Risky Business: Contested knowledge over safe birthing services for Aboriginal women
Maternity services in Australia are becoming rationalised with contemporary, authoritative knowledge driving the provision of services under the premise that birth in larger regional and tertiary settings is the safest option.
There is increasing evidence that families who live in rural and remote areas are not satisfied with having to travel long distances and be absent from their homes for weeks at a time for childbirth. This is particularly problematic for remote dwelling Aboriginal women, with evidence suggesting current maternity services and relocation for birth are culturally, socially and emotionally unsatisfactory and unsafe.
The Indigenous knowledge around birthing that still exists in remote communities today, is not being acknowledged or incorporated into health service provision with the current 'risk equation' excluding the social, emotional and cultural risks that have been identified by the women themselves. Unlike the Inuit situation in Canada, which could provide leadership and advice for Australia, there has not been sufficient dialogue in Australia around the construction of risk and its importance in the birthing environment, particularly for Aboriginal women.
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sociology, birth, Aboriginal, risk, safety, authoritative knowledge, Inuit
PP: 387 - 396
Risk in childbirth is an emotive issue, with personal experiences, professional experience, different cultural values and vested interests all influencing the debate. Maternity services in Australia, as with many other countries, are progressively becoming rationalised. Many smaller units, particularly those without caesarean section facilities, are closing requiring women to travel increasing distances from their home for birth (Rural Doctors Assocation Australia 2005). Considerable evidence suggests that current maternity services in Australia, which require relocation for birth, are socially, culturally and emotionally unsatisfactory and, as a consequence, potentially unsafe (Biluru Butji Binnilutlum Medical Service 1998, Fitzpatrick 1995, Hirst 2005, Kildea 1999, NSW Health 1998). For many, childbirth is a normal life event, and should not require relocation from home and family. Though this paper reports mainly on Aboriginal women and their experiences, many issues are similar for non-Aboriginal women who live in remote, and increasing numbers of rural, areas.
This paper discusses remote area birthing services, cultural safety and current health issues facing remote-dwelling Aboriginal women in Australia. It argues that the authoritative knowledge driving the provision of birthing services needs to be contested, and should incorporate Indigenous knowledge around birthing. The current 'risk equation', measuring risk and safety in birth, does not include the social, emotional and cultural risks that have been identified by the women themselves. To date there has there been insufficient open dialogue in Australia around risk construction and its importance in the birthing environment, particularly for Aboriginal women. Until this occurs it is unlikely that the maternity services will meet the needs of these Australians.
Authoritative knowledge and its relationship to childbirth practice was first described by Brigitte Jordan in Birthing in Four Cultures as the knowledge that is the most persuasive (Jordan 1993). That is, the knowledge that influences decision making and actions in a particular area, often guiding policy direction and practice (Jordan 1993). The reality of authoritative knowledge is that it is not necessarily correct, nor evidence-based, rather it is influential and more powerful (Jordan 1997). Currently policies and practices directing birthing services in remote settings are not well grounded in evidence, but as in other areas around the world, driven by a hegemonic Western medical view of risk and safety (Davis-Floyd 2000, Saxell 2000). So pervasive is the generalised view that it is too dangerous to birth in remote areas lacking on-site medical practitioners or operating theatres, that it is difficult to find it codified or documented in policy documents. Aboriginal women themselves are also seen as a 'high-risk' group and thought by many to be much safer when birthing in tertiary settings. Yet in other countries with similar geographies and demographics, birthing services are provided successfully in very remote areas to Indigenous women whose health profile and living conditions are similarly poorer than national levels (Leeman and Leeman 2002, Morewood-Northrop 2000, Robinson 1990).
The context: Remote Australia
Australia is a large country with only 2.6% of the total population living in remote or very remote areas, and only 2.4% of the total population identify as Aboriginal or Torres Strait Islander Australians (ABS 2003, AIHW 2003). The proportion of Aboriginal people in the population increases with remoteness, varying from approximately 1% in the major cities to 45-100% in remote and very remote areas (ABS 2003, AIHW 2003). Current research in Australia shows that those who live in rural and remote regions suffer poorer health than their urban counterparts, independent of the influence that Indigenous Australians have on these statistics (AIHW 2003, Dixon and Welch 2000). Low educational levels and employment, both important determinants of health, are associated with increasing remoteness as is reduced life expectancy (AIHW 2003, Dixon and Welch 2000). Many remote communities only offer primary school education (AMA 2003), the price of healthy food can be up to three times what it is in the regional centre and overcrowding is common, as are the diseases related to it (tuberculosis, scabies and rheumatic heart disease) (McLennan and Madden 1999).
Aboriginal and Torres Strait Islander families have significantly lower incomes, home ownership and employment rates with national imprisonment rates 15 times higher than that of non-Indigenous imprisonment rates (AMA 2003). Maternal and perinatal mortality rates are considerably higher (2-5 times) than for non-Indigenous Australians (Trewin and Madden 2005) with double the percentage of low birth weight infants (Laws and Sullivan 2005). Research in Western Australia has shown increasing disparities in the infant mortality rate which is 3-5 times greater for Aboriginal women compared to non-Aboriginal women and higher in remote areas (Fremantle et al 2006). This research also identified significantly more potentially preventable deaths in Aboriginal infants due to causes including infection, preterm birth and sudden infant death syndrome (Fremantle et al 2006). Other statistics associated with poorer outcomes and amenable to change include higher rates of teenage mothers, complications in pregnancy (eg anaemia urinary tract infection) and women who have had no antenatal care (d'Espaignet et al 1997, Laws and Sullivan 2005, NSW Health Department 2003, Trewin and Madden 2005). These risks sit in juxtaposition with other risks such as: insufficient land rights, no treaty with the Australian government, no apology from the Australian government regarding the forced removal of children over many years and a national reconciliation agenda that fails to address the concerns of many.
Remote area birthing services
Increasingly over the last 40 years, women living in remote areas of Australia have been relocated from their homes to birth in larger hospitals and larger communities. In the Northern Territory (NT) of Australia the proportion of women having babies in hospital increased from 27% in 1965 to 81% in 1981 (Holleley and Preston 1984) and 97.8% in 2002, when only 81 (2.2%) births occurred in either the home or remote health centres (Laws and Sullivan 2005). Many remote areas across Australia no longer have the infrastructure, staff or insurance cover to support on-site birthing. Typically, pregnant women will leave their homes between 36-38 weeks gestation to await birth, usually alone, in the regional setting. The facilities in these settings vary but are often very simple. Some offer hostel type accommodation, some provide food and some provide transport to the local hospital for antenatal visits, though these are not uniform across the country (Hirst 2005, Kildea 1999, King et al 1998, NSW Health Department 2003). Women state they do not like to be away from their families for weeks at a time as worrying about the children left behind and other family members causes immense stress (Biluru Butji Binnilutlum Medical Service 1998, Fitzpatrick 1995, Hirst 2005, Kildea 1999). Most women do not have the capacity to take their children with them as costs of transport, accommodation and a carer for when they are admitted to hospital, make it prohibitive.
If women want support in labour from someone they know, they have to pay additional costs, although some states will pay for this under various conditions, for example women under 16 years (NT). The airfares from remote areas can be more than a fortnight's income and additional costs include food, local transport, long distance phone calls and activities to relieve boredom (Kildea 1999). Current services therefore are not responding to women's needs and it could be argued that as a consequence, are not conducive to good health outcomes. They have led to powerful statements such as: 'It is better to deliver in the community even if it is not as safe' (Kildea 1999: 62). For some Aboriginal women, being separated from their land, language, culture and families during the birth of their children can represent an unacceptable risk (Roberts 2001). Some prefer the knowledge and support of their elders and link birth in hospital, and the lack of appropriate ceremonies at this time, to a weakened spirit in the baby and higher rates of infant mortality (Mills and Roberts 1997, Wardaguga and Kildea 2004).
Holistic maternity services
It is well acknowledged today that social and psychological circumstances which cause stress, and a lack of control over one circumstances in life, are detrimental to health (Wallerstein 1992, Wilkinson and Marmot 1998). In fact it has been argued that unfavourable social conditions and ineffective self-management are greater determinants of health in disadvantaged populations than a lack of access to medical care (Pincus et al 1998). These concepts and not new to Aboriginal Australians, who have always seen health in a broader context than that which is solely related to disease. The Aboriginal and Torres Strait Islander definition of health does not only relate to physical health but incorporates a holistic approach encompassing the social, emotional, spiritual and cultural wellbeing of an individual together with community capacity and governance (National Aboriginal and Torres Strait Islander Health Council 2000).
The concept of a social model of childbirth is not new and exists in many countries (Walsh and Newburn 2002). Under a social 'women focused' model, women are cared for holistically and social support throughout the pregnancy, birth and postnatal period is valued equally with clinical care. In this model, women are cared for locally if at all possible and continuity of midwifery care, community based care, one-to-one care in labour, access to social networks and family are the focus rather than the screening, risk assessment, technology and clinical focus that typify medicalised maternity care today (Walsh and Newburn 2002). The medicalisation of childbirth is seeing rising levels of intervention, specialisation, operations and complications and as Johanson et al (2002) ask: has it gone too far? Providing maternity services within these social models is possible for all women. In fact, evidence suggests that outcomes for women with identified risk factors, including their levels of worry, improve when they receive continuity of care (Farrell et al 2002, Homer et al 2002, Rowley et al 1995).
The social model of birth and recommendations from the 'Changing Childbirth' report in the UK are relevant to the Australian context:
Safety is not an absolute concept. It is part of a greater picture encompassing all aspects of health and wellbeing. We believe that safety, encompassing as it does the emotional and physical well-being of the mother and baby, must remain the foundation of good maternity care (Department of Health Expert Maternity Group 1993:10).
For Aboriginal and Torres Strait Islander Australians recognition of their definition of health would mean that social, emotional and cultural safety, together with community capacity and governance, must all be included in the provision of birthing services as serious components of the risk equation. The concept of cultural danger is described as occurring when Aboriginal culture, values and attitudes are not recognised and incorporated into the health care arena (Dowd and Eckermann 1992). Rawlings (1998) argues that the birthing experience cannot act as a true rite of passage when a women is not surrounded by those who care for her cultural and spiritual needs, even if her physical needs are being met. She provides the example of the Ngaanyatjarra (a remote desert region in Western Australia) women who grieve for the way the placenta is handled when women birth in hospitals (Rawlings 1998). This is true for many Aboriginal women as described below:
[S]moking1 will close up and heal the soreness of childbirth... it should be available in hospital ... the placenta should not be burnt as the mother might then get a sickness in the womb, it is alright to freeze it till it can be buried by the families at home - East Arnhem Aboriginal Health Worker (Kildea 1999: 85).
Molly Wardaguga, a retired senior Aboriginal health worker and respected elder in the Maningrida community in Arnhem Land, believes that the inappropriate birthing experience is directly linked to the breakdown of culture and social dysfunction that are evident in some remote Aboriginal communities today (Kildea 2005). These concerns were highlighted at the Inaugural Aboriginal and Torres Strait Islander Perinatal and Infant Mental Health Conference held in Sydney in May 2006. Also identified at the conference were the difficulties that men have when trying to build a relationship with their babies, particularly when they do not see their newborn for days, or in some cases weeks, following birth. Women have expressed concerns about siblings jealousy, particularly when their mother has been away from home for several weeks and believe that the relationship of the new baby with other family members would be enhanced if they were nearby for the birth (Kildea 1999). Highlighting their relationship to the land, many Aboriginal women report they would prefer to birth 'on their own country':
You are born on country, you belong to that country and your spirit is there - Coordinator of Gumileybirra Women's Clinic (Biluru Butji Binnilutlum Medical Service 1998: 39).
Aboriginal authoritative knowledge involves intricate relationships between birth, land and country and is often unknown to, or misunderstood by, non-Aboriginal people. Authoritative knowledge has been further explored by Daviss (1997) who devised her own analytical framework when working with the Canadian Inuit, to describe the different motivations and practices that guide peoples thoughts and decisions associated with birth. The framework includes eight different types of logic, one of which is cultural logic, which is defined as: 'the development or demise of fundamental beliefs about how a given society should manage birth. This category can include traditional community logic and spiritual logic' (Daviss 1997: 443). In the Australian setting cultural logic could explain why some women are performing their own personal risk assessment and deciding that the risks to their families and themselves, associated with having to leave home for birth, are more of a concern than the obstetric risks they face. These women will stay in their home communities for birth, perhaps choosing not to attend the Western model of antenatal care available through the health service, despite being advised to do otherwise. In some instances they may agree to transfer to a tertiary centre but return to their communities prior to birth, becoming known to the health practitioners when in strong labour or following the birth (Kildea, 1999). Either scenario will result in the baby being born 'on country', and many times the transfer will still occur, though why is often questionable.
Place of birth
This paper does not contest that tertiary level hospitals are the safest place for women with identified risk factors to give birth, but discusses options for birthing women with no identified risk factors. Despite having poorer health outcomes, Aboriginal and Torres Strait Islander women have higher normal vaginal birth rates (71% vs 60%) than non-Indigenous women (Laws and Sullivan 2005). This suggests that the risks these women face are probably best addressed in the year before and the year after birth, rather than during the birth itself. An Australian study examining the safety of small hospitals concluded that lower hospital volume is not associated with adverse outcomes for 'low-risk' women (Tracy et al 2005). Despite this we continue to see the closure of small rural maternity units. In the past ten years 120 such units were closed across Australia (RDAA 2005). Not only are small units closing but options for women to birth at home with skilled attendants are rarely accessible due to the unavailability of indemnity insurance for self-employed midwives. Additionally, publicly funded homebirth is not an option offered in most areas of Australia and not available in any remote setting. A meta-analysis reported in the Cochrane Library (Olsen and Jewell 2001) and other studies, suggest there is no evidence that birth for 'low-risk' women is safer in the hospital setting when compared to birth at home attended by skilled practitioners with appropriate referral mechanisms (Bastian et al. 1998, Campbell and Macfarlane 1994, Johnson and Daviss 2005, Olsen 1997, Olsen and Jewell 1998, Wiegers et al 1996). It would seem that the debate around the safest place to give birth has not resulted in evidence based policy and service provision to Australian women. These points have been acknowledged in a recent review of maternity services in Queensland where recommendations have been endorsed in full by government and include: that the principle of returning birth to Aboriginal communities must be affirmed by government; that care must not only 'be safe' but 'feel safe'; that maternity services be reopened in rural clusters as 'bush bub-hubs' and that a demonstration project in a remote Indigenous community be in place by 2006 (Hirst 2005).
Inuit birthing in remote areas
There are striking similarities between the Indigenous populations of Canada and Australia. Both populations have a history of colonisation, assimilation, loss of land and rapidly changing cultures, especially over the last 50-100 years (Broome 2002, Jasen 1997, Smylie 2001). However the similarities have not continued to this day. Many of the Indigenous Canadian populations have regained control of their land, in some instances their economies, and in some places birthing services (Jasen 1997, Kaufert and O'Neil 1990, Morewood-Northrop 2000, O'Neil and Kaufert 1995, Tookalak 1998). Research from Northern Canada has shown that birthing facilities in very remote areas can offer a safe and viable alternative to routine transfer of women to regional centres, despite initial opposition to doing so (Chamberlain and Barclay 2000, Houd et al 2003, Rawlings 2002, Tookalak 1998).
In the community of Rankin Inlet in Nunavut, following dissatisfaction with the policy of flying out all pregnant women and concerns about land rights, both community and political pressure led to a pilot birthing project for low-risk women (Chamberlain 1997, Morewood-Northrop 2000). The pilot study, completed in 1996, concluded that birthing in isolated areas, managed by experienced midwives, could be a safe, culturally sensitive, satisfactory event for the women, their families and the midwives (Chamberlain 1997). This birthing centre is still operational today. In another example, in the remote town of Puvirnituq in Nunavik (Northern Quebec), the community members decided to re-establish birthing in 1986 (Daviss 1997). Today this centre services seven remote villages and provides on-site training for Inuit midwives (Houd et al 2003, Rawlings 2000). Members of this community link the regaining of dignity and self-esteem, and the fact that once again the community trust their own people, to the birthing project (Tookalak 1998). The Inuit have control of these services and have successfully fought occasional attempts to shut them down (Rawlings 2002). Despite a four hour plane trip to the nearest obstetric services, the perinatal mortality rate has fallen (8.6% to 3.6%) based on almost 1,500 births that have occurred since it opened (Tookalak 1998). Additionally, inductions have halved; episiotomies have decreased from 49% to 3.5%; the transfer rate for births has decreased from 91% to 9.4%; and the community has a 2.4% caesarean section rate (compared to the Quebec rate of 26.8%) (Rawlings 2000). Following these successes a smaller, remote community, Inukjuak (population 1,184), commenced both on-site birthing and training of midwives (Houd et al. 2003, Tookalak 1998). These communities continue to offer birthing services today with local employment, integration of local Inuit knowledge, multidisciplinary case review which includes social and emotional factors, and the involvement of men whose role incorporates the provision of nutritious food in pregnancy all being integral components of the model (Houd et al 2003, O'Neil and Kaufert 1995).
The literature from the Canadian North gives some indication of how the policy of routine evacuation for childbirth was turned around. It is clear that some of the key factors included: self-determination and land rights; local activism and political pressure; regaining control of health funding; open dialogue around the construction of risk; alliances with academics and other non-Indigenous people, and positive media reports (Chamberlain 1997, Daviss 1997, Kaufert and O'Neil 1993, MacDonald and Starrs 2002, Morewood-Northrop 2000, O'Neil and Kaufert 1990, O'Neil and Kaufert 1995). Using the Inuit experience as a guide and an example of a successful social and cultural model of birthing where Indigenous voices have influenced authoritative knowledge, Australians could work together towards a service that better suits remote-dwelling Aboriginal women and their families.
It is clear, that for Aboriginal women, current policies, maternity services, living conditions and health status have contributed to morbidity and mortality rates that are very different from other Australian women (Laws and Sullivan 2005, Slaytor et al 2004), and Indigenous women from equivalent countries (Ring and Firman 1998). It could be argued, that long-term strategies to improve Aboriginal health must include the knowledge and wisdom of the Aboriginal peoples themselves. Authoritative knowledge is socially constructed and open to change (Jordan 1997), but while Aboriginal women's voices are being ignored and suppressed, they are unable to participate in the formation of the authoritative knowledge currently influencing maternity service provision. Integral to this construction of knowledge is defining risk and safety in childbirth. This has clearly been debated in the Canadian North for almost thirty years, where the Inuit voices have influenced the components of the risk equation, the authoritative knowledge and the subsequent service provision (Baskett 1978, Houd et al 2003, Jasen 1997, Kaufert and O'Neil 1993, O'Neil and Kaufert 1995). Perceptions of risk and safety have also been articulated in Australian reports over almost 20 years (Biluru Butji Binnilutlum Medical Service 1998, Carter et al 1987, Fitzpatrick 1995, Hirst 2005, Kildea 1999, Kildea 2003, King et al 1998, NT DHCS 1992, Senate Community Affairs References Committee 1999). However, on the whole, Aboriginal women's voices have not been recognised as contributing to the authoritative knowledge on which childbirth services are planned and enacted in Australia, nor have their concerns been recognised in the risk equation. Imposing ideas and services that are guided by the current Western medically dominated authoritative knowledge has not seen the improvement in mortality and morbidity that was expected.
Efforts to improve the health of Aboriginal Australians must encompass their holistic definition of health, which includes the social, emotional, spiritual and cultural well-being of an individual (National Aboriginal and Torres Strait Islander Health Council 2000). Additional factors that must be incorporated include governance and community capacity, Aboriginal people's obligations to the land, their culture and their people (Morgan et al 1997). This is Aboriginal authoritative knowledge that is currently ignored in maternity care systems in Australia. We must strive to provide maternity services that are safe and 'feel safe' for the women and their families, recognising the social, emotional and cultural risks they describe, and incorporating these risks into the risk equation. Returning birth to the remote setting where Aboriginal communities can begin to address the social, emotional and cultural risks affecting the birthing experience may have far reaching effects for the health and wellbeing of Aboriginal communities as it did for the Canadian Inuit. Programs that acknowledge both Aboriginal and 'Western' knowledge and comprehensively address the year before, and the year after birth, would need to be included in this initiative; as would local Aboriginal governance and increasing community capacity through onsite midwifery education. Progress towards birthing in remote areas needs political commitment, local leadership and control, collaboration between practitioners, consumer involvement, ongoing management commitment and appropriate resourcing. This should be accompanied by improved living conditions, employment opportunities and educational initiatives.
It is time to listen to Aboriginal women and respect their ability to define risk, to make decisions based on their own specific needs and to provide the services that enable this. This is the least we can do for the original inhabitants of this land.
1. The smoking ceremony was commonly performed following birth by many Aboriginal women to decrease bleeding, assist breast-feeding, settle the babies and prevent infection - Kildea S, Wardaguga M, Dawumal M and Maningrida Women (2004) Birthing Business in the Bush Website. http://www.maningrida.com/mac/bwc/index.html, 16 September, 7.6.04.