Study settings
Of the studies included in the review, most (n = 20 of total 28 studies included) were conducted in remote Aboriginal communities in the Top End of the Northern Territory or across both metropolitan and rural and remote settings in Australia [1, 5, 6, 8, 10, 13, 14, 19, 20, 24, 26, 27, 29, 30, 38,39,40,41,42,43]. The studies conducted in the Top End of Australia predominantly focused on Aboriginal community-controlled health services and remote health centres [1, 5, 6, 10, 19, 29, 40], and, in some instances, also included a regional hospital where Aboriginal women relocated for birth [5]. The studies that were conducted across multiple locations usually included a metropolitan or regional hospital as well as a number of remote health centres and explored whether there were links or established referral pathways between these services [1, 5, 6, 8, 13, 19, 24, 29, 44].
The remaining studies were conducted exclusively in metropolitan settings (Sydney, Brisbane, Perth and Adelaide) [11, 26, 39, 44,45,46] or rural towns in New South Wales and Queensland [14, 27, 38]. These studies were predominantly focused on specific Aboriginal birthing or Midwifery Group Practice programs within hospitals, which provided antenatal care to Aboriginal women within a culturally safe environment and were typically staffed by female obstetricians, Aboriginal midwives and Aboriginal Liaison Officers. A further five studies were review articles examining continuity of maternal health services among Aboriginal women and their infants in Australia [4, 7, 12, 19, 30]. One explicitly included maternal and well child health services [4].
Key themes
Lack of continuity of care across the first 1000 days
Studies included in this review reported a general lack of continuity of care and continuity of carer within maternal and infant health services available to Aboriginal mothers and their babies [1, 4,5,6, 13, 19, 29, 30, 42, 43, 45, 47]. Lack of continuity of care and carer were especially common in healthcare services without dedicated Aboriginal antenatal and birthing programs and interventions [1, 4, 6, 10, 13, 27, 29, 30, 42, 45], and were more commonly observed within hospitals than remote health centres [10, 45].
Aboriginal women were particularly disappointed with a lack of continuity of care during labour and birth, as well as postnatally [44]. Similarly, continuity of care was compromised for Aboriginal women who presented to health centres with non-pregnancy related concerns during their pregnancies, as they were treated by a different clinician [10]. This lack of continuity of carer, in some cases after experiencing continuity of carer antenatally, contributed to Aboriginal women feeling abandoned and uncared for [44].
Conversely, one study reported that some Aboriginal women who had been offered a continuity of care model of care delivered by an Aboriginal Maternal Infant Care (AMIC) worker declined the service, stating that they did not wish to be treated by a known health care provider [45]. The decision to opt out of a continuity of care model was primarily motivated by privacy and confidentiality concerns [45].
Midwives highlighted a lack of continuity of care within hospitals, especially in large organisations where midwives were particularly time poor and hospital policies and procedures were inflexible [45]. Health care providers expressed concerns about the lack of continuity of care in early childhood services, particularly with regard to access to a Maternal and Child Health nurse to support a coordinated, culturally responsive approach to service delivery [42].
The observed lack of continuity of care and carer was attributed to inappropriate or inadequate resourcing of remote health services, poor care coordination, poor discharge documentation and communication between hospitals and remote health centres, lack of Aboriginal leadership, a focus on a western model of care provision, attitudes and practices of clinicians, time constraints placed on midwives and other health care providers, staff turnover and rotation, and inflexible hospital policies and procedures [1, 6, 8, 10, 44, 45].
Impact of lack of continuity of care
Lack of continuity of care and carer impacted Aboriginal women’s experiences of and satisfaction with the care they received and influenced their and their infants’ health outcomes. Lack of care continuity was viewed by midwives as a key barrier to effective care provision within the mainstream health system [45]. A lack of continuity of care has been shown to affect communication and quality of care in antenatal and postnatal services for Aboriginal women [4]. This can in turn influence health outcomes, with fragmented care being shown to increase medical risks and compromise patient safety, leading to adverse outcomes for Aboriginal women and their infants [4].
Continuity of care interventions
A number of the included studies described interventions or programs that have been implemented in hospitals and other health care settings to improve continuity of care and carer for Aboriginal mothers and their infants. These programs typically focused on improving continuity of care through ongoing contact throughout pregnancy and birth with a primary midwife, an Aboriginal midwifery student, a district medical officer or AMIC worker [5, 8, 10, 11, 14, 20, 24, 26, 38,39,40,41, 44, 46]. Features of these programs that were most highly valued by Aboriginal women were having a single known care provider throughout their pregnancy, strong community links, and being controlled by Aboriginal communities [5, 12, 14, 39].
Continuity of care following birth was not discussed in detail and did not feature as a component of most continuity of care programs. A small number of studies specifically focused on programs that sought to improve continuity of care postnatally [38, 39]. For example, the Malabar Community Link Service in metropolitan Sydney provided continuity of care for Aboriginal women and their infants postnatally, by referral to child health services following discharge after birth and access to a known care provider who Aboriginal women could call with their queries [39].
Impact of continuity of care interventions
Continuity of care and continuity of carer were highly valued by Aboriginal women. Having both face-to-face and telephone access to a single care provider who was well known to the woman and who “knew their story” and could act as their advocate was very important to Aboriginal women [5, 14, 39, 44, 47, 48]. In particular, Aboriginal women valued care provided by another Aboriginal woman, such as an Aboriginal midwifery student or AMIC worker, which had a positive impact on cultural appropriateness [8, 14].
Programs that offered continuity of care through antenatal and birthing services resulted in greater acceptability of care among Aboriginal women and greater satisfaction with the quality of maternity care they received [5, 27, 43, 44, 49]. Continuity of care programs appeared to have a positive impact on maternal and infant health outcomes, including improvements in antenatal attendance, better monitoring and management of risk factors, lower rates of preterm birth, higher infant birth weight, and lower perinatal morbidity and mortality [19, 24, 26, 41, 44, 47,48,49]. However, the methodological quality of studies reporting improvements in maternal and infant health outcomes has previously been assessed as weak and therefore these findings should be interpreted with caution [4].
Strategies to improve continuity of care
Included studies put forward numerous strategies to improve continuity of care for Aboriginal women and their infants, including in mainstream healthcare settings that do not have dedicated Aboriginal maternal and child health programs. The importance of establishing and maintaining designated leadership positions, such as discharge coordinators, was viewed as a means to improve communication and handover processes between hospitals and remote health services [29]. In order to expand the role of Aboriginal health care providers in mainstream health services, partnerships should be established with universities and Aboriginal communities to improve education and encourage employment of Aboriginal staff in caseload midwifery models of care [14]. Health services should focus on improving communication and building stronger and more trusting working relationships between midwives, Aboriginal health workers and Aboriginal families [45, 47,48,49]. This can be supported through ongoing cultural competency training for staff and greater flexibility in the application of hospital rules and regulations to support culturally safe care provision [11].
Aboriginal women should be actively engaged in the design and delivery of maternity care, and programs designed to improve continuity of care should work with Aboriginal women on identified needs to strengthen outcomes [46]. Efforts should be made to ensure that appropriate maternity care is available as close to Aboriginal women’s homes as possible. Where this is not practicable, Aboriginal women from regional and remote areas should have access to AMIC workers to improve continuity of carer, particularly in instance where women relocate to a large metropolitan hospital for birth [11].