Maternal and infant health

When compared with non-Indigenous Australians, Aboriginal and Torres Strait Islander women experience more complications in pregnancy and birth, including gestational diabetes, hypertension, lower birthweight babies and death of babies. Aboriginal and Torres Strait Islander women have a higher fertility rate, tend to have babies at a younger age, and generally do not present for antenatal care as early when compared with the mainstream average. Some comparative statistics are shown in Box 8.1.

Rural and remote areas

For women in rural and remote Australia, the reproductive health outcomes are worse than for their urban counterparts, highlighting a particular area of need. Trend data show increasing disparities associated with remoteness in the neonatal (2.5 times) and infant (3.4 times) mortality rate for Aboriginal women compared with non-Aboriginal women in Western Australia (Fremantle et al 2006). This research also identified significantly more potentially preventable deaths in Aboriginal infants due to causes including infection, preterm birth and sudden infant death syndrome (Fremantle et al 2006). Preventable and modifiable factors indicate that there is a role for midwives working in primary healthcare models in reducing some of these alarming inequalities.

Colonisation

The burden of disease, poor socioeconomic status, severe disadvantage, and the maintenance of political controlling regimes highlight the discrepancies between Indigenous peoples’ morbidity and eventual mortality and that of the rest of the Australian population. This picture is related to a history of colonisation, genocide, oppression, social exclusion, Western-informed healthcare, loss of land and people, sustained institutionalised racism and the devaluing of Indigenous knowledge, law, languages and culture (Briscoe 2003; Ermine et al 2004; Kunitz 1996; Toussaint 2003; Trudgen 2000; Wilkinson & Marmot 1998). It is the fundamental discrepancies of health status that allow for comparative descriptions such as Third and Fourth World health status in a First-World nation (Bartlett 1998; Bhatia & Anderson 1995). Aboriginal health today must be considered in the light of historical and political circumstances that shaped, engineered and ignored the very basic needs of Aboriginal and Torres Strait Islander Australians.

It is estimated that Aboriginal people have lived in Australia for 40,000 to 60,000 years (Kleinert al 2000), with some evidence to suggest that they may have been here for 120,000 years (Broome 2002). Aboriginal people, however, consider the time to be ‘forever’—as Galarrwuy Yunupingu said, ‘Our ancestors have been here since the beginning of time’ (Yunupingu 1997, p 1). The population was considered to range between 500,000 and 1,000,000 prior to European arrival, but by the 1920s it had been reduced to approximately 60,000 (Broome 2002).

The history of the past 220 years provides the essential context for why and how colonisation was such a brutal and devastating experience for Aboriginal people. With colonisation came new diseases, loss of culture and difficulties in maintaining the hunter–gatherer lifestyle. Many epidemic and endemic diseases were unknown before colonisation (Callaghan 2001).

At first contact, Aboriginal people were observed to be a healthy population. Archaeological evidence suggests that morbidity was related mainly to injury and wear and tear, rather than non-communicable diseases (Saggers & Gray 1991). Diet, exercise and lifestyles linked to the traditional culture and lifestyle ensured general wellbeing on all levels. The injuries caused by invasion and encroachment of land by the new settlers led to loss of land, nutrition, trade, cultural practices and autonomy of action (Reid & Lupton 1991). Settlement occurred over 100 years, commencing in New South Wales in the 1780s and completing in the Northern Territory in the 1880s. This process was resisted by Aboriginal tribal groups and was met with frontier warfare and, later, settler reprisals, now acknowledged as massacres (Connor 2003).

Survivors were incarcerated onto reserves, islands and missions for ‘protection’. The policy of Protection spanned from 1883–1937 and was orchestrated to regulate, manage and control Aboriginal people. It is this policy that fundamentally entrenched many of the determinants that affect Aboriginal health today, and occurred through the enforcement of sedentary lifestyles, extremely poor and overcrowded housing, and appalling diets that were rationed to families (Reid & Lupton 1991). These conditions spelt the beginning of the so-called lifestyle (chronic) diseases among the Aboriginal population, as well as contributing to malnutrition that led to widespread infant and child mortality (Kidd 2000). Government underfunding in the areas of health and housing infrastructure was also established during this era (Kidd 2000).

Under various state and Commonwealth Protection Acts, the authority was given to remove Aboriginal children from their families. The initial premise for removal was the aim of educating and civilising the children. They were removed from loving families and placed in institutions where they were poorly fed and trained as apprentices to work for non-Aboriginal peoples (Haebich 1988). These children are now known as the ‘Stolen Generation’ (HREOC 1997), and their trauma was only officially recognised recently with an apology in 2008 from the Prime Minister to all Aboriginal people and the Stolen Generation for their ‘profound grief, suffering and loss’.

Many men and women sought employment outside of their respective encampments to subsidise family rations. Wages for Aboriginal people up until the 1970s were less than those paid to non-Aboriginal people, although the work was the same. In most cases wages were directed to either local or state ‘Protectors’, entrenching a lifestyle of poverty. These wages were utilised by the government for the building of mainstream infrastructure, leading to the claim of ‘stolen wages’ (Kidd 2000).

Policies of assimilation (1950s to 1960s) and integration (1967–1972) encouraged Aboriginal people to adopt European ways and abandon their culture (Johnston 1991). This was difficult, as they had effectively been denied the privileges and rights other Australians had enjoyed for generations. Aboriginal and Torres Strait Islander peoples continued to have poor access to healthcare services, education, clean drinking water, and suitable housing or employment opportunities.

By 1969, Australian states (except for Queensland) had removed most of the restrictions that were placed on Aboriginal people, granting them full citizenship rights and, in 1962, the opportunity to vote (Broome 2002).

The 1967 referendum enabled Constitutional revision to include Aboriginal peoples in the census and gave the Commonwealth greater authority in the area of law-making for Aboriginal and Torres Strait Islander Australians (Prentis 2009). Thus Aboriginal and Torres Strait Islander health became a funded agenda, and both the Department of Aboriginal Affairs and the self-determination policy were established in 1972. This policy was seriously undermined by the Federal Liberal Party while John Howard, who commenced in 1996, was at the helm. During his terms there was continued underfunding in the area of Aboriginal and Torres Strait Islander health and primary care services.

The battle for equal rights and removal of inequalities continues today, as years of systemic discrimination and racism has led to a ‘multi-causal cycle of poverty’, which was reinforced by a lack of self-determination, access to education, employment, housing and basic healthcare services (Broome 2002).

Connection to country

Apart from the universal value of land as an economic base and a place to live, for Indigenous peoples the land is the foundation of social unity, cultural identity and the source of spiritual sustenance (Durie 2003). When people are dispossessed of their cultural, spiritual, social and economic base, their cultural, spiritual, social and economic wellbeing will suffer—for generations. Therefore, the present circumstances faced by Indigenous peoples are inextricably linked to their past.

Aboriginal people were created through the life-force of their Dreaming ancestors, along with their respective lands, flora and fauna. Each Indigenous person, regardless of their nation, has as a result of this creation a metaphysical and geographical relationship with all of the living and non-living beings of their respective Dreaming creators (Hume 2002).

Deborah Bird Rose writes:

This statement represents Indigenous people’s worldviews (their ways of knowing, being and doing), and is distinctly different to the Western worldview.

For Aboriginal peoples, country is much more than a place. Rock, tree, river, hill, animal, human—all were formed of the same substance, by the ancestors who continue to live in land, water and sky. Country is filled with relations speaking language and following Law, no matter whether the shape of that relation is human, rock crow or wattle. Country is loved, needed and cared for; and country loves, needs and cares for her peoples in turn. Country is family, culture, identity; country is self (Kwaymullina 2005). The connection Aboriginal people have to land or country, through their spiritual and physical ancestry, is transgenerational, experiential and significant. Land is the lifegiver to all peoples in the world and provides for all needs. Aboriginal people have long respected and reciprocated this relationship and have historically endeavoured to maintain their union through law, ceremony, cultural practice and protocols.

The Aboriginal people of Australia are owned by the land. The connection starts at birth and remains until each member is laid back within the earth to again become part of her. To lose connection to country is to cause ill-health. As Bill Neidjie, Aboriginal Elder, explains,

Some women believe that when babies and mothers return from the regional centres, they return in a weak state and need cultural ceremonies such as the ‘smoking ceremony’ to be performed to make them strong again (Carter et al 1987). Failing to observe the relevant rituals and laws during pregnancy and birth presents a grave risk to the health of both the mother and baby and the long-term health of her people. For Aboriginal women, separated from their land, language, culture and families during the birth of their children, removal to the regional hospital represents an at times unacceptable risk (Roberts 2001). Some Aboriginal women identify giving birth in the hospital as the cause of infant mortality. As a result of not being welcomed properly into the world, and the appropriate ceremonies not being performed, the baby’s weakened spirit gets sick (Mills & Roberts 1997).

Social determinants of health

There is indisputable evidence that a person’s social and economic circumstances will strongly affect their health, with those further down the social ladder suffering higher rates of serious illness and premature death (Wilkinson & Marmot 1998). Aboriginal and Torres Strait Islander families have significantly lower incomes, home ownership and employment rates (see Box 8.2), with national imprisonment rates 13 times higher than non-Indigenous imprisonment rates with an increase in both female (46%) and male (27%) imprisonment between 2000 and 2008 (Steering Committee for the Review of Government Service Provision 2009). Importantly, the rate for juvenile detention is 28 times higher than for non-Indigenous Australians and has also been increasing (27%) (Steering Committee for the Review of Government Service Provision 2009). It is likely that many of these children have hearing difficulties and struggle with literacy and numeracy, with the proportion of Aboriginal and Torres Strait Islander 19-year-olds who had completed Year 12 schooling (36%) half that of non-Indigenous 19-year-olds (74%) in 2006 (Steering Committee for the Review of Government Service Provision 2009).

Although Indigenous disadvantage is well documented, almost half of Australian people believe that Aboriginal and Torres Strait Islander people are not disadvantaged (CAR 2000). It is important that these beliefs be explored, as they support the underlying racism in Australian society. The lack of recognition creates disharmony within society and is acted out in ways that further marginalise and discriminate against Aboriginal and Torres Strait Islander Australians.

There are strong links between education, income and health, but it is also known that social and psychological circumstances that cause stress, and a lack of control over one’s circumstances in life, are detrimental to health (Wallerstein 1992; Wilkinson & Marmot 1998). It has been argued that unfavourable social conditions and ineffective self-management are greater determinants of health in disadvantaged populations than is a lack of access to medical care (Pincus et al 1998). These concepts are not new to Aboriginal Australians, who have always seen health in a broader context than that which is solely related to disease.

Equity

There is misunderstanding and a lack of awareness among non-Indigenous communities about Aboriginal and Torres Strait Islander people, their health and healthcare. Education is at the heart of change in this situation, and midwives can play a role in this in society. The marked difference in health statistics does not equate to a corresponding difference in healthcare spending. Aboriginal and Torres Strait Islander Australians have significantly less access to the Medical Benefits Scheme (MBS) and the Pharmaceutical Benefits Scheme (PBS) through reduced access to doctors (Access Economics 2004) and complex funding arrangements. Data regarding per capita spending on health for Aboriginal and Torres Strait Islander Australians versus non-Indigenous people in rural and urban Australia are $2,734 versus $2,277 (Gray et al 2002). When spending on hospitals is excluded in these figures they differ markedly: $930 versus $1351 (Gray et al 2002).

The ‘Close the Gap’ campaign highlighted five estimates all showing the approximate shortfall in funding for Aboriginal and Torres Strait Islander healthcare services—all five put the shortfall between $350 million and $500 million per annum. An additional $460 million per annum would help fix the shortfalls in primary healthcare funding for Aboriginal and Torres Strait Islander Australians (this is just one-quarter of the $1.9 billion Australians spend on confectionery each year).

Although it can be shown that Aboriginal and Torres Strait Islander Australians have significantly decreased access to healthcare services, it is probable that this is not the only cause of their poor health statistics.