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Guiding Principles for Developing a Birthing on Country Service Model and Evaluation Framework, Phase 1

Authors:
Australian Health Ministers’ Advisory Council
Guiding Principles for Developing a
Birthing on Country Service Model
and
Evaluation Framework
Phase 1
Birthing on Country Model and Evaluation Framework 2016
Internet sites
© Commonwealth of Australia 2016
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Australian Health Ministers’ Advisory Council
This document was prepared under the auspices of the Australian Health Ministers’ Advisory Council.
Suggested Citation:
Kildea, S., Lockey, R; Roberts, J; Magick Dennis, F; 2016, Guiding Principles for Developing a Birthing on Country
Service Model and Evaluation Framework, Phase 1, Mater Medical Research Unit and the University of
Queensland on behalf of the Maternity Services Inter-Jurisdictional Committee for the Australian Health
Ministers’ Advisory Council.
Acknowledgements
The authors would firstly like to thank everyone who participated in the workshop and contributed their
thoughts, knowledge and expertise to this Report. In particular we would like to thank those who commented
on the draft Report.
The Report was commissioned by the Maternity Services Inter-Jurisdictional Committee and funded by the
Australian Health Ministers’ Advisory Council
Birthing on Country Model and Evaluation Framework
Contents
Background ............................................................................................................................................. 1
Aim .......................................................................................................................................................... 3
Objectives ............................................................................................................................................... 3
Why Birthing on Country?................................................................................................................... 4
Purpose of this Document .................................................................................................................. 5
Governance ............................................................................................................................................. 7
Individual Birthing on Country Service Governance ........................................................................... 7
Philosophy and Overarching Principles of a Birthing on Country Service .............................................. 8
Service Characteristics ............................................................................................................................ 9
Characteristics of Cultural Competence ........................................................................................... 10
Skill Acquisition, Training and Education .............................................................................................. 11
General Education Characteristics .................................................................................................... 11
Maternal Infant Health and Midwifery: Workforce and Education .................................................. 11
Standards for Establishing Level 2 Services (Primary Maternity Units) ................................................ 12
Australian Rural Birthing Index ............................................................................................................. 14
Risk Management ................................................................................................................................. 14
Risk Assessment Process: Individual Sites ........................................................................................ 15
Risk Assessment Process: Individual Women ................................................................................... 15
Monitoring and Evaluation Framework ................................................................................................ 16
Implementation Guidance .................................................................................................................... 18
Methods ............................................................................................................................................ 19
Approach ........................................................................................................................................... 20
Example Evaluation Questions ...................................................................................................... 20
Example MIH outcome measures ................................................................................................. 21
Funding ................................................................................................................................................. 22
Conclusion ............................................................................................................................................. 23
References ............................................................................................................................................ 25
Appendix 1. Birthing on Country progress to date: Achieving the Actions of the National Maternity
Services Plan ......................................................................................................................................... 28
Birthing on Country Model and Evaluation Framework
1
Background
The National Maternity Services Plan (2011)1 endorsed by the Australian Health Ministers, highlights
the challenges faced by Aboriginal and Torres Strait Islander women and families with regards to
both access to, and acceptability of, maternity services. The Plan also acknowledges the challenges
faced by women and families living in rural and remote Australia, many of whom are also Aboriginal
and Torres Strait Islander. Because of this, the Plan places a high priority on bringing about
improvements in maternity services for both Aboriginal and Torres Strait Islander families and
services in rural and remote areas.
Furthermore the Plan, under the priority area workforce, recognises the low numbers of Aboriginal
and Torres Strait Islander people working in the maternity health care professions. As a result a
number of Actions relate directly to developing and supporting an Aboriginal and Torres Strait
Islander maternity care workforce. Action 2.2 of the Plan aims to: Develop and expand culturally
competent maternity care for Aboriginal and Torres Strait Islander people. A key deliverable is to
establish Birthing on country programs (Action 2.2.3) and is outlined in Table 1 below.
Table 1. Action 2.2.3. National Maternity Services Plan (2011)
The initial year
The middle years
The later years
Signs of success
AHMAC
undertakes
research on
international
evidence-based
examples of
birthing on
country programs
Australian governments develop a framework, including an
evaluation framework, for birthing on country programs.
Australian governments develop a pilot for a birthing on
country program which includes a consultative selection
process with Aboriginal and Torres Strait Islander
communities and local maternity care professionals to identify
initial birthing on country sites
Australian
Governments
establish
birthing on
country
programs
Birthing on
country
programs for
Aboriginal and
Torres Strait
Islander
mothers are
established.
In order to achieve this reform in maternity services a number of steps have been carried out under
the oversight of the Maternity Services Inter-Jurisdictional Committee (MSIJC) and these are
outlined in Appendix 1. The National Maternity Services Plan: First Year Implementation Plan 2010-
2011, Annual Report was endorsed by the Standing Council on Health on 11 November 2011.2
Development of the Implementation Plan for the Middle Years 2012-20133 was led by the Maternity
Services Inter Jurisdictional Committee in consultation with government and non-government
stakeholders who share responsibility for implementing components of the Plan. The specific middle
year actions in relation to Action 2.2.3 are detailed in the Table 2 below.
Table 2. Action 2.2.3. National Maternity Services Plan Middle Years Implementation Plan 2012-2013
The middle year action
Responsibility and
funding
Signs of success
end of year 3
Based on the outcome of investigations,
jurisdictions consider the development of a
birthing on country pilot program that includes
consultation with Aboriginal and Torres Strait
Islander people
Jurisdictions
AHMAC cost -
shared budget
2012-13
A birthing on
country
framework is
developed
Birthing on Country Model and Evaluation Framework
2
To undertake a literature review on ‘Birthing on Country’ the term was defined as:
Maternity services designed and delivered for Indigenous women that
encompass some or all of the following elements: are community based and
governed; allow for incorporation of traditional practice; involve a connection
with land and country; incorporate a holistic definition of health; value
Indigenous and non-Indigenous ways of knowing and learning; risk
assessment and service delivery; are culturally competent; and developed by,
or with, Indigenous people4
The term was further clarified at the Birthing on Country workshop (July 2012, Alice Springs) by an
Aboriginal elder, Djapirri Mununggirritj, a Yolngu woman from north-eastern Arnhem Land in the
Northern Territory, articulated it as follows:
‘Birthing on Country should be understood as a metaphor for the best start in
life for Aboriginal and Torres Strait Islander babies and their families because
it provides an integrated, holistic and culturally appropriate model of care;
not only bio-physical outcomes … it’s much, much broader than just the labour
and delivery … (it) deals with socio-cultural and spiritual risk that is not dealt
with in the current systems. It is important that the Birthing on Country
project move from being aspirational to actual. The Birthing on Country
agenda relates to system-wide reform and is perceived as an important
opportunity in ‘closing the gap’ between Indigenous and non-Indigenous
health and quality of life outcomes.5
This report builds on the previous work undertaken in the initial year on behalf of the MSIJC to
research international evidence-based examples of Birthing on Country programs.4 This document
provides guidance on issues and considerations for the development of a Birthing on Country Service
that should, if implemented in line with recommendations, be culturally competent and make a
significant improvement to health outcomes for Aboriginal and Torres Strait Islander mothers and
babies. This reflects the outcomes from the Birthing on Country Workshop, which was conducted in
Alice Springs on 4 July 2012.5
Additionally, this report provides an Evaluation Framework to measure progress and success. The
Birthing on Country literature review concluded that, based on available evidence, a Birthing on
Country model is likely to produce significantly improved Maternal Infant Health (MIH) outcomes for
Aboriginal and Torres Strait Islander women and babies. The available evidence, along with the
consensus reached at the national Birthing on Country workshop; support such models being
established in a variety of settings; very remote, remote, rural, regional or urban. It is clear that a
strong research and evaluation framework should be used to be able to report on the process,
impact and outcomes of any such developments. Ideally, this would involve a longitudinal design
that provides robust evidence and enables identification of the key factors for success, local
adaption and clearly outlines how barriers and challenges are overcome. This document focuses on
the development of culturally competent birthing services in line with the definition from the Alice
Springs workshop as included above. The proposed approach can be seen as an initial phase and
Birthing on Country Model and Evaluation Framework
3
does not address at this stage service provision areas such as in remote settings with small
populations.
Aim
To develop a Birthing on Country Model of Care and Evaluation Framework, for implementation in
Australia, that has been developed in consideration of the Birthing on Country literature review4
(undertaken In 2011/12 for MSIJC) and the outcomes from the Birthing on Country Workshop5
(conducted on 4 July 2012) in Alice Springs. As per the Terms of Reference this document includes
the following elements:
A draft Birthing on Country Model and Evaluation Framework prepared for consultation and
local adoption once sites are determined
Draft minimum standards document that outlines the optimal governance structure and key
components for the Birthing on Country model.
The model of care presented in this document along with the accompanying monitoring and
evaluation framework build further on previous work and constitutes the next step in achieving
Action 2.2.3 of The Plan and other related Actions within the Plan. The following documents should
all be used to inform future work as the evidence base and rationale underpinning the model is
more detailed in those reports and not repeated here:
‘Birthing on Country,’ Maternity Service Delivery Models: A review of the literature4
Birthing on Country Workshop Report5
The National Aboriginal Health Plan (2013-2023)6
Primary Maternity Services in Australia Framework for Implementation7
National Consensus Framework for Rural Maternity Services8
Core Competency Model and Educational Framework for Primary Maternity Services9
National Midwifery Consultation and Referral Guidelines, 3rd Edition10
Characteristics of culturally competent maternity care for Aboriginal and Torres Strait
Islander women11
National Maternity Services Capability Framework12
Nomenclature for models of maternity care: literature review13
National Guidance on Collaborative Maternity Care14
The Australian Rural Birthing Index Toolkit: A resource for planning maternity services in
rural and remote Australia.15
This is a working document, to be used in the establishment of the initial exemplar sites after which
time it is anticipated there will be a roadmap for establishment of sites in any geographical setting.
Objectives
The objectives of the Birthing on Country Model are to:
1. Improve Aboriginal and Torres Strait Islander maternal and infant health outcomes
2. Establish an effective governance structure that facilitates a partnership between Aboriginal
and Torres Strait Islander communities and the Birthing on Country service
Birthing on Country Model and Evaluation Framework
4
3. Contribute to community healing as evidenced by Aboriginal and Torres Strait Islander
community control and engagement, cultural rejuvenation, knowledge exchange and
workforce development
4. Promote knowledge exchange and strengthen community and health service capacity to
provide the best start to life for Aboriginal and Torres Strait mothers and babies
5. Reduce clinical and cultural risks through the provision of high quality, culturally competent
care from pregnancy to the year after birth.
Why Birthing on Country?
In Australia, there are wide disparities in MIH outcomes between Indigenous and non-Indigenous
families.16-19 Over the last 30 years, repeated consultations with Indigenous women across Australia
have highlighted ‘Birthing on Country’ (Birthing on Country) as something women believe will
improve MIH outcomes.20-23 The health of Indigenous Australians is integrally linked to cultural
beliefs and practices including connection to land and place of belonging,24 a link that is believed to
be strengthened by birthing on the land. Enforced evacuation to distant hospital facilities can break
this connection to land and at present precludes the involvement of family and integration of
traditional attendants and practices in the birthing process. The risk of such practices is the cultural
disconnection experienced by Aboriginal and Torres Strait Islander people in both the current and
future generation. Because of this, Aboriginal and Torres Strait Islander leaders feel strongly that the
cultural risk of not birthing on their land must be acknowledged and included in the risk assessment
process.25
When applied to the remote setting, birthing some distance from Caesarean section facilities
challenges the understandings of many western trained health providers. These concerns are held
also with regard to absence of onsite access to medical technologies and issues relating to medico-
legal liabilities.26 However, some of these steadfast beliefs and practices of requiring clients to travel
to higher-level centres for a number of specialist services are currently being challenged in Australia
through innovative approaches to healthcare such as telehealth, camera technology, virtual
consultation and task shifting approaches. We have seen the application of such innovations enable
the undertaking of complex medical procedures, such as dialysis, in remote settings. Likewise the
quality, safety and accessibility of maternity care can also be greatly improved from utilising these
approaches.
The most effective Birthing on Country model reported in the literature was the Inuulitsivik
Midwifery Service, which is a community based and Inuit-led initiative on the Hudson coast of the
Nunavik region of northern Quebec.27,28 The service covers several discrete communities across a
large geographical area with on-site birthing centres and competency based midwifery training.
Strong referral links remain with higher-level services and when identified as necessary, women,
with both their understanding and consent, can be referred to these higher-level services. The
Nunavik birth centres (n=3) are models for low volume maternity care in three remote primary
health care settings in different geographic locations accessed by plane. Two of the centres provide
care for between 30-50 births and 40-80 pregnant women and babies each per year. The larger
centre in Puvirnituq has about 120 births per year; it is the first level of referral for all surrounding
communities and the planned place of birth for four smaller communities that do not have birth
centres. This service began in 1986 following an escalation in suicides and recognition by the leaders
that the community was in crisis.29 It has proven to be sustainable model, with excellent MIH
outcomes,28 despite being many hours from the nearest surgical services. Based on 3,000 births
Birthing on Country Model and Evaluation Framework
5
since opening, the perinatal mortality rate has fallen and is better (9/1,000) than other comparable
Indigenous populations, Northwest Territories (19/1000) and Nunavut Territory (11/1000).30 A
further seven years of data (another 1,388 births) has since been reported and shown a continuation
of excellent MIH outcomes and a sustainable service.28
A total of 84.0% of the births reported in these studies were attended by midwives; 72.8% of these
were Inuit midwives and 12.0% non-Inuit midwives; 14.6% were attended by physicians, 0.4% nurses
and a small number were unreported. Reports from these communities described a community
development program that links the establishment of a local Birthing Centre to improved health care
and outcomes as well as the greater social functioning of the community. Outcomes reported
include a decrease in domestic violence and sexual assault and increasing numbers of men being
involved in the care of their partners and newborns.29-31 The establishment of the Birthing Centres is
thought to have contributed to community healing and marked a turning point for many families
who suffered from family violence.28 Male elders told the men that if they witnessed their partner
giving birth, they would see that she has been through enough and respect and care for her.28
Community members reported: the regaining of dignity and self-esteem; the building of community
relationships and intergenerational support whilst promoting respect for traditional knowledge;
restoring skills and pride; and capacity building in the community and the of teaching of transcultural
skills, both within the local community and with non-local health care providers. The Inuit midwives
themselves are vital in promoting healthy behaviour and can be effective in this role in ways that
non-Inuit health care workers are not so easily able to be.28 A key factor supporting the change
process appears to have been the open dialogue and debate around risk in childbirth.32 Birth in the
communities was also seen to contribute towards community healing from the effects of
colonisation and rapid social change.27
What does this mean for the Australian context and can we translate the successes from the Inuit
experience? The similarities between the Indigenous populations of Canada and Australia are
striking. Both have significant challenges from the enduring effects of colonisation and these are
reflected in a higher burden of disease, poverty, poor housing, lack of employment opportunities,
reduced access to services and in some cases a lack of social cohesion. The geographical similarities
include isolation and extremes in weather, which make 24/7 access unreliable. The research from
Northern Canada has shown that childbirth in very remote areas can offer a safe, culturally
competent and sustainable alternative to routine transfer of women to regional centres; in spite of
initial fears about safety and opposition to these services.28,30,31,33 With such evidence it is now
incumbent upon others where similar Indigenous disadvantage exists to bring about such service
reform through the planned introduction of similar models. A consensus was reached among the
wide range of stakeholder participants at the Birthing on Country workshop (July 2012, Alice Springs)
that the establishment of such sites should be undertaken in Australia and funded for long-term
success.5 Similar to the Inuit model, the workshop participants recognised the much wider social
implications of Birthing on Country for community healing.
Purpose of this Document
The purpose of this document is to provide a high level framework for developing, implementing and
evaluating a Birthing on Country model that could be adapted for any area in Australia (very remote
to urban). Specific sites would need to be identified before clear pathways can be outlined, as
requirements may vary between different jurisdictions and settings. The model utilises the National
Maternity Service Capability Framework12 whilst further addressing other essential aspects of a
Birthing on Country service identified in the Birthing on Country literature review,4 the Birthing on
Birthing on Country Model and Evaluation Framework
6
Country Workshop5 and the report on the Characteristics of Culturally Competent Maternity
Services.11 It provides a tool for planning and development whilst allowing for individual service
adaption that is community led and driven. In line with the broader definition of Birthing on Country
that was endorsed at the National Workshop, this document provides guidance for any level of
service. However, additional information for establishing a primary maternity unit (Level 2 Service) is
included.
In order to ensure the success and acceptance of such services, it is clear from the literature review,4
the Birthing on Country Workshop,5 and other work in the field of Aboriginal and Torres Strait
Islander health, that the development of services needs to be underpinned by community
development approaches, with the engagement of the community in every step of the process.
Engagement ranges from initial consultation to active participation in all stages of the development
and establishment of a service. Because of this the model proposed in this document must
necessarily avoid being overly prescriptive, allowing for this level of engagement and community
control to take place.
The following diagram identifies the important aspects of successful, culturally competent Birthing
on Country models as evidenced by the literature.4 The model description further expands each
essential area in order to describe key components of a national Birthing on Country model.
Birthing on Country
Maternity services designed by & delivered for Aboriginal & Torres Strait Islander women & families
Governance
Indigenous control, community development approach, shared vision cultural guidance & oversight
Philosophy & Overarching Principles
Respect for & incorporation of Indigenous knowledge & traditional practice / respect for family & mens
involvement / partnership approach / women’s business / continuity of carer / connection with country/
land / capacity building approach - particularly with training & education/ holistic definition of health /
choice / evidenced based clinical practice / social model of health & wellbeing
Skill Acquisition,
Training & Education
Partnership approach/ 2 way
learning; appropriately trained
& supported; competency
based; delivered on-site;
career pathway from
maternity workers to
midwifery, health literacy for
women & families
Service Characteristics
Culturally competent service & staff;
Community based; specific location;
Designated ongoing funding; welcoming
flexible service focusing on relationships &
trust; outreach, transport, child friendly &
group sessions; social, cultural, biomedical
& community risk assessment criteria;
clinical & cultural governance,
interdisciplinary perinatal committee;
effective IT; integrated services
Monitoring &
Evaluation
Designated funding
for monitoring &
evaluation;
continuous quality
assurance; audit
activities &recall
register
Results
Community healing as evidenced by: reduced family separation at critical times, restoration of skills &
pride; capacity building in the community; supporting community & family relationships; reduced family
violence; increased communication & liaison with other health professionals & service providers;
comprehensive, holistic, tailored care; improved maternal & infant health outcomes.
Figure 1. Components of maternity service delivery models for Indigenous mothers and babies
Birthing on Country Model and Evaluation Framework
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Governance
The governance of any service is a critical element in ensuring the service runs smoothly, can
address problems and barriers as they arise, is in keeping with its intended goals as well as re-direct
services if required. In the case of Birthing on Country, community control and the leadership and
engagement of the Aboriginal and Torres Strait islander people for whom the service is intended is
essential, and requires an overall governance system that facilities this. In health services clinical
governance is a key aspect of quality and safety and this also needs to be addressed. In the case of
Birthing on Country whilst clinical governance needs specific attention it must also be well
integrated with a wider overall governance system in place.
Individual Birthing on Country Service Governance
Drawing on successful models internationally, it is critical that the governance is clearly articulated
and understood by all parties. This will need to be decided locally as it will depend on where the
funding is sourced from, who administers it and how local parties agree to the operation of clinical
and other services. Indigenous control is an important factor. In order to achieve this it may be
necessary to establish a local Steering Committee that takes responsibility for the governance of
each individual service. Initial steps in establishing a Birthing on Country program must begin with
the establishment of such a Committee within a location that has been self-selected for a Birthing on
Country service. Training in governance and the role of the Steering Committee may be necessary
and needs be provided in the initial stages of establishment as well as at various intervals during the
life of the committee.
Figure 2. Proposed Governance Structure for Birthing on Country Model
Babies
Mothers
Families
Communitie
s
Birthing on Country Steering Committee
Local Steering Committee
Local Birthing
on Country
Service
Women’s
Cultural
Advisory
Committee
Clinical
Governance
Birthing on Country Model and Evaluation Framework
8
The following are some key points to be addressed in order to bring about community controlled
governance:
Aboriginal and Torres Strait Islander leadership/control through a Aboriginal community
appointed local Steering Committee
Governance is embedded in a community development framework, adopting appropriate
techniques and approaches that ensure inclusivity and access for community members
Aboriginal and Torres Strait Islander women’s cultural advisory group for cultural guidance
and oversight if this is not an integral role of the Steering Committee.
Local governance will also be influenced by the individual sites that are chosen and the jurisdictions
they are in. It is possible that sites will be established in areas where either Government and/or
Community Controlled Aboriginal Health Organisations are the key provider of services. Either way a
partnership arrangement, for example through a non-incorporated joint venture, would allow the
organisations to regulate their relationship and the requirements of the service (Primary Maternity
Unit within an integrated network) by way of agreement (for example Memorandum of
Understanding [MOU]). The agreement would outline the clinical governance structure,
insuranceand financial services support for the clinical services. Insurance is a key factor that needs
to be addressed with all health professionals responsible for ensuring they have the appropriate
insurance to conduct the work that they do. The midwives working in the service must have
insurance to cover intrapartum care either via their employer or as private practicing midwives.
Further information on clinical governance can be found under Risk Management below).
Philosophy and Overarching Principles of a Birthing on Country
Service
To ensure the success and integrity of any Birthing on Country model the philosophy and
overarching principles of Birthing on Country must be embedded within the development and daily
operation of the service. The following outlines the philosophy and overarching principles of Birthing
on Country, informed by the literature review4, the national workshop5 and the philosophy and
model of midwifery care34 and maternity care models more generally.35
This model incorporates Indigenous knowledge, including practices that consolidate and reinforce
connection with culture, land and country. In doing so the model remains mindful of the need for
consistency, high quality of care, management of clinical and cultural risk and the need to improve
maternal and infant health outcomes for Aboriginal and Torres Strait Islander people. An underlying
principle is the commitment to balance an evidence-based approach with a community
development approach that recognises a multiplicity of evidence.
Community participation is a fundamental platform of the underlying philosophy. In this context
community participation refers to the level of engagement each community implementing Birthing
on Country seeks to exert over the planning, development and management of birthing services to
influence:
How problems, issues and challenges are identified and defined
The solutions that are identified, agreed and implemented
The management and/or delivery of culturally appropriate and acceptable solutions, and
Birthing on Country Model and Evaluation Framework
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Monitoring and evaluating, including agreed indicators, data collection processes and
reporting.
The level of participation will be context specific and determined in partnership. The Birthing on
Country Model reflects the following principles:
Privileging Indigenous knowledge and releasing and strengthening local capacity
Aboriginal and Torres Strait Islander cultural guidance and oversight
Woman/family centered holistic care (maximising social, emotional, spiritual and cultural
wellbeing and informed choice) whilst centering on the mother’s choice/mother’s birth plan
and with support and involvement from the whole family as per the mother’s directives
Partnership approach
Birth is a significant life event and a normal physiological process
Continuity of carer by a culturally competent workforce integrated into a maternity services
network
Community development approach
Evidence based approach
Right care by the right person at the right time in the right place
Care is safe and feels safe.
Service Characteristics
The key elements of successful programs that have been developed for Aboriginal and Torres Strait
Islander families in Australia and have been shown to make a difference to MIH outcomes have been
identified in two reviews of the literature.4,36
The following should be considered to be essential characteristics of each service, regardless of
location, and can be used as a starting point in the development of any individual Birthing on
Country service:
Culturally competent service and staff11
Community based services integrated with other health services within the community for
example the Obstetric Outreach Service, Aboriginal Community Controlled Health Service
and the higher-level referral service
A service location intended specifically for women and children, with engagement of fathers,
men and wider family groups as deemed appropriate by mothers and the governing body
Designated ongoing funding for the service to ensure sustainability
A welcoming and safe service environment with flexibility in service delivery and
appointment times; a focus on communication, cultural competence, relationship building
and development of trust
Respect for Aboriginal and Torres Strait Islander people and their culture; and integration of
local Indigenous knowledge with western knowledge within an effective partnership
approach
A service that provides evidence based high quality care integrated with other services
including a 24 hour service for birthing, outreach activities, home visiting, provision of
Birthing on Country Model and Evaluation Framework
10
transport, child friendly, parents/peer support groups, parenting education, services
targeting young women, postnatal support group, support for perinatal mental health
issues, early childhood services all of which include local cultural knowledge as the
foundation of such services, for example a parenting program will be written from a cultural
parenting perspective by local Aboriginal people
Routine orientation to services for all service users
Appropriately trained workforce with support from an interdisciplinary team, quality
assurance framework for continuous evaluation and audit activities that include a recall
register
A risk screening process with risk assessment criteria that includes social, cultural and
psychological factors as well as biomedical ones; risk to be assessed by interdisciplinary
review involving the woman and her nominated companions if she requests
Supportive programs that take a strength based approach to addressing common risk factors
in pregnancy and the postnatal period e.g. anaemia, infections, smoking, drugs and alcohol
Effective information technology services both internally and between services, including
identified referral services
Service to be integrated with higher-level services with clear referral pathways and
formalised networks
Education and employment of local Aboriginal and Torres Strait Islander community
members, across the necessary staff and profession
Effective systems and guidelines for consultation, referral, transfer, risk assessment,
screening and emergency evacuation.
Characteristics of Cultural Competence
The cultural competence of any Birthing on Country service is critical, without this in place then the
service is unlikely to achieve its goals. The characteristics of culturally competent maternity care for
Aboriginal and Torres Strait Islander women, have been outlined in a recent MSIJC document11 and
are addressed in the following areas:
Physical environment and infrastructure
Specific Aboriginal and/or Torres Strait Islander program
Aboriginal and Torres Strait Islander workforce
Continuity of care and carer
Collaborating with Aboriginal Community Controlled Health Organisations and other
agencies
Communication, information sharing and transfer of care
Staff attitudes and respect
Cultural education programs
Relationships
Informed choice and right of refusal
Tools to measure cultural competence
Culture specific guidelines
Birthing on Country Model and Evaluation Framework
11
Culturally appropriate and effective health promotion and behavior change activities
Engaging consumers and clinical governance.11
Each of these characteristics is accompanied by suggested indicators in order to determine the
cultural competence of an overall service. Whilst these characteristics and accompanying indicators
need further testing, they provide the most suitable framework to date for assuring cultural
competence in maternity care settings and need to be fully incorporated into the development of
Birthing on Country services.
Skill Acquisition, Training and Education
Sustainability is a key concern in establishing any service, particularly so in rural and remote settings
where the workforce is often transient with a high turnover. This, along with the need to develop
education and employment opportunities for Aboriginal and Torres Strait Islander people makes this
an essential aspect of the Birthing on Country model. There are a range of employment
opportunities in such a service including the health professions, management and administrative
roles. Access to quality locally based education, along with ongoing support and mentorship, is
essential to the success, goals and sustainability of a Birthing on Country service.
General Education Characteristics
All staff have clearly articulated and documented roles
Professional staff have protected time to undertake their roles as educators and mentors
which is articulated within their job descriptions
A career pathway is articulated and operationalised from maternity care support worker to
midwife through access to competency based midwifery and maternal infant health
education, Certificate level through to Bachelor degree.
Strong partnerships with both a vocational education and training provider and university
education provider are identified and developed
Away from Base models of education are accessed enabling students to stay largely in their
home location, where the Birthing on Country service is based
Students are employed through the service whilst undertaking identified education.
Maternal Infant Health and Midwifery: Workforce and Education
The MIH and midwifery workforce and educational pathways are an essential component of the
Birthing on Country service across all settings. Building the Indigenous workforce and ensuring the
non-Indigenous workforce is culturally competent is critical to increasing culturally competent care.
We understand the midwifery positions in other primary units in Australia are attractive positions for
midwives and we think it is possible these would be even more attractive. This is evidenced in the
Northern Territory where they have found that the Remote Area Midwife positions and the caseload
positions offering midwifery group practice care to Aboriginal women are showing better retention
rates than other nursing and midwifery retention rates.5,37 In fact we believe these models will prove
to be a good workforce solution approach. The possibility of supplying part of the workforce through
the Eligible midwife model is clear following the rapid expansion of these models in Queensland.
The educational pathway must meet the Australian Nursing and Midwifery Board Standards for
Midwifery Education38 and starts by making Certificate Courses (I-IV) available in maternal infant
Birthing on Country Model and Evaluation Framework
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health that articulate through to Bachelor programs. The South Australian Aboriginal Maternal Infant
Care (AMIC) Course provides an example. The AMIC role includes clinical, cultural and social care
from pregnancy through to 6-8 weeks after the birth. These workers work side by side with midwives
to provide culturally competent care. Mentorship and on-site education are critical and as described
above must be reflected in the role descriptions and time allocation of clinical staff to fully enable
them to do this. A step wise competency based approach, as delivered in the Inuit model, should be
considered.
Standards for Establishing Level 2 Services (Primary Maternity Units)
The National Maternity Service Capability framework (NMSCF)12 provides the framework for
planning and establishment of maternity services across a range of levels of service from 1-6, with
level one being primary community based service with no birthing service and level six being the
highest level service with of the full range of specialist services available on site.
The NMSCF is a high level document that describes the minimum service capability requirements for
services in rural, regional and metropolitan settings, whilst also acknowledging the need for local
adaptation and flexibility. The document outlines the minimum requirements for each level of
services including staffing. For the Birthing on Country model we are particularly concerned with
Level 2, where the: The mother and baby have normal care needs for birthing and post partum care12
The level of risk is determined by ‘the presence of certain conditions or circumstances or planned
interventions which influence the probability of an adverse event or undesirable outcome before,
during or after birth. These influences in turn determine the complexity of care and of clinical support
services required by the woman’12 Levels of risk are defined within the document as: Normal Care
Needs; Moderate Complexity; High Complexity and these are fully described on page eight of the
document. For planned birthing within a modified level two Birthing on Country service, regardless
of location, we are focussing on those women with ‘normal care needs’, due to the necessary
attributes for Birthing on Country to be placed within a community setting. The model however will
care for all women, including those with both moderate complexity and high complexity care needs,
during the antenatal and postnatal period. Importantly staff working in the model (the primary
midwife for each woman) will liaise and organise referral and back-transfer in a seamless fashion for
specialist or allied health care for birthing, or at other times as required, with a focus on continuity
and integrated care. Every woman from the community will be a part of the Birthing on Country
service model whether or not she needs to attend higher level services outside of the community.
The women that attend hospital will have an completed Social, Emotional, Cultural and Spiritual
Well-Being (SESCWB) plan that incorporates their express wishes including who they will have
accompany them when they are transferring, what wishes need to be adhered to in the hospital,
(e.g. bring their placenta home) etc.
The NMSCF identifies four components as key elements to best describe the criteria required to
meet the stated objectives and support the minimum standards for the provision of safe maternity
services:
1. Complexity of care
2. Workforce
3. Clinical support services
4. Service networks and integration.
Birthing on Country Model and Evaluation Framework
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A level two service is described on page 17 of the document and these can be usefully applied to
Birthing on Country services in rural, regional and metropolitan settings for which the document is
intended (p.5). It does not however address any of the requirements for culturally competent care
and the other essential components of Birthing on Country as outlined in this document so far.
Additionally, the level two within the NMSCF described does not account for services in remote
settings and a different set of standards is required. The following table (Table 3) provides a
framework for a level two service in a remote or very remote setting, and may also be more
applicable to some rural settings than the level two outlined in the NMSCF, again local nuances will
be necessary. This standard builds on level one of NMSCF and needs to be viewed accordingly.
Table 3. Maternity Service Capability framework for a level two service in a remote or very remote setting
Complexity of care needs
The mother and baby have normal birthing and postpartum care
needs
Antenatal care
Antenatal outpatient and ambulatory postnatal care available
Antenatal home visiting available
Birthing care community based
Planned homebirth (if service is offered) with established
consultation, referral and transfer pathways to higher level
services if required
Birthing care facility based
Birthing care is provided in dedicated birthing rooms in a
community based facility or recognised birthing centre
The equivalent on site neonatal service capability can support
planned birth for women with pregnancy ≥37 weeks gestation
Service capability supports referral for emergency or unplanned
caesarean section
Postnatal care
Postnatal outpatient and ambulatory postnatal care available
Postnatal home visiting available
Workforce
Registered midwives and or
Eligible midwives
Qualifications as per Nursing and Midwifery Board of Australia
Registered midwife with necessary competence and post
graduate experience to meet the requirements of the Registration
Standard for Eligible Midwives of the Nursing and Midwifery
Board of Australia
Aboriginal and Torres Strait
Islander
Health Practitioners
Registered with the Aboriginal and Torres Strait Islander Health
Practitioners Board of Australia
Aboriginal and Torres Strait
Islander Health workers
Such as Maternal Infant Health workers, Aboriginal Maternal
Infant Care workers, Aboriginal education officers, Aboriginal
mental health workers/Aboriginal counselors
Aboriginal Cultural Community
workers
Such as Strong Women Workers, Local Aboriginal cultural
knowledge holders
General Practitioner
Obstetricans
(optional)
For services that are established where General Practitioner
Proceduralists/Obstetricians work as part of the core service they
should be considered as part of the team
Maternal and child health
services
Service which administers support for mothers and infants in
parenting, child health and development in the perinatal period.
Clinical support services
Pathology
Access to designated pathology services off-site to perform
routine pathology services as part of regular care
Pharmacy
On-site pharmacy for approved standing order essential pharmacy
list for midwives
Birthing on Country Model and Evaluation Framework
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Access to off-site pharmacist
Theatre
Access to an appropriately equipped operating theatre with
requisite staff and capability for emergency caesarean section
24/7 (off-site)
Transfer time to be defined and understood in the local context
Perinatal autopsy support
service
Access to a perinatal autopsy service
Service networks and
integration
Documented and formalised
alignment within a maternity
services network
Documented and agreed process for consultation, referral and
acceptance of women with more complex care needs within the
maternity services network
Documented and agreed process for transfer of care, in both
routine and emergency situations, that ensure minimal time for
transfer to be completed
Formal agreement for access to operating theatre with
equipment and staff capable of emergency caesarean section 24
hours with a level 3 service within the maternity services network
Documented and agreed process for acceptance of back transfer
of physiologically stable women and neonates from higher level of
service.
Australian Rural Birthing Index
The Australian Rural Birthing Index (ARBI) is an index that can be used to contribute to planning the
level of maternity service for a particular facility. It has been developed from a similar Canadian
index, which was grounded in extensive fieldwork in British Columbia.39 The Australian index15 has
been based on Australian data for all maternity services in all states and territories, and on fieldwork
in a smaller number of selected locations.40,41 The ARBI applies to rural maternity services in facilities
with catchment populations of 1,000 to 25,000. The term ‘rural’ is used inclusively here to denote
locations with Australian Bureau of Statistics (ABS) remoteness area (RA) categories of Inner
Regional, Outer Regional, Remote and Very Remote (RA categories 2 to 5).
Calculation of the index is based on:
The catchment area of the maternity service, which is used to calculate the population birth
score, which is calculated by the number of births in the catchment population
The social vulnerability score, which is a calculation based on the relative socio- economic
disadvantage of the catchment population compared to the rest of the country
The isolation factor, which is derived from the geographic proximity of the facility, to the
nearest alternative surgical facility that can perform emergency caesarean section.
A weighting is applied to each of the above factors to produce a score that estimates the
appropriate level of maternity service for its particular location based on population need. The ARBI
is a guide only. It is to be used with all other factors that would normally be taken into account when
planning a health service.
Risk Management
The establishment of any new Birthing on Country Model of Care requires an agreed risk
management framework closely aligned to the clinical governance framework. This is to include
Birthing on Country Model and Evaluation Framework
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policies, processes and accountabilities that are directed at ensuring and improving consumer
quality and safety as well as effectiveness and dependability of the service. Such a framework must
also identify relationships to other services, including referral services, that form the Integrated
Maternity Service Networks,12 known as a collaborative services framework also noted in the
Primary maternity services in Australia framework: “The safety and effectiveness of primary
maternity services is underpinned by a collaborative services framework amongst care providers that
ensures appropriate assessment, timely referral and access to secondary services”.7
The Risk Management Framework should include the following:42
Clinical Practice Guidelines
Evidence based practice
Clear role delineation
Continuous professional development and regular annual and mandatory education
Regular processes for consumer participation in health service planning
Documented communication pathway and networking arrangements
Regular risk assessment
Consultation and referral guidelines10
Documented pathway and training for escalating maternity events
Regular data collection and clinical audit processes
Complaints management processes
Process for non-standard maternity care - consultation, informed choice and
documentation10
Evaluation Framework
Research and Development.
Risk Assessment Process: Individual Sites
A risk assessment process should be undertaken with stakeholders at each site prior to
implementation of the model. The methodology of the Australian/New Zealand Standard ISO 31000,
Risk Management - Principles and Guidelines43 (similar to that utilised prior to the introduction of
the redesign of the Ryde Hospital Maternity Services44) provides one example of a suggested
process. The risk assessment should aim to: outline changes to current service arrangements; assess
any threats or risks associated with the changes to service arrangements; analyse threats to the
organisational environment, clinical safety, staff safety and the viability of the service; and identify
controls to manage and monitor the threats and risks. The effective management of risk will enable
maximise opportunities to achieve the aims and objectives.
Risk Assessment Process: Individual Women
Risk assessment in maternity care is complex as what is assessed as low risk at one point in time is
not necessarily predictive of the level of risk encountered over the duration of the pregnancy, birth
and post natal period.12 Additionally, what is considered to be a significant risk factor to one person
may be a totally acceptable risk to another, depending on individual circumstances. The risk
assessment process is discussed in more detail in the workshop report5 which emphasised that the
risk assessment criteria must enable women to identify their own risks within an Aboriginal and/or
Torres Strait Islander cultural framework and ensures equal weight is given to risks associated with
Birthing on Country Model and Evaluation Framework
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spiritual, emotional, and cultural disenfranchisement as is given to clinical, biomedical risks. A risk
assessment process for each woman should be conducted by an interdisciplinary review involving
the woman and her desired support person/people (eg. her choice of family member(s)). This should
occur between 30-34 weeks gestation and include discussions regarding the place of birth. Decisions
may need to be revisited if the situation changes.
The Australian College of Midwives National Midwifery Guidelines for Consultation and Referral10
are an evidence based tool that has been tested within a randomised controlled trial of midwifery
group practice for women of all risk status in an urban setting.45 These should be utilised by
midwives within a Birthing on Country service to inform decision making during the antenatal,
intrapartum and postnatal period. They need to be accompanied by a context specific regard for
transfer times to higher-level facilities, as defined at a local service level, and should be evaluated for
the remote setting and adapted as required.
Monitoring and Evaluation Framework
The introduction of a Birthing on Country model of care must be considered a complex
intervention46,47 and have an appropriate monitoring and evaluation framework that will enable all
stakeholders to understand not only what components were integral to success or failure but why
these components were so important and influential. To inform the monitoring and evaluation
framework, a Program Logic Model that includes high level outcome indicators, has been developed
(Table 4) and has embedded within it the theoretical understandings of how the intervention (the
Birthing on Country model of care) is expected to cause change. Monitoring and process evaluation
are essential to ensure the model is being implemented according to plan, whilst impact and
outcome evaluation is essential for determining the success of the model in contributing to
achievement of the aim and objectives.
Birthing on Country Model and Evaluation Framework
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Table 4. Program Logic Model for Birthing on Country
INPUTS
What is
invested
ACTIVITIES
What is done
OUTPUTS
What is delivered
OUTCOMES
Short medium
results
INDICATORS
Measurment
IMPACT
Longer term results
Cert III or IV MIH
workers
Strong Women
Workers
Aboriginal
Health
Practitioners
Student
Midwives
Midwives
Child Health
Nurse
Administration
staff
Manager
Transport
Governing Body
and Advisory
Committees
Infrastructure
Funding
Partnership
Investment
Antenatal (A/N) Care including
Alcohol and other drugs (AOD) and
support for smoking cessation
Risk assessment
Birthing
Postnatal (P/N) Care (reproductive
health, lactation support etc)
Perinatal Mental Health
Infant Health Care (nutrition, growth
monitoring and developmental
assessment, increasing parental
responsiveness)
Health Promotion (individual or small
groups)
Community Development (CD)
Health Literacy (HL)
Cultural Care
Social Emotional Cultural and
Spiritual Well-Being (SESCWB)
Case review /consultation Referrals
and transfer to specialist and higher-
level care
Measure individual and institutional
cultural competence
Governance
Continuous Quality Improvement
(CQI) System and Planning
Assistance for women to develop a
birth plan
A/N Care scheduled 12 visits
Smoking cessation, alcohol and other drugs support program
Cultural/Clinical Risk Assessment and management system
Birthing on country
Continuity of Care for hospital births
Woman centered care as per MGP schedule
P/N Care to 6 weeks and women’s health checks
Screening and Assessment follow up referral &/or support
Healthy Under 5, child health check
Immunisation service
AOD, nutrition, pregnancy care, sexual and reproductive health (SRH),
Timely identification, management and early intervention of
developmental problems
CD Framework & Action Plan
HL Sessions
SESCWB plan for mum and family including birth plan
Cultural ceremonies/Strong women strong babies strong culture
(SWSBSC) program or equivalent
Full team case review at 34 weeks for all women/shared records
Tracked referral System
Networking/Integrated Care Strategy
Transport
Cultural competence score
Clinical governance framework
Cultural Knowledge Holders Oversight
Monitoring and evaluation plan, reporting against indicators
CQI Plan implemented
CQI System, plan, implementation
Early presentation
Woman Centred Care
A/N screening completed
Normal Births
Continuity of Care
Reduced Smoking in
pregnancy and Fetal
Alcohol Spectrum Disorder
Increased birth spacing
Breast fed @ 6 months
Fully immunised @ 12
months
Reduced Failure to Thrive
Functional effective early
intervention
Community engagement in
health literacy, cultural care
planning, community
healing
Culturally competent care
by a skilled workforce
Complications and risks
managed and mitigated
Exemplar sites established
% preterm births
↑ % normal birth (37-41 weeks,
vaginal birth, vertex presentation,
spontaneous onset of labour)
↑% healthy baby (liveborn,
singleton 37-41 completed weeks
gestation, 2,500-4,499g
birthweight, Apgar score at five
minutes ≥7)
% women with documented case
review at 34 weeks
% women health literacy
certificate
% Infant hospitalisations <12
months
% Breast fed @ 6 months
Immunisation coverage rates @
12 months
No. of Indigenous MIH staff*
MIH staff turnover
CD framework & action items
Self esteem measurement
Functioning governance Board
Completed plans for cultural
safety, risk management
% having SESCWB plan
% having birth plan
% culturally competent staff
Facility cultural competence
score
↑% normal birth
↑% healthy baby
Reduced preterm births and
neonatal nursery admissions
Reduced Infant morbidity
and mortality
Lower rates of
developmental delay
Increased retention of skilled
staff
BoC model for scaling up
Partnerships and Knowledge
Exchange Mechanism
Culturally safe and
responsive services
Community Healing
Sustainable Funding Model
and cost containment
Increased empowerment for
individual women and
communities as a whole
through owning life decisions
Underlying Principles
1. Privileging Indigenous knowledge and releasing and strengthening local capacity
2. Aboriginal and Torres Strait Islander cultural guidance and oversight
3. Woman/family centered holistic care (informed choice) engages men and fathers within culturally appropriate
framework
4. Partnership approach
5. Birth is a significant life event and a normal physiological process
6. Continuity of carer by a culturally competent workforce integrated into a maternity services network
7. Community development approach
8. Evidence based approach
9. Right care by the right person at the right time in the right place
10. Care is safe and feels safe.
Birthing on Country Model and Evaluation Framework
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The process evaluation will enable any lack of impact to determine either implementation failure or
genuine ineffectiveness. Identification of which aspects are integral to the model and which can be
adapted locally is essential. Once the model has been agreed and sites have been selected, a
detailed monitoring plan will be developed that reflects the process indicators, data collection,
storage and analysis methods. Evaluation questions will be developed in collaboration with the local
Steering Committee and other key stakeholders (Draft below). The evaluation will determine the
extent to which the outcomes are achieved and benefits realised for key groups of stakeholders in
the community and the health system. Designated resources for monitoring and evaluation will be
essential to ensure both the process and impact are documented and well understood. The
monitoring will incorporate aspects of a continuous quality assurance framework, including audit
activities.
Implementation Guidance
The following are a suggested guide for the implementation of the model and evaluation framework.
1. Call for Expressions of Interest from communities to be developed as pilot sites’ and
expressions of interest for a Steering Committee at the same time.
a. Establish Steering Committee
b. Steering Committee to assess and choose exemplar sites based on selection criteria
which may include an assessment using the Australian Rural Birthing Index15
2. At each site
a. Appoint a project officer
b. Identify key stakeholders (may need to undertake stakeholder mapping analysis)
c. Request community involvement in planning the service
3. First community meeting regarding creation of Birthing on Country health service
a. All members of the community are automatically members of the Birthing on
Country health service (but have the choice whether to be active or inactive
members) i.e. they do not have to apply to be part of the organisation but just are,
and as such every community member is invited to the Annual General Meeting
4. Establish Local Governance / Steering Committee at each site to provide Indigenous
governance and cultural oversight
5. Undertake risk assessment with key stakeholders
a. Identify service, staff, funding and resource gap
b. Develop plan to address identified gaps
c. Establish systems for consultation, referral and transfer (including emergency
retrieval)
d. Identify insurance cover for lead carers providing intrapartum care
6. Commence baseline data collection at all sites whilst establishing other important
components (which may be already available) for example:
a. Continuity of midwifery carer: within a midwifery group practice model networked
to a regional or higher level service (that may offer outreach or telehealth for
obstetric and other specialised services) offering 24/7 care from a named midwife
from first presentation in pregnancy until handover to child health services at 6
Birthing on Country Model and Evaluation Framework
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weeks postnatal. Care will be provided for all women, and those with no identified
risk factors offered local birth in Level 2 service if established. Women with risk
factors will be carefully monitored and offered support when they travel to higher-
level services.
b. A Birth Unit which incorporates:
i. The Indigenous specific service characteristics for culturally competent care
(described under Service Characteristics above and in more detail other
documents4,5,11) and,
ii. The maternity clinical service capability of a Level 2 unit as per of the
National Capability Framework12
c. Indigenous Health Workers and Strong Women Workers
d. Student midwives who access much of their training (though not all) on site with
onsite tutorial support
e. Cultural and clinical supervision program
f. Monitoring and Evaluation.
Methods
The literature review identified a dearth of high quality evidence from research that has examined
maternity services designed by and delivered for Aboriginal and Torres Strait Islander mothers and
babies. Thus it will be important to have a strong research and evaluation framework to test the
introduction of Birthing on Country Models. A Randomised Controlled Trial (RCT) implementing a
clustered step wedge design comparing standard care to a Birthing on Country model of care could
be considered. This RCT design would provide robust evidence and enable identification of the key
factors for success and local adaption. It would require a phased implementation to allow detection
of underlying trends and to clearly outline how barriers and challenges are overcome. There is
already at least one step wedge RCT being undertaken in the remote Aboriginal and Torres Strait
Islander context and funded by NHMRC: STRIVE Sexually Transmitted infections in Remote
communities: ImproVed and Enhanced primary health care services is a new trial which aims to
reduce levels of STIs in 21 or more participating ‘trial clusters’ over a five year period.
Proposed clusters (communities) could be located in any area across Australia. The unit of
randomisation would be by geographic cluster; 12-20 sites/communities would each be randomised
to a Birthing on Country model of care to commence implementation at distinct time points. Prior to
commencement (first time point), baseline data would be recorded at all sites. At the second time
point randomisation and development of the Birthing on Country Model would begin in several sites
(eg. three sites, across several states). By the third time point several more sites will commence (eg.
a second site across several states). At the fourth time point the remaining sites commence with
ongoing data collection at all sites until the evaluation ends. The model would be consistently
evaluated, fine-tuned and re-evaluated. Regular monitoring and evaluation occurs.
Birthing on Country Model and Evaluation Framework
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Clusters /Communities
9
8
7
6
5
4
3
2
1
1
2
3
4
5
Time point
Standard Care
Birthing on country Model
Figure 3. Step Wedge RCT example
Approach
A participatory action research (PAR)48 and triangulated mixed methods49 approach will be required.
The PAR approach is recommended for research and evaluation in the Australian Aboriginal
context50 and if done correctly it ensures the process will be responsive to Indigenous cultural values
and principles including emancipation, empowerment, community development and collaboration in
research processes. Aboriginal communities themselves stand a better chance of long-term success
in addressing health and social disadvantage. If this is the case, governments must build capacity in
Aboriginal communities to assess need and deliver culturally-appropriate services51 The Birthing on
Country program will enable this by ensuring Indigenous people themselves have the opportunity to
develop culturally-relevant solutions using the skill and cooperation of both Indigenous and non-
Indigenous people. Since the workers in the programs will be community members themselves, and
the management of the program will be via a community based Board, the most appropriate
evaluation approach is the PAR cycle.
A bicultural approach, with reciprocal partnerships between all stakeholders, particularly community
representatives and service users will ensure Aboriginal and Torres Strait Islander ways of being,
doing and knowing are incorporated and followed.52 The way ‘capacity building’ is constructed often
reflects a belief that Indigenous communities and members are somehow deficient and must rely on
others to support their development. Indigenous ways of knowing must be recognised as valuable
and community-based analyses of problems, respect for individuals, commitment to social change,
and an equal partnership between service users, stakeholders and the evaluation team will all be
required. Whole of community meetings (where everyone is invited and those who wish to attend
do so) will be important throughout this process ensuring communities are able to self-evaluate
their service, including from a cultural perspective, to increase ownership and enable reflection and
further planning and action following each cycle of evaluation. Human research ethics committee
approval will be required prior to the research being undertaken.
Example Evaluation Questions
Questions will be developed to provide data on the processes, impact and outcomes related to this
new model of care. The model will be described to report on how outcomes are achieved by
exploring:
Is the model functioning the way it was intended?
Birthing on Country Model and Evaluation Framework
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What makes this model unique when compared to other models of care?
How is the model achieving its objectives?
How do women and their families describe their experiences?
What are the strengths and weaknesses of the model?
Are there any barriers to sustained delivery of this model of care from the perspectives of all
stakeholders?
The impact of this new model of care will be measured by exploring the short-term effects including
any benefits of the program by focusing on areas such as:
What effects does the new model have?
Can the effects be attributed to the new model?
Does the new model achieve its objectives?
The importance of evaluating people’s mental health as associated with cultural revival and
connection to country, increased employment and education opportunities, increased hope for
cultural survival and increased spiritual nourishment needs to be explored for example: how are
communities able to express these changes, how do such changes come about?
Some examples of the types of questions that could be regularly asked during the PAR process
include:
Have we created an environment of cultural safety for everyone here?
Have we increased our wellbeing?
Have we reduced the amount of Family Violence in our lives?
Have we improved our relationships with our family members and each other?
Have we improved our relationship with country?
Have we increased the wellbeing of our country?
Have we found ways to ensure the economic sustainability of families and our community?
Have we been practicing our culture, law/lore and spirituality?
The questions above will firstly form the basis for an observations evaluation and then re-posing the
questions by looking at how community could improve the service with respect to each question will
then form the basis for a reflection evaluation which will lead to plans for further action to improve
our community Birthing on Country service.
Example MIH outcome measures
The MIH outcome measures could include:
Mean gestation 1st A/N visit
Mean number of visits
% women < 20 years
% A/N screening tests
% received full treatment: anaemia, STI, UTI
% smoking, drinking alcohol and other drugs: booking, birth, 6 weeks P/N
Birthing on Country Model and Evaluation Framework
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% births < 32 weeks at least 1 A/N visit first trimester (<13 weeks)
% births < 32 weeks =>5 A/N visits
% interventions in birth
% A/N, Birth, P/N complications
Mean length of stay in hospital & nursery - mothers & infants
% infants admitted to nursery >4 hours
% positive screening EPDS, emotional distress
% intrapartum care from known M/W
% highly satisfied with care
% baby born planned place of birth
Mean birthweight
Mean gestation at birth
% preterm births (< 37 weeks)
% low birth weight (LBW) babies (<2500)
% infants breastfeeding (none, exclusive, predominant, any) discharge, 6 wks, 6 & 12 months
% infants anaemic 6, 12 months.
% who choose to develop a birth plan.
Funding
The cost of implementing the model will be dependent on location and existing resources within
each site. Depending on the anticipated cost additional funding sources may be required. The
infrastructure for the primary birthing rooms may already be in place and require a low technology
approach with family friendly rooms that include easy access to a bath and shower facilities. It is
likely that there may be rooms within the current health facility that could be purposefully fitted out
but these costs would not be large (Approximate costs can be seen in Table 5 below). To provide an
example costings have been sourced from urban birthing centres that have been recently
established however it must be acknowledged that these costs would be increased if construction
was necessary in the remote setting. Telehealth facilities would be strongly recommended. Costs do
not include capital building costs, medical cover, accommodation costs, and consultation, referral
and transfer costs. They only provide baseline examples. A complete budget would need to be built
up once sites were identified.
Table 5. Estimated Establishment Costs
Estimated Establishment Costs
Clinical Equipment
$150,000
Project officer (12 months inc. oncosts)
$140,000
Bed linen and artwork
$10,000
Telehealth set up (based on 2012 rebate figures)
$6,000
Computers, printer & phones
$20,000
Communications (phone & internet charges)
$1000
Office-Stationery Supplies
$500
Travel expenses (other site visits)
$5,000
TOTAL
$331,500
Birthing on Country Model and Evaluation Framework
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Operational costs would also depend on the size of the community, the number of birthing women
and the existing staffing arrangements (it is likely that at least some of the current staff would work
in this program e.g. midwife/s, strong women workers, community based workers and Aboriginal
health workers). Midwives could commence operating in a caseload model with approximately 30
women a year (reduced from the usual caseload of 40 due to remote location, distances for home
visiting, Indigenous context and likelihood that role would include some women’s and child health).
Additionally, the capacity building aspect of this program would require onsite local student
midwives as education would be a large part of this role. A minimum of three midwives would be
required, though four would be better as one would often be away from the community on holidays
or staff training. estimated Costs have been estimated based on four midwives working with two
student midwives, one Aboriginal health worker or maternal infant health worker (Cert IV) and two
part time community based workers (e.g. strong women workers). Costs have also been included to
reimburse Steering Committee attendance and lease 2 cars per annum. Costs that are associated
with transfer and retrieval to higher level services or the medical workforce (and their associated
insurance costs) have not been included as this differs widely depending on context and is better
worked out locally. Where possible it is assumed that the model is integrated with local services
whereby these costs are potentially already being covered.
Table 6. Ongoing operational costs
Estimated Full Year Operational Budget
Manager inc. oncosts
$150,000.00
Caseload Midwives in MGP @ $136,651 p.a. per midwife inc. oncosts
$546,604.00
Aboriginal Health Worker x2 (Cert IV) inc. oncosts (identified position)
$140,000.00
Aboriginal Student x 4 @ $40,000 pa inc. oncosts (identified positions)
$160,000.00
Aboriginal Community based workers/ Strong women 0.5 FTE x 4 (identified positions)
$160,000.00
Aboriginal mental health worker or Aboriginal counsellor (SEWB worker) and trainee
$90,000.00
Local Governance Committee and Cultural Advisory Committee meeting attendance
$10,000.00
Car lease 4WD x2 including fuel and running costs p.a.
$24,000.00
Communications (phones & internet charges)
$5,000.00
Computer Expenses (software licences, email, intranet charges, printer)
$5,000.00
Office-Stationery Supplies
$2,500.00
Drugs-Various
$1,000.00
Pathology Charges
$5,000.00
Repairs And Maintenance
$5,000.00
Catering and Domestic Expenses
$5,000.00
Clinical Supplies
$10,000.00
TOTAL
$1,319,104.00
Conclusion
The National Maternity Services Plan was endorsed by the Australian Health Ministers and released
in 2011. Three priority areas for improving services for Indigenous women include: developing and
expanding culturally competent maternity care; developing and supporting an
Indigenous workforce; and the development of dedicated government programs for ‘Birthing on
Country’: described as a metaphor for the best start in life for Aboriginal and Torres Strait Islander
Birthing on Country Model and Evaluation Framework
24
babies and their families through the provision of an integrated, holistic and culturally appropriate
model of care. The national workshop, hosted by the Maternity Services Inter-jurisdictional
Committee and Central Australian Aboriginal Congress (Alice Springs, 2012) recommended the
development of Birthing on Country sites in urban, rural, remote and very remote areas. This
document provides a draft model and evaluation framework to move forward.
Birthing on Country Model and Evaluation Framework
25
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Birthing on Country Model and Evaluation Framework
28
Appendix 1. Birthing on Country progress to date: Achieving the
Actions of the National Maternity Services Plan
In 2010 AHMAC provided funding to MSIJC to commission a Literature Review of Birthing on
Country4 drawing on international evidence. In 2011 further funding was provided to MSIJC to host a
national workshop on Birthing on Country inviting key stakeholders, this took place on 4th July 2012
in Alice Springs.
Professor Sue Kildea undertook the literature review after being successful in winning the tender
from the Sax Institute. A small advisory group was established in order to guide the work, the
membership of which is outlined in the document.4 This group developed a definition of Birthing on
Country that was adopted and guided both the scope of the literature review and the national
workshop.
Birthing on Country was defined as: maternity services designed and delivered for Indigenous women
that encompass some or all of the following elements:
are community based and governed
allow for incorporation of traditional practice
involve a connection with land and country
incorporate a holistic definition of health
value Indigenous and non-Indigenous ways of knowing and learning; risk assessment and
service delivery
are culturally competent and
are developed by, or with, Indigenous people.4
National Birthing on Country Workshop, 4th July 2012
The National Birthing on Country workshop was organised and hosted by MSIJC in collaboration with
the Central Australian Aboriginal Congress (CAAC), a large and Aboriginal Community Controlled
Health Organisation (ACCHO) in Alice Springs, Northern Territory. Key stakeholders participated from
all states and territories’ as well as Commonwealth representatives. Key Aboriginal and Torres Strait
Islander people and organisation were present or represented, see the workshop report for a full list
of participants’, full report on proceedings and agreed actions of the day.5
... In addition to trust, a First Nations approach emphasizes a widespread understanding that everyone has duties towards their community. Consequently, this holistic approach contrasts with the Western focus on individuality (Kildea et al. 2016). In many First Nations cultures, the community's well-being is placed above individual health. ...
... Consequently, First Nations women and their advocates urged the authorities to allow them to practice BoC, which occurs when a First Nations mother gives birth to her child on the lands of her ancestors (Kildea et al. 2017). For First Nations people, birthing is broader than labor and delivery in a medical facility (Kildea et al. 2016). It "encompasses culturally safe care for First Nations families during pregnancy and after birth" (HealthcareLink 2019). ...
... Hence, BoC refers to maternity services designed by and delivered to First Nations people (Kildea et al. 2016). ...
Article
Despite considerable investment, health outcomes for First Nations people are well below those of the rest of the population in several countries, including Canada, the USA, and Australia. In this paper, we draw on actor-network theory and the case of "Birthing on Country," a successful policy initiative led by First Nations Australians, to explore the decolonization of health services. Using publicly available archival data and the theoretical guidance of actor-network theory, our analysis offers insight into how marketing techniques and technologies can be deployed to achieve improved health outcomes and implement decolonial approaches. The insights provided have theoretical implications for marketing scholarship, social implications for understanding and implementing an agenda of decolonization, and practical implications for healthcare marketing.
... Although these policies are designed to facilitate 'immediate' feelings of safety for First Nations women and families, cultural security also relies on staff being able to link these practical and philosophical understandings to their own practice [13]. The literature [12,13,15] cites cultural security as being linked to the concept of 'Birthing on Country', where maternity models are designed and aligned with First Nations' worldviews [16], providing the 'best start in life' (pp. 8) for First Nations newborns [17]. ...
... First Nations women have often been excluded from how services set up for them are designed and delivered [16], yet input from First Nations women themselves is needed for effective models of maternity care [10]. Recent studies have illustrated this, where models underpinned by First Nations community engagement have been implemented and evaluated across the country, reporting improved perinatal outcomes [8,[18][19][20] and increased antenatal attendance [8,19]. ...
... The 2019 National Strategic Directions for Australian maternity services [5] recommends that models of care are based on the principles of 'Birthing on Country', which should be seen as "a metaphor for the best start in life for Aboriginal and Torres Strait Islander families" (p.8) [17]. Birthing on Country models of care are First-Nations led, strengths-based, multi-faceted and place women at the centre of care [16]. Importantly, the physical act of giving birth on Country may or may not be relevant or possible, depending on the woman's context. ...
Article
Background The Australian maternity system must enhance its capacity to meet the needs of Aboriginal and Torres Strait Islander (First Nations) mothers and babies, however evidence regarding what is important to women is limited. Aims The aim of this study was to explore what women having a First Nations baby rate as important for their maternity care as well as what life stressors they may be experiencing. Methods Women having a First Nations baby who booked for care at one of three urban Victorian maternity services were invited to complete a questionnaire. Results 343 women from 76 different language groups across Australia. Almost one third of women reported high levels of psychological distress, mental illness and/or were dealing with serious illness or death of relatives or friends. Almost one quarter reported three or more coinciding life stressors. Factors rated as most important were privacy and confidentiality (98 %), feeling that staff were trustworthy (97 %), unrestricted access to support people during pregnancy appointments, (87 %) birth (66 %) and postnatally (75 %), midwife home visits (78 %), female carers (66 %), culturally appropriate artwork, brochures (68 %) and access to Elders (65 %). Conclusions This study provides important information about what matters to women who are having a First Nations baby in Victoria, Australia, bringing to the forefront social and cultural complexities experienced by many women that need to be considered in programme planning. It is paramount that maternity services partner with First Nations communities to implement culturally secure programmes that respond to the needs of local communities.
... 12 An overarching movement that aims to address these issues is 'Birthing on Country' (BoC), which was introduced in Australia as a framework to enable access to culturally safe continuity of care models for all First Nations families (including non-First Nations women having a First Nations infant), to return birthing services to First Nations communities, and improve birth outcomes for First Nations women and infants. 13 BoC models are based on underlying principles such as privileging Indigenous knowledge, strengthening the First Nations workforce and community capacity, womancentred holistic care, and culturally competent and safe continuity of care with cultural guidance and oversight. 13 One type of continuity of care in the maternity setting is caseload midwifery, where care is provided by a 'known' midwife through the antenatal, intrapartum and postnatal period. ...
... 13 BoC models are based on underlying principles such as privileging Indigenous knowledge, strengthening the First Nations workforce and community capacity, womancentred holistic care, and culturally competent and safe continuity of care with cultural guidance and oversight. 13 One type of continuity of care in the maternity setting is caseload midwifery, where care is provided by a 'known' midwife through the antenatal, intrapartum and postnatal period. 14 It results in improved outcomes for women and babies, 14 with some studies reporting increased rates of breast feeding (not initiating breast feeding: 1.8% vs 0.7%, 15 and breast feeding on discharge from hospital: 72.6% vs 68.5%, 16 at 6 weeks: 58% vs 44% and at 6 months: 45% vs 32%). ...
Article
Full-text available
Objectives There is an urgent need to improve breast feeding rates for Australian First Nations (Aboriginal and Torres Strait Islander) infants. We explored breast feeding outcomes of women having a First Nations infant at three sites that introduced a culturally specific continuity of midwife care model. Design Women having a First Nations infant booking for pregnancy care between March 2017 and November 2020 were invited to participate. Surveys at recruitment and 3 months post partum were developed with input from the First Nations Advisory Committee. We explored breast feeding intention, initiation, maintenance and reasons for stopping and factors associated with breast feeding. Setting Three tertiary maternity services in Melbourne, Australia. Participants Of 479/926 eligible women approached, 343 (72%) completed the recruitment survey, and 213/343 (62%) the postnatal survey. Outcomes Primary: breast feeding initiation and maintenance. Secondary: breast feeding intention and reasons for stopping breast feeding. Results Most women (298, 87%) received the culturally specific model. Breast feeding initiation (96%, 95% CI 0.93 to 0.98) was high. At 3 months, 71% were giving ‘any’ (95% CI 0.65 to 0.78) and 48% were giving ‘only’ breast milk (95% CI 0.41 to 0.55). Intending to breast feed 6 months (Adj OR ‘any’: 2.69, 95% CI 1.29 to 5.60; ‘only’: 2.22, 95% CI 1.20 to 4.12), and not smoking in pregnancy (Adj OR ‘any’: 2.48, 95% CI 1.05 to 5.86; ‘only’: 4.05, 95% CI 1.54 to 10.69) were associated with higher odds. Lower education (Adj OR ‘any’: 0.36, 95% CI 0.13 to 0.98; ‘only’: 0.50, 95% CI 0.26 to 0.96) and government benefits as the main household income (Adj OR ‘any’: 0.26, 95% CI 0.11 to 0.58) with lower odds. Conclusions Breast feeding rates were high in the context of service-wide change. Our findings strengthen the evidence that culturally specific continuity models improve breast feeding outcomes for First Nations women and infants. We recommend implementing and upscaling First Nations specific midwifery continuity models within mainstream hospitals in Australia as a strategy to improve breast feeding.
... 1,2 In 2019, the National Strategic Directions for Australian Maternity Services 3 recommended developing and implementing culturally safe, evidence-based models of care in partnership with First Nations communities underpinned by so-called Birthing on Country principles. 4 Culturally safe maternity care encompasses the entirety of a woman's needs (physical, psychosocial, spiritual, emotional, and cultural), with culturally safe practitioners treating women with respect and dignity. 3,5 Culturally safe practitioners seek to reduce power dynamics between themselves and the women they care for. ...
... 7,8 These services are co-designed with the local community and include continuity of midwifery carer, a First Nations workforce, partnerships between primary and tertiary services, cultural strengthening programmes, and wrap-around services to support pregnant women and their families. 4 Increasing First Nations control of health services is recommended in national strategic documents. 6 However, the potential for Birthing on Country services to improve clinical outcomes in complex real-life settings is not yet known. ...
Article
Full-text available
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. Funding Australian National Health and Medical Research Council.
Article
Background: Continuity of midwife care is recommended to redress the inequitable perinatal outcomes experienced by Aboriginal and Torres Strait Islander (First Nations) mothers and babies, however more evidence is needed about First Nations women's views and experiences of their care. Aims: This study aimed to explore levels of satisfaction among women having a First Nations baby, who received maternity care at one of three maternity services, where new culturally specific midwife continuity models had been recently implemented. Methods: Women having a First Nations baby who were booked for care at one of three study sites in Naarm (Melbourne), Victoria, were invited to complete one questionnaire during pregnancy and then a follow up questionnaire, 3 months after the birth. Results: Follow up questionnaires were completed by 213 women, of whom 186 had received continuity of midwife care. Most women rated their pregnancy (80 %) and labour and birth care (81 %) highly ('6 or '7' on a scale of 1-7). Women felt informed, that they had an active say in decisions, that their concerns were taken seriously, and that the midwives were kind, understanding and there when needed. Ratings of inpatient postnatal care were lower (62 %), than care at home (87 %). Conclusions: Women having a First Nations baby at one of three maternity services, where culturally specific, continuity of midwife care models were implemented reported high levels of satisfaction with care. It is recommended that these programs are upscaled, implemented and sustained.
Article
Objective This qualitative study explores the experiences and perceptions of new and expectant First Nations fathers in an urban setting in Australia. Background Little is known about the experiences of First Nations men as fathers, including their transition to fatherhood and their strengths and challenges as fathers. Method Eight First Nations men who were expectant or new fathers participated in individual yarning interviews. Data were analyzed using descriptive phenomenological analysis. Results Men perceived a father to be a protector, provider and someone who reflects on how to be a better father. To be a better father, men were trying to heal and learn from their past and build their identity as a father, while managing the stress of fatherhood. Conclusion The study identified four strategies to support new First Nations fathers: (a) create gathering places for men to connect with and learn from other dads, (b) maternity and early childhood services should be inclusive of men and their role as fathers, (c) clinical intervention and supportive pathways into fatherhood, and (d) promote and celebrate the strengths and roles of First Nations fathers. Implications Maternity and early childhood services can better support First Nations men in their transition to fatherhood by being more responsive to their needs and inclusive of their important role in child development and strengthening the family unit.
Article
Full-text available
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.
Research
Full-text available
This 2005 literature review was designed to identify interventions which have been shown to improve health outcomes or intermediate health measures in Aboriginal and Torres Strait Islander mothers, babies and young children (zero to five years of age). It was conducted to provide evidence for the development of maternal and child health policy in the Office for Aboriginal and Torres Strait Islander Health. Seven databases and five websites were searched for relevant literature for the period 1983-2003. Qualitative analyses found that most of the studies were observational with before and after comparisons and no control group, however, many reports were identified which described improved impacts or outcomes associated with antenatal care and/or mother and baby programs in Indigenous communities. A number of common factors were identified for the development of new services or the enhancement of existing ones. Australian Indigenous HealthInfoNet abstract
Article
Full-text available
Objective: This paper articulates the importance of accurately identifying maternity services. It describes the process and challenges of identifying the number, level and networks of rural and remote maternity services in public hospitals serving communities of between 1000 and 25000 people across Australia, and presents the findings of this process. Methods: Health departments and the national government's websites, along with lists of public hospitals, were used to identify all rural and remote Australian public hospitals offering maternity services in small towns. State perinatal reports were reviewed to establish numbers of births by hospital. The level of maternity services and networks of hospitals within which services functioned were determined via discussion with senior jurisdictional representatives. Results: In all, 198 rural and remote public hospitals offering maternity services were identified. There were challenges in sourcing information on maternity services to generate an accurate national picture. The nature of information about maternity services held centrally by jurisdictions varied, and different frameworks were used to describe minimum requirements for service levels. Service networks appeared to be based on a combination of individual links, geography and transport infrastructure. Conclusions: The lack of readily available centralised and comparable information on rural and remote maternity services has implications for policy review and development, equity, safety and quality, network development and planning. Accountability for services and capacity to identify problems is also compromised.
Article
Full-text available
Women at low risk of pregnancy complications benefit from continuity of midwifery care, but no trial evidence exists for women with identified risk factors. We aimed to assess the clinical and cost outcomes of caseload midwifery care for women irrespective of risk factors. In this unblinded, randomised, controlled, parallel-group trial, pregnant women at two metropolitan teaching hospitals in Australia were randomly assigned to either caseload midwifery care or standard maternity care by a telephone-based computer randomisation service. Women aged 18 years and older were eligible if they were less than 24 weeks pregnant at the first booking visit. Those who booked with another care provider, had a multiple pregnancy, or planned to have an elective caesarean section were excluded. Women allocated to caseload care received antenatal, intrapartum, and postnatal care from a named caseload midwife (or back-up caseload midwife). Controls received standard care with rostered midwives in discrete wards or clinics. The participant and the clinician were not masked to assignment. The main primary outcome was the proportion of women who had a caesarean section. The other primary maternal outcomes were the proportions who had an instrumental or unassisted vaginal birth, and the proportion who had epidural analgesia during labour. Primary neonatal outcomes were Apgar scores, preterm birth, and admission to neonatal intensive care. We analysed all outcomes by intention to treat. The trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12609000349246. Publicly insured women were screened at the participating hospitals between Dec 8, 2008, and May 31, 2011. 1748 pregnant women were randomly assigned, 871 to caseload and 877 to standard care. The proportion of caesarean sections did not differ between the groups (183 [21%] in the caseload group vs 204 [23%] in the standard care group; odds ratio [OR] 0·88, 95% CI 0·70-1·10; p=0·26). The proportion of women who had elective caesarean sections (before onset of labour) differed significantly between caseload and standard care (69 [8%] vs 94 [11%]; OR 0·72, 95% CI 0·52-0·99; p=0·05). Proportions of instrumental birth were similar (172 [20%] vs 171 [19%]; p=0·90), as were the proportions of unassisted vaginal births (487 [56%] vs 454 [52%]; p=0·08) and epidural use (314 [36%] vs 304 [35%]; p=0·54). Neonatal outcomes did not differ between the groups. Total cost of care per woman was AUS$566·74 (95% 106·17-1027·30; p=0·02) less for caseload midwifery than for standard maternity care. Our results show that for women of any risk, caseload midwifery is safe and cost effective. National Health and Medical Research Council (Australia).
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[Note: the 1st two chapters are available on the SAGE site] Action Research is an invaluable guide to both novice and experienced researchers from a diversity of disciplines, backgrounds, and levels of study for understanding how action research works in real-life contexts. The Fifth Edition builds on the experiences of the authors by acknowledging the dramatic changes taking place in our everyday lives, including developments of social and digital media that have become central to modern life. Author Ernest T. Stringer and new co-author Alfredo Ortiz Aragón aim to provide a meaningful methodology arising from their extensive field experience for both students and practitioners. Presenting research that produces practical, effective, and sustainable outcomes to real-world problems, Action Research helps students see the value of their research in a broader context, beyond academia, to effecting change on a larger scale. Additional resources can be found at the authors’ website http://www.actionresearch5.com/