Cultural safety and maternity care for Aboriginal and Torres Strait Islander Australians

PurposeTo discuss cultural safety and critique the provision of culturally appropriate maternity services to remote Aboriginal and Torres Strait Islander women in Australia.ProcedureThe literature and policies around ‘culture’ and ‘cultural safety’ are discussed and applied to the provision of maternity services to Aboriginal and Torres Strait Islander women in remote areas of Australia.FindingsThe current provision of maternity services to Aboriginal and Torres Strait Islander women, particularly those living in remote Australia, appears largely inadequate. The provision of culturally safe maternity care requires health system reform at all levels including: the individual practitioner response; the educational preparation of practitioners; the delivery of maternity services and the development of policy at local, state and national level. This paper considers the changes that can be made from the individual practitioner through to the design and implementation of maternity services.Principal conclusionsCultural safety provides a useful framework to improve the delivery of maternity services to remote Aboriginal and Torres Strait Islander women and their families

Maternal mortality and psychiatric morbidity in the perinatal period: challenges and opportunities for prevention in the Australian setting

•Maternal mortality associated with psychiatric illness in the perinatal period (pregnancy to the end of the first year postpartum) has until recently been under-reported in Australia due to limitations in the scope of the data collection and methods of detection.•The recent United Kingdom report Why mothers die 2000–2002 identified psychiatric illness as the leading cause of maternal death in the UK.•Findings from the last three reports on maternal deaths in Australia (covering the period 1994–2002) suggest that maternal psychiatric illness is one of the leading causes of maternal death, with the majority of suicides occurring by violent means.•Such findings strengthen the case for routine perinatal psychosocial screening programs, with clear referral guidelines and assertive perinatal treatment of significant maternal psychiatric morbidity.•Data linkage studies are needed to measure the full extent of maternal mortality associated with psychiatric illness in Australia

‘Tough love’: the experiences of midwives giving women sterile water injections for the relief of back pain in labour

To explore midwives' experiences of administering sterile water injections (SWI) to labouring women as analgesia for back pain in labour.A qualitative study, which generated data through semi-structured focus group interviews with midwives. Data were analysed thematically.Two metropolitan maternity units in Queensland, Australia.Eleven midwives who had administered SWI for back pain in labour in a randomised controlled trial.Three major themes were identified including: i. SWI, is it an intervention?; ii. Tough love, causing pain to relieve pain; iii. The analgesic effect of SWI and impact on midwifery practice.Whilst acknowledging the potential benefits of SWI as an analgesic the midwives in this study described a dilemma between inflicting pain to relieve pain and the challenges encountered in their discussions with women when offering SWI. Midwives also faced conflict when women requested SWI in the face of institutional resistance to its use.The procedural pain associated with SWI may discourage some midwives from offering women the procedure, providing women with accurate information regarding the intensity and the brevity of the injection pain and the expected degree of analgesic would assist in discussion about SWI with women

Supporting aboriginal knowledge and practice in health care: Lessons from a qualitative evaluation of the strong women, strong babies, strong culture program

BackgroundThe Strong Women, Strong Babies, Strong Culture Program (the Program) evolved from a recognition of the value of Aboriginal knowledge and practice in promoting maternal and child health (MCH) in remote communities of the Northern Territory (NT) of Australia. Commencing in 1993 it continues to operate today. In 2008, the NT Department of Health commissioned an evaluation to identify enabling factors and barriers to successful implementation of the Program, and to identify potential pathways for future development. In this paper we focus on the evaluation findings related specifically to the role of Aborignal cultural knowledge and practice within the Program.MethodsA qualitative evaluation utilised purposive sampling to maximise diversity in program history and Aboriginal culture. Semi-structured, in-depth interviews with 76 participants were recorded in their preferred language with a registered Interpreter when required. Thematic analysis of data was verified or modified through further discussions with participants and members of the evaluation team.ResultsAlthough the importance of Aboriginal knowledge and practice as a fundamental component of the Program is widely acknowledged, there has been considerable variation across time and location in the extent to which these cultural dimensions have been included in practice. Factors contributing to this variation are complex and relate to a number of broad themes including: location of control over Program activities; recognition and respect for Aboriginal knowledge and practice as a legitimate component of health care; working in partnership; communication within and beyond the Program; access to transport and working space; and governance and organisational support.ConclusionsWe suggest that inclusion of Aboriginal knowledge and practice as a fundamental component of the Program is key to its survival over more than twenty years despite serious challenges. Respect for the legitimacy of Aboriginal knowledge and practice within health care, a high level of community participation and control supported through effective governance and sufficient organisational commitment as well as competence in intercultural collaborative practice of health staff are critical requirements for realising the potential for cultural knowledge and practice to improve Aboriginal health outcomes

'Facing the wrong way': Exploring the Occipito Posterior position/back pain discourse from women's and midwives perspectives

Objective: to explore back pain in labour from the perspectives of women and midwives. Design: a qualitative study, which generated data through individual semi-structured interviews with postnatal women and focus groups with midwives. Data were analysed thematically. Setting: two metropolitan maternity units in Queensland, Australia. Participants: nine postnatal women and 11 midwives, all of whom had participated in a randomized controlled trial investigating the use of sterile water injections for back pain in labour. Findings: two major themes were identified, including back pain in labour: accounts, rationalisations and coping strategies, and fetal position: destabilising the Occipito Posterior-back pain discourse. Key conclusions: back pain may be severe in labour, may impact negatively upon women's labour and birth experiences, and interfere with their ability to cope as planned. The assumed relationship between fetal position and back pain in labour is a dominant discourse, albeit one which is lacking in empirical credibility. Nonetheless, the information provided to women by maternity professionals tended to reiterate customary practices and beliefs rather than factual knowledge. Increasingly, women refer to other sources, which may challenge the information provided by health professionals. Implications for practice: Back pain in labour is an under-researched area and the lack of solid evidence underpinning the advice provided to women has implications for labour management, and possibly for maternal and fetal outcomes. Care providers might usefully consider back pain as multifactorial, not always associated with OP position, and continue to seek evidence-based management strategies which address women's needs

Returning birthing services to communities and Aboriginal control: Aboriginal women of Shoalhaven Illawarra region describe how Birthing on Country is linked to healing

Background: For almost three decades, Waminda South Coast Women’s Health and Welfare Aboriginal Corporation has provided culturally safe and holistic wellbeing services to the Illawarra Shoalhaven region, New South Wales. Work towards “Birthing on Country” has been a longstanding part of the Waminda’s strategic direction.  Method: Aboriginal ways of knowing and doing informed the multiple methods used. A desktop review of the grey literature and online public databases, then six community yarning circles were conducted in the region. Participants were mothers, grandmothers, community-controlled service providers, and government health providers. A thematic analysis was conducted by two researchers and a Waminda staff member.  Results: Five broad themes were identified and informed the recommendations: (a) redesign maternity and child services, (b) establish a specific wellbeing and birthing place, (c) invest in a clinically and culturally exceptional workforce, (d) strengthen family capacity as pivotal to long-term health and wellness for mother and baby, and (e) community ownership is fundamental.  Discussion: This service model reflects Aboriginal women’s aspiration to have a choice for more culturally safe care during pregnancy and birth. The new model privileges Aboriginal knowledge of pregnancy,  childbirth, and early parenting; which is contrary to the current biomedical model of maternity services available for Australian women. Conclusion: Waminda is best placed to work strategically to implement and evaluate the aspirations of the women and in doing so, has the potential to change the life trajectory of Aboriginal babies born in the Illawarra Shoalhaven region.

Transition from an open plan to a two cot neonatal intensive care unit: a participatory action research approach

Aims and objectives: To facilitate staff transition from an open-plan to a two-cot neonatal intensive care unit design. Background: In 2012, an Australian regional neonatal intensive care unit transitioned from an open-plan to a two-cot neonatal intensive care unit design. Research has reported single- and small-room neonatal intensive care unit design may negatively impact on the distances nurses walk, reducing the time they spend providing direct neonatal care. Studies have also reported nurses feel isolated and need additional support and education in such neonatal intensive care units. Staff highlighted their concerns regarding the impact of the new design on workflow and clinical practice. Design: A participatory action research approach. Methods: A participatory action group titled the Change and Networking Group collaborated with staff over a four-year period (2009–2013) to facilitate the transition. The Change and Networking Group used a collaborative, cyclical process of planning, gathering data, taking action and reviewing the results to plan the next action. Data sources included meeting and workshop minutes, newsletters, feedback boards, subgroup reports and a staff satisfaction survey. Results: The study findings include a description of (1) how the participatory action research cycles were used by the Change and Networking Group: providing examples of projects and strategies undertaken; and (2) evaluations of participatory action research methodology and Group by neonatal intensive care unit staff and Change and Networking members. Conclusion: This study has described the benefits of using participatory action research to facilitate staff transition from an open-plan to a two-cot neonatal intensive care unit design. Participatory action research methodology enabled the inclusion of staff to find solutions to design and clinical practice questions. Future research is required to assess the long-term effect of neonatal intensive care unit design on staff workload, maintaining and supporting a skilled workforce as well as the impact of a new neonatal intensive care unit design on the neonatal intensive care unit culture. Relevance to clinical practice: A supportive work environment for staff is critical in providing high-quality health care

Perineal injury associated with hands on/hands poised and directed/undirected pushing: a retrospective cross-sectional study of non-operative vaginal births, 2011-2016

Clinicians hand position and advised pushing techniques may impact on rates of perineal injury.To assess the association of four techniques used in management of second stage with risk of moderate and severe perineal injury.Retrospective cross-sectional study.A metropolitan maternity hospital and a private maternity hospital in Brisbane, Australia.Term women with singleton, cephalic presentation experiencing a non-operative vaginal birth from January 2011 to December 2016.The research sites perinatal database recorded data on clinicians approach to instructing women during second stage and hand position at birth. Women were identified from matching the inclusion criteria (n = 26,393) then grouped based on combinations of hands-on, hand- poised, directed and undirected pushing. The associations with perineal injury were estimated using odds ratios obtained by multivariate analysis. Primary outcomes were the risk of moderate and severe perineal injury. The significance was set at 0.001.In Nulliparous women there was no difference in the risk of moderate or severe perineal injury between the different techniques. In multiparous women the use of a hands-on/directed approach was associated with a significant increase in the risk of moderate (AOR 1.18, 95% CI 1.10-1.27, p

Is a randomized controlled trial of waterbirth possible? : an Australian feasibility study

Background: The safety of waterbirth is contested because of the lack of evidence from randomized trials and conflicting results. This research assessed the feasibility of a prospective study of waterbirth (trial or cohort). Methods: We conducted a prospective cohort study at an Australian maternity hospital. Eligible women with uncomplicated pregnancies at 36 weeks of gestation were recruited and surveyed about their willingness for randomization. The primary midwife assessed waterbirth eligibility and intention on admission in labor, and onset of second stage. Primary outcomes measured feasibility. Intention-to-treat analysis, and per-protocol analysis, compared clinical outcomes of women and their babies who intended waterbirth and nonwaterbirth at onset of second stage. Results: 1260 participants were recruited; 15% (n = 188) agreed to randomization in a future trial. 550 women were analyzed by intention-to-treat analysis: 351 (waterbirth) and 199 (nonwaterbirth). In per-protocol analysis, 14% (n = 48) were excluded. Women in the waterbirth group were less likely to have amniotomy and more likely to have water immersion and physiological third stage. There were no differences in other measures of maternal morbidity. There were no significant differences between groups for serious neonatal morbidity; four cord avulsions occurred in the waterbirth group with none in the landbirth group. An RCT would need approximately 6000 women to be approached at onset of second stage. Conclusions: A randomized trial of waterbirth compared with nonwaterbirth, powered to detect a difference in serious neonatal morbidity, is unlikely to be feasible. A powered prospective study with intention-to-treat analysis at onset of second stage is feasible

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

© 2014 Barclay et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.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