The rate of smoking during pregnancy by Aboriginal and Torres Strait Islander mothers declined by from 54% to 44%, from 2006 to 2017
2014–15 survey data shows an association between Indigenous mothers having regular pregnancy check-ups and children’s birthweight
were more likely than non-Indigenous mothers to be obese (32% compared with 20%, respectively), in 2017
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 2020). 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 prenatal 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, and inadequate infrastructure (for example affordable housing and water supply)
- 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 et al. 2016).
What does the data tell us?
Perinatal data showed that 44% of Indigenous mothers smoked during pregnancy in 2017. After adjusting for differences in the age structure between the two populations, Indigenous mothers were about 4 times as likely to smoke at any time during pregnancy as non-Indigenous mothers (44% compared with 12%, respectively) (Table D2.21.2). Between 2006 and 2017, the crude proportion of Indigenous mothers who smoked at any time during pregnancy declined from 54% to 44%. After adjusting for differences in the age structure between the two populations, the proportion who smoked during pregnancy declined from 52% to 45% for Indigenous mothers, and declined from 19% to 11% for non-Indigenous mothers (Table D2.21.11, Figure 2.21.1). Please note, the time series data excludes Victoria.
Figure 2.21.1: Age-standardised proportion of mothers who smoked during pregnancy, NSW, Qld, WA, SA, Tas, ACT and NT combined, by Indigenous status, 2006–2017
The 2017 perinatal data showed that there was little difference in the age groups of Indigenous mothers who smoked during their pregnancy. Proportions for Indigenous mothers were lowest for those aged 30–34 (42%) but were only slightly higher (ranging from 44–45%) for all other age groups. For non-Indigenous mothers who smoked during their pregnancy, rates were highest for those aged under 20 (29%), followed by 20–24 (18%) and between 5% and 9% for age groups over 25 (Table D2.21.2, Figure 2.21.2).
Figure 2.21.2: Proportion of mothers who smoked during pregnancy, by age group and Indigenous status, 2017
The rate for Indigenous mothers who smoked during pregnancy was lowest in Tasmania (37%) and highest in the Northern Territory (49%) (Table D2.21.1, Figure 2.21.3).
Figure 2.21.3: Proportion of Indigenous mothers who smoked during pregnancy, by jurisdiction, 2017
After adjusting for differences in the age structure between the two populations, the smoking rates during pregnancy for Indigenous mothers ranged from 38% in Major cities to 53% in Very remote areas. For non-Indigenous mothers, the smoking rates ranged from 10% in Major cities to 16% in Inner regional areas (Table D2.21.2, Figure 2.21.4).
Figure 2.21.4: Age-standardised proportion of mothers who smoked during pregnancy, by Indigenous status and remoteness, 2017
The proportion of Indigenous mothers who smoked after 20 weeks of pregnancy was lower than those who smoked in the first 20 weeks of pregnancy (39% compared with 43%). The reduction in the rates of smoking for Indigenous mothers from the first 20 weeks of pregnancy to after 20 weeks was greater for Indigenous women in Non-remote areas (4.8 percentage points) than Remote areas (3.5 percentage points) (Table D2.21.16, Table D2.21.18).
By jurisdiction, the reduction in the smoking rates for Indigenous mothers from the first 20 weeks of pregnancy to after 20 weeks was largest in South Australia (9.9 percentage points) and smallest in the Northern Territory (2.4 percentage points) (Table D2.21.9, Table D2.21.10, Figure 2.21.5).
Figure 2.21.5: Proportion of Indigenous mothers who smoked during the first 20 weeks of pregnancy and after, by jurisdiction, 2017
Indigenous mothers aged under 20 who smoked during their pregnancy had the largest reduction in the smoking rates after 20 weeks of pregnancy (5.9 percentage points) and those aged 40 and over the smallest reduction (3.6 percentage points) (Table D2.21.17, Table D2.21.19).
For Indigenous mothers who smoked during their pregnancy in 2017, there was a decrease in the average number of cigarettes smoked per day between the first 20 weeks of pregnancy and after 20 weeks. In the first 20 weeks, 19% of Indigenous mothers smoked more than 10 cigarettes per day, compared with 17% of mothers after 20 weeks (Table D2.21.3). The largest decrease was for mothers aged 25–29, where 20% smoked more than 10 cigarettes per day in the first 20 weeks, compared with 16% after 20 weeks (Table D2.21.15).
A multivariate analysis of 2015–17 perinatal data indicates that, excluding pre-term and multiple births, 47% of low birthweight babies born to Indigenous mothers were attributable to smoking during pregnancy, compared with 12% for non-Indigenous mothers. After adjusting for differences in the age structure between the two populations and other factors, it was estimated that if the maternal smoking rate by Indigenous Australians was the same as that of non-Indigenous mothers, the proportion of low birthweight babies could be reduced by 33% (see measure 1.01 Low birthweight) (Table D1.01.9). In 2017, after adjusting for differences in the age structure between the two populations, babies born to Indigenous mothers who smoked were 1.5 times as likely to be pre-term as those born to mothers who did not smoke (18% and 12%, 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 low birthweight (<2,500 grams), 84% had regular check-ups, compared with 98% of mothers of children with a birthweight of 2,500 grams or more (Table D2.21.8).
The 2018–19 National Aboriginal and Torres Strait Islander Health Survey (Health Survey) showed that 32% of mothers of Indigenous children aged 0–3 had smoked during their pregnancy (Table D2.21.6, Figure 2.21.6). This is lower than the rate from the National Perinatal Data Collection; however, it should be noted that the Health Survey data is self-reported and subject to sample error.
Data from Indigenous-specific primary health care organisations 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
Based on self-reported data for mothers of Indigenous children aged 0–3 in 2018–19, the majority of mothers reported they did not consume alcohol (90%) and did not use illicit drugs (97%) during their pregnancy (Table D2.21.6, Figure 2.21.6).
Figure 2.21.6: Use of tobacco, alcohol and illicit drugs during pregnancy, mothers of Indigenous children (0–3 years), 2018–19
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 2017 perinatal data, after adjusting for differences in the age structure between the two populations, Indigenous mothers were more likely than non-Indigenous mothers to be obese (31.8% compared with 19.7%, respectively); be underweight (6% and 4.7%, respectively); have gestational diabetes (15.5% compared with 12.5%, respectively); have pre-existing diabetes (3.4% and 1%, respectively); and to have pre-existing hypertension (1.4% and 0.7%, respectively) (Table D2.21.12, Figure 2.21.7). Note that Victoria is excluded for the diabetes and hypertension data.
Figure 2.21.7: Women who gave birth, by Indigenous status of the mother and selected maternal characteristics, selected jurisdictions, 2017
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).
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 et al. 2019).
There is a need to improve communication regarding the health effects of smoking during pregnancy (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 & 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.
The Australian guidelines to reduce health risks from drinking alcohol (2009) recommend not drinking alcohol during pregnancy, or before conception, as the safest option for women who are pregnant or women planning a pregnancy (NHMRC 2009b). The National Health and Medical Research Council is updating the guidelines to reflect the most recent and best available evidence, with revised guidelines to be finalised in late 2020. 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; estimates vary from 2.7 to 4.7 per 1,000 births (HRSCSPLA 2012). 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 (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 some 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. In particular, 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 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. 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 in the provision of culturally competent care, building the Indigenous maternity workforce and increasing birthing on Country, more effort is needed in these areas (Kildea et al. 2016).
Further research and evaluation of the coverage and effectiveness of existing strategies and programs are needed to understand why improvements in smoking during pregnancy and antenatal care attendance by Indigenous Australian mothers have yet to be translated into significant reductions in the rates of low birthweight at a population level. Further research should also focus on the type of antenatal service and the model of care provided and on identifying ways to better target services particularly for vulnerable Indigenous women at risk of family and domestic violence. 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 et al. 2019). More regional level data on risk factors will assist in targeting interventions, such as using locally adapted approaches to smoking cessation.
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).
Expanding national data on health behaviours during pregnancy will be an important element of monitoring progress in this area.
The policy context is at Policies and strategies.
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