Women and Birth
Volume 20, Issue 2 , Pages 77-80, June 2007

Low birth weight in Aboriginal babies—A need for rethinking Aboriginal women's pregnancies and birthing☆

  • Heather Hancock

      Affiliations

    • Currently on leave from the University of South Australia and has been living and working in the Northern Territory involved in project and consultancy work across maternity services and perinatal Aboriginal health and wellbeing.
    • Corresponding Author InformationTel.: +61 4144 995 44.

PO Box 358, Stirling, SA 5152

Received 11 December 2006; received in revised form 7 February 2007; accepted 8 February 2007.

Article Outline

Summary 

Low birth weight in Aboriginal babies has become a persistent quandary as their average birth weight continues to be lower than that of non-Aboriginal babies. Arguments, reviews and research abound to explain this difference which is deemed unacceptable and needing resolution. A précis review of current theories and findings around low birth weight in Aboriginal babies is presented as a background for much needed alternative considerations of this issue. The low birth weight dilemma requires urgent rethinking of Aboriginal women's experiences and feelings of their pregnancies and possible effects on their unborn babies. There is a critical need for empowerment of Aboriginal women that goes beyond rhetoric and dominant ideologies about what is best for them and their babies, and genuinely enables them to assume control and self-determinism in ways that might make a significant difference, including importantly to their babies’ birth weights.

Keywords: Low birth weight, Midwifery, Continuity of care, Aboriginal and Torres Strait Islander women, Maternity care, Traditional birthing

 

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Introduction 

There were 8958 babies born to their Aboriginal mothers in 2003, comprising 3.5% of all Australian births.1 These babies were more likely to be premature (14.1%) than non-Aboriginal mothers’ babies (7.6%), and in terms of birth weight, 12.9% of them were identified as low birth weight compared to 6.0% of babies born to non-Aboriginal mothers.1 The corollary of prematurity and low birth weight in Aboriginal babies is clear.

Low birth weight is defined by the World Health Organisation (WHO) as the first weight of the baby after its birth that is less than 2500g, with very low birth weight as less than 1500g and extremely low birth weight less than 1000g.2 It is to be noted that there is no definition for normal birth weight, nor ideal birth weight. The WHO2 does prescribe the ideal time for determining birth weight as preferably within the first hour of life before the baby has any significant weight loss, and the ideal measurement of birth weight as to within 10g of accuracy and using an appropriate reading technique, but no more. The National Strategic Framework for Aboriginal and Torres Strait Islander Health – Child and Maternal Health – Policy Development Plan identifies the need for Aboriginal babies to have a ‘healthy’ birth weight but the average expected weight for that ‘healthy’ weight is not specified.3

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Antenatal care and low birth weight 

Antenatal care is important in influencing birth weight but not the sole determinant of it.2, 4 The persisting routine for pregnant women of numerous antenatal visits without a supporting evidence base has only recently received much needed scrutinisation; the majority of women may only need 4 antenatal visits and the other 25% of women may need focused care to meet their specific needs and conditions.5 To claim that numbers of antenatal care visits may correlate with birth weight is not proven.

Effectiveness of the quality and nature of antenatal care itself needs to be substantiated; visits can vary from 10min involving brief physical tasks and little else, that may be conducted by a different person each time the woman presents (who may not have any expertise or qualifications in midwifery or obstetrics); or visits can involve inclusive care across individual, emotional, psychosocial, educational, physiological, cultural, spiritual, family and community foci with a known qualified health professional providing continuity of care and ideally carer. There is still much to be concerned about in terms of antenatal care than there is to claim it as a significant determinant on birth weight6 and birth outcome.

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Identified maternal and related influences on birth weight 

Birth weight can be influenced by maternal risk taking behaviours (such as consuming alcohol, smoking, sniffing inhalants and so on), infections (including sexually transmitted), maternal nutrition, and the environment (ranging from the family home to altitude) for example.2 Socioeconomic disadvantage, maternal age, size and parity, medical conditions during pregnancy, and gestation at birth, among others can also exert an influence.7 ‘Mechanical’ factors such as the equipment and process used to weigh the baby and the time following birth that the baby is weighed, will also influence the weight actually identified.2 Birth weights should also be interpreted in terms of standard deviations as well as means within the appropriate population range; on its own birth weight is simply a number or it can be a profound prognosis. This is not stated to trivialise birth weight but to seek a more critically analytical and innovative approach to interpreting Aboriginal birth weight that goes beyond the numbers and the recognised influences.

Maternal Aboriginality could also be deemed the proxy for other unspecified perinatal factors, and differences in birth weight have served to identify Aboriginal mothers as disadvantaged.8 Sayers’ study proposed that there were no universal findings to support an adverse association between birth weight and outcome in Aboriginal women, and that there was no relationship between antenatal care involvement and birth outcomes.8 Aboriginal women on average, have their babies at a younger age and therefore greater support and care for them both antenatally and postnatally should be the aim, to achieve a positive effect on them and their babies.7 The need for social and psychological support in pregnancy is not new; it should be integral to the care all pregnant women receive.9

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Gestation at birth and birth weight 

A Queensland population based descriptive study of perinatal mortality rates in Aboriginal and non-Aboriginal babies found that Aboriginal babies have a higher risk of death because of their prematurity and small size.10 It was emphasised that priority be given to culturally appropriate primary health care strategies focused on preventing low birth weight and prematurity with a need for empowerment of Aboriginal women for increased ownership and awareness of their health.10

A review of previous studies on low birth weight in Northern Territory (NT) Aboriginal babies11, 12 concluded that programs to improve birth weights should address weight for gestational age as well as prematurity with their focus on the overall population not just high risk pregnancies; small for gestational age babies are not necessarily premature nor are they necessarily low birth weight.13 The NT Midwives’ Data Collection was used to evaluate effects of the Strong Women Strong Babies Strong Culture (SWSBSC) Program (in its pilot phase) on birth weight changes.14 An increase in birth weight of 92–170g was noted in the pilot communities concurrent with the introduction of the program, but whether this could be attributed to the program itself was not determinable. Changes in maternal weight were associated (but not correlated or explainable) with changes in birth weight over time.14 Researchers have also encountered problems with deciding between premature birth and intrauterine growth restriction in Aboriginal babies due to the confounding difficulties of determining their gestational age.15, 16

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The need for alternative considerations 

These studies provide a generally typical picture of the literature surrounding low birth weight in Aboriginal babies. Many more studies, much writing and numerous policy statements and health care programs have been produced surrounding a belief that Aboriginal babies have to weigh on average the same as non-Aboriginal babies.6 So while Aboriginal babies face some, none or all of these varying influences on their birth weight, they also face the consequences of being compared with non-Aboriginal babies. This comparison is unfounded anthropometrically. As population groups, Aborigines are not homogenous, with variances due to geographical and demographic context, skin group, and beliefs and values about life and health for example, which calls to question the reliability of comparing them against and within each other as groups, and against non-Aboriginal babies.

The influences on birth weight identified, while not absolute, do serve to reduce the pregnant woman to a set of behavioural expectations and her pregnancy care to an almost mechanistic set of tasks and management requirements that can negate individual experiences and humanity for the sake of an ideal but unknown birth weight. Consideration that an Aboriginal woman's experience of and feelings about her pregnancy and her maternity care make no difference to her or her baby does not seem to be a high priority in the low birth weight debate.

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Displacement from family, community, country and culture 

The practice of removing pregnant Aboriginal women in rural and remote areas from their families, communities, culture and their country at a designated time prior to term gestation for labour and birth in some other location (possibly a thousand kilometers from home) has been seemingly accepted as a routine for decades. While much emphasis has been given to women in urban settings for the creation of family friendly birth environments and options for community midwifery and home birth for example, these options presumably are irrelevant for Aboriginal women especially in remote settings. When an Aboriginal woman has reached a stage in her pregnancy where the role and place of elder women and appropriate family members for support, guidance and nurturing of her towards the birth of a healthy baby is paramount, the woman is displaced from her family, community and culture. Traditional birthing would have seen this time as one of important anticipation and preparation with cultural practices and beliefs leading the pregnant Aboriginal woman and her supporters.17

Birth requires both physical and spiritual health in Aboriginal women.18 However, a system of medicalisation and authority has determined that removing the Aboriginal woman from her culture and tradition for birthing is far better for her and her baby. “Grandmother's Law … has been violated … Our women are shamed;” yet despite these strong assertions in the significant ‘Borning’ paper17 nearly 20 years ago, too many Aboriginal women's pregnancy and birth experiences have not been better. Nor has there been a dramatic improvement in perinatal statistics to assert that ‘displacement’ of the Aboriginal woman is the only acceptable and substantiated safe way for her to give birth.

That this displacement has no effect on the woman's pregnancy or her baby, especially the baby's growth and development in a woman who is facing impending removal from family, community, culture and country, cannot be negated. How different the woman's own self-esteem, mental health and wellbeing, and accordingly her physical, cultural and spiritual health and wellbeing might be, and therefore how different the wellbeing of her baby might be (and its birth weight), if she could experience the entire continuum of her pregnancy, labour and birth within the nurturing, protection and strength of her family, community, country and culture.

It could be argued that this displacement from family, community, country and culture is undermining the integrity of the culture overall as more and more babies grow into adolescents who have lost their ties to the land and their dreaming. Future generations of Aboriginal babies may well look back on their births as being ‘stolen’ from them, from their family, community, country and their culture because of authoritarian beliefs that were deemed to know what was best for them.

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Powerlessness to achieve choice, control and continuity 

Aboriginal women of all women in Australia, particularly those living in remote communities, are least likely to have, if any, choice and control in their pregnancy care, care-provider, and place of birth. While important and necessary change across Australia in models of care and maternity hospital practices have been taking place, most Aboriginal women have not benefited from them let alone know of them. Their pregnancy, labour and birth are decided for them without their right to exercise control let alone choice. They are deemed negligent if they decide they simply do not want to leave their homes and families and ‘miss the plane’, ‘go out bush’ and/or turn up in late established labour at the nearest clinic to have their baby on their land. This is a supposedly irresponsible mother risking her baby to stay with her family in their community. It is not considered that this is a strong woman expressing her culturally inherent desire (that most of us do not comprehend) for her baby to have its skin name (a baby is born into its skin group and thus shares a skin name with their skin group relatives—a complex system that requires our respect) in every sense and be born on its land. The valued rite of birth for her is viewed as an act of negligence by others who claim to know more about what is really right for her and her baby. If the power of this traditional rite is considered in the context of the consequences it holds for the mother and the health and wellbeing (and ultimately birth weight) of her baby, the effects cannot be underestimated.

Add to this the reality that many Aboriginal women in remote communities may never see a midwife, may never see a General Practitioner, and may only see a Remote Area Nurse (RAN) during their pregnancies, until they are removed to the hospital they are to give birth in. Continuity of qualified care and carer seems an impossibility, despite the beneficial effects of continuity of caregivers for pregnancy,19 let alone achieve care from a qualified maternity care professional. The capacity of a health professional to facilitate a healthy pregnancy for a physically and emotionally well woman to have a well grown and soundly developed baby is undermined by the absence of any appropriate educational qualification to support the necessary knowledge, attitudes and skills. The 2006 Consensus Statement on Medicare Item 16400: Antenatal care in rural and remote communities,20 states that the provision of antenatal care does not fall within the usual scope of practice of nurses who do not have midwifery qualifications yet the Federal Government has seen fit to accept this care as sufficient. Questioning low birth weights in Aboriginal babies cannot be taken seriously under circumstances of accepted compromise in health care for pregnant Aboriginal women.

If the woman does not present for antenatal care she is regarded as careless, not that she has actually made a conscious choice about the kind of pregnancy care she may or may not like and want. Interpretation of the situation places the negativity on the Aboriginal woman not the health system. The quiet, discrete nurturance the woman may receive from an Auntie and/or Grandmother for her pregnancy may far outweigh the shame of her pregnancy being talked about and managed in the local clinic.

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Persisting disempowerment 

In 1997 O’Loughlin21 questioned the achievable reality of safe motherhood insisting astutely that empowerment of women is the key and the only way forward. Being an Aboriginal woman in a remote community must no longer be a justified routine reason for displacement, powerlessness and disempowerment. There has been much rhetoric about maternity care for Aboriginal women and the need for change by the health system; similarly about the issue of low birth weight Aboriginal babies and the need to remedy it. However, the effects of an impassive health system dominated by beliefs (not necessarily sound evidence) about Aboriginal health and wellbeing, have taken precedence over the cultural and humanitarian rights and individualistic needs of Aboriginal women to do what all pregnant women should be able to do; actually enjoy their pregnancy, be fully supported individually, look forward to their baby's birth and celebrate in their satisfaction and triumph after their baby is born.

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Conclusion 

All maternity care providers in Australia must give urgent consideration to the need for a reconciliation of care in pregnancy, labour, birth and postpartum for Aboriginal women focused specifically on their individual preferences and needs, their spirituality and emotional wellbeing, their self-esteem and self-concept, their rights and humanity, their sense of place and culture, their control and empowerment, and their strength and capacity to make a difference to THEIR pregnancy and baby. Our responsibility is to do everything we can to support and value that regardless of our own biases, beliefs and values. We need an urgent Reconciliation Strategy for Aboriginal birthing in Australia and from it a united driven commitment to achieve change, improvement and social determinism in challenging and confronting ways for all of us, but with the common goal of making birthing better for Aboriginal women and their babies.

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Post-script vested interests 

The plea for a Reconciliation Strategy is made without any vested interest for any professional group above any other but in a genuine attempt for all maternity care providers to come together to do something to make a difference, and for researchers to consider the human elements of Aboriginal women's maternity care beyond reductionism for potentially powerful consequences.

The comments about care provision do not in any way denigrate the roles of RANs whose work is highly demanding enough anyway without the special needs of pregnant women.

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References 

  1. Australian Institute of Health and Welfare. Australia's health—The 10th Biennial Health Report of the Australian Institute of Health and Welfare; 2006 AIHW, Canberra.
  2. World Health Organisation 2006 Reproductive Health Indicators Guidelines for their generation, interpretation and analysis for global monitoring, Geneva.
  3. National Strategic Framework for Aboriginal and Torres Strait Islander Health: Australian Government Implementation Plan 2003-08, Australian Government Department of Health and Ageing, Canberra.
  4. World Health Organization 2005. The World Health Report 2005 Make Every Mother and Child Count, Geneva.
  5. AbouZahr C, Wardlaw T. Antenatal care in developing countries-promises achievements and missed opportunities—an analysis of trends levels and differentials 1990–2001. Geneva: WHO; 2003;
  6. Hancock H. Aboriginal women's perinatal needs, experiences and maternity services: a literature review to enable considerations to be made about quality indicators. Alice Springs: Ngaanyatjarra Health Service; 2006;
  7. Australian Institute of Health and Welfare 2004. Indigenous Australians—Mothers and babies, accessed online at http://www.aihw.gov.au/indigenous/health/mothers_babies.cfm
  8. Sayers, S. Birth antecedents and outcomes for Aboriginal babies born at the Royal Darwin Hospital 1987–1990. Unpublished PhD Thesis. University of Sydney; 1999.
  9. Enkin M, Keirse M, Neilson J, et al. A guide to effective care in pregnancy and childbirth. Oxford: Oxford; 2000;
  10. Johnston T, Coory M. Reducing perinatal mortality among Indigenous babies in Queensland: should the first priority be better primary health care or better access to hospital care during confinement?. Aust N Z Health Policy. 2005;2(11):accessed online http://www.anzhealthpolicy.com/content/2/1/11
  11. Coory M. Effect of gestational age misclassification on the pattern of low birth weight in Aborigines. Aust N Z J Public Health. 1997;21(1):84–88
  12. Sayers S, Powers J. Risk factors for Aboriginal low birth weight, intrauterine growth retardation and preterm birth in the Darwin Health region. Aust N Z J Public Health. 1997;2(5):524–530
  13. Mackerras D. Size for gestation in Aboriginal babies: a comparison of two papers. Aust N Z J Public Health. 2000;24:287–290
  14. Mackerras D. Birth weight changes in the pilot phase of the strong women strong babies strong culture program in the Northern Territory. Aust N Z J Public Health. 2001;25(1):34–40
  15. Iams J, Mercer B. In: What we have learned about antenatal prediction of neonatal morbidity and mortality, seminars in perinatology, vol. 27 (3). National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network; 2003;p. 247–252
  16. Smith R, Smith P, McKinnon M, Gracey M. Birth weights and growth of infants in five Aboriginal communities. Aust N Z J Public Health. 2000;24(2):124–135
  17. Carter B, Hussen E, Abbott L, et al. Borning: Pmere Laltyeke Anwerne Ampe Mpwaretyeke. Aust Aboriginal Stud. 1987;1:2–33
  18. Stewart M. Ngalangangpum Jarrakpu Purrurn mother and child. Broome: Magabala Books; 1999;
  19. Hodnett, E. Continuity of caregivers for care during pregnancy and childbirth. The Cochrane Database of Systematic Reviews 2000. Issue 1. Art. No.: CD000062; 2000. doi:10.1002/14651858.CD000062.
  20. Consensus Statement on Medicare Item 16400: Antenatal care in rural and remote communities, 2006. Australian Nursing Federation, Australian College of Midwives, Australian Nursing and Midwifery Council, Royal Australian and New Zealand College of Obstetricians and Gynaecologists, The College of Nursing, Australian Practice Nurses Association, Council of Remote Area Nurses of Australia and The Association of Australian Rural Nurses.
  21. O’Loughlin J. Safe motherhood: impossible dream or achievable reality?. MJA. 1997;167:162–165

☆ For the purposes of consistency the title Aboriginal is used throughout this paper to be inclusive of the title Aboriginal and Torres Strait Islander.

PII: S1871-5192(07)00018-2

doi:10.1016/j.wombi.2007.02.002

Women and Birth
Volume 20, Issue 2 , Pages 77-80, June 2007

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