The maternal and perinatal outcomes of Indigenous mothers and their babies are markedly poorer than those of non-Indigenous women and their babies. In 2006, Indigenous babies had a higher rate of fetal death (11.7 per 1,000 births compared with 7.2 per 1,000 non-Indigenous births);55 a higher rate of neonatal death (7.1 per 1,000 births compared with 2.8 per 1,000 non-Indigenous births);56 a higher rate of preterm birth (13.7 per cent compared with 5.1 per cent);57 and a higher proportion of low birth weight (12.4 per cent under 2,500 g, compared with 6.4 per cent).58 In 2003–05, maternal mortality rates for Indigenous women were more than two and a half times as high as for other women. There were 21.5 deaths per 100,000 women giving birth, versus 7.9 per 100,000 for non-Indigenous women.59
These poorer health outcomes are due to a range of factors. For example, according to statistics available for 2006, Indigenous women were more likely to smoke during pregnancy (52.2 per cent compared with 15.6 per cent)60 and were more likely to give birth while teenagers (20.9 per cent compared with 3.7 per cent). 61
Importantly, Indigenous women are also less likely to access antenatal care in the first trimester of pregnancy when many risk factors could be addressed.62 In the four jurisdictions that recorded information on antenatal care in 2005, 96 per cent of Aboriginal and Torres Strait Islander women accessed antenatal care at some point during their pregnancy. However, compared with other women, access generally occurred later in pregnancy, and less frequently. For example, in New South Wales, 53 per cent of Aboriginal and Torres Strait Islander mothers had their first antenatal session in the first trimester of the pregnancy, compared with 63 per cent for other mothers. In the Northern Territory, 35 per cent of Indigenous mothers had their first antenatal session in the first trimester of the pregnancy, compared with 54 per cent for other mothers. Fewer Aboriginal and Torres Strait Islander mothers access five or more antenatal sessions compared with other mothers in Queensland (72 per cent versus 93 per cent), South Australia (64 per cent versus 88 per cent) and the Northern Territory (77 per cent versus 96 per cent). Indigenous mothers who attended antenatal care were less likely to have low birth weight babies (13 per cent) than those who did not attend (39 per cent); low birth weight babies are also associated with their mothers’ later commencement of antenatal care and attendance at fewer than five antenatal care sessions. 63
The services received by Indigenous women at the onset of labour and during birth are significantly different from those for non-Indigenous women. Between 2001 and 2004, 70 per cent of Indigenous mothers had a spontaneous onset of labour (compared with 57 per cent for non-Indigenous mothers). Of Indigenous mothers, 19 per cent had an induced onset of labour (compared with 26 per cent for non-Indigenous mothers); 5 per cent had instrumental vaginal deliveries (compared with 11 per cent for non-Indigenous mothers); and 22 per cent had caesarean sections (compared with 28 per cent for non-Indigenous mothers). Among Indigenous mothers, spontaneous vaginal deliveries were less common in major cities and areas of greater socioeconomic advantage. 64
Indigenous people face a number of barriers to accessing health services including cost, cultural appropriateness and distance from health services. Barriers to accessing health care when needed, including maternity services, vary between remote and non-remote areas, with cost being a more significant issue in urban Indigenous communities and transport/distance and the lack of availability of services being more important in remote areas. 65
What the Review Team Heard
- A number of submissions that directly addressed Indigenous issues referred to the partnership established by COAG to work with Indigenous communities to ‘close the gap’ on Indigenous disadvantage and ‘close the gap’ in life expectancy. Stakeholders stressed the importance of ensuring that the commitments made by COAG in the Close the Gap Statement of Intent 66 inform the findings of this Review and provide its broader context.67
- A key issue discussed during the Indigenous Perspectives Forum was the need for culturally safe and community-centred models of care in partnership with Indigenous communities in rural, remote and urban settings.
The birthing experience of Aboriginal and Torres Strait Islander women is fundamentally culturally different from that of non-Indigenous women. Birthing is and continues to be—in some communities—a cultural rite of passage where knowledge, practices and beliefs are transferred from older to younger women, identity and links are established to land and connections with country are shared and celebrated. 68
- Submissions and the Indigenous Perspectives Forum raised the importance of understanding the preference of Indigenous women to ‘birth on country’ and respecting the belief that informs this preference. Submissions also referred the Review Team to the Canadian Inuit ‘birthing on country’ model. 69
Land is the birthplace of women, it gives them strength and identity for survival. 70
- The attention of the Review Team was drawn to the particular concerns of Indigenous women in remote communities associated with travelling to a larger centre for maternity care, including isolation and dislocation from their communities, inappropriate accommodation for women and their families while in town, lost wages if a partner had to stop working to look after the family, and risk to other children left in the community while mothers were away.
- Examples of culturally appropriate models of maternity services for Indigenous women identified in the Review are set out below.
- Congress Alukura in Alice Springs provides a range of services under a midwife-led women’s health clinic. The Alukura model involves an agreement with the Alice Springs hospital that has enabled midwives employed by Alukura to attend low-risk women in labour and birth.
- Nganampa Health Council provides a range of services including an antenatal care program, health education to young mothers, and child health including immunisation, nutrition education, growth monitoring and targeted health screening.
- Ngua Gundi Mother Child Project, Woorabinda, Queensland, is a midwifery model of care provided in culturally sensitive settings, with home visiting by the Aboriginal Health Worker and midwife.
- Aboriginal Maternal and Infant Health Strategy (AMIHS), New South Wales, is a community-based maternity service that includes a midwife working in partnership with an Aboriginal Health Worker or Aboriginal education officer to provide care to pregnant Aboriginal women, new mothers and their babies in a culturally safe environment.
- Strong Women, Strong Babies, Strong Culture program, Northern Territory, aims to increase infant birth weights and improve maternal weight status by encouraging earlier attendance for antenatal care. The program is under the control of community women and is culturally based.
There are 3 key elements of Alukura’s underlying philosophy. Firstly, it acknowledges that Aboriginal peoples are distinct and viable cultural groups with our own cultural beliefs & practices, law & social needs. Secondly, it recognises that every woman has the right to participate fully in her pregnancy & childbirth care, and determine the environment and nature of such care. Finally, it recognises that every Aboriginal woman has the right in pregnancy and childbirth to maintain and use her own heritage, customs, language and institutions. 71
Recent Related Initiatives
The Australian Government has committed to halving the gap in mortality rates for Indigenous children under five within a decade. The National Partnership Agreement for Indigenous Early Childhood Development, signed by COAG leaders on 2 October 2008, will make a significant contribution to this target. The Agreement, which comprises $564 million of joint funding over six years, includes a focus on increasing access to and use of antenatal services by young Indigenous women. The Commonwealth is providing $107 million over 5 years from 1 July 2009 to the states and territories to: increase access to and use of antenatal services in the first trimester by young Indigenous mothers; support young Indigenous teenagers to make informed decisions about family planning; and drive improved data collection and reporting by states and territories on outcomes for Indigenous children. States and territories will focus their efforts in areas with significant numbers of young Indigenous women and high numbers of births by teenagers.
This Agreement builds on the existing Commonwealth election commitment of $90 million for New Directions: An Equal Start in Life for Indigenous Children which will provide: improved access to antenatal care; standard information about baby care; practical advice and assistance with parenting; monitoring of developmental milestones; and health checks for Indigenous children before starting school.
The Australian Government is continuing to invest in early childhood initiatives to improve maternal and child health outcomes for Aboriginal and Torres Strait Islander people. The Australian Nurse Family Partnership Program will provide structured and sustained nurse-led home visiting services in targeted regions to women pregnant with an Aboriginal and/or Torres Strait Islander child. Home visits will commence during the antenatal period, and will continue until the child is two years old.
It is well recognised that Indigenous women suffer a disproportionate burden of illness in pregnancy and childbirth and that their babies can also be less healthy. While some of these issues are linked to broader issues such as substance misuse, nutrition and social determinants, there are also factors directly linked to the organisation and delivery of maternity services.
Like other women, Indigenous women seek access to safe, high-quality, evidence-based care in their own community and from their choice of health practitioner. Indigenous women are more likely to access services and will experience better outcomes from services that are respectful and provided in culturally safe places.72 Submissions to the Review have identified a number of effective models for maternity services that have demonstrated significant outcomes for Indigenous people in urban, rural, and remote communities. Some of these programs have been evaluated and documented. These models have focused on midwife and Aboriginal Health Worker care that is culturally appropriate and delivered in a community-based setting.
In contrast, where services are not culturally appropriate, women are less likely to attend. This applies to antenatal and postnatal services as well as to childbirth. Research by Charles Darwin University suggested that between 5 per cent and 22 per cent of births were occurring on site in the three largest remote Indigenous communities because women are avoiding the system or having preterm babies. 73
Although a number of previous reviews as well as Indigenous participants in this Review have advocated greater scope for ‘birthing on country’, travel to birth and the involvement of hospital services is and will remain a core part of service delivery—with both cultural awareness and integration of community-based services important.
It is clear that models for maternity care for Indigenous women should involve mechanisms to ensure ongoing consultation with Indigenous communities and sufficient flexibility to respond to the individual needs of Indigenous women given the variability within and across their communities. It is important that models of care include strategies to address the high rates of risk factors such as smoking, substance misuse, poor nutrition, poor dental health and domestic violence.
The Review Team concluded that:
- Expanding the range of collaborative care models responsive to local needs will provide greater choice for all women in Australia, including Indigenous women. The expansion of collaborative models of care should take account of the successful models for Indigenous women that have been developed in various rural, remote and urban areas.
- Maternity services should acknowledge—and, where possible, accommodate—the particular cultural beliefs concerning childbirth held by many Indigenous families, including a preference for ‘birthing on country’.
- Maternity care health professionals who work with Indigenous women and their families, including those who work in hospital settings, should have appropriate cultural awareness training.
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