Preventing avoidable preterm birth in Aboriginal and Torres Strait Islander families is a major public health priority in Australia, according to the National Aboriginal and Torres Strait Islander Health Plan 2013–2023’s Maternal Health and Parenting Goal.
And a group of UQ researchers and their partner agencies – Aboriginal & Torres Strait Islander Community Health Service Brisbane, Institute for Urban Indigenous Health, and Mater Mothers’ Hospital – have done something about it.
Designing a new program, Birthing in Our Community, they are helping ensure that Aboriginal and Torres Strait Islander mothers and babies get the best possible care and support for a good start to life, as evidenced by a reduction in preterm births (<37 weeks gestation) – from 11.6 per cent to 6.9 per cent – for those participating in the program.
This has excellent implications for long-term Indigenous health as, according to the Australian Department of Health, "Birth weight is important—in a sense, it is the first outcome. It reflects the influence of a number of parental factors, is directly linked with foetal death and is the earliest indicator of proneness to ill health during childhood and to later adult diseases, such as high blood pressure."
In essence, the longer a baby is in-utero, the more likely it is to have a healthy birth weight, and the less likely it will be to die in infancy or develop chronic disease later in life.
In 2010, Professor Sue Kildea, who was working in UQ’s then School of Nursing and Midwifery, conducted a survey of women attending the Mater Mothers’ Hospital specialist antenatal clinic for Aboriginal and Torres Strait Islander women at South Brisbane.
This survey revealed that although the service had an excellent reputation and women were very satisfied with the service received, they were not happy about having no continuous access to a known carer during labour, birth and the early weeks of life.
Her research colleague, Adjunct Professor Sue Kruske, was also aware from international research and her own experience that women appreciate the opportunity to get to know their care providers during pregnancy.
“They become more confident in childbirth and with looking after their baby when they’ve had a trusted professional with whom to share their concerns," she explains.
"We were also aware of the Midwifery Group Practice model of care that had demonstrated a reduction in premature births – one of the greatest challenges of our time – and were keen to replicate it at our clinic.”
Image credit: Getty Images/xavierarnau
Opening image credit: Getty Images/HopeConnolly
Professors Kildea and Kruske and their team began devising a plan that would also help improve the health outcomes of urban Aboriginal and Torres Strait Islander mothers and their babies.
“We acknowledge our mothers as growing the future elders for our community and their important role in growing strong and deadly black families," Professor Kruske says.
"To do this, they need a team who wraps around support to ensure they have secure housing, are free from financial stress and are emotionally resilient.
“Having a trusted source to make health recommendations – such as stopping smoking – can make a big difference in delivering a healthy, full-term baby."
Closing the Gap
Around that time, the federal government announced its Closing the Gap initiative, which aimed to improve the lives of all Aboriginal and Torres Strait Islander Australians.
Since 2008, Australian governments have worked together to deliver better health, education and employment outcomes and to eliminate the gap between Indigenous and non-Indigenous Australians.
A specific health priority, developed from that period and updated in 2018, is that "Aboriginal and Torres Strait Islander children are born healthy and strong", with the target of "By 2028, 90–92 per cent of babies born to Aboriginal and Torres Strait Islander mothers have a healthy birthweight".
There are a number of known modifiable causes of preterm birth, including:
• inadequate antenatal care
• psychosocial stress
• smoking in pregnancy
• teen pregnancy.
Increasing term birth – and reducing avoidable preterm birth – is important because it impacts all other Closing the Gap targets, such as life expectancy, literacy, year 12 completion and employment targets. This is due to the the reduced risk of developmental delays that impact school readiness and attainment, and the reduction in chronic diseases that are a major contributor to premature death.
Preterm birth is also an important contributor to childhood disability and mortality, and marks the genesis of preventable chronic diseases in adult life, including diabetes and cardiovascular and renal disease.
It's for these reasons that the World Health Organization recommends preterm birth be a priority area for research and program innovation.
Image credit: Getty Images/davidf
The program developed by UQ researchers and their colleagues in 2013 is a continuity-of-care model that enables all Aboriginal and Torres Strait Islander mothers planning to birth at the Mater to have the same team of people providing care and assistance from early pregnancy through to around six weeks post-birth.
Mater Research Institute–UQ postdoctoral research officer Dr Sophie Hickey, who has worked on the research evaluation study since its inception, says that every woman has her own midwife on-call 24 hours a day, and a support team that includes Indigenous family support workers, Aboriginal student midwives, social workers, perinatal psychology, doctors and other health professionals.
"With help from our partner organisations, all care provision and government structures are culturally sensitive and provide ‘add-on’ services, such as Aboriginal and Torres Strait Islander family support workers and access to social workers, that enhance the program,” she says.
“We conducted the Indigenous Birthing in an Urban Setting (IBUS) study over a five-year period (2014–2019) to determine whether the new model could indeed reduce the rising rates of preterm births.
“Our results send a strong signal that the preterm birth gap can be reduced through targeted interventions that increase Indigenous governance of, and workforce in, maternity services, as well as continuity of midwifery carer, an integrated approach to supportive family services and a community-based hub."
Dr Hickey says the team recommends that the program be tested in other settings as a key strategy to reduce Indigenous preterm birth rates in Australia.
“Strategies to address disparities are more likely to succeed if they are led by, or conducted in partnership with, Indigenous organisations and build Indigenous capacity and engagement.”
Key components of the Birthing in Our Community program
• Indigenous governance and partnership Steering Committee with strong Indigenous leadership
• Caseload midwifery delivered according to women’s preferences (home, community-based hub, hospital)
• Indigenous workforce strategy that includes training and career development for the carers
• Indigenous-controlled community-based hub, a culturally enabling environment for mothers to connect, interact and learn from each other
• Integrated family services that deliver a full range of primary maternity and infant health and related services, and to transition beyond the six weeks post-birth care.
Image credit: Kristie Watego
While the IBUS study focused on Aboriginal and Torres Strait Islander women and their children in urban settings and achieved positive outcomes, results were not as strong for Indigenous women from remote areas who relocated to an urban setting.
Although these mothers received quality care and caseload midwifery, no reductions in preterm births occurred.
This was possibly because little changed in their home communities in terms of antenatal care and community support services.
The IBUS results suggest that reducing preterm birth is possible when Indigenous mothers receive culturally safe, antenatal care early in their pregnancy and close to home, which fits into Birthing on Country, a concept that is taking on a greater significance worldwide.
Birthing on Country is an international movement to return maternity services to First Nations communities and community control for improved health and wellbeing and its elements are fully embraced within the IBUS research.
“It's not just a matter of ‘place’ (where the birth occurs) but the
“We recommend a RISE framework to implement future Birthing on Country services and believe our results from the IBUS study back this up: Redesign the health service, Invest in the workforce, Strengthen families, and Embed Aboriginal and/or Torres Strait Islander community governance and control.
“The best start to life is a social investment in community wellbeing for generations.”
Visit the Institute for Urban Indigenous Health website to find out more about the Birthing in Our Community program.
The story so far:
1973: The Aboriginal and Torres Strait Islander Community Health Service Brisbane Limited (ATSICHS) is established at South Brisbane.
2004: An Indigenous-specific antenatal clinic is established at Mater Mothers’ Hospital, collocated with the well-respected Indigenous liaison service.
2009: The Institute for Urban Indigenous Health (IUIH) is established.
2010: UQ reseachers conduct a survey of Aboriginal and Torres Strait Islander women attending Mater Mothers’ Hospital specialist antenatal clinic.
2013: The Birthing in Our Community program is established at the Mater Hospital in partnership with IUIH and ATSICHS to ensure mothers have the same team of people providing care and assistance 24/7 from early pregnancy through to around six weeks post-birth.
2014–2019: UQ's undertakes the Indigenous Birthing in an Urban Setting (IBUS) study to evaluate the outcomes of the Birthing in Our Community program.
2019: Results show that the new program significantly reduces the odds of having a preterm birth.
Image credit: Getty Images/LittleBee80
Opening image credit: Getty Images/HopeConnolly
This article was last updated on 27 November 2019.