Breaking the cycle: Effect of a multi-agency maternity service redesign on reducing the over-representation of Aboriginal and Torres Strait Islander newborns in out-of-home care: A prospective, non-randomised, intervention study in urban Australia.

BACKGROUND: Strategies to reduce over-representation of Indigenous children in out-of-home care must start in pregnancy given Indigenous babies are 6 % of infants (<1 year), yet 43 % of infants in out-of-home care. OBJECTIVE: To determine if an Indigenous-led, multi-agency, partnership redesign of maternity services decreases the likelihood of babies being removed at birth. PARTICIPANTS AND SETTING: Women carrying an Indigenous baby/babies who gave birth at the Mater Mothers' Public Hospital, Brisbane (2013-2019). METHODS: A prospective, non-randomised, intervention trial evaluated a multi-agency service redesign. Women pregnant with an Indigenous baby birthing at a tertiary hospital were offered standard care or Birthing in Our Community (BiOC) service. We compared likelihood of babies being removed by Child Protection Services (CPS) at birth by model of care. Inverse probability of treatment propensity score weighting controlled baseline confounders and calculated treatment effect. Standardized differences were calculated to assess balance of risk factors for each copy of multiple imputation. Australian New Zealand Clinical Trial Registry, ACTRN12618001365257. RESULTS: In 2013-2019, 1988 women gave birth to 2044 Indigenous babies, with 40 women having babies removed at birth (9 BiOC, 31 standard care). Adjusted odds of baby removal were significantly lower for mothers in BiOC compared to standard care (AOR 0.37, 95 % CI 0.16, 0.84). In total, 2.0 % of Indigenous babies were removed by CPS; eight times higher than non-Indigenous babies at the same hospital (0.25 %). CONCLUSIONS: BiOC reduced removals of newborn Indigenous babies likely disrupting generational cycles of CPS contact, trauma, and maltreatment, and contributing to short and long-term health and wellbeing benefits for mothers and babies.

Birthing on country service compared to standard care for First Nations Australians: a cost-effectiveness analysis from a health system perspective.

Background: Preterm birth is the leading cause of morbidity and mortality for children under five years with First Nations babies experiencing twice the rate of other Australians. The Birthing in Our Community (BiOC) service was implemented in a metropolitan centre in Australia and showed a significant reduction in preterm birth. We aimed to assess the cost-effectiveness of the BiOC service in reducing preterm births compared to Standard Care, from a health system perspective. Methods: Women who were carrying a First Nations baby and attending the Mater Mothers Public Hospital (Brisbane, QLD, Australia) were allocated to either BiOC or Standard Care service. Birth records were extracted from the hospital's routinely collected and prospectively entered database. The time horizon extended from first presentation in pregnancy up to six weeks after birth for mothers and 28 days for infants, or until discharged from hospital. All direct antenatal, birth, postnatal and neonatal costs were included. The proportion of preterm birth was calculated, and cost was estimated in 2019 Australian dollars. The incremental cost and proportion of preterm birth differences were adjusted using inverse probability of treatment weighting methods. Findings: Between Jan 1 2013, and Jun 30, 2019, 1816 mothers gave births to 1867 First Nations babies at the Mater Mothers Public Hospital. After exclusions, 1636 mother-baby pairs were included in the analyses: 840 in the Standard Care group and 796 in the BiOC service. Relative to Standard Care, the BiOC service was associated with a reduced proportion of preterm birth (-5.34%, [95% CI -8.69%, -1.98%]) and cost savings (-AU$4810, [95% CI -7519, -2101]) per mother-baby pair. The BiOC service was associated with better outcomes and cost less than Standard Care. Interpretation: The BiOC service offers a cost-effective alternative to Standard Care in reducing preterm birth for Australian First Nations families. The cost savings were driven by less interventions and procedures in birth and fewer neonatal admissions. Investing in comprehensive, community-led models of care improves outcomes at reduced cost. Funding: The Australian National Health and Medical Research Council (APP1077036).

Is a randomized controlled trial of waterbirth possible? An Australian feasibility study.

BACKGROUND: The safety of waterbirth is contested because of the lack of evidence from randomized trials and conflicting results. This research assessed the feasibility of a prospective study of waterbirth (trial or cohort). METHODS: We conducted a prospective cohort study at an Australian maternity hospital. Eligible women with uncomplicated pregnancies at 36 weeks of gestation were recruited and surveyed about their willingness for randomization. The primary midwife assessed waterbirth eligibility and intention on admission in labor, and onset of second stage. Primary outcomes measured feasibility. Intention-to-treat analysis, and per-protocol analysis, compared clinical outcomes of women and their babies who intended waterbirth and nonwaterbirth at onset of second stage. RESULTS: 1260 participants were recruited; 15% (n = 188) agreed to randomization in a future trial. 550 women were analyzed by intention-to-treat analysis: 351 (waterbirth) and 199 (nonwaterbirth). In per-protocol analysis, 14% (n = 48) were excluded. Women in the waterbirth group were less likely to have amniotomy and more likely to have water immersion and physiological third stage. There were no differences in other measures of maternal morbidity. There were no significant differences between groups for serious neonatal morbidity; four cord avulsions occurred in the waterbirth group with none in the landbirth group. An RCT would need approximately 6000 women to be approached at onset of second stage. CONCLUSIONS: A randomized trial of waterbirth compared with nonwaterbirth, powered to detect a difference in serious neonatal morbidity, is unlikely to be feasible. A powered prospective study with intention-to-treat analysis at onset of second stage is feasible.

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

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

The Indigenous Birthing in an Urban Setting study: the IBUS study : A prospective birth cohort study comparing different models of care for women having Aboriginal and Torres Strait Islander babies at two major maternity hospitals in urban South East Queensland, Australia.

BACKGROUND: With persisting maternal and infant health disparities, new models of maternity care are needed to meet the needs of Aboriginal and Torres Strait Islander people in Australia. To date, there is limited evidence of successful and sustainable programs. Birthing on Country is a term used to describe an emerging evidence-based and community-led model of maternity care for Indigenous families; its impact requires evaluation. METHODS: Mixed-methods prospective birth cohort study comparing different models of care for women having Aboriginal and Torres Strait Islander babies at two major maternity hospitals in urban South East Queensland (2015-2019). Includes women's surveys (approximately 20 weeks gestation, 36 weeks gestation, two and six months postnatal) and infant assessments (six months postnatal), clinical outcomes and cost comparison, and qualitative interviews with women and staff. DISCUSSION: This study aims to evaluate the feasibility, acceptability, sustainability, clinical and cost-effectiveness of a Birthing on Country model of care for Aboriginal and Torres Strait Islander families in an urban setting. If successful, findings will inform implementation of the model with similar communities. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry # ACTRN12618001365257 . Registered 14 August 2018 (retrospectively registered).

Birthing on Country (in Our Community): a case study of engaging stakeholders and developing a best-practice Indigenous maternity service in an urban setting.

Developing high-quality and culturally responsive maternal and infant health services is a critical part of 'closing the gap' in health disparities between Aboriginal and Torres Strait Islander people and other Australians. The National Maternity Services Plan led work that describes and recommends Birthing on Country best-practice maternity care adaptable from urban to very remote settings, yet few examples exist in Australia. This paper demonstrates Birthing on Country principles can be applied in the urban setting, presenting our experience establishing and developing a Birthing on Country partnership service model in Brisbane, Australia. An initial World Café workshop effectively engaged stakeholders, consumers and community members in service planning, resulting in a multiagency partnership program between a large inner city hospital and two local Aboriginal Community-Controlled Health Services (ACCHS). The Birthing in Our Community program includes: 24/7 midwifery care in pregnancy to six weeks postnatal by a named midwife, supported by Indigenous health workers and a team coordinator; partnership with the ACCHS; oversight from a steering committee, including Indigenous governance; clinical and cultural supervision; monthly cultural education days; and support for Indigenous student midwives through cadetships and placement within the partnership. Three years in, the partnership program is proving successful with clients, as well as showing early signs of improved maternal and infant health outcomes.

Women's, midwives' and obstetricians' experiences of a structured process to document refusal of recommended maternity care.

PROBLEM/BACKGROUND: Ethical and professional guidance for midwives and obstetricians emphasises informed consent and respect for patient autonomy; the right to refuse care is well established. However, the existing literature is largely silent on the appropriate clinical responses when pregnant women refuse recommended care, and accounts of disrespectful interactions and conflict are numerous. Policies and processes to support women and maternity care providers are rare and unstudied. AIM: To document the perspectives of women, midwives and obstetricians following the introduction of a structured process (Maternity Care Plan; MCP) to document refusal of recommended maternity care in a large tertiary maternity unit. METHODS: A qualitative, interpretive study involved thematic analysis of in-depth semi-structured interviews with women (n=9), midwives (n=12) and obstetricians (n=9). FINDINGS: Four major themes were identified including: 'Reassuring and supporting clinicians'; 'Keeping the door open'; 'Varied awareness, criteria and use of the MCP process' and 'No guarantees'. CONCLUSION: Clinicians felt protected and reassured by the structured documentation and communication process and valued keeping women engaged in hospital care. This, in turn, protected women's access to maternity care. However, the process could not guarantee favourable responses from other clinicians subsequently involved in the woman's care. Ongoing discussions of risk, perceived by women and some midwives to be pressure to consent to recommended care, were still evident. These limitations may have been attributable to the absence of agreed criteria for initiating the MCP process and fragmented care. Varying awareness and use of the process also diminished women's access to it.

Maternity Care Plans: A retrospective review of a process aiming to support women who decline standard care.

BACKGROUND: All competent adults have the right to refuse medical treatment. When pregnant women do so, ethical and medico-legal concerns arise and women may face difficulties accessing care. Policies guiding the provision of maternity care in these circumstances are rare and unstudied. One tertiary hospital in Australia has a process for clinicians to plan non-standard maternity care via a Maternity Care Plan (MCP). AIM: To review processes and outcomes associated with MCPs from the first three and a half years of the policy's implementation. METHODS: Retrospective cohort study comprising chart audit, review of demographic data and clinical outcomes, and content analysis of MCPs. FINDINGS: MCPs (n=52) were most commonly created when women declined recommended caesareans, preferring vaginal birth after two caesareans (VBAC2, n=23; 44.2%) or vaginal breech birth (n=7, 13.5%) or when women declined continuous intrapartum monitoring for vaginal birth after one caesarean (n=8, 15.4%). Intrapartum care deviated from MCPs in 50% of cases, due to new or worsening clinical indications or changed maternal preferences. Clinical outcomes were reassuring. Most VBAC2 or VBAC>2 (69%) and vaginal breech births (96.3%) were attempted without MCPs, but women with MCPs appeared more likely to birth vaginally (VBAC2 success rate 66.7% with MCP, 17.5% without; vaginal breech birth success rate, 50% with MCP, 32.5% without). CONCLUSIONS: MCPs enabled clinicians to provide care outside of hospital policies but were utilised for a narrow range of situations, with significant variation in their application. Further research is needed to understand the experiences of women and clinicians.

A randomised trial, conducted by midwives, of perineal repairs comparing a polyglycolic suture material and chromic catgut.

OBJECTIVE: to assess the effect of suture materials (an absorbable synthetic suture material versus catgut) used in perineal repairs undertaken by midwives who had been trained and accredited in repair techniques. DESIGN: randomised controlled trial. SETTING: tertiary obstetric hospital in Australia. PARTICIPANTS: 391 women with a live singleton birth at > or =34 weeks gestation, resulting from a spontaneous vaginal delivery and who required perineal repair due to either an episiotomy or first or second degree tear. INTERVENTION: eligible women were randomly allocated for repair with either polyglycolic acid or chromic catgut. MAIN OUTCOME MEASURES: perineal pain and dyspareunia up to six months postpartum. FINDINGS: of the 194 women allocated to polyglycolic suture 106 (55%) were primipara compared with 79 (40%) of the 197 women allocated to catgut. Due to this unexplained imbalance, odds ratios were estimated with and without adjustment for parity. The parity-adjusted odds ratios were little changed (<11%) from the crude odds ratios. Although there were no statistically significant differences, parity-adjusted odds ratios (aOR) suggest that compared with women sutured with catgut, women sutured with polyglycolic were less likely to experience perineal pain at Day 3 postpartum (aOR=0.70 95% confidence interval [95% CI] 0.46-1.08) but by six months postpartum were somewhat more likely to experience perineal pain (aOR=1.77, 95% CI 0.57-5.47), dyspareunia (aOR=1.21 [0.62-2.33] and require removal of a suture (aOR=2.61 95% CI 0.59-12.41). CONCLUSIONS: the finding of reduced short-term perineal pain in women repaired with polyglycolic compared with catgut is similar to that of a Cochrane Systematic Review. The possibility that polyglycolic is associated with worse longer-term outcomes has not been previously reported but is biologically plausible (catgut causes a local inflammatory reaction but is rapidly absorbed, while polyglycolic causes little inflammation but absorption takes longer). This trial also illustrates the difficulties of undertaking clinical research in a busy delivery ward.