BY BRIANNA HEINKEN — DIRECTOR OF COMMUNITY ENGAGEMENT
Image from the Women’s and Children’s Hospital; Source: http://www.wch.sa.gov.au
Australia is one of the safest places in the world to give birth. In fact, Australia consistently ranks in the top 10 countries to be a mother world-wide[1]. However, despite the safety of being a mother in Australia, recent data has shown that the maternal mortality rate for Indigenous women remains a concern.
A maternal death is defined as the death of a woman while pregnant or within 42 days of the end of pregnancy[2]. Maternal deaths are divided into two categories: direct and indirect. Direct maternal deaths are caused from obstetric complications of pregnancy. Indirect maternal deaths are caused from diseases or conditions that were not due to an obstetric cause, but were aggravated by the physiologic effects of pregnancy. The number of direct and indirect deaths each year are used to calculate Maternal Mortality Rate (MMR), which is the rate of maternal deaths per 100,000 women giving birth.
The Australian Institute of Health and Welfare (AIHW) reported that the MMR for non-Indigenous women was 5.5 per 100,000 women giving birth between 2012 and 2019[3]. The report also revealed that Indigenous women are dying from pregnancy complications at a much higher rate, with an MMR of 17.5 per 100,000 women giving birth in the same period[3]. These poorer health outcomes can be attributed to a wide range of risk factors, including a higher rate of substance abuse among Indigenous women and difficulty accessing health services.
HOW DID WE GET HERE?
Substance abuse during pregnancy, including smoking, harmful use of alcohol, and drug abuse are all associated with poor birth outcomes. Smoking and drug abuse during pregnancy causes major developmental disorders in babies and labour complications for the mother. Harmful use of alcohol during pregnancy causes abnormal development and increased risk of Sudden Infant Death Syndrome (SIDS)[4]. Substance abuse behaviours are more common among Indigenous women than non-Indigenous women, which must be understood as a result of displacement from traditional lands, limited education, economic disadvantage, marginalisation, and other associated losses. For example, about half of all pregnant Indigenous women smoke during pregnancy, compared to one eighth of non-Indigenous pregnant smokers[5]. High rates of smoking, alcohol abuse, and drug use are contributing factors that make Indigenous women more susceptible to pregnancy complications than non-Indigenous women and helps explain the higher Indigenous MMR.
In addition, Indigenous women are less likely to access prenatal care during the first trimester of pregnancy, a time when many risk factors can be addressed. About half of Indigenous women accessed prenatal care at some point in their pregnancy, compared to the national average of two thirds of pregnant women[6]. In addition, compared with non-Indigenous women, access generally occurred later in the pregnancy and less frequently. Without the early intervention of medicine, Indigenous women have a higher risk of pregnancy complications and maternal death.
Most importantly, Indigeous women face a number of barriers to accessing health services, including cost, distance from services, and culturally unsafe healthcare providers. Access to maternity health services varies between remote and non-remote areas, with cost being a more significant issue in urban Indigenous communities and distance being more significant in remote areas[6]. Indigenous women in remote communities are required to travel to larger centres for maternity care, causing isolation and dislocation from their communities. This travel is also associated with inappropriate accommodation for women while in towns and lost wages if a partner has to stop working to care for the family. In addition, culturally unsafe healthcare providers can intentionally or unintentionally diminish the cultural identity and wellbeing of an individual, making them feel unsafe and rejected.
Where to from here?
In order to improve the MMR in Indigenous communities, it is important to recognize that the birthing experience of Aboriginal and Torres Strait Islander women is culturally different from that of non-Indigenous women. In many communities, birthing continues to be a cultural rite of passage where links are established to land, connections with country are celebrated, and knowledge is passed from older to younger women. Many Indigenous communities have specific birthing rituals and desire to give birth on country, rather than travel to metropolitan settings. Improving access to culturally sensitive health professionals in Indigenous communities is an important step to decrease maternal deaths among Indigeous women. Indigenous women often desire access to safe and high quality care in their own community and are more likely to access services that are provided in culturally-safe places. It is important to recognize the importance of culture and country for Indigenous women, and work with cultural leaders to create successful birthing programs.
Pilot programs across Australia have focused on midwives and Aboriginal Health Care workers, which provide culturally-appropriate care in community-based settings. The New Direction Mother and Babies Service is an example of an initiative being piloted for Indigenous families in areas of high risk[7]. This program, funded by the Federal Government, aims to increase access to, and use of, child and maternal healthcare services for Aboriginal and Torres Strait Islander families in three remote communities. If successful in its trial, it is important that this program is expanded to other remote communities throughout Australia.
Increasing the use of midwives providing care throughout a pregnancy and after birth in remote areas is also an important strategy to decrease maternal deaths among Indigenous women. An example of this is the Malabar Community Link Service, which offers midwifery care for women during pregnancy, labour, and six weeks after birth[7]. This service cares for Aboriginal women and their families, women from culturally diverse backgrounds, young mothers, and women with limited resources. So far, results from this program consistently show decreased use of medically-necessary interventions for women who received midwife-led care compared to women who received other models of care.
Although recent data about maternal mortality in Australia remains concerning, we are equipped with the tools to improve health outcomes and birthing experiences nation-wide. In coming years, it will be crucial to incorporate culturally-safe healthcare services, especially in remote communities, to increase access to medical care and decrease the maternal mortality rates in Indigenous communities. ●
REFERENCES
1. Save the Children. “State of the World’s Mothers 2015: The Urban Disadvantage.” Save the Children’s Resource Centre, Save the Children International, 2015, https://resourcecentre.savethechildren.net/document/state-worlds-mothers-2015-urban-disadvantage/.
2. Australian Institute of Health and Welfare. “AIHW: Maternal Deaths Low in Australia, but Indigenous Women Remain at Greater Risk.” Indigenous.gov.au, 2015, https://www.indigenous.gov.au/news-and-media/announcements/aihw-maternal-deaths-lowaustralia-indigenous-women-remain-greater-risk.
3. Australian Institute of Health and Welfare. “Maternal Deaths.” AIHW, Australian Government, Dec. 2021, https://www.aihw.gov.au/getmedia/8b25ea27-7304-441c-b708-48c65ce5bb55/Maternal-deaths.pdf.aspx?inline=true.
4. U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.
5. Walker, R.C., Graham, A., Palmer, S.C. et al. Understanding the experiences, perspectives and values of indigenous women around smoking cessation in pregnancy: systematic review and thematic synthesis of qualitative studies. Int J Equity Health 18, 74 (2019). https://doi.org/10.1186/s12939-019-0981-7.
6. Australian Institute of Health and Welfare. “Aboriginal and Torres Strait Islander Health Performance Framework 2008 Report.” AIHW, 2008, https://www.aihw.gov.au/getmedia/ee2f1311-a955-45f6-871f-bd606076826d/aatsihpf08r-da.pdf.aspx?inline=true.
7. Save the Children Australia. “State of Australia’s Mothers.” Savethechildren.org.au, Save the Children, https://apo.org.au/sites/default/files/resource-files/2016-05/apo-nid63692.pdf.
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