Providing preconception care
Following the identification of women who wish to become pregnant, a thorough reproductive history should be obtained. Current and past contraception use, cervical screening history and STIs are all topics that need exploring.6 History of previous pregnancies should include the number of pregnancies, as well as antenatal complications such as miscarriage, preterm delivery, pre-eclampsia and gestational diabetes.6
Exploring reproductive awareness and providing accurate information may also be needed for some women. Providing advice about how long it can take to become pregnant is recommended, as is the spacing between subsequent pregnancies.1 In order to reduce pregnancy complications such as prematurity, low birth weight and small for gestational age, the WHO recommends at least two years between pregnancies.1 This aligns with the WHO recommendation to continue breastfeeding infants to at least the age of two years.1
An assessment for subfertility and infertility may also be warranted for Aboriginal and Torres Strait Island women. For example, polycystic ovarian syndrome disproportionately affects Aboriginal and Torres Strait Islander girls and women, with an estimated prevalence of 15–30%.21 Weight loss strategies early in the preconception phase can enable successful conception without the need for reproductive interventions.21 Identifying co-existing medical conditions, or risk factors for such conditions, facilitates early intervention. For those women not able to conceive after 12 months and do not have known reproductive or medical conditions, further investigation and referral are warranted. 5
Where appropriate, the health of the father or non-birthing partner, and/or other members of the household, should also be explored and optimised prior to pregnancy. The benefits of screening and early intervention not only improve fertility rates, but also contribute to positive birth outcomes.4 Although no specific guidelines exist for male preconception health within Australia, topics such as STIs, smoking/alcohol/illicit drug use, weight and exercise should be explored. 4
Social and emotional wellbeing
Many Aboriginal and Torres Strait Islander people experience high levels of trauma and stress that can impact negatively on social and emotional wellbeing and mental health.22 Research demonstrates that women experiencing social and emotional wellbeing challenges, including mental health disorders, are less likely to engage in healthcare and are more likely to experience adverse maternal and child health outcomes.23,24
Intimate partner violence, adverse childhood experiences and associated trauma have been identified as significant risk factors in perinatal mental health and are often associated with problematic substance use, self-harm and suicide.23 Intimate partner violence can also include reproductive coercion.2,20 Exploring a woman’s sense of agency in their reproductive health is key to exploring whether reproductive coercion is occurring. It is important healthcare providers do not approach a woman from a place of bias or judgement.24
Supporting Aboriginal and Torres Strait Islander women to have good social and emotional wellbeing is a key component of preconception care. Identifying risks and protective factors can support early recognition of mental health conditions or other social healthcare needs (housing, legal, child protection, food insecurity issues). This allows for the establishment of support and, if needed, intervention prior to the pregnancy period.
Engaging with women in conversations around their social and emotional wellbeing requires the establishment of a non-judgemental space in which women’s strengths are celebrated. Many women have protective factors and are very resilient in managing their stressors and risks.25 Understanding a woman’s whole story (her risk and her protective factors) allows for women-centred healthcare and the provision of appropriate psychosocial support, interventions and referrals to support services if required.
Supporting the wellbeing of Aboriginal and Torres Strait Islander men or non-birthing partners is also an important healthcare consideration during the antenatal period. Programs such as Apunipima Cape York Health Council’s Baby One Program provides an innovative family systems approach to perinatal care.26 Research with Aboriginal and Torres Strait Islander fathers and father-to-be evidences that men face a range of primary health challenges, as well as social and emotional wellbeing stressors, during their partner’s antenatal period.27–30 Research has also found that some Aboriginal and Torres Strait Islander men would like more opportunities to engage with pregnancy healthcare to help support their partner and unborn child, but many found the clinical environment unwelcoming.28 Creating systems that support family functioning while respecting the agency and, if applicable, safety of a pregnant woman is central to the delivery of culturally appropriate and contextually tailored pregnancy care.
Healthy living
Nutrition
Good nutrition prior to and during pregnancy supports general maternal health and plays a vital role in the growth and development of the baby. Although a healthy, balanced diet is always recommended, pregnancy and breastfeeding represent a time where additional nutrients are required.31 National guidelines recommend a varied diet with an adequate intake of vegetables, lean meats and dairy products.7 Foods high in saturated fat, added salt and sugars should be limited or avoided.7 Advice provided by healthcare professionals must consider and address barriers to a healthy diet, including socioeconomic status and access to foods high in iodine, folate and iron.
Weight
The benefits of a healthy weight prior to and during pregnancy are numerous, including improved fertility, better pregnancy outcomes and a reduced need for delivery at a tertiary hospital, which may be far from home and family.6 Aboriginal and Torres Strait Islander women are more likely to be living with a BMI considered to be in the overweight, obese or underweight range.6 Weight outside of the healthy range, defined as a BMI of 18.5–24.9 kg/m2, is also more common in low socioeconomic groups and in rural and remote regions.7
Because weight loss or excessive weight gain is not recommended during pregnancy, the preconception period offers a great opportunity to optimise weight with physical activity and a healthy diet. Essential to developing rapport and engagement with women, recommendations regarding nutrition and exercise should be delivered in a respectful and supportive manner. Healthcare providers also need to recognise and overcome barriers that may exist for Aboriginal and Torres Strait Islander women, including low socioeconomic status, food supply to rural and remote communities and chronic disease burden.7
Physical activity
Establishing and maintaining an exercise routine during preconception not only reduces adverse outcomes during pregnancy, but also supports lifelong health. The amount of exercise recommended depends on whether weight loss is a priority or whether maintaining weight and overall health is desired. In the preconception phase, women should aim for 150–300 minutes of moderate-intensity exercise each week, preferably spread across most days of the week.9 Exercise should include a combination of aerobic and strengthening exercises.9 Muscle strengthening activities are recommended for at least two days of the week. The Physical activity and exercise guidelines for all Australians also recommend limiting sedentary behaviour, with regular breaks to decrease prolonged periods of sitting.9 Regular physical activity should continue throughout pregnancy and the postpartum period. Healthcare providers should encourage and support physical activity, highlighting that exercise during pregnancy is safe and associated with better pregnancy outcomes.
Vitamin supplementation
Folate supplementation
There is good evidence to show that folate supplementation prior to conception and throughout pregnancy decreases the risk of neural tube defects. Historically, folate deficiency and the rate of neural tube defects disproportionately affected the Aboriginal and Torres Strait Islander communities, especially those who live remotely.32 Poor supply of fresh fruit and vegetables into rural and remote communities is a known contributor to folate deficiency, with other contributors including unplanned pregnancies, poor understanding of the importance of folate during pregnancy and health promotion programs that are not culturally appropriate.33
Following the introduction of mandatory fortification of flour in 2009, the rate of neural tube defects dropped nationally.33 A significant decrease was observed in the Aboriginal and Torres Strait Islander population, with the rate of neural tube defects dropping from 2.24 per 1000 births to 0.76 per 1000 births.33
Although mandatory fortification of food with folate has reduced the rate of neural tube defects, dietary intake of folate during pregnancy may not be sufficient. The national Clinical practice guidelines: Pregnancy care continue to recommend additional daily oral folic acid supplementation.7 The standard recommended dose is 0.4 mg daily.7 For women at increased risk of neural tube defects (ie women using anticonvulsant medication and those with a BMI >30 kg/m2, pre-pregnancy diabetes or previous child/family history of neural tube defects), the recommended dose is 5 mg daily.7 Ideally, supplementation should begin one month prior to conception and continue for at least the first three months of pregnancy.7
Iodine supplementation
Because iodine requirements increase during pregnancy, women with normal iodine levels prior to conception may experience iodine deficiency while pregnant and during breastfeeding.34 Iodine is essential for development because the fetus is solely reliant on maternal stores during the first two trimesters of pregnancy.34 Although severe iodine deficiency is uncommon, mild to moderate iodine deficiency during pregnancy may lead to intellectual deficits and neurological impairments.34
In response to the high prevalence of iodine deficiency nationally, mandatory fortification of bread was introduced by the Australian Government in 2009.34 Although iodine levels have improved in the general population, evidence suggests that dietary intake of iodine alone is not sufficient to cover the increased needs during pregnancy and lactation.34 The National Health and Medical Research Council and the National clinical practice guidelines: Pregnancy care recommend additional iodine supplementation to begin when planning for pregnancy or as soon as pregnancy is confirmed.7,10
Substance use
Smoking
Smoking during pregnancy represents the most important modifiable risk factor causing adverse outcomes for both mother and baby.35 The Australian Institute of Health and Welfare (AIHW) identified that in 2016–18 more than 43% of pregnant Aboriginal and Torres Strait Islander women smoked at some stage during their pregnancy, compared with less than 10% of pregnant non-Indigenous Australian women (Figure 1).35
Although the overall trend of smoking during pregnancy is falling, data collected in 2020 on Aboriginal and Torres Strait Islander pregnant women show smoking rates during pregnancy have remained steady at over 40%.36
Figure 1. Percentage of women who smoked during pregnancy, Australia, 2016–18, according to Aboriginal and Torres Strait Islander status.
Reproduced from the Australian Institute of Health and Welfare.35
Smoking cessation prior to or early in pregnancy supports improved health outcomes, especially for the baby. AIHW data have shown that one in six preterm births could be prevented, whereas two in five small-for-gestational-age babies could be born in the healthy weight category.35 There is clearly a considerable opportunity to improve health outcomes if smoking cessation is successful in girls and women of reproductive age. Primary healthcare practitioners can provide education on the risks of smoking during pregnancy, offering culturally appropriate smoking cessation counselling and, where appropriate, pharmaceutical treatments. Although there is not sufficient evidence to support the safety of nicotine replacement therapy or smoking cessation medications (bupropion or varenicline) in pregnancy, these medications can be used in the preconception period, with the aim of smoking cessation prior to pregnancy.37 If behavioural interventions, such as CBT, have not been successful, intermittent-use formulations of NRT such as gum, lozenges, inhaler or tablets may be considered after explaining the risks and benefits.7
The Tackling Indigenous Smoking program supports two projects targeting smoking in Aboriginal and Torres Strait Islander women with a goal of developing evidence-based smoking cessation interventions for this population.38 The Which Way? smoking cessation study recognises that Aboriginal and Torres Strait Islander women want to quit smoking, with a desire for non-pharmaceutical quit support especially during pregnancy.39 This community-led project identified that Aboriginal and Torres Strait Islander women want support that is provided face to face, in a group setting and facilitated by Aboriginal Health Workers.39 iSISTAQUIT is a support program for pregnant Aboriginal and Torres Strait Islander women who want to quit smoking. With a focus on providing best practice training to healthcare workers, the program provides an environment that is culturally appropriate and free from judgement and racism.38
Alcohol
Alcohol is a known teratogen that crosses the placenta resulting in almost equal concentrations of blood alcohol for both the mother and fetus.7 Exposure to alcohol in pregnancy may result in a range of adverse effects for the fetus, collectively known as fetal alcohol spectrum disorder (FASD).7 In addition to FASD, alcohol intake during pregnancy is associated with miscarriage, intrauterine growth restriction and preterm birth.6
Although more Aboriginal and Torres Strait Islander women abstain from alcohol than non-Indigenous Australian women, the rates of risky alcohol consumption are higher for Aboriginal and Torres Strait Islander women.6 It is widely recognised that frequent or intermittent high levels of alcohol consumption contribute to poor outcomes; however, uncertainty remains with regard to outcomes following intake of lower levels of alcohol.7 Thus, no safe limit for alcohol consumption during pregnancy has been established.
Preconception cares offers the opportunity to engage women in discussions about the risks of alcohol intake during pregnancy and to provide education and resources. The Strong Spirit Strong Mind campaign, developed in Western Australia, aims to improve awareness of the harms associated with alcohol intake in pregnancy.40 Designed specifically for the Aboriginal population, the campaign provides a culturally appropriate framework to support the avoidance of alcohol in preconception and pregnancy, and while breastfeeding.
Pre-existing medical conditions
The burden of chronic disease is higher for Aboriginal and Torres Strait Island women of reproductive age, including increased rates of diabetes, hypertension, rheumatic heart disease (RHD) and kidney disease.6 For women without a diagnosed medical condition, preconception care should focus on screening and early detection. Investigation, treatment and specialist referral should be in line with specific clinical guidelines (eg 2020 Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease41). Oral health should be assessed as part of preconception care and any necessary treatment ideally completed prior to conception.6
A medication review should be performed for all women considering pregnancy. Common medications that are known to be teratogenic include antihypertensives, hypoglycaemic agents, psychotropics, anticonvulsants and immunosuppressants.6 Where possible, medication should be stopped or changed to a safer option prior to conception.6 For men considering pregnancy, it is also important to identify medication use that may lower fertility or have a teratogenic effect. Examples include chemotherapy, isotretinoin, spironolactone and finasteride.42 Stopping, or changing to a safer option, is recommended, with advice about the safe timing of conception after medication cessation.42
Diabetes
Screening for diabetes prior to conception is important because the number of Aboriginal and Torres Strait Islander peoples diagnosed with diabetes is rising, with the rate of diabetes almost three-fold higher than in the non-Indigenous Australian population.43 AIHW data report that 17% of the Aboriginal and Torres Strait Islander population are living with diabetes.16 The National Perinatal Data Collection has shown that 2% of Aboriginal and Torres Strait Islander women had diabetes prior to conception, which is over four-fold higher than non-Indigenous Australian women.44
The outcomes of poorly controlled diabetes in pregnancy are well documented. For women, poor control of blood sugars can lead to recurrent miscarriage, hypertensive complications, birth trauma and maternal mortality.45 Outcomes for the infant include an increased rate of congenital malformations, growth restriction, neonatal hypoglycaemia, birth trauma and higher infant mortality.45 The AIHW reports that babies of mothers with diabetes in pregnancy have increased risks of childhood metabolic syndrome, obesity, impaired glucose tolerance and type 2 diabetes later in life.16 The Australasian Diabetes in Pregnancy Society encourages the identification of pre-existing diabetes and optimisation of blood glucose levels prior to conception.45
Rheumatic heart disease
Aboriginal and Torres Strait Islander people account for 92% of all new cases of RHD in Australia.46 The largest disease burden exists with the young, Aboriginal and Torres Strait Islander, female population, with a median age at diagnosis of 23 years.46 Of new cases of RHD, 80% of people diagnosed did not have a recorded history of acute rheumatic fever.46 During pregnancy, there is an increased pressure on heart valves caused by a 30–50% increase of blood volume.41 Women with asymptomatic, undiagnosed RHD may develop symptoms during pregnancy, including shortness of breath, tachycardia and pedal oedema.41 Symptoms are likely to worsen with increasing gestation, peaking at 28–30 weeks gestation.41 RHD is associated with increased mortality for both mother and baby.7 Acknowledging the burden of RHD exists mostly within childbearing ages for Aboriginal and Torres Strait Islander women, screening when planning pregnancy, with early diagnosis and management, may be a lifesaving intervention.
Vaccinations
The Australian immunisation handbook recommends the assessment of vaccination status for all women planning pregnancy. Serological testing for hepatitis B, measles, mumps, rubella and varicella immunity can help identify women who would benefit from further vaccinations.12 Updating vaccinations prior to conception is advised and should include annual influenza and timely COVID-19 immunisations.12 Pregnancy should be avoided for 28 days following live vaccinations, including the measles–mumps–rubella and varicella vaccines. 12
Genetic (single gene mutation/carrier) screening
In the updated RANZCOG prenatal screening guideline published in 2018, the recommendation was changed from ‘carrier screening may be offered’ to ‘carrier screening should be offered’.47 Carrier screening provides information to parents about their likelihood of having a child with a severe genetic condition. Current technology allows testing for and the identification of 750 conditions that cause intellectual disability or neurological or muscular conditions, or those that result in a shorter life expectancy.48 The three most common conditions tested are fragile X syndrome, spinal muscular atrophy and cystic fibrosis (known as the three-gene carrier screening test).49 The current cost for the three-gene carrier screening test is up to $600.49 Since November 2023, a Medicare rebate for the three-gene carrier screening test is available.49 This supports more equitable access to testing. Further in-depth genetic carrier screening remains prohibitively expensive.48 A thorough medical and family history should be gathered to identify those who may benefit from detailed genetic carrier screening.
There is a lack of literature exploring the offer and uptake of prenatal genetic screening in the Aboriginal and Torres Strait Islander population. A study conducted in 2013 found that Aboriginal women wanted to be involved in prenatal testing, with a desire for full disclosure about what tests were available and what the possible outcomes may be.50 Barriers to prenatal screening include low-level knowledge of available services on the part of healthcare providers, geographic proximity to genetic clinics and cost.51 In addition, unethical and inappropriate use of Aboriginal and Torres Strait Islander peoples’ genetic information for past research and clinical practice has led to mistrust.51 Despite this, Aboriginal and Torres Strait Islander women should be offered genetic screening with the provision of culturally safe information about the test, the possible results and management that may be recommended.