Developing and evaluating a Birthing On Country service to determine the effect on maternal and infant health outcomes for First Nations Australians

A Birthing on Country Service is a complex intervention that includes: (i) Aboriginal and/or Torres Strait Islander-led governance of the service (through Aboriginal Community Controlled Health Organisations - ACCHOs) (ii) An Aboriginal and/or Torres Strait Islander workforce strategy with career pathways for staff e.g. cadetships to support Aboriginal and/or Torres Strait Islander midwifery education and positions for workers such as Aboriginal Family Support Workers to work side-by-side with midwives (iii) Continuity of midwifery carer offering 24/7 care from a named midwife from first presentation in pregnancy until handover to child health services 6 weeks after birth. This care is organised as a midwifery group practice integrated with other health services. Midwife-participant contact will involve one-to-one visits conducted either in person, or via video conferencing (or a mixture of both, as required). As with standard care, telephone contact may also occur. These appointments may occur in any setting - primary care (e.g. clinic or community-based health/birth centre), hospital, or home, as they will occur throughout the pregnancy, birth and postpartum periods. (iv) Care throughout the pregnancy to postpartum period in collaboration with the extended healthcare workforce based on need (e.g. obstetrician, pediatrician, psychologist). Care and collaboration needs will be assessed from first presentation until handover to child health services 6 weeks after birth and this is the period of assessment (however, care will not be terminated at the end point, if it is needed on an ongoing basis, and may have been accessed prior to pregnancy). Appointments may occur in a community-based, primary care or secondary (hospital) setting. As with standard care, these additional services will be offered when deemed necessary by the lead maternity carer, and may be more accessible than those offered through hospital-only settings, but similarly women can decide whether the care offered may meet their own specific needs, and care is equally available to intervention and control groups. (v) A focus on strengthening family capacity and cultural connection to improve health and well-being. A variety of delivery mechanisms will be utilised e.g. one-to-one and/or group sessions/workshops, and may include diverse settings e.g. counselling/workshops in community-based settings, home visits, and regular cultural days and camps in the bush. The period of assessment is from first presentation in pregnancy until handover to child health at 6 weeks postpartum, however, services may be accessed beyond that period. Additional services will be offered if deemed potentially helpful, and may be more accessible than those offered through hospital-only settings, but similarly women can decide whether the services/care offered may meet their own specific needs. This may include referral to counselling, case management services, and/or involvement of other community support agencies as required. Model components are administered by ACCHO partners. (vi) Care provided outside of the hospital, for example from a community hub, and if feasible, a free-standing birth centre for women with uncomplicated pregnancies, and for women with complex pregnancies - birthing services will be provided in the local or tertiary hospital. The care model commences from the first day of pregnancy until handover to child health services 6 weeks after birth. The intervention model of maternity care is due to commence in 2021, we plan to study it from the launch (aiming for 36 months duration - including a possible extension of existing period). Care is woman centred, individualised and incorporates traditional practices if women desire it; it recognises the connection between Aboriginal and/or Torres Strait Islander people with land and country; it utilises a holistic view of health, recognising and addressing where possible the social determinants of health; values both Aboriginal and/or Torres Strait Islander and non-Indigenous ways of knowing, learning and risk assessment; and provides a culturally competent service through various activities including cultural supervision. As indicated, the intervention involves a redesign of maternity care and we are working with communities and organisations, capturing both pre- and post-intervention data. Adherence to model fidelity will be assessed concurrently through the embedded process evaluation component.