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

© 2017 The Author(s). 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

The Source of Spontaneous Activity in the Main Olfactory Bulb of the Rat

In vivo, most neurons in the main olfactory bulb exhibit robust spontaneous activity. This paper tests the hypothesis that spontaneous activity in olfactory receptor neurons drives much of the spontaneous activity in mitral and tufted cells via excitatory synapses.Single units were recorded in vivo from the main olfactory bulb of a rat before, during, and after application of lidocaine to the olfactory nerve. The effect of lidocaine on the conduction of action potentials from the olfactory epithelium to the olfactory bulb was assessed by electrically stimulating the olfactory nerve rostral to the application site and monitoring the field potential evoked in the bulb.Lidocaine caused a significant decrease in the amplitude of the olfactory nerve evoked field potential that was recorded in the olfactory bulb. By contrast, the lidocaine block did not significantly alter the spontaneous activity of single units in the bulb, nor did it alter the field potential evoked by electrical stimulation of the lateral olfactory tract. Lidocaine block also did not change the temporal patters of action potential or their synchronization with respiration.Spontaneous activity in neurons of the main olfactory bulb is not driven mainly by activity in olfactory receptor neurons despite the extensive convergence onto mitral and tufted cells. These results suggest that spontaneous activity of mitral and tufted is either an inherent property of these cells or is driven by centrifugal inputs to the bulb

"It's what midwifery is all about": Western Australian midwives' experiences of being 'with woman' during labour and birth in the known midwife model

Background: The phenomenon of being 'with woman' is fundamental to midwifery as it underpins its philosophy, relationships and practices. There is an identified gap in knowledge around the 'with woman' phenomenon from the perspective of midwives providing care in a variety of contexts. As such, the aim of this study was to explore the experiences of being 'with woman' during labour and birth from the perspective of midwives' working in a model where care is provided by a known midwife. Methods: A descriptive phenomenological design was employed with ten midwives working in a 'known midwife' model who described their experiences of being 'with woman' during labour and birth. The method was informed by Husserlian philosophy which seeks to explore the same phenomenon through rich descriptions by individuals revealing commonalities of the experience. Results: Five themes emerged 1) Building relationships; 2) Woman centred care; 3) Impact on the midwife; 4) Impact on the woman; and 5) Challenges in the Known Midwife model. Midwives emphasised the importance of trusting relationships while being 'with woman', confirming that this relationship extends beyond the woman - midwife relationship to include the woman's support people and family. Being 'with woman' during labour and birth in the context of the relationship facilitates woman-centred care. Being 'with woman' influences midwives, and, it is noted, the women that midwives are working with. Finally, challenges that impact being 'with woman' in the known midwife model are shared by midwives. Conclusions: Findings offer valuable insight into midwives' experiences of being 'with woman' in the context of models that provide care by a known midwife. In this model, the trusting relationship is the conduit for being 'with woman' which influences the midwife, the profession of midwifery, as well as women and their families. Descriptions of challenges to being 'with woman' provide opportunities for professional development and service review. Rich descriptions from the unique voice of midwives, provided insight into the applied practices of being 'with woman' in a known midwife model which adds important knowledge concerning a phenomenon so deeply embedded in the philosophy and practices of the profession of midwifery

Remote links: Redesigning maternity care for Aboriginal women from remote communities in Northern Australia - A comparative cohort study.

OBJECTIVE: to compare the quality of care before and after the introduction of the new Midwifery Group Practice. DESIGN: a cohort study. SETTING: the health centers (HCs) in two of the largest remote Aboriginal communities (population 2200-2600) in the Top End of the Northern Territory (NT), each located approximately 500km from Darwin. The third study site was the Royal Darwin Hospital (RDH) which provides tertiary care. METHODS: a 2004-06 retrospective cohort (n=412 maternity cases) provided baseline data. A clinical redesign of maternity services occurring from 2009 onwards focused on increasing Continuity of Carer, Communication, Choice, Collaboration and Co-ordination of Care (5Cs). Data from a 2009-11 prospective cohort (n=310 maternity cases) were collected to evaluate the service redesign. Outcome measures included indicators on the quality of care delivery, adherence to recommended antenatal guidelines and maternal and neonatal health outcomes. FINDINGS: statistically significant improvements were recorded in many areas reflecting improved access to, and quality of, care. For example: fewer women had <4 visits in pregnancy (14% versus 8%), a higher proportion of women had routine antenatal tests recorded (86% versus 97%) and improved screening rates for urine (82% versus 87%) and sexual tract infections (78% versus 93%). However, the treatment of conditions according to recommended guidelines worsened significantly in some areas; for example antibiotics prescribed for urine infections (86% versus 52%) and treatment for anaemia in pregnancy (77% versus 67%). High preterm (21% versus 20%), low birth weight (18% versus 20%) and PPH (29% versus 31%) rates did not change over time. The out of hospital birth rate remained high and unchanged in both cohorts (10% versus 10%). CONCLUSION: this model addresses some of the disparities in care for remote-dwelling Aboriginal women. However, much work still needs to occur before maternity care and outcomes are equal to that of non-Aboriginal women. Targeted program interventions with stronger clinical governance frameworks to improve the quality of care are essential. A complete rethink of service delivery and engagement may deliver better results

Comparing satisfaction and burnout between caseload and standard care midwives: findings from two cross-sectional surveys conducted in Victoria, Australia

BACKGROUND: Caseload midwifery reduces childbirth interventions and increases women’s satisfaction with care. It is therefore important to understand the impact of caseload midwifery on midwives working in and alongside the model. While some studies have reported higher satisfaction for caseload compared with standard care midwives, others have suggested a need to explore midwives’ work-life balance as well as potential for stress and burnout. This study explored midwives’ attitudes to their professional role, and also measured burnout in caseload midwives compared to standard care midwives at two sites in Victoria, Australia with newly introduced caseload midwifery models. METHODS: All midwives providing maternity care at the study sites were sent questionnaires at the commencement of the caseload midwifery model and two years later. Data items included the Midwifery Process Questionnaire (MPQ) to examine midwives’ attitude to their professional role, the Copenhagen Burnout Inventory (CBI) to measure burnout, and questions about midwives’ views of caseload work. Data were pooled for the two sites and comparisons made between caseload and standard care midwives. The MPQ and CBI data were summarised as individual and group means. RESULTS: Twenty caseload midwives (88%) and 130 standard care midwives (41%) responded at baseline and 22 caseload midwives (95%) and 133 standard care midwives (45%) at two years. Caseload and standard care midwives were initially similar across all measures except client-related burnout, which was lower for caseload midwives (12.3 vs 22.4, p = 0.02). After two years, compared to midwives in standard care, caseload midwives had higher mean scores in professional satisfaction (1.08 vs 0.76, p = 0.01), professional support (1.06 vs 0.11, p <0.01) and client interaction (1.4 vs 0.09, p <0.01) and lower scores for personal burnout (35.7 vs 47.7, p < 0.01), work-related burnout (27.3 vs 42.7, p <0.01), and client-related burnout (11.3 vs 21.4, p < 0.01). CONCLUSION: Caseload midwifery was associated with lower burnout scores and higher professional satisfaction. Further research should focus on understanding the key features of the caseload model that are related to these outcomes to help build a picture of what is required to ensure the long-term sustainability of the model