Aboriginal and Torres Strait Islander people, referred to as 'Indigenous Australians', experience significantly poorer health outcomes than non-Indigenous Australians. This is particularly true for Indigenous women. The difference in life expectancy between Indigenous and non-Indigenous women is some 9.5 years, and Indigenous mothers are three times as likely as non-Indigenous mothers to die during childbirth (AIHW, 2014a; AIHW, 2014b). There are many complex, interrelated social factors which impact the health of Indigenous people. This paper provides a critical analysis of the social determinants of health for Indigenous mothers in particular. Education is one of the most fundamental social determinants of health, and this is particularly true for Indigenous Australians. Education enables Indigenous women to access and interpret health-related information to prevent ill health, and it also improves their capacity to engage effectively with the health care system when necessary (Jones et al., 2014). In Indigenous women, higher levels of education are directly linked with positive health outcomes; for example, an Indigenous woman is less likely to smoke if she completes secondary schooling (Australian Government Department of Health & Ageing, 2012; Biddle & Cameron, 2012). However, Indigenous women have poor rates of formal education attainment; just 29% of Indigenous people complete Year 12 compared with a national average of 73% (ABS, 2012). Indigenous women with a lower standard of education are more likely to bear a child in their adolescent years, a particular problem for Indigenous women generally, and are also more likely to have a child with a low birthweight (Comino et al., 2009; Osborne et al., 2013). Additionally, Indigenous mothers with lower standards of education are more likely to children with poor educational outcomes; this highlights the significant problems associated with the intergenerational transfer of health and social risk in Indigenous communities (Benzies et al., 2011). Education is related directly to an Indigenous woman's level of economic participation â€“ specifically, her ability to gain employment and earn an adequate income, both of which are key predictors of health (Osborne et al., 2013). Research suggests that an Indigenous person's chance of gaining employment increases by 40% if they complete Year 10 and by 53% if they complete Year 12 (New South Wales Government Department of Education & Training, 2004). However, as with low education, low employment is a significant problem for Indigenous women; indeed, rates of unemployment for Indigenous women are above 16%, compared with a national average of just 4% (ABS, 2013). Economic disadvantage resulting from unemployment is a significant predictor of poor health. Booth and Carrol (2008) suggest that economic variables can explain up to 50% of the disparity in health between Indigenous and non-Indigenous Australians. Additionally, and demonstrating the cyclical nature of socioeconomic disadvantage and poor health in Indigenous communities, research also suggests that poor health may explain 60% of the disparity in employment participation between Indigenous and non-Indigenous women (Kalb et al., 2011). Unemployment and socioeconomic disadvantage may affect the health of Indigenous women in a range of ways. Primarily, limited disposable income â€“ in combination with a lack of food storage and cooking facilities within households and, particularly within remote communities, lack of access to fresh food itself â€“ means indigenous women have reduced access to nutritionally-appropriate foods and lower food security (Osborne et al., 2013; Browne et al., 2014). Indeed, the diets of Indigenous people in many regions are characterised by a high intake of saturated fats, refined carbohydrates and salt, and little to no intake of fresh fibre-rich foods (ABS, 2006). In Indigenous women, as in all women, nutrition is fundamental to health in the ante-, intra- and post-partum periods (Browne et al., 2014). Poor dietary intake leads to high rates of gestational diabetes mellitus among Indigenous mothers â€“ 5.1%, compared with a national average of 4.5% (2000-2009 estimate) (Chamberlain et al., 2014). Poor nutritional status also underpins the burden of chronic disease evident in Indigenous women and particularly chronic diseases related to obesity, which are a significant problem in Indigenous communities (Liaw et al., 2011). Around 60% of Indigenous women aged 25-55 years have a body mass index which indicates they are 'obese' (ABS, 2006). Because of the risks posed by chronic disease, Indigenous mothers are significantly more likely than non-Indigenous mothers to require antenatal hospital admission (Badgery-Parker et al., 2012). Additionally, maternal chronic disease means that around 11% of indigenous neonates have a low birthweight (ABS, 2014). This is an important marker for increased risk of chronic disease, again demonstrating the cyclical nature of socioeconomic disadvantage and poor health outcomes in Indigenous communities. Socioeconomic disadvantage has a variety of other impacts on Indigenous mothers. For example, lack of employment and poverty mean that many Indigenous women have reduced access to appropriate housing. Up to 28% of Indigenous people live in housing which is severely overcrowded and where basic facilities â€“ including showers, toilets and stoves â€“ are not available or do not work (Osborne et al., 2013). Compounding the issue of poor housing is the fact that Indigenous Australians, and particularly those living in regional and remote communities, have disproportionate access to essential health infrastructure such as safe drinking water, rubbish collection services, sewerage systems and a reliable supply of power (Australian Human Rights Commission, 2007; Osborne et al., 2013). Indeed, lower standards of housing health infrastructure in Australian communities contribute directly to the high rates of parasitic and bacterial infection and increased rates of physical injury â€“ for example, from house fires â€“ among Indigenous women (Bailie & Wayte, 2006). Inappropriate, overcrowded housing has had other impacts on Indigenous mothers. Specifically, it has led to breakdowns in traditional, complex social structures, norms and spiritual practices in Indigenous communities (Osborne et al., 2013). This has resulted in increases in the rates violence, including domestic violence, perpetrated against Indigenous women; indeed, Indigenous women are 40 times more likely than non-Indigenous women to experience violence, and are 35 times more likely to experience intra-familial violence which results in hospitalisation (Osborne et al., 2013). Indigenous people are also significantly more likely than non-Indigenous people to experience sexual assault (Phillips & Park, 2006; ABS, 2009). The Australian Human Rights Commission (2007) notes that a combination of unemployment, the receipt of welfare payments and a lower standard of education also predispose Indigenous women to an increased risk of poor health outcomes due to violence. In Indigenous women in particular, social capital â€“ including a connection with community, country and culture, is positively correlated with wellbeing (Brough et al., 2004; Biddle, 2012; Osborne et al., 2013). The relationship between social capital and mental wellbeing, particularly in Indigenous people, is well-established, however the correlation between social capital and physical wellbeing is now also acknowledged. For example, a number of Australian studies have demonstrated that Indigenous people who are connected to their community, country and culture are less likely to be diagnosed with a range of chronic health conditions including obesity, diabetes mellitus, hypertension and renal disease (Burgess et al., 2009; Campbell et al., 2011). Where there are declines in social capital, therefore, the mental and physical health of Indigenous women also decline. Shepherd et al. (2012) report on the growing body of knowledge which suggests that Indigenous peoples' social environment may significantly affect their mental health. Rates of mental illness among Indigenous women are high; indeed, Indigenous women are 2.6 times as likely as non-Indigenous women to report experiencing psychological distress and are also more likely to engage in self-harm and / or suicide (Australian Human Rights Commission, 2007; Burns et al. 2015, np). Mental illness is also strongly correlated with poverty; for example, Australian research suggests that people in poverty lack a sense of control over their lives and so experience higher levels of psychological stress (Australian Human Rights Commission, 2007). In addition to poor mental health, psychological stress can also lead to poor physical health outcomes â€“ specifically, via negative effects on the immune and cardiovascular systems and metabolic function (Australian Human Rights Commission, 2007; Shepherd et al., 2012). Mental illness is not only underpinned by social health determinants, it is also problematic in terms of modifying the social factors which underpin poor health outcomes in Indigenous communities. For example, Marmot (2011) suggests that, in Indigenous communities, marginalisation results in disempowerment which in turn leads many Indigenous women to perceive little value in efforts to make health-related changes. Social dysfunction and high rates of mental illness in Indigenous communities is driven by â€“ and, indeed, drives â€“ the high rate of substance abuse in these communities (Osborne et al., 2013).Â Indigenous women are twice as likely as non-Indigenous women to smoke on a daily basis, and three times as likely to smoke during pregnancy (Osborne et al., 2013; Passey et al., 2013). Approximately 50% of Indigenous people report consuming alcohol at least once per week, 28% report current regular use of illicit substances including cannabis and other drugs, and 15% engage in 'risky' behaviours related to substance use (ABS, 2006). Substance abuse is an important social determinant of health; the correlation between substance use and poor outcomes in terms of both physical and mental health in adults is well-established. Whilst the prevalence of Indigenous mothers who use alcohol and illicit substances is unknown, rates of fetal alcohol spectrum disorder and neonatal abstinence syndrome are high among Indigenous neonates (AIHW, 2015). Additionally, Indigenous mothers who abuse substances are at greater risk of losing custody of their children; because of the relationship between social capital and health in Indigenous communities, this can itself be perceived as a poor health outcome (Australian Human Rights Commission, 2007; Osborne et al., 2013). As noted by the Australian Government Department of Health and Ageing (2013), poverty limits the access of many Indigenous people to health care services. This is particularly true in regional and remote communities â€“ and approximately 46% of Indigenous women live in an area classified as 'regional' or 'remote' (ABS, 2010). Though many regional and remote Indigenous communities are supported by 'fly-in fly-out' health services, research suggests that fragmented services and discontinuity of care can contribute to poor health outcomes for Indigenous women (Bar-Zeev et al., 2012). Many communities have no health services at all, and to receive medical attention Indigenous women are often required to travel long distances to regional centres. Although the federal government subsidises the transport and accommodation expenses associated with such trips, general living costs borne by Indigenous women are often significant (Kildea et al., 2010). Additionally, the costs for those accompanying a woman are often not subsidised, so women may be required to travel without support (Kildea et al., 2010). These issues affect Indigenous mothers disproportionately; for example, in comparison to non-Indigenous women, Indigenous women tend to access antenatal care both less frequently and later in their pregnancy, and this is underpinned by lack of access to care (Osborne et al., 2013). Further complicating these issues is the fact that the 'risk-prevention' paradigm evident in many medicalised health services is incompatible with the holistic perception of health held by many Indigenous women (Ireland et al., 2011). Additionally, historic protectionist and paternalist attitudes directed towards Indigenous people continue to pervade many medicalised health services in Australia. Durey and Thompson (2012) suggest that racism, both covert and overt, towards Indigenous women in Australian health services remains a significant problem; indeed, the Australian Human Rights Commission (2007) notes that systematic discrimination is a key factor underpinning the lack of opportunity for Indigenous Australians achieve a health status equitable to that of non-Indigenous Australians. These issues associated with 'culturally-safe' service provision often culminate in Indigenous mothers disengaging from medicalised health services. This is a significant problem considering a lack of antenatal and intrapartum care in particular, and health care in general, is fundamental to the high maternal morbidity and mortality rates in Indigenous communities (AIHW, 2014a). This paper has provided a critical analysis of the many social determinants of health for Australia's Aboriginal and Torres Strait Islander peoples â€“ and, particularly, Indigenous mothers. It has demonstrated that social factors underpin the health of Indigenous mothers in both the physical and mental domains. It has also provided evidence for the complex relationship between health and social determinants in Indigenous mothers.
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