3.01 Antenatal care

Key messages

• 68% of Aboriginal and Torres Strait Islander mothers accessed antenatal care services in the first trimester of their pregnancy in 2019, with 89% having 5 or more visits.
• From 2012 to 2019, the proportion of Indigenous mothers who attended antenatal care in the first trimester of their pregnancy increased from 50% to 68%.
• The proportion of Indigenous mothers who attended antenatal care in the first trimester was 8.0 percentage points lower than for non-Indigenous mothers (based on age-standardised rates).
• Indigenous mothers who had their first antenatal visit in the first trimester of pregnancy was highest in Outer regional areas (71%) and lowest in Remote areas (63%) in 2019.
• Indigenous mothers who had their first antenatal care visit during the first trimester of pregnancy were less likely to have a baby of low birthweight (8.9%), compared with those who had their first visit after 20 weeks of pregnancy or did not have any antenatal visits (14%) in 2019.
• In a study involving 344 women who gave birth to an Indigenous baby in South Australia between July 2011 and June 2013, 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.
• A 2012 evaluation found women who attended the Murri Antenatal Clinic, a specialist antenatal clinic for Aboriginal and Torres Strait Islander women, were less likely to experience perineal trauma, undergo an elective caesarean operation or have a baby admitted to the neonatal intensive care unit.
• 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. An analysis of the clinical effectiveness of the Birthing in Our Community service (BiOC) for women who gave birth to an Aboriginal and Torres Strait Islander baby found that women who received the BiOC service were less likely than women receiving standard care to give birth to a pre-term infant.

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 (AHMAC 2012; Arabena et al. 2015; 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).

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 Indigenous 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 supporting indicators on the use of antenatal care by pregnant women).

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

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

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

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

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

Findings

What does the data tell us?

Regular antenatal care in the first trimester (before 14 weeks gestational age) is associated with better maternal health in pregnancy, fewer interventions in late pregnancy and positive child health outcomes.

Based on analysis of the National Perinatal Data Collection, among Aboriginal and Torres Strait Islander mothers:

• 68% (9,594) accessed antenatal care services during the first trimester (less than 14 weeks) of their pregnancy
• 15% (2,109) attended their first visit after the first trimester but before 20 weeks
• 17% (2,355) first attended after 20 weeks or did not attend (Table D3.01.10).

The distribution of duration of pregnancy at first antenatal care visit was relatively consistent across age groups, although mothers aged 25–29 were most likely to attend their first antenatal care visit within the first trimester (70%), while mothers aged under 20 were most likely to first attend after 20 weeks or not at all (21%) (Table D3.01.12, Figure 3.01.1).

Figure 3.01.1: Proportion of Indigenous women who gave birth, by duration of pregnancy at first antenatal visit and age of the mother, 2019

Source: Table D3.01.12. AIHW analysis of the National Perinatal Data Collection.

In 2019, after adjusting for differences in the age structure between the 2 populations, the proportion of Indigenous mothers who attended antenatal care in the first trimester was 8.0 percentage points lower than for non-Indigenous mothers. A higher proportion of Indigenous mothers attended their first antenatal visit after 20 weeks of pregnancy or did not attend antenatal care compared with non-Indigenous mothers (a difference of 7.8 percentage points) (Table D3.01.10).

In 2019, about 9 in 10 Indigenous mothers who gave birth at 32 weeks or more attended 5 or more antenatal visits throughout their pregnancy (89% or 12,222), and nearly all (99%) attended at least once during pregnancy (Table D3.01.1).

In 2019, among women who gave birth at 32 weeks or more:

• 89% (12,222) had 5 or more antenatal visits during their pregnancy
• 8.8% (1,215) attended 2–4 visits
• 1.5% (209) attended one visit, and
• 0.7% (94) attended no visits (Table D3.01.1).

These proportions were consistent across age groups (Table D3.01.3, Figure 3.01.2).

Figure 3.01.2: Proportion of Indigenous women who gave birth at 32 weeks or more gestation, by number of antenatal visits and age of the mother, 2019

Note: // indicates a break in the axis to enable comparisons between age groups easier where proportions of Indigenous women attending antenatal visits were less than 5%. 

Source: Table D3.01.3. AIHW analysis of the National Perinatal Data Collection.

Antenatal care by remoteness and jurisdiction

In 2019, the proportion of Indigenous mothers who had their first antenatal visit in the first trimester of pregnancy was highest for those in Outer regional areas (71% or 2,171) and lowest for those in Remote areas (63% or 666). Those in Remote and Very remote areas were the most likely to first attend antenatal care after 20 weeks or receive no care (23% and 20%, respectively) (Figure 3.01.3).

Based on age-standardised rates, the gap between Indigenous and non-Indigenous mothers in the proportion of mothers first attending antenatal care in the first trimester was higher in remote areas (10.9 percentage points) than in non-remote areas (7.1 percentage points) (Table D3.01.11).

Figure 3.01.3: Proportion of Indigenous women who gave birth, by gestational age at time of first antenatal visit and remoteness, 2019

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. In 2019, the proportion was lowest for Indigenous mothers in Western Australia (55% or 985), while it was highest in Tasmania (82% or 259) (Figure 3.01.4).

Based on age-standardised data, in states and territories where numbers were large enough to support analysis (all except Tasmania and the Australian Capital Territory), the jurisdiction with the largest gap between Indigenous and non-Indigenous mothers attending antenatal care in the first trimester was South Australia, at 18 percentage points, while the jurisdiction with the smallest gap was New South Wales, at 4.2 percentage points (Table D3.01.10).

Figure 3.01.4: Proportion of Indigenous women who gave birth, by gestational age at time of first antenatal visit and jurisdiction, 2019

Note: Due to differences in definitions and methods used for data collection, care should be taken in comparing across jurisdictions. See footnotes of Table D3.01.10 for details.

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. Indigenous mothers living in areas of highest socioeconomic status generally had more antenatal visits than those living in other areas and were more likely to attend in the first trimester of pregnancy.

In 2019:

• 94% (474) of Indigenous mothers living in the highest socioeconomic areas (5^th quintile) had 5 or more antenatal visits during pregnancy, compared with between 88% and 90% of Indigenous mothers in lower socioeconomic areas (1^st, 2^nd, 3^rd, and 4^th quintiles).
• 73% (382) of Indigenous mothers living in the highest socioeconomic areas (5^th quintile) attended antenatal care in the first trimester, compared with 68% across the lowest three socioeconomic areas (1^st, 2^nd, and 3^rd quintiles) (Table D3.01.24, Figure 3.01.5).

Figure 3.01.5: Indigenous women who gave birth and attended 5 or more antenatal care visits, or had their first antenatal visit within the first trimester of pregnancy (<14 weeks), by socioeconomic status, 2019

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

Antenatal care and health conditions

In 2019, the proportion of Indigenous mothers who had their first antenatal visit within the first trimester of pregnancy increased slightly with BMI category, from 68% for those who were underweight to 71% for those who were obese. Indigenous mothers who were obese were more likely to have attended 5 or more antenatal visits during pregnancy (92%) than those who were underweight (87%) (Table D3.01.25).

In 2019:

• of Indigenous mothers with gestational diabetes, 95% had 5 or more antenatal visits during pregnancy and 74% attended their first antenatal visit in the first trimester.
• of Indigenous mothers with pre-existing diabetes, 93% had 5 or more antenatal visits during pregnancy, and 76% had their first visit in the first trimester.
• of Indigenous mothers with gestational hypertension, 94% had 5 or more antenatal visits during pregnancy, and 77% attended their first visit in the first trimester.
• of Indigenous mothers who had pre-existing hypertension, 93% attended 5 or more antenatal visits during pregnancy, and 72% had the first visit in the first trimester (Table D3.01.25).

In 2019, 44% of Indigenous mothers smoked during pregnancy (Table D3.01.4). Of Indigenous mothers who smoked both before and after 20 weeks of pregnancy, 41% had 10 or more antenatal visits, compared with 52% of those who stopped smoking by 20 weeks. A greater number of antenatal visits was associated with an increased likelihood to cease smoking in the second 20 weeks of their pregnancy (Table D3.01.26).

Antenatal care and low birthweight and pre-term babies

In 2019, Indigenous women who gave birth and had their first antenatal care visit during the first trimester of pregnancy were less likely to have a baby of low birthweight (8.9%), compared with those who either had their first visit after 20 weeks of pregnancy or did not have any antenatal care during pregnancy (14.3%) (Table D3.01.14).

Similarly, Indigenous women who gave birth and had their first antenatal care visit during their first trimester of pregnancy were less likely to have a pre-term baby (9.4%), compared with those who had their first visit after 20 weeks of pregnancy or did not have any antenatal visits (15%) (Table D3.01.15).

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 Aboriginal and Torres Strait Islander National Key Performance Indicators (nKPIs) data collection includes an item on antenatal care (PI13) 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 (32%) (Table D3.01.22, Figure 3.01.6).

Figure 3.01.6: Indigenous regular female clients of Indigenous primary health care organisations, by duration of pregnancy at first antenatal visit and remoteness, December 2018

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

Changes over time

Between 2012 and 2019, the proportion of Indigenous mothers who attended antenatal care in the first trimester of their pregnancy increased from 50% to 68% (Table D3.01.21).

Based on age-standardised rates, the proportion of mothers who attended antenatal care in the first trimester of their pregnancy (before 14 weeks gestation) increased by 36% for Indigenous mothers and by 28% for non-Indigenous mothers.

The absolute gap in the age-standardised proportion of Indigenous and non-Indigenous mothers attending antenatal care in the first trimester ranged between 5.7 percentage points (in 2016) to 10.9 percentage points (in 2012) (Table D3.01.21, Figure 3.01.7). The relative gap in rates was largely consistent over the period, with the age-standardised proportion for Indigenous Australians averaging at 0.9 times as high for Indigenous Australians as for non-Indigenous Australians.

Figure 3.01.7: Age-standardised proportion of women who gave birth and attended at least one antenatal care visit during the first trimester (<14 weeks), by Indigenous status, 2012 to 2019

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

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

A multivariate analysis of perinatal data for singleton Indigenous births for the period 2017–2019 indicates that if all Indigenous women who gave birth attended antenatal care in the first trimester, 4% of low birthweight Indigenous births could be prevented (Table D1.01.8). See the HPF feature article Key factors contributing to low birthweight among Aboriginal and Torres Strait Islander babies for additional statistical analysis on birthweight and factors contributing to it.

In 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 (BiOC), which aimed to improve health outcomes and reduce pre-term birth (Kildea et al. 2021). An analysis of the clinical effectiveness of the BiOC service for women who gave birth to an Indigenous baby at this hospital during January 2013–June 2019 found that women who received the BiOC service were less likely than women receiving standard care to give birth to a pre-term infant. These women were also more likely to attend 5 or more antenatal visits and to exclusively breastfeed on discharge from hospital. The results suggest that improving health outcomes of mothers and babies and 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
• strengthening the Indigenous workforce.

A systematic review by Sivertsen et al (2020) highlighted the importance of continuity of care during the antenatal, pre- and postnatal periods towards successful maternal and infant health outcomes of Indigenous Australians. The study identified a lack of continuity of care in both urban and regional settings, especially those without dedicated Indigenous antenatal and birthing programs and interventions. The study found an urgent need to incorporate and extend care through to 2 years of age for successful health outcomes and a need for communities and health care services to provide appropriate and culturally safe care to support strategies for enhancing continuity (Sivertsen et al. 2020).

A longitudinal follow-up study conducted in 2019–20, which interviewed 14 non-Indigenous midwifery students or recent graduates from 2012–14, found that exposure to Indigenous content and community placement opportunities during training had a lasting impact on participants midwifery practice. Most former students reported feeling better prepared to provide culturally safe care, build respectful relationships and advocate for improved services for Aboriginal women (Thackrah et al. 2020).

A study by Brown et al (2015) investigated experiences of antenatal care in South Australia among 344 women who gave birth to an Indigenous baby between July 2011 and June 2013 (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.

A study by Brown et al (2016) drew on the same data to investigate women’s access to antenatal care by geography. Mothers of Indigenous babies who attended regional AFBP services were more likely to access antenatal care in the first trimester and markedly more likely to attend 5 visits during pregnancy than those receiving mainstream regional services. Women receiving these services in urban areas were also more likely to attend at least 5 visits compared with those attending mainstream regional services (Brown et al. 2016).

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 (2020 edition, outlines evidence of successful models of care from these evaluations specifically tailored for Indigenous Australian women, such as the Aboriginal Maternity Group Practice Program (AMGPP); Aboriginal Family Birthing Program (AFBP); and the Aboriginal Maternal and Infant Health Service (AMIHS) (Bertilone C. & McEvoy 2015; Bertilone C M et al. 2017; Department of Health 2020; Middleton et al. 2017; Murphy & Best 2012). 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 (Department of Health 2020). These practices can have quantifiable improvements in antenatal care attendance, pre-term births, birth outcomes, perinatal mortality, and breastfeeding practice.

The guidelines also mention that while these programs have been identified as beneficial, not all Aboriginal and Torres Strait Islander women have access to these types of programs and many still rely on mainstream services such as GPs and public hospital clinics (Clarke & Boyle 2014; Corcoran PM et al. 2017). 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. Hence, it is important that mainstream services embed cultural competency into continuous quality improvement. Participation in a continuous quality improvement initiative by primary health care centres in Aboriginal and Torres Strait Islander communities is associated with greater provision of pregnancy care aimed at addressing lifestyle-related risk factors (Gibson-Helm et al. 2016).

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 beginning 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 start of the program).

An evaluation of the Malabar service—a community‐based culturally appropriate service that addressed the antenatal care needs of Indigenous mothers—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).

Antenatal care also provides the opportunity to affect other outcomes broader than pregnancy and birth. The Australian Nurse Family Partnership Program (ANFPP) is an evidence-based nurse home visiting program for mothers who are pregnant with an Aboriginal or Torres Strait Islander baby, which has been operating in Australia since 2009. It began with three sites and has since expanded to 13 sites servicing four states and two territories across Australia. Funding was approved in 2021 to expand to two additional sites by 30 June 2025.

The implementation of the 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. Further evaluation of the ANFPP is currently underway which was co-designed through a scoping study led by consultants in partnership with key ANFPP stakeholders.

Implications

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). While there have been improvements in antenatal care attendance, there is a need to engage Indigenous Australian mothers earlier in their pregnancy.

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. 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.

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).

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). 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). 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).

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

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

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

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

Australian governments are investing in a range of other 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

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• 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
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