Pro­fes­sor Sue Kildea’s remote mid­wifery career com­menced in the 90s and ulti­mate­ly led to her 11-year tenure as CRANAplus’ Vice Pres­i­dent. More recent­ly, she spent a per­spec­tive-shift­ing decade in the largest mater­ni­ty facil­i­ty in Australia.

“I’ve returned to remote Aus­tralia, near Alice Springs,” Prof. Kildea says, ​“and I can­not believe the state of remote area mater­ni­ty ser­vices, and moth­ers’ and babies’ health.”

The state of remote mater­ni­ty services

“20 to 25 years ago, they thought it would be safer for women to have their babies in the big city hos­pi­tals where you’ve got pae­di­a­tri­cians and obste­tri­cians, the­atres and blood banks,” Prof. Kildea says.

“There’s quite a lot of recog­ni­tion now that we went too far. 

“We should’ve kept many of the small­er mater­ni­ty units open so that healthy women could stay in their com­mu­ni­ties and, I think, only removed women out if they had risk fac­tors and need­ed more inten­sive and spe­cialised care.”

This mind­set ulti­mate­ly led to the clo­sure of rur­al and remote mater­ni­ty units and an exo­dus of mid­wives and GP obste­tri­cians. First Nations women increas­ing­ly had to receive care in cities, even when low risk and for their first child. Fam­i­lies became exclud­ed from births – one of the most joy­ous things in life.

“We sent a lot of [preg­nant] women who didn’t speak Eng­lish away,” Prof. Kildea says. ​“A lot of the time they [didn’t] have an escort and it was real­ly problematic.

“Women don’t like going to the cities. They don’t feel safe; they’re fright­ened, alone. This hasn’t changed.”

The cor­re­spond­ing gap in health out­comes is well doc­u­ment­ed. There’s a lack of res­i­dent mid­wives in remote com­mu­ni­ties where, at the same time, we are see­ing some of the high­est rates of preterm birth in the country. 

“In Aus­tralia rates [of preterm birth] might be around 7 per cent every year,” Prof. Kildea says. ​“They’re 12 to 14 per cent for Abo­rig­i­nal women. In some of the remote areas, that fig­ure is between 15 and 22 per cent.”

This, in turn, cor­re­lates with increased vul­ner­a­bil­i­ty to chron­ic disease.

“I’m not say­ing all women across Aus­tralia can have a local mater­ni­ty ser­vice in their small remote com­mu­ni­ty,” Prof. Kildea acknowledges.

“But there are many remote com­mu­ni­ties that have over 1000 peo­ple in them, and more than 20 women hav­ing a baby every year. And they’ve got no res­i­dent mid­wife. That’s just insane.”

Imple­ment­ing a Birthing on Coun­try model

Prof. Kildea, with Pro­fes­sor Yvette Roe, is cur­rent­ly co-lead­ing sev­er­al projects to change this includ­ing the Nation­al Health and Med­ical Research Council’s five-year, $1.5 mil­lion project ​‘To Be Born Upon a Pan­danus Mat’, and the Djäkamirr (Yolŋu child­birth com­pan­ions) four-year $6.1 mil­lion project fund­ed by the Depart­ment of Health.

These projects are under­pinned by mul­ti­a­gency part­ner­ships and a Steer­ing Com­mit­tee with rep­re­sen­ta­tives from: Charles Dar­win Uni­ver­si­ty (CDU), Miwatj Abo­rig­i­nal Health Cor­po­ra­tion, Yalu Abo­rig­i­nal Organ­i­sa­tion, Aus­tralian Red Cross, Care­flight, the Aus­tralian Doula Col­lege and the North­ern Ter­ri­to­ry (NT) Depart­ment of Health, the Aus­tralian Gov­ern­ment Depart­ment of Health (Indige­nous Health Division). 

The Yalu Abo­rig­i­nal Cor­po­ra­tion Women’s Back­bone Com­mit­tee, com­pris­ing of senior Yolŋu women rep­re­sent­ing the diverse clans in Galiwin’ku, pro­vide lead­er­ship and cul­tur­al authority.

Togeth­er they are aspir­ing to increase con­ti­nu­ity and qual­i­ty of care by redesign­ing mater­ni­ty ser­vices on Galiwin’ku, the north­east Arn­hem Land island with a pop­u­la­tion of around 2500.

The goal is to reduce risk fac­tors asso­ci­at­ed with preterm birth, strength­en mid­wifery care, and inte­grate ear­ly med­ical and allied health refer­ral as required.

This includes pair­ing ​“named mid­wives” with preg­nant women through­out their jour­ney, and ensur­ing mid­wives are recruit­ed and sup­port­ed to stay and be avail­able 24/7.

They will work side-by-side with the Djäkamirr, who will be embed­ded in the ser­vice to pro­vide clin­i­cal­ly and cul­tur­al­ly excep­tion­al care. A Djäkamirr is a Yolŋu woman trained and employed to pro­vide guid­ance and sup­port to a woman dur­ing preg­nan­cy, child­birth and until baby turns two years old.

“At the moment, care is dis­lo­cat­ed [through­out a woman’s jour­ney, which may be from] mul­ti­ple providers with lit­tle con­ti­nu­ity of car­er,” Prof. Kildea says.

“We want each preg­nant woman to have a named Djäkamirr, who will go with her, pro­vid­ing the con­ti­nu­ity of care that the mid­wife can’t, because the mid­wife stays in the community.

“We’ve got a very West­ern med­ical mod­el out there in our com­mu­ni­ties, and almost no mid­wives. We are all miss­ing out on all that incred­i­ble knowl­edge the Indige­nous women have had passed down from 60,000 years of Birthing on Country.”

Pos­i­tive ear­ly signs

The results of Birthing on Coun­try imple­men­ta­tion in an urban set­ting have been excep­tion­al, says Prof. Kildea, refer­ring to the suc­cess­es of the Birthing in Our Com­mu­ni­ty Ser­vice in South East Queens­land as pub­lished in The Lancet.

“We saw a 38 per cent reduc­tion in preterm birth,” Prof. Kildea says. 

“We saw women come ear­li­er in preg­nan­cy, and more often. They felt cul­tur­al­ly safe – and a lot of that is to do with the First Nations workforce. 

“Birthing on Coun­ty ser­vices are also dri­ving changes to the social deter­mi­nants of health with the empha­sis on employ­ment and edu­ca­tion of Abo­rig­i­nal women in these services.

“Women were also more like­ly to breast­feed, we saw few­er elec­tive C‑sections, few­er women hav­ing epidur­al pain relief in labour (less inter­ven­tion in birth), more phys­i­o­log­i­cal birth of the pla­cen­ta and a reduc­tion in neona­tal nursery.” 

“Reduc­ing preterm and increas­ing breast­feed­ing are two of the most pow­er­ful things we can do in the ear­ly days to reduce the risk of chron­ic dis­eases down the track.”

Prof. Kildea’s research team has also received a Med­ical Research Future Fund of $5 mil­lion to work with com­mu­ni­ties to test their RISE Imple­men­ta­tion Frame­work in a rur­al (Nowra, NSW), a remote (Alice Springs) and very remote (Galiwin’ku) site.

The RISE Frame­work has four pil­lars to dri­ve reform: (1) Redesign the health ser­vice; (2) Invest in the work­force; (3) Strength­en fam­i­lies; and (4) Embed First Nations com­mu­ni­ty gov­er­nance and control.

Ref­er­ences

1. Effect of a Birthing on Coun­try ser­vice redesign on mater­nal and neona­tal health out­comes for First Nations Aus­tralians: a prospec­tive, non-ran­domised, inter­ven­tion­al tri­al, Prof Sue Kildea et al, The Lancet
2. Imple­ment­ing Birthing on Coun­try ser­vices for Abo­rig­i­nal and Tor­res Strait Islander fam­i­lies: RISE Frame­work, Prof Sue Kildea et al, Women and Birth