‘Closing the gap’: how maternity services can contribute to reducing poor maternal infant health outcomes for Aboriginal and Torres Strait Islander women

The reproductive health outcomes for Aboriginal and Torres Strait Islander mothers and infants are significantly poorer than they are for other Australians; they worsen with increasing remoteness where the provision of services becomes more challenging. Australia has committed to 'Overcoming Indigenous Disadvantage' and 'Closing the Gap' in health outcomes. Fifty-five per cent of Aboriginal and Torres Strait Islander birthing women live in outer regional and remote areas and suffer some of the worst health outcomes in the country. Not all of these women are receiving care from a skilled provider, antenatally, in birth or postnatally while the role of midwives in reducing maternal and newborn mortality and morbidity is under-utilised. The practice of relocating women for birth does not address their cultural needs or self-identified risks and is contributing to these outcomes. An evidence based approach for the provision of maternity services in these areas is required. Australian maternal mortality data collection, analysis and reporting is currently insufficient to measure progress yet it should be used as an indicator for 'Closing the Gap' in Australia. A more intensive, coordinated strategy to improve maternal infant health in rural and remote Australia must be adopted. Care needs to address social, emotional and cultural health needs, and be as close to home as possible. The role of midwives can be enabled to provide comprehensive, quality care within a collaborative team that includes women, community and medical colleagues. Service provision should be reorganised to match activity to need through the provision of caseload midwives and midwifery group practices across the country. Funding to embed student midwives and support Aboriginal and Torres Strait Islander women in this role must be realised. An evidence base must be developed to inform the provision of services in these areas; this could be through the testing of the Rural Birth Index in Australia. The provision of primary birthing services in remote areas, as has occurred in some Inuit and New Zealand settings, should be established. 'Birthing on Country' that incorporates local knowledge, on-site midwifery training and a research and evaluation framework, must be supported

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

Improving interagency service integration of the Australian Nurse Family Partnership Program for First Nations women and babies: a qualitative study.

BackgroundThe Australian Nurse Family Partnership Program (ANFPP) is an evidence-based, home visiting program that offers health education, guidance, social and emotional support to first-time mothers having Aboriginal and/or Torres Strait Islander (First Nations) babies. The community-controlled sector identified the need for specialised support for first time mothers due to the inequalities in birthing and early childhood outcomes between First Nations' and other babies in Australia. The program is based on the United States' Nurse Family Partnership program which has improved long-term health outcomes and life trajectories for mothers and children. International implementation of the Nurse Family Partnership program has identified interagency service integration as key to program recruitment, retention, and efficacy. How the ANFPP integrates with other services in an Australian urban setting and how to improve this is not yet known. Our research explores the barriers and enablers to interagency service integration for the Australian Nurse Family Partnership Program ANFPP in an urban setting.MethodsA qualitative study using individual and group interviews. Purposive and snowball sampling was used to recruit clients, staff (internal and external to the program), Elders and family members. Interviews were conducted using a culturally appropriate 'yarning' method with clients, families and Elders and semi-structured interview guide for staff. Interviews were audio-recorded and transcribed prior to reflexive thematic analysis.ResultsSeventy-six participants were interviewed: 26 clients, 47 staff and 3 Elders/family members. Three themes were identified as barriers and three as enablers. Barriers: 1) confusion around program scope, 2) duplication of care, and 3) tensions over 'ownership' of clients. Enablers (existing and potential): 1) knowledge and promotion of the program; 2) cultural safety; and 3) case coordination, co-location and partnership forums.ConclusionEffective service integration is essential to maximise access and acceptability of the ANFPP; we provide practical recommendations to improve service integration in this context

Assessment tools measuring health-related empowerment in psychosocially vulnerable populations: a systematic review.

BackgroundMany programs are undertaken to facilitate the empowerment of vulnerable populations across the world. However, an overview of appropriate empowerment measurements to evaluate such initiatives remains incomplete to date. This systematic review aims to describe and summarise psychometric properties, feasibility and clinical utility of the available tools for measuring empowerment in psychosocially vulnerable populations.MethodsA systematic literature review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was completed. A descriptive approach was used for data analysis. Papers were eligible if they explored the development, validation, cross-cultural translation or the utility of an empowerment measurement tool in the context of psychosocially vulnerable populations.ResultsTwenty-six included articles described twenty-six separate studies in which 16 empowerment measurement tools were developed, validated/translated, or used. There was heterogeneity in empowerment constructs, samples targeted, and psychometric properties measured. The measurement of reliability of the included instruments was satisfactory in most cases. However, the validity, responsiveness, interpretability, feasibility and clinical utility of the identified measurement tools were often not adequately described or measured.ConclusionThis systematic review provides a useful snapshot of the strengths as well as limitations of existing health related empowerment measurement tools used with psychosocially vulnerable populations in terms of their measurement properties, and constructs captured. It highlights significant gaps in empowerment tool measurement, development and evaluation processes. In particular, the results suggest that in addition to systematic assessments of psychometric properties, the inclusion of feasibility and clinical utility as outcome measures are important to assess relevance to clinical practice

‘Being the bridge and the beacon’: a qualitative study of the characteristics and functions of the liaison role in child and family health services in Australia

© 2016 John Wiley & Sons Ltd Aims and objectives: This article explores the characteristics and functions of the liaison role in child and family health services in Australia. Background: Liaison roles are increasingly being used to improve communication between health services and professionals and to facilitate access to support for individuals and families in need. Nurses are commonly, although not always, the professionals who undertake these roles. Research on the role and outcomes of liaison positions in child and family health services is limited in Australia and internationally. Design: A qualitative interpretive design informed this study. Interviews and focus groups were conducted with 40 liaison and other health professionals, primarily nurses, working with families with newborn and young children in two Australian States. Data were analysed thematically. Results: Three major themes were identified reflecting the importance of defining the role and tasks which included building bridges between services and professionals, supporting families during transition between services and supporting clinicians. Several facilitators and barriers were identified, including concerns about sustainability of the roles. Conclusions: Professionals working in a liaison role in child and family health services emphasise that these positions have the potential to link services and professionals, thereby providing more effective care pathways for children and families especially for those with complex and multiple vulnerabilities. While a few children and family health services in Australia provide liaison services, the extent of liaison support and the outcomes for families in Australia is unknown. Relevance to clinical practice: Nurses working with children and families are the most likely health professionals to undertake a liaison role. In many nursing contexts, liaison roles are relatively new and those in the role have the responsibility to define the key purpose of their role. Liaison roles are multifaceted requiring the nurse to have excellent communication and negotiation skills to effectively link diverse professionals and services, while simultaneously engaging with and supporting vulnerable families and children. Nurses in these roles also support and educate clinical colleagues

Australian parents’ use of universal child and family health services: A consumer survey

© 2018 John Wiley & Sons Ltd This study aimed to explore Australian parents’ use of universally available well-child health services. It used an online survey of 719 parents of children aged from birth to 5 years in all states and territories to examine patterns of service use and consumer preferences. In Australia, several health professional groups provide advice to pregnant women, infants, children, and parents, offering health promotion, developmental screening, parenting support, and referral to specialist health services if required. The survey examined parents’ use of different child and family health providers, and their preferences for support with several common parenting issues. The study indicated that families with young children obtain primary healthcare from a range of service providers, often more than one, depending on children's ages and needs. Parents frequently visit general practitioners for immunisation and medical concerns. They attend dedicated child and family health nurses for parenting advice and well-child checks and prefer them as an information source for many health issues. However, a substantial proportion of parents (44.1%) do not currently visit a child and family health nurse, often because they not only do not perceive a need but also sometimes because these services are unknown, inaccessible, or considered unsuitable. They may seek advice from less qualified sources. There is potential for increased collaboration between child and family health providers to ensure effective resource use and consistency of parenting information and advice. Nursing services may need to address accessibility and appropriateness of care

Australian parents’ experiences with universal child and family health services

© 2018 Australian College of Nursing Ltd Background: Australian governments provide free services to promote maternal and child health, and to support parenting for families with children up to age five. Services are principally provided by dedicated child and family health nurses, but also by general practitioners, practice nurses, pharmacy nurses and midwives. Aim: This study aimed to examine the experiences of families with young children across Australia in accessing and receiving health care for well children, parenting support and advice from a range of providers. Methods: The study used quantitative and qualitative data from an online survey of 719 parents and carers with children aged up to five years. Findings: On quantitative scales, most respondents rated healthcare providers favourably for accessibility, credibility and their approach to families. However, qualitative responses revealed widely varying reactions to child and family health provision. Parents described both positive and negative experiences, highlighting elements of practice that are critical to consumer engagement. Discussion: Parents require health care and support that are accessible, consistent, affordable, encouraging, trustworthy, evidence-based and non-judgemental. Parents feel more confidence in the information and care provided by health professionals who are well-informed, resourceful and who respect their knowledge and beliefs. Conclusion: The findings demonstrate ways in which child and family health providers can engage and effectively support families with young children

Reconceptualising risk: Perceptions of risk in rural and remote maternity service planning.

OBJECTIVE: to explore perceptions and examples of risk related to pregnancy and childbirth in rural and remote Australia and how these influence the planning of maternity services. DESIGN: data collection in this qualitative component of a mixed methods study included 88 semi-structured individual and group interviews (n=102), three focus groups (n=22) and one group information session (n=17). Researchers identified two categories of risk for exploration: health services risk (including clinical and corporate risks) and social risk (including cultural, emotional and financial risks). Data were aggregated and thematically analysed to identify perceptions and examples of risk related to each category. SETTING: fieldwork was conducted in four jurisdictions at nine sites in rural (n=3) and remote (n=6) Australia. PARTICIPANTS: 117 health service employees and 24 consumers. MEASUREMENTS AND FINDINGS: examples and perceptions relating to each category of risk were identified from the data. Most medical practitioners and health service managers perceived clinical risks related to rural birthing services without access to caesarean section. Consumer participants were more likely to emphasise social risks arising from a lack of local birthing services. KEY CONCLUSIONS: our analysis demonstrated that the closure of services adds social risk, which exacerbates clinical risk. Analysis also highlighted that perceptions of clinical risk are privileged over social risk in decisions about rural and remote maternity service planning. IMPLICATIONS FOR PRACTICE: a comprehensive analysis of risk that identifies how social and other forms of risk contribute to adverse clinical outcomes would benefit rural and remote people and their health services. Formal risk analyses should consider the risks associated with failure to provide birthing services in rural and remote communities as well as the risks of maintaining services

Effect of a Birthing on Country service redesign on maternal and neonatal health outcomes for First Nations Australians: a prospective, non-randomised, interventional trial.

Background: There is an urgency to redress unacceptable maternal and infant health outcomes for First Nations families in Australia. A multi-agency partnership between two Aboriginal Community-controlled health services and a tertiary hospital in urban Australia designed, implemented, and evaluated the new Birthing in Our Community (BiOC) service. In this study, we aimed to assess and report the clinical effectiveness of the BiOC service on key maternal and infant health outcomes compared with that of standard care. Methods: Pregnant women attending the Mater Mothers Public Hospital (Brisbane, QLD, Australia) who were having a First Nations baby were invited to receive the BiOC service. In this prospective, non-randomised, interventional trial of the service, we specifically enrolled women who intended to birth at the study hospital, and had a referral from a family doctor or Aboriginal Medical Service. Participants were offered either standard care services or the BiOC service. Prespecified primary outcomes to test the effectiveness of the BiOC service versus standard care were the proportion of women attending five or more antenatal visits, smoking after 20 weeks of gestation, who had a preterm birth (<37 weeks), and who were exclusively breastfeeding at discharge from hospital. We used inverse probability of treatment weighting to balance confounders and calculate treatment effect. This trial is registered with the Australian New Zealand Clinical Trial Registry, ACTRN12618001365257. Findings: Between Jan 1, 2013, and June 30, 2019, 1867 First Nations babies were born at the Mater Mothers Public Hospital. After exclusions, 1422 women received either standard care (656 participants) or the BiOC service (766 participants) and were included in the analyses. Women receiving the BiOC service were more likely to attend five or more antenatal visits (adjusted odds ratio 1·54, 95% CI 1·13–2·09; p=0·0064), less likely to have an infant born preterm (0·62, 0·42–0·93; p=0·019), and more likely to exclusively breastfeed on discharge from hospital (1·34, 1·06–1·70; p=0·014). No difference was found between the two groups for smoking after 20 weeks of gestation, with both showing a reduction compared with smoking levels reported at their hospital booking visit. Interpretation: This study has shown the clinical effectiveness of the BiOC service, which was co-designed by stakeholders and underpinned by Birthing on Country principles. The widespread scale-up of this new service should be prioritised. Dedicated funding, knowledge translation, and implementation science are needed to ensure all First Nations families can access Birthing on Country services that are adapted for their specific contexts