WOMEN ONLY PAGE - NO MEN
The next three sections (before, during and after birth) contain a collection of stories that have been recorded from one particular area in Arnhem Land. Even in this one relatively small area the rituals and beliefs around pregnancy, childbirth and the postnatal period varied amongst the different language groups and at times even varied within the language groups. This illustrates the importance of talking to individual families about what they want throughout this significant time of their life.
Interwoven amongst the stories are clinical scenarios and events that remote area nurses identified as being areas of concern, and as such would be valuable in this resource. The stories and examples in these sections have been described by practitioners who have been working in remote settings across Australia. Most of the statistics are from the Northern Territory and have been used to illustrate problems that are common in many remote areas. No identifying names have been used, all are pseudonyms (apart from the Aboriginal women who preferred to have their names recorded here and Hellen Matthews RAN/RM who was also happy to have her name recorded). The information was current up until when it was written early 2004.
The women in this community felt it was really important for midwives, nurses and doctors to understand about their culture and beliefs around pregnancy and childbirth. The older women felt that interest and respect from the non-Aboriginal health workers was important for the younger women who may not feel confident to ask or explain about things that are important to them. They believe that one of the fundamental things for improving health in the community is to incorporate an integrated learning process whereby the non-Aboriginal health workers, the AHW's and the older women, 'the grey haired ones', all learn from each other. Together they teach the young girls learning from the younger women during the process. They felt one of the best ways of doing this would be to go on a camp, maybe once or twice a year, to a place where all the women can be together to talk about women's issues and learn from each other. Many of the women felt that all new Health Centre staff coming to work in the community would benefit from going on a camp with the women to learn about Aboriginal ways and receive an orientation to the community.
We should have a camp all together once a year where the young girls and the older women get together with the Health Centre staff to talk about women’s business and teach both ways. Take one of the strong nurses from the clinic and go and explain to them in the bush somewhere, like in a bush shed or near a creek or where there is good territory. (Wendy, Ruby, Esther, Dora and Rosie)
If you don’t have the knowledge about what they may have done in the past, and maybe that’s what they want to do now, you can’t make that suggestion to them and they might be too scared to speak up. So it’s having that knowledge that those things did go on one time, and maybe some of them might still do them if the encouragement’s there. (Hellen Matthews RAN/RM)
You know what’s happened historically is important. You don’t necessarily know what’s historically happened, but if you are aware that there may have been something... I think just asking. (Remote Area Nurse Midwife)
First period story - 'this is the first story, the first step for young girls'.
There was one old lady who used to look after all the young girls when they had their first period. Some times they would dig a really big hole away from the camp and the young girl would have the mat over them all the time. After five days, grand mother or auntie would make a string and that would be placed in a crossover way across the front and the back of their body. They would also get pandanus to make rings for all their fingers and toes and armbands and a headband. Then they would cover her body with red ochre. This would stop her from having babies until the next period comes. After her third period, then she is allowed to go her own way and look after herself. Still today any time a woman has a period she is not allowed to eat any meat from the land or the sea, or anything that her brother catches. If she does then it will ruin the hunting for that area. She can eat only crabs and lombom. The first period is still an important time for young girls. Their grandmother and great grand mother will look after them and tell them stories and explain women's business to them. (Molly and Margaret)
| I’m just waiting for my little girl to have her period. I might tell one of the old ladies to make the shade for her. Maybe for three or four days she can sit down in the shade. They used to make the shade for them and they didn’t walk around, they used to stay in one place in that shade until everything was done and all finished, then they used to come out from the shade and walk around and they used to have a shower and then be nice and clean. (Sonia) |
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There seems to be something here that’s been lost, there was a sort of an initiation period for young women going through puberty it just sounds really lovely, a special time for them. (Remote Area Nurse / Midwife)
When they get their period on Croker and Goulburn Island they put up a big shade for them. They make four sticks with a top like a shade and they sit there for morning, afternoon and night time, maybe for a few days till the period stops. They have other women with them and they are not allowed to eat meat. (Tinica)
I ask the young girls first, have you got a period or something, they don’t eat the fish from the freshwater if they have a period. (Dorothy and Molly)
Once young girls get their first period it is possible that they could have
a pregnancy. Preconceptual health is important and is something that could be
thought about during school screening time. Some girls do not go to school so
you may need to think of other ways of targeting this group. Other girls will
not go to school when they have their period, talk to the school teachers about
this, do they think it is a problem in the community? If so - what are the reasons
for this in the community you are working in and can it be rectified?
Pregnancy is not necessarily acknowledged by Aboriginal women until fetal movements are being felt. This can lead to late presentation for antenatal care. Yearly health checks for all women is one way of ensuring reproductive age women are: at optimum health; not malnourished or anaemic; and have worming treatments made available regularly. This helps to optimise pre-pregnant health (Albendazole should not be given to anyone in pregnancy or if they are breastfeeding). Many communities have a school screening program which will often involve the high school girls. This is an excellent opportunity to assess their health as waiting till women present for antenatal care can mean they have spent some of the first part of their pregnancy in less than ideal health. Regular health education for the high school girls and boys will often involve the health centre staff. Topics covered could include puberty, menstruation, safe sex education and information on pregnancy and sexual health.
If women have other conditions that could be a problem in pregnancy (eg. Rheumatic Heart Disease) it is advisable to have a medical specialist involved from the beginning. This would involve discussions with the woman and her family before pregnancy so they understand why this is important. If you know of women who are planning a pregnancy it is ideal that they have lots of iron and folate in their diet and it is advisable that they take folic acid as a prevention against Neural Tube Defects in the baby (for a minimum of 2 months before pregnancy and 3 months into the pregnancy).[32]
People in rural and remote areas pay up to 50% more for healthy foods with meat and dairy products being two groups of foods most effected by remoteness. Ironically, tobacco and takeaway foods are items where the cost is least effected by remoteness.[33]
How do women conceive?
Molly’s father went hunting for fish and when he came home he said to Molly’s mother I had a dream for you that maybe you will get a little boy or a little girl. When Molly was born she had four little marks on her tummy and these were the ‘fish mark’ from when her father caught her. This story was explained to her by her grandmother. Still today men will have a dream. They will come back and talk to their wife and say 'I had a dream last night that maybe you will have a little boy or a little girl', especially if they have been hunting and caught a big fish. He might say 'in my dream I was carrying two babies' and that will mean that she will have twins. (Molly and Margaret)
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There special places for women when they want to have a baby, special fertility places that they go to in the bush. Everybody knows where the special place to go is. (Phyllis) |
From long time ago, always the husband would dream and tell that lady that she is going to have a baby but that doesn’t happen any more, not these days. (Charlie)
Some of the sisters have asked to have a baby, we take them down there and they might have to have a swim in the lovely clean water, and then they will have a baby. (Molly and Ruby)
If young girls are sexually active it is ideal to discuss the different forms of contraception with them and an older female relative. You should also talk about protection from sexually transmitted infections (STI’s), regular screening and prompt treatment. Regular screening is important as not all infections are symptomatic and untreated STI’s can lead to pelvic inflammatory disease (PID) and infertility.
They don’t really like to go along to groups. The mother or aunty tell them about what’s going to happen when they go into hospital and when they have a baby, they tell them before they go. So when they do the checkups down at the clinic they should be explaining all those things to them, only themselves in the room, one at a time, not a big group. They should have their mother with them for that. (Sonia, Tinica, Molly, Mary and Theresa)
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The Health Centre staff do explain things to the young mothers but they don’t understand it really, it should be two way education, it is better to have older aboriginal women with them, the grey haired ones - always two way. (Alice) |
To be able to have those small groups and just talk to people, sometimes on a quite day when you’ve got some time you’ve got this captive audience and you can just do so much, but you just do not have time to be able to do it all. (Remote Area Nurse Midwife)
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During pregnancy those mothers could go and learn something there at the women’s centre. They should learn from Aboriginal women, health workers and older women, and from Balanda. (Dorothy) |
The biggest issues are the lack of time and the lack of staff to be able to do the primary health care type work. (Remote Area Nurse)
When I was in another community the older woman would go down to where there is a big camp area with the young women and they would camp and stay there. We used to be invited to go down there at night to listen to the stories. The dancing and the singing they would do was great. Although they have lost a lot of the culture because it’s now a Catholic community, this was something that was still really strong. And it wasn’t just because we were nurses you know, it was a community thing to come down. It was helpful to us - being there. (Remote Area Nurse Midwife)
If the nurses are worried then sometimes they can actually go and talk to that young girl themselves, or sometimes the mother, that's OK for the nurses to go and do that. Sometimes the mothers will try and tell the young girls to come for a check up but they don’t always listen. (Sonia)
Mostly they only go and get checkups when they get sick. When young girls do not want to go for a check up it is best to get the grandmother or aunty to come up with them, though some of the young ones are happy to go for a check up with their friends. If they don't come up for check ups and then something goes wrong with that baby, the health centre staff won't get blamed. (Sonia, Wendy and Molly)
Pregnant women are allowed to eat anything they want, when they are eating bush tucker they don’t need medicine. (Charlie)
Its good when sometimes that specialist comes out to visit Maningrida for Women’s Business it means we don't have to go to town. (Wendy)
A new midwife in the community decided it might be a good idea to start antenatal classes once a week. She went and spoke to the non-Aboriginal woman who assisted coordinating the Women’s Centre. They decided to run the classes every Thursday afternoon for two hours as this was the best time for the midwife to get time away from the Health Centre. They organised to start in 3 weeks time, put fliers around the community, asked the Health Workers to spread the word and prepared for this day. The first week no one turned up, the second week they asked the Health Centre for transport and asked the Health Workers to pick up people but still no-one turned up. When no-one came for the third week they decided to give up as no-one was interested. What went wrong?
Answer:
The correct answer is b. Although well meaning, the basic tenets of community
development were not engaged. The idea did not come from discussions with the
community members and there was minimal discussion with community members about
how the program might work. If there had been, the midwife might have discovered
that this is not how the community women want to learn about pregnancy and childbirth.
She could have heard that it had been tried before by another well meaning midwife,
and had not been successful. No 1 and No 3 are also important and the midwife
would have discovered this information if she had had discussions with community
members.
A new midwife in the community decided it might be a good idea to start antenatal classes once a week. She wanted to talk to the community women about her idea. She had started to work through 'the guide' and had already found out which women were to be approached and involved in any activities to do with women’s business and who had been involved with birthing in the past. She held a meeting with the female health workers, elder women and traditional midwives about her ideas. At the meeting the group decided they did not want to have organised antenatal classes as they had been tried before and women did not like them. Instead they decided that a picnic at a women’s place nearby might be better. Here elder women could talk about women’s business to the young girls and teach some of the health staff about Aboriginal ways. The health staff could bring some of their resources and talk about women’s business too, this way the young girls would have the benefit of learning from the elders, the AHW's, midwives, nurses and doctors and everyone could learn from each other. It was decided to do this every three months and next time involve the Women's Centre who could help with collecting bush tucker for the event. This was documented in the planning section of the guide.
topWho should you talk to when you are concerned about the health of a teenage antenate?
| Annabel was a 15yo girl whose mother had
passed away. Her grandmother, who spent most of the time on her outstation,
cared for Annabel. Increasingly Annabel was spending more time in the
local town. A Health Worker told the midwife that Annabel was pregnant
but would not come up for a check up - the health worker said she could
not speak to Annabel as she was a different language group. What should
the midwife do? |
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The midwife was new and used the guide to see who she should speak to. An elder
woman who had been a traditional midwife lived at the same outstation as Annabel’s
grandmother. She was mentioned in the guide as a woman who would assist in any
matters to do with birthing. The midwife approached the elder with her concerns
and was assured the situation would be managed. The next week the elder came
to the Health Centre with Annabel and her grandmother for an antenatal check.
What can be done when a family are having problems funding the costs involved in sending a support person to the regional centre with a woman when she is to give birth?
Are there any organisations in town that would be likely to help out in this situation? Some places (eg. the Women's Centre) will assist families to save money. If the problem has been identified early enough in the pregnancy then putting aside a small amount of money every pay day might assist the family to save enough to pay for an escort for support in labour. It is important to talk about this early in the pregnancy. Aborigninal women have identified that support in labour from someone they know is important to them and there is clear evidence, from randomised controlled trials, that support in labour improves outcomes.[32]
There has been much international debate about the diagnosis and management of anaemia in pregnancy. The World Health Organisation defines anaemia in pregnancy as existing when the haemoglobin drops below 110gms/L. The physiological haemodilution of pregnancy makes it difficult to diagnose anaemia and it is not recommended to use haemoglobin levels alone.[34] Iron deficiency (a decrease in the bodies stores of iron) will occur as the first stage of iron depletion.[35] Low serum ferritin levels can occur at this time but it is important to remember that ferritin can be raised when there is concurrent infection, chronic inflammation and other rarer conditions such as malignancy and liver disease.[35] Other tests that are important include: mean corpuscular volume (MCV - calculated by dividing the haematocrit by the red cell count), serum iron, transferring saturation and red cell protophyrin.[36] A reduction in MCV with anaemia is usually associated with iron deficiency anaemia and occurs when iron deficiency becomes severe, at about the same time as anaemia starts to develop.[36] A cut-off value of around 80 f/ L is accepted as the lower limit of normal in adults. It is important to exclude thalassemia and the anaemia of chronic disease.
A Cochrane review found that routine iron treatment in pregnancy did not have any beneficial effect on pregnancy outcomes though treatment of iron deficiency anaemia is important and definitely recommended.[35] It is also well recognised that Aboriginal Australians are more likely to have iron deficiency anaemia than the general Australian population, although some other groups are also at increased risk eg. vegetarians.[37]
Iron in the diet is present as haem iron (animal flesh) and non-haem, inorganic iron (vegetable iron). Vitamin C consumed in the same meal as non-haem iron improves the absorption of the non-haem iron by up to 50%.[37]
Tea and coffee can inhibit the absorption of iron.[37]
Iron deficiency is the most prevalent nutritional deficiency disorder in Australia and in the world as a whole.[37]
A recent audit of pregnancy care in remote regions of the NT, showed that:
27% of Indigenous women were anaemic (using a definition of Hb < 100gms/L)
at some time in their pregnancy.[38]
Thirty percent (n = 88) in the Top End were anaemic compared to 17% (n = 12)
in the Centre. Women who had commenced antenatal care in the first 12 weeks
of pregnancy were less likely to become anaemic.[38]
The report concluded that the results support continuance of strategies aimed
at increasing first trimester antenatal care.[38]
Improving preconceptual care and early antenatal care for women having their
first baby needs to be discussed further at local levels and with community
women (Strong Women Workers in areas that have this program).
Smoking remains one of the few potentially preventable factors associated with low birth weight, very preterm birth and perinatal death.[39] Studies have shown that rates of smoking in remote communities are very high when compared to the rest of Australia (70% Females & 83% Males;[40] 76% for women aged 20-45years.[41] It has also been shown that smoking cessation programs in pregnancy appear to reduce smoking, low birth weight and preterm birth.[39,77] Given the rates of smoking, low birth weight, very preterm birth and perinatal death in remote communities, smoking cessation programs would seem to be a worthwhile investment of time and resources.
A study in the Ngukurr community (Health Beliefs and Behaviour: the opportunities and practicalities of "looking after yourself" in Ngukurr) found that although people were aware of the complications of smoking they held a fatalistic attitude about it, believing that once you started smoking you were probably going to die of the 'smoking sickness' and there was no point in giving up. They also mentioned the poor example set by staff who work at the health centre and can often be seen sitting outside having a cigarette.[42]
This has been described in other reports as a 'huge credibility gap' by health professionals and a report by the Australian Medical Association[78] suggested one of the biggest barriers to decreasing Indigenous levels of smoking was the number of health workers who smoked. How many staff at your health centre smoke?
In some communities it is very important if a woman has a miscarriage that the products of conception are returned to the family following pathology reporting. Make sure you discuss this with the family.
When a woman has a miscarriage it is OK for it to go into Darwin for tests but it should come back to where it belongs. His father’s country or great grandmother’s country like that, they take it back. (Molly)
The only time they are not allowed to eat bush food is when they miscarry or they lose their baby, that’s the only time they are not allowed to eat fish or any meat that has been hunted, from the sea or from the land. If the pregnant women that’s lost her baby touches any of the meat it might destroy that hunting area, everything just dies and this will make everyone sad. It spoils all the plants and the hunting area. A lady who has lost her baby or had a miscarriage is allowed to eat meat from the shop or from a tin, Balanda food she can eat. Even if the baby was five years old and it passes away, same thing, even ten years old, same thing. But not if that baby is a young woman already and is now eighteen or something, that’s OK, then they can eat it. (Dorothy)
They don’t really need to do the smoking if there is someone who has a miscarriage in the clinic, that is only when older people pass away. Not for babies, it is not so important they are too small. (Ruby and Esther)
One young girl had a miscarriage and that little girl was much happier knowing that her mother had arranged for somebody else to take that little baby away. We went through talking about it a lot and in the end they decided they would take it and bury it, just quietly not a big ceremony or things like that, just quietly next to the aunty. (Hellen Matthews RAN/RM)
It's important to know things like that. It's giving them the decision, the power to actually take it and bury it properly. Maybe they didn’t realise they could actually do that and maybe they did want to do it but even though you suggested it people get used to what actually happens in the medical side of things you know well that’s how it’s done that’s what the nurses do. They don’t always question or speak up. (Remote Area Nurse)
One of the things that can cause miscarriages is infections...Those young girls don’t know about STD sickness and they are going around from man to man and they will not go to the Health Centre unless they are really sick. We should have a get together every year, get all the language groups together and the older women with the Health Centre staff - all together – they like to be together. (Janet, Janice, Deborah, Sonia and Sharon)
A recent audit of pregnancy care in remote regions of the NT, showed that 29% had a urinary tract infection in pregnancy and 24% of women had one or more sexually transmitted infections.[38] Untreated sexually transmitted infections and urinary tract infections are known to cause preterm birth and consequent low birth weight (LBW).
The definition of a urinary tract infection (UTI) in the Women’s Business protocols is urine with a pure growth of >100,000 organisms. There is no definition of the number of epithelial cells in a specimen that indicate contamination and provide an alternative explanation for the MC&S findings. A level of 20 epithelial cells is given for urine sample from infants and children in the CARPA manual however no levels are defined for adult urine samples. The 2001 report showed that 29% of antenatal women from remote areas had a urinary tract infection at some time during pregnancy. When the Midwives Collection definition is applied (any suspected or proven urinary tract infection treated in pregnancy) this proportion increases to 41%. Of 207 urine samples sent for culture, 146 (71%) confirmed a UTI and 61 (29%) did not.[38]
The audit concluded that:
There was considerable variation in diagnosis and treatment of UTI’s across the NT and it is unclear what criteria were used at a health service level to treat based on laboratory results. A high proportion of probable UTI’s remained untreated in this sample and a high proportion of suspected but not confirmed UTI’s were treated.[38]
Non-protocol treatments of confirmed or suspected UTI’s were generally correct drugs using different regimens than those recommended in the protocols. These variations included 5 day courses as recommended in the current CARPA manual, different doses (eg. 1gm rather than 500mgm twice daily doses of Cephalex) and persistence of stat doses of Nitrofurantion.[38]
The audit showed that one third of women in the Centre had an STI during pregnancy compared to 22% in the Top End. Trichomonas was the most common infection (17% n = 64), followed by Chlamydia (9% n = 32) and Gonorrhoea (6% n = 22). Overall 71% (n = 84/118) of STI’s were treated according to protocol, 10% (n = 12) were not treated according to protocol, 6% (n = 7) were untreated and the type of treatment was not documented for 13% (n = 15). Overall STI’s were well managed with the exception of occasional substitution of protocol drugs for those recommended for non-pregnant women. Treatment also occurred later than 2 weeks for more than 50% of first diagnosed infections, this could be improved.[38]
Talking about condoms....
The AHW’s can’t always be the ones to hand them out, sometimes they like to get them from an outsider. The younger men are more likely to use the condoms than the older ones and I am distributing a lot at the moment and they must be using them as the STI rate is dropping. What is working really well at the moment is: there is a nominated 'boss' for each group of guys and they then distribute them to the others. I always have them in my car, even when off duty. (Remote Area Male Nurse)
At one stage we heard about some used condoms in a public place so I spoke to the younger men in the community and told them how shameful it was and it has not happened again, you never see them around the community. (Remote Area Male Nurse)
How do women stop a pregnancy?
Early 60’s and 70’s they used to drink hot water to stop the baby. Hot tea, just hot tea that’s all. They get sick and tired of babies, always carrying babies and babies crying. My grandmother, she used to tell me she drank hot tea to stop that baby. (Dorothy and Molly)
These days they have the needle under the skin, like for three years. My granddaughter is 14 and I took her to the Health Centre last week to have the Depo needle because I saw teenagers the same age as her walking around pregnant. We were both there and I asked the Doctor to do it. They don’t always tell their mothers if they have a boyfriend, some friends of hers they go out and they tell us and that might be how we find out. (Alice)
Contraception is important because they are too young and they don’t treat them properly, they fight all the time, they don’t cook their food properly. Some of them are drinking kava, women and men but mainly gunga that’s why I didn’t like it. (Dora and Molly)
They used to use the condoms but not so much now except those men that do go from girl to girl some of them do. But the girls they say - 'you'd better not run with other girls'. (Verity and Amanda)
| They like to have the Depo – it is good to be able to stop the babies – a new one is going to stop the babies for three years. (Verity - mother of 3) |
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My grandmother told me the women would sometimes have sex with their period to try and fall pregnant. (Molly)
| Here in Maningrida to stop getting a baby you use the long yellow trees. You cut the branches off them and then you cut across the branches put them in water or a cup of tea and you drink the water and then you won’t get babies, in our way. Some mothers do that. If you want babies there used to be places you go to drink the water but they don't really do that anymore. (Tinica) |
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