Antenatal care for asylum seekers

Despite the challenges, the provision of high-quality specialist antenatal health care in immigration detention is a constant

Recent commentaries have criticised health care provision in the Australian immigration detention environment, particularly in the areas of antenatal and postnatal care.1,2 As the contracted health care provider, International Health and Medical Services (IHMS) acknowledges the inherent challenges the immigration detention environment presents. It is our wish to contribute current facts and observations to this topical public debate.

Ongoing enhancement to the antenatal and postnatal care of detainees in immigration detention centres on Christmas Island and Nauru has resulted in a specialist supervised obstetric service providing care at a standard comparable to that on the Australian mainland. Maternity care is provided from the diagnosis of pregnancy until the 6-week postnatal check, paralleling Australian community standards and Royal Australian and New Zealand College of Obstetricians and Gynaecologists guidelines.3 Routine assessments, imaging, pathology tests, hospital referrals and referrals to mental health services all occur as per established Australian standards.

Although there are no resident obstetricians on either island, specialist obstetricians have made visits to Christmas Island and Nauru. In the case of Nauru, this has developed into a continued care model involving subspecialist and specialist obstetricians (accompanied by specialist sonographers) providing obstetric services to detainees for 3 days a month, delivering care commensurate with that in Australian communities. This service is supplemented by 4-monthly visits from specialist paediatricians to both islands. The specialist care complements the primary care delivered by resident general practitioners, emergency physicians, midwives and nurses, both paediatric and adult, with the addition of telemedicine as necessary.

Currently, pregnant detainees on Christmas Island and Nauru are transferred to Australia at gestations of 34 and 28 weeks, respectively, to give birth. The former coincides with the gestation at which local residents “traditionally” depart Christmas Island to give birth on the mainland. Earlier transfers occur when there is a clinical need. In Nauru, this arrangement is pending the recruitment of a permanent obstetrician by the Republic of Nauru Hospital, where the hospital surgeon currently performs interventions such as caesarean sections. While it can certainly be stated that the Republic of Nauru Hospital has limited obstetric facilities when compared with secondary-level or metropolitan hospitals, it has two delivery beds, six postnatal beds, a special care baby unit with a neonatal incubator, an infant warmer, neonatal resuscitation equipment, nasogastric feeding capabilities and a dedicated blood bank, with blood supplied by the Australian Red Cross available to pregnant asylum seekers. Overall, the local perinatal capacity is not dissimilar to many rural obstetric services in Australia.

At Darwin immigration detention sites, antenatal care for detainees is provided by IHMS midwives and GPs. There is a close working relationship with the Royal Darwin Hospital, and a shared care arrangement has been established, similar to the delivery of antenatal care in many other centres on mainland Australia. These arrangements are enhanced by regular meetings between Department of Immigration and Border Protection staff, IHMS and the Department of Obstetrics and Gynaecology at the Royal Darwin Hospital, where situation-specific concerns such as security and patient transfers are formally discussed. The operational model in Darwin has been replicated at facilities in Melbourne and Adelaide.

Breastfeeding for all new mothers is actively encouraged by IHMS at all immigration detention sites. IHMS does not distribute welcome packs with bottles and formula, as reported elsewhere,1 and does not endorse this practice.

We recognise that mental health is a concern in all forms of detention environments. Ready access to high-quality mental health services is provided to pregnant women within detention centres. Mental health care is delivered by a multidisciplinary team including GPs, mental health nurses, psychologists, counsellors and psychiatrists in both offshore and mainland centres. When a mental health disorder, including antenatal or postnatal depression, is diagnosed, it is managed according to established guidelines.4

IHMS takes its role as provider of health care within the immigration detention network seriously. We encourage informed commentary and debate among the public and the medical profession, as this helps us to continually improve the delivery of high-quality health care to people living in immigration detention.

Termination of pregnancy: a long way to go in the Northern Territory

To the Editor: The Northern Territory’s reproductive health services are fraught with access problems due to remoteness and disadvantage. Staff shortages and high staff turnover in the health workforce are well known.1 With the recent resignation from the public health system of the main termination of pregnancy provider in the Top End of Australia, women’s access to basic reproductive health services could be severely diminished and complicated.

Each year, about 1000 women undergo a termination of pregnancy in the NT. The only remaining services providing termination of pregnancy in the NT include one private hospital (at which a few doctors can provide surgical abortions) and one public hospital (Alice Springs Hospital, at which a couple of doctors can provide surgical abortions). Each week, about 20 women present to the public health system in Darwin for a surgical abortion in their first trimester. These women no longer have public access. The question is who will provide this procedure?

One possibility is that women may have to be flown interstate for this procedure. Some state laws prevent this — for example, South Australian law has residency limits on the provision of termination of pregnancy. Also, interstate travel poses a considerable burden for women and girls in terms of delays, logistics and increased stress, and is not cost-effective for the health system.

How acceptable this arrangement will be to women in the NT is yet to be tested. But we already know that women who feel compelled to end their pregnancies will do anything regardless of how demeaning, undignified or dangerous it is.2,3

Another solution would be to reform the Medical Services Act (NT) as in force at July 2014, which prohibits the practice of early medical abortion using misoprostol and mifepristone outside of a hospital setting, thus precluding ambulatory early medical abortion. Currently, the Act limits provision of abortion to obstetrics and gynaecology specialists and limits the type of procedure to surgical methods only. If the Act were reformed, it would be possible for general practitioners in various primary health care settings to provide information and prescriptions for early medical abortions.

There is overwhelming medical evidence showing that early medical abortions are efficacious, safe and well accepted.4,5 In terms of the health system, shifting the task to GPs and freeing up precious theatre resources would be far more cost-effective than flying patients or doctors interstate.

However, the political reality is that politicians are often reluctant to step into the perceived controversy of reproductive health rights for their constituents.

Leading the rebirth of the rural obstetrician

In 2002, 30% of all Australian births occurred in non-metropolitan hospitals, and 57% of these hospitals did not provide specialist obstetric cover.1 Antenatal care led by general practitioner obstetricians is offered in 50% of South Australian and Victorian public hospitals and is the only public sector model in most non-metropolitan hospitals.2 GP obstetric care has been shown to provide safe care for pregnant women at low risk of complications, and access to such services in rural Australia is essential.3–8

A looming crisis in the provision of rural obstetric services in Australia was identified in 2007.9 An important study of survey data from 2003 reported that Victorian GPs were becoming less likely to provide obstetric management and that half of the existing GP obstetricians intended to cease practising in the next 5–7 years. In addition, they found that 71% of GPs who completed a Diploma of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (DRANZCOG) did not then go on to practise independent procedural general practice obstetrics.9

Factors contributing to the forecast deficit in GP obstetric services included a rise in specialisation, centralisation of services, concerns regarding indemnity and litigation, rural workload and difficulty maintaining competence.9,10–13 The problem of maintaining competence in rural environments has been compounded by reported difficulties in accessing appropriate locum coverage to allow attendance at upskilling courses, in addition to the time and travel required to participate.10

The impending shortage of GP obstetricians and the need for strategies to train, retrain and retain GP obstetricians in rural practice have been the integral considerations in developing a comprehensive training and support program offered in the Gippsland region of rural Victoria. The Gippsland region lies east of Melbourne, covering a land mass of 41 524 square kilometres, and has a population of around 240 000.14 The program by Southern GP Training (SGPT) combines training for registrars and upskilling of GP obstetricians with strategies aimed at overcoming the professional isolation confronting rural GP obstetricians. The program (outlined in the Appendix) expanded registrar training at the larger regional (specialist-led) units to include a 3-month rotation on secondment to a metropolitan hospital. Further training was extended to include a state government-funded 6- or 12-month placement in a GP-led obstetric practice (bridging post) with secondments to larger centres; provision of a clear, individualised postdiploma pathway with supported placement in a GP-led, community-based obstetric practice; continued professional development; upskilling of existing GP obstetricians through the DRANZCOG Advanced qualification, which includes competence in performing caesarean sections; regular GP obstetrician meeting days attended by both registrars and practising GP obstetricians; specialist-led support and mentoring through a regular email forum; and specialist involvement in subregional GP perinatal education and morbidity meetings. In this way, the model provides a supported transition from specialist-led hospital obstetric units to GP-led, community-based obstetric services and integrates this with support for practising GP obstetricians.

The program is continuing to evolve, with new developments such as rotations to the Northern Territory and Pacific islands,15 to enrich the experience of the trainees. The implementation of this program has been matched by a period of recovery for Gippsland maternity services with an increase from 31 GP obstetricians in 2007 to 39 in 2013, including an increase from 10 to 23 conducting caesarean sections. This represents a reversal of the pre-existing trend in service closures.9,16 Of the 39 currently practising GP obstetricians, 18 received their training in the SGPT Gippsland obstetric training program.17 Another three trainees went on to practise GP obstetrics elsewhere, meaning that 21/33 program graduands were active in procedural practice.17

Recent government initiatives have supported GP obstetricians through funding professional development, incentive payments for upskilling, annual incentives for continuing GP obstetric practice and indemnity insurance support. These developments have removed some of the structural disincentives identified as barriers to procedural obstetric practice.

The aims of our study were to understand the factors influencing the decisions of rural GPs and GP registrars to practise obstetrics, and to understand the impact of this innovative GP obstetric training and support program on these decisions.

Methods

Our research was conducted in Gippsland in July and August 2013. Within the region, there are three specialist regional centres that offer a GP-led model of obstetrics, and five hospitals with GP-led services only, all with the facilities for caesarean sections.

Participants were identified from training records and the GP database of the past 5 years for the SGPT GP obstetrician and registrar training and support program. Letters of invitation, explanatory statements and consent forms were sent to potential participants.

We adopted a qualitative approach using semistructured face-to-face interviews.18–20 The research questions examined were:

What challenges face rural GPs in practising obstetrics?
What impact has the Gippsland GP obstetric program had on GP obstetric career decisions?

A three-stage framework method of data analysis (data display, data reduction and data interpretation) was applied,21 and measures were employed to augment the validity and reliability of this research. To ensure correct and detailed collection of participants’ experience and views, all interviews were audiotaped, and copies of the transcripts were provided to participants to check for accuracy. Recorded interviews were analysed by two researchers for credibility and validation of the analysis. Analysis of the transcripts, once uploaded into NVivo 10 (QSR International), was conducted independently by two researchers to check interrater reliability of the emerging themes.

Ethics approval was obtained from the Monash University Human Research Ethics Committee for this research.

Results

Of the 60 potential participants contacted, 22 agreed to take part. The sample included registrars, GPs who were upskilling and established GP obstetricians who supported registrars in training. Interviews ranged from 40 to 90 minutes in duration.

Six major themes emerged: isolation, work–life balance, safety, professional support, structured training pathway and effective leadership.

The first three themes relate particularly to the first research question.

The theme of isolation included the subthemes of distance from specialist services, access to assistance, and access to professional development. The challenge of isolation came with the awareness that it was critical to have the confidence and competence to handle difficult situations and that access to assistance and advice was important. When experienced GPs talked about the impact of isolation, their comments were focused on managing a situation, often in the context of access to assistance from a local team.

Neonatal Emergency Transfer Service (NETS) can come down, [but due to] the weather, it may be several hours before they can … the GPs rally around and can keep working on the babies, intubate them, and keep breathing for them. It is not ideal, but it works well most times. (Participant t)

Comments about isolation from registrars and GPs who were at an earlier career stage focused on how access to assistance with the guidance and information available through the SGPT program ameliorated this isolation.

I’ve got someone to call on at the drop of a hat if I am out of my depth at any point, even if it’s just for advice over the phone. (Participant e)

The theme of work–life balance included the subthemes of impact of after-hours call out, the demands of emergency situations, dealing with scheduled patients at the clinic after being at deliveries during the night, and family commitments.

Obstetrics interrupts the rest of life, both clinical, family life, and sleep. You know to be woken up in the middle of the night … isn’t a particularly pleasant thing, and try getting back to sleep after all the excitement. (Participant g)

Being part of a team of GP obstetricians assisted in achieving an acceptable work–life balance.

The theme of safety was mentioned more often by doctors who were at an early point on their career trajectory. This theme included the subthemes of patient safety and practitioner safety. Patient safety was related to backup and competence, while practitioner safety was about feeling supported and having confidence in dealing with the unknown. The SGPT Gippsland program was seen to contribute to improving safety.

Because (obstetrics) is a high-risk area and people burn out. They [SGPT] don’t want us having disastrous situations when we are junior. (Participant a)

The second three themes —professional support, structured training pathway and effective leadership — relate particularly to the second research question. Professional support was mentioned by all 22 participants. Participants from all groups within the cohort commented on the quality and availability of professional support within the Gippsland program. This theme included the subthemes of professional backup, professional networks and a respectful learning culture. With regard to professional backup, the availability of backup from specialists was described as timely and appropriate, as nominated mentors assisted with advice on practice in the clinic, and teams were built to support the training experience. Doctors in training and doctors in independent practice perceived they were well supported professionally.

When you are training you are always first on call, which is fantastic because you have to deal with everything that walks in the door. But you are paired with a consultant on the day. You basically run your assessment with them and see if they are happy with your plan, and for any instrumental deliveries or complicated issues you contact them to come in. So, it is very well supported. (Participant d)

Involvement in the Gippsland program made available both formal and informal professional networks to participants. The professional networks provided an environment where people at all stages of their career received support and timely, up-to-date information. Regular professional development opportunities were a valuable component, strengthening these networks and providing opportunities to reflect on best practice.

Ongoing professional development offered is fantastic, as it keeps you abreast of new developments as well as provides an opportunity for professional networking. (Participant v)

A respectful learning culture with an emphasis on empowering and enabling participants was an important component of professional support.

Respect is a huge factor; the leaders in the program lead by example and are very inclusive and respectful of individuals’ experience and needs. (Participant u)

The structured training pathway theme emerged as an important component of the Gippsland GP obstetric program. This included the subthemes of community-based bridging posts for registrars; secondment for additional experience; and continuous professional development. Registrars rated the bridging posts as critical to offering a safe transition.

I think it is about fostering supported practice and this is a particular time of vulnerability in terms of support … the movement from hospital-based practice to being a new person in community-based practice. (Participant g)

The theme of effective leadership was apparent across all interviews. There was clearly the perception of supportive, knowledgeable and respectful leadership within the program, and this was highly valued.

They are definitely good mentors and good role models and that is part of the reason … to want to keep going with this pathway. (Participant f)

Discussion

The themes of isolation, work–life balance and safety for the practitioners and patients emerged in our study as substantial challenges for rural GPs in practising obstetrics. These findings are consistent with the findings of other researchers who have studied the challenges of rural and remote medical practice more broadly.22,23 Work–life balance is particularly important for sustainable practice24 and is vulnerable to the demands of isolated obstetric practice. Our study indicates that the Gippsland GP obstetric program has contributed to a recovery and retention of maternity units in Gippsland founded on its success in helping doctors deal with these challenges.

Participants found the obstetric program to be professionally supportive, with meaningful backup, advice and support of professional development. The program has also been instrumental in building and supporting professional networks. Reliable, relevant backup and advice ameliorates isolation and enhances patient and practitioner safety. Professional networks remove isolation and enable cooperative rostering, which is a means to improving work–life balance. In this way, the SGPT Gippsland GP obstetric program would seem to have become fundamental for sustaining GP obstetric practice in Gippsland.

Our study suggests that the structure of the Gippsland GP obstetric training enables its trainees to continue into active, independent procedural obstetric practice. The bridging post after the primary training was highly valued. A large decrease in use of procedural skills 1 year after their primary procedural training has been reported previously.9,25 Supported transition after completion of hospital-based training has been found to be an important factor influencing recently qualified GPs to continue into independent procedural practice.25 Structured, respectful clinical supervision by senior role models is vital to effective postgraduate medical education,26 with the supervision relationship being shown to be more important than the supervision method.27

Leadership was clearly a major factor in the impact and success of the SGPT Gippsland GP obstetric program. This leadership was provided by committed specialist obstetricians and active GP obstetricians.

There was a notable absence in the data of mention of financial disincentives to practising GP obstetrics. This suggests that disincentives identified previously1 have been largely removed by recent government initiatives in this area.

This study was conducted in a particular geographic area, so transferability of the results cannot be assumed. In particular, this program was introduced where a shortage of GP obstetricians was forecast but not yet apparent. The participation of GP obstetricians was key to the success of the program. Therefore, this program design may not be as effective where GP obstetrician shortages already exist. However, themes such as isolation, safety and leadership are likely to be relevant in most rural settings, and the strength of these themes across the different practitioner groupings and towns suggests that the findings are generalisable. The stratified sampling method used was a strength of the study.

Our study also suggests that the Gippsland GP obstetric program has had a substantial impact on trainees continuing into active obstetric practice and on GP obstetricians continuing in their obstetric practice. This innovative program was made possible by state and federal government funding, the support of local and metropolitan hospitals, and ownership by both specialist and GP obstetricians. Leadership, organisational support and administrative support by SGPT have provided the scaffolding for the program. Key features of this training include a supported transition into community-based GP obstetrics; adequate clinical exposure through secondments; a culture supportive of GP obstetrics; building and sustaining professional support networks; and inspirational leadership. The increase in numbers of practising GP obstetricians has enabled more acceptable rosters and greater flexibility in accommodating personal commitments. These key features should be foundational considerations in replicating this successful model elsewhere.

The effect of obesity on pregnancy outcomes among Australian Indigenous and non-Indigenous women

Eliminating disparities between the health status of Indigenous and non-Indigenous Australians is a national priority.1 Obesity (body mass index [BMI] ≥ 30.0 kg/m2) is a major contributor to chronic diseases.2,3 As obesity rates at all ages are higher among Indigenous Australians,4 obesity-related health disparities between Indigenous and non-Indigenous Australians are a public health concern.

In Australia, maternal overweight (BMI, 25.0–29.9 kg/m2) and obesity are endemic in obstetric care.5 Consistent with national estimates,4 32% of non-Indigenous women with singleton pregnancies at the Mater Mothers’ Hospital in Brisbane between 1998 and 2009 were overweight or obese before pregnancy.5 The rate among Indigenous women was even higher, at 45%.5 The association between overweight or obesity and pregnancy outcomes in Australia is well described for non-Indigenous women, but less comprehensively understood for Indigenous women. These studies have consistently shown that maternal overweight or obesity is associated with increased risk of maternal complications (including gestational diabetes and hypertensive disorders) and perinatal morbidity and mortality. Further, caesarean section rates are higher among overweight or obese women.5 However, ethnicity may modify the effect of overweight or obesity on maternal and infant outcomes, and its impact at the population level.6–8

We aimed to estimate the prevalence of maternal overweight or obesity among Indigenous and non-Indigenous women separately, and to examine whether the effect of overweight or obesity on maternal complications and perinatal outcomes is modified by Indigenous status.

Methods

We used aggregate data from the population-based Queensland Perinatal Data Collection (QPDC). The QPDC is a legislated statewide collection of information on all hospital and non-hospital births in Queensland of at least 20 weeks’ gestation or at least 400 g birthweight. The study included 15 050 singleton births to Queensland resident Indigenous women and 250 798 to non-Indigenous women between 1 July 2007 and 31 December 2011. Data sourced for this study were sufficiently anonymised to protect patient privacy and confidentiality. Due to these aggregate data not being capable of identifying individual patients, a Public Health Act 2005 (Qld) application for release of these data was not required.

Self-reported pre-pregnancy height and weight are recorded at the first antenatal visit (in most cases, at around 12–16 weeks’ gestation) and have been included in the QPDC since 1 July 2007.

In addition to demographic characteristics of the mother, the QPDC captures information on each birth, including maternal, peripartum and neonatal outcomes. We had the following maternal factors available for analysis: maternal age (< 20, 20–24, 25–29, 30–34, 35–39, and ≥ 40 years); nulliparity (no, yes); remoteness of usual residence (Accessibility/Remoteness Index of Australia [ARIA+]: major city, inner regional, outer regional, remote, and very remote); maternal smoking during pregnancy (no, yes); mode of delivery (vaginal, caesarean section); pre-existing diabetes mellitus (no, yes); pre-existing hypertension (no, yes); hypertensive disorders of pregnancy (HDP; no, yes); and gestational diabetes mellitus (GDM; no, yes). We had the following infant factors available for analysis: gestational age (< 28, 28–31, 32–36, 37–41, and ≥ 42 weeks); birthweight (< 2500 g, 2500–2999 g, 3000–3499 g, 3500–3999 g, 4000–4499 g, and ≥ 4500 g); and Apgar scores at 1 and 5 minutes (score: 0–3, 4–6, and 7–10). To encompass the maternal and infant factors analysed, data are referred to as “Indigenous pregnancies” and “non-Indigenous pregnancies”.

Statistical analysis

Associations between BMI and maternal and infant outcomes were assessed using multivariable log-link Poisson models to estimate prevalence ratios (PRs) and 95% confidence intervals adjusted for maternal age, nulliparity, ARIA+ category and smoking status. Additional adjustment for year did not change the observed PRs, so it was not included in the final model. We assessed effect modification by Indigenous status by including an interaction term in the models. Significance of the interaction term was determined by a likelihood ratio test. In supplementary analyses, we estimated adjusted population-attributable fractions (PAFs) for each outcome associated with overweight or obesity,9,10 and performed analyses additionally stratified by age (< 25, ≥ 25 years), nulliparity and smoking status. Analyses were conducted using SAS 9.3 (SAS Institute) and tests for statistical significance were two-sided at α = 0.05.

Results

Of 265 848 births, 13 582 to Indigenous women and 241 270 to non-Indigenous women had associated maternal BMI recorded in the QPDC. The percentage of missing BMI data in the QPDC was highest in the first 2 years, but decreased from 11% in 2007 to 2% in 2011. Each year, the proportion of missing BMI data was higher for Indigenous than non-Indigenous pregnancies (2007, 23% v 10%; 2011, 4% v 2%).

In 57% of Indigenous pregnancies and 49% of non-Indigenous pregnancies, the mother was overweight, obese or severely obese (Appendix 1). The proportion of pregnancies occurring in overweight, obese or severely obese women remained essentially unchanged over time. BMI and Indigenous status were statistically significantly associated with age, parity, ARIA+ category and smoking during pregnancy.

Maternal outcomes

Prevalence of GDM was higher in Indigenous than non-Indigenous pregnancies (6.9% v 5.5%, P < 0.001), while HDP occurred in 5.0% of all pregnancies (P = 0.14). Overall rates of HDP were similar for Indigenous (5.1%) and non-Indigenous (4.9%) pregnancies; however, rates were higher in normal-weight Indigenous pregnancies (4.0%) versus normal-weight non-Indigenous pregnancies (3.0%).

GDM prevalence increased with increasing BMI (Box; Appendix 2); the association did not vary by Indigenous status (P for interaction, 0.45). In contrast, the PR for HDP associated with obesity was significantly higher for non-Indigenous than Indigenous pregnancies (P for interaction, < 0.001). Prevalence of HDP was significantly lower in pregnancies among underweight women than in those among women with normal BMI.

Delivery outcomes

The prevalence of caesarean section was higher among non-Indigenous than Indigenous women (33% v 25%; P < 0.001). Overweight, obese or severely obese women’s pregnancies were more likely to end in a caesarean section than pregnancies in women with normal BMI, regardless of Indigenous status (P for interaction, 0.13).

Preterm births (spontaneous or medically induced) were more likely among Indigenous than non-Indigenous pregnancies. Prevalence of preterm birth before 32 weeks was twofold higher for pregnancies among underweight Indigenous women; however, there was no consistent association between increasing BMI and preterm birth in either group. We found significantly lower prevalence of preterm birth before 37 weeks for pregnancies in overweight or obese Indigenous women, but no association for pregnancies in non-Indigenous women (P for interaction, < 0.001).

Birthweight was lower than 2500 g in 9% of babies born to Indigenous women, and 4% born to non-Indigenous women. The prevalence of low birthweight was higher in underweight women’s pregnancies; however, while BMI was inversely associated with low birthweight overall, the magnitude of the association was stronger for Indigenous than non-Indigenous pregnancies (P for interaction, < 0.001).

Pregnancies in underweight Indigenous women had a higher prevalence of low Apgar score at 5 minutes, while obesity was associated with a low Apgar score at 1 and 5 minutes in all pregnancies.

Supplemental analyses

We calculated PAFs for each outcome associated with BMI ≥ 25.0 kg/m2. The PAF for GDM was higher for Indigenous (52%; 95% CI, 48%–56%) than non-Indigenous (39%; 95% CI, 38%–40%) pregnancies. Likewise, the PAF for high birthweight was higher for Indigenous (41%; 95% CI, 37%–45%) than non-Indigenous (25%; 95% CI, 24%–25%) pregnancies. In contrast, the PAF for HDP was lower for Indigenous (30%; 95% CI, 24%–36%) than non-Indigenous (41%; 95% CI, 40%–42%) pregnancies.

We observed similar results when we additionally stratified by age, nulliparity and smoking status, and when we excluded births from women with either pre-existing diabetes or hypertension (data not shown).

Discussion

Almost half of all singleton babies born in Queensland between 2007 and 2011 were born to overweight or obese women, with the highest rates observed in Indigenous women. Consistent with the Australian obstetric population as a whole,11 5% and 6% of pregnancies in our study involved HDP and GDM, respectively. Compared with pregnancies in normal-weight non-Indigenous women, the prevalence of HDP or GDM was more than fourfold higher in pregnancies in severely obese non-Indigenous women; 40% of cases of HDP and GDM in non-Indigenous pregnancies may be attributed to overweight or obesity.

To the best of our knowledge, the current study is the first to show that the magnitude of the association between BMI and HDP in Australian women is modified by Indigenous status. Prevalence of HDP was only twofold higher in obese Indigenous women’s pregnancies, and overweight or obesity accounted for only 30% of HDP in Indigenous pregnancies. Similar ethnic differences have been observed in the United States and the United Kingdom.6,7 In contrast, while the association between maternal overweight or obesity and GDM was not modified by Indigenous status, the burden of GDM associated with overweight or obesity was significantly higher for Indigenous pregnancies.

For high birthweight, the magnitude of the association with obesity was stronger for Indigenous pregnancies, and overweight or obesity accounted for a greater proportion of high birthweight babies born to Indigenous than non-Indigenous women. We found no association between overweight or obesity and preterm birth in non-Indigenous pregnancies; however, prevalence of preterm birth before 37 weeks’ gestation was lower in overweight or obese Indigenous women’s pregnancies. Similar disparities have been reported in three US studies, where the risk of preterm birth was lower among obese black women and higher among obese white women.12–14 While studies, including ours, have found higher prevalence of preterm birth in underweight women’s pregnancies, the association with overweight or obesity remains controversial. Two meta-analyses reported a modest increased risk of preterm birth associated with obesity,15,16 although literature shows conflicting results.

The biological basis for associations between overweight or obesity and adverse pregnancy outcomes are unclear. The varying effects by ethnicity, however, may be due to differences in body fat distribution, as Indigenous women have more central body fat for a given BMI than non-Indigenous women.17,18 Furthermore, lean Indigenous women are more likely to be insulin resistant,19 and obesity has been shown to have a greater effect on insulin resistance in non-white than in white women.8,20 It is also possible that there may be genetic differences between Indigenous and non-Indigenous women that explain different rates of pre-eclampsia, and this is an important area for further study. There may also be different behaviours in the younger, normal-weight group of Indigenous women that we cannot measure (eg, shorter periods of sperm antigen exposure, higher burdens of inflammation and endothelial dysfunction relating to chronic infections).

The strengths of our study include the large population-based cohort and collection of information on a range of potential confounders. While no studies have assessed the completeness and accuracy of the QPDC as a whole, validation studies of a similar database in New South Wales report high levels of accuracy for infant and maternal outcomes.21 More missing BMI data from Indigenous pregnancies, likely due to later presentation for antenatal care,22 may be a limitation. Although we found differences between the characteristics of women with and without BMI data, our results were unchanged when we restricted our analyses to years with more complete data. BMI was based on recalled height and weight; however, a previous study in a subset of mothers giving birth in Queensland has shown high correlation (r = 0.95) between maternal estimate of pre-pregnancy weight and weight recorded at the first antenatal visit,23 and any misclassification would attenuate the associations here. It is unclear whether such misclassification would have differed by Indigenous status. Another possible limitation is the use of self-reported Indigenous status. Indigenous mothers who were not enumerated in the QPDC may have influenced the true association with BMI. While we adjusted for potential confounders, we cannot completely exclude residual confounding. Compared with non-Indigenous women, Indigenous women are younger and tend to be thin when they have their first baby; however, they tend to have more children and gain a lot more weight.11 Young age and parity are also risk factors for HDP and may confound the associations with obesity. The higher rates of caesarean section for non-Indigenous women may be due to private health insurance status; however, we did not have data on private health insurance status in this study. Finally, because it is possible that subgroups of women may be more likely than others to be screened, the observed effect for obesity may actually underestimate the true effect as the non-disease groups would be very likely to include women with undiagnosed disease. Confounding by indication could have occurred, as obese women may be more likely to be screened for maternal health indicators than non-obese women. It is unclear whether screening is more or less likely to occur in Indigenous women.

In summary, maternal overweight or obesity is common in obstetric care and is associated with poor pregnancy outcomes. Elucidating the reasons for the varying effects by Indigenous status will help in understanding the pathways leading to these events.

Adjusted prevalence ratios* and 95% confidence intervals for maternal and delivery outcomes, according to Indigenous status and body mass index (BMI) category

Indigenous (n = 13 582)

Non-Indigenous (n = 241 270)

Underweight

Normal†

Overweight

Obese

Severely obese

Underweight

Normal†

Overweight

Obese

Severely obese

P for interaction

No.

857

4966

3776

3353

630

10 864

112 385

66 729

43 837

7455

Maternal outcomes

GDM

1.17 (0.77–1.78)

1.00

1.94 (1.58–2.38)

3.00 (2.47–3.63)

4.44 (3.48–5.67)

1.00 (0.90–1.12)

1.00

1.65 (1.58–1.73)

2.76 (2.64–2.88)

4.47 (4.18–4.78)

0.45

HDP

0.55 (0.34–0.88)

1.00

1.44 (1.18–1.75)

2.00 (1.64–2.43)

2.12 (1.53–2.94)

0.74 (0.65–0.84)

1.00

1.76 (1.68–1.85)

3.12 (2.97–3.27)

4.95 (4.60–5.32)

< 0.001

Delivery outcomes

Caesarean section

0.91 (0.77–1.08)

1.00

1.18 (1.08–1.29)

1.32 (1.21–1.44)

1.81 (1.58–2.07)

0.89 (0.86–0.93)

1.00

1.17 (1.15–1.19)

1.36 (1.33–1.39)

1.59 (1.54–1.65)

0.13

Preterm birth < 32 weeks

1.98 (1.36–2.88)

1.00

1.05 (0.78–1.40)

0.87 (0.63–1.20)

1.28 (0.75–2.18)

1.45 (1.22–1.71)

1.00

0.97 (0.87–1.07)

1.05 (0.94–1.17)

1.36 (1.11–1.68)

0.40

Preterm birth < 37 weeks

1.51 (1.25–1.81)

1.00

0.83 (0.72–0.95)

0.69 (0.59–0.80)

0.76 (0.57–1.01)

1.39 (1.30–1.49)

1.00

0.97 (0.93–1.01)

1.00 (0.96–1.05)

1.09 (0.99–1.19)

< 0.001

Low birthweight (< 2500 g)

1.56 (1.31–1.86)

1.00

0.68 (0.59–0.78)

0.49 (0.42–0.58)

0.49 (0.34–0.69)

1.80 (1.68–1.93)

1.00

0.81 (0.77–0.85)

0.77 (0.73–0.81)

0.84 (0.75–0.94)

< 0.001

High birthweight (≥ 4000 g)

0.65 (0.44–0.97)

1.00

1.70 (1.46–1.99)

2.36 (2.03–2.75)

3.26 (2.64–4.03)

0.50 (0.46–0.54)

1.00

1.44 (1.40–1.48)

1.82 (1.77–1.87)

2.27 (2.16–2.39)

< 0.001

1-minute Apgar score < 7

1.22 (0.97–1.52)

1.00

1.09 (0.95–1.25)

1.23 (1.06–1.42)

1.62 (1.28–2.05)

0.92 (0.86–0.99)

1.00

1.13 (1.09–1.17)

1.27 (1.22–1.32)

1.63 (1.52–1.74)

0.20

5-minute Apgar score < 7

1.71 (1.15–2.54)

1.00

1.06 (0.80–1.42)

1.22 (0.92–1.63)

1.85 (1.18–2.88)

0.95 (0.81–1.11)

1.00

1.02 (0.94–1.10)

1.26 (1.16–1.36)

1.70 (1.46–1.98)

0.16

GDM = gestational diabetes mellitus. HDP = hypertensive disorders of pregnancy. Underweight = BMI, < 18.0 kg/m2. Normal = BMI, 18.0–24.9 kg/m2. Overweight = BMI, 25.0–29.9 kg/m2. Obese = BMI, 30.0–39.9 kg/m2. Severely obese = BMI, ≥ 40.0 kg/m2. * Adjusted for maternal age, nulliparity (yes/no), Accessibility/Remoteness Index of Australia category and smoking status. † Reference category.

What can circle sentencing courts tell us about drug and alcohol problems affecting Aboriginal communities?

In New South Wales, circle sentencing courts take place outside of the courthouse, in a more informal community setting. The circle is made up of the magistrate, prosecutor, victim, offender (and his or her supporters), four respected Aboriginal Elders (who are significant to the offender), a representative of the support agencies and a lawyer from the Aboriginal Legal Service. The group talks about the impact of the crime on the victim and looks at the background of the offender and what caused him or her to get on the wrong path. The discussion can last up to 3 hours, after which the group develops a circle sentencing outcome plan, upon which all parties agree. The most important recommendations are made by the Elders. The outcome has to be acceptable to the magistrate. Nowra’s circle sentencing court has been operating for close to 12 years and the magistrate there has never yet disagreed with the Elders. The circle outcomes also need to suit the ability of offenders to comply with the conditions, as we don’t want them to fail.

How the circle relates to the Aboriginal traditional way of dealing with offenders

Up until the 1860s in the Shoalhaven region, we had a council of karadji men to administer tribal law. A locally known karadji man was Johnny Burriman. Keith Campbell wrote of him in the South Coast Register:

The work of Johnny Burriman to gain recognition for an important place for Aboriginal law in the Australian legal system failed, but the issue has remained. A significant step taken appropriately in the Shoalhaven district in recent years has been the introduction of circle sentencing.1

I believe this was a small but significant step towards recognition of the authority of a council of Elders, if not our traditional lore.

The Nowra circle sentencing court provides for sensitivity in reaching a sentence with as much compassion as the crime allows, but without frustrating Parliament’s intention. The justice carried out is a combination of criminal law and traditional values. Whereas the criminal justice system regards crime as something to be punished, Aboriginal people view it as something that requires healing. The regular courts have recently adopted a similar approach: their concept of it is therapeutic jurisprudence.2

How effective has it been?

The greatest achievements of the circle sentencing courts have been bringing down the barriers between the courts and the Aboriginal community, gaining mutual respect and also gaining a great deal of knowledge around the root causes of crime within Aboriginal communities, especially as it relates to alcohol and drug misuse.

The knowledge that has been obtained through open and honest dialogue between the Elders, the offenders and the victims could be regarded as revolutionary. Information is received “from the horse’s mouth” — from the people who have committed the crime, who are experiencing the disadvantages and suffering of alcohol and drug misuse. They are open and honest about it. Sometimes they break down and cry and volunteer insights about their lives. Some circle members even reveal information about themselves for the first time in their lives.

Aboriginal Elders effectively use the Koori way of obtaining comprehensive information from offenders, through the narrative form rather than questions and answers, as it is our cultural way of communicating. The Elders are also very clever in their use of shame: they make the offenders ashamed of their actions rather than of themselves. They say to an offender, “Be a proud Koori: you come from a good family and a rich culture, but you have got to be ashamed of your actions; this is bad”.

Understanding what underlies drug and alcohol problems

It is well known that the underlying causes of crime are unemployment, poor housing, poor education and poor health. As a result of the honest and open dialogue in each circle sentencing case, we have been able to identify some of the further underlying causes of this for Aboriginal people. We have discerned much self-depreciation, low confidence and low self-esteem, derived from 200 years of demonisation by the media and government and only learning about the negativity of Aboriginality. There is also direct trauma from sexual abuse, assault, other types of violence and racism. Being told you are lazy and good for nothing becomes a self-fulfilling prophecy over time. Additionally, there is indirect transgenerational trauma. Many of our offenders are from the Stolen Generations or are affected by family members who were. Aboriginal and Torres Strait Islander people who have been removed from their families often suffer feelings of abandonment and rejection. Their reactions take numerous forms, including anger, grief, loss of identity, alcohol and substance misuse, violence and other socially unacceptable behaviour, problems in relationships, psychological difficulties and isolation. Lack of identity can be linked to mental illness. As Aboriginal people operate on a collective or community level, the extended family is integral to the recovery process. Many often find themselves feeling caught between two worlds — their Koori heritage and the white world they grew up in. This can lead to a sense of not belonging, or feeling unwelcome in either world, with a crippling sense of isolation.

Problems like these need to be taken into account by the court system. This information does not supply the court with an excuse for an offence but it does supply an understanding of the root causes of crime, which is subsequently helpful in developing and delivering crime prevention programs. It is our belief that if clients have the opportunity to work on these problems, it gives them a chance to heal and not repeat the behaviour that led them to the court.

Often Aboriginal people use alcohol and drugs as an anaesthetic for the pain, fear and loss of cultural identity they are experiencing. The “dual diagnosis” which may result does not just refer to clients with hard-core drug problems and schizophrenia. It also refers to clients with a lifetime history of alcohol use disorder and coexisting mental or other drug disorder. The most common mental disorders among offenders with any drug use disorder are anxiety disorders. Some evidence of the intensity of this problem was provided in the 2009 NSW Young People in Custody Health Survey, which found, among other important and disturbing findings, that 92% of young Aboriginal people in custody had a psychological disorder and 83% were risky drinkers.3 Young Aboriginal people make up 49% of the juvenile population in custody.4 Drug and alcohol problems are not easy to overcome if you don’t know much about the causes. Service providers can learn more about the underlying causes of this problem and how to deal with them by participating in cultural awareness training.

After the circle — providing care

In circle sentencing courts, most offenders, and particularly those who commit the more serious offences, are people with a dual diagnosis. This is where the crime problem really becomes a health problem. To deal with it, Justice Health provides liaison nurses who work in courts and corrective services. We also have drug courts to deal with drug-addicted criminals. However, there still appears to be a problem in dealing with offenders with dual diagnosis, mainly because they don’t recognise or accept their illness. Within our Koori communities, there is a stigma around mental illness that leads to self-medicating with illicit drugs. There are also cultural barriers in accessing mental health services in NSW. Clients move between drug and alcohol and mental health services, and dual diagnosis clients are at risk of falling through the gaps. Most importantly, we need a model to promote community-based recovery rather than reliance on inpatient services, as Aboriginal people won’t remain away from their families for long periods of time.

Overcoming the root causes of drug and alcohol use and resultant crime

We need to develop wellbeing programs that focus on physical, psychological, spiritual and personal wellbeing, so that offenders are able to overcome their drug and alcohol dependency and move on to employment, housing, education and good health. We need to tackle the root of the problem if we are to break the cycle of welfare dependency and drug taking that ends in crime and despair.

In a circle, Elders can only direct offenders to do something about their problems; but these directions are taken seriously by the offenders because they are delivered by their respected Elders. However, Aboriginal and mainstream support services are needed to assist offenders to heal afterwards. Aboriginal organisations act as a link between clients and professional and mainstream services and are able to advocate, refer and liaise as necessary. But mainstream services can be limited by a lack of resources and training of support workers about the cultural and communication barriers that prevent them from working effectively with Aboriginal offenders. Some of our clients have experienced judgemental and patronising staff, including psychiatrists, psychologists, drug and alcohol counsellors and general health workers, who have lacked patience, empathy or cultural insight. Cultural bias still remains in the literature of psychology. We need culturally appropriate training for service providers — training that takes into account our differences in experiences, ways of communicating, values, kinship and families, along with insight into healing that recognises the impact of transgenerational trauma, our history and experiences on the current life situations of our people. At the end of the day, our clients have to access these mainstream services. If we fail in these areas, what good are all the efforts we put into getting our people to these services in the first place?

The need for additional support and training

I believe that the programs and training I am calling for represent the way forward. We need to train those who work in mainstream services to be competent when dealing with our people. In the criminal justice system, we are mostly dealing with Aboriginal people with very poor education who are often isolated from the rest of society. In the past, Aboriginal people were denied an education in Standard English and were only taught a modest amount of the English language, from which developed Aboriginal English. This language is still spoken frequently within Aboriginal communities. There is also the matter of poor health to contend with.

Although there is no one solution to the problem of crime, we have to try a combination of what is working in some areas. We need circles accompanied by cultural programs and specialist counsellors to help our people deal with dual diagnosis and trauma. Men’s group programs such as Red Dust Healing (http://www.thereddust.com) and Rekindling the Spirit (http://www.rekindlingthespirit.org.au) are very effective. The Waminda women’s organisation health and wellbeing program is also very effective for Aboriginal women.5 We need to promote pride in Aboriginal identity and culture, based on the belief that this is central to the health and wellbeing of our people and that knowing who you are as an Aboriginal person is central to any positive life. We also need to forge strong partnerships between organisations and agencies so that our clients don’t fall through the gaps.

Conclusion

When we lost our lore and important cultural and traditional way of life, we reached a point where we began to normalise abnormal behaviour such as substance misuse. This is not our traditional way. It is happening mainly because we have lost our structural system of learning and control. Circle sentencing operates on the understanding that the underlying causes of crime are often broader than a single incident and that they need the active participation of the whole community to fix them.

Circle sentencing highlights a need to develop effective cultural programs that educate our people about the positive aspects of our culture and Aboriginality and enable us to take pride in ourselves. These programs should improve the overall health standards of our people by promoting social and emotional wellbeing, acknowledging culture and identity as pivotal in reaching positive outcomes, and prioritising wellbeing as a vital foundation for belonging and identity. Service providers also need to be educated about Aboriginal communication styles, to ensure equality of access to justice and health services. Courts in NSW have developed a program to overcome this problem at a grassroots level, by employing Aboriginal client service specialists in local courts to service Aboriginal clients directly at the counter, in the registry and in the courtroom. Their most important and demanding task is interpreting court rulings. Only when all of these initiatives are put in place will the statistics on our people coming into contact with the criminal justice system begin to decrease.

Above all, the circle teaches us the need to recognise that the past still affects us today. The trauma and dispossession of colonisation compound the harmful effects on our health and culture. The summary statement of the International Symposium on the Social Determinants of Indigenous Health identified colonisation of Indigenous peoples as a central and undeniable causal factor in ill health.6 Colonisation has resulted in the decimation of much traditional Indigenous culture and customary practices, rituals and systems, particularly for Aboriginal people living in urban and regional areas (Mary Goslett, Masters student, Australian College of Applied Psychology, unpublished research paper).7

We are behind the eight ball when it comes to economic and social status. It is only very recently that our culture has begun to be celebrated and accepted to an extent that will assist our next generation to take pride in themselves as Aboriginal people of this country. Reconciliation is the way forward for us, but it will take time and a lot of effort on both sides to reconcile our differences. Circles, I believe, are reconciling our differences within the criminal justice system. Thoughtful and intelligent people from all walks of life will continue to make true reconciliation happen in this country.