Improving the provision of pregnancy care for Aboriginal and Torres Strait Islander women: a continuous quality improvement initiative

Large disparities in pregnancy outcomes exist between Aboriginal and Torres Strait Islander (Indigenous) women and non-Indigenous women in Australia. Low birth weight, preterm birth, perinatal death and neural tube defects are more common in babies of Indigenous women [1‐3] and lifestyle-related risk factors such as smoking, alcohol use, low peri-conception folate use and poor nutrition are also more common among Indigenous women [2‐6]. These risk factors are associated with socio-economic disadvantage with education, employment, income and housing security generally lower among Indigenous populations relative to other Australian groups [7]. Indigenous women can experience barriers to accessing adequate pregnancy care such as transport, financial or language issues, and availability of culturally appropriate care [8, 9].

Approximately 4 % of all women giving birth in Australia identify as being Indigenous although this varies considerably across jurisdictions from 3 % in New South Wales to 36 % in the Northern Territory [2]. Population size also differs across jurisdictions; the largest absolute number of Indigenous women giving birth is in Queensland (3,646) and the smallest in the Northern Territory (1,414). Across Australia a minority of women (3 %) giving birth live in geographically remote areas although this also varies across jurisdictions (ranging from 0.7 % in New South Wales to 48 % in the Northen Territory) and by Indigenous status (27 % of Indigenous women compared to 2 % of non-Indigenous women) [2]. The type of pregnancy care available in Australia often depends on service availability, the woman’s preferences and her risk profile [8]. It can consist of primary and/or hospital care and often involves a range of health professionals [8]. In remote locations, pregnancy care is usually provided by primary health care centers (PHCs), with women transferring to regional hospitals for the birth. PHCs can either be governed by the jurisdiction’s government or be one of over 150 community-controlled health services initiated and operated by the local Indigenous community to deliver holistic, comprehensive, and culturally appropriate health care [10].

Pregnancy care has a key role in identifying and addressing risks of adverse health outcomes for mother and baby, including lifestyle factors. It provides opportunities for shared decision making and the promotion of good health [8]. However, effective long-term strategies across the diverse range of settings in Australia are needed to ensure Indigenous women receive recommended pregnancy care [11].

One potential strategy is Continuous Quality Improvement (CQI) which is a management approach or set of principles that aims to constantly increase the efficiency and effectiveness of organizational systems to better meet the needs and expectations of patients and other stakeholders [12, 13]. These principles include a positive focus on better functioning of organizational systems rather than isolated issues or personal blame, and organizational-wide involvement to foster ownership and build quality improvement capacity [12, 14]. Implementation of CQI consists of ongoing cycles of systematic data collection, using the data for benchmarking and setting goals related to organizational processes and structures, developing best practice improvement strategies, strategy implementation, and subsequent evaluation using iterative data collection [14]. CQI is an approach that has been used successfully in Indigenous primary health care in Australia relating to chronic disease prevention, diabetes and rheumatic heart disease [15‐17].

Previous research has identified areas for improvement in pregnancy care by PHCs in Indigenous communities. Nearly 50 % of women attended in the first trimester, providing important opportunities for preventive pregnancy care [18]. Women also attended PHCs regularly during their pregnancy yet did not necessarily receive all components of recommended pregnancy care, especially relating to lifestyle factors [18]. Building on this, we investigated whether provision of care related to these risk factors increased after PHC participation in a large-scale CQI initiative implemented across multiple settings. We also explored whether improvements were associated with organizational systems or characteristics.

The study sample comprised 2,220 records from 50 PHCs. Commencement year varied with 19 PHCs beginning to audit maternal health records in 2007, 9 in 2008, 10 in 2009, 6 in 2010 and 6 in 2011. In some years PHCs may focus their CQI activities on other clinical areas; 11 PHCs audited maternal health records in non-consecutive years. Characteristics of PHCs and women attending for pregnancy care are described in Table 1. A range of PHC governance structures, population sizes, locations and states was represented. The majority of women were Indigenous and 47-67 % first attended for pregnancy care in the first trimester.

This large, longitudinal study supports the use of CQI activities to improve provision of recommended pregnancy care for Indigenous women attending PHCs. It also provides evidence of the potential for quality improvement efforts targeting underlying systemic issues to improve pregnancy care in primary care settings in general. Women were more likely to have documented provision of screening and counselling regarding lifestyle factors if they attended after PHCs completed one or more CQI cycles. Opportunities for further improvement included lifestyle counselling and folate prescription. Better self-rated organizational systems were associated with greater provision of outcome measures, and PHC governance and location were associated with pregnancy care provision and changes in service delivery.

Greater provision of pregnancy care regarding lifestyle-related risk factors was associated with participation in this CQI initiative and supports the incorporation of CQI activities into primary care settings to improve pregnancy care. This is an important contribution as there is relatively little international research regarding CQI in pregnancy care and most has been in hospital settings [24‐27]. Additionally, as the ABCD Partnership involves multiple PHCs, it is uniquely placed to identify systemic issues that affect performance across a wide range of settings rather than providing information only relevant locally. Collaborative, multi-center, hospital-based CQI networks in the United States of America (USA) have recently reported decreases in scheduled deliveries without a medical indication (between 36–39 weeks gestation), decreases in bloodstream infections in preterm infants, and improvements in processes to support breastfeeding [24, 25]. CQI approaches have been used in single-center, hospital-based settings to improve care for diabetes in pregnancy in the USA and to improve coordination of antenatal and postnatal care in England [26, 27]. In the Australian context, the national pregnancy care guidelines recommend enquiry about lifestyle-related risk factors for adverse pregnancy outcomes to enable explanation of these risks, offer appropriate lifestyle counselling and arrange treatment or referral if required [8]. Increased provision of these components may contribute to improving the health of Indigenous mothers, closing the gap in perinatal outcomes between Indigenous and other Australian women, and potentially improving the health of the children long-term through an improved intra-uterine environment. Some of the observed increases may reflect improved documentation of existing provision rather than changes in provision, but accurate documentation itself is an important quality indicator, as it improves continuity of care and increases efficiency. This study also identified lifestyle counselling and folate prescription as specific areas where further improvements are needed. Barriers to peri-conception folate prescription and use should be investigated to identify how health center systems and processes could be improved to support this. Prevention of smoking in pregnancy has been described as the single intervention with the biggest potential impact on perinatal outcomes in Indigenous populations in Australia [28]. The findings presented here show that, while enquiry about smoking was almost universal by cycle four, more than one quarter of women who smoked were not provided with cessation advice. Further research is needed to identify optimal ways to support Indigenous women to implement smoking cessation and prevention strategies. To further facilitate benchmarking and implementation of best practice, an important part of the ABCD Research Partnership’s approach is providing these aggregated, large-scale findings to stakeholders at regular meetings designed to share knowledge and focus research priorities [20]. Wider engagement of stakeholders is supported through dissemination of draft reports and encouraging participation in interpreting and using findings to improve practice and policy. An example of such a multidisciplinary strategy is the recently developed health promotion CQI tool [29].

Consistent with the systems focus of CQI, the observed greater likelihood of receiving screening and counselling was not confined to an isolated area but observed across all measures investigated. Better self-rated organizational systems were associated with greater provision of outcomes measures and, in particular, information systems/decision support, and organizational influence/integration were associated with greater provision of several measures, suggesting they affect performance across multiple settings. These may be areas for targeted systems level improvement efforts to improve pregnancy care generally. These findings are supported by related work within the ABCD Research Partnership that noted positive associations between higher SAT scores and higher provision of pregnancy care measures [30]. This is also consistent with diabetes care research, in which greater SAT subscale scores were associated with better adherence to delivery of recommended services [22]. Together these findings indicate that the state of development of organizational systems is reflected in quality of care and highlight the importance of focusing on improving systems and processes, rather than local, isolated problems. However, in the current research, no statistically significant association was observed between changes in SAT scores and changes in provision of outcome measures, potentially reflecting the small number of PHCs for which SAT data were available.

Recent Australian research has emphasized the importance of providing pregnancy care in a culturally safe environment [31‐34]. The current research focused on the overarching strategy of strengthening organizational systems and processes to improve quality of care. Within this, PHCs may have focused their CQI activities on provision of culturally appropriate care or on other aspects of organizational systems. Other research using a quality improvement framework reported improvements in pregnancy care provision at an urban community-controlled health service compared to a historical cohort [35]. Our findings are consistent with this and further indicate CQI’s large-scale potential within primary care by including many PHCs across multiple jurisdictions, serving small and large communities, in urban and remote settings.

Better adherence to recommended service delivery also appeared to be sustained with continuing PHC involvement over a number of cycles, with some evidence that further improvements were gained from each additional CQI cycle. This highlights the importance of supporting long-term participation in CQI, consistent with previous reports of improvements in pregnancy care over six years of annual clinical audits (2000–2005) [35]. The research presented here also provides important long-term information about current provision of pregnancy care by PHCs in Indigenous communities. While some research has recently evaluated pregnancy care for Indigenous women over several years [31‐33], these programs were implemented at one site or in one geographic region, limiting generalizability of the findings.

Our findings indicate that PHC characteristics and context may influence pregnancy care provision and changes in service delivery, however there was no indication that the CQI initiative was only successful in one specific setting. Previous research has identified that maternal risk factors, maternal health service delivery and pregnancy outcomes vary between different settings, such as geographical region and remoteness [18, 36]. Given this diversity, there are likely to be benefits from identifying programs that can be successfully implemented across a range of settings. A strength of collaborative, system-based, CQI initiatives and research is the ability to draw on a shared understanding of issues encountered across settings as well as specific experiences or insights of PHCs [20].

Women attending PHCs that had participated in continuous quality improvement activities were more likely to receive recommended pregnancy care related to screening and brief interventions for modifiable lifestyle-related risk factors for key adverse pregnancy outcomes. These findings support incorporation of continuous quality improvement activities, addressing underlying systemic issues, into primary care settings to improve pregnancy care. Clear areas were identified where further improvements in provision of care are needed to improve pregnancy outcomes in Aboriginal and Torres Strait Islander women in Australia.