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3.01 Antenatal care

Why is it important?

Antenatal care involves recording medical history; undertaking regular clinical assessments to identify individual needs; screening for a range of infections and abnormalities; providing support and information through pregnancy; offering social, lifestyle and self-care advice; and providing first-line management and referral if necessary (AHMAC 2012; WHO 2007). Regular antenatal care has been found to have a positive effect on, and provide the foundation for, good health outcomes for mothers and babies (Eades 2004; AHMAC 2012).

Antenatal care may be especially important for Aboriginal and Torres Strait Islander women as they are at higher risk of giving birth to pre-term and low birthweight babies and 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 (de Costa et al. 2009; AHMAC 2012).

The Clinical Practice Guidelines: Antenatal Care—Module 1 (AHMAC 2012) provide recommendations to support high-quality antenatal care and contribute to improved outcomes for all mothers and babies. The guidelines cover the first trimester of pregnancy, taking a woman-centred approach and include specific discussion of antenatal care for Aboriginal and Torres Strait Islander women to improve their experience and outcomes of care. Presentation for antenatal care within the first 10 weeks of gestation is suggested due to the high information needs early in pregnancy and to allow for timely assessment of risk factors. Depending on need, a schedule of 10 visits is recommended for a woman's first pregnancy, and 7 visits for subsequent uncomplicated pregnancies.

Many factors influence an Indigenous woman's engagement with, and early presentation for, antenatal care including availability of culturally appropriate services, the frequency (or absence) of local clinics, transport, and educational, socio-economic and financial issues. (Arnold et al. 2009; de Costa et al. 2009).

Findings

Perinatal data show that in 2011, 99% of Aboriginal and Torres Strait Islander mothers accessed antenatal care services at least once during their pregnancy, which is similar to non-Indigenous mothers. Since 1998, there has been a statistically significant increase of 4% (for jurisdictions with long-term data: NSW, SA and Qld combined).

However, Aboriginal and Torres Strait Islander mothers, on average, accessed services later in the pregnancy and had significantly fewer antenatal care sessions. In 2011, half of all Indigenous mothers had their first antenatal session in the first trimester of pregnancy compared with 66% of non-Indigenous mothers. Access to care in the first trimester varied by state (61% in NSW compared with 36% in WA) and to a lesser degree by remoteness (e.g. 55% in inner regional areas and 47% in major cities and very remote areas). The gap between Indigenous and non-Indigenous mothers was largest in the NT (30 percentage points). Younger Indigenous mothers were less likely (45%) to have their first antenatal visit in their first trimester than those in age groups over 20 years (50–52%). The later a mother received antenatal care, the more likely she was to have a pre-term and/or low birthweight baby. Compared with women who received care in the first trimester, women who received no antenatal care were 3 times as likely to have a pre-term or low-weight baby and 6–7 times as likely to have a pregnancy that resulted in perinatal death, regardless of Indigenous status.

In 2012, for women who gave birth at 32 weeks gestation or more, 84% of Indigenous mothers had attended 5 or more antenatal sessions compared with 95% for non-Indigenous mothers (age-standardised) (AIHW 2014e).

The 2008 Social Survey data show that 11% of Indigenous mothers with children aged 0–3 years gave birth in a hospital or clinic that was 250 kms or more from their home. Most mothers (96%) had pregnancy checkups. These check-ups involved doctors (61%), nurses (48%), obstetricians (17%), and/or Aboriginal health workers (9%).

The national Key Performance Indicators data collection includes items on antenatal care provided by Australian Government-funded Indigenous primary health care organisations. In December 2013, of the 3,715 Indigenous mothers who were regular clients of these organisations, 38% attended their first antenatal visit in the critical first trimester. Rates were highest in remote areas (44%) and lowest in very remote areas and major cities (32%) (AIHW 2014w).

The National Health Performance Authority reported that the percentage of Indigenous women who had at least one antenatal visit in the first trimester varied across regions ranging from 81% in the Nepean–Blue Mountains region (NSW) to 22% in the Grampians region (Vic) (NHPA 2014).

Implications

Earlier and more regular attendance for antenatal care is required to improve outcomes for Aboriginal and Torres Strait Islander mothers and their babies, as well as continued improvements in the quality of antenatal care received. 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 Aboriginal and Torres Strait Islander maternal health programmes to complement the features detailed above: a specific Aboriginal and/or Torres Strait Islander programme; a welcoming and safe environment; outreach and home visiting; flexibility in service delivery and appointment times; transport; continuity of care and carer integration with other services e.g. AMS 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 child care; appropriately trained workforce; Indigenous staff and female staff; informed consent and right of refusal; and tools to measure cultural competency (Dudgeon et al. 2010; Reibel et al. 2010; Herceg 2005; AHMAC 2012).

An audit of antenatal care in WA found that 75% of services failed to provide a model of care consistent with the principals of culturally competent care to Indigenous woman (Reibel et al. 2010). Studies have also demonstrated how sustained access to community-based, integrated, shared antenatal services improves perinatal outcomes for Indigenous women (NSW Health 2006; Panaretto et al. 2007).

Australian governments are investing in a range of initiatives aimed at improving child and maternal health. The Clinical Practice Guidelines: Antenatal Care—Module 2, is being developed on behalf of all governments and will cover the second and third trimesters of pregnancy. The guidelines are being developed with input from the Working Group for Aboriginal and Torres Strait Islander Women's Antenatal Care to provide culturally appropriate guidance and information for the health needs of Aboriginal and Torres Strait Islander pregnant women and their families.

The 2014–15 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.

In WA, the Aboriginal Maternity Group Practice programmes provide outreach services for pregnant Aboriginal women. The programmes are underpinned by steering groups in each district, which consist of community members and key local maternal and child health service providers. At the steering group meetings, the planning, implementation and evaluation of each of these programmes is discussed and decisions are made about service delivery. The cultural governance is defined by the community participants through every aspect of the programmes' delivery. The programmes have led to positive sustainable cultural change in practices in hospital as well as community settings.

Figure 3.01-1 Age-standardised percentage of mothers who attended at least one antenatal care session, by Indigenous status, NSW, Qld and SA, 1998 to 2011
chart showing Age-standardised proportion

Figure 3.01-1 shows the proportion of Aboriginal and Torres Strait Islander mothers and non-Indigenous mothers who attended at least one antenatal care session in NSW, Queensland and SA. Data is presented annually from 1998 to 2011. For Indigenous mothers, the proportion with at least one antenatal visit during pregnancy increased by 4% during the period and the gap has narrowed. The proportion of non-Indigenous women with at least one antenatal care visit is higher than for Indigenous women across all years.

Source: AIHW/NPESU analysis of National Perinatal Data Collection

Figure 3.01-2 Age-standardised percentage of mothers whose first antenatal care session occurred in the first trimester, by Indigenous status and remoteness, 2011
mothers whose first antenatal care session occurred in the first trimester

Figure 3.01-2 shows the proportion of Aboriginal and Torres Strait Islander mothers and non-Indigenous mothers whose first antenatal care session occurred in the first trimester in 2011. Age-standardised data is presented separately for major cities; inner regional areas; outer regional areas; remote areas; very remote areas, and Australia. Across all remoteness categories, the proportion of non-Indigenous mothers whose first antenatal care session occurred in the first trimester is higher than for Aboriginal and Torres Strait Islander mothers.

Source: AIHW/NPESU analysis of National Perinatal Data Collection

Figure 3.01-3 Age-standardised percentage of mothers whose first antenatal care session occurred in the first trimester, by by Indigenous status and jurisdiction, 2011
mothers whose first antenatal care session occurred in the first trimester

Figure 3.01-3 shows the age-standardised proportion of Aboriginal and Torres Strait Islander mothers and non-Indigenous mothers who attended at least one antenatal care session in 2011. Data are presented for: NSW, Vic, Qld, WA, SA, the NT and a Total. Across all jurisdictions, the proportion of mothers who received antenatal care in the first trimester is higher for non-Indigenous mothers than Aboriginal and Torres Strait Islander mothers.

Note: Australia includes ACT and Tas

Source: AIHW/NPESU analysis of National Perinatal Data Collection

Figure 3.01-4 Relationship between duration of pregnancy at first antenatal care session and age-standardised percentage of mothers with low birthweight babies, by Indigenous status, 2011
timing of first antenatal care session

Figure 3.01-4 shows the relationship between the timing of a mothers first antenatal care session and low birthweight. Data are presented by gestation (in weeks) at first antenatal visit: less than 14 weeks gestation, 14 to 19 week, 20 or more weeks, and those who did not receive antenatal care. The figure shows that women who received no antenatal care were three times more likely to have a low birthweight baby than women who received care.

Source: AIHW/NPESU analysis of National Perinatal Data Collection