Download Regional Family Birthing and Anangu Bibi Birthing Program: The

Regional Family Birthing and Anangu
Bibi Birthing Program: The First 50
Births
Georgie Stamp, Sonia Champion, Pauline Zanet, Geraldine
Anderson, Katrina Coulthard, Katrina Paige, Judy Taylor, Jonathan
Newbury
A report commissioned by Northern and Far Western Regional
Health Service
May 2007
Painting copyright Geraldine Anderson
The painting represents young mothers coming from different groups from the north, north-west
and surrounding areas of Port Augusta and Whyalla. Outside the circle are the salt lakes that
identify the group. Inside the circle darker figures are the young mothers and the lighter figures
represent the bibi. The trees are for making Coolamon for the bibi in birthing. The hand
represents the massage and helping the bibi borning. The grandmothers are in yellow in their
important role in birth with the mother and the bibi. The orange on the hand is the flames of
healing, knowledge and wisdom of grandmothers. The female emu makes a nest for the eggs.
Other marks represent swans in their migration back to their place. The grandmother knows
where the baby can be born.
ISBN 978-0-903073-l-3
Published by Spencer Gulf Rural Health School
The University of Adelaide and the University of South Australia
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Acknowledgements
We thank and acknowledge the following people for their contributions:
Artist Charmaine Wilson and the Port Augusta Aboriginal Women’s Advocacy
Group for permission to use the Anangu Bibi Birthing Program logo on the cover
of this report
Geraldine Anderson for the painting on page 1
Sonia Champion for the photographs on page 1
Mandy Guest for analysis of mainstream rural women’s comparison group
Christine Franks shared her expertise on equivalent inter-cultural partnership
during the design, conduct and writing up of evaluation
Members of the Aboriginal Women’s Advocacy Group
All the stakeholders, AMIC workers and midwives who shared their views of the
program
Professor Judith Lumley and Associate Professor Stephanie Brown for use of
the Victorian new mothers’ questionnaire
Sandy Campbell and Stephanie Brown for use of the modified new mothers’
questionnaire
Northern & Far Western Regional Health Service who funded the evaluation
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Table of contents
Executive summary………………………………………………………..5
Introduction ………………………………………………………………..15
Literature review…………………………………………………………..19
Methods...………………………………………………………………….34
Findings…………………………………………………………………….37
Objective 1 Participants’ views of the program…………...……37
Objective 2 Information about behaviours that may affect
birth outcome………………………………………...40
Objective 3 Process of establishment…………………………..43
Objective 4 Working relationship with AMIC workers………….47
Objective 5 Participants demographic profiles and perinatal
Outcomes…………………………………………….60
Discussion and implications……...……..……………………..……….. 65
Recommendations………………………………………………………..67
References and bibliography…………………………………………….68
Appendices………………………………………………………………..78
Appendices
Appendix 1
Regional Family & Anagu Bibi Birthing Program Screening
tool
Appendix 2
Regional Management Group Terms of Reference
Appendix 3
NHMRC levels of evidence
Appendix 4
International Definition of a Midwife
Appendix 5
Reasons given for lack of birthing at Alukura
Appendix 6
Supplementary Birth Record
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Figures and Tables
Figure 1
Flow chart illustrating program relationships …………………...15
Table 1
Comparisons between rural non-Aboriginal and Aboriginal
mothers using the Victorian new mothers’ questionnaire ……..39
Table 2
Antenatal visits (clinical) for Aboriginal women…………………41
Table 3
Antenatal occasions of service…………………………………...41
Table 4
Gestation at first visit by trimester………………………………..42
Table 5
Aboriginal women tobacco smoking status at time of birth……42
Table 6
Aboriginal women: smoking in second half of pregnancy……..42
Table 7
Smoking-cannabis use in pregnancy first antenatal visit……...43
Table 8
Smoking and cannabis use at postnatal visit…………………...43
Table 9
Stakeholders’ themes about the program implementation……44
Table 10
Midwives’ issues in setting up the program……………………..49
Table 11
Midwives’ themes partnership with AMIC workers…………….52
Table 12
Midwives’ ‘wish list’ to sustain and improve the program……..53
Table 13
Number of births by program site………………………………..60
Table14
Maternal age of all participants…………………………………..61
Table 15.
Parity of all participants…………………………………………..61
Table 16.
Method of birth…………………………………………………….62
Table 17.
Birth weights………………………………………………...........62
Table 18.
Apgar scores………………………………………………………63
Table 19.
Gestation at birth………………………………………………….63
Table 20.
Feeding method at discharge from hospital……………………63
Table 21.
Feeding method at last postnatal visit…………………………..64
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EXECUTIVE SUMMARY
In 2005 and 2006 the Spencer Gulf Rural Health School in partnership
with the Flinders and Far Northern Division of General Practice
conducted an evaluation of the Northern and Far Western Health Service
(NFWRHS) Regional and Family Birthing and Anangu Bibi Birthing
Program. The evaluation includes perspectives of participants and key
stakeholders, sustainability issues and ways the program could be
strengthened.
The program commenced in 2004 in Whyalla and Port Augusta. The
program aims were to improve primary and hospital care by offering
culturally appropriate obstetric support for women by Aboriginal Maternal
and Infant Care (AMIC) workers in partnership with midwives. Aboriginal
women of all ages from Port Augusta and Whyalla and non-Aboriginal
teenage women from Whyalla can take part. Key principles were to
include:
•
•
•
•
AMIC worker led (for Aboriginal women)
Skills exchange between midwives and AMIC workers
Continuity of care-givers
Primary health care
The AMIC workers may be Aboriginal Health Workers, and all have
participated in training, delivered in Port Augusta, in antenatal, birthing,
and postnatal care. The AMIC workers and midwives are allocated a case
load and follow each woman’s care from date of acceptance into the
program until six to eight weeks after the birth, when the baby and mother
are referred to Child Youth Health (CYH).
An important component of the program was the establishment of an
Aboriginal Women’s Advocacy Group to advocate and promote the
cultural issues of the program. Members are respected women and
Elders from several language groups in and around the Port Augusta and
Whyalla areas and beyond. Meetings alternate between Port Augusta
and Whyalla. In addition, a Regional Management Group consisting of
key stakeholders and program staff meets bi-monthly. Its aims are to set
program directions, assist in coordination, build partnerships and address
sustainability issues (Appendix 2).
The program is located on two sites which differ in the care provided. In
Whyalla the Regional Family Birthing Program accepts Aboriginal women
of all ages and teenage women from non-Aboriginal backgrounds;
provides antenatal and postnatal care (excluding labour and birth) and
employs one midwife and AMIC worker. The Port Augusta Anangu Bibi
Birthing Program accepts Aboriginal women of all ages and provides
antenatal, labour and birth and postnatal care with three part-time AMIC
workers and four part-time midwives employed.
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The evaluation focused both on the process of establishing the program
as well outcomes from the first 50 births.
METHODOLOGY
The objectives of the evaluation were to:
1. Seek participants’ views and experience of the program;
2. Obtain information about behaviours that may affect birth
outcomes;
3. Document the process of establishment of the program and any
barriers to its implementation;
4. Investigate aspects of the working relationships between the AMIC
workers and the midwives employed in the program, and
5. Describe participants’ demographic profiles and perinatal
outcomes.
Information to meet the evaluation objectives was gained from seven data
sets:
1. Key stakeholders, AMIC workers and midwives’ interviews
2. Focus groups for Aboriginal and non-Aboriginal teenage women
participants
3. New mothers’ questionnaires (Aboriginal program participants
n=10)
4. New mothers’ questionnaires (for rural comparison group n=54)
5. Supplementary birth records completed by midwives (SA
Pregnancy Outcomes Unit, Appendix 6)
6. A purpose-designed program database maintained by the
NFWRHS
7. Summaries of birth outcomes in 2004 from the SA Pregnancy
Outcome Unit (Chan et al 2006)
FINDINGS
Objective One: To seek participants’ views and experiences of the
program
A focus group of Aboriginal mothers from the Whyalla program
highlighted positive aspects such as; support from the AMIC worker with
appointments and transport to the hospital and clinics; pregnancy care
other than from their GP and the program classes. Overall the women
were disappointed that the Whyalla program had not provided labour and
birthing care. They would have liked access to their AMIC worker or
midwife in early labour to monitor and reassure them and they felt the
lack of a birth attendant they knew during the birth. They believed this
acted as a barrier to being well informed about pain relief, birth options
and support for a normal birth. The women also believed that the cut-off
point for postnatal visits was too soon.
A focus group of non-Aboriginal teenage mothers highlighted that they
had received visits from the midwife at locations such as school, hospital,
home and Nunyara (the Aboriginal Well-being Centre). The midwife gave
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information and education about their health and that of their baby and
other support such as transport. The young mothers felt positive about
the program and their midwife. However, their experiences of the health
system as a whole had been dependent upon the attitudes and skills of
the service providers they saw.
The Victorian new mothers’ questionnaire modified by Campbell & Brown
(2004) for use with Aboriginal women further modified for local use.
Aboriginal researchers conducted interviews with ten Aboriginal mothers
from both sites who had been through the program. Comparisons were
then made between the Aboriginal mothers and 54 rural non-Aboriginal
mothers. Differences were noted, although a larger sample would be
needed to draw statistically significant conclusions. The Aboriginal women
were more likely than the rural women to rate birthing staff as very friendly
and welcoming and to know the midwife who cared for them in labour.
However, they were more likely to have had someone in the labour room
whose presence was not welcomed and also to have wanted more
information in labour. Aboriginal mothers were more likely to receive
contradictory feeding advice than rural women and were less likely to be
breastfeeding at 6-8 weeks.
Objective Two: Obtain information about behaviours that may affect birth
outcomes
The number of antenatal visits and rates of smoking in pregnancy are
program performance indicators
The number of antenatal visits for women enrolled in the program in
Whyalla and Port Augusta were obtained from the supplementary birth
record. For Aboriginal women data were missing for 15 out of 45 records
(33%). When missing data were excluded, 15.6% of Aboriginal women
had fewer than 7 visits (compared with 39% for Aboriginal women and 6%
of non-Aboriginal women SA wide in 2004 (Chan et al 2006).
Gestation at the first visit in the program by trimester of pregnancy was
calculated from data from the program database. Data were missing for 3
out of 52 women (5.8%). Only 17.3% had their first visit in the first
trimester (before the 12th week) and 42.3% did not attend until the third
trimester (after the 24th week). It is possible that women may have had
‘first visits’ to professionals not linked with the program that were not
recorded.
Smoking (including cannabis) was collected at the first antenatal visit and
again at the last postnatal visit. Substantial missing data: (first antenatal
visit n=13, 25%) and: (postnatal visit n=16, 32%) should lead to cautious
interpretation. If missing data are excluded the overall rate of tobacco
smoking at the first visit was 56.4% (Aboriginal women only 59%). This
compares with SA rates for Aboriginal women in 2004 of 57.8%.
Cannabis use was 10.3%. At the postnatal visit 65% were smokers.
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Objective Three: Document the process of establishment of the program
and any barriers to its implementation.
Several themes emerged from interviews with key stakeholders about
implementation of the program.
The important role of the AMIC worker
All stakeholders saw the employment of AMIC workers as a highlight of
the program. The role of AMIC workers in facilitating positive experiences
for the women and “bringing respect for culture” was acknowledged.
However, issues of inadequacy of resources, including the number of
hours AMIC workers were employed; support, training and development
were equally highlighted. The development of formal mechanisms to
ensure that all AMIC workers received adequate support in their roles
was seen as important. The support from working in a team with other
AMIC workers was acknowledged. The Whyalla program was limited in
this respect, having only one AMIC worker.
Operational differences between the two sites
The model of service is complex and all informants spoke about the
issues arising from the operational differences between the two sites.
These included limited funding which meant staff had not been involved
in birthing and labour in Whyalla, and also affected the number and roles
of AMIC workers and midwives in the program.
Role of the Aboriginal Women’s Advocacy Group
All informants were acutely aware of the Advocacy group’s potential to
support the AMIC workers, ensure cultural sensitivity, share their cultural
knowledge, enable community ownership, and to assist in achieving
positive outcomes for the Aboriginal women in the program. However,
most participants thought there was some way to go to fully realise the
benefits of the Advocacy group.
Resources and sustainability
Overall, stakeholders noted that it was important to incorporate the new
program in the mainstream antenatal, birthing, and postnatal care for all
Aboriginal and teenage new mothers in Port Augusta and Whyalla. It was
thought that this would ensure adequate resources, resolution of the
complexities of the management of the program, and ensure
sustainability. To date, the financial and human resources to develop the
program have been considerable. This includes the time of the Advocacy
group. Goodwill, in addition to program funds has ensured its success.
Objective Four: Investigate aspects of the working relationship between
the AMIC workers and the midwives employed in the program
The role and views of AMIC workers
Five AMIC workers were interviewed by an Aboriginal researcher. The
scope of the role was very broad and involved a complex array of tasks
beginning with the antenatal visits.
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We get the girls to come up to the hospital if they want to have
their antenatal screening …and so we have to go out and arrange
that ..(and) bring them into the midwives….the midwives are doing
mainly the antenatal screening on the girl, but us AMIC workers,
well me, I am trained in that area so I also do the checks along
with them. ….also we have come across a lot of girls that need
support in housing and they need support in finances…and we
have a case conference meeting every fortnight …. AMIC worker
Another when asked what she did in her AMIC role replied:
What don’t I do! Basically support – there’s about 20 Aboriginal
women that we get work for the year and we get given a caseload
of women that we take care of. So for me it’s wherever those
women are and I go out and support them as much as possible for
their antenatal care and antenatal education you know helping
them with anything they want to know during pregnancy. Making
sure that their bloods are being done, all those sorts of things, and
being a support for them during their birth, because the majority of
the girls I’ve looked after I have been at the delivery there. So
when they are ready to give birth to their baby… it’s that birth
support as well. After that – postnatal support as well, you know,
help them with breastfeeding, and teaching them how to
breastfeed and like referral too. They might not have much
because its their first baby, they want their own house, after living
with you know, their family, they might want to get a house
organised that sort of thing, help them with that, furniture…, we
use all the services that I can here in Port Augusta, and then, like
when they are referred on to CYH at about 8 weeks. Making sure
they get to that first baby’s health check, making sure that we talk
about contraception you know, what sort of thing they might want
to have and organising that with whoever, and then making sure
they have the check up with their doctor that everything is ok. So it
depends on the individual women what they want. If it’s a more
traditional woman then we make sure we look at.. all the things
that we can offer which language group they belong to, but if not
it’s support with whatever that woman wants really. AMIC worker.
Being able to communicate with women whose first language was not
English or who did not speak any English was considered important.
A crucial part of the role was to advocate for Aboriginal women in a
hospital setting. Sometimes a woman might feel too shy or shame to seek
the help she needed with a non-Aboriginal staff member. According to
one AMIC worker “a lot of the girls that you come across (are) like that,
they don’t want to talk to the nurses, and so they tell you, and they want
you to go and talk to the nurses…”
The value of being able to speak up with confidence when working with or
alongside mainstream services was described:
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I think it’s important to know how to deal with mainstream services.
They don’t know our way and sometimes they push things the
other way, that they want them. But I think its important to have
strong Aboriginal women working in the program so that we can
stop and say: “no, hang on a minute, that not the way to do it that’s
not the way we do it, when it comes to our women, this is how it
should be done.” AMIC worker
When asked specifically about working in partnership with the midwives
in the program there was enthusiasm:
… I think non-Aboriginal people and Aboriginal people working
together is a good way. Non-Aboriginal people can’t offer the
service without us, but we can’t do it without them either… the
clinical knowledge that we learned from the midwives, you know,
without that, we couldn’t do our work properly. But the same thing,
they couldn’t do it without us because they need our cultural
knowledge. They need to know the way we deal with people. And I
think the good thing is this; they teach us the clinical way and we
teach them the cultural way. So it just works really well like that
and in the partnership, between the hospital and Pika Wiya
Aboriginal Health Service. That’s the way it should be that’s the
way it can work, you know. You feel like you can make a difference
for our people if we work that way. AMIC worker
Another AMIC worker felt this model of working together should be
introduced everywhere:
I want our workers, AMIC workers to be everywhere, not just here.
I think Aboriginal health workers should be working with midwives
everywhere, and you can really see the difference it makes, you
know, for women and babies. One of the things that we set up this
program for was that we wanted to increase babies’ weights. If
they don’t look after themselves in pregnancy babies can be
small…. …And breastfeeding, how important that is…Information, I
think a lot of our girls never had that information, and they didn’t
know that these things happened, so the more people are talking
about it- the program set up like that – Aboriginal health workers
doing that work, with our girls it’s got to improve for the women and
for the babies. AMIC worker
Mothers could be more likely to bring up issues when alone with an AMIC
worker. However this changed when the women got to know the
midwives and saw the AMIC workers and midwives working in
partnership:
But after a while though, those girls start to feel comfortable with
the midwives as well, because they can see us working
together…. And because there’s only 4 midwives in the program,
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they are easy to get to know. They are great midwives, they are
easy to talk to and they have worked with Aboriginal people before
and they are willing to listen to what we say and they work along
with all of us. So that’s why when I talk about team they’re our
team as well. AMIC worker
Six midwives were interviewed, three employed in Port Augusta and one
in Whyalla along with both the Nurse Unit Managers (NUMs) who had line
management roles with the midwives and AMIC workers.
All the midwives agreed that a crucial part of the program was the twoway learning that they experienced and that a large and ongoing part of
their role was sharing of their specialised midwifery skills and knowledge
with the AMIC workers.
Themes that arose from the midwives’ interviews about working in
partnership with AMIC workers were:
•
•
•
•
•
•
•
•
•
A commitment to working inter-culturally
Development of relationships took time
Good experiences and outcomes when family structure is strong
Challenges associated with the AMIC worker’s role
AMIC worker’s social, cultural and community knowledge and
connections crucial to women’s attendance and program success
AMIC workers developed excellent clinical skills with increased
experience
Equality in team decision-making and strong AMIC role in client
selection
High personal satisfaction; and
Ongoing two-way learning with AMIC workers
A strong commitment to continuing to develop the partnership model was
highlighted by all the midwives.
Key informants also perceived there to be positive relationships between
AMIC workers and midwives. This had led to increased understanding as
highlighted in the following quote:
I feel there has been a changed attitude and greater understanding
of the non-Aboriginal midwives and staff about the challenges
faced by Aboriginal women. There is increased respect and
understanding. Stakeholder
Objective Five: Describe participants’ demographic profiles and perinatal
outcomes
During the one year timeframe there were 51 births over the two sites
with one perinatal death at 25 weeks gestation.
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Birthweights: Six birthweights were not recorded and were therefore
unavailable for this report. If missing data are excluded, overall, there
were 9 (20%) low birthweight babies (less than 2.5 kg), 8 (18%) of whom
were Aboriginal babies. This compares with low birthweight rate of 8.7%
in all SA births; and is half the reported rate for Aboriginal births in 2004.
Method of feeding: Among all the women for whom data were available,
35 (87.5%) were breastfeeding at discharge from the hospital and 31
(also 87.5%) of the Aboriginal women were breastfeeding at hospital
discharge. At the last postnatal visit at 6-8 weeks rates had dropped to
52.5% of the Aboriginal women breastfeeding and one teenage woman.
DISCUSSION AND IMPLICATIONS
The evaluation revealed challenges in establishment of the program and
some dissatisfaction that the Whyalla site appeared less well resourced.
Longer-term resources would enable what has been achieved to be
consolidated and could provide greater access to the pregnancy, birthing
and postnatal care provided by the AMIC worker and midwife model in
Port Augusta. For example, many Aboriginal people from language
groups in remote communities within the NFWHS region such as the,
Oodnadatta, Coober Pedy or the Flinders Ranges have family
connections in Port Augusta and may present there for antenatal care. In
its present form, the program is not designed to include these women
although small numbers have received care (personal communication
Program Manager). There are no facilities for these women to give birth
in their home communities. They often travel to a regional centre several
weeks before the expected birth. This is usually Port Augusta (or Alice
Springs for women from the Anangu Pitjantjatjara Lands). An AMIC
program is being established in Coober Pedy for antenatal and postnatal
care (personal communication stakeholder).
Although low in number, teenage women were positive about forming a
relationship with their program midwife. Young women stated that they
would have welcomed extra support with transport and other issues such
as that provided by AMIC workers. An equivalent teenage-focused model
could be designed specifically to meet young women’s needs.
The sample of 45 women, although small, is nearly one tenth (9.4%) of
the 484 Aboriginal births recorded in 2004). Women went through a
selection process to secure eligibility to enter the program to identify risk
factors. The effectiveness (sensitivity and specificity) of the screening
process has not been documented therefore it is difficult to determine
whether women in this study were at greater risk. In spite of significant
gaps in the data many outcomes for this group appear comparable with
data for Aboriginal women in South Australia in 2004. The sample was
too small to ascertain perinatal mortality rates.
There was a high prevalence of late booking for antenatal care in this
sample. Only 1 in 6 had their first antenatal visit in the first trimester, and
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2 in 5 did not attend until the third trimester. It is unclear whether any of
the women received care elsewhere although this would be expected to
be written on the hand-held pregnancy record now in wide use.
Nevertheless, Aboriginal women in the program were more likely to have
had more than 7 antenatal visits compared with the SA data for 2004.
The rates of smoking in pregnancy and babies classified as low
birthweight were also comparable with the SA data. Whether the
increased antenatal visits provided by midwives and AMIC workers in the
program (both clinical and supportive) can translate to improved overall
outcomes will require longer term follow-up. Whether an antenatal visit
had been clinical (hands-on) or supportive was not clearly defined in the
program database. Clarification and modification is needed to be able to
assess any potential advantages of both types of visit.
Qualitative findings from the interviews demonstrated that inter-cultural
partnerships between the AMIC workers and midwives do exist, that they
are mutually satisfying and that they have provided opportunities to work
both ways. The recognition and development of equivalent inter-cultural
partnerships between Aboriginal and mainstream workers is a best
practice model that has been successful in other settings (Franks et al
1996). Building on these relationships will be vital in sustaining the
program. Although it was clear that the AMIC worker is pivotal to the
success of the program, an expectation for the program to be “AMIC-led”
may be a misnomer in view of the emerging two-way partnership model
that the evaluation revealed. It is also important to acknowledge that
along with working in the program, AMIC workers, as members of their
communities, have obligations and priorities within their own family
systems. The AMIC worker role will continue to need acknowledgement,
support and development.
The Aboriginal Women’s Advocacy group has a strong role in contributing
to understanding of working both ways and thus moving towards good
birthing practices for healthy Aboriginal mothers and babies. Supportive
links between the Advocacy group and program management need to be
strengthened and sustained and out of pocket expenses acknowledged.
Members were keen to strengthen the cultural support provided by the
program by working in partnership with AMIC workers and directly with
Aboriginal women, especially those with restricted family support.
The substantial amount of missing data is disappointing. Clearly, an
accurate demographic picture of women participating in the program is
crucial. Only then can the program be accurately monitored for any
improvements in clinical outcomes. A long-term aim should be the
achievement of complete data sets, particularly the performance
indicators, especially if the program is to be introduced more widely.
Eight recommendations to strengthen the Regional Family Birthing and
Anangu Bibi Program are suggested.
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RECOMMENDATIONS
1.
The Anangu Bibi AMIC worker/midwife partnership model be
incorporated as a central component of the care offered to any Aboriginal
women presenting for antenatal care in Whyalla or Port Augusta to
increase the program’s sustainability.
2. That the feasibility of developing a model of care for teenage nonAboriginal women equivalent to the AMIC worker/midwife partnership be
considered.
3. As the AMIC worker is pivotal to the success of the program we
recommend that the role be further acknowledged, resourced and
developed.
Strategy:
Support AMIC workers to participate in an established
accredited course that leads to a professional qualification.
4. Set aside funding for increased AMIC worker hours and further
employment opportunities for more AMIC workers from different language
groups with links to the Spencer Gulf region in consultation with the
Aboriginal Women’s Advocacy Group.
5. Develop processes to enable AMIC workers to continue in the care of
mothers and babies beyond the 6-8 week program cut-off point.
Strategy: Encourage working partnerships between AMIC workers with
the CYH Indigenous Culture Consultant to enhance continuity of care for
Aboriginal mothers from a range of language groups.
Strategy: Investigate the feasibility of employment of AMIC workers in the
universal home visiting program of the Child and Youth Health so they
can continue to provide continuity of care.
6. That members of the Aboriginal Women’s Advocacy Group be
provided with further opportunities to directly support mothers and
families in the program.
Strategy Legitimise formal links between the Advocacy group and
program management by funding participation fees.
Strategy Strengthen the cultural support provided by the program through
linking Advocacy group members to those with limited family support and
to women enrolled in the program from outside Port Augusta and
Whyalla.
7. That adequate equipment, space and infrastructure be provided at both
sites for the AMIC workers and midwives who work together in the
program.
8. To refine the program database in consultation with the AMIC worker
and midwife users to simplify the management, collection and analysis of
outcomes and performance indicators and further establish any clinical
benefits of the program.
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INTRODUCTION
This is an evaluation of the Regional Family Anangu Bibi Birthing
Program for the Northern and Far Western Health Services following the
first 50 births in the in Whyalla and Port Augusta hospitals. The program
provides a model of pregnancy and birthing care for Aboriginal and
Torres Strait Islander women and non-Aboriginal teenage women.
The evaluation occurs in the context of important developments in
birthing services being offered to Aboriginal and Torres Strait Islander
women. There is emerging information about the effectiveness or
otherwise of attempts to improve primary and hospital care for Aboriginal
women to achieve healthier mothers and babies. Our evaluation should
be seen in this context. Generally it has been found that mainstream
birthing services do not meet the needs of Aboriginal and Torres Strait
Islander women resulting in low antenatal attendance (Campbell 2000).
There is also evidence to suggest that improving primary health care for
young pregnant women is warranted (Johnson & Coory, 2005).
In 1990 the Victorian Birthing Review (Victorian Health Dept. 1990)
recommended processes to “ensure the continuing involvement of female
Aboriginal health workers in the provision of antenatal and postnatal
support for Aboriginal women” and “to investigate the development of
education programs on birthing issues for health workers of Aboriginal
background, with an emphasis on antenatal and postnatal care; and
encourage the participation of Aboriginal women in the planning of health
services and the establishment of different models of care”(p.76). In
2000 Koori Maternity Services Program presented the report “From her to
maternity.” The report highlighted that Aboriginal midwives are in short
supply and it was likely that teams would involve non-Aboriginal
midwives. Therefore cultural awareness, sensitivity and value placed on
the unique role of the health worker were needed in developing models
(Campbell 2000).
Overview
The Northern and Far Western Region has a population of 53,220. The
756,742 square km area makes this the largest and most sparsely
populated geographical region per km in South Australia (ABS 2006). The
Aboriginal first peoples of the region comprise 6002 (11.3%) of the
population.
At the time the program was planned, at the Port Augusta Hospital, there
were considerable discrepancies between Aboriginal and non-Aboriginal
pregnancy outcome statistics, with Aboriginal women more likely to have
fewer than seven antenatal visits; be under 20 years of age; and have an
emergency caesarean section birth (Boles et al 2004). There had also
15
been ongoing concerns about how Aboriginal babies fared when
compared with the non-Aboriginal South Australian babies. In 2004 the
perinatal mortality rate was more than double for Aboriginal babies, low
birthweight (less than 2.500kg) was 3 times higher and preterm birth
(before 37 weeks gestation) was double. In addition, 57.8 % of Aboriginal
women were smokers at their first antenatal visit compared with 18.9% of
non-Aboriginal women (Chan et al 2006).
During 2003, Statewide Aboriginal women’s workshops were held and
concerns were raised by senior women of the region. A clear statement
was delivered from one workshop:
Healthy pregnancy and birthing is a life process and is an
important issue for the health of all our communities. This issue
should be a priority in health planning processes, with appropriate
and adequate ongoing funding. Aboriginal and Torres Strait
Islander women want to be cared for by Aboriginal and Torres
Strait Islander midwives and Health Workers. August 2003 (in Buckskin
M. 2004)
In 2004, the Northern and Far Western Regional Health Service
(NFWRHS) applied for and received public health outcomes agreement
funding to establish an alternative birthing program for Aboriginal and
Torres Strait Islander and non-Aboriginal teenage women in the region.
Initially known as the “Alternative Birthing Program” in 2005 on the
suggestion of the Aboriginal Advocacy group the name was changed it to
“Family Anangu Bibi Birthing Program for Port Augusta and the “Family
Birthing program” in Whyalla. The combined program is known as Anangu
Bibi Family and Birthing Program. The program is organised at the
regional level under the auspices of the NFWRHS and implemented at
site level with regional support.
Program design
The program is designed to provide culturally appropriate obstetric
support to women of which Aboriginal Maternal and Infant Care (AMIC)
workers are central (Figure 1).
The program aims to provide holistic care; physical, spiritual, emotional
and the social aspects of mother and baby in a culturally appropriate
individual-focused model.
The key principles of the program are:
•
•
•
•
AMIC worker led (for Aboriginal women)
Skill exchange between midwives and AMIC workers
Continuity of care
Primary health care
16
Role and selection of AMIC workers
The AMIC workers are selected because they are trusted and respected
women who can relate to Aboriginal mothers. They may be trained
Aboriginal Health Workers. All have participated in training, delivered in
Port Augusta, in antenatal, birthing, and postnatal care.
The AMIC workers and midwives are allocated a case load and follow
each woman’s care from date of acceptance into the program until
approximately six to eight weeks after the birth, when the baby and
mother are referred to Child and Youth Health.
Aboriginal Women’s Advocacy Group
An important priority in setting up the program was the establishment of
an Aboriginal Women’s Advocacy Group whose role was to advocate and
promote the cultural issues of the program. Members of the group are
respected women and elders from a number of language groups in and
around the Port Augusta and Whyalla areas and beyond. The group
alternates its meetings between Port Augusta Whyalla and meetings are
planned to be monthly.
Regional Management Group
A Regional Management Group consisting of key stakeholders and
program staff was established and meets bi-monthly. Its aims are to set
directions for the program; assist in coordination, build partnerships and
address sustainability issues of the program. The terms of reference of
the group are presented as Appendix 2.
Program location
The program is located in two sites within the region, each with a slightly
different approach and focus:
The Whyalla Regional Family Birthing Program accepts Aboriginal
women of all ages and teenage women from non-Aboriginal
backgrounds; provides antenatal and postnatal care (excluding labour
and birth) and employs one part-time midwife and one part-time AMIC
worker.
The Port Augusta Anangu Bibi Birthing Program accepts Aboriginal
women of all ages and provides antenatal, labour and birth and postnatal
care. Three AMIC workers employed between Port Augusta Hospital and
the Pika Wiya Health Service (1 FTE total) and four part-time midwives
(0.5 FTE) provide the care.
The AMIC workers and midwives are allocated a case load and follow
each woman’s care from date of acceptance into the program until
17
approximately six to eight weeks after the birth, when the baby and
mother are referred to Child Youth Health (CYH).
Participant Eligibility
The program is available to:
•
•
Aboriginal women of all ages in Port Augusta and Whyalla
Non-Aboriginal teenage women from Whyalla
Women are assessed using a purpose-designed selection process of
medical and social risk factors (Appendix 2). Those with certain risk
factors including young age, social disadvantage, substance use, poor
obstetric history such as medical complications in pregnancy or a
previous perinatal death are accepted into the program.
Figure 1 Flow chart illustrating program relationships
Hospital
Management
Committee
Midwife
Young
Teenage
Mothers
Aboriginal
Mothers
& Families
AMIC
Workers
Aboriginal
Women’s
Advocacy
Group
ACCHS
Health
Workers
18
LITERATURE REVIEW
How the literature was accessed
For the literature review evidence from both national and international
sources has been accessed by a variety of methods which include:
electronic searches of Medline, CINAHL and databases that specialise in
Indigenous health such as Australian Indigenous Health Infonet; in
pregnancy, childbirth and maternal and child health such as the Cochrane
Database of Systematic Reviews (CDSR) and obstetric and midwifery
journals; the World Health Organization on line the National Health &
Medical Research Council (NHMRC).
To ensure that wherever possible, the most effective and appropriate
research methods are utilized to guide practice the use of clearly defined
Levels of Evidence when assessing interventions in healthcare is
recommended (NHMRC 1998, Appendix 3). Promoted by Cochrane
(1972) but having its genesis in pregnancy and childbirth (Chalmers et al
1989) this approach is known as evidence-based practice (Sackett,
Richardson et al 1997).
In this literature review, when assessing interventions Level I evidence or
Level II evidence have been utilised where possible (NHMRC 1998a).
On other occasions Level III 1-3 has been used. In the many
circumstances where Levels I-III 1-3 was unavailable, it was necessary to
make use of clinical experience, expert opinion, reports (both published
and unpublished) and occasionally personal communication.
Free access to high quality regularly updated systematic reviews in the
field Pregnancy and Childbirth is available at www.nicsl.com.au/cochrane/
, a service funded by the Australian government.
Introduction
The perinatal mortality rate is used as an important indicator of the quality
of pregnancy care (WHO 2001, Department of Human Services (2001a,
Child Health Research Project 1999). In Australia the perinatal mortality
rate is very low in comparison with developing countries however, for
Aboriginal and Torres Strait Islander women it is double that of other
Australian women (Edwards & Madden 2001; Laws & Sullivan 2004). The
rates increase exponentially with remoteness (Chan et al 2005). As well,
the infant mortality rate varies by state from double to three times that of
the total population (ABS 2004). Aboriginal and Torres Strait Islander
babies are also more likely be classified as being low birth weight (less
than 2.5 kg) and have an increased risk of being born pre-term (before 37
weeks gestation) factors that are associated with increased childhood
morbidity (Humphrey & Holzheimer (2001). Risk factors for low birth
weight include socio-economic status, parity, age, nutritional, smoking
and health status during the pregnancy (Laws & Sullivan 2004).
Barker and colleagues have revealed associations between low birth
weight and poor fetal nutrition and an increased risk of cardiovascular
disease, obesity, diabetes and hypertension as adults (Barker 1992,
19
Barker et al 1992, Barker et al 2005) conditions that are found to be
disproportionately high in Aboriginal and Torres Strait Islander
peoples (ABS 2006).
Interventions in pregnancy have been based on the rationale that
increasing antenatal attendance and identifying health issues in utero in
turn will lead to healthier mothers, babies and children. Several models of
care with this as a major aim have been described and will be discussed
in this literature review.
Mainstream health services
That most mainstream birthing services do not meet the needs of
Aboriginal and Torres Strait Islander women and can lead to low
antenatal attendances is well documented (Campbell 2000).
Mainstream health services provide a range of mostly curative and some
preventative services that includes tertiary, district and community
hospitals and health centres and general medical practices. Before the
advent of community controlled Aboriginal Health Services in the1970s
(Briscoe 1974), mainstream health services were the means by which
most Aboriginal and Torres Strait Islander people accessed nontraditional health care. Such services continue to be an important source
of the healthcare accessed by Aboriginal and Torres Strait Islander
people. Many use it mainly for medical emergencies and childbirth
(Campbell 2000). In the Victorian report “From Her to Maternity” about
Koori birthing Campbell (2000), states “Story after story maintains that
contact with hospitals is regularly a traumatic experience for Aboriginal
people. This trauma is in addition to that caused by their immediate
medical needs.” In recent years increasingly, mainstream health services
have employed Aboriginal and Torres Strait Islander Health Workers and
liaison officers to support their people in what can be an alien and
frightening environment (NHMRC 1997). Research into factors that
limited communication between Aboriginal renal patients and medical,
nursing and allied health staff found that miscommunication was
pervasive and shared understandings of key concepts were rare (Cass,
et al. 2002).
Aboriginal and Torres Strait Islander community controlled health
services
The deficiencies in mainstream health services in meeting the needs of
Aboriginal and Torres Strait Islander people and a move towards toward
self-determination and management following the 1967 referendum saw
the establishment of the first Aboriginal controlled medical service in
Redfern, Sydney in 1971 (Briscoe 1974). There are now over 100
Aboriginal and Torres Strait Islander community controlled health
services throughout Australia and the Torres Strait Islands (House of
Representatives Standing Committee 2000). Most provide integrated
services relating to the health and social issues prevalent within the
community and as such have a high level of community participation
20
(Scrimgeour 1997). In Health is Life, the report of the Standing
Committee on Family and Community Affairs (2000) the National
Aboriginal Community Controlled Health Organisation (NACCHO) is
widely quoted. NACCHO consider that a well resourced community
controlled health service has a number of benefits which include:
•
significantly improved access
•
the full range of primary health care services in one place –
with service delivery being integrated and holistic
•
culturally appropriate care
•
value for money as services can be targeted because they are
based on local knowledge
•
a major source of education and training for Aboriginal people;
and
•
a pool of knowledge and expertise about Aboriginal health
which enables the sector to not only deliver appropriate care
but also to advocate effectively for Aboriginal people in health
House of Representatives Standing Committee 2000 p.38
Role of the Aboriginal Health Worker and associated issues
Aboriginal Health Workers (AHWs) have a crucial role in the health
promotion and well being of their communities. There have been several
efforts to define the role and functions with some disagreement revealed
(NHMRC 1997). Using a central Australian sample, Tregenza & Abbott
(1995) conducted research into stakeholders’ perceptions of the role of
the AHW. Problems identified related to attempts to fit AHWs into a nonAboriginal style of structure, disputes about the role between various
stakeholders and bureaucrats and a slow response to changing situations
in relation to role development. The authors highlight considerable
diversity of the role in individual situations.
Common aspects of the role have been summarised as being: held by an
Aboriginal and Torres Strait Islander person and having a clinical and
health promotion function and a community development and cultural
broker role (Abbott et al 1998). The role of cultural broker or agent is
frequently mentioned in the literature. Soong (1983) undertook research
with AHWs in Arnhem Land, describing the cultural broker role
undertaken by the AHWs observed by her as one of mediating between
two cultures.
The functions of the role of the AHW have been further classified by
Tregenza & Abbott (1995) under seven areas:
1.
2.
3.
4.
5.
6.
traditional health
clinical care and western medicine
health education and promotion
environmental health
community care
administration, management and control; and
21
7. policy development and program planning
Addition of other skills including care during pregnancy and childbirth
There have been concerns expressed at the increasing load AHWs are
expected to carry within a community (Sibthorpe et al 1998, Forrest
1995). The workload can be intense and AHWs are often on call for 24
hours a day. This can lead to high levels of stress. Other factors
contributing to stress are a lack of support from non-Aboriginal nurses
and doctors working within their communities and also from their own
communities, poor career prospects and low pay. All may be combined
with very high expectations of the AHW (Sibthorpe et al 1998, Flick 1997,
Jackson et al 1999). These issues are ongoing and despite slow
progress, should be improved by the development of national criteria for
education, competency and awards, pay and opportunities for career
advancement.
Forrest (1995) has called for the continuing development of specialist
roles for AHWs, which are clearly in under supply within Aboriginal and
Torres Strait Islander communities. Given the importance of maternal and
child health and the ongoing problem of access a case can easily be
made for the development of a specialist AHW role in this area, as is
happening in some centres. Although a female AHW may be the first
point of contact for pregnant women, a lack of maternal health care skills
will reduce her effectiveness in helping improve maternal and child
health. Widespread attempts to strengthen this aspect of the role by
placing AHWs with midwives are being undertaken in several projects in
New South Wales funded by NSW Health (personal communication,
unpublished report 2001) and in Victoria (Campbell 2000).
Women’s health in the reproductive years
Within any culture the birth of a baby has a special significance for the
parents and family as well as the community. Healthy mothers and
babies are the building blocks of robust communities (Health Department
of Victoria 1990). Nevertheless Aboriginal and Torres Strait Islander
Australian women and their babies continue to have unacceptably high
mortality and morbidity (ABS & AIHW 1997 and 2001 NHMRC 1998).
Summaries of international research show poor outcomes to be
associated with poverty, lack of access to basic care, age, parity, poor
nutrition and illiteracy (AbouZahr & Royston 1991). The risk increases for
those pregnancies in women “too young” (adolescent and still growing);
“too old” (aged 40-49); “too close” (having less than a 2 year pregnancy
interval); and “too many” (more than 4 children) (Fathalla 1990). However
pregnancy and birth care with access to a trained professional or
attendant can improve outcomes (Safe Motherhood Initiative 1992).
Low birth weight and intra-uterine growth restriction (IUGR) and smoking
Low birth weight either associated with prematurity or intra-uterine growth
restriction (IUGR) is a major cause of mortality and morbidity in babies. A
high rate of pre-term birth was found in a study in 5 Aboriginal
communities in north-western Australia (Smith et al 2000). In another
22
study, 96 Aboriginal newborns in 4 remote far north Queensland
communities were compared with 96 non-Aboriginal newborns. The
mean birth weight was 450 g lighter for the Aboriginal babies (Humphrey
& Holzheimer 2001). Prematurity may or may not be associated with
IUGR. Small babies are more likely to be growth restricted in developing
countries and among Aboriginal people. On the other hand small babies
are more likely to be preterm in developed countries (Barker & Fall 2001).
There is a deficit in the birthweight in babies born in poor countries when
compared with developed societies that according to Jackson et al (2001)
”may be as great as 800g”. This has implications for later quality of life as
revealed in the Barker hypothesis (Barker 1992, Barker et al 1992, Barker
et al 2005). For fourteen years there has been mounting evidence that
coronary heart disease; hypertension, diabetes and stroke, conditions
common among Aboriginal and Torres Strait Islander Australians
originate from fetal adaptations to malnourishment during pregnancy
(Barker 1994, Barker & Fall 2001). Barker’s hypothesis continues to find
further support from data from adults who were exposed to the Dutch
famine of October 1944 to May 1945 in utero and that timing of the
exposure determines which organ system is involved (Painter et al 2005).
Furthermore, and importantly, when considering Aboriginal health an
overview by Roseboom et al (2001) suggests that maternal malnutrition
may also affect adult health without always affecting birth weight.
Smoking during pregnancy is associated with preterm birth and small for
gestational age (SGA) birth weight (Chan et al 2005). In South Australia
in 2003 the percentage of low birth weight babies (<2500g) was 7%, but
among babies of Aboriginal mothers the proportion was 18% (Chan et al
2005). Using the South Australian data (Chan et al 2005) found that
Aboriginal women had a higher rate of smoking at the first antenatal visit
than non-Aboriginal women (59.3% vs. 19.8%). Data from 2000 found
that women who smoked had a higher relative risk of preterm birth (1.62),
SGA (2.28) and of low birth weight (2.52).
The researchers
recommended smoking cessation programs in an appropriate cultural
context, especially for young Aboriginal women (Chan et al 2001). A
Cochrane systematic review of smoking cessation found that smoking
cessation programs do work in pregnancy and wider population-based
strategies should also be implemented as well as support in the wider
community for strategies to reduce social inequalities Lumley et al
2006)(Level 1 evidence).
A Western Australian study found tobacco smoke exposure of Aboriginal
infants to be higher than the overall population (Eades & Read 1999)
whilst recent ABS figures show Aboriginal and Torres Strait Islander
adults to be more than twice as likely to currently be smokers than other
Australian adults (ABS 2006).
The problem of remoteness
There is consistent evidence that lack of access to appropriate health
services results in poorer outcomes for general health (WHO 2001a) as
well as maternal and perinatal outcomes (WHO 1999, Chan et al 2005).
The provision of maternity services in rural and remote Australia is
23
hampered by a chronic shortage of GP obstetricians and midwives and
closures of smaller maternity units - with 120 having closed in the past 10
years (RDAA 2005). In Australia rural and remote areas carry the greater
burden of deaths (Department of Human Services 2001a).
Access and equity to appropriate health services and professionals are
every-day concerns for pregnant Aboriginal and Torres Strait Islander
women, particularly those in rural and remote areas. Women in remote
areas have to travel into regional centres and await the birth of their
babies away from their cultural ties. The views of Aboriginal women in 9
remote Top End communities were sought on their birthing needs (Kildea
1999). Key findings were related to the need for choice; safety; escorts;
safe hostels with food available; a skilled midwife in every community;
basic equipment; adequate antenatal care; updating skills for AHWs and
nurses; better communication in mainstream hospitals; a birth centre in
Darwin and community birthing for low-risk women (subject to certain
conditions being met) (Kildea 1999).
The Safe Motherhood Initiative has attempted to address this issue in
severely afflicted developing countries in a number of ways that include
strengthening primary health care initiatives at village level (WHO 1998).
Many remote Aboriginal and Torres Strait Islander Australian
communities face problems of the magnitude of developing countries, an
issue that has been cause for concern for several decades (Hertzel et al
1974, Nathan & Leichleitner Japangka 1983, NHMRC 1989,
Commonwealth of Australia 2000, Chan 2005).
Evidence of the benefits of antenatal care
A popular textbook for midwives first published in 1953 stated “It may be
difficult for the modern midwife to realise that until about 1915 few
pregnant women came under the care of doctor or midwife until they
actually went into labour” (Myles 1975 p. 73).
The aim of antenatal care is to screen for any deviation from normal good
health. Therefore, identification of pregnancies that may be at greater
than average risk is an essential part of antenatal care (Enkin et al 1995).
The provision of appropriate reassurance and education are also involved
(Enkin et al 1995).
There is very little agreement among professionals as to what are the
most important components of antenatal care. Haertsch et al (1996)
surveyed the views of a representative sample of midwives and
obstetricians in New South Wales and found 100% agreement on only
one item, the need for blood pressure screening during pregnancy.
In most parts of the world until recently the recommended number of
antenatal visits has followed a largely unquestioned tradition established
in the United Kingdom in 1929 (monthly until 30 weeks, fortnightly until 36
weeks and weekly until birth) (Hall, Mcintyre & Porter 1985). In the UK
and elsewhere the introduction of this regimen of antenatal care along
with improved care in labour comprised a huge leap forward in the care of
pregnant women and coincided with a lowering of maternal and perinatal
mortality. Although many factors were likely to have been involved,
24
universal antenatal care was seen to have been responsible, at least in
part for these improvements (Hall 2001). More than 40 years later
Cochrane (1972) called for randomised controlled trials to evaluate the
benefit of this most common “screening procedure” (Cochrane 1972). In
1980 (Hall et al 1985) undertook a comprehensive before and after study
of antenatal care including women’s views. Their study was ground
breaking in that it raised a number of questions and paved the way for the
randomised trials of reduced visits and other aspects of antenatal care
that were to follow (Villar et al 2002).
Between 1995 and 2001 ten adequately designed randomised trials of
reduced visits (compared with the current local standard number) were
conducted in developed and developing countries involving over 60,000
women (Villar et al 2002). The last of these was a multicentred trial
conducted in Argentina, Cuba, Saudi Arabia and Thailand involving
24,500 women that compared a 5-visit model with an 8-visit standard
model for healthy women (Carroli et al 2001). Findings of the other trials
were confirmed. Having reduced visits did not appear to affect perinatal
and maternal outcomes. The Cochrane systematic review of all the trials
found no differences between the groups for pre-eclampsia; urinary-tract
infection; postpartum anaemia; maternal mortality, low birthweight or
perinatal mortality. In developed countries only, women were less
satisfied with the reduced visit regimens. Reduced visit regimens in
developed countries usually included more visits than standard care in
the less developed countries (Villar et al 2002). These trials demonstrate
that the traditional western style number of visits bestows no real benefit
on outcomes and mostly costs more (Villar et al 2002).
Aboriginal and Torres Strait Islander women have long been considered
to be at risk because many have received little or no antenatal care
(Chan et al 1999-2006). It has long been an aim of improving the
pregnancy care of Aboriginal and Torres Strait Islander mothers and
babies to increase the number of antenatal visits (Chan et al 1990, 2006).
Antenatal guidelines
It is only recently that guidelines in pregnancy and childbirth are being
based on good quality evidence (NHMRC 1995 and 1998a, Women’s &
Children’s Hospital 1996).
Haertsch (1999) examined 7 different
international guidelines then current and found substantial variation in
what was considered to be important components.
The Royal Australian and New Zealand College of Obstetrics and
Gynaecology (RANZCOG) http://www.ranzcog.edu.au, now use antenatal
guidelines based on the best available evidence. Additionally many
hospitals have their own protocols (Women’s & Children’s Hospital 1996).
In Australia evidence-based consensus guidelines were released in
March 2002 (Three Centres Consensus Guidelines on Antenatal Care
Project 2001). Each guideline has a level of the quality of the evidence
used assigned to it (NHMRC 1998)
The guidelines are summarised below:
25
•
timing and number of routine antenatal visits: timing should be
flexible, numbers can be safely reduced for low-risk women
(Levels I and II)
•
models of antenatal care : pregnant women should have written
options; (Level IV) continuity of care, midwife and GP led models
are safe for low-risk women (Levels I, II, III); women should have
the option of carrying their own antenatal card (Level III)
•
smoking cessation: a range of very specific instructions on what
should be offered, i.e. offer all women smoking cessation
interventions that work such as a cognitive-behavioural
modification model, the way questions about smoking are posed
affects accuracy of responses (Levels I, II, III)
•
screening for Down’s syndrome:
(Levels II,IV)
•
offer to all pregnant women, notification of screening result which
should be in a format the woman understands
•
asymptomatic bacteriuria: all women should be offered screening
and appropriate methods described to her (Levels I -IV)
•
routine screening for infections such as HIV, syphilis, Hepatitis C
and B: (supported by mostly Level IV)
•
discharge planning during antenatal visits:
giving women
appropriate written information is suggested (Level IV)
•
routine blood pressure measurement: generally recommended at
each visit to identify potential pre-eclampsia (Level IV), attention
should be given to cuff size, positioning, (Level IV) use of Korotkof
sound for diastolic measurement (Level II) and appropriate
equipment (Level III)
•
routine weighing: is not clinically useful in screening for IUGR,
macrosomia or pre-eclampsia and is likely to incite anxiety in
women (Level IV)
•
symphyseal fundal (S-F) height measurement:
abdominal
palpation and/or S-F to monitor fetal growth is preferable to none
(Level II)
•
routine urinalysis for proteinuria: not recommended in low-risk
pregnancy, but is useful if hypertension identified (Level IV)
•
auscultation of fetal heart: no clinical benefit but reassuring to
mothers and clinicians (consensus opinion)
•
screening for diabetes mellitus: no strong evidence to support or
abandon the practice (consensus opinion)
•
prevention of group B streptococcal disease (GBS): routine
screening and giving IV antibiotics during labour is effective (Level
III)
provide written information,
26
Recently the development of a national evidence-based guideline for
antenatal care has been approved by Health Ministers, and Community
and Disability Services Ministers. A National Working Group set up in
South Australia has been given the task “to prepare an evidence-based
guideline for use throughout Australia dealing with antenatal care for the
healthy pregnant women.” Of relevance to this review is a section that will
“identify, review and assess for inclusion any current guidance relevant to
the antenatal care of Aboriginal and Torres Strait Islander women and
those who live in geographically isolated communities” (National
Evidence Based Guideline for Antenatal Care Scope).
An Aboriginal Women's Issues Working Group has also been
established with advice and input from NACCHO. This group will "review
all guidelines for their appropriateness for the care of Aboriginal
women" (personal communication Dr Julia Vnuk, July 2006). The work
from this group is awaited with interest.
Towards a model of birthing care for Aboriginal and Torres
Strait Islander Health Workers
Programs specific to pregnancy and childbirth within Australia: what
models exist to draw on?
Midwifery models
There has been a worldwide emphasis on midwifery care and ongoing
interest in the expansion of the role that midwives can play in the care of
normal low-risk birth (House of Commons 1992, NHMRC 1996 and
1998c, ICM 2004 & Appendix 4). Randomised trials of midwifery models
of care including team midwifery and birth centre care have shown
increased satisfaction and reduced interventions (aside from caesarean
sections which were the same) although a trend towards a higher
perinatal mortality with midwife care was noted (Waldenstrom & Turnbull
1998).
The National Health and Medical Research Council (NHMRC) report
Options for Effective Care in Childbirth, called for widespread introduction
of midwifery models of care (NHMRC 1996). Furthermore there have
been calls for the strengthening and support of a more autonomous
midwifery practitioner role to work in these models, including the
accreditation of visiting midwife practitioners (NHMRC 1996,1998c). In
addressing an important aspect of midwifery practice, the NHMRC
Services offered by midwives states that the ordering of a range of
pharmacological substances and tests under agreed protocols “should be
considered safe practice as they are integral aspects of comprehensive
care” (NHMRC 1998c p 4.). The same report highlighted the need for
more Aboriginal midwives.
Within Australia, where care is traditionally fragmented, midwifery models
may require the strengthening and development of individual midwifery
skills in a range of competencies to allow safe, effective care for a woman
throughout the entire pregnancy, labour and postpartum period.
27
There is scope for midwives and AHWs to work collaboratively, as is
being introduced in both Victoria and New South Wales (described
below). As Aboriginal midwives remain in short supply it is likely that
most teams will involve non-Aboriginal midwives and specifically
educated AHWs sometimes known as Aboriginal Infant Maternal and
Child health (AMIC) workers. The development of equivalent intercultural
partnerships (Franks et al 1996) and cultural awareness, sensitivity and a
high value placed on the unique role of the AHW are considered crucial in
these developing models (Campbell 2000).
The Alukura model
Alukura was established following consultation with women from over 60
Aboriginal communities in the early 1980s. In1998 an external review of
Congress Alukura was conducted (Carter, Lumley, Wilson & Bell 2004).
A conference report gave some history and outcome data from the review
(Ah Chee, Alley & Milera 2001). The Congress Alukura model was
formally ratified in 1984 and provides:
•
•
•
•
•
•
•
•
Comprehensive antenatal and postnatal care
Gynaecological services and services of a visiting specialist
obstetrician / gynaecologist
A limited mobile bush service
A visiting diabetic educator
Healthy lifestyle education and counselling in nutrition, substance
misuse and sexual health
A liaison service with hospital and specialist services
A transport service
Home visits
Since 1998 an education program for young women 12-20 years has
been delivered in high schools, youth institutions and bush locations
(Congress Alukura – women’s business Ah Chee et al 2001).
Birthing services were provided from 1993-7 but not since June 1997.
Some of the reasons given for women not birthing at Alukura are: a lack
of resources and infrastructure to manage a 24-hour service;
maintenance of staff skills with the relatively low numbers seen; health
status of some clients; personal choice by women to use hospital and a
need to keep other health providers in the region informed about the
service. The need for Alukura midwives to gain Australian College of
Midwives accreditation for independently practicing midwives in order to
obtain visiting rights at Alice Springs Hospital was being addressed (Ah
Chee et al 2001). This would allow continuity of care if transfer in labour
is needed or allow the midwife to care for women in the hospital if that is
their choice of birth location. In a review by Carter et al (2004) a number
of reasons why birthing was not happening at Alukura were given by
respondents including loss of links with Grandmothers’ Law among young
women (See Appendix 5).
28
The review found that:
1. There had been a change in attitude to Alukura among Central
Australian health providers from marked criticism, to Alukura being
described as playing a key role both technically and in the
provision of culturally sensitive birthing care for Aboriginal women
in the region.
2. In the 10 year period from 1986-1995 there had been an increase
in the proportion of urban Alice Springs women who commenced
antenatal care in the in the first 3 months of pregnancy from 21%
in 1986-90 to 33% from 1991-5.
3. In the 10 year period from 1986-1995 mean birth weights of babies
born to urban Alice Springs mothers increased from 3168g in
1986-90 to 3271g from 1991-5, thus narrowing the gap between
Aboriginal and non-Aboriginal babies to just under 50g.
4. In 1994, of 122 Aboriginal women from urban Alice Springs, 98%
received all or some of their antenatal care at Alukura whilst 18%
of rural women had some of their care there.
The authors stated that the data did not establish that Alukura was
responsible for the improvements, and that trends had also happened in
other areas in Northern Territory, however they were not on this scale (Ah
Chee et al 2001).
A recent paper by Carter et al (2004) reporting on the Alukura review
recommended: research funds to maintain routine data on antenatal care
and birthing outcomes; a focused research project to obtain the views of
younger women (16-25 years old) who comprise the highest proportion of
users of Alukura; development of an outreach service in partnership with
key women’s health working groups and the relevant communities; and
the continuation of a visiting women’s health clinic providing services to
selected communities.
The Strong Mothers Strong Babies Strong Culture Program
The Strong Mothers Strong Babies Strong Culture Program is a peer
education program in nine remote Aboriginal communities in the northern
Territory. The educators are women, selected by their community and
educated to provide information about nutrition in pregnancy and develop
activities to improve the nutritional status of pregnant women. They work
in partnership with AHWs, nutritionists, and midwives.
The pilot evaluation of 3 communities showed an increase in the mean
birth weight when compared with ‘comparison locations’ (Makerras 1998).
However the lack of an adequate control group and the inability of the
study to control for the effects of smoking mean that the results should be
interpreted with caution.
29
The Townsville Aboriginal and Islander Health Service (TAIHS) Mums
and Babies Project
The Townsville Aboriginal and Islander Health Service (TAIHS) started
the Mums and Babies Project after concerns about perinatal outcomes
and unpopular mainstream antenatal services. From 456 women who
received the care, there were improvements in the numbers of antenatal
visits but no changes in low birth-weight, perinatal mortality or preterm
birth when compared with historical controls (Panaretto et al 2005).
Funding was made available from Rio Tinto Aboriginal Foundation and
The Ian Potter Foundation for a two-year pilot project. Further health
department funding has now been secured. Clinics are held each
morning for young families and pregnant women. A team of two health
workers, one childcare worker, one driver and two female doctors
provides holistic care and links with other agencies. The service
provides:
•
•
•
•
•
Comprehensive primary health care
Antenatal and postnatal care
Immunization
Growth monitoring
Developmental screening and hearing screening for babies and
children
There was a rapid increase in attendance rates from 40 a month in
February 2000 to 500 a month in January 2001. During that time
antenatal attendance rates doubled to a median of 6 visits per pregnancy
and continued to rise (THAIS 2002).
The Victorian Koori Health Project
As long ago as 1990 the Victorian Birthing Review chaired by Judith
Lumley made recommendations to “ensure the continuing involvement of
female Aboriginal health workers in the provision of antenatal and
postnatal support for Aboriginal women” and “to investigate the
development of education programs on birthing issues for health workers
of Aboriginal background, with an emphasis on antenatal and postnatal
care; and encourage the participation of Aboriginal women in the planning
of health services and the establishment of different models of care”
(p.76). Ten years later Koori Maternity Services Program presented a
report to Victorian Aboriginal Community Controlled Health Service
(VACCHO) and the Victorian Department of Human Services ‘From her to
maternity….” (Campbell 2000).
In the report several recommendations were made, one of which was to
send health workers to James Cook University 1 to attend a specifically
1
Between 1991 and 2001 James Cook University, Townsville offered a 4-week theoretical and
clinical program in maternal health care for AHWs and graduated 245 workers Australia-wide. The
course was evaluated by SGRHS in 2001 for OATSIH but did not receive funding to continue. The
literature review for this report includes updated material from that report (Bradley et al 2003).
30
designed antenatal and maternal skills course for health workers with a
view to developing a similar course designed for Victoria. Six went and a
course was developed which is in modular form, started in 2002 and
continues. Koori Health has funded models for 8 communities; mostly
involving AHW midwife working arrangements. Research from one of
these models The Women’s Business Service at the Mildura Aboriginal
Health Service has been published (Campbell & Brown 2004).Aboriginal
Maternal Infant and Child health workers are involved in the care
provision. Users’ views were compared with rural women Victoria-wide.
One finding was that more users (Aboriginal women) rated their antenatal
care as ‘very good’ although their labour care was rated less highly than
the rural women.
The Gumileybirra Women’s Health Unit
Gumileybirra is part of Danila Dilba in Darwin. It is an Aboriginal
community controlled health service (ACCHS) and was set up in 1994 to
increase and improve services to women. Gumileybirra is a Larrakia
word meaning “women in a group”. The Larrakia people are the
traditional owners of Darwin (Hunt et al 2001).
An evaluation of this service by Hunt et al (2001) included client
feedback, review of attendance, antenatal care and archival material.
Questions were asked about what clients, service providers and
community organizations thought of the services; how data were
collected analysed and used, how systems interacted with other parts of
Danila Dilba; whether Gumileybirra had had an impact on the care of
pregnant women; how such care could be improved and how future
services for women and children might best be planned (Hunt et al 2001).
There were 39 interviews or questionnaires and most women felt positive
about the service offered and the staff attitudes and behaviour.
The waiting time to see a doctor was the most commonly mentioned
negative response. The design of the evaluation meant that it is ongoing
and incorporates a number of documentary outputs such as a time line
poster documenting milestones to help in story telling about Gumileybirra.
Bibbulung Gnarneep (‘Solid Kid’) Project – Health in pregnancy and
antenatal care
“Bibbulung Gnarneep is a collaborative project that with the Derbarl
Yerrigan Health Service, the TVW Telethon Institute for Child Health
Research, and the Perth Aboriginal community that started commenced
in 1994. The initial project comprised a series of five interviews with a
population-based cohort of 270 Aboriginal mothers living in the Perth
area. The data were collected when the infants were aged 6-12 weeks,
with a final interview when the children were aged about two years.
Information on mothers’ health in pregnancy and on the use of antenatal
care was collected at the first interview. Of the 270 mothers, 98% had
seen a doctor at least once during their pregnancy, 65% had at least 6
31
antenatal visits and 26% reported more than 10 visits. Pre-existing
medical problems were common, with 50% of mothers reporting at least
one. The major conditions reported were anaemia, asthma, bronchitis
and kidney conditions. Some 76% of mothers experienced at least one
significant complication during pregnancy, including anaemia,
hypertension, urinary tract infections, bleeding, threatened premature
labour and prolonged rupture of membranes.
With such high levels of health problems and pregnancy complications,
good antenatal care is necessary. A significant proportion of mothers
reported they were unable to access care when they needed it, largely
because of transport and distance difficulties. Around 40% of mothers
said that an antenatal home visiting service would help to overcome
some of these problems. In response to these results, the project team
commenced a pilot research program of home visiting for Aboriginal
women in the Perth area. Women are being enrolled, antenatally where
possible, with visits continuing until the child reaches two years of age.
Advocacy and support for the mothers are major aspects of the program.
The project continues to provide feedback to the community covering
many aspects of maternal, child and family health. Current work is
focussing on the nutrition of the children and their health outcomes, and
on important factors in the rearing of Bibbulung Gnarneep (Solid Kids).”
(personal communication The Bibbulung Gnarneep Team).
In conclusion, a recent literature review of interventions to improve the
health of Aboriginal and Torres Strait Islander mothers, babies and young
children found a lack of strong evidence of interventions on which to base
practice with many studies without a control group. They called for better
quality research to guide practice (Hetceg 2005).
Inter-cultural research – working in partnership
Aboriginal and Torres Strait Islander life is maintained by the kinship
network which has roles and responsibilities that ensure the maintenance
of essential protocols. Protocols exist in regard to women’s public and
private knowledge in which senior women have the responsibility and
authority to share knowledge with young women (Congress Alukura &
Nganampa Health Council 1999). It is therefore important that protocols
are adhered to during any research process or work involving Aboriginal
and Torres Strait Islander peoples (Franks et al 1996). Working interculturally equivalent partnerships developed from a position of mutual
respect have been found to work well. For example research that drew on
the kinship network and applied interventions that arose from the
protocols, was able to substantially contain petrol sniffing in two Central
Australian Aboriginal communities (Franks1989, Franks et al 1996).
Our evaluation occurs at a time when a number of important
developments in birthing services are being offered to Aboriginal and
Torres Strait Islander women Australia-wide. This new, for South
Australia, model of Aboriginal birthing care is being evaluated by a team
experienced in and committed to working in equivalent intercultural
32
partnership. The chief investigator is an Aboriginal researcher working in
partnership with the other investigators.
The importance of the evaluation lies in its ability to:
1. Document and contribute to this growing body of work that
evaluates birthing programs for Aboriginal and Torres Strait
Islander women; and
2. Work in partnership with Aboriginal women and give back
information about the project to their communities so they can
suggest or make changes where required to continue and
strengthen the program.
33
METHODOLOGY
The evaluation focused both on the process of establishing the program
as well as outcomes from the first 50 births. The objectives of the
evaluation were to:
1. Seek participants’ views and experiences of the program;
2. Obtain information about behaviours that may affect birth
outcomes;
3. Document the process of establishment of the program and any
barriers to its implementation;
4. Investigate aspects of the working relationship between the AMIC
workers and the midwives employed in the program, and
5. Describe participants’
outcomes.
demographic
profiles
and
perinatal
Seven data sets:
Key stakeholder interviews
In depth semi-structured interviews and focus groups were conducted
with program AMIC workers and midwives, program managers, nursing
unit managers, midwives, AMIC workers and members of the Aboriginal
Women’s Advocacy group. The interviews covered the participant’s role
in the program, their views about the establishment and value of the
program, and issues with regard to inter-cultural working, and
sustainability.
These key stakeholders were in Whyalla and Port Augusta most people
interviewed had been involved from the beginning of the program either
directly or indirectly.
Ten interviews were held
Aboriginal and non-Aboriginal teenage women program participants’
focus groups
Two focus groups were held, one with Aboriginal participants and one with
non-Aboriginal teenage women from the Whyalla program. Questions
were asked about their experiences of the program. Approximately 10
women participated in focus groups
Aboriginal program participants’ new mothers’ questionnaires
The Victorian Birthing Review new mothers’ structured questionnaire
(Victorian Department of Health 1990) developed by Professor Judith
Lumley and the team at the Centre for Mothers’ and Children’s Health had
been modified in Victoria for use with Aboriginal women (Campbell &
Brown 2004). With guidance from local Aboriginal researchers the
questionnaire was further modified and piloted for use in the program.
34
Aboriginal researchers used the questionnaire as the basis of a face-toface interview. It was readily understood and acceptable to women and
worked well inter-culturally, although found to be somewhat timeconsuming. Ten women participated in interviews. The questionnaire
covered the antenatal, birthing, and postnatal experiences of the women.
Rural new mothers’ questionnaire
Data from rural respondents who completed the new mothers
questionnaire (n=54) was compared with the responses of Aboriginal
women program participants
Program database
A program database was designed and maintained by the NFWRHS to
record a wide range of information such as:
•
•
•
•
•
•
•
•
•
•
•
Age, parity
Number of antenatal visits
Referrals in pregnancy including antenatal admission
Numbers of contact with services and advice given
Gestational age at birth
Mode of birth
Baby’s birth weight
Nursery care
Method of feeding
Postnatal visits
Referral to other services
Information for 50 women who had given birth and were program
participants was obtained.
Supplementary Birth Records
Data were collected from Supplementary Birth Records that are
completed by midwives and returned to the South Australian Pregnancy
Outcomes Unit where they are used to gauge pregnancy outcomes and
published in annual reports (Chan et al 2006) (Appendix 6).
Summaries of birth outcomes in 2004
Summaries of birth outcomes in 2004 from the South Australian
Pregnancy Outcome Unit (Chan et al 2006) were for simple non-statistical
comparisons where possible.
Analysis
Quantitative data is presented as tables using descriptive statistics.
Qualitative data from focus groups was taped recorded with participants
consent or otherwise notes were taken. Tapes were transcribed and
transcriptions returned to participants for checking. These data were then
coded against the objectives of the evaluation. Then themes were
developed where there was a weight of information.
35
Study design limitations
The evaluation has a number of possible limitations:
1. Although sufficient to provide demographic and outcome data the
sample lacks the statistical power to draw conclusions about the
effect of the program on outcomes.
2. The lack of a control group further limits the ability to draw
accurate comparisons about the impact on the program on
outcomes of interest.
3. The large amount of missing data suggests that conclusions
should be interpreted with caution.
36
FINDINGS
The findings of the evaluation are grouped around the objectives:
Objective One: To seek
experiences of the program
participants’
views
and
New mothers’ focus groups
Two focus groups of mothers were held, one at Whyalla High School with
non-Aboriginal young women from the Whyalla teenage women’s
program and the other at Nunyara Wellbeing Centre with AMIC workers
and Aboriginal women who had used the program.
Young women’s focus group
Four young women attended the focus group. Broadly the questions
asked their views about their satisfaction with the program.
All the young women were referred to the birthing program through their
school. They were seen individually by the midwife at a variety of
locations for antenatal visits (school, hospital, own home and Nunyara).
The midwife’s role was seen to involve three areas – firstly to provide
information and education about the health of their baby, secondly to
provide information about their own health and thirdly to provide other
support such as transport.
In the group the young women highlighted that they would have
welcomed extra support such as that provided by the AMIC workers for
the Aboriginal women in the program.
The young women felt positive about their experiences with the program
and program staff but felt that their experiences of the health system as
whole were dependent upon the attitudes and skills of the service
providers they dealt with.
One participant was not satisfied with the care she received from her
medical provider but was hesitant to bring the issue to the attention of the
program midwife because she believed that she did not have a choice
about changing her doctor.
All the young women recall receiving follow up visits from the program
midwife and were seen by CHS workers when their babies were about 6
weeks however, did not recall being told that their involvement in the
birthing program had finished.
Overall the young women’s experience of the program was positive and
particular reference was made to the program midwife who was seen to
37
be “understanding, caring and did not display negative views” about the
circumstances of their pregnancy and this had been important to them.
Whyalla Aboriginal new mothers’ focus group
Four Aboriginal new mothers who had been through the Whyalla Family
birthing program and two AMIC workers took part in a focus group. A
number of positive aspects to the program were highlighted:
•
•
•
•
•
•
Some of the mothers were pleased that they were able to have the
people they wanted in the labour room
There had been support from the AMIC worker with appointments
and transport to the hospital and clinics.
The women could choose not to see own GP for the all the
pregnancy care
The program classes provided at Nunyara were considered to be
very good
The women liked the baby packages: kinbie rugs, jump suits and
pads
Involvement of fathers in classes with other men - “if that is what
they want” was mentioned as an option for some
Overall the group was disappointed that the Whyalla program had not
provided labour and birthing care. They would have liked access to their
AMIC worker or midwife in early labour to monitor and reassure them and
they felt the lack of the presence of a birth attendant they knew during the
birth. They believed this acted as a barrier to being well informed about
pain relief, birth options and support for a normal birth.
For the postnatal period the women would have liked more information
about “postnatal baby blues,” more support from CYH and visits from the
midwife and AMIC worker team for up to 6 months.
Piloting of the Victorian new mothers’ questionnaire
The new mothers’ questionnaire has been used extensively in Victoria for
several years and covers women’s views of care in pregnancy, labour and
birth, and the postnatal period (Lumley et al 1990). Responses from a total
of 10 Aboriginal women were obtained. Initially three Aboriginal women
enrolled in the program were contacted by an Aboriginal researcher who
used the new mothers’ questionnaire (adapted by Campbell and Brown
(2005) for use with Aboriginal mothers) to ask face-to-face questions of the
women. The questionnaire was further modified by two researchers with
guidance from a senior Aboriginal researcher. Seven more women were
then interviewed by an Aboriginal interviewer. All the interviews were
conducted in a place chosen by and acceptable to the woman, which was
usually her home (Anderson, Champion et al 2006).
The questionnaire, although lengthy, was easily understood and appeared
to be culturally acceptable except when men entered the room. A need for
adaptation of several questions and the inclusion of others was highlighted.
Because the questionnaire focused on pregnancy, labour and after birth,
38
and used similar questions about care, some women found it long and
repetitive. Others had family responsibilities to attend to. The questionnaire
was acceptable to the women and worked well inter-culturally but further
refining may be required before its wider use with Aboriginal women, taking
the issues of time and perceived repetition into account. The sensitive
nature of the questions did not appear problematic; however, when men
were present the women became reticent. This relates to very clearly
defined men’s and women’s realms in Aboriginal life because pregnancy
and birthing is women’s business.
Table 1. presents selected summaries from the Aboriginal interviews and
compares them with a sample of 54 non-Aboriginal rural women who gave
birth at Whyalla, Port Augusta and Port Lincoln during 2006 who have
completed the Victorian new mothers’ questionnaire 6 weeks after birth
(research project in progress by author GS). The sample is too small to
draw statistical conclusions however of interest is that the Aboriginal
women in the program were more likely to rate birthing staff as very friendly
and welcoming and to know the midwife who cared for them in labour. But
they were also more likely to have had someone in the labour room whose
presence was not wanted; to have wanted more information in labour; and
to have found feeding advice contradictory than the sample of rural women
and be less likely to be breastfeeding at 6-8 weeks.
Table 1: Comparisons between rural non-Aboriginal and Aboriginal
mothers using the Victorian new mothers’ questionnaire *
Rural
In labour
Birthing staff friendly/welcoming:
very
fairly
not very
Knew midwife who undertook labour
care
Someone there whose presence not
wanted
Wanted more information in labour
often
sometimes
never
After the birth
Hospital stay in days (mode)
Rating of care in hospital
very good
good
mixed
%
n=54
Aboriginal
%
n=10
76
24
-
9
1
90
10
49
7
70
3
6
4
40
n=54
3
10
41
6
18
76
3
7
-
30
70
-
41
13
n=53
26
5-6
39
3-4
n=9
50
29
15
10
54
28
18
3
4
2
n=8
33.3
44.4
22.2
Feeding advice contradictory
often
4
7
sometimes
14
26
never
36
67
Breastfeeding at 6-8 weeks
44
81
* Adapted from Lumley et al 1990 and Campbell & Brown 2004
4
4
0
2
50
50
25
39
Further comments from Aboriginal mothers
One of the Aboriginal mothers was satisfied with the program and was
pleased that the midwife visited her at home. When she first got signs of
labour pains, this mother rang the midwife who collected her and took her
to hospital. The midwife and the AMIC worker were at the birth.
Another Aboriginal mother had not initiated contact with the AMIC
workers at the time of the interview, but had been waiting for another visit
since the birth. She recalled that she received one or two visits within
three days but had not had visits since. This mother would like to know
when her baby appointments are and to see an AMIC worker again.
A third Aboriginal mother said when her doctor told her about the program
she was told that she would have follow up by the AMIC worker for six
months after the birth. She thought that this support would include helping
with her shopping and taking her to appointments. This mother said that
for the first couple of weeks after the birth it was good but she hasn’t seen
the AMIC worker at all for about a month. The baby needed lots of tests
and she wants to know why and would like a midwife or AMIC worker to
explain things to her. Some tests were done over a month ago and she
did not yet know the results.
A common theme from the Aboriginal mothers who were interviewed was
a desire for support to continue over a longer period than 6-8 weeks. The
women had needed a lot of support after the birth. They were sad to see
the time with the midwives and AMIC workers end; a feeling that was also
shared by AMIC worker in their interviews.
Objective Two: Obtain information about behaviours that
may affect birth outcomes
A number of well documented behaviours during pregnancy may affect
birth outcomes. Performance indicators for the program; smoking or
substance use; late attendance for antenatal care and low attendance for
antenatal care were able to be collected from the program database
and/or perinatal statistics forms.
This section summarises data from the program database maintained by
the midwives and data from the supplementary birth forms from the
Pregnancy Outcome Unit (Appendix 6) and includes all women enrolled
since July 2004 until June 30th 2006.
Number of antenatal visits (clinical)
The program supported visits and telephone calls from AMIC workers that
may not have been directly associated with clinical care, although a broad
approach to what constituted care was taken. Therefore data were
collected under a heading ‘occasions of service’ that did not distinguish
40
between support such as transport or other issues or whether some form
of hands-on or clinical care such as a blood pressure or abdominal
palpation had been undertaken. Therefore, in an attempt to gain more
accurate information, the number of antenatal visits for the Aboriginal
women has been taken from the supplementary birth record (Table 2).
When missing data are excluded, 15.6 of Aboriginal women had fewer
than 7 visits (compared with 39% for Aboriginal women and 6% of nonAboriginal women in the 2004 SA data).
Table 2: Antenatal visits (clinical) for Aboriginal women
Port Augusta
Whyalla
Total
%
1-6
7-15
16 +
Missing data
3
12
2
10
2
11
2
5
5
23
4
15
15.6
71.9
12.5
Total
27
20
47
100
Table 3 shows the occasions of service that women were seen either by
a midwife, an AMIC worker or both. Occasions of service could include
follow up visits at the woman’s home, at the hospital, Nunyara Well-being
Centre, Pika Wiya Health Service or other locations or transport activities
and bringing women to appointments.
Table 3: Antenatal occasions of service all women
Home or
hospital visits
1-5
6-10
11-15
16-20
21-25
25 +
Missing
Total
Port Augusta
Program
Aboriginal
women
4
4
1
9
2
2
5
27
Whyalla Program
Total
Aboriginal
1
2
8
3
1
1
4
20
Non
Aboriginal
1
2
2
5
6
6
11
14
3
3
9
52
Gestation at the first visit
The table shows at which trimester of pregnancy women entered the
program. Only 17.3% of the total of women had their first booking visit in
the program in the first trimester (before the 12th week) and 42.3% did not
book until the third trimester (after the 24th week). However, the data did
not include whether any of the women had previously obtained antenatal
care elsewhere for this pregnancy.
41
Table 4: Gestation at first visit by trimester
Pregnancy
trimesters
Port Augusta
First trimester
(before 12 weeks)
Second trimester
Whyalla
Total
%
1
9
17.3
Aboriginal
Aboriginal
Non Aboriginal
5
3
8
8
2
18
34.6
Third trimester
(24 weeks +)
12
9
1
22
42.3
Missing data
2
-
1
3
5.8
Total
27
20
5
52
100.0
(12 – 24 weeks)
Tobacco use in pregnancy (from supplementary birth record)
Table 5 presents the number of Aboriginal women who were a smoker, a
non-smoker or quit before the first visit taken from the supplementary
birth record of the Perinatal Statistics Unit. There remains substantial
missing data making it difficult to draw meaningful conclusions although a
rate of smoking of 75% is calculated when missing data are excluded.
Data about smoking from the program database are presented later in
Table 7. .
Table 5: Aboriginal women tobacco smoking status first visit*
Port Augusta
Aboriginal Women
14
2
-
Whyalla
Aboriginal Women
10
5
1
24
7
1
Missing data
10
4
14
Total
26
20
46
Smoker
Non-smoker
Quit before first visit
* data from the supplementary birth record
Table 6 presents the number of Aboriginal women who were a smoker, a
non-smoker or an occasional smoker in the second half of pregnancy
again taken from the supplementary birth record. The problem of missing
data remains.
Table 6: Aboriginal women: smoking in second half of pregnancy*
Smoker
Non-smoker
Occasional
Missing data
Total
Port Augusta
Aboriginal Women
12
1
1
12
Whyalla
Aboriginal Women
9
5
1
5
21
6
2
18
26
20
46
* data from the supplementary birth record
42
Smoking and cannabis use from visit one to visit three (from program
database)
Data were collected by program staff about substance use (including
tobacco) at visit one (first antenatal visit, Table 7) and again at visit three
(postnatal visit, Table 8), however, there remains the issue of missing
data (n=13, 25%) at the antenatal visit and (n=16, 32%) at the postnatal
visit. If women for whom the smoking status is unknown are excluded, the
overall rate of tobacco smoking at the first visit is 56.4%. Although the
sample is small it compares with the 2004 South Australian rates for
Aboriginal women at the first visit of 57.8%. Cannabis use was 10.3%.
Table 7: Smoking and cannabis use in pregnancy first antenatal
visit*
Port Augusta
Program
Aboriginal
women
14
4
5
4
27
Tobacco
Cannabis
Tobacco & Cannabis
Non smoker
Missing data
Total
Whyalla Program
Aboriginal
5
1
5
9
20
Non
Aboriginal
3
2
5
22
4
1
12
13
52
* from program database
Table 8 presents postnatal smoking and cannabis use from the program
database. At the postnatal visit 65% of those for whom data are available
were smokers. Postnatal data are not collected by the SA Pregnancy
Outcome Unit for comparison.
Table 8: Smoking and cannabis use at postnatal visit
Tobacco
Cannabis
Tobacco & Cannabis
Non smoker
Missing data
Total
Port Augusta
Program
Aboriginal women
11
2
5
7
25
Whyalla Program
Aboriginal
7
4
9
20
Non Aboriginal
3
2
5
21
2
11
16
50
Objective Three: Document the process of establishment
of the program and any barriers to its implementation.
In the interviews with midwives, AMIC workers, and key stakeholders,
issues related to the establishment of the program strengths and
weaknesses and sustainability issues were discussed.
Themes that emerged from interviews appear in Table 9.
43
Table 9: Stakeholders themes about the program implementation
• Role of the AMIC workers
• Operational differences between the two sites
• Issues of coordination and communication between sites
• Role of the Aboriginal Women’s Advocacy Group
• Positive relationships between community, AMIC workers and
midwives
• Sustainability and resource issues
The important role of the AMIC worker
The employment of AMIC workers was viewed as one of the highlights of
the program by all stakeholders. The role the AMIC workers played in
facilitating positive experiences for the women and “bringing respect for
culture” was clearly acknowledged by stakeholders.
What has worked well in the program is the AMIC workers. They
are so fantastic and it has been such a positive experience for the
women involved….. The midwives are supportive and are
delegating and there are wonderful stories after a birth ....… about
a participant having a normal delivery – it has just been what
women have wanted – all women – just not only Aboriginal
women. Stakeholder
However, issues of adequacy of resources, including the number of hours
the AMIC workers were employed, support, training and development
were equally highlighted by the stakeholders. It was seen as important to
develop formal mechanisms to ensure that all AMIC workers receive
adequate support in their roles. Working in a team with fellow AMIC
workers was seen as important for their retention. For example, the
Whyalla program has only one AMIC worker which could be isolating in
her role.
The need to support AMIC workers clinically though education, training
and development opportunities and to maximise their career pathways
was noted by respondents with a general feeling that the role and
responsibilities needed clarification. Whilst it is acknowledged that
training is important, when workers are employed in a part time capacity,
it is possible that time can be perceived to be taken up by training rather
than service delivery.
The service model is complex and issues were raised including difficulties
with cultural brokerage and advocacy and balancing a range of skills such
as clinical, data management and administration.
The current workers have a wide variety of skills – that has
challenges and has strengths – there is no prerequisite training
and their training and development needs to be worked out………
44
It is hard for the AMIC workers to work out … as to what the role is
and the hospital staff knowing what their skills are and what to
delegate. The clinical part is becoming clear but it is a new role
and the relationship stuff is important. Stakeholder
The AMIC workers have a wealth of experience and they are
asked to go to all these meetings including state-wide meetings to
give advice on a whole range of things. And they have only have
limited hours. They have to be there before in antenatal care
seeing women, and afterwards and attend training, and meetings they are constantly negotiating their hours. Stakeholder
Operational differences between the two sites
All informants spoke about the issues arising from operational differences
between the two sites. These differences included funding which meant
staff had not been involved in birthing and labour in Whyalla and also the
number and roles of clinical staff in the program:
Different pathways of care are being implemented and contributed
to the difficultly in overall management of the program …..The
complexities of project management have been the time intensive
nature of establishing two sets of resources, clinical protocols and
health promotion material, and data collection. The time this has
involved has been underestimated. Regional coordination is
necessary to ensure that the program is comparable in both sites.
Stakeholder
Some dissatisfaction was expressed about the allocation of funds,
management of the program between sites and the implications this had
for outcomes at the local level.
I think it would help keep it strong and it would be easier to get
local communities’ participation if they knew that it was local and
managed here (it) would be easier to keep going. There are
differences between Whyalla and Port Augusta and our workers
want to work in their own way. There is a history of ignoring these
differences. ……Port Augusta is stronger and there is a stronger
voice ….. and this influences how we do things. Stakeholder.
Coordination and communication between the sites
The role of regional coordination was seen as important to ensure
communication between all stakeholders, ensure support for the AMIC
workers, and to clarify roles and expectations.
I think that it is very important to have clear roles and
responsibilities and protocols. Perhaps there needs to be service
agreements drawn up and the regional view of things properly
promoted. Stakeholder
45
Initially a project officer had co-ordinated the establishment of the
program. She resigned and at the time of the interviews had not been
replaced.
The program originally had a regional focus and could work the
two areas together and improve the communication between the
two areas, but now this is difficult without the coordinator.
Stakeholder
There was, however, considerable optimism about the program and it
was very positive that the midwives and AMIC workers were working well
together. Informants gave examples such as the positive communication
between the AMIC workers and midwives and joint training opportunities.
One example was Iga Warta, a cultural weekend in the Northern Flinders
hosted by the members of the Andymathanya language group of the
Gawler and Flinders Ranges of South Australia
Role of the Aboriginal Women’s Advocacy Group
All informants were acutely aware of the advocacy group’s potential to
support the AMIC workers, ensure cultural sensitivity, and share their
cultural knowledge, enable community ownership, and to assist in
achieving positive outcomes for the Aboriginal women in the program.
The Advocacy group exemplifies local community participation, Aboriginal
ownership and a means of improving access to the program by Aboriginal
women.
They have a great cultural knowledge and they were great
contributors at Iga Warta. They know about cultural things about
the birthing which they tell us about. It is a really good forum to
share cultural knowledge. Stakeholder
The Advocacy group are keen to play a bigger role and all the
reports about the program say they are playing a very important
role. Stakeholder
However, there were several issues. The links between the group and
overall program management are largely informal. It was reported that the
group had difficulty meeting from time to time partly due to competing
time demands and transport issues. People were trying to fit in the
complex facilitation, legitimisation, and networking necessary to resource
the group on top of their other roles. The issue of a lack of financial
remuneration for participation was raised.
Resources and sustainability
Overall it was noted by stakeholders that it was important to incorporate
the new program in the mainstream antenatal, birthing, and postnatal
care for new mothers in Port Augusta and Whyalla. It was thought that
46
this would ensure adequate resources, resolution of the complexities of
the management of the program, and ensure its sustainability. The
financial and human resources, including the time of the Advocacy group,
to develop the program to date is considerable. Good-will, in addition to
program funds, has ensured its success.
Resources are limited, however, respondents believed that funds to
increase the hours of AMIC workers across both sites and on-call
payments for the worker at the Whyalla site and re-employ an
experienced project co-ordinator needed to be made available. (NB a
part-time co-ordinator has been employed since these interviews)
Funding is also needed to pay sitting fees for the Advocacy group
members.
There is a need for a project worker to do admin, project resource
development, negotiation with time priorities for the AMIC workers,
assisting with statistics evaluation. This then frees up the AMIC
workers and helps coordinate advocacy group meetings.
Stakeholder.
There are usually staffing or operational issues. The midwives of
the program can’t always be expected to pick up these issues as
they have full work loads in addition to this program. Stakeholder.
Some comments were also received about implications for sustainability.
For example, in the approach to June 2005, midwives and AMIC workers
were uncertain whether referrals into the program could be accepted and
this had an impact on bookings and confidence in program viability.
There was recognition that traditional practices did not involve men
(fathers) during labour and birth but that variation existed in what the
women wanted and the AMIC workers were able to support the women
and their partners with their requests where possible.
One stakeholder felt that male partners should be supported as part of
the program, particularly in antenatal and postnatal sessions and also
suggested employment of male AMIC workers. However, in the words of
another stakeholder:
There are men who want to be involved more and the AMIC
workers work with the whole family. How you support the men is
for the AMIC workers and the Advocacy group to resolve.
Stakeholder.
Objective Four: Investigate aspects of the working
relationship between the AMIC workers and the midwives
employed in the program
47
Broadly, the questions asked related to: what the work involved; what, if
any were the issues in setting up the program, their own role and the
roles of other workers including inter-cultural issues; whether they felt it
was a good way to work together; perceived value of the program for the
mothers and babies and a question about anything they would put on a
‘wish list’ that would improve the functioning of their work and the
program.
The midwives all provided direct midwifery care to the women and the
Nurse Unit Managers (NUMs) had an overall managerial role. In the
Anangu Bibi Port Augusta site the midwives fulfilled their role in provision
of antenatal, intrapartum and postpartum care, and found this way of
working very satisfying (ICM 2005 and Appendix 3). Skill sharing with
AMIC workers and support was part of their role.
Application of the program differed in important aspects between the two
sites. The main differences were support and care provision offered by
Pika Wiya Health Service – a well established Aboriginal health service.
Also the Port Augusta site could provide care through labour and birth,
enabling the achievement of continuity of carers as well as continuity of
care (skill maintenance for labour and birthing are an important part of a
midwife’s role). Midwives from both sites commented that Whyalla was
disadvantaged in this area.
We don’t have midwives in the antenatal clinic setting in Whyalla.
Port Augusta does. So I started work, then there were two AMIC
workers. They were very instrumental in meeting the women and
bringing them in to Nunyara. And the selling point was that the
midwife would be there also. Under the birthing program banner I
was then able to start seeing the Aboriginal women and be able to
visit them at home…Midwife
A further issue for Whyalla had been the incorporation of teenage
mothers into the program and the liaising role with the high school.
Although a local teacher had been supportive, this had been
accomplished without the benefit of any equivalent health or youth worker
such as an AMIC worker.
…and we also have the teenage component, there are 5 that have
come through from the high school with the referrals from there for
the antenatal period …but I don’t know that I’d have had time for
many more of them to be honest. Midwife.
Midwives issues in setting up the program
Recurring themes raised by the midwives are highlighted in Table 10.
48
Table 10. Midwives’ issues in setting up the program
•
•
•
•
•
•
•
Marked differences between sites
Lack of clarity about the role of an AMIC worker
Confusion about accountability, lines of responsibility and practice
guidelines
Major role in supporting AMIC workers and sharing skill development
Lack of facilities, space, infrastructure and basic equipment
Negativity from hospital staff highlighted at both sites
Incorporation of non-Aboriginal teenage women into the Whyalla program
There were many issues involved in the setting up of the program. There
is overlap with some of these across questions e.g. the issue of skill
sharing and role development with AMIC workers.
…and you know, what is an AMIC worker? No-one ever produced
a job description per se. They would go to Port Augusta to the
regional meeting, and a lot of the time I would be asking what skills
can we pass on to the AMIC worker and how far can you go? And
the answer I guess was it depends on the skills of the person and
their qualifications - and it does vary – even with the AMIC workers
from Port Augusta. (Midwife).
A Nurse Unit Manager provided the following perspective:
Yes, from the time it was talked about in the beginning to when it
was actually rolled out, I think the focus had changed quite a lot
from what the original intention was and how it was supposed to
work. There has been a lot of – how can I put it? – a lot of non
clarity I guess about how it should be running right from the
beginning. And that is because it is something new and there have
not been really any guidelines to follow. And the hardest part about
it too has been the AMIC worker position, because it’s something
we haven’t worked with before, it’s something new and there were
no set guidelines or anything to follow…Nurse Unit Manager
A midwife described the initial experience of working with the AMIC
workers new to the role thus:
Well yes, it’s been really good, especially the two experienced
ones. But in the beginning, even with the experienced ones it was
like they needed you to constantly be there with them, supporting
them, it was quite intense, you really needed to look after them
and make sure there was someone there each day. And we
realised we didn’t have enough funding, you know, continuity with
the same person there each day to look after them- the same
person. Instead it would be me one day or (names midwife)
another day or one of the other midwives. We have got other work
commitments as well and it’s not like all we have to do. Midwife.
49
The issue of space was paramount in the beginning at both sites as well
as problems with some of the hospital midwifery staff.
In the early days I think it was, the difficulty was with the mid staff,
there were lots of negative comments about a new model of care,
they seemed threatened, didn’t want it to work. Then there were
problems with infrastructure. The biggest concern was to have our
mobile phone to be on call, how can we do it without a mobile
phone? And then we had to sit in the birthing suite at the desks
there, and there was no privacy for us or for the women. It was
really uncomfortable. And you’d be asked to do things all the time,
like ring the doctor, put that test through all that sort of thing, and
the families would be there, sometimes 16 family members and us,
that’s the midwives and AMIC workers….then they gave us a store
room to work in, with the computer in there and no windows, no
light…so yes, I think the lack of infrastructure has been a difficulty.
And the midwives don’t like us being there on the ward, and we
don’t like it either. Midwife.
And from the perspective of one of the NUMs:
I think we just need to …at the moment there is not a lot of contact
between the ward staff and the AMIC worker. I think that needs to
be more closely linked. We have had two, we were training up the
first one and she left and now we have a second one and that’s
still occurring. We are still at that first stage, getting everyone
comfortable, so we haven’t got to that stage where she is able to
work really well with the other midwives yet. Nurse Unit Manager.
All the midwives agreed that an important part of the program was the
two-way learning that occurred and that a large and ongoing part of their
role was sharing of their specialised midwifery skills and knowledge with
the AMIC workers.
Well its certainly mutual for me, they are great. They know where
and how to find people, etc where and when and how long they
have been in town and you know, all that sort of stuff, its fantastic.
They have been great about developing their clinical skills, one of
the big learnings is - you know, we have had a lot that are really
high risk and we have had to learn. Some we don’t take on
because it’s just too much, you know, mental health issues…. that
sort of thing. We discuss it as a team who we take on that
sometimes the AMIC worker will say well I can’t work with that one
- family (kinship) etc and we respect that. They still get the care
from the community midwives who ever they are and that’s just the
way we have to do it. And it’ s very good for the community
midwives to be working alongside and networking with the AMIC
workers and the program…..its a great way to work, and everyone
is learning. Midwife.
50
…very committed - don’t want it to fail, make sure their clinical
skills and competencies are up to date - so they re a happy
member of the team. Midwife.
One midwife described the clinical skills of the AMIC workers very
positively:
Oh they are fantastic. Two of the girls are very experienced, and
we wanted to employ this a brand new role in the hospital, I think
in the beginning we had the vision that they could move through
their role you know bridge that gap between community and
hospital, but that didn’t happen. The midwives were: ‘Well what are
they supposed to do? How do we know exactly what skills they
have got?’ You know there was a lot of that sort of negative stuff
with the hospital staff. Some of them were very good but some
were not. And there was a lot of difficulty with them standing
around without things to do, and they felt shame, but that’s
changed now because the AMIC workers are becoming more
confident. Two of them are really on their feet now. Really (names
AMIC worker) is as good as a midwife no, really, she knows when
the tests are due all that sort of thing. I can say to her “can you
look after this girl” and I know there is nothing she doesn’t know,
she’s as good as a midwife….she knows what’s due for when, and
you know what’s normal what’s not …she knows when to go and
get some help so I could easily go on holidays and she will contact
the doctor if she needs to and I know that girl will be well looked
after…they are fantastic. Midwife.
All the midwives interviewed agreed that this was a rewarding and
effective way of working together and were clear that the program was of
value to the mothers and babies. Of particular note were increases in
antenatal attendance that were achieved by the AMIC workers and their
ongoing links with the women and different Aboriginal community
members. This was particularly rewarding if the kinship links were strong:
I have been to beautiful births with the mothers, the grandmothers,
the aunties and the kids, beautiful, not all the time but we have had
some - and the girls that have got it are the births that do go right.
Midwife.
Table 11 highlights the themes that arose when the midwives spoke
about working in partnership with the AMIC workers.
51
Table 11. Midwives’ themes about working in partnership with AMIC
workers
•
•
•
•
•
•
•
•
•
Commitment to work inter-culturally
Development of relationships took time
Good experiences and outcomes when family structure is strong
Challenges associated with the AMIC worker’s role
AMIC workers social, cultural and community knowledge and connections
crucial to the women’s attendance and program success
AMIC workers developed excellent clinical skills with increased experience
Equality in team decision-making and strong AMIC role in client selection
Personal satisfaction high
Ongoing two-way learning with AMIC workers
In relation to possible improvements there were several suggestions
needed to improve the functioning of the midwives’ work and these
differed between the clinical midwives involved in the program and the
NUMs.
Midwives working on both sites reported a lack of working and storage
space to undertake their duties and maintain the confidentiality of their
clients, and this had made their work frustrating at times.
There was nowhere for us to go. We shared a room with so many
others and then the birthing program started there were then five
more people in the room. ….space is a big issue, perching on the
desk in the birthing suite no privacy 5-6 people using one
computer putting in the data. .. that has been a challenge - it’s all
right if I keep on top of it - but often there is such a crowd in there.
(Eventually given) a store room with no phone, ventilation or
window, 4 ft by 4 ft. Midwife.
In response to the question about whether they felt the program was
helping the mothers and babies the midwives were in agreement.
Well we just did a presentation stats show. Our key performance
indicators (KPIs) are: increases in babies weighing over 2.5 kg,
decreases in smoking, increases in breastfeeding and increases
antenatal visits to above 7. So we have been really successful in
that, because of the contacts and knowing where to find the girls,
and encouraging them to come and look at the birthing suite and
the hospital, and getting to know who their care workers are. We
have had 27 births, 30 something in Whyalla. And now we have
another year’s funding we are just steamrolling now! Mainstream
services were not working so we have made huge increase in the
numbers coming for their antenatal visits its really improving. …..a
great deal of enthusiasm. They get given pictures of their midwife
and AMIC worker. We have 300 births a year and 100 are
Aboriginal so we still have a lot more to get. It’s wonderful when
52
the grandmothers are there and it’s done traditional way, those
ones do really well. It’s so rich and fulfilling - but what is also great
is that they want their midwife. Midwife.
A NUM was impressed with the program:
Well there have already been changes, with the babies’ birth
weights and follow up, I mean the Aboriginal girls may still be high
risk clients, but they are certainly monitored and have more
antenatal visits. We used to get girls coming in labour who had
never seen a doctor in their pregnancy. We are getting less of that
now.
And one of the good connections is that the AMIC workers are
Aboriginal they know what goes on in the community so if
someone new comes in from say Coober Pedy – well, like the
community knows – and they hook them in. Nurse Unit Manager.
One midwife felt that there were certain inequalities related to the
program supposedly being “AMIC worker –led” but the AMIC workers
were paid less than the midwives and did not, like the midwives, get paid
for being on call or for attending births, and that getting back time off in
lieu due did not always happen.
When questioned about what would help sustain and improve the
program there were a number of themes that arose in both sites that are
summarised in Table 12.
Table 12. Midwives’ ‘wish list’ to sustain and improve the program
•
•
•
•
•
•
A space in which to see the women when they visit the hospital or clinic
Adequate storage space for midwifery records to maintain confidentiality
Basic equipment for exclusive use of the program
Cars allocated to the program for home visits
More secure funding arrangements
Clerical support for data management
Additional comments for one midwife recently employed in the program
were:
I would like to know more about the culture of their clans so we
can incorporate it into the system, the role of grandmothers etc. It’s
very good when you see the mother feeding the baby doing it the
proper way for the culture, very interesting to learn. Some people
they tend to be culture sensitive and they think that it’s not for us,
it’s for those people, but we need to learn about these things to be
of assistance and in our work. I’d like more input of the elders, of
the grandmothers so we can have their knowledge, that would be
good… otherwise you feel left out. Midwife.
53
One midwife felt that the benefits of antenatal care were over-rated and
that other more basic issues were more of a priority in the women’s lives.
The role and views of the AMIC worker
Five AMIC workers were interviewed by an Aboriginal researcher four of
whom agreed to be audiotaped. The questions followed a similar format
to those sought from the midwives: what the work involved; what, if any
were the issues in setting up the program, their own role and the roles of
other workers including inter-cultural issues; whether they felt it was a
good way to work together; perceived value of the program for the
mothers and babies and a question about anything they would put on a
wish list that would improve the functioning of their work and the program.
The scope of the role was very broad. An AMIC worker described the
work she undertook in her role thus:
We get the girls to come up to the hospital if they want to have
their antenatal screening up there or wherever they want to have it
done we do the antenatal check on them - and so we have to go
out and arrange that with the girls and bring them into the
midwives….
the midwives are doing mainly the antenatal
screening on the girl, but us AMIC workers, well me, I am trained
in that area so I also do the checks along with them. (The
midwives) mainly do the antenatal screening and a bit of education
and information one to one.… also we have come across a lot of
girls that need support in housing and they need support in
finances and some of them don’t have food in the house so we are
referring them on to Salvation Army and so its looking at it as a
holistic approach….and we have meetings - a case conference
meeting every fortnight on a Tuesday. The AMIC workers and the
midwives get together and we case conference about our clients.
But we do all the running around and getting girls and bringing
them up …. AMIC worker
Another when asked what she did in her AMIC role replied:
What don’t I do!
Basically support – there’s about 20 Aboriginal women that we get
work for the year and we get given a caseload of women that we
take care of. So for me its wherever those women are and I go out
and support them as much as possible for their antenatal care and
antenatal education you know helping them with anything they
want to know during pregnancy. Making sure that their bloods are
being done, all those sorts of things, and being a support for them
during their birth, because the majority of the girls I’ve looked after
I have been at the delivery there. So when they are ready to give
birth to their baby… its that birth support as well. After that –
54
postnatal support as well, you know, help them with breastfeeding,
and teaching them how to breastfeed and like referral too.. They
might not have much because its their first baby, they want their
own house, after living with you know, their family, they might
want to get a house organised that sort of thing, help them with
that, furniture…, we use all the services that I can here in Port
Augusta, and then, like when they are referred on to CYH at about
8 weeks. Making sure they get to that first baby’s health check,
making sure that we talk about contraception you know, what sort
of thing they might want to have and organising that with whoever,
and then making sure they have the check up with their doctor that
everything is ok. So it depends on the individual women what they
want. If it’s a more traditional woman then we make sure we look
at you know all the things that we can offer which language group
they belong to - but if not its support with what ever that woman
wants really. AMIC worker.
The referrals could come from a number of sources:
Well it can be as early as 6-8 weeks as soon as they know- if the
doctor refers them on to us - or often we know, because of working
in the community we find out who’s pregnant just from grapevine.
Other times its referrals from community health service they come
and see Dr...(specialist obstetrician), or they come and see one of
the health workers here, so we get referrals for them. Referrals
from the midwives who are working on the wards there or are
working in the antenatal clinics. The other clinics too, because not
all our women come to Pika Wiya. We look after them so they can
come from these other clinics and these other doctors too.
It had been important to be able to get to know the women and establish
relationships from the time of booking, during the pregnancy, to be there
for the birth and the postnatal care:
It’s all to do with you know, you build up that relationship too. So
that’s really important - like you need to build up that relationship
and that’s how we try to get the girls, as early as possible, so we
can spend a lot of time with them antenatally, so then they build up
that rapport and trust….and they ask: “Are you coming for my
birth?” They look for you and so that’s really good.
Yeah, the girls on the birthing program when they come in and we
talk to them we see if they are interested in being in the program.
What we tell them is like your AMIC worker and the midwife you
will have at your birth. All the girls that I have looked after I have
been there for their birth and its really great. It’s emotional but its and its like it’s like one of your own, its like your sister or one of
your own family members so, you get really emotional. Yeah, you
get excited and you get sad, and so, mixed emotions, but yeah…
and one girl I had who delivered about 3 weeks ago, I didn’t go up
55
there early, like when she was in early labour, but the midwife, she
was telling me like they’re asking for you ‘is (names AMIC worker)
coming up?’ So yeah, I went up for that. AMIC worker
Being able to communicate with women for whom English was not their
first language or who did not speak English at all was of considerable
importance.
One AMIC worker was fluent in five languages with Pitjantjatjara being
her first language. The following conversation between the Aboriginal
researcher and one AMIC worker highlights this
AMIC worker: “The ladies come to me and tell me (in their own
language)”
Aboriginal researcher: And then you interpret that language with the
doctor?
AMIC worker: Yes, the doctor and the nurses.
Other AMIC workers would ask for this AMIC worker:
……and if there’s language barriers well you know we use her
because she speaks 5 different languages…. finding out from the
group and the different family they might have... finding out what
language group they are and support them that way. AMIC worker
Another AMIC worker could usually make herself understood:
We get girls that come down from the Lands and you know just
saying little words like (says a word in language) they feel
comfortable straight away you know as soon you start using those
words, especially if they don’t speak much English. Yeah. But I’ve
come across like.. because we don’t usually cover girls from
Community X – there was this Community X girl in hospital and
she had her friend next to her so the X one was having a lot of
trouble with the midwives, and there was another girl, also an X
girl next to her who could speak good English, like this other girl
could not really speak or understand properly, so what I have done
is like I used her as a middle person, like as an interpreter. AMIC
worker.
Being able to advocate for Aboriginal women in a hospital setting was a
crucial part of the role. Sometimes an Aboriginal woman might feel too
shy or shame to seek the help she needed with a non-Aboriginal staff
member:
56
Yeah well I had an experience where one of the girls that was my
client in the program, she had twins, and I come across her and
she was in the hospital and she had her twins up there and the
twins were in there for about a month, before they could go home,
but anyway she came up there and one of the twins started crying
and he was hungry and this mother, she was like really
embarrassed to go and talk to the nurse and tell them about the
baby being hungry, so shame she was she said Oh you know and
I came along at the right time and I said ‘don’t be shame, you
know’ so I went along to the midwife that was looking after her and
I asked her and I said like ‘she’s a really shy person’ and asked to
make a bottle for her baby, so she said ‘no I’ll deal with her’ so she
went in and said oh she was going to show her around where all
the bottles were and that and so that was really good. Yeah, and a
lot of the girls that you come across like that, they don’t want to
talk to the nurses, and so they tell you, and they want you to go
and talk to the nurses, so yeah. …AMIC worker
Or in the words of another AMIC worker:
…they just come up to us on the ward, and even though we look
after a certain amount of women, because your face is up there on
the ward all the time, often they ask questions. This young girl she
might need help and she can’t talk so we come in as you know, a
cultural broker, just to help them young girls they feel more
comfortable talking to us and whatever might be happening there and we try and deal with it with the midwives. We do a lot of that,
but that’s not even part of our work that’s just being up there, we
do a lot of that as well. AMIC worker
Being able to speak up with confidence was described when working with
or alongside mainstream services:
I think its important to know how to deal with mainstream services
they don’t know our way and sometimes they push things the other
way, that they want them but I think its important to have strong
Aboriginal women working in the program so that we can stop and
say ‘no, hang on a minute, that not the way to do it that’s not the
way we do it, when it comes to our women, this is how it should be
done.’ AMIC worker
When asked whether this was a good way of working together a great
deal of enthusiasm was voiced:
Oh definitely, I think non-Aboriginal people and Aboriginal people
working together is a good way. Non-Aboriginal people can’t offer
the service without us, but we can’t do it without them either. You
know, the clinical knowledge that we learned from the midwives,
you know, without that, we couldn’t do our work properly. But the
same thing, they couldn’t do it without us because they need our
57
cultural knowledge, they need to know the way we deal with
people. And I think the good thing is this; they teach us the clinical
way and we teach them the cultural way. So it just works really
well like that and in the partnership, between the hospital and Pika
Wiya Aboriginal Health Service. That’s the way it should be that’s
the way it can work, you know. You feel like you can make a
difference for our people if we work that way. AMIC worker
One AMIC worker felt this model of working together should be
introduced everywhere:
I want our workers, AMIC workers to be everywhere, not just here.
I think Aboriginal health workers should be working with midwives
everywhere, and you can really see the difference it makes, you
know, for women and babies. One of the things that we set up this
program for was that we wanted to increase babies’ weights. If
they don’t look after themselves in pregnancy babies can be
small…. I think we have proved that, because the amount of
antenatal visits that women go to now. We talk about health and
nutrition and things like that, smoking, drinking, all them sort of
things that affect babies during pregnancy. It’s increased the birth
weights with a lot of our babies so it’s been a really good thing.
And breastfeeding, how important that is…We promote that
because it’s just you know, all of that, all of that stuff. Information, I
think a lot of our girls never had that information, and they didn’t
know that these things happened, so the more people are talking
about it- the program set up like that – Aboriginal health workers
doing that work, with our girls it’s got to improve for the women and
for the babies. AMIC worker
Mothers could be more likely to bring up issues when alone with an AMIC
worker:
Oh well they’re a lot more open with us. Often we find out after
they have been brought in for the antenatal check with the midwife
and we are driving them home and then its this, this and this in the
car, so sometimes we have to do things on the side so we go back
to the midwife and say she might have been a little bit shame and
we bring it up somehow like that………
However this changed when the women got to know the midwives and
saw the AMIC workers and midwives working in partnership:
But after a while though, those girls start to feel comfortable with
the midwives as well, because they can see us working together
with the midwives. And because there is only 4 midwives in the
program, they are easy to get to know, they are great midwives,
they are easy to talk to and they have worked with Aboriginal
people before and they are willing to listen to what we say and
58
they work along with all of us. So that’s why then I talk about team
they’re our team as well. AMIC worker
The following conversation between the Aboriginal researcher and an
AMIC worker was recorded:
Aboriginal researcher: Well are all you mob working with babies?
Yes that’s right and there are so many things that we are learning
as well, like AMIC workers, we go back to the midwives and say
‘what’s this, what’s this about?” What does this mean? And they’re
willing to give us that information and help us … AMIC worker
Researcher: Any young mothers that are worried about what the doctor
has said to them you know I don’t understand it or my BP or ….?
Yep yes, like we do a test for gestational diabetes and some of
them say what does this mean does this mean I have got
diabetes? And sometimes the doctor can say things and they don’t
follow it through and they want more information. And that’s where
we come in, and explain things, this is what it’s about, it doesn’t
mean you’ve got diabetes for the rest of your life. It just means
during pregnancy you gotta eat right and look after yourself but
once baby’s born it you know that diabetes just goes, because
during pregnancy your pancreas is working harder and you are
getting more insulin happening and it shows up high so often you
have to explain a little bit more information that the doctors don’t
……. AMIC worker.
Key informants identified their perception of the positive relationships and
sharing of knowledge and skills between the AMIC workers and the
midwives as a key strength of the program.
I feel there has been a changed attitude and greater understanding
of the non-Aboriginal midwives and staff about the challenges
faced by Aboriginal women. There is increased respect and
understanding. Stakeholder
Another strength of the program was the fact that it was designed to
address the needs of the women.
This program has one of its criteria high risk and younger
Aboriginal women, and it does very well with this. A lot of
alternative birthing programs take low risk women. …..most of the
young women on the program are very vulnerable emotionally and
the program …… is able to sustain good outcomes for the women.
Stakeholder
59
Another identified strength was that the program is women and culturally
focussed, with workers providing assistance to both the woman and her
family in a way that is culturally appropriate and ‘not just medicalised.’
Having an Aboriginal worker assist families in an holistic way,
outside of the regimentation of the ‘nurse’ role. This meant that
AMIC workers could assist with all the multiple issues that the
family experienced, not just the participant, including housing,
financial issues, schooling, benefits etc. Stakeholder.
Other perceived benefits included the profile and awareness of the
program within the local communities. AMIC workers and elder women
from the advocacy group were known and respected in their
communities.
Objective Five: Describe participants’
profiles and perinatal outcomes
demographic
This section summarises data from the program database maintained by
the midwives and data from the supplementary birth record from the
Pregnancy Outcomes Unit completed by all midwives in the state
(Appendix 6). The data include all women enrolled since the introduction
of the program in July 2004 until June 30th 2006.
The Pregnancy Outcomes Unit in 2004 reported 484 Aboriginal births
(2.8% of 17,522 births reported that year) and where possible, simple
comparisons have been made between women in the program and the
SA data (Chan et al 2006). A total of 52 women were registered in the
program - 27 Aboriginal women in Port Augusta, 20 Aboriginal women in
Whyalla and 5 non-Aboriginal women registered in the teenage program
in Whyalla. There was one miscarriage at 18 weeks.
The sections where data are missing are highlighted in the tables.
Number of births
There were 51 births across the two sites with one perinatal death at 25
weeks gestation Table 13.
Table 13: Number of births by program site
Port Augusta
Program
Aboriginal women
Live births
Perinatal death
Total
25
1
26
Whyalla Program
Total
Aborigina
l
20
20
Non -Aboriginal
5
5
50
1
51
60
Maternal age
Table 14 provides a break down of the maternal age of participants and
shows the most commonly reported age (mode) of the Aboriginal women
enrolled in the program to be between 20-24 years (n=19, 37.2%) and
compares with 30.2% (also the mode) in SA in 2004 Aboriginal women
and 15.1% for Caucasian women (Chan et al 2006).
The most commonly reported age for all women who gave birth in SA in
2004 was 30-34 years. Four out of the five young non-Aboriginal women
were aged 15-19 years and one was over 20 years of age.
Table 14:
Maternal age of all participants
15-19
20-24
25-29
30-34
35-39
40-44
Total
Port Augusta
Program
Aboriginal women
7
9
7
2
2
27
Whyalla Program
Aboriginal
2
10
5
2
1
20
Non-Aboriginal
4
1
5
13
20
12
4
1
2
52
First and subsequent births (parity)
In total 25 (50%) of the all the women studied gave birth their first live
baby in care of the program (Table 15). For the Aboriginal participants
the number having their first baby was 21 out of 45 (47%)
Table 15: Parity of all participants
First baby
Second and
subsequent
Total
Port Augusta
Program
Aboriginal
women
13
12
25
Whyalla Program
Aboriginal
8
Non
Aboriginal
4
25
12
20
1
5
25
50
Method of birth
When 5 missing births are excluded (Table 16), twenty eight of all the
women (54.9%) had a normal vaginal birth, compared with 56% of South
Australian women in 2004 (Chan et al 2006). Nine women had an elective
caesarean section and seven had an emergency caesarean (combined
31.4% the same as the population rate of 31.5% from the SA data).
61
Table 16: Method of birth
Normal vaginal
Elective LSCS*
Emergency LSCS
Total LSCS
Instrumental
Missing data
Total
Port Augusta
Aboriginal
12
5
6
11
1
2
26
Aboriginal
13
3
4
4
3
20
Whyalla
Non-Aboriginal
3
1
1
1
5
%
28
9
7
16
2
5
51
54.9
17.6
31.4
3.9
100
* LSCS = lower segment caesarean section
Birthweights
Six birthweights were not recorded. Of those available, there were 31,
(61%) babies born with birthweights of 2500g or above. Four out of five
of the teenage non-Aboriginal women gave birth to babies above 2500g.
Excluding missing data there were 9 (20%) low birth weight babies, 7
(17.9%) of whom were Aboriginal babies. These figures compare with low
birth weight of 8.7% in all SA births in 2004 and double that for Aboriginal
babies. There were two very low birth weight babies (less than 1500g)
(3.8% versus SA 1.3%) one of which was a neonatal death (Table 17).
Table 17: Birthweights
<999
1000-1499
1500-1999
2000-2499
2500-2999
3000-3499
3500-3999
4000-4499
Missing data
Total
Port Augusta
Program
Aboriginal
women
1*
1
3
3
10
1
4
3
26
Whyalla Program
n=51
3
Non
Aboriginal
1
6
3
4
1
3
20
2
1
1
5
11
14
6
5
6
51
Aboriginal
1
1
7
* neonatal death
Apgar scores
The Apgar score is a numerical scoring to evaluate the condition of the
baby at one minute and at five minutes after birth (scored out of a
maximum of 10 points). Six babies born to Aboriginal women had Apgar
scores of less than 7 at one minute (excludes missing data n=8)(Table
18). All babies had Apgar scores of seven or more at five minutes
(excludes missing data n=8).
62
Table 18: Apgar scores
Port Augusta
Whyalla
Aboriginal
Aboriginal
Non Aboriginal
Total
%
6
17
2
25
3
12
5
20
1
3
1*
5
10
32
8
50
24
86
23
2
25
15
5
20
4
1*
5
42
8
50
100
At 1 minute
<7
>7
Missing
Total
At 5 minutes
<7
>7
Missing data
Total
100
* unplanned homebirth
Excluding missing data, seven (14.9%) births in the program were
preterm (less than 37 weeks completed gestation) with 6 of these born to
Aboriginal women (Table 19).
Table 19: Gestation at birth
Port Augusta
Program
Aboriginal women
36 and under
37
38
39
40
41
Missing
Total
4
3
5
8
4
2
26
Whyalla Program
Aboriginal
2
3
6
2
5
2
20
Non Aboriginal
1
1
1
1
1
5
Total
7
7
11
11
10
3
2
51
%
14.9
14.9
23.4
23.4
21.3
6.4
100
Method of Feeding
Table 20 shows the method of breastfeeding at discharge from hospital.
Amongst all of the women for whom data were available, 35 (87.5%)
were breastfeeding at discharge from the hospital and 31 (87.5%) of the
Aboriginal women were breastfeeding at hospital discharge.
Table 20: Feeding method at discharge from hospital
Port Augusta
Breastfeeding
Artificial
Missing
Total
Aboriginal
13
3
9
25
Whyalla
Aboriginal
18
1
1
20
Non-Aboriginal
4
1
5
Total
35
5
10
50
%
87.5
12.5
100
63
Table 21, shows feeding method at the last postnatal visit at 6-8 weeks
that indicates that 52.5% of the Aboriginal women were breastfeeding
and one teenage woman was still breastfeeding.
Table 21: Feeding method at last postnatal visit n=50
Breastfeeding
Artificial
Missing
Total
Port Augusta
Program
Aboriginal women
14
7
4
25
Whyalla Program
Aboriginal
6
12
2
20
Non Aboriginal
1
4
5
Total
21
23
6
50
%
48
52
100
Postnatal occasions of service are presented in Table 22. Excluding
missing data for 10 Aboriginal women, 42% of the women received 6-10
postnatal visits and 8 (20%) received more than 10 visits.
Table 22:
Visits or
phone calls
up to 6-8
weeks
1-5
6-10
11-15
16-20
21-25
25 plus
Missing data
Total
Postnatal occasions of service
Port Augusta
Program
Aboriginal
women
4
11
1
1
8
25
Whyalla Program
Aboriginal
Non Aboriginal
Total
6
4
6
2
2
20
2
2
1
5
12
17
8
2
1
10
50
The next section discusses the findings and summarises the implications
of the main findings.
64
DISCUSSION AND IMPLICATIONS
The evaluation revealed challenges in establishment of the program and
some dissatisfaction that the Whyalla site appeared less well resourced.
Longer-term resources would enable what has been achieved to be
consolidated and could provide greater access to the pregnancy, birthing
and postnatal care provided by the AMIC worker / midwife model in Port
Augusta. For example, many Aboriginal people from language groups in
remote communities within the NFWHS region such as the Anangu
Pitjantjatjara Lands, Oodndadatta, Coober Pedy or the Flinders Ranges
have family connections in Augusta may therefore present there for
antenatal care. In its present form, the program is not designed to
include these women although small numbers have received care
(personal communication Program Manager).
Although low in number, teenage women in the program were positive
about forming a relationship with a midwife in the program. The
establishment of an equivalent teenage-focused model may be designed
specifically to meet young women’s needs as they stated that they would
have welcomed extra support with transport and other issues such as that
provided by AMIC workers.
The sample of 45 women, although small, is nearly one tenth (9.4%) of
the 484 Aboriginal births recorded in 2004). Comparisons of birth
outcomes between this group and all Aboriginal women are difficult to
make because, to secure eligibility to enter the program, these women
went through a selection process to identify risk factors. Because the
effectiveness (sensitivity and specificity) of the screening process has not
been documented it is difficult to determine whether women in this study
were at greater risk. Another factor to consider when looking at the
birthing outcomes is that they vary between metropolitan based
Aboriginal women and those from regional or remote locations. In spite of
significant gaps in the data many outcomes for this group appear
comparable with data for Aboriginal women South Australia wide in 2004.
The sample was too small to ascertain perinatal mortality.
There was a high prevalence in this group of late booking for antenatal
care. Only 1 in 6 had booked for their first antenatal visit in the first
trimester, and 2 in 5 did not attend until the third trimester. It is unclear
whether any of the women received care elsewhere although this would
be expected to be written on the hand-held pregnancy record now in wide
use. Nevertheless, Aboriginal women in the program were more likely to
have had more than 7 antenatal visits compared with the SA data for
2004 (15.6% versus 6%). The rates of smoking in pregnancy and babies
classified as low birthweight were also comparable with the SA data.
Whether the increased antenatal visits provided by midwives and AMIC
workers in the program (both clinical and supportive) can translate to
improved overall outcomes will require longer term follow-up. The issue of
65
whether an antenatal visit was clinical (hands-on) or supportive was
confusing and not specified in the program database. This needs
clarification to be able to assess any potential advantages of both types
of visit.
Although the program design is complex, qualitative findings from the
interviews demonstrated that inter-cultural partnerships between the
AMIC workers and midwives do exist, that they are mutually satisfying
and that they have provided opportunities to work “both ways”. The
recognition and development of equivalent inter-cultural partnerships
between Aboriginal and mainstream workers is a best practice model that
has been successful in other settings (Franks et al 1996). Building on
these relationships will be vital in sustaining the program. Although it was
clear that the AMIC worker is pivotal to the success of the program, an
expectation for the program to be “AMIC-led” may be a misnomer in view
of the emerging two-way partnership model that the evaluation revealed.
It is also important to acknowledge that along with working in the
program, AMIC workers, as members of their communities, have
obligations and priorities within their own family systems. As AMIC worker
role continues to emerge, it will need further support, development and
acknowledgement.
The Aboriginal Women’s Advocacy group has a strong role in contributing
to understanding of working both ways and thus moving towards good
birthing practices for healthy Aboriginal mothers and babies. Formal links
between the Advocacy group and program management need to be
strengthened and sustained and out of pocket expenses acknowledged.
Advocacy group members were keen to strengthen the cultural support
provided by the program by working in collaboration with AMIC workers to
work directly with Aboriginal women, especially those with restricted
family support.
The substantial amount of missing data is disappointing. Clearly, a full
data set is crucial to obtain an accurate demographic picture of women
participating in the program. Only then can the program be accurately
monitored for any improvements in clinical outcomes. The achievement of
more complete data sets from all women, particularly the program
performance indicators, should be a long-term aim especially if the
program is to be introduced more widely.
The next section suggests eight recommendations to progress and
strengthen the Regional Family Birthing and Anangu Bibi Program.
66
RECOMMENDATIONS
1.
The Anangu Bibi AMIC worker/midwife partnership model be
incorporated as a central component of the care offered to any Aboriginal
women presenting for antenatal care in Whyalla or Port Augusta to
increase the program’s sustainability.
2. That the feasibility of developing a model of care for teenage nonAboriginal women equivalent to the AMIC worker/midwife partnership be
considered.
3. As the AMIC worker is pivotal to the success of the program we
recommend that the role be further acknowledged, resourced and
developed.
Strategy:
Support AMIC workers to participate in an established
accredited course that leads to a professional qualification.
4. Set aside funding for increased AMIC worker hours and further
employment opportunities for more AMIC workers from different language
groups with links to the Spencer Gulf region in consultation with the
Aboriginal Women’s Advocacy Group.
5. Develop processes to enable AMIC workers to continue in the care of
mothers and babies beyond the 6-8 week program cut-off point.
Strategy: Encourage working partnerships between AMIC workers with
the CYH Indigenous Culture Consultant to enhance continuity of care for
Aboriginal mothers from a range of language groups.
Strategy: Investigate the feasibility of employment of AMIC workers in the
universal home visiting program of the Child and Youth Health so they
can continue to provide continuity of care.
6. That members of the Aboriginal Women’s Advocacy Group be
provided with further opportunities to directly support mothers and
families in the program.
Strategy Legitimise formal links between the Advocacy group and
program management by funding participation fees.
Strategy Strengthen the cultural support provided by the program through
linking Advocacy group members to those with limited family support and
to women enrolled in the program from outside Port Augusta and
Whyalla.
7. That adequate equipment, space and infrastructure be provided at both
sites for the AMIC workers and midwives who work together in the
program.
8. To refine the program database in consultation with the AMIC worker
and midwife users to simplify the management, collection and analysis of
outcomes and performance indicators and further establish any clinical
benefits of the program.
67
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APPENDICES
Appendix 1
Regional Family & Anagu Bibi Birthing Program Screening
tool
Appendix 2
Regional Management Group Terms of Reference
Appendix 3
Levels of evidence
Appendix 4
International Definition of a Midwife
Appendix 5
Reasons given for lack of birthing at Alukura
Appendix 6
Supplementary Birth Record
78
Appendix 1
Mother’s Name: ………………………………………..
Mother’s Age: ……………...…………………………..
Mother’s Address: …………………………………….
…………………………Postcode: …………………….
Contact Number Home: ….…………Mobile:
…………………………………………………..
Is it safe to ring that number: Y /
N
Is it ok to leave a message on machine or with anybody else?
Preferred Contact Time: ……………………………..
Mother’s date of birth: ………./………/……….
Y
/
N
Obstetric information
Gravida : Parity…………………:……………………
Estimated Date of Confinement: …………………...
Gestation: ………………………………………………
Have you had any obstetric complications?
Past Pregnancies: …………………………………….
………………………………………………………….
This Pregnancy: ……………………………………….
Risk factors
Yes
1. Are you < 20 years of
age?
2. Are you Aboriginal
or Torres Strait
Islander?
3. Past Drug Use
4. Drug Use in this
Pregnancy
5. Past Alcohol Use
6. Drinking alcohol in
this pregnancy
6. Smoking cigarettes in
this pregnancy
7. Pre-existing
medical conditions
8. Mental Health Issues
9. GP Attendance Issues
10. Family Issues / Social
Support Issues
11. Housing Issues
12. Income Issues
13. Transport Issues
No
Specify:
Specify:
79
Regional
Family
Referral By / From: ……………………………………
Date:……………………………………………………...
Selection Tool Completed By: ……..……………….
Interest in Alternative Birthing Services Program:
q Yes
q No
How long staying in Port Augusta after birth:………………
Comments / Reasons WHY Person should be in the Program OR WHY NOT
………………………………………………
………………………………………………
………………………………………………
………………………………………………
………………………………………………
………………………………………………
………………………………………………
………………………………………………
………………………………………………
………………………………………………
Consent to share information with workers involved in the Regional Family Birthing
Program / Child & Youth Health
…………………………………………………………….
Mother’s Signature
OUTCOME OF CASE CONFERENCE
Date: ………………………………………………...
q
q
Accepted into the Alternative Birthing Program
Referral to Community Midwives
Primary Midwife: ………………………………….
AMIC Worker: …..…………………………………
80
Appendix 2
Alternative Birthing Services Program Regional
Management Group
Terms of Reference 2004/5
GOAL
• To improve pregnancy and birthing outcomes for Aboriginal,
young and socially disadvantaged women in Whyalla and Port
Augusta.
OBJECTIVES
• To provide direction to the Alternative Birthing Program and
monitor its progress.
•
To ensure that Aboriginal, young and socially disadvantaged
women are offered maternity care that is:
§ culturally respectful
§ responsive to women’s needs
§ consumer driven
§ promotes choice and
§ based on evidence
•
To engage the Regional Aboriginal Women’s Advocacy Group and
ensure the active participation of Aboriginal women in the
development, implementation and evaluation of the Program.
•
To ensure ongoing commitment and coordination between
services (such as Child and Youth Health) and provide a forum to
discuss sustainability of the Alternative Birthing Program.
•
To enable discussion around strategies to improve Birthing
Outcomes for Aboriginal and teenage women and involve a range
of services and organisations to develop a broader, innovative
approach.
STRUCTURE AND MEMBERSHIP
• The Regional Management Group will consist of service providers,
community representatives and representatives of the Regional
Aboriginal Women’s Advocacy Group.
Reporting To:
Meetings:
NFWRHS Regional Board through Greg Bailey
Held Monthly alternating between Whyalla and
Port Augusta
Chair:
Greg Bailey
Executive Support: Mary Salveron, Alternative Birthing Services Project
Officer
81
Appendix 3
Levels of Evidence
Level I Evidence: obtained from systematic review of all relevant
randomised controlled trials
Level II Evidence: obtained from at least one properly designed
randomised controlled trial
Level III-1 Evidence: obtained from well-designed pseudo-randomised
controlled trials (with alternate allocation or some other method)
Level III-2 Evidence: obtained from comparative studies with concurrent
controls and allocation not randomised (cohort studies), case control
studies or interrupted time series with a control group
Level III-3 Evidence: obtained from comparative studies with historical
controls, two or more single arm studies or interrupted time series without
a parallel control group
Level IV Evidence: obtained from case series, opinions of respected
authorities, descriptive studies, reports of expert committees and case
studies.
In: National Research & Medical Council (1998a). A Guide to the Development,
Implementation and Evaluation of Clinical Practice Guidelines. AGPS, Canberra.
82
Appendix 4
International Definition of a Midwife
Adopted by the International Confederation of Midwives 19 July 2005
A midwife is a person who, having been regularly admitted to a midwifery educational
programme, duly recognised in the country in which it is located, has successfully
completed the prescribed course of studies in midwifery and has acquired the requisite
qualifications to be registered and/or legally licensed to practice midwifery.
The midwife is recognised as a responsible and accountable professional who works in
partnership with women to give the necessary support, care and advice during
pregnancy, labour and the postpartum period, to conduct births on the midwife’s own
responsibility and to provide care for the newborn and the infant. This care includes
preventive measures, the promotion of normal birth, the detection of complications in
mother and child, the accessing of medical or other appropriate assistance and the
carrying out of emergency measures.
The midwife has an important task in health counselling and education, not only for the
woman, but also within the family and community. This work should involve antenatal
education and preparation for parenthood and may extend to women’s health, sexual or
reproductive health and childcare.
A midwife may practice in any setting including in the home, the community,
hospitals, clinics or health units.
83
APPENDIX 5.
Reasons given for lack of birthing at Alukura
•
More extensive practical support, such as food and laundry, is
provided by the hospital than is available at Alukura; in the original
model for Alukura women’s own families had been expected to
provide practical care around the time of birth but the resources
required were rarely available.
•
The hospital is perceived to be a place of safety.
•
Having a baby at the hospital is the norm.
•
There are likely to be relations, friends and people from one’s own
community at the hospital.
•
Loss of links with the Grandmothers’ Law among young women
giving birth and even among their own mothers.
•
Negative views of Alukura and ‘gate-keeping’ by bush clinic staff
directing bush women to the hospital instead.
•
Lack of promotion of Alukura by staff and CAAC.
•
The relative isolation of Alukura and its distance from the town,
shopping and friends in Alice Springs.
•
The extra demands on Alukura staff when a birth is imminent.
•
The higher proportion of Aboriginal women worth serious
pregnancy and birth complications
•
The increasing – although still unusual – preference of partners for
being with women immediately after the birth and occasionally
during the birth.
Table 3: In Carter, Lumley, Wilson & Bell (2004)
84
Appendix 6
Supplementary birth record
85