Around 9.6 out of every 1,000 Aboriginal babies are stillborn, or die in childbirth or the first 28 days of life, compared with 8.1 non-Aboriginal babies. Getting maternity care right for Aboriginal women is critical to closing this gap.
Not all Aboriginal women have access to high-quality, culturally competent maternity care. An audit in Western Australia, for instance, found 75% of services failed to provide maternity care sensitive to Aboriginal culture.
The federal government’s 2014 maternity services review recommends improving access to care for Aboriginal mothers and increasing birthing choices. One such option is for Aboriginal women to choose birthing on country.
What is birthing on country?
Birthing on country generally refers to an Aboriginal mother giving birth to her child on the lands of their ancestors.
A traditional midwife with specialist knowledge would once have provided care. These days non-Indigenous midwives, working in collaboration with community elders and/or traditional midwives, can provide “birthing on country” care. Birthing on country is provided in accordance with traditional and spiritual beliefs, which can vary according to community.
Increasingly, the term is being used to embody broader principles of a “birthing on country model”, which ensures a spiritual connection to the land for an Aboriginal mother and her baby, wherever she chooses to give birth.
Most Aboriginal women live in urban or rural areas and can easily reach a hospital for childbirth. The more difficult debate about birthing on country involves women living in remote areas.
Where birthing on country is not offered or supported, women must leave their families weeks before birth to wait in a regional centre.
Or the mother can choose to give birth in her community without skilled birth attendants (effectively a “freebirth”). This is risky, particularly because Aboriginal women have high rates of pregnancy complications, which make childbirth less predictable and potentially more dangerous for both women and their babies.
So it is critical to have choices between these two polar options.
Why do women want to birth on country?
There are many reasons women may want to birth on country, with and without health care support.
Physical connection to country during birth may be very important to some women’s overall well-being.
Others feel it is simply not possible to have a spiritually and culturally enriching hospital birth, or have had traumatic hospital experiences. Paternalism within medical maternity models and racism are ongoing issues for Aboriginal women.
Other women will have concerns about leaving their family for up to six weeks, with practical and social worries around care for other children and possibly other adult dependants.
Some women choose to birth on country against medical advice and there have been some concerning anecdotal reports of punitive responses in remote areas. These include threatening women who refused to board a plane with sectioning under the mental health act.
While clinicians are understandably fearful and anxious about women giving birth unassisted, Aboriginal women have a legal right to make decisions about their health care.
Culturally sensitive care
It is important service providers can communicate sensitively and build trust to discuss birthing options with Aboriginal women, particularly if the mother is considering an unassisted birth. Clinicians should:
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Ask about and discuss what issues are important to her. This will help the health provider understand each woman’s life, strengths and needs.
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Provide evidence-based information about the models of care available. Encourage discussion about the risks and benefits, while reminding each woman of her right to make decisions.
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If available care options do not meet her needs and she wishes to explore alternatives, including birthing on country without assistance, we need to understand the reasons for this decision.
Some questions include:
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Are there practical issues that can be addressed? Has she had traumatic experiences with services? Is she worried about leaving her family behind? If these were addressed, what would her choice be?
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Are there cultural aspects of birth that could be acknowledged in a hospital setting? What would her choice be if these were provided?
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If a woman chooses to birth outside an existing service model, what can we do to optimise safety and quality? Preparation is safer than a woman turning up in late stages of labour.
It’s safer to encourage and support all birthing choices than to silence women if choices are not respected.
It’s time to strengthen efforts to establish honest and respectful relationships between health professionals and Aboriginal women. We need to understand what women want and ensure they get the maternity care right, including culturally rich births in hospitals, and safer assisted births in the bush.
Catherine Chamberlain receives funding from the National Health and Medical research Council (ECF 1088813). She is affiliated with Council of Aboriginal and Torres Strait Islander Nurses and Midwives.
Rhonda Marriott receives funding from the National Health and Medical Research Council. She is affiliated with the WA Primary Health Alliance (as a Board Director).
Sandy Campbell is supported by an National Health & Medical Research Council (NHMRC) Early Career Fellowship (ECF) Fellowship.