prematurity, low birth weight, maternal smoking in pregnancy, mode of delivery, maternal trauma and hospitalisations for acute respiratory tract infection (ARTI) in the first year of life.

RESULTS

There were 705 (2.7%) children hospitalised at least once for asthma. Risk factors associated with asthma included: being hospitalised for an ARTI (OR 4.06, 95% CI 3.44 to 4.78), area-level disadvantage (OR 1.58, 95% CI 1.28 to 1.94), being born at <33 weeks' gestation (OR 3.30, 95% CI 2.52 to 4.32) or birth weight <1500 g (OR 2.35, 95% CI 1.39 to 3.99). The proportion of asthma attributable to an ARTI was 31%, area-level disadvantage 18%, maternal smoking 5%, and low gestational age and birth weight were 3%-7%. We did not observe a higher risk of asthma in those children who were from remote areas.

CONCLUSION

Improving care for pregnant Aboriginal women as well as for Aboriginal infants with ARTI may help reduce the burden of asthma in the Indigenous population.

Addressing stillbirth inequities in Australia: Steps towards a better future

Persistent disparities in stillbirth risk and care are present in Australia. Eliminating these disparities is possible with a commitment to enhancing and scaling up models of culturally safe maternity care shown to be effective for Aboriginal and Torres Strait Islander women and those of migrant and refugee backgrounds. Campaigns to improve public awareness of stillbirth also play an important role in reducing stillbirth risk and consequences. To achieve reach and impact in communities at risk, messaging needs to be framed around the social and cultural context of women's lives. Here we describe important initiatives underway within the Stillbirth Centre of Research Excellence to develop a coordinated national approach to stillbirth prevention and care in communities that bear a disproportionate burden of stillbirth.

Aboriginal and Torres Strait Islander family access to continuity of health care services in the first 1000 days of life: a systematic review of the literature

Background

Aboriginal women and their infants experience significant disadvantage in health outcomes compared to their non-Aboriginal counterparts. Access to timely, effective and appropriate maternal and child healthcare can contribute to reducing these existing health disparities. However, accessing mainstream healthcare services often results in high levels of fear and anxiety, and low attendance at subsequent appointments among Aboriginal women, due to inefficient communication, poor service coordination and a lack of continuity of care.

Methods

This integrative literature review sought to explore factors that contribute to continuity of care and consider service features that contribute to positive care experiences and satisfaction with care received by Aboriginal women and their infants.

In total, 28 studies were included in the review and were thematically analysed using Braun and Clarke’s six steps of thematic analysis. This was followed by a collaborative, computer-assisted qualitative analysis, which resulted in the emergence of five key themes: lack of continuity of care, impact of lack of continuity of care, continuity of care interventions, impact of continuity of care interventions, and strategies to improve continuity of care.

Results

Most studies focused on health services in rural or remote Aboriginal communities and there was a lack of documented evidence of continuity of care (or lack thereof) for Aboriginal women living and birthing in regional and metropolitan areas. The majority of studies focused explicitly on continuity of care during the antenatal, birthing and immediate postnatal period, with only two studies considering continuity through to an infant’s first 1000 days.

Conclusion

The review highlights a lack of studies exploring continuity of care for Aboriginal families from the antenatal period through to an infants’ first 1000 days of life. Included studies identified a lack of continuity in the antenatal, peri- and postnatal periods in both regional and metropolitan settings. This, along with identified strategies for enhancing continuity, have implications for communities, and healthcare services to provide appropriate and culturally safe care. It also marks an urgent need to incorporate and extend continuity of care and carer through to the first 1000 days for successful maternal and infant health outcomes for Aboriginal peoples.

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

BACKGROUND

Prevention of avoidable preterm birth in Aboriginal and Torres Strait Islander (Indigenous) families is a major public health priority in Australia. Evidence about effective, scalable strategies to improve maternal and infant outcomes is urgently needed. In 2013, a multiagency partnership between two Aboriginal Community Controlled Health Organisations and a tertiary maternity hospital co-designed a new service aimed at reducing preterm birth: 'Birthing in Our Community'.

METHODS

A prospective interventional cohort study compared outcomes for women with an Indigenous baby receiving care through a new service (n = 461) to women receiving standard care (n = 563), January 2013-December 2017. The primary outcome was preterm birth (< 37 weeks gestation). One to one propensity score matching was used to select equal sized standard care and new service cohorts with similar distribution of characteristics. Conditional logistic regression calculated the odds ratio with matched samples.

FINDINGS

Women receiving the new service were less likely to give birth to a preterm infant than women receiving standard care (6·9% compared to 11.6%). After controlling for confounders, the new service significantly reduced the odds of having a preterm birth (unmatched, n = 1024: OR = 0·57, 95% CI 0·37, 0·89; matched, n = 690: OR = 0·50, 95% CI 0·31, 0·83).

INTERPRETATION

The short-term results of this service redesign send a strong signal that the preterm birth gap can be reduced through targeted interventions that increase Indigenous governance of, and workforce in, maternity services and provide continuity of midwifery carer, an integrated approach to supportive family services and a community-based hub.