National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people

Chapter 2. Antenatal care
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☰ Table of contents

Recommendations: Smoking cessation

Preventive intervention type

Who is at risk?

What should be done?

How often?

Level/ strength of evidence

Module/section of Clinical practice guidelines: Antenatal care 3,4

Screening

 All pregnant women Regularly assess smoking status and remind patients to limit/avoid exposure to cigarette smoke At first and subsequent antenatal visits IA Module 1, section 10.1

Behavioural

 Pregnant women who smoke Offer interventions to assist smoking cessation, including brief advice and more intensive, multi-component interventions (refer to Chapter 1: Lifestyle, ‘Smoking’) At first and subsequent antenatal visits IB Module 1, section 10.1

Chemo-prophylaxis

 Pregnant women who have not quit smoking after advice and psychosocial support Consider nicotine replacement therapy (NRT) if smoking cessation counselling is not successful
If women are interested in using NRT, discuss potential benefits and risks. These include the effectiveness of NRT at assisting quitting, and the limited evidence about safety of NRT considered in the context of the known harms of continued smoking
Use intermittent forms of NRT (gum, inhaler, lozenges, spray) rather than continuous (patches), to reduce the total dose of nicotine		 At each antenatal visit IIB Module 1, section 10.1


 

Recommendations: Genitourinary and blood-borne viral infections

Preventive intervention type

Who is at risk?

What should be done?

How often?

Level/ strength of evidence

Module/section of Clinical practice guidelines: Antenatal care 3,4

Screening

 All pregnant women <25 years and all pregnant women from communities with a high prevalence of sexually transmitted infections (STIs), including those in outer regional and remote areas Offer Chlamydia testing, with a nucleic acid amplification test (eg PCR) of a first-void urine, or undeceive swab, or self-collected vaginal swab or tampon specimen Consider repeat screening later in pregnancy in areas of high prevalence At first antenatal visit IIIC Module 1, section 8.5
Pregnant women who have known risk factors or who live in or come from communities with a high prevalence of gonorrhoea, including those in outer regional and remote areas Offer testing for gonorrhoea, with a nucleic acid amplification test (eg PCR) of a first-void urine, or undeceive swab, or self-collected vaginal swab or tampon specimen Consider repeat screening later in pregnancy in areas of high prevalence At first antenatal visit GPP Module 2, section 8.4
Pregnant women with symptoms of trichomoniasis Offer testing for trichomoniasis, with a nucleic acid amplification test (eg PCR) of a vaginal swab or tampon specimen Screening asymptomatic pregnant women for trichomoniasis is not recommended On presentation IIIB Module 2, section 8.5
Pregnant women with symptoms of bacterial vaginosis (BV) Offer testing for BV, with microscopy of
a high vaginal swab Screening asymptomatic pregnant women for BV is not recommended		 On presentation IIB Module 1, section 8.8
All pregnant women Offer either antenatal screening for Group B streptococcus (GBS) colonisation (using microscopy and culture of a self-collected vaginal–rectal swab) or an assessment of risk factors for GBS transmission during labour Screening at 35–37 weeks’ gestation Risk factor assessment during labour IIB–IIIC Module 2, section 8.6
Offer serological testing for syphilis, with a treponemal-specific enzyme immunoassay test (eg Treponema pallidum haemagglutination assay [TPHA] or fluorescent treponemal antibody absorption [FTA-ABS]) Consider repeat screening later in pregnancy in areas of high prevalence At first antenatal visit IIB
GPP		 Module 1, section 8.6
Offer serological testing for HIV, with a combined HIV antigen and antibody test At first antenatal visit IIB Module 1, section 8.1
Offer serological testing for hepatitis B virus (HBV) surface antigen At first antenatal visit IA Module 1, section 8.2
Pregnant women with risk factors for hepatitis C virus (HCV), including intravenous drug use, tattooing and body piercing, and incarceration Offer serological testing for HCV antibodies Note: If HCV antibodies are detected, a HCV RNA PCR test is required to indicate whether HCV infection is past or current Routine screening of pregnant women without risk factors for HCV is not recommended At first antenatal visit IIIC Module 1, section 8.3
All pregnant women Offer testing for asymptomatic bacteriuria with a mid-stream urine microscopy and culture In areas with limited access to pathology testing, dipstick tests may be used to exclude asymptomatic bacteriuria but positive results must be confirmed by mid-stream urine culture At first antenatal visit IA GPP Module 1, section 8.7

Environmental

 Pregnant women with positive results for a genitourinary or blood borne infection Ensure adequate recall systems are implemented for follow-up Recommend partner treatment and contact tracing for STIs (Refer to Chapter 14: Sexual health and blood-borne viruses)   GPP

 

 
 

Recommendations: Genitourinary and blood-borne viral infections

Preventive intervention type

Who is at risk?

What should be done?

How often?

Level/ strength of evidence

Module/section of Clinical practice guidelines: Antenatal care 3,4/ References

Screening

 All pregnant women Measure height and weight and calculate BMI
Advise women about appropriate weight gain during pregnancy (Box 1)

Repeated weighing during pregnancy is recommended only when clinical management is likely to be influenced		 At first antenatal visit

At subsequent visits if clinically indicated		 IIB
IB
GPP		 Module 1, section 7.2
All pregnant women Offer a full blood examination to assess for anaemia At first antenatal visit, 28 and 36 weeks' gestation GPP Module 2, section 8.1
Pregnant women with risk factors for vitamin D deficiency (limited sun exposure, dark skin, BMI >30 kg/m2) Consider serology testing for vitamin D levels, particularly in the non-summer months At first antenatal visit GPP Module 1, section 8.9

Behavioural

 All pregnant women Provide information on the benefits of a healthy diet in pregnancy and give practical, tailored advice on healthy eating (refer to Chapter 1: Lifestyle, ‘Overweight/obesity’) Early in pregnancy GPP Module 2, section 5.1

Chemo-prophylaxis

 All pregnant women and those considering pregnancy Recommend 500 mcg of oral folic acid daily to reduce the risk of newborn neural tube defects At least one month prior to pregnancy and for the first 12 weeks of pregnancy IA Module 1, section 10.4.1
Women with diabetes Recommend a higher dose of 5 mg of folic acid orally daily to reduce the risk of newborn neural tube defects At least one month prior to pregnancy and for the first 12 weeks of pregnancy IIIC Australasian Diabetes in Pregnancy Society guidelines53
Pregnant women with proven vitamin D deficiency Offer vitamin D supplementation because of potential benefits for a woman’s long-term health At diagnosis GPP Module 1, section 8.9
Pregnant women with proven iron deficiency
Pregnant women who are not iron deficient		 Offer iron supplementation (oral or intravenous with the dose titrated according to the clinical situation)

Routine iron supplementation is not recommended		 At diagnosis IIB Module 2, section 8.1.3
National Blood Authority guidelines42

Module 1, section 10.4.4
All pregnant women Offer iodine supplementation with 150 mcg/day At first antenatal visit GPP Module 1, section 10.4.3

 
 

Recommendations: Diabetes

Preventive intervention type

Who is at risk?

What should be done?

How often?

Level/ strength of evidence

Module/section of Clinical practice guidelines: Antenatal care 3,4

Screening

 All pregnant women who do not have diagnosed diabetes Measure fasting plasma glucose to screen for pre-existing diabetes (Box 2)

If not feasible to obtain a fasting blood test, alternatives include random blood glucose or HbA1c (refer to Chapter 12: Type 2 diabetes)		 At first antenatal visit

 		 GPP Module 2, section 8.2.3
All pregnant women who do not have diagnosed diabetes Perform a 75 g two-hour oral glucose tolerance test (GTT)

If a two-hour GTT is consistently difficult to achieve, consider alternative tests such as a random or fasting plasma glucose		 Between 24–28 weeks gestation GPP
GPP		 Module 2, section 8.2.3
Women diagnosed with gestational diabetes who are now post-partum Perform a 75 g fasting glucose tolerance test to assess for the presence of diabetes At six weeks post-partum GPP Module 2, section 8.2.5

Behavioural

 Pregnant women with diabetes Offer advice and resources to promote good glycaemic control throughout pregnancy – encourage healthy diet and exercise

Consider referral to specialist services, and consult specific management guidelines for ongoing care (refer to ‘Resources’)		 At diagnosis GPP Module 2, section 8.2.5
  Non-pregnant women who have a past history of gestational diabetes Advise women about their future risks of developing diabetes and give advice on preventive strategies, including healthy diet, exercise and weight control (refer to Chapter 1: Lifestyle, and Chapter 12: Type 2 diabetes)

Screen for diabetes with a fasting blood glucose (refer to Chapter 12: Type 2 diabetes)		 At post-partum checks and as part of an annual health assessment GPP Module 2, section 8.2.5

 

 

Recommendations: Summary of other antenatal care screening and activities

Preventive intervention type

Who is at risk?

What should be done?

How often?

Level/ strength of evidence

Module/section of Clinical practice guidelines: Antenatal care 3,4

Screening

 All pregnant women

 		 Discuss and plan the schedule of antenatal visits with the pregnant woman based on her individual needs

For an uncomplicated pregnancy, 10 visits are recommended for women having their first pregnancy, and seven visits for women having subsequent pregnancies		 At first antenatal visit

 		 IB Module 1, section 6
Offer an ultrasound scan to determine gestational age and detect multiple pregnancies Best performed between 8 weeks and 13 weeks + 6 days’ gestation IIB
 		 Module 1, section 7.1
Assess blood pressure At first and subsequent antenatal visits IIB Module 1, section 7.3
Test for proteinuria*

Use an automated urinary dipstick analyser, if available, as it is more accurate than visual inspection of a dipstick result

If a urinary dipstick is positive for protein, further assessment with a 24-hour urinary protein or protein:creatinine ratio is required		 At first antenatal visit

Repeat at subsequent visits if clinically indicated – for example, for women with high blood pressure or kidney disease		 GPP Module 1, section 7.4
Auscultate for heart murmurs

Have a low threshold for referral for echocardiography and assessment in areas with a high prevalence of rheumatic heart disease		 At first antenatal visit GPP  
Advise women to have an oral health check and treatment if required (refer to Chapter 8: Oral and dental health) At first antenatal visit IB Module 1, section 10.5
Offer cervical screening if due (refer to Chapter 15: Prevention and early detection of cancer) During first trimester GPP Module 2, section 8.9
National Cervical Screening Program guidelines58
Offer all women rubella serology testing to check their levels of immunity

Follow up women with low rubella immunity after delivery to offer rubella immunisation		 At first antenatal visit IIB Module 1, section 8.4
Check blood group and antibodies At first visit and 28-week visit IIB Module 2, section 8.3
Offer an ultrasound scan to assess for fetal morphology abnormalities and placental location† At 18–20 weeks IIB Module 1, section 6.1
Assess background level of risk of chromosomal abnormalities such as Down syndrome, based on age, family history, past obstetric history and other risk factors

Discuss the purpose and implications of screening for chromosomal abnormalities to promote an informed decision‡		 At first antenatal visit GPP Module 1, section 9.2
Pregnant women who choose first trimester screening for chromosomal abnormalities Offer combined screening for chromosomal abnormalities with ultrasound assessment of nuchal translucency thickness, and serological testing for free betahuman chorionic gonadotrophin and pregnancy-associated plasma protein A Combined screening: blood tests: 9–13 weeks + 6 days’ gestation Ultrasound assessment: 11–13 weeks + 6 days’ gestation IIB Module 1, section 9.3
Pregnant women who present after first trimester and choose to have second trimester blood tests to screen for chromosomal abnormalities Offer screening for chromosomal abnormalities with second trimester serological testing for estriol, free beta-human chorionic gonadotrophin, and alpha fetoprotein (triple test), or with inhibin A added (quadruple test) 14–20 weeks’ gestation IIB Module 1, section 9.3
Pregnant women who have a positive first or second trimester screening test, or a high baseline risk of congenital abnormalities because of risk factors, and who choose to have a second trimester diagnostic test Offer chorionic villus sampling before 14 weeks, or amniocentesis after 15 weeks   IIB Module 1, section 9.4
All pregnant women Ask women about psychosocial factors, including past and current life stressors (housing, finances, grief and loss), family and social supports, and previous or current mental health disorders (refer to Chapter 17: Mental health) Early in pregnancy, and during subsequent visits if clinically indicated GPP Module 1, section 7.6
Use the Edinburgh Postnatal Depression Scale or another validated perinatal mental health assessment tool to assess women for symptoms of depression and anxiety during the antenatal period,§ and follow up women who screen positive

Ask about women’s exposure to family violence (refer to Chapter 16: Family abuse and violence)

If a woman discloses that she is experiencing violence, respond immediately taking into account the woman’s safety and that of children in her care, her individual circumstances and preferences, confidentiality and privacy, family and community structures and support, and local services		 Early in pregnancy, and during subsequent visits if clinically indicated IIB Module 1, section 7.6
beyondblue Clinical practice guidelines for perinatal period60

Immunisation

 All pregnant women Review influenza immunisation status and offer where appropriate (refer to Chapter 9: Respiratory health, ‘Influenza’)

Offer a booster dose of adult pertussis vaccine (dTpa) to all women in the third trimester.

This is to help protect infants against pertussis before they commence immunisations at two months of age		 Opportunistic; influenza vaccination can be given at any time during pregnancy

Pertussis vaccine is recommended in third trimester		 GPP The Australian immunisation handbook61
*Risk factors for pre-eclampsia include age >40 years, first or multiple pregnancy, BMI >30, diabetes, vascular or kidney disease, personal or family history of pre-eclampsia, raised blood pressure at first visit, pregnancy interval >10 years.

†There is emerging evidence that measurement of cervical length at this ultrasound may detect those women at increased risk of pre term delivery and may offer an opportunity for intervention, such as progesterone pessaries.62 However, there is currently insufficient evidence to recommend this as routine practice.

‡First trimester combined screening is with nuchal translucency thickness ultrasound and serological testing for free beta-human chorionic gonadotrophin and pregnancy-associated plasma protein A. Non-invasive prenatal testing (NIPT) involves testing maternal plasma for cell-free DNA, and can be undertaken after 10 weeks’ gestation. While NIPT is more accurate than other approaches to screening, it is also more expensive, and testing is currently not covered by Medicare and therefore incurs significant out-of-pocket costs for women ($500 or more).59
For women who present after the first trimester, second trimester screening with serological testing can be offered, but is less accurate than first trimester screening options. Second trimester screening involves serological testing for oestriol, free beta human chorionic gonadotrophin and alpha fetoprotein (triple test) or with inhibin A added (quadruple test). Second trimester diagnostic tests for congenital abnormalities include chorionic villus sampling or amniocentesis.

§The Edinburgh Postnatal Depression Scale is a validated screening tool that includes 10 questions and leads to a score that indicates levels of risk of depression. The tool and guidance on its interpretation and use can be found on the beyondblue website at www.beyondblue.org.au/ health-professionals/perinatal-mental-health/perinatal-mental-health-questionnaires and in the beyondblue Perinatal Clinical Practice Guidelines.60 The Kimberley Mums Mood Scale (KMMS) is a perinatal mental health assessment tool designed and validated specifically for use with Aboriginal women from the Kimberley region. The tool, as well as training and support materials, are available at Kimberley Mums Mood Scale.

Box 1. Institute of Medicine recommended weight gain during pregnancy by pre-pregnancy BMI4

BMI (kg/m2)

<18.5

18.5–24.9

25.0–29.9

≥30.0

Recommended weight gain during pregnancy (kg)

12.7–18.1

11.3–15.9

6.8–11.3

5–9

Adapted from Australian Health Ministers’ Advisory Council. Clinical practice guidelines: Antenatal care – Module 1. Canberra: Department of Health and Ageing, 2012, Table 7.3.

 

Box 2. World Health Organization and International Association of Diabetes and Pregnancy Study Group criteria for diagnosis of diabetes in pregnancy54

Diagnosing diabetes in pregnancy: One or more of the following criteria are met

Measure

Criteria

Fasting plasma glucose

≥7.0 mmol/L

Two-hour plasma glucose

≥11.1 mmol/L following a 75 g oral glucose load

Random plasma glucose

≥11.1 mmol/L in the presence of diabetes symptoms

Diagnosing gestational diabetes: One or more of the following criteria are met at any time during pregnancy

Measure

Criteria

Fasting plasma glucose

5.1–6.9 mmol/L

One-hour plasma glucose

≥10 mmol/L following a 75 g oral glucose load

Two-hour plasma glucose

8.5–11.0 mmol/L following a 75 g oral glucose load



Introduction

Antenatal care aims to improve health and prevent disease for both the pregnant woman and her baby. While many Aboriginal and Torres Strait Islander women have healthy babies, poor maternal health and social disadvantage contribute to higher risks of having problems during pregnancy and an adverse pregnancy outcome.1,2 The reasons for these adverse outcomes are complex and multi factorial (Figure 1), and together with other measures of health disparity provide an imperative for all involved in caring for Aboriginal and Torres Strait Islander women to ensure they receive the highest quality antenatal care, and, in particular, care that is woman-centred, evidence-based and culturally competent.

This chapter reflects recommendations for Aboriginal and Torres Strait Islander women from two modules of
Australian evidence-based antenatal care guidelines3,4 and incorporates new evidence published subsequently.
For selected antenatal care topics, narrative summaries of evidence relevant to Aboriginal and Torres Strait women are presented below. These are:

  • smoking
  • screening for genitourinary and blood-borne viral infections
  • nutrition and nutritional supplementation
  • diabetes.

Recommendations for other key elements of antenatal care to be provided at the first antenatal care visit and at subsequent visits are summarised in ‘Recommendations: Summary of other antenatal care screening and activities’.
The prevention of fetal alcohol spectrum disorder (FASD) is covered in a separate chapter of the guide (refer to Chapter 3: Child health, ‘Fetal alcohol spectrum disorder’).

Figure 1. Factors that influence pregnancy outcomes in Aboriginal and Torres Strait Islander women5

Figure 1. Factors that influence pregnancy outcomes in Aboriginal and Torres Strait Islander women

Reproduced from Clarke M, Boyle J. Antenatal care for Aboriginal and Torres Strait Islander women. Aus Fam Physician 2014;43(1/2):20–24.

 


Antenatal care – General features

Antenatal care includes providing support, information and advice to women during pregnancy, undertaking regular clinical assessments, and screening for a range of infections and other conditions as well as following up and managing screen-detected problems.4 The key feature of high-quality antenatal care for all women is that it is woman-centred,4 meaning care that includes:

  • focusing on each woman’s individual needs, expectations and aspirations, including her physical, psychological, emotional, spiritual, social and cultural needs
  • being culturally safe
  • supporting women to make informed choices and decisions involving the woman’s partner, family and community, as identified by the woman herself.

High-quality antenatal care for Aboriginal and Torres Strait Islander women includes holistic care that is consistent with the Aboriginal definition of health, being the physical, social, emotional and cultural wellbeing of both an individual and their community.6

Aboriginal and Torres Strait Islander women are cared for by a range of health professionals during pregnancy, and the cultural competence of healthcare providers is of critical importance to women’s engagement with antenatal care and the delivery of high-quality care. Healthcare providers need an awareness of the higher levels of social and economic disadvantage experienced by many Aboriginal and Torres Strait Islander people and to prioritise doing what they can to address these social determinants of health at both individual and system levels.7 Building trust, and respectful communication and developing effective therapeutic relationships are also key features of providing high-quality antenatal care to Aboriginal and Torres Strait Islander women.8
In Australia, antenatal care is delivered in a range of organisational settings including hospitals, general and specialist private practices, government clinics, and Aboriginal Community Controlled Health Services. The involvement of Aboriginal and Torres Strait Islander people in the delivery of care, and in the design and management of services, will improve the quality of care for Aboriginal and Torres Islander women in all settings.4

The ‘first visit’ is an important focus in antenatal care, as provision of advice and a range of assessment and screening activities is best undertaken early in pregnancy to maximise the benefits. It is recommended that the first antenatal care visit occurs before 10 weeks’ gestation.4 While there is some evidence of recent improvements, Aboriginal and Torres Strait Islander women are still less likely than other Australian women to receive antenatal care early in pregnancy.1,9 According to age-standardised national data from 2014, 53% of Aboriginal and Torres Strait Islander women attended antenatal care in the first trimester, compared to 60% of non-Indigenous women, and among Aboriginal and Torres Strait Islander women first trimester attendance was higher for women in outer regional areas (62%) compared to women living in major cities (48%) or very remote areas (51%).1 This suggests the need for ongoing attention by the healthcare system to promoting and facilitating early engagement of pregnant Aboriginal and Torres Strait Islander women, including strengthening cultural safety and addressing local barriers identified by Aboriginal and Torres Strait Islander women.

Current recommendations for antenatal care have shifted from a ‘traditional’ fixed schedule of visits towards a more flexible tailored plan of visits that is developed in consultation with each woman in early pregnancy and designed to meet her individual needs.4 Ten antenatal care visits are recommended for a woman without complications having her first pregnancy, and seven visits for a woman having a subsequent pregnancy.4

Antenatal care frequently involves screening that aims to improve outcomes for the pregnant woman and her baby. For all screening conducted during pregnancy, women must be provided with information and an opportunity to ask questions about the tests and potential treatments beforehand, so that they are able to provide informed consent. Screening test results need to be communicated to women whether they are positive or negative, and appropriate management and follow-up of positive results is critical if the potential benefits of screening are to be realised.


Smoking

Smoking tobacco during pregnancy has a range of negative impacts on the health of women and babies. Adverse birth outcomes are more common among women who smoke during pregnancy and include an increased risk of pre term birth, low birth weight, and stillbirth. Children of women who smoked during pregnancy have higher rates of Sudden Infant Death Syndrome (SIDS), asthma, ear infections and respiratory infections. Quitting smoking before or during pregnancy can reduce these risks.

At a national level, an estimated 44% of Aboriginal and Torres Strait Islander women smoked during pregnancy in 2014.1 The prevalence of smoking during pregnancy for Aboriginal and Torres Strait Islander women is decreasing (down from 52% in 200310); however, it remains much higher than that of non-Indigenous women who are pregnant (12% in 2014). Smoking during pregnancy is more common among young women, those living in rural and remote areas, and those who experience socio-economic disadvantage.1 Factors associated with high smoking rates and low quit rates among Aboriginal and Torres Strait Islander populations include the normalisation of smoking within Aboriginal communities; the presence of social health determinants such as unemployment, poverty, removal from family, and incarceration; personal stressors such as violence, grief and loss; concurrent use of alcohol and cannabis; and lack of access to culturally appropriate support for quitting.11–14 Aboriginal and Torres Strait Islander women have expressed the view that smoking during pregnancy can help them cope with stress and relieve boredom, and that quitting may be of lower priority compared to the many other personal and community problems they face.15

Pregnancy is a particularly opportune time for an intensive focus on the delivery of smoking cessation advice and support to women, because of the potential for improving the health of both mother and baby, and because women are more likely to quit smoking during pregnancy. Aboriginal and Torres Strait Islander women have indicated their support for receiving information, advice and support for quitting from caregivers during pregnancy.16,17 Health professionals, therefore, have an important role to play in providing information and support to women during pregnancy. There is systematic review evidence that psychosocial interventions for smoking cessation during pregnancy are effective at increasing quit rates and improving birth outcomes such as low birth weight.18 Only one randomised controlled trial has assessed the effectiveness of a tailored smoking cessation intervention for Aboriginal and Torres Strait Islander women.19 It did not find a significant difference in quit rates between the intervention group and those receiving usual care, suggesting that more work is needed to optimise smoking cessation strategies in pregnancy for Aboriginal and Torres Strait Islander women.

All pregnant women should be asked about their smoking history and practices, and it is recommended that those who currently smoke or have recently quit be provided with information about the effects of smoking during pregnancy, advised to quit smoking and stay quit, and offered ongoing and tailored support to do so.4 Efforts by health professionals to address smoking during pregnancy for Aboriginal women are more likely to be effective when relationships are non-judgemental, trusting and respectful, as well as empowering and supportive of women’s self-efficacy and agency.12,20 The social context of Aboriginal and Torres Strait Islander women’s lives is very important to consider when designing and delivering smoking cessation advice and support during pregnancy; it has been suggested that addressing stressors, and building skills and coping strategies, are likely to increase the efficacy of smoking cessation efforts.14,15 Involvement of partners and families, as well as community-wide efforts to de normalise and reduce smoking in Aboriginal communities, are also recommended as strategies to address smoking in pregnancy for Aboriginal and Torres Strait Islander women.

While evidence for the effectiveness of nicotine replacement therapies (NRT) during pregnancy is currently limited, trial results suggest NRT can have positive impacts on quit rates and child development outcomes, and there is no evidence of associated harms.21 The use of NRT during pregnancy is recommended when initial quit attempts have not been successful, with preference being for the use of an intermittent mode of delivery (such as lozenges, gum or spray) rather than continuous (such as patches).4 The safety of oral (such as buprenorphine and varenicline) and e-cigarettes, and their effectiveness as measures to support quitting during pregnancy, is not known and therefore they are not recommended for use.21


Screening for genitourinary and blood-borne infections

Urinary tract infections

Asymptomatic bacteriuria is common during pregnancy, and may be more common among Aboriginal and Torres Strait Islander women.22–24 Ascending urinary tract infection during pregnancy may lead to pyelonephritis, and an association with pre term birth and low birth weight has been suggested.4 A Cochrane review has demonstrated that treatment with antibiotics is effective at clearing asymptomatic bacteriuria during pregnancy, and results in a reduced risk of pyelonephritis as well as providing suggestive evidence about a reduced risk of adverse pregnancy outcomes such as pre term birth and low birth weight.25

All women should be routinely offered testing for asymptomatic bacteriuria early in pregnancy using a midstream urine culture.4 Urine dipstick for nitrites is not a suitable test for diagnosing infection, as false positives are frequent; however, a negative dipstick result means infection is unlikely. Appropriate storage of dipsticks is essential, as high humidity and temperature can impact on their accuracy.

Chlamydia

Chlamydia is a common sexually transmitted infection (STI) that can be asymptomatic and can lead to pelvic inflammatory disease, infertility and ectopic pregnancy. Chlamydia infection during pregnancy has been associated with higher rates of pre term birth and growth restriction, and can result in neonatal conjunctivitis and respiratory tract infections.4 Antibiotics are effective at treating Chlamydia, and there is some evidence that treatment during pregnancy reduces the incidence of pre term birth and low birth weight.26,27
Chlamydia prevalence estimates for pregnant Aboriginal and Torres Strait Islander women vary from 2.9% to
14.4%.30,31 Chlamydia is most common among young people, with 80% of diagnoses among Aboriginal and Torres
Strait Islander people being in this group.30 Notification rates for Chlamydia are eight times higher for Aboriginal and Torres Strait Islander people living in remote regions.30
Australian national evidence-based antenatal care guidelines recommend that Chlamydia testing is routinely offered during pregnancy at the first antenatal care visit to pregnant women aged less than 25 years, and to all women who live in areas where Chlamydia and other STIs have a high prevalence.4 Pregnant women who test positive to Chlamydia, and their partners, need follow-up, assessment for other STIs and treatment.

Gonorrhoea

Gonorrhoea is a sexually acquired infection that can cause pelvic inflammatory disease and chronic pelvic pain in women. Gonorrhoea infection during pregnancy is associated with adverse outcomes including ectopic pregnancy, miscarriage, pre term birth and maternal sepsis during and after pregnancy.4 Transmission at the time of birth can lead to neonatal conjunctivitis, which may cause blindness.
Gonorrhoea is most commonly diagnosed in young people, and is more common for Aboriginal and Torres Strait Islander people living in outer regional and remote areas.30 Rates of diagnosis have been declining but remain high in these regions.30

Australian national evidence-based antenatal care guidelines recommend against screening all pregnant women for gonorrhoea, because there is a relatively low prevalence of disease and there is potential for harms associated with false positive test results, particularly in low-risk populations.4 Screening for gonorrhoea is recommended for pregnant women who live in, or come from, areas of high prevalence (outer regional and remote areas), or who have risk factors for STIs. Pregnant women who test positive to gonorrhoea, and their partners, need follow-up, assessment for other STIs and treatment.

Trichomoniasis

Trichomoniasis is a sexually transmitted vaginitis that is commonly asymptomatic, but can cause a yellow–green vaginal discharge and vulval irritation, and may be associated with infertility and pelvic inflammatory disease.3 The implications of trichomoniasis during pregnancy remain unclear; while an association between trichomoniasis and pre term birth and low birth weight has been demonstrated, evidence of a cause and effect relationship is currently lacking.31
The benefits of screening asymptomatic women for trichomonas during pregnancy are uncertain, because there is no evidence that antibiotic treatment improves pregnancy outcomes,3,31 with one trial suggesting a higher rate of pre term birth among pregnant women who were treated for asymptomatic trichomoniasis with metronidazole.31 For this reason screening of asymptomatic, pregnant women is not recommended.3

Bacterial vaginosis

Bacterial vaginosis (BV) is a deficiency of normal vaginal flora (Lactobacilli) and a relative overgrowth of anaerobic bacteria. BV occurs commonly and is often asymptomatic, although it can also cause a greyish vaginal discharge.4

In epidemiological studies, BV has been associated with a higher rate of pre term birth. While antibiotics for BV have been found to be effective at eradicating BV microbiologically, they have not resulted in a reduction in the preterm birth rate.32 For this reason, routine screening of asymptomatic pregnant women for BV is not recommended.4,32 Symptomatic women diagnosed with BV, however, should be treated.

Group B streptococcus

Group B streptococcus (GBS) is a bacteria that commonly colonises the gastrointestinal tract, vagina and urethra, and has the potential to increase the risk of preterm birth and cause serious neonatal infection after birth.4 For women who are colonised with GBS, intravenous antibiotics during labour can prevent more than 80% of neonatal infection.4

Australian estimates suggest a prevalence of GBS colonisation among all pregnant women of around 20%.4
Prevention strategies can involve two main approaches: antenatal screening for GBS in late pregnancy  (at 35–37 weeks’ gestation), or an assessment of risk factors for GBS transmission during labour (including preterm birth, maternal fever and prolonged rupture of membranes). As there is currently no clear evidence supporting one strategy over the other, Australian national evidence-based antenatal care guidelines recommend either strategy can be used.4

Syphilis

Syphilis is an STI with serious systemic sequelae. During pregnancy, syphilis can cause spontaneous miscarriage or stillbirth, or lead to congenital infection that is commonly fatal or results in severe and permanent impairment. Congenital syphilis can be prevented by effective treatment of maternal syphilis  with antibiotics.33

In Australia, notifications of infectious syphilis have been declining but have remained more common for Aboriginal and Torres Strait Islander peoples compared to non-Indigenous populations.30 However, since 2010 there has been a marked increase in notifications of infectious syphilis, driven by an outbreak in northern Australia, including Western Australia, the Northern Territory and Queensland.34 This outbreak has included a total of 22 cases of congenital syphilis being notified nationally between 2011 and 2015, with  14 of these cases being Aboriginal and Torres Strait Islander babies,30 and several infant deaths from syphilis have occurred. 34

All pregnant women should be routinely offered testing to screen for syphilis at the first antenatal visit, and repeat screening later in pregnancy may be appropriate in regions of high prevalence.4 The interpretation of syphilis serology can be complex. To ensure diagnosis, treatment and follow-up are consistent with evidencebased best practice, it is recommended that expert advice is sought if a pregnant woman tests positive for syphilis on an initial screen.4

HIV

While human immunodeficiency virus (HIV) infection is uncommon in Australia, screening during pregnancy for all women at the first antenatal visit is recommended because of the serious consequences of mother-to-child transmission and the availability of treatments effective at reducing this risk.4 These treatments include caesarean section, short courses of selected antiretroviral medications, and the avoidance of breastfeeding. HIV infection currently occurs at similar rates for Aboriginal and Torres Strait Islander and non-Indigenous population groups in Australia.30 Women who test positive for HIV require careful and confidential follow-up, including repeat confirmatory testing, assessment and specialist management.

Hepatitis C

Hepatitis C is a blood-borne virus with the potential for causing serious long-term sequelae, including cirrhosis, hepatocellular carcinoma and liver failure through chronic infection. Hepatitis C infection is diagnosed up to four times more often among Aboriginal and Torres Strait Islander women than nonIndigenous women, and is increasing.30 Perinatal transmission occurs for 4–6% of babies born to women who are positive to both hepatitis C antibody and hepatitis C RNA during pregnancy, and this risk is higher with increasing viral load.4
In recent years, the increased availability of effective anti-viral therapies with fewer adverse impacts than previously available treatments has greatly improved treatment options and outcomes for people with chronic hepatitis C infection.35 However, at the time of writing, anti-viral therapies used for treating for hepatitis C are not approved or recommended for use during pregnancy.35
The lack of antenatal treatment options and the potential psychological harms associated with false positive results of screening tests are the main reasons that routine screening of all women for hepatitis C during pregnancy is not recommended.4 Testing during pregnancy may be considered, however, for women with identifiable risk factors, including intravenous drug use, tattooing and body piercing, and incarceration.4 If an initial hepatitis C antibody test is positive, a confirmatory hepatitis C RNA test is required to assess risks and guide management for the woman and baby, and both should be appropriately followed up.

Hepatitis B

Aboriginal and Torres Strait Islander populations have higher rates of diagnosis of hepatitis B infection than non-Indigenous population groups, and available evidence suggests this pattern is also true of hepatitis B surface antigen positivity during pregnancy.30,36,37 All pregnant women should be offered screening for hepatitis B infection by testing for hepatitis B surface antigen at their first antenatal care visit, and those that test positive should be appropriately followed up.4 Newborn children of women with current hepatitis B infection (hepatitis B surface antigen positive) can be vaccinated after delivery. Vaccination and the provision of immunoglobulin to the baby at birth is approximately 95% effective at preventing perinatal transmission.4


Nutrition and nutritional supplementation

Nutrition

Good nutrition during pregnancy is important for the health of the woman, and the development and growth of the baby. Providing women with information and advice about nutritional needs during pregnancy is an important part of routine antenatal care. In providing this advice to Aboriginal and Torres Strait Islander women, it is important to consider the significance of barriers to accessing nutritious foods (eg fresh fruit, vegetables) because of costs and lack of availability in rural and remote regions (refer to Chapter 1: Lifestyle, ‘Overweight and obesity’).

Weight and body mass index

Overweight and obesity is becoming increasingly common in Australia, and is more common in Aboriginal and Torres Strait Islander population groups.9 In 2014, obesity during pregnancy was documented for 33% of Aboriginal and Torres Strait Islander women compared to 20% of non-Indigenous women.1
Being overweight (body mass index [BMI] ≥25 kg/m2) or underweight (BMI <18.5 kg/m2) before pregnancy are each associated with an increased risk of adverse birth outcomes. Being overweight before pregnancy or having a high weight gain during pregnancy is associated with higher rates of preterm birth, caesarean section, gestational high blood pressure or pre-eclampsia, gestational diabetes, postpartum haemorrhage, and depression, as well as a baby being more likely to be of low birthweight or large for gestational age. Being underweight before pregnancy or having a low weight gain during pregnancy is associated with an increased risk of preterm birth, low birthweight and being small for gestational age.

The national evidence-based antenatal care guidelines recommend routine assessment of a woman’s weight and height, and calculation of BMI at the first antenatal care visit.4 Weighing women at subsequent visits is recommended only when it is likely to influence clinical management.
Recommended weight gain during pregnancy varies with a woman’s estimated pre-pregnancy BMI from a total of 6 kg to 18 kg (Box 1). While weight loss is not an appropriate aim during pregnancy, strong evidence suggests interventions for women who are overweight based on increased physical activity and dietary counselling combined with weight monitoring can reduce inappropriate weight gain during pregnancy, as well as reduce the risks of caesarean section, macrosomia and neonatal respiratory morbidity.38–40

Iron

Aboriginal and Torres Strait Islander populations are at greater risk of anaemia,41 and iron deficiency is the most common cause of anaemia. Routine iron supplementation for all pregnant women is not recommended, because evidence of improved pregnancy outcomes is lacking and there may be adverse impacts.4 However, it is recommended that all women be screened for anaemia at the first and subsequent visits during pregnancy, and that iron supplementation be used to treat iron deficiency if it is detected.4 Management of iron deficiency anaemia during pregnancy includes dietary advice, iron supplementation and follow-up. Pregnant women can potentially benefit by being advised about iron-rich foods and that iron absorption can be aided by vitamin C– rich foods, such as fresh fruit and fruit juice, and reduced by tea and coffee.4,42

Folic acid

Routine folic acid supplementation before and during pregnancy is recommended for all women as it is effective in reducing the risk of neural tube defects.4 The incidence of this group of congenital abnormalities decreased in Australia among non-Indigenous women after folic acid supplementation during pregnancy became widespread.43 However, Aboriginal and Torres Strait Islander women were still experiencing high rates of neural tube defects.43,44 Following mandatory folic acid fortification of bread, which has occurred since 2009, rates of neural tube defects among Aboriginal and Torres Strait Islander women have dropped significantly and are now lower than those of other Australian women.45

Iodine

Increased thyroid activity during pregnancy results in increased maternal requirements for iodine, which is essential for neuropsychological development. While severe iodine deficiency during pregnancy is uncommon in Australia, recent evidence suggests that mild and moderate levels of iodine deficiency during pregnancy may result in negative impacts on the neurological and cognitive development of the child.47 While mandatory iodine fortification of bread since 2009 has improved iodine levels in the general Australian population, available evidence suggests that for many women dietary intake of iodine will not be sufficient to meet needs during pregnancy and breastfeeding.45 As a consequence, it is recommended that all pregnant women take an iodine supplement of 150 mcg daily.4,47

Vitamin D

Vitamin D is essential for skeletal development, and vitamin D deficiency may have a range of negative health impacts, including during pregnancy.4,48 The prevalence of vitamin D deficiency varies geographically and between different population groups, and there have been few estimates of prevalence among Aboriginal and Torres Strait Islander populations.49,50 Risk factors for vitamin D deficiency include limited exposure to sunlight, dark skin and a high BMI. Vitamin D supplementation for women with vitamin D deficiency increases maternal levels of vitamin D, but there is currently no evidence that it improves pregnancy outcomes.4,48 Screening pregnant women for vitamin D deficiency is recommended only if they have risk factors, and women who are found to be vitamin D deficient should be treated with supplementation because of the potential benefits to their long-term health.4,48


Diabetes

Diabetes in pregnancy includes type 1 or type 2 diabetes diagnosed before pregnancy, undiagnosed pre-existing diabetes, and gestational diabetes, where glucose intolerance develops in the second half of pregnancy. All forms of diabetes in pregnancy are associated with increased risks for both the pregnant woman and the baby, with the level of risk depending on the level of hyperglycaemia.3,51–53 Diabetes in pregnancy is associated with an increased risk of induced labour, preterm birth, caesarean section and pre-eclampsia. Babies of mothers with diabetes in pregnancy have higher rates of stillbirth, fetal macrosomia, low APGAR (Appearance, Pulse, Grimace, Activity, Respiration) scores, neonatal hypoglycaemia, and admission to special care/neonatal intensive care units. Babies born to mothers with pre-existing diabetes also have a higher risk of congenital malformations of the spine, heart and kidneys. In addition, raised maternal glycaemic levels are associated with a child having increased adiposity in childhood and other adverse metabolic factors that may increase the risks of later cardiovascular disease and diabetes. Women with gestational diabetes also have an increased risk of developing type 2 diabetes later in life.

The number of women with all types of diabetes in pregnancy is increasing. At a national level in 2014, an estimated 4% of Aboriginal and Torres Strait Islander women had diabetes in pregnancy and 13% had gestational diabetes, and each of these rates was higher than those of non-Indigenous women (3.5 times higher for diabetes and 1.6 times higher for gestational diabetes).1

Given the high prevalence of diabetes in Aboriginal and Torres Strait Islander populations, a significant number of Aboriginal and Torres Strait Islander women are likely to have undiagnosed diabetes at the time they become pregnant. Consequently, screening all Aboriginal and Torres Strait Islander women for pre-existing diabetes is recommended at the first antenatal care visit.3,54 Tests recommended for screening for undiagnosed diabetes are fasting plasma glucose, plasma glucose after a 75 g glucose load, or random plasma glucose.3 The use of HbA1C levels to screen for diabetes during pregnancy has not yet been fully evaluated, but has been proposed as an alternative test to consider for early pregnancy screening if other tests such as an oral glucose tolerance test are not feasible; an HbA1C level above 6.5% suggests pre-existing diabetes.54

Internationally, screening guidelines for gestational diabetes vary in their recommendations about whether screening should be offered to all pregnant women or only to women with risk factors for diabetes. However, given the higher risk of diabetes experienced by Aboriginal and Torres Strait Islander populations, it is recommended that all pregnant Aboriginal and Torres Strait Islander women without pre-existing diabetes are offered screening for gestational diabetes. The recommended timing for gestational diabetes screening to occur is 24–28 weeks’ gestation, and recommended tests include fasting plasma glucose, or plasma glucose one hour and two hours after a 75 g glucose load.3,54

While diagnostic criteria for gestational diabetes continue to be debated, Australian national evidence-based antenatal care guidelines3 and the Australasian Diabetes in Pregnancy Society54 both recommend the use of criteria endorsed by the World Health Organization (WHO) and International Association of Diabetes and Pregnancy Study Group (refer to ‘Recommendations: Diabetes’).

In discussions about screening for diabetes and gestational diabetes, women need information about the risks associated with these conditions and the effectiveness of management in reducing and mitigating these risks.56,57 In general terms, management strategies for diabetes in pregnancy and gestational diabetes include optimising nutrition, increasing physical activity, monitoring and controlling weight gain, additional monitoring activities including of fetal growth and wellbeing, and the use of medications. Medications include insulin and, increasingly, oral hypoglycaemics for women where adequate glycaemic control is not achieved using non-pharmacological measures. Optimising control of gestational diabetes is important to reduce pregnancy-related risks for the woman and baby, and may also have longer term implications on the health of the infant into adulthood.
For women with gestational diabetes, screening for diabetes after delivery is also important as it provides an opportunity for intervention to improve women’s future health.57

 

 

Resources
National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people

 





 
 
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  10. Laws PG, Sullivan EA. Smoking and pregnancy. Sydney: Australian Institute of Health and Welfare National Perinatal Statistics Unit, 2006.
  11. Thomas DP, Briggs V, Anderson IP, Cunningham J. The social determinants of being an Indigenous non‐smoker. Aust N Z J Public Health 2008;32(2):110–16.
  12. Bond C, Brough M, Spurling G, Hayman N. ‘It had to be my choice’. Indigenous smoking cessation and negotiations of risk, resistance and resilience. Health Risk Soc 2012;14(6):565–81.
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  14. Passey ME, D’Este CA, Stirling JM, Sanson‐Fisher RW. Factors associated with antenatal smoking among Aboriginal and Torres Strait Islander women in two jurisdictions. Drug Alcohol Rev 2012;31(5):608–16.
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  17. Passey ME, Sanson-Fisher RW, Stirling JM. Supporting pregnant Aboriginal and Torres Strait Islander women to quit smoking: Views of antenatal care providers and pregnant Indigenous women. Maternal Child Health J 2014;18(10):2293–99.
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  22. Bookallil M, Chalmers E, Andrew B. Challenges in preventing pyelonephritis in pregnant women in Indigenous communities. Rural Remote Health 2005;5(3):395.
  23. Panaretto KS, Lee HM, Mitchell MR, et al. Prevalence of STIs in pregnant urban Aboriginal and Torres Strait Islander women in northern Australia. Aust N Z J Obstet Gynaecol 2006;46(3):217–24.
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  25. Smaill FM, Vazquez JC. Antibiotics for asymptomatic bacteriuria in pregnancy. Cochrane Database Syst Rev 2015;(8):CD000490.
  26. Ryan GM Jr, Abdella TN, McNeeley SG, Baselski VS, Drummond DE. Chlamydia trachomatis infection in pregnancy and effect of treatment on outcome. Am J Obstet Gynecol 1990;162(1):34–39.
  27. McMillan JA, Weiner LB, Lamberson HV, et al. Efficacy of maternal screening and therapy in the prevention of chlamydia infection of the newborn. Infection 1985;13(6):263–66.
  28. Lewis D, Newton DC, Guy RJ, et al. The prevalence of chlamydia trachomatis infection in Australia: A systematic review and metaanalysis. BMC Infect Dis 2012;12(1):113.
  29. Graham S, Smith LW, Fairley CK, Hocking J. Prevalence of chlamydia, gonorrhoea, syphilis and trichomonas in Aboriginal and Torres Strait Islander Australians: A systematic review and meta-analysis. Sex Health 2016;13(2):99–113.
  30. The Kirby Institute. Bloodborne viral and sexually transmissible infections in Aboriginal and Torres Strait Islander people: Surveillance and evaluation report 2015. Sydney: The Kirby Institute, 2016.
  31. Gülmezoglu AM, Azhar M. Interventions for trichomoniasis in pregnancy. Cochrane Database Syst Rev 2011;(5):CD000220.
  32. Brocklehurst P, Gordon A, Heatley E, Milan SJ. Antibiotics for treating bacterial vaginosis in pregnancy. Cochrane Database Syst Rev 2013;(1):CD000262.
  33. Walker GJ. Antibiotics for syphilis diagnosed during pregnancy. Cochrane Database Syst Rev 2001;(3):CD001143.
  34. Bright A, Dups J. Infectious and congenital syphilis notifications associated with an ongoing outbreak in northern Australia. Commun Dis Intell Q Rep 2016;40(1):E7–10.
  35. Thompson A. Australian recommendations for the management of hepatitis C virus infection: A consensus statement. Med J Aust 2016;204(7):268–72.
  36. Graham S, Guy RJ, Cowie B, et al. Chronic hepatitis B prevalence among Aboriginal and Torres Strait Islander Australians since universal vaccination: A systematic review and meta-analysis. BMC Infect Dis 2013;13(1):403.
  37. Schultz R. Hepatitis B screening among women birthing in Alice Springs Hospital, and immunisation of infants at risk. Northern Territory Disease Control Bulletin 2007;14(2):1–5.
  38. Campbell F, Johnson M, Messina J, Guillaume L, Goyder E. Behavioural interventions for weight management in pregnancy: A systematic review of quantitative and qualitative data. BMC Public Health 2011;11(1):491.
  39. National Health and Medical Research Council. Clinical practice guidelines for the management of overweight and obesity in adults, adolescents and children in Australia. Melbourne: NHMRC, 2013.
  40. Muktabhant B, Lawrie TA, Lumbiganon P, Laopaiboon M. Diet or exercise, or both, for preventing excessive weight gain in pregnancy. Cochrane Database Syst Rev 2015;(6):CD007145.
  41. Australian Bureau of Statistics. Australian Aboriginal and Torres Strait Islander health survey: Biomedical results, 2012–13. Canberra: ABS, 2014. 
  42. National Blood Authority. Patient blood management guidelines: Module 5 – Obstetrics and maternity. Canberra: NBA, 2015.
  43. Bower C, D’Antoine H, Stanley FJ. Neural tube defects in Australia: Trends in encephaloceles and other neural tube defects before and after promotion of folic acid supplementation and voluntary food fortification. Birth Defects Res A Clin Mol Teratol 2009;85(4):269–73.
  44. Macaldowie A. Neural tube defects in Australia: Prevalence before mandatory folic acid fortification. Canberra: AIHW, 2011.
  45. Australian Institute of Health and Welfare. Monitoring the health impacts of mandatory folic acid and iodine fortification. Canberra: AIHW, 2016.
  46. National Health and Medical Research Council. Iodine supplementation during pregnancy and lactation – A literature review. Canberra: NHMRC, 2009.
  47. National Health and Medical Research Council. Iodine supplementation: Public statement. Canberra: NHMRC, 2010.
  48. Paxton GA, Teale GR, Nowson CA, et al. Vitamin D and health in pregnancy, infants, children and adolescents in Australia and New Zealand: A position statement. Med J Aust 2013;198(3):142–43.
  49. Benson J, Wilson A, Stocks N, Moulding N. Muscle pain as an indicator of vitamin D deficiency in an urban Australian Aboriginal population. Med J Aust 2006;185(2):76–77.
  50. Vanlint SJ, Morris HA, Newbury JW, Crockett AJ. Vitamin D insufficiency in Aboriginal Australians. Med J Aust 2011;194(3):131–34.
  51. Lowe LP, Metzger BE, Dyer AR, et al. Hyperglycemia and adverse pregnancy outcome (HAPO) study. Diabetes Care 2012;35(3):574–80.
  52. Contreras M, Sacks DA, Bowling FG, et al. The Hyperglycemia and Adverse Pregnancy Outcome (HAPO) Study. Int J Gynaecol Obstet 2002;78(1):69–77.
  53. McElduff A, Cheung NW, McIntyre HD, et al. The Australasian Diabetes in Pregnancy Society consensus guidelines for the management of type 1 and type 2 diabetes in relation to pregnancy. Med J Aust 2005;183(7):373–77.
  54. Nankervis A, McIntyre H, Moses R, et al. ADIPS consensus guidelines for the testing and diagnosis of hyperglycaemia in pregnancy in Australia and New Zealand. Sydney: Australasian Diabetes in Pregnancy Society, 2014.
  55. Crowther CA, Hiller JE, Moss JR, McPhee AJ, Jeffries WS, Robinson JS. Effect of treatment of gestational diabetes mellitus on pregnancy outcomes. N Engl J Med 2005;352(24):2477–86.
  56. Landon MB, Spong CY, Thom E, et al. A multicenter, randomized trial of treatment for mild gestational diabetes. N Engl J Med 2009;361(14):1339–48.
  57. Chamberlain C, McLean A, Oats J, et al. Low rates of postpartum glucose screening among indigenous and non-indigenous women in Australia with gestational diabetes. Maternal Child Health J 2015;19(3):651–63.
  58. Cancer Council Australia Cervical Cancer Screening Guidelines Working Party. National Cervical Screening Program: Guidelines for the management of screen-detected abnormalities, screening in specific populations and investigation of abnormal vaginal bleeding. Sydney: Cancer Council Australia, 2016.
  59. Woolcock J, Grivell R. Noninvasive prenatal testing. Aust Fam Physician 2014;43(7):432–34.
  60. beyondblue. Clinical practice guidelines for depression and related disorders – anxiety, bipolar disorder and puerperal psychosis – in the perinatal period: A guideline for primary care health professionals. Melbourne: beyondblue, 2011.
  61. Australian Technical Advisory Group on Immunisation. The Australian immunisation handbook. 10th edn. Canberra: Department of Health, 2017.
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Downloads

National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people (PDF 9.8 MB)

 Evidence base to a preventive health assessment in Aboriginal and Torres Strait Islander people (PDF 9.4 MB)

 National Guide Lifecycle chart (child) (PDF 555 KB)

 National Guide Lifecycle chart (young) (PDF 1 MB)

 National Guide Lifecycle chart (adult) (PDF 1 MB)