Registrations are now open for the 2022 CRANAplus Conference.

To join the remote healthy community in Adelaide from 4-6 October, head to our conference website.

Healthy mums and babies

19 Jul 2022

At our 39th Annual Conference, Co-Director of the Molly Wardaguga Research Centre and CRANAplus Fellow Sue Kildea will be discussing the state of maternity services in remote Australia and necessary actions to ensure Aboriginal mothers and babies in remote communities experience the same health outcomes as city folk.

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.”

Prof. Yvette Roe (left) and Prof. Sue Kildea (right)

Screen­ing of the Djäkamirr documentary.

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.

If this top­ic inter­ests you, you can catch Pro­fes­sor Sue Kildea’s pre­sen­ta­tion at the 39th CRANAplus Con­fer­ence in Ade­laide this 4 – 6 Octo­ber. For more infor­ma­tion and to reg­is­ter, head to crana​con​fer​ence​.com.

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