Global Maternal Health Reflective

Essay Title: Global Maternal Health Reflective Essay – exploration of the literature and personal/professional recommendation

Word Count: 2509

Background:

For this reflective essay I have chosen to work with Aboriginal women from the Top End in Northern Territory (NT) as they have a cultural identity different to my own. My ethnicity is Anglo-Caucasian and I work as a midwife with Midwifery Group Practice (MGP) at Royal Darwin Hospital (RDH) with the clientele in our team, remote Aboriginal women. I have worked in this position for almost two years and during this time have experienced many challenges on which I can reflect.

This essay aims to explore the childbearing experience of remote Aboriginal women from the NT. A reflection of my own cultural competence will follow with examples of my professional practice which have been enablers or barriers to culturally competent care. Finally, I will make recommendations supported through evidence to enhance my practice and the experience of women and maternal health.

I have searched and reviewed the current literature using the following key words with Boolean operators and multiple combinations – childbearing, birth, experience, Aboriginal, ATSI [sic], Indigenous, women, mother, Midwifery Group Practice, Top End, Northern Territory, Australia. The literature search was limited to research less than 10 years old to ensure articles current relevance.

Women’s Likely Experience of Childbearing in Northern Territory:

Historically, Aboriginal women have experienced great loss over the last century with colonisation of their lands and people. Colonisation led to the introduction of the biomedical model of health usurping many cultural and spiritual beliefs of Aboriginal people including the loss of traditional Aboriginal midwives. By the 1960’s, traditional Aboriginal midwives who had been assisting Aboriginal women to birth for thousands of years were replaced by hospital birthing with religious nurses and midwives within the mission.

And by 1985-1996 women were no longer “allowed” to birth on country and were required to relocate for “confinement” to the nearest large town with birthing services at the hospital, of which could be many hours away from their home (Ireland, Belton, McGrath, Saggers & Wulili Narjic, 2015). These rapid changes in midwifery care mainly occurred without consultation of Aboriginal people, and cultural and spiritual beliefs were not at the core of decision making (Ireland et al., 2015).

Whilst the intention of improving Aboriginal maternity care was honourable and with the aim of saving mothers and their babies lives, the loss of birthing on country has significant effects which are not yet fully recognised. Aboriginal culture often views birthing on their lands as spiritually important ensuring the infant inherits cultural identity and belonging (Ireland, Wulili Narjic, Belton & Kildea, 2011). Social and birthing support is limited and for the most part inaccessible for Aboriginal women when in town for ‘sit down’ and birth. Only women who are under the age of 18, first time mothers or have a high-risk pregnancy requiring a long stay in town are eligible for an escort to come into town with them for support. Other women who do not meet these requirements must either pay for their supports to come into town and stay or they are forced to birth alone without support. This is a travesty as support is vital throughout pregnancy and birth for all women regardless of race or cultural beliefs.

Despite now birthing in a regional or tertiary hospital aimed to improve outcomes, Aboriginal women and their babies still suffer inequitable disparities in their health compared to that of non-Indigenous women (largely because the social / cultural determinants of Aboriginal maternal health have been ignored). Aboriginal mothers are more likely to be teenagers, live in a low socio-economic area, smoke, suffer obesity or have pre-existing diabetes or hypertension (Australian Institute of Health and Welfare [AIHW], 2017). Aboriginal babies are far more likely to be born prematurely, be of low birth weight and experience perinatal death (AIHW, 2017). All of these maternal and neonatal factors have socio-cultural links.

Currently Aboriginal women birthing at Royal Darwin Hospital are referred into one of two Midwifery Group Practice (MGP) teams which caseloads remote Aboriginal women as a priority. This program has been running since 2009 and includes three midwives per team, as well as an Aboriginal Health Practitioner (AHP) and Strong Woman Worker (SWW) (Kildea et al., 2016). MGP aims to deliver woman-centred care to women of all-risk in a culturally responsive service. A study looking at the service showed women accessing this antenatal care had more antenatal visits, had improved screening rates, and similar normal vaginal birth and caesarean section rates. Unfortunately, despite the screening tests showing positive results such as urinary tract infections, almost 50% of women were not treated in MGP or the baseline care at RDH (Kildea et al., 2016). The importance of treating these preventable factors cannot be overstated in reducing outcomes such as pre-term birth and low birth weight infants.

Aboriginal women accessing the MGP service have a known midwife and have access to one of the three midwives 24 hours a day which improves access to care and acceptability. These women are cared for by a known midwife whilst in town for sit down, throughout labour and birth, and postnatally until they return to their community. Working closely with an AHP and SWW ensures women have support culturally and emotionally, and assists with health information sharing between the women and midwives (Kildea et al., 2016). Continuity of care ensures continuity of information, enables women to have more control of their pregnancies, feel more informed and educated, and ensures they are not left feeling isolated or unsupported in labour (Josif, Barclay, Kruske, & Kildea, 2014).

Professional and Personal Reflection:

When reviewing the cultural competency continuum, I believe I am working my way towards cultural competence (Dietsch, 2019). Cultural awareness, sensitivity and safety is a large part of my role as a midwife working with Aboriginal women and wherever applicable, their families. I want to empower women and ensure they are the decision makers. I am present to assist in guiding them through the health service with the aim of positive birth outcomes for mother and baby and implementing good health practices so women can live a healthy life beyond birthing. There is a lot of fear surrounding birth, and this is amplified for women who do not have support in labour due to ineligibility for an escort or unsupportive partners. By learning about their traditional birthing practices, especially through escorts such as aunties or grandmothers, I can show cultural humility and assist in making them feel safe and comfortable in labour.

Cultural safety is critical to enable midwives to provide acceptable midwifery care to Aboriginal women. I have found often the simplest way to create a rapport with women is to ask about their family or friends from community with whom I have previously cared for. By showing genuine interest and alerting women to the fact that I am not a stranger to the family, feelings of safety and trust are created. I acknowledge that coming to the ‘big smoke’ in Darwin is overwhelming for many women so engaging with women about their lives in community is important. My aim is for women to know that whilst they are away from their homelands they are still connected to their culture and families, and their time in Darwin is only temporary.

I found as a junior midwife prior to my experience working within MGP there was a general assumption that Aboriginal women ‘never needed pain relief’. In my naivety I thought ‘wow these women are tough’. Looking back now I wonder if they were too scared to ask for analgesia or they simply didn’t know it was an option available to them. I am previously guilty of not explaining the analgesia options during labour, and assuming women would ask if they needed anything.

Now I am working in MGP, my team has developed a women’s group facilitating labour and birth information which shows all the analgesia options including warm water immersion. I now make sure with each woman in early labour, I discuss the analgesia options again and reassure them they are always available. I have found through knowing they have all these pain relief options women are more likely to be actively labouring and using techniques such as massage, heat, water, TENS rather than just pharmaceutical options.

I believe the patriarchal medical model of health creates a barrier to providing cultural security to Aboriginal women, particularly from remote communities. I am enforced to abide by hospital policy, so despite the cultural wishes and needs of women, I cannot always give woman centred care nor ensure their care is culturally secure or safe. The most recent example of this was my experience with a woman who was 26 weeks pregnant with a known short cervix and had experienced a previous neonatal death at 24 weeks. The recommendation by the obstetric doctor had been to remain in town for ‘sit down’ due to high risk of pre-term birth. Unfortunately, this woman had a family member pass away and was required to attend the funeral (‘sorry business’) despite the doctor recommending she remain close to hospital.

This woman contacted me repeatedly and asked to go home, I felt my hands were tied and I could only tell her was what the doctor advised. She funded her own way home on an expensive flight, and in secret, because she knew that hospital policy demanded she remain in town for her baby’s safety. My care for this woman was culturally unsafe. The woman returned to town shortly after the funeral to attend antenatal care and delivered a healthy baby at 35 weeks. In order to provide culturally competent care, we must acknowledge that while health is important, cultural needs and wishes are equally important. I understand we don’t have an endless supply of money to assist women in travelling to and from Darwin, but this highlights the importance of place-based care and attending antenatal care in their communities as long as possible.

The inequities in the social determinants of health are particularly significant for Aboriginal women and have a far greater impact on pregnancy and birth than current maternity service policy. I am guilty of treating women temporarily living in Darwin as if this is the same life they would be living back in their remote community – I provide evidence-based care and assist with what social determinants of health I can including dietetic review and supplements if needed, diabetic educator reviews for diabetic women, social work assistance for housing, and domestic violence counselling.

However, when these women return back to their communities, I cannot change their access to food security in their homes, nor can I change their status in the household or gender inequity. I want to provide culturally competent care, but I feel even though I have lived and worked in Darwin for a reasonable time with majority of my experience caring for remote Aboriginal women I still lack insight into what life for them is truly like in their individual communities. I feel personally for me the only way to provide truly culturally competent care would be to immerse myself in their culture through working or spending time in their communities.

In order to provide culturally competent care, we also need to stop treating Aboriginal women and their families as if they all share the same culture. There are approximately 500 Aboriginal communities in the Northern Territory (Northern Territory Government, 2017). And each individual community’s cultural beliefs and values are different. Whilst I had attended a cultural awareness program when I commenced working at RDH, I underestimated the vast difference of cultural beliefs between individual communities. I was culturally aware, but I was not showing cultural humility. I was not spending enough time with women getting to know their individual culture and valuing how important their belief systems were.

Recommendations for Transforming Practice to Enhance Maternal Health:

Using an interpreter when a language barrier is present is critical to enhance maternal health (Brown, Middleton, Fereday & Pincombe, 2016). There are hundreds of dialects in the NT alone which can create difficulty in availability of the right language interpreter. However, using an interpreter ensures that a rapport can be developed with the woman, information sharing is possible, and enables informed decision making ultimately enhancing cultural safety.

Women travelling from a remote community to Darwin is a barrier to effective woman centred care. It is also a culturally unsafe practice to isolate these women from their cultural supports (Brown et al., 2016). Birthing on country is a way to provide holistic and culturally appropriate care for mothers and babies and encompasses spirituality and traditional practices (Kildea, Magick, & Stapleton, 2013, as cited in Australian College of Midwives, 2018). Although there is vast work to be done in this arena, reassuring women their time in Darwin is limited and supporting women to return home to community as soon as possible after birth is essential.

A systematic review identified accessibility as a major barrier to culturally appropriate maternity care (Jones, Lattof & Coast, 2017). Accessibility includes poverty and unaffordability of out-of-pocket costs related to maternity care such as bus or taxi fares. To improve accessibility in accessing MGP services, patient travel buses are used free of cost to facilitate appointments. Additionally, as the primary midwife, if this service is not acceptable to the woman, I myself could transport the client for antenatal care promoting cultural safety.

Birthing in an enabling and safe environment will also enhance maternal health and through MGP Aboriginal women are now accessing the birth centre for birthing if they are experiencing a normal pregnancy (Kildea et al., 2016). Our MGP service is based in the birth centre at RDH, so women are familiar and comfortable with the space. The birth centre is now a place where remote Aboriginal women want to give birth whereas traditionally they have been reluctant due to the unfamiliarity.

Providing culturally appropriate services not only antenatally but also through labour and birth will enhance maternal health (Jones et al., 2017). The World Health Organization (WHO) recommends all woman have access to a companion of their choice throughout labour and birth (WHO, 2018). Devastatingly this is not available to remote Aboriginal women who are ineligible for an escort. These women are required to pay for their support person to attend their birth which is generally impossible due to cost. Culturally appropriate services could be delivered through offering all women the support of the AHP or SWW as an advocate and support person in labour. I will continue to advocate for all women to be entitled to an escort, and if this is not possible, endeavour to help Aboriginal women find a suitable birthing companion from Darwin whether this is family residing in town or the AHP or SWW.

Conclusion:

This reflective case study has examined the current experiences of Aboriginal women experiencing childbirth in the NT, Australia. It has briefly highlighted the inadequacies of the service in ensuring culturally competent care. Reflection of my own personal experiences working with Aboriginal women shows an imbalance between providing culturally competent care and following hospital policy and the medical model of health. Working with MGP is improving culturally appropriate services and we must endeavour to keep antenatal care as close to home as possible and continue striving towards birthing on country for Aboriginal women. Until we achieve this, we will never be able to provide consistently culturally secure care as a system to Aboriginal women.

References

Australian College of Midwives. (2018). Joint Birthing on Country position statement. Retrieved from: https://0-midwives.cdn.aspedia.net/sites/default/files/uploaded -content/field_f_content_file/birthing_on_country_position_statement_0.pdf

Australian Institute of Health and Welfare. (2017). Australia’s mothers and babies 2015 in brief. Retrieved from: https://www.aihw.gov.au/getmedia/728e7dc2 -ced6-47b7-addd-befc9d95af2d/aihw-per-91-inbrief.pdf.aspx?inline=true

Brown, A. E., Middleton, P. F., Fereday, J. A., & Pincombe, J. I. (2016). Cultural safety and midwifery care for Aboriginal women – A phenomenological study. Women and birth, 29, 196-202. http://dx.doi.org/10.1016/j.wombi.2015.10.013

Dietsch, E. (2019). 8047NRS: Global Maternal Health Module, 5.1 [Course Notes]. Retrieved from: https://bblearn.griffith.edu.au/webapps/blackboard/execute/ displayLearningUnit?course_id=_72515_1&content_id=_4158858_1

Ireland, S., Belton, S., McGrath, A., Saggers, S., & Wulili Narjic, C. (2015). Paperbark and pinard: A historical account of maternity care in one remote Australian Aboriginal town. Women and birth, 28, 293-302. http://dx.doi.org/10.1016/j.wombi. 2015.06.002

Ireland, S., Wulili Narjic, C., Belton, S., & Kildea, S. (2011). Niyith Nniyith Watmam (the quiet story): Exploring the experiences of Aboriginal women who give birth in their remote community. Midwifery, 27, 634-641. http://dx.doi.org/10.1016/j.midw. 2010.05.009

Josif, C. M., Barclay, L., Kruske, S., & Kildea, S. (2014). ‘No more strangers’: Investigating the experiences of women, midwives and others during the establishment of a new model of maternity care for remote dwelling Aboriginal women in northern Australia. Midwifery, 30, 317-323. http://dx.doi.org/ 10.1016/j.midw.2013.03.012

Kildea, S., Gao, Y., Rolfe, M., Josif, C. M., Bar-Zeev, S. J., Steenkamp, M., … Barclay, L. M. (2016). Remote links: Redesigning maternity care for Aboriginal women from remote communities in Northern Australia – A comparative cohort study. Midwifery, 34, 47-57. http://dx.doi.org/10.1016/j.midw.2016.01.009

Northern Territory Government. (2017). Services to remote communities and homelands. Retrieved from: https://nt.gov.au/community/local-councils -remote-communities- and-homelands/services-to-remote-communities-and-homelands

World Health Organization. (2018). WHO recommendations: Intrapartum care for a positive childbirth experience. Retrieved from: https://apps.who.int/iris/ bitstream/handle/10665/260178/9789241550215-eng.pdf;jsessionid= B39FE801B9E4474CA427E4460A886F01?sequence=1