This section introduces several different definitions of health. It uses currently available data to look more specifically at the health of mothers and babies in remote areas, particularly Indigenous mothers and babies. There is a brief overview of issues that are specific to birthing in the Northern Territory.
The Aboriginal and Torres Strait Islander definition of health does not only relate to physical health but is a holistic approach which encompasses the social, emotional, spiritual and cultural wellbeing of an individual together with community capacity and governance.[6] A holistic approach recognising the diversity of Aboriginal and Torres Strait Islander cultures is also necessary.[6] Health programs must address and acknowledge all of these issues if they are to provide a service that is appropriate to Indigenous Australian peoples.[6]
Comprehensive primary health care (PHC) has been identified as the most appropriate model of care for Indigenous Australians.[6] The Alma Ata declaration states that primary health care “requires and promotes maximum community and individual self-reliance and participation in the planning, organization, operation and control of the health service”.[7] Being involved in planning maternity services is one step towards achieving primary health care at a community level.
The World Health Organisation defines health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.[7] This definition is complimentary to the Aboriginal and Torres Strait Islander Definition of health as described above.
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| Family Ceremonies Following the right way Happy families - no fighting Clean houses, environmental business Young kids following the rules Parents talking to their kids about how to behave Young kids shouldn't smoke gunga Keeping the culture strong It would make the mothers and the babies healthier and stronger if we did the smoking ceremony |
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We often think about health in stereotypes. For example, 'people are healthier in the country', but this isn't necessarily the case. Socio-economic disadvantage, decreased educational levels, and unemployment, all important determinants of health, all increase the further you get from the cities.[8,9] Reduced access to services, reduced transport options, a shortage of health care providers and greater exposure to injury and accidents are all contributors to the health divide between city dwellers and those in the bush.[8,9,10]
But it is not all bad news. In many remote Aboriginal communities the outstation movement is assisting people to move back to their outstations and anecdotal evidence suggests that people living out bush, on their own land, could be healthier that those living in the remote centres.
It is impossible to make historical analysis and comparisons of health statistics prior to 1967 when Indigenous Australians were not included in the Australian census.[11] Even today, reporting on differences in health between the Indigenous and non-Indigenous populations of Australia relies on the accuracy of the data that is collected. The 1996 census recorded a 33% increase in the Indigenous population since the 1991 census was collected.[12] This is more likely to be related to increasing numbers of people recording their Indigenous status and more thorough data collection rather then a true increase in the population.[12]
Despite difficulties in data collection and analysis, the difference in health status for Indigenous Australians when compared to non-Indigenous Australians is well documented. In fact recent comparisons show that Australia’s Indigenous population have worse health statistics and less access to health care than any other Indigenous population in comparable countries.[13] This makes you wonder 'what are we doing wrong?'. In Australia, the life expectancy is approximately twenty years lower for Indigenous males and females.[14] Child, infant and maternal mortality are all higher as are adult and childhood morbidity.[8,9,14] Maternal mortality for Indigenous women (34.8/100,000) is significantly higher than it is for non-Indigenous women in Australia (10.1/100,000).[15]
The perinatal death rate for Indigenous babies (21.8/1,000) is over twice the rate for non-Indigenous babies (9.7/1,000) and the percentage of low birth weight infants is also double (12.4% vs 6.2%).[16] The rate of teenage mothers is almost five time higher in the Indigenous population, complications in pregnancy are more frequent, and the percent of women who have had no antenatal care is higher.[16,17,18]
We asked the women in the community what they thought was important for improving health.
The younger ones need to follow the rules, they need to listen.
The culture is still very important, following the rules keeps us strong, if you don't, then you can get sick.
Those young girls they should have the older women to talk to them. Like Margaret and Molly the Health Workers, they used to talk to us. It's no good just the Balanda talking to them, it has to be both ways.
We should use more bush medicine.
Well the main things causing problems are having the young fight, they fight in the streets somewhere in the school in the night you know when they steal their boyfriend or girlfriend and all that troubles come from there. That can lead to the families fighting, we need to talk together to stop the fighting.
Gunga is a problem that is causing husband and wife to fight. He needs some money for gunga, they don’t buy food and they spend all the money on gunga, though some, they spend it on kava. Mothers they drink kava too, but not many. They need to stop the gunga coming into the community. It will make them cranky but they still need to stop it.
Talking to people in the community made me aware that many will go to see the traditional healer either before, or alongside going to the health centre. Many believed that you needed to do both to get better. This is not unlike the high use of complimentary therapies in Australia today, many of which will also be based on well established traditions.
There are still traditional healers out bush, both men and women. They learn that business, they are not born with it. They do special things with their hands to make them better. People go for flu, diarrhoea or anything. You have to pay the traditional healer if you go to see him. (Phyllis)
All the time, they still do see that traditional healers and use bush medicine, before they go to the health centre. If that baby has diarrhoea you get the bark from that tree over there, you grind it all up and then you make a fire. The smoke from that fire will stop the diarrhoea. (Molly)
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Charlie Nanguwerr is a very respected
traditional healer from Marrkolidjban. People from the whole community
come to see him when they are sick. People will often come and see Charlie
before they go the the Health Centre. Sometimes the Health Centre and
Charlie will work together to help someone get better. In this photo Charlie
is showing how paper bark was used to carry water. |
A Review of Birthing Services in the Northern Territory (NT) was conducted in the early nineties.[19] This review had extensive recommendations for changing the provision of care for women in the NT and was endorsed by the Territory Health Service (THS) Executive in 1995.
Seven major issues underpin the recommendations from this review:
The report recommended major changes to the provision of care for Aboriginal women. In particular it recommended:
R 4.5 THS develop and formalise a clear policy in relation to birthing outside hospitals including in rural and remote communities;
R 4.6 THS recognise and provide support to remote and rural area women who choose to birth in their community;
R 4.7 Two community birthing pilot programs are established in remote areas. These programs are adequately resourced and evaluated to provide the basis for further expansion of community birthing;
R 5.2 Cross cultural education is provided for all care givers;
R 8.1 The skills and expertise of the traditional birth attendants are recognised and their role as an integral part of the midwifery team is promoted;
R 11.5 The role of the traditional birth attendants in antenatal care is recognised and promoted;
R 17.1 Alternative models of care that provide a choice for women from rural and remote areas, as discussed elsewhere in the report, are implemented as soon as possible.
The report also acknowledged that women from remote areas had not been adequately consulted and recommended this occur.
Consultations did take place with Aboriginal women in the Top End in relation to providing culturally appropriate care during birth and the issues related to birthing in remote communities. The following two documents are the result of these consultations.
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This report was from the Women's Business Meeting in Darwin in 1998. Many women come from all across the Top End to attend this meeting. Many of the concerns that had been raised in the 1992 review were still an issue and one of the recommendations was that the resources and support be provided to enable women to birth ‘on country’. Copies of this report can be obtained from Danila Dilba Gumileybirra Women's Clinic in Darwin. 'You are born on country, you belong to that country and your spirit is there'- Coordinator of Gumileybirra Women’s Clinic.[20] |
The other report was a consultation that was conducted out in the remote regions. It was called 'And The Women Said... Reporting on Birthing Services for Aboriginal Women from Remote Top End Communities'.[5] The key findings across the districts were remarkably similar and are explored in more detail in the report.
The key findings relate to:
Safety - on the community and in the regional centre;
Choice - the lack of choice for women and the unattractiveness of available options;
Escorts - support in labour often leads to shorter labour with less intervention, less caesarean sections and less complications following the birth, many women do not have support in labour from someone they know;
Hostels - Two major problems were identified with hostels:
the lack of security in many of the hostels for both the women and their personal
property; and, the lack of food in some hostels;
Human Resources - all communities need a skilled, experienced midwife;
Infrastructure and Equipment - there is no standardisation of basic equipment;
Antenatal Women - culturally appropriate educational material and models of care are lacking in both the regional and remote area settings;
Continuing Education - needed for both Aboriginal Health Workers, midwives and nurses, and rotation of staff from remote areas for updating clinical midwifery skills;
Regional Hospitals - the main issues relate to inappropriate and ineffective communication between staff and patients, including the absence of interpreters;
Birth Centre in Darwin - unanimous support for a birth centre in Darwin; and,
Community Birthing - the majority of people consulted felt that community
birthing should be available for low risk multiparous women, providing a number
of conditions were met. Most service providers felt that a pilot project was
the only way to determine if community birthing would compromise the safety
of the mother or the infant. Many felt that outcomes may be improved.
The primary advantages of providing a remote area birthing service would be:
"Pmere Laltyeke Anwerne Ampe Mpwaretyeke = we want to have babies in our traditional country" - Aboriginal women from Central Australia.[21]
In the mid eighties in Central Australia, a project was undertaken to talk to the Aboriginal women from the area to discuss their beliefs, practices and preferences around childbirth business, also termed ‘borning’. Several hundred women from over 30,000 square kilometres and 60 different communities were involved.[21] A comprehensive document outlining: cultural beliefs and traditions around borning, examples of how current obstetrical practices are almost diametrically opposed to traditional practices, and a list of recommendations to improve birthing services was one of the outcomes of this project. This document is titled 'Borning: Pmere Laltyeke Anwerne Ampe Mpwaretyeke, Congress Alukura by the Grandmothers Law'.[21] Some of the key points from this document and several other references are presented here:
Consultations across Australia suggest that many women, particularly Indigenous women, would prefer to give birth in their home town. Many government sponsored documents recommend changing current models of care but have been recommending this for decades and still it is not occurring.[19,20,21,23,24,25,26,27] Is this because it is perceived to be too risky?
Some women feel that their relationship to the land, established through the birthing experience, is vitally important to their culture and may be compromised by birthing in hospitals where many do not feel ‘culturally safe’ when experiencing a ‘western medical model’ of childbirth.[5,20,21,23,24,28]
Some Aboriginal women identify giving birth in the hospital as the cause of infant mortality. As a result of not being welcomed properly into the world, when the appropriate ceremonies not being performed, the baby’s weakened spirit gets sick[29].Young girls should not go to Darwin to have their babies, it is a bad way to have babies, it's bad for the culture and they are coming back sick with infections. Some don't even breastfeed - that bottle is no good for our babies - it's OK if white women do it but not black women - it's no good! (Molly)
Some women are performing their own 'risk assessment' and decide against leaving their homes and families for birth, preferring to present to local health centres in strong labour, when it is too late to be transferred.
Service providers working in these areas are concerned about the risks of: something going wrong; delays in transport to regional centres blame; litigation; rising professional indemnity costs; difficulties in maintaining skills and the impact of providing a 24 hour service on their personal lives. They face unexpected emergencies and a lack of remuneration. Yet many also believe low risk women would have better outcomes if they gave birth in their home communities, with family support around them. Against this setting, employers struggle with the recruitment and retention of skilled maternity service providers as more are opting not to work in the current system. Midwives are frustrated by being unable to practice the full range of skills and though Australia has many trained midwives more and more are electing not to work in midwifery. Doctors too are choosing not to practice in obstetrics and the shortages seen in urban settings are exacerbated in remote and rural areas.
It is possible that:
all contribute to hospitals being 'risky' places for some women to give birth.
You mob just don't listen. (Molly)
It is past the time to listen to Aboriginal women and respect their ability to juggle a variety of risks and make decisions based on their own specific needs. Imposing ideas and services that suit both the professions and the system has not worked for anyone.
Just as it is important to non-Aboriginal women, choice around childbirth decisions, is something women is something women highlighted over and over again.
They should stop and have the baby here with the health workers if they want that. (Ruby and Esther)
The young girls are too shy to go into Darwin, some don’t speak English and don’t understand. I think it should be up to them. (Sonia)
| It is up to the woman where she has her baby, but if it is in the Health Centre it is important to have her grandmother, mother or auntie with her. (Wendy, Mary) When it is their first they should have it here, they need their auntie with them. (Tinica) |
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Some they like to go to Darwin and some to stay in Maningrida, its up to them. Some ladies they don’t like to go to Darwin Hospital, some even talk English properly, but still they get upset in there. Sometimes with their second baby they can have it here in Maningrida, they can have their mothers maybe or sisters or cousins or sister in law or mother in law with them, it’s safe to do that. (Janice, Janet, Deborah, Sharon) |
Some women don’t mind going to Darwin because they have this new way to deliver babies there, they have a machine and an operation, but in the olden days they just deliver the babies by themselves and cut the cord in your own way. (Alice)
I didn’t want to go to Darwin and leave Gary, my other baby, here by himself. (Phyllis)
The young girls think it is safer to go to Darwin to have their babies as they have the oxygen there and they might have problems with bleeding too much. They are doing it like Balanda way but it's no good, they should do it Aboriginal way. (Nellie and Molly)
Darwin hospital is all run by Balanda, it would be better if there were Aboriginal women working there, they send them too early we see the husband caring for all the children, its too hard. (Dorothy)
There is no family in Darwin and there is too much humbug from the drunks who want to take your money. (Deborah)
Some of these young girls do like to go to Darwin to have babies. They like walking around in Darwin and it’s good for doing the shopping, like to buy all the children’s clothes, it’s too expensive here. But it is hard for the husbands when they go into hospital because they have to look after all the kids. There should be more health workers working at the hospital, even if they were from another community it would be OK. (Dora, Rosie, Joy, Verity, Amanda and Sarah–Lee)
Darwin is good because they have the gas, they don't have it here. (Verity, Amanda and Sarah–Lee)
They can get medicine in Darwin and they like that, they can use the gas there, and they can go shopping. They should have the gas machine here, but the girls would still like to go in for shopping, they don’t have any baby clothes here. (Phyllis, Trudy and Julie-Anne)
Like Balanda way when a woman goes into labour their husband comes inside and is beside her, but it is not our way, not even for the young girls. (Dora, Rosie, Joy, Verity, Amanda and Sarah–Lee)
Maybe parent will take them like mother or aunty will take them to hospital. They shouldn't go by themself. (Alice and Sonia)
Cultural safety can only occur when differences in culture are recognised and respected and these differences are incorporated into health service delivery.[30] Australia has not progressed very far towards providing cultural safety for the Aboriginal population. This is particularly evident in the area of childbirth.[21] Many hospitals do not offer interpreter services for Aboriginal languages (though they will have many other interpreters available); there are limited numbers of Aboriginal people working in hospitals; and the provision of female health providers for anything to do with ‘women’s business’ is considered ‘just too hard to achieve’ with little incentives provided to try and achieve them.[5,20,25,26,27] Additionally it is difficult to find guidelines or policies covering cultural safety in maternity care for Aboriginal or Torres Strait Islander women. Simple things such as Aboriginal artwork on the walls, encouragement of squatting for birth, discussions of how to cut the cord and what to do with the placenta, and ensuring all staff have participated in cultural awareness training are often absent from the birthing environment.
Rawlings[31] argues, when women are not surrounded by those who care for their cultural and spiritual needs in birth, even though their physical needs are being met, then the birthing experience cannot act as a true rite of passage. She provides the example of the Ngaanyatjarra women who grieve for the way the placenta is handled when women birth in hospitals.[31] Some women believe that when babies and mothers return from the regional centres they return in a weak state and need cultural ceremonies such as the smoking ceremony to be performed to make them strong again.[21] They suggest that it is the hospital birth itself, and the lack of being properly welcomed into the world, are the cause of the high rates of perinatal mortality that are seen today.