Pregnancy and parenting in young Aboriginal people and Torres Strait Islanders: what are the issues and implications for care providers?

RANZCOG 2011 Indigenous Women’s Health Meeting, June, Cairns

Dr Sarah Larkins GP, Associate Professor and AHW, Indigenous Health AcademicSchool of Medicine and DentistryJames Cook Universitysarah.larkins@jcu.edu.au

Outline

• Sources• Background information

– Indigenous young people and teenage pregnancy– Scope, associations and outcomes– Scope, associations and outcomes

• Issues in service delivery for pregnancy and parenting Indigenous young people– Issues for clinical practice– Issues for policy– Best practice in supporting young parents

Major sources

• Clinical and research work (team) in young people’s sexual and reproductive health 10 years at TAIHS

• PhD research, done through TAIHS/JCU • Literature review and case studies of best • Literature review and case studies of best

practice (funded by Queensland Health) –Indigenous reference group

• Current work with FPQ and QH into access to SRH services for rural and regional young people

Why is this an issue?

• Aboriginal and Torres Strait Islander young people over-represented in sexual and reproductive health morbidity and teenage pregnancy

• For Indigenous women, teenage fertility • For Indigenous women, teenage fertility rate is 70 per 1000 women aged 15-19(compared with 16 per 1000 women for all women) (ABS, 2007)

• Barriers for young people in accessing PHC services (Booth et al 2004, Haller et al 2007)

Measuring young parenthood

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Teenage birth rates by country and ethnicity per 1000 women aged 15-19

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(From ABS 2006 and Alan Guttmacher Institute 2006)

And in Australia…..

• In 2007, teenage fertility rate was 16 babies per 1000 women (between 15 and 19)

• Higher in more rural and economically disadvantaged areas (10-20x)

• For Indigenous women, teenage fertility rate is • For Indigenous women, teenage fertility rate is 70 per 1000 women (ABS, 2007)

• Teenage births are about 20% of all Indigenous births and 4% of all Australian births

• Indigenous women tend to have more babies and at a younger age (2.4 babies per woman compared with 1.9 babies)

Outcomes of teenage pregnancy

• Some evidence of worse obstetric outcomes- higher maternal and perinatal mortality – higher rates of low birthweight, prematurity

• Mostly determined by socioeconomic status, access to services and lifestyle factors rather access to services and lifestyle factors rather than age or Indigenous status (AIHW 2008, ABS 2007)

• Importance of accessibility and acceptability of antenatal care

Longer term outcomes

• Association with lower SES and less schooling – but can’t attribute cause.

• Substance use – higher before pregnancy, but young Indigenous mums more likely to cease – opportunity to gain control and autonomy (Quinlivan 2004)

• With adequate support, many use pregnancy as a positive turning point

Preventable morbidity during pregnancy

• Infections during pregnancy contribute to low birthweight (small for gestational age) and prematurity.

• 456 Indigenous singleton births in Townsville • 456 Indigenous singleton births in Townsville – 64% of mothers smoked – 15% drank alcohol at harmful/hazardous levels– 13% other recreational drugs– 20% STI during pregnancy – 50% had any infection (Panaretto et al 2006).

“ U Mob Yarn Up” project

• 20.2% of pregnant women seen at local AICCHS younger than 20 (Panaretto et al 2005)

• “U Mob Yarn Up” young parents’ project devised based on support needs expressed by young Indigenous mothers

• Aimed to investigate complex social attitudes and behaviours related to sex, contraception and pregnancy among Indigenous adolescents in Townsville

ConsultationTAIHS, schools, steering committee

Formation of Young Mums’ Group8 meetings – expert panel and key participants

School 138 CASI

4 FGD

School 236 CASI

4 FGD

School 397 CASI

3 FGD

Youth shelter15 CASI surveys

Field work (young mums as peer interviewers)

4 FGD 4 FGD 3 FGD

Individual interviews with young mothers (10)

Young Mums’ Group Meetings (4)

Feedback of results and program designTAIHS, schools, steering committee, wider community

Results

Figure 1. Age of participants

18 years

17 years

16 years

13 years

12 years

Missing

Figure 2. Ethnicity of participants

Other

South Sea Islander

Aboriginal & TSI

Missing

16 years

15 years

14 years

Torres Strait Island

Aboriginal

Summary of findings: students

• Imbalance between educational aspirations and resources

• Very traditional gender/power relationships• Patchy knowledge about STIs and access to

contraception contraception • Shame and limited communication resulting

in inconsistent contraceptive use• Few wanted to become pregnant in teens, but

would receive support and not consider abortion if became pregnant

Summary of findings from young mothers

• Young mums from very disadvantaged backgrounds

• Pregnancies unplanned but not unwanted

• Pregnancy and childbirth the impetus for • Pregnancy and childbirth the impetus for “transformation” in terms of taking responsibility and making positive changes

• Remained disadvantaged and in need of appropriate practical support, but more a sense of creating their own futures

• May be one way of achieving an adult identity

‘Cos see, my mum’s mum had my mum when she was 14...so it was really young…Everyone starts young in my family [16-year-old Aboriginal and TSI woman] Nah, like after I had [son] I

settled down, like with the settled down, like with the breaking in and everything, I’m like, look, I can’t keep doing this, because I’m a mum now, and I’ve got to

start acting like one [15 year old Aboriginal woman]

I knew I was having that baby…I knew I made my bed and now I had to sleep in it... always had a place since then, we never been

homeless…[18 year old Aboriginal woman]

Key issues impacting on young Indigenous parents

• With adequate support, pregnancy and parenthood can be impetus for positive change

• Poverty, educational disengagement and unemployment

– housing, transport, mobility, childcare– housing, transport, mobility, childcare

• Social and emotional wellbeing,

– Postnatal depression, stigma and judgement, inadequate social support, perceived lack of parenting skills, family violence, substance abuse

• Issues with accessibility of services

• Knowledge of contraception

Implications for health care providers

� Sensitive and non-judgmental antenatal and postnatal care for young mothers and their families – avoiding stigma

� Small local Young Mums’ Groups with dedicated IHW� Support, education and linkage functions

� Assisting young mothers and pregnant women to take the steps they feel necessary to be a “good mother”

Implications for health care providers (2)

• Increasing access for young Indigenous people to contraception, STI testing and treatment and abortion

• Adequate and realistic information to all young people about pregnancy, birth and childcare

Implications for policy-makers

� “Shame-free” safe sex education � Access to health care and contraception

� School nurses and youth health clinics with outreach programs

� Adequate funding for support and service � Adequate funding for support and service linkage for young parents

Best practice in supporting young parents

• Holistic integrated services (linkage function)

• Co-location with other services (one stop shop)

• Strengths-based parenting education

• Soft-entry points for engagement

• Committed warm Indigenous program staff• Committed warm Indigenous program staff

• Support for young fathers

• Strategies to overcome practical barriers (transport, childcare, food)

• Group activities and peer-education (social function)

Role of Indigenous Young Parent Support Workers (IYPSW)

• New initiative of Queensland Health• Two positions recently piloted with four

more now in place• Provide support for young Indigenous

parents during the antenatal and postnatal parents during the antenatal and postnatal period.

• Education, support, and service linkage functions

• Evaluation recently completed

Key Points

• Although improving, still unacceptable levels of poor outcomes for young Indigenous women in pregnancy

• Can be improved with appropriate accessible antenatal and child health care – needs to be holistic and consider whole person and contextholistic and consider whole person and context

• Can be a great opportunity for health promotion and educational interventions

• Building trust and relationships with young people really important

• Involve young people and Indigenous staff

ThanksQuestions?

References

• Australian Bureau of Statistics (2008). Births Australia, 2005, • Australian Bureau of Statistics: Australian Institute of Health and Welfare (2008). The

Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples. Canberra.• Australian Institute of Health and Welfare. Australia's young people: their health and

wellbeing 2003. Canberra: Australian Institute of Health and Welfare 2003. Report No.: AIHW Report No: PHE-50.

• Booth ML, Bernard D, Quine S, Kang M, Usherwood T, Alperstein G, et al. Access to health care among Australian adolescents: young people's perspectives and their socio-demographic distribution. Journal of Adolescent Health 2004;34(1):97-103.

• Couzos and Murray (2007). Aboriginal Primary Health Care, an Evidence-Based • Couzos and Murray (2007). Aboriginal Primary Health Care, an Evidence-Based Approach. 3rd Edition, Oxford University Press

• Haller DM, Sanci LA, Patton GC, Sawyer SM. Toward youth friendly services: a survey of young people in primary care. Journal of General Internal Medicine. 2007 June;22(6):775-81

• Herceg, A. (2005). Improving health in Aboriginal and Torres Strait Islander mothers, babies and young children: a literature review: Department of Health and Aging.

• Holmes W, Stewart P, Garrow A, Anderson I, Thorpe L. Researching Aboriginal health: experience from a study of urban young people's health and well-being. Social Science and Medicine. 2002;54:1267-79

• Kang M, Bernard D, Booth ML, Quine S, Alperstein G, Usherwood T, et al. Access to primary health care for Australian young people: service provider perspectives. British Journal of General Practice. 2003;53(12):947-52.

• Kang M, Bernard D, Usherwood T, Quine S, Alperstein G, Kerr-Roubicek H, et al. Primary health care for young people: are there models of service delivery that improve access and quality? Youth Studies Australia. 2006 June;25(2):49-60.

References (2)

• Kruske, S., Kildea, S., & Barclay, L. (2006). Cultural safety and maternity care for Aboriginal and Torres Strait Islander Australians. Women and Birth, 19(3), 73-77.

• Larkins, S.L, Page RP, Panaretto K et al (2011). The transformative potential of young parenthood for Indigenous women in Townsville. MJA. 16th May 551-555.

• Larkins, S. L. (2007). Attitudes and behaviours of teenage Indigenous women in Townsville, Australia, with respect to relationships and pregnancy: The "U Mob Yarn Up" Young Parents' project [Unpublished PhD thesis]. James Cook University, Townsville.

• Larkins, S. L., Page, R. P., Panaretto, K. S., Scott, R., Mitchell, M. R., Alberts, V., et al. (2007). Attitudes and behaviours of young Indigenous people in Townsville concerning relationships, sex and contraception: the "U Mob Yarn Up" project. Medical Journal of Australia, 186, 513-518

• Larkins, S and McGinty S (2009) Review of literature, evaluations and research on Australian Indigenous Young Parents’ Programs. Queensland Health.

• Panaretto, K. S., Lee, H. M., Mitchell, M., Larkins, S. L., Manessis, V., Buettner, P., et al. (2005). Impact of a collaborative shared care antenatal care program for urban Indigenous women: a prospective cohort study. Medical Journal of Australia, 182(10), 514-519.

• Panaretto, K. S., Lee, H. M., Mitchell, M., Larkins, S. L., Manessis, V., Buettner, P., et al. (2006). Risk factors for preterm, low birthweight and small for gestational age birth in urban Aboriginal and Torres Strait Islander women in Townsville. Australian and New Zealand Journal of Public Health, 30(2), 163-170.

• Tylee A, Haller DM, Graham T, Churchill R, Sanci LA. Youth-friendly primary-care services: how are we doing and what more needs to be done? The Lancet. 2007;369(May 5):1565-73 .

• Veit F, Sanci LA, Coffey CM, Young D, Bowes G. Barriers to effective primary health care for adolescents. Medical Journal of Australia. 1996;165:131-3