Improving systems of care during and after a pregnancy complicated by hyperglycaemia: A protocol for a complex health systems intervention.

BACKGROUND: Many women with hyperglycaemia in pregnancy do not receive care during and after pregnancy according to standards recommended in international guidelines. The burden of hyperglycaemia in pregnancy falls disproportionately upon Indigenous peoples worldwide, including Aboriginal and Torres Strait Islander women in Australia. The remote and regional Australian context poses additional barriers to delivering healthcare, including high staff turnover and a socially disadvantaged population with a high prevalence of diabetes. METHODS: A complex health systems intervention to improve care for women during and after a pregnancy complicated by hyperglycaemia will be implemented in remote and regional Australia (the Northern Territory and Far North Queensland). The Theoretical Domains Framework was used during formative work with stakeholders to identify intervention components: (1) increasing workforce capacity, skills and knowledge and improving health literacy of health professionals and women; (2) improving access to healthcare through culturally and clinically appropriate pathways; (3) improving information management and communication; (4) enhancing policies and guidelines; (5) embedding use of a clinical register as a quality improvement tool. The intervention will be evaluated utilising the RE-AIM framework at two timepoints: firstly, a qualitative interim evaluation involving interviews with stakeholders (health professionals, champions and project implementers); and subsequently a mixed-methods final evaluation of outcomes and processes: interviews with stakeholders; survey of health professionals; an audit of electronic health records and clinical register; and a review of operational documents. Outcome measures include changes between pre- and post-intervention in: proportion of high risk women receiving recommended glucose screening in early pregnancy; diabetes-related birth outcomes; proportion of women receiving recommended postpartum care including glucose testing; health practitioner confidence in providing care, knowledge and use of relevant guidelines and referral pathways, and perception of care coordination and communication systems; changes to health systems including referral pathways and clinical guidelines. DISCUSSION: This study will provide insights into the impact of health systems changes in improving care for women with hyperglycaemia during and after pregnancy in a challenging setting. It will also provide detailed information on process measures in the implementation of such health system changes.

Diabetes care in remote Australia: the antenatal, postpartum and inter-pregnancy period.

BACKGROUND: Aboriginal and Torres Strait Islander women experience high rates of diabetes in pregnancy (DIP), contributing to health risks for mother and infant, and the intergenerational cycle of diabetes. By enhancing diabetes management during pregnancy, postpartum and the interval between pregnancies, the DIP Partnership aims to improve health outcomes and reduce risks early in the life-course. We describe a mixed methods formative study of health professional's perspectives of antenatal and post-partum diabetes screening and management, including enablers and barriers to care. METHODS: Health professionals involved in providing diabetes care in pregnancy, from a range of health services across the Northern Territory, completed the survey (n = 82) and/or took part in interviews and/or focus groups (n = 62). RESULTS: Qualitative findings highlighted factors influencing the delivery of care as reported by health professionals, including: whose responsibility it is, access to care, the baby is the focus and pre-conception care. The main challenges were related to: disjointed systems and confusion around whose role it is to provide follow-up care beyond six weeks post-partum. Quantitative findings indicated that the majority of health professionals reported confidence in their own skills to manage women in the antenatal period (62%, 40/79) and slightly lower rates of confidence in the postpartum interval (57%, 33/58). CONCLUSION: These findings regarding whose role it is to provide postpartum care, along with opportunities to improve communication pathways and follow up care have informed the design of a complex health intervention to improve health systems and the provision of DIP related care.

A candidate redshift z ≈ 10 galaxy and rapid changes in that population at an age of 500 Myr.

Searches for very-high-redshift galaxies over the past decade have yielded a large sample of more than 6,000 galaxies existing just 900-2,000 million years (Myr) after the Big Bang (redshifts 6 > z > 3; ref. 1). The Hubble Ultra Deep Field (HUDF09) data have yielded the first reliable detections of z ≈ 8 galaxies that, together with reports of a γ-ray burst at z ≈ 8.2 (refs 10, 11), constitute the earliest objects reliably reported to date. Observations of z ≈ 7-8 galaxies suggest substantial star formation at z > 9-10 (refs 12, 13). Here we use the full two-year HUDF09 data to conduct an ultra-deep search for z ≈ 10 galaxies in the heart of the reionization epoch, only 500 Myr after the Big Bang. Not only do we find one possible z ≈ 10 galaxy candidate, but we show that, regardless of source detections, the star formation rate density is much smaller (∼10%) at this time than it is just ∼200 Myr later at z ≈ 8. This demonstrates how rapid galaxy build-up was at z ≈ 10, as galaxies increased in both luminosity density and volume density from z ≈ 10 to z ≈ 8. The 100-200 Myr before z ≈ 10 is clearly a crucial phase in the assembly of the earliest galaxies.

Hydrogen 21-centimeter emission from a galaxy at cosmological distance.

We have detected the neutral atomic hydrogen (HI) emission line at a cosmologically significant distance [redshift (z) = 0.18] in the rich galaxy cluster Abell 2218 with the Westerbork Synthesis Radio Telescope. The HI emission originates in a spiral galaxy 2.0 h65(-1) megaparsecs from the cluster core. No other significant detections have been made in the cluster, suggesting that the mechanisms that remove neutral gas from cluster galaxies are efficient. We infer that fewer than three gas-rich galaxies were accreted by Abell 2218 over the past 10(9) years. This low accretion rate is qualitatively consistent with low-density cosmological models in which clusters are largely assembled at z > 1.