Remote links: Redesigning maternity care for Aboriginal women from remote communities in Northern Australia – A comparative cohort study
Introduction
In Australia, maternal and infant health (MIH) outcomes for Aboriginal and Torres Strait Islander (here after called Aboriginal) women, compared with non-Indigenous women, are poorer. For example, Aboriginal women more often give birth to low birth weight (LBW) infants (11.8% versus 6.0%) and have higher preterm birth (14.3% versus 8.3%) and perinatal mortality (14.9 versus 9.4 per 1000) rates. Compared with non-Indigenous women, Aboriginal women more frequently experience risk factors such as teenage pregnancy (18.6% versus 3.0%) and smoking in pregnancy (48.1% versus 10.7%) (Hilder et al., 2014). A much larger percentage of Aboriginal birthing women (compared to non-Aboriginal women) live in remote areas of Australia (24.1% versus 1.8%) where reduced services, higher costs of living and higher rates of poverty are more common; as is relocation for birth (Smith, 2007). Other contributing factors to the higher rates of adverse MIH outcomes among Aboriginal women include the enduring effects of colonisation, social exclusion, sustained institutionalised racism and stark inequities across many of the social determinants of health including income, employment, education and access to goods, services and health care (Australian Government, 2013, Broome, 2002, Calma, 2007, McDonald, 2004, Wilkinson and Marmot, 1998). An important determinant of health for Aboriginal Australians is their strong connection to the land, which is the foundation of their cultural identity and a source of spiritual sustenance (Durie, 2003; Australian Government, 2013, Durie, 2003). To enable this connection to impact positively on health outcomes Aboriginal women have stated (many times) that returning locally based birthing services would improve the health and well-being of their mothers and infants (Kildea, 1999, NT DHCS, 1993; Banscott Health Consulting Pty Ltd., 2007, Barclay and Kildea, 2006, Lowell et al., 2015), with some women choosing to birth locally even when maternity services are not provided (Ireland et al., 2010). Although a trial of birthing in remote communities has been recommended in many reports over many years (AHMAC, 2011, Banscott Health Consulting Pty Ltd., 2007, Fitzpatrick, 1993, Kildea, 1999, NT DHCS, 1993), there has not been one to date and Aboriginal people do not have sufficient control over their traditional lands and health services to make ׳Birthing on Country’ a reality. This lack of control has been reported as a cause of distress (Aboriginal and Torres Strait Islander Social Justice Commissioner, 2006, Calma, 2007, Kildea, 2003, Kildea et al., 2013, Pincus et al., 1998, Wilkinson and Marmot, 1998).
The National Aboriginal and Torres Strait Islander Health Plan (an evidence-based policy framework designed to guide government policies and programs to improve Aboriginal and Torres Strait Islander health until 2023) recognises the importance of addressing the social determinants of health. It articulates a vision that includes access to effective, high quality health systems that are free of racism (Australian Government, 2013). Mothers and babies are a priority target group identified in the Plan, which also emphasises care that recognises the importance of culture, human rights, Aboriginal community control, accountability and working in partnership. Key strategies aim to improve the clinical effectiveness of the health system and to enhance health system performance in areas of access, co-ordination, integration, responsiveness and the use of technology (Australian Government, 2013).
Australia׳s National Maternity Services Plan (AHMAC, 2011) identified three priority areas for improving services for Aboriginal women: 1) developing and expanding culturally competent maternity care; 2) developing and supporting an Aboriginal workforce; and 3) developing dedicated programs for ‘Birthing on Country’- a term that has various interpretations of meaning but has been described as best practice and culturally responsive MIH services for Aboriginal women (Kildea et al., 2013). A key deliverable in the Plan was to undertake a literature review to help inform the development and implementation of best practice models of care. For the literature review Birthing on Country was defined as: ‘maternity services designed and delivered for Indigenous women that encompass some or all of the following elements: are community based and governed; allow for incorporation of traditional practice; involve a connection with land and country; incorporate a holistic definition of health; value Indigenous and non-Indigenous ways of knowing and learning; risk assessment and service delivery; are culturally competent; and developed by, or with, Indigenous people (Kildea and Van Wagner, 2012, p. 5).’
The review identified the following features commonly found in successful programs: the presence of enthusiastic community champions, services being community based and/or community controlled, developed with or by community, involving elders and incorporating traditional knowledge and skills, services provided at a location specifically designated for women and children, continuity of care in service provision and continuity of midwifery carer, service integration (shared care, hospital based liaison), outreach activities, home visiting, and valuing Aboriginal and Torres Strait Islander staff, particularly female staff (Herceg, 2005, Rumbold and Cunningham, 2008Herceg, 2005, Kildea and Van Wagner, 2012, Rumbold and Cunningham, 2008). A national Birthing on Country workshop was held to obtain agreement on how to progress and implement Birthing on Country programs including identification of pilot sites. Aboriginal elder, Djapirri Mununggirritj, a Yolngu woman from north-eastern Arnhem Land in the Northern Territory (NT), stated that Birthing on Country programs must address ‘not only bio-physical outcomes … (but) deal with socio-cultural and spiritual risk that is not dealt with in the current systems (Kildea et al., 2013, p. 24).’ Workshop participants recommended that the Birthing on Country programs be seen as system-wide reform to assist in ‘closing the gap’ between Indigenous and non-Indigenous health and quality of life outcomes with a range of sites established, including in remote Australia (Kildea et al., 2013).
One of the exemplary Birthing on Country models identified in the literature review was the community birthing program in three remote Inuit communities in Canada (Kildea and Van Wagner, 2012). Reports describe a community development program that links the establishment of local birthing centres (without onsite access to caesarean section) to improved health care and outcomes, as well as the greater social functioning (Rawlings, 2002; Houd, 2003, Houd et al., 2003, Rawlings, 2002, Van Wagner et al., 2007). The return of local birthing is thought to contribute to community healing from the effects of colonisation and rapid social change (Van Wagner et al., 2008) marking a turning point for many families who suffered from intergenerational trauma, suicide and family violence (Rawlings, 2002, Van Wagner et al., 2012). Community members reported: the regaining of dignity and self-esteem, the building of community relationships and intergenerational support whilst promoting respect for traditional knowledge, restoring skills and pride, and capacity building in the community that included onsite midwifery training (Van Wagner et al., 2012). ‘Women are cared for in Innutitut, [their own language], and children are born into their culture, in the presence of family. Inuulitsivik’s maternity service builds local capacity, reclaims meaningful roles for Inuit midwives, empowers childbearing women and involves fathers and other family members in childbirth’ (Van Wagner et al., 2008, p. 3). Maternal and perinatal outcomes, for example caesarean section and perinatal mortality rate, are as good, but mostly they are far better, when compared to other first nations communities in Canada or the whole Canadian population (Van Wagner et al., 2012). Key factors cited as contributing to success include the open dialogue and debate around risk in childbirth (Kaufert and O׳Neil, 1993) with a recognition that: ‘the cultural aspect of birth … is essential to perinatal health… it is from within the culture and community that real positive changes in the health of the people begins (Stonier, 1990, p. 71).’ The risk screening process is seen as a social, cultural, and community process rather than simply a biomedical one; and an interdisciplinary perinatal committee reviews each woman׳s case at 32–34 weeks gestation for both medical and social factors, prior to creating a care plan for birth (Couchie and Sanderson, 2007). The Society of Obstetricians and Gynaecologists of Canada strongly support the return of birthing services to rural and remote communities with a policy statement endorsed by the Indigenous Physicians Association of Canada, the Canadian Association of Midwives, and the Aboriginal Council of Midwives (Society of Obstetricians and Gynaecologists of Canada, 2010).
This paper reports findings from a five-year mixed method National Health and Medical Research Council-funded study: ‘1+1=A healthy start to life’ (No. 476200). The study was set in the NT of Australia, a large (1,349,129 km2) sparsely populated jurisdiction with the highest proportion of Aboriginal people in Australia, i.e., 27% compared to <4% in all other jurisdictions (ABS, 2011). More than 80% of NT Aboriginal residents live in small, remote communities where over 100 traditional languages are spoken. Roughly, 3600 babies are born annually in the NT with approximately 1400 being born to Aboriginal mothers, two-thirds of whom live remotely compared with 5% of non-Aboriginal birthing mothers (Thompson et al., 2012). Pregnant women are separated from their families at around 38 weeks (earlier for women with risk factors) and transferred to regional centres for birth. Multiple reports of maternity services in the Top End of the NT (i.e., the monsoonal north) from women and service providers have identified problems with this system, particularly in relation to cultural insecurity in the main regional centre (Darwin) where most of the women from the Top End give birth (Kildea, 1999, NT DHCS, 1993, Watson et al., 2002a, Watson et al., 2002b; Banscott Health Consulting Pty Ltd., 2007, Dunbar, 2011, Kildea, 1999, NT DHCS, 1993, Watson et al., 2002a, Watson et al., 2002b). Previous research has also identified a lack of adherence to antenatal guidelines as an issue of concern (Bar-Zeev et al., 2014, Hunt, 2003, Rumbold et al., 2011; Bar-Zeev et al., 2014). These guidelines include the Women׳s Business Manual, a culturally respectful resource developed by multidisciplinary panels to guide treatment and best practice in the remote setting (Congress Alukura and Nganampa Health Council Inc., 2008). In 2006, a workshop brought together Aboriginal women from two remote communities, policymakers, clinicians and researchers to discuss improving MIH and a research proposal was developed (Barclay and Kildea, 2006). Participants identified the 5Cs (Choice, Communication, Co-ordination, Collaboration, Continuity) as priority areas for action in a redesign of maternity care. All participants agreed the current system was unsafe for women in the areas of birth (no) choices, accommodation, transport, families and children who are left behind (Barclay and Kildea, 2006). Part of the recommended service redesign was a culturally tailored, Enhanced Midwifery Group Practice (MGP) model of care (detailed below) for women when they came to Darwin for maternity care. Despite a recommendation that the service redesign should incorporate facilities and support to birth in the remote communities (similar to the Canadian Inuit model) this recommendation did not get the high level government support that was required to take it forward. Thus it was not written into either the funding proposal for the service redesign or the research proposal.
Section snippets
Aim
To compare various aspects of maternity care before and after the introduction of a new model of care for remote-dwelling Aboriginal women giving birth in Darwin and make recommendations for future service development.
Discussion
This early evaluation of the first 21 months of the new service was associated with significant improvements in many areas and indicated greater service uptake e.g., fewer women with less than four ANC visits in pregnancy. However, the results show an excessive burden of illness with some of the highest preterm, low birth weight and PPH rates in Australia, and indeed globally (Howson, C. P., Kinney, M. V., & Lawn, J. E. (Eds.). (2012). The Global Action Report on Preterm Birth, Born Too Soon.
Conclusion
This study has identified that the new maternity model available to remote-dwelling Aboriginal women improved continuity of midwifery carer; choice (access to birth centre but not community-supported birth), co-ordination of care, collaboration and communication between providers (Bar-Zeev et al., 2012b, Bar-Zeev et al., 2014, Bar-Zeev et al., 2013b, Barclay et al., 2014, Josif et al., 2012). Significant improvements in the quality of care, some MIH outcomes and cost-efficiency were also
Conflict of Interest
The authors declare that they have no conflict interests.
Acknowledgements
Funding for the study came from ‘a Healthy Start to Life’ NHMRC Grant (422503), an ARC linkage grant (LP0669519) partnered with the NT Department of Health and Community Services and Danila Dilba Aboriginal Medical Service and the NT Health Department provided additional funding for the MGP evaluation. We acknowledge the following people and organisations who contributed to our research: our Advisory Committee; staff at the Royal Darwin Hospital and remote health centres; the elders and health
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