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Tier 3 - Health system performance

3.01 Antenatal care

Key facts

Why is it important?

Antenatal care is the professional health care provided to mothers during pregnancy to ensure the best health conditions for both mother and baby. Antenatal care includes risk identification, prevention and management of pregnancy-related or concurrent diseases, health education and health promotion (AHMAC 2012; WHO 2016). Regular antenatal care that commences early in pregnancy has been found to have a positive effect on health outcomes for mothers and babies (Arabena et al. 2015; AHMAC 2012; Eades 2004). Well-managed discharge processes and programs that continue after birth have also shown benefits for child health, development and family wellbeing (Sivak et al. 2008).

Antenatal care is especially important for Aboriginal and Torres Strait Islander women, as they face a higher risk of giving birth to pre-term and low birthweight babies. Indigenous Australian mothers also have greater exposure to other risk factors and complications such as anaemia, poor nutritional status, chronic illness, hypertension, diabetes, genital and urinary tract infections, smoking and high levels of psychosocial stressors (AHMAC 2012; de Costa & Wenitong 2009).

The recently established National Agreement on Closing the Gap has identified the importance of ensuring Aboriginal and Torres Strait Islander children are born healthy and strong with a specific outcome, target and indicators to direct policy attention and monitor progress in this area. Reporting arrangements for the new agreement are being established. The data presented in this report predates the establishment of the agreement.

Findings

What does the data tell us?

Perinatal data show that in 2017, 99.2% (12,874) of Indigenous mothers accessed antenatal care services at least once during their pregnancy, which was similar to the percentage of non-Indigenous mothers (99.9% or 276,810), although the difference is statistically significant. After adjusting for differences in the age structure between the two populations, Indigenous mothers, on average, accessed services later in pregnancy and had fewer antenatal care visits than non-Indigenous mothers (Table D3.01.1, Table D3.01.10).

From 2012 to 2017, after adjusting for differences in the age structure between the two populations, the proportion of Indigenous mothers who attended antenatal care in the first trimester (fewer than 14 weeks) of their pregnancy increased by 27% (from 51% to 63%). For non-Indigenous mothers, the proportion increased from 61% to 71% over the period (Table D3.01.21, Figure 3.01.1).

Figure 3.01.1: Age-standardised proportion of mothers who attended at least one antenatal care session during the first trimester (<14 weeks), by Indigenous status, 2012 to 2017

This line chart shows that the proportion of Indigenous mothers who attended at least one antenatal care session during the first trimester of pregnancy was lower than non-Indigenous mothers over the 2012–17 period with proportions increasing from 51% to 63%. For non-Indigenous mothers the proportion increased from 61% to 71% over the same period.

Source: Table D3.01.21. AIHW analysis of the National Perinatal Data Collection.

In 2017, after adjusting for differences in the age structure between the two populations, the proportion of Indigenous mothers who attended antenatal care in the first trimester was lower than for non-Indigenous mothers by 8 percentage points (63% compared with 71%, respectively). A higher proportion of Indigenous mothers attended their first antenatal visit after 20 weeks of pregnancy compared with non-Indigenous mothers (19% compared with 11%, respectively) (Table D3.01.10, Figure 3.01.2).

Figure 3.01.2: Age-standardised proportion of women who gave birth, by duration of pregnancy at first antenatal visit and Indigenous status of the mother, 2017

This bar chart shows that 63% of Indigenous mothers had their first antenatal visit in the first trimester of pregnancy compared with 71% of non-Indigenous mothers. The proportion of Indigenous and non-Indigenous mothers who visited between 14 and 19 weeks was similar. 1% of Indigenous mothers did not have any antenatal care compared with 0% of non-Indigenous mothers.

Source: Table D3.01.10. AIHW analysis of the National Perinatal Data Collection.

In 2017, 87% of Indigenous mothers who gave birth at 32 weeks or more had 5 or more antenatal visits during their pregnancy, and 10% attended 2–4 visits, after adjusting for differences in the age structure between the two populations. For non-Indigenous mothers, 94% attended 5 or more visits, and 4% attended 2–4 visits (Table D3.01.1, Figure 3.01.3).

Figure 3.01.3: Age-standardised proportion of women who gave birth at 32 weeks or more gestation, by number of antenatal visits and Indigenous status of the mother, 2017

This bar chart shows that 87% of Indigenous mothers had 5 or more antenatal visits compared with 94% of non-Indigenous mothers. 10% of Indigenous mothers and 4% of non-Indigenous mothers had between 2 and 4 visits while 2% of Indigenous mothers and 1% of non-Indigenous mothers attended only a single visit.

Source: Table D3.01.1. AIHW analysis of the National Perinatal Data Collection.

After adjusting for differences in the age structure between the two populations, the proportion of Indigenous mothers attending at least one antenatal visit increased over time, from 98.5% in 2007 to 99.2% in 2017 in the four jurisdictions with data of adequate quality (New South Wales, Queensland, South Australia and Northern Territory) (Table D3.01.8).

Antenatal care by remoteness and jurisdiction

In 2017, after adjusting for differences in the age structure between the two populations, the proportion of Indigenous mothers who had their first antenatal visit in the first trimester of pregnancy was highest for those in Inner regional areas (65%) and lowest for those in Outer regional areas (61%). For non-Indigenous mothers, the rate increased with increasing remoteness, with the lowest rate in Major cities (70%) and highest in Remote areas (75%) (Table D3.01.11, Figure 3.01.4).

Figure 3.01.4: Age-standardised proportion of women who gave birth, by first antenatal visit within the first trimester of pregnancy (<14 weeks), Indigenous status of the mother and remoteness, 2017

This bar chart shows that the proportion of Indigenous mothers having their first antenatal visit in the first trimester of pregnancy was similar across remoteness areas, ranging from 61% in Outer regional areas to 65% in Inner regional areas. The non-Indigenous proportion was higher than the Indigenous in all reported remoteness areas and ranged from 70% in major cities to 75% in remote areas.

Source: Table D3.01.11. AIHW analysis of the National Perinatal Data Collection.

The proportion of Indigenous mothers who had their first antenatal visit in the first trimester of pregnancy varied by jurisdiction, after adjusting for differences in the age structure between the two populations. In 2017, of the jurisdictions with publishable data, the proportion was lowest for Indigenous mothers in Western Australia (56%) and highest in New South Wales (68%) and the Northern Territory (68%).

The jurisdictions with the largest gaps between Indigenous and non-Indigenous mothers attending antenatal care in the first trimester were South Australia and the Northern Territory (a gap of 21 and 18 percentage points, respectively) (Table D3.01.10, Figure 3.01.5).

Figure 3.01.5: Age-standardised proportion of women who gave birth, by first antenatal visit within the first trimester of pregnancy (<14 weeks), by Indigenous status of the mother and jurisdiction, 2017

This bar chart shows that the proportion of Indigenous mothers having their first antenatal visit in the first trimester of pregnancy differed between jurisdictions, being lowest in Western Australia (56%) and highest in the Northern Territory and New South Wales (both 68%). Non-Indigenous proportions were higher in all reported jurisdictions and ranged from 47% in the Australian Capital Territory to 89% in Tasmania.

Source: Table D3.01.10. AIHW analysis of the National Perinatal Data Collection.

Antenatal care by socioeconomic status

Socioeconomic status in this measure is based on the 2016 SEIFA (Socio-Economic Indexes for Areas) Index of Relative Socio-Economic Disadvantage. In 2017, Indigenous mothers living in areas of highest socioeconomic status generally had more antenatal visits than other areas, with 91% of Indigenous mothers in the highest two quintiles (4th and 5th quintiles) having 5 or more antenatal visits during pregnancy. The rates in lower socioeconomic areas ranged from 85%–87%.

Indigenous mothers living in the highest socioeconomic areas were also more likely to have their first antenatal visit within the first trimester of pregnancy (67% in the 4th quintile and 66% in the 5th quintile), compared with 61% in the lowest socioeconomic areas (1st quintile) (Table D3.01.24, Figure 3.01.6).

Figure 3.01.6: Women who had their first antenatal visit in the first trimester of pregnancy (<14 weeks), by Indigenous status of the mother and socioeconomic status, 2017

This bar chart shows that that the proportion of Indigenous mothers having their first antenatal visit in the first trimester of pregnancy increased slightly with each increase in income quintile up to the fourth bracket. A similar trend can be observed for non-Indigenous mothers. Indigenous proportions increased from 61% in the first quintile to 67% in the fourth while non-Indigenous proportions increased from 67% to 73%.

Source: Table D3.01.24. AIHW analysis of the National Perinatal Data Collection.

Antenatal care and health conditions

In 2017, Indigenous mothers were more likely to have a first antenatal visit within the first trimester of pregnancy, if they were underweight (68%) or obese (67%) than those who were overweight (64%) or of normal body weight (63%). Indigenous mothers who were obese were more likely to have attended 5 or more antenatal visits during pregnancy (91%) than those who were underweight (87%) (Table D3.01.25).

For Indigenous mothers with gestational diabetes, 93% had 5 or more antenatal visits during pregnancy and 66% attended their first antenatal visit in the first trimester of pregnancy. Among those with pre-existing diabetes, 92% had 5 or more antenatal visits during pregnancy, and 73% had their first visit in the first trimester. For Indigenous mothers with gestational hypertension, 91% had 5 or more antenatal visits during pregnancy, and 63% attended their first visit in the first trimester of pregnancy. Of Indigenous mothers who had pre-existing hypertension, 91% attended 5 or more antenatal visits during pregnancy, and 72% had the first visit in the first trimester. Note that this excludes mothers who gave birth in Victoria, as data were not available (Table D3.01.25).

In 2017, 44% of Indigenous mothers smoked during pregnancy (Table D3.01.4). Of Indigenous mothers who smoked after 20 weeks of pregnancy, 42% had 10 or more antenatal visits, compared with 52% of those who stopped smoking by 20 weeks (Table D3.01.26).

Low birthweight and pre-term babies

In 2017, Indigenous women who had their first antenatal care visit during the first trimester of pregnancy were less likely to have a baby of low birthweight (10%), compared with those who did not have any antenatal visits during pregnancy (30%) (Table D3.01.14).

Similarly, Indigenous women who had their first antenatal care visit during their first trimester of pregnancy were less likely to have a pre-term baby (11%), compared with those who did not have any antenatal visits in pregnancy (36%) (Table D3.01.15).

Self-reported antenatal care

The 2014–15 National Aboriginal and Torres Strait Islander Social Survey showed that 94% of mothers of Indigenous children aged 0–3 reported that they had regular pregnancy check-ups during their pregnancies of those children (Table D3.01.18).

Primary health care organisations

The national Key Performance Indicators data collection includes items on antenatal care provided by Indigenous-specific primary health care organisations. In December 2018, of the 6,606 Indigenous mothers who were regular clients of these organisations, 42% attended their first antenatal visit in the first trimester (note these data report <13 weeks rather than <14 weeks). The attendance rates varied with remoteness and were highest in Remote areas (48%) and lowest in Major cities (Table D3.01.22, Figure 3.01.7).

Figure 3.01.7: Duration of pregnancy at first antenatal visit, Indigenous regular female clients of Indigenous primary healthcare organisations, by remoteness, December 2018

This bar chart shows that the proportion of Indigenous mothers having their first antenatal visit in the first 13 weeks of pregnancy differed between remoteness categories, ranging from 32% in Major cities to 48% in Remote areas. The proportion of mothers attending between 13 to less than 20 weeks and 20 weeks plus was relatively unchanged between remoteness areas.

Source: Table D3.01.22. AIHW analysis of the National Key Performance Indicators for Aboriginal and Torres Strait Islander Primary Health Care collection.

What do research and evaluations tell us?

The literature suggests that improved access, to and use of, antenatal care services improves outcomes for Indigenous mothers and babies, as studies have shown an association between inadequate antenatal care and increased risk of stillbirths, perinatal deaths, retardation of fetal growth, low birthweight and pre-term births (AIHW 2014; Taylor et al. 2013). Culturally secure and comprehensive antenatal care also addresses risk factors such as smoking and alcohol use during pregnancy (AIHW 2014).

In 2013, a multi-agency partnership between two Aboriginal Community Controlled Health Services (ACCHSs) and a Brisbane tertiary maternity hospital co-designed the Birthing in Our Community service, which aimed to reduce pre-term birth (Kildea et al. 2019). An analysis of pre-term birth outcomes for women who gave birth to an Indigenous baby at this hospital during 2013–2017 found that women who received the Birthing in Our Community service were less likely than women receiving standard care to give birth to a pre-term infant. The results suggest that reducing pre-term birth is possible when Indigenous Australian women are targeted early in their pregnancies for antenatal care, through:

  • providing culturally safe continuity of care
  • providing a holistic service
  • providing a service with high levels of community investment (collective understanding and valuing of a program), ownership (the program is ‘ours’), and activation (high-level of community participation)
  • health service leadership across partner organisations.

Women who gave birth to an Indigenous baby between July 2011 and June 2013 participated in a study to investigate experiences of antenatal care in South Australia (Brown et al. 2015). Women who received antenatal care that was consistent with their culture and needs were more likely to rate the services they received as ‘very good’ compared with women attending mainstream services. Only 36% of women receiving mainstream public care described their antenatal care as “very good” compared with 65% of women attending an Aboriginal Health Service, 63% of women receiving care from a metropolitan Aboriginal Family Birthing Program (AFBP), 54% of women attending a regional AFBP service, and 53% of women receiving care from a midwifery group practice.

The Aboriginal Maternity Group Practice Program (AMGPP) employed Aboriginal Grandmothers, Aboriginal Health Officers and midwives working in a partnership model with existing antenatal services in Perth. A study compared outcomes for Indigenous Australian women who received AMGPP services and gave birth between 1 July 2011 and 31 December 2012 with historical and contemporary control groups. Babies born to AMGPP participants were less likely than other babies in the study to be born pre-term, to require resuscitation at birth or to have a hospital length of stay over 5 days (Bertilone C. & McEvoy 2015). Another study of qualitative data from the program found that the partnership model positively affected the level of culturally appropriate care provided by other health service staff, particularly in hospitals. Providing transport, team home visits and employing Indigenous staff improved access to care, in particular Aboriginal Grandmothers brought young women into the program and were able to positively influence healthy lifestyle behaviours for clients (Bertilone Christina M et al. 2017).

Many factors have been identified that influence an Indigenous Australian woman’s engagement with, and early presentation for, antenatal care including the availability of culturally appropriate services, the frequency (or absence) of local clinics, transport, and educational, socioeconomic and financial issues (Arnold et al. 2009; de Costa & Wenitong 2009). 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 (AIHW 2017).

A suite of evaluations has 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 (2019 edition) outlines evidence of successful models of care from these evaluations specifically tailored for Indigenous Australian women. These programs highlight the importance of 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 positively influencing maternal healthy lifestyle behaviours during pregnancy and attendance at care sessions (DoH 2018). These practices can have quantifiable improvements in antenatal care attendance, pre-term births, birth outcomes, perinatal mortality and breastfeeding practice. However, significant reductions in low birthweight are yet to be demonstrated.

An evaluation of the Murri Antenatal Clinic found that the majority of women who attended the clinic felt understood and respected by the staff. These individuals were statistically less likely to experience perineal trauma, undergo an elective caesarean operation or have a baby admitted to the neonatal intensive care unit. However, the limited clinic opening hours were insufficient to meet demand, which presented a barrier to attendance for women (Kildea et al. 2012).

Panaretto and others (2005) evaluated the effect of a community‐based, collaborative, shared antenatal care intervention (the Mums and Babies program) for Indigenous Australian women in Townsville. This program was based on continuity of care, cultural currency and a family‐friendly environment (Panaretto et al. 2005):

  • Women in the intervention group had significantly more antenatal care visits, improved timeliness of the first visit and fewer pregnancies with inadequate care compared with the control group (Panaretto et al. 2005).
  • There were significantly fewer pre-term births in the intervention group. The use of the Mums and Babies antenatal care service increased significantly over time, with 60% of Townsville‐based pregnant Indigenous women attending by 2003, after the commencement of the program in 2000 (Panaretto et al. 2005).
  • This study showed that integrated services delivered in a culturally aware and safe environment increased access to antenatal care in the Indigenous community. It is possible for this model to be adapted to other urban centres that have significant Indigenous populations, community‐controlled health services and multiple providers of antenatal care (Panaretto et al. 2005).

Panaretto and others (2007) also showed that the Townsville Mums and Babies program sustained these improvements, and later improved perinatal outcomes for participants, with the reduction in pre-term births later translating into reduced perinatal mortality (Panaretto et al. 2007). Among Townsville-based participants, there was also an increase in mean birthweight, compared with the control group (prior to the commencement of the program).

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 rate of smoking after 20 weeks gestation, but similar rates of pre-term birth, 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.

In contrast, an audit in Western Australia that explored the usage, frequency and characteristics of services in publicly funded antenatal services for Indigenous Australian women in metropolitan, rural and remote regions identified significant gaps. The audit found that around three-quarters of the antenatal services used by Indigenous Australian women had not achieved a model of service delivery consistent with the principles of culturally responsive care (Reibel & Walker 2010).

Many Indigenous Australian women do not have access to Indigenous-specific maternal health programs and rely on mainstream health services such as  general practitioners and hospital clinics (Clarke & Boyle 2014). As such, the Clinical Practice Guidelines—Pregnancy Care (2019 edition) emphasise the importance of mainstream services to embedding cultural competence into continuous quality improvement activities for services.

However, maternity services are often under-resourced and lack systems to provide culturally responsive care that meets the needs of women experiencing multiple social and health issues during pregnancy.

Antenatal care also provides the opportunity to affect other outcomes broader than pregnancy and birth. The implementation of the Australian Nurse Family Partnership Program (ANFPP) in Central Australia, delivered by a large ACCHS, was evaluated for its effect on child protection outcomes among children in the program (Segal et al. 2018). This evaluation found that the program may have reduced child protection system involvement, especially among younger or first time mothers, and reduced the incidence of out-of-home care placements among children in the program. While the ANFPP has an antenatal focus, participants remain in the program until their children are two years old. Therefore, the outcomes reported in this evaluation are not solely attributable to the antenatal care stage of the program. The study recommends further evaluation using a randomised design to test these findings.

Implications

Over the period 2014–2018, the perinatal mortality rate was around 1.3 times as high for Indigenous babies as non-Indigenous babies (10.1 per 1,000, and 7.6 per 1,000, respectively, see measure 1.21 Perinatal mortality). In 2017, excluding multiple births, Indigenous mothers were twice as likely to have a low birthweight live born baby compared with non‑Indigenous mothers, (11% and 5%, respectively, see measure 1.01 Low birthweight). While there have been improvements in antenatal care attendance, there is a need to engage Indigenous mothers earlier in their pregnancy. 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 for pre-term birth, low birthweight and small for gestational age babies should be an important focus of antenatal care delivery. Being born with a low birthweight may have consequences later in life. The fetal origins hypothesis associated with David J. Barker posits that chronic, degenerative conditions of adult health, such as type 2 diabetes and heart disease, may be triggered by circumstances in utero (Almond & Currie 2011). An analysis of deaths in a cohort of young adults born in a remote Indigenous community between 1956 and 1985 found that low birthweight was associated with higher death rates, and the effect was particularly prominent for deaths that occurred at under 41 years of age and with deaths from respiratory conditions or sepsis and unusual causes (Hoy & Nicol 2019).

Appropriate antenatal care (including improved management of high-risk pregnancies) and a healthy environment for the mother can improve the chances that the baby will have a healthy birthweight (Herceg 2005; Taylor et al. 2013). Further research is needed into understanding why improvements in smoking during pregnancy and antenatal care attendance have yet to be translated into significant reductions in the rate of low birthweight at a population level. In particular, despite the recent decline in the rate of smoking during pregnancy, the rate remains high at 44%. Further research should also focus on the type of antenatal service and model of care provided and on identifying ways to better target services, in particular for vulnerable Indigenous women. Recent research suggests that culturally safe and appropriate antenatal care achieves better outcomes for women giving birth to Indigenous babies compared with standard care (Kildea et al. 2019). 

Many Indigenous Australians live in urban or inner regional areas and receive health care through mainstream services, and it is important for all practitioners to be aware of how to optimise care to Indigenous Australian women (Clarke & Boyle 2014). Some Indigenous women may prefer to go to an Aboriginal Health Service or ACCHS, but there may also be a preference for privacy and a reluctance to use a service where they are known to employees, especially early in the pregnancy when having the time to tell family members before other people find out is important (Reibel & Morrison 2014; Reibel et al. 2015).

The features that have been identified for quality primary maternity services in Australia include high-quality care that is enabled by evidence-based practice, coordinated according to the woman’s clinical needs and preferences, based on collaborative multidisciplinary approaches, woman-centred, culturally appropriate and accessible at the local level (AHMAC 2012).

Reviews of the literature have identified the following key success factors in Indigenous maternal health programs to complement the features detailed above:

  • a safe and welcoming environment
  • outreach and home visiting
  • flexibility in service delivery and appointment times
  • access to transport
  • continuity of care and carer integration with other services (for example, ACCHS or hospital)
  • a focus on communication, relationship building and trust
  • involvement of women in decision-making
  • respect for Aboriginal and Torres Strait Islander culture
  • respect for privacy, dignity and confidentiality
  • family involvement and childcare; appropriately trained workforce
  • Indigenous staff and female staff; informed consent and right of refusal
  • tools to measure cultural competency (AHMAC 2012; Bertilone C. & McEvoy 2015; Dudgeon et al. 2010; Herceg 2005; Kildea et al. 2012; Kildea & Van Wagner 2013; Murphy & Best 2012; Reibel & Walker 2010; Wilson 2009).

The new National Agreement on Closing the Gap was developed in partnership between Australian governments and the Coalition of Aboriginal and Torres Strait Islander Peak Organisations. The agreement has recognised the importance of ensuring Aboriginal and Torres Strait Islander children are born healthy and strong by establishing the following outcome and target to direct policy attention and monitor progress:

  • Outcome 2 — Aboriginal and Torres Strait Islander children are born healthy and strong.
    • Target — By 2031, increase the proportion of Aboriginal and Torres Strait Islander babies with a healthy birthweight to 91 per cent.

Australian governments are investing in a range of initiatives aimed at improving child and maternal health. These are described in detail in the Policies and strategies section.

The policy context is at Policies and strategies.

References

  • AHMAC (Australian Health Ministers’ Advisory Council) 2012. Clinical Practice Guidelines: Antenatal Care – Module 1. (ed., Department of Health and Ageing). Canberra: AHMAC.
  • AIHW (Australian Institute of Health and Welfare) 2014. Timing impact assessment of COAG Closing the Gap targets: Child mortality. Canberra: AIHW.
  • AIHW 2017. Spatial variation in Aboriginal and Torres Strait Islander women's access to 4 types of maternal health services. Canberra
  • Almond D & Currie J 2011. Killing me softly: The fetal origins hypothesis. Journal of economic perspectives 25:153-72.
  • Arabena K, Howell-Muers S, Ritte R, Munro-Harrison E & Onemda VicHealth Koori Health Unit 2015. Making a World of Difference - The First 1,000 Days Scientific Symposium report Melbourne.
  • Arnold JL, De Costa CM & Howat PW 2009. Timing of transfer for pregnant women from Queensland Cape York communities to Cairns for birthing. The Medical Journal of Australia 190:594-6.
  • Bertilone C & McEvoy S 2015. Success in Closing the Gap: favourable neonatal outcomes in a metropolitan Aboriginal Maternity Group Practice Program. The Medical Journal of Australia 203.
  • Bertilone CM, McEvoy SP, Gower D, Naylor N, Doyle J & Swift-Otero V 2017. Elements of cultural competence in an Australian Aboriginal maternity program. Women and Birth 30:121-8.
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  • de Costa CM & Wenitong M 2009. Could the Baby Bonus be a bonus for babies? The Medical Journal of Australia 190:242-3.
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  • Eades S 2004. Maternal and Child Health Care Services: Actions in the Primary Health Care Setting to Improve the Health of Aboriginal and Torres Strait Islander Women of Childbearing age, Infants and Young Children. Darwin: OATSIH.
  • Hartz DL, Blain J, Caplice S, Allende T, Anderson S, Hall B et al. 2019. Evaluation of an Australian Aboriginal model of maternity care: The Malabar Community Midwifery Link Service. Women and Birth 32:427-36.
  • Herceg A 2005. Improving health in Aboriginal and Torres Strait Islander mothers, babies and young children: a literature review. (ed., Office for Aboriginal and Torres Strait Islander Health, Department of Health and Ageing). Canberra: OATSIH.
  • Homer C, Foureur M & Allende T 2012. It’s more than just having a baby’ women’s experiences of a maternity service for Australian Aboriginal and Torres Strait Islander families. Midwifery 28.
  • Hoy WE & Nicol JL 2019. The Barker hypothesis confirmed: association of low birth weight with all-cause natural deaths in young adult life in a remote Australian Aboriginal community. Journal of Developmental Origins of Health and Disease 10:55-62.
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  • Kildea S & Van Wagner V 2013. 'Birthing on Country' maternity service delivery models: a rapid review An Evidence Check review brokered by the Sax Institute for the Maternity Services Inter-Jurisdictional Committee for the Australian Health Ministers’ Advisory Council Sydney: Sax Institute
  • Murphy E & Best E 2012. The Aboriginal Maternal and Infant Health Service: a decade of achievement in the health of women and babies in NSW. New South Wales Public Health Bulletin 23:68-72.
  • Panaretto K, Lee HM & Mitchell MR 2005. Impact of a collaborative shared antenatal care program for urban Indigenous women: a prospective cohort study. The Medical Journal of Australia 182:514-9.
  • Panaretto KS, Mitchell MR, Anderson L, Larkins SL, Manessis V, Buettner PG et al. 2007. Sustainable antenatal care services in an urban Indigenous community: the Townsville experience. Medical Journal of Australia 187:18-22.
  • Reibel T & Morrison L 2014. Young Aboriginal Women's Voices on Pregnancy Care. Western Australia.
  • Reibel T, Morrison L, Griffin D, Chapman L & Woods H 2015. Young Aboriginal women's voices on pregnancy care: Factors encouraging antenatal engagement. Women and Birth 28:47-53.
  • Reibel T & Walker R 2010. Antenatal services for Aboriginal women: the relevance of cultural competence. Quality in Primary Care 18:65-74.
  • Segal L, Nguyen H, Gent D, Hampton C & Boffa J 2018. Child protection outcomes of the Australian Nurse Family Partnership Program for Aboriginal infants and their mothers in Central Australia. PloS one 13.
  • Sivak L, Arney F & Lewig K 2008. A Pilot Exploration of a Family Home Visiting Program for Families of Aboriginal and Torres Strait Islander Children Report and Recommendations: Perspectives of Parents of Aboriginal Children and Organisational Considerations. Adelaide: ACCP.
  • Taylor LK, Lee YY, Lim K, Simpson JM, Roberts CL & Morris J 2013. Potential prevention of small for gestational age in Australia: a population-based linkage study. BMC Pregnancy & Childbirth 13:210.
  • Wilson G 2009. What do Aboriginal women think is good antenatal care? Consultation report. Darwin: CRCAH.
  • World Health Organisation (WHO) 2016. WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience.

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