Developing Maternity Services for Aboriginal Communities

For the purpose of this essay, when referring to Aboriginals, this is inclusive of all Aboriginal and Torres Strait Islander peoples. Whilst many Aboriginal women experience healthy pregnancies, it has been recognised that a variety of demographic, social and cultural factors have ultimately resulted in Aboriginal women experiencing greater risk of complications during pregnancy, labour and birth than non-indigenous women (Bertilone & McEvoy 2015). Over the years, a variety of contemporary healthcare strategies, programs, models of care and practices have been implemented in an attempt to minimise the risk of complication during this period for Aboriginal women and diminish the disparity between the Aboriginal and Torres Strait Islander peoples and the non-Indigenous peoples perinatal experience. Aboriginal Maternity Group Practice Program is an example of a model of care implicated to improve perinatal outcomes. This service is responsible for providing care to Aboriginal women throughout the perinatal period and has provided many favourable impacts towards Aboriginal women throughout pregnancy, birth and beyond.  This service contributes to Australia’s commitment to ‘Overcome Indigenous disadvantage’ and ‘Close the Gap’ in health outcomes between Aboriginals and non-Indigenous Australians (Kildea, Kruske, Barclay & Tracy 2010).

The high rates of social, environmental and economic disadvantage amongst Aboriginal women, results  in lack of access to primary health care services such as antenatal care leading to poorer outcomes for Aboriginals as a whole (Corcoran, Catling & Homer 2017). An analysis of pregnancy and birthing of Aboriginal women outlines the impact socioeconomic factors have had on health outcomes for Aboriginal and non-Indigenous women (Brown, Fereday, Middleton & Pincombe 2016). Australian Institute of Health and Welfare (2016) states culturally competent antenatal care is a women-centred service provided to women, where an understanding of local cultural and an endeavour to meet the needs of the woman in an emotional, cultural and practical sense exists. Culturally appropriate care can have a positive impact on access, uptake and acceptability of health services for Indigenous women (Brown, Fereday, Middleton & Pincombe 2016). In a study, it was discovered that 49% of Aboriginal women did not attend an antenatal visit in the first trimester, substantially lower than that of non-indigenous women (Australian Institute of Health and Welfare 2016). Restricted access to culturally competent services, has contributed to the limited uptake of antenatal care and other health care services by Aboriginal women (Bertilone & McEvoy 2015). Comprehensive antenatal care services address a variety of factors such as maternal health issues, maternal behaviours including smoking, alcohol use and nutrition. Inadequate antenatal care has been associated increased risk of stillbirths, perinatal deaths, low birthweight and pre-term births (Australian Institute of Health and Welfare 2016), this is supported by the Aboriginal perinatal statistics. The lack of these services offered to Aboriginal women has resulted in a maternal mortality ratio which is more than two times higher than non-Indigenous women as well as a perinatal death rate, low birth rate and preterm birth rate which is twice as high for Aboriginal infants (Bar-Zeev, S, et al. 2014). A significant disparity was also outlined in maternal condition including increased prevalence of teenage pregnancy, smoking in pregnancy, gestational diabetes and hypertensive disorders (Bar-Zeev, S, et al. 2014).

Key demographic, social and cultural factors distinguish Aboriginal women’s pregnancy, birthing and parenting experience from non-Indigenous Australians. Disadvantage in these key factors compared to non-Indigenous people, results in limited access to primary health care services such as antenatal care (Corcoran, Catling & Homer 2017). Demographic factors have a substantial impact on the life of Aboriginal peoples, particularly pregnancy, birth and parenting. The primary demographic factors include the lower education level which is closely linked to the high unemployment rate and lower incomes amongst Aboriginal populations, this leads to difficulty in gaining access to health care services required to improve foetal and maternal outcomes (Department of Health 2019). Lack of finances and transport to gain access to these services, which are easily accessible for non-indigenous Australians including perinatal appointments, transport, perinatal education and frequent health checks and monitoring for mother and baby, are responsible for the disparity between the perinatal outcomes. Inadequate infrastructure including housing and water and food supply is another demographic factor which greatly impacts Aboriginal woman’s pregnancy experience (Department of Health 2019). Restricted access to shelter and sufficient nutrition and water also contributes to decreased standard of living for Aboriginals.

Key social factors such as lack of physical activity, poor nutrition, harmful levels of alcohol intake, smoking and higher psychosocial stressors such as deaths in families, violence, serious illness, financial pressures and the enduring effects of colonisation, resulting in decreased general health amongst the Aboriginal populations (Department of Health 2019). These factors are not properly recognised in the Aboriginal community as factors which are harmful to pregnancy. Lack of education and information surrounding the importance of physical activity, proper nutrition, overall mental and physical health and no consumption of alcohol and smoking as factors which are vital for a healthy, low-risk pregnancy, means Aboriginal women’s often do not know any better and consequently this impacts on their pregnancy experience or birthing outcomes.

Cultural factors have an overarching impact on Aboriginal pregnancy, birthing and parenting experience. Aboriginal culture adopts a holistic view of wellbeing and has many strengths that provide a positive influence on well-being and resilience for Aboriginal women and their families. This includes supported extended family network and kinship, connection to their country and active cultural practices in language, art and music (Department of Health 2019). These factors remain at the heart of Aboriginal culture. Their connection to their country is so fundamental that if given a choice, Aboriginals will choose to birth on their land surrounded by their family opposed to a hospital environment. Limited access to resources such as birthing equipment and birthing assistants required for the safe delivery of the infant may result in adverse outcomes for both mother and infant.

Aboriginal Maternity Group Practice Program (‘AMGPP’) is a community-based antenatal program with the aim to improve timely access to existing antenatal and maternity services and as a result, indirectly increase the number of Aboriginal women delivering safely in a local hospital (Bertilone & McEvoy 2015). This partnership model, which operates at various locations near and in Perth, focuses on improving antenatal experiences for Aboriginals, by delivering culturally competent and holistic antenatal care services for Aboriginal women (Bertilone & McEvoy 2015). The program encourages early access to antenatal care by providing transport and home care alternatives, employment of Aboriginal staff and holistic care including awareness of the social determinants of health  (Bertilone & McEvoy 2015).

The program facilitates the women’s needs by addressing their cultural, social and demographic factors through direction by Aboriginal grandmothers, Aboriginal health officers in collaboration with midwives (Bertilone et al 2017). These individuals collaborate to work in a partnership model with pre-existing maternity services in the area provide the best antenatal care for pregnant women (Bertilone et al 2017). The model incorporated education for Aboriginal women and families surrounding healthy living with particular emphasis on healthy pregnancy and childbirth. Areas of education included smoking and alcohol interventions, antenatal education workshops and sexual health education services leading women to make more informed decisions about their health and the health of their babies.

In a trial conducted to report differences in neonatal health outcomes for the AMGPP antenatal program, compared with two matched control groups eligible for standard antenatal care,  the outcomes of the model showed benefits for both mother and infant  (Bertilone & McEvoy 2015). Babies born to women in the program were significantly less likely to be born preterm and/or require resuscitation at birth or having a hospital length of stay more than five days compared to the control group (Department of Health 2019), whilst the mothers were less likely to have a caesarean delivery. No significant differences were found in the number of Aboriginal women who attended an antenatal appointment within the first trimester of their pregnancy, similarly no significant differences existed in the percentage of low birth weight infants birthed in the AMGPP trial compared to the control. Analysing qualitative data from patient feedback methods such as 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 (Department of Health 2019).

The Australian Institute of Health and Welfare (2016) outlines the characteristics of culturally competent maternal care services, including Indigenous-specific programs, having Aboriginal and Torres Strait Islander staff members, providing continuity of care, viewing women as partners in their care, having a welcoming physical environment and ensuring that cultural awareness and safety is the responsibility of all staff members in the service. The AMGPP possesses many features which align with these characteristics and ultimately contribute to improving health outcomes for Aboriginal women, babies and their families during pregnancy. The AMGPP is a an Indigenous specific program which is led by Aboriginal staff members including Aboriginal grandmothers, Aboriginal health officers who work in collaboration with midwives to achieve the best possible perinatal outcomes. These grandmothers, who are well respected and possess good community networks, are able to identify pregnant women, and through this trust, develop a partnership to assist with access to services and provide support as well as advise on cultural and health promotion matters  (Bertilone & McEvoy 2015).

The key cultural factors of Aboriginals were addressed through a variety of services. The AMGPP midwifes work to deliver antenatal care in partnership with the local antenatal care providers to satisfy cultural needs of individuals. The cultural governance is outlined by the community participants throughout every aspect of the programmes delivery, leading to positive sustainable cultural change in maternity practices in hospital as well as community settings (Australian Government 2017). A home-visiting service is available and outreach clinics were provided in various locations, including women’s refuges, Aboriginal community centres and mobile GP services to provide safe birthing on land options.

The key social and demographic factors of Aboriginal pregnancy were addressed through a variety of education classes delivered by AMGPP staff. This included information about the stages of pregnancy, managing problems during pregnancy, healthy lifestyle behaviours, mental health, available services, birth registration, breastfeeding, baby care and the prevention of sudden infant death syndrome. The importance of Pap smears, and contraception was discussed as part of the sexual health education, including the symptoms of sexually transmitted infections and how to minimise the spread. In addition to this culturally appropriate, brief interventions were delivered by Aboriginal staff to assist with stopping smoking and alcohol use (Bertilone & McEvoy 2015).

There already exists an established link between increased uptake of antenatal care and improved perinatal outcomes for pregnant women. In order to improve perinatal outcomes for the Aboriginal population and diminish the gap between non-Indigenous Australians and Aboriginal perinatal outcomes, focus should be placed on increasing uptake of antenatal care then the rest will fall in place. The social, cultural and demographic factors influencing the life of an Aboriginal woman differ vastly from a non-Indigenous Australians, therefore assuming the same health care services would be satisfactory for different populations is incorrect. Aboriginal women can experience a lack of cultural understanding in mainstream services which are considered acceptable for non-Indigenous Australians. Focusing on the different social, cultural and demographic factors in the life of an Aboriginal women, with particular emphasis on their connection to their family, friends and support people and connection to their land is vital to supply health care services which will increase uptake of Aboriginal women and result in improved perinatal outcomes for the Aboriginal population.  The AMGPP as a model of care has executed this and a result led to overall increased maternal satisfaction with their maternity care and improved a variety of perinatal outcomes for Aboriginal women by shifting the focus of the services to suit their cultural needs.

Reference list

• Australian Government 2017, Aboriginal and Torres Strait Islander Health Performance Framework 2017 Report, Australian Government, viewed 20 August 2019, < https://www.pmc.gov.au/sites/default/files/publications/2017-health-performance-framework-report_1.pdf>

• Australian Institute of Health and Welfare 2016, Australia’s Health 2016, Australian Institute of Health and Welfare, Australian Government, viewed 20 August 2019, < https://www.aihw.gov.au/getmedia/9844cefb-7745-4dd8-9ee2-f4d1c3d6a727/19787-AH16.pdf.aspx>

• Bar-Zeev, S., Barclay, L., Kruske, S & Kildea, S 2014 ‘Factors affecting the quality of antenatal care provided to remote dwelling Aboriginal Women in Northern Australia’, Midwifery: A International Journal, vol. 30, no.3,  pp. 289-296, viewed 20 August 2019, < https://www.midwiferyjournal.com/article/S0266-6138(13)00127-7/fulltext>

• Bertilone, C. & McEvoy, S 2015, ‘Success in Closing the Gap: favourable neonatal outcomes in a metropolitan Aboriginal maternity group Practice Program’, The Medical Journal of Australia, doi: 10.5694/mja14.01754, viewed 20 August 2019, < https://www.mja.com.au/journal/2015/203/6/success-closing-gap-favourable-neonatal-outcomes-metropolitan-aboriginal>

• Bertilone, CM., McEvoy, SP., Gower, D., Naylor, N., Doyle J., Swift-Otero, V 2017, ‘Elements of cultural competence in an Australian Aboriginal maternity Program’, Women and Birth, vol.30, no.2, viewed 20 August 2019, < https://www.sciencedirect.com/science/article/pii/S1871519216301123?via%3Dihub>
• (Bertilone et al 2017)

• Brown, AE, Fereday, JA., Middleton, PF and Pincombe, JI 2016 ‘Aboriginal and Torres Strait Islander women’s experiences accessing standard hospital care for birth in South Australia – A phenomenological study’, Women and Birth, vol.29, no.4, pp.350-358, viewed 20 August 2019, < https://www.sciencedirect.com/science/article/pii/S187151921600024X?via%3Dihub>

• Corcoran, P., Catling, C. & Homer, CSE 2017 ‘Models of Midwifery care for Indigenous women and babies: A meta-synthesis’, Women and Birth, vol.30, no.1, pp.77-86, viewed 20 August 2019, < https://www.womenandbirth.org/article/S1871-5192(16)30076-2/abstract>

• Department of Health 2019, Pregnancy care for Aboriginal and Torres Strait Islander women, Department of Health, Australian Government, viewed 20 August 2019, < https://www.health.gov.au/resources/pregnancy-care-guidelines/part-a-optimising-pregnancy-care/pregnancy-care-for-aboriginal-and-torres-strait-islander-women>

• Kildea, S., Kruske, S., Barclay, L & Tracy, S 2010, ‘Closing the Gap’: How maternity services can contribute to reducing poor maternal infant health outcomes for Aboriginal and Torres Strait Islander women’, Rural and Remote Health, vol.10, no.3, viewed 20 August 2019, <https://www.rrh.org.au/journal/article/1383>