Closing the Gap targets: key findings and implications

Target

The target associated with Outcome 2 in the 2020 National Agreement is to increase the proportion of Aboriginal and Torres Strait Islander babies of a healthy birthweight to 91% by 2031. 

Background

Birthweight is a key indicator of infant health and a principal determinant of a baby’s chance of survival and good health.

Babies with a low birthweight are more likely to experience illness or die in infancy, have poorer development of their mental functioning abilities, and have an increased risk of chronic diseases in adulthood. Low birthweight is also associated with poorer cognitive development.

The drivers of low birthweight identified in the literature include factors associated with birth, mother’s background, health, and health behaviours, such as:

• preterm births (births at less than 37 weeks of gestation)
• maternal smoking, alcohol consumption and drug use during pregnancy
• extremes of maternal age (especially mothers younger than 16 or older than 40)
• not having timely and regular antenatal visits
• maternal infections and chronic conditions
• exposure to environmental factors (for example, indoor air pollution)
• facing physical, emotional or sexual abuse during pregnancy.

Having a high birthweight baby has been shown to be associated with factors including (Ng et al. 2010):

• maternal diabetes
• pre-pregnancy overweight and obesity
• education level of the mother (higher education level is protective against having a high birthweight baby).

Aboriginal and Torres Strait Islander (First Nations) women are at an increased risk for low birthweight and premature births, due to factors that include intergenerational trauma, colonisation, stigma and racism. Racism also affects access to social resources such as education, employment, and stable housing and these factors may moderate or mediate associations between racism and birth outcomes.

Current status

In 2021, 89.6% (16,444) of liveborn singleton First Nations babies were of healthy birthweight compared with 94.2% of non-Indigenous babies. This proportion has increased from 89% in 2014, however the gap between First Nations and non-Indigenous populations has been relatively consistent over this period.

In 2021, the proportion of liveborn singleton babies considered to be of low birthweight was about 9.1% among First Nations babies, twice as high as among non-Indigenous babies.

In 2021, the proportion of First Nations babies born with a healthy birthweight was above the projected 2021 national trajectory point of 89.4%, and above or very close to the 2031 national target in 5 of the 8 states and territories. The highest proportion of healthy birthweight babies was recorded in Victoria, followed by Tasmania and Queensland; the lowest was recorded in the Northern Territory, Western Australia and South Australia.

The proportion of First Nations babies of healthy birthweight was considerably lower in Remote (86%) and Very remote (85%) areas than in non-remote areas (90–91%).

The proportion of First Nations healthy birthweight babies in 2021 was at or above the projected 2021 national trajectory point of 89.4% in all except the most disadvantaged areas (Index of Relative Socioeconomic Disadvantage [IRSD] first quintile), where about 40% (or 7,300) of First Nations babies live.

Key findings

The results of the modelling analyses carried out in this chapter indicated:

Nationally, the proportion of mothers smoking tobacco any time during pregnancy has fallen, from 43% (6,840 women) in 2014 to 38% (6,950 women) in 2021. This decline was mostly seen in Major cities, Outer regional and Inner regional areas, while in Remote and very remote areas the rate of smoking at any time during pregnancy among mothers of First Nations babies has remained relatively constant over time.

The proportion of healthy birthweight First Nations babies was over 92% where the mother did not smoke during pregnancy – above the 91% target set for 2031. The rate of a healthy birthweight outcome was also considerably higher where the mother was smoking in the first half of pregnancy, but discontinued in the second half.

Previous studies have shown that an estimated 37% of low birthweight births among First Nations babies could be attributed to smoking during pregnancy. A large study of over 18,000 babies born to First Nations mothers in New South Wales between 2010 and 2014 suggested that around 27% of perinatal deaths, 26% of preterm births and 48% of small for gestational age outcomes could be attributed to smoking in pregnancy.

The proportion of First Nations births where the mother had her first antenatal visit in the first trimester of pregnancy has increased from about 56% in 2014 to 73% in 2021.

However, First Nations mothers, on average, access antenatal care later than non‑Indigenous mothers and access fewer antenatal visits across their pregnancy. Research has found that poorer access to culturally safe primary health care services with maternal/antenatal services was associated with higher rates of smoking and low birthweight. First Nations women in Remote and very remote areas, compared with other remoteness areas, had the lowest levels of access to maternal health services.

In 2021, the proportion of liveborn singleton First Nations births where the mother attended 5 or more antenatal care visits was about 89%. This proportion has been relatively consistent over time. The proportion of healthy birthweight First Nations babies is considerably higher among those whose mother attended 5 or more antenatal care services throughout the pregnancy (92%) compared with those with fewer than 5 visits (83%).

However, these associations should not be interpreted as protective factors. Despite resulting in a birthweight within a healthy range due to metabolic disbalance, maternal diabetes is known to increase the risk of diabetes and/or obesity in adulthood for the offspring and cause pregnancy complications. Similarly, overweight and obesity are associated with adverse outcomes both for the mother and the baby.

Strategies for improvement

A number of strategies and approaches have been suggested for improving health outcomes for First Nations mothers and babies:

• systematic approaches to mitigate socioeconomic disadvantage, improve education and health literacy
• family-based approaches to improve social and lifestyle factors, such as prevention and cessation of tobacco and alcohol use, supporting social and emotional wellbeing and nutrition
• better access to and improvement in culturally safe and trusted services both in community-controlled and mainstream sectors
• particular support to women in rural and remote communities for accessing care
• continuous improvement of clinical guidelines aimed at meeting the needs of First Nations pregnant women.

At the community level, interventions include stopping smoking during and after pregnancy; providing perinatal care that is affordable, accessible, culturally appropriate and gender sensitive; and providing mothers with social support.

To improve healthy birthweight rates in the First Nations population, it is imperative that women, particularly in rural and remote areas, have improved access to, and take up of, culturally appropriate and holistic antenatal care services and programs specifically designed by and for First Nations people.

These programs have been shown to have a considerable impact on maternal smoking and alcohol use during pregnancy, maternal nutrition and breastfeeding practices, which, in turn, reduce the low birthweight rate, and the incidence of preterm births and child mortality.

Evidence shows that culturally safe and appropriate models of care that address the needs of First Nations women result in quantifiable improvements in antenatal care attendance, preterm births, birth outcomes, perinatal mortality and breastfeeding practice.

The successful models of care are based on culturally appropriate and safe care, continuity of care, collaboration between midwives and First Nations health workers, and involvement of senior family members such as grandmothers in the care of pregnant women.

Investing in health services operated and governed by the First Nations community, such as Aboriginal Controlled Community Health Services, which play an important role in providing culturally appropriate antenatal care to First Nations women, will help progress towards the healthy birthweight outcome, as well as support Priority Reform 2 in the 2020 National Agreement on Closing the Gap, aimed at increasing funding for First Nations programs and services through community-controlled organisations.

References

Ng SK, Olog A, Spinks AB, Cameron CM, Searle J and McClure RJ (2010) ‘Risk factors and obstetric complications of large for gestational age births with adjustments for community effects: results from a new cohort study’, BMC Public Health, 10:1–10.