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Coomealla Health Aboriginal Corporation (CHAC) is an Aboriginal Community Controlled Health Service (ACCHS) in western New South Wales. We provide health services and GP services to the Wentworth Shire. Our Community Midwifery Outreach Program (CMOP) was implemented under the Healthy For Life initiative, allowing for employment of a midwife two days per week.  Our focus is on high risk behaviours of young, adolescent, indigenous, antenatal and postnatal clients.

We address the lack of sustained continuity in care, often noted in main stream services, by indigenous women. We specifically address missed appointments and reasons for, education and reduction in risk taking behaviours, importance of ante/post natal care, thus ensuring a more positive outcome for both mothers and babies at birth.

Aim:

Promote healthy birth outcomes, by increasing the overall mean birth-weight, thus decreasing the number of birth weights under 2500g.

Objectives:

1. Increase the knowledge within our community of antenatal services available at CHAC.
2. Promotion of the CMOP as one which encourages perinatal education, friendships, honesty, assistance, help and safety, in a non threatening, holistic environment.
3. Have majority of client’s first antenatal visits, with in first trimester.
4. Reduce risk taking behaviours (eg. smoking, alcohol/drug intake), during pregnancy.
5. All clients, referred to outside services (eg. Obstetric, imaging department, drug and alcohol rehab), attend.
6. Develop communication pathways/partnerships, with these outside services.

Outputs:

1. Advertisement in February 2007 to wider community of commencement of CMOP at CHAC, via – letters posted to house holds (300+) within Wentworth shire, to other related professionals with in Sunraysia District (GP’s, Obstetricians, imaging departments and other Community Services), personal visits by midwife to homes within the Coomealla district, posters advertising position placed in shops at Dareton, introducing midwife at community gatherings and CHAC meetings and finally, word of mouth.
2. To help bridge any cultural/communication gaps and to allow for culturally appropriate care, an Aboriginal Health Worker accompanied midwife always (especially with in that first year).  Thus allowing a trusting relationship to develop with the Aboriginal community.
3. Development of a clinic room which is as less institutionalised as possible.  One with a warm, friendly, homely, feeling where adolescents feel safe and welcoming
4. Education sessions to promote the importance of early antenatal visits.  Conducting one on one sessions and group, specifically targeting our community’s adolescent females.
5. Routinely asking every antenatal client in both first and third trimester, about their risk taking behaviours.  Promotion of measures/resources to both educate and help those in need.
6. Education of clients requiring outside services, about these services-how and why they are required, to promote compliance for attendance.
7. Facilitation to these outside services by various means.
8. Financial assistance (via bulk billing method) for payment of these services. 

Performance Indicators:

1. There has been a steady increase in CMOP client base numbers.
2. The midwife employed is culturally appropriate and has developed relationships with in the community, as clients requesting home visits, as well as clinic visits.
3. The positive comment feed back from the many adolescents (and other clients, staff) who access the CMOP clinic room – "it is such a bright, homely feeling room, with its - purple colour theme, ornaments placed around room (vase of flowers, pictures), procedure bed covered in purple sheets and scatter pillows, medical equipment out of sight. Such a welcoming place".
4. That we have a greater than 50% first antenatal visit, with in the first trimester.
5. That there is a decrease from first to third trimester, in clients with risk, taking behaviours.
6. That 99% of CMOP clients referred to outside services attend appointment.

Employment of a midwife two days/week, commenced Jan 2007 with funding supplied from the Healthy for Life (HFL) program.  CHAC is one of four partners in the "Healthy for Life along the Murray" consortium, consisting of Mildura, Robinvale, Swan Hill and our selves (Dareton).

Though CHAC is situated in NSW, Dareton is a boarder town with Mildura (Vic) and it is here, that all our women birth.  In emergency situations, women are flown out to either Melbourne or Adelaide, to territory centres. However, the majority of our birth statistics are represented in Mildura's.

The 1996 Perinatal confinement statistics comparing Koori and Non Koori confinement figure's (especially in the Mildura area), highlighted the need for greater emphasis to be placed on decreasing our adolescent pregnancy numbers and focusing on those who are.

It was this statistical supporting evidence, along with personal experience from the midwife employed. She had previously worked several years on night duty at Mildura Base Hospital (MBH) in birth suite and experienced numerous cases where Indigenous, adolescent, clients, presented with nil, or little, antenatal care, in labor.

The need and the evidence mandated that the CMOP at CHAC focus mainly on our community’s young, adolescent, indigenous population and any accompanying problems/concerns they have, in an effort to decrease numbers and promote better outcomes for both mums and babies.

Commencement of the CMOP was from scratch (CHAC had not employed a midwife previously). An appropriate room had to be sought at CHAC for antenatal purposes.  Some midwifery related equipment was found in storage however ordering of required stock was quite extensive.  This was billed and ordered through Healthy For Life.

Meetings with the Healthy For Life consortia members (especially midwifery and maternal and child health related staff), commenced Jan – April 2007 (with yearly revision updates).  Object- to establish paperwork specific to antenatal documentation to be used within our consortia.

Though working independently at CHAC, the midwife has active involvement with Professor Ian Pettigrew -Mildura Obstetrician (Prof), whom share cares high risk clients. Prof organised for indigenous women to be bulked bill for services (to relieve financial burden and promote compliance).  Can also refer to CHAC GP as necessary (i.e for medications required for clients).

Monthly meetings at MBH attended by Prof,  the NUM of midwifery at MBH, booking in midwife for special needs clients and Aboriginal liaison officers of MBH, Consortia midwifes and other associated health professionals (midwives Greater West Area Health Service).  Involved with these from Jan 07, thus allowing for communication improvements and cohesion of care for Sunraysia Aboriginal clients, facilitating healthier birth outcomes.

Early 2007-Memorandum of Understanding being developed with Aboriginal Liaison officers at MBH & associated services (as listed above).  ENOCC (Early Notification Of Complex Clients) CHAC form developed for MBH, to enhance communication and client care, upon discharge from hospital.

Midwife attends relevant training seminars, education and studies, to ensure information to CMOP clients is relevant, up to date and research based.

The midwives job role often falls outside the norm of a midwives job description.  However, to ensure that continuity of care for these clients continues with healthy outcomes, it is often necessary to widen the scope of your job description.  CMOP allows this, for we focus mainly on the young, adolescent, indigenous women, with associated high risk behaviours. Hence, time management is divided up appropriately, with a minimum of an hour, per client, per visit. 

Thus allowing for all the job roles outside the norm eg. -

• Acting as a social worker organising birth certificates, Medicare cards, housing and whatever else is necessary.
• Organising appointment times and transport for both CMOP and referral visits.
• Accompanying clients to various external referral services for moral support.
• Chasing up of clients when appointments are missed.  Often requiring getting in the car and physically finding the client out in the community.
• Texting clients for appointment reminders, when on days off (midwife works 2 days/week) – to ensure that appointment is kept (remember some of these clients are 14 and 15 years).
• Implementing a policy for easy access mode to contacting the midwife -24 hours/day, 7 days per week, for all clients.  Work, mobile and home phone numbers given to all clients. Can ring me for any emergency/query they may have.  Have never yet had an inappropriate call!  It just reinforces a feeling of safety/comfort for the girls. Some one is out there for them should they need it.
• Birth support at MBH is not included in this program, though informed they can ring and speak to midwife whilst in labor, if seeking advice. (I do have the advantage of knowing most of the midwives working at MBH).

As of April 2009, the CMOP has had 12 indigenous babies born, one miscarriage and there are currently 4 pregnant. Two clients moved away in third trimester, prior to birthing. Of those 12 births, there was only one baby whose birth weight came in under 2500g (2305g). Of the 16 (12 birthed + 4 antenates), 12 had their first AN visit within their first trimester (75%).

Risk taking behaviours:

Smoking 

• 11 of 12 clients smoked cigarettes in first trimester (will exclude AN, as comparing 3rd trimester).
• 7 of these 12 had cut down amount smoked by third trimester (58%).
• 1 had quit (8%).
• 3 smoked the same amount (25%).

Alcohol

• 6 had drank in first trimester (50%), however 4(33%) had ceased immediately when realized pregnant.
• 2 drinking all through first trimester (16%).
• In third trimester 1 had continued drinking (8%).

Illicit drugs

• 4 of 12 clients using during first trimester (33%).
• Nil using by third trimester.  Note however, these were the cigarette smokers at third trimester.

The statistics are quite encouraging and support the appropriateness of the CMOP. 

We have evidence that the female adolescent population are now coming into CHAC, to seek advice/education from our midwife, on a whole range of topics.  The environment and its non threatening approach, appears to work. The up front/open/honest answers, given to clients in a language aimed to suit their cognitive level is appreciated.  We now have word of mouth referrals, from the adolescents themselves.  

100% of external referrals made, were kept (even if some were re-booked)        

Coomealla Health Aboriginal Corporation
Phone: 03 50274824