Box 2 Family Anangu Bibi Birthing Program in SA

Perinatal outcomes for Aboriginal women and infants in South Australia have been consistently much poorer than those for non-Indigenous women and infants. A state-wide consultation was undertaken in the context of a project I coordinated for the Aboriginal Health Division. In 2003 a framework was developed at an Aboriginal women’s workshop for the creation and support of models of maternity care for Aboriginal women that could make a difference in health outcomes. Feedback from meetings and gatherings with Aboriginal women and communities resulted in the following important consensus statement:

‘Healthy Pregnancy and Birthing is a life process and is an important issue for the health of all of our communities. This issue should be a priority in health planning processes, with appropriate and adequate ongoing funding. Aboriginal and Torres Strait Islander women want to be cared for by Aboriginal and Torres Strait Islander midwives and Health Workers.’

Encouraged by examples of midwifery continuity of care models and effective models of maternity care for Indigenous women in other countries and interstate, and building on years of community demand for culturally appropriate care, a group of dedicated people in the northern communities of Port Augusta and Whyalla proposed to develop a new model of care. Support and in-kind contribution to the program came from the local hospital services, Aboriginal community health services, the Child Youth Health service, as well as some top-up Commonwealth Alternative Birthing Services Program funding.

The project piloted a dedicated role for Aboriginal health workers in maternal and infant care, which they called the ‘AMIC’ (Aboriginal Maternal Infant Care) Worker. The Family Anangu Bibi Birthing Program provides antenatal, intrapartum and postnatal care to women and their infants by AMIC Workers in partnership with midwives. The first 18 months of this Program have been evaluated and its success has led to the recommendation that it be expanded across country regions of South Australia. Two of the care providers in the Family Anangu Bibi Birthing Program explain why it works below.

Deanna Stuart-Butler, Aboriginal Maternal and Infant Care Worker in the model, describes the principles.

‘The Family Anangu Bibi Birthing Program model is based on the principles of continuity of care. What makes this particular model unique is that the caseload care is coordinated by Aboriginal Maternal and Infant Care Workers who are backed up by a team of midwives. Aboriginal women are cared for by Aboriginal women. We target 20 women per year here in Port Augusta. Our clients are young Aboriginal and socially disadvantaged women with priority given to high-risk obstetric situations. Our program is also overseen by a community-based Aboriginal Women’s Advocacy Group that ensures the service respects cultural safety.

‘Personally, I feel the Program works firstly because Aboriginal women are getting what they have always wanted after years of consultation—they want to be cared for by Aboriginal women, to have consistent, known caregivers. Secondly, we work in partnership with midwives. We could not be successful without the midwives sharing their clinical expertise and they couldn’t do it without us, sharing our cultural knowledge. It’s not about us taking away the role of the midwives, but it’s about sharing that knowledge, so as to make a difference in the service delivery for Aboriginal women in mainstream hospitals. We are concerned about the problems reflected in the South Australian Birth Outcome Statistics and wanted to make a difference for our women and children—now and hopefully with future generations.’

Cheryl Boles is the midwife who works in the model with Deanna. She says:

‘I agree with Deanna, I think the model works because of the commitment to working as a team. As team members we work as equals with each person bringing a special skill and experience that is valued and respected by the whole team. No one is perceived as being in charge. We are all very clear that it takes both sides of the team, both AMIC and Midwifery, to deliver a service that is culturally and clinically safe. Commitment to open communication at fortnightly team case conferencing meetings has also been a cornerstone to our success.

‘I also think our model works because it is based on 10 years of consultation with the local community. The people who contributed to the application for funding have also been the same people (both AMIC Workers and midwives) to implement and work in the program. I think that this has been important in achieving the commitment that has been required.

‘What makes us different to other continuity of care models is that we are holding hands with the AMIC Workers to deliver a style of care that would not be possible for midwives to do on their own.’

Box 3 An example of midwifery continuity of care in remote Australia

Over the last 40 years across remote Australia, women have increasingly been relocated from their homes to give birth in regional centres. Typically, they will leave their homes at 36–38 weeks gestation to await birth, usually alone, in the regional setting. Women state they do not like to be away from their families for weeks at a time as worrying about the children left behind and other family members causes immense stress (Biluru Butji Binnilutlum Medical Service 1998, Fitzpatrick 1995, Hirst 2005, Kildea 1999). Many remote areas no longer have the infrastructure, staff or insurance cover to support on-site birthing. These policies are driven by a belief that birth in remote areas is too ‘risky’. Important contributors to a positive experience of maternity care are often lacking in this model, namely: continuity of care, choice of care and place of birth and the right to maintain control (Homer et al. 2001). It is clear that the model of care is not socially or culturally acceptable to women and their families, nor is it satisfying for the health care providers (Biluru Butji Binnilutlum Medical Service 1998, Carter et al. 1987, Fitzpatrick 1993, Kildea 1999, 2006, NSW Health 1998).

Midwives working in these areas are often faced with ethical challenges for which there are no clear guidelines and, in many instances, no easy answer. They are frequently the only skilled maternity service provider resident in a community providing a service for Aboriginal women. Ideally, to increase their effectiveness in the community, they will work side by side with Aboriginal Health workers, though there is a current shortage of these professionals also. In many instances the women do not want to leave their communities for birth, yet they do what is advised, believing it is best for their baby, despite their worries and concerns. Others will avoid antenatal care so as not to be sent away from their families for birth. Some women will tell you early in their pregnancy that they are staying in the community for birth, no matter what. Others will be sent out at 38 weeks, returning before their babies are born and presenting to the Health Centre in strong labour, too late to be transferred back to town. In some instances, midwives who work with women and provide birthing assistance on site have been targeted as ‘dangerous practitioners’ who ‘collude with women’ who are ‘taking their life in their hands’.

The following story is one of many which outline some of the challenges when working as a remote midwife in these areas. Wanting to provide midwifery continuity of care for the women, who you believe in your heart would have better health outcomes if they could birth in their communities.

Barbara is an Aboriginal woman who lives on a small outstation, 2 hours’ drive from a remote community in the north of Australia, which is an hour’s flight to the regional centre. The traditional culture and land ownership values of the people in this region remain strong with many speaking English as their third or fourth language and some not understanding English at all.

‘I was the remote area nurse midwife who usually worked in the ‘women’s room’ providing antenatal and postnatal care (for around 35 woman at any one time), as well as performing routine and emergency ‘women’s business’ care. During my time in this community, approximately ten women a year would choose to have their babies in the community.

‘When I first met Barbara she was presenting for a ‘check up’ and it was clear she was pregnant. Barbara was very shy and did not understand English. One of the Aboriginal health workers (AHWs) spoke her language and agreed that she would be appropriate to work with me to provide Barbara’s care. [There are times when AHWs are not appropriate to assist, depending on their relationship with the person involved. These avoidance rules are an important part of the kinship system.] Reading Barbara’s notes I found she had a previous pregnancy, eight years prior, with one antenatal visit performed in her outstation documenting elevated blood pressure (180/110) and proteinuria (++). She had birthed her baby on her ‘land’ with her family in attendance (no health care providers) and her medical records stated she had ‘a big bleed’ following the birth.

‘Barbara had a 28 cm fundal height, a blood pressure of 180/110 (which settled to 150/85 after resting) and proteinuria (+). I called the district medical officer (DMO) to discuss the situation and we advised Barbara to go to town for a ‘check up’ to assess both maternal and fetal wellbeing. However Barbara said she would not go as she was frightened and had never been away from the community before, let alone travelled on a plane. The last time she had a baby she did not have any complications and felt safer at home surrounded by family. Additionally, she planned to birth at her outstation, on ‘her own land’. If her baby was not born there the correct ceremonies will not be performed and the family believed the baby could have problems establishing a connection to the land.

‘As a midwife I was concerned with the clinical signs, thinking: we have no on-site doctors; very little equipment for emergencies; she could develop eclampsia on the outstation and lose her baby, or her life. Additionally, I could get ‘blamed’ by other community members or my employers (clearly she needed referral) if I ‘allowed’ her to stay, especially if something went wrong. Together, with the AHW, we explained to Barbara why it was important to go to Darwin. Initially, the district medical officer refused to authorise an escort to accompany her and act as an interpreter, stating ‘we have an interpreter service and this is not her first baby’. [The patient assisted travel scheme (PATS) stated that women are only allowed an escort if they are having their first baby and if they are under 16; additionally the PATS budget was overspent with DMOs told to be very strict with who is allowed to come in.] Advocating on Barbara’s behalf led to a compromise where Barbara agreed to go to the regional centre with an escort, for review only, and on the understanding that she could return to await the birth at home (even if this was against medical advice). When she did return she had been commenced on anti-hypertensive medications and stated she would not be going back to the regional centre for the birth as she had been too frightened there. Her medical referral had recommended that she return at 34 weeks to await the birth, and over the following weeks there was a lot of pressure from the visiting doctor for her to do so.

‘Further negotiation with Barbara led to an agreement that she would come in from her outstation and stay with relatives as she neared her due date. She also agreed to let me know when she was in labour. I was called to the birth minutes after the baby was born and found Barbara with her baby sitting by the campfire surrounded by aunties and sisters. All were well and very happy. Barbara returned to her outstation two days later.’

Though the outcome is not always positive when women choose to avoid the care we offer, it is our job to work with them to provide safe high quality care where possible. It is inappropriate to ‘growl them’ when they present late and frighten us with complications that we are not always able to control. Shepherding their way through the system, making up stories to ensure they have escorts, protecting them from bullying health professionals, and providing services for those who will not leave the community, are all necessary components of a model that is not meeting the women’s needs. Advocating on behalf of remote dwelling women, and changes to the services we offer, need to be core business for midwives if we are ever going to see a return of birthing services to these communities. Canada and New Zealand have shown us it can be done!

Box 4 Continuity of care in a remote area of New Zealand

‘I work as an LMC midwife as one of a team of four. We work within the full scope of autonomous practice. From the tap on the shoulder in the supermarket, “… have you got a moment?” to the “… is my baby ok?” … during a difficult labour when the heartbeat drops for no obvious reason, at the same time as ours increases significantly. We become deeply involved by dipping into the lives of new or familiar families, sharing the joys and trials of having a new baby until we hand over care to the Well Child team of GP and Child Health Nurse at six weeks after the birth.

‘We are employed by the local district health board and our 3-bed unit is attached to a 15-bed community hospital. We share the running of the unit by having two midwives on 24-hour call at all times. Four days and nights on and four off; this arrangement works for us and the women in our community. Over the span of a year about 60 women book with us, about a third have their babies in the base hospital because of previous caesarean sections, babies in unusual positions, known medical–obstetric problems, and babies who seem to want a prolonged stay in their mother’s uterus. About another third are divided between the very few unexpected emergencies such as cord prolapse, fetal distress and bleeding, and difficult labours requiring serious pain relief or intervention in labour. The remaining third of women just “get on with it” and have amazing births.

‘Very few women plan for epidural pain relief as they are unable to get one with us as we are very definitely a primary birthing place. Normal birth, at home or in hospital, and normal labour pain is accepted as part of the culture of rural women and midwives. The women would have to uproot their families and travel 2 hours over the winding Takaka Hill from their homes in Golden Bay, which is north-west of Nelson in the South Island, 2 hours away, but they do come back for postnatal care.

‘The daily life of a rural midwife can be encapsulated by my reflection on a recent callout. I remember it was a dark and stormy night and I was woken by the phone at 11.39 p.m. I had not long drifted off to sleep after a very busy day. After a brief consultation with a woman in labour, we decided to meet up at the local community hospital: another baby on its way. I put comfortable birthing clothes on, trying not to awaken my sleeping partner before I leave. While driving my car I check to identify the outline of the hills surrounding us—this is to check the visibility. We need good visibility if a helicopter has to land and retrieve. Otherwise it is a gruelling ambulance trip over winding terrain. We are at least 2 hours away from a base hospital if we need to transfer. The trip to the hospital gives me some time to review the information I have about this woman and her family. I pass rapidly from sleep-mode to midwife-mode.

‘I call my back-up midwife. We attend another amazing birth in a place we all call home. A new baby joins a social network of around 5000 country people. All of us in this rural community are connected. Everything I do affects others, and that affects me too.

‘Back home to a warm bed for a few hours, and then up again for a busy clinic day. Potentially it’s a routine day, but there is never anything routine in midwifery. Dealing with low or high blood pressure, lifestyle changes, organising scans and blood tests, helping to sort out relationship issues, having in-depth discussions and coming up with diagnoses. Those difficult “grey areas”. What level of intervention? Treating urine infections, finding out why they have them, trying non-medical measures first. Questions like: is this baby growing well, or not? What is causing this abdominal pain if it isn’t labour? Is it an APH, appendicitis or gastro? I must have clear boundaries around where my scope of practice ends and medicine begins. I can’t ring a bell to summon an obstetrician, and need to be clear about reasons for referral before organising a 2-hour journey for a consultation or transfer of care.

‘I experience feelings of isolation and aloneness at times, which can be quite overwhelming when major decisions have to be made around transfer or when some emergency occurs. The most challenging aspects of rural midwifery for me are around decision making. Aside from the 2-hours-away issue, the weather or road conditions have to be factored into the process. This is a major upheaval for any family. I have to be proficient at dealing with all non-operative obstetric emergencies, resuscitation, haemorrhage, cannulation and suturing. Again the isolation: I can’t just wait to see how things turn out. I have to make the right decisions.

‘The most rewarding aspect of rural midwifery for me is that while I am involved in my clients’ lives, so are they in mine. Midwifery consultations happen on the fly at parties, supermarkets and the coffee shops that we all go to. What makes this style of midwifery work for us is the freedom from influence and pressure from the medical model of maternity care. Collegial support is vital and always available. Our remoteness works for us and the women because of the Takaka Hill, which separates us by 2 hours from the base hospital. We have to work things out with what we have. It is a big decision to transfer a woman and her family out of their home area. This same benefit of isolation has the potential for causing the most stress too. We have to get it right. However this serves to make us have very clear boundaries of what is normal and what is not.

‘But that is what it is all about: the weight of autonomy in an isolated area is balanced by the reward of being an integral member of a rural community. Experience is a great teacher and so are the women.’

Box 5 Continuity of care on a Scottish island

The Western Isles are the most westerly populated archipelago of islands in the UK. Home to a mainly ageing population of 27,000 people, the main employers are the health board, the council and fishing-related industry. The main hospital provision is situated in Stornoway, a town with a population of 12,000 and a small consultant-led maternity unit with an average of 200 births per annum of low- to mid-risk women.

Three of the smaller islands with a population of approximately 5000 are served by a small general practitioner-led hospital, and maternity care is provided by two full-time midwives and one bank midwife. The caseload of 40–60 women per annum is managed by the midwives, who live locally and are part of the community. The model is one of holistic case-led management, working in true partnership with the woman and her family, as well as the other professional members of the maternity care team. Using an ongoing risk assessment at each contact with the women, the midwives care for all pregnancies whatever risk factor they are classed as. Currently any woman wishing to give birth on the island has to meet stringent ‘low risk’ criteria but all antenatal and postnatal care is provided locally no matter where the woman is booked to have intrapartum care. This means the midwifery team must be up-to-date with evidence-based practice, and they do this by using a philosophy of normalising every woman’s pregnancy experience as much as possible. Using the risk management model on an island setting means that the midwives must be able to detect deviations from the normal pathway at the earliest opportunity. Time is such an important factor, and bad weather can mean that transport is unavailable when an emergency does occur.

The target group is all women of reproductive age living on these islands. The midwives provide advice and contact from pre-conception to 6 weeks postnatal, therefore their knowledge base and expertise is comprehensive rather than being specialist. Without this service, local women would find it difficult to remain at home while pregnant—never mind give birth locally. This is very important to these women as many of them are descendants of generations of island families. The islands need young people to keep the community alive and the midwifery service is an essential part of community viability.

The service works due to the commitment and flexibility of the midwives. Not all midwives would relish being on call when a birth is due but these midwives provide this service and enjoy it. This is really appreciated by the local population and it is mutual respect and communication that makes the service successful. The service is not about numbers of women but rather the individualised care that all of them receive. Whatever a woman’s obstetric history is, the midwife will get to know her and plan her visits accordingly. The place of the visit is also very negotiable, some clinics are centralised but many visits are provided at home whenever that is most appropriate to the women. Good communication with mainland maternity units is also essential, and the midwives have been commended on their standard of record keeping. Indeed these midwives used a form of woman-held records, developed locally, which has informed the Scottish woman-held maternity record now used nationally. This coordination of care for all women makes the midwife the key professional in an effective individualised service, which is valued by all concerned.

In implementing the service, the midwives peer-evaluated themselves and gained the necessary experience. This, for example, was in obstetric emergencies, newborn life support and scanning. They also used successful negotiating skills as the intrapartum service had been withdrawn for approximately one year in 2000 due to a shortage of skilled staff. These midwives were committed to restore this service and developed local protocols based on published evidence-based practice. Involving the local professionals and women in the service development also assisted with ownership of the service by all concerned.

To keep the service sustainable, the midwives evaluate their skills annually and are facilitated to work in other units as required. This ensures that they keep an essential network with other midwives and learn from other units. Of course much learning is taken by them to the other units, and other midwives are welcome to come and experience this unique service in one of the most beautiful remote parts of the world. Scottish maternity care guidance now supports the development of locally accessible midwife-led services for all women and the normalisation of birth. This national support will also assist in keeping this service model sustainable.

We found it useful to develop local protocols based on evidence-based practice, and to debrief after each of the early births with all concerned, including the hospital manager, to increase the confidence of all concerned with the new service.

Box 6 Continuity of care in remote Inuit regions of Canada

Asiniaq is a Canadian Inuit woman living on the east coast of Hudson Bay, in the remote village of Salluit. Asiniaq has just given birth in the small birthing centre that is part of the local health centre. Her birth was attended by local midwives, who have known her as part of village life since she was a baby. When Asiniaq is ready, the midwives turn on a set of small lights in the window of the birth room, which announce to the community that a baby has been born. Relatives and community begin to visit.

Asiniaq’s grandmother, Alacie, gave birth ‘on the land’ in summer tents and in igloos, the traditional winter snow houses of the Inuit. Alacie was attended by traditional midwives and, when no help was available, by her husband Paulosie. In a nomadic hunting culture it was essential that all of the people understood the basics of assisting a woman in labour and helping at a birth.

When Asiniaq’s mother, Elisapee, gave birth the people had moved into villages and local priests and teachers had forbidden traditional healing. Midwifery and traditional healing had gone underground and people feared the power of the authorities. Elisapee’s first birth was in the nursing station, staffed by nurses with midwifery training. She was also attended by her Aunt Minnie, the local midwife. Despite the lack of respect for her skills, Minnie continued to go with women in labour and provide suggestions and support in Inuit, which the nurses could not speak. When Elisapee gave birth to Asiniaq several years later she was flown ‘south’ to a hospital staffed with physicians, where none of the caregivers spoke her language. According to the authorities babies were no longer to be born in the village. Elisapee waited weeks for labour to begin, worried about her children and her husband back in the village. She was disoriented being away from home and community, her language and traditional foods and frightened in the big city. She cried with loneliness and called out for her mother and aunt as she laboured alone in the hospital.

For her next child, she refused to leave the village. The nurse in the nursing station had no experience with birth and threatened her and told her that the baby might die. She quietly but strongly refused to leave and trusted in her body and the advice of the elders. When talk of bringing birth back to the communities began in the villages of the Hudson Coast, Elisapee joined the local women’s group and the work to reclaim Inuit midwifery and local birth. Minnie began to teach traditional ways to the young women who wanted to learn. The young midwives learned both traditional and southern ways to help at births.

Now Asiniaq has given birth in the birth centre that her mother fought to establish, with her mother and her great aunt beside her. The midwives who attend her not only know her, but her language and her culture.

In the remote communities of the Inuit regions of Canada, where local activism has returned birth and midwifery to the communities, continuity of care means continuity of place, culture, language and tradition. Continuity of carer flows from reclaiming birth as part of the life of the community. For the Inuit, local birth means continuity not only of your caregiver but with your family, your language, the land and Inuit history.

Box 7 Continuity of care for disadvantaged women in an urban setting

‘It is 3 a.m. and the mobile phone on my bedside table suddenly wakes me up with a loud ring tone—it amazes me that it doesn’t wake my husband or children. They never hear me getting up and ready to go out in the middle of the night and often only know I’ve gone when I’m not in bed when morning comes!

‘It is Shazia calling, one of the women I have booked on my caseload. She is 39 weeks pregnant and has been having contractions for 4 hours, but they are now strong and coming regularly every 5 minutes. She reports that the baby has been active, her waters have not broken and she has a blood-stained loss when she goes to the toilet. Shazia would like me to go to assess her at home prior to going into hospital to have her baby.

‘As I get ready, I make a quick call to the delivery suite to let them know the address I am going out to. I get in my car 10 minutes after Shazia’s call to drive the 5 miles from my house to hers. I am confident that Shazia will be established in labour and that this won’t be a false alarm. It is her third baby and she has had two fairly quick, straightforward normal births without intervention. Physiologically, she has good pregnancies and labours. However, Shazia has mental health problems and this is the reason she was referred for one-to-one caseload midwifery care with our group practice. She has a long-term history of severe depression but has also recently started to hear voices, which she has found extremely distressing. Shazia is very well supported by her family, and we have all worked together in partnership with the health visitor, GP and community psychiatric nurse to provide the best possible support.

‘As I drive along the empty roads I reflect on how the group practice has evolved since it was established 3 years ago. The group practice was originally based within a Sure Start area (Sure Start 2007) to provide caseload midwifery care to women living in that area. It was a joint project between maternity services, a Sure Start local program, and the midwifery research department of the local university. It was seen as an opportunity to use funding allocated for midwifery services in the Sure Start program in a different way (Byrom & Downe 2007). Six midwives were appointed, 3 full time and 3 part time, with each midwife carrying their own individual caseload of up to 36 women per year, depending on the number of hours worked.

‘Good outcomes demonstrated by the group practice in the first 2 years by way of increased normal birth rates and lower intervention rates have resulted in funding being secured from the local borough council to expand the service to women from the most vulnerable groups within a larger geographical area, rather than being concentrated in one locality (Fleming et al. 2007, Fleming & Downe 2007). The women offered this care include those with severe mental health problems, complex child protection issues, HIV positive women, young teenagers (under 16 years), fetal abnormality with poor prognosis, and women who have experienced a previous traumatic birth. The aim of the group practice is to provide intensive support in an attempt to optimise their potential for normal or positive birth, and through enhancing their birth experience to maximise opportunity for improved outcomes for mothers and babies.

‘I am now outside Shazia’s house, and her husband is at the front door waiting for me. He knows me, and as he shows me into the house he explains that he has already put Shazia’s bags into the car so they are ready to set off whenever we are ready. Shazia is standing in the dining room leaning over the back of a chair, breathing through a contraction. The look of relief on her face and the exclamation that she is very happy to see me makes my job so worthwhile and rewarding, and I smile as I prepare to help Shazia through the coming hours, thinking what an honour it is to be involved at such a special, important event in this woman’s life.’