The next challenge for Aboriginal antenatal care

In the last week I have returned to some interviews done by Glenda Taylor and other colleagues at CURCH. Aboriginal women were asked about their experiences with antenatal services at Aboriginal medical services, private general practitioners and hospitals. The research affirmed what many studies of this type have found but also highlighted some new issues that must be addressed if there will be significant gains in Aboriginal maternal and child health.

The transcripts had lovely descriptions of women of how pleased they were with the care they got from some midwives. There were horror stories as well but those were rarer. Mostly women just got on with their life and their pregnancy, doing the best they could for their baby and were grateful to be treated by a kind health professional who would spend time with them and answer their questions clearly and patiently.

The research was structured around a quality of care framework. The idea was to find out what aspects of care mattered most to women. Unsurprisingly, being in a comfortable Aboriginal environment where the midwives knew you and answered your questions simply was very important. Free care and not having to wait were also important. But as I waded through the transcripts and earnest research papers on quality of antenatal care for other poor or marginalised women, I realized that something was missing.

Patient centred care is not just about kind, respectful health providers, it is about offering care that met women’s needs; care that not only takes into account women’s preferences but also helps them to have a healthy, safe pregnancy and to look after a healthy infant. Many of the women we interviewed did that. They choose their own providers based on how they were treated, they took in information and made decisions about their diet, how frequently they attended antenatal care, what tests to have, what specialists to see and where to give birth being. As much as possible they were in control of their pregnancy. They might not have done everything the health providers wanted but both were clearly working toward the same goal.

Many of the women we interviewed did not have such power. These women dodged the health services, ignoring messages left, appearing for tests in distant towns late and discharging themselves early. In some cases they did this because they feared the consequences of lengthy stay away from their home and other responsibilities. In other cases the medical priorities were the furtherest from women’s minds. These women had more pressing problems: relationships turned bad, no housing, mental health issues, child removed.  When health care providers heard about these things they tried to do what they could to make it possible for the women to have a healthy pregnancy.

What was missing for these women was a service that helped them gain the kind of control that some of their sisters had. They needed time and trust to be able to discuss options of the kind of care that they wanted rather than well meaning directives that permit no choice, only compliance or defiance. There are no protocols about giving less care when women neither want nor need to participate in frequent antenatal visits which evidence shows does not benefit low risk pregnancies.

For those whose life are even more out of control there is no alignment of services that stretch from midwives to mental health, housing, justice or even child health.

Services know that chaos is the realty for many of their Aboriginal clients and they do whatever they can to help someone in crisis.  But there is no standard practice to anticipate housing stress, relationship crises, parenting challenges that so many of these women are at risk of facing until it has reached the point where it’s impact on pregnancy outcomes are medically obvious.

The 2005 World Health Report observed that future gains in infant and maternal health will have to come by addressing the issues that cause the medical problems the precipitate a tragic end.  Australia needs to move beyond counting number of antenatal visits and recognise that culturally safe clinical environments is only the start of antenatal care which can close the gap.

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