Publications by authors named "Renae Kirkham"

13 Publications

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Incorporating Aboriginal women's voices in improving care and reducing risk for women with diabetes in pregnancy - A phenomenological study.

BMC Pregnancy Childbirth 2021 Sep 16;21(1):624. Epub 2021 Sep 16.

Menzies School of Health Research, Charles Darwin University, NT, Darwin, Australia.

Background: There is a high burden of gestational diabetes (GDM) and type 2 diabetes in pregnancy for Aboriginal and Torres Strait Islander women. Postpartum diabetes programs have the potential to prevent recurrent GDM and improve management of type 2 diabetes. However, data on such programs are limited, particularly in the Indigenous context. We aimed to explore Aboriginal Australian women's and health providers' preferences for a program to prevent and improve diabetes after pregnancy.

Methods: A phenomenological methodology underpinned semi-structured in-depth interviews with eleven Aboriginal women and seven health professionals across the Northern Territory from October 2019- February 2020. Interviews were analysed using an inductive analysis framework to address the barriers and enablers of proposed diabetes prevention programs identified by participants.

Results: Identified structural barriers to lifestyle change included: food insecurity, persuasive marketing of unhealthy food options, lack of facilities and cultural inappropriateness of previous programs. Enablers to lifestyle change included: a strong link between a healthy lifestyle and connection with Country, family and community. Suggested strategies to improve lifestyle included: co-designed cooking classes or a community kitchen, team sports and structural change (targeting the social determinants of health). Lifestyle change was preferred over metformin to prevent and manage diabetes after pregnancy by participants and health care providers.

Conclusions: We recommend individual level programs be designed alongside policies that address systemic inequalities. A postpartum lifestyle program should be co-designed with community members and grounded in Aboriginal conceptions of health to adequality address the health disparities experienced by Aboriginal people in remote communities.
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http://dx.doi.org/10.1186/s12884-021-04055-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8445012PMC
September 2021

The Adaptation of a Youth Diabetes Prevention Program for Aboriginal Children in Central Australia: Community Perspectives.

Int J Environ Res Public Health 2021 Aug 31;18(17). Epub 2021 Aug 31.

Menzies School of Health Research, Charles Darwin University, Casuarina 0810, Australia.

This study reports on integrating community perspectives to adapt a family-focused, culturally appropriate behavioural intervention program to prevent diabetes among Aboriginal children (6-11 years) in Central Australia. A participatory action research approach was used to engage a range of service providers, cultural advisors, and family groups. Appropriateness, acceptability, content, and delivery of a prevention program within the Central Australian context were discussed through a series of workshops with twenty-five service providers and seven family groups separately. The data obtained were deductively coded for thematic analysis. Main findings included: (i) the strong need for a diabetes prevention program that is community owned, (ii) a flexible and culturally appropriate program delivered by upskilling community members as program facilitators, and (iii) consideration of social and environmental factors when implementing the program. It is recommended that a trial of the adapted prevention program for effectiveness and implementation is led by an Aboriginal community-controlled health service.
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http://dx.doi.org/10.3390/ijerph18179173DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8430517PMC
August 2021

Improving systems of prenatal and postpartum care for hyperglycemia in pregnancy: A process evaluation.

Int J Gynaecol Obstet 2021 Jul 31. Epub 2021 Jul 31.

Division of Wellbeing and Preventable Chronic Disease, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia.

Objective: To identify successes to date and opportunities for improvement in the implementation of a complex health systems intervention aiming to improve prenatal and postpartum care and health outcomes for women with hyperglycemia in pregnancy in regional and remote Australia.

Methods: A qualitative evaluation, underpinned by the RE-AIM framework (reach, effectiveness, adoption, implementation, maintenance), was conducted mid-intervention. Semi-structured interviews were conducted with the participants, who included clinicians, regional policymakers and managers, and study implementation staff.

Results: Interviewees (n = 45) reported that the early phase of the intervention had resulted in the establishment of a clinician network, increased clinician awareness of hyperglycemia in pregnancy, and improvements in management, including earlier referral for specialist care and a focus on improving communication with women. Enablers of implementation included existing relationships with stakeholders and alignment of the intervention with health service priorities. Challenges included engaging remote clinicians and the labor-intensive nature of maintaining a clinical register of women with hyperglycemia in pregnancy.

Conclusion: The early phase of this health systems intervention has had a positive perceived impact on systems of care for women with hyperglycemia in pregnancy. Findings have informed modifications to the intervention, including the development of a communication and engagement strategy.
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http://dx.doi.org/10.1002/ijgo.13850DOI Listing
July 2021

Exploring differences in perceptions of child feeding practices between parents and health care professionals: a qualitative study.

BMC Public Health 2021 07 23;21(1):1449. Epub 2021 Jul 23.

Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, 0810, Australia.

Background: Evidence on child feeding practice is often based on the perspectives and experiences of parents and less that of health practitioners. In this study, we explored child feeding practice in Aboriginal communities in northern Australia from both the parents and health practitioners' perspectives with the aim of informing nutrition improvement programs.

Methods: Qualitative research methods were employed. Using semi-structured interviews, parents (n = 30) of children aged 2-5 years, and 29 service providers who were involved in the delivery of child health and nutrition programs in the same communities, were asked about child feeding attitudes and practices. Responses were analyzed through inductive and deductive analysis, recognizing that worldviews influence child feeding practices.

Results: Sharing food was a central practice within families. Parents highly valued development of child independence in food behavior but were conflicted with the easy access to unhealthy food in their communities. This easy access to unhealthy food and inadequate food storage and kitchen facilities for some families were major challenges to achieving optimal diets for children identified by Aboriginal families and service providers. The responsive style of parenting described by parents was often misunderstood by service providers as sub-optimal parenting when viewed through a dominant western lens.

Conclusions: Approaches to support healthy feeding practices and optimal child nutrition require health-enabling food environments. Along with a community-based Aboriginal health workforce, it is paramount that the non-Aboriginal workforce be supported to be reflective of the impact of worldview on their practice, to ensure a culturally safe environment for families where parenting styles are understood and appropriately supported.
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http://dx.doi.org/10.1186/s12889-021-11493-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8299622PMC
July 2021

Enablers and barriers to primary healthcare for Aboriginal and Torres Strait Islander adolescents: study protocol for participatory mixed-methods research that builds on WHO global standards.

BMJ Open 2021 04 29;11(4):e046459. Epub 2021 Apr 29.

Wardliparingga Aboriginal Health Equity Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia

Introduction: One-third of Australia's Aboriginal and Torres Strait Islander population are adolescents. Recent data highlight their health needs are substantial and poorly met by existing services. To design effective models of primary healthcare, we need to understand the enablers and barriers to care for Aboriginal and Torres Strait Islander adolescents, the focus of this study.

Methods And Analysis: This protocol was codesigned with Apunipima Cape York Health Council that supports the delivery of primary healthcare for 11 communities in Far North Queensland. We framed our study around the WHO global standards for high-quality health services for adolescents, adding an additional standard around culturally safe care. The study is participatory and mixed methods in design and builds on the recommended WHO assessment tools. Formative qualitative research with young people and their communities (exploring concepts in the WHO recommended quantitative surveys) seeks to understand demand-side enablers and barriers to care, as well as preferences for an enhanced response. Supply-side enablers and barriers will be explored through: a retrospective audit of clinic data (to identify current reasons for access and what can be strengthened); an objective assessment of the adolescent friendliness of clinical spaces; anonymous feedback from adolescent clients around quality of care received and what can be improved; and surveys and qualitative interviews with health providers to understand their perspectives and needs to provide enhanced care. This codesigned project has been approved by Apunipima Cape York Health Council and Far North Queensland Human Research Ethics Committee.

Dissemination And Implications: The findings from this project will inform a codesigned accessible and responsive model of primary healthcare for Aboriginal and Torres Strait Islander adolescents.
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http://dx.doi.org/10.1136/bmjopen-2020-046459DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8094354PMC
April 2021

Misoprostol for the prevention of post-partum haemorrhage in Mozambique: an analysis of the interface between human rights, maternal health and development.

BMC Int Health Hum Rights 2020 04 8;20(1). Epub 2020 Apr 8.

Bixby Center for Population, Health and Sustainability, University of California-Berkeley, University Hall, Berkeley, CA, 94720-6390, USA.

Background: Mozambique has high maternal mortality which is compounded by limited human resources for health, weak access to health services, and poor development indicators. In 2011, the Mozambique Ministry of Health (MoH) approved the distribution of misoprostol for the prevention of post-partum haemorrhage (PPH) at home births where oxytocin is not available. Misoprostol can be administered by a traditional birth attendant or self-administered. The objective of this paper is to examine, through applying a human rights lens, the broader contextual, policy and institutional issues that have influenced and impacted the early implementation of misoprostol for the prevention of PPH. We explore the utility of rights-based framework to inform this particular program, with implications for sexual and reproductive health programs more broadly.

Methods: A human rights, health and development framework was used to analyse the early expansion phase of the scale-up of Mozambique's misoprostol program in two provinces. A policy document review was undertaken to contextualize the human rights, health and development setting in Mozambique. Qualitative primary data from a program evaluation of misoprostol for the prevention of PPH was then analysed using a human rights lens; these results are presented alongside three examples where rights are constrained.

Results: Structural and institutional challenges exacerbated gaps in the misoprostol program, and sexual and reproductive health more generally. While enshrined in the constitution and within health policy documents, human rights were not fully met and many individuals in the study were unaware of their rights. Lack of information about the purpose of misoprostol and how to access the medication contributed to power imbalances between the state, health care workers and beneficiaries. The accessibility of misoprostol was further limited due to dynamics of power and control.

Conclusions: Applying a rights-based approach to the Mozambican misoprostol program is helpful in contextualising and informing the practical changes needed to improve access to misoprostol as an essential medicine, and in turn, preventing PPH. This study adds to the evidence of the interconnection between human rights, health and development and the importance of integrating the concepts to ensure women's rights are prioritized within health service delivery.
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http://dx.doi.org/10.1186/s12914-020-00229-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7140325PMC
April 2020

Primary Health Care for Aboriginal Australian Women in Remote Communities after a Pregnancy with Hyperglycaemia.

Int J Environ Res Public Health 2020 01 22;17(3). Epub 2020 Jan 22.

Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT 0810, Australia.

Background: Hyperglycaemia in pregnancy contributes to adverse outcomes for women and their children. The postpartum period is an opportune time to support women to reduce cardiometabolic and diabetes risk in subsequent pregnancies.

Aims: To identify strengths and gaps in current care for Aboriginal women after a pregnancy complicated by hyperglycaemia.

Methods: A retrospective review of the 12 month postpartum care provided by primary health centres in remote Australia in 2013-2014 identified 195 women who experienced hyperglycaemia in pregnancy (gestational diabetes (GDM) (n = 147), type 2 diabetes (T2D) (n = 39), and unclear diabetes status (n = 9)).

Results: Only 80 women (54%) with GDM had postpartum glycaemic checks. Of these, 32 women were diagnosed with prediabetes (n = 24) or diabetes (n = 8). Compared to women with GDM, women with T2D were more likely to have their weight measured (75% vs. 52%, p <0.01), and smoking status documented as "discussed" (65% vs. 34%, p < 0.01). Most women (97%) accessed the health centre at least once in the 12 month postpartum period but, during these visits, only 52% of women had service provision, either structured or opportunistic, related to diabetes.

Conclusion: High rates of dysglycaemia among women screened for T2D after GDM in the 12 month postpartum period highlight the need for increased screening and early intervention to prevent the development of T2D and its complications. Whilst a clear strength was high postpartum attendance, many women did not attend health services for diabetes screening or management.
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http://dx.doi.org/10.3390/ijerph17030720DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7037226PMC
January 2020

My experiences with kidney care: A qualitative study of adults in the Northern Territory of Australia living with chronic kidney disease, dialysis and transplantation.

PLoS One 2019 19;14(12):e0225722. Epub 2019 Dec 19.

Wellbeing and Preventable Chronic Disease Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia.

Background: Australian healthcare quality and safety accreditation standards recommend health services partner with health care users, to ensure the highest quality of care. Aboriginal Australians with chronic and end stage kidney disease have high health care access needs.

Aim: To describe the experiences of health care users of a large government kidney healthcare service provider.

Methods: Within a government renal health service in the Top-End of the Northern Territory, we undertook a qualitative study involving in-depth interviews with 26 adult clients from urban, regional and remote settings who were living with kidney health conditions.

Results: Client characteristics included a mean age of 55 years, 55% female and 81% identifying as Aboriginal. The kidney related conditions of client participants included CKD (11, 42.3%), haemodialysis (12, 46.2%), peritoneal dialysis (1, 3.9%), and transplant (2, 7.7%). Key themes emerging from patient interviews related to perceived gaps for clients and carers including: 1) knowledge gaps about the health condition, 2) the impact of relocation in order to access centrally-based renal care, 3) healthcare staff professionalism and qualities and 4) service environments. Overall, the experiences centred on a greater need for client-centred, respectful and culturally based healthcare support. Clients recommended the need for patient-led collective care, including sustaining an Indigenous Patient Reference Group to support ongoing healthcare service decision processes. Participants included in almost equal proportion, clients with CKD (without dialysis) and clients utilising renal replacement therapy, which adds significant weight to the client-identified recommendations for highest quality of kidney care across a wide spectrum of kidney function.

Conclusion: Four major themes identified by clients related to their experience with renal care provided by this major regional health care provider: knowledge gaps of their own condition, the lived impacts of relocating to access health care, service environments, and Health Care Provider Quality. An Indigenous Patient Reference Group was one mechanism recommended to support the co-design of preferred care models.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0225722PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6922340PMC
March 2020

Improving Models of Care for Diabetes in Pregnancy: Experience of Current Practice in Far North Queensland, Australia.

Front Public Health 2019 19;7:192. Epub 2019 Jul 19.

Wellbeing and Preventable Chronic Disease Division, Menzies School of Health Research, University Drive North, Casuarina, NT, Australia.

To map health practitioners' experiences and describe knowledge regarding screening and management of Diabetes in Pregnancy (DIP) in Far North Queensland, Australia. Mixed methods including a cross-sectional survey (101 respondents) and 8 focus groups with 61 health practitioners. All participants provided clinical care for women with DIP. A wide range of healthcare professionals participated; 96% worked with Indigenous women, and 63% were from regional or remote work settings. Universal screening for gestational diabetes at 24-28 weeks gestation was reported as routine with 87% using a 75 g Oral Glucose Tolerance Test. Early screening for DIP was reported by 61% although there was large variation in screening methods and who should be screened <24 weeks. Health practitioners were confident providing lifestyle advice (88%), dietary, and blood glucose monitoring education (67%, 81%) but only 50% were confident giving insulin education. Electronic medical records were used by 80% but 55% also used paper records. Dissatisfaction with information from hospitals was reported by 40%. In the focus groups improving communication and information technology systems were identified as key areas. Other barriers described were difficulties in care coordination and access for remote women. Communication, information technology systems, coordination of care, and education for health professionals are key areas that will be addressed by a complex health systems intervention being undertaken by the DIP Partnership in North Queensland.
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http://dx.doi.org/10.3389/fpubh.2019.00192DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6659099PMC
July 2019

Real-world experience of metformin use in pregnancy: Observational data from the Northern Territory Diabetes in Pregnancy Clinical Register.

J Diabetes 2019 Sep 19;11(9):761-770. Epub 2019 Feb 19.

Population Health Research, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia.

Background: In Australia's Northern Territory, Indigenous mothers account for 33% of births and have high rates of hyperglycemia in pregnancy. The prevalence of type 2 diabetes (T2D) in pregnancy is up to 10-fold higher in Indigenous than non-Indigenous Australian mothers, and the use of metformin is common. We assessed birth outcomes in relation to metformin use during pregnancy from a clinical register.

Methods: The study included women with gestational diabetes (GDM), newly diagnosed diabetes in pregnancy (DIP), or pre-existing T2D from 2012 to 2016. Data were analyzed for metformin use in the third trimester. Regression models were adjusted for maternal age, body mass index, parity, and insulin use.

Results: Of 1649 pregnancies, 814 (49.4%) were to Indigenous women, of whom 234 (28.7%) had T2D (vs 4.6% non-Indigenous women; P < 0.001). Metformin use was high in Indigenous women (84%-90% T2D, 42%-48% GDM/DIP) and increased over time in non-Indigenous women (43%-100% T2D, 14%-35% GDM/DIP). Among Indigenous women with GDM/DIP, there were no significant differences between groups with and without metformin in cesarean section (51% vs 39%; adjusted odds ratio [aOR] 1.25, 95% confidence interval [CI] 0.87-1.81), large for gestational age (24% vs 13%; aOR 1.5, 95% CI 0.9-2.5), or serious neonatal adverse events (9.4% vs 5.9%; aOR 1.32, 95% CI 0.68-2.57). Metformin use was independently associated with earlier gestational age (37.7 vs 38.5 weeks), but the risk did not remain independently higher after exclusion of women managed with medical nutrition therapy alone, and the increase in births <37 weeks was not significant on multivariate analysis.

Conclusions: We found no clear evidence of any adverse outcomes related to the use of metformin for the treatment of hyperglycemia in pregnancy.
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http://dx.doi.org/10.1111/1753-0407.12905DOI Listing
September 2019

'We can work together, talk together': an Aboriginal Health Care Home.

Aust Health Rev 2019 Oct;43(5):486-491

Menzies School of Health Research, Charles Darwin University, PO Box 1096, Casuarina, NT 0811, Australia. Email.

Objective The aim of this study was to identify an Aboriginal community's aspirations for health service improvement during implementation of the Commonwealth's Health Care Homes (HCH) reform. Methods This study was a qualitative study consisting of Aboriginal-controlled phenomenological enquiry in a large Aboriginal community in north-central Arnhem Land. Results A representative sample of 60 Aboriginal health service users identified shortcomings in their current experience of primary health care, including low cultural security. These shortcomings reduced access to care. Participants described several ways that care could be reorientated to match their needs during HCH implementation. Principally, patients voiced the need for: (1) restructuring care teams to foster culturally secure relationship-based care; and (2) reorientating the Aboriginal Health Practitioner role from acute care to strength-based competencies as the focal point of care continuity: self-management support, care coordination and navigation, health coaching and cultural mentorship for non-Aboriginal staff. Conclusions For HCH to be successful, service providers need to engage with service users to identify and implement patient-centred strategies to improve access, acceptability and patient activation. What is known about the topic? Success of the Commonwealth's HCH reform is contingent on improving care access and patient activation to better manage chronic conditions What does this paper add? This is the first opportunity that this Aboriginal community has had to articulate their aspirations for high quality healthcare. Beyond the strong alignment with the HCH building blocks, their care preferences posit practical and achievable workforce and delivery system reforms that may improve primary health care in other remote Aboriginal communities. What are the implications for practitioners? The long-term success of the HCH reform will require iterative engagement with service users to identify and implement patient-centred strategies to improve access and acceptability of care. Service model alignment with patient care preferences will improve patient activation and is particularly important when working with vulnerable populations.
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http://dx.doi.org/10.1071/AH18107DOI Listing
October 2019

Improving postpartum screening after diabetes in pregnancy: Results of a pilot study in remote Australia.

Aust N Z J Obstet Gynaecol 2019 06 2;59(3):430-435. Epub 2018 Oct 2.

Menzies School of Health Research, Darwin, Australia.

Background: The postpartum period is a critical time to improve health outcomes for Aboriginal women, particularly for those who have chronic conditions.

Aims: To assess enhanced support methods (for women following diabetes in pregnancy (DIP)) to improve completion rates of recommended postpartum health checks.

Materials And Methods: Fifty-three Aboriginal women in the Northern Territory (NT) were contacted in the postpartum period to encourage medical check-ups. Messages were delivered through phone (call or text messages) or other methods (Facebook or email). The primary outcome was postpartum blood glucose testing (oral glucose tolerance testing (OGTT), random or fasting glucose and HbA1c).

Results: Establishing contact with women was difficult. Of 137 messages sent to 52 women, 22 responded (42%). Phone was the most common contact method with successful contact made from 16 of 119 (13%) attempts. Rates of postpartum OGTT completion were higher in the group successfully contacted (32% vs 7%). However, for any postpartum glucose testing (including OGTT and HbA1c) rates were 25 of 42 (60%) and neither success in making contact nor the contact method was associated with higher rates.

Conclusions: The small sample size limits our conclusions; however, results highlight that engaging remote women postpartum is difficult. While rates of postpartum OGTT completion differed according to successful contacts, rates of any postpartum blood glucose testing did not. Further research is needed to explore feasible intervention methods to improve postpartum screening after a pregnancy complicated by diabetes.
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http://dx.doi.org/10.1111/ajo.12894DOI Listing
June 2019

Implementation of a diabetes in pregnancy clinical register in a complex setting: Findings from a process evaluation.

PLoS One 2017 4;12(8):e0179487. Epub 2017 Aug 4.

Wellbeing and Preventable Chronic Disease Division, Menzies School of Health Research, Darwin, Australia.

Background: Rates of diabetes in pregnancy are disproportionately higher among Aboriginal than non-Aboriginal women in Australia. Additional challenges are posed by the context of Aboriginal health including remoteness and disadvantage. A clinical register was established in 2011 to improve care coordination, and as an epidemiological and quality assurance tool. This paper presents results from a process evaluation identifying what worked well, persisting challenges and opportunities for improvement.

Methods: Clinical register data were compared to the Northern Territory Midwives Data Collection. A cross-sectional survey of 113 health professionals across the region was also conducted in 2016 to assess use and value of the register; and five focus groups (49 healthcare professionals) documented improvements to models of care.

Results: From January 2012 to December 2015, 1,410 women were referred to the register, 48% of whom were Aboriginal. In 2014, women on the register represented 75% of those on the Midwives Data Collection for Aboriginal women with gestational diabetes and 100% for Aboriginal women with pre-existing diabetes. Since commencement of the register, an 80% increase in reported prevalence of gestational diabetes among Aboriginal women in the Midwives Data Collection occurred (2011-2013), prior to adoption of new diagnostic criteria (2014). As most women met both diagnostic criteria (81% in 2012 and 74% in 2015) it is unlikely that the changes in criteria contributed to this increase. Over half (57%) of survey respondents reported improvement in knowledge of the epidemiology of diabetes in pregnancy since establishment of the register. However, only 32% of survey respondents thought that the register improved care-coordination. The need for improved integration and awareness to increase use was also highlighted.

Conclusion: Although the register has not been reported to improve care coordination, it has contributed to increased reported prevalence of gestational diabetes among high risk Aboriginal women, in a routinely collected jurisdiction-wide pregnancy dataset. It has therefore contributed to an improved understanding of epidemiology and disease burden and may in future contribute to improved management and outcomes. Regions with similar challenges in context and high risk populations for diabetes in pregnancy may benefit from this experience of implementing a register.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0179487PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5544201PMC
October 2017
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