Antenatal Care and Indigenous Australians The primary health care approach
Health and Australian Indigenous Peoples Antenatal Care and Indigenous Australians: The Primary Health Care Approach By Kathryn Terrill Why Do We Need To Look At Indigenous Antenatal Care in Australia? In Australia, there are ongoing concerns and criticisms regarding antenatal care. Most of these are centred around lack of continuity of care and caregivers, prolonged waiting times, and inaccessible clinics.1 If these are the concerns of the general population, where do our Indigenous women and babies fit in? Maternal mortality carries a greater risk if you are an Indigenous woman, and the risk of infant mortality is three to four times greater for Indigenous babies than for non-Indigenous babies.2 In the Kingaroy region, of southern Queensland, obstetric outcomes of Indigenous women were compared to those of non-Indigenous women.3 Aboriginal women were found to present later in their pregnancy for antenatal care than their non-Indigenous counterparts. ... The above findings could be thought attributed to the rural setting in which these Aboriginal women lived, for instance the fact that they were 45 kilometres from Kingaroy Base Hospital and lived together in a community, somewhat removed from educational institutions and health services. ... At King George V Memorial Hospital in Camperdown, Sydney, Aboriginal women were again found to present later in their pregnancy for antenatal care, and were again more likely to give birth to low birthweight babies.4 Other findings include increased pre-term births, hypertension, urinary tract infection, renal disease and cigarette smoking in the Indigenous women. ... Obviously these workers, or their utilisation, are not enough to bring Indigenous obstetric outcomes in line with the national standard. ... 6 One author reports that predictors for having a small for gestational age (SGA) infant are low maternal pregnancy weight, low gestational weight gain, presenting for antenatal care after 20 weeks, and low maternal age and parity.7 The King George V Memorial Hospital study also identifies that late presentation for antenatal care strongly correlates with low birthweight births in Aboriginal women. ... 10 Presenting earlier for antenatal care could not only directly reduce the risk of giving birth to a SGA baby, as the above research suggests, but could also reduce the prevalence of other perceived causes of low birthweight. ... So, the question is, what can be done to improve Indigenous women’s access to antenatal services? The Primary Health Care Approach First we need to ask ourselves why Indigenous women do not present themselves regularly to mainstream antenatal services. One investigation11 found that the main reason given by Indigenous women for their unwillingness to attend these services was the difficulty they had with communicating with and relating to hospital staff. ... The Primary Health Care model offers solutions to these problems through an entirely different approach to mainstream health care. The concept of Primary Health Care (PHC) was formally endorsed in 1978, with the Declaration of Alma-Ata, which was supported by representatives from 134 nations. The declaration emerged from international concern that health care systems had become focused on costly high technology care, whilst compromising the provision of even basic health care services for the majority of the world’s people.12 The PHC approach emphasises equity, social justice, community participation and responsiveness to the needs of the local people. ... The process involves using approaches which are affordable, and therefore sustainable, and ideally involves all levels of the health care system to address the root causes of ill-health.13 There is a recognition that new health services alone are not the solution, rather a major reorientation is needed in the way we both think about and act on health issues. Health promotion (HP) is an important component of PHC. The Ottawa Charter for Health Promotion, derived in 1986 from the first International Conference on Health Promotion, describes HP as a process that enables people to gain greater control over, and therefore improve, their health.14 The main principles include strengthening community action, developing personal skills, creating supportive environments, reorientating health services, and enabling people to meet their fullest health potential. HP is also focused on mediating between differing interests in society for the pursuit of health, and advocating favourable political, economic, social, environmental, cultural, behavioural and biological conditions through the advocacy of health.15 Health Promotion is implemented by and with people, not on or to people.16 Primary Health Care and Health Promotion in Australia It is fundamental that all health promotion workers are knowledgable about the cultural and sociopolitical context that frames their work. This is essential when working with Indigenous people, who are likely to have a different concept of health than most other Australians. ... Health promotors must have a thorough understanding of Indigenous people’s cultural views of the land, family, law and community.18 For this reason it is crucial that Aboriginal Health Workers be the prime deliverers of programs. Successful PHC antenatal programs have been implemented in Australia. ... The service offers care, encouragement, and support for Aboriginal women and non-Aboriginal women with an Aboriginal partner, who live within a 100 kilometre radius of Tamworth. The service employs two Aboriginal Health Education Officers (HEOs) and a community midwife, and is accessible between the beginning of the antenatal period to the end of the first year of the baby’s life. ... The service is staffed primarily with Indigenous workers who are mothers themselves. ... As well as the strong links forged with the community, the AMS works closely with numerous services and agencies such as Mental Health, Social Workers, Paediatricians, Women’s Refuge, Family Day Care, Aboriginal Housing Organisations, Community Transport, Centrelink and the Department of Community Services (DOCS). The aim of the AMS is to assist women with accessing mainstream services as well as providing information on all aspects of antenatal and postnatal care, including information on breastfeeding, vaccinations, contraception, nutrition and exercise, smoking, and general mothering skills. ... The AMS is a fine example of how PHC at a community level can potentially make a significant improvement to the health status of Indigenous women and their babies. ... Ngua Gundi was also funded by the ABS program, and employed a full-time midwife, a part-time Aboriginal health worker, and an Aboriginal driver, who went on to complete a Diploma in Primary Health Care. The service was appropriately located in a residential home in an area of Rockhampton where the majority of Indigenous people reside. ... In January, 1997, the midwife and health worker were awarded an Australia Day medallion, which seemed to instil an even greater sense of pride for the service within the community. ... Ngua Gundi was a successful program run at little cost, that provided not only improved education and access to antenatal services, but instilled a sense of hope, pride and ‘self determination’ into the local community. ... How Do Community-Based Antenatal Care Programs for all Australians Compare to Indigenous Antenatal Care Programs? Community-based antenatal services are uncommon in the Australian public health system.22 In response to ongoing dissatisfaction with hospital antenatal care, a study was conducted between January 1997 and March 1999, with the objective of evaluating women’s perceptions of a community-based model of care. The model chosen was called the St George Outreach Maternity Project (STOMP)23, which was found to be very successful in providing easier access to care and reduced waiting times. Women also reported a higher perceived ‘quality’ of antenatal care compared with the control group. ... Care was provided at two outreach clinics staffed by team midwives and an obstetrician or obstetric registrar. ... Nowhere in the article was the provision of culturally appropriate strategies for Indigenous women mentioned. In fact Indigenous women were not even mentioned at all. This is a good example of how the people with the greatest need in this country for improved antenatal care are largely invisible in the eyes of the very people with the power to improve it. Primary Health Care Worldwide: Maternal and Child Health Programs in Ethiopia In Ethiopia, it has been recognised that community-based approaches are important in developing and sustaining maternal and child health programs.24 The Ethiopian government has engaged in a health-sector reform that will decentralise and reorient the health system in the hope of providing better access to improved quality health care. ... This process requires the health workers to engage in adequate training to communicate with the communities in an ongoing dialogue, and form working groups with community representation. The goal is for the health staff and the communities to jointly identify and prioritise health problems, and then develop plans to solve them. ... Much of the communication that took place regarding the prevalence or importance of maternal and child health issues was done using local materials, such as sticks or berries, for tallying and ranking by the local people. ... One year after implementation, follow up studies have shown statistically significant improvements in several indicators including breastfeeding and antenatal care. ... The health system is extremely poor, with access even poorer. Only 55 percent of the population are within one hour’s walk or travel to health facilities. ... Hopefully, the success of the reform will continue and Ethiopia will set a fine example of the efficacy of a community-based approach that will be headed by other health organisations around the world. The Role of a Naturopath in Indigenous Health The PHC programs discussed above encompass a holistic framework, which is very similar to the practice and philosophy of Naturopathy. Although the profession of Naturopathy is not commonly utilised in our current health service for Indigenous Australians, there is much that Naturopaths can offer. ... Naturopathic philosophy also has much in common with traditional ways of Indigenous healing. Personally, I believe I have much to offer in the area of Indigenous health. ... As a non-Indigenous person I see my role as a supportive one, that would be led by those that make up the community in which I work. Through this I would offer advice and support, whilst always focussing on empowering the Indigenous workers. ... I would certainly not arrive immediately preaching all that I know about health and wellness. ... I don’t think this would be a huge issue, though, as for me, seeing the rewards of empowering the Indigenous people and helping to bring about change would far outweigh the rewards of power and control. ... Conclusions and Recommendations Antenatal care for Indigenous Australians is in a very poor state. Indigenous mothers and their babies are far more likely to become ill or die than their non-Indigenous counterparts. Major factors contributing to this are maternal practices such as undernourishment, disease or smoking; the late presentation for antenatal care by Indigenous mothers; and the low birthweights of Indigenous babies. Cultural factors contributing to reduced access to mainstream antenatal care have been identified as a major breakdown in achieving improved health and wellbeing for Aboriginal mothers and their babies. Primary Health Care programs have proved important in bridging these gaps. ... Both Indigenous antenatal care services discussed in this paper were funded through the Commonwealth Government’s Alternative Birthing Services program. ... 28 The STOMP program discussed above provides a fine example of integrating community-based antenatal care into already existing services without the need for additional funding. Unfortunately, Indigenous people were not considered in their project. What is needed is a greater recognition at all levels for the need of culturally sensitive programs for Indigenous women, which are catered for via a restructuring of the existing system, not additional funding. ... What do women feel about community-based antenatal care? Australian and New Zealand Journal of Public Health. ... Health in Australia: Sociological Concepts and Issues. ... Rural Health. ... Australian and New Zealand Journal of Public Health. ... Early Life Influences on Later Health: The Role of Nutrition. ... Australian and New Zealand Journal of Public Health. ... Early Life Influences on Later Health: The Role of Nutrition. ... Daruk Aboriginal Medical Service and Western Sector Public Health Unit (1998). Evaluation of the Daruk AMS Antenatal Program 1998. Report to the National Health and Medical Research Council. ... Promoting Health: The Primary Health Care Approach. ... Promoting Health: The Primary Health Care Approach. ... World Health Organisation (1996). ‘The Ottawa Charter for Health Promotion, 21st day of November’. In Wass A (1998) Promoting Health: The Primary Health Care Approach. ... World Health Organisation (1996). ‘The Ottawa Charter for Health Promotion, 21st day of November’. In Wass A (1998) Promoting Health: The Primary Health Care Approach. ... World Health Organisation (1997). ‘The Jakarta Declaration in Leading Health Promotion into the 21st Century, 21st July.’ In Wass A (1998) Promoting Health: The Primary Health Care Approach. ... Health Promotion: Principles and Practice in the Australian Context. ... Health Promotion: Principles and Practice in the Australian Context. ... Aboriginal and Islander Health Worker Journal. ... Aboriginal and Islander Health Worker Journal. ... Aboriginal and Islander Health Worker Journal. ... What do women feel about community-based antenatal care? Australian and New Zealand Journal of Public Health. ... What do women feel about community-based antenatal care? Australian and New Zealand Journal of Public Health. ... Community Assessment and Planning for Maternal and Child Health Programs: A Participatory Approach in Ethiopia. ... Community Assessment and Planning for Maternal and Child Health Programs: A Participatory Approach in Ethiopia. ... Community Assessment and Planning for Maternal and Child Health Programs: A Participatory Approach in Ethiopia. ... Community Assessment and Planning for Maternal and Child Health Programs: A Participatory Approach in Ethiopia. ... What do women feel about community-based antenatal care? Australian and New Zealand Journal of Public Health. ... Health and Australian Indigenous Peoples Antenatal Care and Indigenous Australians: The Primary Health Care Approach By Kathryn Terrill Why Do We Need To Look At Indigenous Antenatal Care in Australia? In Australia, there are ongoing concerns and criticisms regarding antenatal care. Most of these are centred around lack of continuity of care and caregivers, prolonged waiting times, and inaccessible clinics.1 If these are the concerns of the general population, where do our Indigenous women and babies fit in? Maternal mortality carries a greater risk if you are an Indigenous woman, and the risk of infant mortality is three to four times greater for Indigenous babies than for non-Indigenous babies.2 In the Kingaroy region, of southern Queensland, obstetric outcomes of Indigenous women were compared to those of non-Indigenous women.3 Aboriginal women were found to present later in their pregnancy for antenatal care than their non-Indigenous counterparts. ... The above findings could be thought attributed to the rural setting in which these Aboriginal women lived, for instance the fact that they were 45 kilometres from Kingaroy Base Hospital and lived together in a community, somewhat removed from educational institutions and health services. ... At King George V Memorial Hospital in Camperdown, Sydney, Aboriginal women were again found to present later in their pregnancy for antenatal care, and were again more likely to give birth to low birthweight babies.4 Other findings include increased pre-term births, hypertension, urinary tract infection, renal disease and cigarette smoking in the Indigenous women. ... Obviously these workers, or their utilisation, are not enough to bring Indigenous obstetric outcomes in line with the national standard. ... 6 One author reports that predictors for having a small for gestational age (SGA) infant are low maternal pregnancy weight, low gestational weight gain, presenting for antenatal care after 20 weeks, and low maternal age and parity.7 The King George V Memorial Hospital study also identifies that late presentation for antenatal care strongly correlates with low birthweight births in Aboriginal women. ... 10 Presenting earlier for antenatal care could not only directly reduce the risk of giving birth to a SGA baby, as the above research suggests, but could also reduce the prevalence of other perceived causes of low birthweight. ... So, the question is, what can be done to improve Indigenous women’s access to antenatal services? The Primary Health Care Approach First we need to ask ourselves why Indigenous women do not present themselves regularly to mainstream antenatal services. One investigation11 found that the main reason given by Indigenous women for their unwillingness to attend these services was the difficulty they had with communicating with and relating to hospital staff. ... The Primary Health Care model offers solutions to these problems through an entirely different approach to mainstream health care. The concept of Primary Health Care (PHC) was formally endorsed in 1978, with the Declaration of Alma-Ata, which was supported by representatives from 134 nations. The declaration emerged from international concern that health care systems had become focused on costly high technology care, whilst compromising the provision of even basic health care services for the majority of the world’s people.12 The PHC approach emphasises equity, social justice, community participation and responsiveness to the needs of the local people. ... The process involves using approaches which are affordable, and therefore sustainable, and ideally involves all levels of the health care system to address the root causes of ill-health.13 There is a recognition that new health services alone are not the solution, rather a major reorientation is needed in the way we both think about and act on health issues. Health promotion (HP) is an important component of PHC. The Ottawa Charter for Health Promotion, derived in 1986 from the first International Conference on Health Promotion, describes HP as a process that enables people to gain greater control over, and therefore improve, their health.14 The main principles include strengthening community action, developing personal skills, creating supportive environments, reorientating health services, and enabling people to meet their fullest health potential. HP is also focused on mediating between differing interests in society for the pursuit of health, and advocating favourable political, economic, social, environmental, cultural, behavioural and biological conditions through the advocacy of health.15 Health Promotion is implemented by and with people, not on or to people.16 Primary Health Care and Health Promotion in Australia It is fundamental that all health promotion workers are knowledgable about the cultural and sociopolitical context that frames their work. This is essential when working with Indigenous people, who are likely to have a different concept of health than most other Australians. ... Health promotors must have a thorough understanding of Indigenous people’s cultural views of the land, family, law and community.18 For this reason it is crucial that Aboriginal Health Workers be the prime deliverers of programs. Successful PHC antenatal programs have been implemented in Australia. ... The service offers care, encouragement, and support for Aboriginal women and non-Aboriginal women with an Aboriginal partner, who live within a 100 kilometre radius of Tamworth. The service employs two Aboriginal Health Education Officers (HEOs) and a community midwife, and is accessible between the beginning of the antenatal period to the end of the first year of the baby’s life. ... The service is staffed primarily with Indigenous workers who are mothers themselves. ... As well as the strong links forged with the community, the AMS works closely with numerous services and agencies such as Mental Health, Social Workers, Paediatricians, Women’s Refuge, Family Day Care, Aboriginal Housing Organisations, Community Transport, Centrelink and the Department of Community Services (DOCS). The aim of the AMS is to assist women with accessing mainstream services as well as providing information on all aspects of antenatal and postnatal care, including information on breastfeeding, vaccinations, contraception, nutrition and exercise, smoking, and general mothering skills. ... The AMS is a fine example of how PHC at a community level can potentially make a significant improvement to the health status of Indigenous women and their babies. ... Ngua Gundi was also funded by the ABS program, and employed a full-time midwife, a part-time Aboriginal health worker, and an Aboriginal driver, who went on to complete a Diploma in Primary Health Care. The service was appropriately located in a residential home in an area of Rockhampton where the majority of Indigenous people reside. ... In January, 1997, the midwife and health worker were awarded an Australia Day medallion, which seemed to instil an even greater sense of pride for the service within the community. ... Ngua Gundi was a successful program run at little cost, that provided not only improved education and access to antenatal services, but instilled a sense of hope, pride and ‘self determination’ into the local community. ... How Do Community-Based Antenatal Care Programs for all Australians Compare to Indigenous Antenatal Care Programs? Community-based antenatal services are uncommon in the Australian public health system.22 In response to ongoing dissatisfaction with hospital antenatal care, a study was conducted between January 1997 and March 1999, with the objective of evaluating women’s perceptions of a community-based model of care. The model chosen was called the St George Outreach Maternity Project (STOMP)23, which was found to be very successful in providing easier access to care and reduced waiting times. Women also reported a higher perceived ‘quality’ of antenatal care compared with the control group. ... Care was provided at two outreach clinics staffed by team midwives and an obstetrician or obstetric registrar. ... Nowhere in the article was the provision of culturally appropriate strategies for Indigenous women mentioned. In fact Indigenous women were not even mentioned at all. This is a good example of how the people with the greatest need in this country for improved antenatal care are largely invisible in the eyes of the very people with the power to improve it. Primary Health Care Worldwide: Maternal and Child Health Programs in Ethiopia In Ethiopia, it has been recognised that community-based approaches are important in developing and sustaining maternal and child health programs.24 The Ethiopian government has engaged in a health-sector reform that will decentralise and reorient the health system in the hope of providing better access to improved quality health care. ... This process requires the health workers to engage in adequate training to communicate with the communities in an ongoing dialogue, and form working groups with community representation. The goal is for the health staff and the communities to jointly identify and prioritise health problems, and then develop plans to solve them. ... Much of the communication that took place regarding the prevalence or importance of maternal and child health issues was done using local materials, such as sticks or berries, for tallying and ranking by the local people. ... One year after implementation, follow up studies have shown statistically significant improvements in several indicators including breastfeeding and antenatal care. ... The health system is extremely poor, with access even poorer. Only 55 percent of the population are within one hour’s walk or travel to health facilities. ... Hopefully, the success of the reform will continue and Ethiopia will set a fine example of the efficacy of a community-based approach that will be headed by other health organisations around the world. The Role of a Naturopath in Indigenous Health The PHC programs discussed above encompass a holistic framework, which is very similar to the practice and philosophy of Naturopathy. Although the profession of Naturopathy is not commonly utilised in our current health service for Indigenous Australians, there is much that Naturopaths can offer. ... Naturopathic philosophy also has much in common with traditional ways of Indigenous healing. Personally, I believe I have much to offer in the area of Indigenous health. ... As a non-Indigenous person I see my role as a supportive one, that would be led by those that make up the community in which I work. Through this I would offer advice and support, whilst always focussing on empowering the Indigenous workers. ... I would certainly not arrive immediately preaching all that I know about health and wellness. ... I don’t think this would be a huge issue, though, as for me, seeing the rewards of empowering the Indigenous people and helping to bring about change would far outweigh the rewards of power and control. ... Conclusions and Recommendations Antenatal care for Indigenous Australians is in a very poor state. Indigenous mothers and their babies are far more likely to become ill or die than their non-Indigenous counterparts. Major factors contributing to this are maternal practices such as undernourishment, disease or smoking; the late presentation for antenatal care by Indigenous mothers; and the low birthweights of Indigenous babies. Cultural factors contributing to reduced access to mainstream antenatal care have been identified as a major breakdown in achieving improved health and wellbeing for Aboriginal mothers and their babies. Primary Health Care programs have proved important in bridging these gaps. ... Both Indigenous antenatal care services discussed in this paper were funded through the Commonwealth Government’s Alternative Birthing Services program. ... 28 The STOMP program discussed above provides a fine example of integrating community-based antenatal care into already existing services without the need for additional funding. Unfortunately, Indigenous people were not considered in their project. What is needed is a greater recognition at all levels for the need of culturally sensitive programs for Indigenous women, which are catered for via a restructuring of the existing system, not additional funding. ... What do women feel about community-based antenatal care? Australian and New Zealand Journal of Public Health. ... Health in Australia: Sociological Concepts and Issues. ... Rural Health. ... Australian and New Zealand Journal of Public Health. ... Early Life Influences on Later Health: The Role of Nutrition. ... Australian and New Zealand Journal of Public Health. ... Early Life Influences on Later Health: The Role of Nutrition. ... Daruk Aboriginal Medical Service and Western Sector Public Health Unit (1998). Evaluation of the Daruk AMS Antenatal Program 1998. Report to the National Health and Medical Research Council.