Introduction

Urged by a national public awareness campaign in 2008, the Council of Australian Governments (COAG) formally committed to “Closing the Gap” between the health outcomes of Indigenous and non-Indigenous Australians within a generation.[1] Almost a decade since this agreement, significant discrepancies persist.

This cycle of poor health outcomes is underpinned by more than two hundred years of systematic dispossession and underinvestment; exacerbated by a distinct lack of accessible facilities offering culturally sensitive resources to Indigenous women. The responsibility to overcome this entrenched cycle of endemic disadvantage compels all members of civil society, government policy makers, and key stakeholders in the education, health and social support spheres to “Close the Gap.”

The Department of Health and Aging stipulates that Australia is considered to be one of the safest countries in the world for a woman to experience pregnancy and childbirth.[2] However, this statement is not an absolute certitude, as it remains grossly inconsistent with the reality of many women living within Australia.[3]

Within the contemporary Australian context, there exists a vast disparity in the outcomes relating to maternal, antenatal, and perinatal and infant health among Indigenous women and infants when compared to non-Indigenous Australians.[4] Merely four per cent of women who gave birth during 2012 in Australia identified as Indigenous,[5] however these women are disproportionately affected by higher rates of maternal morbidity and mortality compared to non-Indigenous women.[6] Their infants suffer higher incidences of foetal, neonatal, and infant death than their non-Indigenous co-residents.[7]

Evidently, these discrepancies in health status do not exist within a vacuum. The intersectional disadvantage experienced by Indigenous women on the basis of their gender, ethnicity, and socioeconomic status has consistently lead to marginalisation and oppression from the economic and social mainstream. As a result, health problems inevitably have and will continue to proliferate unless these root causes are recognised and addressed.[8]

These barriers discourage Indigenous women from engaging with the limited health facilities available to them, thus perpetuating a vicious, transgenerational cycle of poor health throughout the woman’s life and particularly during pregnancy and childbirth.[9] In order to overcome the multidimensional barriers that hinder the provision of culturally sensitive healthcare demands, the issue requires the development of equity-based policies that prioritise the operationalization of community consultation. This will ensure that holistic strategies are developed with, and not merely for, the Indigenous women and infants of Australia.

Australia’s Indigenous health status in a global context

Having mandated the complex and multifaceted area of health as a focus for the UN Permanent Forum on Indigenous Issues,[10] international rhetoric around the issue continues to espouse health as a fundamental human right, echoing the constitution of the World Health Organisation.[11]Specifically, improving access to adequate reproductive healthcare for women and decreasing maternal and infant mortality rates have been posited as global priorities by the UN over the last 15 years. These aims were codified in the Millennium Development Goals (MDG)[12] and have since been included in Goal 3 of the Sustainable Development Goals (SDGs) that replaced the MDGs in September 2015.

The 2015 UN evaluation of the MDG targets considered national progress between countries and excluded explicitly assessing sector-specific trends.[13] This is significant as the OECD stipulates that countries acknowledge the socioeconomic spectrum that underpins the health status of its population.[14] Sustainable Development Goal 10 “Reduced Inequality” directly addresses the dire situation still facing Indigenous populations.[15] Despite these efforts, poor health status among Indigenous populations remains an acute and urgent global issue.[16]

Indigenous populations of developed nations such as New Zealand, Canada and the United States have consistently lower life expectancies coupled with higher incidences of disease throughout the lifespan of women and children.[17] Research indicates that health disparities between Indigenous and non-Indigenous people in Australia are far more severe when compared to those of other developed countries.[18]

Australia and Nepal have the highest inequality in life expectancy between Indigenous and non-Indigenous people.[19] Indigenous Australian males can expect to live approximately eleven years less than non-Indigenous Australian males, while non-Indigenous females have a life expectancy at birth that exceeds that of Indigenous females by approximately nine years. Indigenous Australians are also disproportionately affected by higher incidences of chronic systemic conditions such as cardiovascular disease across their lifespan.[20] The fact that the process of birth and pregnancy presents a significantly increased risk for Australian Indigenous women and their infants is not an anomaly.[21]

The importance of accurate health-related data

The Australian Bureau of Statistics’ (ABS) Census of Population and Housing provides a database of estimates relating to Australia’s Indigenous population.[22] The ABS then undertakes an independent post enumeration survey (PES) to calculate the net undercount.[23] The resultant estimated Indigenous resident population (ERP) is instrumental in reporting the current health status disparities between Indigenous and non-Indigenous co-residents of Australia, including those relating to maternal-infant health.[24]

Ensuring that robust and comprehensive methodology is used to collect reliable data is crucial to ensuring that the magnitude of inequality existing between Indigenous and non-Indigenous Australians is illustrated accurately. Indigenous Australians were disproportionately represented in the 2011 PES undercount, which reached almost 17 per cent in some parts of Australia. One million Census records denoted an unknown Indigenous Status.[25] This significant undercount is highly problematic as the Australian Census data is influential in guiding investment aimed at reducing inequality between cohabitating populations, as well as monitoring the effectiveness of government policy and programs.[26]

The ABS and the Australian Institute of Health and Welfare (AIHW) acknowledge that geographical locations hindered the collection of reliable data for the Indigenous population.[27] While the majority of Indigenous Australians live within metropolitan or regional areas, 142,900 Indigenous Australians are reported to live in remote or rural locations.[28] Their disproportionate level of poor health occurs as result of environment-specific factors that include: increased distance to adequate health infrastructure; social isolation; and increased socioeconomic disadvantage.[29] The consequences of applying collected data about metropolitan-dwelling Indigenous Australians to those who are geographically isolated has likely led to a statistical underestimation of the severity of the health status disparities between Indigenous and non-Indigenous maternal-infant mortality and morbidity.[30]

Data collection and subsequent investment into the provision of needs-based public healthcare is generally the principal responsibility of respective State and territory governments.[31] However, it is crucial that the development and implementation of a comprehensive Indigenous data collection strategy incorporates a top-down approach that outlines achievable commitment targets for COAG and the healthcare sector. Nationally endorsing the recommended standardised question format to obtain Indigenous self-identification data in a culturally respectful manner within health facilities is a feasible goal that will result in improved measurement of all Indigenous Australians, geographical location notwithstanding.

Social determinants of health and disparities in maternal health status

Policy-makers can engage with the social determinants of health as a theoretical concept and tool for understanding the complex interplay of socioeconomic factors that cause increased risk of morbidity and mortality in Indigenous Australian mothers and infants.[32] Since 1990, the global maternal mortality rate has been reduced by almost 50 per cent.[33] Despite this, Indigenous Australian women are three times more likely to die during pregnancy and childbirth and have double the risk of experiencing severe maternal morbidity during their pregnancy than non-Indigenous women.[34]

It is widely understood that poor maternal health care during pregnancy and childbirth severely impacts the foetus and increases its risk of lifelong health problems.[35] The ABS suggests that Indigenous children aged up to four years old are twice as likely to die during their first year of life[36] and as such are considered to be the most vulnerable group of children within Australia.[37] This statistic is often further complicated by isolating geographical factors: the predisposition of Indigenous women and infants to poor health and limited engagement with healthcare services.

International research suggests that discrepancies in the health status of pregnant Indigenous women may be attributed to both a lack of high quality, antenatal care, which adequately responds their cultural needs and the intersecting categories of socioeconomic disadvantage facing them.[38] Indigenous women are less likely to have completed secondary school, limiting the proportion of them who pursue tertiary education, which subsequently greatly reduces their ability to find employment opportunities and achieve sustained financial stability.[39]

Prioritising cultural sensitivity and community consultation on healthcare

Safeguarding culturally sensitive healthcare services that maintain spirituality, customs and traditions are vital for Indigenous Australians to feel comfortable seeking the services they need.

Indigenous women are more likely to access and improve their health outcomes during pregnancy and childbirth within a system underpinned by holistic healthcare facilities. Community-centric, Indigenous-staffed healthcare services can be implemented throughout rural and remote communities to assist in achieving this outcome. The Townsville Aboriginal and Islander Health Service’s Mums and Babies Project and Daruk Aboriginal Community Controlled Medical Service in Western Sydney are examples of effective and culturally responsible initiatives.[40] These facilities respect Indigenous customs, emphasise maternal autonomy in decision making and create a demand for Indigenous health care practitioners, subsequently increasing the amount of Indigenous mothers engaging with antenatal care.[41]

Significant reductions in rates of maternal and infant mortality can be realised through the nationwide implementation of such holistic, community-centric facilities. To achieve this, intersecting divisions of COAG can actively engage to consult with spokespeople of rural and remote Indigenous communities. Such engagements must encourage the right to be self-determinant in assessing the healthcare needs of Indigenous people and contribute to developing the relevant infrastructure. This is in line with Article 23 of the United Nations Declaration on the Rights of Indigenous Peoples, which states that Indigenous peoples “have the right to be actively involved in developing and determining health…economic and social programmes affecting them and….administer such programmes through their own institutions.”[42]

Since the abolition of the Aboriginal and Torres Strait Islander Commission in 2005, there is a distinct lack of legitimate platforms through which Indigenous Australians have the opportunity to be formally involved in the policy processes that affect them.[43] This current status quo is a barrier to the formulation of legitimate, needs-based national health policy and infrastructure.

Indigenous Australians are chronically under-represented in the healthcare workforce across all sectors.[44] This under-representation is a barrier to the provision of culturally sensitive healthcare that adequately responds to the needs of Indigenous women.[45] As international evidence suggests that Indigenous women are more likely to engage with health services when delivered by Indigenous health professionals,[46] it is recommended that secondary schools strive to develop partnership programmes with both mainstream and Indigenous community-run healthcare services. These partnerships will act as channels through which Indigenous youth can positively engage with, and be mentored by role models in the healthcare sector.

Finally, secondary schools, universities, TAFEs and other key stakeholders should pledge to implement scholarships for Indigenous youth to gain qualifications that will enable them to work in healthcare both within their own communities and in the sector more broadly. A national operationalisation of this initiative would complement existing schemes such as the South Australian Aboriginal Health Scholarship, while also striving to actively encourage Indigenous students to complete secondary school.[47] Over time, increasing the Indigenous healthcare workforce will engage more Indigenous mothers with safe, respectful antenatal care, thus reducing the overall prevalence of maternal and infant health problems.[48]

Conclusion

Historically, Australians who belong to the lower level of social stratification experience exponentially worse health outcomes. This unfortunate reality should compel the Australian Government to devise and implement robust, evidence-based policy that rectifies the human rights failings and socioeconomic disadvantages faced by Indigenous mothers and infants. The ultimate success of these strategies is dependent on the accuracy of ABS data on Indigenous Australians in tandem with the maintenance of respectful partnerships and ongoing consultation with Indigenous communities to develop and implement culturally sensitive maternal-infant healthcare.

References: 

[1] Department of Families, Housing, Community Services and Indigenous Affairs (FaHCSIA). (2012). Closing the Gap: Prime Minister’s report 2012. FaHCSIA, Canberra, Australian Capital Territory.

[2] Department of Health and Aging. (2008). Improving maternity services in Australia: A discussion paper from the Australian Government. Canberra, ACT: Commonwealth of Australia.

[3] Kildea, S., Kruske, S., Barclay, L., & Tracy, S. (2010). ‘Closing the Gap’: How maternity services can contribute to reducing poor maternal infant health outcomes for Aboriginal and Torres Strait Islander women. Rural and Remote Health, 10.

[4] AIHW: Australian Institute of Health and Welfare (2014a). Hilder L, Zhichao Z, Parker M, Jahan S, Chambers G. M. (2014). Australia’s mothers and babies 2012. Perinatal statistics series no. 30. Cat. no. PER 69. Canberra: AIHW.

[5] AIHW: Australian Institute of Health and Welfare (2014b). Johnson S, Bonello MR, Li Z, Hilder L & Sullivan EA. 2014. Maternal deaths in Australia 2006–2010, Maternal deaths series no. 4. Cat. no. PER 61. viewed 14 April 2016, http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129548375

[6] AIHW: Australian Institute of Health and Welfare (2014a).

[7] Ibid.

[8] Bowleg, L. (2012). The problem with the phrase women and minorities: intersectionality—an important theoretical framework for public health. American journal of public health, 102(7), 1267-1273.

[9] Reibel, T., Morrison, L., Griffin, D., Chapman, L., & Woods, H. (2015). Young Aboriginal women’s voices on pregnancy care: Factors encouraging antenatal engagement. Women and Birth, 28(1), 47-53.

[10] United Nations Permanent Forum on Indigenous Issues. (2015). State of the World’s Indigenous Peoples : 2nd Volume, available at: http://www.refworld.org/docid/55c89dac4.html [accessed 29 April 2016]

[11] World Health Organization. (2006). Constitution of the World Health Organization. Basic Documents, Supplement, October 2006. Geneva, Switzerland: WHO. http://www.who.int/governance/eb/who_constitution_en.pdf

[12] Travis, P., Bennett, S., Haines, A., Pang, T., Bhutta, Z., Hyder, A. A., & Evans, T. (2004). Overcoming health-systems constraints to achieve the Millennium Development Goals. The Lancet, 364(9437), 900-906.

[13] Hill, K., Barker, B., & Vos, T. (2007).

[14] de Looper, M. Lafortune, G. (2009) ‘Measuring Disparities in Health Status and in Access and Use of Health Care in OECD Countries’, OECD Health Working Papers, no. 43, OECD Publishing, http://dx.doi.org/10.1787/225748084267

[15] United Nations. (2016). Sustainable Development Goals: Goal 10 Reducing Inequality within and among nations. Retrieved 30 April, 2016, from https://sustainabledevelopment.un.org/sdg10

[16] Hill, K., Barker, B., & Vos, T. (2007). Excess Indigenous mortality: are Indigenous Australians more severely disadvantaged than other Indigenous populations? International Journal of Epidemiology, 36(3), 580-589.

[17] Cunningham, C., & Stanley, F. (2003). The health status of indigenous peoples and others. Human Rights, 2.

[18] Anderson, I., Crengle, S., Kamaka, M. L., Chen, T. H., Palafox, N., & Jackson-Pulver, L. (2006). Indigenous health in Australia, New Zealand, and the Pacific. The Lancet, 367(9524), 1775-1785.

[19] United Nations Permanent Forum on Indigenous Issues. (2015).

[20] ABS: Australian Bureau of Statistics. (2013a). Australian Aboriginal and Torres Strait Islander Health Survey: Updated Results, 2012–13 cat. no 4727.0.55.006, viewed 14 April 2016, http://www.abs.gov.au/ausstats/abs@.nsf/0/5A9A320939BC0A3DCA257CEF002323C3?Opendocument; ABS: Australian Bureau of Statistics (2015). Deaths, Australia, 2014. ABS cat. no. 3302.0. viewed 14 April 2016, http://www.abs.gov.au/AUSSTATS/abs@.nsf/Latestproducts/3302.0Main%20Features72014?opendocument&tabname=Summary&prodno=3302.0&issue=2014&num=&view=

[21] AIHW: Australian Institute of Health and Welfare (2014a).

[22] ABS: Australian Bureau of Statistics. (2012) Census of Population and Housing – Details of Undercount, 2011 cat. no 2940.0, viewed 29 April 2016, http://abs.gov.au/ausstats/abs@.nsf/mf/2940.0

[23] Ibid.

[24] Ibid.

[25] Ibid.

[26] AIHW: Australian Institute of Health and Welfare (2013). Towards better Indigenous health data. Cat. no. IHW 93. Canberra: AIHW.

[27] AIHW: Australian Institute of Health and Welfare (2013).

[28] ABS: Australian Bureau of Statistics (2014) Estimates and projections, Aboriginal and Torres Strait Islander Australians, 2001 to 2026 cat. no. 3238.0, viewed 14 April 2016, http://www.abs.gov.au/ausstats/abs@.nsf/Products/C19A0C6E4794A3FACA257CC900143A3D?opendocument

[29] Leveratt, M. (2006). Rural and remote Australia-equity of access to health care services. Australian Health Consumer, 2(2006-2007), 16.

[30] AIHW: Australian Institute of Health and Welfare (2013). Towards better Indigenous health data. Cat. no. IHW 93. Canberra: AIHW.

[31] Lindquist, A. C., Kurinczuk, J. J., Wallace, E. M., Oats, J., & Knight, M. (2015). Risk factors for maternal morbidity in Victoria, Australia: a population-based study. BMJ open, 5(8), e007903.

[32] Hankivsky, O., Grace, D., Hunting, G., Giesbrecht, M., Fridkin, A., Rudrum, S. & Clark, N. (2014). An intersectionality-based policy analysis framework: critical reflections on a methodology for advancing equity. International journal for equity in health, 13(1), 119.

[33] Travis, P., Bennett, S., Haines, A., Pang, T., Bhutta, Z., Hyder, A. A., & Evans, T. (2004).

[34] AIHW: Australian Institute of Health and Welfare (2014a).

[35] Arabena, K. (2014). The ‘First 1,000 Days’: Implementing Strategies across Victorian Government Agencies to Improve the Health and Wellbeing Outcomes for Aboriginal Children and their Families, Indigenous Health Equity Unit, The University of Melbourne, Melbourne.

[36] ABS: Australian Bureau of Statistics (2015).

[37] Arabena, K. (2014).

[38] de Looper, M. Lafortune, G. (2009).

[39] ABS: Australian Bureau of Statistics. (2012).

[40] Maternity Services Inter-Jurisdictional Committee (MSIJC). (2014). The Characteristics of culturally competent maternity care for Aboriginal and Torres Strait Islander women.

[41] Ibid.

[42] United Nations General Assembly. (2008). United Nations Declaration on the Rights of Indigenous Peoples (A/RES/61/295)

[43] Kildea, S., Kruske, S., Barclay, L., & Tracy, S. (2010).

[44] Reibel, T., Morrison, L., Griffin, D., Chapman, L., & Woods, H. (2015).

[45] Bertilone, C., & McEvoy, S. (2015). Success in Closing the Gap: Favourable neonatal outcomes in a metropolitan Aboriginal Maternity Group Practice Program. The Medical journal of Australia, 203(6), 262-262.

[46] Kildea, S., Kruske, S., Barclay, L., & Tracy, S. (2010).

[47] Maternity Services Inter-Jurisdictional Committee (MSIJC). (2014).

[48] Ibid.