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Position Statement: Birthing in the Bush **UNDER REVIEW**

Increasingly, through the 1970-80’s women in remote Australia have been encouraged to transfer to regional centres, for childbirth.


The rationale behind these policies is for women to have prompt access to appropriate services should complications occur. As birthing services have become less available in remote areas, it has become increasingly difficult to recruit midwives. As a result, many remote communities currently have no resident midwife and long-term staff are commonly de-skilled due to lack of exposure to birthing women. Many small rural towns across Australia are also withdrawing maternity services, resulting in women having to travel greater distances for birth.

This policy, which is fairly standard across Australia, does not take into account community or cultural wishes of women who wish to birth in their own communities (ref.1, 2, 3, 4). Recent evidence from Canada, the First Nations of the USA and New Zealand provide evidence that birthing services can be provided in remote areas (ref.5, 6, 7). In particular, Inuit communities in the Canadian North, are providing remote area birthing services that are showing remarkable outcomes in terms of maternal and perinatal statistics, and community cohesiveness (ref.8, 9, 10, 11, 12). Key features of these models include incorporation of Inuit childbirth beliefs and practices, locally based training of Inuit midwives, a multidisciplinary approach and the establishment of a Perinatal Committee who regularly review and discuss pregnant women in the community (ref.12).

Australian statistics show that Indigenous women are three times more likely to die in childbirth and twice as likely to lose their babies in birth (ref.13, 14); with this being particularly so for women from remote areas (ref.15, 16). Research in remote Australia has shown that Aboriginal women have their own view on the reasons for these poor health outcomes, but these beliefs are not included in the ‘risk equation’, nor are they incorporated into service provision. 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 (ref.3, 4, 17). Some Aboriginal women identify giving birth in the hospital as the cause of infant mortality. When babies are not welcomed properly into the world, and do not have the appropriate ceremonies performed at birth, the baby’s weakened spirit gets sick (ref.18). The current model of remote area maternity service fails altogether to take into account the importance of culture as a determinant of health.

Australia is also failing to meet the Safe Motherhood goals of ensuring all women have access to a skilled attendant during pregnancy, birth and the postnatal period (ref.19). The United Nations International Millennium Goals include a substantial reduction of child mortality and improvement in maternal health by the year 2015 (ref.20). Australia will need to improve its services in remote areas to reach these goals and national resources must be made available. It is time to listen to Indigenous Australians and work together to provide the services they are requesting.

CRANA calls on:

The Federal, State and Territory governments to support Indigenous communities to establish appropriately resourced birthing services in their remote communities. The Inuit model could be used as a guide.
Providers of maternity services to work with remote communities to ensure their needs are better met.
The Federal government to expand the John Flynn Scholarship to include midwifery, nursing and allied health students to access remote area experience during their training, with the aim of nurturing future remote area practitioners.
The Federal, State and Territory governments to provide incentives to increase the number of Aboriginal and Torres Strait Islander midwifery students in Australia.

CRANA calls for:

Immediate Federal, State and Territory commitment to the provision of adequate midwifery resources throughout Australia, especially in its remote communities.

CRANA resolves to:

Work with other organisations with the aim of ensuring all women in Australia receive care in pregnancy and birth from someone who is skilled in this area.
Provide training on maternity emergency care to remote practitioners who have not had training in this area.
Support remote communities who wish to establish birthing services on site.
Raise the awareness of remote maternity service provision in State, Territory and National forums.

Issue Date: 20 Sep 2004
Review Date: 20 Sep 2004
Endorsed by: BoM 27 Sep 2004

1. Carter, E., et al., 'Alukura... for my daughters and their daughters and their daughters'. A review of Congress Alukura. Australian and New Zealand Journal of Public Health, 2004. 28(3): p. 229-34.
2. Fitzpatrick, J., Obstetric health services in Far North Queensland: is choice an option? Australia Journal of Public Health, 1995. 19(6): p. 580-588.
3. Kildea, S., And the women said... Report on birthing services for Aboriginal women from remote Top End communities. 1999, Territory Health Service: Darwin.
4. Biluru Butji Binnilutlum Medical Service, Women's Business Meeting, Darwin, Nov 2-3, Report and Recommendations. 1998, Danila Dilba: Darwin.
5. British Columbia Reproductive Care Program, Consensus Symposium Summary. 2000: British Columbia.
6. Leeman, L. and R. Leeman, Do all hospitals need cesarean delivery capability?: An outcomes study of maternity care in a rural hospital without on-site cesarean capability. The Journal of Family Practice, 2002. 51(2): p. 129-134.
7. Health Funding Authority, Maternity services: A reference document. 2000, Health Funding Authority: Hamilton.
8. Morewood-Northrop, M., Community birthing project: Northwest Territories, in The New Midwifery, L. Page and P. Percival, Editors. 2000, Churchill Livingstone: Edinburough.
9. Couchie, C. and H. Nabigon, A path towards reclaiming Nishnawbe birth culture: Can the midwifery exemption clause for Aboriginal midwives make a difference?, in The New Midwifery: Reflections on Renaissance and Regulation, F. Shroff, Editor. 1997, Women's Press: Toronto, Canada.
10. Daviss, B., Heeding warnings from the canary, the whale and the Inuit, in Childbirth and Authoritative Knowledge, Cross Cultural Perspectives, Davis-Floyd R and Sargent C, Editors. 1997, University of California Press: Berkely.
11. Tookalak, N., Birthing in Puvirnituq in remote Artic Canada. Birthplace Magazine, 1998. Summer 2000-01 edition.
12. Houd, S., J. Qinuajuak, and B. Epoo. The outcome of perinatal care in Inukjuak, Nunavik, Canada 1998-2002. in 12th International Congress on Circumpolar Health. 2003. Nuuk, Greenland: Int J Circumpolar Health.
13. AIHW, Rural, regional and remote health: a study on mortality (summary of findings), in PHE 49. 2003, Australian Institute of Health and Welfare, (Rural Health Series Number Three): Canberra.
14. Slayter, E., E. Sullivan, and J. King, Maternal Deaths in Australia 1997-1999, in Maternal Deaths Series 1. 2004, AIHW National Perinatal Statistics Unit: Sydney.
15. Trewin, D. and R. Madden, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples, in 4704.0, AIHW, Editor. 2003, ABS: Canberra.
16. Roberts, C.L. and C.S. Algert, The urban and rural divide for women giving birth in NSW 1990-1997. Australian and New Zealand Journal of Public Health, 2000. 24(3): p. 291-296.
17. Senate Community Affairs References Committee, Rocking the Cradle, A Report into Childbirth Procedures. 1999, Commonwealth of Australia: Canberra.
18. Mills, K. and J. Roberts, Remote Area Birthing Discussion Paper. 1997, Territory Health Services: Darwin.
19. MacDonald, M. and A. Starrs, Skilled Care During Childbirth, Information Booklet. 2002, Family Care International: New York.
20. United Nations, UN Millennium Developed Goals (MDG). 2002.

This CRANAplus Position Statement is currently under review
For more information, please contact Geri Malone


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