This is an interesting and controversial area. As in all areas of bioethical enquiry, it is useful to start with the facts. Some of the facts are:

  • Maternal mortality for Indigenous women (34.8/100,000) is significantly higher than it is for non-Indigenous women in Australia (10.1/100,000).

  • The perinatal death rate for Indigenous babies (21.8/1,000) is over twice the rate for non-Indigenous babies (9.7/1,000), and the percentage of low birth weight infants is also double (12.4 vs 6.2%).

  • The rate of teenage mothers is almost five times higher in the Indigenous population, complications in pregnancy are more frequent, and the percentage of women who have had no antenatal care is higher.

These facts come from the “Birthing in the bush” project site from Maningrida [1]. If you look at this website, you will see that much of the information is labelled “women only.” As a (non-Aboriginal male) doctor, should I be looking at this information? Should all information about birth be left to women, or is this a legitimate concern for men as well? Should all information about Aboriginal people be left to Aboriginal people, or is this a legitimate concern for non-Aboriginal people as well?

Aboriginal cultures differ greatly from each other, but all maintain secret areas of knowledge, and all differentiate women’s knowledge from men’s knowledge (Should I even call it ‘knowledge’? Would ‘belief’ be a better word?). Older women in the communities are the keepers of some of this knowledge. But these communities are also flooded with Western ideas from videos, health information resources, and television. And young women in these communities may have different ideas to their elders [2].

Traditional cultures are important to many people in communities, and have a mystique for many other Australians. We tend to see cultures other than our own almost as monoliths – but how do we account for individual variation within cultures? An older Aboriginal woman may see that the maintenance of tradition (and thereby the power structure that maintains her position) is important, and many older women would like younger women to ‘play by the rules.’ But young women are not greatly empowered in many Aboriginal cultures. They may want to give birth in the community. Or they may want to go to a big centre to give birth, either because of its better standards of safety, or to buy clothes, make friends, and experience life in the big city. Either of their preferences may arise from careful consideration, from whim, or from coercion (either from health workers or their traditional cultures). How do we weigh these preferences?

As is usual in ethics, there are more questions than answers. Does a community have rights to maintain its culture even if it is at the expense of some mothers and babies? Does the mother have rights to stay in the community to give birth, even if this requires difficult-to-sustain levels of staff and training? Does the mother (or baby) have the right to sue if the outcome is sub-optimal? Does a mother have a right to come into town for a birth – or the right to a caesarean? Does the baby have a right to the best possible start to life – a start without the high-risk flight to the neonatal intensive care unit after being born in a remote area with complications? What about the baby’s right to be born into its own ancient culture with its own ways of birthing?

I understand why health systems bring women in to the towns for birthing. But doing it the other way also warrants consideration and requires clinical trials – something that is currently happening in the Northern Territory of Australia. After that we will have more facts, but many of the truly difficult questions will remain.