” The gap between the health of Aboriginal and Torres Strait Islander children and non-Indigenous children begins before birth, with babies born to Aboriginal and Torres Strait Islander mothers significantly more likely to have been exposed to tobacco smoke in utero, to be born pre-term, and to have a low birthweight (weighing less than 2,500 grams at birth) (AIHW 2015b).

These inequalities continue throughout early childhood for Aboriginal and Torres Strait Islander children, with higher mortality rates and higher rates of illness and poor health.

 This report presents the findings of a project which assessed Aboriginal and Torres Strait Islander women’s access to hospitals with public birthing services and 3 other types of maternal health services across Australia, then investigated possible high-level associations between access, maternal risk factors and birth outcomes.”

Download the report here

AIHW Indigenous Maternal Health .pdf

The findings of a project which assessed Aboriginal and Torres Strait Islander women’s access to hospitals with public birthing services and 3 other types of maternal health services across Australia,

Access to services

The study examined the geographic access of Indigenous women of child-bearing age (15–44) to 4 types of on-the-ground maternal health services: hospitals with a public birthing unit; Indigenous-specific primary health-care services (ISPHCSs); Royal Flying Doctor Service clinics; and general practitioners (GPs).

Using 1 hour drive time boundaries around these locations and population counts from the 2011 Census at a range of geographic levels (SA2, remoteness, jurisdiction), the study found:

• approximately one-fifth (25,600 or 21%) of Indigenous women of child-bearing age lived outside a 1 hour drive time from the nearest hospital with a public birthing unit
• nearly all (97%) Indigenous women of child-bearing age had access to at least 1 type of maternal health service within a 1 hour drive time. The lowest levels of access were for women in Very remote and Remote areas, where 84% and 93%, respectively, had access to at least 1 type of service.
• Indigenous women of child-bearing age in Major cities, Inner regional and Outer regional areas had more types of services available to them within a 1 hour drive time than did women in more remote areas. Thus, they had more choice in which service they use

Association with area-level maternal risk factor and birth outcomes

Examining possible associations between geographic accessibility to services, maternal risk factors and birth outcomes at the Indigenous Region level, the study found that poorer access to:

• GPs was associated with higher rates of pre-term birth and low birthweight
• ISPHCSs with maternal/antenatal services was associated with higher rates of smoking and low birthweight
• hospitals with public birthing units was associated with higher rates of smoking, pre-term birth and low birthweight
• at least 1 service was associated with higher smoking rates and higher rates of pre-term delivery and low birthweight

An analysis at Primary Health Network (PHN) level found fewer significant associations, which is likely to be due to the PHNs’ size—particularly in jurisdictions with large Indigenous populations (such as the Northern Territory and Western Australia)—which may mask important intra-area variation.

This report was not able to take into account ISPHCSs which did not report to the Online Services Report collection, including state or territory maternal health services, outreach services, and antenatal/postnatal clinics conducted from hospitals which do not have birthing units.

It also focused on spatial accessibility and did not take into account other aspects of maternal health services such as cultural competency. Future analyses could incorporate other indicators or measures of access, maternal risk factors and birth outcomes.

1.Introduction

The gap between the health of Aboriginal and Torres Strait Islander children and non-Indigenous children begins before birth, with babies born to Aboriginal and Torres Strait Islander mothers significantly more likely to have been exposed to tobacco smoke in utero, to be born pre-term, and to have a low birthweight (weighing less than 2,500 grams at birth) (AIHW 2015b).

These inequalities continue throughout early childhood for Aboriginal and Torres Strait Islander children, with higher mortality rates and higher rates of illness and poor health.

The factors that contribute to poor infant and child health are complex and include maternal health (maternal weight, pre-existing health conditions); maternal risk factors (smoking and alcohol consumption during pregnancy, maternal nutrition); maternal age; social determinants (socioeconomic position and education); cultural determinants; and access to health services (such as antenatal care and child health services).

While access to health services will not eliminate the health gap between Indigenous and non-Indigenous babies and young children on their own, services have an important role to play in ameliorating the effects of the other factors listed above.

This report focuses on Aboriginal and Torres Strait Islander women’s geographic access to public birthing units and maternal health services, in order to identify areas with potential gaps in these services.

The report then examines whether there is an association between accessibility to services, maternal risk factors during pregnancy, and birth outcomes. It builds on a series of analyses the AIHW has been undertaking which are aimed at identifying geographic areas with potential gaps in services for Aboriginal and Torres Strait Islander Australians (AIHW 2014a, 2015c).

Background

Fetal health and development represents an intersection between physiological processes and the greater social context and environment. Inequalities in infant health outcomes are not randomly distributed throughout society, but are a reflection of broader social, environmental, historical, economic and cultural conditions (known as the ‘social determinants’ of health).

Figure 1.1 provides a conceptual overview of these processes, illustrating how these higher-level factors (‘distal’ determinants) affect contextual factors and individual mothers’ resources (intermediate factors)—which, in turn, affect ‘proximal’ determinants of both maternal health and maternal risk factors. These proximal determinants are those which then have a direct effect on fetal development.

Distal determinants (such as the long-term effects of colonisation and its effect on factors such as self-determination, the disruption of ties to land), and the adverse impact of racism, have all had an effect on Aboriginal and Torres Strait Islander people’s socioeconomic and psychosocial well-being (Osborne et al. 2013; Reading & Wein 2009).

Compared with non-Indigenous mothers, Aboriginal and Torres Strait Islander women have higher rates of the factors associated with poor infant health outcomes: on average, they have poorer socioeconomic status, lower levels of education, higher levels of psychosocial distress, are more likely to live in poor housing and are more likely to live in areas with fewer health services (intermediate determinants).

These intermediate determinants affect the proximal determinants of maternal health and maternal risk factors during pregnancy, which then have physiological effects on fetal health and development and increase the likelihood of pre-term birth. Available data show that Indigenous mothers have higher rates of a variety of health risks: they are 1.6 times as likely to be obese as non-Indigenous mothers and to have higher rates of pre-existing hypertension and pre-existing diabetes (which are linked with poorer birth outcomes) (AIHW 2016).

One of the strongest behavioural risk factors for poor birth outcomes and subsequent infant mortality and child mortality is smoking. Maternal smoking during pregnancy has been linked with intrauterine growth restriction (IUGR), poor lung development, stillbirth, pre-term birth, and placenta abruption. IUGR and low birthweight can increase the risk of poor perinatal outcomes such as necrotising enterocolitis and respiratory distress syndrome, and have long-term effects such as increased risks for short stature, cognitive delay, cerebral palsy, and poor cardiovascular health (Reeves & Bernstein 2008). Babies born to mothers who smoke during and after pregnancy are also more likely to die from Sudden Infant Death Syndrome.

AIHW multivariate analyses of perinatal data for the period 2012–2014 indicates that, excluding pre-term and multiple births, 51% of low birthweight births to Indigenous mothers were attributable to smoking, compared with 16% for non-Indigenous mothers (AIHW 2017). Evidence suggests that maternal exposure to second-hand smoke reduces birthweight as well.

While rates of smoking during pregnancy have decreased, data from 2013 show that 47.3% of Indigenous mothers smoked during pregnancy, compared with 10% of non-Indigenous mothers (AIHW 2016). The likelihood of smoking is not randomly distributed throughout society, but is related to the intermediate and proximal determinants shown in Figure 1.1.

Role of services

Figure 1.1 positions antenatal care/birthing services as mediating factors that can ameliorate the effects of distal, intermediate and proximate determinants, by working in partnership with Aboriginal and Torres Strait Islander mothers to ensure they have the knowledge, medical care, practical support and social support they require to improve their chances of having a healthy baby.

For example, early access to care can improve infant health through promoting positive change (such as reducing or stopping smoking), and identifying physiological risk factors which may require more specialised management (AIHW 2014b). High-quality, evidence-based and culturally competent (refer to Box 1.1) maternal and child health services, working in partnership with pregnant Aboriginal and Torres women, can help improve maternal and birth outcomes.

Women’s use of antenatal care services is affected by a number of factors, however, such as the availability and the financial and cultural accessibility of services as described above, as well as maternal factors such as early recognition of pregnancy and the perceived value attached to antenatal care (Kruske 2011; Pagnini & Reichman 2000).

Previous work has shown that, while nearly all Aboriginal and Torres Strait Islander mothers access antenatal care prior to giving birth, they are less likely than non-Indigenous mothers to access care early in the pregnancy (51% of Indigenous mothers attend an antenatal visit in the first trimester, compared with 62% of non-Indigenous mothers).

Spatial variation in Aboriginal and Torres Strait Islander women’s access to maternal health services 3 Box 1.1: Culturally competent maternal and child health services Culturally competent antenatal care services are those in which woman-centred care is provided in ways that are respectful, understanding of local culture, and meet the emotional, cultural, practical and clinical needs of the women. There are a number of aspects which characterise culturally competent maternal care services, some of which include having Indigenous-specific programs, having Aboriginal and Torres Strait Islander staff members, providing continuity of care, viewing women as partners in their care, having a welcoming physical environment, and ensuring that cultural awareness and safety is the responsibility of all staff members in the service (Kruske 2011).

Part 2 Prevalence of FASD Among Youth Under the Care of Juvenile Justice in Western Australia: How Shall We Work Together to Close this Gap? [webinar]

The Australian Indigenous Alcohol and Other Drugs Knowledge Centre (the Knowledge Centre) is hosting a Fetal alcohol spectrum disorder (FASD) webinar on Wednesday 29 November with guest presenter Dr Raewyn Mutch from the Telethon Kids Institute.

The theme for the webinar is Prevalence of FASD among youth under the care of Juvenile Justice in Western Australia: how shall we work together to close this gap? The webinar will run for approximately one hour, and will discuss a recent program that investigates FASD and the criminal justice system.

Dr Mutch is a Consultant Paediatrician, and works with Refugee Health at the Department of General Paediatrics, Princess Margaret Hospital for Children, as well as the Alcohol, Pregnancy and FASD department at Telethon Kids Institute. In addition, Dr Mutch also works as a Clinical Associate Professor at the School of Medicine, Dentistry and Health Sciences at the University of Western Australia.

The webinar will be free to attend, but you will need a browser with the latest version of Flash, and a stable internet connection. We’d recommend that participants use a pair of headphones, rather than their computer’s sound, as the sound quality will be better.

The webinar will be held at:

• 1pm AEDT (NSW, Vic, Tas, ACT)
• 12.30pm ACDT (SA)
• 12pm AEST (Qld)
• 11:30am ACST (NT)
• 10am AWST (WA).

To attend the webinar, please click on this link about five minutes before it’s due to commence. If you have any queries about the webinar please refer to the contact details below.

Contacts

Millie Harford-Mills
Research Officer
Australian Indigenous HealthInfoNet
Ph: (08) 9370 6358
Email: m.harford-mills@ecu.edu.au