Refugee child health: a systematic review of health conditions in children aged 0-6 years living in high-income countries.

This study describes the extent, quality and cultural appropriateness of current research on the health conditions of refugee children aged 0-6 years settled in high-income countries. A systematic review was conducted, including original articles published on the health conditions experienced by refugee children. A total of 71 papers were included. The studies varied considerably in their research design, population characteristics and health conditions. Studies included information on 37 different health conditions, with the majority non-communicable diseases, in particular growth, malnutrition and bone density. Although the studies identified a wide range of health issues, a coordinated effort to prioritise research on particular health topics was lacking, and health conditions studied do not align with the global burden of disease for this population. Additionally, despite being rated medium-high quality, most studies did not describe measures taken to ensure cultural competency and community involvement in their research. We suggest a coordinated research effort for this cohort, with greater emphasis on community engagement to improve the evidence-base of the health needs of refugee children after settlement.

A Systematic Review of Culturally Competent Family Violence Responses to Women in Primary Care.

Existing culturally competent models of care and guidelines are directing the responses of healthcare providers to culturally diverse populations. However, there is a lack of research into how or if these models and guidelines can be translated into the primary care context of family violence. This systematic review aimed to synthesise published evidence to explore the components of culturally competent primary care response for women experiencing family violence. We define family violence as any form of abuse perpetrated against a woman either by her intimate partner or the partner's family member. We included English language peer-reviewed articles and grey literature items that explored interactions between culturally diverse women experiencing family violence and their primary care clinicians. We refer women of migrant and refugee backgrounds, Indigenous women and women of ethnic minorities collectively as culturally diverse women. We searched eight electronic databases and websites of Australia-based relevant organisations. Following a critical interpretive synthesis of 28 eligible peer-reviewed articles and 16 grey literature items, we generated 11 components of culturally competent family violence related primary care. In the discussion section, we interpreted our findings using an ecological framework to develop a model of care that provides insights into how components at the primary care practice level should coordinate with components at the primary care provider level to enable efficient support to these women experiencing family violence. The review findings are applicable beyond the family violence primary care context.

Matching of woman and doula, and the generation of trust in an Australian volunteer doula program: Findings from a realist evaluation.

How women are cared for while pregnant and having a new baby can have profound and lasting effects on their health and well-being. While mainstream maternity care systems aspire to provide care that is woman-centred, women with fewest social and economic resources often have reduced access. Community-based doula support programs offer complementary care for these women and are known to, on average, have positive outcomes. Less understood is how, when and why these programs work. A realist evaluation of an Australian volunteer doula program provided for women experiencing socioeconomic adversity explored these questions. The program provides free non-medical, social, emotional, and practical support by trained doulas during pregnancy, birth and new parenting. This paper reports the testing and refinement of one program theory from the larger study. The theory, previously developed from key informant interviews and rapid realist review of literature, hypothesised that the cultural matching of woman (client) and doula led to best outcomes. This was tested in realist interviews with women and focus groups with doulas, in January-February 2020. Seven English speaking, and six Arabic speaking clients were interviewed. Two focus groups were conducted with a total of eight doulas from diverse cultural and professional backgrounds. Data were analysed in NVivo. The study found cultural matching to be valued by some but not all women, and only when the doula was also genuinely interested, kind, timely and reliable. These approaches (with or without cultural matching) generate trust between the doula and woman. Trust theory, reflexivity theory and social relations theory supported explanatory understanding of the causal contribution of a doula knowing what it takes to build trust, to a woman deciding to trust her doula.

How and when doula support increases confidence in women experiencing socioeconomic adversity: Findings from a realist evaluation of an Australian volunteer doula program.

How women are cared for while having a baby can have lasting effects on their lives. Women value relational care with continuity-when caregivers get to know them as individuals. Despite evidence of benefit and global policy support, few maternity care systems across the world routinely offer relational continuity. Women experiencing socioeconomic adversity have least access to good quality maternity care. Community-based doula support programs offer complementary care for these women and are known to, on average, have positive outcomes. Less understood is how, when, and why these programs work. A realist evaluation of an Australian volunteer doula program explored these questions. The program provides free social, emotional, and practical support by trained doulas during pregnancy, birth, and early parenting. This paper reports the testing and refinement of one program theory from the larger study. The theory, previously developed from key informant interviews and rapid realist review of literature, hypothesised that support increased a woman's confidence via two possible pathways-by being with her and enabling her to see her own strength and value; and by praising her, and her feeling validated as a mother. This study aimed to test the theory in realist interviews with clients, focus groups with doulas, and with routinely collected pre-post data. Seven English-speaking and six Arabic-speaking clients were interviewed, and two focus groups with a total of eight doulas were conducted, in January-February 2020. Qualitative data were analysed in relation to the hypothesised program theory. Quantitative data were analysed for differential outcomes. Formal theories of Recognition and Relational reflexivity supported explanatory understanding. The refined program theory, Recognition, explains how and when a doula's recognition of a woman, increases confidence, or not. Five context-mechanism-outcome configurations lead to five outcomes that differ by nature and longevity, including absence of felt confidence.

Teach-Back in Interpreter-Mediated Consultations: Reflections from a Case Study.

BACKGROUND: Women with a refugee background and their families who have settled in a new country can be expected to have low health literacy, and this may be a contributing factor to poor perinatal outcomes. Brief description of activity: Effective communication is critical for meaningful engagement with patients. Teach-Back is an interactive tool that can assist health professionals confirm whether they are communicating effectively so they are understood and their patients can apply health information. However, evidence for its effectiveness in interpreter-mediated appointments is lacking. IMPLEMENTATION: An antenatal clinic caring for women with a refugee background provided an opportunity to explore the benefits and challenges of using Teach-Back with this population. Staff had access to informal on-site training on health literacy and Teach-Back, tried using Teach-Back in their clinical work, and were then asked to provide feedback on what it was like using Teach-Back. RESULTS: This case study identified several challenges when applying Teach-Back in interpreter-mediated antenatal health care appointments associated with differing cultural nuances and cultural practices. LESSONS LEARNED: Building interpersonal and cross-cultural communication capabilities among health professionals is essential in advancing health literacy workforce practice to improve the health literacy of non-English speaking refugee communities. Although Teach-Back may have the potential to be a powerful tool in promoting the health literacy of these women during pregnancy, further research is required to ensure that its use promotes safe and equitable health care. [HLRP: Health Literacy Research and Practice. 2021;5(3):e256-e261.] Plain Language Summary: This article reports a case study of using Teach-Back in pregnancy appointments involving a midwife and an interpreter. Several challenges for using Teach-Back were identified due to differences in cross-cultural communication. Supporting clinicians and interpreters to work together to implement Teach-Back is required to improve cross-cultural communication and women's health literacy.

HARMONY: a pragmatic cluster randomised controlled trial of a culturally competent systems intervention to prevent and reduce domestic violence among migrant and refugee families in general practice: study protocol.

INTRODUCTION: Domestic violence and abuse (DVA) is prevalent, harmful and more dangerous among diaspora communities because of the difficulty accessing DVA services, language and migration issues. Consequently, migrant/refugee women are common among primary care populations, but evidence for culturally competent DVA primary care practice is negligible. This pragmatic cluster randomised controlled trial aims to increase DVA identification and referral (primary outcomes) threefold and safety planning (secondary outcome) among diverse women attending intervention vs comparison primary care clinics. Additionally, the study plans to improve recording of DVA, ethnicity, and conduct process and economic evaluations. METHODS AND ANALYSIS: Recruitment of ≤28 primary care clinics in Melbourne, Australia with high migrant/refugee communities. Eligible clinics need ≥1 South Asian general practitioner (GP) and one of two common software programmes to enable aggregated routine data extraction by GrHanite. Intervention staff undertake three DVA training sessions from a GP educator and bilingual DVA advocate/educator. Following training, clinic staff and DVA affected women 18+ will be supported for 12 months by the advocate/educator. Comparison clinics are trained in ethnicity and DVA data entry and offer routine DVA care. Data extraction of DV identification, safety planning and referral from routine GP data in both arms. Adjusted regression analysis by intention-to-treat by staff blinded to arm. Economic evaluation will estimate cost-effectiveness and cost-utility. Process evaluation interviews and analysis with primary care staff and women will be framed by Normalisation Process Theory to maximise understanding of sustainability. Harmony will be the first primary care trial to test a culturally competent model for the care of diverse women experiencing DVA. ETHICS AND DISSEMINATION: Ethical approval from La Trobe University Human Ethics Committee (HEC18413) and dissemination by policy briefs, journal articles and conference and community presentations. TRIAL REGISTRATION NUMBER: ANZCTR- ACTRN12618001845224; Pre-results.

Group Pregnancy Care for refugee background women: a codesigned, multimethod evaluation protocol applying a community engagement framework and an interrupted time series design.

INTRODUCTION: Pregnancy and early parenthood are key opportunities for interaction with health services and connecting to other families at the same life stage. Public antenatal care should be accessible to all, however barriers persist for families from refugee communities to access, navigate and optimise healthcare during pregnancy. Group Pregnancy Care is an innovative model of care codesigned with a community from a refugee background and other key stakeholders in Melbourne, Australia. Group Pregnancy Care aims to provide a culturally safe and supportive environment for women to participate in antenatal care in a language they understand, to improve health literacy and promote social connections and inclusion. This paper outlines Froup Pregnancy Care and provides details of the evaluation framework. METHODS AND ANALYSIS: The evaluation uses community-based participatory research methods to engage stakeholders in codesign of evaluation methods. The study is being conducted across multiple sites and involves multiple phases, use of quantitative and qualitative methods, and an interrupted time series design. Process and cost-effectiveness measures will be incorporated into quality improvement cycles. Evaluation measures will be developed using codesign and participatory principles informed by community and stakeholder engagement and will be piloted prior to implementation. ETHICS AND DISSEMINATION: Ethics approvals have been provided by all six relevant authorities. Study findings will be shared with communities and stakeholders via agreed pathways including community forums, partnership meetings, conferences, policy and practice briefs and journal articles. Dissemination activities will be developed using codesign and participatory principles.

'It requires something drastic': Interviews with health care leaders about organisational responses to social disadvantage.

PROBLEM: Persisting disparities in maternal and child health outcomes in high income countries require new insights for health service response. BACKGROUND: Significant social hardship, including factors related to migration, are associated with perinatal morbidity and mortality. The universality of maternity and child health care offers opportunities to reduce health disparities. Process evaluation of health service initiatives to address refugee health inequalities in Melbourne, Australia, is the setting for the study. AIM: To explore the views of health service leaders about health system and service capacity to tailor care to address social adversity and reduce disparities in maternal and child health outcomes. METHODS: In-depth interviews with leaders of maternity and maternal and child health services with questions guided by a diagram to promote discussion. Thematic analysis of transcribed interviews. FINDINGS: Health care leaders recognised the level of social complexity and diversity of their clientele. The analysis revealed three key themes: grappling with the complexity of social disadvantage; 'clinical risk' versus 'social risk'; and taking steps for system change. DISCUSSION: Priority given to clinical requirements and routine practices together with the rising demand for services is limiting service response to families experiencing social hardship and hampering individualised care. System change was considered possible only if health service decision makers engaged with consumer and community perspectives and that of front-line staff. CONCLUSION: Achieving equity in maternal and child health outcomes requires engagement of all key stakeholders (communities, clinicians, managers) to facilitate effective system re-design.

Addressing stillbirth inequities in Australia: Steps towards a better future.

Persistent disparities in stillbirth risk and care are present in Australia. Eliminating these disparities is possible with a commitment to enhancing and scaling up models of culturally safe maternity care shown to be effective for Aboriginal and Torres Strait Islander women and those of migrant and refugee backgrounds. Campaigns to improve public awareness of stillbirth also play an important role in reducing stillbirth risk and consequences. To achieve reach and impact in communities at risk, messaging needs to be framed around the social and cultural context of women's lives. Here we describe important initiatives underway within the Stillbirth Centre of Research Excellence to develop a coordinated national approach to stillbirth prevention and care in communities that bear a disproportionate burden of stillbirth.

Evaluation of systems reform in public hospitals, Victoria, Australia, to improve access to antenatal care for women of refugee background: An interrupted time series design.

INTRODUCTION: Inequalities in maternal and newborn health persist in many high-income countries, including for women of refugee background. The Bridging the Gap partnership programme in Victoria, Australia, was designed to find new ways to improve the responsiveness of universal maternity and early child health services for women and families of refugee background with the codesign and implementation of iterative quality improvement and demonstration initiatives. One goal of this 'whole-of-system' approach was to improve access to antenatal care. The objective of this paper is to report refugee women's access to hospital-based antenatal care over the period of health system reforms. METHODS AND FINDINGS: The study was designed using an interrupted time series analysis using routinely collected data from two hospital networks (four maternity hospitals) at 6-month intervals during reform activity (January 2014 to December 2016). The sample included women of refugee background and a comparison group of Australian-born women giving birth over the 3 years. We describe the proportions of women of refugee background (1) attending seven or more antenatal visits and (2) attending their first hospital visit at less than 16 weeks' gestation compared over time and to Australian-born women using logistic regression analyses. In total, 10% of births at participating hospitals were to women of refugee background. Refugee women were born in over 35 countries, and at one participating hospital, 40% required an interpreter. Compared with Australian-born women, women of refugee background were of similar age at the time of birth and were more likely to be having their second or subsequent baby and have four or more children. At baseline, 60% of refugee-background women and Australian-born women attended seven or more antenatal visits. Similar trends of improvement over the 6-month time intervals were observed for both populations, increasing to 80% of women at one hospital network having seven or more visits at the final data collection period and 73% at the other network. In contrast, there was a steady decrease in the proportion of women having their first hospital visit at less than 16 weeks' gestation, which was most marked for women of refugee background. Using an interrupted time series of observational data over the period of improvement is limited compared with using a randomisation design, which was not feasible in this setting. CONCLUSIONS: Accurate ascertainment of 'harder-to-reach' populations and ongoing monitoring of quality improvement initiatives are essential to understand the impact of system reforms. Our findings suggest that improvement in total antenatal visits may have been at the expense of recommended access to public hospital antenatal care within 16 weeks of gestation.

Afghan families and health professionals' access to health information during and after pregnancy.

BACKGROUND: Having a baby in a new country can be challenging, especially if unable to communicate in a preferred language. The aim of this paper is to explore the provision of health information for Afghan women and men during pregnancy, childbirth and the first year after birth in Melbourne, Australia. METHODS: Community engagement underpinned the study design. Qualitative study with bicultural researchers conducting semi-structured interviews. Interviews and focus groups were also conducted with health professionals. RESULTS: Sixteen Afghan women and 14 Afghan men with a baby aged 4-12 months participated. Thirty four health professionals also participated. Verbal information provided by a health professional with an interpreter was the most common way in which information was exchanged, and was generally viewed favourably by Afghan women and men. Families had limited access to an interpreter during labour and some families reported difficulty accessing an interpreter fluent in their dialect. Availability of translated information was inconsistent and health professionals occasionally used pictures to support explanations. Women and men were unsure of the role of health professionals in providing information about issues other than pregnancy and infant wellbeing. CONCLUSION: Both individual and health system issues hinder and enable the availability and use of information. Consistent, understandable and 'actionable' information is required to meet the needs of diverse families. Health professionals need to be supported with adequate alternatives to written information and access to appropriate interpreters. Inconsistent provision of information is likely to contribute to low health literacy and poor maternal and child health outcomes.

An Australian doula program for socially disadvantaged women: Developing realist evaluation theories.

PROBLEM: Volunteer doula support has achieved favourable outcomes for socially disadvantaged women around the world. There is limited explanatory understanding of how, why and when doula support programs improve outcomes. BACKGROUND: A community organisation is providing free doula support for women experiencing socioeconomic disadvantage in Melbourne, Australia. The program aims to complement the mainstream maternity care system, to promote equity in women's care, and experiences of pregnancy, birth and early parenting. This program is the first of its kind in Australia and has not previously been evaluated. AIM: To develop hypothesised program theories for the realist evaluation of an Australian doula program. METHODS: As the first stage of a realist evaluation, three key informant interviews and rapid realist review of literature were conducted in December 2017 - January 2019. FINDINGS: Seven theories were developed in four categories: critical elements of implementation (Attracting and activating the right doulas, and Good matching); outcomes for women (Being by her side, and Facilitating social connection), outcomes in maternity care system (Complementing or enhancing maternity care, and Doula as a witness - demanding accountability in others), and outcomes for doulas (Doulas as beneficiaries). These theories were framed in accordance with a realist understanding of causation, as Context - Mechanism - Outcome (CMO) configurations. DISCUSSION AND CONCLUSION: The development of theories from multiple sources of evidence provides a strong theoretical base for program evaluation. The theories hypothesise how, why, for whom and when the doula program works. Subsequent stages of the evaluation will test and refine the theories.

Interventions with pregnant women, new mothers and other primary caregivers for preventing early childhood caries.

BACKGROUND: Dental caries is one of the most common chronic diseases of childhood and is associated with adverse health and economic consequences for infants and their families. Socioeconomically disadvantaged children have a higher risk of early childhood caries (ECC). OBJECTIVES: To assess the effects of interventions with pregnant women, new mothers or other primary caregivers of infants in the first year of life, for preventing ECC (from birth to six years of age). SEARCH METHODS: Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 14 January 2019), Cochrane Pregnancy and Childbirth Group's Trials Register (to 22 January 2019), Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Register of Studies, to 14 January 2019), MEDLINE Ovid (1946 to 14 January 2019), Embase Ovid (1980 to 14 January 2019) and CINAHL EBSCO (1937 to 14 January 2019). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on language or publication status. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing one or more interventions with pregnant women, mothers, or other caregivers of infants in the first year of life (intervention types included clinical, oral health education/promotion such as hygiene education, breastfeeding and other dietary advice, and policy or health service), versus standard care or placebo or another intervention. For inclusion, trials had to report at least one caries outcome. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial eligibility, extracted data, assessed risk of bias, and assessed certainty of evidence using the GRADE approach. MAIN RESULTS: We included 17 RCTs (4 cluster-randomised), involving 23,732 caregivers (mainly mothers) and their children. Eleven RCTs assessed four oral health education/promotion interventions against standard care: child diet advice, child diet and feeding practice advice, breastfeeding promotion and support, and oral hygiene with child diet and feeding practice advice. Six trials assessed clinical interventions in mother's dentition, four trials chlorhexidine (CHX, a commonly prescribed antiseptic agent) or iodine-NaF application and prophylaxis versus placebo, and two trials xylitol against CHX or CHX + xylitol. At most, three trials (maximum of 1148 children and 130 mothers) contributed data to any comparison. For many trials, risk of bias was judged unclear due to lack of methodological details reported, and there was high risk of attrition bias in some trials. None of the included trials indicated receiving funding that is likely to have influenced their results. The trials were performed in high-, middle- and low-income countries. In nine trials, participants were socioeconomically disadvantaged. For child diet and feeding practice advice versus standard care, we observed a probable 15 per cent reduced risk of caries presence in primary teeth with the intervention (RR 0.85, 95% CI 0.75 to 0.97; 3 trials; 782 participants; moderate-certainty evidence), and there may be a lower mean dmfs (decayed, missing, filled primary surfaces) score (MD -0.29, 95% CI -0.58 to 0; 2 trials; 757 participants; low-certainty evidence); however, we are uncertain regarding the difference between the groups in mean dmft (decayed, missing, filled teeth) score (MD -0.90, 95% CI -1.85 to 0.05; 1 trial; 340 participants; very low-certainty evidence). For breastfeeding promotion and support versus standard care, we observed that there may be little or no a difference between groups in the risk of caries presence in primary teeth (RR 0.96, 95% CI 0.89 to 1.03; 2 trials; 1148 participants; low-certainty evidence), or mean dmft score (MD -0.12, 95% CI -0.59 to 0.36; 2 trials; 652 participants; low-certainty evidence). Dmfs was not reported for this comparison. We are uncertain whether child diet advice only compared with standard care reduces risk of caries presence in primary teeth (RR 1.08, 95% CI 0.34 to 3.37; 1 trial; 148 participants; very low-certainty evidence). Dmfs and dmft were not reported for this comparison. For oral hygiene, child diet and feeding practice advice versus standard care, we observed little or no reduced risk of caries presence in primary teeth (RR 0.91, 95% CI 0.75 to 1.10; 2 trials; 365 participants; low-certainty evidence), and are uncertain regarding difference between the groups in mean dmfs score (MD -0.99, 95% CI -2.45 to 0.47; 1 trial; 187 participants; very low-certainty evidence) and dmft score (MD -0.30, 95% CI -0.96 to 0.36; 1 trial; 187 participants; very low-certainty evidence). We observed there may be little or no difference in risk of caries presence in primary teeth between antimicrobial and placebo treatment in mother's dentition (RR 0.97, 95% CI 0.80 to 1.19; 3 trials; 479 participants; very low-certainty evidence). No trials assessing this comparison reported dmfs or dmft. For xylitol compared with CHX antimicrobial treatment, we observed there may be a lower mean dmft score with xylitol (MD -2.39; 95% CI -4.10 to -0.68; 1 trial, 113 participants; low-certainty evidence); however, we are uncertain regarding the difference between groups in caries presence in primary teeth (RR 0.62, 95% CI 0.27 to 1.39; 1 trial, 96 participants; very low-certainty evidence). Neither trial evaluating this comparison reported dmfs. No trials assessed a health policy or service intervention. AUTHORS' CONCLUSIONS: Moderate-certainty evidence suggests that providing advice on diet and feeding to pregnant women, mothers or other caregivers with children up to the age of one year probably leads to a slightly reduced risk of early childhood caries (ECC). The remaining evidence is low to very low certainty and is insufficient for determining which, if any, other interventions types and features may be effective for preventing ECC. Large, high-quality RCTs of oral health education/promotion, clinical, and policy and service access interventions, are warranted to determine effects and relative effects of different interventions and inform practice. We have identified 12 studies currently in progress. Those designing future studies should describe the intervention components, setting and participants, consider if and how effects are modified by intervention features and participant characteristics, and adopt a consistent approach to measuring and reporting ECC.

Common maternal health problems among Australian-born and migrant women: A prospective cohort study.

BACKGROUND: Migrant women of non-English speaking background make up an increasing proportion of women giving birth in high income countries, such as Australia, Canada and the United Kingdom. The aim of this study was to assess the prevalence of common physical and psychosocial health problems during pregnancy and up to 18 months postpartum among migrant women of non-English speaking background compared to Australian-born women. METHODS: Prospective pregnancy cohort study of 1507 nulliparous women. Women completed self-administered questionnaires or telephone interviews in early and late pregnancy and at 3, 6, 9, 12 and 18 months postpartum. Standardised instruments were used to assess incontinence, depressive symptoms and intimate partner violence. FINDINGS: Migrant women of non-English speaking background (n = 243) and Australian-born mothers (n = 1115) reported a similar pattern of physical health problems during pregnancy and postpartum. The most common physical health problems were: exhaustion, back pain, constipation and urinary incontinence. Around one in six Australian-born women (16.9%) and more than one in four migrant women (22.5%) experienced intimate partner abuse in the first 12 months postpartum. Compared to Australian-born women, migrant women were more likely to report depressive symptoms at 12 and 18 months postpartum. CONCLUSION: Physical and mental health problems are common among women of non-English speaking background and Australian-born women, and frequently persist up to 18 months postpartum. Migrant women experience a higher burden of postpartum depressive symptoms and intimate partner violence, and may face additional challenges accessing appropriate care and support.

Initiation and duration of breastfeeding of Aboriginal infants in South Australia.

BACKGROUND: Benefits of breastfeeding are well-established. Few studies have examined initiation and duration of breastfeeding of Aboriginal infants. METHODS: Population-based study of women giving birth to an Aboriginal infant in South Australia, July 2011-June 2013. FINDINGS: 344 women took part. Participants were representative in relation to maternal age, infant birthweight and gestation. Eighty-six percent initiated breastfeeding, declining to 54% at 12 weeks postpartum. Women living in remote areas were more likely to be breastfeeding at 12 weeks than women living in Adelaide (Odds Ratio=2.6, 95% Confidence Interval 1.5-4.7). Two-thirds of women (67%) attending standard public antenatal care in regional areas and 61% attending regional Aboriginal Family Birthing Program Services were breastfeeding at 12 weeks, compared to one third of women (36%) attending standard metropolitan public antenatal care and 49% of women attending metropolitan Aboriginal Family Birthing Program Services. Less than half of women (45%) described their postnatal care as 'very good', and 40% were not always able to access support with infant feeding when needed. The most common reasons for switching to formula before 6 weeks were: low milk supply/baby not gaining weight, mastitis/sore breasts or other feeding problems. Mothers also identified their own health as a factor. CONCLUSION: While the findings must be treated with caution due to small numbers, they suggest benefits for women attending Aboriginal Family Birthing Program services in the urban environment where rates of initiation and continued breastfeeding are lowest. Provision of culturally appropriate support to Aboriginal women during and after pregnancy is key to improving outcomes.

Enhancing general practice referrals for women of refugee background to maternity care.

This paper presents the findings from a quality improvement project implemented by a maternity hospital located in a region of high refugee settlement. The project was designed to improve the completeness of general practice referral information to enable triage to maternity care that would best meet the needs of women of refugee background. Referral information included four data items - country of birth, year of arrival in Australia, language spoken and interpreter required - used in combination to provide a proxy measure of refugee background. A communication strategy and professional development activity engaged general practitioners (GPs) in the rationale for collecting the four data items on a new referral form. Audits of referrals to the maternity hospital before, and at two time points following the quality improvement activity, indicated that very few referrals were completed on the new form. There were modest improvements in the recording of two items - country of birth and interpreter required. Overall, two-thirds of referrals did not contain information on interpreter requirements. Changing practice will require a more cohesive approach involving GPs in the co-design of the form and development of the quality improvement strategy.

Improving the ascertainment of refugee-background people in health datasets and health services.

Ascertainment of vulnerable populations in health datasets is critical to monitoring disparities in health outcomes, enables service planning and guides the delivery of health care. There is emerging evidence that people of refugee backgrounds in Australia experience poor health outcomes and barriers to accessing services, yet a clear picture of these disparities is limited by what is routinely collected in health datasets. There are challenges to improving the accuracy of ascertainment of refugee background, with sensitivities for both consumers and providers about the way questions are asked. Initial testing of four data items in maternity and early childhood health services (maternal country of birth, year of arrival in Australia, requirement for an interpreter and women's preferred language) suggests that these are straightforward items to collect and acceptable to service administrators, care providers and to women. In addition to the four data items, a set of questions has been developed as a guide for clinicians to use in consultations. These new approaches to ascertainment of refugee background are essential for addressing the risk of poor health outcomes for those who are forced to leave their countries of origin because of persecution and violence.

The physical and mental health problems of refugee and migrant fathers: findings from an Australian population-based study of children and their families.

OBJECTIVES: The aim of this study was to report on the physical and mental health of migrant and refugee fathers participating in a population-based study of Australian children and their families. DESIGN: Cross-sectional survey data drawn from a population-based longitudinal study when children were aged 4-5 years. SETTING: Population-based study of Australian children and their families. PARTICIPANTS: 8137 fathers participated in the study when their children were aged 4-5 years. There were 131 (1.6%) fathers of likely refugee background, 872 (10.7%) fathers who migrated from English-speaking countries, 1005 (12.4%) fathers who migrated from non-English-speaking countries and 6129 (75.3%) Australian-born fathers. PRIMARY OUTCOME MEASURES: Fathers' psychological distress was assessed using the self-report Kessler-6. Information pertaining to physical health conditions, global or overall health, alcohol and tobacco use, and body mass index status was obtained. RESULTS: Compared with Australian-born fathers, fathers of likely refugee background (adjusted OR(aOR) 3.17, 95% CI 2.13 to 4.74) and fathers from non-English-speaking countries (aOR 1.79, 95%CI 1.51 to 2.13) had higher odds of psychological distress. Refugee fathers were more likely to report fair to poor overall health (aOR 1.95, 95% CI 1.06 to 3.60) and being underweight (aOR 3.49, 95% CI 1.57 to 7.74) compared with Australian-born fathers. Refugee fathers and those from non-English-speaking countries were less likely to report light (aOR 0.25, 95% CI 0.15 to 0.43, and aOR 0.30, 95% CI 0.24 to 0.37, respectively) and moderate to harmful alcohol use (aOR 0.04, 95% CI 0.10 to 0.17, and aOR 0.14, 95% CI 0.10 to 0.19, respectively) than Australian-born fathers. Finally, fathers from non-English-speaking and English-speaking countries were less likely to be overweight (aOR 0.62, 95% CI 0.51 to 0.75, and aOR 0.84, 95% CI 0.68 to 1.03, respectively) and obese (aOR 0.43, 95% CI 0.32 to 0.58, and aOR 0.77, 95% CI 0.61 to 0.98, respectively) than Australian-born fathers. CONCLUSION: Fathers of refugee background experience poorer mental health and poorer general health than Australian-born fathers. Fathers who have migrated from non-English-speaking countries also report greater psychological distress than Australian-born fathers. This underscores the need for primary healthcare services to tailor efforts to reduce disparities in health outcomes for refugee populations that may be vulnerable due to circumstances and sequelae of forced migration and to recognise the additional psychological stresses that may accompany fatherhood following migration from non-English-speaking countries. It is important to note that refugee and migrant fathers report less alcohol use and are less likely to be overweight and obese than Australian-born fathers.

Cultural safety and belonging for refugee background women attending group pregnancy care: An Australian qualitative study.

BACKGROUND: Refugee women experience higher incidence of childbirth complications and poor pregnancy outcomes. Resettled refugee women often face multiple barriers accessing pregnancy care and navigating health systems in high income countries. METHODS: A community-based model of group pregnancy care for Karen women from Burma was co-designed by health services in consultation with Karen families in Melbourne, Australia. Focus groups were conducted with women who had participated to explore their experiences of using the program, and whether it had helped them feel prepared for childbirth and going home with a new baby. RESULTS: Nineteen women (average time in Australia 4.3 years) participated in two focus groups. Women reported feeling empowered and confident through learning about pregnancy and childbirth in the group setting. The collective sharing of stories in the facilitated environment allowed women to feel prepared, confident and reassured, with the greatest benefits coming from storytelling with peers, and developing trusting relationships with a team of professionals, with whom women were able to communicate in their own language. Women also discussed the pivotal role of the bicultural worker in the multidisciplinary care team. Challenges in the hospital during labor and birth were reported and included lack of professional interpreters and a lack of privacy. CONCLUSION: Group pregnancy care has the potential to increase refugee background women's access to pregnancy care and information, sense of belonging, cultural safety using services, preparation for labor and birth, and care of a newborn.