Alison Bush memorial oration: supporting First Nations community‐designed and led maternal health initiatives

Positionality statement

As a Palawa woman, my standpoint is grounded in my cultural identity, community obligations and lived experience. This work is informed by the teachings of my Elders and the responsibilities I hold to my family, Country and community. My positionality shapes the questions I ask, the way I engage with knowledge, and how I share it, guided by the principle that research must be accountable to the people and places it represents. By writing from a First Nations standpoint, I seek to centre First Nations voices and ways of knowing, challenge colonial narratives, and contribute to scholarship that supports and honours First Nations priorities and futures.

I never met Sister Alison Bush, but she is as present today in the lives of First Nations midwives, as she was during her trailblazing career in the fields of nursing and midwifery, and more generally in advocating for improvements in First Nations peoples' health.

Like Sister Bush, I am a First Nations woman, a midwife, an advocate for improving the perinatal outcomes of First Nations women and babies, and an advocate for the empowerment of First Nations women.

First Nations women have multiple voices — we do not just hold voice for ourselves, but for our children, our families and our communities, and we demand that our voices be heard.

Today, 14 October 2024, is a significant day for many First Nations Australians. One year ago, a referendum that proposed enshrining an Indigenous Voice to Parliament in the Australian Constitution was defeated. Unlike our sister states, the nation of Australia was not built on the notion of equality, there were no treaties, no acknowledgement of our rights, or even of our right to exist. Instead, the nation began with genocidal acts that sought to erase our peoples, that stole our children and that stole our land. Genocidal acts that denied cultural knowledge, denied cultural practices, and denied us the use of our languages — all justified under Acts of the State and inhumane policies of protectionism and assimilation.

At the time of the nation's federation in 1901 and the enactment of the Australian Constitution, not only were First Nations people explicitly excluded from it, we were also not entitled to vote for or against it. This right, to vote in federal elections or referenda, did not extend to us until 1962.

Section 51, paragraph xxvi, of the Australian Constitution, known as the Race Power, gave the Australian Parliament the authority to make laws for “the people of any race, other than the aboriginal [sic] race…for whom it is deemed necessary to make special laws”.1 This section's wide scope and lack of restrictions were deliberate choices of the drafters of the Constitution and, many have argued, were firmly embedded in their desire to uphold a “white” image.

The Constitution also, at Section 127, expressly excluded Aboriginal people from being counted in the national census. It was as if, by not counting us, the State could pretend that we did not exist. At the same time, our children were being stolen, sent to missions and children's homes for the dual purpose of being trained for free farm labour or domestic service, and in the eugenic belief that our Aboriginality could be bred out. Yet we are a resilient people, and our population survives and is growing.

The Race Power and the census provision were both amended by referendum in 1967, with over 90% voter support.2 We would now be counted in national censuses, and the words “other than the aboriginal [sic] race” would be removed from the Constitution, paving the way for the federal government to make laws about First Nations people.

There is a view that the significant “Yes” vote represented a change in race relations, that public sentiment had shifted in favour of recognition and reconciliation. My view is that rather than it being a positive shift in sentiment, it was a collective sigh of relief that responsibility, and therefore blame, was shifted elsewhere, because despite the Race Power, First Nations Australians did not and still do not have an equitable place in society. This is evidenced by the ever‐increasing child removal rates, the poorer maternal and infant health outcomes, high incarceration rates, high suicide rates, and the gap in life expectancy brought about by these acts and intergenerational harms.3

Proponents of the Voice to Parliament suggest that this is because there is no mechanism through which First Nations peoples can have a say on the laws and policies that affect us. Accordingly, if non‐First Nations people, who make up 97% of the Australian population, control all the mechanisms that exclude First Nations people from having a voice, as well as all the mechanisms that can reverse that exclusion, then we must call on non‐First Nations Australians to walk with us in our pursuit of truth‐telling, justice and healing.

This is exactly what the 2017 Uluru Statement from the Heart, which I am a signatory to, and which gave birth to last year's referendum, so eloquently invited Australians to do — to walk with First Nations people as part of a movement for truth‐telling and structural reform.

Alison Bush well understood this concept. She was committed to improving the experiences and outcomes of First Nations women and infants. She strived to ensure that First Nations women received culturally appropriate care and were empowered to make informed choices about the health of ourselves and our children, because overall, our health systems are still colonialist constructs, racist constructs, designed for Western models of care.

Current Australian maternal and infant health data demonstrate this. The data show that First Nations families continue to experience a disproportionate burden of adverse perinatal outcomes. First Nations women are 3 to 5 times more likely than other women to experience maternal mortality, and First Nations babies are 2 to 3 times more likely to be born preterm, have a low birthweight or to die before their first birthday.4

Australia's signature Indigenous strategy, the National Agreement on Closing the Gap, contains 19 socio‐economic targets relating to First Nations people's life outcomes. The agreement recognises that when First Nations people have a genuine say in the design and delivery of policies, programs and services that affect us, then better life outcomes are achieved.

The latest Productivity Commission's report on Closing the Gap shows that just five of the 19 targets are on track to be achieved by 2030. One of those five, that First Nations babies are born healthy and strong, is reported to be on track and improving. However, in the seven years to 2021, the percentage of First Nations babies born at a healthy weight rose just over half a percentage point, from 89% to 89.6% and the relative difference has remained constant at around 94%.5

The improvements that have occurred are being attributed to the increasing number of First Nations community designed and led initiatives such as Birthing on Country models of care. These models of care are maternity services designed and delivered with and for First Nations people, emphasising community governance and cultural oversight. They incorporate a holistic family‐centred approach, safety and collaboration, the privileging of First Nations knowledges and continuity of care from a workforce that practises in a culturally safe way. They can be implemented wherever a First Nations baby is born.

For improvements to continue to occur, we need long term secure government investment. Involving us, empowering us, working with us as partners in relation to both our lives and our children's lives does make a difference. We have the evidence.

A Birthing on Country model of care based in Brisbane saw significantly improved outcomes in its first five years, including women presenting earlier and more often for antenatal care, increased rates of breastfeeding, fewer preterm births, fewer low birthweight babies, fewer planned caesarean births and fewer admissions to neonatal intensive care units.6

This program has also identified intrapartum cost savings of around $4800 per mother–baby pair, demonstrating that investing in these models of care not only improve outcomes for women and babies, they do so at a reduced cost.7

There is also evidence that community‐led continuity models of care are a protective factor in preventing the removal of First Nations babies by child protection agencies.8

Understanding the historical and ongoing practice of child removals is essential for health professionals to comprehend the entrenched trauma experienced by First Nations peoples across multiple generations. The continued removal of our children perpetuates the disruption of cultural connections and the cycle of intergenerational trauma. By recognising this, health professionals can provide culturally safe care that dismantles and decolonises these systems and aids healing.

Birth is our first ceremony. A gift from our ancestors that connects us to our Country, people and cultures. First Nations women and families should have access to services where our voices are heard. Safe environments where we can thrive. Places that honour our ways of knowing, being and doing and that put our ways at the forefront of care.

While the Voice referendum failed, it shouldn't mean that the nation, and the people and systems who make up the nation, continue to fail us. Rather, it can be a stimulus, a mechanism for positivity, progress and better outcomes. People, systems, the country, all must do better.

Although it would be ideal to have a formal mechanism that ensures our voices are heard, must we have a Voice enshrined in the Constitution before we can work together to achieve universally improved outcomes? First Nations people know what works, we have proven it, and the benefits are undeniable. Listen to us, hear us, and have the courage and commitment to act and walk with us on our trek to justice and healing.