Background: Strategies to reduce over-representation of Indigenous children in out-of-home care must start in pregnancy given Indigenous babies are 6 % of infants (<1 year), yet 43 % of infants in out-of-home care. Objective: To determine if an Indigenous-led, multi-agency, partnership redesign of maternity services decreases the likelihood of babies being removed at birth. Participants and setting: Women carrying an Indigenous baby/babies who gave birth at the Mater Mothers' Public Hospital, Brisbane (2013-2019). Methods: A prospective, non-randomised, intervention trial evaluated a multi-agency service redesign. Women pregnant with an Indigenous baby birthing at a tertiary hospital were offered standard care or Birthing in Our Community (BiOC) service. We compared likelihood of babies being removed by Child Protection Services (CPS) at birth by model of care. Inverse probability of treatment propensity score weighting controlled baseline confounders and calculated treatment effect. Standardized differences were calculated to assess balance of risk factors for each copy of multiple imputation. Australian New Zealand Clinical Trial Registry, ACTRN12618001365257. Results: In 2013-2019, 1988 women gave birth to 2044 Indigenous babies, with 40 women having babies removed at birth (9 BiOC, 31 standard care). Adjusted odds of baby removal were significantly lower for mothers in BiOC compared to standard care (AOR 0.37, 95 % CI 0.16, 0.84). In total, 2.0 % of Indigenous babies were removed by CPS; eight times higher than nonIndigenous babies at the same hospital (0.25 %). Conclusions: BiOC reduced removals of newborn Indigenous babies likely disrupting generational cycles of CPS contact, trauma, and maltreatment, and contributing to short and long-term health and wellbeing benefits for mothers and babies.

Background Preterm birth is the leading cause of morbidity and mortality for children under five years with First Nations babies experiencing twice the rate of other Australians. The Birthing in Our Community (BiOC) service was implemented in a metropolitan centre in Australia and showed a significant reduction in preterm birth. We aimed to assess the cost-effectiveness of the BiOC service in reducing preterm births compared to Standard Care, from a health system perspective. Methods Women who were carrying a First Nations baby and attending the Mater Mothers Public Hospital (Brisbane, QLD, Australia) were allocated to either BiOC or Standard Care service. Birth records were extracted from the hospital's routinely collected and prospectively entered database. The time horizon extended from first presentation in pregnancy up to six weeks after birth for mothers and 28 days for infants, or until discharged from hospital. All direct antenatal, birth, postnatal and neonatal costs were included. The proportion of preterm birth was calculated, and cost was estimated in 2019 Australian dollars. The incremental cost and proportion of preterm birth differences were adjusted using inverse probability of treatment weighting methods. Findings Between Jan 1 2013, and Jun 30, 2019, 1816 mothers gave births to 1867 First Nations babies at the Mater Mothers Public Hospital. After exclusions, 1636 mother-baby pairs were included in the analyses: 840 in the Standard Care group and 796 in the BiOC service. Relative to Standard Care, the BiOC service was associated with a reduced proportion of preterm birth (-5.34%, [95% CI -8.69%, -1.98%]) and cost savings (-AU$4810, [95% CI -7519, -2101]) per mother-baby pair. The BiOC service was associated with better outcomes and cost less than Standard Care. Interpretation The BiOC service offers a cost-effective alternative to Standard Care in reducing preterm birth for Australian First Nations families. The cost savings were driven by less interventions and procedures in birth and fewer neonatal admissions. Investing in comprehensive, community-led models of care improves outcomes at reduced cost.

Urbanisation is a global phenomenon. The World Health Organization reported in 2015 that 55% of the global population lived in cities and is predicting this to increase to 68% by 2050.1 First Nations peoples globally are disproportionately affected by urbanisation, with major drivers being climate change, deforestation and increased pressures created by globalisation. Despite this, there is limited research to address urbanisation and its impact on human health and wellbeing. Similarly, there is an urgent need for a focus on improving health and wellbeing outcomes for urban First Nations peoples in Australia given the rapid urbanisation of First Nations people. Between 2011 and 2021, First Nations populations residing in Australia's capital cities increased overall by 67% and, at the same time, the number of non-Indigenous Australians residing in cities increased by 21%.2 During this same period, Brisbane and Melbourne experienced the greatest increase in First Nations populations (80% each) and Darwin the least (a 31% increase).2 However, there is a limited policy and research focus on urban First Nations populations in Australia. The prevailing discourse of equal access to health care, employment, educational opportunities, and all the available services necessary to close the persistent health gap may be true in theory for urban populations, but these fail to account for the social, structural, political and economic determinants that affect First Nations peoples in contemporary Australia.3 Urbanisation can contribute to significant health inequities and can diminish opportunities for facilitating social and cultural cohesion, which are important for First Nations peoples in maintaining cultural identity, culture, and connection to kin. Moreover, people in cities can easily be isolated from communities and often in areas of greater social dysfunction.3 Urbanisation places additional pressures and burden on an already extended health care system, especially in the context of First Nations health care, affecting health system performance and access to, and utilisation of, health care services by First Nations people. In 2021, 37% of First Nations Australians were reported as living in the major capital cities of Australia.2 Yet, in 2018, urban First Nations people accounted for 56% of the total disease burden, 61.4% of the non-fatal burden and 50.4% of the fatal burden of all First Nations Australians.2 The life expectancy of a First Nations person born in a major city in 2021 is about eight years shorter than for a non-Indigenous Australian.4 Almost a third of First Nations people in non-remote areas, aged 18 years and over, self-reported high or very high levels of psychological distress5; and only 48% of people living in major cities reported their health status as excellent or very good compared with 47% living in very remote areas.6 Health system performance for urban First Nations people in Australia remains suboptimal. The proportion of pregnant women in major cities who attend primary health care organisations for antenatal visits was highest in remote areas (48%) and lowest in major cities (32%),7 and the rate ratio of potentially preventable hospitalisations between urban First Nations and non-Indigenous peoples living in capital cities is 2.1.8 Conversely, we know that when First Nations-led health care is adequately resourced and implemented in cities, these clinics and programs can result in significant improvements in health care access, utilisation and outcomes.9, 10 Further, two Australian First Nations urban health research reviews have highlighted major gaps in research effort and investment. In 2010, the first review found that just 11% of all articles in the previous five years focused on urban First Nations health, despite almost 55% of the total First Nations population living in urban areas (including inner regional areas).11 In 2021, a second review showed that up to three times as many research articles focused on remote First Nations health than urban First Nations health issues.12 In addition, health care research is increasingly dependent on digital health data and platforms. This capability is almost absent in First Nations research, creating a “digital divide”.13 This imbalance is a persistent problem that inhibits the holistic understanding of health issues and responses for large First Nations populations in urban settings. In order to ameliorate First Nations health disadvantage nationally, much more investment and effort must focus on urban populations and communities. This perspective article provides a rationale for why there should be a greater focus on urban First Nations people's health and wellbeing in Australia, as well as a framework for implementing research on this issue. This research centres Indigenous ways of knowing, being and doing by privileging Indigenous voices and world views, underpinned by Indigenous methodologies that encompass the principles of ethical research with First Nations people in Australia.15 As we move forward in striving to close the gap in health and wellbeing outcomes for First Nations peoples in Australia, we have to move toward a greater focus on urban populations. At the same time, we are not advocating for decreasing efforts to improve health and wellbeing outcomes in regional and or remote areas, we stress that it cannot be one or the other. To improve First Nations health disadvantage nationally, considerably more effort and investment in research, policy and clinical services must focus on urban populations and communities, especially with a focus on Aboriginal community-controlled health care. Here, we have outlined the UQ Poche Centre Indigenous Urban Health Research Agenda, which enables research to be driven by communities and conducted by a First Nations-led research centre. We also call to action governments and research funding bodies to reimagine understandings of First Nations health research in Australia and to provide greater policy focus and funding allocation to urban First Nations health research. The UQ Poche Centre for Indigenous Health is generously supported by philanthropists Greg Poche AO and Kay Van Norton Poche. We acknowledge Dr Anton Clifford-Motopi of the UQ Poche Centre for undertaking yarning sessions with members of the Research Alliance for Urban Community-Controlled Health Services and analysis to inform and develop its research priorities. Open access publishing facilitated by The University of Queensland, as part of the Wiley - The University of Queensland agreement via the Council of Australian University Librarians. No relevant disclosures. Not commissioned; externally peer reviewed.

BackgroundThere is an urgency to redress unacceptable maternal and infant health outcomes for First Nations families in Australia. A multi-agency partnership between two Aboriginal Community-controlled health services and a tertiary hospital in urban Australia designed, implemented, and evaluated the new Birthing in Our Community (BiOC) service. In this study, we aimed to assess and report the clinical effectiveness of the BiOC service on key maternal and infant health outcomes compared with that of standard care.MethodsPregnant women attending the Mater Mothers Public Hospital (Brisbane, QLD, Australia) who were having a First Nations baby were invited to receive the BiOC service. In this prospective, non-randomised, interventional trial of the service, we specifically enrolled women who intended to birth at the study hospital, and had a referral from a family doctor or Aboriginal Medical Service. Participants were offered either standard care services or the BiOC service. Prespecified primary outcomes to test the effectiveness of the BiOC service versus standard care were the proportion of women attending five or more antenatal visits, smoking after 20 weeks of gestation, who had a preterm birth (<37 weeks), and who were exclusively breastfeeding at discharge from hospital. We used inverse probability of treatment weighting to balance confounders and calculate treatment effect. This trial is registered with the Australian New Zealand Clinical Trial Registry, ACTRN12618001365257.FindingsBetween Jan 1, 2013, and June 30, 2019, 1867 First Nations babies were born at the Mater Mothers Public Hospital. After exclusions, 1422 women received either standard care (656 participants) or the BiOC service (766 participants) and were included in the analyses. Women receiving the BiOC service were more likely to attend five or more antenatal visits (adjusted odds ratio 1·54, 95% CI 1·13–2·09; p=0·0064), less likely to have an infant born preterm (0·62, 0·42–0·93; p=0·019), and more likely to exclusively breastfeed on discharge from hospital (1·34, 1·06–1·70; p=0·014). No difference was found between the two groups for smoking after 20 weeks of gestation, with both showing a reduction compared with smoking levels reported at their hospital booking visit.InterpretationThis study has shown the clinical effectiveness of the BiOC service, which was co-designed by stakeholders and underpinned by Birthing on Country principles. The widespread scale-up of this new service should be prioritised. Dedicated funding, knowledge translation, and implementation science are needed to ensure all First Nations families can access Birthing on Country services that are adapted for their specific contexts.FundingAustralian National Health and Medical Research Council.

In this call to action, a coalition of Indigenous and non-Indigenous researchers from Australia, Aotearoa New Zealand, United States and Canada argue for the urgent need for adequately funded Indigenous-led solutions to perinatal health inequities for Indigenous families in well-resourced settler-colonial countries. Authors describe examples of successful community-driven programs making a difference and call on all peoples to support and resource Indigenous-led perinatal health services by providing practical actions for individuals and different groups.

Efforts to address Indigenous health disadvantage require a refocus on urban settings, where a rapidly increasing majority (79%) of Indigenous Australians live. Proximity to mainstream primary care has not translated into health equity, with the majority of the Indigenous burden of disease (73%) remaining in urban areas and urban Indigenous people continuing to face significant barriers in accessing comprehensive and culturally appropriate care. This paper presents a case study of how the Institute for Urban Indigenous Health (IUIH) has strategically responded to these challenges in South East Queensland - home to Australia's largest and equal fastest growing Indigenous population. The IUIH has developed a new regional and systematised model - a regional health 'ecosystem' - for how primary care is delivered and intersects with the broader health system. Through intentional action, which strengthens the self-efficacy of community, the IUIH System of Care has delivered real gains for the Indigenous population of the region and has the capacity to deliver similar improvements in health access and outcomes in other regions.

With persisting maternal and infant health disparities, new models of maternity care are needed to meet the needs of Aboriginal and Torres Strait Islander people in Australia. To date, there is limited evidence of successful and sustainable programs. Birthing on Country is a term used to describe an emerging evidence-based and community-led model of maternity care for Indigenous families; its impact requires evaluation.

BACKGROUND:With persisting maternal and infant health disparities, new models of maternity care are needed to meet the needs of Aboriginal and Torres Strait Islander people in Australia. To date, there is limited evidence of successful and sustainable programs. Birthing on Country is a term used to describe an emerging evidence-based and community-led model of maternity care for Indigenous families; its impact requires evaluation. METHODS:Mixed-methods prospective birth cohort study comparing different models of care for women having Aboriginal and Torres Strait Islander babies at two major maternity hospitals in urban South East Queensland (2015-2019). Includes women's surveys (approximately 20 weeks gestation, 36 weeks gestation, two and six months postnatal) and infant assessments (six months postnatal), clinical outcomes and cost comparison, and qualitative interviews with women and staff. DISCUSSION:This study aims to evaluate the feasibility, acceptability, sustainability, clinical and cost-effectiveness of a Birthing on Country model of care for Aboriginal and Torres Strait Islander families in an urban setting. If successful, findings will inform implementation of the model with similar communities. TRIAL REGISTRATION:Australian New Zealand Clinical Trial Registry # ACTRN12618001365257 . Registered 14 August 2018 (retrospectively registered).

Hospitals Association (AHHA), Australia's national peak body for public health care providers

Developing high-quality and culturally responsive maternal and infant health services is a critical part of 'closing the gap' in health disparities between Aboriginal and Torres Strait Islander people and other Australians. The National Maternity Services Plan led work that describes and recommends Birthing on Country best-practice maternity care adaptable from urban to very remote settings, yet few examples exist in Australia. This paper demonstrates Birthing on Country principles can be applied in the urban setting, presenting our experience establishing and developing a Birthing on Country partnership service model in Brisbane, Australia. An initial World Café workshop effectively engaged stakeholders, consumers and community members in service planning, resulting in a multiagency partnership program between a large inner city hospital and two local Aboriginal Community-Controlled Health Services (ACCHS). The Birthing in Our Community program includes: 24/7 midwifery care in pregnancy to six weeks postnatal by a named midwife, supported by Indigenous health workers and a team coordinator; partnership with the ACCHS; oversight from a steering committee, including Indigenous governance; clinical and cultural supervision; monthly cultural education days; and support for Indigenous student midwives through cadetships and placement within the partnership. Three years in, the partnership program is proving successful with clients, as well as showing early signs of improved maternal and infant health outcomes.

presented at the World Congress of Cardiology, Dubai, United Arab Emirates, 18-21 April 2012.

Medical Journal of AustraliaVolume 184, Issue 10 p. 530-531 Training and Workforce The manager Cindy Shannon DSocSc, MBA, Corresponding Author Cindy Shannon DSocSc, MBA Senior Policy Advisor cindyshannon@qaihc.com.au Townsville Aboriginal and Islanders Health Services, Townsville, QLD.Correspondence: cindyshannon@qaihc.com.auSearch for more papers by this authorAdrian Carson, Adrian Carson CEO Townsville Aboriginal and Islanders Health Services, Townsville, QLD.Search for more papers by this authorRachel C Atkinson MBA, BSocWk, Rachel C Atkinson MBA, BSocWk CEO; Chair Townsville Aboriginal and Islanders Health Services, Townsville, QLD.Search for more papers by this author Cindy Shannon DSocSc, MBA, Corresponding Author Cindy Shannon DSocSc, MBA Senior Policy Advisor cindyshannon@qaihc.com.au Townsville Aboriginal and Islanders Health Services, Townsville, QLD.Correspondence: cindyshannon@qaihc.com.auSearch for more papers by this authorAdrian Carson, Adrian Carson CEO Townsville Aboriginal and Islanders Health Services, Townsville, QLD.Search for more papers by this authorRachel C Atkinson MBA, BSocWk, Rachel C Atkinson MBA, BSocWk CEO; Chair Townsville Aboriginal and Islanders Health Services, Townsville, QLD.Search for more papers by this author First published: 15 May 2006 https://doi.org/10.5694/j.1326-5377.2006.tb00354.xCitations: 3Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume184, Issue10May 2006Pages 530-531 RelatedInformation