Experts say we need to ask difficult questions about how to reduce the number of Australian children in out-of-home care.

An article in the Medical Journal of Australia (MJA) says more needs to be done to strengthen and support the family into which children are born.

Most controversially, it asks whether policies should be developed that encourage disadvantaged families to have fewer children.

As of 30 June 2015, there were 43,399 children in out-of-home care (OOHC) in Australia.

Recent statistics show that 93.4 per cent of all children in OOHC in Australia live in home-based care, with 81 per cent in care for more than 1 year, and 41 per cent of that group remaining in OOHC for over 5 years.

Children in care experience poorer mental health outcomes, including increased rates of attention deficit hyperactivity disorder, depression, and attachment and conduct disorders.

Children in care are less likely than other children to continue their education beyond the age of compulsion. They have usually experienced trauma and neglect. More than 90 per cent of the children in OOHC in Australia have been placed there after a court order, and most of their parents are from marginalised groups.

The rate at which Indigenous children are being placed in care has more than tripled over the past 18 years, and more than doubled for non-Indigenous children.

One in 19 Indigenous children are currently in OOHC.

“In Australia, OOHC has been assumed to be the safest option for vulnerable children if there is any suggestion of risk of further harm to the child,” Professor Peter Jones, Dean of Medicine at Bond University on the Gold Coast, wrote.

“This assumption needs to be challenged.

“There is no evidence to indicate that OOHC reduces the prevalence of mental health problems in this population” and that “a major concern is that there is evidence that children in OOHC in Australia may experience an increased risk of harm while in care compared with children who have never been in care.”

“Community concerns about the risk of a child protection matter leading to the death of a child are out of proportion with the statistics. The homicide rate for children has remained the same at about 0.8 per 100 000 for the past two decades,” he wrote.

Other countries including the US and New Zealand Both have reduced the number of children in OOHC by focusing on keeping children in care for a limited length of time (US) and by having agreements to have the children placed with kin without formally placing those children under the guardianship of the court (NZ).

“We need to ask politically charged questions, such as should we be developing policies that encourage disadvantaged families to have fewer children?” Professor Jones writes.

“We need to aggressively invest in young vulnerable mothers when they have their first child in disadvantaged circumstances, and not wait until there have been documented problems with child neglect before the child protection and social services systems react.

“We must incrementally reduce our reliance on OOHC as a key goal in overcoming the complex problem of child abuse, neglect and increasing inequity in Australia.”