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Utilising the RISE Framework to implement birthing services for First Nations families

Published:October 07, 2022DOI:https://doi.org/10.1016/j.wombi.2022.10.001
      In October 2022, First Nations community representatives, researchers, health service providers, policy advisors and clinicians will travel to Mparntwe, (pronounced mm-BARN-doo-uh), Alice Springs, for a national gathering on Central Arrernte land. The gathering provides an opportunity for delegates from across Australia to showcase exemplary models of care, to share new research and ideas, and to network and invest in a shared vision to address inequities in maternal and infant health services and outcomes for First Nations mothers and babies. Health services will showcase how they have redesigned and delivered their care to make a profound impact on Closing the Gap Target 2: First Nations children are born healthy and strong.
      First Nations mothers and babies experience profound health inequities compared to other Australians. A disproportionate number experience adverse outcomes in pregnancy and birth [
      • Australian Institute of Health and Welfare
      Antenatal Care Use and Outcomes for Aboriginal and Torres Strait Islander Mothers and Their Babies 2016-2017.
      ,
      • Australian Institute of Health and Welfare
      Australia’s Mothers and Babies 2018-in Brief.
      ] with mothers being 3–5 times more likely to die in childbirth [
      • Australian Institute of Health and Welfare
      Maternal Deaths in Australia 2009–2018.
      ], and their babies 2–3 times more likely to be born too preterm, low birth weight and to die in their first year (infant mortality) [
      • AIHW
      Australia's Mothers and Babies, 2019.
      ]. Inequity increases with remoteness with two thirds of First Nations birthing mothers live in rural and remote areas compared to 27% of other Australian women [
      • AIHW
      Australia's Mothers and Babies, 2019.
      ]. Many remote communities have inadequate access to services [
      • Rolfe M.
      • Donoghue D.A.
      • Longman J.
      • et al.
      The distribution of maternity services across rural and remote Australia: does it reflect population need?.
      ,
      • Barclay L.
      • Kornelsen J.
      • Longman J.
      • et al.
      Reconceptualising risk: perceptions of risk in rural and remote maternity service planning.
      ], do not have local midwives or birthing services [
      • Rolfe M.
      • Donoghue D.A.
      • Longman J.
      • et al.
      The distribution of maternity services across rural and remote Australia: does it reflect population need?.
      ,
      • Longman J.
      • Kornelsen J.
      • Pilcher J.
      • et al.
      Maternity services for rural and remote Australia: barriers to operationalising national policy.
      ] and this has worsened in recent decades [
      • Allen J.
      • Kildea S.
      • Stapleton H.
      How does group antenatal care function within a caseload midwifery model? A critical ethnographic analysis.
      ] with a 41% reduction in rural maternity services over 20 years, and a 47% increase in babies born before arrival at hospital [
      • Rolfe M.
      • Donoghue D.A.
      • Longman J.
      • et al.
      The distribution of maternity services across rural and remote Australia: does it reflect population need?.
      ]. In the Northern Territory, where our gathering is being held, some communities are classified as ‘very remote’ and here we see the highest preterm rates in Australia: one in five babies born preterm (22%) [
      • Li L.
      • O’Neil L.
      Mothers and Babies 2017: Northern Territory Midwives’ Collection.
      ]. We simply must prioritise the role of the midwife in these settings. Many risk factors for preterm birth [
      • Kildea S.V.
      • Gao Y.
      • Rolfe M.
      • Boyle J.
      • Tracy S.
      • Barclay L.M.
      Risk factors for preterm, low birthweight and small for gestational age births among Aboriginal women from remote communities in Northern Australia.
      ], maternal mortality [
      • Australian Institute of Health and Welfare
      Maternal Deaths in Australia 2015–2017.
      ] and other poor outcomes are modifiable and/or treatable. We do not need midwives who are also nurses. Nurse midwives will always have to prioritise the sick, will need to take their share of the on-call roster and may then miss out on what was planned for the following day. Routine antenatal and postnatal can be cancelled and women can miss out. This becomes dangerous. For greatest impact and effectiveness, midwives must be available 24/7 to work holistically in the community (not necessarily the health centre) side-by-side with First Nations workers (e.g. Strong Women, Family Support workers, and home visiting teams such as the Australian Family Partnership Program or the Maternal Early Childhood Sustained Home-visiting teams). Our gathering will showcase how to redesign services for greater impact. We have evidence to show ‘how’ redesigned services, led by the Aboriginal community-controlled health services in partnership with mainstream, increase effectiveness. We now need to make it happen.
      The Best start to life for First Nations families national gathering is an initiative of the Molly Wardaguga Research Centre (Birthing on Country Centre for Research Excellence) at Charles Darwin University and the Central Australian Aboriginal Congress, a large Aboriginal Community Controlled Health Service (ACCHS) based in Central Australia. Congress is one of the most experienced Aboriginal health organisations in the country, a national leader in primary health care, and home to Congress Alukura women’s health service, established in 1987. The first national Birthing on Country Workshop was held in Mpartnwe, hosted by Congress and the Australian Maternity Services Inter-Jurisdictional Committee. We will explore the progress that has been made against the recommendations from a decade ago. A key outcome of the gathering will be a strategic roadmap for the redesign of maternity services that lead to direct health benefits for future generations. The roadmap will be underpinned by the RISE SAFELY translation framework (Fig. 1) [
      • Kildea S.
      • Hickey S.
      • Barclay L.
      • Kruske S.
      • Nelson C.
      • Sherwood J.
      • Allen J.
      • Gao Y.
      • Blackman R.
      • Roe Yvette L.
      Implementing Birthing on Country services for Aboriginal and Torres Strait Islander families: RISE Framework.
      ]. This framework has been developed to guide research translation, adaptation and scale-up, focusing on the four RISE pillars: Redesigning the health service; Investing in the workforce; Strengthening First Nations families; and Embedding First Nations community engagement, governance and control in all aspects of the services [
      • Kildea S.
      • Hickey S.
      • Barclay L.
      • et al.
      Implementing birthing on country services for Aboriginal and Torres Strait Islander families: RISE framework.
      ]. Our framework was developed from a synthesis of the learnings from major maternity service redesigns: testing continuity of care for women of any risk in pregnancy [
      • Allen J.
      • Kildea S.
      • Hartz D.L.
      • Tracy M.
      • Tracy S.
      The motivation and capacity to go 'above and beyond': qualitative analysis of free-text survey responses in the [email protected] randomised controlled trial of caseload midwifery.
      ,
      • Tracy S.
      • Hartz D.
      • Tracy M.
      • et al.
      Caseload midwifery care versus standard maternity care for women of any risk: [email protected], a randomised controlled trial.
      ] adapting this model in the First Nations remote setting to improve care for women travelling to Darwin for birth (2007–12) [
      • Barclay L.
      • Kruske S.
      • Bar-Zeev S.
      • et al.
      Improving Aboriginal maternal and infant health services in the 'Top End' of Australia; synthesis of the findings of a health services research program aimed at engaging stakeholders, developing research capacity and embedding change.
      ,
      • Kildea S.
      • Gao Y.
      • Rolfe M.
      • et al.
      Remote links: redesigning maternity care for Aboriginal women from remote communities in Northern Australia – a comparative cohort study.
      ,
      • Gao Y.
      • Gold L.
      • Josif C.
      • et al.
      A cost-consequences analysis of a midwifery group practice for Aboriginal mothers and infants in the top end of the Northern Territory, Australia.
      ], and in the urban First Nations setting (2014–20) (Figure 2) [
      • Kildea S.
      • Gao Y.
      • Hickey S.
      • et al.
      Reducing preterm birth amongst Aboriginal and Torres Strait Islander babies: a prospective cohort study, Brisbane, Australia.
      ,
      • Kildea S.
      • Gao Y.
      • Hickey S.
      • et al.
      Effect of a birthing on country service redesign on maternal and neonatal health outcomes for First Nations Australians: a prospective, non-randomised, interventional trial.
      ]. Women and culture are at the centre of care and the framework is underpinned by Aboriginal relationality (interconnectedness) to ‘Country’, people (centre), dreaming (creation), law/lore (cultural practices, customs, laws and protocols), and ceremony [
      • Kildea S.
      • Hickey S.
      • Barclay L.
      • et al.
      Implementing birthing on country services for Aboriginal and Torres Strait Islander families: RISE framework.
      ].
      This special issue reflects on current research aimed at understanding ‘how’ to improve First Nations maternity and birthing services. The articles have been categorised using the RISE Framework and have been published since the 2019 ‘Birthing on Country in Australia’ special issue that was collated by leading First Nations academics Prof Cath Chamberlain and Prof Rhonda Marriot. They noted the ‘critical socio-cultural and spiritual dimensions of Birthing on Country’ and the slow government response to the Inter-jurisdictional report recommending these services be established in 2013 [
      • Marriott R.
      • Chamberlain C.
      Change is in the air: reclaiming ancestral wisdom through birthing on country in Australia.
      ]. It is pleasing to see further progress has been made since then – though we still have a long way to go.

      Redesign the health service

      Current maternal and birthing data reflect systemic structural barries which result in First Nations health inequities. We need to interrogate the existing colonial structures and redesign a system that is clinically, and culturally safe centring mothers’, babies and families. We need to a system that embeds the aspirations of First Nations people. In the first paper First Nations author Pamela McCalm and team describe what women (n = >300) believe is important including: privacy and confidentiality (98%), feeling that staff were trustworthy (97%), unrestricted access to support people during pregnancy appointments, (87%) birth (66%) and postnatally (75%), midwife home visits (78%), female carers (66%), culturally appropriate artwork, brochures (68%) and access to Elders (65%).
      Paper two describes the experiences of women from the Kimberley region of Western Australia.
      Most women described positive experiences and highlighted the valuable role of family support and the Aboriginal workers during the antenatal period. Many women described travelling long distances for both antenatal care and birth, often spending many hours on bumpy roads and some flying to regional centres, including Perth without partners or escorts. These stories echo a continuing legacy of system failure that is unfair and unjust, far from women centred. Our challenge is to reopen services closer to home and family, where this isn’t possible, every woman should have an escort of their choosing.

      Invest in the workforce

      This pillar focuses on a clinically and culturally exceptional workforce that provides continuity of care across the maternity journey from both the midwifery workforce and the First Nations wrap around services. Growing First Nations midwives in Australia is a national priority. Paper three helps us understand ‘how’ research works to drive service improvement. It describes the Participatory Action Research approach used to mentor two young First Nations women as research assistants on the Indigenous Birthing in an Urban Setting study. The women’s narratives where reported to the Steering Committee for immediate action.
      Paper four provides a integrative literature review exploring Aboriginal Bachelor of Midwifery student experiences in Australia, to provide an insight into their perceptions of enablers and barriers to success. Cultural safety, kinship and support, access to role models and mentors were all important factors. Barriers to successful completion of the BMID degree included racism, financial concerns, feelings of isolation, and lack of confidence and literacy.

      Strengthening the capacity of First Nations families

      The third pillar is about working with women and their families to strengthen their capacity across the first 1000 days (pregnancy to 2-years). Privileging the voices of women papers five and six highlight the work of Prof Chamberlain and her team as they explore how best to provide culturally appropriate support for parents experiencing complex trauma. Goals for trauma-aware culturally safe care include nurturing authentic partnerships; a skilled workforce educated in trauma awareness; empowering and compassionate care for building trust and safe and accessible environments to facilitate parent engagement.
      Papers seven and eight describe the latest evidence regarding breastfeeding with a systematic review highlighting the limitations associated with current data, and that First Nations women do not meet the internationally recognised rates for breastfeeding. Paper nine provides an insight to why this may be the case with four factors influencing women’s breastfeeding practice; sources of support including community knowledge and support, family and partner support and breastfeeding mentor programmes, culturally appropriate care, intention to breastfeed and social determinants (e.g. education).

      Embed First Nations community engagement, governance and control

      We need a system that embeds the aspirations of First Nations people. How to do this is clearly outlined in the paper nine in this issue by where collaborators Associate Professor Yolŋu knowledge holder Lawurrpa Mapilama, Dr Sarah Ireland and team describe the transferability of the RISE Framework from an urban setting to a culturally, linguistically and historically distinct area in East Arnhem Land. Importantly, women describe that being born on ‘their country’ is interpreted by Yolŋu as their ancestral lands [
      • Ireland S.
      • Maypilama E.L.
      • Roe Y.
      • Lowell A.
      • Kildea S.
      Caring for mum on country: exploring the transferability of the birthing on country RISE framework in a remote multilingual Northern Australian context.
      ]. In the context of Birthing on Country Services they need to incorporate Yolŋu sovereignty over their lands and bodies; and provide opportunities for women to be cared for and give birth in a safe and home-like environment physically connected to their ‘home’ ground i.e. place of usual residence – wäŋa and their gurruṯu – kinship networks. Through the process of transforming the RISE Framework they highlight the RISE pillars as foundational beliefs and values required for maternity services to adequately care for Yolŋu women and families. The team are working with stakeholders across the area to respond to community requests to return childbirth services to the island. They will be redesigning care to embed Djakamirrs (Yolŋu childbirth companions) into the workforce, ensuring the kinship networks can be present, even when women need to leave home for birth [
      • Ireland S.
      • Roe Y.
      • Moore S.
      • et al.
      Birthing on country for the best start in life: returning childbirth services to Yolŋu mothers, babies and communities in North East Arnhem, Northern Territory.
      ].
      Current maternity and birthing services in Australia are hospital-centric and fail to reflect the aspirations of First Nations people as described in our last articles of this issue. 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 programmes 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 [
      • Hickey S.
      • Roe Y.
      • Ireland S.
      • et al.
      A call for action that cannot go to voicemail: Research activism to urgently improve Indigenous perinatal health and wellbeing.
      ].
      In summary, the Indigenous Birthing in an Urban Setting study [
      • Kildea S.
      • Gao Y.
      • Hickey S.
      • et al.
      Reducing preterm birth amongst Aboriginal and Torres Strait Islander babies: a prospective cohort study, Brisbane, Australia.
      ,
      • Kildea S.
      • Gao Y.
      • Hickey S.
      • et al.
      Effect of a birthing on country service redesign on maternal and neonatal health outcomes for First Nations Australians: a prospective, non-randomised, interventional trial.
      ] highlighted what can be gained when services work in partnership with RISE principles providing a framework forward. The leadership from the Institute for Urban Indigenous Health, the Mater Hospital, and the Aboriginal and Torres Straight Islander Community Controlled Health Service, Brisbane found unprecedented success with the ACCHSs now planning scale out across South-East Queensland.
      Prof McLachlan and her team successfully translated this evidence into practice for First Nations women in three maternity services in Victoria, Australia [
      • McLachlan H.L.
      • Newton M.
      • McLardie-Hore F.E.
      • et al.
      Translating evidence into practice: implementing culturally safe continuity of midwifery care for First Nations women in three maternity services in Victoria, Australia.
      ]. Key enablers included co-design with First Nations people, staff cultural competency training, identification of First Nations women and regular engagement between caseload midwives and First Nations hospital and community teams. Translation into a rural setting was not successful. It is the rural and remote settings, and how to ‘scale out’ that now needs urgent further.
      The first Birthing on Country National Conference in 2012 laid a solid foundation of capturing the aspirations and vision for First Nations women. The Best Start to Life gathering continues to build on this foundation to ensure that First Nations mothers and babies get the best start in life. The RISE Framework presents a phased approach for the implementation of Birthing on Country services aimed at improving services and outcomes for First Nations families.
      This special edition seeks to shine a light on the urgency of addressing maternal and birthing services for First Nations mothers and babies as well as showcasing the research and celebrating the success of what is occurring in this area.

      Funding

      The authors have several NHMRC and MRFF grants that are helping to establish and evaluate new services for the Best Start to Life for First Nations families.

      Ethics approval and consent to participate

      The authors accept complete responsibility for the views expressed in this Editorial and acknowledge that these views are their own and do not necessarily reflect those of the editors or the Journal. Where information on policy and views on Birthing on Country have been drawn, these have been acknowledged and fully referenced.

      Author agreement

      The editorial is the original work of the authors, Sue Kildea and Yvette Roe. The editorial has not received prior publication and is not under consideration for publication elsewhere. Both authors have seen and approved the editorial manuscript being submitted. Both authors abide by the copyright terms and conditions of Elsevier and the Australian College of Midwives.

      Author contributions

      This is a true statement that all authors meet the criteria for authorship and that all people entitled to authorship are listed as authors. All authors contributed equally to conceiving, writing, revising and proof reading this editorial.

      Conflict of interest

      None declared.

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