Having a baby in the new land : a qualitative exploration of the experiences of Asian migrants in rural Tasmania, Australia

Introduction: Australia is a land of cultural diversity. Cultural differences in maternity care may result in conflict between migrants and healthcare providers, especially when migrants have minimal English language knowledge. The aim of the study was to investigate Asian migrant women’s child-birth experiences in a rural Australian context.

Method: The study consisted of semi-structured interviews conducted with 10 Asian migrant women living in rural Tasmania to explore their childbirth experiences and the barriers they faced in accessing maternal care in the new land. The data were analysed using grounded theory and three main categories were identified: ‘migrants with traditional practices in the new land’, ‘support and postnatal experiences’ and ‘barriers to accessing maternal care’.

Results: The findings revealed that Asian migrants in Tasmania faced language and cultural barriers when dealing with the new healthcare system. Because some Asian migrants retain traditional views and practices for maternity care, confusion and conflicting expectations may occur. Family and community play an important role in supporting migrant women through their maternity care.

Conclusions: Providing interpreting services, social support for migrant women and improving the cross-cultural training for healthcare providers were recommended to improve available maternal care services.

Folate fortification : a case study of public health policy-making

Introducing Evidence Based Health Policy: Problems and Possibilities, Section 1: What is the Problem?, 1: Competing Rationalities: Evidence based Health Policy, 2: Beyond Two Communities, Section 2: What does Evidence Mean?, 3: Evidence based Medicine - The Medical Profession and Health Policy, 4: Mind The Gap: Assessing the Quality of Evidence for Public Health Problems, 5: Health Policy and Normative Analysis: Ethics, Evidence and Politics, 6: What is New in Health Information? Evidence for Health Consumers and Policy Making, 7: From Evidence based Medicine to Evidence based Public Health, Section 3: Policy Case Studies, 8: The Viagra Affair: Evidence as the Terrain for Competing Partners, 9: Folate Fortification: A Case Study of Public Health Policy-Making in a Food Regulation Setting, 10: The Supply and Safety of Blood and Blood Products - Evidence, Risk and Policy, 11: The Development of Nurse Practitioner Policy, 12: Creating Healthy Public Policy for Oral Health: How was the Evidence Used?, 13: Regulation of Traditional Chinese Medicine in Victoria, 14: The Victorian Primary Health Care Reforms: A Case Study of Evidence-based Policy Making, 15: Evidence-based Practice in the Australian Drug Policy Community, 16: Challenging the Evidence - Women's Health Policy in Australia, 17: Evidence and Aboriginal Health Policy, 18: The Limits to Technical Rationality in the Health Inequalities Policy Process, 19: Evidence-based policy: A Technocratic Wish in a Political World, Section 4: Is the transfer of evidence into policy possible?, 20: The Community Model of Research Transfer, 21: Getting Research Transfer into Policy and Practice in Maternity Care, 22: Improving the Research and Policy Partnership: An Agenda for Research Transfer and Governance, 23: Framing and Taming 'Wicked' Problems

Evaluation of a decision aid for prenatal testing of fetal abnormalities : a cluster randomised trial [ISRCTN22532458]

Background: By providing information on the relative merits and potential harms of the options available and a framework to clarify preferences, decision aids can improve knowledge and realistic expectations and decrease decisional conflict in individuals facing decisions between alternative forms of action. Decision-making about prenatal testing for fetal abnormalities is often confusing and difficult for women and the effectiveness of decision aids in this field has not been established. This study aims to test whether a decision aid for prenatal testing of fetal abnormalities, when compared to a pamphlet, improves women's informed decision-making and decreases decisional conflict.

Methods/design: A cluster designed randomised controlled trial is being conducted in Victoria, Australia. Fifty General Practitioners (GPs) have been randomised to one of two arms: providing women with either a decision aid or a pamphlet. The two primary outcomes will be measured by comparing the difference in percentages of women identified as making an informed choice and the difference in mean decisional conflict scores between the two groups. Data will be collected from women using questionnaires at 14 weeks and 24 weeks gestation.

The sample size of 159 women in both arms of the trial has been calculated to detect a difference of 18% (50 to 68%) in informed choice between the two groups. The required numbers have been adjusted to accommodate the cluster design, miscarriage and participant lost – to – follow up.

Baseline characteristics of women will be summarised for both arms of the trial. Similarly, characteristics of GPs will be compared between arms.

Differences in the primary outcomes will be analysed using 'intention-to-treat' principles. Appropriate regression techniques will adjust for the effects of clustering and include covariates to adjust for the stratifying variable and major potential confounding factors.

Discussion: The findings from this trial will make a significant contribution to improving women's experience of prenatal testing and will have application to a variety of maternity care settings. The evaluation of a tailored decision aid will also have implications for pregnancy care providers by identifying whether or not such a resource will support their role in providing prenatal testing information.

Working together : collaboration between midwives and doctors in public hospitals

While collaborative, multidisciplinary teamwork is widely espoused as the goal of contemporary hospitals, it is hard to achieve. In maternity care especially, professional rivalries and deep-seated philosophical differences over childbirth generate significant tensions. This article draws on qualitative research in several Victorian public maternity units to consider the challenges to inter-professional collaboration. It reports what doctors and midwives looked for in colleagues they liked to work with — the attributes of a “good doctor” or a “good midwife”. Although their ideals did not entirely match, both groups respected skill and hard work and sought mutual trust, respect and accountability. Yet effective working together is limited both by tensions over role boundaries and power and by incivility that is intensified by increasing workloads and a fragmented labour force. The skills and qualities that form the basis of “professional courtesy” need to be recognised as Aust Health Rev 2009: 33(2): 315–324 essential to good collaborative practice.

Difficult birth for power sharing

There is meant to be collaboration between doctors and midwives in maternity care but this is being hindered by unequal and disrespectful cultures and practices.

Primary prevention of gestational diabetes for women who are overweight and obese : a randomised controlled trial

Background: Gestational Diabetes Mellitus (GDM) has well recognised adverse health implications for the  mother and her newborn that are both short and long term. Obesity is a significant risk factor for developing GDM and the prevalence of obesity is increasing globally. It is a matter of public health importance that clinicians have evidence based strategies to inform practice and currently there is insufficient evidence regarding the impact of dietary and lifestyle interventions on improving maternal and newborn outcomes. The primary aim of this study is to measure the impact of a telephone based intervention that promotes positive lifestyle modifications on the incidence of GDM. Secondary aims include: the impact on gestational weight gain; large for gestational age babies; differences in blood glucose levels taken at the Oral Glucose Tolerance Test (OGTT) and selected factors relating to self-efficacy and psychological wellbeing. 

Health cosmopolitanism: melding universality and difference – the case of childbirth in post-conflict Timor Leste

ABSTRACTThis study will consider the case of TBAs (traditional birth attendants) under the health cosmopolitan banner. Fifteen interviews with health administrators, obstetricians, midwives, traditional birth attendants and women in Timor Leste, provide evidence : (1) that the WHO (1992) directive to dismiss the inclusion of TBAs within the formal maternity care system has been precipitous (2) that TBAs could, with adequate training in emergency obstetric techniques and hygienic practices, assist in meeting MDG No 5, and (3) that TBAs may assist in sustaining hybrid cosmologies and serving other cultural aims. Although Millennium Development Goals embrace the idea of the universal right to health, a human rights framework remains abstract and legalistic. I argue that health cosmopolitanism offers a more inclusive lens. Applied to maternity care it shifts childbirth to a central focus of government policy, obliges all nations to contribute international aid yet recognises the interpretation of complex needs at the local level. It defines a philosophy of care that is person-centred (not professional or institution-centred), ensures equal access to quality care (based not on ability to pay or other obstacles such as geographical distance) and choice of carer and modality (Western, traditional or hybrid). It underlines the argument here that TBAs trained in emergency obstetric care and hygiene and funded by international agencies would ensure every woman has a known carer, plus choice of location, modality and provider. Health cosmopolitanism thus embraces universality, individual autonomy, reciprocal respect and global responsibility.

Pluralist risk cultures: the sociology of childbirth

Western medical approaches to childbirth typically locate risk in women’s bodies,making it axiomatic that ‘good’ maternity care is associated with medically trainedattendants. This logic has been extrapolated to developing societies, like Vanuatu, anIsland state in the Pacific, struggling to provide good maternity care in line with theWorld Health Organization’s Millennium Development Goals. These goals include thereduction of maternal mortality by two-thirds by 2015, but Vanuatu must overcomechallenging hurdles – medical, social and environmental – to achieve this goal.Vanuatu is a hybridised society: one where the pre-modern and modern coincide inparallel institutions, processes and practices. In 2010, I undertook an inductive study of30 respondents from four main subcultures – women living in outer rural communitieswith limited access to Western-trained health workers; women from inner urbancommunities with ease of access to medical clinics; traditional birth attendants whoare formally untrained but highly specialised and practised mainly in remote communities;and Western-trained medical clinicians (obstetricians and midwives). I invitedall the participants to comment on what constituted a ‘good birth’. In this article, Ishow that participants interpreted this variously according to how they believed theuncertainties of childbirth could be managed. Objectivist approaches that define risk asan objective reality amenable to quantifiable measurement are thus rendered inadequate.Interpretivist approaches better explain the reality that social actors not only findrisk in different sites but gravitate towards different practices, discourses and individualsthey can trust especially those with whom they feel a strong sense of community.Strategies are, therefore, formed less through scientific rationality but according tofeelings and emotions and the lived experience. The concept of risk cultures conveysthis complexity; they are formed around values rather than calculable rationalities. Riskcultures form self-reflexively to manage contingent circumstances.

The return of the traditional birth attendant

The World Health Organization has noted much progress towards the realisation of Millennium Development Goals related to maternal and child health. Eighty percent of women in many developing economies now receive at least one visit during pregnancy by a skilled birth attendant (although only 52% had the recommended four visits), and 68% of women across developing regions receive skilled health attendant care (up from 56% in 1990). However, disparities follow regional and urban-rural gaps. Sub-Saharan Africa and Southern Asia lag behind other regions in the provision of antenatal care and skilled attendance at birth (although typically attended by a family member or villager) and over 32 million of the 40 million births not attended by skilled health personnel in 2012 occurred in rural areas. Overall, one-quarter of women in developing nations still birth alone or with a relative to assist them. While increased numbers of medically-trained midwives and health workers or midwife assistants would increase coverage by up to 40%, these are longer-term solutions. In the short term, gross disparities in services in some resource-poor areas have been alleviated by recruiting Traditional Birth Attendants (TBAs) re-trained in emergency obstetric skills to deal with emergency situations and to refer women onto health facilities when necessary. Samoa and Bangladesh are examples. For many women for a range of reasons TBAs are preferable to hospital care. It therefore makes sense to recognise their place within maternity care, to offer basic and ongoing training and to set up registration procedures thus better ensuring the monitoring of outcomes. Incorporating TBAs into the formal healthcare system would meet both physiological and relational components of birth. In terms of the latter, TBAs would act as cultural brokers between Western and traditional cosmologies and provide women with continuity of care from a known carer; in the West a demonstrably simple but effective intervention promoting physiological safety and reducing the need for higher level medical interventions.

The plasticity of professional boundaries: a case study of collaborative care in maternity services

A case study of twenty-nine midwives and nine obstetricians working in a regional, public sector Australian hospital demonstrates the plasticity of professional boundaries within a post-welfare state. Driven by new discourses of globalisation, marketisation, managerialism and consumerism, professional boundaries in health care are being blurred, reordered and reconstituted. Government policies that call for a new interdisciplinarity between maternity professionals may be seen as responses to the above pressures. However, there remain considerable barriers to achieving collaborative models including conflicting interpretations of risk, of women's bodies and of childbirth; the veto power of decision-making retained by obstetricians; questions of professional accountability; and diversity over appropriate styles of micro-interaction. Collaboration demands a new egalitarianism to eclipse the old vertical system of obstetric dominance and this means that midwives need to create a distinctive professional specialty, or new object of knowledge. Midwives' skill in 'emotion management' could provide this speciality in addition to their rational-technical knowledge and thus elevate midwifery to an equivalent professional status with obstetrics but as yet neither obstetrics nor midwifery have realised its professionalising potential

Multiple visions or multiple aversions? Consumer representation, consultation and participation in maternity issues

This paper reviews the Commonwealth government's policy of 'purposeful reporting to consumers'. I argue that the notion of consumer participation is underdeveloped. Consumers' needs will not be fully met by confining consumer representation at the administrative level; that is, in assuming that consumer advocates may speak for other consumers of health care services. The partnership objective at the heart of 'purposeful reporting' may be addressed fully only when practitioners and providers recognise the reciprocal expertise of the consumer in defining their own health priorities. This would require a new model of knowledge, of ethics and of the clinical encounter. The problem is not one of information deficit but of contrasting views of knowledge.

Report of the mid-term review of Victoria's maternity services program

Substantial State Government funding has bun committed in Victoria for the enhancement of maternity services. The funding is intended to improve the quality of care for women and meet consumer expectations for choice and continuity of care in maternity services. This paper reports on a mid-term review (the 'review') of the Victorian Maternity services Program. which was conducted by the authors on behalf of the Victorian Department of Human Services. Documentary analysis was conducted for the review, and workshops and key informant interviews were held throughout Victoria with midwives, medical staff and Department of Human Services staff. The review found that there had been many gains as a result of the Maternity services Program and identified directions for further development. Issues of change and facilitators of change processes in maternity services are highlighted in this article.

Still suffering from the `silo effect`: lingering cultural barriers to collaborative care

This research project sought to draw out the contesting definitions of collaborative care among professional subgroups in maternity services. The paper contrasts medical and social models of knowledge and reports on qualitative evidence from midwives and doctors in Australian hospitals. The evidence indicates that collaborative care is welcomed by both midwives and doctors but that there remains a lingering residue of the ‘silo effect’ of the ‘old’ professionalism, characterized by hierarchical relations, divergent philosophies and competing domains. Although a ‘new professionalism’ has emerged that challenges the old hierarchies and professional dependencies, it too harbours lingering residues of the former dichotomy between midwives and obstetricians. These tensions and enmities will need to be resolved before genuine collaboration may take full effect. The objective is a relationship focused model of care that transcends professional or woman-focused models. The ‘new’ professionalism may be expedited through mediation strategies, a version of which is the ‘sociological intervention method’ discussed in this article.

Maternity waiting homes in Southern Lao PDR : the unique 'silk home'

The concept of maternity waiting homes (MWH) has a long history spanning over 100 years. The research reported here was conducted in the Thateng District of Sekong Province in southern Lao People’s Democratic Republic (PDR) to establish whether the MWH concept would be affordable, accessible, and most importantly acceptable, as a strategy to improve maternal outcomes in the remote communities of Thateng with a high proportion of the population from ethnic minority groups. The research suggested that there were major barriers to minority ethnic groups using existing maternal health services (reflected in very low usage of trained birth attendants and hospitals and clinics) in Thateng. Unless MWH are adapted to overcome these potential barriers, such initiatives will suffer the same fate as existing maternal facilities. Consequently, the Lao iteration of the concept, as operationalized in the Silk Homes project in southern Lao PDR is unique in combining maternal and infant health services with opportunities for micro credit and income generating activities and allowing non-harmful traditional practices to co-exist alongside modern medical protocols. These innovative approaches to the MWH concept address the major economic, social and cultural barriers to usage of safe birthing options in remote communities of southern Lao PDR.

Mothers' transition back to work and infants' transition to child care : does work-based child care make a difference?

The overall aim in this study was twofold: to compare the use of work-based (WB) and non-work-based (NWB) child care on the transition back to the workplace for women after a period of maternity leave, and on the transition into child care for the infants of these women. Thirty-five mothers with infants in WB centres and 44 mothers with infants in NWB centres completed a battery of questionnaires, retrospectively, in relation to their first four weeks of resuming work and their infant’s transition into child care. We first explored whether the mothers of infants in WB centres were less stressed and anxious
about separating from their infant, were more satisfied with their child care, and whether they felt more productive and supported at work than mothers of infants in NWB child
care centres. Our findings revealed no differences between mothers using WB centres and NWB centres in their transition to work. In exploring whether infants placed in WB centres settled faster and more easily than infants placed in NWB centres, the findings, once again, revealed no differences in the infant’s affective states at child care and maintenance of their routines, such that all infants were equally settled and happy irrespective of the type of care used. The theoretical and practical implications of our findings are discussed.