Pregnancy care for Aboriginal and Torres Strait Islander women

While the diversity of circumstances and experiences is acknowledged, this chapter highlights general considerations in providing antenatal care for Aboriginal and Torres Strait Islander women.^[9]

While many Aboriginal and Torres Strait Islander women experience healthy pregnancies, poor health and social complexity contribute to worse overall perinatal outcomes than those experienced by non-Indigenous women.

3.1 Background to culturally safe antenatal care

Cultural respect is achieved when the health system is a safe environment for Aboriginal and Torres Strait Islander peoples and where cultural differences are respected. AHMAC 2004

History and politics have shaped and continue to shape the lives and health of Aboriginal and Torres Strait Islander peoples. Social complexity and family disruption are continuing effects of government policies that have contributed to Aboriginal and Torres Strait Islander peoples having by far the worst health status of any identifiable group in Australia and the poorest access to services (Couzos & Murray 2008). This is reflected in the overall health of Aboriginal and Torres Strait Islander women and their babies. 

In 2014, among registered births in Australia, 5.3% of babies had one or two parents who identified as Aboriginal and Torres Strait Islander peoples and 4.2% had mothers who identified as Aboriginal and Torres Strait Islander peoples AIHW 2016b. While this chapter focuses on the care of Aboriginal and Torres Strait Islander women during pregnancy, it is important to remember that pregnancies in which the father of the baby is of Aboriginal or Torres Strait Islander background may have similar issues in terms of perinatal outcomes (Clarke & Boyle 2014). 

There is a disproportionate burden of adverse perinatal outcomes for Aboriginal and Torres Strait Islander mothers and their babies compared to non-Indigenous mothers and babies, including increased maternal mortality (13.8 vs 6.6 deaths per 1,00,000 women who gave birth in 2008–2012) (Humphrey et al 2015), preterm birth (140 vs 80 per 1,000 births), low birth weight (118 vs 62 per 1,000 births) and perinatal deaths (14 vs 9 per 1,000 births) AIHW 2016a. Aboriginal and Torres Strait Islander women are also less likely to attend an antenatal visit in the first trimester compared to non-Indigenous women (53 vs 60%) or to attend five or more antenatal visits (86% vs 95%) AIHW 2016a. 

All health professionals need to be aware of these disparities and have a role in optimising the care of Aboriginal and Torres Strait Islander pregnant women to aid in ‘closing the gap’ in health outcomes between Aboriginal and Torres Strait Islander and other peoples (Clarke & Boyle 2014).

3.2 Providing woman-centred care

Have a good chat with them, gain their trust, make ’em feel secure ... words, the way you talk to them means a lot ... especially young ones, that’s what they’re looking for. (Older Aboriginal woman from remote community, Central Australia as quoted in Wilson 2009

This section discusses issues specific to providing appropriate antenatal care for Aboriginal and Torres Strait Islander women. The cultural beliefs, practices and needs of Aboriginal and Torres Strait Islander women vary, both between and within culturally defined groups, and respect for the views and beliefs of individual women and of local communities is needed (Hunt 2008).

3.2.1 Understanding the woman’s context

Many Aboriginal and Torres Strait Islander women experience healthy pregnancies. The women having babies are generally younger and, on average, have more children during their reproductive life than non-Indigenous women (Clarke & Boyle 2014). Aboriginal and Torres Strait Islander culture takes a more holistic view of wellbeing and has many strengths that provide a positive influence on well-being and resilience for Aboriginal and Torres Strait Islander women and their families. These include a supportive extended family network and kinship, connection to country, and active cultural practices in language, art and music.

For women who experience adverse events in their pregnancies, the reasons are diverse and occur throughout the life course (Clarke & Boyle 2014): 

• socioeconomic factors: lower income, higher unemployment, lower educational levels, inadequate infrastructure (eg affordable housing, water supply), increased rates of incarceration
• health factors: diabetes mellitus, cardiovascular disease (including rheumatic heart disease), respiratory disease, kidney disease, communicable infections, injuries, poor mental health, overweight and underweight 
• lifestyle factors: lack of physical activity, poor nutrition, harmful levels of alcohol intake, smoking, higher psychosocial stressors (deaths in families, violence, serious illness, financial pressures, contact with the justice system).

In addition, “racism constitutes a ‘double burden’ for Aboriginal and Torres Strait Islander Australians, encumbering their health as well as access to effective and timely health care services” (Kildea et al 2016).

3.2.2 Cultural safety

Although maternity services in Australia are designed to offer women the best care, they largely reflect western medical values and perceptions of health, risk and safety. Achieving culturally safe maternity services is critical to improving health for Aboriginal and Torres Strait Islander mothers and babies (Kildea et al 2016) and this is underpinned by cultural awareness among health professionals.

Cultural safety acknowledges that health consumers feel safest when health professionals have considered power relations, cultural differences and individuals’ rights (NT Health 2016). Cultural safety is defined by the individual’s experience of health care they receive, ability to access services and to raise concerns. Part of this process requires health professionals to examine their own realities, beliefs and attitudes. Cultural safety incorporates cultural awareness which is defined as ‘an understanding of how a person’s culture may inform their values, behaviours, beliefs and basic assumptions, recognising that we are all shaped by our cultural background, which influences how we interpret the world around us, perceive ourselves and relate to other people RACGP 2011.

The provision of culturally safe care requires a willingness to gain the knowledge, understanding and skills to communicate sensitively and effectively with Aboriginal and Torres Strait Islander people and to acknowledge and respect cultural differences. Cultural safety is also relevant to Aboriginal and Torres Strait Islander health professionals.

An emerging area in developing a culturally responsive workforce is trauma-informed care, in which health professionals understand the ongoing impact of intergenerational trauma resulting from historical injustices, colonisation, removal from and dispossession of land, and continuing racism (Kildea et al 2016). This is particularly important given that Aboriginal and Torres Strait Islander children are over-represented in out-of-home care compared with non-Indigenous children (9.5 times more likely), with some women encountering the child protection system during pregnancy, leading to removal of their babies soon after birth.

While further developments in cultural safety education are required (Kildea et al 2016), a recent study found that providing cultural safety training as an assessable component of practice and recognising that it is as important as the physical aspects of care for the women would improve the experiences of women and support midwives in practice (Brown et al 2016).

Cultural awareness education programs and tools for evaluating individual and organisational cultural responsiveness have been developed (see Section 3.7).

3.2.3 Improving women’s experience of antenatal care

Taking an individualised approach

Factors that may improve a woman’s experience of antenatal care include (Clarke & Boyle 2014): 

• creating a comfortable and welcoming physical space
• taking time to establish rapport and trust
• providing continuity of carer
• ensuring privacy and confidentiality
• involving her partner/the father of the baby, where this is agreed by the woman
• having some knowledge about the woman’s community
• endeavouring to have flexible scheduling of appointments.

Ideally a nominated person within a practice should be able to ensure the woman is receiving appropriate care from other healthcare team members and to assist to coordinate services if required.

Providing information and support so that women can make decisions

There is indirect evidence that, in some settings, Aboriginal and Torres Strait Islander women have fewer opportunities to make decisions about their care than non-Indigenous women, or fewer than is desirable (Hunt 2003). This may be improved through providing information to women and their partners in a culturally appropriate way and providing strategies to help them achieve positive change (Clarke & Boyle 2014) and by working in partnership with Aboriginal health professionals, women and communities.

Aboriginal community worker involvement

Where available, assistance from Aboriginal and/or Torres Strait Islander health workers, community workers or Aboriginal and/or Torres Strait Islander liaison officers should be sought as they can facilitate understanding between the woman and her healthcare provider and provide assistance for attending appointments and coordinating care (Clarke & Boyle 2014). This may be particularly important when English is not the woman’s first language.

3.3 Successful models of antenatal care

Aboriginal peoples and Torres Strait Islanders should access services and health care not just at a level enjoyed by other Australians (principle of equality) but at one that reflects their much greater level of health care need (principle of equity). (Couzos & Murray 2008)

A range of programs have been implemented around the country to improve the delivery of antenatal services to Aboriginal and Torres Strait Islander women. Evaluations have shown their success in improving uptake of care earlier in the pregnancies, for the duration of the pregnancy and often postnatally, which allows other opportunistic healthcare interventions, such as family planning, cervical screening and improving breastfeeding rates (Clarke & Boyle 2014). This shows that if services cater for their needs, women will utilise them.

Evaluated programs include:

• Midwifery group practice: A midwifery group practice (staffed by midwives, Aboriginal Health Workers, Aboriginal midwifery students and an Aboriginal ‘senior woman’) was introduced in a regional centre in the Northern Territory to provide continuity of care for women from remote communities transferred to the centre for antenatal care and birth (Barclay et al 2014). There were improvements in antenatal care (fewer women had no antenatal care and more had more than five visits), antenatal screening and smoking cessation advice and a reduction in fetal distress in labour. The experiences of women, midwives and others during the establishment and the first year of the midwifery group practice were also reported positively and women’s engagement with the health services through their midwives improved. Cost-effective improvements were made to the acceptability, quality and outcomes of maternity care.
• Midwifery continuity of care: A meta-synthesis of qualitative studies undertaken in Australia and Canada found that overall the experience of midwifery services was valuable for Indigenous women, with improved cultural safety, experiences and outcomes in relation to pregnancy and birth (Corcoran et al 2017). The most positive experiences for women were with services that provided continuity of care, had strong community links and were controlled by Indigenous communities (Corcoran et al 2017). Continuity of midwifery care can be effectively provided to remote dwelling Aboriginal women and appears to improve outcomes for women and their infants (Lack et al 2016). However, there are barriers preventing the provision of intrapartum midwifery care in remote areas (Corcoran et al 2017). A study among midwives in a large tertiary hospital in South Australia found that communication and building support with Aboriginal health workers and families were important to midwives working with Aboriginal women and identified the following barriers to provision of care (Brown et al 2016):
  • time constraints in a busy hospital
  • lack of flexibility in the hospital protocols and polices
  • the system whereby women were required to relocate to birth
  • lack of continuity of care
  • lack of support 24 h a day from the Aboriginal workforce
  • the speed at which women transitioned through the service.

  The midwives had some difficulty differentiating the women’s physical needs from their cultural needs and the concept of cultural safety was not well understood. The midwives also determined that women who were living in metropolitan areas had lesser cultural needs than the women who were living in rural and remote areas. Stereotyping and racism was also identified within the study.

• Aboriginal Maternity Group Practice Program (AMGPP): The AMGPP employed Aboriginal grandmothers, Aboriginal Health Officers and midwives working in partnership with existing antenatal services to provide care for pregnant Aboriginal women residing in south metropolitan Perth (Bertilone & McEvoy 2015). Babies born to women in the program were significantly less likely to be born preterm (9.1% vs 15.9% in historical controls [adjusted odds ratio (aOR) 0.56; 95%CI 0.35 to 0.92]; vs 15.3% in contemporary controls [aOR 0.75; 95%CI 0.58 to 0.95]); to require resuscitation at birth (17.8% vs 24.4% in historical controls [aOR 0.68; 95%CI 0.47 to 0.98]; vs 31.2% in contemporary controls [aOR 0.71; 95%CI 0.60 to 0.85]) or to have a hospital length of stay greater than 5 days (4.0% vs 11.3% in historical controls [aOR 0.34; 95%CI 0.18 to 0.64]; vs 11.6% in contemporary controls [aOR 0.56; 95%CI 0.41 to 0.77]) (Bertilone & McEvoy 2015). Analysis of qualitative data from surveys and interviews found that the model had a positive impact on the level of culturally appropriate care provided by other health service staff, particularly in hospitals. Two-way learning was a feature. Providing transport, team home visits and employing Aboriginal staff improved access to care. Grandmothers successfully brought young pregnant women into the program through their community networks, and were able to positively influence healthy lifestyle behaviours for women (Bertilone et al 2016).
• Aboriginal Family Birthing Program (AFBP): The AFBP provides culturally competent antenatal, intrapartum and early postnatal care for Aboriginal families in some parts of South Australia, with women cared for by an Aboriginal Maternal and Infant Care worker and a midwife in partnership. The Aboriginal Maternal and Infant Care worker has a clinical role. Compared with women attending mainstream public antenatal care, women attending metropolitan and regional AFBP services were more likely to report positive experiences of pregnancy care (aOR 3.4, 95%CI 1.6 to 7.0 and aOR 2.4, 95%CI 1.4 to 4.3, respectively). Women attending Aboriginal Health Services were also more likely to report positive experiences of care (aOR 3.5, 95%CI 1.3 to 9.4) (Brown et al 2015). Even with greater social disadvantage and higher clinical complexity, pregnancy outcomes were similar for AFBP and Aboriginal women attending other services (Middleton et al 2017).
• Aboriginal Maternal and Infant Health Service (AMIHS): the AMIHS was established in New South Wales to improve the health of Aboriginal women during pregnancy and decrease perinatal morbidity and mortality for Aboriginal babies (Murphy & Best 2012). The AMIHS is delivered through a continuity-of-care model, where midwives and Aboriginal Health Workers collaborate to provide a high-quality maternity service that is culturally sensitive, women-centred, based on primary health-care principles and provided in partnership with Aboriginal people.

An evaluation of the AMIHS found:

• the proportion of women who attended their first antenatal visit before 20 weeks increased (65 vs 78% in 2004, OR 1.2; 95%CI 1.01 to 1.4; p=0.0.03)
• the rate of low birthweight babies decreased (13 vs 12%, not statistically significant)
• the proportion of preterm births decreased (20 vs 11%; OR 0.5 95%CI 0.4–0.8–1.4; p=0.001)
• perinatal mortality decreased (from 20.4 per 1,000 births in 1996–2000 to 14.4 per 1,000 births in 2001–2003; not statistically significant owing to small numbers)
• breastfeeding rates improved (from 67% initiating breastfeeding and 59% still breastfeeding at 6 weeks in 2003, to 70% initiating breastfeeding and 62% still breastfeeding at 6 weeks in 2004).

While these programs have been identified as beneficial, not all Aboriginal and Torres Strait Islander women have access to these types of programs and many still rely on mainstream services such as GPs and public hospital clinics (Clarke & Boyle 2014). Hence, it is important that mainstream services embed cultural competence into continuous quality improvement. Participation in a continuous quality improvement initiative by primary health care centres in Aboriginal and Torres Strait Islander communities is associated with greater provision of pregnancy care regarding lifestyle-related risk factors (Gibson-Helm et al 2016b). For example, screening for cigarette smoking increased from 73% at baseline to 95% (OR 11, 95%CI 4.3 to 29) after four cycles (Gibson-Helm et al 2016b).

3.4 Birthing on country

There is a strong relationship between distance to maternity services and poorer clinical and psychosocial outcomes (Kildea et al 2016). For some Aboriginal and Torres Strait Islander women, the social risks of not birthing on country include cultural risk (eg the belief that birthing away from country may be the cause of ill health as it breaks the link between strong culture, strong health and the land) and emotional risks (having to spend weeks removed from family and other children while awaiting the birth) (Kildea et al 2016). These factors cause distress to women and families and increase clinical and medical risks (eg women not attending antenatal care, or presenting late in labour, to avoid being flown out of their community for birth). 

In a study of birthing services in rural and remote areas, very remote communities were least likely to have a local birthing facility (Rolfe et al 2017). In addition, services were influenced by jurisdictional policy rather than identified need.

3.5 Adolescent mothers

Adolescent motherhood occurs more often within communities where poverty, Aboriginal and Torres Strait Islander status and rural/remote location intersect (Marino et al 2016). Adolescent pregnancy has been typically linked to a range of adverse outcomes for mother and child. In Australia, the proportion of births among adolescent women is higher among Aboriginal and Torres Strait Islander women than among non-Indigenous women (17 vs 2%) AIHW 2016a and the risk of poorer psychosocial and clinical outcomes is greater if these women are not well supported during pregnancy and beyond (Reibel et al 2016). However, a study in the NT suggests that problems usually associated with Aboriginal adolescent births (such as low birth weight) are not due to maternal age but are related to the underlying poor health, socioeconomic disadvantage and a system that is challenged to support these young women, both culturally and medically (Barclay et al 2014).

Drawing on existing literature and consultations with young Aboriginal women and health professionals supporting pregnant Aboriginal women, a West Australian study found that engagement with the health system is encouraged and health outcomes for young mothers and their babies improved through destigmatising of young parenthood and providing continuity of caregiver in culturally safe services with culturally responsive health professionals (Reibel et al 2016). Another study noted the critical role of general practitioners in identifying at-risk adolescent women, preventing unintended adolescent pregnancy, clinical care of pregnant adolescents and promoting the health and wellbeing of adolescent mothers and their children (Marino et al 2016).

3.6 Improving outcomes

System-wide strategies to strengthen health centre and health system attributes that support best-practice antenatal health care for Aboriginal and Torres Strait Islander women are needed. Some strategies can be implemented within health centres while others need partnerships with communities, external services and policy makers (Gibson-Helm et al 2016a).

Approaches to improving the health outcomes for Aboriginal and Torres Strait Islander women and their babies in pregnancy include the following:

• systems-based approaches to address socioeconomic disadvantage, education and health literacy (Boyle & Eades 2016)
• health services approaches to provide trusted, welcoming and culturally appropriate health services in both community-controlled and government sectors, facilitate better communication between primary and hospital-based services and utilise initiatives such as continuous quality improvement practices that lead to improved services, particularly where staff turnover is high (Boyle & Eades 2016)
• families-based approaches, to address social and lifestyle factors (eg smoking prevention and quitting (Boyle & Eades 2016), drinking alcohol, social and emotional wellbeing and nutrition) (Gibson-Helm et al 2016a)
• clinical guidelines to address specific needs of Aboriginal and Torres Strait Islander women in pregnancy (eg screening for infection in young women and women from areas where risk is high) (Boyle & Eades 2016)
• supports for the particular needs of rural and remote women in accessing care (eg access to ultrasound services) (Boyle & Eades 2016)
• strengthened systems to ensure workforce support, retention and recruitment; patient-centred care; and community capacity, engagement and mobilisation (Gibson-Helm et al 2016a).

3.7 Resources

• Couzos S & Murray R (eds) (2008) Aboriginal Primary Health Care: An Evidence Based Approach (3rd edition). Melbourne: Oxford University Press.
• Queensland Health Aboriginal and Torres Strait Islander Cultural Capability Framework 2010 to 2033.
• RACGP (2011) Cultural Awareness Education and Cultural Safety Training . The RACGP National Faculty of Aboriginal and Torres Strait Islander Health.
• Remote Primary Health Care Manuals. (2017). Women’s Business Manual (6th edition). Alice Springs, NT: Centre for Remote Health.
• Walker R (2010) Improving Communications with Aboriginal Families . A Resource for Hospital Staff, Women’s and Newborns’ Health Network, WA Department of Health.
• Walker R & Reibel T (2009) Developing Cultural Competence for Health Services and Practitioners . Background paper for the TICHR & Women’s and Newborn Health Network antenatal services and maternal services project.
• Wilson G (2009) What Do Aboriginal Women Think Is Good Antenatal Care? Consultation Report . Darwin: Cooperative Research Centre for Aboriginal Health.

3.7.1 Websites

• HealthInfoNet
• Closing the Gap
• Maternity care in the bush