Barclay Lesley, Kruske Sue, Bar-Zeev Sarah, Steenkamp Malinda, Josif Cathryn, Narjic Concepta Wulili, Wardaguga Molly, Belton Suzanne, Gao Yu, Dunbar Terry, Kildea Sue
University Centre for Rural Health, North Coast, Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
BMC Health Serv Res. 2014 Jun 2;14:241. doi: 10.1186/1472-6963-14-241.
Health services research is a well-articulated research methodology and can be a powerful vehicle to implement sustainable health service reform. This paper presents a summary of a five-year collaborative program between stakeholders and researchers that led to sustainable improvements in the maternity services for remote-dwelling Aboriginal women and their infants in the Top End (TE) of Australia.
A mixed-methods health services research program of work was designed, using a participatory approach. The study area consisted of two large remote Aboriginal communities in the Top End of Australia and the hospital in the regional centre (RC) that provided birth and tertiary care for these communities. The stakeholders included consumers, midwives, doctors, nurses, Aboriginal Health Workers (AHW), managers, policy makers and support staff. Data were sourced from: hospital and health centre records; perinatal data sets and costing data sets; observations of maternal and infant health service delivery and parenting styles; formal and informal interviews with providers and women and focus groups. Studies examined: indicator sets that identify best care, the impact of quality of care and remoteness on health outcomes, discrepancies in the birth counts in a range of different data sets and ethnographic studies of 'out of hospital' or health centre birth and parenting. A new model of maternity care was introduced by the health service aiming to improve care following the findings of our research. Some of these improvements introduced during the five-year research program of research were evaluated.
Cost effective improvements were made to the acceptability, quality and outcomes of maternity care. However, our synthesis identified system-wide problems that still account for poor quality of infant services, specifically, unacceptable standards of infant care and parent support, no apparent relationship between volume and acuity of presentations and staff numbers with the required skills for providing care for infants, and an 'outpatient' model of care. Services were also characterised by absent Aboriginal leadership and inadequate coordination between remote and tertiary services that is essential to improve quality of care and reduce 'system-introduced' risk.
Evidence-informed redesign of maternity services and delivery of care has improved clinical effectiveness and quality for women. However, more work is needed to address substandard care provided for infants and their parents.
卫生服务研究是一种阐述清晰的研究方法，并且可以成为实施可持续卫生服务改革的有力工具。本文概述了利益相关者与研究人员之间开展的一项为期五年的合作项目，该项目使澳大利亚北部地区（TE）偏远地区的原住民妇女及其婴儿的孕产妇服务得到了可持续改善。
采用参与式方法设计了一个混合方法的卫生服务研究工作计划。研究区域包括澳大利亚北部地区的两个大型偏远原住民社区以及为这些社区提供分娩和三级护理的区域中心（RC）的医院。利益相关者包括消费者、助产士、医生、护士、原住民卫生工作者（AHW）、管理人员、政策制定者和支持人员。数据来源包括：医院和健康中心记录；围产期数据集和成本数据集；母婴卫生服务提供情况及育儿方式的观察；对提供者、妇女进行的正式和非正式访谈以及焦点小组。研究内容包括：确定最佳护理的指标集、护理质量和偏远程度对健康结果的影响、一系列不同数据集中出生人数的差异以及对“院外”或健康中心分娩及育儿的人种学研究。卫生服务部门引入了一种新的孕产妇护理模式，旨在根据我们的研究结果改善护理。对五年研究项目期间引入的一些改进措施进行了评估。
在孕产妇护理的可接受性、质量和结果方面实现了具有成本效益的改进。然而，我们的综合分析发现了全系统存在的问题，这些问题仍然导致婴儿服务质量不佳，具体表现为：婴儿护理和家长支持的标准不可接受；就诊量和病情严重程度与具备提供婴儿护理所需技能的工作人员数量之间没有明显关系；以及“门诊”护理模式。服务的特点还包括缺乏原住民领导力以及偏远地区和三级服务之间协调不足，而这对于提高护理质量和降低“系统引入”风险至关重要。
基于证据对孕产妇服务和护理提供进行重新设计提高了妇女的临床疗效和护理质量。然而，仍需要开展更多工作来解决为婴儿及其父母提供的不合格护理问题。
