 to let us know a little bit more about you. Now, just like to take a minute before we move on to today's presentation to introduce our speaker today. Helen Rogers is a registered nurse and midwife with 25 years experience working in Australia, in the UK, and it's out Sudan as well as Sri Lanka. She has also worked with WHO and CDC in Sudan. Helen's current role as the early parenting program coordinator in South Eastern Sydney Local Health District in Australia is focusing on addressing inequities in access to maternity and child health services. In this role, Helen manages the cross-cultural workers in maternity, child and family health services model of care. But this model presents and supports women and families from immigrant and refugee backgrounds on their pregnancy and early parenting journey. And it is also the topic of Helen's current part-time PhD candidature. Her research aims to evaluate the CCW service in terms of effectiveness, acceptability from the perspective and experience of women, their partners, service providers and the impact on maternal and infant healthcare. Want to join me in welcoming Helen today as she speaks to us. Helen, the floor is yours. Excellent, thank you very much, Suzanne. And happy International Women Midwives Day from over here in Sydney to the rest of you over the world. And thank you for this opportunity to present the cross-cultural workers in maternity and child and family health services. So I'd just like to start by reflecting on what migration looks across the world currently. And in 2019, the number of international migrants was estimated to be almost 272 million worldwide who were residing in a country that wasn't their place, country of birth. And that included 70.8 million people who have been forcibly displaced, which includes almost 26 million refugees and three and a half billion asylum seekers who are fleeing their country of origin due to persecution, conflict, violence and human rights violation. This is the highest number of people who have been forcibly displaced on record and that is at the end of 2018. We know that that journey of resettlement is very challenging and significant in many ways, which I'll talk about today, and especially on that impact on the pregnancy and early parenting journey. So what we know in that journey is an arrival in a new country, resettling a new country is known as a social determinant of health and has a major impact on that journey. For women who are arriving in that country many of the questions they will ask is how does this health system work here? Will they understand my situation or ask about my situation? Will they speak my language and most importantly on the back of that is will I have access to an interpreter to support me in understanding what the healthcare worker is saying? How much will it cost and will they respect my cultural beliefs and practices? Although women from migrant and refugee backgrounds have the same access to services as women in the host country, we know that there are challenges in accessing those services due to cultural differences, language barriers, limited health literacy, insufficient supports, transport issues, and limited financial capacity. What does the literature tell us more specifically about what it means for perinatal outcomes for women and migrant and refugee background? And this is for women who are living in a high income country. So we know that those adverse perinatal outcomes include mental health issues so that can be from anxiety to depression. There are high incidents of caesarean section, also higher incidents of maternal and infant mortality, congenital anomalies, preterm birth, stillbirth, and admission to newborn care. That could be a neonatal intensive care unit. We also know that the physical and mental health needs of women in a new country is recognised internationally as a public health priority, and that's come from a number of academic researchers and also from the World Health Organization. So how do we respond to that in our own everyday working world in maternity and early parenting services? We know, and it's recognised by researchers, there needs to be models of care that are responsive to women from migrant and refugee backgrounds. But what models of care are out there? What do they look like and what are most beneficial to women and their families? What we set out to do was to look at what the literature showed us, and we undertook a systematic scoping review that was published early this year. We looked, what we were looking at are models of care during pregnancy and the early parenting period. So that is up to 12 months postnatal that improve access for women, improve accessibility that are acceptable to women and families, and also that improve perinatal outcomes. What we found was over 17 studies and that involved almost 1,500 women and 203 service providers. What we discovered was those models of care looked very different in different settings for women of migrant and refugee background. Some of the models included bilingual and bicultural workers working with women and families, also peer mentors, it may have been a group model of anti-natal care or education that brought women either from the same migrant group together or they may have been a more heterogeneous group. It also, we also found that some of the interventions were a specialised clinic for women of refugee backgrounds. These were all set within high income countries and we looked at the period from 2008 through to 2019. What we did find from the literature was that models of care were very different in different settings, but there was a real need and a focus to be on looking at those models of care that included both qualitative and quantitative approaches to not only ascertain the experience of women and families so we'd access them, but also what service providers found them to be like and also what the impact was on perinatal outcomes. What we did find from those 17 studies was there were 13 key components of culturally responsive care that improved not only access, but also improved accessibility for women from migrant and refugee background. And the key factors that came out that the services must be culturally responsive. They must ask women about what their needs are, their cultural beliefs and practices. Most importantly, and this is a cornerstone for our work as midwives and in maternity care and it's an early parenting care, is that it should be woman centred and there should be continuity. So they also proved to be key factors for women of migrant and refugee background. There was a real need that in language information was available and that there was access to interpreters. Preferably those interpreters were female as was the service providers that were involved in the care for women and families. It was also very important that support was given to navigate services, that services were accessible and they're being flexible around their appointment times were close to public transport for women and families as well. It was also essential that there was co-design. So local communities were asked about what was important to them and that services were responsive to what was provided. Communication was obviously key as was the ability to provide psychosocial and practical support and to have a trauma-informed perspective in the care that we were providing. So moving on from those key elements of improving service access, we look at what the situation is in South East Sydney where I am based. And in our health district, which is our area, we have over 10,000 births a year and that is in three major public health hospitals that provide maternity services. Our community is very culturally diverse with 40% of women being born overseas and 38% being from a non-English-speaking country, 35% of which did not speak a language other than English and 6% spoke little or no English. We wanted to also see what our data showed us with regards to outcomes for women and newborns. And we found our findings were not that dissimilar to what was found internationally. The key outcomes that we found that showed a significant difference between women of Australian who were Australian born and that excludes women of Aboriginal or Torres Strait Islander, so Indigenous women. So we looked at Australian born women but not Indigenous women. And we found that Edinburgh depression scores of 13 or above, which is a significant sign of anxiety and depression. Were quite high amongst women born in Bangladesh, Egypt and Brazil. We also found that Caesarean birth amongst first-time mothers was also much higher for women who were born in Bangladesh, being 40% compared to 26% of Australian born women and also much higher for women born in Thailand, Brazil and the Philippines all being in there late early 30s, 30% I should say. We also found the same for women for Caesarean section for women who it was their second or third pregnancy in that the Caesarean rate was much higher in women born in Egypt and Bangladesh followed by India and the Philippines. We looked at birth weight also and that was low birth weight of less than 2.5 kilograms when the baby was a single pregnancy and a baby born at two. So we found that women from Bangladesh and India and Nepal, the birth weights were between 3% and 2% compared to Australian born women being 0.8%. We looked at admission to newborn nursery sorry. And that was also women, singleton pregnancies and at term was significantly higher for women born in Nepal, Bangladesh, India, the Philippines, Egypt. And breastfeeding on discharge was also differences. So this was discharged from the maternity hospital. And we found that women born in China, Indonesia and Philippines was slightly different to Australian born women. So if having a look at that data and also having conversations with our local communities, we looked at ways and how we could be more responsive to the needs of women and families from modern refugee background. So in late 2017, we implemented the cross-cultural workers in maternity and child and family health services. So just looking at that model of care in more detail, what it aims to do is support women from modern refugee backgrounds to access and also to maintain engagement with our services for pregnancy through that continuum into early parenting period. So that support continues up until a child is five years of age. Why did we want to do that? Well, most importantly, we wanted to improve access to our services and we want to improve perinatal health outcomes. And most importantly, to provide culturally responsive care to our local communities. So who are our cross-cultural workers? Well, there's a great picture there of our three cross-cultural workers. Bandana, Rabina in the centre and Galoo on my right. So they are three part-time workers and that equates to about three to two days a week that they work each. They don't provide clinical services and they're all from migrant background. Our focus is women who are newly arrived. So I've been living in Sydney or Australia, I should say for less than five years who work in Nepali and Bangladeshi background. So Bandana and Rabina, both Nepali and Bangladeshi workers. Our other focus was women who are Medicare ineligible. So that means if they're on temporary visas or international students, they don't have the same access to free maternity care that we have in Australia if we're an Australian citizen. We also had a focus on women who have known psychosocial issues, who are isolated, who have limited support and have financial issues. So the aim of the three cross-cultural workers is to, they work in partnership as part of the multidisciplinary team. So that includes doctors, midwives, nurses, child and family health nurses, social workers, allied health staff. So physiotherapists, social workers and occupational therapists, all working together to support women to navigate services, to provide practical and emotional support, to link women to community supports as well. So what's out there locally, what women's groups are available, ways if they wanted to or needed to, to access English classes and also lots of women and families also wanna know about what employment opportunities. So a large degree of support goes into what comes after the pregnancy journey or what's also happening there. Most importantly, to provide culturally appropriate information and education to women and families. A key part of their role is advocacy. So how our services can be as accessible as they possibly can be. The cost may be an issue depending on the visa that a woman may have. Another key aspect of their roles is also to collaborate with local communities and services. So what can we do with GPs in the local area with non-government organisations, with local councils to really work to providing the services that women and families from migrant and refugee backgrounds need and how we can all do that together actively. So the referral pathway is usually where midwives, nurses and doctors will actually either pick up the phone or email the cross-cultural workers to and provide a detailed history of what the needs of the women are. They also have, there are meetings that may involve the cross-cultural worker to also connect them to support women and families. So the type and what those contacts look like, they may be home visits. So that may be a joint home visit with a child and family health nurse or a health visitor in the local area. It may be a community-based clinic. So it may be a clinic that an occupational therapist or a speech therapist or a doctor or a nurse in the local community. It may also be hospital appointments. So they could be anti-natal clinic appointments. It could also be women who are on the postnatal and anti-natal ward, just checking to see how they're going and how they can provide additional support. It may be as simple as an email to a mum, a telephone call or a text message or an SMS to a woman as to see how she's travelling and what her needs may be. The cross-cultural workers spend a lot of time providing education in a group setting and that is usually always in collaboration with a midwife or a child and family health nurse. So once again, really working part of the multidisciplinary team. So part of the cross-cultural worker service that we've been almost three years running was to look at that service and to see what impact it has. So the main questions that we're asking with the evaluation of the service is does engagement with the cross-cultural worker service improve outcomes for women and families? Has the service improved access and engagement? So supported women to access our services not only early, but also to maintain that engagement with services from that pregnancy through to that early parenting journey. And also to have an understanding of what some of the barriers and enablers have been in establishing the services within our larger health district. The main objectives, I'll slow this slide coming up, to look at the feasibility, the appropriateness, how wide has been the reach? How many women and families have we been able to engage with and how acceptable has that service been? We really want as part of the evaluation to explore the experiences and the level of satisfaction that women may have, that their partners have, that service providers have and the cross-cultural workers themselves have in accessing and in this model of care. Once again, what the barriers and enablers are and to also identify the resource implications. We know working in health, it's always about how much a service costs, not only what impact did it have with regards to supporting women and families and improving outcomes. So our findings to date, what we've used, the methods we've used has been maternal surveys. So a survey is provided at 36 weeks at six months and 12 months. And I should highlight that these surveys have been translated in three different languages, in Nepali, Bangladeshi and Bahasa, Indonesia, because they're our largest groups and they have been pilot tested. We also really wanted to look at what the partners perspective has been in being involved in that journey as well with accessing the cross-cultural worker service. We also are undertaking focus groups and interviews when the baby is six and 12 months and also undertaking surveys and interviews with service providers, which has also all received ethics approval in our local health district. So now findings to date, and this research is very much ongoing, and I'm just gonna report back on the findings that we have from the 61 anti-natal surveys that we've received to date. And also then a little bit later on, I'll look at what the service providers have talked about with regards to their witnessing of the service. So from the perspective of mothers, most of our mothers have completed the surveys, there's 44% have been from Nepal, followed by Indonesia and Bangladesh and smaller numbers of women from the Thailand, Thailand, Philippines and Peru and China. On average, the length of time that the women have been in Australia is anywhere between four months and five years. 96% of women, it has been their first baby. And the main, their first contact with the cross-cultural worker has predominantly been between 15 and 19 weeks pregnant, a little bit less between 20 and 24 weeks pregnant, followed by 12% being less than 14 weeks pregnant. So what have the women said so far? So 61% of the women had at least had contact with the women on four or more visits and 15% or three or more visits. So there was a level of continuity there and there was quite a number of visits that had been undertaken at that 36 weeks at the time of the survey. 100% of women had felt supported in their understanding of pregnancy, birth and parenting by engaging with the cross-cultural worker service. 84% had had a positive experience with the service in connecting them and engaging them with the health and navigating health services. 60% were very satisfied and 38% were satisfied with the model of care. We asked the question, would women recommend the service to their family and friends? 85% saying they definitely will. And 15% saying they probably will. Looking more into what the service providers said, so 18 months following the implementation of the service, we surveyed 69 service providers. So that includes midwives, doctors, child and family health nurses, our colleagues who work in the non-government space, social workers, allied health. So the survey was broadly distributed to everyone in LHD who had had contact with the cross-cultural worker and had referred women to the cross-cultural worker service. I'm just going to give you a snapshot of some of the findings of what we found from that. The key questions firstly were was, did service providers feel that it had any impact on the care that women received? And you can see from that table, we categorized that in five different categories from one being not at all to five being a great deal with also the option to put not applicable because some we found some people who completed the survey had not had any contact with the cross-cultural worker so we're not familiar with the service but they still completed the survey. So 41% or 59% of service providers felt it had improved care for women and 23% followed with, they thought it had had a significant impact as well. We also wanted to know that perception of whether they thought it had improved outcomes for women. So 46% of service providers said that they felt it had and 22% also felt that it improved outcomes. We also wanted to know, and this was kind of a very broad question whether service providers felt it had enhanced the engagement between the local communities and the services that they provide by the cross-cultural workers having contact with the women. And 27 or 39% of service providers felt that it had and 30% had also felt to some degree it had. There was some degree of neutrality around that or not being applicable because it may have been that generally the service providers didn't think there'd been an impact at all or had not kind of had that contact with a non-government organization or a service to identify whether there had been an impact there. Another important question we asked was the collaboration. Do you think the cross-cultural worker had enhanced that collaboration between community-based services and health service is in health promotion activity and community development initiatives? So you can see there that almost 71% of people felt that it had had an impact and 20% kind of in the neutral zone have not been sure whether it had or not. Also what we asked service providers was we undertook interviews. So there were 19 interviews that we have with service providers and that included midwives, child and family health nurses, doctors and workers in the non-governmental organization space. And the key findings from those qualitative interviews were that they really felt that the cross-cultural worker had provided continuity of care with women having a key point of contact through their pregnancy and early parenting journey. They felt it had definitely enhanced communication between women and service providers. So the cross-cultural worker really provided a link there in doing so. They felt that the supportive and trusting relationship that was maintained between women and the cross-cultural worker really enhanced trust, not only in the cross-cultural worker but that connection into healthcare and trust in the healthcare system. The service providers also felt that it really empowered women to take control of their own health. And it also opened up discussion about taboo subjects. And with those taboo subjects, I'm talking about domestic violence, talking about domestic violence, disclosure of domestic violence in a safe space that was culturally nuanced. Also about mental health as well and how mental health is culturally nuanced as well and having a greater perspective of what that looked like from a cultural perspective. Also taboo subjects were about female genital mutilation and cutting and having those conversations with clients. In addition, service providers also highlighted and this was reinforced from the surveys as well that it really improved care and satisfaction of care for women with services. It increased access to services and a couple of quotes that were used by service providers. They felt that it really provided a breach to health. A number of healthcare workers and service providers felt that it really supported that transition from the maternity services into early parenting services. So often that transition can be very challenging and women are kind of in a space of what happens now. They've been discharged from midwifery care and then accessing care in the early parenting space with a different set of service providers was really supported by that connection of the cross-cultural worker. They really felt it built their capacity to have a greater understanding of what culturally responsive service provision looked like and a key strength of the service was the cross-cultural workers that were employed in the role. We've had the same three workers for three years now which has been extremely beneficial, not just for that connection with service providers but also with the women themselves and many women are now returning from them their subsequent pregnancies, knowing the worker that they met the first time around. So what were some of the key limitations that the service providers highlighted? Not surprisingly, we found that the part-time hours were reduced the ability to fully meet the needs that we hoped to meet. There was a huge demand with the number of referrals that were received to actually spend more time collaborating with non-government organisations and other community services in the area was challenged by the part-time hours of the workers. Also promoting the service as well with the rotation of doctors in anti-natal and maternity settings. It was really some doctors were not familiar and others were familiar. Same goes for midwives. So there was a real constant need that the service needed to be promoted more and obviously the time available for the cross-cultured workers to do that was challenged. Even though the service providers said it had built staff capacity, they also thought that more could be done to build capacity if there was greater hours of the cross-cultural worker. So the key recommendations were to increase the number of hours of the cross-cultural worker and possibly also to increase the number of workers in the role. As I've already mentioned, there was a real need to increase awareness of the role and what the services that the cross-cultural worker was able to provide. So service providers having a greater awareness of that. And as I've mentioned previously, it was always also to build the capacity of the workforce so how we can be more responsive to the needs of women from migrant and refugee background and their families. So in summing up what that means for our practice, I guess what was the most overwhelming thing about setting up the service was we never anticipated from the get-go that the demand would be so huge even when the orientation process was in place for the cross-cultural workers. There was already service providers saying, asking when are they starting? When are they starting? But women that we really want to refer to them. A key part of the service is really to have support systems in place. It's a very different role from clinical services. So to support the cross-cultural workers in that role, they have monthly supervision. They're also able to readily access me and managers of the service. There is regular contact so they're able to discuss issues as they arise and we're able to respond to them as best we can and meet their needs most importantly. It's a very demanding role and there's lots of possibility of burnout. So we're very lucky in that we've been able to provide clinical supervision, which is very separate from the management system that I provide with my colleagues and other managers. As comes with any service that's newly implemented, there are gaps that are identified that we need to respond to and most of those gaps are around the provision of in-language information and education. And we're talking about a very diverse population of people and a very high heterogeneity of languages spoken and different cultural beliefs. So how do we respond to that most appropriately? As we know in the pregnancy and in the postnatal period, we always screen for psychosocial risk factors. So we've noticed that the tools we use are not ideally culturing nuance. So the cross-cultural workers have spent a lot of time with service providers about how we unpack disclosures of domestic violence and mental health issues in a more culturally appropriate way that kind of makes the women feel still very supported in that disclosure and supporting them afterwards. Another factor that's come up in the implementation of this program is the cost of maternity services. And when I talk about this for women and families who have Medicare or have access to our public health system through permanent residency, they are able to access our services without a cost. However, women who are on temporary visas or international students or waiting for their refugee status to be processed, there is a cost of maternity services. So we are very aware of the barriers and the inequities that mean. So how do we respond to that most appropriately, bearing in mind keeping the needs of women and families at the centre of everything that we do? So that's, thank you very much for your time. So I'll open it up over to you, Suzanne, with any questions that you may have. I'd like to acknowledge as well the great work before I take questions of Bandana Galur and Rabina, who are our cross-cultural workers, to my supervisors, the Doctor of Manager Henry and Professor Caroline Homer. To Lily Hogan, who undertake the interviews and the analysis of the service providers and Dominic Coates, who supported her in doing that. And also to all of the midwives, children, family, health nurses, doctors and allied health who completed the survey and interviews. And to Sue and Virginia Speer, who provided me with all of our quantitative data that we're still looking at the outcome, herinatorial outcomes for women and families who have access to the cross-cultural worker service. Thank you. Thank you so much, Helen, for that very informative presentation. We have looked at things in a way we had not thought of before in terms of some of the ways we can support migrants with their healthcare and also maternity care. In terms of questions, there is a question here from Sarah. How are you increasing cultural responsiveness in the midwifery staff? So lots of it is centered around having conversations with staff. So the cross-cultural workers spend a lot of time talking broadly and even more specifically about the different cultural practices and beliefs that women and families may have. And that's done on a very individual by individual basis rather than very broadly. Obviously it starts very broad, but we take it down to there's always differences within every single culture. So it's really looking at from a broad and then a more specific sense. It may be in services with midwives. It's often we also have larger meetings from a governance point of view. We have high-level meetings with our managers, but we also have meetings with people who are working locally on the ground. So really we're sharing the experiences of what women and families are saying about our services and how we respond to those in the most appropriate way and also how we can involve the local communities. Because a key part of the services we provide and often is time and the challenges that come when we're working day to day on the wards and in clinics is having conversations with what the community thinks about what we're providing. So there's also those conversations that are had by the cross-cultural workers with local NGOs and local councils and local community organizations. So that's the way that we look at the from a culturally responsive perspective in that education space. Does that answer your question? I believe it does. We'll just move on to the next question. Sarah, I hope that answers your question. Do let us know if we need to go into a bit more detail. So I'll take another question here from Lean. So first she says very valuable information that was well presented. And her question is, are all culturally diverse women assessed psychosocially, postnatally and how are referrals addressed? Did you get that, Helen? Do we still have you, Helen? Can you hear me? Yes, I can hear you. Sorry about that, that's a cool issue. And I'll take the question again. Yes, please. So Lean said that the information was valuable and well presented. So she was asking, are all culturally diverse women assessed psychosocially, postnatally and how are referrals addressed? So all women in our public health space are assessed both in the anti-natal period. So every woman at booking, also their first anti-natal appointment receives psychosocial assessment. That is always undertaken by a midwife. In the child and family health space, that's undertaken by a child and family health nurse. So the cross-cultural workers may be part of that joint visit, but certainly the cross-cultural workers have a conversation prior with women to say, will we ask questions about this? The reason we ask you questions about psychosocial wellbeing is so that we can support you, because there's quite a bit of uncertainty as to why those questions are asked. So for all women in our public health services, they are all asked psychosocial questions. And then a referral pathway is in place and always done in a multidisciplinary setting about how we best respond to those needs that have been identified. Fantastic. So I'll take two last questions and there's one from Catherine which says, have you come across cases where women are more comfortable with traditional birth attendants and not going to hospital? And how do you deal with that? I'm not so familiar, not in this cross-cultural worker problem programme, because most of the women who come to us are met in the anti-natal space and within a hospital setting. So they're already engaged with the service and they're happy to maintain that engagement. To be honest, from the whole time that the cross-cultural workers have been in place, I'm not aware and it's not come to my attention with regards to women preferring to use a traditional birth attendant in the community. Dualers sometimes for sure and then that would still be part of our multidisciplinary team. So as far as traditional birth attendants, I'm not familiar with them. So very much the cross-cultural workers who are in the hospital and community-based setting, supporting women to engage with our public health services. Our home birth rate in Sydney is exceptionally low and in the three years there's been a no involvement of the cross-cultural workers in a home birth. Okay, thank you for that. The last question we will take is from Sheila and she says, thank you for the presentation. She thinks she missed something. She asks, did you have a baseline set of indicators that would allow you to determine impact and effectiveness for this community? The baseline indicators that we have was just the perinatal outcome data we had. So the brief snapshot I gave you which was about slide number four was what our data showed us in regard to perinatal outcomes. So cesarean section, psychosocial risk factors, intervention, the gestation of this booking. So that was our baseline data that was from 2015. We looked at that data. So for the cross-cultural worker evaluation, we will look at the perinatal data outcomes again for women who've engaged. We've worked with the service and had at least three visits or more compared to women who were offered the service but decided not to engage with the service. So our baseline indicators were basically our maternity data at the beginning and then we'll reflect on that. This year is my aim to analyze that data so to see those outcomes as a consequence of engagement with the service. Fantastic, thank you so much, Helen. Thank you everyone for joining us today for this session for the questions and for the comments.