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Molly Wardaguga Research Centre, Charles Darwin University, Ellengowan Drive, Casuarina, NT 0909, AustraliaThe Northern Institute, Charles Darwin University, Ellengowan Drive, Casuarina, NT 0909, Australia
Birthing On Country (BOC) is an international movement for returning childbirth to First Nations peoples and their communities. The RISE Framework was developed to guide evidence-based BOC implementation but has not yet been tested in a remote Australian community setting.
To test the transferability and acceptability of the RISE Framework in a remote multilingual setting in a Yolŋu (First Nations) community in Northern Australia.
Working in partnership with one remote Yolŋu community, we used a decolonising participatory action research (D-PAR) approach to begin co-designing services and test the acceptability of the RISE Framework. A three-phased transferability process was developed: Warming the ground; Co-Interpreting; and Acceptability Testing.
The RISE Framework was customized to the local Yolŋu context and called ‘Caring for Mum on Country’. It was articulated in two languages: Djambarrpuyŋu and English. We successfully used it to guide discussions at a community gathering privileging the voices of senior women to inform the design of local maternity services.
Using the D-PAR approach, the RISE Framework was readily adapatable to this complex, remote and multilingual setting. It resonated with the Yolŋu community and proved useful for identifying current limitations of existing maternity services and importantly facilitating the design of Yolŋu centred strength-based maternity services.
The RISE Framework, combined with our transformative methodology, offers a promising approach to guiding complex interventions for returning services to First Nations communities in diverse contexts. Testing in other settings will further contribute to growing an evidence-base for BOC service planning and implementation.
A Birthing On Country (BOC) implementation framework has been developed and not tested in a remote community setting.
What is already known
BOC has become an international movement and there is a paucity of implementation evidence.
What this paper adds
We showcase a successful example of a BOC implementation framework being adapted and tested for acceptability in a complex remote and multilingual Australian setting as the first step in returning birthing services.
Birthing on Country is an international social justice movement to redress the impacts of colonisation and return childbirth back to First Nations people and their communities’ control [
]. In an Australian context, documentation of the movement’s beginning is first recorded in the landmark 1980s report titled: Borning Ampe Mbwareke Pmere Alatye- The Congress Alukura by the Grandmother's Law [
]. Resulting from a Central Australian project involving hundreds of women from over 30,000 square kilometres, 60 different communities and 11 language groups, the report explores First Nations cultural beliefs and traditions around childbirth; and explains the detrimental domination of Western obstetrical practices over First Nations childbirth knowledges. The report makes many recommendations for improving maternity services including the crucial need to support First Nations women to birth on their ancestral lands, yet many recommendations remain un-actioned.
Since its publication, many other reports over the decades have continued to recommend the implementation of Birthing on Country [
] services, both as an approach to addressing entrenched First Nations health inequities; and also for meeting the longstanding requests of many First Nations women and communities to have childbirth practices returned to their communities and control. Despite national recommendation [
] for Birthing on Country services there has been slow progress; and this may in part be attributed to a lack of understanding of what Birthing on Country services are and can do, resistance to the concept of supporting birthing out of hospitals and a dearth of quality implementation evidence to guide the transition of standard care models to Birthing on Country services [
]. Drawing on theoretical, policy and research literature, alongside retrospective synthesis of two empirical studies, researchers have devised a framework that provides essential guidance on the implementation of Birthing on Country services. Underpinned by the First Nation epistemologies of relationality and connection to Country, dreaming and lore, the four lettered RISE acronym stands for: 1) Redesign the health system, 2) Invest in the workforce; 3) Strengthen families capacity; and 4) Embed community governance and control [
].Theoretically, it is proposed that the four domains can be transitioned, either individually or ideally concurrently, through an implementation spectrum from ‘standard care’ towards the outcome of a fully-implemented Birthing on Country Service. The RISE Framework draws on learning outcomes from two high quality empirical studies in an urban [
], it is generally established that First Nations women living in geographically remote areas experience increased reproductive health inequities and are also disproportionally impacted by limited and often non-existent access to childbirth services. Due to these inequities, research involving the reform of remote maternity care to Birthing on Country services should be prioritised.
1.1 Research setting
In this paper we report on the transferability and acceptability testing of the RISE Framework in a remote First Nations community. The testing was embedded in a project called ‘Caring for Mum on Country’. With senior Yolŋu (First Nations) knowledge holders and leadership (author #2), the project has worked in partnership with one remote North East Arnhem Land Yolŋu community exploring remote maternity services, health literacy and piloting the delivery of Indigenous doula [
] childbirth companion training. While the implementation of Birthing on Country Services was not the project’s primary aim, we were interested in using the principles of the RISE Framework to guide the project approach; and also as an explicit structure for discussions at a community gathering around future community maternity services.
This Arnhem Land community is a compelling site to explore transferability of the RISE Framework. This is due in parts to its entrenched health, social and economic inequities, remote location, and social complexity which are counterbalanced by strong local Yolŋu leadership and engagement and an appetite for maternity service innovation. The island community is geographically isolated and during the monsoonal season many of the smaller townships become inaccessible by road. The community’s supermarket supplies are serviced by a regular sea barge from Darwin, the closest capital city. While there is a community health centre providing primary care, tertiary medical care is only possible via aeromedical evacuation to Darwin involving about a one hour flight. This remote setting is overlayed by the region’s inequitable reproductive health outcomes, including the highest documented rate of preterm birth in Australia at around 21.5% [
]. In the recent past, numerous epochs of local Methodist Mission hospitals provided childbirth care on the island; all pregnant Yolŋu women are now routinely transferred to regional settings to give birth in hospital, profoundly dislocating them from their home, family and social support networks.
Social complexity is highlighted by the languages spoken in the community. Over 90% of the community identify as Yolŋu, and English is the minority language – spoken at home by only 4.9% of the population [
]. However, English remains the language of choice for the delivery of most civic, welfare and medical services; and by default is often an essential pre-vocational skill barring many Yolŋu from well-paid employment. In contrast to the majority of Australian communities, Djämbarrpuyŋu is the dominant language – spoken by the majority of people (78.1%) along with the less frequent Yolŋu languages of Galpu (2.4%), Gumatj (1.9%), Daṯiwuy (1.3%) and Warramiri (0.5%) [
]. They highlighted First Nations languages as being ‘a tool for communication, education, social integration and development, but also as a repository for each person’s unique identity, cultural history, traditions and memory’ [
]. With this in mind, the remote community’s many First Nations languages are a rich source of cultural diversity and have immeasurable educational, historical and heritage value. It is this incredible diversity that increases the social complexity of the community.
As a team compromising of Yolŋu, First Nations and non-First Nations scholars we were united in using a a decolonising participatory action research approach [
] (D-PAR). In this D-PAR paradigm we sought to explicitly privilege Yolŋu ways of being, doing and seeing; and openly share agency between Yolŋu and non-Yolŋu researchers and participants, in shaping the research design, methods, and processes. To achieve this, we were committed to building relationships between researchers, participants, and the broader community. As Sherwood [
] explains, the rigour of health research and data collection is enhanced when guided by First Nations experts; and in the context of our research this was Yolŋu women living and dealing with the consequences of inequitable health services, outcomes and reproductive care access.
3. Methods & participants
While our overarching Caring for Mum on Country project used many qualitative investigative methods and engaged with 65 participants to explore Yolŋu childbirth knowledge and practices, this paper is a retrospective synthesis reporting on the D-PAR processes used to transfer and test the RISE Framework. Our retrospective synthesis draws on our project’s documentation, written observations, and the reflexivity of our research team that includes Yolŋu and other First Nations, as well as non-Indigenous scholars. Based on cross-cultural dialogue, PAR enabled sufficient responsiveness and flexibility to develop processes and methods to meet our context while being ‘orientated towards empowerment and transformation’ [
]. Retrospective synthesis of our research processes allowed us to identify three distinct phases we passed through to transform and test the RISE framework. These phases were: 1) Warming the ground; 2) Co-interpreting; and 3) Acceptability Testing; more details below in the results section.
Caring for Mum on Country has ethics approval from Charles Darwin University Human Research Ethics Committee (Application #HI8031). The ethics protocol was guided by the national document Ethical conduct in research with Aboriginal and Torres Strait Islander peoples and communities: Guidelines for researchers and stakeholders [
] for explaining the culturally responsive process of gaining access and building rapport in preparation for undertaking collaborative research with First Nations people and their communities. Warming the ground in our context involved recruitment of senior Yolŋu leadership alongside adherence to procedural and cultural protocols for gaining permission and building rapport with the community, Elders, Cultural Knowledge Authorities and potential paticipants. In this way warming the ground had dual accountabilities to meet expectations of the Yolŋu community as well as the Western academy.
Yolŋu leadership was provided by author #2 who is a First Nations woman, senior knowledge holder from the research community and an experienced senior scholar and researcher in a Australian university. Equipped with this vast experience and knowledge in both Western and Yolŋu knowledge systems, she was highly skilled in leading the team in a Yolŋu-styled process of community engagement, rapport building and consultation. Crucially, she mentored non-Yolŋu scholars in establishing community relationality and respectfully communicating these connections. Relationality and connection gave the research team cultural integrity and accountability for using Yolŋu ways of sharing and generating knowledge. This was a decolonising approach as it positioned Yolŋu as the authortities in their community and disrupted colonial power dynamics. Some team members had relationality spanning many decades of work with the community; while other team members only began developing relationality and connection through the current project.
Author #2 also provided guidance on local Cultural Knowledge Authorities and promoting clear intercultural communication so that researchers and participants could reach shared understandings about the project aims and objectives. Intercultural communication was enhanced by the establishment of the Marŋgithinyaraw Ŋaraka Ḏälkunhamirr Mala – a Community Backbone Committee (research reference group). Author #2 facilitated feedback to the committee which strengthened connections between the project, research topic and broader community.
Additional procedural protocols were also important to warming the ground and were progressively achieved. This started with obtaining a Northern Land Council Permit for the researchers to initially visit the community and discuss with senior women the possibility of collaborating on the project. Then Author #2 presented to the Local Shire to discuss the project, seek community permission and obtain written community support. Community support evidenced by these consultations and associated written documentation was used to underpin a University ethics protocol submission. After the Ethics protocol was successfully approved, we applied for a research permit from the Northern Land Council to formally begin the research. While many of these procedures are not formally recognised by Yolŋu, they ensured Western research rigour and accountability to the academic institution.
5.2 Phase two: co-interpreting
Once the ground was adequately warmed, we sought to develop shared understanding of the RISE Framework. During this phase, Yolŋu and non-Yolŋu researchers worked alongside a Yolŋu Interpretor to transform the English academic RISE Framework into a culturally congruent concept expressed and written in the locally dominant Djämbarrpuyŋu language. We undertook three steps to achieve this (see Table 1). The first step was unpacking and adapting the RISE terminology and concepts into simple English applicable to the context of our project. Led by Yolŋu researchers working as a small group, the second and third steps involved the cultural interpretation and modification of the plain English to better suit a Yolŋu worldview; and then translation into written Djämbarrpuyŋu. The second and third steps involved many cycles of reflection and modification over several months until Yolŋu group consensus on the phrasing was met.
Table 1Steps involved in phase two: co-interpreting the RISE framework.
Original RISE Terminology
Plain English adaptation contextualised to our project setting
Yolŋu group cultural interpretation of plain English
Yolŋu group translation into Djambarrpuyŋu
Birthing on Country
Caring for Mum on Country
How we look after a pregnant woman in our own home environment/community
For example, one of the challenging issues was to find consensus on respectfully communicating sensitive topics about female reproduction to an all-gender audience. At the beginning of the process there was explicit use of the Djämbarrpuyŋu word for pregnancy but deep protracted discussions led this to being discarded. Instead consensus was found by using a euphemism that was a known Yolŋu metaphor for pregnancy – describing a woman as being ‘heavy’. Similarly, the Aboriginal-English term of ‘country’ describing the location of childbirth was problematic. The majority of Yolŋu live in a large central community (originally established as a Methodist mission) for a range of reasons, although their ancestral lands spread across a vast geographic region and in often isolated areas. Some family groups continue to live on their ancestral lands but for many Yolŋu continual occupancy is no longer possible and they live on the ancestral lands (country) of others. In this remote setting, it is unlikely that maternity services will ever be able to support all women in birthing on their ‘country’ which Yolŋu interpret as their ancestral lands. In this context Birthing on Country Services need to incorporate Yolŋu sovereignty over their lands and bodies; and provide opportunities for women to be cared for and give birth in a safe and home-like environment physically connected to their ‘home’ ground i.e. place of usual residence – wäŋa and their gurruṯu – kinship networks. Through the process of transforming the RISE Framework to connect with local cultural concepts, we began to understand the RISE pillars as guiding principles – that is foundational beliefs and values required for maternity services to adequately care for Yolŋu women and families.
5.3 Phase three: acceptability testing
Shared understandings of the RISE Framework facilitated the development of a localised framework of ‘Caring for Mum on Country’ (see Fig. 1). There were several iterations and many changes to the spelling as written protocols for Djambarrpuyŋu are in their infancy. Yolŋu reported the co-intepreting dicussions were empowering as they reinforced the value of their cultural practices and the importance of maintaining and continuing them; for non-Yolŋu researchers, it enhanced their capacity to understand community aspirations related to childbirth care. Our framework, coupled with a deeper shared understanding of the four RISE pillars as principles, was used to inform the research process; and also to shape priority topics for community consultation.
Participants were provided with a printed version of the Yolŋu RISE Framework at community gatherings to discuss maternity services and the four pillars used as themes to guide small group discussions with senior Yolŋu women. While the findings from these consultations will be published elsewhere, the Framework proved a useful communication tool allowing for rich multilingual discussions around the limitations and aspirations for maternity care services to meet the needs of Yolŋu women and families. It allowed an efficient and authentic evidence-based consultation which captured key community change priorities and challenges to transisitioning standard care to Birthing on Country Services.
6. Discussion and conclusion
This paper begins to address a known literature gap in implementation evidence for transitioning standard maternity care towards Birthing on Country Services. Though our research is limited by its one Yolŋu community location, it provides a compelling example of how the RISE Framework can be innovatively used as a Birthing on Country planning and implementation tool; and also as guiding foundation principles for First Nations maternity reform. Further research on the acceptability of the RISE Framework more broadly across the research site community and involving males, fathers and younger women of childbearing age, would be beneficial and strengthen understanding of its use in this complex setting.
Our D-PAR approach, based on the strengths of collaborative processes and power-sharing, was well suited to exploring and testing the transferability of the RISE Framework. To our knowledge, this is the first time the RISE Framework has been adapted, interpreted into a First Nations language and its acceptability tested in a remote multilingual community. Our process of warming the ground, co-interpreting and acceptability testing are likely transferable to other Australian First Nations communities both in remote, regional and urban settings and also in similar international First Nations settings. There remain many opportunities for exploring the use of the RISE Framework in different service settings such as with Aboriginal Community Controlled Health Services and Public hospitals; and as an explicit approach for consulting other participant cohorts in service redesign such as with Aboriginal and Torres Strait Islander health practitioners, midwives, doctors and other health practitioners providing maternity services to First Nations women and families.
While our paper may bring welcomed contributions to better understanding the use, acceptability and transferability of the RISE Framework, significant barriers continue to disempower First Nations communities and prevent the return of childbirth services to their control. In Australia, these barriers include an entrenched lack of interest from policy makers and politicians to lead significant maternity service reform [
], a lack of control of maternity services and health funding by First Nations organisations, a reluctance to establish maternity services without caesarean section capacity and concerns about risk, clinical safety and workforce competencies [
For the Yolŋu women and families who live with the highest Australian rate of preterm birth and profound inequities sustained by health services that do not meet their needs, the risks associated with not having a local service and being required to travel for birth mean that maternity service reform has never been more urgent. Calls for action need to be heard: consumers [
] have all advocated for significant service reform. This reform needs to incorporate and prioritise the critical socio-cultural and spiritual dimensions of childbirth, during what is arguably one of the most important life events for any family, and ensure the best start in life for First Nations babies.
Funding for our research was provided by an Australian Commonwealth Governement’s Aboriginal Benefits Account grant [#4-1F39XNR] and an Australian internal Charles Darwin University Rainmaker Grant [#0702 6433].
Caring for Mum on Country has ethics approval from Charles Darwin University Human Research Ethics Committee (Application #HI18031).
Conflict of interest
The authors have no conflict of interest to declare.
We gratefully acknowledge the contributions made to our project by Ms Rachel Baker, Ms Miriam Yirrininba and Yurranydjil who were pivotal in the interpretation, translation and spelling of the RISE Framework.
We thank our project’s Research Technologist – Patrick Josse for his support and assistance in producing digital resources.
We also express our gratitute to the Red Cross Baby Hub and staff who supported the project by kindly hosting our community gathering; and Yalu Margithinyaraw Aboriginal Organisation who hosted the Research Backbone Committee.
Finally we acknowledge the collegiality and critical comment provided by Sophie Hickey, Emily Armstrong, Sandy Campbell and other scholars at the The Molly Wardaguga Research Centre journal club.
Van Wagner V.
‘Birthing on Country’ Maternity Service Delivery Models: An Evidence Check Rapid Review.
Brokered by the Sax Institute on half of the Maternity Services Inter-Jurisdictional Committee for the Australian Health Ministers’ Advisory Council,