Women worse off when it comes to natural disasters

http://theconversation.com/women-worse-off-when-it-comes-to-natural-disasters-21717

The Philippines. Pakistan. New Orleans. Sri Lanka. All have suffered catastrophic disasters in recent times. And the emergence of “climate refugees” – populations displaced by extreme weather events – is now a well-documented phenomenon.

Many developing countries are particularly vulnerable to natural disasters such as floods, tsunamis, and earthquakes. And like many human and natural disasters, extreme weather events affect certain populations disparately and unfairly. Not only are extreme events more likely to affect particular communities in naturally vulnerable geographic locations – such as small Pacific islands – but some people also tend to come out worst.

Typhoon Haiyan, for example, devastated some of the most impoverished regions of the Philippines, such as the Eastern Visayas, where families living in poverty were (and still are) especially vulnerable to loss of livelihood with no material or financial resources to fall back on.

Even in developed countries such as the US, with relatively robust infrastructure and social systems, an extreme climate event can affect certain members of the community unequally. Hurricane Katrina was a stark example of how a natural disaster can split a region into haves and have-nots. Poor and marginalised groups such as women, the elderly, people with a disability and those from ethnic minorities in New Orleans experienced unfair allocation of resources (or sometimes none at all) and bore a disproportionate burden of suffering.

During the disaster

Women are particularly vulnerable when it comes to humanitarian or natural disasters, yet issues relating to their specific needs tend to be overlooked or excluded as a disaster unfolds.

Women are far more likely to be injured or die than men – estimates suggest three times as many women than men died in the 2004 Boxing Day tsunami in Asia. Why? Because women are more likely in some cultures to wear clothing that is heavy and overly restraining; have long hair that is more likely to get tangled in debris; and have a lack of education on how to swim. It may even come down to a choice of saving a male family member over a female. These have all been identified as factors that are dangerous and sometimes deadly to women.

Women also don’t receive necessary healthcare; specific care, such as for pregnant women, isn’t often a consideration during the relief effort, which is often also a male-dominated affair. It is estimated that 150,000 women were pregnant when the Asian tsunami struck in 2004, of which 50,000 were in their third trimester. Yet a lack of access to obstetric care leaves women at risk of miscarriage or complications, made worse by poor sanitation.

In areas that didn’t have these services before the disaster (in pre-Tsunami Banda Ache, for example, only two thirds of all births were attended by skilled health personnel), the loss of midwives and healthcare infrastructure only makes the situation worse.

After the disaster

Disasters interrupt the most fundamental of community processes and resources. Communities are often physically displaced, seeking shelter in temporary accommodation or refugee camps, where conditions can be overcrowded and lack food and basic sanitation.

For women, new dangers include sexual violence and sexually transmitted infections. And in the chaos and displacement that is the aftermath of a natural disaster, child abuse and neglect, violence against a partner, and exploitation and trafficking are likely to increase. Following the Mt Pinatubo eruption in the Philippines, Hurricane Mitch in Nicaragua, and the Loma Prieta Earthquake in the US, the WHO reported that intimate partner violence signficantly increased. Likewise, reports from the Sri Lanka and Indonesia following the Asian Tsunami focused on concerns over the protection of women from sexual violence.

In the recovery after a major natural disaster, women are often the first to mobilise. According to a report from the Global Fund For Women, Guatemalan women took over the traditionally masculine tasks of rebuilding homes and digging wells following the devastation of Hurricane Mitch. Up to 70% of all local organisations involved in the rebuilding processes in Banda Aceh following the Asian tsunami were women’s organisations or mainly staffed by women.

But despite their efforts, women are often marginalised or excluded from the decisions made about a disaster and the policies that follow leaving them to ongoing economic and social vulnerability. On top of this they also have the double-burden of family duties and caring, and providing financially for the family in the event of the loss of males. Disturbingly, some men are known to abandon families and use relief aid for themselves, and this has been observed in Miami, Bangladesh, the Caribbean and Brazil following natural disasters.

Lower literacy levels and lack of land ownership also place women in an economically vulnerable position and can be a factor in pushing women into prostitution and positions of exploitation.

What next?

The Global Fund For Women and the Women’s Refugee Commission have suggested that active measures put in place to respond to sexual violence. Women’s reproductive health needs, such as contraception and basic obstetric care need to be accounted for and women’s livelihoods need to be promoted through programmes to help survivors re-establish a sustainable income. This will have downstream effects on the health and well-being of the entire family and protect girls and women from situations of exploitation and trafficking.

The needs of women during a natural disaster don’t simply begin and end within the disaster itself – they play out long after the event. Women need to be recognised in all the decision making, from planning, provision and evaluation of aid services if problems are to be prevented from happening or spiralling once the actual disaster has passed.

Domestic Violence and Indigenous Australia

1. Introduction

Another night in the emergency department of a rural Australian hospital. Another night of suturing wounds, applying plaster to broken bones, applying pressure to nose-bleeds, filing reports to police and social services, and allowing people to “sober-up.” Another night of witnessing first-hand the physical and psychological consequences of domestic violence in Australia’s Aboriginal communities. This scenario is not uncommon to hospitals in both rural and urban Australia. Domestic violence is reported to be at crisis levels in Indigenous Australian communities in Australia. Despite being recognised as a serious problem over 20 years ago by academics and advocates alike, it remains an endemic concern within Australia’s Aboriginal communities. (1) Violence against women is a serious human rights abuse and public health issue. (2) Domestic violence entails an abuse of women’s fundamental human rights to physical safety and non-discrimination. (2) Specific to Indigenous women is the balance (or alternatively, conflict) between their rights as women and their identity as an Indigenous person. This paper sets out to achieve the following: 1.To discuss and analyse a case of domestic violence in an Indigenous young woman encountered through the public health system in Australia, 2.To define domestic and family violence as it occurs in Indigenous Australia, 3.To explore the broad human rights concepts surrounding a) domestic violence and b) Indigenous peoples, 4.To explore and analyse the issues of domestic violence in Indigenous Australian communities from a health and human rights approach, 5.To present an international perspective on domestic violence occurring in other Indigenous communities around the world.

2. Case Study

A nine-year old girl presented to a remote Australian Emergency Department after being brought in by social services. She had been physical assaulted by her two brothers and father, who struck her with metal poles, threw stones and plastic piping at her and attempted to strangle her with a hose. Her parents were reported to have been drinking alcohol heavily for the last few days and were fighting violently between themselves. Her mother subsequently left the household to stay with distant relatives. Subsequently her brothers and father became violent and angry with her and blamed her for causing her mother to leave, thus commencing to physically and verbally abuse her. She denies any sexual abuse. Eventually, she escaped to her neighbour’s place, who then took her to a youth crisis centre until social services arrived. This child was known to social services secondary to previous family episodes of family violence and domestic disputes. Due to her parents’ dysfunctional relationship, history of domestic violence, alcohol and drug abuse, and violent crime and incarceration, she was unable to attend school or afford books or clothing, rarely had food to eat at home and often escaped to a friend or relative’s house. On arrival at the emergency department, her injuries included bruising, lacerations, grazing and strangulation marks consistent with her history. She had no sign of sexual assault and no fractured bones. She decided, after counselling about her options, to report the incident to the police and to enter into a protective care program through social services. Following the arrival of the police and child protection services, she became upset and worried about “telling” on her father and brothers. She said she felt ashamed of telling her story and was worried about the consequences of telling child protection about the episode of domestic violence and possibly being removed from home. She also knew one of the police officers personally and was embarrassed because of that. A cultural support officer was present, as all other staff were non-Indigenous. An hour later, she absconded from hospital to home whilst no one was looking and refused to re-tell her story to the authorities. She told her brothers that she was “just at a friend’s house.” This case identifies some extremely complex issues relating to domestic violence in Indigenous Australia. Firstly, the rural Australian setting means that the community size is small and many staff who work within the healthcare and law-enforcement system knew the victim’s family. Further to this, the victim of domestic violence is, herself, physically isolated due to the small and remote location of the community in which she was raised. This means that she does not have ready access to a full range of culturally-appropriate health and social resources; the closest major city is over 2000km away. The second issue apparent within the case is that of non-reporting. Whilst the victim arrived in a safe facility, the subjectively experienced pressure of her community “norms” plus a sense of shame regarding her presentation meant that she eventually felt compelled to leave and not follow-through with prosecution or even documentation of her story. As a young girl, her embarrassment of being the victim of such family violence was ultimately the largest barrier to her seeking appropriate care and meant that she did not report the incident. Beyond these immediate issues lies a more disturbing picture of this individual’s family dysfunction. Her parents had a long history of a tumultuous relationship, perpetrating violence against the other person, alcohol and drug abuse, and crime. Due to her parents’ arguments, the individual of our case study was unable to attend school, rarely had food to eat and often escaped to her friend or relative’s house for respite. This life of violence and disorder became her norm. Unfortunately this “normalisation” of violence within families is widespread in communities and has passed between generations. The victim of violence was known to child protection services – family incidents and school non-attendance were reported repeatedly in the year prior to her current presentation. However, child protection services in this region of Australia were extremely resource-poor and, for many reasons, not able to intervene unless in the event of a crisis situation. This lack of access to appropriate child protection services meant that this young girl’s life was endangered despite multiple reports to child protection services. In terms individual human rights violations occurring in the above case, the above individual’s right to safety and security of person was impaired. Her right to education was also, indirectly, impaired due to her chaotic personal situation. Being female and experiencing violence, her fundamental human rights as recognised in documents such as the Declaration on the Elimination of Violence against Women were impeded. Specific to child status, specific rights violated involve lack of protection against child abuse and neglect, lack of adequate food, formal education, primary health care, leisure and recreation, cultural activities and information about their rights.

3. Background and Definitions

3.1 Australian Aboriginal and Torres Strait Islander People

3.1 a) Definition

Indigenous Australians are the original inhabitants of Australia. “Aboriginal” is broadly applied to Indigenous people from the Australian mainland, whereas “Torres Strait Islander” applies to people indigenous to the Torres Strait Islands. Aboriginal is defined as: “adj. (of human races, animals, and plants) inhabiting or existing in a land from the earliest times or from before the arrival of colonists; indigenous.” (3)(4) Contemporaneously, ‘Aboriginal people’ or ‘Australian Aboriginals’ are more appropriate uses of the word in accordance with cultural protocols. (3) The most recent Indigenous population estimate comes from the 2006 Australian Census, adjusted for unknown Indigenous status and net undercount. (5) This estimate relies on people self-identifying as Indigenous, which is a complex process of cultural and genealogical identity. The final estimated resident Indigenous population of Australia as at 30 June 2006 was 517,000 people, 2.5% of the total Australian population. (5)

3.1 b) History and Demography

Indigenous people have inhabited Australia for over 40,000 years. (3) The broad term Aboriginal applies to many smaller, distinct groups that identify with a specific Indigenous language. Indigenous Australia is an extremely diverse and rich culture. There are over 200 Indigenous languages but only 20 are widely spoken. (3) Whilst Indigenous Australian culture is widely associated with rural living, a large proportion of people actually live in urban setting. Whilst Indigenous people are ten times more likely than non-Indigenous people to live remotely, (3) the majority of Indigenous people live in capital cities (32% of the population) or regional centres (43% of the population). (5) The Indigenous population is also younger than the non-Indigenous population of Australia, with a mean age of 20.5 years (versus 36.1 years) and only 3% of the population is over 65 years of age. (6)

3.1 c) Health Issues

As with many Indigenous populations worldwide, Australian Aboriginals are over-represented in lower socioeconomic strata. Low socioeconomic status is associated with poor health and increased exposure to risk factors such as overcrowding, smoking, alcohol misuse and violence. (3)(6) These have culminated in an approximate life expectancy gap of 12 years compared to the general Australian population. (6) Health issues pertinent to Indigenous people include cardiovascular disease, mental health issues and suicide, and interpersonal and domestic violence. (3) Around one-in-eight Indigenous people have a form of cardiovascular disease, especially in rural areas. A higher proportion of people living with diabetes was reported in the Australian National Diabetes Register between 2005-2007 were recorded as Indigenous. (3) Mental illness and mental health problems have been recognised as ‘a major difficulty for most [Indigenous] communities.’ (3) Indigenous adults were more than twice as likely than non-indigenous people to feel symptoms of psychological distress. (3) Risk factors specific to poor health outcomes Indigenous people face include poor nutritional status and associated obesity, sedentary lifestyle, drug and alcohol use, smoking and geographical isolation. (3)

3.2 DOMESTIC VIOLENCE

3.2 a) Definition

Domestic violence is defined as behaviours used by one person within a relationship to control the other. Examples include physical harm, sexual assault, intimidation and threats, withholding money or resources, and emotional or psychological threats. (9) However, many Indigenous people have indicated their preference for the term “family violence” as opposed to “domestic violence.” (1)(10) This is secondary to the tensions that exist between Indigenous and non-Indigenous Australians in their definition of and solution to violence. Essentially, due to the damaging effects of white colonialisation and dispossession, the solution to violence in Indigenous communities lies in ‘healing’ rather than punishing the perpetrators. (1) This is in opposition with the mainstream definition of and approaches to violence where the response sought is through the criminal justice system. In other words, the solution to violence in indigenous communities is in healing the family rather than isolating and persecuting the individual offender. (1)(10) Given this context, the term “family violence” will be used interchangeably with “domestic violence” in order to encompass all forms of violence occurring in the family and in other relationships of mutual obligation and support. (1) It is recognised that the definition and labelling of domestic violence is a controversial issue in the discourse of Australian family violence. (11) There seems a large gap between the rhetoric of those who study domestic violence and those who experience it. Many research participants do not identify their situations as domestic violence until
they specifically read the behaviours expressed by external observers. (12) Indigenous people may not use explicit descriptive words such as family violence, domestic violence and sexual assault to describe their experiences. (13) Phrases such as ‘we were arguing,’ ‘he was acting up,’ ‘being cheeky,’ and ‘we were drinking’ may be used to describe domestic violence. In reality, these phrases may describe something more sinister such as rape or serious assault. (13)

3.2 b) Global Epidemiology of Domestic Violence

Domestic violence against women is a serious public health problem. The reported lifetime prevalence of physical or sexual partner violence varies from 15% to 71% globally. (2) In western countries it is estimated that about 25% of women experience intimate partner violence over their lifetimes. (14) Garcia, however, argues that very few public health problems a have such an “invisible iceberg” effect: domestic violence affects about 25% of the population but only a few of those affected, between 2.5% and 15%, report that they are suffering from that condition. (14) Women at greatest risk for injury from domestic violence include those with male partners who abuse alcohol or use drugs, are unemployed or intermittently employed, have less than a high-school education, and are former husbands, estranged husbands, or former boyfriends of the women. (15)

3.3 Domestic Violence and Human Rights

The discourse of human rights provides a legal standard of minimal protection that might be recognised as mandatory for the maintenance of human dignity and the entitlement of all human beings. (16) The first formal recognition of women’s rights as human rights occurred in the 1970s when the Convention for the Elimination of All Forms of Discrimination Against Women (CEDAW) was drafted and adopted member states of the United Nations. (17) However, domestic violence has not been traditionally recognized in mainstream human rights discourses. Craven recognises that the primary focus of the CEDAW is on issues of discrimination occurring in the public sphere, such as protection from political and economic discrimination. (18) Feminist critiques argue that human rights abuses occurring within the private sphere such as domestic violence are ignored by the CEDAW and that this further reinforces the public-private dichotomy, hence further oppressing women. (18) In 1992, gender-based violence was recognized by the UN Committee on the Elimination of Discrimination Against Women as constituting a form of gender discrimination and therefore could amount to a breach of specific provisions of the CEDAW, regardless of whether those provisions expressly mentioned violence. (18) Subsequently, the 1993 Declaration on the Elimination of Violence Against Women was proclaimed and a Special Rapporteur was appointed by the Commission on Human Rights to seek and receive information on violence against women. (18) The Beijing Platform for Action (BPFA) developed at the 1995 World Conference for Women identifies twelve areas of concern for women’s equality and includes Violence Against Women. (18) With the increasing international human rights recognition of gender-based violence as a form of discrimination, there is growing international material such as the Declaration on the Elimination of Violence Against Women and the BPFA which form international standards and norms in the protection of women from violence. (18)

3.4 Indigenous rights and Human Rights

The United Nations Declaration of the Rights of Indigenous People recognised the historical injustices of colonialisation and dispossession of lands and territories, affirms that Indigenous peoples are equal to all other peoples, while recognizing their right to consider themselves different, and reaffirms that they should be free from discrimination of any kind. (19) Whilst the General Assembly Declaration is not a legally binding instrument in itself, it represents a shift in international consciousness towards protecting and promoting the human rights of Indigenous peoples worldwide. As mentioned in the preamble to the Declaration, Indigenous people’s human rights must be conceptulised as equal to all other peoples but separate and unique. (19) The 46 articles of the Declaration re-state the fundamental human rights as described within the United Nations Declaration of Human Rights. Beyond this, they build on protecting and promoting the human rights specific Indigenous people, valuing conservation of culture, heritage and land rights. (19)

4. Domestic Violence in Indigenous Communities – a Health and Human Rights perspective

Indigenous family violence is an abuse of the fundamental human rights of Indigenous women and children. It involves violations of basic human rights such as security of the person and non-discrimination. Blagg reports that Indigenous people are 4.6 times more likely to be the victims of violent crime than non-Indigenous people. (20) Indigenous women are particularly at risk of violence, being 12 times more likely to be the victims of assault than non-Indigenous women. Memmott and colleagues demonstrated that violence occurs disproportionately within Indigenous communities and has a significant traumatic impact. (21) Violence has increased in Indigenous communities since the 1970s. (1) The violence is often perpetrated by the women’s partners or close relatives. (1)(20) In 53% of cases of violence the offender was known to the victim. (1) Violence between Indigenous people is more likely to be directed at people intimate to the family or social setting than at strangers. (1)(21) In Western Australia, Indigenous women are 45 times more likely to be a victim of domestic violence than non-Indigenous women. (1) However, statistics around domestic violence may vary across Australian states and territories and within individual communities, and may not always be available or methodologically reliable. (1)(21) There is much heterogeneity within Indigenous communities, how they report their Indigenous status and how they report episodes of domestic or family violence. (1)(3) Domestic and Family Violence is an indication of community dysfunction. It is not, as falsely believed, part of customary local law but instead a sign of the breakdown of traditional Indigenous governance mechanisms in communities. (22) In order to understand the pattern of violence within Indigenous communities, Keel argues that the broader sociocultural context must be understood (1) Historically, Indigenous people experienced massive physical, social and cultural ramifications of western colonization, including land dispossession, disease, loss of cultural identity and marginalization. (1)(3)

4.1 Causes of Domestic Violence in Indigenous Communities

Analysis of domestic violence in contemporary Indigenous communities must also be located within an historical context. (1) A complex historical picture of disadvantage and oppression combines to set the scene for interpersonal acts of violence. (1) Blagg identifies marginalisation and dispossession, loss of land and traditional culture, breakdown of community kinship systems and Aboriginal law, entrenched poverty, racism, alcohol and drug abuse, the effects of institutionalisation and removal policies and the “redundancy” of the traditional Aboriginal male role and status, compensated for by an aggressive assertion of male rights over women and children as root “causes” of Violence in indigenous communities. (20) Furthermore, other contributing factors such as alcohol add to the historical context of violence in Indigenous communities. However, the relationship between alcohol and violence is complex: not all perpetrators of violence use alcohol, and many Indigenous people who drink are not violent. (23) Loss of spirituality and traditions are also key contributors to Domestic Violence that are often poorly understood or misinterpreted by non-Indigenous people. Atkinson refers to violence stemming from a trauma that affects every generation of Aboriginal people and, in order for change to occur, a process of healing must first take place. (23) The following areas are critical to understanding sexual assault in Indigenous communities (24): 1.“There is a “normalisation” of sexual violence that is now becoming intergenerational; 2.The issues have to be addressed in a holistic way if any real outcomes are to be achieved; 3.The issue is widespread and “endemic”; 4.Very few victims report the issue to police or seek assistance; and 5.Child sexual abuse is still very much hidden” (24)

4.2 “Normalisation” of Domestic Violence and Intergenerational behaviours in Indigenous Communities

“The harsh reality is that many families are now trapped in environments where deviance and atrocities have become accepted as normal behaviour and as such, form an integral part of the children’s socialisation” (25)

Violence has, unfortunately, become an ingrained aspect of many Aboriginal family behaviours. “Endemic” levels of domestic violence and the subsequent inter-generational normalization within communities may be reflected by the language often used to describe the violence. Phrases such as ‘we were arguing’, ‘my husband was acting up’, ‘he was being cheeky’, ‘it was just a little fight’ and
‘we were drinking’ are common phrases used in discussions about violence in Indigenous communities. (10) This language may reflect the normalization process, but may also reflect the shame in expressing the true nature of the situation. (10) Such language also may hinder the communication of true levels of domestic violence. For example, a seemingly harmless phrase such as “we were drinking” may not be interpreted by a non-Indigenous doctor as an episode of domestic violence and subsequently may not be reported. In order to address the issue of domestic and family violence, a long-term approach must be taken in order to reverse the process of normalization and promote a process of attitudinal change. The solution – most likely – is inter-generational, drawing upon strong role models and community leaders to affect change amongst younger generations and break the cycle of normalization.

4.3 The diversity of Aboriginal Communities in Australia

Aboriginal people represent an extremely diverse mixture of cultures, languages and people. Indigenous people share many common cultural and historical bonds and in mainstream literature are often referred to as one people. (3) However, Indigenous groups across Australia take pride in their personal and language group identity, identities which vary across time and space and which are important to recognise when evaluating Indigenous people and domestic violence. Despite the diversity, Aboriginal people no matter where they come from are recognised and recognise each other as one people. (26) In essence, the term “unity and diversity” may best describe this situation. (26) When addressing Indigenous domestic violence it is important to recognise the “unity and diversity” of Indigenous people. Communication of domestic violence within a family and community setting may differ depending on the traditions and behaviours specific to the individual community. Furthermore, access to opportunities for reporting or coping with domestic violence may differ, being affected by geographical location, physical remoteness, language barriers and cultural specific communication styles. Defining domestic violence within Indigenous communities has separate and specific challenges regarding demography and definitions. (1) Indigenous women may experience domestic violence perpetrated by Indigenous partners in the same community setting. They may also experience domestic violence by Indigenous partners external to the community. Indigenous women may have non-Indigenous partners who are either located within or external to the community. (1) Victims of domestic violence themselves may not actually be located within their original community and may lack connections to their original people. Furthermore, people with Indigenous ancestry may choose not to identify with Indigenous culture at all, or choose to identify as Inidgenous at only some points in their life. (1) These situations reflect the complexity of trying to attach specific definitions to the situation of domestic violence in indigenous Australia.

4.4 Gender Identity versus Indigenous Identity

Jonas argues that ultimately, Aboriginal women often do not have the luxury of choosing between asserting their rights as women as opposed to their rights as Indigenous people. There exists the unacceptable choice that many Indigenous women face between having to prioritise between issues of race and gender. Unfortunately, for Aboriginal women, it appears that issues of race would almost always hold dominance over issues of gender. (22) Therefore, Aboriginal women experience domestic violence in multiple ways and forms. Not only do these women experience racial marginalization, but also may be victims of gender-related discrimination from within their own race. Furthermore, racist marginalization may render ‘usual’ strategies to overcome violence, instate coping mechanisms, or access resources inaccessible or inappropriate. In combination with oppression and violence within their own communities, this contributes to hopelessness and resignation among many women. (22)

4.5 Failure to report Domestic Violence

As with domestic violence experienced in the wider community, Indigenous women fail to report episodes of domestic violence; therefore current estimates probably grossly under-estimate it occurrence. Lievore (2003) notes that despite gross under-estimation by Police and the criminal justice system, Indigenous women are still over-represented as victims of sexual assault. (27) Literature in this field indicates that as little as one third of incidents of domestic violence and only one in ten episodes of sexual violence are reported to police in the general population. This is likely a lot less in indigenous women in Australia. (27)(28)(29)(30) Actually capturing a true sense of domestic violence experienced by Indigenous women is difficult. Firstly, methodological flaws in data collection may result in under-reporting and subsequent under-estimation of episodes of domestic violence. Secondly, there is a complex array of interpersonal race and gender relations that may be difficult to quantify or define. For example, non-Indigenous men may be the perpetrators of sexual or inter-personal violence against Indigenous women. Some of the proposed reasons Indigenous women do not report sexual assault include: intimidation by authority figures and white people in general; closeness of communities leading to fear of reprisals or shame; the relationship of the survivor to the perpetrator; unfamiliarity with legal processes; and a fear that the perpetrator will be sent to prison (21)(25)(31)(32) The Women’s Task Force (2000) reports many cases of sexual assault which occurred in a domestic situation were not identified as rape by Indigenous women. (25) The 1996 study undertaken by the Department for Women in New South Wales further attested to this when they reported Aboriginal women were ten times more likely than non-Aboriginal women to be a complainant of a sexual assault. (25)

4.6 Failures and shortcomings of service provision

Mainstream approaches to domestic violence are often problematic and may not be as effective when applied to an Indigenous population. Prosecution of the perpetrator through the mainstream criminal justice system may be ineffective for a variety of reasons: 1.It does not address the underlying cause of violence, including the inter-generational sense of loss of culture and traditional values; 2.Due to the normalization and endemic nature of violence, perpetrators may be temporarily detained in prison but will eventually be reinstated into their home communities and back into a harmful environment which promotes violence; 3.It does not include the whole community in the healing process but serves to isolate specific members further; and 4.The criminal justice system of Australia is inaccessible and intimidating – through language or cultural barriers – to many Indigenous people. Whilst Indigenous-specific programs have arisen from the inadequacy of mainstream responses, Calma has identified that there is a lack of knowledge about the effectiveness of responding to and reducing the violence in the communities in which they operate. (33) Therefore, investment in a more thorough evaluation process is crucial for understanding what works in indigenous communities. (1) Support services for Indigenous women who experience domestic violence are often under-resourced and over-worked. Subsequent to this, staff exhaustion may be problematic. Staff who work in this area may indeed need to partake in a healing process themselves.

4.6.1 The Northern Territory Response

In 2007, the Australian Government announced a ‘national emergency response’ to protect Aboriginal children in the Northern Territory from sexual abuse and family violence, also known as the Northern Territory Intervention. (33) This was catalysed by the report into community violence and sexual abuse of children, Ampe Akelyernemane Meke Mekarle: ‘Little Children are Sacred’. (30) The intervention, in theory, included: consultations with local communities, introduction of child safety services, restrictions of alcohol sales, establishment of emergency treatment and rehabilitation services, financing schooling and education, investment in meal programs, and commitment to public housing. However, in reality, elements of the intervention entailed wage quarantining for school non-attendance, changes to the structure of land ownership which enabled non-Indigenous people to enter Indigenous lands without a permit, and alcohol restrictions in Indigenous communities. The intervention, when instigated, aimed to protect human rights of children as set out by the Convention on the Rights of the Child, and aimed to represent a furtherance of human rights legislation in Australia. (33) However, many people believed that these interventions constituted breaches of human rights. Many of the measures are deemed racially discriminative by targeting and restricting Indigenous behaviours disproportionately to non-Indigenous people, such as in the case of wage quarantining and alcohol restrictions. Beyond the Northern Territory Intervention, a national apology was issued by the Australian Prime Minister in 2008. (34) Whilst this is a step forwards in many ways for Indigenous Australians, there is a long way to go to address the complex issues of our past. The apology occurred as part of a national government plan to “close the gap” in Indigenous mortality in Australia. However, Altman argues that focusing on a top-down governmental approach will provide at best a partial solution for Indigenous issues and may exacerbate existing concerns of power imbalances between black and white people. (34)

5. International Comparisons

Family violence experienced in Australian Indigenous peoples manifests in similar ways in other indigenous populations around the world. Much research has been performed with Canadian Aboriginal people; some Australian literature overlaps or has been derived from Canadian writings. Other Indigenous populations that recognise family violence include first-nation people of North America and Maori New Zealanders. Canadian Aboriginal family violence shares many similarities with Australian Aboriginal family violence. Bopp and colleagues recognise that family violence in Canada comproses: “1) a multi-factoral social syndrome and not simply an undesirable behaviour; (2) resides within Aboriginal individuals, families and community relationships, as well as within social and political dynamics; (3) typically manifests itself as a regimen of domination that is established and enforced by one person over one or more others, through violence, fear and a variety of abuse strategies; (4) is usually not an isolated incidence or pattern, but is most often rooted in intergenerational abuse; (5) is almost always linked to the need for healing from trauma; (6) is allowed to continue and flourish because of the presence of enabling community dynamics, which as a general pattern, constitutes a serious breach of trust between the victims of violence and abuse and the whole community; and finally, (7) the entire syndrome has its roots in Aboriginal historical experience, which must be adequately understood in order to be able to restore wholeness, trust and safety to the Aboriginal family and community life.” (35) Maori authors also recognize the historical context of colonization as a contributing factor in the widespread nature of domestic violence. Tipu states that it “is a reflection of the breakdown of the social fabric of the Maori way of life, prior to, during and after colonisation… In simple terms this means the loss of social and traditional (whanau based) structures, systems of discipline and justice, the language, beliefs, values, philosophies and loss of identity…Also, isolation through moving to urban centres means many Maori have been dislocated from vital support networks. Add to this hardships linked to low educational achievement, low incomes and restricted employment opportunities and you’d think the picture looks bleak.” (36) Therefore, despite unique aspects of each separate Indigenous culture, they are tied together by extraordinarily strong historical influences including white colonialisation, dispossession of land, marginalization of their culture and alienation from their traditions. While continuing to be mindful of international differences, it may indeed be useful to draw on the range of post-colonial experiences Indigenous people face world-wide in order to understand better how Indigenous Australian women experience family violence. Beyond understanding, it seems extremely important to draw on international resources to work towards future, inter-generational, long-term solutions.

6. The way forward: healing and family violence

Indigenous authors refer to the extent to which “Indigenous family violence stems from a trauma that affects every generation of Aboriginal people and, in order for change to occur, a process of healing must first take place.” (1) Healing involves a community-driven response which includes and “heals” the perpetrator as opposed to socially isolating and blaming them. As a non-Indigenous person, it is imperative to work in collaboration and consultation with Indigenous women. This concept has been continuously stresses by many working groups in the area of family violence: “in providing a way forward, it was constantly stressed [to the Task Force] that Indigenous and non-Indigenous people must work together to halt the violence and reverse the longstanding disadvantages suffered by Indigenous Australians” (25) Given the context of previous institutionalized racism experienced historically by Indigenous people promoted by people in positions of power historically, it is often difficult for Aboriginal people to trust and work together with government representatives, doctors, teachers and social workers. (1) It is important to work side-by-side with women who experience violence themselves or are working face-to-face with these issues; who are “Walking the talk,” so to speak, by “…taking action within communities to raise awareness, to provide counselling support, and to train and educate communities about stopping family violence.” (1) Given the extreme difficulties that Indigenous rape victims face in court (and subsequently serve to dis-incentivize against reporting and prosecuting episodes of rape), it has been argued that courts be closed to the public, and that support people should accompany women. (1) Indigenous women are exposed to directly and indirectly discriminatory practices, racism, ignorance of their culture, and over-questioning of drug use, sexual behavior and overall intimidation and slurring their personal credibility as a witness. (1) It has also been argued that courts should be more culturally sensitive and allow for judges and juries to hear anthropological evidence. (1) A good example of a culturally-sensitive and grass-roots approach to family violence in Indigenous communities is “women’s patrols,” “women’s shelters” and “sobering up” shelters. (1) Often these are run by Indigenous worker, who are mindful of the cultural and situational factors involved in family violence in Indigenous communities. (1) Having Indigenous workers means that women may feel more inclined to attend for assistance if they need it, and more inclined to feel safe and non-threatened. However, often these shelter programs are poorly funded and over-worked, risking over-crowding and staff burn-out due to the nature of the work. As Calma suggests, more resources are needed not only in the provision of these services but also in the evaluation of the services. (33)

7. Conclusion

In summary, domestic and family violence remains an endemic problem in Australian Indigenous communities. It entails the abuse of fundamental individual human rights. Indigenous Australian women who experience domestic violence experience human rights issues unique to both Indigenous people and to women simultaneously. Despite unique aspects of each separate Indigenous culture world wide and within Australia, the commonalities stemming from white colonialisation creates a strong historical and cultural bond. While continuing to be mindful of international differences, it may indeed be useful to draw on the range of post-colonial experiences Indigenous people face world-wide in order to understand better how Indigenous Australian women experience family violence. Whilst past strategies have been focused on individual crimes, many indigenous authors argue on focusing on “healing” the community in order to address historical causes of community dysfunction and violence. In doing this, strong role models may be created in order to start an inter-generational process of change. Acknowledgements I would like to acknowledge the Yawuru people and the Turrbal people who are the traditional owners of the lands on which this paper was written and on which this research was undertaken. References 1.Keel, M. Family violence and sexual assault in Indigenous communities:
”Walking the talk” Australian Institute of Family Studies. ISSN 1448-8140 (Print); ISSN 1448-8167 2.Garcia-Moreno C, Jansen H, Ellsberg M, Watts C. Prevalence of intimate partner violence: findings from the WHO multi-country study on women’s health and domestic violence. The Lancet. 2006; 368 (9543): 1260 – 1269 3.Australian Indigenous HealthInfoNet. Summary of cervical cancer among Indigenous women [homepage on the internet]. Australia: Australian Indigenous HealthInfoNet; [updated 2007; cited 2010 November]. Available from: http://www.healthinfonet.ecu.edu.au/population-groups/women/reviews/our-review-cervical 4.The Oxford English Dictionary. Oxford: Oxford University Press; 2010 5.Australian Bureau of Statistics. Experimental Estimates of Aboriginal and Torres Strait Islander Australians, June 2006. 2008 [cited 2010 November]; Cat. No. 3238.0.55.001. Avaiable from: http://www.abs.com.au 6.Australian Institute of Health and Welfare. The Health and Welfare of Australia’s Aboriginal and Torres Strait islander people 2008. 2008 [cited 2010 November]. ABS Catalogue No. 4704.0. Avaiable from: http://www.abs.com.au 7.Tizona. Map of Australia [website]. [Visited Nov 2010] Available at: http://tizona.wordpress.com/2008/08/28/quote-of-the-day-4/australia-map/ 8.Horton, D. Aboriginal Australian Map. Australia: Aboriginal Studies Press, AIATSIS and Auslig/Sinclair, Knight, Merz; 1996. 9.Domestic Violence.org Introduction. 2002. [cited Feb 2012] http://www.domesticviolence.org 10.Cripps, K 2010, Indigenous family violence: pathways forward in Working together : Aboriginal and Torres Strait Islander mental health and wellbeing principles and practice, eds. N. Purdie, P. Dudgeon and R. Walker, Australian Institute of Health and Welfare, Canberra 11.Barnett, O. W., Miller-Perrin, C. L., & Perrin, R. D. Family violence across the lifespan: An introduction. Thousand Oaks, CA: Sage Publications. 1997 12.Bagshaw, D., Chung, D., Couch, M., Lilburn, S., & Wadham, B. Reshaping responses to domestic violence: Executive summary. Adelaide: University of South Australia. 1999 13.Cripps, K. Enough family fighting: Indigenous community responses to addressing family violence in Australia & the United States. Unpublished PhD thesis. Monash University, Melbourne. 2004 14.Garcia, E. Unreported cases of domestic violence against women: towards an epidemiology of social silence, tolerance, and inhibition J Epidemiol Community Health 2004;58:536-537 15.Kyriacou DN, Anglin D, Taliaferro E, Stone S, Tubb T, Linden J, Muelleman A, Barton E, Kraus J. Risk Factors for Injury to Women from Domestic Violence N Engl J Med 1999; 341:1892-1898 16.Miller, D. Knowing your rights: implications of the critical legal studies critique of rights for Indigenous Australians. Australian Journal of Human Rights. 1998; 5(1): 48-78. 17.Halliday, S. International Women’s Day 2001: CEDAW Information Package. Human Rights and Equal Opportunity Commission & Sex Discrimination Commissioner Publication, Sydney, 2001. 18.Craven, Z. Australian Domestic and Family Violence Clearinghouse Topic Paper: Human Rights and Domestic Violence 19.Australian Human Rights Commission. Social justice and human rights for Aboriginal and Torres Strait Islander peoples. 2012 [cited Feb 2012] http://www.hreoc.gov.au/social_justice/info_sheet.html 20.Blagg, H. Crime, Aboriginality and the decolonisation of justice. Sydney: Hawkins Press, 2008 21.Memmott, P., Stacy, R., Chambers, C. & Keys, C. Violence in Indigenous Communities, Commonwealth Attorney General’s Department, Canberra, 2001 22.Jonas, W. Family violence in Indigenous communities: Breaking the silence? Aboriginal and Torres Strait Islander Social Justice Commissioner, Human Rights and Equal Opportunity Commission, Sydney, 2002 23.Atkinson, J. Stinking thinking: Alcohol, violence and government responses. Aboriginal Law Bulletin. 1999; 2(51): 4-6. 24.Thorpe, L., Solomon, R. & Dimopoulos, M. From Shame to Pride: Access to Sexual Assault Services for Indigenous People, Elizabeth Hoffman House, Melbourne, 2004 25.Aboriginal and Torres Strait Islander Women’s Task Force on Violence. The Aboriginal and Torres Strait Islander Women’s Task Force on Violence Report, Department of Aboriginal and Torres Strait Islander Policy and Development, Queensland, 2001. 26.Horton D R. Unity and Diversity: The history and culture of Aboriginal Australia. Australian Yearbook, Australian Bureau of Statistics, 1994. 27.Lievore, D. Non-reporting and Hidden Recording of Sexual Assault: An International Review, Report prepared by the Australian Institute of Criminology for the Commonwealth Office of the Status of Women, Commonwealth of Australia, Canberra, 2003. 28.Gordon, S., Hallahan , K., & Henry, D. Putting the picture together: Inquiry into response by government agencies to complaints of family violence and child abuse in Aboriginal communities. Perth: State Law Publisher. 2002 29.Robertson, B. The Aboriginal and Torres Strait Islander Women’s Taskforce on Violence Report. Brisbane: Queensland Government. 1999 30.Wild, R., & Anderson, P. Ampe Akelyernemane Meke Mekarle: ‘Little Children are Sacred’. Report of the Northern Territory Government Inquiry into the Protection of Aboriginal Children from Sexual Abuse. Darwin: Department of the Chief Minister, 2007 31.Greer, P. & Breckenridge, J. “They throw the rule book away: Sexual assault in Aboriginal communities”, in J. Breckenridge & M. Carmody (eds) Crimes of Violence: Australia’s Responses to Rape and Child Sexual Assault, Allen and Unwin, Sydney, 1992. 32.Moore, E. Not Just Court: Family Violence in Rural NSW, Centre for Rural Social Research, Charles Sturt University, NSW, 2002. 33.Calma, T. Social justice report 2007. Sydney: Human Rights and Equal Opportunity Commission, 2008. 34.Altman, J. Beyond Closing the Gap: Valuing Diversity in Indigenous Australia CAEPR Working Paper No. 54/2009 ANU Centre for Aboriginal Economic Policy Research. 35.Bopp M, Bopp J, Lane P. Aboriginal Domestic Violence in Canada. The Aboriginal Healing Foundation, Canada, 2003. 36.Tipu M. When enough is enough: Breaking the cycle of domestic violence. Ngai Tahu magazine: “Te Karaka” New Zealand, 2003.

“Women’s Business” – Indigenous Australian Women and the intersection of Health, Gender, Culture and Human Rights

Indigenous Women’s Health Indigenous women experience poor health outcomes across all areas of health compared to non-Indigenous women. [1] Indigenous women suffer from alarmingly high rates of chronic diseases, and have higher mortality rates from screening-detectable cancers such as cervical and breast cancers. [2] Large proportions of emergency admissions are from violence-related health problems. Our Indigenous women are dying too young, too soon. An Indigenous girl born today has on average a 12-year shorter life expectancy than a non-Indigenous Australian. [2] Being Indigenous is a strong predictor of early mortality and increased morbidity from chronic diseases. Because our Indigenous women are dying so young, we as a society are loosing the opportunity to learn from our elders and derive precious Indigenous knowledge. Australia not only is loosing the expertise and productivity of a generation of over-50 Indigenous women, but – in the context of an already overburdened health system – we are also spending valuable resources in caring for sick Indigenous women and men who require resource-intensive care for chronic illness and end-of-life care. And most of these illnesses are preventable. Most illnesses that Indigenous women experience are preventable. For example, breast and cervical cancers are largely preventable through screening and early treatment. The effects of renal disease, diabetes, and cardiovascular disease are able to be attenuated through healthy lifestyle and diet, and can be treated medically. High rates of maternal and child mortality and morbidity should be able to be reduced in a country such as Australia with an advanced healthcare system and effective maternity care. Prevention is available, and infinitely more effective than treating illnesses as they arise. So why is it that Indigenous women still suffer from alarmingly high rates of disease? Many Indigenous health problems are symptomatic of much larger, complex social and anthropological issues: “…Indigenous women suffer health problems due to the context of their lives.” [3] Failure to seek treatment for kidney disease may be symptomatic of complex home and cultural issues which are insurmountable barriers to healthcare. Such barriers to healthcare may include: housing barriers such as overcrowding, lack of running water, and lack of electricity meaning an inability to store medicines in the fridge; language barriers for Indigenous women whose first language is not English; and cultural barriers such as feeling deeply uncomfortable talking to a male doctor about female health issues (also known as “women’s business”). [3] The indigenous perspective of health is holistic one. It encompasses everything important in a person’s life including land, environment, physical body, community, relationships and law. The social, emotional, and cultural wellbeing of the whole community, including the cyclical concept of life-and-death, is as important to an individual as their own health. The wellbeing of the whole community is and the wellbeing of the self are concepts linked to the sense of being Indigenous [4]. In fact there is no separate term for health as it is understood in western society. [5] Therefore, the unequal health outcomes for Indigenous people are symptoms of a myriad of much greater underlying behavioural and socioeconomic problems relating to the disruption of traditional culture and disempowerment of the community. Much prior health policy has failed to consider the social, cultural, and economic lives of Indigenous women and therefore have failed to make lasting and meaningful impacts. Primary Healthcare interventions will only be effective if core issues of education, cultural identity and infrastructure are addressed. Given the interconnectedness of health, culture and community for Indigenous women, it is important to understand Indigenous history and the events that have shaped the disempowerment and marginalisation of Indigenous people in Australia. History, McKinley and colleagues argue, provides an important vehicle to view and understand the contemporary positioning of Indigenous Australian women in relation to issues of law, human rights, justice and health. [6] Therefore, this article provides an overview of Indigenous culture and historical and the events that have impacted significantly on Indigenous people. Subsequently, it will examine key political milestones from a human rights perspective. Finally, this paper will look at health issues specific to Indigenous women and ways forward toward better health and human rights outcomes. Historical and Cultural Background Indigenous Australia Indigenous Australians, the original inhabitants of Australia, have lived on this continent for over 60,000 years. Indigenous people include both Aboriginal – people from the Australian mainland – and Torres Strait Islanders – people indigenous to the islands of the Torres Strait – and are jointly referred to as Aboriginal and Torres Strait Islanders (ATSI). These two groups are linked by similar historical experiences, but maintain unique culture, customs and traditions. [7] Within these two major cultures exist hundreds of different cultures with their own customs and languages. Indigenous people may identify with their language group and/or their broader geographical region. For example, a person from north of Brisbane may identify with the Waka Waka mob (their language group) or may call themselves a Murri (a term for Indigenous people from the east coast of Queensland). [7] Sadly, due to Anglicisation of Indigenous people and cultures, only 20 Indigenous languages are widely spoken. It was believed that over 700 languages originally existed, but only 200 Indigenous languages still survive. [7] (Figure 1) Today, an Aboriginal or Torres Strait Islander is identified as a) being a person of Aboriginal or Torres Strait Islander descent, b) who identifies as an Aboriginal or Torres Strait Islander, and c) who is accepted by the Aboritginal community in which he or she lives. [8] The most recent Indigenous population estimate comes from the 2006 Australian Census, adjusted for unknown Indigenous status and net undercount. [9] This estimate relies on people self-identifying as Indigenous, which is a complex process of cultural and genealogical identity. The final estimated resident Indigenous population of Australia as at 30 June 2006 was 517,000 people, 2.5% of the total Australian population. [9] Whilst Indigenous people are ten times more likely than non-Indigenous people to live remotely, [10] the majority of Indigenous people live in capital cities (32% of the population) or regional centres (43% of the population). [11] Geographical location is defined in Table 1. The Indigenous population is also much younger than the non-Indigenous population of Australia, with a mean age of 20.5 years (versus 36.1 years) and only 3% of the population is over 65 years of age. [12] As with many Indigenous populations worldwide, Australian Aboriginals are over-represented in lower socioeconomic strata. Low socioeconomic status is associated with poor health and increased exposure to risk factors such as overcrowding, smoking, alcohol misuse and violence. [9] These have culminated in an approximate life expectancy gap of 12 years compared to the general Australian population. [9] Health issues pertinent to Indigenous people include cardiovascular disease, mental health issues and suicide, and interpersonal and domestic violence. [10] Around one-in-eight Indigenous people have a form of cardiovascular disease, especially in rural areas. A higher proportion of people living with diabetes was reported in the Australian National Diabetes Register between 2005-2007 were recorded as Indigenous. [9] Mental illness and mental health problems have been recognised as ‘a major difficulty for most [Indigenous] communities.’ [9] Indigenous adults were more than twice as likely than non-indigenous people to feel symptoms of psychological distress. [9] Risk factors specific to poor health outcomes Indigenous people face include poor nutritional status and associated obesity, sedentary lifestyle, drug and alcohol use, smoking and geographical isolation. [9] Culture and Spirituality – Women’s business, gender, and empowerment To understand pertinent human rights issues facing Indigenous women in Australia, it is important to contextualise it to our history and culture. History – both recent and distant – has an extremely important and emotive influence in many Indigenous Australians lives. From ancient culture and ways of life to more recent disastrous government policy, history, culture and spirituality are integral to the experiences of contemporary Indigenous people. Connection to country (the land on which you were born), family relationships and obligations, culture and ceremony, dreaming, spirituality and language are extremely important cultural factors. Much of this predominantly verbal culture is passed from one generation to another through storytelling, song and dance. [13] The ancient Australian Aboriginal mythology of the Dreamtime refers to “…a sacred era in which totemic ancestral beings created the world.” [14] Dreamtime legends are a complex collection of stories specific to geographic regions and language groups. Aboriginal people believed the world was created by the Ancestors, back in the Dreamtime. The Ancestors took the form of animals, such giant snakes. Their actions created sacred sites such as caves or rivers, and they demonstrated how the Creator intended humans to function and live. [15] The Dreaming establishes the structures of society, the interaction of people with the land, and the rules of social behaviour. [14] The Dreaming determines cultural lore and ceremonies. [14] Contemporaneously, Indigenous Australian spirituality and traditions are guided by cultural lore passed inter-generationally. Such lore is derived from the Dreaming, and is passed down by community Elders. Women have many responsibilities as mothers, grandmothers, sisters, daughters, wives and partners. Often it is the women in households who have the main responsibility for looking after the health of other family members. [3] Indigenous women comprise just over 1% of Australia’s population (2.5% of Australia’s female population). [3] Their women’s voices are slowly being heard both in Australia and – to a lesser extent – around the world. There has been, and still is, a notable absence of Australian Aboriginal women in much mainstream teaching of our history as a nation. Through a predominantly western, masculine historical lens, Indigenous women are rarely mentioned in perspectives of Australian history. [6] There has been “…historical ignorance, trivialisation and misreading of Aboriginal women’s distinct and separate social, religious and legal role in Aboriginal society by largely White male observers.” [16] Since British colonization, a Eurocentric and patriarchal framework of values – such as gender inequity – was imposed upon Indigenous women, leading to further disempowerment and marginalisation. [6] Prior to colonization, however, Indigenous women were members of an egalitarian Aboriginal society, where women’s and men’s “business” fulfilled separate but equally important roles. [17] Today, “women’s business” is still a protected and separate component of Indigenous women’s lives. Women’s business refers to cultural aspects of life that are sacred to women and cannot be discussed with men. [6] For example, certain rights of passage are sacred women’s business. More generally, women’s business may refer to issues of health involving breasts or reproductive organs, and birth. Women may not feel comfortable discussing these issues with men, and this is a source of much tension in our western model of healthcare or legal system where these extremely private issues are discussed openly. [6] Today, Indigenous women are discriminated against in multiple ways. They experience violations of their human rights based not only on their Indigenous status but also on their gender. Jonas argues that ultimately, Aboriginal women often do not have the luxury of choosing between asserting their rights as women as opposed to their rights as Indigenous people. There exists the unacceptable choice that many Indigenous women face between having to prioritise between issues of race and gender. Unfortunately, for Aboriginal women, it appears that issues of race would almost always hold dominance over issues of gender. [18] Furthermore, the western health and legal systems practiced in Australia further marginalises Indigenous women, through language barriers, alienating court procedures and culturally insensitive practices. [16] An example on Indigenous women’ s subordination through our court system is in the case of Kina vs R. In 1988 Kina, an Aboriginal woman was convicted and received a life sentence for the murder of her non-Aboriginal de facto partner. The initial case lasted half a day: Kina did not give evidence in her defence, but pleaded not guilty on the grounds of provocation and lack of intent. [16] In fact, her partner had threatened both her and her niece the morning of his murder, and had perpetrated multiple acts of sexual and physical violence in the past. She did not give evidence: she was silenced by an all- male courtroom that was insensitive to issues of “women’s business,” Aboriginality, and “shame.” Kina held that she couldn’t talk about her history of abuse due to “shame.” Mackinley explains that: “Shame is a central term in Aboriginal Australia and difficult to translate into non-Aboriginal English. Despite the ravages of colonisation, the centrality of kinship and family to Aboriginal peoples and cultures has continued, a value system of mutual aid and cooperation has been preserved – shame is the linchpin that keeps these altogether and perpetuates them.”[6]Kina did not talk as she felt “shamed” about her history of sexual assault, violence, and did not want to “shame” her family by talking about these issues publically. [6] History and Disempowerment The history of Indigenous Australia is marred with abuses of fundamental human rights. From the first contact with white settlers, Indigenous people have experienced genocide, disease, loss of land, suppression of culture and identity, loss of wages, disconnection from family, and harmful governmental policies. Whilst seemingly well intentioned, the application of government policies for over two centuries has led to further human rights abuses and disempowerment. Even today, much government policy is discriminatory, and some even in breech of international human rights law. The most basic oversight by many governments is failing to include Indigenous people in decision making, further serving to marginalize and disempower. Indigenous Australians originally lived a semi-nomadic “hunter-gatherer” life. [19] Respect for the land on which they lived was vital; to maintain the fragile balance of the ecosystem and avoid over-harvesting Indigenous people would only settle in a certain area for a period of time. Indigenous groups divided the land through the use of geographical landmarks such as rivers or mountains. Such knowledge was passed from the Elders of the community to the younger generations verbally. Prior to European contact, Aboriginal communities established complex trade routes over the continent. [19] Evidence also exists of trading between Indigenous people and the islands of Indonesia and Timor. [20] The first catastrophic interruption to Indigenous culture occurred with European contact. Whilst Dutch and Spanish explorers first encountered Indigenous Australians between 1606 and 1770, it was Britain who colonized Australia, sending the “first fleet” of ships to Botany Bay (now Sydney) in 1788. [20] Subsequent to British colonization, massacres of Indigenous people, annihilation of Indigenous people through the spread of smallpox and other foreign diseases, and mass dispossession of land occurred. [20] The continued violence between white colonizers and the Indigenous people resulted in further death, loss of land, and hardening of the relationship between black and white people. Following a significant reduction in the Aboriginal population and growing consciousness of the mistreatment of Aboriginal people, the Protectionist movement was formed. [20] From 1837, state-specific Protectors were appointed, to address abuses of Indigenous people and provide basic rations for living. [21] [22] Although originally well-intentioned to serve Indigenous peoples’ needs, over the 19th century these gestures morphed into more formal and extensive policies aimed at isolating and segregating “full blooded” Aboriginal people on reserves and restricting “interbreeding,” whilst simultaneously encouraging assimilation of “half-castes” into mainstream white Australia. [23] Indigenous people incurred huge restrictions of their civil rights, including restrictions on the right to marry and the right to freedom of movement and employment. [22] Government policies resulted in the forced removal from their families of Aboriginal and Torres Strait Islander children from 1909 to 1969, under the management of the Aborigines Protection Board (APB). [24] This government board had the power to forcibly remove Aboriginal children from their homes without consent or forewarning, and place them into an institution or dormitory, so that they could become “white” in their religion and behavior and reject Aboriginality. [24] It is estimated that 100,000 Indigenous children were taken from their families up to the 1960s. These children are today known as the “Stolen Generation.” [24] Those members who are still alive today still experience the consequences of past trauma, displacement, and disempowerment, as reflected in increased rates of depression, imprisonment and early death. [24] Finally, in 1967, the Constitution was amended to include Indigenous Australians in the national census. Australia had finally recognized Aboriginal Australians as citizens and afforded them full voting rights. This led to increased political voice and participation. However, it is argued that many Indigenous Australians still face barriers to voting and political participation. [25] Data from the 2007 federal election indicates that Indigenous Australians are under-represented in voting participation; barriers to participation include poorer literacy and numeracy, transience, and remoteness. Also, Indigenous people are over-represented in our prisoner population and therefore have their right to vote restricted. [25] Social Issues The health disadvantages experienced by Indigenous females and males can be considered historical in origin [26], but perpetuation of the disadvantages owes much to contemporary structural and social factors, embodied in what are termed the ‘social determinants’ of health [27][28][29]. Education Indigenous females attendance at school is significantly lower than non-Indigenous females. Only 10-50% of Indigenous girls complete Grade 12 (the senior high school year). [3] (Figure 4) Only 20% of Indigenous women have a post-school qualification and only 5% have graduated with a Bachelor degree or above. [3] Income and Employment Subsequent to lack of education and formal qualifications, employment an income are significantly affected. For those who do not have any post-school qualifications, 16% are unemployed (compared to 5% non-Indigenous females). However, for those who achieve a Bachelor degree or higher, rates of employment – almost full employement – are enjoyed by both Indigenous and non-Indigenous women alike. [3] [30] Mean household income is less in Indigenous households compared with non-Indigenous households: $521 per week compared with $730 per week. For individual females, the median gross weekly income in 2006 was $278 compared with $367 for non-Indigenous females. [30] Incarceration There is hardly an Aboriginal woman in Australia untouched by the operation of criminal justice in her life, whether directly or through the repeated criminalisation of her children, her kin, her men or through her own victimisation of various crimes [6][31] Indigenous people are massively over-represented in the criminal justice system of Australia. [53] According to the 2009 national prison census, Indigenous prisoners accounted for 25% of the total prison population, 10 times higher than the proportion of Indigenous Australians (2.5% of the Australian population). [53] Indigenous Australians were 14 times more likely to be imprisoned compared with non-Indigenous Australians. [32] In New South Wales between 1997 and 2004, Indigenous people were nine times more likely to appear in court, 11 times more likely to appear for sexual assault charges, 17 times more likely for robbery and 19 times more likely for aggravated assault. [33] Indigenous imprisonment rates range from 471 prisoners per 100,000 population for Tasmania to 3,329 per 100,000 for Western Australia [32] Indigenous offenders come from a largely socially disadvantaged background. Many inmates had not completed grade 10 of school (86% of Inidgenous inmates had not completed grade 10), [34] over half of the offended were unemployed prior to committing their offence, and 11% of people were homeless prior to incarceration. [35] Those who are incarcerated are more likely to have been placed in care as a child. About 20% of all offenders have a parent incarcerated when they were a child. [35] Health Issues Maternal health The process of birth and delivery is a key part of a woman’s lifecycle to improve both physical health and empower women to be strong role models for their children and their community. From a purely physical perspective, it is postulated that a deprived intrauterine environment for the developing fetus may predispose individuals to chronic diseases later in life: also known as the Barker Hypothesis. [36] For Indigenous families, who suffer from chronic disease at disproportionately high rates, it is critical to ensure babies are born in best possible physical health by breaking the cycle of poor maternal health. Women also play a key role as carer in Indigenous communities. [3] Empowering young women and mothers culturally and emotionally is an important step towards strong maternal role models. Unfortunately, our Indigenous population experiences higher rates of maternal mortality, higher rates of fertility, lower birth weights and become pregnant at a younger age compared with non-Indigenous Australians. [3] The maternal mortality ratio (MMR) for Indigenous women in the period of 2003-2005 was 21.5 per 100,000 confinements (births) which is almost three times higher than for non-Indigenous women (MMR 7.9 per 100,000 confinements). [3][37] Indigenous women not only have more babies, but also have them at a younger age. [3] In 2008, teenage births comprised 20% of all Indigenous births, compared to 4% of births to non-Indigenous women; the median age of Indigenous mothers was 24.7 years compared with 30.7 years for all women. (Figure 5) Overall fertility rates were 2,515 births per 1,000 Indigenous women and 1,969 per 1,000 for all women (Figure 6). [37] In 2007, the average birthweight of an Indigenous baby was 3182 grams, over 200 grams less than a non-Indigenous baby. Indigenous women were twice as likely to give birth to low birthweight (LBW) babies. [3][37] LBW babies are exposed to higher risk of death in infancy and other chronic health problems. Indigenous women who smoked Tobacco had even smaller babies. The birthweight further decreases if a woman used tobacco, alcohol and marijuana during her pregnancy. [3] Domestic Violence Indigenous family violence is an abuse of the fundamental human rights of Indigenous women and children. It involves violations of basic human rights such as security of the person. Blagg reports that Indigenous people are 4.6 times more likely to be the victims of violent crime than non-Indigenous people. [38] Indigenous women are particularly at risk of violence, being 12 times more likely to be the victims of assault than non-Indigenous women. Memmott and colleagues demonstrated that violence occurs disproportionately within Indigenous communities and has a significant traumatic impact. [39] Violence has increased in Indigenous communities since the 1970s. [40] The violence is often perpetrated by the women’s partners or close relatives. (1)(20) In 53% of cases of violence the offender was known to the victim. [40] Violence between Indigenous people is more likely to be directed at people intimate to the family or social setting than at strangers. [39][40] In Western Australia, Indigenous women are 45 times more likely to be a victim of domestic violence than non-Indigenous women. [40] However, statistics around domestic violence may vary across Australian states and territories and within individual communities, and may not always be available or methodologically reliable. [39][40] There is much heterogeneity within Indigenous communities, how they report their Indigenous status and how they report episodes of domestic or family violence. [40][41] Indigenous people may not use explicit descriptive words such as family violence, domestic violence and sexual assault to describe their experiences. [42] Phrases such as ‘we were arguing,’ ‘he was acting up,’ ‘being cheeky,’ and ‘we were drinking’ may be used to describe domestic violence. In reality, these phrases may describe something more sinister such as rape or serious assault. [42] The harsh reality is that many families are now trapped in environments where deviance and atrocities have become accepted as normal behaviour and as such, form an integral part of the children’s socialisation [43] Violence has, unfortunately, become an ingrained aspect of many Aboriginal family behaviours. “Endemic” levels of domestic violence and the subsequent inter-generational normalization within communities may be reflected by the language often used to describe the violence. Phrases such as ‘we were arguing’, ‘my husband was acting up’, ‘he was being cheeky’, ‘it was just a little fight’ and
‘we were drinking’ are common phrases used in discussions about violence in Indigenous communities. [42] This language may reflect the normalization process, but may also reflect the shame in expressing the true nature of the situation. [42] Such language also may hinder the communication of true levels of domestic violence. For example, a seemingly harmless phrase such as “we were drinking” may not be interpreted by a non-Indigenous doctor as an episode of domestic violence and subsequently may not be reported. Domestic and Family Violence is an indication of community dysfunction. It is not, as falsely believed, part of customary local law but instead a sign of the breakdown of traditional Indigenous governance mechanisms in communities. [18] Analysis of domestic violence in contemporary Indigenous communities must also be located within an historical context. [40] A complex historical picture of disadvantage and oppression combines to set the scene for interpersonal acts of violence. [40] Blagg identifies marginalisation and dispossession, loss of land and traditional culture, breakdown of community kinship systems and Aboriginal law, entrenched poverty, racism, alcohol and drug abuse, the effects of institutionalisation and removal policies and the “redundancy” of the traditional Aboriginal male role and status, compensated for by an aggressive assertion of male rights over women and children as root “causes” of Violence in indigenous communities. [38] Furthermore, other contributing factors such as alcohol add to the historical context of violence in Indigenous communities. However, the relationship between alcohol and violence is complex: not all perpetrators of violence use alcohol, and many Indigenous people who drink are not violent. [44] Loss of spirituality and traditions are also key contributors to Domestic Violence that are often poorly understood or misinterpreted by non-Indigenous people. Atkinson refers to violence stemming from a trauma that affects every generation of Aboriginal people and, in order for change to occur, a process of healing must first take place. [44] The following areas are critical to understanding sexual assault in Indigenous communities: [45] 1.“There is a “normalisation” of sexual violence that is now becoming intergenerational; 2.The issues have to be addressed in a holistic way if any real outcomes are to be achieved; 3.The issue is widespread and “endemic”; 4.Very few victims report the issue to police or seek assistance; and 5.Child sexual abuse is still very much hidden” [45] In order to address the issue of domestic and family violence, a long-term approach must be taken in order to reverse the process of normalization and promote a process of attitudinal change. The solution – most likely – is inter-generational, drawing upon strong role models and community leaders to affect change amongst younger generations and break the cycle of normalization. Human Rights and Violence The discourse of human rights provides a legal standard of minimal protection that might be recognised as mandatory for the maintenance of human dignity and the entitlement of all human beings. [46] The first formal recognition of women’s rights as human rights occurred in the 1970s when the Convention for the Elimination of All Forms of Discrimination Against Women (CEDAW) was drafted and adopted member states of the United Nations. [47] However, domestic violence has not been traditionally recognized in mainstream human rights discourses. Craven recognises that the primary focus of the CEDAW is on issues of discrimination occurring in the public sphere, such as protection from political and economic discrimination. [48] Feminist critiques argue that human rights abuses occurring within the private sphere such as domestic violence are ignored by the CEDAW and that this further reinforces the public-private dichotomy, hence further oppressing women. [48] In 1992, gender-based violence was recognized by the UN Committee on the Elimination of Discrimination Against Women as constituting a form of gender discrimination and therefore could amount to a breach of specific provisions of the CEDAW, regardless of whether those provisions expressly mentioned violence. [48] Subsequently, the 1993 Declaration on the Elimination of Violence Against Women was proclaimed and a Special Rapporteur was appointed by the Commission on Human Rights to seek and receive information on violence against women. [48] The Beijing Platform for Action (BPFA) developed at the 1995 World Conference for Women identifies twelve areas of concern for women’s equality and includes Violence Against Women. [48] With the increasing international human rights recognition of gender-based violence as a form of discrimination, there is growing international material such as the Declaration on the Elimination of Violence Against Women and the BPFA which form international standards and norms in the protection of women from violence. [48] The United Nations Declaration of the Rights of Indigenous People recognised the historical injustices of colonialisation and dispossession of lands and territories, affirms that Indigenous peoples are equal to all other peoples, while recognizing their right to consider themselves different, and reaffirms that they should be free from discrimination of any kind. [49] Whilst the General Assembly Declaration is not a legally binding instrument in itself, it represents a shift in international consciousness towards protecting and promoting the human rights of Indigenous peoples worldwide. As mentioned in the preamble to the Declaration, Indigenous people’s human rights must be conceptulised as equal to all other peoples but separate and unique. [49] The 46 articles of the Declaration re-state the fundamental human rights as described within the United Nations Declaration of Human Rights. Beyond this, they build on protecting and promoting the human rights specific Indigenous people, valuing conservation of culture, heritage and land rights. [49] Future directions The social determinants of health – the many factors that determine health behaviour and access to healthcare – are exceedingly important to improving Indigenous women’s health. [3] By focusing on the community’s empowerment, individual health gains may occur. In other words, Indigenous women’s health in Australia is a demonstration of the interconnected nature of human rights, and how the loss of certain human rights affects all facets of life including health. Application of a human rights-based approach to Indigenous health issues may be another successful, holistic way to approach culture, identity, empowerment and ultimately influence better health outcomes. Policy developments The Australian Government developed a National Women’s Health Policy in 2010. This policy aims to continue to improve the health of all women in Australia, and in particular improve the health of those at the greatest risk of poor health. This policy recognizes the need to consider the social determinants of health and how these influence female health outcomes. It highlights the significance of gender as a key determinant of health, acknowledges the women’s health needs differ over the span of life, prioritises the needs of women who are at greatest risk of poor health, focuses on illness prevention and health promotion, and supports the development of gender-specific research. Indigenous women are specifically recognized as a marginalize group at risk of poor health outcomes in this strategy. The National Indigenous Women’s Health Strategy promotes the social view of health and disease, and supports the inclusion of the social determinants of health in the policy. Past advances in Indigenous women’s health include the Council of Australian Government’s (COAG) committed to ‘close the gap’ – not only in health outcomes, but also in social disadvantage – between Indigenous and non-Indigenous Australians. COAG agreed on the specific targets of: ■Close the life expectancy gap within a generation; ■Halve the gap in mortality rates for Indigenous children under five within a decade; ■Ensure access to early childhood education for all Indigenous four year olds in remote communities within five years; ■Halve the gap in reading, writing and numeracy achievements for children within a decade; ■Halve the gap for Indigenous students in year 12 attainment rates by 2020; and ■Halve the gap in employment outcomes between Indigenous and non-Indigenous Australians within a decade [85]. COAG has committed $4.6 billion over four years across early childhood development, health, housing, economic participation and remote service delivery, and has also achieved a number of supportive commitments by the corporate and community sectors [85]. Agreement has been reached also on the establishment of a new national Indigenous representative body. [3] There has recently been research into the benefits of investing specifically in Indigenous women. The AMP report, The Best of Every Woman, believes that investing time and money in Indigenous females from the grass-roots up can help promote: ■“Social justice—working to address past and present inequities in the treatment and status of 
Aboriginal people within Australian society ■Gender equity—confronting direct and indirect forms of discrimination that prevent Aboriginal 
women and girls from accessing opportunities that are available both to men and non-Aboriginal 
women, and ■Social change—supporting Aboriginal women and girls to realise their aspirations and potential 
and act as leaders in the community and drivers for social change.” [52] For a program’s success, multiple factors have been identified, including: embracing long-term engagement, recognition of cultural differences, awareness of diversity of Australian Aboriginal culture and that a “one size fits all” approach isn’t effective, consulting with community members, listening and communicating. [52] References 1.Australian Department of Health and Ageing (2009) Development of a new national women’s health policy – consultation discussion paper 2009. Canberra: Australian Department of Health and Ageing 2.Shannon G, Pashayan N, Powles J, Franco O. Cervical cancer and Indigenous Women: the case of Australia. Maturitas. 2011;70(3):234-45 3.Burns J, Maling CM, Thomson N (2010) Summary of Indigenous women’s health. Retrieved Nov 2012 from http://www.healthinfonet.ecu.edu.au/women-review 4.Queensland Aboriginal and Islander Health Forum (1999) Queensland Aboriginal and Islander Health Forum corporate plan. Brisbane: Queensland Aboriginal and Islander Health Forum 5.National Aboriginal Health Strategy Working Party (1989) A national Aboriginal health strategy. Canberra: Department of Aboriginal Affairs 6.Mackinlay E, Thatcher K, Seldon C. Understanding Social and Legal Justice Issues for Aboriginal Women. Australian Journal of Indigenous Education. 2004;33:23-30 7.Australian Broadcasting Corporation. Indigenous Resources. (2012) Visited Nov 2012 at http://www.abc.net.au/indigenous/education/links.htmAustralian Bureau of Statistics. Population Census Evaluation. (1993) Visited at http://www.abs.gov.au 8.Australian Museum. Indigenous Australia, Introduction. Visited Nov 2012 at: (http://australianmuseum.net.au/Indigenous-Australia-Introduction) 9.Wikipedia. Australian Dreamtime (2012) Visited Nov 2012 at: en.wiki.org/Dreamtime 10.Australian History. Indigenous History. Visited Nov 2012 at http://www.Australianhistory.org 11.Upton, J. (1992). By violence, by silence, by control: The marginalisation of Aboriginal women under white and ‘black’ law. Melbourne University Law Review, 18, 867-873. 12.Whitney, K. (1997). Dually disadvantaged: The impact of Anglo-European law on Indigenous Australian women. James Cook University Law Review 4, 137-38. 13.Indigenous Australia. Indigenous trade routes. Visited Nov 2012 at http://www.indigenousaustralia.info/culture/trade-routes.html) 14.Australian Museum. Indigenous Australia, Introduction. Visited Nov 2012 at: (http://australianmuseum.net.au/Indigenous-Australia-Timeline-1500-to-1900) 15.Rowley, C. D. 1978. The destruction of Aboriginal society. Canberra: Australian National University Press. 16.Australian Law Reform Commission. Recognition of Aboriginal Customary Laws. (ALRC report 31) Published on 12 June 1986. Last modified on 19 July 2012. http://www.alrc.gov.au/publications/8.%20Aboriginal%20Customary%20Laws%3A%20Recognition%3F/arguments-recognition-aboriginal-customary-l 17.Douglas H. Namatjira citizenship and prohibition. Found Nov 2012 at http://www.law.uq.edu.au/documents/kriewaldt/issues/alcohol-regulation/Namatjira-Citizenship-Prohibition.pdf 18.Reconciliation Australia. Stolen Generations. Visited Nov 2012 at: http://reconciliaction.org.au/nsw/education-kit/stolen-generations/#impact 19.Australian Human Rights Commission. The Right to Vote is ot enjoyed equally by all Australian. (2010) Visited Nov 2012 at: (http://www.humanrights.gov.au/human_rights/vote/index.html)Saggers S, Gray C (1991) Policy and practice in Aboriginal health. In: Reid J, Trompf P, eds. The health of Aboriginal Australia. Marrickville, NSW: Harcourt Brace Jovanovich Group [Australia] Pty Ltd: 381-420 20.Carson B, Dunbar T, Chenhall RD, Bailie R, eds. (2007) Social determinants of Indigenous health. Crows Nest, NSW: Allen and Unwin 21.Marmot M (2004) The status syndrome: how social standing affects our health and longevity. New York: Holt Paperbacks 22.Wilkinson R, Marmot M (2003) Social determinants of health: the solid facts. Denmark: World Health Organization 23.Steering Committee for the Review of Government Service Provision (2009) Overcoming Indigenous disadvantage: key indicators 2009. Canberra: Productivity Commission, Australia 24.Pickering, S., & Alder, C. (2000). Challenging reforms for feminists and the criminal justice system. In D. Chappel & P. Wilson (Eds.), Crime and the criminal justice system in Australia: 2000 and beyond (pp. 222-239). Sydney: Butterworths. 25. Australian Bureau of Statistics (2009) Prisoners in Australia, 2009. Canberra: Australian Bureau of Statistics 26.Snowball L, Weatherburn D (2006) Indigenous over-representation in prison: the role of offender characteristics. Sydney: NSW Bureau of Crime Statistics and Research 27.Australian Institute of Health and Welfare (2010) The health of Australia’s prisoners 2009. Canberra: Australian Institute of Health and Welfare 28.Indig D, Topp L, Ross B, Mamoon H, Border B, Kumar S, McNamara M (2010) 2009 NSW inmate health survey: key findings report. Sydney: Justice Health 29.The Barker Foundation. The Barker Theory: Ending Chronic Disease http://www.thebarkertheory.org/ 30.Australian Bureau of Statistics (2009) Births, Australia, 2008. Canberra: Australian Bureau of Statistics 31.Thorpe, L., Solomon, R. & Dimopoulos, M. From Shame to Pride: Access to Sexual Assault Services for Indigenous People, Elizabeth Hoffman House, Melbourne, 2004 32.Fredericks, Bronwyn, Adams, Karen, Angus, Sandra & the Australian Women’s Health Network Talking Circle. 2010. National Aboriginal and Torres Strait Islander Women’s Health Strategy. Australian Women’s Health Network, Melbourne, Victoria. 33.Commonwealth of Australia. National Women’s Health Policy 2010 http://www.health.gov.au/internet/main/publishing.nsf/Content/national+womens+health-1 34.Doyle, L. & Hill, R., The Best of Every Woman: An Overview of Approaches for Philanthropic Investment in Aboriginal Women and Girls, AMP Foundation, NSW, 2012. 35.Grace J, Krom I, Maling C, Butler T, Midford R (2011) Review of Indigenous offender health. Retrieved Nov 2012 from http://www.healthinfonet.ecu.edu.au/offender_health_review 36.Calma, T. Social Justice Report 2007. Aboriginal and Torres Strait Islander
Social Justice Commission http://humanrights.gov.au/social_justice/sj_report/sjreport07/index.html 37.Australian Institute of Health and Welfare. The Health and Welfare of Australia’s Aboriginal and Torres Strait islander people 2008. 2008 [cited 2010 November]. ABS Catalogue No. 4704.0. Available from: http://www.abs.com.au 38.Australian Indigenous HealthInfoNet. Summary of cervical cancer among Indigenous women. Australia: Australian Indigenous HealthInfoNet; (2007) Visited Nov 2012 at http://www.healthinfonet.ecu.edu.au/population-groups/women/reviews/our-review-cervical 39.Australian Bureau of Statistics. Experimental Estimates of Aboriginal and Torres Strait Islander Australians, June 2006. 2008 [cited 2010 November]; Cat. No. 3238.0.55.001. Avaiable from: http://www.abs.com.au 40.Australian Institute of Health and Welfare. The Health and Welfare of Australia’s Aboriginal and Torres Strait islander people 2008. 2008 [cited 2010 November]. ABS Catalogue No. 4704.0. Avaiable from: http://www.abs.com.au 41.Jonas, W. Family violence in Indigenous communities: Breaking the silence? Aboriginal and Torres Strait Islander Social Justice Commissioner, Human Rights and Equal Opportunity Commission, Sydney, 2002 42.Blagg, H. Crime, Aboriginality and the decolonisation of justice. Sydney: Hawkins Press, 2008 43.Memmott, P., Stacy, R., Chambers, C. & Keys, C. Violence in Indigenous Communities, Commonwealth Attorney General’s Department, Canberra, 2001 44.Keel, M. Family violence and sexual assault in Indigenous communities:
”Walking the talk” Australian Institute of Family Studies. ISSN 1448-8140 (Print); ISSN 1448-8167 45.Australian Indigenous HealthInfoNet. Summary of cervical cancer among Indigenous women [homepage on the internet]. Australia: Australian Indigenous HealthInfoNet; (2007) Visited Nov 2012 at: http://www.healthinfonet.ecu.edu.au/population-groups/women/reviews/our-review-cervical 46.Cripps, K. Enough family fighting: Indigenous community responses to addressing family violence in Australia & the United States. Unpublished PhD thesis. Monash University, Melbourne. 2004 47.Aboriginal and Torres Strait Islander Women’s Task Force on Violence. The Aboriginal and Torres Strait Islander Women’s Task Force on Violence Report, Department of Aboriginal and Torres Strait Islander Policy and Development, Queensland, 2001. 48.Atkinson, J. Stinking thinking: Alcohol, violence and government responses. Aboriginal Law Bulletin. 1999; 2(51): 4-6. 49.Miller, D. Knowing your rights: implications of the critical legal studies critique of rights for Indigenous Australians. Australian Journal of Human Rights. 1998; 5(1): 48-78. 50.Halliday, S. International Women’s Day 2001: CEDAW Information Package. Human Rights and Equal Opportunity Commission & Sex Discrimination Commissioner Publication, Sydney, 2001. 51.Craven, Z. Australian Domestic and Family Violence Clearinghouse Topic Paper: Human Rights and Domestic Violence 52.Australian Human Rights Commission. Social justice and human rights for Aboriginal and Torres Strait Islander peoples. (2012) Visited Feb 2012 at: http://www.hreoc.gov.au/social_justice/info_sheet.html

Blood availability in developing countries

Background

In the developing world, too many women die from complications of labour and delivery. It is estimated that more than half a million women die from complications of pregnancy and childbirth annually. (Bates, 2008) The majority of these deaths can be attributed to haemorrhage, sepsis, eclampsia, uterine rupture, and unsafe abortions – all readily identifiable and preventable conditions. The maternal mortality ratio (MMR) in 2005, defined as maternal deaths related to pregnancy expressed per 100 000 live births, was 920 in Africa, 330 in Asia and 10 in Europe.

Post partum haemorrhage – excessive loss of blood from the reproductive tract following delivery – is a common cause of maternal death. In fact, haemorrhage during labour, delivery and post partum accounts for one third of all maternal deaths and is the leading cause of death in Africa (34% of maternal deaths attributed to haemorrhage) and Asia (31% of maternal deaths attributed to haemorrhage). (Khan, 2006) The majority of deaths from haemorrhage occur in the post partum period.

In developed countries, mortality and morbidity from post partum haemorrhage is on the whole preventable through the following interventions:

1. Active management of the third stage of labour, where oxytocic drugs are administered at the delivery of the neonate and the placenta is encouraged to deliver through controlled cord traction;
2. Use of oxytocic drugs (drugs that encourage uterine contraction)
3. Surgical interventions such as manual removal of the placenta, uterine compression sutures and hysterectomy; and,
4. Blood transfusions

There has been much focus on preventing maternal deaths through the international Safe Motherhood initiative and the Millennium Development Goals (MDG5 in particular). (WHO) However, Bates and colleagues argue that access to blood products and blood transfusions are a neglected component of essential medical care. (Bates, 2008) Post partum haemorrhage, as it develops so rapidly in the post-partum period and may be fatal within hours, is a complication of delivery where rapid access to safe blood transfusion is crucial.

The reality of blood transfusions in developing countries

An all-too common scenario in low-income countries has been portrayed via the online video “No Woman Should Die Giving Birth: Maternal Mortality in Sierra Leone:” A woman arrives at the local healthcare centre, carried in by her family from a local village, and her baby has already died in-utero before she arrives. She begins to bleed heavily and may require a caesarean section to stop the bleeding. The doctor begs her family to find and pay for blood or donate some themselves, and they must desperately find a way to access blood urgently to save this woman’s life. The hospital is under-resourced and has no access to blood transfusions at the hospital, and the family cannot afford to pay a donor. There is no mention of blood safety or screening in the face of such desperation. (Amnesty International, 2009)

Reasons identified for lack of blood or delays in transfusions identified in the literature include:

1. Inability of women to pay for blood in advance;(Adetoro 1987, Adetoro 1988, Gohou 2004, Oladapo 2006)
2. Lack of blood donors; (Walraven 2000,Mbaruku 1995)
3. Unwillingness of relatives to donate blood; (Price 1983, Adetoro 1987, Adetoro 1988)
4. Lack of supplies; (Price 1983, Adetoro 1987)
5. Lack of blood storage facilities; (Price 1983, Adetoro 1987)
6. Transport. (Price 1983, Adetoro 1987)

For many patients, the cost of a unit of blood is simply unaffordable. The cost of a unit of blood may be around $16 to $60, well over the average wage of many people who live below $1 a day in Sub Saharan Africa. (Bates, 2008) Moreover, many low-middle income country health systems do not have a national, regulated blood transfusion system nor a national health or insurance system that ensures access to blood transfusions for everyone. (Bates, 2008)

There are two major issues in blood supply in developing countries: adequacy (the volume of blood supplied to meet population demands) and safety (quality of blood, screening for blood borne viruses).

Adequacy of supply: major shortfalls

It is estimated that the world is short of approximately 40 million units of blood annually. (Zarocostas, 2004) Blood supply and demand are mismatched: whilst the developing world is home to over 80% of the world’s population, only 39% of blood is donated there.

The World Health Organisation use “whole blood donation rates” as an indicator for the general availability of blood in a country. (WHO, 2012) While a median of 36.4 donations per 1000 people are received annually in high-income countries, only 11.6 per 1000 people in middle-income countries, and 2.8 per 1000 people in low-income countries.

It is estimated that about one quarter of maternal deaths in Sub-Saharan Africa due to haemorrhage could be prevented by adequate and timely access to blood transfusions. (Bates, 2008)

Safety of supply: lack of resources and education

Women who experience complications of anaemia or haemorrhage often do not have access to safe blood that is donated from healthy, voluntary donors and is appropriately screened for blood borne viruses. Instead, they often have to find private (paid) donors, or convince family members to donate for them. They may or may not have access to facilities that screen for blood-borne diseases such as HIV, Hepatitis B, Hepatitis C or Syphilis.

Safe blood donors

 

It is known that the best blood supply base is obtained through voluntary, unpaid donors who donate on a regular basis. (WHO 2012) This group of people also have the lowest prevalence of blood borne viruses. (WHO 2012) It is the WHO’s goal that by 2020 all countries will obtain blood supplies entirely through voluntary, unpaid donors. (WHO, 2012) The WHO uses the proportion of voluntary unpaid donors as a percentage of all blood donations as an indicator of the safety and reliability of the blood donation system. Please refer to http://www.who.int/mediacentre/factsheets/fs279/en/index.html for a visual representation of the proportion of voluntary unpaid donors globally.

Transfusion-transmissible disease screening

Screening blood for blood borne viruses is a disease control priority and essential component of a safe blood system. (WHO 2012) In low-income countries, access to test kits and ability to screen all donated blood is minimal. However, it is these countries which have a higher median prevalence of transfusion-transmissible infections and a greater need for screening. It is reported that the median prevalence rate of HIV in low income countries is 0.5%, compared with 0.06% in middle-income countries and 0.001% in high income countries. (WHO, 2012)

The WHO reports that 39 countries worldwide are still not able to test for HIV, Hepatitis B, Hepatitis C, or Syphilis. Only an average of 53% of blood donations in low income countries are appropriately screened. One of the main reasons for not testing is lack of supply of testing kits. (WHO, 2012)

Blood processing

Blood can be used most effectively if the donated unit it divided into multiple blood components. This way, it can be used for more than one patient at more than one time for various different indications.  Whole blood can be separated into components such as packed red cells, platelets, cryoprecipitate, and fresh frozen plasma (WHO, 2012) Sadly, only 31% of patients in low-income countries have access to specific blood components.

Inequities in blood supply

 

Whist most people in high income countries have access to subsidised, reliable, affordable and standardised blood transfusions, those in developing countries must pay exorbitant amounts for a un-safe and un-screened blood product. In developing countries, this un-regulated and often private system favours those who have money and severely disadvantages the poor.

Across all areas of blood safety and supply, large gradients of inequity are seen between the developed and developing words, the rich and the poor. There are massive inequities in blood transfusion availability, donor types, safety of supply, ability to screen and ability to process blood. The following is an overview of some grossly inequitable gradients between low and high-income countries:

• Only 58% of countries worldwide have specific legislation governing blood supply: (WHO, 2012)
  • 69% high income countries
  • 61% middle-income countries
  • 37% low income countries
• The median blood donation rate indicates access to blood (WHO, 2012)
  • 36.4 donations per 1000 people in high income countries
  • 11.6 donations per 1000 people in middle-income countries
  • 2.8 donations per 1000 people in low-income countries
• Blood donors. Safety of blood donors represented by percentage of family or paid donors as a proportion of total blood donations (WHO, 2012)
  • 0.3% of family or paid donors in high income countries
  • 27% of family or paid donors in middle-income countries
  • 36% of family or paid donors in low-income countries
• Blood screening refers to the capacity of countries to adequately screen donated blood for any transfusion-transmissible infections such as HIV, Hepatitis B, Hepatitis C, or Syphilis (WHO, 2012)
  • 97% of donations screened for blood borne infections in high income countries
  • 82% of donations screened for blood borne infections in middle-income countries
  • 53% of donations screened for blood borne infections in low-income countries
• Blood processing: the ability to break-down blood into various useful components and therefore ensure greater efficiency of transfusions. (WHO, 2012)
  • 91% in high income countries
  • 72% in middle-income countries
  • 31% in low-income countries
• National systems of clinical guidelines, policy and standardisation (WHO, 2012)
  • A national haemo-vigilance system is in place in 78% of high income countries compared with 13% low income countries
  • iMechanisms to monitor clinical transfusion practice exist in 83% hospitals in high income countries, 56% in middle-income countries, and 47% low income countries
  • Finally, the use of blood transfusions in clinical practice is extremely different between high and low-income countries. Whereas in high-income countries, blood transfusion is often used as supportive therapy, low-income countries often utilise blood in pregnancy-related complications and severe childhood anaemia. In developed countries, blood is transfused mainly to people over the age of 65; in developing countries, the majority of transfusions are given to children under the age of 5 years.

Future directions

The WHO strategy for blood safety and availability recommends the following points: (WHO, 2012)

1. The establishment of a nationally-coordinated transfusion service to ensure access to blood transfusions for all patients in need;
2. The collection of blood from voluntary unpaid donors from low-risk populations;
3. Quality and reliable testing for transfusion transmissible infections;
4. Safe and appropriate use of blood and avoidance of unnecessary transfusions;
5. Quality systems monitoring the entire blood transfusion process.

Bates and colleagues recommend preventative strategies to avoid transfusion where possible in the acute phase of labour and delivery: (Bates, 2008)

1. Antenatal and pre-pregnancy management of anaemia through dietary interventions, treatment of underlying disease such as malaria, and iron supplementation. Ensuring a woman is not anaemic prior to labour and delivery shifts her individual threshold and means she may be more resilient to any acute blood loss.
2. Active management of the third stage of labour
3. Early recognition of obstetric haemorrhage and appropriate and rapid referral to a resourced facility
4. Management of bleeding with oxytocics
5. Surgical interventions.

Finally, monitoring of the clinical appropriateness of blood use is an essential feedback and quality mechanism for those physicians and staff who prescribe blood transfusions. Not only to unnecessary blood transfusions expose patients to the risk of transfusion reactions and blood-borne diseases, but also it reduces the blood supply for those who are most in need. (WHO, 2012)

REFERENCES

Adetoro OO. Maternal mortality—a twelve-year survey at the University of Ilorin Teaching Hospital (U.I.T.H.) Ilorin, Nigeria. Int J Gynaecol Obstet 1987;25:93–8.

Adetoro OO, Okwerekwu FO. Maternal mortality at Ilorin, Nigeria. Trop J Obstet Gynaecol 1988;1:18–22.

Amnesty International. No Woman Should Die Giving Birth: Maternal Mortality in Sierra Leone. 2009 http://www.youtube.com/watch?v=oHjwc4a57Vo (visited 2012)

Bates I, Chapotera GK, McKew S, van den Broek N.  Maternal mortality in sub-Saharan Africa: the contribution of ineffective blood transfusion services. BJOG. 2008 Oct;115(11):1331-9.

Gohou V, Ronsmans C, Kacou L, Yao K, Bohoussou KM, Houphouet B, et al. Responsiveness to life-threatening obstetric emergencies in two hospitals in Abidjan, Cote d’Ivoire. Trop Med Int Health 2004;9:406–15.

Khan KS, Wojdyla D, Say L, Gülmezoglu LM, Van Look PFA. WHO analysis of causes of maternal death: a systematic review. Lancet 2006; 367: 1066–74

Mbaruku G, Bergstrom S. Reducing maternal mortality in Kigoma, Tanzania. Health Policy Plan 1995;10:71–8.

Okogbenin SA, Gharoro EP, Otoide VO, Okonta PI. Obstetric hysterectomy: fifteen years’ experience in a Nigerian tertiary centre. J Obstet Gynaecol 2003;23:356–9.

Oladapo OT, Lamina MA, Fakoya TA. Maternal deaths in Sagamu in the new millennium: a facility-based retrospective analysis. BMC Pregnancy Childbirth 2006;6:6.

Price TG. Preliminary report on maternal deaths in the Southern Highlands of Tanzania in 1983. J Obstet Gynaecol East Cent Africa 1984;3:103–10.

Walraven GE, Mkanje RJ, Van Roosmalen J, Van Dongen PW, Dolmans WM. Assessment of maternal mortality in Tanzania. J Obstet Gynaecol 1994;101:414–17.

WHO Media Centre. Blood safety and availability. Fact Sheet No 279. June 2012. http://www.who.int/mediacentre/factsheets/fs279/en/index.html (visited 2012)

WHO. Maternal mortality in 2005: estimates developed by WHO, UNICEF, UNFPA, and the World Bank. 2007. World Health Organisation, Geneva.

Zarocostas J. Blood donations must be safer in poor nations, says WHO. Lancet 363(9426):2060

Maternity referral systems in developing countries

 

Summary

• An effective maternity referral system is an essential component of district primary healthcare for women in reducing maternal mortality. It is a dynamic process whereby a health-seeking individual is referred – either through a self-presentation or a professional referral process – to a higher level of healthcare when she requires it: before, during or after delivery.
• Maternity referral systems are specific to each region or district and are created in the context of existing local structures.
• The referral system can be conceptualised by the “sender-transport-receiver” model: the “sender” is often a locally based health professional referring to a major hospital; the transport is often individually organised; the receiver is often the district hospital. However, in reality, maternity referral systems are extremely complex and there are a huge amount of factors influencing these three components of the model.
• Different levels of referral facilities are:
  • Individual/community,
  • Local healthcare facility,
  • Regional or district Hospital.
• Maternity referral systems have been evaluated by the following measures:
  • The spread of births within a district,
  • The utilization of resourced hospitals by women with obstetric complications,
  • The progress towards reduction of maternal mortality at referral facility level,
  • Inappropriate use of EOC level facility,
  • Perinatal outcomes at peripheral-level facility,
  • Cost-effectiveness analysis.
• Key barriers to and determinants of maternity referral systems include cost, geographic and transport, political focus, local education and health system communication between all levels of care. Access to an appropriate level of care is influenced by geography, transport, culture and perceived quality of care at the service provider.
• Current interventions in developing countries focus on education at a community level, reducing geographical and financial barriers and on improving transport and communication.
• Inequity is still a prolific issue in the implementation of and access to maternity healthcare in developing regions, including effective referral. Poor-rich inequity, rural-urban inequity and inequity in marginalised communities are examples.
• There is a wealth of knowledge in the area of implementing effective maternal health programs in developing countries. Wide-scale international awareness of maternal mortality in developing countries has been around for over 25 years, with the instigation of the Safe Motherhood Initiative.

Background

Approximately 26% of the world’s maternal deaths occur in India annually (Shah, Divakar and Meghal 2006). Of the total 529 000 annual global maternal deaths, 136 000 occur in India (Shah, Divakar and Meghal 2006). India’s maternal mortality ratio (MMR) – defined as the number of maternal deaths per 100 000 livebirths – was 437 per 100,000 live births in 1991 (Shah, Divakar and Meghal 2006). According to the Indian Sample Registration System, the MMR has declined further from 301 during 2001-2003 to 254 in 2004-2006 (UNICEF http://www.unicef.org/india/health.html). However, for every 1 maternal death, 20 additional women are reported to experience serious harm relating to delivery (The UK All Party Parliamentary Group on Population, Development and Reproductive Health, 2009).

Post partum haemorrhage – excessive loss of blood from the reproductive tract after delivery – is the leading cause of death, contributing to 29.6% of all maternal deaths in India (Shah, Divakar and Meghal 2006). Other leading causes of maternal death include infections, eclampsia, and unsafe abortions.

India is a large country. 70% of the population lives in rural areas (Shah, Divakar and Meghal 2006). Of the 25 million annual deliveries in India, 18 million occur in peripheral areas, which, through its nature, translates into less ready access to healthcare and services (Shah, Divakar and Meghal 2006).

Strategies employed to prevent maternal deaths include risk identification, increasing the proportion of births attended by skilled health professionals, improving access to emergency obstetric care, and ensuring a functional referral system. These strategies have various associated historical levels of success and evidence. In India, the proportion of births attended by a skilled attendant increased 25.5% in 1992 to 39.8% in 2002. Although previously a large focus, training of Traditional Birth Attendants has not been shown to be effective in reducing maternal mortality. Likewise, risk prediction – attempting to screen all pregnant women and categorise those most at risk of an adverse pregnancy outcome – has proven inaccurate, with little effect on maternal mortality (Shah, Divakar and Meghal 2006). It is difficult to predict those who will suffer from a post partum complication through risk factor identification alone(Shah, Divakar and Meghal 2006). This has led to the recommendation of “every woman is a at risk.” (WHO 1991). Shah, Divakar and Meghal recommend three key elements of obstetrics care that have the ability to reduce maternal mortality:

(1) A skilled attendant at delivery;

(2) Access to emergency obstetric care (EOC);

(3) A functional referral system.

(Shah, Divakar and Meghal 2006).

Of course, appropriate human utilization of limited resources in a healthcare system are essential to ensure optimal health outcomes for women and children. Delays in care may occur at any level and may be attributed to both material and non-material factors. A model proposed by  Shah, Divakar and Meghal (Shah, Divikar, Meghal 2006) suggests that delays in healthcare opportunities that lead to maternal death can be summised by three factors:

(1) Delay in deciding to seek care;

(2) Delay in reaching care;

(3) Delay in getting treatment at the facility.

Strengthening the referral system is important to reduce delays.   A strong referral system equates to women being referred in a timely, proactive and efficient way. Especially, in the case of maternal mortality, time is of the essence due to the nature of rapidly evolving medical emergencies. As Shah puts it, inefficiency is deadly.

Unfortunately, it has been reported that widespread ‘failures’ in maternity referral systems are often present in developing countries. (Shah, Divakar and Meghal 2006). Moreover, these failures detrimentally affect women from a poor and marginalized background. There appears to be a chasm between theory and reality when it comes to a functional and effective referral system. A review by Murray and Pearson found that academic conceptualization of an ideal referral system may have a dangerously tenuous relationship to realities on the ground. (Murray and Pearson 2006)

What is a maternity referral system?

The referral system is an essential component of district health systems. It is a dynamic process whereby a health-seeking individual (in this case, the pregnant woman) mobilises directionally through a healthcare system to realise optimal healthcare for her condition. Jahn and de Brouwere define referral as: “any upwards movement of health care seeking individuals in the health system” and categorise maternity referrals as (Jahn and de Brouwere 2001):

(1) institutional or self-referral, depending on the involvement of first line services;

(2) antenatal, delivery or postnatal referral; and

(3) elective or emergency referral

Effective primary healthcare requires adequate referral systems in place to facilitate access to emergency healthcare for those who need it. An effective referral system allows primary healthcare to be provided by local professionals close to the patient’s home whilst serving as a back-up in case of emergency.

Each referral system operates within the broader context of the regional healthcare system and is appropriated to this system. In general, health systems are defined by the World Health Organisation (WHO) as: “all the activities whose primary purpose is to promote, restore, or maintain health” (WHO 2000).  An individual healthcare system, therefore, is extremely complex, encapsulating healthcare facilities, health education, health system financing, health regulatory systems and non-government organizations.

Levels of referral

Regarding regional maternity services, the following levels of healthcare have been identified (WHO 1996):

1. District or sub-district hospital, to which a woman at high risk is referred prenatally or sent for emergency obstetric care, and where the following essential services should be available:
   • surgical obstetrics,
   • anaesthesia,
   • medical treatment,
   • blood replacement,
   • manual procedures and monitoring labour,
   • management of women at high risk,
   • family planning support and
   • neonatal special care (WHO 1991).
   1. Local health centre
   2. Family and community

These levels of care are dynamically linked by a system of referral from one level to another.  In the case of obstetric emergencies, women who are unwell would be referred by their local health centre to a hospital where they could receive adequate medical, surgical and neonatal care.

Linking levels of care through referral

The dynamic process of referrals is an essential element of primary healthcare systems. It ensures that healthcare centres can function locally and can link into more advanced care if needed (King 1966). The back-up function of a referral system plays an integral role in pregnancy and childbirth, where a range of life-threatening complications may occur rapidly and require more advanced medical care. (Jahn and de Brouwere 2001).

Elements of the referral system

A referral system involves both physical and process components. Jahn and Brouwere conceptualized the sender-transport-receiver model of healthcare referrals. It identifies the main actors and actions in the system linking the locations and processes of referral between levels of healthcare. (Jahn and De Brouwere 2001) For example, having communication with a referral hospital will not be effective if there is no form of transport to get from A to B. Likewise, despite efficient transport, if local stigma prevents women from attending hospitals, this system will fail.

With such a complex system, each part is integral to the whole. In the sender-transport-receiver models, many different elements play an important role, including individuals, policy makers, health workers, transport systems and finances. While a simplified model, it is apparent how complex this would become in real life.

It is important to support and educate the sender/referrers in this system to ensure only adequate referrals are obtained. In the context of most district hospitals being overburdened already, this is an important mechanism to reduce this workload and streamline patients appropriately. Moreover, it has been demonstrated that adequate outreach services in the community have the capacity to reduce the burden on hospital systems. Bypassing by healthy women of local clinics in preference for a district hospital continues to be a problem and may be representative of lack of confidence in quality of care or of perceived or actual inefficiency in the local referral services (Murray and Pearson 2006)

Elements of an effective maternity referral system include:

• Adequately resourced referral centre
• Communication and feedback systems
• Designated transport
• Agreed setting-specific protocols for the identification of complications
• Personnel trained in their use
• Teamwork between referral levels
• Unified record system
• Meachanisms to ensure patients do not bypass a level of the referral system eg patient education, information and a structured fee/exemption systems (Murray et al 2001)

Types of maternity referrals

Many different referrals are made during pregnancy.  Studies from a rural Tanzanian hospital indicate that the most common referral pattern is self-referral, whereby referral to a hospital for delivery is made by the individual based on individual thought processes and perceptions of the pregnancy (Jahn 1998). In the above hospital, 70% of all admissions for delivery were self-referral, compared with only 30% of women being referred through a local clinic or institution. This pattern has been reflected in Burkina Faso, and Nepal (Jahn and de Brouwere 2001). This represents a skewed pattern of referral, with many women by-passing primary care options altogether (Jahn and de Brouwere 2001). Of note also, is that emergency referrals only comprised 1.2% of all referrals to high-level obstetric care, the remainder being elective referrals.

Benefits of the referral system

Full access to and utilization of all proven, effective interventions in pregnancy and childbirth would avert two-thirds of child deaths and three-quarters of maternal deaths (Wagstaff and Claeson (2004) (Jones and others 2003). Half of the maternal deaths could be averted through access to essential emergency care for a) haemorrhage, b) sepsis, c) eclampsia and d) obstructed labour. (Murray and Pearson 2006). The referral system is what links women from the community into appropriate emergency care.

Monitoring referral systems

To thoroughly monitor the effectiveness of a regional health centre’s maternity referral system, Murray et al (2001) proposed a measurement tool consisting of five different elements:

1. The distribution of births within a district, across levels of different facilities and the population coverage of maternity services achieved
   1. The spread and number of women who deliver at home, in a local health centre, or in hospital
   2. How many deliveries are covered by health services
2. The utilization of resourced hospitals by women with obstetric complications
   1. Pregnancy related referrals to hospitals
   2. “Met need” for hospital-based pregnancy; it is usually estimated that around 15% of women will require essential hospital care during pregnancy or delivery
   3. Intrapartum referral rates; are women who have acute labour problems referred in a timely way
   4. Caesarean section rates, a surrogate measure for complicated deliveries
3. The progress towards reduction of maternal mortality at referral facility level
   1. Case fatality rates
   2. Maternal mortality reviews
4. Inappropriate use of EOC level facility
   1. The proportion of births who self-referr who have “simple” deliveries
5. Perinatal outcomes at peripheral-level facility
   1. Intra-partum stillbirths
   2. Apgar scores of newborns, a measure of neonatal wellbeing and is a inaccurate indicator of birth asphyxia (Murray et al 2001)

A cost effectiveness analysis of strategies for maternal and neonatal health was performed by Adam et al (Adam, 2005). The most effective interventions, measured by the cost per disability adjusted life year averted in the year 2000 in two poor global regions in Africa and South-east Asia, include community-based newborn care package, maternity care programs (involving tetanus immunization, screening for pre-eclampsia, screening and treatment of syphilis), skilled attendance at birth, and emergency obstetric care around birth. Although not measured directly, the referral system plays an important role in the delivery of such interventions.

The determinants of a maternity referral system

Barriers to accessing maternity care through a referral system include issues of distance and geography, access to transport, financial constraints of families, cultural constraints, and individual perceptions of quality of care provided at the local hospital. Other determinants of a maternity referral system include political willpower, money, communication between levels of care, and education of local individuals and staff to know when to refer.

Issues of funding play a prominent role in any health service or health intervention. However, as Freedman et al argue, “the financial costs of meeting the maternal and child health Goals are dwarfed by what the world spends on preparing for and waging war. Indeed, they are dwarfed by the enormous sums already spent on interventions that do not reach those who need them—and by the terrible price being paid in human lives as a result.” (Freedman et al. 2007)

On an individual level, costs of procuring transport to present to hospital, and costs involved of hospital care can sometimes be exorbitantly expensive for individual families. In areas such as cost of transport to get from the community to the hospital may be as much as 20 times the mean daily salary. 18% of all deaths in a South Africa-wide maternal deaths enquiry were attributed to lack of access to transport (National Committee on Confidential Enquiries into Maternal death 2000). If geographic factors present a barrier to ready-access to a hospital, then it often becomes an unachievable individual option to hire or access a mode of transport.

Political will at both regional and local levels also is a powerful force in the creation and implementation of maternity referral systems, and in creation of health and social policies that will facilitate this. The Millennium Development Goals (MDGs), aspirational targets set at the United National Millennium Summit, serve as powerful and measurable international targets to which national governments are accountable. The MDG 5, reducing maternal mortality, puts maternal health and delivery healthcare systems at the forefront of polical view. Unfortunately, of the eight targets, maternal health is one that is lagging behind the most in achieving the targets.

Gender and cultural issues present unique challenges to healthcare systems, even more so in the area of childbirth, where often cultural normal and traditions play an enormous role. Jahn and De Brouwere argue that rural women in particular fear stigmatization and discrimination; they are concerned of loss of dignity, an unfamiliar environment, and loss of emotional support, to name a few (Jahn and De Brouwere 2001).  With limited resources, it is often difficult to provide a spectrum of services to cater for individual specific needs. However, cultural training and appropriate mix of medical professionals are strategies employed to overcome these.

Likewise, perceived quality of care by an individual accessing hospital care is an important yet difficult-to-measure barrier in the decision making process of individuals in accessing hospital services. It is interesting to note that, in a referral hospital in Karachi in 1993, the 118 women who died during childbirth lived within an 8km radius of the hospital (Jafarey & Korejo 1993). The lack of easily measurable physical barriers means that important cultural, communication and quality aspects of care are less readily identified and measured.

Communication between health professionals and levels of healthcare, not only during emergencies, but also for education and prevention, is a key concern. Whilst – reported in a South African maternal death inquiry – 18% of deaths were attributable to lack of transport, a huge 57% were due to in-service problems. Communication is essential to overcome this. (National Committee on Confidential Enquiries into Maternal death 2000).

Recognition of obstetric complications at a local level will allow timely referral to appropriate care facilities. To ensure swift recognition of these issues, investing in education and communication between levels of care plays a vital role.

The Current Situation

It has been demonstrated that hospital-based obstetrics care referrals predominantly consist of self-referrals with a low level of emergency referrals. It has also been demonstrated that to reduce maternal mortality, it is imperative to improve emergency referral processes. (Jahn and de Brouwere 2001).

The end-point of a patient’s journey through the referral system in most instances is the secondary or tertiary hospital. In order to realize the full potential of the maternity referral process, hospital-based care must be of an adequate standard. Unfortunately, it is often the case that in developing regions, hospital care is of a sub-standard quality and may contribute to maternal mortality. (Jahn and de Brouwere 2001).

Current interventions in developing countries focus on education at a community level, reducing geographical and financial barriers and on improving transport and communication.

In the field of community education, Sierra Leone (Kandeh et al. 1997) and Nigeria (Nwakoby et al. 1997) report promotion of utilisation of obstetric care through community activists, educating local communities in referral of obstetrics emergencies. A Ugandan project focused on improving multiple areas of the referral system including linking trained birth attendants to hospitals through walkie-talkies and radio systems. This has increased obstetric referrals by threefold. (Inter-agency group for safe motherhood 1997)

Improving accessibility to healthcare centres has been a focus of many past and current programs. For example, the Safe Motherhood program in Tanzania demonstrated difficulty in keeping vehicles on the road due to lack of maintenance and fuel (Jahn and de Brouwere 2001). Olaniran (Olaniran et al. 1997) describe a loan scheme to fund local car owners who act as on-call transport in the case of local obstetric emergencies. Likewise, in Mali, referral loan funds are available and are managed by local health committees. (Jahn and De Bouwere 2001)

The global Safe Motherhood Initiative was implemented in 1987. This project encouraged international developmental focus on maternal mortality in pregnancy and childbirth. The main killers of women during childbirth were identified and the barriers to accessing care were explored. Aspects of the Safe Motherhood Initiative have been incorporated into much international and national health policy. (Inter-agency group for Safe Motherhood 2012)

There is still a long way to go in strengthening maternity referral systems in developing countries. The current situational failures of maternal healthcare in developing countries can be summarised by the “Three Delays” model. This model identifies three crucial points that may critically affect access to maternal health services:

1. Phase 1 delay. Delay in decision to seek care
   1. Failure to recognise complications
   2. Acceptance of maternal death

1. Low status of women
2. Socio-cultural barriers to seeking care: women’s mobility, ability to command resources, decision-making abilities, beliefs and practices surrounding childbirth and delivery, nutrition and education
3. Phase 2 delay. Delay in reaching care
   1. Poor roads, mountains, islands, rivers – poor organisation
   2. Phase 3 delay. Delay in receiving care
      1. Inadequate facilities, supplies, personnel
      2. Poor training and demotivation of personnel
      3. Lack of finances

(Maternity Worldwide, 2012)

Inequities and Failures

Effective strategies to reduce maternal mortality in developing countries such as a maternity referral system have been written about for over 25 years (Say and Raine 2007). The concept of a maternity referral system is not a new idea. Despite a large volume of academic literature on the subject, it seems that frustratingly there has been slow, if any, actual progress. Key health programs and interventions continue to have limited uptake in developing countries.

Within countries, poor-rich inequities in access to maternal healthcare remains a huge problem. In particular, there is a large gap in accessing professional care for delivery between the top socioeconomic quintile and the bottom socioeconomic quintile of women in a region.  Even delivery care provided by nurses and midwives favours the rich (Howelling 2007).

Marginalized women, especially religious or ethnic minorities, and women from a rural background may find accessing healthcare services difficult. It is recognized that women often fear stigmatization and discrimination; they are concerned about loss of dignity, an unfamiliar environment, and loss of emotional support (Jahn and De Brouwere 2001).  Religious, language, and financial barriers all culminate in an often-insurmountable barrier to accessing care through the maternity referral system.

What can be done?

The ideal scenario is this: as part of an integrated primary healthcare system, every birth, whether it takes place at home or in a facility, is attended by a skilled birth attendant, backed up by facilities that can provide emergency obstetric care and essential newborn care and by a functioning referral system that ensures timely access to the appropriate level of services in case of a life-threatening complication. (Freedman et al. 2007)

Strategies for tackling maternal and neonatal mortality should focus on delivery and the immediate postpartum period. This requires an effective referral system to ensure access to care when clinically indicated. The following recommendations have been collated from a review of the current literature. To ensure an effective referral system the following must occur:

1. Ensure referral hospital facility is of an adequate standard of care, including a 24/7 service, adequate resources, and adequate staff training. This can be audited, monitored, improved through targeted goals.
2. Raising awareness of complications and danger signs of obstetric emergencies so that community members are able to identify and refer women in a timely manner
3. Ensure adequate community resources for emergency communication and transport
4. Engagement of local community members and health workers (Murray and Pearson 2006)
5. A referral strategy informed by assessment of population needs and health system capabilities
6. Active collaboration between referral levels and across sectors
7. Formalized communication and transport arrangements
8. Agreed setting-specific protcols for referrer and receiver
9. Accountability for provider’s performance and supportive supervision
10. Pro-poor protection against the costs of emergency referral
11. Capacity to monitor effectiveness
12. Policy support (Murray and Pearson 2006), preventing excessive segmentation of the health system and increasing the power of the poor and other marginalized groups. (Freedman et al. 2007)
13. Focus on building capacity at a local level through solid primary healthcare systems and a focus on district-level care (Freedman et al. 2007)
14. Health systems must be valued as core social institutions that will assist in the reduction of poverty and inequity and for advancing human rights.
15. Increase funding in areas of need through bilateral donors and international financial institutions
16. User fees should be abolished at a local level so it does not become another financial burden on an already impoverished population
17. Future capacity planning to create a workforce of local skilled birth attendants—the health workers key to reducing maternal deaths.

REFERENCES

Adam et al Cost effectiveness analysis of strategies for maternal and neonatal health in developing countries. BMJ 2005;331:1107

Gareth Jones, Richard W Steketee, Robert E Black, Zulfiqar A Bhutta, Saul S Morris, and the Bellagio Child Survival Study Group. How many child deaths can we prevent this year? The Lancet. 2003;362

Houweling TAJ, Ronsmans C, Campbell OMR & Kunst AE. Maternity care in developing countries: a study of inequalities. Bulletin of the World Health Organization .2007;85:745–754

Jahn A, De Brouwere V. Referral in pregnancy and childbirth: Concepts and strategies. Stud Health Service Organisation Policy 2001; 17: 229-246.

Jahn A, Kowalewski M & Kimatta SS (1998). Obstetric care in Southern Tanzania: Does it reach those in need? Tropical Medicine and International Health 3,926-932.

Jafarey SN & Korejo R (1993). Mothers brought dead: An inquiry into causes of delay. Social Science and Medicine 36,371-372.

Kandeh et al. Community motivators promote use of emergency obstetric services in rural Sierra Leone. International Journal of Gynecology & Obstetrics. 1997;59(2):S209-S218

Kowalewski M, Jahn A & Kimatta SS (2000). Why do at-risk mothers fail to reach referral level care? Barriers beyond distance and cost. African Journal of Reproductive Health 4,100-109.

Lynn P, Freedman RJ, Waldman H de Pinho, Wirth ME. Who’s got the power? Transforming health systems for women and children. UN Millenium Project Task Force on Child Health & Maternal Health, 2005:77–95

Maternity Worldwide. The three delays model. Visited 2012

http://www.maternityworldwide.org/about-us/information-and-resources/the-3-delays-model/

Murray SF, Buller AM, Bewley S,  Sandall J. Metrics for monitoring local inequalities in access to maternity care: developing a basket of markers from routinely available data. Qual Safe Health Care 2010;19:e39.

Murray SF, Pearson SC. Maternity referral systems in developing countries: Current knowledge and future research needs. Social Science and Medicine. 2006:62;2205-2215

Murray SF, Pearson S. 2004. “Maternity Referral Systems in Developing Countries: Challenges and Next Steps. A Scoping Review of Current Knowledge.” Background paper commissioned by the UN Millennium Project Task Force on Child Health and Maternal Health and the World Health Organization. New York.

National Committee on Confidential Enquiries into Maternal death (2000). A review of maternal deaths in South Africa during 1998. National Committee on Confidential Enquiries into Maternal Deaths. S.Afr.Med J. 90,367-373.

Nwakoby et al. Community contact persons promote utilization of obstetric services, Anambra State, Nigeria. International Journal of Gynecology & Obstetrics. 1997;59(2):S219-S224

Safe Motherhood Group. Safe Motherhood Group Website. Visited 2012

http://www.safemotherhood.org/priorities/initiatives.html

Say L, Raine R. A systematic review of inequalities in the use of maternal health care in developing countries: examining the scale of the problem and the importance of context. Bulletin of the World Health Organization .2007;85:812–819

Shah, Divakar and Meghal. Combating Postpartum Hemorrhage In India: Moving Forward. In B-Lynch C, Keith L, Lalonde A, Karoshi M. A Textbook of Postpartum Hemorrhage. A comprehensive guide to evaluation, management and surgical intervention. Jaypee Brothers Publishers. 2006

The UK All Party Parliamentary Group on Population, Development and Reproductive Health, 2009

UNICEF. Indian Health Information. Visited 2012. http://www.unicef.org/india/health.html

Wagstaff and Claeson. The millennium development goals for health : rising to the challenges. The World Bank, 2004.

WHO. Essential elements of obstetric care at first referral level, Macmillan Press Ltd., London, 1991.

WHO. Care in Normal Birth: a practical guide, Maternal and Newborn Health/Safe Motherhood Unit, Family and Reproductive Health, WHO, Geneva, 1996

WHO Mother-Baby-Package: Implementing safe motherhood in countries, Maternal Health and Safe Motherhood Programme, WHO, Geneva, 1994

Women Deliver. Homepage. Visited 2012.

http://www.womendeliver.org/about/the-issue/three-core-strategies-to-save-lives/

Preconception health care and congenital disorders

Below is the abstract to a recent paper I published looking at the impact of preconception healthcare on congenital disorders in England. On exploration of the models of preconception healthcare delivery, I found many interesting ethical qandries, including that of the maternal-fetal conflict. Furthermore, in developed countries such as England, preconceptional healthcare is relatively achievable at a population level, compared to preconception healthcare indeveloping countries. That is not to say that the burden of congenital diseases is any less in developing countries; infact congenital diseases are thought not only to contribute to disease burden alone, but also to increased morbidity and mortality from other communicable and non-communicable diseases. For example, a child born with cerebral palsy may be more susceptible to malnutrition, a large contributor to under 5 mortality worldwide. 

An interesting project addressing the burden of congenital disorders in middle-income countries can be found through the PHG Foundation.

 

Preconception health care and congenital disorders: mathematical modelling of the impact of a preconception care programme on congenital disorders

Shannon G, Alberg C, Nacul L, Pashayan N. Preconception health care and congenital disorders: mathematical modelling of the impact of a preconception care programme on congenital disorders.BJOG 2012; DOI: 10.1111/1471-0528.12116

http://onlinelibrary.wiley.com/doi/10.1111/1471-0528.12116/abstract

Objective

This study aims to model the impact of preconception care on births with congenital disorders at a national level.

Design

Mathematical cross-sectional model based on life-table methodology.

Setting

Research conducted in Cambridge, United Kingdom.

Population

Women aged 15–45 years in England, 2001.

Methods

A mathematical model was constructed based on cross-sectional data from women aged 15–45 years in England undertaking one of three interventions, so as to reflect different strategies of preconception care: folic acid supplementation and fortification (representing national, universal interventions); alcohol intervention (reflecting primary care strategies); and diabetes management (targeting a population of high-risk women with a known chronic disease).

Main outcome measure

Reduction in the prevalence of congenital disorders at birth.

Results

Between 585 (lower estimate) and 1085 (upper estimate) congenital disorders could be prevented with a national preconception programme, based on a single-year national cohort in England. This represents an 8–15% reduction in annual notifications of congenital disorders in live births annually. According to modelled estimates, folic acid fortification or supplementation, alcohol intervention, and diabetic management may result in a 46, 32–62, 53, and 54% reduction in the live birth prevalence of specific congenital disorders, respectively. In an ideal scenario, the application of this model decreases the total annual number of congenital disorder notifications by approximately one-sixth.

Conclusion

A preconception care programme comprising three different strategies potentially can reduce the number of infants born with congenital disorders at a national level. This model provides strong support for preconception care to become a healthcare priority, and has major implications for healthcare planning.

http://onlinelibrary.wiley.com/doi/10.1111/1471-0528.12116/abstract