Pregnancy care

Providing pregnancy care

Social and emotional wellbeing and perinatal mental health

Nutrition, physical activity and weight

 

Dietary supplementation

Smoking and alcohol

 

Genitourinary and blood-borne infections

Hypertensive disorders

Diabetes

Vaccinations

Chromosomal screening

  

Table 1. Screening for common chromosomal abnormalities9
Test	Timing
Combined first trimester screening Ultrasound of nuchal translucency Maternal plasma β-human chorionic gonadotropin and pregnancy-associated placental protein-A	Ultrasound: Between 11 weeks and less than 14 weeks Blood test: Between 9 weeks and less than 14 weeks
NIPT (also known as cfDNA testing)	Blood test from 10 weeks
Triple test: α-fetoprotein, β-human chorionic gonadotropin, unconjugated oestrogen OR Quadruple test: triple test plus inhibin A	Blood test between  14 and 20 weeks
cfDNA, cell-free DNA; NIPT, non-invasive prenatal testing.

 

• Ensure your clinic has culturally appropriate health promotion resources related to pregnancy, including smoking cessation, alcohol reduction, healthy eating and physical activity.
• Promote staff training to improve knowledge and confidence in delivering culturally appropriate and trauma-informed antenatal care.
• Support and foster conversations within the clinical environment to ensure a family-systems approach to the delivery of pregnancy care while not compromising women’s choices, agency and safety.
• Establish a recall system for antenatal visits, antenatal tests and vaccinations.
• Identify indicators for a clinical audit; for example, how many women are offered first trimester screening and how many chose to undergo testing; how many women were screened for mental health disorders; how many women were identified as at moderate and severe risk of perinatal depression and/or anxiety and what were the care pathways provided to them?

Clinical guidelines and protocols

• National clinical practice guidelines: Pregnancy care 
• Remote Primary Health Care Manuals: Minymaku Kutju Tjukurpa Women’s Business manual 
• The Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine: Australian STI management guidelines for use in primary care 
• KAHPF: Perinatal depression and anxiety protocol using the Kimberly Mum’s Mood Scale (KMSS)

Health campaigns and resources

• Replanting the Birthing Trees research project 
• WellMob: Social and emotional wellbeing 
• KMMS 
• Emerging Minds training 
• iSISTAQUIT for pregnant Aboriginal and Torres ait Islander women who want to quit smoking 
• Tackling Indigenous Smoking 
• National Aboriginal Community Controlled Health Organisation: Strong born campaign 
• Dental health Aboriginal and Torres Strait Islander resources 
• Strong Spirit Strong Future 
• YourChoice: Prenatal screening for chromosome conditions 

Background

Improving outcomes in Aboriginal and Torres Strait Islander maternal and child health is a matter of national priority and is reflected in key documents such as the National Agreement on Closing the Gap.¹ Although significant disparities in maternal and child health outcomes between Aboriginal and Torres Strait Islander and non-Indigenous Australians continue, the Australia’s mother and babies 2020 report demonstrated some positive traction on a range of indicators for Aboriginal and Torres Strait Islander mothers.⁴ This includes an increased number of mothers attending an antenatal visit in the first trimester, more mothers attending five or more antenatal care appointments, a decrease in maternal smoking rates, and a decrease in pregnancies for women aged 20 years and under.⁴

Improvements in pregnancy outcomes are enhanced by the provision of pregnancy care that is culturally safe and contextually tailored. The availability of Aboriginal and Torres Strait Islander healthcare providers within the community is ideal to the provision of culturally safe care. Although this may not always be possible, Aboriginal and Torres Strait Islander women highly value continuity of care throughout their pregnancy. Aboriginal and Torres Strait Islander women have also identified healthcare provider qualities, such as being non-judgemental, kind, welcoming and warm, and a strengths-based approach as important in pregnancy care.^{1–5,23–25} Midwife-led pregnancy care models^7,26 and opportunities for women to birth on Country^12,27 are associated with high levels of cultural safety and positive maternal and child health wellbeing outcomes.^26,28

Delivering healthcare with a trauma-informed approach represents a further means of progressing health equity for Aboriginal and Torres Strait Islander mothers and their children.^6,29,30 This approach to care recognises the high prevalence of trauma for Aboriginal and Torres Strait Islander women and considers the intersecting impacts of systemic and interpersonal violence, and structural inequalities.^5,30 Trauma- and violence-informed care commences with the provision of education to healthcare providers focusing on Aboriginal and Torres Strait Islander peoples’ history, the effects of colonisation and the impacts of adverse and enduring government policies.⁶ Trauma- and violence-informed care aims to safely assess and respond to maternal (and paternal) adverse childhood experiences, intergenerational trauma and current psychosocial stressors to promote healing and recovery for mother, baby and family.²⁹

Supporting the health and 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 the Apunipima Cape York Health Council Baby One Program provide an innovative family-systems approach to perinatal care.⁸ Research with Aboriginal and Torres Strait Islander fathers and fathers-to-be describes a range of health challenges, as well as social and emotional wellbeing stressors, during their partner’s antenatal period.^12,31–33 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.³¹ 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.

Pregnancy represents a time when women and their partners may be more receptive to health promotion messages and experience increased motivation to make behaviour changes.^2,3 Behavioural advice recommended during pregnancy includes smoking cessation, avoiding alcohol, good nutrition, vitamin supplementation, appropriate weight gain and adequate physical activity.⁹ Healthcare professionals need to be confident in delivering health promotion and interventions to women and their families during the antenatal period. This should be supported with the availability of culturally appropriate resources. Care should be taken to space the timing and frequency of antenatal health promotion messaging to ensure women are not overwhelmed or experience shame if they are not able to achieve the desired change.²

Supporting and strengthening Aboriginal and Torres Strait Islander women’s health, including social and emotional wellbeing, during pregnancy is critical to achieving good health outcomes and health equity. Pregnancy care recommendations provided in this chapter are based on the Australian pregnancy care guidelines.⁹ Additional recommendations from Royal Australian and New Zealand College of Obstetricians and Gynaecologists,^21,34–37 the Centre of Perinatal Excellence (COPE)³⁸ and jurisdictional guidelines^14,39–41 are also included. Wider resources have also been used to ensure all recommendations are in line with specific national guidelines and align with the National Aboriginal and Torres Strait Islander health plan 2021–2031.⁴² Although this chapter does not provide a full list of all recommendations for antenatal care, it does provide rationale and recommendations for delivering pregnancy care specifically to the Aboriginal and Torres Strait Islander population.

Pregnancy visits and screening tests

Engaging in early and regular antenatal care is associated with a reduction in perinatal deaths and improved birth outcomes. Attending an initial antenatal consultation within the first trimester, defined as before 14 weeks gestation, is associated with positive birth outcomes.⁴ The initial antenatal visit allows healthcare providers to engage with mothers regarding their pregnancy needs and can include an assessment of emotional and social wellbeing, the provision of care and a discussion about the timing and scheduling of subsequent antenatal visits. The Australian pregnancy care guidelines recommend regular antenatal visits throughout pregnancy, and that first-time mothers attend at least 10 antenatal visits.⁹ Mothers with subsequent uncomplicated pregnancies are encouraged to attend at least seven visits.⁹ The frequency and timing of subsequent visits depend on the mother’s and family’s needs. The rate of attendance in the first trimester for Aboriginal and Torres Strait Islander women is improving, with 71% of pregnant women attending an antenatal visit in 2020, compared with 50% in 2012.⁴

Screening tests are recommended at the initial consult and throughout pregnancy for all women.⁹ These tests allow for the identification of infections and other conditions that may cause adverse pregnancy and birth outcomes. Current national guidelines recommend testing for:

• sexually transmissible infections (syphilis, chlamydia) and blood-borne viruses (HIV, hepatitis B, hepatitis C)
• haemoglobin (and ferritin where the prevalence of iron deficiency is high)
• rubella immunity
• blood group and antibody status
• asymptomatic bacteriuria
• gestational diabetes mellitus (GDM), as well as assessing the risk of hyperglycaemia.⁹

Cervical screening, assessment of the risk of pre-eclampsia, a morphology scan and screening for mental health/social and emotional wellbeing (see below) should also be offered in all pregnancies.

Additional tests are recommended based on maternal preference, such as first trimester screening, or for those in higher-risk groups or areas.

Social and emotional wellbeing and perinatal mental health

The physical and emotional demands of pregnancy, changes in hormones, psychosocial environment and existing mental health profile contribute to a woman’s social and emotional wellbeing during pregnancy. Poor social and emotional wellbeing can diminish a woman’s capacity to make good decisions for herself and her baby, lead to complications during pregnancy and disrupt maternal–infant bonding and attachment.⁴³ These complications can include a higher incidence of prematurity and low birth weight.⁴³ Screening for social and emotional wellbeing challenges and mental health disorders is a recommended component of appropriate pregnancy care.

Current clinical guidelines focus on screening and support for perinatal mental health disorders.⁹ Although perinatal mental health disorders include severe psychotic and bipolar disorder, the most common disorders experienced relate to depression and anxiety.^6,38 In Australia, approximately one in five women are understood to experience mood and/or anxiety-based mental health disorders perinatally.³⁸ For Aboriginal and Torres Strait Islander women, whose social ecology is shaped by the impact of colonisation and the enduring disparities related to the social and political determinants of health, the risk of perinatal mental health disorders is amplified.^12,44,45 Social health issues such as housing problems, family conflict and the death of family members contribute to a two- to three-fold increase in psychological distress in the perinatal period.⁴⁵

The early detection, support and treatment of mental health disorders are associated with positive recovery outcomes. This is particularly evident for mild to moderate forms of perinatal mental health disorders, such as depression and anxiety.¹² Aligning screening to the cultural background and context of women is a means of progressing health equity.^7,46 The KMMS is a two-part screening tool codesigned with Aboriginal women and their healthcare providers.⁴⁷ Part 1 is a modified version of the Edinburgh Postnatal Depression Scale, and Part 2 is a yarning template for exploring psychosocial areas of stress and resilience in a woman’s life.⁴⁷ The KMMS has been validated in a small clinical trial of 91 women.⁴⁷ Another study showed that the KMMS could effectively identify women with moderate or high severity depression or anxiety.⁴⁴ The acceptability of the KMMS has been studied for a range of Aboriginal women inside and outside of the Kimberley region, with the tool and training freely available online (see Useful resources). Healthcare providers should consider using the KMMS when screening Aboriginal and Torres Strait Islander women for perinatal depression and anxiety.

The early detection, support and treatment of mental health disorders are associated with positive recovery outcomes. This is particularly evident for mild to moderate forms of perinatal mental health disorders, such as depression and anxiety.¹² Aligning screening to the cultural background and context of women is a means of progressing health equity.^7,46
 
The KMMS is a two-part screening tool codesigned with Aboriginal women and their healthcare providers.⁴⁷ Part 1 is a modified version of the Edinburgh Postnatal Depression Scale, and Part 2 is a yarning template for exploring psychosocial areas of stress and resilience in a woman’s life.⁴⁷ The KMMS has been validated in a small clinical trial of 91 women.⁴⁷ Another study showed that the KMMS could effectively identify women with moderate or high severity depression or anxiety.⁴⁴ The acceptability of the KMMS has been studied for a range of Aboriginal women inside and outside of the Kimberley region, with the tool and training freely available online (see Useful resources). Healthcare providers should consider using the KMMS when screening Aboriginal and Torres Strait Islander women for perinatal depression and anxiety.
 

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, additional nutrients are required in pregnancy and while breastfeeding.³⁴ National guidelines recommend a varied diet with adequate intake of vegetables, lean meats and dairy products.⁹ Foods high in saturated fat, added salt and sugars should be limited or avoided. Specific food advice exists, with the recommendation to avoid raw meat, raw eggs, soft cheeses and unpasteurised dairy products due to the risk of bacterial contamination and subsequent maternal infection.⁹ Advice provided by healthcare professionals must consider and address barriers to a balanced diet, including socioeconomic status, rural and remote locales and cultural attitudes. 

Physical activity

Physical activity during pregnancy is safe and should be encouraged and supported by healthcare providers. The health benefits of regular exercise include supporting healthy weight and lowered risks of GDM, pre-eclampsia and neonatal complications, as well as improved psychological wellness.⁹ Establishing and maintaining an exercise routine during pregnancy also supports lifelong health and movement. The current recommendations for physical activity for women during pregnancy are the same as for non-pregnant women. Women should aim for 150–300 minutes of moderate-intensity exercise each week, preferably spread across most days of the week.³⁵ Exercise should include a combination of aerobic and strength exercises.³⁵ During the second and third trimesters, the type of exercise may need to be adapted to account for the woman’s changing body and risk of injury to the gravid abdomen.⁹

Weight

The benefits of a healthy weight prior to and during pregnancy are numerous, including reduced risks of GDM and hypertension, and a reduced need to deliver at tertiary hospitals, which may be far from home and family.⁴⁸ Weight outside the healthy range, defined as a BMI of 18.5–24.9 kg/m², is more common for Aboriginal and Torres Strait Islander mothers.⁴ In 2020, the Australian Institute of Health and Welfare (AIHW) reported that 57% of Aboriginal and Torres Strait Islander mothers were overweight or obese and that 6.3% of mothers were underweight.⁴⁸

Weight gain is expected in pregnancy and supports the growth and development of the baby. The recommended weight gain during pregnancy varies from mother to mother and depends on the mother’s existing height, weight and BMI⁹ (see Table 2). Healthy weight gain during pregnancy is associated with improved outcomes, including a reduced risk of pre-eclampsia, GDM and the need for caesarean section.⁴⁰ Studies have also demonstrated that healthy weight gain reduces the risk of obesity and hypertension for the child.⁹ Measuring height and weight, and the calculation of BMI, is recommended for the first antenatal consult.⁹ Subsequent measuring of weight is not advised unless a specific concern and goal can be identified.⁹ Counselling regarding appropriate weight gain should be discussed early in pregnancy, with the provision of culturally appropriate interventions if required.

Table 2. The US Institute of Medicine’s recommendations for weight gain in pregnancy49
Pre-pregnancy BMI (kg/m2)	Recommended weight gain (kg)	Mean (range) weight gain in the second and third trimesters (kg/week)
<18.5	12.5–18.0	0.51 (0.44–0.58)
18.5–24.9	11.5–16.0	0.42 (0.35–0.50)
25.0–29.9	7.0–11.5	0.28 (0.23–0.33)
≥30	5.0–9.0	0.22 (0.17–0.27)
Reproduced from Australian pregnancy care guidelines9 based on US Institute of Medicine recommendations. BMI, body mass index.

 

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.⁴⁰ Poor supply of fresh fruit and vegetables into rural and remote communities causing folate deficiency contributed to higher rates of neural tube defects, as well as factors such as unplanned pregnancy, poor understanding of the importance of folate during pregnancy and health promotion programs that are not culturally appropriate.⁵⁰

Following the introduction of mandatory folate fortification of flour in 2009, the rate of neural tube defects dropped nationally.⁵⁰ A significant decrease in neural tube defects was observed in the Aboriginal and Torres Strait Islander population, with the rate dropping from 2.24 per 1000 births to 0.76 per 1000 births and thus closing the gap in the rates of neural tube defects between Aboriginal and Torres Strait Islanders and non-Indigenous Australians.⁵¹

 Although the mandatory fortification of food with folate has reduced the rate of neural tube defects nationally, dietary intake of folate during pregnancy may not be sufficient. The Australian pregnancy care guidelines continues to recommend additional oral folate supplementation.⁹ This should ideally begin one month prior to conception and continue for at least the first three months of pregnancy.⁹
 

Iodine supplementation

Because iodine requirements increases during pregnancy, women with normal levels prior to conception may experience iodine deficiency while pregnant and during breastfeeding.⁵² Iodine is essential for development, with the fetus solely reliant on maternal stores in the first two trimesters of pregnancy.⁵² Although severe iodine deficiency is uncommon, mild to moderate iodine deficiency during pregnancy may lead to intellectual deficits and neurological impairments.⁵²

In response to the high prevalence of iodine deficiency nationally, mandatory fortification of bread was introduced by the Australian Government in 2009.⁵² Although iodine levels have improved in the general population, evidence suggests that dietary intake of iodine alone is not sufficient to cover increased needs during pregnancy and lactation.⁵² National guidelines therefore suggest additional iodine supplementation in pregnancy and while breastfeeding.⁹

Vitamin D

Vitamin D deficiency is commonly observed in women with darker skin, limited sun exposure and a BMI >40 kg/m².⁴¹ The prevalence of vitamin D deficiency varies between seasons and with geographical location. It is estimated that one in four Aboriginal and Torres Strait Islander people are vitamin D deficient, with a higher prevalence observed in rural and remote areas.⁵³ Vitamin D deficiency in pregnancy may be associated with a higher risk of hypertension, pre-eclampsia and GDM, but current evidence is of low quality with inconsistent findings.⁹ For the baby, there is a theoretical concept that adequate vitamin D levels in pregnancy support infant bone mass; however, again, the current evidence is limited.⁹ The Australian pregnancy care guidelines recommend targeted screening of women who are at high risk of vitamin D deficiency.⁹ The national guidelines, along with the National Health and Medical Research Council, recommend vitamin D supplementation during pregnancy for women found to be deficient (serum vitamin D <50 nmol/L).^9,15 Routine supplementation without proven deficiency is not recommended.⁹

Iron

Iron deficiency is the most common cause of anaemia during pregnancy.¹⁴ There is a higher prevalence of iron deficiency anaemia among Aboriginal and Torres Strait Islander women than among non-Indigenous Australian women, with large geographical variation. Studies from remote Northern Territory communities report a prevalence of 50%, whereas Western Australia and South Australia report a prevalence of 23–25%.⁹ There is no clear evidence that mild to moderate iron deficiency anaemia causes maternal or fetal adverse effects. The goal of identifying and treating iron deficiency anaemia is to improve maternal symptoms, including tiredness and shortness of breath, to improve the tolerance of blood loss during delivery and to optimise iron stores in the infant (see Chapter 5: Child health: Childhood anaemia).⁹ All pregnant women should be offered testing for serum haemoglobin levels at the initial antenatal visit and the test repeated at 28 weeks gestation.⁹ Women at higher risk of iron deficiency can be offered serum ferritin testing at the initial antenatal visit.⁹

Smoking

Smoking during pregnancy represents the most important modifiable risk factor causing adverse outcomes for both mother and baby.⁴⁸ The AIHW identified that during 2016–18 more than 43% of pregnant Aboriginal and Torres Strait Islander women smoked at some stage during their pregnancy,⁴⁸ compared with less than 10% for non-Indigenous Australian women (Figure 1). 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%.⁵⁴

Figure 1. Percentage of women who smoked during pregnancy, Australia, 2016–18, according to Aboriginal and Torres Strait Islander status

Reproduced from Australian Institute of Health and Welfare.⁴⁸

 

Smoking cessation prior to or early in pregnancy supports improved health outcomes, especially for the baby. Population studies undertaken by the AIHW have shown that one in six preterm births could be prevented, whereas two in five small-for-gestational-age babies could be born into the healthy weight category.⁴⁸ Given the health outcomes that can be achieved by not smoking during pregnancy, appropriate health promotion messaging should be developed for girls and women of reproductive age. Healthcare practitioners are tasked with providing education on the risks of smoking during pregnancy and offering culturally appropriate smoking cessation counselling.

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. The Which Way? smoking cessation study identified that Aboriginal and Torres Strait Islander women want to quit smoking, with a desire for non-pharmaceutical quit support, especially during pregnancy.⁵⁵ The study provides evidence that women want support provided face to face, in a group setting and facilitated by Aboriginal and Torres Strait Islander health workers.⁵⁵ iSISTAQUIT focuses on providing best practice smoking cessation training to healthcare providers. The program aims to increase quit rates by ensuring healthcare providers deliver smoking cessation care that is culturally appropriate, free from judgement and racism, and with adequate resources to support quit attempts.⁵⁵

Alcohol

Alcohol is a known teratogen that crosses the placenta, resulting in almost equal concentrations of blood alcohol for the mother and fetus.⁹ Exposure to alcohol in pregnancy may result in a range of adverse effects for the fetus, collectively known as fetal alcohol spectrum disorder (FASD).⁹ In addition to FASD, other conditions caused by or associated with alcohol intake during pregnancy include miscarriage, intrauterine growth restriction and preterm birth.⁵⁶

Although more Aboriginal and Torres Strait Islander women abstain from alcohol than non-Indigenous Australian women, the rates of high-risk alcohol consumption are higher for Aboriginal and Torres Strait Islander women.⁴⁰ For all women who consume alcohol in pregnancy, rates of drinking are higher up to 20 weeks of pregnancy, which may represent the period between conception and the diagnosis of pregnancy.⁴ After 20 weeks gestation, 4% of Aboriginal and Torres Strait Islander mothers consumed alcohol, compared with 0.7% of non-Indigenous Australian mothers.⁴ Although it is widely recognised that frequent or intermittent high levels of alcohol consumption contribute to poor outcomes, there remains uncertainty with regard to outcome with lower levels of alcohol intake.⁹ Thus, no safe limit of alcohol consumption during pregnancy has been established.

Addressing alcohol consumption during pregnancy reduces the risk of preterm birth, low birthweight and FASD. The Australian pregnancy care guidelines recommend advising all pregnant women, and those planning pregnancy, to avoid alcohol consumption.⁹ The Strong Spirit Strong Future campaign, developed in Western Australia, aims to improve awareness of the harms associated with alcohol intake in pregnancy.⁵⁷ Designed specifically for the Aboriginal population, the Strong Spirit Strong Future campaign provides a culturally appropriate framework to support the avoidance of alcohol throughout pregnancy and breastfeeding⁵⁷ (see Chapter 6: Child health, Fetal alcohol spectrum disorder).

 

Syphilis

The early identification and treatment of maternal syphilis reduces the risk of miscarriage, stillbirth and congenital syphilis infection; therefore, screening is recommended for all pregnant women.⁹ There have been increasing rates of syphilis reported since 2011, especially but not exclusively in young Aboriginal and Torres Strait Islander people, with 77 cases and 24 deaths due to congenital syphilis nationally, of which 39 and 14, respectively, were among Aboriginal and Torres Strait Islander people.⁵⁸ This has led to recommendations of more frequent testing throughout pregnancy.⁵⁹

The National strategic approach for responding to rising rates of syphilis in Australia 2021 and the National strategic approach for an enhanced response to the disproportionately high rates of STI and BBV in Aboriginal and Torres Strait Islander people have identified three national targets:

• reduce the incidence of syphilis overall, with a focus on women of reproductive age
• eliminate congenital syphilis
• control outbreaks among Aboriginal and Torres Strait Islander peoples in Queensland, the Northern Territory, Western Australia and South Australia.^59,60

In keeping with the national strategies, Aboriginal and Torres Strait Islander mothers should be offered repeat screening for syphilis throughout pregnancy. The Western Australian Silver book recommends initial and then repeat screening at 28 and 36 weeks gestation for all pregnant women residing in Western Australia¹⁷ (see Table 3). For women living in Aboriginal communities with ongoing outbreaks, additional testing on delivery and at six weeks postpartum are the current recommendations.¹⁷ The Australian pregnancy care guidelines supports retesting early in the third trimester and at birth for women at a high risk of infection.⁹

 

Table 3. Sexually transmissible infection screening for pregnant and postpartum women residing in Western Australia
Timing	Women living in WAA	Women living in regions affected by the ongoing syphilis outbreak in Aboriginal communities (ie Kimberley, Pilbara and Goldfields)
At first antenatal visit	Chlamydia and gonorrhoea (SOLVS plus [if history of unprotected oral or anal sex] throat and anorectal swab) Hepatitis B and C serology Syphilis serology HIV serology	Chlamydia and gonorrhoea (SOLVS plus [if history of unprotected oral or anal sex] throat and anorectal swab) Hepatitis B and C serology Syphilis serology HIV serology
28 weeks gestation	Syphilis serology	Syphilis serology HIV serology
36 weeks gestation or at delivery if preterm birth	Syphilis serology	Chlamydia and gonorrhoea (SOLVS plus [if history of unprotected oral or anal sex] throat and anorectal swab) Syphilis serology
Delivery		Syphilis serology
6 weeks postpartum		Syphilis serology
SOLVS, self-obtained low vaginal swab; WA, Western Australia. Reproduced from Government of Western Australia.17

 

Hepatitis B

Hepatitis B, a blood-borne virus, is commonly transmitted via intravenous drug use, needlestick injury and sexual contact.⁹ Due to the national hepatitis B vaccination program, notification rates have been declining, yet for Aboriginal and Torres Strait Islander women the rate of new diagnoses remain 1.2-fold higher than for non-Indigenous Australian women.⁹ With the aim of identifying undiagnosed infections and commencing risk modification, the Australian pregnancy care guidelines supports universal screening for all pregnant women.⁹ Due to the complexities of management, women who test positive for hepatitis B infection require early referral and engagement with specialist care.

The most serious risk posed by hepatitis B infection in pregnancy is transmission to the baby, known as ‘vertical transmission’. Perinatal transmission is greatly influenced by the maternal viral load and can occur during pregnancy through placental leakage or at the time of delivery via exposure to contaminated blood and fluids.⁹ Mothers with a high viral load have a 70–90% risk of transmitting the virus to their baby.³⁶ A key strategy to reduce the vertical transmission of hepatitis B is the administration of hepatitis B vaccine (preferably within 24 hours and definitely within seven days of birth) and hepatitis B immunoglobulin (preferably within 12 hours and definitely within 48 hours of birth).³⁶ Antiviral medication, such as tenofovir, can also be used safely in pregnancy and has been shown to reduce congenital hepatitis B infection.³⁶ 

Hepatitis C

The rates of hepatitis C infection, a blood-borne virus, have been declining nationally since 2000, yet the rate of new cases diagnosed within the Aboriginal and Torres Strait Islander population remains three- to five-fold higher than non-Indigenous Australians.⁶¹ Hepatitis C infections during pregnancy represent a unique challenge because there is risk of transmission to the baby. The risk of transmission is estimated to be 5% for mothers who are antibody positive and RNA positive.⁹ Transmission to the baby is influenced by the maternal viral load, coinfection with HIV, prolonged rupture of membranes and intrapartum invasive procedures.⁹ The risk of transmission is not influenced by mode of delivery or breastfeeding.⁹

Historically, testing for hepatitis C infection was only offered to pregnant women at high risk of infection. Women considered high risk are those who use/used intravenous drugs, have tattoos and have undergone invasive medical procedures overseas.⁹ Since 2016, treatment for hepatitis C infection has been readily available in Australia.⁶² Although using direct-acting antivirals is not recommended during pregnancy due to teratogenicity, identifying infection during pregnancy can ensure the risk of transmission during delivery is reduced, and a plan instigated for treatment with direct-acting antivirals in the postpartum period.⁶² In response to treatment advances, the Australian pregnancy care guidelines supports screening for all pregnant women.⁹

Chlamydia

Chlamydia continues to affect Aboriginal and Torres Strait Islanders at a rate of approximately three-fold that of non-Indigenous Australians.⁶³ Aboriginal and Torres Strait Islander women have notification rates 1.8-fold higher than Aboriginal and Torres Strait Islander men, with most notifications made among those aged 15–24 years.⁶³ Asymptomatic infection occurs in up to 70% of women⁶³ and can lead to pelvic inflammatory disease, ectopic pregnancy and infertility.¹⁸

Chlamydia infections during pregnancy are associated with adverse outcomes, including preterm birth, low birth weight and perinatal mortality.⁹ Treatment of infection is recommended during pregnancy, with early treatment in young women shown to reduce preterm birth rates.⁹ In line with international guidelines, the Australian pregnancy care guidelines recommends targeted screening for pregnant women deemed at higher risk. In Australia, this includes women aged under 30 years, those residing in a high-prevalence area and Aboriginal and Torres Strait Islander mothers.¹⁷ Repeat testing every three months should be considered for mothers who continue to be at high risk.¹⁷

Gonorrhoea

Gonorrhoea, a sexually transmitted bacterial infection, is most common in young people, with notification rates for Aboriginal and Torres Strait Islander people seven-fold higher than among non-Indigenous Australians.⁶³ Like chlamydia infections, untreated gonorrhoea can cause pelvic inflammatory disease, ectopic pregnancy and infertility.¹⁷ Infection during pregnancy is associated with adverse outcomes including miscarriage, preterm labour and postpartum infection.⁹ Vertical transmission from the mother’s genital tract to the baby can occur during birth, causing neonatal conjunctivitis.⁹ If left untreated, the infection can lead to blindness.⁹

Current national guidelines recommend against the routine screening of all pregnant women.⁹ Instead, the guidelines recommend screening pregnant women with known risk factors or those who reside in a high-prevalence area.⁹ Healthcare providers need to be aware of the rates of gonorrhoea within their community and offer screening accordingly.

Trichomoniasis

Trichomoniasis is a sexually transmissible infection that causes vulval irritation with a yellow–green discharge.⁶⁴ Although prevalence varies greatly among Australian populations and regions, the incidence of infection for Aboriginal and Torres Strait Islander women living in remote regions is higher.⁹ Infection during pregnancy may be associated with prematurity and low birth weight and has been associated with genital and respiratory infections in the infant.⁹ Treatment of asymptomatic pregnant women has failed to show a reduction in preterm birth and low birth weight.⁹ The safety of treatment also needs to be considered, with current guidelines suggesting the use of metronidazole, a Category B2 medication, or tinidazole, a Category B3 medication.⁶⁴ Women using metronidazole in pregnancy were, in fact, more likely to give birth preterm and have a baby with a low birth weight.⁶⁴ For these reasons, universal screening of all pregnant women is not recommended.

Bacterial vaginosis

Bacterial vaginosis occurs when there is a deficiency of Lactobacillus species and an overgrowth of anaerobic bacteria in the vagina.⁶⁵ Bacterial vaginosis during pregnancy has been associated with preterm birth. The evidence suggests that women diagnosed early in pregnancy are at a higher risk of adverse outcomes.⁹ Treatment has been shown to effectively eradicate bacterial vaginosis, but no improvements in the preterm birth rate have been demonstrated.⁹ The adverse effects of treatment have also not been fully explored. The Australian pregnancy care guidelines recommends testing for women with symptoms but recommends against screening all women who are pregnant.⁹

Group B streptococcus

Group B streptococcus colonisation in the vagina, urethra and gastrointestinal tract is common, with an estimated 20–24% of pregnant women affected.⁹ Although most women are asymptomatic, the bacteria can be passed from mother to baby during labour and delivery. Vertical transmission is associated with serious neonatal infections, usually in the first week of life, but late-onset infections can develop up to three months of age.⁹ Colonisation with Group B streptococcus can be effectively treated with intravenous antibiotics during labour, reducing neonatal infections by 86–89%.⁹

Two major screening approaches currently exist, both nationally and internationally. The first approach is an assessment of risk factors during labour and, if the woman is identified as being at high risk, appropriate treatment should be commenced.⁶⁶ Risk factors include previous infant infection with Group B streptococcus, preterm birth, fever and prolonged rupture of membranes.⁶⁶ The second approach is to offer antenatal screening for Group B streptococcus between 35 and 37 weeks gestation with a vaginal–rectal swab.⁹ Because there is no evidence to suggest one approach is better than the other, the Australian pregnancy care guidelines supports the use of either approach.⁹

Hypertension is the most common disorder experienced during pregnancy.⁴⁸ There are different types of hypertensive disorders that can exist in pregnancy, including chronic hypertension (hypertension prior to pregnancy or diagnosed before 20 weeks gestation), gestational hypertension, pre-eclampsia and eclampsia.⁹ The risks associated with hypertensive disorders during pregnancy affect both mother and child and can include placental abruption, preterm delivery, low birth weight and perinatal death.⁹ Although rates of gestational hypertension have remained steady in Australia between 3% and 4%, Aboriginal and Torres Strait Islander women are considered at higher risk.⁴

All pregnant women should be assessed and screened for hypertensive disorders during pregnancy. The Australian pregnancy care guidelines advise measuring a woman’s blood pressure at the first antenatal consult to identify pre-existing hypertension.⁹ In addition to recording blood pressure, a risk assessment should be performed to identify women at higher risk of developing hypertension and pre-eclampsia. A thorough history focusing on risk factors should include a previous diagnosis of hypertension or pre-eclampsia, autoimmune disease, chronic kidney disease, multiple pregnancy, advanced maternal age and obesity^67,68 (see Box 1).

For pregnant women identified as being at moderate to high risk of developing pre-eclampsia, preventive treatment with low-dose aspirin (50–150 mg/day) should be initiated, commencing prior to 16 weeks gestation and continuing to 36 weeks gestation.^9,69 There is also strong evidence to support the use of calcium supplements in women with a low daily calcium intake (defined as calcium intake of less than 900 mg/day) considered to be at moderate to high risk of developing pre-eclampsia.⁹ Women should also be educated on the symptoms of pre-eclampsia, with instructions to seek immediate medical care if any should develop.⁶⁹

Although proteinuria can be used to diagnose pre-eclampsia, it is important to note that routine screening is not helpful in predicting pre-eclampsia.⁹ Screening all pregnant women is therefore not recommended, with the exception of an initial test at the first antenatal consult (in an attempt to identify pre-existing kidney disease).⁹ Testing for proteinuria should be performed for women at high risk of developing pre-eclampsia or with pre-eclampsia symptoms, elevated blood pressure levels and sudden weight gain.⁹

Outpatient management on Country may be appropriate for women with uncomplicated mild to moderate hypertension.⁶⁸ Initiation of antihypertensive therapies can be undertaken as per relevant guidelines, with the frequency of antenatal reviews increased to weekly.⁷⁰ Further risk assessment for pre-eclampsia can also be undertaken with the measurement of biochemical and sonographic markers.⁶⁷ For women with severe hypertension and/or signs of pre-eclampsia, urgent specialist engagement is recommended, even if this means transferring care to a tertiary facility.⁶⁹

GDM is the fasting growing type of diabetes in Australia, with an estimated 500,000 new cases predicted to be diagnosed in the next decade.³⁷ GDM disproportionately affects Aboriginal and Torres Strait Islander women, with a rate 1.6-fold higher than among non-Indigenous Australian mothers.³⁷ Risk factors for GDM are listed in Table 4.

Pre-existing diabetes, both type 1 and 2, is also more common in Aboriginal and Torres Strait Islander women; in 2020, 0.1% of Aboriginal and Torres Strait Islander women who gave birth had type 1 diabetes, 1.9% had type 2 diabetes and 15% had GDM (versus 0.3%, 0.4% and 14%, respectively, of non-Indigenous Australian women).⁷¹ (See also Chapter 17: Type 2 diabetes.)

The adverse outcomes of diabetes in pregnancy are well documented. For mothers, poor control of blood sugars can lead to recurrent miscarriage, hypertensive complications, birth trauma and maternal mortality.⁷² Outcomes for the infant include an increased rate of congenital malformations, growth restriction, neonatal hypoglycaemia and infant mortality.⁷² The AIHW reports that diabetes in pregnancy also increases the lifetime risk of diabetes for the infant, known formally as intergenerational risk transmission.⁴
 
Pregnant women should be assessed for risk factors for hyperglycaemia and diabetes at the initial antenatal visit or during the first trimester, and women identified with risk factors should be offered first trimester screening by HbA1c or fasting blood glucose.⁹ Screening for hyperglycaemia using an oral glucose tolerance test is recommended for all pregnant women between 24 and 28 weeks gestation, including those with a negative early screening result.⁹ Healthcare providers need to be mindful that accessing and completing the test may be difficult for some women, especially in rural and remote regions.
 
Aboriginal and Torres Strait Islander women require culturally appropriate delivery of information regarding diabetes testing, diagnostic thresholds and the impacts of hyperglycaemia during pregnancy on both the mother and baby. Information provided needs to include the role of diet, physical activity, safe levels of weight gain during pregnancy and the benefits of breastfeeding.⁹ For women diagnosed with hyperglycaemia or GDM, early engagement with a multidisciplinary team is beneficial. Registration with the National Gestational Diabetes Register should be completed at diagnosis, which reflects the increased lifetime risk of type 2 diabetes following a diagnosis of GDM.³⁷ 
 

Table 4. Risk factors for gestational diabetes

Maternal age ≥ 40 years BMI ≥30 kg/m2 (pre-pregnancy or on entry to care) Polycystic ovarian syndrome Previous GDM Previous elevated blood glucose Previous macrosomia (birth weight >4500 g or >90th percentile) Family history of diabetes (first-degree relative or sister with GDM) Ethnicity (Asian, Indian subcontinent, Aboriginal and Torres Strait Islander, Pacific Islander, Māori, Middle Eastern, non-White African) Medication (corticosteroids, antipsychotics)

BMI, body mass index; GDM, gestational diabetes. Adapted from Australasian Diabetes in Pregnancy Society, Australian Diabetes Society, Australian Diabetes Educators Association and Diabetes Australia.73

 
 

Historically, two vaccines were recommended to all pregnant women: influenza immunisation and whooping cough immunisation (as part of the diphtheria, tetanus and acellular pertussis immunisation [dTpa]).¹⁹ Following the COVID-19 pandemic, a third vaccination, the COVID-19 immunisation, is now recommended for all pregnant women.²⁰

A 2015 study based in Western Australia found that most Aboriginal mothers were recommended the influenza and pertussis immunisations. Subsequent uptake of the influenza vaccine was recorded at 62%, whereas the pertussis vaccine uptake was recorded at 63%.⁷⁴ Aboriginal and Torres Strait Islander mothers cited the main reason for vaccination uptake was to protect their babies. The study concluded that vaccination uptake for Western Australian Aboriginal mothers was comparable to the rates reported for non-Indigenous Australians. The single most important factor for maternal uptake of vaccinations was recommendation by their health professional.⁷⁴ Healthcare professionals should be aware of the immunisation recommendations during pregnancy, actively encourage mothers to receive vaccines and set up recall systems to ensure vaccinations are provided at the correct time.

The Australian pregnancy care guidelines recommend offering all pregnant women first trimester screening to identify fetal chromosomal abnormalities early in pregnancy⁹ (see Table 1). Prior to performing the test, women must be educated on the purpose of the test, and the implications of an abnormal result, in a culturally appropriate manner. Given time constraints in primary healthcare, written information should be provided to mothers explaining the timing of the test, the method of testing and how to access the service within their community. In Australia, there are currently two first-line screening tests available: combined first trimester screening, which is rebated under Medicare; and NIPT, which is not covered by Medicare and has substantial out-of-pocket costs.²¹ Women with high-risk screening results should be offered diagnostic testing (chorionic villous sampling or amniocentesis) and/or referred to a specialist for appropriate counselling.^9,21

Research into the uptake of first trimester screening in Aboriginal and Torres Strait Islander mothers is scarce. A study performed in 2005–06 in Western Australia found the lowest uptake of first trimester screening among Aboriginal and Torres Strait Islander mothers, with just 14.9% undergoing testing.⁷⁵ Another study undertaken in 2004 by the Menzies School of Health Research found large geographical variations for testing, noting that just 17% of all pregnant women residing in the Northern Territory opted for first trimester screening compared with 80% of all pregnant women in South Australia.⁷⁶

 No specific data were collected on the uptake for Aboriginal and Torres Strait Islander mothers, but it is assumed that the percentage is likely to be significantly lower. Overcoming barriers such as late pregnancy presentation, time constraints, competing priorities during antenatal care, the cost of the tests and access to testing will help improve uptake of first trimester screening among Aboriginal and Torres Strait Islander mothers.⁷⁷