Smoking during pregnancy among Indigenous mothers was higher in more remote areas (54% in Very remote areas compared with 37% in Major cities)
Proportion of Indigenous mothers who smoked after 20 weeks of pregnancy (38%) was lower than the proportion who smoked in the first 20 weeks (43%)
- Many Aboriginal and Torres Strait Islander women have healthy pregnancies. Indigenous cultures take a holistic view of wellbeing and have many strengths that provide a positive influence on wellbeing and resilience for Indigenous women and their families.
- For women who experience adverse events in their pregnancies, the factors that influence these outcomes can be diverse, reflecting a range of the social determinants of health as well as health behaviours, biomedical risks and poor access to appropriate services.
- An estimated 37% of low birthweight births of Indigenous singleton babies in 2017–2019 were attributable to smoking during pregnancy, based on a multivariate analysis.
- The rate of smoking any time during pregnancy among Aboriginal and Torres Strait Islander mothers is 44% in 2019 – a decline from 52% in 2009.
- Differences are evident by remoteness – for example, the rate of smoking during pregnancy among Indigenous mothers was higher in more remote areas. In Major cities, 37% of Indigenous women who gave birth in 2019 smoked during pregnancy, compared with 54% in Very remote Access to maternal health services is also lower in remote areas.
- The vast majority of Indigenous women did not consume alcohol in the first 20 weeks of pregnancy or after 20 weeks – ranging from 89% to 100% for the 6 jurisdictions reported in 2019.
- Among mothers of Indigenous children aged 0–3 in 2018–19, most reported that they did not consume alcohol (90%) and did not use illicit drugs (97%) during their pregnancy.
- A study of the spatial variation in Indigenous women’s access to maternal health services found that poorer access to at least one type of maternal health service was associated with higher rates of smoking, pre-term delivery and low birthweight. One-fifth of Indigenous women lived more than one hour from the nearest hospital with a public birthing unit.
Why is it important?
The origins of health behaviours are located in a complex range of socioeconomic, family and community factors, arising from environments shaped by political, social and economic forces (Nettleton et al. 2007). These social determinants of health are the conditions in which people are born, grow, live, work and age, and are mostly responsible for health inequalities (WHO 2022). The health and wellbeing of women during pregnancy is vitally important to ensuring healthy outcomes for mothers and their babies (AIHW 2020). Many factors contribute to and can have beneficial or adverse effects on the health and wellbeing of a mother and her baby during pregnancy and birth, as well as outcomes for children later in life. Women who eat well, exercise regularly and receive regular antenatal care are less likely to have complications during pregnancy. They are also more likely to give birth successfully to a healthy baby. Smoking, drinking, or taking illicit drugs can lead to increased risk of pregnancy complications, poor perinatal outcomes (such as low birthweight), and ongoing health concerns.
Many Aboriginal and Torres Strait Islander women have healthy pregnancies (Clarke & Boyle 2014). Indigenous cultures take a holistic view of wellbeing, and have many strengths that provide a positive influence on wellbeing and resilience for Indigenous women and their families. These include a supportive extended family network and kinship, connection to country and cultural practices such as languages, art, and music. For women who experience adverse events in their pregnancies, the factors that influence these outcomes can be diverse, reflecting a range of the social determinants of health as well as health behaviours and biomedical risks. These include:
- socioeconomic factors—lower income, higher unemployment, lower educational levels, inadequate infrastructure (for example affordable housing and water supply), and lack of access to culturally safe health services (including maternal health services)
- health factors—diabetes, cardiovascular disease (including rheumatic heart disease), respiratory disease, kidney disease, communicable infections, injuries, poor mental health, and being overweight or underweight
- lifestyle and social factors—lack of physical activity, poor nutrition, harmful levels of alcohol intake, smoking and higher psychosocial stressors (for example deaths in families, violence, serious illness, financial pressures and contact with the justice system).
In addition, racism constitutes a ‘double burden’ for Indigenous Australians, affecting their health as well as access to adequate and timely health care services (Kildea S. et al. 2016).
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 Australian 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 (with smoking during pregnancy and alcohol use during pregnancy as supporting indicators).
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.
The Health Plan is discussed further in the Implications section of this measure.
What does the data tell us?
Smoking during pregnancy among Indigenous mothers
Around 44% of Indigenous mothers smoked tobacco during pregnancy in 2019, according to self-reported data from the National Perinatal Data Collection (Figure 2.21.1).
In 2019, across maternal age groups, the proportion of Indigenous mothers who smoked during their pregnancy ranged from just under 42% among those aged 30–34, to 46% among those aged 35–39 (Table D2.21.2).
Across states and territories, the proportion of Indigenous mothers who smoked during pregnancy in 2019 ranged from 35% (in the Australian Capital Territory) to 50% (in the Northern Territory) (Figure 2.21.1).
Figure 2.21.1: Proportion of Indigenous mothers who smoked during pregnancy, by state and territory, 2019
The rate of smoking during pregnancy among Indigenous mothers was higher in more remote areas. In Major cities, 37% of Indigenous women who gave birth in 2019 smoked during pregnancy, compared with 54% in Very remote areas (Table D2.21.2, Figure 2.21.2).
Figure 2.21.2: Proportion of Indigenous mothers who smoked during pregnancy, by remoteness, 2019
In 2019, the proportion of Indigenous mothers who smoked after 20 weeks of pregnancy (38%) was lower than the proportion who smoked in the first 20 weeks of pregnancy (43%). The reduction in smoking rates for Indigenous mothers from the first 20 weeks of pregnancy to after 20 weeks was 6.1 percentage points in remote areas, and 4.1 percentage points in non-remote areas (Table D2.21.16, Table D2.21.18).
Across states and territories, the reduction in smoking rates for Indigenous mothers between the first 20 weeks of pregnancy and after 20 weeks was largest in South Australia (14.1 percentage points) and smallest in the New South Wales (2.2 percentage points) (Table D2.21.9, Table D2.21.10, Figure 2.21.3).
Figure 2.21.3: Proportion of Indigenous mothers who smoked during the first 20 weeks of pregnancy and after, by state and territory, 2019
By maternal age, in 2019 among Indigenous mothers, the largest reduction in smoking rates between the first 20 weeks of pregnancy and after 20 weeks of pregnancy occurred for those aged under 20 (5.8 percentage points), while the smallest reduction occurred among those aged 40 and over (2.1 percentage points) (Table D2.21.17, Table D2.21.19).
Smoking during pregnancy by Indigenous status
Indigenous mothers were more likely than non-Indigenous mothers to smoke tobacco during pregnancy across all age groups (Figure 2.21.4). Among Indigenous women who gave birth in 2019, the proportion who smoked during pregnancy ranged between 42% and 46% across maternal age groups. Among non-Indigenous women who gave birth in 2019, rates of smoking during pregnancy were higher in younger than in older age groups – 28% among those aged under 20, 18% among those aged 20–24, and between 5% and 9% among those in the older age groups.
After adjusting for differences in the age structure between the 2 populations, Indigenous mothers were 3.9 times as likely to smoke at any time during pregnancy as non-Indigenous mothers (Table D2.21.2).
Figure 2.21.4: Proportion of mothers who smoked during pregnancy, by age group and Indigenous status, 2019
The difference in smoking rates between Indigenous and non-Indigenous mothers was higher in remote than non-remote areas. In 2019:
- in remote areas, smoking rates during pregnancy for Indigenous mothers were 4.7 times as high as for non-Indigenous mothers
- in non-remote areas, the rate of smoking during pregnancy for was 3.8 times as high for Indigenous mothers as for non-Indigenous mothers (Table D2.21.2).
Smoking and birthweight outcomes
Babies are born with a low birthweight because they are born early (pre-term) or because their growth during pregnancy is restricted resulting in the baby being small for their gestational age (SGA), or both. Maternal smoking increases the chances that a baby will be born with a low birthweight. The main contributing factors to pre-term births and SGA births differ somewhat, but maternal smoking increases the chances that a baby will be born pre-term or SGA (AIHW 2022).
In 2019, babies born to Indigenous mothers who smoked were:
- 1.5 times as likely to be pre-term as those born to Indigenous mothers who did not smoke (15% and 10%, respectively).
- 1.4 times as likely to weigh less than 1,500 grams (very low birthweight) as those born to Indigenous mothers who did not smoke (1.9% and 1.4%, respectively).
- 2.3 times as likely to weigh 1,500-2,499 grams (low birthweight, excluding very low birth weights) as those born to Indigenous mothers who did not smoke 13% and 5.7%, respectively) (Table D2.21.4).
The 2014–15 National Aboriginal and Torres Strait Islander Social Survey data shows an association between mothers having regular pregnancy check-ups and children’s birthweight. Of Indigenous mothers of children with a birthweight of 2,500 grams or more, 98% had regular check-ups compared with 84% among mothers of children with low birthweight (<2,500 grams), (Table D2.21.8).
Data for Indigenous-specific primary health care organisations from the National Key Performance Indicators (nKPI) collection showed that 48% of their regular female clients who gave birth in 2018 were current smokers. This varied by remoteness area and was lowest in Major cities and Inner regional areas (both 43%) while being highest in Very remote areas (54%) (Table D2.21.13).
Alcohol and drugs use during pregnancy
Based on self-reported data from the National Aboriginal and Torres Strait Islander Health survey, among mothers of Indigenous children aged 0–3 in 2018–19, most did not consume alcohol (90%) and did not use illicit drugs (97%) during their pregnancy (Table D2.21.6, Figure 2.21.5).
Figure 2.21.5: Use of alcohol and illicit drugs during pregnancy, mothers of Indigenous children (0–3 years), 2018–19
In the National Perinatal Data Collection, standardised data items on alcohol consumption during pregnancy were requested for the first time in 2019. The data items are currently voluntary – jurisdictions provide the data if possible, with a view to these items becoming mandatory items in the future.
For 2019, information about alcohol consumption during pregnancy was available from most jurisdictions (except New South Wales and South Australia), though to differing extents (Table 2.21-1). Due to differences in definitions and methods used for data collection, care should be taken when comparing data across jurisdictions.
Data are presented in this section for Victoria, Queensland, Western Australia, and the Northern Territory. Data for Tasmania and the Australian Capital Territory are also available (see Table 2.21-1 below and data Tables D2.21.23 and D2.21.24), but not shown here due to relatively small numbers of Indigenous mothers.
Table 2.21-1: Availability of data on alcohol use during pregnancy in the NPDC, by state and territory, 2019
The vast majority of Indigenous women did not report consuming alcohol in the first 20 weeks of pregnancy or after 20 weeks – ranging from 89% to 100% for the 6 jurisdictions reported in 2019 (Table D2.21.23, Table D2.21.24).
In 2019, the proportion of Indigenous mothers who reported consuming alcohol during the first 20 weeks of pregnancy was 11% in the Northern Territory (or 111 women), 10% in Queensland (195 women) and 9% in Western Australia (150 women) (Figure 2.21.6).
In each of these states and territories, the rate of alcohol consumption after 20 weeks of pregnancy was less than half the rate during the first 20 weeks of pregnancy (Table D2.21.23, Table D2.21.24).
Figure 2.21.6: Alcohol consumption among Indigenous mothers, Vic, Qld, WA and NT, 2019
Folate intake and other maternal health characteristics
Based on the National Aboriginal and Torres Strait Islander Social Survey, in 2014–15, 60% of mothers of Indigenous children aged 0–3 took folate before or during their pregnancy. The proportion was highest in Inner regional areas (70%) and lowest in Very remote areas (33%) (Table D3.01.19).
According to data from the National Perinatal Data Collection, in 2019, among Indigenous mothers:
- 37% had a normal body weight pre-pregnancy as indicated by their Body Mass Index (BMI), 56% were overweight or obese, and 6.5% were underweight
- 2.2% had pre-existing diabetes, and 12% had gestational diabetes
- 1.1% had pre-existing hypertension, and 2.8% had gestational hypertension (Table D2.21.12, Figure 2.21.7).
Based on age-standardised rates, among women who gave birth in 2019, Indigenous women were:
- 1.6 times as likely as non-Indigenous women to be obese pre-pregnancy
- 1.2 times as likely as non-Indigenous women to be underweight pre-pregnancy
- 1.3 times as likely as non-Indigenous women to have gestational diabetes
- 4.1 times as likely as non-Indigenous women to have pre-existing diabetes
- 2.2 times as likely as non-Indigenous women to have pre-existing hypertension (1.6% and 0.7%, respectively) (Table D2.21.12).
Figure 2.21.7: Indigenous women who gave birth, by selected maternal characteristics, 2019
Between 2009 and 2019, smoking during pregnancy among Indigenous mothers decreased from 52% to 44% (based on crude rates).
Based on age-standardised rates, the proportion of Indigenous mothers who smoked during pregnancy declined by 13%, while for non-Indigenous mothers the proportion declined by 38% (Table D2.21.20, Figure 2.21.8).
Reflecting the higher percentage reduction for non-Indigenous mothers, the relative gap in the smoking rates of the 2 populations generally increased between 2009 and 2019. In 2009, the smoking rate among Indigenous mothers was 3.1 times as high as for non-Indigenous mothers, compared with 3.9 times as high in 2019 (Table 2.21.20, Figure 2.21.8).
The absolute reduction in rates of smoking during pregnancy was more similar for Indigenous and non-Indigenous mothers (annual reductions of 0.6 and 0.5 percentage points, respectively). The absolute gap in the rates ranged between 32 and 34 percentage points between 2009 and 2019 (Table 2.21.20, Figure 2.21.8).
Figure 2.21.8: Age-standardised proportion of mothers who smoked during pregnancy and changes in the gap, Australia, by Indigenous status, 2009 to 2019
What do research and evaluations tell us?
Tobacco smoking increases the risk of pregnancy complications (for example miscarriage, placental abruption and premature labour) and poor perinatal outcomes such as low birthweight, intrauterine growth restriction, pre-term birth and perinatal death (England et al. 2004; Hodyl et al. 2014; Laws & Sullivan 2005; Pringle et al. 2015; Wills & Coory 2008). Maternal exposure to second-hand smoke also increases these risks for babies (Crane et al. 2011) (for effects of second-hand smoke exposure after birth see measure 2.03 Environmental tobacco smoke). There is evidence that smoking cessation, particularly in the first trimester, can reduce these risks (Bickerstaff et al. 2012; Hodyl et al. 2014; Yan & Groothuis 2015).
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 2017–2019 from the National Perinatal Data Collection indicates that 37% of low birthweight births of Indigenous singleton babies were attributable to the mother smoking during pregnancy, compared with 9% of low birthweight births of non-Indigenous singleton babies, after adjusting for maternal age and other factors. It was estimated that if the rate of smoking 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% (see measure 1.01 Birthweight) (Table D1.01.8).
Separate multivariate analyses of 2017–2019 data looking at pre-term births and SGA births as outcomes indicates that, excluding multiple births:
- 22% of pre-term births of Indigenous babies were attributable to smoking during pregnancy, compared with 5% of pre-term births of non-Indigenous babies, after adjusting for maternal age and other factors. It was estimated that if the rate of smoking during pregnancy among mothers of Indigenous babies was the same as that among mothers of non-Indigenous babies, the proportion of babies that were pre-term could be reduced by 17% (see measure 1.01 Birthweight) (Table D1.01.9).
- 39% of small-for-gestational age (SGA) births of Indigenous babies were attributable to smoking during pregnancy, compared with 7% of SGA births of non-Indigenous babies, after adjusting maternal age and other factors. It was estimated that if the rate of smoking during pregnancy among mothers of Indigenous babies was the same as that among mothers of non-Indigenous babies, the proportion of babies that were SGA babies could be reduced by 31% (see measure 1.01 Birthweight) (Table D1.01.23).
The HPF feature article ‘Key factors contributing to low birthweight among Aboriginal and Torres Strait Islander babies’ includes analysis of the impact of smoking on birthweight. Findings include that while the rate of maternal smoking is decreasing, it is not projected to decrease to the estimated level required to reduce the low birthweight rate to a level consistent with the healthy birthweight Closing the Gap target for 2031. Based on modelling work, at a national level and assuming other explanatory factors stay constant, it was estimated that the Indigenous maternal smoking rate would need to fall to about 27% by 2031 in order to meet the target (down from 44% in 2019).
Indigenous Australian women are motivated to stop smoking during pregnancy and are making attempts to quit (Colonna et al. 2020). A study conducted between November 2016 and July 2017 of 22 pregnant Indigenous Australian women attending Aboriginal Community Controlled Health Services (ACCHSs) located in New South Wales, Queensland and South Australia found that most were intending to quit smoking, with all intending to at least reduce consumption during pregnancy (Bovill et al. 2020). During the 12-week study period, 14 women attempted to stop smoking, and three quit smoking. The researchers concluded that interventions should be tailored to address the strength of nicotine dependence despite low consumption and that prolonged support is recommended. Involving pregnant Indigenous women’s partners, support people and family in education on the adverse effects of smoking and the benefits of smoking cessation strategies, may have a positive effect on attempts to stop smoking, as this can lead to the women being supported in their decision to quit (Harris B. M. et al. 2019).
A review on tobacco use among Indigenous Australians, found that there is a need to improve communication regarding the health effects of smoking during pregnancy. The review argues that effective anti-tobacco programs need to be culturally appropriate and expanded through long-term funding and rigorous evaluation (Colonna et al. 2020). Yarning circles conducted with Indigenous Australian women found that targeted resources on smoking cessation during pregnancy needed to be visually attractive and interactive, and include additional scientific content on the health consequences (Bovill et al. 2019). Developing effective health promotion materials requires more than a culturally appropriate adaptation of mainstream resources, and the diversity of Indigenous communities needs to be considered when developing interventions.
There is limited evidence on effective tobacco smoking cessation or education strategies aimed at Indigenous Australian women (Eades et al. 2012; Hefler & Thomas 2013; Lucas et al. 2014). However, research has recommended approaches that consider social and environmental contexts; increase knowledge of harm and cessation methods; are tailored to clients’ needs; are provided in a way that does not cause embarrassment or distress or deter further antenatal care; are culturally targeted with Indigenous health worker involvement; include partners, families and communities; are provided before, during and after pregnancy; and include alternative stress reduction and coping strategies (Bond et al. 2012; Bridge 2011; Elliott DJ & Silverman 2013; France et al. 2010; Gould et al. 2013; Marley et al. 2014; van der Sterren & Fowlie 2015; Wood et al. 2008).
An evaluation of the Malabar service—a community‐based culturally appropriate service that addressed the antenatal care needs of Indigenous women—found that the continuity of care was the most valued aspect of the service. The midwives and Indigenous health workers were seen as friendly, supportive, engaged, and approachable. The development of trust was a recurring theme during the evaluation (Homer et al. 2012). Malabar was considered to provide more than just a maternity service, with women stating that it also helped to establish social networks and play-groups. A more recent evaluation of the Malabar service over 2007 to 2014 found a 25% reduction in the rates of smoking after 20 weeks gestation, but similar rates of preterm birth and breastfeeding at discharge, and a higher rate of low birthweight babies, compared with mainstream services (Hartz et al. 2019). Malabar outcomes were better than state and national outcomes.
The Ynan Ngurra-ngu Walalja Halls Creek Community Families Program was a community-based maternal and child health education and prevention home visiting program for Indigenous families (Walker 2010). Experienced Indigenous mothers and grandmothers were trained as community care workers to provide a range of culturally appropriate activities, including home visiting support. A 2011 evaluation of the program found evidence of families reducing smoking around pregnant women and having an increased awareness of the influences of alcohol during pregnancy. The evaluation found the program to be culturally responsive and adapted to meet the specific needs of the local Indigenous community.
A study into the spatial variation in Indigenous women’s access to maternal health services found that poorer access to at least 1 maternal health service (hospitals with a public birthing unit; Indigenous-specific primary health-care services; Royal Flying Doctor Service clinics; or general practitioners) was associated with higher smoking rates and higher rates of pre-term delivery and low birthweight. The study also found that one-fifth of Indigenous women lived more than 1 hour from the nearest hospital with a public birthing unit. Access to at least 1 type of maternal health service was lowest for Indigenous women in Remote and Very remote areas (AIHW 2017).
The Australian guidelines to reduce health risks from drinking alcohol (2020) recommend that women who are pregnant or planning a pregnancy should not drink alcohol; nor while breastfeeding, as the safest option for their baby (NHMRC 2009b). Drinking alcohol while pregnant may have consequences for fetal development of the brain and can cause miscarriage, stillbirth, low birthweight, intrauterine growth restriction and pre-term birth and has been shown to result in a range of potentially lifelong physical, mental, behavioural and neurodevelopmental abnormalities and learning issues, collectively referred to as Fetal Alcohol Spectrum Disorders (FASD) (France et al. 2010; Mutch et al. 2015; Srikartika & O'Leary 2015).
Nationally, the true prevalence of FASD for Indigenous Australians is not known. A study in WA estimated a FASD prevalence of 2.76 per 1,000 births among Aboriginal for children born between 1980 and 1997, based on data from the WA Birth Defects Registry and from the Rural Paediatric Service (RPS) (Bower et al. 2018). A study in the Top End of the Northern Territory estimated a FASD prevalence of between 1.87 and 4.7 per 1000 live births for children born between 1990 and 2000, based on a retrospective review of medical records and outpatient letters of children seen by Royal Darwin Hospital paediatric staff (Harris K. R. & Bucens 2003). A recent study in the Fitzroy Valley, where Indigenous Australian women led the way in developing the Marulu Strategy to deal with FASD, found rates to be 120 per 1,000 children based on a population-based active method of case ascertainment (Elliott et al. 2012; Fitzpatrick et al. 2015). While existing research has limitations, risks of harm are said to increase with the amount and frequency of alcohol consumed (O'Leary et al. 2010). Large, population-based studies are needed to strengthen the evidence base.
A review of family-centred care that examined studies on the provision of mentoring to support healthy family behaviours found that mentoring by Indigenous Elders and health professionals was provided to encourage reduced or no alcohol use, reduced smoking and improved nutrition in pregnancy (McCalman et al. 2017). In the Fitzroy Valley, Indigenous women identified the need to address FASD in 2008. Community leaders partnered with local service providers and researchers to develop the community-led Marulu FASD Prevention Strategy, which commenced in 2010 (Elliott et al. 2012; Fitzpatrick et al. 2017). Between 2010 and 2016, a range of community-led FASD prevention activities were implemented, including television and radio mass media advertisements; targeted health promotion messaging coordinated and delivered through local Indigenous organisations; and screening of all pregnant women by community midwives for alcohol use, with referral and encouragement to access services if needed (Symons et al. 2020). Community leaders invited researchers to perform an evaluation of Marulu, which found that Fitzroy Valley women reporting the consumption of alcohol during pregnancy reduced significantly from 61% in 2010 to 32% in 2015 over a period during which community-led prevention efforts took place. First trimester use reduced significantly from 45.1% in 2008 to 21.6% in 2015. This project demonstrates the importance of Indigenous-led research, and genuine partnerships where research is conducted with the community rather than about the community (Elliott et al. 2012). Further place-based research in other communities is needed.
There is limited research evidence on the effectiveness of implementation strategies to improve antenatal care that addresses the consumption of alcohol during pregnancy (Kingsland et al. 2018). A randomised trial in the Hunter New England Local Health District in New South Wales will examine the effectiveness of changes to the model of care delivered by public antenatal services to improve the provision of care to address alcohol consumption during pregnancy. Changes include the use of the Alcohol Use Disorders Identification Test Consumption (AUDIT-C) tool to assess the alcohol consumption of pregnant women, and Indigenous Australian women with a Medium Audit-C risk level will be offered the option of a referral to counselling services at a local ACCHS.
Use of illicit drugs (for example heroin and cannabis) and unsafe use of licit drugs (for example medicines) during pregnancy can pose health risks to the mother (for example overdose and accidental injuries) as well as significant obstetric, fetal and neonatal complications (Kennare et al. 2005; Kulaga et al. 2009; Ludlow et al. 2004; Wallace et al. 2007) and behavioural and cognitive problems that emerge in later life (Passey et al. 2014). Concurrent use of multiple substances and clustering of risk factors, particularly for women of lower socioeconomic status, also need to be considered and addressed through holistic approaches (Brown et al. 2016; Eades et al. 2012; Passey et al. 2014; Wen et al. 2010).
Nutrition before and during pregnancy is also essential for fetal development (McDermott et al. 2009; Wen et al. 2010). Eating the recommended number of daily serves of the five food groups and drinking plenty of water is important during pregnancy. Maintenance of folate levels is particularly important to decrease the risk of neural tube defects such as spina bifida (AHMAC 2012), which in the past has been twice as common among babies born to Indigenous women as those born to non-Indigenous women (data for New South Wales and Western Australia combined due to data quality issues) (Macaldowie & Hilder 2011). However, following mandatory flour fortification with folic acid in 2009 there have been reductions in neural tube defects among Indigenous Australian infants, and this has closed the gap with non-Indigenous infants in the rates of neural tube defects (D'Antoine & Bower 2019).
Sufficient iodine levels are particularly important for women of childbearing age as a deficiency could impede the normal growth and development of the fetus if these women were to become pregnant (WHO et al. 2007). The 2012–13 Health Survey measured the iodine levels of Indigenous Australians, using a urine test (ABS 2014). The results showed that nationally, Indigenous Australian women aged 18-44 were iodine sufficient in 2012–13, with a population median urinary iodine concentration (UIC) of 135.0μg/L. However, for pregnant and lactating women, the World Health Organization recommends a UIC level of 150 to 249μg/L (NHMRC 2009a). Research in the Top End of the Northern Territory in 2005–2008 found that young Indigenous Australians were classified as mildly to moderately iodine deficient prior to the mandatory fortification of bread with iodised salt in Australia in 2009 (Mackerras et al. 2011). A subsequent research project compared the iodine status of young Indigenous Australians in the Top End in 2006–2007 (prior to fortification) to iodine status in 2013–2015 (post-fortification) (Singh et al. 2019). An analysis of the results found that while the median UIC of the urban Indigenous Australian youth increased post-fortification, and this group achieved adequate iodine levels, young Indigenous Australian women from Remote areas remained mildly iodine deficient. While the results suggested an increase in median UIC among the small group of pregnant young Indigenous Australian female participants post-fortification, their median UIC remained below the recommended minimum of 150μg/L for pregnant women.
In addition to adverse birth outcomes, poor maternal nutrition has been linked with an increased risk of developing insulin resistance and obesity in children (Drake & Reynolds 2010; Nelson et al. 2010). In some cases, access to healthy food is problematic due to geographical location and the high cost of fresh food in Remote areas.
Exercise during pregnancy is beneficial for the mother and fetus during gestation, with benefits persisting for the child into adulthood. It is associated with a reduced risk of preeclampsia, gestational diabetes, and pre-term birth, as well as improved pain tolerance, lower total weight gain and less fat mass gain, and improved self-image. Exercise during pregnancy also decreases the risk of chronic disease for both mother and child (Moyer et al. 2016).
Preconception care is emerging as an important part of public health efforts to improve maternal and child health. The Royal Australian College of General Practitioners recommends that every woman of reproductive age be considered for preconception care to identify and modify risks to a woman’s health or pregnancy (RACGP 2018). A study of preconception care in a Very remote ACCHS found a high proportion of women who had a pregnancy during the study period had received preconception care, but this was lower for younger women particularly in screening for modifiable risk factors (Griffiths et al. 2020). The study suggests that ACCHSs can play an important role in supporting reproductive health literacy, particularly among younger women.
Although maternity services in Australia are designed to offer women the best care, they mostly reflect Western medical values and perceptions of health, risk, and safety. Achieving culturally safe maternity services is critical to improving health for Indigenous Australian mothers and babies (Kildea S. et al. 2016), and this is underpinned by cultural awareness among health professionals.
A key component of improving pregnancy outcomes is early and ongoing engagement in antenatal care, which is facilitated by the provision of culturally appropriate and evidence-based care relevant to the local community (Clarke & Boyle 2014). Strategies addressing potentially modifiable risk factors (such as smoking, alcohol and substance use) as well as fostering positive health behaviours (such as healthy diet and exercise) should be a primary focus of antenatal care delivery. Community awareness campaigns are essential.
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.
Women who are healthy before and during pregnancy are more likely to have a healthy baby. Approaches that can lead to better outcomes for Indigenous women and their babies include improving access to maternal health services for women in Remote and Very Remote areas and enabling access to culturally appropriate health care in both Aboriginal community-controlled and mainstream health services (Boyle & Eades 2016; Gibson-Helm et al. 2016).
Protective factors such as not smoking during pregnancy and cultural-based resilience among mothers (related to social, emotional wellbeing and connection to the community) could reduce the risk of adverse perinatal health outcomes (Westrupp et al. 2019). Recent research suggests that culturally safe and appropriate antenatal care delivered in partnership with ACCHSs achieves better outcomes for women giving birth to Indigenous babies compared with standard care (Kildea S et al. 2019). More regional level data on risk factors will assist in targeting interventions, such as using locally adapted approaches to smoking cessation (Westrupp et al. 2019).
Partnerships between ACCHSs and mainstream services can help address the long-held issues around mistrust of mainstream health services (Rumbold & Cunningham 2007) and improve the quality of antenatal care (Campbell et al. 2018). Indigenous community-led prevention and intervention strategies have been shown to be an effective approach. While progress has been made to strengthen maternity services to support the provision of culturally competent care, build the Indigenous maternity workforce and increase Birthing on Country, more effort is needed in these areas (Kildea S. et al. 2016).
Preconception care, including improving reproductive health literacy, typically through primary health care providers, can be an important avenue to address risk factors for women of reproductive age. However, time constraints and competing priorities for preventative health in the primary health care setting may mean preconception care is underutilised, particularly among Indigenous Australian women at the younger and older ends of reproductive age. Integrating preconception care into existing clinical practice with existing Medicare items such as health assessments and chronic disease management would provide more opportunities for brief interventions (Griffiths et al. 2020).
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 (Department of Health 2021).
The policy context is at Policies and strategies.
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