Mapping Aboriginal and Torres Strait Islander maternal and infant health programs and services in Victoria, Australia

Introduction

Before colonisation, Aboriginal and Torres Strait Islander people thrived on a balanced relationship with the land, sea and waterways, adapting to the environment and enabling strong, thriving peoples and cultures.¹ Colonisation, including forced child removal and disruption of traditional food systems, interrupted this balance, resulting in detrimental health outcomes.² Contemporary manifestations of colonisation include shorter life expectancy, infectious and chronic diseases, mental health disorders and substance dependence.¹ Experiences of racism and state-sanctioned child removal have led to widespread mistrust among Aboriginal people towards mainstream institutions, including health services.³ This article will respectfully use the term ‘Aboriginal’ when referring to the First Peoples of mainland Australia.

Aboriginal Community Controlled Health Organisations (ACCHOs) were established in the 1970s to respond to unmet primary health care needs for Aboriginal communities. The first ACCHO was founded in Sydney in 1971, followed by the Victorian Aboriginal Health Service in Melbourne in 1973. Since then, the sector has progressively grown to 145 ACCHOs in over 550 sites.⁴ In Victoria, the Victorian Aboriginal Community Controlled Health Organisation (VACCHO) is the peak body for ACCHOs, supporting 33 member ACCHOs and advocating for better health for Aboriginal communities.⁵ A priority for VACCHO is supporting health in the early years of life for Aboriginal families.⁵ In 2021 there were 4144 Aboriginal infants (aged 0–2 years) in Victoria, equivalent to 6% of the Victorian Aboriginal population.⁶

Ensuring a healthy start to life is vital for establishing health throughout life and strengthening future generations.^1–3 In Australia, healthy birthweights and early childhood development are key priorities within the Closing the Gap agenda, agreed by all levels of government and the ACCHO sector.⁷ The National Aboriginal and Torres Strait Islander Early Childhood Strategy prioritises healthy births, early childhood development, connection to culture, safe and supporting environments, and contribution to better service systems.⁸ Therefore, the provision of maternal and infant healthcare by ACCHOs, grounded in community and culture, is essential for Aboriginal and Torres Strait Islander families.

Education about and support for pregnancy, breastfeeding, nutrition, oral health, active play and sleep are essential components of comprehensive maternal and infant healthcare to support healthy growth and development.^1–3 A recent review found that having access to culturally appropriate infant health services was a key determinant of infant feeding decisions for Aboriginal and Torres Strait Islander families.⁹ In Victoria, Maternal and Child Health (MCH) Services are funded by the state government as a ‘universal’ primary health service for all Victorian families with children from birth to 3.5 years. MCH nurses provide 10 key ‘age and stage’ visits including growth monitoring and provision of information and support.⁷ Evidence suggests some Aboriginal families are concerned about racism and cultural safety and do not feel comfortable attending mainstream MCH services.⁸ Consequently, engagement with MCH services is lower for Aboriginal families than for other Victorian families. For example, at 12 months, 67.5% of Victorian Aboriginal families attend the scheduled MCH visit, compared with 83.4% of non-Aboriginal families.⁷ Thus, many Aboriginal families may be missing out on growth assessment and important support for various health issues.

Maternal and infant services for Aboriginal and Torres Strait Islander families differ across the country, with each state unique in its policy context. For example, in 14 sites across the country with one located in Victoria, ACCHOs work in partnership with the Australian Nurse-Family Partnership Program to deliver maternal and infant services through a nurse-home visiting model.¹⁰ Two examples of Aboriginal-specific services in Victoria are Koori Maternity Services (KMS) and the Aboriginal Maternal and Child Health (Aboriginal MCH) Initiative. Both are funded by the Victorian Department of Health with coordination provided by VACCHO. These Aboriginal-specific services are designed to meet the specific cultural and healthcare needs of Aboriginal families. Similar maternal and infant health programs are provided in other states, such as the Aboriginal Maternal and Infant Health Service in New South Wales and the Apunapima Baby One program in Far North Queensland, which have demonstrated improvements in the provision of antenatal and postnatal care for Aboriginal babies.^11–13

KMS provide care for Aboriginal mothers from conception to around 6 weeks postpartum. The service is usually delivered at an ACCHO (three within public hospitals), with services delivered by a midwife in partnership with an Aboriginal health worker.^14,15 The Aboriginal MCH initiative was established in response to advocacy from VACCHO to provide MCH nurses for Aboriginal families at certain ACCHOs. Both KMS and Aboriginal MCH provide the same level of staffing to funded services regardless of population size. Although these Aboriginal-specific services provide a culturally safe alternative to mainstream health services, they are not available in all communities; thus, not all Aboriginal families have access to culturally appropriate maternal and infant healthcare. To inform future Aboriginal and Torres Strait Islander maternal and infant health service planning in Victoria, it is important to understand the geographical distribution of Aboriginal-specific maternal and infant services across Victoria in relation to the Aboriginal infant population. Mapping studies can be a useful method for evaluating the availability and location of services and have been undertaken internationally¹⁶ and within Australia;¹⁷ however, no mapping studies have focused specifically on Aboriginal and Torres Strait Islander maternal and infant health.

Therefore, the aim of this study was to compare the distribution of Aboriginal-specific services for maternal and infant healthcare with the Aboriginal infant population across all local government areas (LGAs) of Victoria and identify gaps in service availability.

Methods

Results

Of the 79 Victorian LGAs, 21 (27%) offered Aboriginal-specific services in either pregnancy or maternal child health, and 12 (15%) offered both, providing continuity of Aboriginal-centred care throughout the first 1000 days. Figs 1 and 2 provide maps of services across regional and metropolitan LGAs, shaded according to the Aboriginal infant population. The maps indicate the location of ACCHOs and public hospitals that provide Aboriginal-specific maternal and infant health services.

Fig. 1.

Location of Aboriginal-specific maternal and infant services by local government area (LGA) according to the number of Aboriginal infants aged 0–2 years (Victoria). Koorie Maternity Services (KMS). Both KMS and Aboriginal Maternal Child Health (MCH) Services. Aboriginal MCH Services. Aboriginal maternal and infant health service within a mainstream facility.

Fig. 2.

Location of Aboriginal-specific maternal and infant services by local government area (LGA) according to the number of Aboriginal infants aged 0–2 years (Metropolitan Melbourne). Koorie Maternity Services (KMS). Both KMS and Aboriginal Maternal Child Health (MCH) Services. Aboriginal MCH Services. Aboriginal maternal and infant health service within a mainstream facility.

Table 1 lists 50 of the 79 Victorian LGAs by Aboriginal infant population on the basis of the 2021 Census. Sixteen LGAs had an Aboriginal infant population above the state average (>100), yet 7 of these 16 LGAs had no Aboriginal-specific maternal and child health services. Gaps in service provision were particularly apparent in high-growth LGAs in outer-metropolitan Melbourne. For example, the city of Melton is the fastest-growing municipality in Victoria²² and does not have any Aboriginal-specific maternal and infant health services, indicating a major gap in early years service provision. Likewise, the Casey LGA has services available in neighbouring LGAs; however, access to these services is dependent on the availability of transport, either personal or public. By contrast, regional LGAs such as Ballarat would require Aboriginal families to travel longer distances to access Aboriginal-specific services. The median population of Aboriginal infants in LGAs that had some services was significantly higher than in areas offering no service (81.0 vs 19.5, P < 0.001).

Discussion

This is the first study in Australia, to our knowledge, to map the availability of Aboriginal maternal and infant health services and compare their geographical distribution with the Aboriginal and Torres Strait Islander population. Our analysis found that areas offering Aboriginal-specific services tended to have a higher Aboriginal infant population, which is a positive finding. There are Aboriginal maternity care services available at three LGAs within metropolitan Victoria that offer care to Aboriginal women throughout pregnancy and after birth. However, our analysis also suggests there are some major gaps in Aboriginal early years health service provision in Victoria, with only one in four LGAs offering Aboriginal-specific maternal and infant health services. Concerningly, some LGAs with the highest populations of Aboriginal infants (aged 0–2 years) offer no Aboriginal-specific services. Furthermore, very few LGAs (15%) offer continuity of Aboriginal-specific maternal and infant healthcare across pregnancy and the early childhood period.

Barriers to accessing maternal and infant healthcare for Aboriginal families extend beyond the physical distance to a service. Aboriginal and Torres Strait Islander people continue to experience the ongoing effects of colonisation including intergenerational trauma, systemic racism and forced removal of children.²⁴ This forced removal of children, known as the Stolen Generations, perpetuates mistrust in government institutions and has interrupted kinship systems and parenting styles.²⁵ Lack of culturally safe care, experiences of racism, limited numbers of Aboriginal staff in the health workforce and under-resourcing of services further affect the continuity of care for Aboriginal mothers and their babies.^26–28 The Strong Mums, Solid Kids program operated by the Nunkuwarrin Yunti ACCHO²⁹ offers continuity of care from pregnancy to early childhood for Aboriginal families in Adelaide. Evidence shows that Aboriginal-led, culturally safe models of maternal and infant healthcare improve service engagement, smoking cessation and maternal and infant health outcomes.^30–33 Providing an Aboriginal-specific pregnancy care service and an Aboriginal-specific maternal and child health service in the same location is likely to enhance continuity of care, which has been shown to contribute to improved health outcomes.^26,27

We identified 18 LGAs that had at least one Aboriginal-specific maternal and infant health service (an Aboriginal pregnancy service and/or an Aboriginal MCH service) and a further three LGAs within the metropolitan Melbourne area that offer Aboriginal-specific pregnancy services within public hospitals. Therefore, Aboriginal families residing outside of these three LGAs have no option other than to access the public health service that does not offer specific Aboriginal maternity and infant healthcare. Mainstream maternal and infant healthcare does not align with Aboriginal ways of infant care as culture is not paramount when approaching service delivery, which can lead to a lack of continuity of care.³⁴ There is evidence that Aboriginal-specific maternity and infant healthcare results in positive health outcomes, as Aboriginal mothers are more likely to engage in maternal and infant health programs.^35,36

A strength of this study was the leadership by an Aboriginal researcher as part of a project undertaken in partnership with VACCHO, the peak body for Aboriginal health in Victoria. Another strength was the use of geospatial mapping software for visual representation of the target population in relation to the location of Aboriginal maternal and infant health service delivery in Victoria. This approach highlighted the gaps in service delivery and, coupled with data about underlying population composition, can help guide future investment. This spatial display of data can be a valuable tool for health services research because of its ability to integrate various data sources to produce visual maps that VACCHO and other Aboriginal organisations can use for service planning and advocacy. This type of approach has been used to inform physical accessibility, relative to distance, to healthcare services^37–39 along with health workforce planning.⁴⁰ This is the first study to apply spatial methods to Aboriginal and Torres Strait Islander maternal and infant health service delivery in Victoria. The visual map representing early years services available in relation to the location of the Victorian Aboriginal communities has been provided to VACCHO as a tool to identify gaps in service delivery and inform their policy advocacy.

A limitation of this study is that it only included services focused on maternal and infant healthcare and did not capture other early childhood services such as Aboriginal playgroups, which may be delivered at ACCHOs or elsewhere in the community, where there is an opportunity for sharing of infant health information. Another limitation is that population data were obtained from the 2021 Census; however, service availability data used for mapping were obtained in 2023. However, it is unlikely this affected the findings, as LGAs with the highest Aboriginal and Torres Strait Islander populations remained relatively stable between the 2016 and 2021 Censuses.⁴¹

This study was a preliminary mapping exercise to understand the distribution of Aboriginal-specific maternal and infant health services in Victoria in relation to the population of Aboriginal and Torres Strait Islander infants. These population data were available at the LGA level rather than at postcode level, as has been used in other mapping studies.³⁹ Thus, a more detailed analysis of actual travel distances to services was not possible given LGAs cover numerous postcodes, an important limitation of this study. The issue of physical access to services, particularly using public transport, is an important area for future research. Although our visual map provides some insight into the physical accessibility of services for Aboriginal families, it does not provide insight into service size, staff capacity, cultural safety or the effectiveness of services in meeting the needs of the Aboriginal population residing within the area.

Service planning should prioritise areas that have no specific Aboriginal and Torres Strait Islander maternal and infant health service but have a high population of Aboriginal infants aged 0–2 years. Maternal and infant health services should ideally be delivered through ACCHOs as part of holistic comprehensive primary health care.³⁴ Further research is needed with Aboriginal families and service providers to understand specific supports required to enhance health during pregnancy and early childhood, which will be undertaken in the next phase of this project. This will involve interviews with Aboriginal families and service providers in Victoria to explore their views, experiences and preferences regarding access to early years services, with a specific focus on the provision of information and support about infant nutrition and active play. Together with the services map, this qualitative study will provide important context about access to early years services in Victoria.

Conclusion

This study highlights several areas of Victoria that have a high Aboriginal infant population yet no Aboriginal-specific maternal and infant health services, and continuity of maternal and infant healthcare is available in only a limited number of LGAs. It is unclear where and how Aboriginal families living in these areas are accessing health information and support during pregnancy and the first 1000 days of life. To enhance continuity of care in the first 1000 days, services need to be planned on the basis of population needs and, where possible, through an ACCHO to ensure cultural safety. Aboriginal and Torres Strait Islander infants are our future; therefore, ensuring a healthy start to life can contribute to healthy outcomes for Australia’s First Peoples.