Providing the right tools before the start of life
Authors: Kiarna Brown
Journal: The Lancet Global Health (2021)

Starting life on an even field remains a challenge for First Nations babies. The perinatal mortality rate for Australian Indigenous babies was 16 deaths per 1000 births in 2018.1Australian Institute of Health and WelfareAustralia's mothers and babies 2018—in brief. Australian Institute of Health and Welfare, Canberra2020Google Scholar This is vastly disproportionate to the perinatal mortality rate for non-Indigenous babies, which was 9 perinatal deaths for every 1000 births in the same year. One of the leading causes of perinatal mortality for Australian Indigenous babies is spontaneous preterm birth. Nationally, in 2016–17, 14% of babies born to Indigenous mothers were preterm, compared with 8% of babies of non-Indigenous mothers.2Australian Institute of Health and WelfareAntenatal care use and outcomes for Aboriginal and Torres Strait Islander mothers and their babies 2016–2017. Australian Institute of Health and Welfare, Canberra2020Google Scholar The odds of preterm birth are increased when Indigenous mothers have minimal antenatal care and pre-existing medical conditions such as hypertension and diabetes. The message is simple: Indigenous babies are dying far too frequently. They are born too early far too often. Unfortunately, very little has changed over time, despite the Australian Government pledging to close the health gap. It is time to investigate why this is happening and how to safely reduce such deplorable statistics. In The Lancet Global Health, Sue Kildea and colleagues published the first Australian study in which we have seen profound improvements in perinatal outcomes for Indigenous babies.3Kildea S Gao Y Hickey S et al.Effect of a Birthing on Country service redesign on maternal and neonatal health outcomes for First Nations Australians: a prospective, non-randomised, interventional trial.Lancet Glob Health. 2021; 9: e651-e659Summary Full Text Full Text PDF PubMed Scopus (4) Google Scholar The authors evaluated the new Birthing in Our Community (BiOC) service, a redesign of maternity services where holistic and culturally safe care are at the core, which has proven to be considerably beneficial. Kildea and colleagues enrolled women carrying a First Nations baby, who intended to birth at the study hospital and had a referral from a family doctor or Aboriginal Medical Service. Participants were then offered either standard care services or the BiOC service. Over the course of the study, 1422 women received either standard care (656 participants) or the BiOC service (766 participants) and were included in the analyses. Women receiving the BiOC service had improved antenatal care attendance (adjusted odds ratio 1·54, 95% CI 1·13–2·09; p=0·0064) and were more likely to exclusively breastfeed on discharge from the hospital (1·34, 1·06–1·70; p=0·014). But the most monumental finding was a significant reduction in preterm birth rates (0·62, 95% CI 0·42–0·93; p=0·019). This has not been seen before, and it shows that, when communities are equipped with the right tools, health outcomes ultimately benefit. The redesigning of maternity services to create the BiOC service, reported by Kildea and colleagues, had six key aspects. First, the service was a collaboration of multiagency partnerships driven by First Nations leadership and governance; second, it involved a model of community-based midwifery continuity of care; third, there was an investment in a First Nations workforce; fourth, the service ensured that all staff were trained to work within a culturally safe framework; fifth, there was a holistic approach to the care provided, with a focus on social and emotional health issues being addressed; and sixth, the service co-ordinated care between multiple stakeholders, including primary and tertiary health-care services. Kildea and colleagues argue that these are all very much reproducible ingredients for other services. But why are these components important? When services do not purposefully cater to the needs of a population, the consequence is substandard outcomes. Racism, whether occurring through passive inaction or deliberate action, has major adverse effects on the health of Indigenous Australians and substantially hinders their access to effective health care in mainstream health services.4Awofeso N Racism: a major impediment to optimal Indigenous health and health care in Australia.Aust Indig Health Bull. 2011; 11: 3Google Scholar Hence, it is crucial that health services for Indigenous people are comprised of Indigenous leadership and workforce, and that they also encompass a culturally safe environment. It might not be financially feasible for governments and health services to extend this type of model to all Indigenous Australians, but it is certainly crucial that considerations are made for our most vulnerable populations. A major effort would be needed to redesign services, particularly where tertiary hospital services are part of key stakeholders, but there is much to gain. The flow-on effect in improved health outcomes would surely lead to cost savings. Government policy needs to align with this concept. Financial considerations aside, Indigenous perinatal outcomes are unlikely to change unless we take a revised approach on how services are delivered and who funding is given to. Kildea and colleagues' study examines a fresh approach to delivery of maternity care that has clearly shown better health outcomes. The authors highlight perinatal outcomes that are superior to those observed in mainstream standard care. One of the major challenges in replicating this redesign will be adapting the services for other locations and ensuring that they are appropriate for each location. When health services are constructed to meet the needs of Indigenous populations, they have the potential to highlight gaps in our knowledge regarding specific pathologies. For example, if pregnant Indigenous women are receiving good quality, safe, and holistic care during pregnancy, but a large gap in preterm birth remains, we are in a better position to develop strategies to examine why. In their Article, Kildea and colleagues investigated a redesign of maternity services for Indigenous women in an urban setting that incorporated key aspects with cultural sensitivity at their core. In what appears to be a fairly simple, but very achievable restructuring of services, they have addressed crucial issues that affect Indigenous health outcomes. Institutionalised racism and lack of understanding of needs in standard care is one such issue. Kildea and colleagues have shown that addressing social determinants of health, including workforce, education, social standing, social support, cultural pride, housing, financial support, and transport, leads to health improvements. This is what should drive health policy. I declare no competing interests. Effect of a Birthing on Country service redesign on maternal and neonatal health outcomes for First Nations Australians: a prospective, non-randomised, interventional trialThis study has shown the clinical effectiveness of the BiOC service, which was co-designed by stakeholders and underpinned by Birthing on Country principles. The widespread scale-up of this new service should be prioritised. Dedicated funding, knowledge translation, and implementation science are needed to ensure all First Nations families can access Birthing on Country services that are adapted for their specific contexts. Full-Text PDF Open Access