1.01 Birthweight

Key messages

• 89.5% of Aboriginal and Torres Strait Islander babies born in 2019 had a healthy birthweight.
• At a national level, the low birthweight rate for Indigenous babies (9.2% in 2019) did not change significantly between 2013 and 2019.
• The proportion of low birthweight babies is lower in Major cities (8.0%) than in Very remote areas (13.2%), and higher among those whose mothers lived in the most disadvantaged socioeconomic group, compared with mothers living in the least disadvantaged socioeconomic group (10.5% compared with 7.0%).
• Smoking during pregnancy is a risk factor for having a low birthweight baby. Rates of smoking during pregnancy have declined among Indigenous mothers, from 52% in 2009 to 44% in 2019.
• Aboriginal and Torres Strait Islander mothers who attended 5 or more antenatal visits during pregnancy were less likely to have a low birthweight baby (7.2%), compared with 2 to 4 antenatal visits (16.9%) or one antenatal visit (24.2%). Access to appropriate antenatal care services is critical to address the factors associated with low birthweight.
• Evidence shows that models of care tailored specifically for Indigenous women result in quantifiable improvements in antenatal care attendance, pre-term births, birth outcomes, perinatal mortality, and breastfeeding practice. These models include culturally appropriate and safe care as well as continuity of care, collaboration between midwives and Indigenous health workers, and involvement of family members such as grandmothers.

Why is it important?

Birthweight is a key indicator of infant health and a principal determinant of a baby’s chance of survival and good health. A healthy birthweight (newborns weighing 2,500 grams to less than 4,500 grams) helps to lay the foundations for lifelong health. Most Aboriginal and Torres Strait Islander babies are born with a healthy birthweight, but the low birthweight rate among Aboriginal and Torres Strait Islander babies remains relatively high compared with non-Indigenous babies.

Women who are healthy before and during pregnancy have a better chance of having a healthy baby. Addressing risk factors such as maternal smoking and alcohol consumption during pregnancy (see measure 2.21 Health behaviours during pregnancy); lower rates of attendance at antenatal care (see measure 3.01 Antenatal care); the nutritional status of the mother; illness during pregnancy; pre-existing high blood pressure and diabetes; and socioeconomic disadvantage can lead to improved outcomes for Aboriginal and Torres Strait Islander women and babies (ABS & AIHW 2008; AIHW 2011; Brown et al. 2016; Eades et al. 2008; Khalidi et al. 2012; Sayers & Powers 1997).

Babies with birthweights outside the healthy range are at greater risk of illness, poor development, perinatal death, and poorer health in adulthood. Babies with a low birthweight (<2,500 grams) are more likely to experience illness or die in infancy, have poorer development of their mental functioning abilities, and have an increased risk of chronic diseases in adulthood (WHO 2014). A high birthweight can also have adverse consequences (4,000–4,500 grams). High birthweight is associated with an increased risk of adverse maternal outcomes such as emergency caesarean section and postpartum haemorrhage, impairment and injury of the newborn, and hypertension, obesity, and type 2 diabetes in later life (Beta et al. 2019; Cartwright et al. 2020; Chiavaroli et al. 2014; Turkmen et al. 2018).

In July 2020, the National Agreement on Closing the Gap (the National Agreement) identified the importance of making sure Aboriginal and Torres Strait Islander people enjoy long and healthy lives, and ensuring Aboriginal and Torres Strait Islander children are born healthy and strong. To support these outcomes the National Agreement specifically outlines the following targets to direct policy attention and monitor progress:

• Target 1—Close the Gap in life expectancy within a generation, by 2031, (with infant and child mortality as supporting indicators)
• Target 2—By 2031, increase the proportion of Aboriginal and Torres Strait Islander babies with a healthy birthweight to 91 per cent.

For the latest data on the Closing the Gap targets, see the Closing the Gap Information Repository.

The new National Aboriginal and Torres Strait Islander Health Plan 2021-2031 (the Health Plan), provides a strong overarching policy framework for Aboriginal and Torres Strait Islander health and wellbeing and is the first national health document to address the health targets and priority reforms of the National Agreement.

‘Healthy babies and children (Age range: 0-12)’ is one of the key life course phases focused on in the Health Plan, and two objectives specifically address this age range:

• Objective 4.2. Deliver targeted, needs-based and community-driven activities to support healthy babies
• Objective 4.3. Deliver targeted, needs-based and community-driven activities to support healthy children.

Both the National Agreement and the Health Plan are discussed further in the Implications section of this measure.

Burden of disease

In 2018, infant and congenital conditions contributed 5% of the total disease burden for Indigenous Australians. The leading causes were pre-term and low birthweight complications, accounting for 28% of infant and congenital total burden (AIHW 2022).

Findings

What does the data tell us?

Data in the Findings section of this measure refer to singleton live births. A singleton birth is the birth of one baby during a pregnancy. Multiple births are associated with low birthweight and as a result are generally excluded from analysis on low birthweight (AIHW 2020).

In addition to this measure, see the Aboriginal and Torres Strait Islander Health Performance Framework (HPF) feature article Key factors contributing to low birthweight among Aboriginal and Torres Strait Islander babies for additional statistical analysis on birthweight and factors contributing to it.

In previous Aboriginal and Torres Strait Islander HPF reporting, data on birthweight were based on the Indigenous status of the mother. In this section, most reporting is based on the Indigenous status of the baby—this information is available from 2013 onwards. Some information is reported based on the Indigenous status of the mother—this information has been available for a longer period (from 2005 onwards), with information of a suitable quality for all states and territories available from 2011.

In 2019, the average birthweight of singleton Indigenous babies (based on the Indigenous status of the baby) was 3,265 grams, slightly higher than the average birthweight for babies of Indigenous mothers (based on the Indigenous status of the mother), which was 3,240 grams (Table D1.01.5).

The healthy birthweight rate among Indigenous babies was also slightly higher than that for babies born to Indigenous mothers in 2019—89.5% compared with 88.5%.

Table 1.1: Healthy birthweight, by Indigenous status of baby and Indigenous status of mother, 2019

	All live births   Number	Singleton live births   Number	Healthy birthweight – singleton births   Number	Healthy birthweight – singleton births  %
Indigenous babies	17,917	17,421	15,596	89.5
Births to Indigenous mothers	14,315	13,888	12,297	88.5

Source: Tables D1.01.1 and D1.01.17. AIHW analysis of the National Perinatal Data Collection.

In 2019, for Indigenous singleton babies:

• the majority were born with a healthy birthweight (89.5% or 15,596 babies)
• 9.2% (1,610 babies) were born with a low birthweight
• 1.2% (204 babies) were born with a high birthweight.

For non-Indigenous singleton babies:

• the majority were born with a healthy birthweight (93.9% or 255,339 babies)
• 4.9% (13,246 babies) were born with a low birthweight
• 1.2% (3,138 babies) were born with a high birthweight (Table D1.01.14).

Between 2013 and 2019, the proportion of Indigenous babies born with a healthy birthweight remained steady (88.7% in 2013 and 89.5% in 2019) (Table D1.01.18).

The remainder of this section focuses on low birthweight, since reducing low birthweight is the main way in which the healthy birthweight rate can be improved (given it is much more prevalent than high birthweight).

In 2019, the low birthweight rate for singleton Indigenous babies varied by state and territory. The rate was highest in the Northern Territory (12.7%) (Table D1.01.20, Figure 1.01.1).

Figure 1.01.1: Low birthweight liveborn singleton babies, by Indigenous status of the baby and state and territory, Australia, 2019

Source: Table D1.01.20. AIHW analysis of the National Perinatal Data Collection.

The rate of Indigenous babies born with a low birthweight was significantly higher in Very remote areas (13.2% or 204 babies) compared with Major cities (8.0% or 515 babies) (Table D1.01.22; Figure 1.01.2).  

Figure 1.01.2: Low birthweight liveborn singleton babies, by Indigenous status of the baby and remoteness, Australia, 2019

Source: Table D1.01.22. AIHW analysis of the National Perinatal Data Collection.

Babies born pre-term with low birthweight

Low birthweight is closely associated with pre-term births (gestational age before 37 completed weeks) (AIHW 2020). In 2019, most Indigenous liveborn babies (including multiple births) were born full-term (88.5% or 15,849), while 11.5% (2,065) were born pre-term. For non-Indigenous babies, 92.3% (258,328) were born full-term, while 7.7% (21,572) were born pre-term.

Among Indigenous liveborn babies born pre-term in 2019 (2,065), 60.0% had a low birthweight (1,238 babies).

Pre-term babies accounted for 65.0% (1,238) of all Indigenous low birthweight babies, compared with 68.4% (12,131) of non-Indigenous low birthweight babies (Table D1.01.21).

Maternal age and birthweight 

In 2019, the healthy birthweight rate among Indigenous babies ranged from 87.0% among mothers aged 35 and over (1,590 Indigenous babies) and 87.3% among those aged less than 20 (1,677 babies), to 90.3% among mothers aged 20–24 (4,766 babies), and 90.1% among mothers aged 25–29 (4,575 babies) or 30–34 (2,987 babies).

Accordingly, the low birthweight rate among Indigenous babies was higher for mothers aged under 20 (11.6% of Indigenous babies) and those 35 and over (11.4%), than among mothers aged between 20 and 34 (ranging between 8.6% and 8.7%) (Table D1.01.22, Figure 1.01.3).

Figure 1.01.3: Low birthweight liveborn singleton babies, by Indigenous status of the baby and maternal age, Australia, 2019

Source: Table D1.01.22. AIHW analysis of the National Perinatal Data Collection.

Smoking and low birthweight

Around 4 in 10 Indigenous women who gave birth in 2019 smoked tobacco during pregnancy (44%). The rate of smoking during pregnancy among Indigenous women declined from 52% in 2009 to 44% in 2019. Based on age-standardised rates, in 2019, Indigenous women were 3.9 times as likely to smoke during pregnancy as non-Indigenous women (Table D2.21.20).

In 2019, 13.9% of Indigenous babies born to a mother who smoked during pregnancy had a low birthweight, compared with 5.7% of Indigenous babies born to a mother who did not smoke during pregnancy (Table D1.01.22).

In 2019, Indigenous babies born to mothers who smoked during pregnancy were 1.4 times as likely to have a low birthweight as non-Indigenous babies born to mothers who smoked during pregnancy (14% and 10%, respectively). For babies of mothers who did not smoke during pregnancy, rates of low birthweight were 5.7% for Indigenous babies and 4.4% for non-Indigenous babies (Table D1.01.22).

Maternal smoking and birth outcomes such as low birthweight and pre-term birth are key drivers of change in infant and child mortality. For more information see Closing the Gap Targets: 2017 Analysis of Progress and Key Drivers of Change.

Antenatal care and low birthweight

The 2014–15 National Aboriginal and Torres Strait Islander Social Survey showed that mothers with low birthweight babies were less likely to have had regular check-ups during their pregnancy than those who had babies who were not of low birthweight (84% and 98%, respectively) (Table D2.21.8).

Data from the National Perinatal Data Collection for 2019 showed that Indigenous babies (singleton live births) whose mothers attended antenatal care in the first trimester were less likely to have a low birthweight (8.1%) compared with Indigenous babies whose mothers attended after the first trimester or not at all (11.1%) (Figure 1.01.4).

Data by Indigenous status of the mother showed the same pattern. Indigenous mothers who attended antenatal care in the first trimester of pregnancy (before 14 weeks) were less likely than mothers who attended after the first trimester or not at all (8.9% compared with 12.3%) (Table D3.01.14).

Indigenous mothers who attended 5 or more antenatal visits during pregnancy were significantly less likely to have a low birthweight singleton baby (7.2%), compared with Indigenous mothers who had 2 to 4 antenatal visits (16.9%) or Indigenous mothers who had one antenatal visit (24.2%) (Table D3.01.5).

Low birthweight and other selected characteristics

In 2019, among Indigenous singleton babies, the low birthweight rate was higher among those whose mothers:

• lived in the most disadvantaged socioeconomic group (1^st quintile) (10.5% low birthweight rate), compared with mothers living in the least disadvantaged socioeconomic group (5^th quintile) (7.0%).
• were underweight pre-pregnancy (21.0% low birthweight rate), compared with those born to mothers who were a normal weight (10.0%), overweight (7.3%) or obese (5.9%) (Table D1.01.22, Figure 1.01.4).

The low birthweight rate was also higher among Indigenous babies whose mothers had pre-existing hypertension (19.8%), and among those whose mothers had pre-existing diabetes (15.4%) (compared with 9.2% among all Indigenous singleton babies) (Table D1.01.22, Figure 1.01.4).

Figure 1.01.4: Low birthweight rate among liveborn Indigenous singleton babies, by selected maternal characteristics, Australia, 2019

Source: Table D1.01.22. AIHW analysis of the National Perinatal Data Collection.

International birthweight comparisons

For the purposes of presenting comparable results across different countries, this section presents some birthweight results that differ from those presented elsewhere in this measure. Specifically, while most of the results presented elsewhere in this measure relate to liveborn singleton babies (Indigenous status of the baby, the definition used for the Closing the Gap target), the following section presents information for all liveborn babies (including multiple and singleton babies) and information based on the Indigenous status of the mother.

Note that international rate comparisons should be treated with caution because of the differences in methods used to classify and collect data, and the variations in the quality and reliability of the data available in each country.

In Australia in 2019, among all live births (including multiple and singleton), 10.6% of Indigenous babies were born with low birthweight, compared with 6.3% of non-Indigenous babies (Table D1.01.17). In New Zealand, 7.0% of Māori babies were born with low birthweight, compared to 5.7% of other New Zealander babies (Table D1.01.10).

Based on the Indigenous status of the mother, in 2019 in Australia, 11.7% of babies born to Indigenous mothers were born with low birthweight compared with 6.4% of babies born to non-Indigenous mothers. In Canada, 7.2% of mothers from Inuit inhabited regions had babies of low birthweight compared with 6.1% of all mothers (2009–2013). In 2019, the proportion of low birthweight babies among American Indian or Alaska Native mothers was comparable to Other American mothers (8.0% compared with 8.3%) (Table D1.01.10).

Changes over time

The low birthweight rate for Indigenous babies did not change significantly over the period 2013 to 2019. However, the low birthweight rate for non-Indigenous babies increased significantly from 4.5% to 4.9%.

The absolute gap in the low birthweight rates between Indigenous and non-Indigenous babies generally decreased over the period, from 5.2 percentage points in 2013 to 4.4 percentage points in 2019. In 2013, the relative gap was 2.2 times as high for Indigenous babies compared with non-Indigenous babies, while in 2019 this was 1.9 times as high for Indigenous babies (Table D1.01.20, Figure 1.01.5).

Figure 1.01.5: Proportion of low birthweight liveborn singleton babies and changes in the gap, by Indigenous status of the baby, Australia, 2013 to 2019

Source: Table D1.01.20. AIHW analysis of the National Perinatal Data Collection.

Between 2013 and 2019, the average birthweight of Indigenous babies remained similar (3,256 grams in 2013 and 3,265 grams in 2019), while the average birthweight for non-Indigenous babies decreased slightly over the same period (by 6.4%) (Table D1.01.5, Figure 1.01.6). As a result, the difference in average birthweight between Indigenous and non-Indigenous babies decreased slightly over the period (Figure 1.01.6).

Figure 1.01.6: Average birthweight of liveborn singleton babies, by Indigenous status of the baby, Australia, 2013 to 2019

Note: Difference is the average (mean) birthweight of non-Indigenous babies minus the average (mean) birthweight of Indigenous babies.

Source: Table D1.01.5. AIHW analysis of the National Perinatal Data Collection.

What do research and evaluations tell us?

Babies born with low birthweight have been found to experience lifelong and broad ranging health complications. Studies have identified that low birthweight is associated with:

• greater risks of serious health problems, including pulmonary hypertension, cerebral palsy, intellectual impairment, chronic lung disease, and vision and hearing loss (Howson et al. 2012; Hoy & Nicol 2010)
• increased risk of a range of chronic diseases in adulthood such as obesity, cardiovascular disease, hypertension, type 2 diabetes, and kidney disease (Arnold et al. 2016; Hovi et al. 2007; Hoy & Nicol 2010; Phillips 2006; Tappy 2006; White et al. 2010).

Children with extremely low birthweight (less than 1,000 grams) are more likely to face psycho‑social problems and difficulties at school. It has been found that teenagers who had extremely low birthweight are less likely to do well at school and experience lower achievements on intellectual measures, particularly arithmetic (AIHW 2011).

A complex range of maternal health and social and demographic factors can contribute to low birthweight.

Multivariate analysis is a type of statistical modelling used to examine relationships between multiple explanatory variables (e.g. maternal health status, maternal smoking and use of antenatal care) simultaneously and an outcome of interest (e.g. birthweight). This type of analysis can assess the significance of each explanatory variable, while accounting for the effects of the other explanatory variables included in the model.

A multivariate analysis of perinatal data for singleton births for the period 2017–2019 indicates that 37% of low birthweight Indigenous births were attributable to smoking, compared with 9.2% for non-Indigenous births (Table D1.01.8). After adjusting for differences in the age structure between the 2 populations, and other factors, it was estimated that if the smoking rate among mothers of Indigenous babies was the same as that among mothers of non-Indigenous babies, the proportion of low birthweight Indigenous babies could be reduced by 28% (Table D1.01.8).

Maternal exposure to domestic violence has been found to be associated with significantly increased risk of low birth weight and pre-term birth (Coker et al. 2004; Shah & Shah 2010; Webster 2016). 

Other maternal health factors that contribute to low birthweight include excessive alcohol consumption during pregnancy, nutritional status, substance abuse, low or high body mass index, and maternal age (Howson et al. 2012; Kildea et al. 2017; Kramer et al. 2001; Moutquin 2003; Poulsen et al. 2015).

See the HPF feature article Key factors contributing to low birthweight among Aboriginal and Torres Strait Islander babies for more detailed analysis of smoking and other factors contributing to birthweight.

A study of the geographic access for Indigenous women of child‑bearing age (15–44 years) to maternal health services found that poorer access to Indigenous-specific primary health care services with maternal/antenatal services was associated with higher rates of smoking and low birthweight. The study found that approximately one-fifth of Indigenous women of child-bearing age lived outside a one hour drive time from the nearest hospital with a public birthing unit. The lowest levels of access for maternal health services were for Indigenous women in Remote and Very remote areas, compared with other areas (AIHW 2017).

The literature suggests that one way to improve outcomes for Indigenous mothers and babies is through improved access to, and take up of, antenatal care services (AIHW 2014). Antenatal care programs for Indigenous women have been shown to have a quantifiable impact on maternal smoking and alcohol use during pregnancy, maternal nutrition and breastfeeding practices, and that this, in turn, can reduce the low birthweight rate, pre-term birth, and child mortality.

A suite of evaluations have been published across Australia on programs to improve the delivery of antenatal services to Indigenous Australian women with the intent of improving birth outcomes. The Clinical Practice Guidelines—Pregnancy Care (2020 edition), outlines evidence of successful models of care from these evaluations specifically tailored for Aboriginal and Torres Strait Islander women. This includes culturally appropriate and safe care as well as continuity of care; collaboration between midwives and Indigenous health workers; and the role of family members such as grandmothers in attending antenatal care sessions and positively influencing maternal healthy lifestyle behaviours during pregnancy (Department of Health 2020).

Many Indigenous Australian women do not have access to these specific programs and rely on mainstream health services such as general practitioners and hospital clinics (Clarke & Boyle 2014). As such, the Guidelines also urge the importance for mainstream services to embed cultural competence into continuous quality improvement activities for services.

Implications

The association between low birthweight and chronic disease in adult life suggests improvements in the rate of low birthweight are essential for improving health outcomes well into the future. The rate of low birthweight among Indigenous babies has not changed significantly since 2013, despite an intensified focus on reducing smoking during pregnancy and increasing early and regular access to antenatal care. The HPF feature article Key factors contributing to low birthweight among Aboriginal and Torres Strait Islander babies presents more detailed statistical analysis on low birthweight including trend analysis of gestational age (pre-term, early term, full term births), birthweight and key contributing factors such as maternal health, smoking during pregnancy and antenatal care attendance. It also provides analysis of the level of improvement required in smoking rates to meet the birthweight target in the National Agreement.

The multivariate analysis of perinatal data suggests that large improvements will result from lowering the rate of smoking during pregnancy. The inclusion of alcohol consumption during pregnancy is a useful addition to the National Perinatal Data Collection, from 2019, that will aid the analysis of maternal risks and birth outcomes in coming years.

Perinatal data indicate that the earlier an expectant mother first accesses antenatal care, the lower the likelihood of having a baby with low birthweight (see measure 3.01 Antenatal care). There is a need for early, high quality, culturally responsive, and women‑centred care delivered for Indigenous Australian women in Major Cities, Regional and Remote areas (Barclay et al. 2014; Sivertsen et al. 2020). A recent systematic review focused on efforts aimed at improving the delivery of effective health services for Indigenous Australians, including antenatal care, and found improved outcomes when services were designed specifically for and with Indigenous Australians. This finding supports the important role of Aboriginal Community Controlled Health Services (ACCHS) in the design and delivery of services.

Australian governments are investing in a range of initiatives aimed at improving child and maternal health. Detailed descriptions are included in the Policies and strategies section and include the Australian Nurse-Family Partnership Program, Connected Beginnings, the National Tobacco Campaign’s Tackling Indigenous Smoking (TIS) program and the National Fetal Alcohol Spectrum Disorder (FASD) Strategic Action Plan. See also measures 3.01 Antenatal care and 2.21 Health behaviours during pregnancy.

Enhanced primary care services and continued improvement in, and access, to culturally appropriate antenatal care have the capacity to support improvements in the health of the mother and baby. This highlights the important role ACCHS have in leading culturally safe and responsive health care within their communities. ACCHS are operated and governed by the local community to deliver holistic, strengths-based, comprehensive and culturally safe primary health services across urban, regional, rural and remote locations. Further work to ensure mainstream services can provide culturally safe and responsive care for Indigenous Australians is also critically important. These two dimensions of health care for Indigenous Australians have been emphasised in the Health Plan which places culture at the foundation for Aboriginal and Torres Strait Islander health and wellbeing as a protective factor across the life course.

The Health Plan, released in December 2021, is the overarching policy framework to drive progress against the Closing the Gap health targets and priority reforms. Implementation of the Health Plan aims to drive structural reform towards models of care that are prevention and early intervention focused, with greater integration of care systems and pathways across primary, secondary and tertiary care. It also emphasises the need for mainstream services to address racism and provide culturally safe and responsive care, and be accountable to Aboriginal and Torres Strait Islander people and communities.

The Health Plan suggests that efforts should be targeted at providing strengths based, culturally safe and holistic, affordable services to ensure a strong start to life. Birthing on Country services have the potential to support healthy pregnancies and should be explored as a way to offer an integrated, holistic and culturally safe model of care. For example, Birthing on Country services can support reduction and cessation of smoking in pregnancy through health-literacy approaches.

As part of the National Agreement, the health sector was identified as one of 4 initial sectors for joint national strengthening effort and the development of a 3-year Sector Strengthening Plan. The Health Sector Strengthening Plan (Health-SSP) was developed in 2021, to acknowledge and respond to the scope of key challenges for the sector, providing 17 transformative sector strengthening actions. Developed through strong consultation across the Aboriginal and Torres Strait Islander community-controlled health sector and other Aboriginal and Torres Strait Islander health organisations, the Health-SSP will be used to prioritise, partner and negotiate beneficial sector-strengthening strategies.

The policy context is at Policies and strategies.

References

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