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Objective To examine the use of evidence based leaflets on informed choice in maternity services. Design Non-participant observation of 886 antenatal consultations. 383 in depth interviews with women using maternity services and health professionals providing antenatal care. Setting Women's homes; antenatal and ultrasound clinics in 13 maternity units in Wales. Participants Childbearing women and health professionals who provide antenatal care. Intervention Provision of 10 pairs of Informed Choice leaflets for service users and staff and a training session in their use. Main outcome measures Participants' views and commonly observed responses during consultations and interviews. Results Health professionals were positive about the leaflets and their potential to assist women in making informed choices, but competing demands within the clinical environment undermined their effective use. Time pressures limited discussion, and choice was often not available in practice. A widespread belief that technological intervention would be viewed positively in the event of litigation reinforced notions of "right" and "wrong" choices rather than "informed" choices. Hierarchical power structures resulted in obstetricians defining the norms of clinical practice and hence which choices were possible. Women's trust in health professionals ensured their compliance with professionally defined choices, and only rarely were they observed asking questions or making alternative requests. Midwives rarely discussed the contents of the leaflets or distinguished them from other literature related to pregnancy. The visibility and potential of the leaflets as evidence based decision aids was thus greatly reduced. Conclusions The way in which the leaflets were disseminated affected promotion of informed choice in maternity care. The culture into which the leaflets were introduced supported existing normative patterns of care and this ensured informed compliance rather than informed choice.

BackgroundIndigenous Australians are a small, widely dispersed population. Regarding childbearing women and infants, inequities in service delivery and culturally unsafe services contribute to significantly poorer outcomes, with a lack of high-level research to guide service redesign. This paper reports on an Evaluation of a specialist (Murri) antenatal clinic for Australian Aboriginal and Torres Strait Islander women.MethodsA triangulated mixed method approach generated and analysed data from a range of sources: individual and focus group interviews; surveys; mother and infant audit data; and routinely collected data. A retrospective analysis compared clinical outcomes of women who attended the Murri clinic (n=367) with Indigenous women attending standard care (n=414) provided by the same hospital over the same period. Both services see women of all risk status.ResultsThe majority of women attending the Murri clinic reported high levels of satisfaction, specifically with continuity of carer antenatally. However, disappointment with the lack of continuity during labour/birth and postnatally left some women feeling abandoned and uncared for. Compared to Indigenous women attending standard care, those attending the Murri clinic were statistically less likely to be primiparous or partnered, to experience perineal trauma, to have an epidural and to have a baby admitted to the Neonatal Intensive Care Unit, and were more likely to have a non-instrumental vaginal birth. Multivariate analysis found higher normal birth (spontaneous onset of labour, no epidural, non-instrumental vaginal birth without episiotomy) rates amongst women attending the Murri clinic.ConclusionsSignificant benefits were associated with attending the Murri clinic. Recommendations for improvement included ongoing cultural competency training for all hospital staff, reducing duplication of services, improving co-ordination and communication between community and tertiary services, and working in partnership with community-based providers. Combining multi-agency resources to increase continuity of carer, culturally responsive care, and capacity building, including creating opportunities for Indigenous employment, education, and training is desirable, but challenging. Empirical evidence from our Evaluation provided the leverage for a multi-agency agreement to progress this goal within our catchment area.

This paper explores the cross-cultural application of the Edinburgh Postnatal Depression Scale (EPDS) and the difficulties associated with administration to women from refugee backgrounds. Assessing women's comprehension of individual scale items identified problems associated with "Western" terminology and concepts. Re-interpretation of discrete items on the scale was often necessary, raising doubts about the objectivity and reliability of scores. Our findings call for a closer examination of the ethnocentric assumptions underpinning the EPDS items, and the need to incorporate a more diverse range of cross-cultural understandings into future iterations.

Providing comprehensive and culturally responsive maternity care for women from refugee backgrounds is achievable, however it is also resource intensive. The production of translated information which is high quality in terms of production and content, whilst also taking account of languages which are only rarely encountered, is problematic. Cultural competency programmes for staff, ideally online, require regular updating in light of new knowledge and changing political sensitivities.

The current study examined the effects of a natural disaster (a sudden onset flood) as a stressor in pregnancy on infant fine and gross motor development at 2, 6, and 16 months of age. Whether the timing of the stressor in pregnancy or sex of the infant moderated the impact of the prenatal maternal stress on motor development was also explored. Mothers' objective experiences of the flood, emotional reactions and distress, and their cognitive appraisal of the event were assessed retrospectively. Infants' fine and gross motor skills were assessed with the Ages and Stages Questionnaire, and results showed age-related changes in the effects of prenatal maternal stress on these domains. At 2 months, higher levels of prenatal maternal stress was positively related to infant motor development, yet at 6 and 16 months of age there was a negative association, particularly if flood exposure occurred later in pregnancy and if mothers had negative cognitive appraisals of the event. Results also showed differential effects of the maternal stress responses to the floods on infants' fine and gross motor development at each age and that infant sex did not buffer these effects. © 2016 Wiley Periodicals, Inc. Dev Psychobiol 58: 640-659, 2016.

Medication errors are a common and significant problem, particularly when patients transition between healthcare providers. Discrepancies are especially prevalent on hospital admission and discharge. People with complex medication regimens, older people, those with mental health problems, people who are poor or have low literacy, and Aboriginal and Torres Strait Islander and migrant populations are particularly at risk of medication discrepancies. A patient-centred approach is a necessary shift towards reducing medication discrepancies and errors. The patient is the one 'constant' as they progress through GP and ancillary primary care services, hospital services, and specialist outpatient and private clinics. Patients and their carers need to be involved as active participants in this process. Maintaining an accurate, comprehensive and up-to-date medicines list that follows the patient, reduces serious medication error. Pivotal to this record is a medicines reconciliation review at error-prone transition points. Multiple health professionals involved in a patient's journey through healthcare services need to embrace accountability for medicines-related outcomes. Emerging technologies for communication between primary care and specialist or secondary services will facilitate this, but importantly, there needs to be commitment from each health professional to undertake this approach. medicines GPs think they are taking at home, medicines listed in GP referral letters, medicines people obtain from pharmacies, the medicines recorded when they are admitted to hospital, and when they leave hospital, and the medicines detailed in their official discharge summary. These discrepancies often relate to medicine omissions. 6-8 In mental health community care, medication discrepancies cause particular problems. Psychiatrists often remain involved in prescribing and reviewing psychotropic medicines, while GPs are expected to manage medicines related to other conditions. Patients may take a number of medicines in complex regimens so there is a high potential for drug interactions, particularly given the substantial comorbidity and mortality rates in this population. 9,10 Recent research on clozapine has shown that discrepancies with concomitant medications can have potentially fatal outcomes (see Box). 11,12 Indigenous or migrant people, and those who are socially disadvantaged or have low literacy, experience health outcomes that reflect their difficulties when navigating the healthcare system. 13-16 Culturally appropriate delivery of health services is crucial to effective engagement and uptake, and this may be challenging to do well.

BackgroundStatewide (Queensland) Clinical Guidelines reflecting current best practice have recently become available for the management of pregnancy-related obesity. Our aim was to assess staff knowledge about, adherence to, and characteristics that influence delivery of care according to these Guidelines.MethodsAn online survey, available over a three week period (May-June 2011), was disseminated to obstetric, midwifery and allied health staff working in a tertiary maternity hospital. Outcomes included knowledge of guideline content, advice given, knowledge of obesity pregnancy-related complications, previous training, referral patterns, and staff characteristics, including lifestyle habits, body satisfaction, and Body Mass Index (BMI).ResultsSeventy-three staff completed surveys (59.6% response rate). Mean self-reported BMI was 24.2 ± 4.1 kg/m2 (17.9-36.4); 28.5% of staff were overweight (19%) or obese (9.5%), and 27.4% were underweight. However, 28.6%, 2.4%, and 1.2% ‘self-classified’ themselves as overweight, obese, and underweight, respectively. Almost 40% were dissatisfied/extremely dissatisfied with their weight. While the majority reported overweight/obesity (ow/ob) as an important/very important general obstetric issue and most correctly identified associated perinatal complications, only 32.1% were aware of existing guidelines, with only half correctly identifying BMI categories for ow/ob. A quarter indicated they did not provide women with gestational weight gain (GWG) advice relative to BMI category. Staff identified they would like more training in the area of supporting women to achieve and understand the need for healthy GWG. Staff role was significantly associated with guideline adherence (p=0.03) and association with BMI category approached significance (p=0.07). An association was observed between staff’s BMI and their belief in the influence of their advice on women’s GWG (p=0.013) and weight satisfaction and belief in women having the resources to make the changes they recommend (p=0.003).ConclusionsWhilst lack of guideline knowledge provides a barrier to best-practice care, our findings suggest an interplay between staff confidence and personal characteristics in delivering such care which deserves recognition in staff education and training, and service development programs and future research.