From hospital to home: The quality and safety of a postnatal discharge system used for remote dwelling Aboriginal mothers and infants in the top end of Australia

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Connecting Obstetric, Maternity, Pediatric and Preventive Child Health Care: A Comparative Prospective Study Protocol

Collaboration between birth care and Preventive Child Health Care (PCHC) in the Netherlands is so far insufficient. The aim of the Connecting Obstetric; Maternity; Pediatric and PCHC (COMPLETE) study is to: (1) better understand the collaboration between birth care and PCHC and its underlying mechanisms (including barriers and facilitators); (2) investigate whether a new multidisciplinary strategy that is developed as part of the project will result in improved collaboration. To realize the first aim, a mixed-method study composed of a (focus group) interview study, a multiple case study and a survey study will be conducted. To realize the second aim, the new strategy will be piloted in two regions in an iterative process to evaluate and refine it, following the Participatory Action Research (PAR) approach. A prospective study will be conducted to compare outcomes related to child health, patient reported outcomes and experiences and quality of care between three different cohorts (i.e., those that were recruited before, during and after the implementation of the strategy). With our study we wish to contribute to a better understanding of collaboration in care and develop knowledge on how the integration of birth care and PCHC is envisioned by stakeholders, as well as how it can be translated into practice.

Women's experiences of their interactions with health care providers during the postnatal period in Australia: a qualitative systematic review protocol

OBJECTIVE

The objective of the review is to explore and evaluate women's experiences of interactions with health care providers during their postnatal period.

INTRODUCTION

The postnatal period is a transformative time for women. Women experience significant change and adaptation, which could impact upon parenting confidence, health, and psychological outcomes during this time. The interaction women have with their health care providers during the postnatal period plays an integral role in improving these health outcomes.

INCLUSION CRITERIA

This qualitative review will explore the experiences of primiparous and multiparous women during the postnatal period with a key focus on evaluating the interactions they have with health care providers. It will include all studies that utilize qualitative methods (such as interviews and focus groups). Articles that explore the postnatal care experiences of women who have endured a pregnancy loss, given birth to a baby with complex needs, or those that solely focus on describing the neonatal and intensive care experiences, will not be included.

METHODS

PubMed, CINAHL, Embase, Emcare, and PsycINFO will be searched. Studies published from 2000 onwards and written in English will be assessed for inclusion. Studies that are selected initially will be assessed for methodological quality by two independent reviewers utilizing the JBI critical appraisal instrument for qualitative research.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020186384.

Identification of relevant performance indicators for district healthcare systems in Ethiopia: a systematic review and expert opinion

PURPOSE

To identify potential performance indicators relevant for district healthcare systems of Ethiopia.

DATA SOURCES

Public Library of Medicine and Agency for Healthcare Research and Quality of the United States of America, Organization for Economic Cooperation and Development Library and Google Scholar were searched.

STUDY SELECTION

Expert opinions, policy documents, literature reviews, process evaluations and observational studies published between 1990 and 2015 were considered for inclusion. Participants were national- and local-healthcare systems. The phenomenon of interest was the performance of healthcare systems. The Joanna Briggs Institute tools were adapted and used for critical appraisal of records.

DATA EXTRACTION

Indicators of performance were extracted from included records and summarized in a narrative form. Then, experts rated the relevance of the indicators. Relevance of an indicator is its agreement with priority health objectives at the national and district level in Ethiopia.

RESULTS OF DATA SYNTHESIS

A total of 11 206 titles were identified. Finally, 22 full text records were qualitatively synthesized. Experts rated 39 out of 152 (25.7%) performance indicators identified from the literature to be relevant for district healthcare systems in Ethiopia. For example, access to primary healthcare, tuberculosis (TB) treatment rate and infant mortality rate were found to be relevant.

CONCLUSION

Decision-makers in Ethiopia and potentially in other low-income countries can use multiple relevant indicators to measure the performance of district healthcare systems. Further research is needed to test the validity of the indicators.

Customised approaches to vocational education can dramatically improve completion rates of Australian Aboriginal students

Objective Completion rates in vocational education are typically poor for Aboriginal students (<30%). A scholarship program was designed for Australian Aboriginal students using five enablers of success previously identified for Aboriginal preregistration tertiary nursing students. The purpose of this study was to evaluate whether the five enablers contributed to the success of Aboriginal students in vocational education and whether there were any other enablers. Methods Semistructured interviews were conducted with two groups of Aboriginal students in Certificate III and IV Dental Assisting and Certificate IV in Allied Health Assistance, and their teaching and support staff. The data were initially coded inductively. Initial codes were then categorised according to the five enablers identified to contribute to the success of Bachelor of Nursing students. New categories were created for data not assigned to the enablers. Results Twenty students (64.5% of the cohort) and six staff (75%) consented to participate. The five enablers were perceived to have contributed to the success of the scholarship recipients and two additional enablers were identified. A completion rate of 96.8% was achieved by the scholarship recipients (30 completions of 31 enrolments). Conclusions In contrast with the state average, a completion rate of 96.8% was achieved using seven enablers in this study. To improve completion rates for Aboriginal students, vocational education programs need to be customised to cultural, family and community context. The seven enablers in this study should be subject to a larger study to inform policy, funding, design and delivery of vocational training for Aboriginal students. What is known about the topic? It is well established in the literature that Aboriginal students have poorer educational outcomes than other students. What does this paper add? This paper validates five previously identified enablers to improve outcomes for Aboriginal students and an additional two for vocational education. These enablers may also be applicable to other types of education. What are the implications for practitioners? Practitioners can use the enablers in this study to design and implement vocational education programs and improve educational outcomes for Aboriginal students.

Improving the efficacy of healthcare services for Aboriginal Australians

Objective The aim of the present systematic review was to examine the enablers for effective health service delivery for Aboriginal Australians. Methods This systematic review was undertaken in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Papers were included if they had data related to health services for Australian Aboriginal people and were published between 2000 and 2015. The 21 papers that met the inclusion criteria were assessed using the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies. Seven papers were subsequently excluded due to weak methodological approaches. Results There were two findings in the present study: (1) that Aboriginal people fare worse than non-Aboriginal people when accessing usual healthcare services; and (2) there are five enablers for effective health care services for Australian Aboriginal people: cultural competence, participation rates, organisational, clinical governance and compliance, and availability of services. Conclusions Health services for Australian Aboriginal people must be tailored and implementation of the five enablers is likely to affect the effectiveness of health services for Aboriginal people. The findings of the present study have significant implications in directing the future design, funding, delivery and evaluation of health care services for Aboriginal Australians. What is known about the topic? There is significant evidence about poor health outcomes and the 10-year gap in life expectancy between Aboriginal and non-Aboriginal people, and limited evidence about improving health service efficacy. What does this paper add? This systematic review found that with usual health care delivery, Aboriginal people experience worse health outcomes. This paper identifies five strategies in the literature that improve the effectiveness of health care services intended for Aboriginal people. What are the implications for practitioners? Aboriginal people fare worse in both experience and outcomes when they access usual care services. Health services intended for Aboriginal people should be tailored using the five enablers to provide timely, culturally safe and high-quality care.

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.

An evidence-based policy brief: improving the quality of postnatal care in mothers 48 hours after childbirth

Introduction

Malawi is experiencing slow progress in postnatal care of mothers within the first 48 hours after childbirth. Malawi Demographic and Health Survey (MDHS) 2015–16 reported a slow progress in postnatal care of mothers in the first 48 hours at 42% from 41% in 2010 despite a high number of institutional births. This is a critical period as a large proportion of maternal deaths occur during this period, currently at 439 per 100,000 live births. During postnatal care the mother is given important information to assist in caring for herself and her baby. The lack of well documented guidelines and funding to employ more midwives to manage mothers in postnatal ward contributes to poor quality of postnatal care.

Methods

This is an evidence-based policy brief that was prepared to inform policy makers, health workers, clients, community and other stakeholders to consider the available evidence about the impact of the suggested options in order to improve postnatal care.

Results

Several factors that contribute to low utilization of postnatal care among mothers after childbirth were identified. Factors included lack of clear guidelines on postnatal care, shortage of skilled health workers and inadequate resources.

Conclusion

Implementation of the identified policy options may improve postnatal care.

Primary Health Care for Aboriginal Australian Women in Remote Communities after a Pregnancy with Hyperglycaemia

Background: Hyperglycaemia in pregnancy contributes to adverse outcomes for women and their children. The postpartum period is an opportune time to support women to reduce cardiometabolic and diabetes risk in subsequent pregnancies. Aims: To identify strengths and gaps in current care for Aboriginal women after a pregnancy complicated by hyperglycaemia. Methods: A retrospective review of the 12 month postpartum care provided by primary health centres in remote Australia in 2013–2014 identified 195 women who experienced hyperglycaemia in pregnancy (gestational diabetes (GDM) (n = 147), type 2 diabetes (T2D) (n = 39), and unclear diabetes status (n = 9)). Results: Only 80 women (54%) with GDM had postpartum glycaemic checks. Of these, 32 women were diagnosed with prediabetes (n = 24) or diabetes (n = 8). Compared to women with GDM, women with T2D were more likely to have their weight measured (75% vs. 52%, p <0.01), and smoking status documented as “discussed” (65% vs. 34%, p < 0.01). Most women (97%) accessed the health centre at least once in the 12 month postpartum period but, during these visits, only 52% of women had service provision, either structured or opportunistic, related to diabetes. Conclusion: High rates of dysglycaemia among women screened for T2D after GDM in the 12 month postpartum period highlight the need for increased screening and early intervention to prevent the development of T2D and its complications. Whilst a clear strength was high postpartum attendance, many women did not attend health services for diabetes screening or management.

Improving postpartum screening after diabetes in pregnancy: Results of a pilot study in remote Australia

BACKGROUND

The postpartum period is a critical time to improve health outcomes for Aboriginal women, particularly for those who have chronic conditions.

AIMS

To assess enhanced support methods (for women following diabetes in pregnancy (DIP)) to improve completion rates of recommended postpartum health checks.

MATERIALS AND METHODS

Fifty-three Aboriginal women in the Northern Territory (NT) were contacted in the postpartum period to encourage medical check-ups. Messages were delivered through phone (call or text messages) or other methods (Facebook or email). The primary outcome was postpartum blood glucose testing (oral glucose tolerance testing (OGTT), random or fasting glucose and HbA1c).

RESULTS

Establishing contact with women was difficult. Of 137 messages sent to 52 women, 22 responded (42%). Phone was the most common contact method with successful contact made from 16 of 119 (13%) attempts. Rates of postpartum OGTT completion were higher in the group successfully contacted (32% vs 7%). However, for any postpartum glucose testing (including OGTT and HbA1c) rates were 25 of 42 (60%) and neither success in making contact nor the contact method was associated with higher rates.

CONCLUSIONS

The small sample size limits our conclusions; however, results highlight that engaging remote women postpartum is difficult. While rates of postpartum OGTT completion differed according to successful contacts, rates of any postpartum blood glucose testing did not. Further research is needed to explore feasible intervention methods to improve postpartum screening after a pregnancy complicated by diabetes.

Remote dwelling Aboriginal Australian women and birthing: A critical review of literature

PROBLEM

Australian Aboriginal women's aspirations for birthing on country (having our babies born on our traditional land) are increasingly being reported in Australian scholarly and policy literature. However given the paucity of publications authored by Aboriginal Australians from remote areas of Australia, how well can the current knowledge base in Australia inform the development of culturally appropriate maternity services for our communities?

OBJECTIVE

The aim of this literature review is to critically analyse the policy documents informing maternity services policy and scholarly literature on the birthing experiences (including the provision of maternity services) of Aboriginal Australian women from remote communities from an Indigenous standpoint.

METHOD

Policy documents and scholarly literature were critically analysed to identify who the authors were, their background, approaches and perspectives; and emergent themes. A further analysis of the literature drew on Fairclough's ideas on discourse, power and hegemony.

FINDINGS

A critical discourse analysis of this literature exposed how these texts are ideologically shaped to give voice (and power) to the medical fraternity, maternity care services practitioners and policy makers (whose knowledge is valued) while simultaneously silencing the voices of Aboriginal Australians that pose a challenge to that power.

CONCLUSION

This critical review of current literature highlights the importance of ongoing critique of maternity services policy and practice discourse necessary to combat western medical hegemony that maintains the disenfranchisement of Aboriginal Australians.

Risk factors for preterm, low birthweight and small for gestational age births among Aboriginal women from remote communities in Northern Australia

OBJECTIVE

To identify the risk factors for preterm birth, low birthweight and small for gestational age babies among remote-dwelling Aboriginal women.

METHODS

The study included 713 singleton births from two large remote Aboriginal communities in Northern Territory, Australia in 2004-2006 (retrospective cohort) and 2009-2011 (prospective cohort). Demographic, pregnancy characteristics, labour and birth outcomes were described. Multivariate logistic regression analysis was conducted and adjusted odds ratios were reported.

RESULTS

The preterm birth rate was 19.4%, low birthweight rate was 17.4% and small for gestational age rate was 16.3%. Risk factors for preterm birth were teenage motherhood, previous preterm birth, smoker status not recorded, inadequate antenatal visits, having pregnancy-induced hypertension, antepartum haemorrhage or placental complications. After adjusting for gender and birth gestation, the only significant risk factor for low birthweight was first time mother. The only significant risk factor for small for gestational age baby was women having their first baby.

CONCLUSIONS

Rates of these events are high and have changed little over time. Some risk factors are modifiable and treatable but need early, high quality, culturally responsive women centred care delivered in the remote communities themselves. A different approach is recommended.

The quality of health services provided to remote dwelling aboriginal infants in the top end of northern Australia following health system changes: a qualitative analysis

Background

In Australia the health outcomes of remote dwelling Aboriginal infants are comparable to infants in developing countries. This research investigates service quality, from the clinicians’ perspective and as observed and recorded by the researcher, in two large Aboriginal communities in the Top End of northern Australia following health system changes.

Methods

Data were collected from semi-structured interviews with 25 clinicians providing or managing child health services in the two study sites. Thirty hours of participant observation was undertaken in the ‘baby-rooms’ at the two remote health centres between June and December 2012. The interview and observational data, as well as field notes were integrated and analysed thematically to explore clinicians’ perspectives of service delivery to infants in the remote health centres.

Results

A range of factors affecting the quality of care, mostly identified before health system changes were instigated, persisted. These factors included ineffective service delivery, inadequate staffing and culturally unsafe practices. The six themes identified in the data: ‘very adhoc’, ‘swallowed by acute’, ‘going under’, ‘a flux’, ‘a huge barrier’ and ‘them and us’ illustrate how these factors continue, and when combined portray a ‘very chaotic system’.

Conclusion

Service providers perceived service provision and quality to be inadequate, despite health system changes. Further work is urgently needed to improve the quality, cultural responsiveness and effectiveness of services to this population.

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-017-0849-1) contains supplementary material, which is available to authorized users.

A comparison of two models of dental care for Aboriginal communities in New South Wales

BACKGROUND

Aboriginal people, and particularly those in rural areas, continue to suffer very high levels of dental disease despite significant reductions in the wider Australian population in the past 30 years. Until recently, there has been a shortage of oral health clinicians and the majority have provided care in major cities. The NSW Government funded various models of care for rural and regional areas and vulnerable population groups including Aboriginal people. This study utilizes a comparative retrospective analysis to compare two models of oral health care for Aboriginal people including those living in rural NSW to inform future policy decisions.

METHODS

Two models (Model A - Fly in Fly out and Model B - Collective impact) of public oral health care for Aboriginal patients in NSW were examined using publicly available descriptive information. Two years of funding and Dental Weighted Activity Units (DWAUs) data were analysed for the two different models and regression analysis was used to compare the trends of monthly time series of DWAUs.

CONCLUSIONS

Based on the standardized national weighted pricing for public dentistry, model B offers significantly more services for less financial resources.

Open, trusting relationships underpin safety in rural maternity a hermeneutic phenomenology study

BACKGROUND

There are interwoven personal, professional and organisational relationships to be navigated in maternity in all regions. In rural regions relationships are integral to safe maternity care. Yet there is a paucity of research on how relationships influence safety and nurture satisfying experiences for rural maternity care providers and mothers and families in these regions. This paper draws attention to how these relationships matter.

METHODS

This research is informed by hermeneutic phenomenology drawing on Heidegger and Gadamer. Thirteen participants were recruited via purposeful sampling and asked to share their experiences of rural maternity care in recorded unstructured in-depth interviews. Participants were women and health care providers living and working in rural regions. Recordings were transcribed and data interpretively analysed until a plausible and trustworthy thematic pattern emerged.

RESULTS

Throughout the data the relational nature of rural living surfaced as an interweaving tapestry of connectivity. Relationships in rural maternity are revealed in myriad ways: for some optimal relationships, for others feeling isolated, living with discord and professional disharmony. Professional misunderstandings undermine relationships. Rural maternity can become unsustainable and unsettling when relationships break down leading to unsafeness.

CONCLUSIONS

This study reveals how relationships are an important and vital aspect to the lived-experience of rural maternity care. Relationships are founded on mutual understanding and attuned to trust matter. These relationships are forged over time and keep childbirth safe and enable maternity care providers to work sustainably. Yet hidden unspoken pre-understandings of individuals and groups build tension in relationships leading to discord. Trust builds healthy rural communities of practice within which everyone can flourish, feel accepted, supported and safe. This is facilitated by collaborative learning activities and open respectful communication founded on what matters most (safe positive childbirth) whilst appreciating and acknowledging professional and personal differences.

Improving access to primary care for Aboriginal babies in Western Australia: study protocol for a randomized controlled trial

Background

Despite a decade of substantial investments in programs to improve access to primary care for Aboriginal mothers and infants, more than 50 % of Western Australian Aboriginal babies are still not receiving primary and preventative care in the early months of life. Western Australian hospitals now input birth data into the Western Australian electronic clinical management system within 48 hours of birth. However, difficulties have arisen in ensuring that the appropriate primary care providers receive birth notification and clinical information by the time babies are discharged from the hospital. No consistent process exists to ensure that choices about primary care are discussed with Aboriginal families.

Methods/Design

We will undertake a population-based, stepped wedge, cluster randomized controlled trial of an enhanced model of early infant primary care. The intervention is targeted support and care coordination for Aboriginal families with new babies starting as soon as possible during the antenatal period or after birth. Dedicated health professionals and research staff will consult with families about the families’ healthcare needs, provide information about healthcare in the first 3 months of life, offer assistance with birth and Medicare forms, consult with families about their choice for primary care provider, offer to notify the chosen primary care provider about the baby’s health needs, and offer assistance with healthcare coordination at the time of discharge from the hospital.

We will evaluate this model of care using a rigorous stepped wedge approach. Our primary outcome measure is a reduced hospitalization rate in infants younger than 3 months of age. Secondary outcome measures include completed Aboriginal and Torres Strait Islander child health screening assessments, immunization coverage, and satisfaction of the families about early infant primary care. We will also assess the cost effectiveness of the model of care.

Discussion

This study will be conducted over a 4-year period in partnership with birthing hospitals and primary care providers including Western Australian Aboriginal Community Controlled Health Services and the new Primary Health Networks. The results of our trial will be used to develop improved primary care models and to improve health outcomes for all Aboriginal infants. These are vital steps toward more equitable health service delivery for the Aboriginal and Torres Strait Islander children in Australia.

Trial Registration

Australian New Zealand Clinical Trials Registry

Registration number: ACTRN12615000976583 

Date registered: 17 September 2015

Models of Postnatal Care for Low-Income Countries: A Review of the Literature Abstract

PURPOSE:This review aims to identify the key features of effective models of postnatal care involving midwifery personnel and to determine which models may be appropriate for implementation in low-income countries.

STUDY DESIGN:A narrative synthesis of English language, peer-reviewed articles from 2004 to 2014 was undertaken. Four online library databases were searched. Inclusion/exclusion criterion and a quality appraisal were applied.

MAJOR FINDINGS:Twenty-two studies were included in the review, but only 4 were from low-income countries. Midwifery-led models of postnatal care are cost-effective to provide high-quality care in every settings for every women in respect of 2 core components of quality care that are woman-centered care and continuity of care. Midwifery postnatal care is provided at hospital, in community settings, and at home, all presenting different strengths and weaknesses. Combinations of models of midwifery postnatal care and collaboration between stakeholders have had positive impacts on the quality of postnatal care. To be completely effective, this requires a better management and support of midwifery personnel though. Women and midwifery personnel’s satisfaction needs to be considered to identify the local means and needs and to plan a suitable model of midwifery postnatal care at each location.

MAIN CONCLUSION:Low-income countries could develop a midwifery-led model of postnatal care. This will require identifying women and midwifery personnel’s needs and the available resources and involving the stakeholders collaboratively to provide a suitable model of midwifery postnatal care. Education and practice will need to be addressed as well as promotion to the population. There is a need to conduct more research on midwifery postnatal care in low-income countries to evaluate how to best use them and what aspect of the midwifery postnatal care can be strengthened.

The logics of planned birthplace for remote Australian Aboriginal women in the northern territory: A discourse and content analysis of clinical practice manuals

OBJECTIVE

the aim of this research is to review the content, and describe the structural and contextual discourse around planned birthplace in six clinical practice manuals used to care for pregnant Aboriginal women in Australia׳s remote Northern Territory. The purpose is to better understand where, how and why planned birthplaces for Aboriginal women have changed over time.

METHODS

content and discourse analysis was applied to the written texts pertaining to maternal health care and the results placed within a theoretical framework of Daviss׳s Logic.

FINDINGS

the manuals demonstrate the use of predominantly scientific and clinical logic to sanction birthplace. Planned birthplace choices have declined over time, with hospital now represented as the only place to give birth. This is in opposition to Aboriginal women׳s longstanding requests and is not supported by robust scientific evidence.

CONCLUSIONS

despite scientific and clinical logics dominating the sanctioning of birthplace for Aboriginal women, conjecture is apparent between assumed logics and evidence. There needs to be further critical reflection on why Aboriginal women do not have planned birthplace choices, and these reasons, once identified, debated and addressed both in research agendas and policy re-development.

Implementing a national approach to universal child and family health services in Australia: professionals' views of the challenges and opportunities

Australia has a well-accepted system of universal child and family health (CFH) services. However, government reports and research indicate that these services vary across states and territories, and many children and families do not receive these services. The aim of this paper was to explore professionals' perceptions of the challenges and opportunities in implementing a national approach to universal CFH services across Australia. Qualitative data were collected between July 2010 and April 2011 in the first phase of a three-phase study designed to investigate the feasibility of implementing a national approach to CFH services in Australia. In total, 161 professionals participated in phase 1 consultations conducted either as discussion groups, teleconferences or through email conversation. Participants came from all Australian states and territories and included 60 CFH nurses, 45 midwives, 15 general practitioners (GPs), 12 practice nurses, 14 allied health professionals, 7 early childhood education specialists, 6 staff from non-government organisations and 2 Australian government policy advisors. Data were analysed thematically. Participants supported the concept of a universal CFH service, but identified implementation barriers. Key challenges included the absence of a minimum data set and lack of aggregated national data to assist planning and determine outcomes; an inconsistent approach to transfer of information about mothers and newborns from maternity services to CFH nursing services or GPs; poor communication across disciplines and services; issues of access and equity of service delivery; workforce limitations and tensions around role boundaries. Directions for change were identified, including improved electronic data collection and communication systems, reporting of service delivery and outcomes between states and territories, professional collaboration, service co-location and interprofessional learning and development.

Aboriginal and Torres Strait Islander maternal and child health and wellbeing: a systematic search of programs and services in Australian primary health care settings

Background

Persistent disparities in pregnancy and birth outcomes between Aboriginal and Torres Strait Islander and other Australians evidence a need to prioritise responsive practice in Maternal Child Health (MCH). This study reviewed the existing knowledge output on Aboriginal and Torres Strait Islander MCH programs and services with the objective to advance understanding of the current evidence base and inform MCH service development, including the identification of new research priorities.

Methods

A systematic search of the electronic databases Informit, Proquest, PubMed, Scopus, Wiley, and Cinahl, and 9 relevant websites was undertaken for the period 1993–2012. The reference lists of MCH program reviews were hand-searched for additional relevant studies which met the eligibility criteria. The study designs of included publications were classified and the characteristics extracted and categorized. Evaluation quality was assessed using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for Quantitative Studies and the Critical Appraisal Skills Program (CASP) tool for qualitative studies.

Results

Twenty-three search results were identified for inclusion, with the majority published in 2003–2012. Fifty two percent of publications reported on programs and services operating out of Aboriginal Community Controlled Health Organisations, with antenatal and postnatal care the main intervention type/s, and health promotion/education and advice/support the most common intervention component. Outcomes such as increased antenatal attendance and higher infant birth weights were reported in some intervention studies, however methodological quality varied considerably with quantitative studies typically rated weak.

Conclusion

The prevalence of community controlled and/or community-based programs is significant given the health and wellbeing implications of self-determination. While the literature highlights the promise of many intervention models and program components used there are some significant gaps in the documentation and implementation of important MCH interventions. Similarly, while positive health outcomes were reported there are issues with key measures used and study quality. This review highlights the need to improve the quality of evaluations of MCH programs for Aboriginal and Torres Strait Islander women and to address the key evidence gaps in responding to their health and wellbeing needs.

Nature and frequency of services provided by child and family health nurses in Australia: results of a national survey

OBJECTIVE

Australia has a system of universal child and family health (CFH) nursing services providing primary health services from birth to school entry. Herein, we report on the findings of the first national survey of CFH nurses, including the ages and circumstances of children and families seen by CFH nurses and the nature and frequency of the services provided by these nurses across Australia.

METHODS

A national survey of CFH nurses was conducted.

RESULTS

In all, 1098 CFH nurses responded to the survey. Over 60% were engaged in delivering primary prevention services from a universal platform. Overall, 82.8% reported that their service made first contact with families within 2 weeks of birth, usually in the home (80.7%). The proportion of respondents providing regular support to families decreased as the child aged. Services were primarily health centre based, although 25% reported providing services in other locations (parks, preschools).The timing and location of first contact, the frequency of ongoing services and the composition of families seen by nurses varied across Australian jurisdictions. Nurses identified time constraints as the key barrier to the delivery of comprehensive services.

CONCLUSIONS

CFH nurses play an important role in supporting families across Australia. The impact of differences in the CFH nursing provision across Australia requires further investigation. What is known about the topic? Countries that offer universal well child health services demonstrate better child health and developmental outcomes than countries that do not. Australian jurisdictions offer free, universal child and family health (CFH) nursing services from birth to school entry. What does this paper add? This paper provides nation-wide data on the nature of work undertaken by CFH nurses offering universal care. Across Australia, there are differences in the timing and location of first contact, the frequency of ongoing services and the range of families seen by nurses. What are the implications for practitioners? The impact for families of the variation in CFH nursing services offered across Australia is not known. Further research is required to investigate the outcomes of the service provision variations identified in the present study.

Improving Aboriginal maternal and infant health services in the 'Top End' of Australia; synthesis of the findings of a health services research program aimed at engaging stakeholders, developing research capacity and embedding change

Background

Health services research is a well-articulated research methodology and can be a powerful vehicle to implement sustainable health service reform. This paper presents a summary of a five-year collaborative program between stakeholders and researchers that led to sustainable improvements in the maternity services for remote-dwelling Aboriginal women and their infants in the Top End (TE) of Australia.

Methods

A mixed-methods health services research program of work was designed, using a participatory approach. The study area consisted of two large remote Aboriginal communities in the Top End of Australia and the hospital in the regional centre (RC) that provided birth and tertiary care for these communities. The stakeholders included consumers, midwives, doctors, nurses, Aboriginal Health Workers (AHW), managers, policy makers and support staff. Data were sourced from: hospital and health centre records; perinatal data sets and costing data sets; observations of maternal and infant health service delivery and parenting styles; formal and informal interviews with providers and women and focus groups. Studies examined: indicator sets that identify best care, the impact of quality of care and remoteness on health outcomes, discrepancies in the birth counts in a range of different data sets and ethnographic studies of ‘out of hospital’ or health centre birth and parenting. A new model of maternity care was introduced by the health service aiming to improve care following the findings of our research. Some of these improvements introduced during the five-year research program of research were evaluated.

Results

Cost effective improvements were made to the acceptability, quality and outcomes of maternity care. However, our synthesis identified system-wide problems that still account for poor quality of infant services, specifically, unacceptable standards of infant care and parent support, no apparent relationship between volume and acuity of presentations and staff numbers with the required skills for providing care for infants, and an ‘outpatient’ model of care. Services were also characterised by absent Aboriginal leadership and inadequate coordination between remote and tertiary services that is essential to improve quality of care and reduce ‘system-introduced’ risk.

Conclusion

Evidence-informed redesign of maternity services and delivery of care has improved clinical effectiveness and quality for women. However, more work is needed to address substandard care provided for infants and their parents.

'Choice, culture and confidence': key findings from the 2012 having a baby in Queensland Aboriginal and Torres Strait Islander survey

BACKGROUND

To describe the maternity care experiences of Aboriginal and/or Torres Strait Islander women in Queensland, Australia and to identify areas for policy and practice improvements.

METHODS

A culturally-tailored survey requesting both quantitative and qualitative information was completed by respondents either independently (online or in hard copy) or with the assistance of a trained peer-interviewer. Data were analysed using descriptive statistics and thematic analysis.Eligible women were over 16 years of age, identified as Aboriginal and/or Torres Strait Islander, resided in Queensland, and had a live, singleton birth between the first of July 2011 and the first of July 2012.

RESULTS

187 women of 207 respondents were included in analyses. Women reported high rates of stressful life events in pregnancy, low levels of choice in place of birth and model of care and limited options to carry out cultural practices. High levels of confidence in parenting were also reported. Women were less likely to report being treated with kindness, understanding and respect by maternity care staff than women answering a similar mainstream survey.

CONCLUSIONS

Aboriginal and Torres Strait Islander women have additional needs to mainstream Australian women. This study identified a number of recommendations to improve services including the need to enhance the cultural competence of maternity services; increase access to continuity of midwifery care models, facilitate more choices in care, work with the strengths of Aboriginal and Torres Strait Islander women, families and communities, and engage women in the design and delivery of care.

Use of maternal health services by remote dwelling Aboriginal women in northern Australia and their disease burden

BACKGROUND

Disparities exist in pregnancy and birth outcomes between Australian Aboriginal women and their non-Aboriginal counterparts. Understanding patterns of health service use by Aboriginal women is critical. This study describes the use of maternal health services by remote dwelling Aboriginal women in northern Australia during pregnancy, birth and the postpartum period and their burden of disease.

METHODS

A retrospective cohort study of maternity care for all 412 maternity cases from two remote Aboriginal communities in the Northern Territory of Australia, 2004-2006. Primary endpoints were the number and type of maternal health-related complications and service episodes at the health centers and regional hospital during pregnancy, birth, and the first 6 months postpartum.

RESULTS

Ninety-three percent of women attended antenatal care. This often commenced late in pregnancy. High levels of complications were identified and 23 percent of all women required antenatal hospitalization. Birth occurred within the regional hospital for 90 percent of women. By 6 months postpartum, 45 percent of women had documented postnatal morbidities and 8 percent required hospital admission. The majority of women accessed remote health services at least once; however, only one third had a record of a postnatal care within 2 months of giving birth.

CONCLUSION

Maternal health outcomes were poor despite frequent service use throughout pregnancy, birth, and the first 6 months postpartum suggesting quality of care rather than access issues. These findings reflect outcomes that are more aligned with the developing rather than developed world and have significant implications for future planning of maternity services that must be urgently addressed.

Factors affecting the quality of antenatal care provided to remote dwelling Aboriginal women in northern Australia

OBJECTIVE

there is a significant gap in pregnancy and birth outcomes for Australian Aboriginal and Torres Strait Islander women compared with other Australian women. The provision of appropriate and high quality antenatal care is one way of reducing these disparities. The aim of this study was to assess adherence to antenatal guidelines by clinicians and identify factors affecting the quality of antenatal care delivery to remote dwelling Aboriginal women.

SETTING AND DESIGN

a mixed method study drew data from 27 semi-structured interviews with clinicians and a retrospective cohort study of Aboriginal women from two remote communities in Northern Australia, who gave birth from 2004-2006 (n=412). Medical records from remote health centres and the regional hospital were audited.

MEASUREMENTS AND FINDINGS

the majority of women attended antenatal care and adherence to some routine antenatal screening guidelines was high. There was poor adherence to local guidelines for follow-up of highly prevalent problems including anaemia, smoking, urinary tract infections and sexually transmitted infections. Multiple factors influenced the quality of antenatal care.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

the resourcing and organisation of health services and the beliefs, attitudes and practices of clinicians were the major factors affecting the quality of care. There is an urgent need to address the identified issues in order to achieve equity in women's access to high quality antenatal care with the aim of closing the gap in maternal and neonatal health outcomes.

Measuring what matters in delivering services to remote-dwelling Indigenous mothers and infants in the Northern Territory, Australia

PROBLEM

In the Northern Territory, 64% of Indigenous births are to remote-dwelling mothers. Delivering high-quality health care in remote areas is challenging, but service improvements, informed by participative action research, are under way. Evaluation of these initiatives requires appropriate indicators. Few of the many existing maternal and infant health indicators are specifically framed for the remote context or exemplify an Indigenous consumer perspective. We aimed to identify an indicator framework with appropriate indicators to demonstrate improvements in health outcomes, determinants of health and health system performance for remote-dwelling mothers and infants from pregnancy to first birthday.

DESIGN

We reviewed existing indicators; invited input from experts; investigated existing administrative data collections and examined findings from a record audit, ethnographic work and the evaluation of the Darwin Midwifery Group Practice.

SETTING

Northern Territory.

PROCESS

About 660 potentially relevant indicators were identified. We adapted the Aboriginal and Torres Strait Islander Health Performance Framework and populated the resulting framework with chosen indicators. We chose the indicators best able to monitor the impact of changes to remote service delivery by eliminating duplicated or irrelevant indicators using expert opinion, triangulating data and identifying key issues for remote maternal and infant health service improvements.

LESSONS LEARNT

We propose 31 indicators to monitor service delivery to remote-dwelling Indigenous mothers and infants. Our inclusive indicator framework covers the period from pregnancy to the first year of life and includes existing indicators, but also introduces novel ones. We also attempt to highlight an Indigenous consumer.