Suzanne Belton

Niyith Nniyith Watmam (the quiet story): Exploring the experiences of Aboriginal women who give birth in their remote community

OBJECTIVE to investigate the beliefs and practices of Aboriginal women who decline transfer to urban hospitals and remain in their remote community to give birth. DESIGN an ethnographic approach was used which included: the collection of birth histories and narratives, observation and participation in the community for 24 months, field notes, training and employment of an Aboriginal co-researcher, and consultation with and advice from a local reference group. SETTING a remote Aboriginal community in the Northern Territory, Australia. PARTICIPANTS narratives were collected from seven Aboriginal women and five family members. FINDINGS findings showed that women, through their previous experiences of standard care, appeared to make conscious decisions and choices about managing their subsequent pregnancies and births. Women took into account their health, the babys health, the care of their other children, and designated men with a helping role. KEY CONCLUSIONS narratives described a breakdown of traditional birthing practices and high levels of non-compliance with health-system-recommended care. IMPLICATION FOR PRACTICE standard care provided for women relocating for birth must be improved, and the provision of a primary maternity service in this particular community may allow Aboriginal Womens Business roles and cultural obligations to be recognised and invigorated. International examples of primary birthing services in remote areas demonstrate that they can be safe alternatives to urban transfer for childbirth. A primary maternity service would provide a safer environment for the women who choose to avoid standard care.

Consequences of birth policies and practices in post-reform China.

This paper comments on the provision of birthing services in Sichuan and Shanxi Provinces in China within a policy context. The goal was to understand possible unintended and harmful health outcomes for women in the light of international evidence, to better inform practice and policy development. Data were collected from October 2005 to April 2007 in 25 hospitals across 13 counties and one city. Normal and caesarean birth records were audited, observations made of facilities and interviews conducted with officials, administrators, health workers, women who delivered in hospital facilities and women who delivered at home. We argue that in the context of a neo-liberal health economy with poorly developed government regulatory policies, those with the power to pay for maternity care may be vulnerable to a new range of risks to their health from those positioned to make a profit. While poor communities may lack access to basic services, wealthier socio-economic groups may risk an increase in maternal morbidity and mortality through the overuse of avoidable intervention. We recommend a stronger evidence base for hospital maternity services and changes to the role of the State in countering systemic problems. Résumé Cet article examine les services de maternité des provinces chinoises du Sichuan et du Shanxi dans un contexte politique. Il s’agissait de cerner d’éventuels effets indésirables pour les femmes à la lumière des données internationales, afin de mieux informer la pratique et la définition des politiques. Les données ont été recueillies d’octobre 2005 à avril 2007 dans 25 hôpitaux de 13 comtés et une ville. Les dossiers des accouchements normaux et par césarienne ont été contrôlés, les équipements et les fonctionnaires ont été observés, des entretiens ont été organisés avec des administrateurs, des agents de santé, des femmes qui avaient accouché à l’hôpital ou à la maison. Dans le contexte d’une économie de santé néolibérale avec des politiques régulatrices gouvernementales mal définies, il apparaît que les individus ayant les moyens de payer des soins de maternité peuvent être vulnérables à un nouvel éventail de risques sanitaires créés par ceux qui souhaitent faire des bénéfices. Alors que les communautés pauvres n’ont parfois pas accès aux services essentiels, les groupes socio-économiques plus aisés risquent de subir une hausse de la morbidité et de la mortalité maternelles en raison du recours excessif à des interventions superflues. Nous recommandons d’appuyer les services hospitaliers de maternité sur une base factuelle plus solide et préconisons de changer le rôle de l’État pour corriger les problèmes systémiques. Resumen Este artículo trata de la prestación de servicios de parto en las provincias de Sichuan y Shanxi, en China, en un contexto de políticas. El objetivo era entender posibles resultados de salud imprevistos y peligrosos para las mujeres en vista de la evidencia internacional, con el fin de informar mejor las prácticas y la formulación de políticas. Se recolectaron datos desde octubre de 2005 hasta abril de 2007, en 25 hospitales de 13 condados y una ciudad. Se realizaron auditorías de los registros de partos normales y por cesárea, se observaron los establecimientos de salud y se realizaron entrevistas con funcionarios, administradores, trabajadores de la salud, mujeres que dieron a luz en instalaciones hospitalarias y mujeres que dieron a luz en su hogar. Argumentamos que, en el contexto de una economía de salud neo-liberal con políticas reguladoras gubernamentales mal formuladas, aquéllas con el poder para pagar por atención de maternidad posiblemente sean vulnerables a una nueva gama de riesgos a su salud de aquéllos posicionados para hacer ganancias. Aunque las comunidades pobres carecen de acceso a los servicios fundamentales, es posible que los grupos socioeconómicos más adinerados afronten una tasa más elevada de morbimortalidad materna debido al uso excesivo de intervención evitable. Recomendamos una base de evidencia más sólida para los servicios obstétricos hospitalarios, así como cambios a la función del Estado en contrarrestar los problemas sistémicos.

Growing Up Our Way: The First Year of Life in Remote Aboriginal Australia

In this study, we attempted to explore the experiences and beliefs of Aboriginal families as they cared for their children in the first year of life. We collected family stories concerning child rearing, development, behavior, health, and well-being between each infant’s birth and first birthday. We found significant differences in parenting behaviors and child-rearing practices between Aboriginal groups and mainstream Australians. Aboriginal parents perceived their children to be autonomous individuals with responsibilities toward a large family group. The children were active agents in determining their own needs, highly prized, and included in all aspects of community life. Concurrent with poverty, neocolonialism, and medical hegemony, child-led parenting styles hamper the effectiveness of health services. Hence, until the planners of Australia’s health systems better understand Aboriginal knowledge systems and incorporate them into their planning, we can continue to expect the failure of government and health services among Aboriginal communities.

'Jumping around': exploring young women's behaviour and knowledge in relation to sexual health in a remote Aboriginal Australian community

Sexual health indicators for young remote-living Aboriginal women are the worst of all of Australian women. This study aimed to describe and explore young womens behaviour and knowledge in relation to sexual health, as well as to provide health professionals with cross-cultural insights to assist with health practice. A descriptive ethnographic study was conducted, which included: extended ethnographic field work in one remote community over a six-year period; community observation and participation; field notes; semi-structured interviews; group reproductive ethno-physiology drawing and language sessions; focus-group sessions; training and employment of Aboriginal research assistants; and consultation and advice from a local reference group and a Cultural Mentor. Findings reveal that young women in this remote community have a very poor biomedical understanding of sexually transmitted infections and contraception. This is further compounded by not speaking English as a first language, low literacy levels and different beliefs in relation to body functions. In their sexual relationships, young women often report experiences involving multiple casual partners, marijuana use and violence. Together, the findings contribute to a better understanding of the factors underlying sexual health inequity among young Aboriginal women in Australia.

Improving Aboriginal maternal and infant health services in the ‘Top End’ of Australia; synthesis of the findings of a health services research program aimed at engaging stakeholders, developing research capacity and embedding change

BackgroundHealth services research is a well-articulated research methodology and can be a powerful vehicle to implement sustainable health service reform. This paper presents a summary of a five-year collaborative program between stakeholders and researchers that led to sustainable improvements in the maternity services for remote-dwelling Aboriginal women and their infants in the Top End (TE) of Australia.MethodsA mixed-methods health services research program of work was designed, using a participatory approach. The study area consisted of two large remote Aboriginal communities in the Top End of Australia and the hospital in the regional centre (RC) that provided birth and tertiary care for these communities. The stakeholders included consumers, midwives, doctors, nurses, Aboriginal Health Workers (AHW), managers, policy makers and support staff. Data were sourced from: hospital and health centre records; perinatal data sets and costing data sets; observations of maternal and infant health service delivery and parenting styles; formal and informal interviews with providers and women and focus groups. Studies examined: indicator sets that identify best care, the impact of quality of care and remoteness on health outcomes, discrepancies in the birth counts in a range of different data sets and ethnographic studies of ‘out of hospital’ or health centre birth and parenting. A new model of maternity care was introduced by the health service aiming to improve care following the findings of our research. Some of these improvements introduced during the five-year research program of research were evaluated.ResultsCost effective improvements were made to the acceptability, quality and outcomes of maternity care. However, our synthesis identified system-wide problems that still account for poor quality of infant services, specifically, unacceptable standards of infant care and parent support, no apparent relationship between volume and acuity of presentations and staff numbers with the required skills for providing care for infants, and an ‘outpatient’ model of care. Services were also characterised by absent Aboriginal leadership and inadequate coordination between remote and tertiary services that is essential to improve quality of care and reduce ‘system-introduced’ risk.ConclusionEvidence-informed redesign of maternity services and delivery of care has improved clinical effectiveness and quality for women. However, more work is needed to address substandard care provided for infants and their parents.

Conflict and Development: Challenges in Responding to Sexual and Reproductive Health Needs in Timor-Leste

In April and May 2006, internal conflict in Timor-Leste led to the displacement of approximately 150,000 people, around 15% of the population. The violence was most intense in Dili, the capital, where many residents were displaced into camps in the city or to the districts. Research utilising in-depth qualitative interviews, service statistics and document review was conducted from September 2006 to February 2007 to assess the health sector’s response to reproductive health needs during the crisis. The study revealed an emphasis on antenatal care and a maternity waiting camp for pregnant women, but the relative neglect of other areas of reproductive health. There remains a need for improved coordination, increased dialogue and advocacy around sensitive reproductive health issues as well as greater participation of the health sector in response to gender-based violence. Strengthening neglected areas and including all components of sexual and reproductive health in coordination structures will provide a stronger foundation through which to respond to any future crises in Timor-Leste. Résumé En avril et mai 2006, le conflit interne au Timor-Leste a déplacé près de 150 000 personnes, environ 15% de la population. La violence était particulièrement intense à Dili, la capitale, où beaucoup d’habitants ont été placés dans des camps en ville ou dans des districts. Une recherche utilisant des entretiens qualitatifs approfondis, les statistiques des services et une étude de documents, menée de septembre 2006 à février 2007, a évalué la réponse du secteur de la santé aux besoins de santé génésique pendant la crise. L’étude a révélé une priorité aux soins prénatals et à un camp où les femmes enceintes attendaient leur accouchement, mais une relative inattention à d’autres domaines de la santé génésique. Il faut améliorer la coordination, accroître le dialogue et le plaidoyer autour de questions sensibles de santé génésique tout en relevant la participation du secteur de la santé en réaction à la violence sexiste. Le renforcement des domaines négligés et l’inclusion de toutes les composantes de la santé génésique dans les structures de coordination constitueront un fondement plus solide à partir duquel répondre à toute crise future au Timor-Leste. Resumen En abril y mayo de 2006, el conflicto interno en Timor-Leste llevó al desplazamiento de aproximadamente 150,000 personas, un 15% de la población. La violencia fue más intensa en Dili, la capital, donde muchos residentes fueron desplazados a campamentos en la ciudad o a los distritos. Desde septiembre de 2006 hasta febrero de 2007, se realizaron investigaciones con entrevistas cualitativas a profundidad, estadísticas de servicios y revisión de documentos, a fin de evaluar la respuesta del sector salud a las necesidades de salud reproductiva durante la crisis. El estudio reveló énfasis en la atención antenatal y un campo maternidad de espera para las mujeres embarazadas, pero el relativo descuido de otras áreas en salud reproductiva. Aún existe la necesidad de mejorar la coordinación y ampliar el diálogo y las actividades de promoción y defensa en torno a los aspectos delicados de la salud reproductiva, así como incrementar la participación del sector salud en respuesta a la violencia basada en género. Al fortalecer las áreas desatendidas e incluir todos los elementos de la salud sexual y reproductiva en las estructuras de coordinación, se creará una base más sólida a partir de la cual se pueda responder a toda crisis futura en Timor-Leste.

Borders of Fertility: Unplanned Pregnancy and Unsafe Abortion in Burmese Women Migrating to Thailand

Burmese women are forced to migrate to find work and security in Thailand due to the social, political, and economic disarray present in Burma. Unplanned pregnancies are common in this area, and one third of pregnancy loss is self-induced. Poverty, lack of employment rights, and domestic violence are important factors in deciding to terminate the pregnancy. Women face multiple barriers in managing their fertility and use traditional techniques often with the help of lay midwives. The research methods include a retrospective review of medical records held in Thai and Burmese-led health facilities, as well as semistructured interviews and group discussions with Burmese women experiencing a pregnancy loss, Burmese traditional and modern health workers, and their husbands and community members.

Maternal deaths in eastern Indonesia: 20 years and still walking: an ethnographic study.

BackgroundThe delays in receiving adequate emergency maternal care described by Thaddeus and Maine twenty years ago are still occurring, as exemplified in this study of cases of maternal deaths in a subdistrict in rural eastern Indonesia.MethodsAn ethnographic design was conducted, recruiting eleven families who reported on cases of maternal deaths in one sub-district of Indonesia, as well as assessing the geographical and cultural context of the villages. Traditional birth attendants and village leaders provided information to the research team which was thematically and contextually analysed.ResultsTwo stages to the first and second delays have been differentiated in this study. First, delays in the decision to seek care comprised time taken to recognise (if at all) that an emergency situation existed, followed by time taken to reach a decision to request care. The decision to request care resided variously with the family or cadre. Second, delays in reaching care comprised time taken to deliver the request for help and then time for help to arrive. A phone was not available to request care in many cases and so the request was delivered by walking or motorbike. In two cases where the decision to seek care and the delivery of the request happened in a timely way, help was delayed because the midwife and ambulance respectively were unavailable.ConclusionsThis study, although a small sample, confirmed that either a single delay or a sequence of delays can prove fatal. Delays were determined by both social and geographic factors, any of which alone could be limiting. Initiatives to improve maternal health outcomes need to address multiple factors: increased awareness of equitable access to maternal health care, village preparedness for emergency response, improved access to telecommunications and geographic access.

Attitudes towards the legal context of unsafe abortion in Timor-Leste

The authors examine changes in public attitudes toward abortion in the United States. They suggest that control of abortion is being removed from the federal courts and put into the hands of elected officials at both federal and state levels and that public opinion on abortion will therefore come to play an increasing role in the molding of abortion policy. They examine the factors that influence peoples abortion attitudes the role of religion in shaping those attitudes and the consequences of abortion attitudes for electoral politics. (ANNOTATION)Abstract The new Penal Code in 2009 was an opportunity for Timor-Leste to allow some legal grounds for abortion, which was highly restricted under Indonesian rule. Public debate was contentious before ratification of the new code, which allowed abortion to save a woman’s life and health. A month later, 13 amendments to the code were passed, highly restricting abortion again. This paper describes the socio-legal context of unsafe abortion in Timor-Leste, based on research in 2006–08 on national laws and policies and interviews with legal professionals, police, doctors and midwives, and community-based focus group discussions. Data on unsafe abortions in Timor-Leste are rarely recorded. A small number of cases of abortion and infanticide are reported but are rarely prosecuted, due to deficiencies in evidence and procedure. While there are voices supporting law reform, the Roman Catholic church heavily influences public policy and opinion. Professional views on when abortion should be legal varied, but in the community people believed that saving women’s lives was paramount and came before the law. The revised Penal Code is insufficient to reduce unsafe abortion and maternal mortality. Change will be slow, but access to safe abortion and modern contraception are crucial to women’s ability to participate fully as citizens in Timor-Leste.

Health reporting system in two subdistricts in Eastern Indonesia: Highlighting the role of village midwives

OBJECTIVE to describe the system of health reporting by village midwives and two rural clinics in eastern Indonesia and solve some of the problems in this system through consultation. DESIGN participatory action research model where problems are identified by those most affected and solutions sought. Clinic staff were observed and interviewed regarding their work roles and reporting duties. Allocation of work time to various tasks was recorded by all clinic staff before and after the implementation of a new health recording system. Several information sessions and focus group discussions were held with village midwives and other health staff to identify and address problems. SETTING Indonesia initiated a programme in 1989, aiming to place a midwife in every village, in response to high maternal mortality rates and low rates of births attended by trained birth assistants. Remote rural villages in eastern Indonesia have difficulty recruiting and retaining village midwives. These midwives play a crucial role in health reporting. During 2010 a new system of recording and reporting by clinics was implemented. PARTICIPANTS village and clinic health staff in two rural subdistricts in eastern Indonesia. FINDINGS there was incomplete coverage by village midwives in the two subdistricts studied; 28% of villages had a resident midwife, 48% had a visiting midwife and 24% had only monthly visits by a mobile clinic. Village midwives performed duties additional to their official duties and training. Village midwives had problems associated with the reporting system including inconsistency in reporting, poor access to individual patient histories and poor access to clinics. These problems resulted in incompleteness and poor timeliness of data transfer. KEY CONCLUSIONS midwives in remote villages felt compelled to provide services for which they were not trained. Poor quality of data reporting resulted from inconsistent reporting methods. Local staff can successfully change and manage reporting systems if given appropriate support and training. IMPLICATIONS FOR PRACTICE socialisation of health reporting systems among all staff involved can lead to improved data consistency and completeness. Effective systems for data transfer and reporting may reduce time spent on these tasks by some staff. Improvements to accuracy of data and availability of individual patient histories have the potential to contribute to improved health care. Quality of health care by village midwives should be addressed by adequate training and improved transport.