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Assessing the quality of maternal health care in Indigenous primary care services

Alice R Rumbold, Ross S Bailie, Damin Si, Michelle C Dowden, Catherine M Kennedy, Rhonda J Cox, Lynette O’Donoghue, Helen E Liddle, Ru K Kwedza, Sandra C Thompson, Hugh P Burke, Alex D Brown, Tarun Weeramanthri and Christine M Connors
Med J Aust 2010; 192 (10): 597-598.

To the Editor: Improving access to appropriate, good-quality care in the antenatal and postnatal period is a key part of closing the acknowledged gap between Indigenous and other Australians in perinatal outcomes.1 Previous research in a large Aboriginal medical service in Queensland demonstrated sustained improvements in perinatal outcomes associated with a quality improvement approach.2 Here we describe patterns of the delivery of maternity care and service gaps on a broad scale, using data from baseline clinical audits in 34 Indigenous primary health centres participating in a national quality improvement intervention.3

Participating services were located across the Northern Territory (Top End and Central Australia), North Queensland, Far West New South Wales and Western Australia. Details of the audit methods have been described previously.4 Briefly, a random sample of up to 30 clinical records in each service was assessed to determine the degree of adherence to recommended protocols and procedures in the antenatal and postnatal periods.5 Records of women with an infant aged 2–14 months and who had been resident in the community for at least 6 months of the infant’s gestation were considered eligible for our study. The study was approved by the human research ethics committees in each region, and their Indigenous subcommittees where required.

Clinical records of 535 women were assessed. Eighty-nine per cent of the women were Indigenous. However, compared with services in the NT, WA and North Queensland, services in Far West NSW had a higher proportion of non-Indigenous women presenting for antenatal or postnatal care (34% v 0–6%; P < 0.05). Overall, less than half of all women presented for care in the first trimester of pregnancy (Box). Documentation of routine antenatal investigations and brief interventions or advice regarding health behaviour varied, but generally these services appeared to be underutilised. There was relatively good documentation of follow-up of identified problems relating to hypertension or diabetes, with over 70% of identified women being referred to a general practitioner or obstetrician. However, follow-up of other identified problems, such as inadequate rubella immunity, was poor.

Although 53% of women had a recorded postnatal visit, documentation of advice regarding health risk factors during the postnatal period was poor. For about half of all women there was documentation about breastfeeding advice and contraception. But advice about smoking, nutrition or mood (depression) was recorded for only 19%–21% of all women, and advice about sudden infant death syndrome prevention, injury prevention or infection/hygiene was recorded for only 4%–5% of all women.

The clinical audit data presented here indicate that participating services had both strengths and weaknesses in delivering maternal health care. Nevertheless, improving adherence to recommended screening investigations and brief interventions or advice about health behaviours, particularly smoking cessation, in the antenatal and postnatal period were identified as clear areas for improvement across all services.

This information represents baseline data to inform the long-term monitoring of a quality improvement intervention. More broadly, it should be useful for informing local, regional and national efforts to promote and assess the quality of primary maternal health care for Indigenous women, and thus help address the persisting unacceptably high rates of poor Indigenous perinatal outcomes in Australia.

Documented pregnancy care across regions

Characteristic

NT Top End

NT Central Australia

Far West NSW

Western Australia

North Queensland

Total


Number of health centres | number of client records audited

13 | 136

2 | 45

6 | 103

9 | 193

4 | 58

34 | 535

Proportion of women with estimated gestational age < 12 weeks at first antenatal visit

49%

44%

35%

42%

34%

42%

Mean number of antenatal visits

9

10

5

6

7

7*

Proportion of women with folate prescribed before 20 weeks

29%

49%

3%

33%

24%

27%*

Any use of:

Cigarettes

41%

40%

39%

42%

55%

43%

Alcohol

12%

27%

19%

25%

31%

22%*

Illicit drugs

7%

2%

17%

8%

7%

9%

Brief interventions or counselling

Smoking cessation

48%

67%

35%

49%

41%

46%

Antenatal education

51%

93%

51%

46%

47%

52%*

Nutrition

53%

76%

18%

32%

59%

41%*

Breastfeeding

21%

51%

17%

25%

19%

24%

Alcohol and other substance abuse

37%

56%

12%

39%

34%

34%*

Investigations at first antenatal assessment

Blood group/Rh

96%

100%

65%

77%

79%

82%*

Antibodies

93%

100%

66%

70%

78%

79%*

Midstream urine (MSU)

91%

96%

40%

67%

76%

71%*

Full blood examination (FBE)

95%

100%

64%

73%

79%

80%*

Rubella

92%

100%

61%

70%

78%

77%*

Hepatitis B surface antigen

91%

100%

56%

75%

79%

78%*

Syphilis serology

94%

100%

58%

55%

81%

72%*

HIV

80%

89%

14%

72%

59%

63%*

Offered anomaly screening

6%

33%

17%

20%

0%

15%*

Other investigations

Ultrasound before 16 weeks

32%

49%

38%

39%

24%

36%

Ultrasound at 16–20 weeks

47%

69%

31%

41%

34%

42%

50g or 75g glucose challenge test (GCT) or
glucose tolerance test (GTT)

78%

49%

33%

38%

66%

51%*

FBE (20–28 weeks)

82%

69%

24%

46%

60%

54%*

Low vaginal swab for group B streptococcus
(34–37 weeks)

49%

62%

31%

29%

10%

35%*

Follow-up of abnormal findings

Record of abnormal standard GCT

17% (23/136)

22% (10/45)

10% (10/103)

4% (7/193)

17% (10/58)

11% (60/535)*

GTT undertaken

87% (20/23)

90% (9/10)

80% (8/10)

43% (3/7)

60% (6/10)

77% (46/60)

Anaemia (Hb < 100 g/L)

14% (19/136)

22% (10/45)

11% (11/103)

12% (24/193)

3% (2/58)

12% (66/535)*

Iron prescribed

84% (16/19)

100% (10/10)

91% (10/11)

75% (18/24)

50% (1/2)

83% (55/66)

Follow-up FBE or Hb test done

42% (8/19)

90% (9/10)

36% (4/11)

46% (11/24)

50% (1/2)

50% (33/66)

Nitrites detected by dipstick

21% (28/136)

33% (15/45)

5% (5/103)

24% (46/193)

10% (6/58)

19% (100/535)*

Urine sent for culture and sensitivity

96% (27/28)

100% (15/15)

100% (5/5)

93% (43/46)

100% (6/6)

96% (96/100)

Oral antibiotic prescribed

93% (26/28)

60% (9/15)

80% (4/5)

37% (17/46)

83% (5/6)

61% (61/100)*

Record of a normal follow-up MSU

46% (13/28)

100% (15/15)

40% (2/5)

26% (12/46)

83% (5/6)

47% (47/100)*

Rubella antibodies negative or low-titre

35% (47/136)

7% (3/45)

15% (15/103)

15% (28/193)

7% (4/58)

18% (97/535)*

Rubella vaccination given postnatally

36% (17/47)

67% (2/3)

13% (2/15)

32% (9/28)

0 (0/4)

31% (30/97)


GTT = glucose tolerance test. Hb = haemoglobin. NSW = New South Wales. NT = Northern Territory. * P < 0.05 for comparisons between regions.  Among those who used cigarettes: NT Top End (n = 56), NT Central Australia (n = 18), Far West NSW (n = 40), WA (n = 82), North Queensland (n = 32); total N = 228.

Alice R Rumbold, Senior Research Fellow1
Ross S Bailie, Senior Principal Research Fellow2
Damin Si, Postdoctoral Research Fellow3
Michelle C Dowden, Manager of Primary Health Care4
Catherine M Kennedy, Data Analyst and Far West NSW Hub Coordinator, ABCD Project5
Rhonda J Cox, Quality Improvement Project Officer and WA Hub Coordinator, ABCD Project6
Lynette O’Donoghue, Health Promotion Quality Improvement Facilitator2
Helen E Liddle, Central Australian Hub Coordinator, ABCD Project7
Ru K Kwedza, Program Manager Quality Improvement and ABCD Project8
Sandra C Thompson, Professor, Centre for International Health6
Hugh P Burke, Public Health Physician5
Alex D Brown, Director9
Tarun Weeramanthri, Executive Director10
Christine M Connors, Northern Territory Preventable Chronic Disease Program Leader11
1 Department of Obstetrics and Gynaecology, University of Adelaide, Adelaide, SA.
2 Menzies School of Health Research, Darwin, NT.
3 Centre for Chronic Disease, University of Queensland, Brisbane, QLD.
4 Ngalkanbuy Health Service, Elcho Island, NT.
5 Maari Ma Health Aboriginal Corporation, Broken Hill, NSW.
6 Curtin University of Technology, Perth, WA.
7 Menzies School of Health Research, Alice Springs, NT.
8 Queensland Health, Brisbane, QLD.
9 Centre for Indigenous Vascular and Diabetes Research, Baker IDI Heart and Diabetes Institute, Alice Springs, NT.
10 Public Health Division, Department of Health, Government of Western Australia, Perth, WA.
11 Northern Territory Department of Health and Families, Darwin, NT.
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