Aboriginal and Torres Strait Islander women's health: Acting now for a healthy future

Australian and New Zealand Journal of Obstetrics and Gynaecology 2008; 48: 526–528 DOI: 10.1111/j.1479-828X.2008.00962.x Invited Editorial Blackwell Publishing Asia Aboriginal and Torres Strait Islander women’s health: Acting now for a healthy future This paper summarises the recent RANZCOG Indigenous Women’s Health Meeting with recommendations on how the College and its membership can act now to improve the health of Aboriginal and Torres Strait Islander women and infants. Introduction ‘I believe that all those employed in the medical professions must undertake the difficult task of recognising, in all its implications, that, by definition, health work is political work. If the health professions ignore the shocking state of Indigenous health in this country then they exacerbate the problems of history. On the other hand, if they take the initiative to act, to advocate and to work for significant change, they assist in the crucial work of reconciliation between black and white Australians’.1 There is an increasing interest and a political will in Australia to improve Indigenous health, with a strong focus from government on maternal and early childhood intervention. In recognition of this, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) held a conference on Indigenous women’s health in Darwin this year. This paper describes the conference outcomes with recommendations on how RANZCOG can act to improve the health of Indigenous Australians. Overview of Indigenous health in Australia Aboriginal and Torres Strait Islander peoples comprise 2.5% of the Australian population. The majority of Indigenous people live in New South Wales and Queensland in major cities or regional areas; however, they are over ten times more likely to live in remote areas than non-Indigenous Australians,2 which has implications for access to primary and specialist services. Indigenous people remain disadvantaged on a range of health and socioeconomic indicators relative to other Australians; a discrepancy beginning in utero and evident throughout life. The reasons for the disadvantage are multifactorial and complex, ranging from social determinants of health to service delivery challenges, so that addressing the inequality is often dismissed as being too hard. Indigenous women experience a disproportionate health burden in relation to reproductive outcomes, with higher rates of sexually transmitted infections (STIs), cervical cancer and pregnancy complications when compared with other Australian women.2 Approximately 3.6% of all mothers are Indigenous and this is as high as 39% in the NT.2,3 On average, Indigenous women give birth at a younger age than non-Indigenous mothers (median age 25 years versus 30 respectively), and 526 teenage births are five times more common among Indigenous women particularly in rural and remote areas.2,3 Compared with their non-Indigenous counterparts, Indigenous maternal mortality is five times higher; perinatal mortality is 1.5 times higher; and premature delivery and low birthweight are doubled.2 Neonatal mortality is also disproportionately higher, as is the prevalence of anaemia, urinary tract infections, smoking and STIs in pregnancy in some jurisdictions.2–4 Issues that contribute to poorer outcomes in pregnancy and childbirth include: increased smoking in pregnancy, diabetes and other medical comorbidities, late presentation to antenatal care and fewer visits. Improving maternal care and outcomes in Indigenous women has important flow on effects as a poor start to life can increase the risk of adult chronic disease.5 The RANZCOG Indigenous Women’s Health Meeting 2008 In August this year, the College organised a conference to highlight the health issues faced by Indigenous women, enable networking among Indigenous health-care providers and to develop frameworks to enable RANZCOG to contribute to improving Indigenous women’s health. Around 350 people attended from across Australia and overseas, a reflection of both the interest in and commitment to this area. Delegates were from a diversity of backgrounds and included many Aboriginal and Torres Strait Islander health professionals. Almost half the presenters were Indigenous people, many of whom shared reflections on their own personal experiences and spoke with passion, warmth and wisdom. An inspiring moment was a breakfast workshop designed to facilitate greater cooperation between professional organisations where six of the eight panel members were Indigenous doctors. Many Indigenous delegates commented on how proud they felt seeing this and they hoped the future would see this capacity increase further. The conference program covered a wide range of topics (see Box 1) from cultural competence to the developmental origins of health and disease in an Indigenous context. Across the presentations, a set of consistent key messages and strategies emerged for improving the health of Indigenous women and babies, and these are: Provision of culturally safe health care Often unrecognised and neglected, culturally safe care is the key issue in health-care provision if we are to overcome language and cultural barriers, and alienation from mainstream health services. Improving access to culturally safe health care is facilitated by increasing the Indigenous © 2008 The Authors Journal compilation © 2008 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists Editorial Box 1 Topics covered in the RANZCOG Indigenous Women’s Health Conference Demographic overview of the health of Aboriginal and Torres Strait Islander people Culturally appropriate and safe antenatal care and birthing Service delivery in the Top End and Central Australia Medical problems in pregnancy Programs addressing cultural competence for non-Indigenous health providers Developmental origins of health and disease Mental well-being Keeping families strong Sexual health, infertility and contraception Current political efforts to improve Indigenous health nationally and in the Northern Territory health professional workforce, increasing the number of non-Indigenous providers who undergo cultural competence training and are mentored in their work, and recognising and utilising the skills of Aboriginal and Torres Strait Islander health workers. Understanding and respecting the complexity of health beliefs that are often inextricably linked to spiritual connections to country and family are particularly important. These issues are particularly pertinent in women’s health when rural and remote women have to birth in a hospital a long way from home. Apart from the difficulties all rural and remote women face being alone and away from family and friends at such an important time there are additional cultural considerations, such as the fact that the child will not be born ‘on country’ and the importance of traditional practices such as ‘smoking ceremonies’ or keeping the placenta which are neither understood nor facilitated in many locations. Increasing the Indigenous workforce Indigenous people remain underrepresented in all professions. The medical profession is no exception, where the proportion of Indigenous medical practitioners is approximately 0.18%. The benefits of Indigenous practitioners caring for Indigenous people are well recognised, particularly in relation to empathy, adopting a comprehensive approach to care, providing positive role models and advocacy for communities.6 Increasing the number of Indigenous providers will require a long-term commitment to improving educational opportunities. In the short-term expansion of existing efforts to increase training pathways for Indigenous people such as the Puggy Hunter Memorial Scholarship Scheme is needed. Improving cultural competence among non-Indigenous providers Training in cultural competence is essential for non-Indigenous providers caring for Indigenous people. The conference highlighted the ongoing development of cultural competency programs such as those provided by the Royal Australian College of General Practitioners (RACGP), the Royal Australasian College of Surgeons (RACS) and RANZCOG. These programs must be supported and integrated with existing programs for medical students in order to build on current knowledge. Recognition of the roles of Aboriginal and Torres Strait Islander health workers Aboriginal health workers have a critical role in all aspects of care, and health providers need to understand, respect and acknowledge the role they play. Their skills must be utilised appropriately and across the health-care spectrum, including mainstream care. There is need for a national system of competencies and registration and improved career pathways for those seeking to specialise in women’s and children’s health, including the re-instatement of training programs. Recognition of the social determinants of health Many speakers highlighted the contribution of persistent and profound socioeconomic disadvantage to poorer health outcomes, recognising the need for broad commitment and policies from government that address housing, education, participation in the workforce and other determinants, in conjunction with service delivery issues. Effective collaboration Active collaboration across the medical colleges, midwifery college, Aboriginal community-controlled health organisations, Australian Indigenous Doctors Association, Office for Aboriginal and Torres Strait Islander Health (OATSIH), non-government organisations and governments is essential to improving advocacy and action to improve Indigenous women’s health. Research and evaluation Improved health outcomes can be achieved, as evidenced by successful women’s health programs such as the Townsville Mums and Babies program,7 and the Strong women, Strong Babies, Strong Culture program in Northern Territory.8 Nevertheless, there remain many gaps in knowledge about Indigenous women’s health; only a small amount of current research has a focus in this area and even less is led by Indigenous researchers. Research is needed to improve the evidence base for current programs in this area and the application of mainstream programs to Indigenous contexts. Key recommendations At the conclusion of the conference the organising committee presented a series of recommendations. Foremost, there must be an active and participatory Indigenous Advisory Committee within RANZCOG. This committee needs to © 2008 The Authors Journal compilation © 2008 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists; 48: 526–528 527 Editorial be given clear direction, support and authority to make recommendations in relation to training, implementation of policy and service provision. In order to be effective, this may require involvement from Indigenous representatives who are non-members of the College, as there is only one Indigenous obstetrician and gynaecologist in Australia. The College must strengthen its training around Indigenous health issues and culturally safe service provision for current and future Fellows, in order to produce effective and culturally competent practitioners. This should include facilitating greater utilisation of the online training program developed by RACS and RANZCOG and the inclusion of questions relevant to Indigenous health in membership exams. These are measures that can be enacted immediately. More broadly, RANZCOG is well placed to contribute to raising the profile of working with Indigenous people and communities and facilitate pathways for practitioners to engage with Aboriginal women’s health through service provision and/or advocacy. In order to do this and help address recruitment and training of Indigenous women’s health providers, it will be essential for RANZCOG to engage in active partnerships with Government, Aboriginal Medical Services, National Aboriginal Community Controlled Health Organisation (NACCHO) and other medical colleges. In contributing to improved service delivery for Indigenous women, the College must also consider evaluating the safety, practicalities and other issues with birthing ‘on country’ and cultural practices for women birthing in hospital/town. RANZCOG can also continue to increase the understanding of and raise the profile of Indigenous women’s health in very practical ways. For example, it could seek ways to obtain funding for the research foundation specifically for fellowships in Indigenous women’s health, and continue to provide a focus on Indigenous health in all subsequent Annual Scientific Meetings (ASM). It is encouraging to see that Indigenous health has already been included in the program for the 2010 ASM in Adelaide. In closing, we would like to finish with a quote from Jackie Huggins, co-chair of Reconciliation Australia, in her speech for the 2006 Garma Festival: ‘... you can’t receive what you hear about Aboriginal health and education in a passive mode. It does affect you, no matter whether you work in business, in government, in the media or in education.... It matters what you think and what you say. And it matters most what you believe about this stuff ...’ ... It also matters what we do. 528 Acknowledgements Indigenous Health providers were supported to attend through sponsorship from Menzies School of Health Research, OATSIH, Northern Territory Department of Health and Families, and AirNorth. Jacqueline BOYLE,1,2 Alice R. RUMBOLD, Marilyn CLARKE,3 Chris HUGHES4 and Simon KANE5 1 Menzies School of Health Research, Darwin, Northern Territory, 2Discipline of Obstetrics and Gynaecology, The University of Adelaide, South Australia, 3Coffs Harbour Health Campus, New South Wales, 4North-eastern Hospital, Campbelltown, South Australia, and 5Department of Obstetrics and Gynaecology, Alice Springs Hospital, Alice Springs, Northern Territory, Australia 1,2 References 1 O’Donoghue L Towards a culture of improving Indigenous health in Australia. Aust J Rural Health, 1999; 7 (1): 67. 2 Australian Institute of Health and Welfare (AIHW) and Australia Bureau of Statistics. The health and welfare of Australia’s Aboriginal and Torres Strait Islander Peoples, 2008. AIHW Catalogue No. IHW 21, Canberra, ACT: AIHW. 3 Australian Institute of Health and Welfare (AIHW), Leeds KL, Gourley M, Laws PJ, Zhang J, Al-Yaman F & Sullivan EA. Indigenous mothers and their babies, Australia 2001–2004. AIHW Catalogue No. PER. 38. Perinatal Statistics Series No. 19. Canberra: AIHW, 2007 4 Hunt J. Pregnancy Care and Problems for Women Giving Birth at Royal Darwin Hospital. Victoria, Australia: Centre for the Study of Mothers’ and Children’s Health, La Trobe University, 2004. 5 deBoo H, Harding JE. The developmental origins of disease (Barker) hypothesis. Aust NZ J Obstet Gynaecol 2006; 46: 4– 14. 6 Australian Indigenous Doctors Association (AIDA). Indigenous doctors [cited September 2008]. Available at URL: http:// www.aida.org.au/indigenous.asp 7 Panaretto KS, Mitchell MR, Anderson L, Larkins SL, Manessis V, Buettner PG, Watson D. Sustainable antenatal care services in an urban Indigenous community: the Townsville experience. Med J Aust 2007; 187 (1): 18–22. 8 D’Espaignet ET, Measey ML, Camegie MA, Mackerras D. Monitoring the ‘Strong Women, Strong Babies, Strong Culture Program’: the first eight years. J Paediatr Child Health, 2003; 39: 668–672. © 2008 The Authors Journal compilation © 2008 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists; 48: 526–528