On today’s program, we look at how many Australian women have access to midwifery continuity of care and why it’s important. We also discuss a new report on Indigenous suicide and how to engage nurses in research papers.

https://soundcloud.com/thinkhealth/40-access-to-midwifery-continuity-of-care-teaching-nurses-how-to-read-research

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Speakers:
Katie Cameron – Mother of Macy and Ruby
Caroline Homer – Professor of Midwifery, University of Technology Sydney
Jane Sandall – Professor of Social Science and Women’s Health at King’s College London
Anthony Dillon – Lecturer, Faculty of Health Sciences, Australian Catholic University
Louise Hickman – Associate Professor, Faculty of Health University of Technology Sydney
Caleb Ferguson – Postdoctoral Research Fellow, Graduate School of Health University of Technology Sydney

Producer/Presenter: Ellen Leabeater
Producer: Ninah Kopel

START OF TRANSCRIPT

Ellen Leabeater: Hi, Ellen Leabeater with you. Today – what suicide prevention in indigenous communities could look like; and a novel way for nurses to engage with research papers.

Caleb Ferguson: …So we came up with the idea of a Twitter journal club, whereby students would engage through a Twitter account and engage with the critical appraisal of a research article.

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Ellen Leabeater: But first on the show. If you’ve ever seen multiple GPs in a year, you know how frustrating it can be to explain your health story, your family history of disease, the medication you’re on, your allergies… Now imagine, if during pregnancy, you had to tell up to 30 people your story every time you went to an antenatal appointment. You had to tell them about your previous pregnancies, what you wanted for your labour – who your partner is. This is one of the downfalls in the way maternity care is currently delivered to the majority of pregnant women in Australia. There is a renewed push for midwifery “continuity of care” to be made available across the country as more and more evidence links this model of care to improved outcomes for women.

Katie Cameron: My name is Katie Cameron and I’m a mother of two girls: Macy who was born in May 2013 and Ruby who’s 2 and was born in 2014.

Ellen Leabeater: What you’re about to hear is the tale of two births and of multiple midwives and doctors. Katie is a mother of two who lives in Toowoomba 120km west of Brisbane in Queensland. Four years ago, when Katie found out she was pregnant with Macy, she booked in to see a midwife.

Katie Cameron: You sort of go up into the clinic and you sit and…you’ve sort of got an appointment time, but you see the midwife and they take you in and do the whole intake process and decide whether you’re low-risk or high-risk and go through all the different programs they’ve got up at the hospital.

Ellen Leabeater: There were three options of care for Katie at Toowoomba Base Hospital. She could opt for shared care with her GP and the maternity clinic. She could have all her appointments go through the hospital maternity clinic, or she could choose the Midwifery Group Practice (MGP). Katie was told that if she chose the Midwifery Group Practice or MGP, she wouldn’t have access to an epidural. As a first time Mum, Katie wanted to keep her options open, so she opted for shared care. Going through the maternity clinic meant that each time Katie presented for an antenatal appointment, she met whichever midwife was on shift.

(TO KATIE) And when you went to your antenatal appointments at the hospital, were you seeing the same midwife each time?

Katie Cameron: No. If you were lucky you may have – so I may of seen one of the midwives a couple of times throughout my pregnancy, but I didn’t have the same midwife each time, so each time the midwife had to read the file and read the pregnancy health record and speak to me about health issues in the family, whether I had any symptoms… all of that sort of thing. You had to go through it each time.

Ellen Leabeater: For Katie, this was especially hard because this was actually her second pregnancy. She’d had a miscarriage before getting pregnant with Macy.

(TO KATIE) Did you have to tell the midwives about your previous miscarriage?

Katie Cameron: Yes, each time. So they’d ask “Is it the first pregnancy?” and you’d have to say, “Actually no, it’s the second one.” So…

Ellen Leabeater: And how did that make you feel having to explain that at every appointment?

Katie Cameron: It does get frustrating having to explain everything each appointment – especially having to explain that you’ve had a miscarriage before and all that sort of thing – so that was one of the only risk factors. But, yeah… it’s frustrating to have had to explain it time and time again.

Ellen Leabeater: Katie’s pregnancy progressed more or less as normal. Her labour was a different story though. She ended up having a 29 hour labour. Katie had an epidural which slowed things down. Macy was vacuumed out and Katie ended up having stitches and a catheter.

Katie Cameron: It was a fairly rough ride.

Ellen Leabeater: Yeah!

Katie Cameron: Yeah, about 29 hours from the first contraction time through till when she was born. It was a long couple of days. I think at Ben’s calculation, by the time he got home from the hospital very early Saturday morning, he’d been up for 49 hours.

Ellen Leabeater: Ben being Katie’s husband. So, for the second time round, Katie was determined to do things differently. After talking to the midwives, she found an epidural was actually possible in Midwifery Group Practice.

Katie Cameron: I’d learnt from the midwives at that point that if I did need an epidural while I was in the birth centre program, I could have one. They just needed to move me out to a different room. So that sort of calmed the nerves a bit and I was more determined to avoid one, because that’s what had caused the labour to halt the first time.

Ellen Leabeater: The other advantage was that Katie would know her midwife throughout pregnancy. At the Midwifery model of care at Toowoomba, the midwives work in pairs, so if your primary midwife is unavailable, another midwife can step in.

(TO KATIE) And so how important was it for you to know your midwife?

Katie Cameron: It was a lot more calming the second time knowing the midwife and having her routinely throughout the appointments. I knew when I rang her if I had an issue because the baby had been moving or I’d had headaches or I was unwell. She knew my file and she knew the background and the health, and I’d had my appointments with her, so she knew sort of what was norm and what wasn’t norm for us.

Ellen Leabeater: And her labour with second baby Ruby? It went much more smoothly. Katie went into labour in the early hour of Monday morning.

Katie Cameron: I had Ruby and that was at quarter past ten in the morning and we were discharged about four o’clock that afternoon, so we were sort of home within twelve hours of being at the hospital. I had a few stitches with Ruby where my scar tissue had torn, but otherwise it was all standard and healthy.

Ellen Leabeater: The positive experience Katie had with her second child – well, she’s lucky she had it. It’s estimated only 8% of women in Australia have access to midwifery continuity of care.

Caroline Homer: We don’t really know how many women have access. There’s been a nice study from my colleagues in Melbourne that’s come out recently where they have surveyed midwifery managers across the country – not all the midwifery managers, but as many as they could – and then they’ve done an estimation, and they’ve estimated that it’s probably about 8% of women getting midwifery continuity of care.

Ellen Leabeater: This is Caroline Homer, Professor of Midwifery at the University of Technology Sydney. She has recently written a narrative review in the Medical Journal of Australia examining the evidence for midwifery continuity of care.

Caroline Homer: Midwifery continuity of care is where women get to know their midwife – sometimes more than one midwife, but usually not more than four. So they have the same midwives through pregnancy and the same midwives will attend them in labour and birth and the same midwives will attend to them in the postnatal period. So rather than the current system where you end up meeting possibly up to 30 different midwives in your child-bearing experience, you hopefully will only meet 3-4.

Ellen Leabeater: As you heard before with Katie, she saw multiple midwives throughout her pregnancy. Not only that, she had seven other people in the room when she gave birth, not including husband Ben.

Katie Cameron: I ended up… there was sort of 2-3 midwives plus a student midwife, then the obstetrician and the paediatrician and the special care nurse at that point, and then we also had the student doctor in. And I suppose at that point you sort of become unconcerned after everything else that’s been going on during the rest of the day.

Caroline Homer: I’ve always been shocked that the most vulnerable moments of our lives i.e. having a baby – we think it’s quite fine to have a bunch of strangers around you, and midwifery continuity of care is making sure that the most vulnerable moment of your life – and probably for many women the most important – you have people around you who you know.

Ellen Leabeater: Midwifery continuity of care isn’t just important for women’s sense of comfort during pregnancy and labour. It’s been proven to have positive health outcomes for mothers and babies.

Caroline Homer: We’ve got now really good evidence – so from what’s called the Cochrane Review. The Cochrane Library is a sort of international collection of research evidence where researchers pull together all the different trials on a certain topic. So for us, we now have a Cochrane Review on midwifery models of care, and that now shows really good outcomes for mothers and babies. Both for reduced intervention, for outcomes for babies – so less overall deaths, less pre-term births and less costs for the organisations.

Ellen Leabeater: Jane Sandall was the author of that Cochrane Review. Jane is a Professor of Social Science and Women’s Health at King’s College in London.

Jane Sandall: So, the findings of that review are that women are 24% less likely to have a premature baby; they’re less likely to lose their baby before 24 weeks. They’re less likely to have an instrumental birth, to have sutures on their perineum. They’re less likely to have pain relief and more likely to be very satisfied with the care they’ve had, and it’s cheaper.

Ellen Leabeater: And this isn’t just for low-risk women. Midwifery continuity of care can benefit high-risk women as well, who will consistently see the same midwife as well as an obstetrician throughout pregnancy.

Jane Sandall: I would say it’s also applicable to all women. Every woman needs a midwife, whatever her risk factor and whatever complications she’s got. Some women will need a doctor as well, but every woman will still need a midwife all the way through, and if you have a midwife who is navigating the system, who’s coordinating her care, who’s responsible, who’s accessible, who’s at the end of a phone line – it means that women feel that they have someone on their side.

Ellen Leabeater: Despite the evidence, only 30% of hospitals in Australia are offering continuity of care models. Most states have guidelines on how midwifery continuity of care should be implemented, and it is on the increase. But Caroline Homer says that there are barriers that prevent faster uptake.

Caroline Homer: For the most part, there’s great buy-in from government. So most governments – State governments (maternity care is predominately State Government run) – have policies supporting midwifery-led models of care, and supporting continuity of care. The challenge is actually making it happen on the ground and getting buy-in from managers, getting start-up resources, because sometimes you do need a little bit of money to get started. You perhaps need to re-arrange the roster, which takes a bit of energy and time; you need perhaps to provide midwives with some additional training…

Ellen Leabeater: Here in NSW, an estimated 22% of hospitals offer midwifery models of care, despite policy documents encouraging their implementation. A spokesperson for NSW Health said in a statement:

Female voice actor: NSW Health supports the development and provision of midwifery continuity of care models within a safety and quality framework. Local health districts are responsible for developing collaborative models of midwifery continuity of care that meets the needs of local populations. These may take various forms. The Ministry does not hold details of the numbers or locations of these programs.

Ellen Leabeater: For these services to be accessible, women need to ask for them. Katie says it’s a shame that many Australian women miss out on the type of care she had for baby number 2.

(TO KATIE) They reckon only 8% of women in Australia get access to midwifery continuity of care…

Katie Cameron: … which is the scary thing. You’d think in the case of high-risk pregnancies that it’d be more of a concern for them to be having continuity of care, than the essential low-risk day-to-day normal pregnancies. That’s essentially because it would take a lot of the stress out. The pregnancy with Ruby was a lot less stressful than the pregnancy with Macy because of the familiarity with the midwife.

Ellen Leabeater: If you’d like to find out more from that story including the full statement from NSW Health, you can head to the website at 2ser.com/thinkhealth.

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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: Aboriginal women are 34 times more likely than non-indigenous women to end up in hospital because of family violence. This is just one part of what Indigenous health advocates are calling a violence crisis. Josephine Cashman, entrepreneur, lawyer and Indigenous advocate, was part of a discussion at the National Press Club this week.

Josephine Cashman: There is a clear link that the Crime Commission found between suicide, self-harm and associated alcohol and substance abuse and domestic violence, relationship breakdowns and early life trauma from child abuse. Service providers and community members are limited in their ability to address mental health issues and identify children at risk.

Ellen Leabeater: And it is Indigenous children themselves who are particularly vulnerable, with Indigenous children comprising 30% of suicide deaths among those under 18 years of age. Indigenous 15-24 year old are also five times as likely to suicide than their non-indigenous peers. To try and address this issue, the Federal Government has released a new report titled “Solutions that work: What the evidence and our people tell us”. Ninah Kopel spoke with Anthony Dillon, lecturer in the Faculty of Health Sciences at the Australian Catholic University, to find out what we can learn from this latest report.

Anthony Dillon: We know for example that when people are in environments where parents are working in meaningful jobs, kids are in school, mental health problems, self-harm, suicide – that sort of thing – are less likely to be a problem. The problem is, for far too many Indigenous people, they just don’t live in the sorts of places where they have access to the things you and I take for granted.

Ninah Kopel: So, it’s a really difficult complex problem. Is it best to be dealing with communities as a whole, or should be dealing with case-by-case situations.

Anthony Dillon: As the report sets out, they approach this at a few different levels, which is good. So yes, you do need individual attention, but you also need approaches at the family and community level as well, so it needs to be a multi-layered approach.

Ninah Kopel: And what would that look like?

Anthony Dillon: It would look like you have people that are being cared for, that are being seen as whole people – and I think most importantly, you’d have the situation where suicide is not just dealt with from a crisis point of view. We will always need crisis intervention, but when you fix a lot of the problems upstream, you fix them before they become suicide issues – does that make sense?

Ninah Kopel: Yeah it does – and I think one of the things that came up in the report was cultural security and appropriateness. Is that something you could address in schools even?

Anthony Dillon: Look, each person in each community is different. Sometimes culture can be important. Ideally, families should be taking care of culture themselves, so again I think if you have families where there’s one parent working and they’re in a safe, stable home, well then healthy culture will just be a natural outcome of that. Personally I don’t think classes and programs in culture should be the frontline treatment. Basically, the sort of culture Aboriginal people need is the same sort of culture you and I and the authors of the report have. You know, access to modern services, safe environments – that sort of thing.

Ninah Kopel: And this idea of empowerment that you and the report brought up – what does that mean in the context of looking after people’s psychological and physical health?

Anthony Dillon: It means that you can have some choice about what happens in your life, some choice in how you respond – you can’t always choose your circumstances, but at least you can have some say in how you can respond. So it’s individuals, families and communities making some decisions for themselves. And that could mean that one community choose to go about a suicide issue slightly differently to another community –they do what they think is best for them. Certainly, there’s a common denominator, but there needs to be that variation at the individual and community levels.

Ninah Kopel: So if we are talking about empowerment and about each community making the decisions for themselves about what works best, is there anything that the government from a federal or state level actually can be doing?

Anthony Dillon: Yes, I think government can… the big issue is you’ve either got to have services come to the people or people go to the services. In the case of some remote communities, it’s just not viable to set up modern services, and government have a part to play there. If a community is sustainable and viable, then government should invest whatever it takes to get that community started up. And if it’s not viable, the government should pay the bill for sensitively relocating those people to where they do have opportunities.

Ninah Kopel: That’s quite hard to achieve though in a sensitive way. When it’s done wrong it can result in a huge media outcry. Is there an example of somewhere where it has been done successfully?

Anthony Dillon: Look, not on a large-scale basis. Individuals are making choices to move towards where the opportunities are. So, yes, it does have to be done sensitively – people need to be told about the success stories of people who have made the move and let them know they’ll be supported the whole way.

Ninah Kopel: One of the things that came up was this idea of employment. You’ve mentioned that if a child is in a family with parents who are securely employed, it makes a big difference – and it comes back to that idea of empowerment. Is the government’s current policy on generating jobs working?

Anthony Dillon: That’s hard for me to say at this stage. Certainly, we read the success stories about jobs being created and Indigenous people moving into jobs. We always celebrate that and that’s great, but there are pockets around the country where there are so few jobs that it’s not going to make a big difference at all.

Ninah Kopel: What would you like to see happen in the future? I know that’s a big question, but what’s the priority for you?

Anthony Dillon: OK, the priorities for me are within the Indigenous population; we need to identify those who are most at risk. One of the strengths of the report is that it isn’t just one size fits all. It does recognise that there is diversity among Indigenous people. So, identify those who are most at risk and focus on them initially.

Ellen Leabeater: Anthony Dillon, lecturer in the Faculty of Health Sciences at the Australia Catholic University talking with Ninah Kopel.

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Male: You’re listening to Think:Health on 2ser 107.3

Ellen Leabeater: When it comes to healthcare, you’d hope that what’s happening in hospitals and aged care is evidence-based. But, that’s not always the case, as doctors and nurses get stuck in the trap of “this is the way we’ve always done things”. And there’s also a lack of interest when it comes to reading and analysing new research papers. Caleb Ferguson and Louise Hickman from UTS set out to change this among postgraduate nursing students. They set up what’s called a Twitter journal club to see if they could improve student engagement and understanding of research papers.

Louise Hickman: Hi, my name’s Louise Hickman – I’m an Associate Professor in the Faculty of Health at UTS.

Caleb Ferguson: My name’s Caleb Ferguson – I’m a postdoctoral research fellow in the Faculty of Health at UTS.

Ellen Leabeater: So when we talk about evidence-based practice, what’s the gap between what we know is evidence and what actually happens in hospitals?

Caleb Ferguson: So I guess in terms of nursing and the care that patients receive in hospitals should be based on the best available evidence. And so, evidence-based practice really comprises of a few different elements. One of it is the best available research evidence that’s out there, and the clinician’s own expertise, and then also the individual patient’s own personal circumstances. So when we’re providing care to patients, we need to consider all three of these things to make health care decisions and to provide care to patients based around these three elements as well.

Ellen Leabeater: So how do we go about explaining to students what is the best academic research to use?

Louise Hickman: Most health degrees in Australia have always had subjects in their curriculum that focus on evidence-based practice and research and what they entail and what they need to know, but what we’ve lacked is real engagement in those subjects and a love of learning those subjects – a love of wanting to know that information. They’ve been notoriously dry and unengaging and quite methodological in their approach.

Ellen Leabeater: You’ve both taught these subjects –what is it like for a student? What do you see in the students?

Caleb Ferguson: I guess traditionally, as Louise has said, students find these subjects quite boring and dry – they’d be the two words that students use in feedback. As educators we try and make these subjects really exciting for students to help them engage with the content and to achieve the objectives of the subject. In the past we’ve tried to select really cool and funny papers particularly. The BMJ (British Medical Journal) do a Christmas edition for example. So some of the weird and wonderful methods are around about different topics…

Ellen Leabeater: We talk about evidence in nursing – what evidence is there in engaging students in their learning?

Louise Hickman: Well, that’s sort of how these papers that we’ve published have come about. We did a systematic review to find out what are the best teaching and learning strategies to engage students in evidence-based practice and research in health – in those sort of subjects. And there is no high-level evidence out there.

Ellen Leabeater: So there’s nothing to guide you…

Louise Hickman: There’s some nice qualitative studies, but when you want to look at it across larger numbers and you want a higher quality study that robustly says these things actually help, it hasn’t yet been done, so we’ve sort of had to really go back to the drawing board and really start unpacking and exploring what we do and how we do it – really doing some good groundwork with students. This is how Caleb has come up with his Twitter journal club.

Ellen Leabeater: Yeah, let’s go back a step – what is the journal club?

Caleb Ferguson: Yeah, so, journal clubs have been around for quite a long time. Usually it follows the standardised format whereby participants of the journal club receive a paper and you come together and look at some of the key hallmarks of the paper, some of the limitations and really building a good critical appraisal of the research design, and an interpretation of some of the findings.

Ellen Leabeater: Caleb, you’ve taken this journal club one step further. What have you done?

Caleb Ferguson: I’ve had a huge interest in the last few years around using social media in Health and I’ve wanted to apply some of this to nurse education in particular. So, really I think the idea for this also came from… on Twitter we have things called moderated tweet chats, which aren’t really a new thing, but there’s a really strong group called “We Nurses”. So those chats are based around a certain topic and use a hashtag and people can engage on them on Twitter quite easily. So we took that idea and that model and then thought about how we can apply that in the classroom. So we came up with the idea of a Twitter journal club, whereby students would engage through a Twitter account and engage with the critical appraisal of a research article.

Ellen Leabeater: You said this was a very dry topic area – did the use of Twitter or social media improve the engagement?

Caleb Ferguson: Yeah, I’ve never ever seen anything like this in my whole entire time of teaching in a classroom. We have a really cool picture that we took of the students in the classroom and they’re all sitting there – about 60 students in the first class… and we had some additional tech support and academic support… but the classroom was dead silent. They were all focused on the task with their device and really engaged with the topic and the questions. And I don’t know if this was really related to the novelty aspect of it, but it was a really awesome experience.

Louise Hickman: You know, the principle is participation. They own it. They are in charge. They can participate at all different levels where they feel comfortable, and it was done on a very safe and inclusive forum.

Ellen Leabeater: It’s one thing to be across all this information, but how do you then go into your healthcare team – say as a junior in the team – and speak up to those senior members who might be saying something different to the research?

Louise Hickman: Communication can be really difficult, and if you look at a lot of issues even when things go wrong – often when you drill down it’s not something that’s easily quantifiable. It comes down to either larger system problems or communication issues, so really, up-skilling people on how to have difficult conversations in a non-confrontational way… so as a professional, whether you’re a junior nurse or a junior doctor working with another consultant, you’ve potentially got completely different views and agendas – how do you best come together? For me, I always come from the perspective of the patient. So what is in the patients’ best interest – all of us are there to advocate for the patient regardless of discipline. So I’d say ask questions – that’s the easiest way to do it without pointing fingers. You know, “can you tell me about this – I’ll read about it” or “do you know about this”. And they might say, “Yes, we’re quite aware of that, but at the moment, we’re doing this because of this particular patient’s needs”. So it is complex, and that’s why the ability to communicate clearly is really important – it’s important to ask questions.

Ellen Leabeater: Caleb Ferguson and Louise Hickman from University of Technology Sydney ending that story.

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Ellen Leabeater: If you’d like to find out more about anything you’ve heard today, head to 2ser.com/thinkhealth. Think:Health is available wherever you are. You can search “Think Health” on your favourite podcast app. And, if today’s show has raised any questions with you, go and see your GP. This show is produced with the support of the University of Technology Sydney and 2ser. I’m Ellen Leabeater, thanks for your company.

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