Submission to the Select Committee on Stillbirth Research and Education Inquiry into the future of stillbirth research and education in Australia
This submission has been developed by the Multicultural Centre for Women’s Health (MCWH), the national voice for immigrant and refugee women’s health and wellbeing.
MCWH is a Victorian women’s health service established in 1978 that works both nationally and across Victoria to promote the health and wellbeing of immigrant and refugee women through advocacy, social action, multilingual education, research and capacity building.
MCWH works to provide research, expert advice, and professional development to key stakeholders on improving the health and wellbeing of immigrant and refugee women across Australia. It does this through research and publication, participation in advisory groups and committees, written submissions, training and seminar programs, and presentations of our work.
MCWH also works directly with women in the community providing capacity building and multilingual education on women’s health and wellbeing, across a wide range of issues and topics, through the use of trained, community-based, bilingual health educators (see MCWH Annual Report 2017).
Given MCWH’s role as a national, community based organisation committed to the achievement of health and wellbeing for and by immigrant and refugee women, this submission focusses on the need for stillbirth research and education for women and babies from immigrant and refugee backgrounds.
Specifically, in relation to the Committee’s terms of reference, this submission seeks to respond to the issues of:
e. research and education priorities and coordination, including the role that innovation and the private sector can play in stillbirth research; and
f. communication of stillbirth research for Australian families, including culturally and linguistically appropriate advice for Indigenous and multicultural families, before and after a pregnancy.
In 2013-14, 1,531 of the 4,419 still births (34.6%) that occurred in Australia were born to women born in countries other than Australia. However, most research and data related to stillbirths focuses on the mainstream population. Furthermore, the available data relating to immigrant and refugee women raises questions which need further research and analysis. Specifically, this submission wishes to draw attention to the following findings:
1. The latest data indicates that babies born in Australia to women born in a number of overseas countries had a far higher rate of stillbirth than women born in Australia. Women born in Oceania (9.3), India (9.1), Africa (9.0) and other Middle East and North Africa (9.0) all had a stillbirth rate of at least 9.0 per 1,000 births, in contrast to both women born in Australia who had a stillbirth rate of 6.9 per 1,000 (AIHW, 2018).
2. A number of Australian state-based studies have also shown that:
- Compared with other refugee groups, women from West African humanitarian source countries were found to have the highest stillbirth incidence (4.4% compared to 1.2% and 1.6% from other regions) (Gibson-Helm et al 2014).
- South Asian born women were more than twice as likely to have a late pregnancy antepartum (i.e. not long before birth) stillbirth than either Australian-born or South-East Asian born women (Drysdale et al 2012).
- Lebanese born women had the highest rates of stillbirth (7.2 per 1000 births) compared with low risk women born in Australia and other women born overseas (Dahlen et al 2013).
- While most available research indicates that many women born overseas experience significantly more risk of stillbirth than women born in Australia, some women born overseas had lower rates of stillbirth than women born in Australia.
While the available evidence indicates differences in women’s risk of stillbirth in relation to their country of birth, more research is needed to shed light on the specific causes and contributing factors which have led to these outcomes. Current research shows that in general, immigrant and refugee women are at a greater risk of suffering poorer maternal and child health outcomes (MCWH Sexual and Reproductive Health Data Report 2016). Based on available evidence, this submission would like to highlight the following issues for further research and development:
1) Immigrant and refugee women’s late presentation to antenatal care.
Antenatal care is associated with better maternal health, fewer interventions in late pregnancy and positive child health outcomes. Australian Antenatal Guidelines recommend that the first antenatal visit occur within the first ten weeks of pregnancy and that 10 visits should be adequate for a woman’s first pregnancy without complications and that 7 visit should be adequate for subsequent uncomplicated pregnancies.
In 2013-14, babies born to women who accessed 6 or more antenatal visits had a lower stillbirth rate than babies born to women who accessed fewer antenatal visits or had not accessed antenatal care at all (AIHW 2018).
Women born overseas who gave birth in Australia in 2013 were found to have attended their first antenatal visit at later gestational ages than Australian born mothers (MCWH 2016). This finding suggests that immigrant women are less likely to attend antenatal care and need to be linked to appropriate health supports and have access to perinatal education.
Access to and provision of an appropriately qualified workforce relies on workers being trained to deliver culturally appropriate care that meets the specific needs of immigrant and refugee women.
2) Disparity in stillbirth rates between rural and regional and metropolitan locations.
Data suggests that women who live in regional, remote or very remote parts of Australia increases the likelihood that they may experience stillbirth (AIHW 2018). Although this data was not disaggregated in order to understand the number of immigrant and refugee women in this data set, we know that immigrant and refugee women who live in rural and regional areas face multiple disadvantages accessing a range of health services compared to their metropolitan counterparts.
Women in rural areas are less likely to obtain health care from medical specialists and more likely to rely on hospital care (NRHA 2012). However, for immigrant women, access to mainstream services do not always provide the culturally appropriate care women need.
While the majority of immigrants and refugees live in metropolitan regions of Australia, the population of new migrants living in rural areas is growing, and in many areas, exceeding the population growth of the general population.
3) Need for increased culturally and linguistically appropriate health care, education and support.
A systematic and comparative review of studies in five countries (including Australia) of immigrant and non-immigrant’s women’s experiences of maternity care has shown that all women – both immigrant and non-immigrant – want maternity care that is safe, high-quality, attentive and individualised, with adequate information and support (Small et al 2014). However, the same study has also shown that:
- immigrant women were less positive about their care than non-immigrant women.
- communication problems and lack of familiarity with care systems impacted negatively on immigrant women’s experiences.
- immigrant women reported problems with discrimination or prejudice. (Yelland et al 2015)
Other Australian studies (Hennegan et al 2015; Yelland et al 2015; Lansakara et al 2010; Bandyopahyay et al 2010; Mengesha et al 2016) highlight the impacts of immigrant and refugee women’s interactions with health professionals on their access to healthcare.
4) Identification of best practice.
MCWH works within an intersectional feminist framework, which recognises that immigrant and refugee women experience multiple and interlocking forms of oppression and discrimination. An intersectional approach recognises that gender alone is not a sufficient lens through which to view women’s health and access to services.
MCWH has published research and best practice guides, which draw on an intersectional framework and recommend culturally responsive health service delivery, such as provision of interpreters, bilingual health professionals and female health professionals.
In a systematic global mapping of interventions to reduce maternal and newborn mortality that addressed cultural factors affecting women’s use of skilled maternity care, Coast et al. identify a range of effective strategies, including the use of bilingual health workers; culturally appropriate health education activities and participatory approaches (Coast et al 2013).
Evaluations from the Multicultural Centre for Women’s Health bilingual health education program over the last 40 years indicate that non-didactic, peer-based multilingual health education sessions increase women’s willingness to access health services, take initiative about their health and share information about their health with others (MCWH Annual Report, 2017).
In summary, MCWH recommends that the Inquiry be attentive to the need for further research that:
- is inclusive of immigrant and refugee women’s experiences of stillbirth and support.
- is specifically focused on immigrant and refugee women’s experiences of stillbirth and support.
- is both qualitative and quantitative, to better understand the causes and contributing factors that lead to higher stillbirth rates among immigrant and refugee women in Australia.
- amplifies migrant and refugee women’s voices by following a participatory research model and utilising trained bilingual interviewers. The methodology followed for the ASPIRE research project, a collaboration between the University of Melbourne, the University of Tasmania and the Multicultural Centre for Women’s Health, provides an example (Vaughan et. al. 2015).
- Includes the collection, measurement and monitoring of robust data across core areas relating to immigrant and refugee women’s perinatal health, care and wellbeing.
In reference to education, MCWH recommends that the inquiry be attentive to the need for migrant and refugee women to be appropriately informed and educated about pregnancy, antenatal care and stillbirth. Specifically, delivery of education should be:
- evidence-informed and follow best practice models;
- delivered via bilingual peer support and education initiatives, particularly for newly-arrived women;
- complemented by culturally appropriate multilingual resources and education materials that have been developed in consultation with communities and migrant women who have experienced stillbirth;
- complemented by referrals to antenatal care provided by an appropriately qualified workforce trained to deliver culturally responsive care.
Australian Institute of Health and Welfare (2018) Perinatal deaths in Australia: 2013-14. Cat. No. PER 94. Canberra: AIHW.
Bandyopadhyay M, Small R, Watson L & Brown S (2010) Life with a new baby: how do immigrant and Australian-born women’s experiences compare? Aust N Z J Public Health, 34: 412-421.
Coast E, Jones J, Portela A, Lattof, S (2014) Maternity care services and culture: a systematic global mapping of interventions. PLOS One, 9 (9).
Dahlen, HG, Schmied, V, Dennis C-L & Thornton C (2013) Rates of obstetric intervention during birth and selected maternal and perinatal outcomes for low risk women born in Australia compared to those born overseas, BMC Pregnancy and Childbirth, 313: 100.
Drysdale H, Ranasinha S, Kendall A, Knight M & Wallace EM (2012) Ethnicity and the risk of late-pregnancy stillbirth, Med J Aust, 197 (5): 278-281.
Gibson-Helm M, Teede H, Block A, Knight M, East C, Wallace EM, & Boyle J (2014) Maternal health and pregnancy outcomes among women of refugee background from African countries: a retrospective, observational study in Australia, BMC Pregnancy Childbirth, 14: 392.
Hennegan J, Redshaw M, Kruske S (2015) Another country, another language and a new baby: A quantitative study of the postnatal experiences of migrant women in Australia, Women Birth, 28(4): 124-33.
Lansakara N, Brown S & Gartland D (2010) Birth outcomes, postpartum health and primary care contacts of immigrant mothers in an Australian nulliparous pregnancy cohort study, Maternal Child Health Journal,14(5): 807-16.
Mengesha ZB, Dune T & Perz J (2016) Culturally and linguistically diverse women’s views and experiences of accessing sexual and reproductive health care in Australia: a systematic review, Sexual Health: http://dx.doi.org/10.1071/SH15235
National Rural Health Alliance (2012) ‘Women’s Health in Rural Australia’, Fact sheet 31. March: NRHA.
Small R, Roth C, Raval M, Shafiei T, Korfker D, Heaman M, McCourt C & Gagnon A (2014) Immigrant and non-immigrant women’s experiences of maternity care: a systematic and comparative review of studies in five countries. BMC Pregnancy and Childbirth, 14: 152
Vaughan C, Davis E, Murdolo A, Chen J, Murray L, Quiazon R, Block K, and Warr D (2015) ‘ASPIRE: A multi-site community-based participatory research project to increase understanding of the dynamics of violence against immigrant and refugee women in Australia’, BMC Public Health, 15(1).
Yelland J, Riggs E., Small R & Brown S (2015) Maternity services are not meeting the needs of immigrant women of non-English speaking background: Results of two consecutive Australian population based studies, Midwifery, 31(7): 664-70.