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.

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.

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.

Psychosocial stress and methamphetamine use: A mixed-methods study of intersectional stigma and Aboriginal and Torres Strait Islander methamphetamine use.

BACKGROUND: Regular methamphetamine use can cause a range of physical, psychological and social harms. Stigma is one factor that impacts engagement and successful completion of treatment. In Australia, Aboriginal and Torres Strait Islander people who regularly use methamphetamine experience multiple stigmas, which further compounds access to treatment and quality of life. This paper explores the cumulative and compounding effects of participating in a stigmatised activity such as illicit drug use in relation to the stigma experienced by Aboriginal and Torres Strait Islander people as a population marginalised through colonisation. METHODS: Ten sites nationally participated in a cross-sectional survey measuring a range of factors including psychosocial stress in methamphetamine users. The survey sample size was 734, with 59% identifying as Aboriginal and Torres Strait Islander (n = 433). In addition, a total of 147 mainly Aboriginal and Torres Strait Islander people who use methamphetamine, community and family members, and service providers took part in a total of 19 focus groups and 7 interviews. RESULTS: Aboriginal and Torres Strait Islander participants experienced multiple psychosocial stressors at significantly higher rates than non-Indigenous participants. These stressors include diminished access to health care (33%), experiences of racism (34%), grief and sorrow (39%), worry for family (46%), and child welfare experiences (46%). The qualitative findings highlight the cumulative impact of historical, political and social stressors on an already stigmatised population. CONCLUSIONS: The findings of this unique analysis demonstrate the disruptive impact of methamphetamine use on the lives of those who use methamphetamines and their family members. They also illustrate challenges, such as stigma, that may confront those seeking assistance for drug-related issues. Aboriginal and Torres Strait Islander community involvement is necessary to provide support and education for the individual, the family, and the community as a whole. Stigma reduction is therefore a worthy target for intervention.

"This has changed me to be a better mum": A qualitative study exploring how the Australian Nurse-Family Partnership Program contributes to the development of First Nations women's self-efficacy.

BACKGROUND: The Australian Nurse-Family Partnership Program is based on the Nurse-Family Partnership program from the United States, which was designed to support first-time mothers experiencing social and economic disadvantage from early in pregnancy until their child's second birthday. International trials have demonstrated this program measurably improves family environment, maternal competencies, and child development. The Australian program has been tailored for mothers having a First Nations baby. AIM: This study aimed to understand how the program impacts self-efficacy using a qualitative interpretive approach. METHODS: The study took place in two sites within one Aboriginal Community Controlled Health Service in Meanjin (Brisbane), Australia. Twenty-nine participants were interviewed: first-time mothers having a First Nations baby who had accessed the program (n = 26), their family members (n = 1), and First Nations Elders (n = 2). Interviews were conducted either face-to-face or by telephone, using a yarning tool and method, to explore women's experiences and perceptions. Yarns were analysed using reflexive thematic analysis. FINDINGS: Three main themes were generated: 1) sustaining connections and relationships; 2) developing self-belief and personal skills; and 3) achieving transformation and growth. We interpret that when the program facilitates the development of culturally safe relationships with staff and peers, it enables behaviour change, skill development, personal goal setting and achievement, leading to self-efficacy. DISCUSSION: Located within a community-controlled health service, the program can foster cultural connection, peer support and access to health and social services; all contributing to self-efficacy. CONCLUSION: We recommend the program indicators are strengthened to reflect these findings and enable monitoring and reporting of activities that facilitate self-efficacy, growth, and empowerment.

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).

Study protocol: peer delivered early intervention (Learning through Everyday Activities with Parents for Infants at risk of Cerebral Palsy: LEAP-CP) for First Nation Australian infants at high risk of cerebral palsy - an RCT study.

INTRODUCTION: Cerebral palsy (CP) is the most common childhood physical disability with rates approximately 50% higher in First Nations Australian children. This study aims to evaluate a culturally-adapted parent-delivered early intervention programme for First Nations Australian infants at high risk of CP (Learning through Everyday Activities with Parents for infants with CP; LEAP-CP). METHODS AND ANALYSIS: This study is a randomised assessor masked controlled trial. Infants with birth/postnatal risk factors will be eligible for screening. Infants at high risk of CP ('absent fidgety' on General Movements Assessment, and/or 'suboptimal score' on the Hammersmith Infant Neurological Examination) aged 12-52 weeks corrected age will be recruited. Infants and their caregivers will be randomised to receive LEAP-CP (intervention) or health advice (comparator). LEAP-CP is a culturally-adapted programme of 30 home visits delivered by a peer trainer (First Nations Community Health Worker); and includes goal-directed active motor/cognitive strategies, CP learning games and caregiver educational modules. The control arm receives a monthly health advice visit, based on the Key Family Practices, WHO. All infants continue to receive standard (mainstream) Care as Usual. Dual child primary outcomes are Peabody Developmental Motor Scales-2 (PDMS-2) and Bayley Scales of Infant Development-III. The primary caregiver outcome is the Depression, Anxiety and Stress Scale. Secondary outcomes include function, goal attainment, vision, nutritional status and emotional availability. SAMPLE SIZE: total of 86 children (43/group) will enable an effect size of 0.65 on the PDMS-2 to be detected (80% power, α=0.05; 10% attrition). ETHICS AND DISSEMINATION: Ethics approval through Queensland ethics committees and Aboriginal Controlled Community Health Organisation Research Governance Groups, with families providing written informed consent. Findings will be disseminated with guidance from the Participatory Action Research, in collaboration with First Nations communities; peer-reviewed journal publications and national/international conference presentations. TRIAL REGISTRATION NUMBER: ACTRN12619000969167p.

Developing and evaluating Birthing on Country services for First Nations Australians: the Building On Our Strengths (BOOSt) prospective mixed methods birth cohort study protocol.

BACKGROUND: With the impact of over two centuries of colonisation in Australia, First Nations families experience a disproportionate burden of adverse pregnancy and birthing outcomes. First Nations mothers are 3-5 times more likely than other mothers to experience maternal mortality; babies are 2-3 times more likely to be born preterm, low birth weight or not to survive their first year. 'Birthing on Country' incorporates a multiplicity of interpretations but conveys a resumption of maternity services in First Nations Communities with Community governance for the best start to life. Redesigned services offer women and families integrated, holistic care, including carer continuity from primary through tertiary services; services coordination and quality care including safe and supportive spaces. The overall aim of Building On Our Strengths (BOOSt) is to facilitate and assess Birthing on Country expansion into two settings - urban and rural; with scale-up to include First Nations-operated birth centres. This study will build on our team's earlier work - a Birthing on Country service established and evaluated in an urban setting, that reported significant perinatal (and organisational) benefits, including a 37% reduction in preterm births, among other improvements. METHODS: Using community-based, participatory action research, we will collaborate to develop, implement and evaluate new Birthing on Country care models. We will conduct a mixed-methods, prospective birth cohort study in two settings, comparing outcomes for women having First Nations babies with historical controls. Our analysis of feasibility, acceptability, clinical and cultural safety, effectiveness and cost, will use data including (i) women's experiences collected through longitudinal surveys (three timepoints) and yarning interviews; (ii) clinical records; (iii) staff and stakeholder views and experiences; (iv) field notes and meeting minutes; and (v) costs data. The study includes a process, impact and outcome evaluation of this complex health services innovation. DISCUSSION: Birthing on Country applies First Nations governance and cultural safety strategies to support optimum maternal, infant, and family health and wellbeing. Women's experiences, perinatal outcomes, costs and other operational implications will be reported for Communities, service providers, policy advisors, and for future scale-up. TRIAL REGISTRATION: Australia & New Zealand Clinical Trial Registry # ACTRN12620000874910 (2 September 2020).

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.

Study protocol: primary healthcare transformation through patient-centred medical homes-improving access, relational care and outcomes in an urban Aboriginal and Torres Strait Islander population, a mixed methods prospective cohort study.

INTRODUCTION: For over 40 years, Aboriginal and Torres Strait Islander Community-Controlled Health Services (ACCHS) in Australia have led strategic responses to address the specific needs of Aboriginal and Torres Strait Islander populations. Globally, there has been rapid growth in urban Indigenous populations requiring an adaptive primary healthcare response. Patient-centred medical homes (PCMH) are an evidenced-based model of primary healthcare suited to this challenge, underpinned by principles aligned with the ACCHS sector-relational care responsive to patient identified healthcare priorities. Evidence is lacking on the implementation and effectiveness of the PCMH model of care governed by, and delivered for, Aboriginal and Torres Strait Islander populations in large urban settings. METHOD AND ANALYSIS: Our multiphased mixed-methods prospective cohort study will compare standard care provided by a network of ACCHS to an adapted PCMH model of care. Phase 1 using qualitative interviews with staff and patients and quantitative analysis of routine primary care health record data will examine the implementation, feasibility and acceptability of the PCMH. Phase 2 using linked survey, primary care and hospitalisation data will examine the impact of our adapted PCMH on access to care, relational and quality of care, health and wellbeing outcomes and economic costs. Phase 3 will synthesise evidence on mechanisms for change and discuss their implications for sustainability and transferability of PCMHs to the broader primary healthcare system ETHICS AND DISSEMINATION: This study has received approval from the University of Queensland Human Research Ethics Committee (2021/HE00529). This research represents an Aboriginal led and governed partnership in response to identified community priorities. The findings will contribute new knowledge on how key mechanisms underpinning the success and implementation of the model can be introduced into policy and practice. Study findings will be disseminated to service providers, researchers, policymakers and, most importantly, the communities themselves.

Supporting Aboriginal and Torres Strait Islander Families to Stay Together from the Start (SAFeST Start): Urgent call to action to address crisis in infant removals.

Reducing the rate of over-representation of Aboriginal and Torres Strait Islander children in out-of-home care (OOHC) is a key Closing the Gap target committed to by all Australian governments. Current strategies are failing. The "gap" is widening, with the rate of Aboriginal and Torres Strait Islander children in OOHC at 30 June 2020 being 11 times that of non-Indigenous children. Approximately, one in five Aboriginal and Torres Strait Islander children entering OOHC each year are younger than one year. These figures represent compounding intergenerational trauma and institutional harm to Aboriginal and Torres Strait Islander families and communities. This article outlines systemic failures to address the needs of Aboriginal and Torres Strait Islander parents during pregnancy and following birth, causing cumulative harm and trauma to families, communities and cultures. Major reform to child and family notification and service systems, and significant investment to address this crisis, is urgently needed. The Family Matters Building Blocks and five elements of the Aboriginal and Torres Strait Islander Child Placement Principle (Prevention, Participation, Partnership, Placement and Connection) provide a transformative foundation to address historical, institutional, well-being and socioeconomic drivers of current catastrophic trajectories. The time for action is now.

'Even though you hate everything that's going on, you know they are safer at home': The role of Aboriginal and Torres Strait Islander families in methamphetamine use harm reduction and their own support needs.

INTRODUCTION: First Nations people who use methamphetamine are overrepresented in regional and remote Australia and more likely to turn to family for support. This can place strain on families. The support needs of family members of individuals using methamphetamine are poorly understood. METHODS: We conducted 19 focus groups and seven interviews with mostly First Nations community, family members and service providers. In total, 147 participants across six sites participated as part of a larger study investigating First Nations perspectives of how to address methamphetamine use and associated harms. We applied a social and emotional wellbeing framework to examine support needs and role of family in mitigating methamphetamine harms. RESULTS: Findings highlighted the importance of families in providing support to people using methamphetamine and in reducing associated harms, often without external support. The support provided encompassed practical, social, emotional, financial, access to services and maintaining cultural connection. Providing support took a toll on family and negatively impacted their own social and emotional wellbeing. DISCUSSION AND CONCLUSIONS: First Nations families play an important and under-recognised role in reducing methamphetamine-related harms and greater efforts are required to support them. Professional resources are needed to deal with impacts of methamphetamine on families; these should be pragmatic, accessible, targeted and culturally appropriate. Support for families and communities should be developed using the social and emotional wellbeing framework that recognises wellbeing and healing as intrinsically connected to holistic health, kinship, community, culture and ancestry, and socioeconomic and historical influences on peoples' lives.

Improving interagency service integration of the Australian Nurse Family Partnership Program for First Nations women and babies: a qualitative study.

BACKGROUND: The Australian Nurse Family Partnership Program (ANFPP) is an evidence-based, home visiting program that offers health education, guidance, social and emotional support to first-time mothers having Aboriginal and/or Torres Strait Islander (First Nations) babies. The community-controlled sector identified the need for specialised support for first time mothers due to the inequalities in birthing and early childhood outcomes between First Nations' and other babies in Australia. The program is based on the United States' Nurse Family Partnership program which has improved long-term health outcomes and life trajectories for mothers and children. International implementation of the Nurse Family Partnership program has identified interagency service integration as key to program recruitment, retention, and efficacy. How the ANFPP integrates with other services in an Australian urban setting and how to improve this is not yet known. Our research explores the barriers and enablers to interagency service integration for the Australian Nurse Family Partnership Program ANFPP in an urban setting. METHODS: A qualitative study using individual and group interviews. Purposive and snowball sampling was used to recruit clients, staff (internal and external to the program), Elders and family members. Interviews were conducted using a culturally appropriate 'yarning' method with clients, families and Elders and semi-structured interview guide for staff. Interviews were audio-recorded and transcribed prior to reflexive thematic analysis. RESULTS: Seventy-six participants were interviewed: 26 clients, 47 staff and 3 Elders/family members. Three themes were identified as barriers and three as enablers. Barriers: 1) confusion around program scope, 2) duplication of care, and 3) tensions over 'ownership' of clients. Enablers (existing and potential): 1) knowledge and promotion of the program; 2) cultural safety; and 3) case coordination, co-location and partnership forums. CONCLUSION: Effective service integration is essential to maximise access and acceptability of the ANFPP; we provide practical recommendations to improve service integration in this context.

Quality management systems in Aboriginal Community Controlled Health Services: a review of the literature.

BACKGROUND: A national accreditation policy for the Australian primary healthcare (PHC) system was initiated in 2008. While certification standards are mandatory, little is known about their effects on the efficiency and sustainability of organisations, particularly in the Aboriginal Community Controlled Health Service (ACCHS) sector. AIM: The literature review aims to answer the following: to what extent does the implementation of the International Organisation for Standardization 9001:2008 quality management system (QMS) facilitate efficiency and sustainability in the ACCHS sector? METHODS: Thematic analysis of peer-reviewed and grey literature was undertaken from Australia and New Zealand PHC sector with a focus on First Nations people. The databases searched included Medline, Scopus and three Informit sites (AHB-ATSIS, AEI-ATSIS and AGIS-ATSIS). The initial search strategy included quality improvement, continuous quality improvement, efficiency and sustainability. RESULTS: Sixteen included studies were assessed for quality using the McMaster criteria. The studies were ranked against the criteria of credibility, transferability, dependability and confirmability. Three central themes emerged: accreditation (n=4), quality improvement (n=9) and systems strengthening (n=3). The accreditation theme included effects on health service expenditure and clinical outcomes, consistency and validity of accreditation standards and linkages to clinical governance frameworks. The quality improvement theme included audit effectiveness and value for specific population health. The theme of systems strengthening included prerequisite systems and embedded clinical governance measures for innovative models of care. CONCLUSION: The ACCHS sector warrants reliable evidence to understand the value of QMSs and enhancement tools, particularly given ACCHS (client-centric) services and their specialist status. Limited evidence exists for the value of standards on health system sustainability and efficiency in Australia. Despite a mandatory second certification standard, no studies reported on sustainability and efficiency of a QMS in PHC.

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.

Community-Based Sexual and Reproductive Health Promotion and Services for First Nations People in Urban Australia.

CONTEXT: Little is known about sexual and reproductive health (SRH) access and health promotion for First Nations peoples in Australia. This study aimed to better understand community preferences, knowledge and access to contraception and SRH services, and use this understanding to make recommendations which support approaches led by local Aboriginal community-controlled health organisations (ACCHOs). METHODS: Qualitative First Nations-led yarning circles were conducted with 55 community members and health service providers using and/or working at ACCHOs in urban South East Queensland. Cultural protocols ensured women's and men's interviews were separately collected and analysed. Thematic analysis was conducted by multiple coders, privileging interpretations by First Nations researchers. RESULTS: Family, kin and friends were described as key knowledge holders and ACCHOs as knowledge spaces for sharing information about maintaining positive SRH and wellbeing for First Nations people. Interviewees wanted accurate and timely information in an accessible, culturally appropriate way. Making informed choices about family planning was described as an important process of agency and self-determination for First Nations people, and contextualized within broader aspirations for growing strong families and healthy relationships. CONCLUSION: Understanding SRH through the concept of "knowledge spaces" and "knowledge holders" highlights the collective importance of community relationality to support individual agency and informed SRH decision-making. ACCHOs appear to be acceptable knowledge spaces for SRH information; and evidence-based recommendations may increase their reach. Health services should consider upskilling community SRH knowledge holders to share consistent, accurate and accessible SRH information.

A realist review to explore how midwifery continuity of care may influence preterm birth in pregnant women.

BACKGROUND: Midwifery continuity of care models are the only health system intervention associated with both a reduction in preterm birth (PTB) and an improvement in perinatal survival; however, questions remain about the mechanisms by which such positive outcomes are achieved. We aimed to uncover theories of change by which we can postulate how and why continuity of midwifery care models might affect PTB. METHODS: We followed Pawson's guidance for conducting a realist review and performed a comprehensive search to identify existing literature exploring the impact of continuity models on PTB in all pregnant women. A realist methodology was used to uncover the context (C), mechanisms (M), and outcomes (O) and to develop a group of CMO configurations to illuminate middle-range theories. RESULTS: Eleven papers were included from a wide variety of settings in the United Kingdom, Australia, and the United States. The majority of study participants had low socioeconomic status or social risk factors and received diverse models of midwifery continuity of care. Three themes-woman-midwife partnership, maternity pathways and processes, and system resources-encompassed ten CMO configurations. Building relationships, trust, confidence, and advocacy resulted in women feeling safer, less stressed, and more secure and respected, and encouraged them to access and engage in antenatal care with more opportunities for early prevention and diagnosis of complications, which facilitated effective management when compliance to guidelines was ensured. Organizational infrastructure, innovative partnerships, and robust community systems are crucial to overcome barriers, address women's complex needs, ensure quality of care, and reduce PTB risk. CONCLUSIONS: Pregnant women living in different contexts in the United Kingdom, Australia, and the United States at low and mixed risk of complications and with low socioeconomic status or social risk factors experienced continuity models in similar ways, and similar underlying mechanisms may have influenced PTB outcomes. Further research is required to understand how continuity models may influence behavioral change, physiological stress levels, ethnic disparities in PTB and care coordination, and navigation of health services.