The high prevalence and impact of rheumatic heart disease in pregnancy in First Nations populations in a high-income setting: a prospective cohort study.

OBJECTIVE: To describe the epidemiology of rheumatic heart disease (RHD) in pregnancy in Australia and New Zealand (A&NZ). DESIGN: Prospective population-based study. SETTING: Hospital-based maternity units throughout A&NZ. POPULATION: Pregnant women with RHD with a birth outcome of ≥20 weeks of gestation between January 2013 and December 2014. METHODS: We identified eligible women using the Australasian Maternity Outcomes Surveillance System (AMOSS). De-identified antenatal, perinatal and postnatal data were collected and analysed. MAIN OUTCOME MEASURES: Prevalence of RHD in pregnancy. Perinatal morbidity and mortality. RESULTS: There were 311 pregnancies associated with women with RHD (4.3/10 000 women giving birth, 95% CI 3.9-4.8). In Australia, 78% were Aboriginal or Torres Strait Islander (60.4/10 000, 95% CI 50.7-70.0), while in New Zealand 90% were Maori or Pasifika (27.2/10 000, 95% CI 22.0-32.3). One woman (0.3%) died and one in ten was admitted to coronary or intensive care units postpartum. There were 314 births with seven stillbirths (22.3/1000 births) and two neonatal deaths (6.5/1000 births). Sixty-six (21%) live-born babies were preterm and one in three was admitted to neonatal intensive care or special care units. CONCLUSION: Rheumatic heart disease in pregnancy persists in disadvantaged First Nations populations in A&NZ. It is associated with significant cardiac and perinatal morbidity. Preconception planning and counselling and RHD screening in at-risk pregnant women are essential for good maternal and baby outcomes. TWEETABLE ABSTRACT: Rheumatic heart disease in pregnancy persists in First Nations people in Australia and New Zealand and is associated with major cardiac and perinatal morbidity.

Can the fetal fibronectin test be used by remote dwelling pregnant women to predict the onset of labour at term and delay transfer for birth in regional settings?

INTRODUCTION: The closure of rural maternity units in Australia means an increasing number of women are transferred into major centres to await birth. Accurately excluding the onset of labour could delay relocation. The fetal fibronectin (fFN) test is used to predict preterm birth; however, the accuracy of this test for determining impending term birth is unclear. METHODS: 75 women were recruited to this study from two remote maternity units. Eligibility criteria were: aged ≥18 years, singleton pregnancy, 37+0-40+3 weeks (37 weeks to 40 weeks and 3 days gestation) and no indication for induction of labour or caesarean section in next 7 days. The Quikcheck fFN® test was performed at 37 weeks and then repeated at 7 day intervals. Time-to-birth from test date was modelled using linear regression. Logistic regression models estimated odds of birth within 7 days. Separate models considered first and last test results and those at 38 weeks; adjusted for use of lubricant and gestational age. RESULTS: A shorter time-to-birth was found in women with positive compared with negative fFN tests; significant at first fFN test (adjusted mean difference [AMD] 5.4 days, 95% CI 2.0-8.8) and 38 weeks (AMD 5.7 days, 95% CI 2.2-9.2 days). A positive test was also associated with a significant increase in the odds of birthing within 7 days: first fFN test adjusted odds ratio (AOR) 11.0 (95% CI 2.5-48.7), 38 weeks test AOR 14.4 (95% CI 3.4-60.2), last fFN test AOR 8.1 (95% CI 1.6-39.8). However, of women who gave birth within 7 days of testing a significant proportion had a negative fFN result; first fFN test 8/17(47.1%), 38 weeks test 4/14(28.6%) and last fFN test 29/58(50.0%). CONCLUSION: The presence of fFN in cervical secretions was associated with impending term birth but its absence did not reliably exclude the onset of birth. Delaying transfer based on these findings would result in some women birthing in their home communities.

Educational preparation for maternal, child and family health nurses in Australia.

AIM: The study aims to map and critique the current postgraduate educational nursing programmes offered to nurses and midwives in maternal, child and family health in Australia. BACKGROUND: Nursing specialties that focus on the early years of child health and development are based on international recognition of the developmental needs of the growing infant and of the social, health and economic consequences of failing to support families to raise their children in optimal environments. Little is known whether the educational programmes that prepare maternal, child and family health nurses (MCFHNs) for practice in Australia have kept up with new knowledge and understanding of the early years of life. METHODS: A survey of all maternal, child and family health education programmes offered in Australia was undertaken. FINDINGS: Marked variations in course titles, length, content, clinical exposure and award exist across the 12 institutions offering such programmes in Australia. Many institutions provide inadequate preparation in some of the core skills required of the workforce. CONCLUSION: The establishment of minimum standards for the education of MCFHNs across Australia is required. This study also highlights the need for further research around the scope of practice of MCFHNs, and the role of midwives who are not nurses, in this specialty area.

'Closing the Gap': how maternity services can contribute to reducing poor maternal infant health outcomes for Aboriginal and Torres Strait Islander women.

CONTEXT: The reproductive health outcomes for Aboriginal and Torres Strait Islander mothers and infants are significantly poorer than they are for other Australians; they worsen with increasing remoteness where the provision of services becomes more challenging. Australia has committed to 'Overcoming Indigenous Disadvantage' and 'Closing the Gap' in health outcomes. ISSUES: Fifty-five per cent of Aboriginal and Torres Strait Islander birthing women live in outer regional and remote areas and suffer some of the worst health outcomes in the country. Not all of these women are receiving care from a skilled provider, antenatally, in birth or postnatally while the role of midwives in reducing maternal and newborn mortality and morbidity is under-utilised. The practice of relocating women for birth does not address their cultural needs or self-identified risks and is contributing to these outcomes. An evidence based approach for the provision of maternity services in these areas is required. Australian maternal mortality data collection, analysis and reporting is currently insufficient to measure progress yet it should be used as an indicator for 'Closing the Gap' in Australia. LESSONS LEARNED: A more intensive, coordinated strategy to improve maternal infant health in rural and remote Australia must be adopted. Care needs to address social, emotional and cultural health needs, and be as close to home as possible. The role of midwives can be enabled to provide comprehensive, quality care within a collaborative team that includes women, community and medical colleagues. Service provision should be reorganised to match activity to need through the provision of caseload midwives and midwifery group practices across the country. Funding to embed student midwives and support Aboriginal and Torres Strait Islander women in this role must be realised. An evidence base must be developed to inform the provision of services in these areas; this could be through the testing of the Rural Birth Index in Australia. The provision of primary birthing services in remote areas, as has occurred in some Inuit and New Zealand settings, should be established. 'Birthing on Country' that incorporates local knowledge, on-site midwifery training and a research and evaluation framework, must be supported.

Culture-specific programs for children and adults from minority groups who have asthma.

BACKGROUND: People with asthma who come from minority groups have poorer asthma outcomes and more asthma related visits to Emergency Departments (ED). Various programmes are used to educate and empower people with asthma and these have previously been shown to improve certain asthma outcomes. Models of care for chronic diseases in minority groups usually include a focus of the cultural context of the individual and not just the symptoms of the disease. Therefore, questions about whether culturally specific asthma education programmes for people from minority groups are effective at improving asthma outcomes, are feasible and are cost-effective need to be answered. OBJECTIVES: To determine whether culture-specific asthma programmes, in comparison to generic asthma education programmes or usual care, improve asthma related outcomes in children and adults with asthma who belong to minority groups. SEARCH STRATEGY: We searched the Cochrane Register of Controlled Trials (CENTRAL), the Cochrane Airways Group Specialised Register, MEDLINE, EMBASE, review articles and reference lists of relevant articles. The latest search was performed in March 2007. SELECTION CRITERIA: All randomised controlled trials (RCTs) comparing the use of culture-specific asthma education programmes with generic asthma education programmes, or usual care, in adults or children from minority groups who suffer from asthma. DATA COLLECTION AND ANALYSIS: Two review authors independently selected, extracted and assessed the data for inclusion. We contacted authors for further information if required. MAIN RESULTS: Three studies were eligible for inclusion in the review. A total of 396 patients, aged from 7 to 59 years were included in the meta-analysis of data. Use of a culture-specific programme was superior to generic programmes or usual care, in improving asthma quality of life scores in adults, pooled WMD 0.25 (95% CI 0.09 to 0.41) and asthma knowledge scores in children, WMD 3.30 (95% CI 1.07 to 5.53). There was no significant difference between groups in occurrence of asthma exacerbations, but the width of the confidence interval means that effects on exacerbation rates cannot be ruled out, rate ratio 0.93 (95% CI 0.80 to 1.10). AUTHORS' CONCLUSIONS: Culture-specific programmes for adults and children from minority groups with asthma, have been found to be more effective than generic programmes in improving some (Quality of Life and asthma knowledge) but not all asthma outcomes. This evidence is limited by the small number of included studies and the lack of reported outcomes. Further trials are required to answer this question conclusively.

Clinical pathways for chronic cough in children.

BACKGROUND: Chronic cough (a cough lasting longer than 4 weeks) is a common symptom presenting to primary care in Australia and internationally. Chronic cough costs the community, is distressing to parents, and ignoring cough may lead to delayed diagnosis and illness progression of serious underlying respiratory disease. Clinical guidelines have been shown to provide more efficient and effective patient care and can clarify clinical decision making. Cough guidelines have been designed to facilitate management of chronic cough, however treatment recommendations vary and specific clinical pathways for the treatment of chronic cough in children are important, as the cause and treatments for cough in a child vary significantly adults. Therefore, it would be beneficial to clinical practice to systematically evaluate the use of clinical pathways for the treatment of chronic cough in children. OBJECTIVES: To evaluate the effectiveness of using a clinical pathway in the management of children with chronic cough. SEARCH STRATEGY: The Cochrane Register of controlled Trials (CENTRAL), the Cochrane Airways Group Specialised Register, MEDLINE, EMBASE, review articles and reference lists of relevant articles were searched. The search was carried out in May 2007. SELECTION CRITERIA: All randomised controlled trials with parallel group design comparing use vs non-use of a clinical pathway for treatment of chronic cough in children. DATA COLLECTION AND ANALYSIS: Results of searches were reviewed against the pre-determined criteria for inclusion. Two reviewers independently selected the studies and it was planned that data extraction would have been done in duplicate. MAIN RESULTS: The search identified 471 potentially relevant titles but no studies met criteria for inclusion in the review. AUTHORS' CONCLUSIONS: Without further available evidence, recommendations for the use of clinical pathways for the treatment of chronic cough in children cannot be made. Until further evidence is available, the decision for further investigation and treatment for the child presenting with chronic cough should be made on an individual basis (i.e. dependent on symptoms and signs) with consideration for existing data from other Cochrane reviews on specific treatments for cough. Trials are required to provide evidence on the effectiveness of clinical pathways for the treatment of chronic cough in children.

An iron treatment trial in an aboriginal community: improving non-adherence.

OBJECTIVE: To compare supervised vs unsupervised oral iron treatment in anaemic Aboriginal children living in a remote community with a 40% prevalence of iron deficiency anaemia. METHODOLOGY: A randomised unblinded clinical trial in children < 6 years presenting to a remote Health Centre with anaemia. Oral iron prescribed as a daily unsupervised dose (group A) was compared to twice weekly supervised administration (group B) over 12 weeks. Parenteral iron (group C) was reserved for failure of oral treatment. RESULTS: Only 3 of 25 children in group A responded to treatment compared to 23 of 26 children in group B (odds ratio = 7.7, 95% confidence interval 2.6-25.0). After six weeks of treatment, the mean haemoglobin rise was 0.96 g/L in group A compared to 10.9 g/L in group B and 12.4 g/L in group C. On entry to the study, 29.4% of subjects were underweight, 33.3% stunted and 35.3% microcephalic. The mean catch-up in weight/height on iron treatment over the study was only 0.28 (0.08, 0.48) Z-scores. CONCLUSIONS: Oral iron as directly observed twice weekly treatment is superior to unsupervised therapy. In view of the poor compliance with unsupervised treatment and the high prevalence of iron deficiency anaemia (along with stunting and microcephaly) in Aboriginal children in northern Australia, we propose to undertake in partnership with communities a nutritional intervention program with a high energy weaning food fortified with micronutrients (iron, vitamin A, zinc, folate) as the most effective strategy to address these nutritional problems in the weaning period.