Aboriginal and Torres Strait Islander Health Performance Framework (HPF) 2012
Tier 2—Health behaviours—2.21 Health behaviours during pregnancy
Why is it important?:Health behaviours during pregnancy can have major impacts on the health outcomes of mothers and their children. Smoking is a major risk factor for adverse events in pregnancy and is associated with poor perinatal outcomes such as low birthweight, pre-term birth, foetal growth restriction, congenital anomalies and perinatal death (AIHW 2004b; WHO et al. 2012; Sullivan et al. 2006). Smoking during pregnancy is also associated with increased risk of miscarriage, ectopic pregnancy, gestational diabetes, pre-term labour and ante partum haemorrhage (Laws et al. 2005; England et al. 2004).
Drinking alcohol while pregnant may result in a range of impairments in cognitive, social and emotional functioning over the child’s lifetime (France et al. 2010). These are referred to collectively as foetal alcohol spectrum disorders (FASD) (NHMRC 2009), and have been identified as a risk factor for cerebral palsy (O’Leary et al. 2012). While existing research on alcohol consumption during pregnancy has limitations, it has been shown that risks of harm increase with the amount and frequency of alcohol consumption (France et al. 2010; Bridge 2011). The National Health and Medical Research Council recommend not drinking alcohol during pregnancy as the safest option (NHMRC 2009).
Use of illicit drugs (e.g., heroin, marijuana) and some licit drugs (e.g., medicines) during pregnancy can involve health risks to the mother. These include overdose and accidental injuries, and significant obstetric, foetal and neonatal complications (Kulaga et al. 2009; Wallace et al. 2007).
Nutrition before and during pregnancy is also critical to foetal development (McDermott et al. 2009). It is recommended that women eat an additional daily serving of both fruit and vegetables, as well as foods containing protein such as meat, fish, poultry or eggs during pregnancy (NHMRC 2003a), and take a folate supplement before pregnancy and during the first trimester to reduce the risk of neural tube defects such as spina bifida (ABS and AIHW 2008).
Findings:In 2009, 52% of Aboriginal and Torres Strait Islander mothers smoked during pregnancy. After adjusting for the different age structures of the two populations, the proportion of Aboriginal and Torres Strait Islander mothers who smoked during pregnancy was 3.7 times that of non-Indigenous mothers. The 2008 NATSISS found that 57% of mothers of children aged 0–3 years who had used tobacco during pregnancy had used less of it during their pregnancy. In 2009, for non-Indigenous mothers, the youngest age group (under 20 years) had the highest rate of smoking (34%) compared to around 10% of women aged 30 years and over. There was no clear pattern of smoking by age group for Indigenous mothers. Teenage mothers were not the group with the highest rate of smoking. Smoking rates for Indigenous Australians were lower in major cities (46%) compared to regional and remote areas (52%–57%).
During the period 2006–08, 33% of all low birthweight babies born to Indigenous mothers were attributable to smoking during pregnancy, compared with 13% for other mothers. Smoking during pregnancy accounted for 24% of the gap in low birthweight births between Indigenous and other mothers.
Studies have found that smoking during pregnancy among Indigenous women is associated with low socioeconomic status; stress; social norms, including number of smokers in the household; and lack of knowledge regarding consequences of smoking during pregnancy (Johnston et al. 2011; Wood et al. 2008; Passey et al. 2012). Additionally, Gilligan et al. (2010) found additional risk through environmental tobacco smoke.
Eighty per cent of mothers of Indigenous children aged 0–3 years surveyed in the 2008 NATSISS reported they did not consume alcohol during pregnancy, with the greatest proportion of abstinence in the NT (85%). Approximately 16% drank less alcohol than usual during pregnancy and 3% drank the same or more. The vast majority (95%) reported that they did not use illicit drugs during their pregnancy. On average, 52% of Indigenous mothers took folate before or during their pregnancy, although in remote areas this fell to 39%.
A study of 476 Aboriginal and Torres Strait Islander women attending 34 Indigenous community health centres across Australia found that 46% of those who smoked received documented advice about smoking cessation (Rumbold et al. 2011). Only 27% of women in the same study were prescribed folic acid prior to 20 weeks gestation and even fewer (8%) prior to conception. These findings may reflect later presentation for antenatal care (see measure 3.01) (Robinson 2011).
In the 2008 NATSISS, mothers of Aboriginal and Torres Strait Islander children who sought advice during pregnancy were less likely to smoke during pregnancy than those who did not seek advice (64% compared with 53%), and were more likely to take folate than those who did not.Top of Page
Implications:Expanding national data on health behaviours during pregnancy will be an important element of monitoring progress in this area. Interventions by health professionals can be effective in encouraging women to reduce or cease smoking and alcohol use, and meet their nutritional needs during pregnancy. However, these interventions need to be tailored to their clients’ needs (Gould et al. 2011; Wood et al. 2008; France et al. 2010; Bridge 2011; Pyett et al. 2008).
Australian studies have found that Aboriginal health workers and midwives have expressed concern that providing smoking cessation advice would potentially damage their relationship with the mother (Wood et al. 2008; Passey et al. 2012). A better knowledge of smoking cessation options suitable to pregnant woman and a positive attitude towards cessation advice were associated with higher rates of smoking assessment by staff. Less significant associations include staff being a non-smoker themselves and having inadequate skills to dispense advice (Passey et al. 2012). This study identified the need to improve the training of carers and to provide culturally appropriate resources.
Through the National Partnership Agreement on Indigenous Early Childhood Development, the Australian Government supports 85 New Directions Mothers and Babies Services, the Australian Nurse Family Partnership Program for over 400 families and the Healthy for Life programs, which all have a focus on improving health behaviours during pregnancy.
A model for provision of drug, alcohol and mental health services for pregnant Aboriginal women has been developed in NSW as part of the Agreement. The model aims to improve identification and early intervention for pregnant women with vulnerabilities, and to strengthen the structures that support effective continuum of care between antenatal care providers, hospitals and community providers following birth.
Under the National Maternity Services Plan, states and territories have committed to progress investigation of evidence-based maternity care models for at-risk women, including women using cigarettes, alcohol and other illicit substances. The Department of Health and Ageing is currently developing new National Evidence Based Antenatal Care Guidelines on behalf of all Australian governments. The Guidelines are designed to cover the antenatal care of healthy pregnant women, and present recommendations based on the clinical evidence. Module 1 of the Guidelines covers the first trimester of pregnancy and provides advice on over 20 topic areas including tobacco smoking, alcohol and nutritional supplements. The Guidelines have been developed with input from the Working Group for Aboriginal and Torres Strait Islander Women’s Antenatal Care. They will provide culturally appropriate guidance and information for the health needs of Aboriginal and Torres Strait Islander pregnant women and their families. The current Dietary Guidelines for Australian Adults (2003) and the Australian Guide to Healthy Eating provide dietary advice for pregnant and breastfeeding mothers. The guidelines are currently under review with the revised version expected to be released late 2012.Top of Page
Figure 136—Proportion of mothers who smoked during pregnancy, by Indigenous status and state/territory, 2009
a) Total is age-standardised
Source: National Perinatal Statistics Unit National Perinatal Data Collection
Figure 137—Proportion of mothers who smoked during pregnancy, by Indigenous status and age of mother, 2009Top of Page
a) Total is age-standardised
Source: National Perinatal Statistics Unit National Perinatal Data
Figure 138—Alcohol consumption by child's mother during pregnancy, Indigenous children aged 0–3 years, 2008Top of Page
Source: AIHW analyses of 2008 NATSISSTop of Page
Figure 139—Proportion of mothers who used illicit drugs or substances during pregnancy, Indigenous children aged 0–3 years, by state/territory, 2008
Source: AIHW analyses of 2008 NATSISSTop of Page