First Nations women's health 2023

To celebrate the eve of the National Aborigines and Islanders Day Observance Committee (NAIDOC) Week 2023, this edition of ANZJOG showcases studies published in the journal from the last four years, with a First Nations focus. NAIDOC Week celebrates the history, culture and achievements of Aboriginal and Torres Strait Islander peoples. Although it is sometimes difficult to find celebration in health outcomes for First Nations people, it is a good reminder why it is vital that health services and care provided meet the needs of First Nations people. A large part of the disparity in health outcomes between First Nations Australians and non-First Nations Australians is explained by disparities in social determinants, in particular income, employment and education. First Nations Australians have lower access to healthcare services for a range of reasons, which include the lack of culturally appropriate health services.1 For First Nations Australians to have better health outcomes, improvements in our health systems must extend beyond current practice. To achieve this, adequate and meaningful research exploring how to do better is required. There have been some key positive changes in health outcomes for First Nations Australians over time. There has been a decline in death rates due to cardiovascular and kidney disease. Levels of educational attainment have improved. The proportion of First Nations Australians who had a year 12 or equivalent qualification increased from 45% in 2008 to 66% in 2018–2019. Household incomes for First Nations Australians have also seen some improvement. Participation rates in BreastScreen among First Nations women aged 40 and above have improved.1 Encouragingly, we have seen marked improvements in antenatal care. There has been a notable increase in the proportion of First Nations mothers attending an antenatal visit in the first trimester (from 49% in 2012 to 70% in 2020). There has been an increase in the proportion of First Nations mothers attending five or more antenatal visits. There has been a decrease in the proportion of First Nations women who reported smoking in the first 20 weeks of pregnancy (48% in 2011 to 43% in 2020).2 This suggests an improvement in culturally safe antenatal care and gives impetus to the Birthing in Country movement. However, death rates due to cancer and suicide have increased since 2010 in First Nations Australians. Suicide accounted for 5.5% of all First Nations deaths in 2015–2019. Incarceration rates continue to climb, and the gap in these rates between First Nations and non-First Nations people continues to widen. For First Nations women, life expectancy remains lower and of almost eight years’ difference, compared to non-First Nations women. In 2018 the leading causes of disease burden among First Nations women were mental health/substance use, injuries including suicide, cardiovascular disease and cancer. Hospitalisation rates due to assault have increased. There has been no significant change in child death rates nor in perinatal deaths. As a society, these statistics should not be accepted, and there should be outrage. Collectively, we need to do what we can to address these unacceptable disparities. To see improvements in health outcomes, services and providers must actively engage in innovations to engage First Nations people. This is made evident in several of the research papers highlighted in this edition that have explored ways to improve services for First Nations women. The last time ANZJOG released an edition highlighting the collection of First Nations health research was in an online edition in 2018.3 Since then, a further 10 research articles have been published in the journal dedicated to First Nations women's health. Once again, we see a preponderance of research in the obstetric versus the gynaecology field. The two gynaecology articles examine issues of pelvic floor dysfunction and cervical screening. Milroy et al.4 reported on mixed methods research that examined the burden of pelvic floor dysfunction in women attending an Aboriginal Medical Service in urban New South Wales. They found a high burden of disease, and that the women were reluctant to seek care for the condition due to embarrassment and fear of judgement. Many women had succumbed to accepting their symptoms. The authors concluded that culturally appropriate resources were required and that delivery of information and care should be performed in a culturally safe manner, ultimately by a consistent and female healthcare worker. Following this an expansion of their service occurred. In a cluster randomised controlled trial in New Zealand, MacDonald et al.5 reported on rates of self-collected human papilloma virus (HPV) testing in under-screened Māori women versus standard care. They highlighted the inequity in screening rates between Māori and non-Māori women and demonstrated that offering self-testing improved the uptake of screening almost thrice. Although self-collected HPV screening is underway in Australia, this research provided evidence for the benefit of self-testing in New Zealand, particularly for Māori women, who are more often under-screened. The burden of chronic disease in First Nations women is frequently greater than that in non-First Nations women. A condition almost exclusively found in First Nations women is rheumatic heart disease (RHD). Lam et al.6 describe the maternal characteristics and pregnancy outcomes of women with RHD in the Northern Territory (NT). Many women compensated well with positive maternal and neonatal outcomes. A key finding was that women who were managed in a local setting with an informed and dedicated multidisciplinary team had safe pregnancies. Diabetic retinopathy (DR) is a condition that can progress during pregnancy in women with pre-gestational diabetes. Pre-gestational diabetes represents another condition that is experienced more frequently in First Nations women, with rates three to four times higher.7 Adherence to screening for DR in women with pre-gestational diabetes was examined by a team in the NT.8 DR screening was shown to be poor. Rates were significantly lower than those documented in other similar studies, even in areas where pre-gestational diabetes is high. The authors suggest that improved and culturally appropriate health education tools, improved health staff education, better access to appropriate services to provide the screening and adhering to recommended guidelines are required. Phillips et al.9 described the experience of the introduction of a retinal camera in a diabetes in pregnancy clinic in Western Australia (WA). The result was an impressive increase in screening rates, diagnosis and management of DR when equipment and staff training were introduced. This demonstrated a feasible solution for what might otherwise be a missed opportunity and proved that adequate education and training for existing staff saw improvement in adherence to guidelines and ultimately improved care. A study from Queensland (QLD) evaluated the impact of asthma in pregnancies and evaluated the adequacy of existing services. Clifton et al.10 found that 24% of First Nations pregnant women reported a history of asthma, and these rates were higher when compared to non-First Nations women (17%). Women with asthma were more likely to have poor birth outcomes including preterm birth, low birth weight, neonatal intensive care unit admissions and perinatal mortality. The researchers concluded that improvements in management were needed. They proposed culturally-specific education material, recruitment of Aboriginal health workers and appropriate pregnancy asthma management plans. Wu et al.11 evaluated the management of syphilis in pregnancy in their QLD population and compared it to existing guidelines. Although the data did not specifically describe rates in First Nations women, it did highlight the increasing prevalence especially in urban areas and the significant gaps in management in pregnant women and newborns. Late presentation for antenatal care was a factor in adequate screening and treatment. The evaluation led to the implementation of new state-wide guidelines to ensure improved management strategies. The need for education for healthcare workers and the public to address the stigma of sexually-transmitted infections and to improve testing was emphasised. Post-caesarean section infection rates were examined by Sekhon et al. in regional WA.12 The team compared infection rates before and after the implementation of targeted prevention strategies, in a predominantly First Nations population. They found a statistically significant improvement in the infection rates after implementation, highlighting the need to comply with appropriate guidelines and to ensure hospital standards and protocols are in line with the best practice, particularly for vulnerable and high-risk women in whom the burden is greatest. Adane et al.13 assessed the risk of recurrent preterm birth in state-wide data from a 35-year period. The data were not specific to First Nations women but showed that gestational age of the immediately preceding pregnancy and the number of preterm births strongly predicted subsequent pregnancy outcomes. This is important knowledge for First Nations women as the burden is consistently reported to be higher than that for non-First Nations women and reinforces the importance of preventative strategies. Finally, Kilcullen et al.14 examined stillbirth rates, risk factors and causes for stillbirth in North QLD where the First Nations population is approximately 8%. Stillbirth rates were similar for First Nations and non-First Nations women. Rates of substance use including smoking were high in First Nations women who suffered a stillbirth. They suggested the need for improved screening for mental ill-health and a more holistic approach to care for improved pregnancy outcomes. In summary the studies show similar themes. Although burden of disease and poorer perinatal outcomes are higher in First Nations women, well-informed and dedicated health services that better address the gaps in care lead to improved outcomes. Services that are innovative in improving screening and management can successfully narrow the gaps. The workforce should be culturally respectful, and care should be holistic. Many of the articles proved that altering services, while potentially difficult and costly in the short term, has major benefits for longer-term outcomes, particularly for the most vulnerable women. NAIDOC Week is an opportunity for all Australians to learn about First Nations cultures and histories and participate in celebrations of the oldest continuous living cultures on earth. This edition of ANZJOG provides an opportunity to reflect upon strategies to make improvements in care for First Nations women and families in our local settings. Closing the gap entails innovation and commitment. This year, Australians are engaged in an important conversation on a Voice to Parliament and will be given a once-in-a-generation opportunity to vote in a referendum on this issue. The principles we see in effective health services for First Nations people are that they are driven by First Nations people, with engagement from the beginning. This is the same principle being considered in the proposal for a Voice to Parliament, where it will be enshrined in the Constitution that we are able to have a say in issues that will affect us. We hope this issue will help in your reflection on how you may choose to vote in the referendum. The authors report no conflicts of interest.

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