Dear Dr Weaver. Introduction

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1 Dr Ted Weaver Chair Training Program Review Working Party Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) College House Albert Street East Melbourne VIC 3002 Dear Dr Weaver Thank you for your letter dated 14 January 2011, inviting the Australian Indigenous Doctors Association (AIDA) to comment on the RANZCOG Training Program Review. Introduction AIDA is a not-for-profit, non-government organisation dedicated to the pursuit of leadership, partnership and scholarship in Aboriginal and Torres Strait Islander health, education and workforce. There are approximately 150 Indigenous medical graduates and 160 Indigenous medical students in Australia. As Indigenous medical practitioners, we offer a special combination of clinical and cultural competence and expertise, and have a unique and central role in advocating for, and improving the health and wellbeing of Aboriginal and Torres Strait Islander peoples. We are keen to ensure that the needs of Indigenous communities and their respective health needs are articulated, protected, advocated for and respected. AIDA is represented on approximately fifty government and non-government health, education and workforce groups, including the National Indigenous Health Equality Council, the Close the Gap Indigenous Health Equality Steering Committee, as well as a range of Indigenous Health Committees (Australian Medical Association (AMA), Royal Australasian College of Physicians (RACP), Royal Australian College of General Practitioners (RACGP), Royal Australian and New Zealand College of Psychiatrists (RANZCP), Royal Australasian College of Surgeons (RACS). We work closely with Medical Deans Australia and New Zealand, the Committee of Presidents of Medical Colleges and the Australian Medical Council to ensure that the medical education and training system is inclusive of Indigenous health content, is culturally appropriate and recruits, supports and graduates Aboriginal and Torres Strait Islander people into medicine and medical specialties.

2 The health of Indigenous mothers and their babies The poor health of the Indigenous population in Australia is well documented. Some issues relating to the relatively poor health of Indigenous mothers and their babies is outlined below: Aboriginal and Torres Strait Islander babies continue to experience poor perinatal outcomes, thereby compromising their developmental wellbeing. Indigenous perinatal statistics remain at twice that of the non- Indigenous population for rates of preterm birth, low birthweight and perinatal mortality. 1 Birthweight and prematurity contribute directly to the higher death rate among babies of Aboriginal and Torres Strait Islander women. Aboriginal and Torres Strait Islander women tend to have more babies and have them at younger ages than non-indigenous women. The peak age group for births to Indigenous women was years compared with years for all women; the birth rate among teenage Indigenous women was more than four times the rate for all teenage women 2, 3. In the period , the total per cent of low birth weight babies (less than 2500g) to Indigenous mothers was 13% 4. Risk factors for low birth weight include socioeconomic disadvantage, the size and age of the mother, the number of babies previously born, the mother s nutritional status illness during pregnancy and the duration of the pregnancy. A mother s alcohol consumption and use of tobacco and other drugs during pregnancy can also impact on the size of her baby. Tobacco, in particular, has a major impact on birthweight 5. In the period , the total per cent of preterm births (less than 37 weeks) to Indigenous mothers was 14% 6. In Australia in six (10%) of the 60 maternal deaths where Indigenous status was known were of Indigenous women (Indigenous status was not reported in 8% of the deaths). Reflecting the higher rate of confinements, the maternal mortality ratio for Indigenous women in was 21.5 deaths per 100,000 confinements, almost three times higher than the ratio of 7.9 per 100,000 for non-indigenous women For direct maternal deaths, the ratio for Indigenous women was 7.2 per 100,000 compared with 3.6 per 100,000 for non-indigenous women. 7 1 Australian Bureau of Statistics (2007) Births 2006, Australian Bureau of Statistics, Canberra. 1 ABS-AIHW (2008), The Health and Welfare of Australia s Aboriginal and Torres Strait Islander 2 Australian Bureau of Statistics (2007) Births 2006, Australian Bureau of Statistics, Canberra. 3 ABS-AIHW (2008), The Health and Welfare of Australia s Aboriginal and Torres Strait Islander Peoples, Commonwealth of Australia, Canberra. 4 AIHW (2005), Indigenous mothers and their babies: Australia , AIHW, Canberra. 5 Australian Indigenous HealthInfoNet (2008), Births and pregnancy outcome, 6 AIHW (2005), Indigenous mothers and their babies: Australia , AIHW, Canberra. 7 Burns J, Maling CM, Thomson N (2010) Summary of Indigenous women's health. Retrieved [23 March 2011 from

3 Feedback to the RANZCOG Training Program Review AIDA has consulted with those of our membership who have an interest in this area, and provide feedback as follows. The need for trainees to understand Indigenous women s health issues The desired outcome of the RANZCOG training program is to produce O&G specialists who have an understanding of the health disparities in maternal health, as highlighted above, to understand the historical and socio-cultural context in which these health issues occur, and who practice their craft in a culturally safe manner in their encounters with Aboriginal and Torres Strait Islander women. It is our understanding that the trainees curriculum currently contains one online module on Culture & women s health issues which includes a small section on Aboriginal and Torres Strait Islander women. There is potential for this module to be significantly improved to provide a more comprehensive coverage of the health issues of Aboriginal and Torres Strait Islander women, particularly as these issues are very complex. The module needs to be user friendly for busy registrars so that they will effectively engage with it and gain a useful understanding of Indigenous health issues. We would strongly suggest that that any review and update of this module should be undertaken with the input of an Aboriginal and/or Torres Strait Islander person. Indigenous health issues should be examinable. If not, this gives give a message to trainees that it is not important. Well designed case studies can be an effective learning tool, but caution needs to be undertaken in avoiding a superficial and stereotypical understanding of the issues. Case scenarios that perpetuate negative stereotypes without examining underlying issues should be avoided. There is scope to present trainees with cases that challenge trainees thinking and perhaps preconceptions about Indigenous women s issues, and that highlight a holistic approach to health care. Trainees baseline knowledge of Aboriginal and Torres Strait Islander women s health issues should be considered in this context, and taken into account in reviewing the Indigenous health content of the curriculum. Knowledge should be vertically integrated from their medical school education. Questioning their depth of knowledge on entering the training program may help inform this process. For example, a question along the lines of "What do you know about health concerns specifically relating to Indigenous women in your surrounding community". Consideration should also be given to how Indigenous health issues can be better incorporated into the Fellowship CME, to again vertically integrate the Indigenous health knowledge base.

4 We would encourage RANZCOG to explore opportunities for registrars to gain clinical experience working in the field of Aboriginal and Torres Strait Islander health, whether through Aboriginal Community Controlled Health Organisations, or placements in areas with a high proportion of Aboriginal and/or Torres Strait Islander population, e.g. outreach services to central Australia, Top End, Far North Queensland. As a research project is a compulsory component of training, trainees should be encouraged to consider projects in the field of Aboriginal and Torres Strait Islander health. We strongly encourage RANZCOG to consider how it may incorporate cultural competency training into its curriculum. There are examples RANZCOG could look to in other medical colleges, and this issue is being explored as part of the CPMC Indigenous health subcommittee (see section below). RANZCOG representation on the Committee of Presidents of Medical Colleges (CPMC) Indigenous health subcommittee AIDA would like to draw to the attention of the reviewers, the Committee of Presidents of Medical Colleges (CPMC) Indigenous Health Subcommittee. The Subcommittee is co-chaired by AIDA President, Associate Professor Peter O Mara and Professor Geoffrey Metz on behalf of CPMC. You will be aware that RANZCOG is represented by Dr Marilyn Clarke. The subcommittee has produced a report, National Aboriginal and Torres Strait Islander Medical Specialist Framework for Action and Report, attached. The report makes a range of recommendations, including those about curriculum and cultural competency: To develop a learning module or modules in Indigenous health, based upon the principles of vertical integration, using existing examples from General Practice and Psychiatry and consistent with recommendations from the Med Ed 2009 conference. The CDAMS National Indigenous Health Curriculum should be drawn upon here. To develop a training module to support AMC accreditation teams to adequately assess College standards of cultural competence. AIDA recommendations to the RANZCOG Training Program Review That Indigenous women s health be given a higher priority within the RANZCOG training program as follows: a) A separate and detailed training module for RANZCOG trainees; b) an Indigenous health professional be involved in its design; c) the module content is examinable. That the College facilitate opportunities for registrars to gain experience working in the field of Aboriginal and Torres Strait Islander health;

5 That the College encourage research projects in the field of Aboriginal and Torres Strait Islander health; That the College be guided by the recommendations of the National Aboriginal and Torres Strait Islander Medical Specialist Framework for Action and Report, referred to above, with a view to increasing its recruitment of Indigenous fellows. That the College engage with the Australian Indigenous Doctors Association (AIDA) to discuss ways in which it might increase recruitment of Indigenous fellows. In 2008, AIDA made a submission to the Maternity Services Review Board, to which we would like to draw to the attention of the College. The submission is attached, and can also be viewed at the AIDA website at: AIDA believes that in order to improve the highly unsatisfactory status of Indigenous women s health that specialists need to have a better understanding of Indigenous maternal issues. In addition, developing the workforce by attracting more Indigenous doctors to train with the College would be an important step towards achieving this goal. AIDA would be pleased to discuss with the College, ways in which we could work together to encourage our members to consider undertaking fellowship with RANZCOG. For example, a number of Colleges have participated in AIDA Symposiums in recent years. If you have any questions in relation to the above, please do not hesitate to contact Mr Romlie Mokak, Chief Executive Officer, AIDA, ( ) in the first instance. Yours sincerely Associate Professor Peter O Mara President Australian Indigenous Doctors Association 31 March 2011

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