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

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

Improving Aboriginal maternal and infant health services in the \u27Top End\u27 of Australia; synthesis of the findings of a health services research program aimed at engaging stakeholders, developing research capacity and embedding change

BackgroundHealth 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. MethodsA 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. ResultsCost 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. ConclusionEvidence-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

A randomised non-inferiority controlled trial of a single versus a four intradermal sterile water injection technique for relief of continuous lower back pain during labour

Background: Almost one third of women suffer continuous lower back pain during labour. Evidence from three systematic reviews demonstrates that sterile water injections (SWI) provide statistically and clinically significant pain relief in women experiencing continuous lower back pain during labour. The most effective technique to administer SWI is yet to be determined. Therefore, the aim of this study is to determine if the single injection SWI technique is no less effective than the routinely used four injection SWI method in reducing continuous lower back pain during labour.Methods/design: The trial protocol was developed in consultation with an interdisciplinary team of clinical researchers. We aim to recruit 319 women presenting at term, seeking analgesia for continuous severe lower back pain during labour. Participants will be recruited from two major maternity hospitals in Australia. Randomised participants are allocated to receive a four or single intradermal needle SWI technique. The primary outcome is the change in self-reported pain measured by visual analogue scale at baseline and thirty minutes post intervention. Secondary outcomes include VAS change scores at 10, 60, 90 and 120 min, analgesia use, mode of birth and maternal satisfaction.Statistical analysis: Sample size was calculated to achieve 90% power at an alpha of 0.025 to detect a non-inferiority margin of ≤ 1 cm on the VAS, using a one-sided, two-sample t-test. Baseline demographic and clinical characteristics will be analysed for comparability between groups. Differences in primary (VAS pain score) and secondary outcomes between groups will be analysed by intention to treat and per protocol analysis using Student's t-test and ANOVA.Conclusion: This study will determine if a single intradermal SWI technique is no less effective than the routinely used four injection technique for lower back pain during labour. The findings will allow midwives to offer women requesting SWI during labour an evidence-based alternative technique more easily administered by staff and accepted by labouring women. Trial Registration: ACTRN12609000964213

Use of health services by remote dwelling Aboriginal infants in tropical northern Australia: a retrospective cohort study

<p>Abstract</p> <p>Background</p> <p>Australia is a wealthy developed country. However, there are significant disparities in health outcomes for Aboriginal infants compared with other Australian infants. Health outcomes tend to be worse for those living in remote areas. Little is known about the health service utilisation patterns of remote dwelling Aboriginal infants. This study describes health service utilisation patterns at the primary and referral level by remote dwelling Aboriginal infants from northern Australia.</p> <p>Results</p> <p>Data on 413 infants were analysed. Following birth, one third of infants were admitted to the regional hospital neonatal nursery, primarily for preterm birth. Once home, most (98%) health service utilisation occurred at the remote primary health centre, infants presented to the centre about once a fortnight (mean 28 presentations per year, 95%CI 26.4-30.0). Half of the presentations were for new problems, most commonly for respiratory, skin and gastrointestinal symptoms. Remaining presentations were for reviews or routine health service provision. By one year of age 59% of infants were admitted to hospital at least once, the rate of hospitalisation per infant year was 1.1 (95%CI 0.9-1.2).</p> <p>Conclusions</p> <p>The hospitalisation rate is high and admissions commence early in life, visits to the remote primary health centre are frequent. Half of all presentations are for new problems. These findings have important implications for health service planning and delivery to remote dwelling Aboriginal families.</p

Maternity emergency care: Short course in maternity emergencies for remote area health staff with no midwifery qualifications

OBJECTIVE: To improve the maternity emergency skills and knowledge of health service providers, without midwifery qualifications, in remote Australia. DESIGN: A descriptive paper utilising data from a needs assessment and course evaluations used to develop and refine a short course in maternity emergencies. SUBJECTS: Remote area health providers. INTERVENTIONS: A multidisciplinary short course, targeting non-midwives in remote areas, aimed at improving knowledge and skills in detection, management and referral of maternity emergencies. RESULTS: Ten courses have been delivered to 175 participants. Evaluations demonstrate a highly valued program, well received and supported by remote health staff. CONCLUSIONS: The course is an important strategy to improve the maternity services offered to women in remote Australia

An account of significant events influencing Australian breastfeeding practice over the last 40 years

Background: Low breastfeeding duration rates reflect the pain and distress experienced by many women who discontinue breastfeeding in the early weeks and months of life. This paper explores modern key historical events that have significantly influenced Australian breastfeeding education and practice. Method: Relevant literature reviewed from 1970 to 2010 identified key events that appear to have contributed to the decrease in Australian breastfeeding rates and the increase in women experiencing breastfeeding complications, particularly nipple pain and trauma. Findings and discussion: The rise in institutionalisation and medical intervention in labour and birth has also medicalised midwifery practice. Technocratic intrusion and institutionalised care is contributing to the separation of the mother and newborn at birth. Delayed mother-baby initiation of breastfeeding and interruption of the duration of the first, and subsequent breastfeeds, negatively affects the innate ability of the mother and newborn to establish and sustain breastfeeding. The 'pathologising' of breastfeeding that involve midwives teaching women complicated and unnatural breastfeeding techniques interfere with instinctive sensory and mammalian behaviours and further contributes to the high complication rates. Conclusion: Midwives are encouraged to reflect on their role as 'experts' in the breastfeeding process and give confidence to women so that they utilise their instinctive ability to breastfeed by self-determined techniques that encourage mammalian skills for newborn sustenance and survival