Karel Williams, is an Aboriginal midwife based in Canberra, with family connections to the Palawa and Western Arrernte Nations.
Read more about Birthing on country.
Find out more about the Congress of Aboriginal and Torres Strait Islander Nurses and Midwives (CATSINaM).
RUTH DE SOUZA (host) — What role does community play in childbirth?
KAREL WILLIAMS (guest) — The health providers should be able to value and acknowledge that those things are important to the women in one of the most vulnerable times of their lives. It’s really not rocket science.
Karel Williams is my guest. She’s an Aboriginal woman with family connections to the Palawa and Western Arrernte Nations, and she’s an experienced Indigenous policy advisor and midwife who champions the practice of Birthing on Country.
So we see, or I see Birthing on Country as one way that we can ensure that our babies are being born connected, belonging and strong in their identities.
This is Birthing and Justice with Ruth De Souza. In this series, I’m having conversations about birth, racism and cultural safety with some of the leaders in maternal health. I started my professional life as a nurse in Aotearoa, but my family go back to Goa and I was born in East Africa, in Tanzania. I grew up in Kenya and now I’m in Australia, a migrant myself, and an uninvited guest living on unceded Boonwurrung Country. And it’s from this position—a migrant, a researcher, a nurse and an educator—that I start the conversation with Karel Williams, about how her cultural traditions rub up against Western medicine and midwifery. Karel Williams, thank you for being here.
Thank you, Ruth.
Karel, I’m asking a question of all of my guests, which is: why do you care about birth and maternity?
I don’t think that’s an easy question. I just remember that I’ve… I always had a fascination, or I was just amazed by pregnancy and birth and everything around it. I think I said I would either have a baby or be a midwife and having a baby came first. [Laughs] But you know I do care because I’ve seen the difference it makes when you have a caring, supportive midwife who advocates for you, for your needs. I mean, when you think about hospitals previously, they were places where Aboriginal babies were taken, and then they were removed, and old people, or sick people wouldn’t go to the hospitals because you go to hospital and you die, or you never come home. So hospitals and other systems are places—you know, such as the justice system, education systems—where there’s a lot of mistrust and fear. So I wanted to be the sort of midwife who can address those fears and help the women feel supported and comfortable and make sure that they get the care that they need so that they do have a joyous—wherever possible—birth and experience.
I worked on a postnatal ward because I was thinking about becoming a midwife—this is in the ‘90s—and I was so devastated by what I saw on postnatal wards. I’d been working in mental health as a community mental health nurse, and I kind of thought, ‘Oh hooray, I’m going to be part of this beautiful moment in the life of a family.’ And what I saw instead was this factory production, a lot of cultural unsafety, which has meant that my life’s work for the last twenty years has been about cultural safety and maternity, because I was so disheartened, I was so saddened at the kind of violences that I saw in hospitals. And then as soon as I had a chance I was involved in setting up a maternal mental health service in Auckland. And what was really lovely about doing that work, is I felt in a far better position to support women and their families in that role, than I did in hospitals, where it felt like it was all about throughput. And I kind of did not want to be a part of this kind of brutalising machine, among people who supposedly were caring. And I saw no evidence of that care.
Yeah, you articulate that very well. So I left, I did my grad[uate] year and I left for the same reasons. I felt I could do more as an advocate on, you know, in policy and at CATSINaM [Congress of Aboriginal and Torres Strait Islander Nurses and Midwives] than I could in the system. I found that being the only… well I was on birthing, and I was the only Aboriginal midwife; the fact that I’d had nearly thirty years experience in the public service and I was quite senior when I left, I was confident and would lead a lot of the work and education around issues for Aboriginal staff. When I started in the hospital as a graduate midwife I was very vulnerable; I was treated, you know, like I was stupid because I’m a grad[uate] midwife, I’m new, so I don’t know anything. I found it very hard to stand up to the bullying and the racism that I saw, and to the factory. I think where you’ve got to—what I call a critical mass of people—then we can support each other and feel more included and valued in the workplace. But when you’re one person and they haven’t had anybody like you there before, and they were very dismissive, uncaring, and it was just a really, really difficult place to be. So, yes, I completely empathise with what you’re talking about Ruth, in your experience in postnatal ward. So I was in birthing, but I did see it across all areas, and a lack of will or desire to improve. People were comfortable.
You’ve said before that inequality starts early, and that pregnancy, birth and early childhood are critical periods for mothers and babies. From your experience, what are the challenges for Indigenous people birthing in Australia?
Yeah where do I begin! Goodness me. We know that there’s a disproportionate burden of adverse perinatal outcomes for Aboriginal and Torres Strait Islander women and babies compared to other women. And, you know, we’re still feeling the effects of colonisation, and the legacy of the practice of removing babies from their families. You know Aboriginal women have been birthing in their communities for millennia, and it was only when… with colonisation, that women decided to be removed from communities to be birthing in health centres and hospitals. And those systems are inflexible; they require women to adhere to the system’s expectations about what it thinks is good for women. It doesn’t take account of our worldviews and our cultural values and the fact that our kinship systems and family obligations take priority over everything else. And because of this history of racism and negative experiences, culturally inappropriate services, culturally unsafe care, a lot of women are reluctant to access antenatal care early in their pregnancy. There’s talk around Aboriginal women having insufficient or late antenatal care, and the reasons often cited for that are because of the lack of available or appropriate services, lack of Aboriginal health professionals, poor communication, lack of childcare and transport, and those sorts of things. But there doesn’t seem to be much focus on women’s lack of trust in the health services because of those negative experiences.
Absolutely. And one of the things that I’m conscious of is, there’s this lack of trust like you say in the health system, but then even when Aboriginal women do things the right way, they’re dismissed. And we are letting down Aboriginal women and their families; we’re letting them down badly in this country. And so what I’m wondering is, how you see Birthing on Country, what it means for women living both in urban centres and those who return to and from Country and community. You know, why are you so passionate about Birthing on Country? What does it bring women and their families?
Yeah, first I think, I have a belief that the… you know, the notion or the concept’s not really well understood. I think there’s a view that Birthing on Country is, you know, in the bush, under a tree having a baby, but it’s not. So I might explain that its genesis really was in rural and remote areas where women were being removed from communities to go to a major centre to have their babies, and they were being removed, you know, four weeks before their due date, and they were on their own and didn’t know anybody, very often couldn’t speak the language—English—let alone understand medical and, or medico-legal terms. But Birthing on Country is described as a metaphor for the best start in life for Aboriginal and Torres Strait Islander babies and their families, which provides an appropriate transition to motherhood and to parenting, and an integrated, holistic and culturally appropriate model of care. If you take that definition, or that explanation, Birthing on Country models of care can be incorporated in any setting, anywhere. If you say Birthing with Country, that means that the women can bring in their family supports, they can bring in earth or plants or ochre, or whatever’s important to them at the time of that birth. The health providers should be able to value and acknowledge that those things are important to the women in one of the most vulnerable times of their lives. It’s really not rocket science.
Absolutely, and what I love about what you’re saying is that it doesn’t just matter about physiological care, but this cultural care and this connection to Country is so fundamental to the experience of birth, and so necessary. And I’m kind of wondering, you know, how cultural safety comes into this, because you’re a very strong advocate for including it in midwifery practice?
Well, I’d have to say not very well. I don’t think… this is another concept that I don’t think there’s a really good understanding of, because I often find that people are using it interchangeably with cultural awareness, cultural respect, cultural competency, and all of those sorts of things. So sometimes I’ll describe it as the final stop on a continuum of care. So if the beginning of the continuum is cultural awareness, and the ultimate is cultural safety—with all of those other things in between—and cultural safety… so if you think about cultural awareness, it’s about people learning about us. It others us, and it often risks people seeing us as homogenous peoples. So they’re learning about us, but cultural safety is about midwives learning about themselves. So they’re asked to suspend their own views and values in favour of respecting our worldviews, cultural practices, and putting our preferences and needs first. And so we’re asking them to understand—or we’re demanding, even—them to understand that their assumptions and worldviews, practices and beliefs, are… that they may in fact be harmful when they’re judging us, or the Aboriginal women that they caring for—and I use that word loosely—by their own worldviews and values.
Yeah. So prior to becoming a midwife, you were telling us that you’d become a mother, and you’d also worked in Aboriginal and Torres Strait Islander policy. Has that shaped how you think about midwifery, and about institutions and practices?
Yeah in many respects it has. It’s given me the background and the confidence to understand not just about midwifery, but the whole social and wellbeing environment that we’re in—you know the social determinants of health, socioeconomic factors, racism, which is of course a double burden. I didn’t work in health when I was in the public service; I was largely in education. And I think I learned a lot about teachable moments, and I take every opportunity I can in the midwifery space to educate in a way that’s… well I try not to be confronting, but sometimes it’s, you know, it’s hard. When I was a student, I was really upset by an episode, a racist episode. And I went to the midwifery unit manager and tried to explain what had happened and how, just how awful it was. And she just wanted to tell me everything she knew about Aboriginal people. And then she dismissed my complaint saying that, ‘Well, you never know that midwife might’ve been raped by an Aboriginal man once.’ So that justifies her response, you know, this was in 2013 or ‘14 or something.
Oh my goodness!
Well, I know there are lots and lots of other examples where we’ve… our people have been, you know, not believed.
Yeah, too many. And I’m kind of wondering what gives you hope, what keeps you going in this very overwhelming context? You know, I’ve moved here from Aotearoa to Australia. I’m still learning very much about this environment that we’re in, but there’s a heavy load that I think Aboriginal women particularly carry, you know, and you carry this load and I’m kind of… one of the terms that I find useful in health is the idea of weathering, which is all the microaggressions, all the systemic injustices, they have a weathering effect on the body. You know it’s like rain on a car, or saltwater on the car—it wears it away, you know? How do you keep going in your work?
Well it’s like the feminist mantra, isn’t it, ‘The personal is political,’ in some ways? And you know, when I look at my family and our experiences, and my husband’s family’s, so my husband’s… both his parents were removed, my husband was removed when his mother was in a hospital having a baby, and some of our niece’s children have been removed at birth. And I see all of that, and my daughter sees that and she says ‘Well, I don’t… I’m not going to have any children ‘cause they’re just going to be taken away.’ We don’t want that to keep happening to our people, but on the other hand, we know that Birthing on Country models of care work, we’ve seen… there’s international evidence. If you look at the modelling, Nunavut—which started in about 1998—it’s about eight hours by plane trip from any hospital. And what they saw was that when the women were being removed and the babies were being born away from Country, there was this disconnect. And anyway, and that’s the same as what’s happening here. There’s all of this community dysfunction, gender-based violence and all of that stuff. And they were seeing that that was a direct result of children being born off Country and the families not being able to thrive in their own environment. So they set about establishing their own midwifery service in these communities. So they’ve… and they choose the women who will become midwives, because of their character. And that has been so successful. The perinatal deaths are far fewer than what ours are, Aboriginal babies, and our babies are born in hospitals. Their caesarean rate is less than two percent. And in Australia it’s up around thirty-five percent, and they report that their communities are back together, you know? And so then we see in Australia, the birthing in our community model in Brisbane, it’s been going since about 2013, but it’s a continuity model of care at the Mater Hospital. And the women have their own midwives—that’s continuity of care—it’s flexible, it’s culturally appropriate and safe. And they’ve had a fifty percent reduction in preterm births. They’ve had a reduction in caesarean deliveries, fewer babies being admitted to NICU [newborn intensive care unit] and special care nursery, women are attending more appointments and they’re more likely to be breastfeeding on discharge. So these are really extraordinary outcomes, and this is only in the last twelve months or so that these results are coming out. So I keep going, keep promoting this because we know that it works and we know how important it is. So we see, or I see Birthing on Country as one way that we can ensure that our babies are being born connected, belonging and strong in their identities. And I hope that, you know, not too far into the distant future, all of our babies will be born in places and among people who respect and value their cultural identities, ensuring that they do have the best start to life.
I’m kind of wondering if we can shift focus for a second, because you’ve also been involved in another kind of vision that I think will be really of interest to people who are listening. And that is, you’ve been part of a team responsible for coordinating Indigenous dialogues around Australia that have culminated in the 2017 National Constitutional Convention at Uluru, from which the Uluru Statement from the Heart was issued. Karel, can you tell us how this beautiful work around the Uluru Statement from the Heart, how it links to your other work on Birthing on Country, and what you think it offers future generations of Aboriginal and Torres Strait Islanders?
How I came to do that work was through my connections with former colleagues in the Australian Public Service. It was a really interesting time. Again, there was some misunderstandings around the process. People were seeing it as just constitutional recognition, which it wasn’t, it was about reform of the constitution, not just, you know, a preamble. So these dialogues, or this process, was set up by the Indigenous Steering Committee of the Referendum Council. And overwhelmingly people said, ‘We don’t just want this poetry in front of the constitution, we want meaningful reform, we want this voice to Parliament so that we can have a say on policies and legislation that impact our lives.’ We’re asking, or demanding, that our worldviews and our values and our needs and our experiences are valued and acknowledged and addressed. And, you know, there’s been lots of different inquiries and reports over the years that haven’t achieved much, and we’re still seeing the same level of suicides, early deaths, preventable deaths, poor housing, you know, all of those social determinants. And if, you know, we’ve got a Voice to Parliament and at last our voices are being heard, then surely that’s going to translate to our future generations being heard, feeling like they belong and being connected and valued.
Yes, absolutely. Yes! And in terms of future thinking as well, I’d love your thoughts about the future of the midwifery profession in Australia. What are your hopes for it?
Well my first thoughts around that is increasing the number of Aboriginal and Torres Strait Islander midwives. If you think, we’re about three percent—well Aboriginal people and Torres Strait Islander people are about three percent of the Australian population—our birth rate is about five percent, but our midwifery workforce is about one percent. Yeah. So when… and not all of our midwives, like myself, I’m not doing any, or much clinical work at the moment, and many others are also working in policy and advocacy spaces rather than in the clinical environment. So when you consider our birth rate, wouldn’t it be great if every Aboriginal woman, or every woman having an Aboriginal baby, had an Aboriginal midwife. But we also need midwives who understand the concept of cultural safety, and who practise in a culturally safe way.
Yes, absolutely. Karel I’ve loved having you on the show. Thanks for sharing so much of your knowledge and expertise and your deep, deep, deep commitment to communities here in Australia. I’ve really appreciated the time you’ve taken to speak with us, and I wish you all the best with the work that you’re continuing to do. Thank you for joining us.
Thank you for inviting me, Ruth.
OUTRO — Thanks for listening to Birthing and Justice with Ruth De Souza. This podcast is written and hosted by me, Ruth De Souza. Recorded at Windmill Studios in Melbourne on the traditional lands of the Eastern Kulin Nation. Sound design and mix by Regan McKinnon, artwork by Atong Atem, designed by Ethan Tsang, title track by Raquel Solier and produced and edited by Pipi Films.
LINKS & RESOURCES:
–CATSINaM is the Congress of Aboriginal and Torres Strait Islander Nurses and Midwives
–Nunavut is the largest and northernmost territory of so-called Canada, Turtle Island.
END NOTES — Audio transcript edited and designed by Abbra Kotlarczyk, 2022. Note: the purpose of this audio transcript is to provide a record and pathway towards accessing all Birthing and Justice conversations. Editorial decisions around the omission of certain words and non-verbal utterances have been made purely for stylistic purposes towards greater legibility, and do not infer a desired ethics of speech.