This guide has been developed as a tool to assist you to become more familiar with the maternal health issues that are important to the community within which you are working. The time it takes to work through this guide is totally dependent on you and how it suits your working environment. It may take several months to progress through this guide or you may find that it can be done in a shorter time frame. Under each heading there is a suggested section that can be done early after your arrival in the community and a second section that can be done soon after you have been in the community for a while. The section titled ‘Clinical Audit’ shows you some of the statistics important to women’s health in remote areas. Once again it is up to you if you decide to fill out every section. There are no ‘right’ answers and some of the questions may not be appropriate to the area you working in.
The guide has been developed with women in Maningrida, a remote community in Arnhem Land, Northern Territory (NT), and many of the health concerns are taken from NT statistics (though the issues are very similar across remote Australia). Many of the answers will need to be discussed with health workers and local community women and it will be as you talk with them that you will learn more about the issues that are important to them and their community. The Guide has been developed as a companion to the Birthing in the Bush Website and looking through this Website (see address below) will let you see how the issues in the community you are working in differ, or are similar to, the Maningrida area.
There is strong evidence to support the value of community participation in health care planning but little has been done to adapt these principles to remote areas.[81] Some communities will have local Community Health Boards and although many of these are being newly established and receive variable length of training in health and management issues, it is important to work with these elected members of the community towards joint planning of services. Similarly health care providers have not been given training to support them to work in this type of role and the overwhelming acute load in remote communities can sometimes mean that you never really get out of the Health Centre to do the things that have a more primary health care approach. This makes talking to community members about what they think can be done to improve health difficult. It is hoped this guide can assist you to become more familiar with the community. Most importantly, it aims to integrate community beliefs and values into maternal health care planning which in turn will assist the health service in meeting the needs of the community.
This guide is not meant to replace any other processes that are already in place. Some of the questions may seem simple and others obvious, but they are designed to help the newly arriving practitioner who will be involved in women’s health, become familiar with the community, the health centre environment, and people in the community. This guide can be printed off on a yearly basis and some, though not all, of the sections could be updated. When you leave the community this guide would be a good resource and historical account for the new staff that replace you. It would be best for them to commence working through a new guide themselves; however the information you have collected helps to leave a record of things that were important at that time in the community. The Women’s Business Manual[2] also has a lot of information about Women’s Business and Birthing and should be used in conjunction with this Guide and Website.
Have you asked the health workers if they want to be involved in Women’s Business? (If there is a health worker who is interested in Women’s Business make sure you do all of the following activities together. If not perhaps there is someone in the community you could be buddied up with to assist you).
Many communities have a Community Atlas or Community Profile that will give you an overview of the community and will contain the answers to some of these questions.
How many people live in the community?
How many outstations are there and do people live there all year round?
Do you provide health visits to the outstations and if so how often?
What languages are spoken in the community? Some communities will only have one language that everyone speaks whereas others will have many. An example is Maningrida where there are 3 major languages and 11 dialects.
Who are the landowners for the local area?
How many Health Workers and other staff are there working in the health centre, and what language group/s and family group/s do they belong to?
Have you met all the health workers? Some may not be currently working, may have recently retired, or could be on leave. These health workers are often invaluable when you need assistance with members of their extended family, particular when there are differences in understandings around health issues. It is helpful to have met them and introduced yourself. Perhaps you could ask one of the other health workers to introduce you to them. You could list their names, family groups and the languages they speak here.
Is there a Health Board (or equivalent) in the community? Where is it
and who is on it?
Is there a Women’s Centre or similar organisation in the community where women meet (Arts and Crafts / Pottery or Sports Centre)? Go and visit and see what activities they do there. Talk to the co-ordinator and the women who meet there to organise a time to talk about Women’s Business. What do they think is important for women in the community?
Does the community have the Strong Women Strong Babies Strong Culture program (SWSBSC), or similar (Grandmothers Program, Community Nutrition Workers, Maternal Child Health Community Program? If yes, then organise a time to meet with these women to talk about working together on Women’s Business. Think about organising regular meetings to share ideas and planning. This is particularly important if there is an antenatal woman or a mother with her new baby you are concerned about. The Strong Women can help you talk to family members and find solutions to issues of concern. List the groups and women with their family and language group here.
What types of Women’s Business activities have happened in the
past? For example Women’s Weeks, Skinny Kids Program and Meals
on Wheels. It is important to know what has happened in the past, every community
is different and what works in one will not necessarily work in another.
What have the women in your community recommended? In Maningrida the women identified a wish to go bush and camp together once a year with the young girls, the health centre staff and the elders in the community to share stories, ideas and education. It may take some time to build a relationship of trust before such ideas are given.
When women go to the regional centre for birth are they funded to have a support person (escort) go with them and if so how is this organised in the community? The role of the escort is to support and keep company. They should not be a minor and need to be able to stay with the woman the whole time she is in the regional centre.
If there is no support person funded is this something that is considered important to the woman and her family?
Is there any way the community can assist families to save money before the baby is due, so a family member can go to the regional center as an escort?
Ask each of the current and retired health workers what experience they have in maternal and infant care or if they have done any midwifery training. Listen to their stories. Many of the older AHW’s may have been into the regional centre for several months midwifery training and others have done apprenticeship training on site. Many will have had a lot of experience birthing babies. Like Molly and Margaret in Maningrida, some will also be experienced in birthing in the traditional way. Write some notes here.
Does school screening involve anything special for the teenage girls that will help them be better prepared for a healthy planned pregnancy? eg. contraception, safe sex, pregnancy education or Hb testing? Ensuring reproductive age women are not malnourished or anaemic and have worming treatments made available regularly helps to optimise pre-pregnant health. If you know of women who are planning a pregnancy it is ideal that they take folic acid as prevention against Neural Tube Defects.
How can you be involved in the next school screening and what should you plan to do?
Who do you need to talk to about health promotion activities at the school? In some communities the health centre staff are involved in regular education sessions at the school. This is an excellent time to talk to the young girls and can be a lot of fun too. If you are not sure what to talk about, or what resources to use, talk to the AHW’s and Women’s Health Educator in your area. If you do not do this regularly then perhaps talk to the teachers about doing occasional health promotion sessions with the schoolgirls. Make sure you involve AHW’s or senior community women in any sessions you do.
What foods are recommended in pregnancy and freely available in the community?
Are there any foods that are not allowed during pregnancy amongst the different groups in this community?
If you have concerns about an antenatal women who is it best to talk to in your community? This differs depending on the community. In some areas there are Strong Women Workers and this is a part of their job, in other areas you should talk to the health workers or the woman’s auntie or mother. Talk to the women in the community about this and see what they suggest. If you need to explain things to the family it is important to involve an AHW (still working or retired) who could sit with the family to help you explain the problem to avoid misunderstandings.
Are there any foods that should be avoided if a woman has had a miscarriage? Ask 5-10 antenatal women about this. (In Maningrida women who have had a miscarriage are not allowed to eat foods that have been hunted).
What should be done if a woman has a miscarriage or a stillbirth in the health centre? In some areas the health centre may need to be smoked, others will not require this. Ask the health workers what should occur. Sometimes the family may want to bury the baby in a special place, often with another relative (eg. great grandmother) who has already passed away. To find the cause of the miscarriage or stillbirth you may need to discuss the possibility of sending the products of conception, or the baby, into the regional centre for pathology testing or autopsy. If the family are happy for this to occur, once completed, the baby can be returned home for the appropriate burial and ceremony, though some families may not want this done. If you have a camera in the community it is a good idea to ask about taking photos and they can be left in the file. Many families will return, sometimes years later, and ask for these. Did you know there is a Northern Territory SIDS support group. Women from remote communities have used the phone service for support, make sure you give them the number to use if they want to. You may need to ask again after 1-2 weeks.
Who should be with the women when they birth and which community members could you call if a woman goes into labour in the community? In addition to other health professionals it is important to encourage support people (aunty, grandmother, health worker, traditional midwife, and for some women their partner) to come and stay with the woman in labour, there is strong evidence to suggest that the presence of support people improve outcomes in labour and birth.
If there is no medical backup in the community who can you call to assist you if a women is going to give birth? You may need to have different women listed below for different language or family groups.
What is the husband’s / partner’s role in birth? Ask 5-10 antenatal women about this. Though traditionally, partners/fathers did not attend the birth some couples today are deciding they should both be present for birth or the partner may want to be nearby.
What are the roles of the mother, auntie, sister and elders during birth? Ask 5-10 antenatal women and / or elders about this.
What positions are used for birth? Traditionally women were in upright positions for birth, this position should be encouraged as it assists birth. Often placing a mattress on the floor is the best way of doing this, as with any labouring woman they may find it difficult to move off the bed once getting on it and they might just want to sleep. If they are in labour you should facilitate and encourage upright positions. If the labour is progressing quickly you may not want a woman in the upright position until you are prepared for the birth. In this situation the ‘all fours position’ may be appropriate.
Discuss with the other health staff in the community what you should do if a woman wants to have her baby in the community? Does your organisation have a policy about this? Women all over Australia are starting to demand better choices in childbirth. This can be difficult in the community setting where there are limited resources. It is important to remember that what ever you say, women perform their own risk assessment and make decisions that are best for their families.
Discuss with the other health staff in the community how they feel about non-Aboriginal women who want to stay in the community for birth? (As mentioned above there is a groundswell of women around Australia making choices in childbirth that are not necessarily in line with the current health care policies. Informing women about the available resources, discussing the available options, respecting a woman’s choice and documenting these conversations in the medical records are important considerations for health care providers).
Does this differ for different groups within the community?
Is there some form of ceremony (like the smoking ceremony) that is important for women and babies following childbirth? If so, ask if you could attend one and learn about it. Often these occur in the community and the health centre staff can be unaware of them. If any woman is having problems with breastfeeding or infections then this ceremony could be important, as described in the Website, it will assist in making the milk strong, stopping the bleeding and preventing infections.
In some communities there are women who have been involved in birthing babies for many years, though many are old and have not done so for quite some time. In this guide we have called them ‘traditional midwives’. It is particularly important to know who these women are (as well as the AHW’s experienced in childbirth) if there is no midwife in the community.
Do they have a special name for these women in your community?
Who are the traditional midwives in the community?
If you have not met the traditional midwives then ask the health workers if it would be acceptable to go and listen to them tell you about their experience. You may need to do this with interpreters and/or family members present. Be guided by the health workers. Listening to the women’s stories can often guide you about cultural issues that are still important today.
Do any of these women still want to be involved in birthing business or could they assist you when talking to the younger girls about birthing issues? Working in partnership with these senior women could take place in the Health Centre whilst doing antenatal checkups or education; at the school; Women’s Centre; or other community venue. Try to involve AHW’s as well.
Ask if there are local ‘traditional healers’ in the community and if pregnant women use them. Do many of the community members utilise the skills of these practitioners? Traditional healers are also known as: medicine men / witch doctors / Ngungkari and bush doctors. Often working together can lead to better outcomes, though this may not be appropriate in the community you are working in, or for pregnant women. It may take time for you to learn and be sensitive when asking such questions. People may not want to answer truthfully if they think you will be critical of their practices and beliefs.
Are you and your health centre collecting many statistics locally?
If so, what do they tell you about the community and is there anything in particular that pertains to women’s health?
How many women in the community are of childbearing age (14-45yrs)?
If you have a population list, this will be easy to find out. If not it might
be more difficult to find out this information and you may have to estimate.
Is anaemia a problem in the community? In 2001 an audit of 18 remote health centres in the NT showed that 27% of antenatal women had a Hb <100g/L at some stage of their pregnancy. The figures were higher in the Top End; for women having their first baby; and for women who presented later in pregnancy.
How many pregnant women had anaemia in the last calendar year and what percentage of these women had a Hb above 100gms/L by the time they birthed? You may need to find the birth book to see who has had a baby in this time period. If you are in a small community perhaps increase the time frame to more than one year to make sense of these small numbers of women across the population. You can estimate the prevalence of anaemia by seeing what percentage of pregnant women had anaemia during pregnancy and you can compare it to the 27% found in the above audit. Add your figures to the table titled ‘Problems During Pregnancy’.
How many women had a urinary tract infection in pregnancy in the last calendar year and were these infections treated appropriately according to your local protocols? The above-mentioned audit found significant variation in diagnosis and treatment of UTI’s across the NT. A high proportion of probable UTI’s remained untreated and a high proportion of suspected but not confirmed UTI’s were treated. The only way of checking this is by looking back over the history and comparing the treatment to your local protocols. Add this information to the table titled ‘Problems During Pregnancy’.
How many women had a sexually
transmitted infection in pregnancy in the last calendar year and did they
have appropriate follow up according to your local protocols? Add this
information to the table titled ‘Problems During Pregnancy’.
| Problems During Pregnancy | ||
|---|---|---|
| Year | 2000* |
|
| Number of babies born | 364 |
|
| Number of women HB < 100 gm/l | 100/364 |
27% |
| Number of women UTI** in pregnancy | 146/364 |
40% |
| UTI treated per protocol | 62/146 |
42% |
| Number of women STI*** in pregnancy | 87/364 |
24% |
| STI treated per protocol | 84/118 |
71% |
* 18 remote Health Centres[38]
** UTI defined as per Women’s Business Manual[82]
*** Treatment was not always documented
**** STI’s in this report included: Chlamydia, Gonorrhoea and Trichomonas.
When you have this information think about what you would like to do about
it. Is there something in particular you would like to talk to the women
about and try to improve? If you put the information in the table then
it would make it easier to compare the above results again next year to measure
your progress.
How many births usually occur in the community?
Are these births in the health centre or outside the health centre?
How many women presented with preterm labour (note preterm labour not preterm birth) in the last calendar year? This information could be available where you record data about medical retrievals from the community.
What do you think caused the women in your community to experience preterm labour? You would need to look at their notes to get more accurate information about this.
How many babies from this community were born preterm (< 37 weeks) in the last calendar year? Use your community’s statistics to fill in the charts below. (1999 Statistics have been used as they were the most complete for the information recorded in the following two charts).
| Percent of Preterm Births in 1999[58] |
||
| Indigenous |
Non-Indigenous |
|
| Australia | 13% |
6.5% |
| Northern Territory | 15% |
9% |
| Your Community 1999 | ||
| Average per year in your community since 1999 | ||
Were any of these preterm births associated with a UTI or STI, if so
how many?
How many babies were born with a low birth weight (<2,500gms) from
this community in the last calendar year? You will only have a small
number of births, which makes comparisons difficult - but it is interesting
to check.
| Percent of Low Birth Weight Babies in
1999[58] |
||
| Indigenous |
Non-Indigenous |
|
| Australia | 12.4% |
6.2% |
| Northern Territory | 14% |
7.5% |
| Darwin Rural | 13.2% |
14.7% |
| Darwin Urban | 8.9% |
7.7% |
| East Arnhem | 18.6% |
9.4% |
| Barkley | 8.9% |
7.1% |
| Katherine Region | 15.4% |
8% |
| Alice Remote | 16.6% |
no births |
| Alice Urban | 8.5% |
4.8% |
| Your Community 1999 | ||
| Average per year in your community since 1999 | ||
When women return from giving birth they should have regular visits for their baby, but don’t forget to ask how they are going. If they were anaemic before birth or had a post partum haemorrhage then they should have extra iron in their diet and may need supplements. If they had an STI in pregnancy it is important to check that it was appropriately treated and followed up as they can lead to a secondary post partum haemorrhage. Women usually have a ‘Women’s Check’ six weeks after birth. Look in your local protocols to see what this involves.
How many women, in the last calendar year, had a post partum haemorrhage
after birth?
Have you met the regional Women’s Health Educator (WHE) (or equivalent) for your region?
If not, you should take the time to contact this person, as they will often have knowledge about the community and past Women’s Business activities in the community. They will also be able to assist you with resources and may be able to help you with education in the community.
Education is often more appropriate if the elders and the health centre staff conduct it together. Then everyone can learn from one another and work with the younger girls more effectively. You may be able to apply for health promotion grants from the cancer prevention unit in Darwin to assist in health promotion projects in the community. The WHE will be able to help you with this.
Write down the local words next to these words in case you need them in a hurry some time when you are waiting for a health worker or interpreter to arrive. There may be several different terms and possibly slang words used in the community that represent some of the terms below. Add other words that you think would be useful.
After working through this guide and talking to the women in the community use this section to record what you, the health workers, and the women you have discussed this with, consider to be the three most important things to do regarding Women’s Business in the community.
What have women said they want? It will take some time to establish relationships of trust with the women and the more time you spend with them the more you will learn.
How will we do it?
Outcomes.