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).

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.

Recognition and management of hypertension by nurses: action in patients with diabetes is critical.

The Canadian Hypertension Education Program (CHEP), Canadian Hypertension Society, Blood Pressure Canada, Canadian Diabetes Association, College of Family Physicians of Canada, Canadian Pharmacists Association, Heart and Stroke Foundation of Canada, and the Canadian Council of Cardiovascular Nurses issued a recent call for all health care professionals in Canada to double their efforts to assist patients with diabetes in maintaining target blood pressures (Campbell et al., 2009b). Blood pressure (B/P) in diabetic individuals should be less than 130 mmHg systolic and less than 80 mmHg diastolic (CHEP 2009). Considering recognition and treatment of hypertension in people with diabetes can result in reductions in disability and death, control of hypertension must become an interdisciplinary priority. Maintaining B/P less than 130/80 mmHg requires lifestyle modification as the cornerstone to treatment and often two or more B/P medications (Campbell et al., 2009a). The cost of multiple drugs required for B/P control in diabetic individuals is one of the few treatments estimated to reduce overall health costs and related cardiovascular disease complications (Gillies, Abrams, & Lambert, 2007). Nurses are essential partners in assessing and assisting diabetic patients and all patients with hypertension to reduce overall cardiovascular risks. Nurses may also be key practitioners in assessing and monitoring patient difficulties with adherence to lifestyle or pharmacological interventions (Jayasinghe, 2009; McLean et al., 2008). Individualized lifestyle counselling and treatment modification are recommended to maintain target B/P and treat dysglycemia, dyslipidemia, smoking or any other cardiovascular risks in diabetic individuals.

2007 Hypertension Education Program (CHEP) recommendations: management of hypertension by nurses.

Recent data from the World Health Organization (WHO) indicate that nearly one billion people in the world are suffering from hypertension. Forecasts suggest that, with the aging of the population, this number could reach 1.5 billion by 2025 (Kearney, Whelton, & Reynolds, 2005). In developed countries, more than one in five adults have hypertension (Vasan, Beiser, Seshadri, Larson, Kannel, & D'Agostino, 2002). Statistics for Canada reveal that fewer than 15% of those diagnosed with hypertension are adequately controlled (Joffres, Hamet, MacLean, L'italien, & Fodor, 2001). Part of the effort to improve hypertension detection, assessment and treatment is an annual process to produce and update evidence-based recommendations for the management of hypertension and to implement the recommendations (Zarnke, Campbell, McAlister, & Levine, 2000; Campbell, Nagpal, & Drouin, 2001). The most up-to-date 2007 Canadian recommendations for the assessment and management of hypertension are presented. Contemporary nursing practice requires that nurses take responsibility and a role in the primary prevention, detection and treatment of hypertension.

What is the experience of men and women with congestive heart failure?

Congestive heart failure (CHF) is increasing in incidence and prevalence in both men and women in Canada. Research findings to date have been inconsistent with respect to whether gender differences influence quality of life, treatment and survival. There is a paucity of qualitative research describing the experience of patients with CHF This qualitative case study approach used semistructured interviews with women and men with New York Heart Association (NYHA) class three or four CHF who were referred to a CHF clinic. In addition to quality of life measures, data related to medical history, medical management and NYHA scores were collected to offer a thorough description of these clients' experiences. Three hypotheses were generated from 13 themes that emerged. First, the psychosocial impact of CHF outweighs the physical impact. Second, sex differences exist in relation to living with CHF with men being more accepting of CHF and more likely to experience social isolation and loss than women, while women are more likely to describe fear. Third, the experience of CHF is influenced by age with physical experiences and depression mentioned more frequently in younger age groups. Findings from this study have generated nursing implications and recommendations for further research.