Accepted Manuscript

Implementation of midwifery continuity of care models for Indigenous

women in Australia: perspectives and reflections for the United
Kingdom

C. Fernandez Turienzo , Y. Roe , H. Rayment-Jones ,

A. Kennedy , D. Foster , CSE. Homer , H. McLachlan , J. Sandall

PII: S0266-6138(18)30335-8
DOI: https://doi.org/10.1016/j.midw.2018.11.005
Reference: YMIDW 2377

To appear in: Midwifery

Received date: 21 September 2018

Accepted date: 17 November 2018

Please cite this article as: C. Fernandez Turienzo , Y. Roe , H. Rayment-Jones , A. Kennedy ,
D. Foster , CSE. Homer , H. McLachlan , J. Sandall , Implementation of midwifery continuity of care
models for Indigenous women in Australia: perspectives and reflections for the United Kingdom, Mid-
wifery (2018), doi: https://doi.org/10.1016/j.midw.2018.11.005

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 ACCEPTED MANUSCRIPT

Implementation of midwifery continuity of care models

for Indigenous women in Australia: perspectives and
reflections for the United Kingdom

Fernandez Turienzo Ca, Roe Yb, Rayment-Jones Ha, Kennedy Ac, Foster Dd,e,, Homer CSEf,g,
McLachlan He and Sandall Ja,g

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a
Department of Women and Children’s Health, School of Life Course Sciences, Faculty of
Life Sciences and Medicine, King’s College London, United Kingdom

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b
Midwifery Research Unit, Mater Medical Research Institute, University of Queensland,
Australia

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Midwifery Group Practice, Alice Springs Hospital, Central Australian Health Service
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d
The Royal Women’s Hospital, Melbourne, Australia

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Judith Lumley Centre, School of Nursing and Midwifery, La Trobe University, Australia
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f
Centre for Midwifery, Child and Family Health, Faculty of Health, University of Technology
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Sydney, Australia

g
Burnet Institute, Melbourne, Australia
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Corresponding author: Cristina Fernandez Turienzo, Department of Women and Children’s

Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s
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College London, United Kingdom. Email: cristina.fernandez_turienzo@kcl.ac.uk ; Tel:

07723953703

Conflict of Interest
None declared

Ethical Approval
Not applicable

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Funding sources
CFT is supported by The Florence Nightingale Foundation and The General Nursing Council
for England and Wales Trust. CFT and JS are supported by the NIHR Collaboration for
Leadership in Applied Health Research and Care South London at King’s College Hospital
NHS Foundation Trust. The views expressed are those of the authors and not necessarily
those of the NHS, the NIHR or the Department of Health.

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ABSTRACT
Maternity models that provide midwifery continuity of care have been established to increase
access to appropriate services for Indigenous Australian women. Understanding the
development and implementation of continuity models for Indigenous women in Australia
provides useful insights for the development and implementation of similar models in other
contexts such as those for vulnerable and socially disadvantaged women living in the United

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Kingdom. To ensure better health outcomes for mothers and babies, it is crucial to promote

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culturally competent and safe public health models in which midwives work collaboratively
with the multidisciplinary team.

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SHORT COMMUNICATION / COMMENTARY
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Disparities in health outcomes between Aboriginal and Torres Strait Islander peoples
(hereafter referred to as Indigenous Australians) and non-Indigenous Australians are well
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known. The health status of Indigenous Australians is universally described within a deficit
model i.e. life expectancy is 10–11 years less than their Australian counterparts, and they
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more likely experience chronic and communicable diseases, cancer, poor eye and dental
health, social and emotional distress, and family violence 1. Compared with non-Indigenous
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women, pregnant Indigenous women are more likely to die during childbirth, smoke during
pregnancy and have more low birthweight babies and preterm births 2. This health profile is
very representative of intergenerational social economic disadvantage experienced by
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Indigenous people worldwide. Contributing factors are complex and range from the enduring
effects of colonialism, social exclusion, systemic institutional racism, genetic predisposition
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and lifestyle issues1. For decades, Indigenous women in many countries including Australia
have been championing culturally safe health services that promote health and wellbeing and
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includes a suite of services that improve pregnancy and birthing outcomes; prevention, early
detection and treatment to address risk factors, reduce the burden of disease and increase
survival rates2. To guarantee better health outcomes, public health strategies need to include
knowledge and awareness of the Indigenous history, experience, culture and rights.

There have been a number of reports and strategies in Australia (i.e. Royal Commission into
Aboriginal Deaths in Custody 1991 and the National Aboriginal Health Strategy 1989) as

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well as national campaigns that have aimed to close the health and life expectancy gap
between Indigenous and non-Indigenous Australians. One national initiative has been the
‘Close the Gap’ Campaign3 which has intended to reduce neonatal and child mortality and to
improve access to culturally appropriate health care. The Australian National Maternity
Services Plan4 was also used to highlight the importance of promoting access to models of
care that provide continuity of care to improve health outcomes for Indigenous mothers and
babies5. Several maternity models that provide midwifery continuity of care have since been
established to increase access to appropriate maternity services for Indigenous women in

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Australia6. Some examples include the Malabar Midwifery Community Service in South

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Eastern Sydney7 ; The Murri Antenatal Clinic in South Brisbane which informed the Birthing

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in Our Community inter-agency life-course approach programme8; the Baggarrook Yurrongi
(Woman’s Journey) project in Melbourne and three more Victorian health services9; and the
Midwifery Group Practice at the Alice Springs Hospital in the Northern Territory (NT) 10.

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This commentary paper is the result of a study tour organised to understand the development
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and implementation of continuity of care models for Indigenous women in Australia and
reflect on observations and lessons that could be useful for the development and
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implementation of continuity models for women living socially complex lives in the United
Kingdom (UK). Meeting with Australian colleagues has been crucial to understand the
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complex redesign of maternity services and the implementation and sustainability of

continuity of care models for Indigenous women who are living in the cities of Sydney,
Melbourne and Brisbane, and the remote town of Alice Springs in the centre of the country.
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The study tour provided important insights into the diversity of service models in different
geographic areas and the challenges faced by women accessing services and health services
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providing services. Collectively the sites shared similarities and differences. Each site was
unique and there are numerous lessons to learn. Lessons learnt suggest that four
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implementation strategies were crucial: (1) establishing cohesive partnerships and

collaborations to enhance funding, (2) having a shared vision and good leadership, (3)
communicating clearly and engaging regularly with stakeholders (3) and promoting culturally
and clinically competent public health models in which midwives work collaboratively with
the multidisciplinary team including Indigenous health workers or health education officers,
public health officers, obstetricians, general practitioners, psychologists, mental health nurses
and support workers, paediatricians, and family and child nurses to facilitate a smooth
transition to community and primary health services.

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While these observations and lessons are from Australia and are highly contextualised
(particularly the NT), there may be aspects that we can apply in other contexts, like the UK.
Indigenous women, babies and families in Australia as well as many women, babies and
families living socially complex lives in the UK often have a common experience of social
and economic disadvantage, which results in poor health outcomes. Similarly, to some
Indigenous women, socially disadvantaged women in the UK (e.g. those living in poverty;
migrants, refugees and non-English speakers; domestic violence, substance abuse; young

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motherhood)11 are more likely to have poorer birth outcomes, including more preterm births,

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stillbirths and both maternal and neonatal deaths. They also have more negative experiences

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of care than any other group of women and struggle to access and engage with maternity
services12,13. Although the reasons for this are not fully understood, there are similar
contributing factors: inequality of access to services, language barriers, fear of surveillance or

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disclosure to border agencies, unfamiliarity with processes, discrimination, or maternity care
having less priority for women dealing with other more important issues such as poverty and
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gender violence.

In the UK, there is maternal policy focusing on increasing continuity of care models14 and
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prioritizing the reduction of poor outcomes experienced by socially disadvantaged

populations and women living socially complex lives12,13. This is a far cry from the reality of
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what the current fragmented maternity system provides. The fragmented approach is the
current standard maternity care for most vulnerable women and usually involves women
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seeing a number of different healthcare professionals throughout pregnancy and postnatally.

Few services across the country provide continuity of care throughout pregnancy and
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childbirth to women with social risk factors15. Identifying effective implementation strategies
is crucial to develop and scale up continuity of care models that work for vulnerable women
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in the UK. A culturally competent and community-based model which adopts a life course
approach similar to Australian models, might help to close the gap, facilitate care
coordination with primary health services and improve the outcomes and experiences of
socially disadvantaged populations and women living socially complex lives.

Declaration of interests
All authors declare no competing interests.

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