Lifestyle and sociodemographic risk factors for stillbirth by region of residence in South Australia: a retrospective cohort study.

BACKGROUND: Stillbirth rates remain a global priority and in Australia, progress has been slow. Risk factors of stillbirth are unique in Australia due to large areas of remoteness, and limited resource availability affecting the ability to identify areas of need and prevalence of factors associated with stillbirth. This retrospective cohort study describes lifestyle and sociodemographic factors associated with stillbirth in South Australia (SA), between 1998 and 2016. METHODS: All restigered births in SA between 1998 ad 2016 are included. The primary outcome was stillbirth (birth with no signs of life ≥ 20 weeks gestation or ≥ 400 g if gestational age was not reported). Associations between stillbirth and lifestyle and sociodemographic factors were evaluated using multivariable logistic regression and described using adjusted odds ratios (aORs). RESULTS: A total of 363,959 births (including 1767 stillbirths) were included. Inadequate antenatal care access (assessed against the Australian Pregnancy Care Guidelines) was associated with the highest odds of stillbirth (aOR 3.93, 95% confidence interval (CI) 3.41-4.52). Other factors with important associations with stillbirth were plant/machine operation (aOR, 1.99; 95% CI, 1.16-2.45), birthing person age ≥ 40 years (aOR, 1.92; 95% CI, 1.50-2.45), partner reported as a pensioner (aOR, 1.83; 95% CI, 1.12-2.99), Asian country of birth (aOR, 1.58; 95% CI, 1.19-2.10) and Aboriginal/Torres Strait Islander status (aOR, 1.50; 95% CI, 1.20-1.88). The odds of stillbirth were increased in regional/remote areas in association with inadequate antenatal care (aOR, 4.64; 95% CI, 2.98-7.23), birthing age 35-40 years (aOR, 1.92; 95% CI, 1.02-3.64), Aboriginal and/or Torres Strait Islander status (aOR, 1.90; 95% CI, 1.12-3.21), paternal occupations: tradesperson (aOR, 1.69; 95% CI, 1.17-6.16) and unemployment (aOR, 4.06; 95% CI, 1.41-11.73). CONCLUSION: Factors identified as independently associated with stillbirth odds include factors that could be addressed through timely access to adequate antenatal care and are likely relevant throughout Australia. The identified factors should be the target of stillbirth prevention strategies/efforts. SThe stillbirth rate in Australia is a national concern. Reducing preventable stillbirths remains a global priority.

Looking after bubba for all our mob: Aboriginal and Torres Strait Islander community experiences and perceptions of stillbirth.

The stillbirth rate among Aboriginal and Torres Strait Islander women and communities in Australia is around double that of non-Indigenous women. While the development of effective prevention strategies during pregnancy and improving care following stillbirth for women and families in communities has become a national priority, there has been limited progress in stillbirth disparities. With community permission, this study aimed to gain a better understanding of community experiences, perceptions, and priorities around stillbirth. We undertook an Indigenous researcher-led, qualitative study, with community consultations guided by a cultural protection protocol and within an unstructured research framework. A total of 18 communities were consulted face-to-face through yarning interviews, focus groups and workshops. This included 54 community member and 159 health professional participants across remote, regional, and urban areas of Queensland, Western Australia, Victoria, South Australia, and Northern Territory. Thematic analysis of consultation data identified common themes across five focus/priority areas to address stillbirth: Stillbirth or Sorry Business Baby care needs to be family-centered; using Indigenous "ways of knowing, being, and doing" to ensure cultural safety; application of Birthing on Country principles to maternal and perinatal care; and yarning approaches to improve communication and learning or education. The results underscore the critical need to co-design evidence-based, culturally appropriate, and community-acceptable resources to help reduce existing disparities in stillbirth rates.

Inequitable use of health services for Indigenous mothers who experience stillbirth in Australia.

OBJECTIVES: The purpose of this study was to identify differences in health service expenditure on Indigenous and non-Indigenous women who experience a stillbirth, women's out-of-pocket costs, and health service use. METHODS: The project used a whole-of-population linked data set called "Maternity1000," which includes all women who gave birth in Queensland, Australia, between July 1, 2012, and June 30, 2018 (n = 396 158). Multivariable analysis was undertaken to assess differences in mean health service expenditure; and number of health care services accessed between Indigenous and non-Indigenous women who had a stillbirth from birth to twelve months postpartum. Costs are presented in 2019/20 Australian dollars. RESULTS: There was a total of 1864 babies stillborn to women in Queensland between July 1, 2012, and June 30, 2018, with 135 being born to Indigenous women and 1729 born to non-Indigenous women. There was significantly lower total expenditure per woman for Indigenous women compared with non-Indigenous women ($16 083 and $18 811, respectively). This was consistent across public hospital inpatient ($12 564 compared with $14 075), outpatient ($1127 compared with $1470), community-based services ($198 compared with $313), pharmaceuticals ($8 compared with $22), private hospital ($434 compared with $1265), and for individual out-of-pocket fees ($21 compared with $86). Mean expenditure on emergency department services per woman was higher for Indigenous women compared with non-Indigenous women ($947 compared with $643). Indigenous women who experienced a stillbirth accessed fewer general practitioners, allied health, specialist, obstetrics, and outpatient services, and fewer pathology and diagnostic test than their non-Indigenous counterparts. CONCLUSIONS: Inequities in access to health services exist between Indigenous and non-Indigenous women who experience a stillbirth.

Addressing stillbirth inequities in Australia: Steps towards a better future.

Persistent disparities in stillbirth risk and care are present in Australia. Eliminating these disparities is possible with a commitment to enhancing and scaling up models of culturally safe maternity care shown to be effective for Aboriginal and Torres Strait Islander women and those of migrant and refugee backgrounds. Campaigns to improve public awareness of stillbirth also play an important role in reducing stillbirth risk and consequences. To achieve reach and impact in communities at risk, messaging needs to be framed around the social and cultural context of women's lives. Here we describe important initiatives underway within the Stillbirth Centre of Research Excellence to develop a coordinated national approach to stillbirth prevention and care in communities that bear a disproportionate burden of stillbirth.

Community engagement in the Aboriginal Families Study: Strategies to promote participation.

BACKGROUND: Aboriginal women and families are under-represented in Australian research on pregnancy and childbirth. The Aboriginal Families Study aimed to investigate the views and experiences of a representative sample of women giving birth to an Aboriginal baby in South Australia between July 2011 and June 2013, using methods designed to respect Aboriginal culture and communities. METHODS: A team of 12 Aboriginal researchers facilitated community engagement and recruitment of Aboriginal and non-Aboriginal mothers of Aboriginal infants in urban, regional and remote areas of South Australia over a two-year period. RESULTS: A total of 344 women took part, around a quarter of all Aboriginal women giving birth in South Australia in the study period (39% urban, 35% regional and 25% from remote areas). Participants were representative in relation to maternal age (mean age of 25 years, range=15-43 years). Over half of women (56%) first heard about the study via a member of the fieldwork team making contact with them through community connections. Other major sources of recruitment were: Aboriginal health services/programs (20%) and public maternity hospitals (16%). Almost all of the women (95%) recruited via community networks of the fieldwork team completed the questionnaire. In contrast, 51% of women recruited via public hospitals completed the questionnaire (odds ratio=0.1, 95% confidence interval 0.0-0.1, p<0.001). CONCLUSIONS: Aboriginal researchers' community knowledge and leadership is critical to the conduct of successful Aboriginal health research. High levels of participation in research by 'harder to reach' populations are achievable when researchers take time to build relationships and work in partnership with communities.

Initiation and duration of breastfeeding of Aboriginal infants in South Australia.

BACKGROUND: Benefits of breastfeeding are well-established. Few studies have examined initiation and duration of breastfeeding of Aboriginal infants. METHODS: Population-based study of women giving birth to an Aboriginal infant in South Australia, July 2011-June 2013. FINDINGS: 344 women took part. Participants were representative in relation to maternal age, infant birthweight and gestation. Eighty-six percent initiated breastfeeding, declining to 54% at 12 weeks postpartum. Women living in remote areas were more likely to be breastfeeding at 12 weeks than women living in Adelaide (Odds Ratio=2.6, 95% Confidence Interval 1.5-4.7). Two-thirds of women (67%) attending standard public antenatal care in regional areas and 61% attending regional Aboriginal Family Birthing Program Services were breastfeeding at 12 weeks, compared to one third of women (36%) attending standard metropolitan public antenatal care and 49% of women attending metropolitan Aboriginal Family Birthing Program Services. Less than half of women (45%) described their postnatal care as 'very good', and 40% were not always able to access support with infant feeding when needed. The most common reasons for switching to formula before 6 weeks were: low milk supply/baby not gaining weight, mastitis/sore breasts or other feeding problems. Mothers also identified their own health as a factor. CONCLUSION: While the findings must be treated with caution due to small numbers, they suggest benefits for women attending Aboriginal Family Birthing Program services in the urban environment where rates of initiation and continued breastfeeding are lowest. Provision of culturally appropriate support to Aboriginal women during and after pregnancy is key to improving outcomes.

COLLABORATION AND CULTURAL SAFETY: SAFE SLEEP SPACE ALTERNATIVES WITH ABORIGINAL FAMILIES.

Despite a marked reduction in Aboriginal and Torres Strait Islander infant deaths from 1998 to 2012 (AIHW 2015) Aboriginal and Torres Strait Islander infants remain over-represented in sudden and unexpected infant death rates.

Primary health care for Aboriginal women and children in the year after birth: findings from a population-based study in South Australia.

OBJECTIVE: To investigate the extent to which Aboriginal women access primary care for themselves and their infant in the year after childbirth. METHOD: Cross sectional population-based survey of women giving birth to Aboriginal babies in South Australia between July 2011 and June 2013. RESULTS: A total of 344 women took part in the study 4-9 months after giving birth. The majority had seen a primary health care practitioner since the birth: 86% had seen a Child and Family Health Service (CaFHS) nurse, 81% a general practitioner (GP), and 61% an Aboriginal health worker (AHW). Women living in remote areas were more likely to have seen primary care practitioners than women living in Adelaide (GP: OR 2.3, 95% CI 1.0-5.2; CaFHS: OR 2.4, 95% CI 1.0-5.8; AHW: OR 5.2, 95% CI 2.8-9.8). Around 16% of women with gestational diabetes and 10% with hypertension had not seen a GP since the birth, and 24% of women who had a low birthweight infant had not seen a CaFHS nurse. CONCLUSIONS: Despite high prevalence of maternal and infant morbidity, a sizeable minority of women did not access primary care practitioners postpartum. Implications for public health: Stronger efforts are needed to ensure Aboriginal women and families receive appropriate postnatal follow-up.

Stressful events, social health issues and psychological distress in Aboriginal women having a baby in South Australia: implications for antenatal care.

BACKGROUND: Around 6% of births in Australia are to Aboriginal and Torres Strait Islander families. Aboriginal and Torres Strait Islander women are 2-3 times more likely to experience adverse maternal and perinatal outcomes than non-Aboriginal women in Australia. METHODS: Population-based study of mothers of Aboriginal babies born in South Australia, July 2011 to June 2013. Mothers completed a structured questionnaire at a mean of 7 months postpartum. The questionnaire included measures of stressful events and social health issues during pregnancy and maternal psychological distress assessed using the Kessler-5 scale. RESULTS: Three hundred forty-four women took part in the study, with a mean age of 25 years (range 15-43). Over half (56.1%) experienced three or more social health issues during pregnancy; one in four (27%) experienced 5-12 issues. The six most commonly reported issues were: being upset by family arguments (55%), housing problems (43%), family member/friend passing away (41%), being scared by others people's behavior (31%), being pestered for money (31%) and having to leave home because of family arguments (27%). More than a third of women reporting three or more social health issues in pregnancy experienced high/very high postpartum psychological distress (35.6% versus 11.1% of women reporting no issues in pregnancy, Adjusted Odds Ratio = 5.4, 95% confidence interval 1.9-14.9). CONCLUSIONS: The findings highlight unacceptably high rates of social health issues affecting Aboriginal women and families during pregnancy and high levels of associated postpartum psychological distress. In order to improve Aboriginal maternal and child health outcomes, there is an urgent need to combine high quality clinical care with a public health approach that gives priority to addressing modifiable social risk factors for poor health outcomes.

Use of cannabis during pregnancy and birth outcomes in an Aboriginal birth cohort: a cross-sectional, population-based study.

OBJECTIVES: Indigenous women continue to experience rates of stillbirth, preterm birth and low birth weight, two to three times higher than other women in high-income countries. The reasons for disparities are complex and multifactorial. We aimed to assess the extent to which adverse birth outcomes are associated with maternal cannabis use and exposure to stressful events and social health issues during pregnancy. DESIGN/SETTING: Cross-sectional, population-based survey of women giving birth to Aboriginal babies in South Australia, July 2011-June 2013. Data include: maternal cannabis use, exposure to stressful events/social health issues, infant birth weight and gestation. PARTICIPANTS: 344 eligible women with a mean age of 25 years (range 15-43 years), enrolled in the study. Participants were representative in relation to maternal age, infant birth weight and gestation. RESULTS: 1 in 5 women (20.5%) used cannabis during pregnancy, and 52% smoked cigarettes. Compared with mothers not using cannabis or cigarettes, mothers using cannabis had babies on average 565 g lighter (95% CI -762 to -367), and were more likely to have infants with a low birth weight (OR=6.5, 95% CI 3.0 to 14.3), and small for gestational age (OR=3.8, 95% CI 1.9 to 7.6). Controlling for education and other social characteristics, including stressful events/social health issues did not alter the conclusion that mothers using cannabis experience a higher risk of negative birth outcomes (adjusted OR for odds of low birth weight 3.9, 95% CI 1.4 to 11.2). CONCLUSIONS: The findings provide a compelling case for stronger efforts to address the clustering of risk for adverse outcomes in Aboriginal and Torres Strait Islander communities, and point to the need for antenatal care to address broader social determinants of adverse perinatal outcomes. Integrated responses--collaboratively developed with Aboriginal communities and organisations--that focus on constellations of risk factors, and a holistic approach to addressing social determinants of adverse birth outcomes, are required.

Improving Access to Antenatal Care for Aboriginal Women in South Australia: Evidence from a Population-Based Study.

INTRODUCTION: Aboriginal and Torres Strait Islander women are two to three times more likely to experience adverse maternal and perinatal outcomes than non-Aboriginal women in Australia. Persisting health inequalities are at least in part explained by late and/or inadequate access to antenatal care. METHODS: This study draws on data collected in a population-based study of 344 women giving birth to an Aboriginal infant between July 2011 and June 2013 in South Australia to investigate factors associated with engagement in antenatal care. RESULTS: About 79.8 percent of mothers accessed antenatal care in the first trimester of pregnancy, and 90 percent attended five or more antenatal visits. Compared with women attending mainstream regional services, women attending regional Aboriginal Family Birthing Program services were more likely to access antenatal care in the first trimester (Adj OR 2.5 [1.0-6.3]) and markedly more likely to attend a minimum of five visits (Adj OR 4.3 [1.2-15.1]). Women attending metropolitan Aboriginal Family Birthing Program services were also more likely to attend a minimum of five visits (Adj OR 12.2 [1.8-80.8]) compared with women attending mainstream regional services. Women who smoked during pregnancy were less likely to attend a visit in the first trimester and had fewer visits. CONCLUSIONS: Scaling up of Aboriginal Family Birthing Program Services in urban and regional areas of South Australia has increased access to antenatal care for Aboriginal families. The involvement of Aboriginal Maternal Infant Care workers, provision of transport for women to get to services, and outreach have been critical to the success of this program.

Improving Aboriginal women's experiences of antenatal care: findings from the Aboriginal families study in South Australia.

BACKGROUND: Aboriginal and Torres Strait Islander families experience markedly worse maternal and child health outcomes than non-Aboriginal families. The objective of this study was to investigate the experiences of women attending Aboriginal Family Birthing Program services in South Australia compared with women attending mainstream public antenatal care. METHOD: Population-based survey of mothers of Aboriginal babies giving birth in urban, regional, and remote areas of South Australia between July 2011 and June 2013. RESULTS: A total of 344 women took part in the study around 4-9 months after giving birth; 93 percent were Aboriginal and/or Torres Strait Islanders, and 7 percent were non-Aboriginal mothers of Aboriginal babies. Of these, 39 percent of women lived in a major city, 36 percent in inner or outer regional areas, and 25 percent in remote areas of South Australia. Compared with women attending mainstream public antenatal care, women attending metropolitan and regional Aboriginal Family Birthing Program services had a higher likelihood of reporting positive experiences of pregnancy care (adjOR 3.4 [95% CI 1.6-7.0] and adjOR 2.4 [95% CI 1.4-4.3], respectively). Women attending Aboriginal Health Services were also more likely to report positive experiences of care (adjOR 3.5 [95% CI 1.3-9.4]). CONCLUSIONS: In the urban, regional, and remote areas where the Aboriginal Family Birthing Program has been implemented, the program has expanded access to culturally responsive antenatal care for Aboriginal women and families. The positive experiences reported by many women using the program have the potential to translate into improved outcomes for Aboriginal families.

Aboriginal maternal and infant care workers: partners in caring for Aboriginal mothers and babies.

INTRODUCTION: Aboriginal Maternal and Infant Care (AMIC) workers and midwives work in intellectual and inter-cultural partnerships in a new perinatal care model the Anangu Bibi Family Birthing Program that aims to provide culturally focussed perinatal care for Aboriginal mothers and families at two sites in regional South Australia. This study investigated the views of the AMIC workers and midwives about their roles, their partnership and the program, following the first 45 births. METHODS: Semi-structured interviews with all five AMIC workers and four of the five midwives working in the program were conducted. Tapes were transcribed and main themes extracted. RESULTS: The AMIC workers' role included clinical, cultural, social and aspects from the confirmation of pregnancy through to 6-8 weeks after the birth. Themes relating to their work role included: clinical work; social and emotional support; language and advocacy for the partnership: mutually equivalent roles and for the program: clinical benefits and cultural safety. The midwives' role included clinical practice, skill-sharing and mentoring. Midwives were guided by AMIC workers' social, cultural and community knowledge. Themes that emerged for the midwives on the partnership were: time and commitment to working inter-culturally; issues with the new AMIC worker role; clinical skill sharing and mentoring; resistance of some hospital midwives; respect for AMIC workers' cultural knowledge and community links; and two-way learning. Themes of perceived benefit were: increased use of services and cultural benefits. CONCLUSIONS: The study provides a snapshot of a living, developing, inter-cultural partnership established to tackle the vitally important issue of Aboriginal mothers' and babies' health. Development of the partnership took commitment and time. There were issues initially with resistance from hospital staff. Skill sharing and two-way learning engendered mutual respect. Clear benefits of the care model were highlighted by both the AMIC workers and midwives while cultural safety was maintained for the Aboriginal mothers and families. The AMIC worker role will continue to require acknowledgement, support and development. This equivalent inter-cultural partnership model has the potential for much wider application and evaluation. Future programs should factor in the time required to build and sustain partnership relationships.