Poche Opinion – Birthing on Country
BIRTHING ON COUNTRY
On 30 May 2018, the Poche Indigenous Health Network hosted its 9th Key Thinkers Forum, bringing together professionals, community members, academics, students and policy makers. This ‘Poche Opinion’ explores some of the key thematic issues raised during the forum. Professor Tom Calma AO, Patron and Chair of the Poche Network, facilitated the forum, guiding the conversation between audience members and a panel of guest speakers.
Panel members included:
- Cherisse Buzzacott, Project Officer for the Birthing on Country Project, Australian
College of Midwives;
- Renee Blackman, Director of Health Services for the Brisbane Aboriginal and Torres
Strait Islander Community Health Service.
- Dr Donna Hartz (RN, RM, M Mid Studies, PhD, FACM), Acting Director of the
National Centre for Cultural Competence (USYD); and
- Janine Mohamed, CEO of the Congress of Aboriginal and Torres Strait Islander
Nurses and Midwives (CATSINaM)
In order to stimulate the discussion, a Briefing Paper was made available prior to the event, and the Forum was accessible online via the University of Sydney IT team. The video recording is available HERE. You can download a copy of the event program HERE and PowerPoint presentations HERE.
Poche Opinion- Birthing on Country
What it is
Birthing on Country is not just one element, it as a whole concept; “a metaphor for the best
start in life for Aboriginal and Torres Strait Islander babies and their families, an appropriate
transition to motherhood and parenting for women, and an integrated, holistic and culturally
appropriate model of care… not only bio-physical outcomes … it’s much, much broader
than just the labour and delivery … (it) deals with socio-cultural and spiritual risk that is not
dealt with in the current systems (1)”
(1) Birthing on Country Workshop Report 2012
From the discussion at the Key Thinkers Forum, it was clear that this is not a new area of
consideration or exploration. The issue is one that has existed ever since health care has
become more mainstream and integrated in its approach in Australia. Though there has
been progress within the last two hundred years, there have also been many setbacks and
more recently the closure of rural and remote birth centres stands as one of the greatest
barriers to making real progress in this area.
The health inequities are often a result of compounding grief and trauma, long term suffering
and poor health outcomes among Indigenous populations. Much research has been done
into what could and would improve outcomes for Aboriginal mothers and babies. There is
clear evidence that affected mothers and babies have gotten lost in a system, and that local
community support is sorely lacking. Not only is there evidence as to the detrimental
outcomes of such a system, but it has also been established what would assist in the
improvement of these outcomes.
This includes (but is not limited to) many factors:
- The inclusion of Aboriginal and/or Torres Strait Islander programs in birthing and
- Informed choice and right of refusal for mothers and families
- Appropriate health promotion – the translation of mainstream health messages to
ensure they are widely understood
- Building and strengthening of relationships within birthing and midwifery practices to establish trust
- Aboriginal governance of birthing and midwifery practices.
The Rise Model sums these factors up:
Redesign health service delivery
Invest in Indigenous Maternal Infant Health (MIH) workforce
Embed community investment/ownership/activation
Improvement in birthing and midwifery practices is not only a matter of convenience for
affected women and families, it is a matter of spirit. The lack of cultural training and
therefore cultural safety in the larger rural and urban centres becomes writ large and
increases the risk of danger for the Aboriginal mothers and babies. Some women even find
themselves unable to check themselves and their babies in to such services due to fear of
the outcome and how they will be treated. The obvious possible repercussions of avoiding
the existing services multiplies the risk to these women and babies.
While Aboriginal governance has been proven to improve outcomes, it is also accepted that
services need to work in with the mainstream health care. In fact, the safest intervention of all is an educated midwife and if this midwife is Aboriginal and provides continuity of care,
then most of the fear and risk can be taken out of the equation. In the absence of Aboriginal
governance, or arguably in conjunction with Aboriginal governance, there needs to be a
strong focus on cross cultural training and awareness of diversity of needs of Indigenous
people within the health system. It must also be remembered that cultural safety is defined
by the recipient of care, rather than the caregiver or practitioner!
While it’s fair to say that not every remote town can have a birth centre, access needs to
improve to services, workforce and community education. It has been identified that we
require 600 more Indigenous midwives to reach parity with non-Indigenous midwives.
Nurses and midwives are the largest group in the health workforce and if cultural safety
were the foundations of their care, the health outcomes for mothers and babies would
Though it is important to look at the issue from a strengths base, it is also important to
acknowledge that institutional racism and unconscious bias are issues in Australia and in
the area of health. The statistics are confronting. For example, Indigenous mothers still
suffer three times the mortality rate of non-Indigenous mothers. Premature babies are
double the rate when compared to non-Indigenous babies and this is the same for low
birthweight babies. Indigenous peoples continue to have a greater disposition to chronic
disease in later life and a clear link has been made to complications in utero and around the
time of birth. A significant contributing behaviour is both active and passive smoking by
Indigenous mothers that is over three time the rate of non Indigenous mothers.
Health care service delivery must acknowledge the intersections of the ongoing impacts on
colonisation, dispossession, ‘white privilege’, dominant culture values and the impact this
continues to have on the wellbeing of Indigenous people. Practitioners must be holistic and
self-aware of our own biases and our embodiment of socio-cultural and institutional norms,
which may perpetuate the current state of race relations and discrimination.
We need improvement in these areas and we know the ways to achieve that. We need to reconnect
with family and community and build the Aboriginal workforce so there is a firm
basis of support for mothers and babies throughout pregnancy and birth. Facilities need to
become culturally safe, respectful and welcoming. Equity measures are required to achieve
Policy surrounding this issue is still lacking in the concept of the ‘sense of belonging’.
Connection to country is felt as a spiritual imperative by Aboriginal people and there have
been instances whereby mothers put their own place of birth on the certificates of their
babies so as to acknowledge this connection and sense of belonging. The onus on the
health service should be to ask the mothers who their community is, and to follow up that
relationship and consult with that community.
While well researched, Birthing on Country is still an area that needs more growth and
funding. The focus needs to be on workforce, population health education, including
smoking cessation and non take-up and connection and belonging. This is the only way that
we can reduce inequity and inequality that currently exists.
Work of the Poche Centre and Network
The Poche Centre for Indigenous Health, along with the Poche Indigenous Health Network
are working towards improvement in Birthing on Country. Aside from our ongoing
collaboration with the leading experts and academics in this area, the Poche Centre offers a
Scholarship program, which is focussed around building the Indigenous workforce. The
Centre is also working with NSW Ministry of Health (including several local health districts)
and the Rhodanthe Lipsett Charitable Midwives Trust and the National Centre for Cultural
Competence on a demonstration project in Aboriginal midwifery. This project aims to build
the workforce and subsequently improve the outcomes in order to build evidence for future
improvement in policy.
The Poche Centre for Indigenous Healthwill continue to work with and support the
Congress of Aboriginal and Torres Strait Islander Nurses and Midwives (CATSINaM),
the Australian College of Midwives and Indigenous communities to advocate for
Birthing on Country.