Foundations for participation
The First 1000 days of Life
by Professor David Ellwood
Every Queenslander deserves a healthy start to life. The first 1000 days signifies the critical time from conception to the end of the first two years of a child’s life. Much scientific research over the last two or three decades has underscored the importance of this time for an individual’s long term social, psychological and physical wellbeing.
Our recent understanding of the developmental origins of health and disease has emphasised how events around the time of birth and in the early neonatal period can program an individual for a life of health or disease. Hypertension, diabetes, obesity and other chronic diseases can all have their origins in the perinatal period, and getting all children off to the best possible start should greatly reduce this burden of disease later in life, for individuals and the community. This critical time is an essential period, which lays the foundations for participation in all of the activities of an inclusive and prosperous society.
Health policy can have a significant impact on women’s use of maternity and early childhood services, maternal satisfaction with care, and the outcomes of pregnancy and infancy. Women need to be able to access culturally safe, and woman-centred care and the available evidence show that the best way to do this is with continuity of midwifery care. Pregnancy and birth outcomes are better if women feel supported, and managed with care and compassion by someone they trust.
There has been a recent surge in political activity around maternity services with calls for an increase in the medicalisation of childbirth. That this would improve outcomes for women and their babies is not supported by research, all of which supports that the best approach is when primary maternity care is provided by a known midwife, working collaboratively with support when needed from obstetricians and general practitioners. Continuity of care models also help with the transition to motherhood, a time when women are often at they’re most vulnerable and may not readily access other primary health services. Emotional and physical recovery after childbirth can be a very challenging time, made easier by the support of a midwife who can visit the home. Also, if pregnancy does not go well and a family experiences the loss of their baby (as happens at least six times every day in Australia), the close emotional ties that have developed with their midwife can be an invaluable adjunct to effective bereavement care.
Queensland is characterised by its large size and for some our population who live in rural and remote areas there are major issues of equity of access to health services. For some this can mean travelling long distances to major centres for basic maternity care. The family dislocation involved in this can be very traumatic at a time of heightened vulnerability. Whilst there are some reasonable arguments based on safety and cost-effectiveness for the closure of very small maternity units, the evidence strongly supports the provision of services as close to where women live as is reasonably possible. There are some good examples of where services that have previously closed have been reopened (e.g. Beaudesert) and are now providing high-quality maternity care for women within their own community. This is an ideal we should strive for where it is achievable without compromising safety.
The provision of community-based maternity services for all Aboriginal and Torres Strait Island women, to ensure that they can birth on or near to country and community, would be a major step forward and further help to close the gap. Early and positive engagement with maternity and child services is more likely to establish a pattern of involvement with these services rather than a lifetime of exclusion.
A problem, which has been highlighted recently in the media, is that the next generation of Queenslanders may not be as healthy as the last. The major public health crisis of overweight and obesity, especially in young women, is starting to translate into worse outcomes for their offspring. There is a real risk now of an intergenerational effect, with worse pregnancy outcomes for women of high BMI affecting the long-term health of their children. Whilst pre-pregnancy counselling might help reduce some of the risk factors for adverse pregnancy outcome, such as smoking and alcohol use, there is little evidence that interventions just before, or during pregnancy, can alter weight-related outcomes. If public policy is going to make a real difference the target time has to be well before women reach their reproductive ages, with an emphasis on healthy eating, exercise and a less sedentary lifestyle. The time to do this effectively is whilst young female Queenslanders are still at school, with a major focus on diet and activity, setting patterns of behaviour that are life-long.
Another important aspect of pregnancy and birth is that unplanned and unwanted pregnancy can be associated with major maternal morbidity. This state has the most restrictive legal framework in Australia in which termination or pregnancy services are provided, and this causes major problems for women and health care providers. It would be a major service to the women of Queensland if a more modern approach to the laws around termination of pregnancy were introduced and supported by the next Parliament.
There are examples from other Australian jurisdictions in which changes to the law have been successfully implemented, as well as international models in which women who need to end their pregnancies can do so without feeling the stigma of knowing they could be breaking the law. This should be a health/law policy priority for any incoming government.
Investing in the future of this state is a vital function of government and there can be no more important investment than in the future of its people’s health and wellbeing. There are many areas of public health policy, which can impact on the health of families and their children, some of which can have life-long impacts on the next generation. Ensuring that women and their families have timely, affordable and equitable access to health services is an essential responsibility of government. This starts with the first 1000 days, and ensuring that all women and their babies get the best possible start to life, lays the foundations for participation in all that Queensland has to offer.
ABOUT THE AUTHOR
Professor David Ellwood did his initial medical studies at Oxford where he also completed a Doctorate in Reproductive Biology, working in the Nuffield Department of Obstetrics & Gynaecology. After completing clinical training at Cambridge he began training in Obstetrics & Gynaecology in Oxford and then relocated to Australia, working in Newcastle, NSW.
Professor Ellwood’s specialist and sub-specialty training was completed at Royal Prince Alfred Hospital, Sydney and with his first academic appointment as Associate Professor of Obstetrics & Gynaecology at the new Nepean Hospital Clinical School in 1991. In 1995 he took up the post of Professor of Obstetrics & Gynaecology at the Canberra Clinical School and was very involved thereafter in the development of the ANU Medical School.
Professor Ellwood became Head of the Clinical School in 2002 and then Deputy Dean in 2006. More recently he has been a Director of the Australian Medical Council and the Chair of the Medical Schools Accreditation Committee. He continues to be both clinically and research active and is currently a Chief Investigator on several NHMRC grants involving birth outcomes, particularly serious morbidity and mortality. The title of Professor Ellwood’s thesis is “The uterine cervix in pregnancy”.
Professor Ellwood became Deputy Head of School Research within the School of Medicine, Griffith University in 2015.