2.21 Health behaviours during pregnancy
Why is it important?
Many lifestyle factors contribute to, and can have adverse effects on, the health and wellbeing of a woman and her baby during pregnancy, birth and beyond.
Smoking tobacco increases the risk of complications such as miscarriage, ectopic pregnancy, placental abruption and gestational diabetes (Laws et al. 2005; England et al. 2004) and is associated with low birthweight, foetal growth restriction, pre-term birth, congenital anomalies and perinatal death (WHO et al. 2012; Sullivan et al. 2006). Passive exposure to smoke is also associated with low birthweight, foetal growth restriction and perinatal death (see measure 2.03) (Crane et al. 2011; Gilligan et al. 2010). There is evidence that smoking cessation, particularly within the first trimester, can reduce these risks (Yan et al. 2014; Scollo et al. 2012).
Drinking alcohol while pregnant may result in low birthweight, pre-term birth and perinatal death (Crane et al. 2011) and has been shown to result in a range of impairments in cognitive, social and emotional functioning over the child's lifetime, collectively referred to as foetal alcohol spectrum disorders (FASD) (NHMRC 2009; France et al. 2010; Fitzpatrick et al. 2012). The true prevalence of FASD for Indigenous Australians is not known; estimates vary from 0.15 to 4.7 per 1,000 births (Burns et al. 2013). While existing research has limitations, risks of harm are said to increase with the amount and frequency of alcohol consumed (O'Leary et al. 2010; France et al. 2010; Bridge 2011). The NHMRC recommends not drinking alcohol during pregnancy as the safest option (NHMRC 2009).
Use of illicit drugs (e.g. heroin, cannabis) and some licit drugs (e.g. medicines) during pregnancy can involve health risks to the mother (including overdose and accidental injuries) as well as significant obstetric, foetal and neonatal complications (Wallace et al. 2007; Kulaga et al. 2009) and behavioural and cognitive outcomes that emerge in later life (Passey et al. 2014; Behl et al. 2013).
Nutrition before and during pregnancy is also critical to foetal development (McDermott et al. 2009; Wen et al. 2010). Pregnant women and women considering pregnancy are advised to have a balanced diet. Maintenance of folate levels are particularly important to decrease risk of neural tube defects such as spina bifida (AHMAC 2012), which is twice as common among babies born to Indigenous women than non-Indigenous women (AIHW 2011e). In addition to adverse birth outcomes, poor maternal nutrition has been linked with increased risk of developing insulin resistance and obesity (Sloboda 2011).
Perinatal data for 2011 show that half of Aboriginal and Torres Strait Islander mothers smoked during pregnancy. Since 2005, there has been a small significant decline in smoking rates among Indigenous mothers (from 54% to 50%) (AIHW 2014i). After adjusting for the different age structures of the two populations, Indigenous mothers were 4 times as likely to smoke during pregnancy as non-Indigenous mothers (12%). There was no clear pattern of smoking by age group for Indigenous mothers (and teenage mothers were not the group with the highest rate). For non-Indigenous mothers, those under 20 years of age had the highest rate of smoking (33%) while the lowest rates were in the age groups 30 years and over (all 8%). Smoking rates for Indigenous mothers were lower in major cities (46%) compared with regional and remote areas (51%–53%). In 2012, Indigenous mothers were half as likely to stop smoking during pregnancy as non-Indigenous mothers (12% compared with 23%) (AIHW 2014e). In the 2008 Social Survey, 42% of the mothers of Indigenous children aged 0–3 years reported using tobacco during pregnancy. Of those, 57% reported using less tobacco while pregnant.
A multivariate analysis of 2009–2011 perinatal data indicates that (excluding pre-term and multiple births), 51% of low birthweight births to Indigenous mothers were attributable to smoking during pregnancy, compared with 19% for other mothers. After adjusting for age differences and other factors, it was estimated that if the Indigenous maternal smoking rate was the same as that of other mothers, the proportion of low birthweight babies could be reduced by 26% (see measure 1.01). Babies born to Indigenous mothers who smoked were 1.4 times as likely to be pre-term as those who did not smoke.
Studies have found that smoking during pregnancy among Indigenous women is associated with low socio-economic status; stress; social norms, including number of smokers in the household; and lack of knowledge regarding consequences of smoking during pregnancy, which in turn influence incentives and support to quit (Johnston et al. 2011; Wood et al. 2008; Passey et al. 2012; Thrift et al. 2011).
In the 2008 Social Survey, 80% of mothers of Indigenous children aged 0–3 years reported that 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 pregnancy, with as few as 39% in remote areas. Mothers of Indigenous children who sought health advice during pregnancy were less likely to smoke during pregnancy (36%) than those who did not (47%), and were more likely to have taken folate.
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 this 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).
Expanding national data on health behaviours during pregnancy will be an important element of monitoring progress in this area.
Studies suggest that pregnant Indigenous women require comprehensive approaches to addressing nutrition and smoking/substance use during pregnancy which: consider environmental contexts, increase knowledge of harm, are tailored to clients' needs, are provided in a way that does not cause distress or embarrassment or deter further antenatal care, and are culturally targeted with community involvement (Gould et al. 2011; Wood et al. 2008; France et al. 2010; Gould et al. 2013; Bridge 2011; Lucas et al. 2014). Concurrent use of multiple substances and clustering of risk, particularly for women of lower socio-economic status, also need to be considered (Passeyet al. 2014; Wen et al. 2010; Eades et al. 2012).
National evidence-based antenatal care guidelines have been developed for the first trimester and work is underway on guidelines for the second and third trimesters (see measure 3.01). The guidelines aim to provide culturally appropriate information for the health needs of Indigenous pregnant women and their families. They include advice on health behaviours during pregnancy.
The 2014–15 Federal Budget provides Australian Government funding of $94 million over three years from July 2015, for the Better Start to Life approach. This includes:
- $54 million to increase the number of sites providing New Directions: Mothers and Babies Services from 85 to 136. These services provide Indigenous families with access to antenatal care, practical advice and assistance with parenting, and health checks for children.
- $40 million to expand the Australian Nurse Family Partnership Program (ANFPP) from 3 to 13 sites. The ANFPP aims to improve pregnancy outcomes by helping women engage in good preventive health practices, support parents to improve their child's health and development, and help parents develop a vision for their own future, including continuing education and finding work.
The 2014–15 Federal Budget also commits $25.9 million in 2014–15 for a new Indigenous Teenage Sexual and Reproductive Health and Young Parent Support measure. Implemented by states and territories, these services will provide information to young people to make informed decisions about their reproductive health and health behaviours during pregnancy.
On 25 June 2014, the Australian Government announced funding of $9.2 million for the National Fetal Alcohol Spectrum Disorders (FASD) Action Plan, which includes funding for Indigenous-specific prevention and promotion activities. The FASD Action Plan is directed at the frontline of dealing with risky alcohol consumption—providing better diagnosis and management, development of best practice interventions and services to support high-risk women. The Australian Government promotes the current NHMRC guidelines that recommend not drinking alcohol is the safest option during pregnancy (NHMRC 2009).
The National Tobacco Campaign—More Targeted Approach is aimed at reducing smoking prevalence among high-risk and hard-to-reach groups. Materials featuring Indigenous women have been included in the Quit for You, Quit for Two component, targeting pregnant women and their partners. Evaluation research found this campaign effectively promoted positive attitudes and intentions among Indigenous audiences towards not smoking.
Figure 2.21-1 shows the proportion of Aboriginal and Torres Strait Islander mothers and non-Indigenous Australian mothers who smoked during pregnancy in 2011. Age-standardised data is presented separately for each remoteness area (major cities, inner regional, outer regional, remote and very remote), and Australia as a whole. The graph shows that rates of smoking during pregnancy are disproportionately higher among Aboriginal and Torres Strait Islander mothers than non-Indigneous mothers across all remoteness areas.
Source: AIHW/NPESU analysis of 2011 National Perinatal Data Collection
Figure 2.21-2 shows the proportion of Aboriginal and Torres Strait Islander mothers and non-Indigenous Australian mothers who smoked during pregnancy in 2011. Data is presented for the following age groups (age of mother): less than 20 years; 20-24 years; 25-29 years; 30-34 years; 35-39 years; and 40 years and over. Across all age groups, rates are higher for Indigenous mothers than non-Indigenous mothers. For Aboriginal and Torres Strait Islander women, rates are high across all age groups. For non-Indigenous mothers, rates decline as the age of the mother increases.
Source: AIHW/NPESU analysis of 2011 National Perinatal Data Collection
Figure 2.21-3 shows the proportion of mothers of Aboriginal and Torres Strait Islander children aged 0-3 years who drank: more, less and not at all during pregnancy in 2008. The graph shows that the majority of Aboriginal and Torres Strait Islander mothers did not drink during pregnancy.
Source: AIHW analysis of 2008 NATSISS
Figure 2.21-4 shows the proportion of mothers of Aboriginal and Torres Strait Islander children aged 0–3 years who used illicit drugs or substances during pregnancy in 2008. Data is presented separately for each jurisdiction (Tasmania and ACT combined), and Australia as a whole. Rates are highest in Vic and WA.
Source: AIHW analysis of 2008 NATSISS