Following on from last week, we look at whether freestanding midwifery units could be used in Australia to promote birth on country among Aboriginal and Torres Strait Islander women. We also look at how Cambodia is tracking on improving maternal and infant birth outcomes. Finally, we discuss how communications breakdowns in the health system can be avoided.

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Speakers:
Donna Hartz – Spokesperson, CATSINaM
Sue Kildea – Professor of Midwifery, University of Queensland
Lesley Barclay – Emeritus Professor, University of Sydney
Angela Dawson – Lecturer, UTS Faculty of Health
Dr Ponndara Ith – Vice Head of the Bureau of Research and Planning at the University of Health Sciences, Phnom Penh
Diana Slade – Professor of Applied Linguistics, UTS & Director of the International Research Centre for Communication in Healthcare

Presenter: Ellen Leabeater
Producers: Sam King, Ninah Kopel

START OF TRANSCRIPT

Ellen Leabeater: Hi, welcome to the show. Ellen Leabeater with you. Today, how communication can resolve critical incidents in hospital. And:

Angela Dawson: They’re often working in difficult situations, particularly in rural settings with poor equipment. They have to attend to the woman in the middle of the night with no lights, so by torchlight…

Ellen Leabeater: The importance of skilled birth attendants in developing countries.

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Ellen Leabeater: Last week on the program, we discussed the importance of freestanding midwifery units in Australia. Freestanding midwifery units are for healthy women expecting to have an uncomplicated birth, and they are staffed by midwives only. If a woman does experience complications like gestational diabetes or a slow labour, they will need to transfer to hospital where they can be seen by an obstetrician. Australia currently has 17 such units, and midwives and communities around the country are calling for more, especially to promote birthing on Country for Aboriginal and Torres Strait Islander women. Babies born to Aboriginal and Torres Strait Islander women are more likely to have a lower birth weight or be preterm than babies born to non-Aboriginal women. They also have a higher rate of perinatal mortality. So, could freestanding midwifery units help close the gap?

Donna Hartz: Aboriginal women have babies younger. What happens in places such as the remote parts of the Northern Territory and Western Australia, women are airlifted… say from the Northern Territory they’ll go to Darwin or Alice Springs. There have been some models set up where they get their own midwives – a caseload model so they get some continuity; they get a familiar face while they’re out in their own community. But for many of these young girls, it’s the first time away from home, they’re family can’t afford to go… I mean they don’t have that sort of money. They’re alone, they’re often frightened, worried, because with many of these young women from remote communities, English is sometimes their second language, so, for these young women it’s a very isolating and difficult time. I mean, giving birth for the first time is a difficult time enough in a woman’s life without having good support around you.

Ellen Leabeater: As we discovered last week, moving hours away from your home to give birth is a scenario typical of women living in rural and remote Australia, however, it is even more pronounced among Aboriginal and Torres Strait Islander women. Donna Hartz has pointed out Aboriginal women are younger, usually speaking English as a second or even third language, and are likely to face institutional racism when they do give birth in the big smoke. Donna is a Research Fellow with the Poche Centre for Indigenous Health.

Donna Hartz: And CATSINaM asked me to speak on their behalf…

Ellen Leabeater: CATSINaM is the Congress of Aboriginal and Torres Strait Islander Nurses and Midwives. Donna also has Kamilaroi heritage.

Donna Hartz: We had a midwife present at one of our NSW State Conferences a few years ago and she talked about the story of a young girl coming from Adelaide back up to the lower part of Northern Territory. The bus brought her up there. So there’s a young teenager with a brand new baby in summer temperatures in the middle of Australia being dropped off on the bus at a place that resembled a town, probably a tree and a shack, to wait for somebody to come and pick her up whenever. I mean, this is happening in Australia, now.

Ellen Leabeater: It something we certainly take for granted in urban Australia: the right to choose where we have birth, and to have friends, families and partners supporting us during that time. But for many Aboriginal women, this joyous moment is stressful and lonely, and you can add premature babies to the list of negative health outcomes that stress causes. And it’s not just the stress of knowing you should move to a hospital to have your baby. Indeed, many women will hide from health services so they can choose to birth at home. It’s actually the stress that comes when those same health services knock on your door and read you the riot act.

Lesley Barclay: The other Aboriginal evidence that’s come out of this study that I’d never heard of before… I mean after over ten years of work in Aboriginal Australia, I’ve heard some pretty shocking things… but this was where the manager of the local health service knocked on the door and threatened a mother if she didn’t move to the regional centre. She was in the last weeks of pregnancy preparing to move, not thinking that she would stay behind, but threatened with child welfare department and told that her child would be under scrutiny because the woman hadn’t moved already.

Ellen Leabeater: It’s actions like these that have been described as “the pregnancy Gestapo”. In a recent study by Lesley Barclay. Lesley is an Emeritus Professor from the University of Sydney.

Not wanting to leave your family and not having enough money to do so – these are all fringe issues of course that are applicable to Aboriginal and non-Aboriginal women in rural and remote Australia. But for Aboriginal women in particular, the most distressing part about moving to birth is the fact that they are removed from their traditional Country. Donna Hartz explains why birthing on Country is important.

Donna Hartz: It’s a concept where culture, traditions, spirit, biological needs all comes together in a way that is meaningful to the women and is safe and is appropriate. So that often means that they’re able to – if they’re not on their own and can’t treat it – the model of care that they’re in is cultural appropriate. You know, they’ve got Aboriginal people or Aboriginal health workers supporting them and their needs are met. They have a sense of self-determination in that.

Ellen Leabeater: CATSINaM released a new position statement on birthing on Country in March this year. The statement is critical of the slow process to close the gap between Aboriginal and non-Aboriginal health outcomes, and says that pregnancy and early childhood are critical periods to do so. CATSINaM says that providing services that promote birthing on country will improve maternal and infant outcomes because of the important connection between land and birthing. In practice, these services would be more inclusive of traditional practices and be more community-based and governed. The 2010 National Maternity Services Plan also recommends that birthing on Country programs be piloted around Australia, but those plans have stalled. Although, these sorts of culturally-appropriate services are applicable in urban areas as well. Sue Kildea is a Professor of Midwifery at the University of Queensland. She is part of a team that is setting up an urban birth on Country program in Brisbane.

Sue Kildea: Certainly in Brisbane, we’re setting up what we’d like to be the urban birthing on Country exemplar model of care. So we’re moving towards all those things that underpin the evidence base, so, 24/7 care from a primary midwife working within a midwifery group practice. Care alongside by Aboriginal maternal infant healthcare workers. We’ve got an overarching Indigenous governance through the steering committee because we’re doing it in partnership with a hospital and two Aboriginal community controlled health organisation. So we’re trying to put the package of birthing on Country together for the women in our area.

Ellen Leabeater: And Sue says they’re not the only ones pushing for the change.

Sue Kildea: Burke out of NSW want to be able to do it. Tennant Creek want to be able to do it. Maningrida and Wadi are two remote communities, Galawinku, Yarrabah… there’s so many places that want to be able to do it.

Ellen Leabeater: Freestanding units are beneficial in these towns, because providing 24/7 access is difficult due to cost and workforce issues. Caseload midwifery on the other hand, is much easier to deliver. The push to have these units is backed up by research in New Zealand and Canada. Both countries have multiple freestanding units geographically separate from obstetric services that are highly frequented by their Indigenous populations. And both have much better health outcomes for their Indigenous populations. Sue says that giving birth back to these communities has benefits that extend beyond the obvious.

Sue Kildea: I’d bet money that it’s going to save the Australian government money and that it’s going to help close the gap and that it’s going to address improved maternal infant health outcomes, with many more broader benefits like employment for Indigenous women, education for Indigenous women.

Ellen Leabeater: Although, are these units really the right solution when Aboriginal women face poor health outcomes as it is.

(to Donna Hartz) Aboriginal women do have a lot of health difficulties especially when they’re pregnant. They’ve got higher rates of mortality and morbidity. Surely, in some cases, being in hospital is in these women’s best interest?

Donna Hartz: Yeah, you would think so, however, we have to realise that it’s very complex in terms of why these women have such co-morbidities. But with the co-morbidities, it’s more complex than just putting someone in hospital when they’re pregnant. It’s about all the things I’ve been talking about – about trying to support women to be self-determining, listening to them, finding out what they’re needs are, providing culturally appropriate and culturally safe environments, and when you go back to that birth on Country concept, that’s what that is all about, you know, ensuring that the women will want to come there and that they’re being listened to. So in terms of should they be in hospital? I’m sure that every woman that has any kind of morbidity whether they’re Aboriginal or not would choose the best and safest for their baby, but that’s their choice.

Ellen Leabeater: At the end of the day, this all comes down to a woman’s right to choose where they give birth, and Donna says, we are denying this right to too many women across Australia.

Donna Hartz: Women should be able to make choices about where they give birth… about being able to do what is natural and appropriate in an environment that they’re choosing. So, we’re actually denying women a basic human right.

Ellen Leabeater: If you’d like to find out more about that story, head to 2ser.com/thinkhealth.

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Female: You’re listening to Think:Health.

Male: On 2ser 107.3

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Ellen Leabeater: Well, as we just heard, our maternity services in Australia aren’t perfect, but they are nowhere near as dangerous as the maternity services offered in Cambodia. Imagine having to give birth in the dark, with only the most basic tools to help if something goes wrong. That’s the reality for birthing women in Cambodia. It’s not as bad as it once was, but as Sam King explains, there’s still a long way to go.

Angela Dawson: The life of a midwife in Cambodia is challenging. There are not enough midwives, so there’s a chronic shortage of health workers. They’re working conditions are challenging, so they may be not only short staffed, salaries are very low, sometimes they don’t get paid… They’re often working in difficult situations, particularly in rural settings, with poor equipment and no drugs, sometimes no light. Sometimes there’s no petrol for the generator and the power goes down. They have to attend to a woman in the middle of the night with no lights, so by torchlight.

Sam King: Dr Angela Dawson there from the University of Technology’s Faculty of Health. I wanted to paint you a picture here of the true importance of skilled birth attendants. They’re one of the unsung heroes of any society, and nowhere is this more apparent than in the southeast Asian nation of Cambodia.

Angela Dawson: Cambodia is one of the poorest countries in Southeast Asia. 36% of the population live under the poverty line, and it also has one of the largest youthful populations in the region. So 1 in 3 Cambodians are aged between 15 and 25, so that’s a huge group of people at the bottom end of the population.

Sam King: And this young population is one of the scars still left from the Khmer Rouge genocide in the 70s, in which almost 1 in 4 Cambodians were killed.

Angela Dawson: But since that period, the population has been increasing, and although that stabilised about 10 years ago, what’s been interesting in terms of the youthful population is the increasing adolescent fertility rate. And that has been increasing than any other nation in Southeast Asia.

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Sam King: So you’ve got a country with a massive fertility rate and poor access to maternal healthcare, and what you’re left with is a nation where in the year 2000, had one maternal death for every 200 live births. And what’s even more shocking was the infant mortality rate, around 90 per 1000 live births, almost 1 in 10. And that’s the same as it was in 1985. No difference at all in over a decade. But around the year 2000, Cambodia committed to Millennium Development Goal Five, to reduce neonatal mortality by three-quarters. And that’s when things started to change. Today, that figure, 90 infant deaths per 1000 live births has fallen to 24. So what happened?

Ponndara Ith: This is first of all related to the policy imposed by the government that all women should go to deliver their baby in the health facility.

Sam King: This is Dr Ponndara Ith, speaking to us from Phnom Penh. He did his PhD on maternal healthcare in Cambodia at the University of Technology Sydney.

Ponndara Ith: And there is improvement in the infrastructure, because now we have roads, there is not the problem related to geographic areas like before. And there are some policies to restrict TBAs giving births at home.

Sam King: So in case you missed it, there’s a policy to restrict TBAs giving home births. Now, TBAs, that’s traditional birth attendants. They’re untrained midwives relied upon to perform home births in Cambodia. According to the Phnom Penh Post, in 2002, TBAs delivered almost two-thirds of Cambodia’s babies. They’d use techniques like speeding up labour by pushing on the mother’s abdomen and pulling on the babies head, or stretching the vulva by hand. I’ve read reports of TBAs cutting the umbilical cord with a rusty razor or a piece of bamboo, and then just sort of tying it up with string. I mean, not all TBAs did this, but it was completely unregulated.

Ponndara Ith: The government strictly prohibited all TBAs from conducting deliveries at home, because there are a lot of women who died due to their malpractice, you know.

Sam King: So to move away from this, Cambodia has been replacing TBAs with skilled birth attendants and encouraging women to give birth at health facilities. And if you look at the numbers, it’s making a huge difference.

Angela Dawson: Skilled birth attendants save lives because they know what to do, they know how to prevent bleeding, they can care for a woman, they can deliver needed commodities, drugs to prevent bleeding, to prevent high blood pressure. These midwives are highly important to any society.

Sam King: But there is still a long way to go.

Angela Dawson: There is about a 70% coverage rate of skilled birth attendants with that higher in urban areas, yet there are still high numbers of deaths that are unacceptable because they’re preventable. Women die of bleeding after birth – we call that postpartum haemorrhage – and they die of high-blood pressure or preeclampsia, which can be easily addressed through the use of drugs.

Ponndara Ith: Even though there are some improvements in some rural and urban areas, there are still some problems related to the eastern part of the country such as Ratanakiri and Mondulkiri and (unclear).

Sam King: Ratanakiri and Mondulkiri are some of the more remote provinces in the east of Cambodia.

Ponndara Ith: There are still improvements, for example, now we even have 95% of mothers receiving care from skilled providers, but in some provinces, it’s not this kind of number, but it has increased 60-70% as well.

Sam King: And a 60-70% increase is not bad, but hey, this is where it gets more complicated.

Angela Dawson: The poor pay of these midwives, as we found in our study, resulted in unnecessary interventions.

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Ponndara Ith: Yeah, so, some people they tried to do some sort of medical interventions so that they could earn extra money from the patients.

Angela Dawson: Although Cambodia has a public health system, women pay moment for additional services, and sometimes those services aren’t actually needed, so, in the case of a woman who can deliver normally, sometimes extra interventions are provided that are not needed, that may have a knock-on effect. So, there might be an epidural or an episiotomy, a cut that’s not needed but is delivered in order to make more money.

Sam King: And I don’t want to start moralising here. When you need to feed your family, you do whatever it takes. But this illustrates why Cambodia is pushing to move births out of the home and into better health facilities with properly trained midwives and skilled birth attendants who aren’t under as much pressure.

Angela Dawson: The government recognises this and has a very good strategic plan to improve the quality of maternal care, so increasing the number of midwives is number 1, and in 2012, the first cohort of midwives graduated from a three year university level midwifery course, so that’s the beginning of an exciting time of improvement in midwifery. Also improving the quality of supervision of those midwives and supervision of lower carter staff members involved in looking after women right in the community, and improving the quality of health services themselves, providing more equipment, ensuring better procurement and distribution of drugs and equipment.

Sam King: So, Ponndara, Cambodia’s made incredible improvements to maternal healthcare, quartering neonatal and maternal deaths from 2000 to 2016. Are you optimistic that things will continue to improve?

Ponndara Ith: Yes, I hope so, because the National Maternal Health Centre have worked with basically all the policy makers to implement policy in the health facilities, and they also work in collaboration with all the NGOs that are involved in maternal and newborn healthcare in Cambodia, so I think, in the future, it will reduce maternal mortality to rates seen in developed countries, yes.

Ellen Leabeater: Dr Ponndara Ith ending that story from Sam King.

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Ellen Leabeater: You’re listening to Think:Health on 2ser 107.3, online at 2ser.com or on your favourite podcast app.

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Ellen Leabeater: In Australia, approximately 10% of hospital patients will suffer an avoidable critical incident, and almost all of these are related to errors in communication. Critical incidents are accidents that cause harm to patients that could otherwise be avoided. To discuss how linguistics can help health research to fight this communication breakdown, producer Ninah Kopel spoke with Diana Slade. Diana is a Professor of Applied Linguistics in the Faculty of Arts and Social Sciences at the University of Technology Sydney.

Diana Slade: So let’s call the patient Mandy. She was admitted to a local hospital in Australia to give birth to a second child. She suffered from schizophrenia but had been coping with regular use of anti-psychotic medication. Her psychiatrist care was very well managed by a community mental health team, and she saw a psychiatrist regularly. Then she got pregnant. Her psychiatrist wrote verbal and written handovers to her GP. Her GP then, when she was going to hospital to have the baby, was coordinating with the obstetric ward, but did not pass onto the hospital the medication that she was on and the treatment that she was on. So this meant that the clinical team in hospital that was dealing with Mandy’s delivery, didn’t understand the significance of her condition or her medication. So although Mandy did take it with her, the clinical staff didn’t know. So what happened is she had a relapse of her mental health, she was transferred to the mental health unit and then once again, the transfer from the obstetric unit to the mental health unit didn’t include anything about the medication, nor her condition, her mental health condition. That was left out completely. So after the birth of the child, she became psychotic again. She ingested a corrosive substance, was secluded and restrained. Ten days after admission, she had a cardiac arrest and died. And so, it was a series of handover communication issues.

Ninah Kopel: So your research, a lot of that has been based on you and other people sitting in hospitals and watching those interactions happen.

Diana Slade: That’s right.

Ninah Kopel: What was it that you found?

Diana Slade: Well, what I realised first of all, is that as a communications specialist or a linguist, we can’t do it alone. We can’t just go in there and observe and try to be arrogant enough or presumptuous enough to try and understand that very complex phenomenon of healthcare. We recorded 82 patients across four emergency departments in NSW and the ACT, and we recorded their journey. The overwhelming finding was that the medical profession understandably – and I’m not being at all critical of anyone in the emergency departments… I’m constantly impressed by their extraordinary level of expertise and the conditions under which they work. But what we found was the lack of attention to the interpersonal needs of the patient. The common response was, “We are too busy. We have not got time.”

Ninah Kopel: Isn’t that a valid point though? Do they just not have time to have those personal interactions?

Diana Slade: That’s right. What we found – and this is after our study of three years – we’ve got the largest database in the world now of authentic interactions. So just before I answer that question, what our findings were based on were 82 patients. We transcribe verbatim exactly the interactions. But what’s important about the actual recordings is what clinicians say they do is often very different from what they do. And it’s not that they’re being deceptive, it’s just when you’re in interaction, it’s very spontaneous and you rarely have a chance to look back and reflect on how you interacted in that process. So, what we found is that the more effective interactions really involved the patients being listened to. So for example, even that very basic question: “Now what do you think is wrong with you?” And if the patient was really listened to, then it’s much more likely to reach and effective diagnosis. And then, with an effective diagnosis and the patient feeling validated, they’re more likely to comply with the treatment and much less likely to have unnecessary readmissions, much less likely to have negative patient outcomes in a sense, at a cost to the system.

Ninah Kopel: Is this as simple as saying we should treat our nurses and doctors better?

Diana Slade: Look, I think that health systems around the world are chronically underfunded. It’s increasing exponentially. So often, many of them don’t need an emergency department, but because it is free, they go there because they might financially feel there’s no choice. So yes doctors are under enormous stress. Pouring more funds obviously would really help, but I think governments would say that’s a really tough one. I believe we must have more durable electronic health records, and there’s been a lot of work trying to get that. I am stunned that around the world despite how many billions have been spent on attempts to get durable and really effective forms of patient records and electronic patient records, that it’s still not a very effective process anywhere. Some countries do it much better. Hong Kong has got a much better system and they’re pouring money in to improving that, however there’s often very little relationship between what’s spoken to the patient and what’s written down. We’re now doing training – we’ve developed training based on the authentic. So we’ve got training for medical and medical handover, we’ve also got training for nurses on involving patients in the hand over process.

Ninah Kopel: And what would that handover look like?

Diana Slade: That’s an interesting thing. There was somebody called Peter Garling, he had a special commission of inquiry into acute health services in NSW a couple of years ago. He stated that the quality of patient-clinician communication in NSW hospitals was unacceptable in a civilised society, let alone a system of patient-centred healthcare. He recommended as one of his many recommendations that handovers should be at the bedside. But we can’t have patient-centred care as our main policy platform around Australia in every state as it is internationally, without the patient even hearing the information that’s being handed over. And as you can imagine, with handovers, if the patient is there, they can say, “No, no, sorry, you got it wrong! I haven’t had two Panadeine in the last… you know, this was a particular example that came up in the data… “No, no, I haven’t had the Panadeine Forte yet.” So, they can correct it and they often do. So what he recommended was that all handovers, as much as possible be done at the bedside involving the patient.

Ninah Kopel: So what are you working on now? What’s the next thing that you’re looking into to try and bridge this communication gap in our healthcare system.

Diana Slade: If you use this metaphor of the patient journey… we’ve gone from patient-clinician interactions in Emergency Departments, looking at handover across the hospital. What we realised then was also critical was what happens to the patient when they leave hospital? When they leave and get discharged, are they given accurate information? Is it clear what they need to do? Is the information handed to them, or with elderly patients, is it handed to the aged care services? Etcetera… So we’ve just started looking at patients’ actual discharge consultation. So not just looking at the medical records, which are important – what happens to them and where do they go – but actually recording the discharge consultations, whether it be with a nurse or with the doctor to the patient, interviewing the patient afterwards, finding out whether they’ve actually understood. In the one hospital another member of the team is doing research in, 70% of patients are not getting their discharge summaries. So, at some hospitals, there’s a rule that you have 48 hours after the patient leaves. So by definition, the patient can’t be given it. And so what happens often, there are big gaps. The patient isn’t really aware of what they’re supposed to be doing. So there are gaps. It’s not incompetence – it’s the system complexity, but there need to be system changes and much better electronic health records.

Ellen Leabeater: Diana Slade from the University of Technology Sydney speaking with producer Ninah Kopel.

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Ellen Leabeater: If you’d like to find out more about anything you heard today visit 2ser.com/thinkhealth. You can also find us on your favourite podcast app. Just search Think:Health. This show is produced with the support of the University of Technology Sydney, Faculty of Health. As always, if this show has raised any concerns, go and see your GP. I’m Ellen Leabeater, see you next week for more in health research.

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