Closing the Gap ’ : How maternity services can contribute to reducing poor maternal infant health outcomes for Aboriginal and Torres Strait Islander women

Context: The reproductive health outcomes for Aboriginal and Torres Strait Islander mothers and infants are significantly poorer than they are for other Australians; they worsen with increasing remoteness where the provision of services becomes more challenging. Australia has committed to ‘Overcoming Indigenous Disadvantage' and ‘Closing the Gap’ in health outcomes. Issues: Fifty-five per cent of Aboriginal and Torres Strait Islander birthing women live in outer regional and remote areas and suffer some of the worst health outcomes in the country. Not all of these women are receiving care from a skilled provider, antenatally, in birth or postnatally while the role of midwives in reducing maternal and newborn mortality and morbidity is underutilised. The practice of relocating women for birth does not address their cultural needs or self-identified risks and is contributing to these outcomes. An evidence based approach for the provision of maternity services in these areas is required. Australian


Introduction
Australia is considered one of the 'safest countries in the world in which to give birth or be born' (p.3) 1 . However, there are wide disparities in maternal infant health (MIH) outcomes for Aboriginal and Torres Strait Islander Australians and women in remote and rural areas of Australia when compared with other Australians. There are many contributing factors including: the enduring effects of colonisation, a higher burden of disease, and poverty reflected in poor housing, lack of employment and reduced access to services. This article reviews current services, national initiatives and international examples and proposes strategies to address the disparities. It is argued that strategies to address MIH in other comparable countries, particularly where Indigenous populations have also suffered from colonisation, should be applied in Australia.
Specifically we argue for a greater recognition of the public health role of midwifery, and changing the way midwives work to enable 'birthing on country' for Indigenous women.
Successful Inuit models have incorporated traditional knowledge and onsite midwifery training and have shown extraordinary results. This article also argues for an increased emphasis on the collection, analysis and reporting of maternal deaths in Australia to have more accurate reporting of the maternal mortality ratio (MMR).

Primary maternity services
Australia has committed to extending and enhancing Primary Maternity Services as the 'preferred approach to providing pregnancy and birthing services to women with uncomplicated pregnancies'(p.1) 2 . Primary maternity services include antenatal, birth and postnatal care for women with low-risk pregnancies. The safety and effectiveness of these services relies on them having networks with timely referral to, and treatment in, secondary and tertiary services, if required. The provision of culturally appropriate care as close to home as possible is also now supported by government 2 . This is a significant shift in direction for Australia. The logistics of how and where these services will be established and supported are currently being debated.

National reforms
he healthcare reform agenda of the current Australian National Government has a strong emphasis on community based services, primary care and improving care for rural and remote areas and Indigenous communities (Closing the Gap, National Health and Hospitals Reform Commission, Primary Maternity Services in Australia: A Framework for Implementation and the Report of the Maternity Services Review. One resultant initiative will promote a much stronger community profile for midwives by enabling 'eligible' midwives access to Medicare Benefits Scheme (MBS) and the Pharmaceutical Benefits Scheme. These Government initiatives present an opportunity to increase midwifery services with a new funding stream to rural and remote areas where health expenditure has never equalled urban areas nor matched the need 3 . However, the current eligibility criteria has the potential to make the Medicare reforms unworkable. Of particular concern is the successful lobbying from the Australian Medical Association (AMA) for Medicare registered midwives to have 'collaborative arrangements' with one or more named medical practitioners. The combination of an extraordinary turnover of doctors in some settings (locums may relieve for as little as 2 weeks); doctors' fear of being held responsible for midwives' practice and resistance to a perceived expanded role for midwives from the AMA and some rural doctors organisations could jeopardise the workability of this reform. We propose a flexible model where midwives can consult and transfer to any maternity service, thus reducing the risk of delay to care when needed (detailed below and similar to the model in many Canadian provinces) (Fig1).
There are a number of issues that currently influence the delivery of maternity services and the experiences of women accessing the services in Australia. These issues will now be outlined with recommendations provided to each issue.

Issue 1: Measuring progress
Maternal mortality is commonly used as an indicator of a country's development status and as a measurement of the safety and quality of maternity services. The relative safety of birth in Australia has fostered a shift in reporting, from survival, to other indicators such as interventions in birth and fetal outcomes 4 (Table 1). At a minimum, the data must be validated prior to publication.

Issue 2: Australian maternal infant health outcomes
The following statistics highlight the enormous disparity between Aboriginal and Torres Strait Islander and non-  Although there is no demonstrated causal pathway and the numbers are small, Table 2 shows that the proportion of maternal deaths to women who were resident in remote areas (7%) was higher than the proportion of women who gave birth from these areas (3%). These are all amenable to targeted interventions with the Queensland study recommending primary healthcare initiatives to reduce the prevalence of low birth weight and preterm birth and a public health approach inclusive of a domestic violence focus 16 . Funding is allocated to prioritise the collection, analysis and reporting of the MMR with consideration to a national systematic review process such as the confidential enquiries. 2 The MMR be added as 'Close the Gap' indicator for measuring progress in overcoming Indigenous disadvantage. 3 All women in Australia receive antenatal, birthing and postnatal care from a skilled attendant with midwifery knowledge and skills, as close to home as possible. 4 Expand the Specialist Outreach Program, Obstetric, Medical and Midwifery (in its infancy) Locum Schemes, the Outreach Midwifery Program and the Strong Women Program across rural and remote Australia. 5 The 16400 Medicare item be amended to ensure only skilled providers are on the eligible list of care providers. 6 The midwifery workforce is reorganised to match activity to need, through the establishment of rural and remote-based MGP that sit within an enabling environment and have government support for set up, mentoring and evaluation. 7 Increased clinical training positions for student midwives to sit within rural and remote MGPs. 8 Active promotion and financial support for Aboriginal and Torres Strait Islander women to undertake the BMid. 9 All midwifery group practices reduce their caseload and incorporate an education role for training student midwives and medical students, who are embedded within the groups. 10 Targetted funding to test, modify and validate the Rural Birth Index in Australia. 11 Establish an evidence base for safe transfer from primary to higher level care. D-D interval of 75 min is not used to limit the establishment of primary services in the rural and remote maternity setting. 12 Increased research funding for rural and remote and Aboriginal and Torres Strait Islander research. 13 'Birthing on Country' that incorporates local knowledge, onsite midwifery training and a research and evaluation framework, is supported in a minimum or four remote communities.

Issue 3: Workforce
Globally, skilled attendants are thought to be crucial to improving maternal infant health outcomes 18

Issue 4: Inefficient use of the midwifery workforce
Of the three professional groups that match the definition of

Issue 5: Relocating women to regional centres to birth
In the last 15 years Australia has seen the closure of 158 birthing services that performed less than 500 births per annum with more than 50% (130) of rural units closed 36 (Table 3). These closures have been based on the belief that the loss of medical services makes them unsafe and unviable rather than a national planning approach. This ad hoc approach resulted in some communities of less than 50 births a year retaining birthing services versus other communities with over 100 births a year loosing services. Workforce shortages, lack of access to on-site emergency caesarean section, concerns about safety and perceived higher costs have contributed to these closures 37,38 . This is despite studies that show there is no evidence that birth for 'low-risk' women is safer in the large hospital setting when compared with birth at home or in small units where skilled attendants work in integrated systems [39][40][41][42][43][44][45][46][47][48] . Research into the impact of the closure of small units highlight the subsequent loss of maternity care providers, the de-skilling of those who stay and the cost shifting that has occurred to families (fuel, childcare, takeaway food, mobile phone etc) who are traveling further for all maternity care [49][50][51] . Additionally there is mounting evidence that health outcomes for women and babies worsen following the closure of local units 38,52 with some women risking dangerous road travel and babies born on the side of the road 53 . We believe a reversal of this trend is warranted.

Issue 6: Planning services
The primary maternity services framework will be challenging to implement in the context of ad hoc non-evidence based closure and reopening services will require a new approach.
There is little published work to guide the planning process for commencing or re-establishing primary maternity services. The   Women have repeatedly identified birthing on country as something they believe will improve maternal and perinatal health outcomes 37,[69][70][71] . These women have stated that their relationship to the land is compromised by birthing in hospitals where many also feel culturally unsafe 37,50,[69][70][71]73,76,77 . Some women also worry about the safety of the children they must leave behind and believe that the relationship between baby, siblings and father would be better if they were nearby for the birth 37,69,71,76,78 . This data has again been reported in our NT NHMRC study showing little change over time.

The health of Aboriginal and Torres Strait Islander
Australians is integrally linked to their culture and the land 79 , a link that is strengthened by birthing on their land 70,78 . Social and psychological problems which produce stress, ineffective self-management and a lack of control over circumstances in life are thought to be greater determinants of health in disadvantaged populations than a lack of access to medical care [84][85][86]  Some of the key factors in the success of these services are the collaborative community development approach to care; local employment; on-site midwifery training; integration of Inuit knowledge with western knowledge; the involvement of men; a risk screening process that includes social and cultural risks in addition to biomedical risks; and the interdisciplinary perinatal committee. This committee reviews each woman's case 32-34 weeks gestation for all risks, and creates a care plan for birth 100 .

Conclusion
In conclusion, there are increasing rather than decreasing challenges to the delivery of safe maternity services in rural and remote areas of Australia. Changing the way care is delivered could promote substantial improvements.
Maternity providers must demonstrate the competencies required of skilled birth attendants. The midwifery workforce should be enabled to work to their full scope of practice with referral support from general practitioners with obstetric skills and specialist obstetric services, neither of which need to be 'named' or on site. With changes to the funding model in Australia, the provision of skilled, culturally appropriate care as close to home as possible for all women must be seen as a non-negotiable national priority. With slow progress being made towards closing the gap in MIH outcomes and culturally acceptable maternity care across Australia, and likely underreprting of poorer outcomes, it would seem appropriate to learn from others. Comparable counties, particularly Canada and New Zealand, have made substantial progress towards closing this gap.
These countries come from similar colonial histories yet are leading the way, both in innovation of service models, midwifery in primary care settings and health outcomes for their Indigenous peoples 103 . Providing primary maternity services 'on country' must be explored. This should be done within a rigorous research framework using a community development approach that incorporates the training of Indigenous women as midwives and is led by the Indigenous community itself with support from an integrated network (Recommendation 13). We can no longer ignore the extraordinary results from the remote based Inuit models, particularly the unpredicted effects that are contributing to building community capacity and resilience. Communities that self identify this as a goal must be supported even when obstacles are described as insurmountable by service providers.
We also believe Australia must take note of the millennium development goal and aim to reduce the MMR for Indigenous Australians from 45.9 per 100 000 (2000-2002) to 11.5 per 100 000 by 2015.