Improving Maternal Health Outcomes for Indigenous Australian Women - Literature review Example

Research Topic: The Effectiveness of Lifestyle-based Interventions beyond Antenatal Care in Improving Maternal Health Outcomes for Indigenous Australian Women Research Statement According to the Australian Bureau of Statistics (2004) and the WHO (2005) the reduction in maternal deaths for indigenous Australians over the last two decades has been on average 30% less than non indigenous Australians (Sullivan et al 2008). This became a public health concern in Australia (Macklin and Roxan 2008) indicating that interventions aimed at reducing maternal mortality for indigenous women which have primarily focused on improving the quality and access to antenatal care have been less effective than intended. One of the major reasons for this is that provision of antenatal care does not redress the socio-economic disadvantages faced by indigenous women and some of their lifestyle choices which act as maternal risk factors. This study examines the effectiveness of interventions beyond antenatal care that focus on lifestyle changes in reducing maternal mortality among indigenous Australian women. In particular, it will identify the risk factors in the lifestyles of Aboriginal and Torres Islander Strait women of child bearing age which contribute to the prevalence of high maternal mortality rates. The study will also assess the effectiveness of public health interventions that which emphasize lifestyle changes such as proper nutrition and hygiene, cessation of smoking, reduction in drinking and sexual health in reducing maternal mortality for indigenous Australian women. Literature Review: Causes of worse maternal outcomes for indigenous women Panaretto et al (2005: 2007) cite the poor access to antenatal services for Aboriginal and Torres Strait Islander women as largely responsible for the negative maternal health and perinatal outcomes in Queensland. The Australian Bureau of Statistics (2004) indicates that despite the increase in the number of Aboriginal and Torres Strait Islander women giving birth at hospitals, indigenous women often access antenatal services late in their pregnancies. The number of indigenous women giving birth at home is also significantly higher than those of non indigenous women due to socio-economic and cultural barriers in accessing antenatal care. De Costa and Wenitong (2009) have identified some of the barriers to antenatal care and improved maternal health for indigenous women such as socio-economic constraints, geographical distance from health services and lack of affordable transport. However, while such social disadvantages have been cited as the primary factor, poor health habits such as higher incidence of cigarette smoking and alcohol abuse among indigenous women is another contributing factor (Nel and Pashen 2003). As De Costa and Wenitong (2009) pointed out, a significant percentage of the maternal and perinatal deaths among Aboriginal and Torres Strait Islanders are attributable to some of their behaviors such as excessive drinking and smoking. Justification While research has been conducted on the impact of public health interventions based on increasing access to and quality of antenatal care, few studies have explored the impact of interventions which address lifestyle changes in reducing maternal mortality among indigenous women. Therefore, research needs to be conducted on long term interventions aimed at reducing maternal mortality and improving maternal care by focusing on initiatives that promote healthy lifestyles among Aboriginal and Torres Strait Islander women of child bearing age. Such research would provide evidence for public health interventions and policies that focus beyond antenatal care in improving maternal health for indigenous Australians. Research Objectives The aim of this study is to assess and evaluate the effectiveness of interventions that focus on lifestyle changes such as cessation of alcohol and tobacco consumption, sexual health and promotion of proper nutrition and diet for pregnant women and child bearing age in reducing maternal mortality among indigenous Australian women. Specific objectives are: To identify the causes of the prevalent inequality in delivery of maternal health services between indigenous and non-indigenous Australian women of child bearing age. To identify the risk factors in the lifestyles of Aboriginal and Torres Islander Strait women of child bearing age which contribute to the prevalence of high maternal mortality rates. To assess the effectiveness of public health interventions that target lifestyle changes beyond antenatal care such as proper nutrition and hygiene, cessation of smoking, reduction in drinking and sexual health in reducing maternal mortality for indigenous Australian women. Based on the findings of the study, to forward practical recommendations to policy makers and inform the design of more effective interventions to reduce maternal mortality. METHODOLOGY The study will use a cross sectional survey Aboriginal and Torres Strait Islander women who have participated in antenatal care programs within the last 12 months provided by public hospitals in Townsville, Queensland. The study will particularly focus on antenatal care programs that include lifestyle or attitude change components such as rehabilitation for drug and alcohol problems, campaigns to promote cessation of smoking and drinking among pregnant women, promotion of sexual health practices such as having protected sex or limiting sexual activity to reduce risk of exposure to sexually transmitted diseases and proper hygiene and nutrition for pregnant women. The study will, with the permission of the hospitals, public health workers and the women in the sample themselves, collect and analyse demographic and antenatal visits data such as frequency of smoking/drinking/drug use prior to the program, weight, education status, household income levels, frequency of sexual activity and incidence of exposure to STIs and other such antenatal information as shall be deemed necessary. The study will stratify and compare these statistics with perinatal morbidity or mortality rates for the same group and conduct tests of significance (t-test for samples below 30) and 2 tests for best fit. Research Instruments The study will use semi structured interviews with community and public health nurses who have participated in antenatal care programs. The interviews will be topic based and will enquire into areas such as: Drug and alcohol abuse among patterns women of Aboriginal and Torres Strait Islander women childbearing age who enter antenatal care programs in public hospitals The generally observed hygienic standards and living conditions of Aboriginal and Torres Strait Islander women participating in antenatal care programs. The frequency and exposure to infectious diseases among Aboriginal and Torres Strait Islander women. The documented frequency of treatment for sexually transmitted diseases for Aboriginal and Torres Strait Islander women in antenatal care programs. The general socio-economic status of Aboriginal and Torres Strait Islander women who attend antenatal care programs such as income and education levels. The incidence of domestic abuse-which includes both physical and psychological abuse-and the mental health of Aboriginal and Torres Strait Islander women. The frequency and access to antenatal care services by Aboriginal and Torres Strait Islander women in terms of distance from health centers, affordability of antenatal services and the cultural appropriateness of such services. Participants The participants of the study will be public health nurses who have worked in antenatal care programs in Townsville, Queensland, and the subjects will be the Aboriginal and Torres Strait Islander women who have attended such programs. Townsville has been selected as a good sample source since the highest number of indigenous births in Australia occurs in the state of Queensland and Townsville has a high concentration of indigenous births in Queensland. The eligibility criteria for data collected for the survey is that it must be for Aboriginal and Torres Strait Islander women who have participated in or attended antenatal care programs in a public health center in Townsville within the last 12 months. This will enable comparison with the latest national and regional statistics by the Australian Bureau of Statistics. Sampling Frame The study will use judgment sampling in selecting participants based on their relevance to research objectives. The study will first utilize a key informant sample of nurses from public health centers in Townsville with established antenatal care programs (more than 10 years). Since the availability of nurses and their willingness to participate in the interviews is unknown, the study will attempt to make 3 visits to each selected health center to ensure maximum coverage within the typical 8-hour shifts. The data for Aboriginal and Torres Strait Islander women will also be collected from public health institutions and local authorities in Townsville. Sample Size The sample size estimation is based on historical data collected through similar studies by Panaretto et al (2005, 2007) which indicated that the average annual attendance and participation of Aboriginal and Torres Strait Islander women in such antenatal care programs over a ten year period is 1000. The study sample size for the data collected is dependent on the availability of data. Using a power of 80% and a confidence level of 5%, the typical desired sample size for each health center is n=100. Research Ethics The study will proceed to collect data once granted ethical approval by the University of New South Wales, the relevant local authorities in Townsville Queensland and the consent of the officials of public health centers in Townsville. Issues of ethical concern include the treatment of confidential patient data from antenatal visits such as the results of screening for sexually transmitted diseases, history of domestic abuse, drug and alcohol abuse-related data and income levels or education status. Women who have participated in such programs may tend to be sensitive about the revelation of such data out of the fear of being socially ostracized and stigmatization as such information may negatively impact on issues such as future employment. To resolve the ethical issues arising out of the treatment of confidential data, the study shall request and uphold the anonymity of such data to protect the identities of Aboriginal and Torres Strait Islander women who have attended such care programs. The study will refrain from making any direct or indirect references to the identities or locations of the subjects in the sample. Data Analysis The data collected for this study will mainly be secondary data. Data will mainly be collected from public hospitals (with their approval), the Australian Bureau of Statistics, the local authorities in Townsville and from auxiliary sources such as NGOs, indigenous women’s advocacy groups and other public health institutions in the region. Data from semi-structured interview will be collected by hired medical and nursing students from the region. The secondary data collected will first be checked for accuracy to eliminate any outliers. The data will then be classified according to descriptive statistics such as level of drug and alcohol abuse, exposure to sexually transmitted diseases, income and education levels or vulnerability to domestic violence. Multivariate regression models will then be developed using statistical software (SPSS) to predict the relationship between independent variables such as cigarette/alcohol consumption and exposure to sexually transmitted diseases and the dependent variable of actual incidence of perinatal, maternal or child mortality. The models will be testes for autocorrelation to enhance the reliability of the study. This model shall then be compared with national statistics which represent actual population values to establish their significance. Significance tests using Z-tests shall be conducted at 5% level of confidence and best fit estimated using 2 tests. All statistical tests will be conducted using SPSS, version 12.0. Timeline TASKS TO BE PERFORMED J F M A M J J A S O N D 1. Finalize research proposal and submit for clearance 2. Prepare interview schedules 3. Identify research assistants 4. Obtain clearance from UNSW, public health officials and local authorities in Townsville 5. Train research assistants 6. Pre-test/simulate study, collect materials and finalize procedures 7. Collect data and conduct interviews 8. Process data and make preliminary observations and interpretation 9. Analyze data and prepare preliminary report 10. Solicit feedback and discuss report with public health officials. Present, disseminate and discuss findings to UNSW staff, Townsville community members and policy makers 11. Draft preliminary plan of action 12. Meet with public health officials, Townsville community members and policy makers (local authorities) to discuss plan of action 13. Follow up on implementation of plan of action Stakeholder/Community Participation The study will ensure extensive engagement with and consultation of Townsville community members and public health officials. Meetings will be scheduled with the respective heads of public hospitals and public antenatal service providers to Aboriginal and Torres Strait Islander women (such as midwives) to discuss the importance and implications of the findings of this study. Prior to data collection, extensive consultations will be held with the stakeholders who include local public health services providers, policy makers such as ministry of health representatives from Queensland, the local authorities (town/municipal council of Townsville), medical and nursing training institutions and representatives from NGOs and advocacy groups for Aboriginal and Torres Strait Islander women to facilitate their participation and co-operation in data collection. At these meetings, the importance of the study and the forthcoming policy recommendations will be discussed. Copies of the report, its findings and recommendations will also be disseminated to schools, public libraries and the various stakeholders. Importance of the Research As this research study has demonstrated most programmes that aim at improving health outcomes for indigenous women mainly focus on the provision of antenatal care. However, there seems to be little focus on initiatives to promote healthy lifestyles as a means of reducing maternal mortality (DeCosta & Wenitong, 2009). The findings of this study will depict the effectiveness of lifestyle-based interventions beyond antenatal care in improving maternal health outcomes for indigenous Australian women. The study will highlight the persistent factors that explain the inequality of access to and delivery of antenatal services between indigenous and non indigenous Australian women. This study will evidently provide great insight that can be used to implement positive changes relating to the maternal health of indigenous women in Australia. The findings of this study can assist policy makers and the administrators of health institutions in Queensland and the larger Australia to make decisions that promote the use effective interventions to address issues revolving around the increasing rate of maternal mortality especially amongst indigenous women. It will enable public health officials to evaluate their priorities in combating maternal mortality and to make more efficient use of the available resources in achieving desired targets. This study has provided evidence base for interventions and policies that focus beyond antenatal care as an intervention in improving maternal health for indigenous Australians. References Australian Bureau of Statistics (ABS), Australian Institute of Health and Welfare (AIHW) (2004).The health and welfare of Australia’s Aboriginal and Torres Strait Islander peoples.ABS Catalogue No. 4704.0. Canberra: Commonwealth of Australia. Biro, A.M. (2011). What has public health got to do with midwifery? Midwives’ role in securing better health outcomes for mothers and babies. Women and Birth 24 (1), 17- 23. De Costa, C.M., Wenitong, M. (2009). “Could the Baby Bonus be a bonus for babies?” Medical Journals of Australia 190 (5), 242-243. Kruske, S.,Kildea, S., & Barclay, L. (2006). Cultural safety and maternity care for Aboriginal and Torres Strait Islander Australians. Women and Birth 19 (3), 73-77. Macklin N., Roxan N. (2008).Media release: maternal deaths high for indigenous women. Canberra: Minister for Families, Housing, Community Services and Indigenous Affairs (Jenny Macklin) and Minister for Health and Ageing (Nicola Roxon); May 2, 2008. Nel, P., Pashen, D. (2003). “Shared antenatal care for Indigenous patients in a rural and remote community.”Australian Family Physician, 32(3), 127–131. Panaretto, K. S., et al. (2005). Impact of a collaborative shared antenatal care program for urban Indigenous women: a prospective cohort study. The Medical Journal of Australia, 182(10), 514–519. Panaretto, K.S., et al (2007). “Sustainable antenatal care services in an urban Indigenous community: the Townsville experience”. Medical Journals of Australia 187 (1) 18-22. Sullivan E.A., Hall B., King J. (Eds.) (2008). Maternal deaths in Australia 2003—2005. Sydney: AIHW National Perinatal Statistics Unit; 2008. World Health Organization (WHO) (2005).The World Health Report 2005 Make every mother and child count, Geneva. Read More