1. Bingji Bingji Booris
(Heavily pregnant to babies – Yuin Language)
Aboriginal Health Manager
Clinical Midwifery and Maternity Risk
2. Acknowledgement of Country
We would like to acknowledge and pay our respects to the first people,
the Gadigal people of the Eora nation, past, present and future and all
other Aboriginal people here today we recognise the continuing
connection of Aboriginal and Torres Strait Islander peoples to their
country, lands and family.
Case for change
• The continuum of care for women accessing Aboriginal Maternal
Infant Health Service (AMIHS) was fragmented
• Only 14% of women were booking in before 14 weeks
• Near misses and adverse incidents highlighted the need for early
access and referrals for support
• Women’s and stakeholder’s stories demonstrated that Aboriginal
Cultural Awareness and Sensitivity could be strengthened.
• Makita’s journey
4. Mapping AMIHS Woman’s Journey
1. By July 2016 50% AMIHS women will be booked in before
2. By December 2015 Implement the recommended standards
for Diabetes Screening, Renal Diseases and Quit Smoking
3. To increase the postnatal continuity of care capacity so that
100% AMIHS women will be followed up by the AMIHS Midwife
for two weeks after birth
• Women’s stories guided by
Indigenous Pie (10)
• Staff interviews (10)
• Tagalongs (3)
• Process Mapping
• Key Performance Indicators
• Brainstorming workshops
• One to one consultations (12)
• Consultation with external stakeholders
• Literature search
• Incident Information Management
System (IIMS) review
• Complaints review
7. Summary of Key Issues – The 3 Cs
• Continuity of Care
86% of women did not receive
early assessment & intervention
• Cultural Awareness
There was poor compliance to the
Respecting The Difference e-
• Cultural Aesthetics
Some of the AMIHS women
identified that the maternity
service environment was not
culturally welcoming for them
Dec 2014 0% 0%
April 2015 100% 15%
Dec 2015 100% 100%
8. The New Journey for AMIHS Women
My ideal Maternity Service would be…..
The home visits are convenient, the supports are amazing, the ability to
call with concerns when needed - great, as at times maternity at the
hospital is too busy or too clinical for me to understand
(Melissa, reflecting on things after one year)
9. Summary of Key Solutions
1. Raising Cultural
• Managers - monitor
compliance with HETI
• Cultural Inclusion Checklist
(Maternity Services) –
complete and implement
• Develop and facilitate the
Respecting the Difference
face-to-face training for all
10. Summary of Key Solutions cont.
2. Standardized the
clinical pathways and
continuity of support
• Improve community awareness
about early access with the
use of approved social media
• Adapt clinical pathways to
include culturally appropriate
service delivery and educate
staff in VTE, diabetes and
• Ensure continuity of care with
known Midwife and Aboriginal
11. Summary of solutions cont
3. Develop and support the local workforce
• Clinical Supervision
• New Directions Funding to enhance the Allied Health
• Providing leave relief for clinicians (backfilling)
• Implement Intake Meetings
• Include in Perinatal reviews
• Aboriginal Health Workforce
13. Results to Date
On Target In Progress
1. By July 2016 50% AMIHS women
will be booked in before 14 weeks
2. By December 2015 Implement the
recommended standards / assessments
for Quit Smoking, Diabetes, Renal
Diseases, VTE screening
• VTE screening draft tool in
• Awaiting for CEC maternity
To increase the postnatal continuity of
care so that 100% AMIHS women will be
followed up by the AMIHS Midwife for
two weeks after birth
• Still a challenge due to
workload and workforce
• Need to seek additional
resources for clinical staff hours
for continuity of care
• Recruitment of AMIHS Manager
progressing – unable to recruit
for 7 months
14. Results to Date
Other benefits achieved:
• Information exchange from other Aboriginal
Health programs to assist to review
practices and models of care
• Successful applications to date:
New Directions (Commonwealth Dept
Health) for Allied Health enhancement to AMIHS
• Capital Works to enhance the workplace/clinic space for AMIHS
Women and staff - culturally appropriate and safe AMIHS
clinic and work spaces
• Trauma informed care training
• Smoking cessation workshops attended
• The Maternity Service is interested in Redesign Processes to
establish a Midwifery Group Practice!
15. The Next Steps
1. Continue with implementing Respecting the Difference face to face training
2. Improve pregnancy screening and clinical pathways
3. Continue and improve communication with clinicians
4. Continue learning from women’s stories
5. Recruit the AMIHS Team Leader
6. Continue to explore ways to fund and offer full of continuity of care
through pregnancy, labour, birth and postnatal care so that we can have
the first sustainable AMIHS continuity of care program in NSW
7. Share lessons learned with AMIHS services in SNSWLHDS and across the
8. Inspire Eurobodalla Maternity Service to use Redesign Methodology to explore
Midwifery Group Practice models
16. Lessons learned during the Implementation Phase
• The importance of valuing and understanding women’s
stories and their individual journeys This impacts
significantly on how our care may impact upon women’s
• That Respecting the Difference Training makes a
difference by increasing the awareness of complexities.
• Culturally sensitive and appropriate environments
Aesthetics are important for women and also for
• Community development is an essential part of
engagement with women and their journey.
• Sharing lessons learned supports others when
developing and enhancing continuity of care paths
• Women and families who have generously shared their stories,
enabled tagalong experiences, assisted and donated photos for the
project. Coolamon made by Raw Kreations - Mary Moore for her
nephew baby Alfred Moore
• SNSWLHD Executive Sponsor - Executive DONM Julie Mooney &
Cherie Puckett, Nurse Manager Leadership and Practice
• Steering Committee and Project Team members
• AMIHS/BSF Manager and Clinicians
• Eurobodalla Maternity Services Management, Clinicians and
SNSWLHD Clinical Midwifery Consultant
• SNSWLHD Manager Redesign & Innovation - Judith Hallam
• Support from everyone at the NSW Agency for Clinical Innovation
Makita was pregnant with her second baby when she entered our health service. Staff knew her as she regularly used mental health and drug and alcohol services.
As an adult she drank alcohol and used illegal drugs to self medicate and manage the trauma and pain from her past.
She was born with fetal alcohol syndrome and had a less than ideal childhood.
Behavioural issues led to the removal of her first child and placement into foster care.
Makita is now a little bit older and more self aware of her issues.She realises that at 28 years of age time is running away and she wants to keep her baby.
She has a partner, but they don’t live together.
Makita is now clean from drugs and alcohol. She knows that to receive appropriate care is the best thing to guide her for her future.
She met our wonderful AMIHS M/W and AHW and developed trust for their professional and supportive approach. Her mental health continued to be fragile at times and much multidisciplinary team support was needed to get her safely through her pregnancy.
At about 30 weeks she developed gestational diabetes, and required close monitoring and a birth plan with the tertiary maternity hospital.
A few weeks later she developed pre-eclampsia, was transferred to a tertiary maternity service, about 250 kms from her home and support network. Her fetal alcohol syndrome meant that she had a volatile behaviour and limited understanding of clinical terms and procedures.
Makita was isolated, frightened and absconded from the hospital. Somehow she hitched travel back to her local community and presented straight away to AMIHS and local hospital, as she knew she needed help to safely birth her baby, when her BP was very high.
Antihypertensives, monitoring, communication and listening occurred, plus a care management plan was developed in partnership with the tertiary hospital.
A couple of days later she was transferred back to the tertiary hospital when her condition became more unstable. This resulted in an emergency C/S. The AHW and Makita’s partner hot footed it to provide birth support as she was mistrustful of people she didn’t know and was fearful of what was happening.
The C/S went as planned and a large baby girl was born at 36 weeks.
Following the C/S she was discharged from the hospital to onsite accommodation. This wasn’t to the most convenient place for a new mother to stay. Every day she had to walk from her accommodation to the NICU with her cut belly to breastfeed her baby until the baby was stable enough to be transferred back to her home town hospital.
Once back in her own environment there were still some hurdles to overcome with the hospital team caring for her. She was very anxious and suspicious of everyone as she was worried that this baby would be taken from her.
Despite her mental health, fetal alcohol and child protection issues, the AMIHS team and then the BSF team continue to provide ongoing care and support and now some six months later both she and her baby are still together.
This journey illustrates some of the general complexities and the necessity of providing continuity of care.
The hand is nurturing and supporting the seed and community. The tree represents the nurses and midwives as they develop personally and professionally in caring for their community, and shows the community growing, as it benefits from the care they are receiving. The tree is sprouting out of the seed, which is the nurses and midwives’ community and cultural identity, which the hand is helping to grow and strengthen.
The word 'dturali' is from the Darug language and means 'to grow'. Aunty Edna Watson (a Darug Elder) provided this word from language she learnt from her mother and grandfather.
By July 2016 50% AMIHS women will be booked in before 14 weeks
Now twice as many women are booking in before 14 weeks
By December 2015 Implement the recommended standards/assessments for Quit Smoking, Diabetes, Renal Diseases, VTE screening
QUIT Smoking Aboriginal Project Officer assisting
Smoking Cessation education workshops x held
Clinician confidence improved
Renal screening implemented
Diabetes screening encouraged
Consultation and referral to diabetes educators
VTE screening – draft tool in development whilst waiting for CEC maternity
3. To increase the postnatal continuity of care so that 100% AMIHS women will be followed up by the AMIHS Midwife for two weeks after birth
Clinical Supervision implemented
Mindful of staff burnout
Still a challenge due to workload and workforce constraints
Need to seek additional resources for clinical staff hours
Recruitment of AMIHS Manager progressing – unable to recruit for 7 months