National Aboriginal and Torres Strait Islander Child and Maternal Health Exemplar Site Initiative: Site Reports 2005

This report is a synthesis of reports provided by Nganampa Health Council, Townsville Aboriginal and Islanders Health Services and Durri Aboriginal Medical Service under the National Aboriginal and Torres Strait Islander Child and Maternal Health Exemplar Site Initiative. The report has been compiled by the Office for Aboriginal and Torres Strait Islander Health (OATSIH), in consultation with each of the Exemplar Sites.

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Table of Contents

1. Introduction
2. Nganampa Health Council Child and Maternal Health Program
3. Townsville Aboriginal and Islanders Health Services Mums and Babies Program
4. Durri Aboriginal Medical Service Djuli Galban Program

1. Introduction

The National Aboriginal and Torres Strait Islander Child and Maternal Health Exemplar Site Initiative was funded by the Office for Aboriginal and Torres Strait Islander Health (OATSIH) from 2002-03 to 2005-06. The primary aim of the initiative was to document the elements of successful child and maternal health service provision to Aboriginal and Torres Strait Islander communities to inform child and maternal health policy and program development.

A Child and Maternal Health Exemplar Site is an identified Aboriginal community controlled health service selected as a 'best practice' site in the regional delivery of child and maternal health services in a comprehensive primary health care setting.

Three sites were established under the initiative:

• Townsville Aboriginal and Islander Health Service’s Mums and Babies Program (June 2002)
• Nganampa Health Council’s Child and Maternal Health Program (May 2003)
• Durri Aboriginal Health Service Djuli Galban Program (May 2004).

The Exemplar Sites operate in very different contexts and have developed models of service delivery to reflect the unique situation and needs of their client populations. For the purpose of this report, each Exemplar Site has provided valuable information on the context of their child and maternal health service delivery and what factors they have found are important to ensuring successful outcomes.

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2. Nganampa Health Council Child and Maternal Health Program

Nganampa Health Council (NHC) is an Anangu community controlled health organisation providing comprehensive primary health care services to all people living on the Anangu Pitjantjatjara Yankunytjatjara Lands, a region of 120,000 sq km, situated in the far northwest of South Australia. There are six major clinics and three clinics in smaller communities, plus an additional Health Worker Station. The administrative centre is based at Umuwa and there is also an office in Alice Springs to house finance, supply and purchasing, payroll, mail services, data entry, hospital liaison and transport and as a base for some program coordination.

In addition to twenty-four hour primary clinical care, the organisation delivers a range of public health and targeted program activity and health worker training and support.

The permanent population is approximately 2,700 but there are a large and increasing number of people who spend some time on the lands each year as well as large numbers of visitors.

Components of the NHC Child and Maternal Health Program include:

• An Antenatal Care Program;
• Development and delivery of Key Messages Health Education Packages for young mothers; and
• Child Health Program including:
  • childhood immunisation
  • protocolised growth monitoring for under 5s
  • targeted child health screening at ages 5, 10 and 14.

Antenatal Care Program

In this region the most recent population census performed by NHC showed that 51.6% of the population are women, 31.2% of these are less than 15 years of age and 63.1% under 30 years of age. There are 277 children under 5 years of age. There are generally 45 to 50 births per year.

There are no available data on antenatal care or health status prior to the establishment of NHC. However at that time very few women presented for care prior to the end of the second trimester and it is estimated that very few women would have received adequate care. Towards the end of the 1980s NHC began the process of developing a more systematic and sustained approach to improving antenatal care. This has involved the implementation of a number of steps which include:

• making antenatal care a key focus for staff;
• developing a standardised proforma for assessing and recording antenatal care;
• regular review of antenatal care data with a special focus on birth weight; and
• a policy of employing a midwife in each clinic.

NHC has also committed to:

• developing a close relationship between midwives and pregnant women;
• developing mechanisms for supporting pregnant women in hospital and preparing them for delivery in hospital; and
• utilising the relationship between midwives and pregnant women to begin delivering key messages about early maternal practice and infant care.

The Antenatal Care Program continues to be a major priority for NHC and in particular increasing the links between antenatal care and early childhood development and growth. Service clinics employ either a midwife or a nurse trained in Maternal Emergency Care. In addition to day-to-day care on the Lands, women who visit Alice Springs for ultrasound, obstetric or gynaecological appointments are able to access the support of a midwife.

Antenatal support and education continues in Alice Springs whilst women are waiting to birth ("sitting down") at Mt Gillen Accommodation facility. The support and education has a key focus on any specific medical conditions the woman may have, the forthcoming labour and birth process and postnatal issues. An important process is a midwife escorting pregnant women to town and visiting the hospital and delivery ward prior to the delivery period. This has been very successful for NHC. Midwives continue to offer support once women have returned to the community after delivering. In general it is not possible for NHC midwives to participate in births in the Alice Springs hospital.

NHC has developed a series of targets for antenatal care which focus on:

• early presentation;
• more than 5 antenatal visits;
• standardised testing, screening and surveillance;
• optimal timing of ultrasound performance; and
• birth weight.

In the past almost no pregnant women presented to the clinic in the first trimester and most had few antenatal visits. There has been incremental improvement in all outcome measures.

2003-04 Program data indicate:

• 32 women accessed the Antenatal Care Program (there were fewer births than most years);
• 60% of women presented at or prior to 16 weeks of pregnancy;
• Number of antenatal visits:
  • under 2 visits - 6%
  • 5-10 visits - 50%
  • over 10 visits - 34%
  • not provided - 9%; and
• 6% of babies were born with low birth weight compared to 15% in the mid 1980s.

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Key Messages Health Education Package for Anangu Girls and Young Women

The "Young Women Choosing Wisely Program" has commenced in most communities across the Lands. Through the Program nurses and health workers work together with senior community women or Anangu education workers or school teachers to teach about reproduction, contraception, pregnancy, birth and sexual health issues.

A teaching package covering key health messages for young mothers is expected to be finalised in 2005. The delivery of this education program will link closely with the Antenatal Care Program.

Child Health Program

The Child Health Program delivers services in the areas of child growth and development, school aged screening and immunisation. Clinic staff strive to deliver services through a range of strategies that involve health promotion, disease prevention and health screening processes that facilitate early detection and treatment or referral of children to secondary and tertiary services.

Child Growth and Development

Nutrition and child growth education and support, including referral/follow-up is provided to parents/carers.

Growth monitoring is undertaken with children aged 0-5 years and is supported by the use of clinical policy and process guides (based on WHO guidelines) and resources to assess and facilitate access to early intervention requirements. A database has been established by the Child Health Team to monitor weight gain progress of all children participating in the program.

Growth Action Plans are developed with parents/carers. These are supported by culturally appropriate resource materials that outline required nutritional intake for optimum growth and menus that are simple to prepare with food that is accessible within the community.

Current Growth Status

In 2003/2004 NHC conducted a cross-sectional study of all children born between July 1999 and June 2003. There were 151 term children (gestational age >=37 weeks). The average birth weight of these children was 3.3kg. Weight-for-age and height-for-age fell markedly in the second year of life. There was a moderately high prevalence of stunting in the second and third years of life but there was essentially no wasting (severe malnutrition). This is a pattern of significant improvement in comparison to surveys in the mid 1980s when wasting rates were as high as 15% in some communities and to the mid 1990s when rates of stunting were higher than those in this survey.

School Aged Screening Program

NHC, in partnership with local community schools, parents and children, conduct school aged health screens every year on children 5 years, 10 years and 15 years in every community across the Lands. The Program also provides health education for the child and their family. Program data (2000-2004) indicate:

• 83% of all 5 year olds were screened;
• 80% of all 10 year olds were screened; and
• 66% of all 15 year olds were screened.

Anaemia

Program data demonstrate high rates of anaemia in the 6 month - 5 year age group. In 2004 the rate was 41%. At follow-up, treatment of anaemia was required in half these children.

The origins of anaemia are complex. It is likely that low maternal iron stores and high rates of infection are important contributors. A major problem is that oral iron therapy is often ineffective while there are some practical problems in parenteral administration. On the basis of data from this program NHC will explore, with other key agencies (including NT Health), how to further investigate the causes of anaemia and developing policy approaches including input into the new national guidelines for Aboriginal child nutrition.

Ear and Hearing Health

The focus of identifying children with ear disease is to try and implement clinical management based on the Recommendations for Clinical Care Guidelines on the Management of Otitis Media in Aboriginal and Torres Strait Islander Populations, developed by OATSIH in 2001. These have been adapted for the current Central Australian Rural Practitioners Association (CARPA) Standard Treatment Manual. There are huge practical difficulties in the management of ear disease particularly because most medical treatments have a small effect on the disease.

Childhood Immunisation Program

The NHC Childhood Immunisation Program is a primary health care strategy that aims to reduce and eliminate vaccine preventable disease in the Anangu population living on the APY Lands.

The Health Service faces many challenges in delivering an immunisation program to Indigenous residents living in a remote setting. Some of these challenges include:

• A mobile population that moves over a large geographical area both locally and interstate;
• Difficulty in accessing an accurate immunisation history for some children relating to the lag time in data entry or lack of reporting by some health providers;
• Increasingly complex childhood immunisation schedules, 'catch up' schedules and national immunisation programs offered for a specific target group;
• The need for improving vaccine uptake in the older age groups; and
• Cultural and language barriers and issues of informed consent.

Despite these challenges, NHC has demonstrated continued improvements in the coordination, sustainability and delivery of the childhood immunisation program at the local community level. This is demonstrated by the following outcomes achieved from the Program:

• In 2003, 84% of permanent and visitor children on the APY Lands were fully vaccinated;
• In 2004, 92% of permanent and visitor children were fully vaccinated;
• In 2003, 94% of permanent resident children were fully vaccinated; and
• In 2004, 95% of permanent resident children were fully vaccinated.

These compare to NHC estimates of coverage of about 50% when the service assumed responsibility for health care. In the late 1990s there were reasonably high rates of coverage but significant problems with timeliness which have now been addressed.

The major lessons from this program have been the need for focus, prioritisation, systems organisation and recording. None of this can be achieved in remote settings without dedicated program positions to constantly monitor and oversee the program and improve outcomes.

Established systems and resources are used and regularly updated to support the delivery of the Childhood Immunisation Program, including:

• An immunisation database, which produces an immunisation schedule for each child aged 0-15 years based on the current vaccination schedule;
• An immunisation recall system which generates recall lists to identify children who are due/overdue for immunisation;
• Audit and quality review of data:
  • weekly audits are conducted on immunisation encounters provided by local community health clinics
  • weekly follow-up of any suspected errors in documentation or administration of immunisation encounters
  • monthly audit of immunisation data entered on the database
  • reports are requested from the Australian Childhood Immunisation Register on a regular basis for review and follow-up;
• Immunisation information and resources for staff are included in an immunisation page on the NHC intranet site; and
• Participation in a project coordinated by the Central Australian Division of Primary Health Care to produce an immunisation resource titled "Immunisation For All". This resource aims to assist practitioners with client education via disease photos and illustrated concepts that will help the client make informed decisions relating to immunisation. The resource is used by all vaccine providers with all clients in rural and remote Central Australia. The resource includes a practitioners booklet, CD Rom, VHS video and website. The CD Rom and video include immunisation concepts animated for clients in four languages, including Pitjantjatjara.

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Coordination of Service Delivery and Referral Mechanisms

Systems for data collection and monitoring have been established to support program delivery, including:

• A child health database stores health information collected from the child health surveillance activities with children aged 0-15 years residing on the Lands. The database is regularly reviewed and upgraded to reflect the emerging needs of the child population and the organisation;
• A Child Growth and Promotion page on the NHC Intranet Site provides staff with access to information and resources relating to child health service delivery;
• A recall system generates comprehensive child health reports, recall lists and follow-up plans; and
• A Cervical Screening Database is maintained to ensure referral and follow up for women.

Partnerships

In order to provide a comprehensive and seamless service, the Child Health Team has developed strong working relationships with a number of other agencies and service providers in the region. Monthly Child Health meetings are held with all agencies involved, which include:

• Mt Gillen Safe House Accommodation Service - Alice Springs

Mt Gillen provides safe accommodation for women and children and houses the Child Health Team Training and Education Resource Centre. The Centre operates 3 mornings per week and contains a kitchen, dining room, bathroom/toilet, weighing and change room, play room and outdoor play area.

Educational activities with mothers/carers provided through the Centre include cooking, preparing snack boxes for children, using educational nutrition resources, educational videos, playtime, health and hygiene advice and monitoring child growth.

• Paediatric Team - Alice Springs Hospital

The Alice Springs Hospital Paediatric Team undertake field visits to NHC clinics approximately three times per year. The team provides clinical assessment and growth review to children on the Lands. NHC accompanies clients to Alice Springs hospital and liaises with the Paediatric Team regarding medical and nutritional interventions required.

• Ngaanyatjatjara Pitjantjatjara Yankunytjatjara Women’s Council (NPYWC) Nutrition Team - Alice Springs

Regular meetings are held with the NPYWC Nutrition Project Team to review and follow-up clients. The NPYWC Nutrition Team regularly visits communities to provide nutrition education workshops and support for mothers and carers.

• Ngaanyatjatjara Health - Strong Women Strong Babies Growth Assessment and Action Program - Alice Springs

Ngaanyatjatjara Health - Strong Women Strong Babies Program has introduced the Growth Assessment and Action Program planning process to Western Desert communities. This Program provides resources for women who stay in the Mt Gillen Safe Accommodation facility and is an active member of the Child Health Program. They have coordinated service with NHC through the provision of a playgroup for clients and toys for the Child Health Centre at Mt Gillen Safe Accommodation.

• Central Australian Aboriginal Congress (CAAC) - Under 2's Child Health Team

The CAAC Under 2’s Program is provided to Indigenous people living in Alice Springs. The Program provides child health reviews, growth monitoring and home visits. NHC liaise with the CAAC Child Health Team on case management of common clients.

• Northern Territory Health Nutrition Coordinator (Central Australia) and Urban Nutritionist

The Northern Territory Health Nutritionists attend the monthly interagency meetings and provide nutritional advice and support for service provision through Mt Gillen Safe House Accommodation.

• Visiting Eye Health Team

A small number of children fail the visual acuity test and are referred to the visiting eye health team. The visiting eye health team is funded by OATSIH and undertake two visits per year for each community.

• Australian Hearing

Australian Hearing provides a twice yearly visiting service to two of the NHC communities. Audiologists provide further assessment of referred children. There are a multitude of problems in implementing management for severely hearing impaired children but some significant successes do occur for individual children. On occasions children seen by AHS are referred back to the clinic for antibiotic treatment.

Summary of Program Data

Available program data indicate:

• Rates of low birth weight have fallen to the level of the national Australian figure and are substantially better than those in many other Aboriginal communities;
• Substantial improvements in growth and nutritional status since the mid 1990s with essentially no children with wasting and a peak of stunting of approximately 35% of children approaching 3 years of age;
• 84% of pregnant women have at least 5 antenatal visits during pregnancy;
• Two thirds of all pregnant women have a first antenatal assessment in the first trimester;
• 83% of all 5 year olds, 80% of 10 year olds and 66% of all 15 year olds participated in child health screening;
• Rates of childhood anaemia are high varying between 32% and 41% of 0 to 5 year olds in 2003 to 2004; and
• Immunisation coverage is high with rates well over 90% in most communities.

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3. Townsville Aboriginal and Islanders Health Services Mums and Babies Program

At Townsville Aboriginal and Islanders Health Services (TAIHS), prior to the Mums and Babies program, the health of the young mother and father were considered as separate service requirements, and were either catered for by general clinic business, or by men’s and women’s health clinics. This is the case in many mainstream and Aboriginal community controlled health services. As such there is no focus on a particular stage of life: that of the young family; men and women contemplating parenthood; or with, or caring for, children up to early school age, teenagers or adolescents.

This approach is derived from conventional mainstream health services which have either compartmentalised health service delivery, hospitals and child health services, or lumped everyone together in general practice clinics. There is considerable scope for the integration of a life course approach into the services, which would remove the 'silo effect' and embed maternal and child health requirements within a much broader focus on health care and service delivery.

The TAIHS Mums and Babies program was an attempt to provide comprehensive integrated primary health care for young families. It has taken a 'one stop shop' approach to prenatal, antenatal, postnatal and infant care for young families, delivered from an Aboriginal community controlled primary health care service by GPs, Aboriginal Health Workers, midwives and child health nurses. Services provided through the program include:

• maternal/paternal and child health, acute care, preventive care and follow-up;
• one-on-one education/health promotion (eg antenatal and postnatal health, nutrition, substance use, family violence);
• transport;
• shared antenatal care with the Townsville Hospital;
• immunisation;
• growth and developmental monitoring; and
• referral, advocacy and social support.

The team holds a clinic every morning for families and pregnant women. The clinic, which is separate but adjacent to the TAIHS main medical clinic, runs without appointments and provides a supervised playgroup environment in which children can participate whilst waiting for their parents.

Mums and Babies program - Integrated antenatal service delivery

• Integrated team approach: each patient is seen by:
  • Aboriginal Health Workers: TAIHS Maternal and Child Health staff
  • Midwives/child health nurses: Community Health, Queensland Health
  • Doctors: TAIHS female doctors
  • Obstetric Team: Townsville Hospital - Queensland Health;
• Pregnancy register: monthly recalls;
• Daily walk in clinics - no appointments;
• Family orientation: playground, educational toys, weekly playgroup;
• Care plans emphasising essential elements of care;
• Standard shared antenatal care protocols;
• Monthly recall;
• PCR testing for Sexually Transmitted Infections;
• Lower vaginal swab for Group B Strep;
• Transport; and
• Brief intervention for risk factors: smoking cessation, nutrition, antenatal education, breastfeeding, Sudden Infant Death Syndrome (SIDS).

Establishment and implementation of the program - Key Elements

The program concept was developed through a community based forum where the local community identified the need for improved maternal and child health service delivery and outcomes. A Reference Group was established to support the development and implementation of the program and to seek initial funding (this group continues to meet bi-monthly and oversees the program). Membership of the Reference Group includes TAIHS staff, Child Health Staff, Midwives, Townsville Hospital staff and consumer representatives.

Funding for the Project was secured through philanthropic sources for a two year pilot project, commencing in February 2000 and the Office for Aboriginal and Torres Strait Islander Health commenced funding the Project as a Child and Maternal Health Exemplar Site in June 2002.

Coordination of Service Delivery and Referral Mechanisms

A key objective of the program is the integration of service providers delivering care from TAIHS. All service providers/organisations listed below were involved in child and maternal health service delivery prior to the commencement of the program. However, communication and coordination were poor, resulting in services being duplicated and community access restricted.

The Mums and Babies program service providers are:

• Townsville Aboriginal and Islanders Health Services
  TAIHS provides two Aboriginal Health Workers, one childcare worker, one driver, two female doctors.
• Queensland Health - Aboriginal and Islander Health Program
  This Program provides an Aboriginal Health Worker one morning each week,who undertakes liaison between TAIHS and the hospital.
• Queensland Health - Child Health Program
  This Program provides a midwife and a child health nurse four mornings per week who support clinic activities such as immunisation and child development as well as running child health programs such as positive parenting and early family intervention programs.
• Townsville Hospital - Department of Obstetrics
  The hospital participates at TAIHS in shared antenatal care, through agreed antenatal care protocols, and supports TAIHS clients antenatally, through birth and postnatally. The hospital also provides a midwife to the project one morning a week to participate in and support the clinic activities.
• Queensland Health - Tropical Public Health Unit
  Supports the Project through the development of relevant programs such as breastfeeding and child nutrition.
• Indigenous Health Unit, School of Public Health and Tropical Medicine, James Cook University
  The University has assisted the Project through the provision of specialised training in Maternal and Child Health for Aboriginal Health Workers.
• Townsville Division of General Practice
  The Division has assisted with the development of new antenatal shared care booklets and posters for the Project and organises continuing education for medical staff.

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All the women are offered one-on-one antenatal education and nutrition counselling. An extensive range of resources have been developed to go with the project, as well as a customised antenatal shared care record.

The clinic also sees large numbers of infants and children. These children are offered comprehensive primary health care including immunisations, regular monitoring of growth, development, sight, and hearing. One of the team of Aboriginal Health Workers has had specialised training in ear health audiometry, and tympanometry. Any child found to have problems is referred to Townsville Hospital or Community Health for specialist paediatric care.

The integration of a range of service providers has enabled TAIHS to provide comprehensive primary health care, antenatal care and postnatal care for Indigenous women, along with immunisations, growth monitoring, developmental screening and hearing screening for the infants and children attending the clinic.

TAIHS provides the following services:

• Clinic;
• Aboriginal Health Workers;
• Doctors;
• Allied health; and
• Transport.

Townsville Hospital provides the following services:

• Midwife;
• Shared care;
• Specialist care for high risk pregnancies; and
• Birth suite.

Child Health provides the following services:

• Midwife/child health nurses;
• Access to early intervention programs, Positive Parenting Program; and
• Specialist programs.

Complementary programs delivered by TAIHS include:

• The B.E.S.T (Breastfeeding Education and Support Team) Program
  12 women from the community have been trained as peer counsellors and provide support on maternal nutrition, breastfeeding and infant nutrition to the women attending the Mums and Babies clinic. Over 110 women have been enrolled in the program to date.
• Child Nutrition Program
  TAIHS works with three primary schools in the Townsville region to facilitate an improvement in childhood nutrition. Breakfast programs, nutrition information in newsletters and changes in canteens have been developed in each school.
• Early Family Intervention Program
  The Program is staffed by a Coordinator and four Aboriginal Health Workers who work with families identified as at risk (through the Mums and Babies program and the general community) to link to required support agencies. Families with financial difficulties, substance use and violence issues are targeted.
• Health Worker Education
  TAIHS supports the Mums and Babies clinic staff to access appropriate training to enable them to engage not only in clinical activity, but also in the management and monitoring of programs delivered through the service. Further work will be undertaken with James Cook University to develop appropriate vocational based training for this purpose.

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Antenatal Care

The Mums and Babies program has demonstrated a number of improvements in antenatal and perinatal outputs and outcomes:


Access for Antenatal Care: No. Indigenous women attended for ANC with a singleton birth

In terms of antenatal care outputs, significant changes have occurred over the last four years.

• Access to Antenatal Care by pregnant clients has risen to 200 in 2004 under the Mums and Babies Program compared to 60 in the period before July 2000.
• The number of antenatal visits per pregnancy has also increased from 3 per pregnancy in the period before July 2000 to 8 visits under the Mums and Babies program.
• In terms of pregnancy outcomes pre-term births (less than 37 weeks) have decreased from 17 percent before July 2000 to 9 per cent under the Mums and Babies program.
• The number of babies with a birth weight of below 2500g has decreased also from 16 percent pre July 2000 to 11 percent in 2004 under the Mums and Babies program.
• As a result of these decreases the mean birth weight has risen from 3043g pre July 2000 to 3239g under the Mums and Babies program.

(Source: TAIHS Program Data, 2004)

Additional Outcomes

Health service delivery

A positive but unforeseen outcome of the Mums and Babies program has been in the changes that have occurred at TAIHS to the overall delivery of patient care. The Mums and Babies program, due to its rapid expansion, moved to rooms adjacent to the main building when TAIHS relocated to the new facility in Garbutt. This resulted in the development of a "main clinic" with a focus on chronic diseases and prevention, and the Mums and Babies clinic, which has a wellness and prevention focus. This has enabled staff in both clinics to become more focussed in the education and care they deliver to two sets of patients with quite different needs.

Capacity building

Prior to the advent of the Mums and Babies program, the medical section at TAIHS was primarily practising reactive acute care medicine, with little program delivery and prevention activity. While there was a degree of resistance to the program initially, watching the program and changes to health service delivery evolve over the four years has brought an acceptance that health service delivery could be improved and that there are immediate, as well as long term, benefits. The more immediate benefits lie with capacity building in terms of numbers of staff employed, expansion of staff skills, and the increased involvement of the service in the community. This has become a source of pride to the service and the staff. It also led to recognition that grant funding can enhance service delivery and that it can lead to permanent change for the better.

Dissemination and Reporting

Information about the Mums and Babies program has been published and presented at a number of fora, including:

• Perinatal Society of Australia and New Zealand (PSANZ) Conference, March 2001;
• Presentation at the NACCHO 2002 Annual General Meeting;
• PSANZ Conference, March 2003;
• Produced Exemplar Site Report, July 2003;
• Presented paper at the Public Health Association of Australia Conference, September 2003;
• Perinatal Indigenous Network (PIN) and PSANZ meeting, March 2004;
• Berrimpa, Hearing Health Seminar, June 2004; and
• Panaretto et al, 2005, Impact of a Collaborative Shared Antenatal Care Program for Urban Indigenous Women: a prospective cohort study, Medical Journal of Australia; 182 (10): 514-519.

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4. Durri Aboriginal Medical Service Djuli Galban Program

The Djuli Galban Program (formerly known as Maternal Neonatal program) is situated at Durri Aboriginal Medical Service (AMS) in Kempsey, New South Wales, but provides outreach services to all the Aboriginal communities of the Macleay Valley. The program is staffed by a full-time midwife and Aboriginal maternal health worker team.

The Djuli Galban program, Djuli meaning child and Galban meaning women in the local Dunghutti language, provides accessible community based, culturally sensitive outreach services to Aboriginal women and their infants, focusing on the health needs of the family during pregnancy and the infant period.

The program was developed at Durri AMS in 1992 as a pilot project funded by the NSW Alternative Birthing Services Program, in response to the large Aboriginal population and high perinatal morbidity and mortality rates experienced by Aboriginal women. The funding is allocated specifically for antenatal and postnatal (up to 8 weeks) care.

The program has expanded and evolved since its inception to meet the needs of the community, greatly increasing the access of Aboriginal women and their children to health services and the associated improved health outcomes.

As a result of these health outcomes the Djuli Galban Program has continued to be refunded over the past 13 years, as well as being recognised nationally as a model of excellence in the delivery of Aboriginal maternal and infant health services.

Being part of Durri AMS the Djuli Galban Program is able to benefit from the utilisation and referral to complementary in-house programs which include:

• Diabetes Educator - education, support and monitoring for gestational and pre-existing diabetes;
• Audiometry - childhood screening and assessment;
• Mental Health - counselling, assessment, support and referral;
• Drug and Alcohol - counselling, support, education and assessment;
• Sexual Health - screening, education, support and referral;
• Families First - support and advocacy. The identified need for longer term follow-up support services led to the establishment of an Aboriginal Family Support Worker position, funded by NSW Health under the 'Families First' Program;
• Juvenile Diabetes - school based education and screening program;
• Medical Clinic - assessment and referral to Specialist Paediatricians, general health for adults and children;
• Dental - adult and child assessment and treatment;
• Transport - provision of transport to access Durri AMS services and specialist appointments; and
• Physiotherapy - education, pain relief and treatment.

Antenatal Services

Antenatal care is a major component of the Djuli Galban work load and has continued to change with the needs of the community. A weekly antenatal clinic is provided at Durri AMS on a shared care basis between the midwife and GP obstetrician. Antenatal care is also provided at other times or at home when required.

Participating women are provided with individualised, flexible and supportive care and education that is appropriate to their individual needs. This care also includes close monitoring for high risk pregnancies, appropriate referrals and support to access other services (including the hospital for birthing) and recalling women for antenatal care.

Participating women are assisted with transport for clinic, screening and specialist appointments. Group antenatal education sessions have not been successful with these women, so antenatal education is provided in the form of one-to-one sessions at each pregnancy check-up and/or at other times.

In some cases, younger women have been supported to access a young parent antenatal class conducted by the young parent worker and midwife from Kempsey Hospital.

The program undertakes development of antenatal care and child health resources as it has been found that the resources developed through NSW Health are not always appropriate for these women.

Antenatal Recall System

In recognition of some women’s irregular antenatal care attendance, the program has established a client recall system. This includes maintaining and using a database to record and monitor attendance and care, and hand delivering or posting a reminder for their next antenatal visit. The program has found this effective in reminding and encouraging women to access antenatal services.

Booking into Hospital

All participating women are encouraged and supported to book into hospital for the birth of their baby. Support provided includes assistance with completing the maternity booking papers and transport to the hospital.

Access to Antenatal Care

The Djuli Galban Program continues to be the major provider of antenatal care for the Aboriginal communities of the Macleay area.

Between 1998 and 2005 the number of Aboriginal women accessing the antenatal service remained constant, at 75% - 85% of all Aboriginal women who have given birth in the Macleay region.

The number of Aboriginal women who used the Durri AMS antenatal services over this period was as follows:

1997/1998 - 59
1998/1999 - 52
1999/2000 - 57
2000/2001 - 61
2001/2002 - 51
2002/2003 - 46
2003/2004 - 52
2004/2005 - 57

This is compared to non-Aboriginal women using the services

1997/1998 - 18
1998/1999 - 36
1999/2000 - 43
2000/2001 - 18
2001/2002 - 23
2002/2003 - 4
2003/2004 - 8
2004/2005 - 5

During 1999-2000 the number of non-Aboriginal women accessing the service greatly increased in direct response to the cessation of bulk billing by Kempsey general practices. In late 2000 Durri AMS implemented a general policy of not accepting any new non-Aboriginal patients, unless they had family members already as clients. This is reflected in the number of non-Aboriginal women utilising this service.

Teenage Pregnancies

Teenage pregnancy continues to be a focus for the program, with 26% of all women giving birth being 19 years of age or under in 2004-05. This figure is consistent with the state-wide data reported in the 2003 NSW Midwives Data Collection.

Sexual and reproductive health education is provided on an informal and individual basis and is coordinated with the Sexual Health Worker where possible.

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Gestation at first antenatal presentation

In 2004-05, 88% of Aboriginal women in the Macleay area presented for antenatal care before 20 weeks gestation, which is higher than the overall rates for Aboriginal women in NSW (71%), as reported in the 2003 NSW Midwives Data Collection. The rate is also higher than for non-Indigenous women in NSW (87%).

Risk Factors

Smoking and drug use during pregnancy continue to be an issue for the program. In 2004-05, 58.5% of clients smoked during their pregnancy, 21% admitted to using marijuana (yarndi) and 6% regularly consumed a significant amount of alcohol during pregnancy. The program provides brief intervention education modes as the patients present for antenatal care and referral to addictions programs for counselling and cessation options is offered.

Gestation at Birth

A premature infant is defined as 'an infant born before 37 weeks gestation' and is a risk factor for the later development of chronic disease. In 2004-05, 10.5% of babies born to Aboriginal mothers in the Macleay region were premature. This rate is lower than the rate for all Aboriginal babies in NSW (12.1%) and higher than for non-Indigenous babies in NSW (6.9%), as reported through the 2003 NSW Midwives Data Collection. The rate is also higher than previous years, where from 1999-2003, the rate has varied from 6.3% to 16.6%.

Birth weight

Low birth weight is defined as a birth weight less than 2,500 grams and is a risk factor for developmental delays and the development of chronic disease later in life.

In 2004-05, 13.2% of babies were low birth weight, with the majority of them being pre-term. Of the babies delivered at term, 4.4% were low birth weight.

The 2003 NSW Midwives Data Collection reports that the state-wide rate of low birth weight was 12.4% for Aboriginal and Torres Strait Islander babies. The rate for non-Indigenous babies was 6.1%.

Postnatal Services

Postnatal follow-up is available to all Aboriginal women in the Macleay area, including Aboriginal women who delivered elsewhere and returned to the Macleay Valley. The service is also offered to non-Aboriginal women with Aboriginal partners.

The postnatal follow-up service is flexible and offered either as home visits or clinic visits, whichever the women prefer. These visits are provided weekly or more frequently as needed, usually up to eight weeks postnatally. This service provides support and education to the mothers, in relation to their parenting, life issues, infant care and breastfeeding and ensures that their infants are growing optimally.

The women are contacted while in hospital, when possible, and offered the follow up service. Referrals are also received from the hospital, other agencies and via the community.

Utilisation of the postnatal service has increased from 60% in 1994 to 93% in 2004.

Child Health Services

As most Aboriginal women do not access mainstream Early Childhood Nursing services despite referral, there has been an increased need for the Djuli Galban Team to facilitate and provide child health services on a limited basis. These services follow on from the postnatal service which generally runs to 8 weeks, and are predominantly provided through the weekly immunisation clinic service.

Identified need includes:

• premature infant;
• 'at risk' infant due to social/environmental factors and child protection issues; and
• need for extra support in parenting, dealing with postnatal depression and social isolation.

Some women will ask to see the Djuli Galban team with questions such as "my baby’s sick, can you look at him?", "what's this rash?", "baby's not right, what should I do?" After assessing the infant, referral to the GP is provided if required. At times the team is called on by the GPs to assist with the assessment of infants, or to talk to and support the infant’s mother.

Immunisation Services

The Djuli Galban team provides 99% of all childhood immunisations provided at Durri AMS. A weekly morning immunisation clinic is held, with transport assistance provided. The provision of a weekly immunisation clinic assists in maintaining ongoing contact with women and their children beyond the antenatal and postnatal period. As part of the immunisation clinic service, parents/carers are provided with education regarding the importance of immunisation, vaccines available and associated side effects, as well as immunisation certificates for school and Centrelink, as required.

The clinic also provides the ideal opportunity to check child growth and development and discuss health and parenting issues and provides a venue for parents/carers to ask questions and discuss concerns.

The Djuli Galban childhood immunisation rates have increased from 50.6% in 1997 to 95.2% in May 2005, as per the Australian Childhood Immunisation Register (ACIR).

The maintenance of a computerised immunisation register and recall system enables recall and follow-up of children due or overdue for immunisation. Recall letters are often hand delivered and parents/carers reminded wherever possible.

Djuli Galban is not directly funded for the provision of immunisation services, however the program utilises the funding generated by the Immunisation Incentive Payment Scheme to support the provision of immunisation services.

Women’s Health Issues

The program also provides pregnancy testing, support and referral. Women also access the program for other reasons, sometimes to 'have a chat' and talk about health issues, family and relationship issues, and stress in their lives.

The women are provided with a listening ear, informal counselling, support and referral to other services if required.

Healthy Mothers and Babies Project

During 2004 a small amount of non-recurrent funding was made available from NSW Health for a community development activity targeting Aboriginal Maternal and Infant Health.

This funding enabled the development and production of the healthy messages calendar, as well as the continued development of pregnancy and child health resources.

Healthy messages calendar

The calendar was developed as a simple, non-threatening and non-invasive way of delivering healthy messages to the community, targeting pregnant women, families with small children and other community members.

Short targeted health messages were included each month covering a variety of topics, including antenatal care, postnatal care, smoking, alcohol and other drugs, breastfeeding, introducing solids, Sudden Infant Death Syndrome (SIDS) and the importance of self care.

The calendar was also personalised by using photographs collected over the years by the Djuli Galban team of clients and children, with consent obtained for each photograph used.

The Cultural Resource Class at the Djigay Centre, Kempsey TAFE, which studies the Dunghutti language and consists of several community elders, was approached to develop a healthy message for the calendar, which was then included in English as well as Dunghutti.

The calendar was made available to all members of the Aboriginal community and distributed to Aboriginal organisations in the area and other service providers.

The response and positive feedback from community members, health workers and other service providers has been tremendous, with calendars being displayed in most Aboriginal homes and in some local business houses.

Liaison and Consultation

The Djuli Galban Program liaises and consults with a variety of agencies in order to provide a comprehensive child and maternal health program. These include:

• Kempsey Women’s Refuge;
• NSW Departments of Health and Community Services;
• Paediatricians;
• Australian Childhood Immunisation Register (ACIR);
• Port Macquarie Division of General Practice;
• Other Durri AMS programs;
• Other Aboriginal Medical Services;
• Preschools;
• Mid North Coast Area Health Service:
  • early childhood
  • population health
  • Kempsey Hospital
  • Port Macquarie Base Hospital;
• Kempsey Family Support Services; and
• Aboriginal Health and Medical Research Council (AHMRC).

Meetings/Committees/Projects

The Djuli Galban Program participates in a number of interagency fora, including:

• Mid North Coast Aboriginal Maternal and Infant Health Strategy Advisory Group;
• Mid North Coast Area Health Service Women’s Health Advisory Group;
• Mid North Coast Families First Implementation Group; and
• Mid North Coast Area Health Service Child and Family Health Nurses Network.

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Page currency, Latest update: 01 June, 2006

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