Trying to make a difference: Improving pregnancy outcomes, care

Trying to make a difference: Improving pregnancy outcomes, care
and services for Aboriginal and Torres Strait Islander women
Dr Jenny Hunt, Centre for the Study of Mother’s and Children’s Health, La Trobe
University, Melbourne
Abstract
Dr Hunt’s presentation will critically examine pregnancy health care and services for
Aboriginal and Torres Strait Islander women to explore the question of what might
‘make a difference’. More antenatal care, and in particular Indigenous women
attending for care earlier and more often, is often put forward as necessary to
improve pregnancy outcomes as well as the health of future populations. Jenny will
problematise this assertion by drawing on epidemiological, clinical and health
services evaluation evidence collected as part of her PhD. She will argue that
pregnancy health care and services need to change to allow Indigenous women to
have more say in decision-making at both individual and institutional levels.
Walkin’ about at Night: Young women and their relationships in a
remote Aboriginal community
Dr Kate Senior, Research Fellow, Centre for Health Service Delivery and the Institute
for Social Change and Critical Enquiry, University of Wollongong
Abstract
Dr Senior’s presentation draws on her research at Ngukurr, NT, where she worked
with young women (aged 13-25) to explore their views, their lives, their role in the
community and their aspirations for the future. Kate will discuss the young women’s
decision making regarding sexual relationships and pregnancy. She focuses on the
young women’s perceptions of their capacity to make choices and to control their
circumstances. Teenage pregnancy is the norm in the community and many of the
young women considered that pregnancy was an inevitable outcome of their
lifestyles.
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Trying to make a difference:
Improving pregnancy outcomes,
care and services for Aboriginal
and Torres Strait Islander women
Jenny Hunt
Centre for the Study of Mother’s and
Children’s Health,
La Trobe University
Jenny: I am a public health doctor by background, and for most of the last 10 years I
have been working at Aboriginal community controlled health services, in clinical
practice and public health practice. For the last four years I have been doing a PhD,
looking at pregnancy care and services for Aboriginal women; that has been
supervised by Judith Lumley, at La Trobe University.
Obviously, I am not going to have time to tell you all about everything I have looked
at and learnt in the last four years. What I thought I would do is just to focus on a
couple of my conclusions and responses to the question of what people working
within the health system can do to try and make a difference to the health and wellbeing of Aboriginal women during pregnancy, and their babies.
My interest in pregnancy health care for Aboriginal women really got going from
about 1993 when I started work at Danila Dilba, which is an Aboriginal health service
in Darwin. I worked there as a doctor and was involved in establishing a women’s
health service called Gumileybirra. Through my work there I talked to and looked
after a lot of Aboriginal women, including during pregnancy, and I also looked after
their babies and children. Like most of us, I guess, I knew about all the statistics that
show high rates of low birth weight, pre-term births, perinatal mortality, and almost
every measure of sickness that you care to mention. But one of the many things I
learnt during my time at Danila Dilba was how these health statistics translated into
the day-to-day experiences in the lives of the Aboriginal people who were my clients
and colleagues.
Like many health professionals working in Aboriginal community controlled health
services, I became increasingly aware of all the historical, political and socio-
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economic factors that were explanations for Aboriginal ill-health, but also I was a
doctor and keen to work out what I and the health system could do to make a
difference to health. And in my case I was interested in women and babies.
I was really disturbed that some of the women we looked after during pregnancy were
really sick, and yet they refused – either by point-blank by saying they would not go,
or by not attending – to go the hospital for care. So we worked very hard to set up
Gumileybirra as an alternative to that hospital option, where women could feel
comfortable to attend. It seemed to me that it was worth looking more closely at
some of these issues, and so I decided to do a PhD, which I started in 1999.
My general approaches
z
z
z
z
z
‘The health system’ and its components as
the main object of research
Collaborative/participatory approaches working with Aboriginal people and
organisations, and with other health
practitioners and organisations
Applied/action-oriented - aiming for change
Using ‘unobtrusive’ methods
Multiple projects and methods
My decision to focus on the health system rather than other factors that might
contribute to ill-health was one of the ways I decided to respond to the substantial
critiques of Indigenous health research ethics and practice articulated by people like
Ian Anderson. You would probably be aware of those. I decided to study the
practices, institution and cultures of which I, as a non-Aboriginal doctor, was a part,
including those associated with epidemiology, research, public health and clinical
practice. In doing this work, I tried to work in participatory and collaborative ways,
both with Aboriginal people and organisations I had really well-developed
relationships with, mainly in Darwin, as well as with the health professionals who
were my mob, including doctors, midwives and policy makers. I tried to do research
that was applied and action orientated, that tried to evaluate and improve the situation,
rather than simply document problems.
For quite a few projects I used what Kelleher has called unobtrusive research
methods, meaning that I reviewed and analysed existing data or data sources, because
I felt that using existing records would be less intrusive as well as less demanding of
resources, both mine and other people’s. So I did several projects using a number of
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different methodological approaches. I am not going to describe them all in detail,
but I will just outline some of them.
The Northern Territory, the
Top End and Darwin
NT - 190,000 people
28% Aboriginal
5 regional hospitals
Each year 3,524 women
give birth, 96% in hospital
Darwin urban - 100,000 people
10% Aboriginal
Darwin rural - 12,000 people
75% Aboriginal
Most of the work that I did was based in Darwin and the Top End of the Northern
Territory (NT), mainly because that is where I knew people and was known by them.
I have included this slide to give people a bit of background information about the NT
and people there, just a few basic facts and figures.
I started out by looking at guidelines and protocols about antenatal care, and I
critically reviewed what guidelines and protocols there were nationally, and then the
ones that were used in the NT.
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Royal Darwin Hospital
project
A review of pregnancy care for
Indigenous and non-Indigenous
women giving birth at Royal
Darwin Hospital in 1999
Based on hospital records for all 516
Indigenous women who gave birth
and a random sample of 143 nonindigenous women
I then looked at what happened in practice, by reviewing the medical records of
Aboriginal and non-Aboriginal women who gave birth at Royal Darwin Hospital in
1999. My main focus was on identifying specific and practical ways in which the
health care of women during pregnancy could be improved.
Provider interview project
Views and experiences of
providers of care to Aboriginal
women of the Top End
In-depth interviews with 22 health
practitioners - midwives and doctors
- working in community and hospital
settings
After I did this project, I became more interested in finding out more about the views
and experiences of practitioners who cared for women during pregnancy, so I did
in-depth interviews with 22 practitioners who were midwives and doctors working in
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hospital and community settings, and I undertook a qualitative analysis of those
interviews.
Gumileybirra project
An evaluation of the Gumileybirra
Women’s Health Unit of Danila
Dilba Health Service
Multifaceted collaborative review
including a detailed description of
activities, review of systems and
client feedback assessment
I also spent eight months based at Danila Dilba, working with the staff to undertake
an evaluation of Gumileybirra, the women’s health unit I had been involved in setting
up. We used a lot of different sub-projects to describe and develop the services and
activities of Gumileybirra, including asking women for feedback about the service,
using questionnaires and interviews.
Literature review questions
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How and why do pregnancy outcomes vary?
What is the capacity of pregnancy care to improve pregnancy
outcomes, and in particular to reduce inequalities between
population groups?
How can routine antenatal care, and its component activities, be
evaluated?
How has the Australian health system (including policy,
research, services) defined and responded to the issues of
pregnancy care and outcomes for Aboriginal and Torres Strait
Islander women?
What Indigenous-specific services have been developed?
What have Indigenous women said about mainstream and
specific services?
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I also did a lot of literature based work for my PhD, and these are some of the
questions that I looked at.
When I first started, I was really keen to talk to Aboriginal women about their views
and experiences of pregnancy care and make that a major focus of my work, but
eventually I decided it just wasn’t going to work. Because I wasn’t Aboriginal, and I
was a doctor, it was really hard to imagine how I could do interviews with women
where they were going to feel comfortable to talk frankly about their experiences.
And I did not have resources to employ someone else to work with me on that. So
instead I tried to find any available accounts where women had talked about their
experiences, and I actually, surprisingly, found quite a few in reviews of birthing
services and evaluations of programs.
I was also fortunate in having a number of friends and colleagues who were
Aboriginal women, some of them health professionals, who I could talk with
informally throughout the course of my PhD about my research findings and
interpretations.
So that has given you a bit of an idea about the sort of work I have been doing. If
anyone is interested in finding out about any more of those specific projects, please
contact me.
I am just going to move on to talk about a couple of my conclusions about how
pregnancy care and, in particular, antenatal care, could be improved. I want to make
it clear that when I am saying ‘antenatal care’, what I mean is when women who are
pregnant go to the clinic to see a doctor, a midwife or a health worker, and the health
care that happens there and, for some women, in hospital.
Antenatal care
“Adequate pre-natal supervision is generally
recognised as being one of the most effective
means of preventing unnecessary mortality or
morbidity associated with pregnancy or childbirth.
Obstetric examination will enable many possible
defects or abnormalities to be foreseen and
appropriate steps taken to ensure the safety of
mother and child; whereas if the condition is not
observed before hand and treatment postponed
until an emergency actually arises, the chances of
a favourable issue may be lost or greatly reduced”
Campbell, 1930. Report on maternal and child
welfare in Australia, Commonwealth Department of
Health, Canberra.
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In countries like Australia, antenatal care has been institutionalised since the early
1900s. Initially it was promoted as a way of improving the health of populations,
through a belief that medical supervision could have an impact on infant and maternal
mortality. In some cases this belief turned out to be unsupported. For example,
reviews of historical trends in maternal mortality by Loudon and others have
demonstrated clearly that in the days before antibiotics, if you were attended by an
obstetrician you had a greater chance of dying than if you weren’t, because the
obstetricians spread the bacteria causing infection from one woman they attended to
the next.
Over the years, an increasing number of tests and procedures have been added to what
is considered routine care during pregnancy, and reviewing this history shows several
examples of tests that have been adopted without their safety being assessed
adequately, or at all, beforehand. For example, X-rays were used from the time they
were invented in the early 1900s, to diagnose or exclude pregnancy and assess
gestation. Their use continued for many years, right up until the 1950s when
ultrasound took over as a way of visualising the baby, and persisted even well after
evidence began to emerge that they were harmful and they caused childhood cancer.
It seems unlikely that new technologies in pregnancy care introduced in our times will
have dramatic adverse impacts like that. Since the 1970s the evidence-based health
care and consumer movements have stressed the importance of better evaluation of
health technologies in general. However, there is an on-going tendency for
evaluations of new technologies in medicine to focus primarily on positive impacts on
easily quantified health outcomes, and to under-emphasise possible harms or adverse
impacts.
In the case of new technologies relating to pregnancy, there is a general preference
evident when reviewing the medical literature to focus on potentially positive impacts,
particularly on babies, and to downplay or ignore impacts on women, particularly
those which might be negative or have psycho-social dimensions. For example,
commentary on research evaluating the merits of screening and managing gestational
diabetes, which is a condition defined as a specific level of glucose intolerance in
pregnancy, is most commonly focused on possible impacts of management on babies’
birth weights and other outcomes. It is very unusual for reports to spend much or any
time talking about the possible adverse impacts of screening and management of this
condition on women and their families. These might include those related to labelling
women as ‘high risk’, increased surveillance, hospitalisation, dietary interventions,
having labour induced, the side effects of insulin – the list goes on.
My review of the medical literature about pregnancy care suggests to me that
women’s views and experiences are not always taken into account when tests and
approaches are evaluated, despite the growth of the consumer and women’s
movements in maternity care stressing the importance of this happening.
Moving on to think about antenatal care for Aboriginal women: research and policy
interest in pregnancy care for Aboriginal women has been a relatively recent
development. Published reports with coverage of this issue have been largely limited
to the years since 1970, and in common with other content areas of Indigenous health
research, most research has been descriptive analyses of large databases of routinely
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collected data. Typically, reports include analyses showing high frequencies of
adverse outcomes for babies, accompanied by commentaries calling for women to
have better health care in pregnancy. But only very few studies have evaluated
pregnancy care or services, or focused on the health and well-being of Aboriginal
women during pregnancy. Even fewer pieces of research have been done by, or
engaged with, Aboriginal women themselves, or even acknowledged the importance
of women’s subjective views.
One of the most consistent findings of routine data collection and research analyses
about antenatal care, including mine, is that Aboriginal women attend later and less
frequently for antenatal care than other groups of women.
Antenatal care attendance
for Top End women
100%
80%
13+ visits
60%
5-12 visits
40%
1-4 visits
No care
20%
0%
Darwin
Darwin rural
Darwin
urban
Indigenous
urban non-
Indigenous
Indigenous
In my study of women giving birth at Royal Darwin Hospital, Aboriginal women
were about twice as likely as non-Indigenous women to have no records of antenatal
care, although as you can see here – those bars down at the bottom are the people with
no care – the numbers of women who had no care at all were very small. But it is
certainly pretty clear that Aboriginal women, whether they live in urban or rural
settings, have fewer visits than non-Aboriginal women, despite the higher number of
health problems they experience.
In Australia and elsewhere, descriptive analyses have repeatedly confirmed that
women in population groups acknowledged as being disadvantaged have both fewer
antenatal visits and more frequent adverse birth outcomes such as low birth weight.
Making this association has been used to argue that if women would just attend more
often for antenatal care, their worse outcomes would improve. However, I would like
to challenge this justification for a policy approach focused on increasing attendance.
My first point is to suggest that there are many other explanations besides cause and
effect for the relationship between less frequent attendance and adverse outcomes.
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One obvious issue is that women who give birth pre-term, which is itself considered
an adverse outcome, are pregnant for less time, so they can have fewer visits because
they are not pregnant for so long. It is similar for people who spend a lot of time in
hospital.
These are specific examples of the general observation that women who do not attend
as often for antenatal care almost invariably have a lot of other problems, which are
contributing to adverse outcomes independent of their not attending for care. For
example, women who do not attend are also more likely to be poor, sick, exposed to
violence or racism, et cetera, et cetera – each of which has clear associations with
adverse birth outcomes. While pregnancy care and services designed to meet their
needs may have many positive impacts on the health and well-being of these women
and their babies, it seems unrealistic to expect that a few health care visits will reverse
the impacts of a lifetime of disadvantage on outcomes like birth weight.
Now, I’m not meaning by this that antenatal care is a waste of time and has no
benefits, or that there are no women who would benefit from having more care during
pregnancy. But what I am saying is that we need to question the argument that
increasing antenatal care attendance will necessarily improve outcomes such as low
birth weight. We need to subject antenatal care to the same critical evaluation we
should any health care activity, and that includes evaluating the impacts of different
activities and approaches on a range of outcomes, including women’s experiences,
and explicitly considering the possibility of negative impacts as well as positive ones.
‘Standard’ schedule of
antenatal care visits
z
4-weekly visits until 28 weeks
gestation
Then 2 weekly visits until 36
weeks gestation
Then weekly visits until delivery
z
Total of 12-14 visits
z
z
The currently standard schedule of antenatal visits shown here is often used as the
criteria against which attendance rates are measured. I was interested and rather
surprised to find out that this schedule dates back to a 1929 policy recommendation
from the UK. This is still the current standard schedule. Since then there have been
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large trials of schedules of antenatal care with less frequent routine visits,
systematically reviewed by Villar and others from WHO, and these have shown no
adverse impact on outcomes in either developed or developing country settings from
attending less frequently. Conversely, trials of enhanced antenatal care, in a range of
settings, have consistently shown no demonstrable improvements in perinatal
outcomes.
In the United States, a huge investment of resources has been made over the past two
decades supporting a policy approach of increasing attendance, and to provide
programs of enhanced antenatal care for groups identified as being disadvantaged.
Recently published analyses looking at changes in attendance and outcomes have
shown that this policy has definitely increased attendance – people are attending more
often – but there has been no improvement in outcomes, and in some cases the
disparities between more and less advantaged women have widened.
In my experience and from my research, a policy and practice focus on ‘encouraging’
Aboriginal women to attend for antenatal care often means measures that I believe
would be more accurately termed coercion. In one report about a pregnancy care
program in Queensland I found reference to the police being used to bring Indigenous
women who were not attending to the clinic for care, as recently as the 1990s. While
this is likely to be an extreme case, at least in recent times, providers I interviewed
described using various tactics and spending a lot of time and energy making sure
women attended regularly for antenatal care according to this schedule.
For remote community women this could include visiting women’s homes repeatedly
– one provider said that she had been up to 20 times to someone’s house. Now, if that
happened to me, I would call it harassment. Providers also described how, when they
were talking to women, they stressed adverse outcomes in order to make women
fearful about the consequences of not attending for care. These approaches were no
doubt motivated by concern by practitioners for the health of women and babies, but I
have serious concerns about whether these sorts of measures have a net benefit for
women and babies.
Another way of interpreting the less frequent attendance of Aboriginal women for
care is one of the many examples of what Tudor Hart has called the inverse care law,
that those most in need of the best health care are the least likely to get it. I believe
that this interpretation is useful in focusing practitioners and health service resources
towards making sure that the care women receive is of high quality, rather than being
overly focused on the number of visits in women’s attendance. This could include
critically evaluating the specific activities and approaches, and designing and
operating pregnancy care services in ways that better meet women’s needs, and I
would now like to spend a little time talking about some of the ways I think this could
happen.
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Content of antenatal care recommendations
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z
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No Australian national guidelines
Variable recommendations in
Australian protocols
Issues important for Aboriginal and
Torres Strait Islander women in
pregnancy not well covered in
protocols
Need for national evidence-based
guidelines
When I first started my studies, I was really surprised to find out that there were no
Australian guidelines about antenatal care. Since 250,000 women give birth in
Australia each year, I would have thought that was a pretty good justification for
having some. While I was waiting for my PhD projects to be negotiated, I decided to
collect and review protocols used by public hospitals and Divisions of General
Practice around Australia, and I obtained copies of more than 100 different protocols.
What I found is that although there was some common ground in what they
recommended, there was also a lot of variability in what they covered and
recommended about specific schedules, tests and checks – things like how to screen
for gestational diabetes, anaemia, HIV, that sort of thing. Specific health issues of
particular significance for Aboriginal women, like smoking and screening for and
managing genital and urinary tract infections, were rarely covered in these protocols,
and where they were, they gave very variable recommendations.
So one way I think the quality of antenatal care could be improved is by the
development and implementation of national guidelines about antenatal care. If there
were national guidelines, these could be adapted by local providers, institutions and
communities to meet their specific needs and circumstances, and could also be used as
a basis for providing information for women about their care.
Over the last couple of years, the three major maternity hospitals in Victoria have
developed guidelines about some routine antenatal care activities. They are called the
Three Centres Consensus Guidelines and they are available on the Internet, if anyone
is interested in having a look at them. It is a really big job, because there are lots of
things in antenatal care, so it would make sense to build on that work and other work
that is being undertaken in the UK to develop the guidelines.
In other policy areas the development of Indigenous specific companion guidelines to
a national guideline has been endorsed, and I think that could work well for antenatal
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care as well. Obviously, Aboriginal women would be in the best position to decide
about the scope of those guidelines and interpreting evidence for their development.
Antenatal care in practice
in the Top End
z
Variable approaches
z
Under-management
z
Over-management
• Screening tests for genital tract
infection
• Smoking
• Treatment of genital and urinary tract
infections
• Screening and management of
gestational diabetes
• Presumptive treatment UTIs
Of course, guidelines are only a source of information and guidance, rather than any
guarantee that best practice will actually happen. When I reviewed what actually
happened in practice for women in Darwin and the Top End, I found many specific
areas where I felt care could be improved.
There was a lot of variability in how women were screened for genital tract infections,
for example. Some women who had no symptoms were screened four or five times
during pregnancy with a wide variety of different tests, and some women had no tests
at all. To me that indicates that someone is not getting optimal screening.
There were several areas where problems were identified but not managed well or at
all – for example, women who had infections diagnosed but not treated – and most of
the more than 50 per cent of women who smoked had no documented discussion or
other intervention relating to smoking cessation.
I also found examples of what I considered to be over-diagnosis and overmanagement, several of which were in the area of gestational diabetes. I spoke a little
bit about that before, but gestational diabetes in the health literature is a very
controversial area. A lot of debate goes on about the relative benefits and harms of
screening and management. I am not going to really go into that, but in the light of
the controversies that exist it is my view that some of the approaches to screening and
diagnosing and managing gestational diabetes in the Top End were overly zealous.
For example, some women had up to four glucose challenge or tolerance tests during
pregnancy. For people that don’t know what they involve, basically you have to hang
around the clinic for several hours and have between one and three blood tests. It just
seems totally excessive to be doing that three or four times during your pregnancy.
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Of the 36 Aboriginal women who were diagnosed with gestational diabetes, five had
all the test results completely normal so it was very unclear to me on what basis that
diagnosis had been made. All Aboriginal women who were diagnosed were
hospitalised, in some cases just to be educated about diabetes and to have their blood
sugars monitored. Again that perhaps could be much better done in the community.
In each case I think it is unclear that these management decisions to ‘do something’
would have resulted in a net benefit to women.
Another example was that about half of all Aboriginal women from outside the urban
areas were given antibiotics in their pregnancy for urinary tract reasons, but only
about half of those – so a quarter in total – actually had a urinary tract infection at any
time during their pregnancy. This raises questions about the potentially negative
impacts of high levels of antibiotic use: things like side effects, resistance and costs.
In each of these cases I believe there needs to be consideration of the possibility that
better antenatal care might involve less screening and less management, rather than
more.
These were just a few of many specific aspects of antenatal care where my review
identified room for improvement in the Top End, and during and since my PhD I have
been working with Top End service providers and policy makers to try and address
some of these issues by developing guidelines and various things to improve
practices.
I would like to finish by moving on to talk a little about the health service context in
which antenatal care is delivered.
Criticisms of mainstream
pregnancy care health services
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z
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Long waiting times
Little continuity of carer
Short consultation times
Impersonal and unfriendly
environments
Lack of interpreters
Lack of Indigenous staff including
health professionals
Women report experiences of racism
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As I explained earlier, I did not do a major project asking Indigenous women about
their views and experiences of pregnancy care. However, we did ask women for
feedback as part of the Gumileybirra evaluation, and I have also had many
conversations over the years with Aboriginal women whom I have looked after as
patients or whom I have worked with or who have been friends. As part of my PhD I
collected published accounts I could find of what Aboriginal women had to say about
pregnancy care and service when they had been asked – which was not that often, but
more often than I had thought. These included groups of women from most states and
territories. I also talked to providers of care about their views. There were some
pretty notable consistencies in what these different groups had to say about pregnancy
health services, and I just want to finish off by talking about some of these points of
convergence.
Firstly, mainstream services. Basically, everyone was extremely critical about
mainstream antenatal care services that they had been associated with. It is still the
case, when I was last in Darwin – and I expect it is in many other places – that women
using the public hospital system for antenatal care wait several hours, to see someone
they have never met before, for a few minutes. Now, I wouldn’t bother going if that
were the case. It is interesting and pretty depressing that commentaries from the
1930s about antenatal care in Australian hospitals talk about their production-line
atmosphere, and it seems that for at least some women not much has changed.
In some places there have been institutional measures designed to improve continuity
of care and women’s experiences, including things like midwives clinics and shared
care arrangements between hospital and community providers. However, these
options are often less accessible to Aboriginal women because they are labelled as
high risk and so they are not allowed to use these options. The lack of Indigenous
staff and health professionals has been highlighted in almost every published review
of birthing and pregnancy services and other accounts of women’s views of care. The
various policies and programs to encourage and support Aboriginal people to train as
doctors, midwives and health workers, and to work in the various settings in which
pregnancy care is delivered, could be expected to have major impacts on improving
women’s experiences.
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Indigenous specific
pregnancy care services
-
Congress Alukura in Alice
Springs
Ngua Gundi in Rockhampton
Townsville AIHS Mums and
Babies program
Daruk antenatal program in
western Sydney
Gumileybirra in Darwin
A range of different programs and services catering for Aboriginal women have been
developed in various locations around Australia over the past decade or so, and these
are some examples where there are some published accounts of them, although it is
not common for them to be documented in that way. Many of these are at community
controlled health services or other community based locations.
Gumileybirra features
z
z
z
z
z
z
z
z
Designed, staffed and operated by Aboriginal
women for Aboriginal women
Transport and child care for women who need
them
Flexible appointments
Women-only area on clinic days
Aboriginal Health Workers provide care and
support to women
Holistic care – women, families, communities
Strong community links
Accepted, valued and well developed role in
advocacy and policy development
Some of the features of Gumileybirra, which is the one that I know the most about,
but which are also features of other services, are listed here. The services are
designed, staffed and operated by Aboriginal women and have flexible appointment
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systems, free transport and child care. Aboriginal Health Workers are a really integral
part of providing care and information for women, and the care is holistic, in that the
whole woman is looked after, not only her pregnancy; her children are looked after,
and her family; and the Aboriginal health service is part of developing the community
and does a lot of other things besides simply providing health care.
I believe there is a strong case that has been made in many forums to support the
initiatives of Indigenous women and organisations to provide health care, including
pregnancy care services. I also think these programs and services are very useful
models for mainstream services to try and lift their game.
The reviews and research I worked on for my PhD suggested to me that most people,
including Aboriginal women and many of the providers who work in the area, are
pretty clear on what needs to happen to improve pregnancy care and services for
Aboriginal women. However, as in most areas in Aboriginal health, finding the
resources and the political support for making change happen is an ongoing struggle.
I hope that this presentation has given you some food for thought, and also that it
might help with developing ideas about how we can continue working towards that
goal of improving pregnancy care and services for Aboriginal women.
Thank you.
Contact details
Email: [email protected]
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Walkin’ about at Night
Young women & their relationships
in a Remote Aboriginal Community
Walkin’ about at night:
Kate Senior
Young women and their
The University
Relationships in a remote
of Wollongong
Aboriginal Community
Kate: Good afternoon everybody. I would like to begin by acknowledging the
Ngunnawal people, on whose land we are today – and every day when we are in
Canberra.
I also want to acknowledge the Ngukurr community. The work I am talking about
today is part of a three-year project that has been carried out in that community by the
South-East Arnhem Land Collaborative Research Project. The work that was carried
out in this project was directed by community members, and they considered this
work with the young women to be particularly important and were very enthusiastic
supporters of this sort of work. This work was conducted at the end of the three-year
period of research because we thought it was going to be quite difficult work that
needed a lot of familiarity with the community and a lot of community support to
actually do.
My thanks to the young women who participated with such enthusiasm in this work,
and the Ngukurr Community Education Centre, who provided support and are keen to
address – and are addressing – some of the issues that we raised in this period of
research.
What I am talking about today is the set of factors before you get to Jenny’s stage.
This paper examines the sexual relationships of young women in Ngukurr and how
they consider the consequences of these relationships: pregnancy and marriage. I also
look at the level of information that they have about sexuality and the level of
information they have about relationships between men and women. The title of the
paper, ‘Walkin’ about at Night’, is the term that Ngukurr community people use to
describe the nocturnal activities of young women in the community. It is a very coy
description, I think.
18
Walking about at night is, for young people in Ngukurr, a defining feature of
adolescence. The motivations are two-fold: to find a boyfriend and to maintain a
relationship with him. Young women talk about walking about at night as the
highpoint in their lives. They devote huge amounts of time and energy to planning
this activity and conducting this activity. But when we look at it in the context of
young women’s view of their community and their lives, it starts to become
problematic. It reveals ideals that appear to be both inconsistent and contradictory,
and we will start to look through those in this talk.
Young women have few romantic notions of marriage. In the large, they seem to be
rather ambivalent about pregnancy. And yet they single-mindedly devote themselves
to the activity of walking about at night, in which these outcomes are considered to be
almost inevitable.
Background
Burbank’s study of Maidenhood (1988)
Peer pressure in adolescent relationships
Competition & prestige
Perceptions of normal sex roles
Understanding and knowledge about the body &
sex.
In terms of the background to the study, the major previous study of adolescence was
Vicky Burbank’s study in a community that was not very far away from Ngukurr.
She describes the period between the onset of fertility and marriage as Maidenhood.
She describes it as something that was new in the community, as previously adults
had arranged a girl’s marriage prior to the onset of puberty. She describes
Maidenhood as a time when parents attempt to see that their daughters are married
correctly, and a time when adolescent girls attempt to resist their parents’ efforts – the
Maidenhood, as with adolescence in general, was a time of conflict, where parents
tried to get the young girls to do one thing and the young girls tried to defy them.
And girls resisted their parents by forming sexual relationships with partners of their
own choosing, and pregnancy with these partners. In most cases it resulted in
marriage with the father of their child and the partner of their choice.
19
But is the desire to ensure the husband of their choice the only motivating factor that
guides female adolescent decision making? Recent research points to the importance
of other factors, most notably peer pressure and competition. Establishing
relationships can be seen as a very important source of prestige, in a setting that
allows few other opportunities for young people to be successful. As a background
we also have to be aware of young women’s restricted understanding of sex roles and
their understandings of acceptable behaviour within relationships.
Context
Remote community
Poor educational outcomes
Few opportunities for employment
Marked differences in power between men
and women.
If you have internalised Jenny’s map and you think of Darwin, then Katherine, and
across to the Gulf of Carpentaria, Ngukurr is across towards the Gulf from Katherine.
It is a very remote community. Katherine is 300 kilometres away; access is cut off for
much of the year because the roads are cut off by the rising water levels. There are
900 Aboriginal people in the community, and about 60 non-Aboriginal people who
are in a service role – in the clinic, in the school, in the council.
There is a school in the community but educational careers are very short, and once
people finish school there are very few opportunities for employment within the
community. These factors form a very important consideration for the situation of
young people, as they influence their experience and what their expectations are of
what constitutes a normal life. Normality for women is motherhood, and motherhood
begins very early in this community.
We have to also think about the position of women within this community.
Relationships between the sexes are distinguished by quite marked differences in
power, and women, particularly young women, are expected to be submissive and
subservient to men. Women who attempt to redress this inequality – and they quite
frequently do – are often put at risk of male anger and, unfortunately not infrequently,
violence.
20
Method
Ethnographic research
Local young female research assistant
Two groups of young women:
School leavers, unemployed,with small
children (17-20 yrs)
Secondary school students(13-19 yrs)
As I said, this research came at the end of a long period of research in this
community. My previous research had actually been looking at people’s perceptions
of health and their understanding of health and their health services, and I also did
some work on people’s understanding of the role of the school and education. So this
seems to be a nice bringing together of those two factors.
The main body of the research was conducted in four months at the beginning of
2002, and since then I have been back to the community for several shorter-term
visits. I had a young woman who worked with me, not only on this project but for the
whole of the South-East Arnhem Land project, who was very, very helpful and
basically this work could not have been done without her. She was important in
initiating contact with the young women in the community and explaining what we
were actually going to do.
I worked with two groups of young women. The first was a group of school leavers,
all with young babies and all unemployed. I was able to offer this group of young
women some work experience in the community, because another thing we do is to
run the local community newspaper. Through that they were able to get some
experience in writing, computing and office management. I talked to these young
girls in small groups or individually, and each during the course of the work wrote
their own life story. We started with an initial group of three young women, and by
the end of the period of work eight young women were coming in on a regular basis
to work with us.
The second group was a group of women who were still at school. They ranged in
age from 13 to 19. Two were unmarried mothers. With these girls we had a series of
workshops where they explored their ideas about relationships, pregnancy and
marriage and their hopes and expectations for the future.
21
Here is one of those workshops in the secondary school.
Just recently I have been back to discuss the results of this work with the young
women who participated, and I have also maintained communication with the school
about the work that we did.
Walkin’ about at night
A defining act of being a teenager
Drama
Planning
A euphemism for having sex:
‘When you are walking around in groups and a
girl wants to meet her to find her boyfriend, she
sends her friends to find him and tell him that they
will meet in a secret place. That’s how they get
together for a long time alone (Age 15).
As I said, walking about at night is a defining act of being a teenager. It flouts
parental rules, it creates a group of people who replace the family as the central pivot
22
in an individual’s life. The after-dark world in Ngukurr is full of drama for those who
are walking about. Parents are evaded, there is romance, intrigue, gossip and fighting.
It is not a spontaneous or random activity: it requires a deal of planning. Young
women arrange to slip out of sight at the end of the movie, the disco and the
basketball game. In Ngukurr ‘walking about at night’ is a coy euphemism for having
sex. Young women work together to ensure that their friends are able to meet with
existing boyfriends or develop new relationships. It is characterised by cooperation
within a girls group and intense rivalry and competition between the groups.
This is one of the young women, who said, ‘When you’re walking around in groups
and a girl wants to find her boyfriend, then she sends her friends to find him and tell
him that they’ll meet in a secret place. That’s how they get together for a long time
alone.’
Holding on to a boy
Boys expected to move between
relationships
Challenge for the girl to “hold on to a boy”
Prestige of having a relationship
They are nice they do things for you..they
buy you stuff like jewellery or tee-shirts and
maybe finger rings. (Age 15)
In the eyes of the young women in the community, men and boys have a very
enviable freedom. As one woman explained, ‘Boys have more freedom. Boys can
find their own life. They can go and live somewhere else, they can go away from
here.’ This freedom extends to their relationships. They are expected to move freely
between relationships, and the challenge for the girl is to attempt to hold on to the
boy. There is a great deal of prestige in managing to hold on to a boy. Girls talk
about the things that being in a relationship bestows upon them: they talk about
showing off their boyfriend by going for a walk together, and the presents that a boy
might give them. This is another girl who said, ‘They are nice. They do things for
you. They buy you stuff like jewellery or T-shirts or maybe finger rings.’
23
Costs of holding on to a boy
Boy’s expectation that the girl will have sex with
him, or he will move on to someone else.
Sleeping with boys is scary, but if you get used to
it is OK. Its different if you like him, but its still
scary because you worry about getting pregnant
(Age 14)
Jealousy/Violence
They think that its not right for you to talk to
another boy. That’s how they get bit jealous and
start bashing their girl friend.(Age 15)
But there are costs of holding on to a boy. Many of the young women talk about their
ambivalence or even their quite extreme fear about having sex. Most of the young
women said that they were frightened of having sex, but if they didn’t have sex with a
boy he would move on to someone who did. This is a 14-year-old who said,
‘Sleeping with boys is scary, but if you get used to it it’s okay. It’s different if you
like him but it’s still scary, ’cause you worry about getting pregnant.’
Another fear involved or a cost of holding on to a boy is the acknowledgment that
boys could be violent and that girls had to be very careful not to provoke his jealousy.
As one girl said, ‘They think it’s not right for you to talk to another boy. That’s how
they get a bit jealous and start bashing their girlfriend.’
24
Ambivalence about pregnancy
An unwelcome outcome?
Pregnancy is both a necessary aspect of
growth and a future trap.
Young women see pregnancy as a loss of
freedom
Older women comment that young mothers
are not able to care for their babies properly
Young women are aware that walking about at night is a high-risk activity: walking
about at night and teenage pregnancy are seen as inseparable by most of the young
women. It is seen as a way to get married, but it is not without risk as boys may move
on before a young woman knows that she is pregnant. As one young woman
commented, ‘Sometimes you don’t know if you’re pregnant for that boy you’ve just
broke up with. You just have to go and get another boyfriend and then you’ll just
have to blame the baby you’ve got on him.’
Having a baby is an important step to being considered an adult, and it is how a girl
progresses to being considered an adult woman. Women in the community are
expected to have babies very young. No-one expressed any concern about 16- and
17-year-olds getting pregnant. Community anxiety centres around those pregnancies
among the girls they call ‘young girls’, girls who are under 15.
Young women invariably describe motherhood as a loss of freedom, a loss of the
freedom of their childhood and their adolescence. Older women talk about their fear
that very young mothers do not have the skills to look after their babies properly, and
the health of babies with young mothers is often poor.
25
Pregnancy ctd
Young girls don’t know how to look after the baby,
don’t know about proper diet, sickness sores,
checkups. Sometimes babies die.
Its not funny because you feel lonely and you don’t
know what to do. You sit around by yourself and
you see your friends and you want to follow the
but you have to look after the baby. Your mum
says “you can’t go, you have a baby to look after”
(age 17).
A very common adult view was, ‘Young girls don’t know how to look after the baby,
don’t know about proper diet, sickness or sores, check-ups. Sometimes babies die.’
And the view of the young women is, ‘It’s not funny, because you feel lonely and you
don’t know what to do. You sit around by yourself and see your friends and you want
to follow them, but you have to look after the baby. Your Mum says, “You can’t go.
You’ve got a baby to look after.”’
On the positive side, pregnancy is a way to become an adult. It is also known to be a
way to achieve an independent income: most of the young women talked about the
possibility of getting parenting allowance through Centrelink. And whatever initial
parental anger there might be, the general love of babies in the community generally
overrides this in the end.
26
Expectations of marriage
Few young women have a conception that
marriage is a comfortable & desirable state.
Young married women are expected to stay at
home and do housework. When they are married
they are expected to wear dresses past their knees.
Married women are not allowed to shave their
legs, pluck their eyebrows, wear earrings.
Boys don’t help in the house. He’d kill you if you
didn’t wash his clothes, he’d bash you up (age 15)
The young women view pregnancy and marriage as an inevitable part of their lives,
but they don’t have any illusion of marriage being a particularly comfortable state.
They describe marriage as a loss of freedom, where the husband attempts to assume
control of the young woman’s life. This is from a young married woman, who said,
‘Young married women are expected to stay at home and do housework. When they
are married they are expected to wear dresses past their knees. Married women are
not allowed to shave their legs, pluck their eyebrows or wear earrings.’ The
unmarried women, despite their continued efforts to hold on to a boy, had few
romantic notions about marriage and their future husbands. The words used to
describe husbands were ‘bossy’, ‘violent’, ‘drunk’ and ‘unfaithful’. The theme of
husbands bashing their wives to punish them for laziness or for acting in a way to
provoke their jealousy was frequent. A 15-year-old commented, ‘Boys don’t help in
the house. He’d kill you if you doesn’t wash your clothes. He’d bash you up.’
27
Sex education
Responsibility of others, Missionaries,
clinic nurses, teachers.
Basic information on physical function &
development coupled with warnings &
prohibitions.
Little use to sexually active teenagers
I will turn now to the level of information and education that these young women are
actually making their decision based on. There is very, very little sex education for
adolescents in the community. It was not part of the school curriculum, and adults are
very reluctant to talk about sex with their children. Sex education, however, is not
unknown. Many adults talk about this responsibility being taken on in the past by
missionaries and nursing sisters and teachers. When I asked mothers about the sort of
information they provided their daughters with, the standard answer was, ‘The mother
should talk to the girl, explain things like monthlies, tell her she can’t go running
about at night, tell her that she might have a baby.
This minimum of information, coupled with warnings about staying away from boys,
is the sort of information that the missionaries actually provided to their mothers and
their mothers’ mothers in the past.
But the missionaries also managed to control female sexual liaisons, by enforced
separations of boys and girls. As one older woman explained, ‘The dormitory was
really strict. Nobody was allowed to see men. You were not allowed to go home and
sleep in the house with your Mummy and Daddy. We just used to play in that
dormitory. There was a big fence around that dormitory.’
However, for the modern young women there are no big fences and they are free to be
sexually active. Sex education that is based on threats and warnings to stay away
from boys is of little practical use to them. The older women, and the parental
generation, express a great deal of reluctance to talk any further with their children
about sex. Women say that it is not in their culture to talk about such things, and they
feel embarrassed and ashamed about talking about these things, and that the
responsibility must be directed elsewhere. As one parent said, ‘People get
embarrassed talking about things. It’s embarrassing talking about things like
condoms, and anyway you can’t get them in the community. There should be a way
28
of supplying these to the young kids. These young kids just don’t know what will
happen to them. The school should provide this sort of information.’
Education about communication and relationships, about proper relationships between
men and women, what is actually acceptable behaviour, is a very important and
necessary precursor to safe sex so that women are actually able to negotiate and
communicate within a relationship.
Why such an emphasis on
walking about?
Ambivalent about sex
Worried about pregnancy
Boyfriends at best unreliable/at worst
violent
Why then do they place so much emphasis
on walking about at night?
So why is there such an emphasis on walking about? Young women in Ngukurr are at
best ambivalent about sex. They are worried about pregnancy, they know from
experience that boyfriends at best are unreliable and at worst violent. Their view of
marriage is tainted by the observation of male bullying and violence in the
community. Why then do they actually place so much emphasis on walking about at
night?
29
What it represents to the young
women
Dramatic high point of their lives.
Space and freedom
Capacity to organise
Relationships are an important area where
young people can compete with each other
and demonstrate success.
Walking about at night, as I said, is the dramatic highpoint of their lives. It marks the
departure from childhood and the approach of adulthood. It is a time and space that
adolescents create for themselves, and as such is a treasured moment of freedom.
Those girls who are prevented by their parents from going out describe their feelings
of being left out and cruelly deprived of the things that make other girls’ lives
exciting: the gossip, the intrigue, the frequent fights over boys all form an antithesis to
the daytime life of families, small children and school.
Walking about at night provides the young women with an opportunity to demonstrate
their capacity to organise and plan for outcomes that they consider desirable. They
have few other opportunities to do this. Relationships are an important area where
young people can compete with each other, demonstrate success and win the
admiration of their peers.
30
Conclusions
Young women experience freedom, as
adults have little desire to intervene in their
lives.
But their freedom to develop their sexuality
is compromised by:
Limited communication about sex
No formal sex education
Experiences and expectations of relationships
Walking about at night is not condoned by adults in the community, but many young
women utilise the freedom which stems from adults’ reluctance to intervene in their
lives. Their freedom to develop their sexuality is compromised, however, by their
very limited communication with their parents about sex and their lack of formal sex
education. The power and balance of the society influences their experiences and
expectations of relationships, where boys are expected to be dominant and a level of
violence is tolerated.
Adults in Ngukurr continually emphasise that sex education is important and it should
be happening in the community, but that someone else should take responsibility.
Very often schoolteachers are put in that position, to take responsibility. An inclusion
of sex education is an important step to assist young women to make informed
decisions about their sexuality. This information, however, must move beyond how
adults talk about sex education as ‘how the body works’ and address issues
surrounding relationships, including the non-acceptability of violence. Sex education
must be sustained, and in Ngukurr, as in many communities, it is important to provide
this information very early in school careers, as sexual activity begins at a very young
age and retention of students past primary school years is very low.
Thank you.
31
DISCUSSION
Chairperson – Would anyone like to ask some questions?
Question 1 – I’ve got a question for Jenny. Jen, you know the Strong Women, Strong
Babies, Strong Culture model has been put up there frequently as a good model for
improving pregnancy outcomes in Aboriginal women. Have you got any comments on
the model itself and its implementation in the Northern Territory?
Jenny Hunt – That is a really interesting program. For people that don’t know about
it: my understanding is that it is a model where women from the community are
employed to work with community women, addressing culture and talking about
various things. It started off as primarily a nutritional program. I have read quite a bit
about it and talked to people about it, and I guess one of the concerns that I have had
about the program is that it has always been quite unclear what those Strong Women
workers actually do. It has never really been documented. I know the first evaluation
of the program showed quite dramatic improvements in outcomes; that was why it
was rolled out. But I guess that without knowing what people were actually doing it
has become quite hard to reproduce it in other communities. In the most recent
evaluations that I have seen, by the people in Darwin, basically the same sorts of
results have not be reproduced in other communities.
So I guess I just think there was room for some qualitative evaluation at an early
stage, that the opportunity was lost for now, in some ways, because no-one really
knows what those workers were actually doing. Obviously, they were doing some
things that people liked – people attempted things and probably some very good
things happened, but without knowing what actually that consisted of, it is quite hard
to know how useful it can be in other places.
Question 2 – I am from the Australian College of Midwives. I have a question and a
comment for Jenny. I was very interested in your presentation, Jenny, and the
comment I would make is that I think the conclusions that you come to there about
how antenatal care needs to be evaluated were certainly relevant to non-Indigenous
communities also.
The question I have relates to the point you picked up on about continuity of carer.
You mentioned a number of comments that Indigenous women had made about
meeting a stranger after a long wait. I am aware of some research done in both New
Zealand and Canada with Indigenous women in those countries. Obviously the
unique needs and requirements of each Indigenous community are probably distinct,
but it would seem that there is some fairly strong evidence to suggest that the birth
outcomes, in particular the infant mortality rates, can be significantly improved
through continuity of care – continuity of ‘carer’, I suppose is a better term – rather
than handing over a report on a piece of paper about a particular woman’s case, but
particularly when that care can be provided by Indigenous women themselves, when
you are actually able to train Indigenous people to be health carers, midwives and
doctors who then can offer maternity care.
I wondered, in terms of your experience of the communities you have worked in,
whether you think that kind of approach, if it were to be resourced and supported – it
32
would obviously take considerable time –would have a likelihood of similar success
with Indigenous Australians.
Jenny Hunt – I totally agree that it would be great if there were enough Aboriginal
doctors, midwives and nurses to staff clinics, but I do think that is probably not going
to happen in my lifetime, for Aboriginal people. But I agree that it is something that
we should do everything to promote, because when I talk to Aboriginal women they
very much appreciate having Aboriginal providers, definitely. But I also think that
the point about continuity of carer is a really good one, whoever that carer is.
Certainly, once you get to know people, you have better relationships, all sorts of
things become much easier.
I know that for people living in remote communities there are a few models of care
where there is a team of midwives who are associated with a particular remote
community. So they go and visit women in the community, and when women come
to the hospital they are cared for by someone that they have at least met before. That
is a model that I believe happens in Queensland, and certainly some of the midwives I
spoke to put it forward as something that would be good for Darwin.
I think there is just so much room for improvement, in terms of continuity of care. I
just think the public hospital system is shocking, but how do you manage change?
We can do all sorts of amazing things with technology, but we haven’t got the really
basic things sorted, in terms of making health services meet people’s basic needs
without their having to wait hours and see a different person each time instead of
someone you can talk with. The interpreter service in Darwin was only established in
1999, which is incredible to me when half their patients in hospital are Aboriginal.
There are so many things.
Question 3 – Thanks, Jenny and Kate. Those talks were really interesting. I just
want to ask Kate: it was really fascinating hearing the views of young women. Is that
community interested in pursuing a similar kind of research project with young men?
Kate Senior – I would say the answer is yes. There was a model project that was
actually done as part of the research project with the men in the community. I think it
was actually quite different in the sort of material it brought up, in the sense that the
young man who was conducting the research was an ethnomusicologist, so his focus
was very much on the band and the sport – it was the boy things that boys do, rather
than how they actually feel about situations in their lives. It was very descriptive of
things that they do – and were important to be able to do. It would be very nice to go
back and actually do that sort of study again with the boys.
Question 3 (cont) – Yes, it would be interesting to see if it dominated their life as
much as the young women’s.
Kate Senior – Yes. And really, I suppose, the only perspectives of how things work
with the boys is what the young women were actually telling me.
Question 4 – I am from the National Women’s Health Alliance. I wanted to ask a
question: what you have described and told us about is the endemic and cyclical
arrangement. Is there any sight on the horizon of something that is going to break the
33
cycle? Are women going to look for education or different opportunities? Is there
any hope?
Kate Senior – I think the fact that the community themselves were so behind the
study is a hopeful sign in itself, that they actually wanted to find out what the young
women were thinking in the community and they could see this problem in the
community that they didn’t know what to do about. So I think that, firstly, defining a
problem and then initiating some sort of action to look at why that problem actually
exists was important for them.
In terms of bigger pictures it is very difficult. I worked on a very small picture; I had
to do things like involve the local school so they know the sorts of things that they
should be addressing in their education. But even that is very difficult, because while
I have got a nice set of teachers who are understanding and supportive this year, they
won’t all be back next year. There will be a whole new set of people, who may not
actually think that that has got particularly high priority. That is just a part answer, I
am afraid.
Question 5 – I enjoyed both your papers. I’m a bush baby but I’m also an Indigenous
nurse. The question I want to know, and maybe you can answer it, Jen, because it’s
years since I worked in the Centre: does NT Health visualise an obstetrician to go out
to the clinic for tests? In Cairns that is done, and those obstetricians, one set who
goes up and does the antenatal, but the babies still have to come down to Cairns. I
am just wondering has the NT got something like that.
Jenny Hunt – There is a specialist obstetrician that is based in Darwin but flies out to
remote communities in the area. I think that has been running for about five years,
with a woman called Margaret O’Brien. She visits the communities, and I guess that
she mainly sees people if the people in the community ask her to. So she doesn’t see
everyone. Most people get their antenatal care from midwives and doctors and health
workers that live in or visit that particular community, but Margaret sees people that
have problems. She carries around an ultrasound and things like that. So it does
mean that women can have more care in their community, but still, like in Far North
Queensland, it is a policy decision that everyone has to come to town at 37 weeks to
have their baby.
Over the last five years or so there has been a lot of talking about birthing centres on
communities. I know that a midwife called Sue Kildea – she is just the person I know
and I am sure there are lots of other people involved with the project – has been
looking at how that might happen at Maningrida. There have been a couple of really
big meetings, one that was organised by Danila Dilba, of hundreds of women coming
to talk about that. A lot of people are very keen on working out what you need to
make birthing safe for people that haven’t got problems. So it is sort of on the
agenda, but I guess it has been on the agenda for a really long time. A lot of people
feel like things aren’t moving.
Question 6 – I have another question for Kate. I was wondering: in Ngukurr what
kind of access do the young women have to contraception and contraception choices?
It is all very well for them to have information, but if they can’t actually act on that
information is there a reflection of their access to the health services there?
34
Kate Senior – Contraceptives are available; most adult women are on long-term
contraceptive injections. It is quite common in Aboriginal communities. You have to
be 17 to be on those injections, and you have to be confident enough to actually go
down to the clinic and negotiate that, and have discussions with the nursing sister or a
health worker, who is probably a member of the family, about why you want to
actually do that. In that sense, contraceptives for young girls are very, very difficult.
It is the usual situation at Ngukurr of a very, very busy clinic providing acute care,
rushed off its feet, so it doesn’t have much time to actually go out in the community
and do health promotion or health education, either. So that’s missing out. So, no,
contraceptives are very difficult to get in the community, and there is very little
knowledge about them.
Question 7 – Are the women interested in them?
Kate Senior – My word, absolutely. They say things like, ‘I know there’s that
injection that stops you having babies, but I’m too scared to go down and talk to the
sister about it.’
Question 8 – Do you get the feeling that teenage pregnancy is more of a problem for
non-Indigenous people than young Indigenous women?
Kate Senior – There are some very, very young girls that are getting pregnant and
obviously not coping very well. I think generally once these girls are pregnant and
have their babies, they cope extraordinarily well, because they’ve got such good
family support. But they are generally dropping out of school at that stage in their
life, so they are missing out on the very limited bits of education they can actually
pick up in the community. If their school careers are very short, their chances of
getting any employment are very minimal too, once they have a child or a couple of
children. They have got lots of support, but it does cut out some of their opportunities
of life as well.
Question 9 – How strong is the perception among the young people that they are
diverging from a traditional approach to relationships?
Kate Senior – It is absolutely strong. That they are doing it their way is a very strong
perception.
Question 10 – But not only doing it their way, are they conscious of former ways and
a very conscious departure from those?
Kate Senior – Yes. They talk about, ‘Before people used to be promised.’ And still
young girls do get promised in that community, but generally young women say, ‘Oh,
we like to choose for ourselves. We don’t want to marry a man who is older than us.
We want to go out with a boy who’s our same age.’
Question 11 – Jenny, is there much hope for getting together a national policy, that is
for the whole country? You mentioned it during your talk. Is there hope?
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Jenny Hunt – Oh, I think so. I have published a paper from that protocol project, and
there has been an editorial in the Medical Journal of Australia, and there have been
three others in the past two years calling for that to happen. So I guess that is a start.
There are certainly people around that I know are interested in working towards that,
and people have been trying to get it up for years and years. But I guess that it would
take quite a lot of resources to do it well, and it has to compete with everything else,
really. I think so; I think it’s pretty likely but I can’t give a timeframe.
Question 12 – It is obviously very important to try and get it up as soon as possible.
Has Commonwealth Health shown an interest?
Jenny Hunt – I don’t know.
Question 13 – A few years ago I was involved with research about women’s choices.
We went up and did it in the Cape. We found the younger women liked to go away to
have their babies, like most young women they liked the shops and everything. The
older women wanted to bring tradition back. And so that went off to the
Commonwealth government. But from where I stand they’ve given the birthing
choices then to the white women to have their birthing centre, and the black women
still have to come down to have their babies.
I was looking at it from a native title aspect. Being born on the land establishes that
claim. The older women were also looking at it that way. When I went to a land
council meeting – like most of them they’re all full of boys – what I suggested was that
we know women are sick, not healthy, but perhaps we can somehow get the whole
system changed so that the birth certificates have the mother’s country, so that their
child can have that legitimate claim. To me, I envision that years down the track they
will have this established. You know, the white policy is saying you have got to have
connection.
Question 13 (cont) – Could I supplement the previous question by asking: is there
any possibility, in your view of the matter, of the young people who are experiencing
this freedom going on to be a little bit more assertive in terms of resisting and
controlling the violence to which they are currently subjected on occasions? Can that
freedom be linked to better equality, if you like, in the gender relationship – or
insistence on better equality?
Kate Senior – I think people first need to know that that is not what happens in
relationships, that there is no need for women to be punished for not doing the
housework or for behaving in a way that provokes someone’s jealousy by violence
and that. Most women think that’s a perfectly acceptable thing to happen, that if a girl
doesn’t do something, or if she is a lazy wife, then yes, it is perfectly acceptable to be
hit by her husband. There has to be a change in young women’s attitudes about what
is actually acceptable, before they can start to get to the level that you are talking
about.
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Question 14 – But the societal changes, the changes in the society that have led to the
present situation have already been fairly marked. It seems possible that that process
might continue. Is that unrealistic?
Kate Senior – No, I don’t think it is unrealistic. I’m not entirely sure what the
dynamics of that are actually going to be.
Question 15 – This is to either of you: how important is funding to Aboriginal health?
Say you doubled the funding, would health improve dramatically? Or can the existing
funding be spent more effectively?
Jenny Hunt – That’s the big question. Isn’t John Deeble talking in next week’s
seminar? He might be a better person to answer that question. But when you work in
an Aboriginal community controlled health service, they are such resource poor
organisations and there is just this huge amount of need, you are always struggling for
money – having to apply for funding here and justify it there. I guess it is really hard
not to imagine how much more you could do, if you just had more resources to
employ more staff to provide more services. Obviously, health services are not the
answer to Aboriginal health, but I think they could do a lot more if they had more
resources. I guess there are people that know a lot more about financing issues then I
that have worked out how much more, but that’s just my take on it.
Question 16– I think John Deeble would say that with that 7 million dollar surplus,
probably a good use for it would be to spend some of that money in the Indigenous
health area.
Question 17 – This is for Kate. What were the difficulties for a non-Aboriginal
woman interviewing Aboriginal women?
Kate Senior – I think it has to be seen in the perspective that I had been working
there for a long time. I had been working in that community for about four years on
research. I actually think that in this case it was a benefit, because these young
women didn’t want to talk to their parents, they didn’t want to talk to the health
worker, they didn’t want to talk to anybody they knew about these issues, because it
was their private thing, something that they were a bit worried about. They were
worried that stories might spread about them in the community. But on the other hand
they desperately, desperately wanted to tell their story. They really wanted to sit
down and say, ‘Look, this is happening to us. Try to understand that this is happening
to us. This is how we experience our lives.’ So I think being an outsider in this case
was actually quite beneficial to the study. The other people that young women tend to
talk to are the non-Aboriginal schoolteachers in the community and maybe the health
workers more than people who are actually related to them.
Question 18 – Did the young women talk about rape much, and negotiating around
protection from this?
Kate Senior – Some young women did talk about rape, and certainly one of the
young women I talked to had been raped. But actually talking about it, negotiating
was completely out of their experience. These young girls were very, very young;
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they had experienced a very frightening event in their lives, but they couldn’t see how
that could be avoided. They didn’t know how they could do anything.
Question 18 (cont) – So they didn’t go together as groups to protect each other?
Kate Senior – No. When they are walking round at night time, yes, they are in
groups and they do protect each other. I think the cases of rape that I saw were within
families and behind closed doors, and weren’t something where a young woman
could get or obtain any protection from her friends.
Question 19 – One thing that the last question raises is: did women, however,
actually perceive what we would term as rape in relationships with boyfriends as
rape?
Kate Senior – No. ‘Rape’ was a very rarely used term and it was only for very
violent incidents.
Chairperson – If there are no more questions, on behalf of you all I would like to
thank Jenny and Kate for their wonderful talks today.
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