By Kaitlyn Krahe
Kaitlyn represented Victoria University at the 2016 OECD Forum in Paris.
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 (FaHCSIA, 2012). Almost a decade since this agreement, significant discrepancies persist. Of particular concern and even greater urgency are the pervasive inequalities which render Australian Indigenous women twice as likely to experience severe maternal morbidity and three times more likely to die during pregnancy compared to non-Indigenous women (ABS, 2015). Similarly, infants of Indigenous descent have double the risk of dying during their first year of life (AIHW, 2014a). The onus of overcoming this entrenched cycle of endemic disadvantage, underpinned by more than two hundred years of systematic dispossession, exacerbated by decades of underinvestment and a distinct lack of accessible facilities offering culturally competent resources, compels all members of civil society, government policy makers and key stakeholders in the education, health and social support spheres to “Close the Gap”. This paper will posit strategies for improving maternal-infant health outcomes by addressing the root socioeconomic causes which give rise to inequality, better accounting for all Indigenous people in national data collection and developing culturally appropriate and inclusive healthcare using a rights-based, community focused framework.
Recommendation 1: Enhance the accuracy of maternal-infant health outcome statistics by improving the collection of robust, comprehensive Census data with focus on widening the geographical scope of data collection to include all rural and remote Indigenous communities.
Recommendation 2: Endorse standardised, culturally respectful Indigenous identification procedures across Australian health services.
Recommendation 3: COAG and key stakeholders should seek partnership with spokespeople of rural and remote Indigenous communities to conduct ongoing community consultations aimed at reviewing current legislative and policy measures which affect them.
Recommendation 4: Through community consultation and partnership, allow Indigenous spokespeople to posit policy strategies to improve the delivery of culturally appropriate and community-centric maternal-infant health services.
Recommendation 5: Australian secondary schools, universities and TAFEs commit to implementing scholarships for Indigenous people in to gain qualifications which will enable them to enter the mainstream and/or Indigenous health workforce as healthcare practitioners.
Recommendation 6: Secondary schools, universities and TAFEs should establish partnerships with mainstream and Indigenous community controlled health services and;
- Implement co-curricular mentorship programs wherein Indigenous students can positively engage with Indigenous and non-Indigenous role models with the healthcare workforce and;
- Implement exchange programs as a curricular adjunct wherein Indigenous students and non-Indigenous students experience placement in mainstream and Indigenous environments respectively.
Recommendation 7: Where adequate maternal and infant resources and services are yet to be implemented within rural and remote Indigenous communities, develop culturally and socially competent patient transport systems for Indigenous women to be transferred temporarily to mainstream health care facilities.
The Department of Health and Aging stipulates that Australia is considered to be one of the safest countries in the world in which a woman can experience pregnancy and childbirth (Department of Health and Aging, 2008). However, this statement is not an absolute certitude, as it remains grossly inconsistent with the reality of many women living within Australia and the infants born to them (Kildea, Kruske, Barclay & Tracy, 2010). Within the contemporary Australian context, there exists a vast disparity in the outcomes relating to maternal, antenatal and perinatal and infant health amongst Aboriginal and Torres Strait Islanders (hereafter referred to as Indigenous) women and infants when compared to other Australians (AIHW, 2014a).
Whilst only 4% of women who gave birth during 2012 identified as Indigenous (AIHW, 2014b), these women are disproportionately affected by higher rates of maternal morbidity and mortality (AIHW, 2014a) and their infants suffer higher incidences of foetal, neonatal and infant death than their non-Indigenous coresidents (AIHW, 2014a). 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, from which health problems inevitably have and will continue to proliferate unless these root causes are rectifed (Bowleg, 2012).
Inevitably, these barriers discourage Indigenous women from engaging with the limited health facilities available to them, thus perpetuating a vicious, transgenerational cycle of poor health across the lifespan, especially during pregnancy and childbirth (Reibel, Morrison, Griffin, Chapman, & Woods, 2015). Overcoming the multidimensional barriers which hinder the provision of culturally competent health care demands the development of equity-based policies which prioritise the operationalisation of community consultation to ensure that holistic strategies are developed with and not merely for the Indigenous women and infants of Australia.
Contextualising Australian Indigenous Health Status using a Global Perspective
Having mandated the complex and multifaceted of area health as a focus for the United Nations (UN) Permanent Forum on Indigenous Issues (UN, 2015), international rhetoric around the issue continues to echo the constitution of the World Health Organisation, which postulates health as a fundamental human right (WHO, 2006). Specifically improving access to adequate reproductive healthcare for women and decreasing maternal and infant mortality rates have further been posited as global priorities by the UN over the last 15 years, with these aims being quantified within the Millennium Development Goals (MDG) (Travis et al, 2004). Despite these efforts, poor health status amongst Indigenous populations remains an acute and urgent global issue (Hill, Barker, & Vos 2007).
The respective Indigenous populations of developed countries such as New Zealand, Canada and the United States have consistently lower life expectancies coupled with higher incidences of disease throughout the lifespan (Cunningham & Stanley). Research indicates that health disparities between Indigenous and non-Indigenous people in Australia are far more severe when compared to that of other developed countries (Anderson et al, 2006). In fact according to the United Nations (UN), Australia and Nepal have the worst life expectancy inequalities between non Indigenous and Indigenous people globally (United Nations, 2015). Within Australian, Indigenous males can expect to live approximately eleven years less than non-Indigenous males, whilst non-Indigenous females have a life expectancy at birth that exceeds that of Indigenous females by approximately nine years. Australian Indigenous people are also disproportionately affected by higher incidences of chronic, systemic conditions such as cardiovascular disease across the lifespan (ABS, 2013a) (ABS 2015). As such, 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 (AIHW, 2014a).
Using data equality as a means to achieve long term health equality
Information obtained during the Australian Bureau of Statistics Census of Population and Housing is utilised to collate a database of estimates relating to the Indigenous population (ABS, 2012). Following the Census, an independent post enumeration survey (PES) is untaken in order calculate the net undercount (ABS, 2012). The resultant Indigenous estimated resident population (ERP) is instrumental in reporting the current health status disparities between the Indigenous and Non Indigenous co-residents of Australia, including those relating to maternal-infant health (ABS, 2012). As such, ensuring that robust and comprehensive methodology is utilised to collect reliable data is imperative to ensuring that the magnitude of inequality existing between Indigenous and non-Indigenous Australian may be illustrated accurately in derived statistics. For example, Indigenous Australians were disproportionately represented in the 2011 PES undercount, which reached almost 17 per cent in some parts of Australia and further one million Census records denoted an unknown Indigenous Status (ABS, 2012). This significant undercount is highly problematic, as the Australian Census data is formative in guiding investment aimed at attenuating inequality between cohabitating populations, as well as monitoring the success, or otherwise, of government policy and programmes (AIHW, 2013).
The Australian Bureau of Statistics (ABS) and the Australian Institute of Health and Welfare (AIHW) acknowledge that geographical location has hindered the collection of reliable data pertaining to the Indigenous population (AIHW, 2013). Whilst the majority of Indigenous people live within metropolitan or regional areas, 142,900 Indigenous Australians are reported to live within remote and rural environments (ABS, 2014). Those living in remote and rural areas are disproportionately affected by poor health status as a result of unique, environment-specific factors stemming from the increased distance to adequate health infrastructure, social isolation and increased socioeconomic disadvantage (Leveratt, 2006). As such, the consequences of generalising collected data about metropolitan-dwelling Indigenous people 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. (AIHW, 2013).
Data collection and subsequent investment into the provision of needs-based public healthcare is the generally a principal responsibility of respective State and territory governments (Lindquist, Kurinczuk, Wallace, Oats, & Knight, 2015). However, it is crucial that the development and implementation of a comprehensive Indigenous data collection strategy incorporates a top-down approach, outlining commitment targets which sectors of COAG and the healthcare workforce visibly advocate for. 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 and one example of better accounting for all Indigenous Australians, geographical location and other barriers notwithstanding.
Using the Social Determinants of Health to Understand Disparities Between Health Status of Indigenous and non-Indigenous mothers and infants
The 2015 UN evaluation of the MDG targets was tacitly expressed in terms of national progress between countries, without explicitly assessing the trends occurring within them (Hill, Barker, & Vos 2007). This is significant, as the Organisation for Economic Cooperation and Development (OECD) stipulates that permeating almost all countries irrespective of their status as developed or developing, is a socioeconomic spectrum which underpins the health status of cohabiting populations within them (de Looper & Lafortune, 2009). The UN Sustainable Development Goals (SDG) were launched in 2015 upon the expiry of the MDGs (UN, 2016). The SDGs directly address the dire situation still facing Indigenous residents of developed countries such as Australia, positing the need to “reduce inequality within and among counties”.
Since 1990, the global maternal mortality rate has been reduced by almost fifty percent (Travis et al,2004). Despite this, Australian Indigenous 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 (AIHW, 2014a). 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 (de Looper & Lafortune, 2009) and the intersecting categories of socioeconomic disadvantage facing them (de Looper & Lafortune, 2009). Indigenous women are less likely to have completed secondary school, which inevitably limits the proportion of them who pursue tertiary education (ABS 2012). Consequently, employment opportunities are greatly reduced, as well as the ability to achieve sustained financial stability (ABS 2012).
Poor maternal health care during pregnancy and childbirth inevitably impacts the foetus and increases their risk of serious health problems (Arabena, 2014). The ABS posits that Indigenous children aged up to 4 years old are twice as likely to die during their first year of life (ABS 2015) and as such are considered to be the most vulnerable group of children within Australian (Arabena, 2014). Often further complicated by isolating geographical factors, the predisposition of Indigenous women and infants to poor health and decreased engagement with health resources is deeply rooted in a cycle of endemic poverty, where intergenerational socioeconomic barriers become entrenched and increasingly difficult to escape (de Looper & Lafortune, 2009).
Creating Culturally Competent Maternal-Infant Health Care and Prioritising the reinvigoration of partnerships with the Indigenous community
The UN postulates that Indigenous women have the right to access high-quality, culturally competent and evidence-based healthcare within their own community, from their preferred health practitioner which also enables them to maintain their unique spirituality, customs and traditions (UN, 2008). In order to operationalise a paradigm underpinned by holistic healthcare facilities which Indigenous women are likely to access and improve their health outcomes during pregnancy and childbirth as a result, community-centric, Indigenous staffed health services should be implemented throughout rural and remote communities. Examples of effective and culturally responsible initiatives are the Townsville Aboriginal and Islander Health Service’s Mums and Babies Project and Daruk Aboriginal Community Controlled Medical Service in Western Sydney (MSIJC, 2014). These facilities are respectful of 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 as a result (MSIJC, 2014).
Significant reductions in rates of maternal and infant mortality may be realised through the nationwide implementation of such holistic, community-centric facilities. To achieve this, intersecting divisions of COAG should actively engage to consult with spokespeople of rural and remote Indigenous communities. These partnerships must encourage their right to be self determinant in assessing the health care needs of Indigenous people and contribute to developing the relevant infrastructure as per their fundamental right to access appropriate healthcare. This recommendation is in congruence with article 23 of the United Nations Declaration on the Rights of Indigenous Peoples, which posits 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” (UN, 2008).
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 which affect them (Kildea, Kruske, Barclay & Tracy, 2010). This current status quo is a barrier to the formulation of legitimate, needs-based national health policy and infrastructure.
Furthermore, Indigenous Australians are chronically under-represented in the healthcare workforce across all sectors (Reibel, Morrison, Griffin, Chapman & Woods, 2015) and his paucity presents a barrier to the provision of culturally competent healthcare which adequately responds to the needs of for Indigenous women. (Bertilone & McEvoy, 2015). As international evidence suggests that Indigenous women are more likely to engage with health services when delivered by Indigenous health professionals (Kildea, Kruske, Barclay & Tracy, 2010) it is recommended that secondary schools strive to develop partnership programmes with both mainstream and Indigenous, community run health care services. These partnerships will act as channels through which Indigenous youth can positively the engage with the healthcare workforce and be mentored by role models within the field.
Furthermore, secondary schools, universities, TAFEs and other key stakeholders should pledge to implement scholarships for Indigenous youth to gain qualifications which will enable them to enter the healthcare workforce both within their own communities and in the mainstream sector. A national operationalisation of this initiative would complement existing schemes such as the South Australian Aboriginal Health Scholarship program which have a similar aim, whilst also striving to actively encourage Indigenous students to complete high school (MSIJC, 2014). Over time, increasing the Indigenous healthcare workforce will engage more Indigenous mothers with safe, respectful antenatal care, thus reducing the overall the prevalence of maternal and infant health problems (MSIJC, 2014).
This paper concludes that future policy should engage with the social determinants of health as a theoretical concept and operation tool for understanding the complex interplay of socioeconomic factors such as gender, education, ethnicity and class which gives rise to the increased risk of morbidity and mortality faced by Australian Indigenous mothers and infants (Hankivsky et al, 2014). The distribution of health status over a historically entrenched social gradient, wherein belonging to lower levels of social stratifications exponentially worsens health outcomes (de Looper & Lafortune, 2009), compels Australia to devise and implement robust, evidence-based policy which rectifies the human right indictments and the socioeconomic disadvantage faced by Indigenous mothers and infants. The ultimate success or otherwise of these strategies is dependent on the universal visibility of Indigenous people within Australia data collection in tandem with the maintenance of respectful partnerships and ongoing consultations with Indigenous communities within Australia to develop and implement culturally competent maternal-infant health care.
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