"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.

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.

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.

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.

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.

Niyith NiyithWatmam [corrected] (the quiet story): exploring the experiences of Aboriginal women who give birth in their remote community.

OBJECTIVE: to investigate the beliefs and practices of Aboriginal women who decline transfer to urban hospitals and remain in their remote community to give birth. DESIGN: an ethnographic approach was used which included: the collection of birth histories and narratives, observation and participation in the community for 24 months, field notes, training and employment of an Aboriginal co-researcher, and consultation with and advice from a local reference group. SETTING: a remote Aboriginal community in the Northern Territory, Australia. PARTICIPANTS: narratives were collected from seven Aboriginal women and five family members. FINDINGS: findings showed that women, through their previous experiences of standard care, appeared to make conscious decisions and choices about managing their subsequent pregnancies and births. Women took into account their health, the baby's health, the care of their other children, and designated men with a helping role. KEY CONCLUSIONS: narratives described a breakdown of traditional birthing practices and high levels of non-compliance with health-system-recommended care. IMPLICATION FOR PRACTICE: standard care provided for women relocating for birth must be improved, and the provision of a primary maternity service in this particular community may allow Aboriginal Women's Business roles and cultural obligations to be recognised and invigorated. International examples of primary birthing services in remote areas demonstrate that they can be safe alternatives to urban transfer for childbirth. A primary maternity service would provide a safer environment for the women who choose to avoid standard care.