To Be Born Upon a Pandanus Mat- Redesigning maternity services for Yolngu mothers and babies living on Elcho Island Northern Territory (NT), using Birthing on Country principles and the RISE translational Framework, to reduce preterm birth and improve health outcomes: A prospective, non-randomised, intervention trial

Birthing on Country' service will be established in Galiwin’ku, Elcho Island, Arnhem Land, Darwin, Australia, a very remote, demonstration site. We will partner with key stakeholders through our community-based Participatory Action Research approach to redesign very remote maternity services and increase support for Yolngu women in both the primary and tertiary setting. The intervention will commence in 2023 and continue throughout the duration of the five-year project. Prospective qualitative and quantitative data will be collected and regularly reviewed throughout the intervention phase to assess intervention compliance and fidelity. Through the co-design process data variables will be identified and then reported on. Key components of the intervention include: • Multi-agency Partnership Committee providing culturally responsive overarching governance (of redesign and research), leadership and community engagement in co-designing care interventions • Antenatal care interventions using Indigenous knowledges will be co-designed to address modifiable preterm risk factors. A midwife will always be available on site in Galiwin’ku. (Antenatal care interventions will be codesigned with Yolngu Cultural Authortities, djakamirr and midwives. Intervention elements will likely include continuity of care, enhancing reproductive health literacy, enabling early care access and privelleging First Nations languages and knowledge. ) • Women have 24/7 phone access to midwife or djakamirr (Indigenous doula). • Women are flown to either Darwin or Nhulunbuy for specialist antenatal appointments and at term for a planned hospital birth. • A midwifery group practice (remote MGP) will be established in Nhulunbuy (one already exists in Darwin) where midwives work in partnership with djakamirr with weekly teleconference to the remote team. (Midwifery group practices are well described in Australian maternity literature. We will follow this evidence base alongside remote clinical practice guidelines stipulated in the Minymaku Kutju Tjukurpa Women’s Business Manual to provide comprehensive maternity care for Yolngu women and families across the pregnancy, childbirth, and postnatal continuum. Teleconferences will be used as needed to discuss clinical priorities, undertake continuous quality improvement, deliver professional development, and review barriers/challenges. ) • All women are cared for during labour from a known midwife and/or djakamir. (Djakamirr care will commence as soon as a woman presents to services and consents to receiving djakamirr care, with an emphasis of care commencing as soon as possible in the first trimester of pregnancy. This will predominantly be face- to- face support and education and we anticiapte that two djakamirr care packages will be delivered each trimester alongside a transfer, birth, and post-natal care package. ) • After birth, when the women and baby return to the community, the midwife and djakamirr provide postnatal care and access to other support services as required (case managed). Djakamirr and Strong Women Workers and support agencies to continue engagement and support up to 2-years. • Djakamirr care during pregnancy and childbirth is provided by an employed Strong Women Worker, who has undergone accredited Western and Yolngu training. • Djakamirr will facilitate informed consent of all procedures in the woman’s primary language in and out of business hours. • Care is delivered in the women’s first language. Djakamirr workforce will be increased to at least 4-FTE. • Frontline staff are provided with regular clinical and cultural supervision with a focus on effective intercultural communication and working with Interpreters. (Frontline staff will be provided a package of Clinical Mentoring and Reflective Supervision. Clinical Mentoring delivered by an experienced Endorsed Midwife will be available 24/7 via phone. Reflective Supervision will be delivered by a clinical psychologist via regular one-hour fortnightly sessions. Depending on location and challenges of remote access this may include face-to-face, online meeting platform or by phone. ) • A community-based hub provides a culturally responsive and safe place for women, families, caregivers and Elders to undertake cultural activities that allow connection, sharing and learning from each other within a strength-based approach to birthing and parenting. • There is access to early pregnancy testing and transport services, a strong emphasis on hunting and collecting (exercise) iron rich traditional foods (e.g. shellfish), with regular cook-ups and cultural activities. • Established referral pathways between services and to community support agencies