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A call for action that cannot go to voicemail: Research activism to urgently improve Indigenous perinatal health and wellbeing

      Abstract

      In this call to action, a coalition of Indigenous and non-Indigenous researchers from Australia, Aotearoa New Zealand, United States and Canada argue for the urgent need for adequately funded Indigenous-led solutions to perinatal health inequities for Indigenous families in well-resourced settler-colonial countries. Authors describe examples of successful community-driven programs making a difference and call on all peoples to support and resource Indigenous-led perinatal health services by providing practical actions for individuals and different groups.

      Keywords

      1. Too many dead and harmed brown and black mothers and babies [
      • Anderson I.
      • Robson B.
      • Connolly M.
      • et al.
      Indigenous and tribal peoples’ health (The Lancet-Lowitja Institute Global Collaboration): a population study.
      ]

      As an international coalition of Indigenous and non-Indigenous researchers, we are gravely concerned by the lack of meaningful action to calls on Indigenous [
      • Horton R.
      Indigenous peoples: time to act now for equity and health.
      ] and perinatal health [
      • Horton R.
      Healthy motherhood: an urgent call to action.
      ,
      • Koblinsky M.
      • Moyer C.A.
      • Calvert C.
      • et al.
      Quality maternity care for every woman, everywhere: a call to action.
      ]; as are others [
      • Geia L.
      • Baird K.
      • Bail K.
      • et al.
      A unified call to action from Australian nursing and midwifery leaders: ensuring that Black lives matter.
      ,
      • Kozhimannil K.B.
      Indigenous Maternal Health—A Crisis Demanding Attention.
      ]. Many Indigenous families in well-resourced settler-colonial countries remain unable to access clinically and culturally safe services. Families must birth in a health system that contributes to unacceptable and harmful healthcare experiences, resulting in higher rates of adverse outcomes, including death, in the perinatal period [
      • Dawson P.
      • Jaye C.
      • Gauld R.
      • Hay-Smith J.
      Barriers to equitable maternal health in Aotearoa new Zealand: an integrative review.
      ,
      • Kildea S.
      • Tracy S.
      • Sherwood J.
      • Magick-Dennis F.
      • Barclay L.
      Improving maternity services for Indigenous women in Australia: moving from policy to practice.
      ,
      • Smylie J.
      • Crengle S.
      • Freemantle J.
      • Taualii M.
      Indigenous birth outcomes in Australia, Canada, New Zealand and the United States — an overview.
      ,
      • Stevenson K.
      • Filoche S.
      • Cram F.
      • Lawton B.
      Te Ha o Whanau: a culturally responsive framework of maternity care.
      ]. Pregnancy and birth are critical periods for the best start to life, with cultural significance for Indigenous families:“[Birth] is about cultural interconnectedness… we revitalise and renew our traditional practices for mother and babies… it is a connection to country…it’s the start of our first ceremony.” Jody Currie, Mununjahli Yugambeh woman [
      • 98.9 FM Brisbane Indigenous Media Association
      Jody Currie and Professor Sue Kildea.
      ]
      We call out leaders, researchers, educators and service providers to uphold the United Nations Declaration on the Rights of Indigenous Peoples (UNDRIP) [
      • United Nations
      ]: the right to quality, culturally safe healthcare; be self-determining and participate in the design of health services; and include/revitalise cultural practices, languages and medicines [
      • United Nations
      ,
      • Hill D.M.
      Traditional medicine and restoration of wellness strategies.
      ]. This commitment should drive changes to healthcare delivery; calls to action can no longer go to voicemail.

      2. Research activism

      In the absence of meaningful government action, we use research to support Indigenous peoples to determine their own transformative change. We affirm Indigenous knowledges as foundational and relational to health research and service delivery [
      • Hill D.M.
      Traditional medicine and restoration of wellness strategies.
      ,
      • Ireland S.
      • Maypilama E.L.
      • Roe Y.
      • Lowell A.
      • Kildea S.
      Caring for mum on country: exploring the transferability of the birthing on country RISE framework in a remote multilingual Northern Australian context.
      ,
      • Kildea S.
      • Hickey S.
      • Barclay L.
      • et al.
      Implementing birthing on country services for Aboriginal and Torres Strait Islander families: RISE framework.
      ,
      • Smylie J.
      • Phillips-Beck W.
      Truth, respect and recognition: addressing barriers to Indigenous maternity care.
      ,
      • Lawton B.
      • Storey F.
      • Sibanda N.
      • et al.
      He Korowai Manaaki (Pregnancy wraparound care): study protocol for a cluster randomised clinical trial.
      ]. For Indigenous Yolŋu in Northern Australia, this is ‘both ways’ working, integrating knowledges at every level of the system [
      • Ireland S.
      • Maypilama E.L.
      “We are sacred”: an intercultural and multilingual approach to understanding reproductive health literacy for Yolŋu girls and women in remote Northern Australia.
      ]. Across countries, we respect the role of ancestors in knowledge production and guard our privileged position as temporary custodians of shared knowledge. We test innovative ways to decolonise institutions and redesign services to embrace what is sacred for Indigenous wellbeing.

      3. This approach works

      Our Australian colleagues in Lancet Global Health demonstrate profound life-changing impacts of a Birthing on Country service for Indigenous families [
      • Kildea S.
      • Gao Y.
      • Hickey S.
      • et al.
      Effect of a Birthing on Country service redesign on maternal and neonatal health outcomes for First Nations Australians: a prospective, non-randomised, interventional trial.
      ].
      A partnership between local Indigenous organisations and a hospital redesigned a service and improved health outcomes (e.g. preterm birth, breastfeeding, antenatal care attendance), reduced medical interventions [
      • Kildea S.
      • Gao Y.
      • Hickey S.
      • et al.
      Effect of a Birthing on Country service redesign on maternal and neonatal health outcomes for First Nations Australians: a prospective, non-randomised, interventional trial.
      ], improving healthy life trajectories [
      • World Health Organization
      Born Too Soon: the Global Action Report on Preterm Birth.
      ,
      • World Health Organization
      Statement: Exclusive Breastfeeding for Six Months Best for Babies Everywhere.
      ,
      • World Health Organization
      WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience.
      ].
      Birthing on Country services respond to families’ needs by: privileging Indigenous knowledges and solutions, embedding Indigenous governance, ensuring continuity of midwifery carer, increasing the Indigenous workforce, focusing on family wellbeing, strength-based approaches and improving cultural capabilities of non-Indigenous staff [
      • Kildea S.
      • Hickey S.
      • Barclay L.
      • et al.
      Implementing birthing on country services for Aboriginal and Torres Strait Islander families: RISE framework.
      ].
      With customised services like these making a difference in Australia, Canada [
      • Van Wagner V.
      • Epoo B.
      • Nastapoka J.
      • Harney E.
      Reclaiming birth, health, and community: midwifery in the Inuit villages of Nunavik, Canada.
      ] and Aotearoa-New Zealand [
      • Adcock A.
      • Storey F.
      • Lawton B.
      • et al.
      He Korowai Manaaki: mapping assets to inform a strengths-based, Indigenous-led wrap-around maternity pathway.
      ,
      • Lawton B.
      • the Hapū Māmā Connecting Rōpū team
      Covid-19: an urgent threat and an opportunity for Indigenous and minority groups in high-income countries.
      ], we have strong evidence that Indigenous leadership in health service planning and provision improves outcomes for Indigenous peoples [
      • Smylie J.
      • Phillips-Beck W.
      Truth, respect and recognition: addressing barriers to Indigenous maternity care.
      ,
      • Smylie J.
      • Kirst M.
      • McShane K.
      • Firestone M.
      • Wolfe S.
      • O’Campo P.
      Understanding the role of Indigenous community participation in Indigenous prenatal and infant-toddler health promotion programs in Canada: a realist review.
      ,
      • Tipene-Leach D.
      • Abel S.
      Innovation to prevent sudden infant death: the wahakura as an Indigenous vision for a safe sleep environment.
      ].

      4. This urgent work needs immediate resourcing

      We call on all peoples to support and resource Indigenous-led health services.
      Communities and families: You have the right to access quality safe care that meets your needs.
      Service providers: Create opportunities for community and families to participate in all care provision and planning. Partner with local Indigenous communities and inquire how you might support them with their healthcare aspirations. Show commitment to providing quality safe and culturally responsive care, and be accountable to service users. Nurture and facilitate positive family and community relationships.
      Policy makers: Seek leadership from Indigenous peoples in policy development, implementation and evaluation. Consider unintended and/or disproportionately negative consequences that might adversely affect Indigenous peoples (e.g. visitor restrictions, closing rural/remote facilities).
      Health service funders: Ensure Indigenous community-controlled health organisations have sustainable funding and insurance cover.
      Research funders: Prioritise funding for studies that use Indigenous knowledges and are led by/partnered with Indigenous communities and organisations. Provide grants for meaningful relationship building and for the co-designing of studies with community. Ensure funded researchers evidence their accountability to Indigenous peoples.
      Government and political leaders: Mandate, resource and monitor implementation of UNDRIP [
      • United Nations
      ]. Address systemic racism. You are responsible for driving evidence-based change through policy and practice to equitability improve health and wellbeing of your constituents.
      Everyone else: We urge you to support widespread scale-up of Indigenous-led health services such as #BirthingOnCountry services to protect #OurFirstCeremony. Donate money to Indigenous-led perinatal programs, create scholarships or directly support Indigenous midwifery students; have zero tolerance for racism. Reflect on how you contribute to and can challenge a colonial system that does not serve Indigenous peoples, and on what is required to safeguard futures where Indigenous families flourish.

      Authors’ statement

      SH drafted the original manuscript based on group discussion in which all authors made intellectual and strategic contributions to the conceptualisation of the manuscript. YR, SI, SKi, BL, AA contributed to the drafting. All authors critically reviewed, edited and approved the final version.

      Conflict of interest

      None declared.

      Ethical statement

      None declared.

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