Djäkamirr: Exploring principles used in piloting the training of First Nations doulas in a remote multilingual Northern Australian community setting.

PROBLEM AND BACKGROUND: There is growing evidence in First Nations doula care as a strategy to address perinatal inequities and improve maternal care experiences. However, there is no evidence around the approach and principals required to successfully deliver First Nations doula (childbirth) training. QUESTION/AIM: To explore and describe the approach and principles used in piloting the training of First Nations doulas in remote, multilingual Northern Australian community settings. METHODS: Case study with participant interviews to identify principles underpinning our Decolonising Participatory Action Research (D-PAR) approach and training delivery. FINDINGS: Reflections on our D-PAR research process identified enabling principles: 1) Use of metaphors for knowledge reflexivity, 2) Accommodate cultural constructions of time 3) Practice mental agility at the Cultural Interface, 4) Advocate and address inequities, 5) Prioritise meaningful curriculums and resources, 6) Establish cross-cultural recognition and validity; and 7) Ensure continuity of First Nations culture and language. DISCUSSION: The success of our doula training pilot disrupts a pervasive colonial narrative of First Nation deficit and demonstrates that respectful, genuine, and authentic partnerships can power transformative individual and collective community change. Our D-PAR approach assumes mutual learning and expertise between community and researchers. It is well suited to collaborative design and delivery of First Nations reproductive health training.

Enabling the context for Aboriginal and Torres Strait Islander Community Controlled Birthing on Country services: Participatory action research.

PROBLEM: Establishment of Birthing on Country services owned and governed by Aboriginal and Torres Strait Islander Community Controlled Health Services has been slow. BACKGROUND: Birthing on Country services have demonstrated health and cost benefits and require redesign of maternity care. During the Building On Our Strengths feasibility study, use of endorsed midwives and licensing of birth centres has proven difficult. QUESTION: What prevents Community Controlled Health Services from implementing Birthing on Country services in Queensland and New South Wales? METHODS: Participatory action research identified implementation barriers. We conducted iterative document analysis of instruments to inform government lobbying through synthesis of policy, economic, social, technological, legal, and environmental factors. FINDINGS: Through cycles of participatory action research, we analysed 17 documents: 1) policy barriers prevent Community Controlled Health Services from employing endorsed midwives to provide intrapartum care in public hospitals; 2) economic barriers include lack of sustainable funding stream and inadequate Medicare-billing for endorsed midwives; and 3) legal barriers require a medical practitioner in a birth centre. While social barriers (e.g., colonisation, medicalisation) underpin regulations, these were beyond the scope; technological and environmental barriers were not identified. DISCUSSION: Findings are consistent with the literature on barriers to midwifery practice. Recommendations include a national audit of barriers to Birthing on Country services including healthcare practice insurance, and development of a funding stream. Additionally, private maternity facility regulation must align with evidence on safe birth centre operation. CONCLUSION: Government can address barriers to scale-up of Aboriginal and Torres Strait Islander Community Controlled Birthing on Country services.

"It's all about cultural understanding": A reflexive thematic analysis of women's experiences at a dedicated refugee midwifery group practice service.

BACKGROUND: Inequitable maternity care provision in high-income countries contributes to ongoing poor outcomes for women of refugee backgrounds. To address barriers to quality maternity care and improve health equity, a co-designed maternity service incorporating community-based group antenatal care, onsite social worker and interpreters, continuity of midwifery carer through a caseload design with 24/7 phone access was implemented for women of refugee background. OBJECTIVE: To explore and describe women's experiences and perceptions of care from a dedicated Refugee Midwifery Group Practice service. DESIGN: Qualitative exploratory descriptive study using focus group discussions and interpreters. SETTING: The study was conducted at a community-based Refugee Midwifery Group Practice service in a tertiary maternity hospital in Brisbane, Australia. METHODS: We conducted three focus group discussions (June - December 2020) with 16 women, born in six different countries, in three language groups: Sudanese Arabic, Somali, and English. We used reflexive thematic analysis to interpret women's perspectives and generate informed meanings of experiences of care. RESULTS: We generated four themes 1) accessibility of care, 2) women feeling accepted, 3) value of relationality, and 4), service expansion and promotion. Results demonstrate positive experiences and acceptability due to easy access, strong woman-midwife relationships, and culturally safe care. CONCLUSION: The service addressed concerns raised in an early evaluation and provides evidence that redesigning maternity services to meet the needs of women with a refugee background speaking multiple languages from many countries is possible and promotes access, use, and satisfaction with care, contributing to improved health equity and perinatal outcomes.

Effect of an Australian community-based caseload midwifery group practice service on maternal and neonatal outcomes for women from a refugee background.

BACKGROUND: Women from a refugee background who resettle in high-income countries experience poorer perinatal outcomes in comparison to women from host countries. There is a paucity of research on how best to improve these outcomes. AIM: To report on the effectiveness of an Australian Refugee Midwifery Group Practice service on perinatal outcomes. METHODS: We used inverse probability of treatment weighting to balance confounders and calculate treatment effect and compare maternal and neonatal outcomes for women from a refugee background who received Refugee Midwifery Group Practice care (n = 625), to those receiving standard care (n = 634) at a large tertiary hospital (1 January 2016-31 December 2019). Prespecified primary outcomes included: proportion of women attending ≥ 5 antenatal visits, preterm birth (<37 weeks), spontaneous onset of labour, epidural analgesia in the first stage of labour, normal birth (term, spontaneous onset, vertex, spontaneous vaginal birth, no epidural, no episiotomy), and exclusively breast-feeding at discharge. FINDINGS: Women who received Refugee Midwifery Group Practice care were more likely to have spontaneous onset of labour (adjusted odds ratio 2·20, 95% CI 1·71-2·82; p < 0·0001), normal birth (1·55, 1·23-1·95; p < 0·0001), and less likely to use epidural analgesia (0·67, 0·50-0·89; p = 0·0067) and have a preterm baby (0·60, 0·36-0·99; p = 0·047). There was no difference between groups in women attending ≥ 5 antenatal visits and exclusive breastfeeding at discharge from hospital. DISCUSSION: A Refugee Midwifery Group Practice is feasible and clinically effective. CONCLUSION: Similar services could potentially improve outcomes for women from a refugee background who resettle in high-income countries.

First Nations doulas: Training needs and industry support in the Top End, Northern Territory, Australia.

PROBLEM AND BACKGROUND: First Nations doulas offer an innovative approach for strengthening capacity and increasing the Australian First Nations maternity workforce to improve access to services that produce optimal outcomes. Currently, there is no published evidence on the training needs and health sector industry support for developing a First Nations doula workforce. QUESTION/AIM: In the context of the 'Top End,' Northern Territory, Australia, the aim of this article is to document Industry feedback on the training needs and support for developing a First Nations doula workforce. METHODS: Ten purposively recruited Industry representatives participated in a facilitated workshop using the Kaospiolit Vision Backcasting education design tool. FINDINGS: Participants identified and reached consensus on almost all the underpinning skills, knowledge, mindset, and attitudes required to work as a First Nations doula. Overall participants indicated strong Industry appetite and support for formally developing the doula role. DISCUSSION: There was participant consensus that accredited doula training would be a 'game-changer', addressing inadequacies and inequities in NT's reproductive and maternal health services for remote-living First Nations women. CONCLUSION: More research is required to explore First Nations doula practice in addressing perinatal inequities and workforce issues. Investigation is required to identify funding and appropriate workforce models.

Räl-manapanmirr ga dhä-manapanmirr - Collaborating and connecting: Creating an educational process and multimedia resources to facilitate intercultural communication.

Purpose: Yolŋu (First Nations Australians from North-East Arnhem Land, Northern Territory) and Balanda (non-Indigenous people) often encounter communication challenges at a cultural interface during the provision of health and education services. To address these challenges, our project co-created an educational process and resources to inform and facilitate intercultural communication. During interactive workshops, participants and researchers from different cultural backgrounds reflected on their communication practice together in small groups. Reflection and discussion during the workshops were supported by multi-media resources designed to be accessible and resonant for both Yolŋu and Balanda partners. Participants explored and implemented strategies during intercultural engagement within and beyond the workshop. In this article we explain our processes of co-creating intercultural communication education and share features of our educational process and resources that resonated with participants from both cultural groups.Method: Our intercultural team of researchers used a culturally-responsive approach to Participatory Action Research (PAR) to co-create an intercultural communication workshop and multi-media resources collaboratively with 52 Yolŋu and Balanda end-users.Result: Collaborating (the power and value of genuine collaboration and engagement throughout the process) and connecting (the meeting and valuing of multiple knowledges, languages and modes of expression) were key elements of both our methods and findings. Our processes co-created accessible, inclusive, collaborative spaces in which researchers and participants were actively supported to implement intercultural communication processes as they learned about them.Conclusion: Our work may have relevance for others who are developing educational processes and resources for facilitating intercultural communication in ways that honour participants' voices, challenge inaccessible systems, resonate with diverse audiences and create opportunities for research translation.Explanation of terms• Yolŋu are First Nations Australians from North-East Arnhem Land in the Northern Territory of Australia.• Balanda is a term used by speakers of Yolŋu languages to refer to non-Indigenous people.• First Nations Australians is used to include diverse Aboriginal and Torres Strait Islander peoples in Australia. This term recognises the identities of First Nations peoples who hold unceded sovereignty over their lands and waters.• The pronouns we, us and our are used to refer to the intercultural research team who are also authors (i.e. Emily, Gapany, Läwurrpa, Yuŋgirrŋa and supervisors Anne, Lyn and Sarah). When sharing other people's perspectives, or the voices of individual researchers, the text will specify whose voice is being shared.

Clinically Applicable Segmentation of Head and Neck Anatomy for Radiotherapy: Deep Learning Algorithm Development and Validation Study.

BACKGROUND: Over half a million individuals are diagnosed with head and neck cancer each year globally. Radiotherapy is an important curative treatment for this disease, but it requires manual time to delineate radiosensitive organs at risk. This planning process can delay treatment while also introducing interoperator variability, resulting in downstream radiation dose differences. Although auto-segmentation algorithms offer a potentially time-saving solution, the challenges in defining, quantifying, and achieving expert performance remain. OBJECTIVE: Adopting a deep learning approach, we aim to demonstrate a 3D U-Net architecture that achieves expert-level performance in delineating 21 distinct head and neck organs at risk commonly segmented in clinical practice. METHODS: The model was trained on a data set of 663 deidentified computed tomography scans acquired in routine clinical practice and with both segmentations taken from clinical practice and segmentations created by experienced radiographers as part of this research, all in accordance with consensus organ at risk definitions. RESULTS: We demonstrated the model's clinical applicability by assessing its performance on a test set of 21 computed tomography scans from clinical practice, each with 21 organs at risk segmented by 2 independent experts. We also introduced surface Dice similarity coefficient, a new metric for the comparison of organ delineation, to quantify the deviation between organ at risk surface contours rather than volumes, better reflecting the clinical task of correcting errors in automated organ segmentations. The model's generalizability was then demonstrated on 2 distinct open-source data sets, reflecting different centers and countries to model training. CONCLUSIONS: Deep learning is an effective and clinically applicable technique for the segmentation of the head and neck anatomy for radiotherapy. With appropriate validation studies and regulatory approvals, this system could improve the efficiency, consistency, and safety of radiotherapy pathways.

A call for action that cannot go to voicemail: Research activism to urgently improve Indigenous perinatal health and wellbeing.

In this call to action, a coalition of Indigenous and non-Indigenous researchers from Australia, Aotearoa New Zealand, United States and Canada argue for the urgent need for adequately funded Indigenous-led solutions to perinatal health inequities for Indigenous families in well-resourced settler-colonial countries. Authors describe examples of successful community-driven programs making a difference and call on all peoples to support and resource Indigenous-led perinatal health services by providing practical actions for individuals and different groups.

"We are sacred": An intercultural and multilingual approach to understanding reproductive health literacy for Yolŋu girls and women in remote Northern Australia.

ISSUE ADDRESSED: Indigenous women continue to experience reproductive health inequities. While enhancing health literacy is suggested as an approach for reducing disparities and increasing equity, there is a paucity of literature exploring Indigenous women's conceptualisation of reproductive health literacy. This paper demonstrates one approach to developing a reproductive health literacy framework for Yolŋu (Indigenous) women in a remote Northern Australian setting. METHODS: Using a decolonising participatory action research approach, a senior Yolŋu researcher led interviews, group story sharing sessions, historic site visits and on-country cultural demonstration sessions with participants on reproductive health topics. Data were collected in the participants' first language(s) and occasionally in English. Data were digitally recorded on camera, Dictaphone, video and in handwritten notes. The senior Yolŋu researcher worked with a Yolŋu interpreter to translate the data into English. Data underwent a progressive verbal relational content analysis to map and build a framework. RESULTS: A reproductive health literacy framework that privileges Yolŋu reproductive knowledge, practices and language was successfully co-designed. The framework was embedded in the metaphor of Pandanus mat and uses key cultural domains of Yolŋu identity as a connecting foundation to women's reproductive knowledges and ceremonial milestones. CONCLUSIONS: The framework offers a culturally responsive and multilingual approach to sensitively discuss and operationalise reproductive health literacy. The framework empowers Yolŋu cultural identities; accounts for both Yolŋu and Western medical knowledges; and honours participants' requests for "Two-Way" learning. SO WHAT?: This research demonstrates an innovative approach to co-designing a culturally responsive framework for reproductive health literacy in a complex and multilingual context. Such approaches offer a promising way forward for empowering Indigenous women to define reproductive health literacy and contribute to improving their reproductive health outcomes.

Caring for Mum On Country: Exploring the transferability of the Birthing On Country RISE framework in a remote multilingual Northern Australian context.

BACKGROUND & PROBLEM: Birthing On Country (BOC) is an international movement for returning childbirth to First Nations peoples and their communities. The RISE Framework was developed to guide evidence-based BOC implementation but has not yet been tested in a remote Australian community setting. AIM: To test the transferability and acceptability of the RISE Framework in a remote multilingual setting in a Yolŋu (First Nations) community in Northern Australia. METHODS: Working in partnership with one remote Yolŋu community, we used a decolonising participatory action research (D-PAR) approach to begin co-designing services and test the acceptability of the RISE Framework. A three-phased transferability process was developed: Warming the ground; Co-Interpreting; and Acceptability Testing. FINDINGS: The RISE Framework was customized to the local Yolŋu context and called 'Caring for Mum on Country'. It was articulated in two languages: Djambarrpuyŋu and English. We successfully used it to guide discussions at a community gathering privileging the voices of senior women to inform the design of local maternity services. DISCUSSION: Using the D-PAR approach, the RISE Framework was readily adapatable to this complex, remote and multilingual setting. It resonated with the Yolŋu community and proved useful for identifying current limitations of existing maternity services and importantly facilitating the design of Yolŋu centred strength-based maternity services. CONCLUSION: The RISE Framework, combined with our transformative methodology, offers a promising approach to guiding complex interventions for returning services to First Nations communities in diverse contexts. Testing in other settings will further contribute to growing an evidence-base for BOC service planning and implementation.

'I didn't feel judged': exploring women's access to telemedicine abortion in rural Australia.

INTRODUCTION Regardless of geographical location, safe and legal abortion is an essential reproductive health service. Accessing an abortion is problematic for women in rural areas. Although telemedicine is globally established as safe and effective for medical abortion in urban settings, there is a paucity of research exploring access to telemedicine abortion for women in rural locations. AIM The aim of this qualitative research is to explore and better understand women's access to telemedicine abortion in Australian rural areas. METHODS Structured interviews were conducted with women (n=11) living in rural areas who had experienced a telemedicine abortion within the last 6 months. Phone interviews were recorded and transcribed verbatim. Data underwent a Patient-Centred Access framework analysis and were coded according to the domain categories of approachability/ability to perceive, acceptability/ability to seek, availability/ability to reach, affordability/ability to pay, and appropriateness/ability to engage. RESULTS Rural women had severely limited access to abortion care. The five domains of the Patient-Centred Access model demonstrated that when women with the prerequisite personal skills and circumstances are offered a low-cost service with compassionate staff and technical competence, telemedicine can innovate to ensure rural communities have access to essential reproductive health services. DISCUSSION Telemedicine offers an innovative model for ensuring women's access to medical abortion services in rural areas of Australia and likely has similar applicability to international non-urban contexts. Strategies are needed to ensure women with lower literacy and less favourable situational contexts, can equitably access abortion services through telemedicine.

Indigenous Doulas: A literature review exploring their role and practice in western maternity care.

OBJECTIVE: The purpose of this article is to establish a body of literature exploring the emergent topic of Indigenous doulas, in relation to Indigenous communities in remote locations, where women are routinely evacuated and no longer supported to give birth. In doing so the article will synthesise and critique key concepts in the literature and identify gaps for prioritisation in future research. DESIGN: The methodology is influenced by Indigenous, decolonising and feminist theoretical standpoints. A combined methodological approach of an integrative and scoping literature review was undertaken. Only published research, grey literature and grey data written in English and created between the years 2000 and 2018 was included. The search engines used were CINAHL plus, MEDLINE full text, Informat, Cochrane, Google Scholar and Google Search. SETTING: Resources originating from only Canada and America identified and despite regional similarities, no literature from Australia or Greenland was sourced. PARTICIPANTS: Of the entirety of identified resources two author's Indigenous identity was readily identifiable; and in the research articles there was a total of 191 research participants identified as Indigenous. Much of the grey literature and grey data included quotations from Indigenous women. INTERVENTIONS (IF APPROPRIATE): N/A. MEASUREMENTS AND FINDINGS: Key concepts about the role and practice of Indigenous doulas were identified: reclaiming and supporting cultural practices; sovereignty over lands and bodies; strengthening families, training, work models and defiance of evacuation policies on the pathway to returning birth. Critique of these concepts suggests that Indigenous doulas have a unique role and practice scope in Western maternity care, which is readily distinguished from standard doula practice. Research gaps worthy of future research prioritisation include: Indigenous women's perspectives as recipients of Indigenous doula care, Indigenous doulas as a pathway into midwifery, escort policy and impacts on Indigenous doula provision; evaluation and alternative research settings. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The role and practice of Indigenous doulas offers a promising approach to redressing the colonisation of Indigenous childbirth while contributing to improving Indigenous maternal and infant outcomes. Indigenous doula practice shares many best-practice characteristics with Indigenous Healing Programs and as such is also likely to also promote inter-generational healing. Most of the resources located were descriptive, but this emergent topic is worthy of further applied research.

The logics of planned birthplace for remote Australian Aboriginal women in the northern territory: A discourse and content analysis of clinical practice manuals.

OBJECTIVE: the aim of this research is to review the content, and describe the structural and contextual discourse around planned birthplace in six clinical practice manuals used to care for pregnant Aboriginal women in Australia׳s remote Northern Territory. The purpose is to better understand where, how and why planned birthplaces for Aboriginal women have changed over time. METHODS: content and discourse analysis was applied to the written texts pertaining to maternal health care and the results placed within a theoretical framework of Daviss׳s Logic. FINDINGS: the manuals demonstrate the use of predominantly scientific and clinical logic to sanction birthplace. Planned birthplace choices have declined over time, with hospital now represented as the only place to give birth. This is in opposition to Aboriginal women׳s longstanding requests and is not supported by robust scientific evidence. CONCLUSIONS: despite scientific and clinical logics dominating the sanctioning of birthplace for Aboriginal women, conjecture is apparent between assumed logics and evidence. There needs to be further critical reflection on why Aboriginal women do not have planned birthplace choices, and these reasons, once identified, debated and addressed both in research agendas and policy re-development.

Paperbark and pinard: A historical account of maternity care in one remote Australian Aboriginal town.

BACKGROUND AND AIM: Maternity care in remote areas of the Australian Northern Territory is restricted to antenatal and postnatal care only, with women routinely evacuated to give birth in hospital. Using one remote Aboriginal community as a case study, our aim with this research was to document and explore the major changes to the provision of remote maternity care over the period spanning pre-European colonisation to 1996. METHODS: Our research methods included historical ethnographic fieldwork (2007-2013); interviews with Aboriginal women, Aboriginal health workers, religious and non-religious non-Aboriginal health workers and past residents; and archival review of historical documents. FINDINGS: We identified four distinct eras of maternity care. Maternity care staffed by nuns who were trained in nursing and midwifery serviced childbirth in the local community. Support for community childbirth was incrementally withdrawn over a period, until the government eventually assumed responsibility for all health care. CONCLUSIONS: The introduction of Western maternity care colonised Aboriginal birth practices and midwifery practice. Historical population statistics suggest that access to local Western maternity care may have contributed to a significant population increase. Despite population growth and higher demand for maternity services, local maternity services declined significantly. The rationale for removing childbirth services from the community was never explicitly addressed in any known written policy directive. Declining maternity services led to the de-skilling of many Aboriginal health workers and the significant community loss of future career pathways for Aboriginal midwives. This has contributed to the current status quo, with very few female Aboriginal health workers actively providing remote maternity care.

'Jumping around': exploring young women's behaviour and knowledge in relation to sexual health in a remote Aboriginal Australian community.

Sexual health indicators for young remote-living Aboriginal women are the worst of all of Australian women. This study aimed to describe and explore young women's behaviour and knowledge in relation to sexual health, as well as to provide health professionals with cross-cultural insights to assist with health practice. A descriptive ethnographic study was conducted, which included: extended ethnographic field work in one remote community over a six-year period; community observation and participation; field notes; semi-structured interviews; group reproductive ethno-physiology drawing and language sessions; focus-group sessions; training and employment of Aboriginal research assistants; and consultation and advice from a local reference group and a Cultural Mentor. Findings reveal that young women in this remote community have a very poor biomedical understanding of sexually transmitted infections and contraception. This is further compounded by not speaking English as a first language, low literacy levels and different beliefs in relation to body functions. In their sexual relationships, young women often report experiences involving multiple casual partners, marijuana use and violence. Together, the findings contribute to a better understanding of the factors underlying sexual health inequity among young Aboriginal women in Australia.