Jongen et al. BMC Pregnancy and Childbirth 2014, 14:251http://www.biomedcentral.com/1471-2393/14/251

RESEARCH ARTICLE Open Access

Aboriginal and Torres Strait Islander maternal andchild health and wellbeing: a systematic search ofprograms and services in Australian primaryhealth care settingsCrystal Jongen, Janya McCalman*, Roxanne Bainbridge and Komla Tsey

Abstract

Background: Persistent disparities in pregnancy and birth outcomes between Aboriginal and Torres Strait Islanderand other Australians evidence a need to prioritise responsive practice in Maternal Child Health (MCH). This studyreviewed the existing knowledge output on Aboriginal and Torres Strait Islander MCH programs and services withthe objective to advance understanding of the current evidence base and inform MCH service development,including the identification of new research priorities.

Methods: A systematic search of the electronic databases Informit, Proquest, PubMed, Scopus, Wiley, and Cinahl,and 9 relevant websites was undertaken for the period 1993–2012. The reference lists of MCH program reviewswere hand-searched for additional relevant studies which met the eligibility criteria. The study designs of includedpublications were classified and the characteristics extracted and categorized. Evaluation quality was assessed usingthe Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for Quantitative Studies and the CriticalAppraisal Skills Program (CASP) tool for qualitative studies.

Results: Twenty-three search results were identified for inclusion, with the majority published in 2003–2012. Fiftytwo percent of publications reported on programs and services operating out of Aboriginal Community ControlledHealth Organisations, with antenatal and postnatal care the main intervention type/s, and health promotion/education and advice/support the most common intervention component. Outcomes such as increased antenatalattendance and higher infant birth weights were reported in some intervention studies, however methodologicalquality varied considerably with quantitative studies typically rated weak.

Conclusion: The prevalence of community controlled and/or community-based programs is significant given thehealth and wellbeing implications of self-determination. While the literature highlights the promise of manyintervention models and program components used there are some significant gaps in the documentation andimplementation of important MCH interventions. Similarly, while positive health outcomes were reported there areissues with key measures used and study quality. This review highlights the need to improve the quality of evaluationsof MCH programs for Aboriginal and Torres Strait Islander women and to address the key evidence gaps in respondingto their health and wellbeing needs.

Keywords: Antenatal, Postnatal, Indigenous Australians, Pregnancy, Women’s health

* Correspondence: janya.mccalman@jcu.edu.auThe Cairns Institute, James Cook University, PO Box 6811, Cairns QLD 4870,Australia

© 2014 Jongen et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly credited. The Creative Commons Public DomainDedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,unless otherwise stated.

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BackgroundEarly life experiences, beginning with those of the devel-oping foetus, play an important role in creating thefoundations for health and wellbeing throughout the life-time [1]. Due to the impact of Maternal and Child Health(MCH) on general population health, enhancing MCH isa key global health issue and a significant focus of world-wide public health strategies [2]. While improvementshave been made in health outcomes for mothers andinfants globally, Indigenous people worldwide still ex-perience much poorer MCH outcomes compared tonon-indigenous populations [3]. The significant gapsin health and wellbeing equity between Indigenous andnon-Indigenous populations in Australia, as in othersettler colonial countries, have been well described; as hasbeen evidence of achievement of health targets whichhas shown that it is possible to improve health [4].There is a lack of a quality evidence base to guide In-

digenous health and wellbeing programs globally, andparticularly of intervention research focused on testingand analysing the effectiveness of potential solutions [5,6].In contrast, reviews of Aboriginal and Torres Strait Is-lander MCH in Australia have identified literature docu-menting MCH responses and interventions. However,they also identified important gaps in the evidence baseguiding Aboriginal and Torres Strait Islander primaryhealth care MCH strategies. Prior to embarking on newinitiatives in primary health care research or practice, itis important to assess the current state of evidence.Two prominent early reviews of the literature provide

a range of evidence on MCH issues and responses forAboriginal and Torres Strait Islander women and babies[7,8]. Assessing studies of standout Aboriginal and TorresStrait Islander MCH programs, these reviews reportedon outcomes identified in the literature, such as im-provements in antenatal attendance, decreased pre-termbirths and improvements in infant birth weight, associ-ated with MCH programs. Eades [8] provided informa-tion on factors affecting key poor birth outcomes mostlikely to be associated with primary health care, includ-ing genital infections, urinary tract infections (UTI’s),sexually transmitted infections (STI’s) and tobacco andalcohol consumption during pregnancy. Herceg [7] alsoidentified a number of common factors present in suc-cessful Aboriginal and Torres Strait Islander MCH pro-grams, including programs being community-basedand/or community controlled, the presence of Aboriginaland Torres Strait Islander and female staff, outreach,home-visiting and transport.Importantly, the review by Herceg [7] identified evi-

dence gaps for key MCH issues such as tobacco, alcoholand other drug use in pregnancy and effective health pro-motion interventions. This review highlighted the lack ofquality evidence for interventions, and stressed the need

for high quality evaluations of programs. A later reviewextended this assessment in a review of evaluations ofantenatal care programs for Aboriginal and Torres StraitIslander women [9]. This review found particular weak-ness in the diversity of evaluation designs and the qualityof reported data in studies assessed. The authors reiteratedthe need to collect and report good quality longitudinaldata about care programs to demonstrate clinically rele-vant differences in perinatal outcomes.This systematic search was developed in response to

the Queensland Government Centre for Social ScienceInnovation (QCSSI) research priority area of Aboriginaland Torres Strait Islander MCH. This review providesan overview of the literature describing or evaluatingAboriginal and Torres Strait Islander MCH programsand services in Australian primary health care settingsfrom 1993–2012. Primary health care responses includedin this review are first level health care services provid-ing antenatal and postnatal care, and maternal and childcare. These primary care responses, operating out ofmainstream community health services, governmenthealth services and Aboriginal Community ControlledHealth Services, are increasingly being recognised asthe preferred approach for effecting key MCH out-comes, such as reducing the prevalence of low infantbirth weight and pre-term births [8]. The review aimsto: 1) identify the number of publications on MCH pro-grams and services; 2) describe their main characteristics;3) outline the reported outcomes; and 4) assess the meth-odological quality of intervention studies. The objective ofthis review is to advance understanding of the current evi-dence base guiding Aboriginal and Torres Strait IslanderMCH and wellbeing practices and to informprimary healthcare MCH service development, including the identificationof new research priorities.

MethodsSearch strategyFigure 1 summarises the databases searched, the searchterms used, the exclusion criteria, and classification ofstudies. Consistent with methods detailed in Cochraneguidelines for systematic reviews [10] and those used inprevious systematic reviews [11,12], the search strategycomprised three steps. First, consultation with a quali-fied librarian identified six electronic databases: Infor-mit, Proquest (Health and Medical and Social Sciences),PubMed, Scopus, Wiley, and Cinahl. The following termswere searched in either the title or abstract, article orMESH heading of publications: (Aborigin* or Indigen* orTorres Strait Island* or oceanic ancestry group or austral-oid*) and (wellbeing or health) and (Australia) and (childor maternal or parent* or women* or pregnan* or infan*)and (program* or service*) (n = 3507). Second, to maxi-mise coverage of the grey literature, the same librarian

Searches 1 and 2 = 4753 publications (journal articles, reports, book chapters, books, fact sheets, newsletter articles)

Manual search of 4765 citations/abstracts

31 articles categorised by type of publication

EXCLUDEDDuplicates =42Non child and/or maternal health = 837Non-Indigenous Australian = 1587 Not primary health = 429Were not journal articles, reports or book chapters = 621Were reviews, discussion papers, commentaries or case reports = 984 Animal study = 3Published pre 1993 = 231

Additional articles from hand search of reference lists of 3 reviews n = 12

Descriptive research

n= 0

Intervention Research

n= 18

Program Descriptions

n= 13

SEARCH 1

Databases searched:Informit, ProQuest (Health and Medical and Social Sciences), PubMed, Scopus, Wiley and Cinahl

Separate searches for each database using database specific subject headings and keywords:

Search strategy: Keywords used in title or abstract or MESH heading:

(Aborigin* or Indigen* or Torres Strait Island* or oceanic ancestry group or

australoid*) and (wellbeing or health) and (Australia) and (child or maternal or parent* or women* or pregnan* or infan*) and (program* or service*).

Years searched: 1993 – current

Search 1 = 3507 publications (after electronic removal of duplicates)

SEARCH 2

Websites searched:

Australia: Australian Indigenous Health Infonet, Lowitja Institute, National

Aboriginal Community Controlled Health Organisation (NACCHO), National

Aboriginal and Torres Strait Islander Child and Maternal Health Exemplar

Site Initiative, Telethon Institute for Child Health Research, Secretariat of

National Aboriginal and Islander Child Care Resource Clearinghouse

(SNAICC), Australian Institute of Aboriginal and Torres Strait Islander

Studies, Australian Government Office of Aboriginal and Torres Strait

Islander Health (OATSIH), and the Australian Institute of Family Studies

Search strategy: Keywords and/or the appropriate topic headings in each website: (Aborigin* or Indigen* or Torres Strait Island* or oceanic ancestry

group or australoid*) and (wellbeing or health) and (Australia) and (child or

maternal or parent* or women* or pregnan* or infan*) and (program* or service*).The search was limited to the period 1993– current.

Search 2 = 1246 publications (including duplicates)

Measurement Research

n= 0

Figure 1 Flowchart of search strategy.

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searched 9 websites and clearinghouses related to Aborigi-nal and Torres Strait Islander child and maternal health.Included were the Australian Indigenous Health Infonet,Lowitja Institute, National Aboriginal Community ControlledHealth Organisation, National Aboriginal and Torres StraitIslander Child and Maternal Health Exemplar Site Initiative,Telethon Institute for Child Health Research, Secretariatof National Aboriginal and Islander Child Care ResourceClearinghouse, Australian Institute of Aboriginal and TorresStrait Islander Studies, Australian Government Officeof Aboriginal and Torres Strait Islander Health, and the

Australian Institute of Family Studies (n = 1246). The datelast searched was 17/05/2013. Third, a researcher (CJ)hand-searched the reference lists of reviews of Aboriginaland Torres Strait Islander health and wellbeing interven-tions identified by the electronic database search for rele-vant studies not yet identified (n = 12). The initial searchyielded 4765 search results.

Step 1: Identification of studies for exclusionStudies were excluded if they: (a) were duplicates (n = 42);(b) did not focus on child and/or maternal health, or if the

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outcomes or predictor variables did not include or specif-ically relate to child and/or maternal health (n = 837); (c)did not focus on Indigenous people in Australia (n =1587); (d) were not on primary health care programsand services (n = 429); e) were not journal articles, re-ports or book chapters (n = 621); f ) were reviews, dis-cussion papers, commentaries or case reports (n = 984);g) were focused only on child health (n = 8) and h) werepublished pre 1993 (n = 234). Step 1 excluded 4726 ref-erences, leaving 23 search results.

Step 2: Classification of studiesThe remaining 23 studies were examined to identify stud-ies that were; 1) Intervention research: defined as studieswhich test the effectiveness of public health Aboriginaland Torres Strait Islander child and maternal health re-sponses or examines the impact of interventions designedto alter health-related knowledge, attitudes or behaviours,or to improve health care delivery; or 2) Program descrip-tions: defined as literature which describes the methodsor processes applied to implement a child and maternalhealth response, but in which no data-based evaluationwas reported [6].

Data extractionThe characteristics of studies of Aboriginal and TorresStrait Islander child and maternal health responses werecategorised by: 1) 1st author & year; 2) publication typeand study type; 3) location and organisational setting; 4)intervention issue; 5) intervention types and components;6) target group, sample; 7) outcomes or effects; and8) study design and study quality (intervention studiesonly). Two researchers reviewed the publication character-istics and agreed on 22 out of 23, achieving 95.6% inter-rater reliability.

Study quality assessmentMethodological quality of quantitative studies were assessedusing the Dictionary for Effective Public Health PracticeProject (EPHPP) Quality Assessment Tool for QuantitativeStudies [13]. Sections A to F (A. selection bias; B. studydesign; C. confounders; D. blinding; E. data collectionmethods; and F. withdrawal and drop-outs) were codedweak, moderate or strong, consistent with the componentrating scale of the Dictionary. For Sections G (interventionintegrity) and H (analyses) descriptive information will berecorded, in line with the Dictionary recommendations.For qualitative studies,the Critical Appraisal Skills Pro-gram (CASP) quality assessment tool was used [14]. Thistool assesses the clarity of study objectives, the quality ofthe methodology, research design, data collection and ana-lyses, ethical considerations, whether there is a clear state-ment of findings and the value of the research. To assessthe study quality of those using mixed-methods study

design, the qualitative and quantitative components wereassessed separately using both of the aforementionedtools.

ResultsTable 1 summarises the characteristics of included studies.

Publication year and study designFrom a low during the 1990’s, there was a significant in-crease in publications from 2003. With only three studiespublished in the period from 1993–2002 (13%) [15-17],the largest number of publications found were for theperiod 2003–2007 (9/23, 39%) [18-26] and another five(22%) were published in the period 2008-2012 [27-31].Publication dates were not available for a further 6 (26%)search results as these were from websites and no dateswere recorded [32-37]. Fifty two percent (12/23) of thepublications were intervention studies i.e., evaluations ofprograms or services [16-18,20-26,28,31]. The other 48%(11/23) were program descriptions [15,19,27,29,30,32-37].

Location and organisation settingThe programs and services identified in the literatureoperated from a range of locations throughout Australia.The distribution of documented programs and servicesby state was Western Australia (5/23, 22%) [16,32-34,37],New South Wales (4/23, 17%) [18,21,27,29], the NorthernTerritory (4/23, 17%) [17,20,25,36], Queensland (3/23,13%) [15,23,24], South Australia (3/23, 13%) [19,28,35],the Australian Capital Territory (2/23, 9%) [30,31] andVictoria (1/23, 4%) [22]. One additional publication re-ported on three programs operating in South Australia,New South Wales and Queensland [26].The majority of publications reported on programs

and services operating from Aboriginal CommunityControlled Health Organisations (ACCHO) (12/23, 52%)[20-24,26,29-31,35-37]. There were 5 publications docu-menting government programs (22%) [17,18,25,27,32] and3 documenting programs operating out of mainstreamprimary health services (13%) [15,33,34]. One study docu-mented a program delivered by an Aboriginal Maternaland Infant Care team across a range of sites, includinglocal Aboriginal Health Service’s [19]. Another study wason a community initiated program operating across sev-eral communities using a government developed programdelivered by local Aboriginal women [16]. There was alsoan evaluation of a joint government and community initia-tive [28].

Target population and intervention issueSix of the publications stated the target group for pro-grams and services generally as Aboriginal and TorresStrait Islander mothers and their children/babies/families(6/23, 26%) [20,21,26,28,30,32] without specifying whether

Table 1 Aboriginal and Torres Strait Islander MIH program study characteristics

1st authorand year

Program/servicename

Publication typeand Study Type

Location andOrganisation

Setting

InterventionIssue

Intervention Typeand Components

Target Group,and Sample Size

Outcomes or Effects Study Design andStudy Quality

(intervention studiesonly)

Murphey, E. et al.(2012) [27]

The AboriginalMaternal and InfantHealth Service (AMIHS)

Journal ArticleProgramdescription(Outcomes basedon previousevaluation of theNSW AboriginalMaternal andInfant HealthStrategy)

NSW State wideGovernmentstrategy deliveredthrough localgovernment areas(LGA) with careprovided in thecommunity

Health ofAboriginal womenduring pregnancyand perinatalmorbidity andmortality ofAboriginal infants

-Antenatal andpostnatal care-Training andsupport formidwives andAboriginal HealthWorkers

Target Group:Aboriginal womenand their babies,from conceptionup to 8 weekspostpartum

-Increased antenatalattendance -Higherbirth weights-Decreased pretermbirths -Decreasedperinatal mortality-Improved breastfeedingrates

N/A – ProgramDescription

NSW Health(2005) [18]

NSW AboriginalMaternal and InfantHealth Strategy(AMIHS)

Evaluation ReportInterventionResearch

NSW State wideGovernmentstrategy deliveredthrough localgovernment areas(LGA) with careprovided in thecommunity

Health ofAboriginal womenduring pregnancyand perinatalmorbidity andmortality ofAboriginal infants

Targeted antenatal/postnatal programs

Target Group:Aboriginal womenand their babies,from conceptionup to 8 weekspostpartumSample Size: careprovided towomen in 2003and 2004 n=689peopleinterviewedn=201

-Improved antenatalattendance prior to 20weeks gestation-Improved breastfeedingrates -Decrease in lowbirth weight babiesDecrease in perinataldeaths -No change inproportion of womensmoking duringpregnancy

Study Design:Prospective programspecific quantitative datacompared withpopulation-based datafrom the NSW MidwivesData Collection.Qualitative data collectedthrough Interviews andfocus groups. Study Qual-ity: Mixed-method Quan-titative - Weak Qualitative- Weak

Boles, C. et al.(2005) [19]

The AlternativeBirthing Project:Anangu Bibi

Conference paperProgramdescription

Port Augusta andWhyalla SA –Northern and FarNorthern RegionalHealth Service SA(rural) Delivered inpeople’s homesand across a rangeof local servicesand organisationsincluding localAboriginal HealthServices.

Poor Aboriginalmaternal andinfant health, lowantenatalattendance, lowinfant birthweight, highteenagepregnancy rates

-Continuum-of-caremodel led byAboriginal maternaland infant careworkers supported bymidwives, GP andobstetricianPregnancy checkups-Assessing for riskfactors and educa-tion about earlywarning signs ofcomplications-Healthpromotion andeducation-Postnatalsupport up to 8weeks after birth

Target Group:Teenage mothersand youngAboriginal women

N/A N/A – ProgramDescription

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Table 1 Aboriginal and Torres Strait Islander MIH program study characteristics (Continued)

Carter, E. et al.(2004) [20]

Congress Alukurra Journal ArticleInterventionResearch

Alice Springs,Central Australia(remote) ACCHO –Congress Alukurra

Women’s health -Comprehensiveantenatal andpostnatal care-Sharedmaternity care-Gynaecologicalservices -Sexualassault anddomestic violencecounselling andexaminations -Healtheducation-Transportation -Healthworker training-Mobile bush clinic

Target Group:Aboriginal womenand childrenSample Size: Notavailable

-Increased client visits-Increase in womenhaving first trimesterantenatal visit -Slightincrease in mean birthweight of infants from1986-89 to 1991-95 and1996-99.

Study Design: Analysis ofdocuments and reportsand secondary analysisof published andunpublishedepidemiological datafrom Alukurra and theNorthern TerritoryMidwives Collection.Routinely collectedclient information andchanges in those factorsover the previous fiveyears was summarised.Interviews andconsultations wereconducted forqualitative studycomponents. StudyQuality: Mixed-method;Quantitative - WeakQualitative – Moderate

Jan, S. et al.(2004) [21]

Daruk AboriginalMedical ServiceMidwifery Program

Journal ArticleInterventionresearch

Mt Druitt, WesternSydney (urban)ACCHO – DarukAboriginal MedicalService

Aboriginalperinatal andmaternal health

-Antenatal andpostnatal care-Antenatal checkups-Hospital booking-Transport -Homevisits -Labour supportand delivery -Hospitalvisits -Assistance withinfant feeding

Target Group:Aboriginalwomen/mothersand their infantsSample Size: Notavailable

-Lower gestational ageat first visit -Highernumber of antenatalvisits -Women reportedpositive experienceswith Daruk

Study Design: Measuresof antenatal attendanceand perinatal outcomesin clinical records werecompared with the NSWMidwives DataCollection. Interviewsand focus groups wereused for the qualitativecomponent. StudyQuality: Mixed-method;Holistic economicevaluation Quantitative- Moderate Qualitative –Moderate

AustralianIndigenousHealth Infonet

Healthy for LifeMaternal and ChildHealth Program,Derbarl YerriganHealth Service

WebpageProgramDescription

Perth, WA (urban)ACCHO – DerbarlYerrigan HealthService

Aboriginalmaternal andchild health

Goals: To improvepre-pregnancyhealth of women,increase pre-pregnancyimmunisation, parentaleducation and support,and home-visits

Target Group:Aboriginalwomen/mothersand children upto 5 years

N/A N/A – ProgramDescription

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Table 1 Aboriginal and Torres Strait Islander MIH program study characteristics (Continued)

Campbell, S.et al. (2004)

Women’s BusinessService Mildura

Journal ArticleInterventionresearch

Mildura, VIC (rural)ACCHO – MilduraAboriginal HealthService

Maternity care -Pregnancy screening-Antenatal andpostnatal care-Education andinformation -Supportduring labour andbirth -Check-up’s

Target Group:Aboriginal womenin Mildura SampleSize: clientsinterviewed n=25survey participantsn=333

Women attending theservice were significantlymore positive aboutmany aspects of theircare than womenattending other ruralpublic maternity services

Study Design: Interviewswere conducted usingand structured interviewschedule based on theVictorian Survey ofRecent Mothers 2000.The views andexperiences of womenattending the Women’sBusiness Service wereassessed and contrastedwith those of ruralwomen whoparticipated in the 2000state wide survey. StudyQuality: Qualitative -Strong

AustralianIndigenousHealth Infonet

Moort Boodjari Mia(Family PregnancyHouse)

WebpageProgramdescription

Perth, WA (urban)Mainstreamcommunity healthservice – NorthMetropolitanHealth Service

Maternal healthcare

-Antenatal andpostnatal clinical care-Guidance, supportand education

Target Group:Indigenouswomen, mothersand families,during pregnancyup to 4 weekspostpartum

N/A N/A – ProgramDescription

Panaretto, K. S.et al. (2007)[23]

Mums and Babies(MB) Program

Journal ArticleInterventionResearch

Townsville, QLD(rural) ACCHO –TownsvilleAboriginal andIslander HealthService

Aboriginal andTorres StraitIslander Infant andmaternal health

-Integrated model ofantenatal sharedcare Integrated teamapproach betweenAboriginal HealthWorker, midwives/child health nurses,Doctors and Obstetricteam -Indigenousoutreach healthworker -Pregnancyregistrar -Walk in clinic-Familyorientation -Careplans -PCR testing forSTI’s -Transport serviceBriefintervention for riskfactors (smokingcessation, nutrition,antenatal education,breast feeding, suddeninfant deathsyndrome)

Target Group:Indigenouswomen SampleSize: MB groupn=781 PreMBgroup n=84

-Decrease in perinatalmortality -Increase inantenatal visits-Improvements in careplanning -Completion ofcycle-of-care -Antenataleducation

Study Design:Comparative study withhistorical controlgroupStudy Quality:Quantitative - Weak

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Table 1 Aboriginal and Torres Strait Islander MIH program study characteristics (Continued)

Panaretto, K.et al. (2005)[24]

Mums and Babies(MB) Program

Journal ArticleInterventionResearch

Townsville, QLD(rural) ACCHO –TownsvilleAboriginal andIslander HealthService

Aboriginal andTorres StraitIslander Infant andmaternal health

Integrated model ofantenatal shared care

Target Group:Indigenouswomen SampleSize: MB groupn=45 PreMBgroup n=84Contemporarycontrol groupn=540

-Increase in number ofomen attending therogram who gave birthhospital -Increase in

umber of antenatalsits -Reduction inre-term births

Study Design:Comparative study withhistorical control groupand contemporarycontrol group StudyQuality: Quantitative -Weak

AustralianIndigenousHealth Infonet

Nganampa HealthCouncil Child andMaternal HealthProgram

Web pageProgramdescription

AnanguPitjantjatjara/

Yankinytjatjaralands,SA (remote) ACCHO -Nganampa HealthCouncil

Aboriginal childand maternalhealth

n antenatal carerogram -Developmentd delivery of keyessages healthducation packages forung mothers -Childealth program:rotocolised growthonitoring for childrennder 5 years of aged targeted childealth screening ates 5, 10 and 14

Target Group: Aboriginalmothers and children0-14 years

N/A N/A – ProgramDescription

Power, C. et al.(2008) [28]

Ngangkitta NgartotdliKarpandi (SupportingMums and Babies)Program

Evaluation ReportInterventionResearch

Adelaide, SA(urban) Jointgovernment andcommunityinitiative

Aboriginal andTorres StraitIslander womenand babies health

Framework for anintegrated maternitycare service forIndigenous womenand their babies.Accessible andprovides culturallyresponsive andtimely maternityservices

Target Group:Indigenousmothers and theirbabies SampleSize: Womenenrolled in projectduring evaluationn=14

ll attending womenad a antenatal planomen successfullygaged with thervice -All womenirthed at their localaternity servicencrease in referrals topropriate supportrvices -Womenported positiveperiences of services

Study Design: Six phaseAction Research design.Quantitative datacollected from toolsdeveloped to measurekey performanceindicators were collatedand compared to data forAboriginal women andinfants in the SouthernAdelaide Health Servicecatchment area from thePregnancy OutcomesUnit of the SouthAustralian Department ofHealth. Face to faceinterviews with clientsand telephone interviewswith service providerswere conducted for thequalitative studycomponent. Study Quality:Mixed-method; ActionResearch - Quantitative -Weak Qualitative - Strong

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wpatnvip

-ApanmeyohPmuanhag

-Ah-Wensebm-Iapsereex

Table 1 Aboriginal and Torres Strait Islander MIH program study characteristics (Continued)

Dorman, R.et al. (1997)[15]

Ngua Gundi (Motherand Child) Program

Journal ArticleProgramDescription

Rockhampton,QLD (rural)Mainstreamcommunity healthservice

Indigenousmaternal andinfant health

-Antenatal clinic-Midwifery model ofcare - referrals toother medicalpractitioners -homevisits -antenataleducation -under5’s clinic

Target Group:Indigenousmothers andchildren frompre-pregnancy to5 years

N/A N/A – ProgramDescription

Smith, R. M.et al. (2000)[16]

Strong Women,Strong Babies, StrongCulture (WA)

Journal ArticleInterventionResearch

Aboriginalcommunitiesacross theKimberley andPilbara regions,WA (remote)Communityinitiated programdelivered byAboriginal womenacross 5communities. SW,SB,SC is agovernmentdevelopedprogramadministeredthrough theTerritory HealthServices Darwin

Infant birthweights and childgrowth

-Nutritionalintervention toimprove birthweights and growthof infants andchildren -Nutritionalassessment of infantsand children-Counselling ofmothers and carers-Implementation ofmaternal supportprogram

Target Group:Aboriginalmothers andchildren 0-3 yearsSample Size: Notavailable

e intervention wasot accompanied byy change in full-termirth weight but wassociated withcreased weight gainter 6 months.

Study Design:Comparative study withhistorical control groupStudy Quality:Quantitative - Weak

Mackerras, D.(2001) [17]

Strong Women,Strong Babies, StrongCulture (NT)

Journal ArticleInterventionResearch

NT (remote)Community-basedprogram – pro-gram developedby the NorthernTerritoryDepartment ofHealth andCommunityServices in con-junction withAboriginalpeople

Infant birthweight

-Increased attendancefor antenatal care infirst trimester -Riskassessment for potentialcomplications-Introduced nutritionalassessment andmonitoring intoprenatal care-Strategies to improvematernal nutritionand increase maternalweight gain

Target Group:Aboriginal womenwho are pregnantor of childbearingage Sample Size:Not available

crease in the meanirth weight of infantsf Aboriginal womenhanges in maternaleight were associatedith changes in birtheight over time

Study Design:Data fromthe NT MidwivesCollection and fromantenatal charts forbirths in thecommunities were usedto determine changes inmean birth weights ofinfants in the three pilotcommunities comparesto other NTcommunities. StudyQuality: Quantitative -Weak

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Thnanbasinaf

-Inbo-Cwww

Table 1 Aboriginal and Torres Strait Islander MIH program study characteristics (Continued)

Tursand’Espaignet, E.et al. (2003)[25]

Strong Women,Strong Babies, StrongCulture (NT)

Journal ArticleInterventionresearch

NT (remote)Community-basedprogram – programdeveloped by theNorthern TerritoryDepartment ofHealth andCommunity Servicesin conjunction withAboriginal people

Perinatal healthand infant birthweight

-Senior women incommunities helpingyounger womenprepare forpregnancy -Antenatalcare -Advice andencouragement toimprove nutrition(including increase inuse of bush foods)-Encouragingreduction in alcoholand tobaccoconsumptionEncouragement toseek medicalassistance

Target Group:Aboriginal womenwho are pregnantor of childbearingage Sample Size:Group 1 Pre-interventionn=577 Post-interventionn=829 Controlgroup 1 Pren=2118 Postn=3070 Group 2Pre n=814 Postn=322 Controlgroup 2 Pren=3511 Postn=1677

-Significantimprovements in infantbirth weight wasreported in oneintervention group

Study Design: Acomparison of pre andpost intervention birthweights in interventionand controlcommunities wasperformed Study Quality:Quantitative - Weak

Crook, L. et al.(2012) [29]

Waminda Mums andBubs Program

Journal ArticleProgramdescription

Nowra, NSWSouth Coast (rural)ACCHO –Women’s healthand welfareservice

Aboriginalmaternal andchild health

-Antenatal andpostnatal care-Health anddevelopmentinformation aboutinfant care -Practicaladvice and assistancewith breastfeeding,nutrition and parentingskills -Monitoringchildren’s weight,immunisation statusand growth mile-stones -Early testingto detect issues withchildren’s hearing,sight speech andother developmentalissues prior tocommencing school -Health checks-Physical examinations-Screening -Pathology-Home visiting-Immunisation-Health assessments-Education sessions

Target Group:From pre-conception, toantenatal, birthing,postnatal andcontinuous care(lifelong care forall females andmales up to 14years)

N/A N/A – ProgramDescription

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Table 1 Aboriginal and Torres Strait Islander MIH program study characteristics (Continued)

Adams, E. et al.(2011) [30]

WinnungaNimmityjah Perinataland infant mentalhealth service

Journal ArticleProgramdescription

ACT (urban)ACCHO - WinnungaNimmityjah

Perinatal andinfant social andemotional wellbeing(mental health)

Perinatal and infantmental health service

Target Group:Aboriginalmothers and theirbabies

N/A N/A – ProgramDescription

Wong, R. et al.(2011) [31]

WinnungaNimmityjahAboriginal MidwiferyAccess Program(AMAP)

Journal ArticleInterventionResearch

ACT (urban)ACCHO -WinnungaNimmityjah

Aboriginalmaternal andchild health

-Antenatal care -Birthsupport -Postnatalcare - Full antenatalcare -Home visits-Assistance withappointments-Transport -Birthsupport -Post natalfollow up-immunisations

Target Group:Aboriginal andTorres StraitIslander women inACT Sample Size:Attended AMAPWomen n=187Babies n=193

AMAP clients had-Higher smoking rates-Lower caesarean ate-Lower proportion ofpre-term births -Lowerproportion of low birthweight babies

Study Design:Comparison betweenAMAP client data andACT Maternal andPerinatal Collection dataStudy Quality:Quantitative - Weak

AustralianIndigenousHealth Infonet

Wurli Wurlinjangchild and maternal/women’s healthprogram

Web pageProgramdescription

Katherine andsurrounding areas,NT (remote)ACCHO - WurliWurlinjang

Child andmaternal/women’shealth

-Health promotionand education.Preventative healthcare -childhoodimmunisations-growth assessment-child health checks-education aroundsubstance misuseand nutrition in earlychildhood develop-ment PAP screening

N/A N/A N/A – ProgramDescription

AustralianIndigenousHealth Infonet

Boodjari Yorda(Pregnant women’s)Program

Web pageProgramdescription(Outcomesprovided with nosupportingdocumentation)

Wheat belt region,WA (rural)Governmentprogram

Women’s/maternal health

-Antenatal andpostnatal care-Home visits-Assistance attendingappointments -Sexualand reproductivehealth education-Nutrition educationsupport

Target Group:Indigenouswomen and theirfamilies

Reduction in overdueimmunisations andimproved nutritionalstatus

N/A – ProgramDescription

AustralianIndigenousHealth Infonet

Moorditj Boodjareeyorgers (maternalhealth)

Web pageProgramdescription

Bentley-Armadalearea, WA (urban)Mainstreamcommunityservice – MedicareLocal

Maternal health -Antenatal andpostnatal support-Home check ups-Information, educationand resources aboutpregnancy, nutritionand taking baby home-At home post-natalsupport up to 6 weeksafter birth -Informationand resources aboutbreastfeeding,immunisation,services and groups

Target Group:Indigenousmothers andbabies up to 6weeks postpartum

N/A N/A – ProgramDescription

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Office forAboriginal andTorres StraitIslander Health(OATSI H),(2005) [26]

Aboriginal and TorresStrait Islander Childand Maternal HealthExemplar SiteInitiative: Sire Reports2005 NganampaHealth Council Childand Maternal HealthProgram (SA)Townsville Mums andBabies Program(QLD) DurriAboriginal MedicalService Djuli GalbanProgram (NSW)

ReportInterventionResearch

AnanguPitjantjatjara/Yankinytjatjaralands, SA ,Townsville QLD,Kempsey NSW(remote and rural)ACCHO - Nga-nampa HealthCouncil ACCHO -Townsville Mumsand Babies ProgramAboriginal MedicalService - DurriAboriginal MedicalService

Indigenousmaternal andchild health

Nganampa Antenatalcare program-Development anddelivery of KeyMessages HealthEducation Packagesfor young mothers-Child health programincluding; childhoodimmunisation,protocolised growthmonitoring forunder 5’s, andtargeted healthchecks at ages 5, 10and 14 Mums andBabies -maternal/paternal and childhealth, acute care,preventive care andfollow-up -one-on-one education/health promotion(eg antenatal andpostnatal health,nutrition, substanceuse, family violence)-transport -sharedantenatal care withthe TownsvilleHospital-immunisation-growth anddevelopmentalmonitoring -Referral,advocacy and socialsupport. Djuli Galban-Antenatal andpostnatal services-Brief interventioneducation aroundrisk factors such assmoking and druguse during pregnancy-Child health services-Immunisationservices

Target Group:Indigenouswomen/mothersand childrenSample Size: Notavailable

Nganampa Earlierantenatal attendanceIncreased antenatalattendance -Decrease inbabies born with lowbirth weight -Decreasedrates of malnutrition andstunting -Higher rates ofchildhood immunisationcoverage Mums andBabies -Increased accessto antenatal care-Increase in number ofantenatal births perpregnancy -Decrease inpre-term births-Decrease in babies bornwith low birth weight-Increase in mean birthweight Djuli Galban-High rates of antenatalattendance prior to 20weeks gestation -Nosignificant changes inrates of pre-term birthsand babies with lowbirth-weight -Increasedrates of childhoodimmunisation

Information on studydesign and methods notprovided Weak

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care was provided pre-pregnancy and until what age afterbirth. Aboriginal and/or Torres Strait Islander or Indigen-ous women (4/23, 17%) [22-24,31], Aboriginal womenwho are pregnant or of childbearing age [17,25] and teen-age mothers and young Aboriginal mothers [19] were alsostated target groups. Several of the studies documentedprograms and services which provide post natal and childhealth services for infants and children of ages varyingfrom 4 weeks up to 14 years [24-31]. There were onlythree publications which specified that the service was forwomen prior to pregnancy [15,20,29].Nineteen of studies reviewed (19/23, 83%) [15,18-24,

26-29,31-33,36,37] identified a general intervention issue(eg. ‘perinatal and maternal health’, ‘maternity care’ and‘child and maternal health’) which were grouped under thebroad category of Aboriginal and Torres Strait Islandermaternal and child health and wellbeing. This general cat-egorisation is underpinned by an extensive literature baseoutlining the key MCH needs of Aboriginal and TorresStrait Islander peoples targeted by programs and services.More specific or targeted intervention issues such aslow antenatal attendance [19], low infant birth weight[16,17,19,25], high teenage pregnancy rates [19], poorchild growth [16] and perinatal and infant social andemotional wellbeing (mental health) [30] were also re-ferred to in the literature.

Intervention type and componentsAntenatal and postnatal care were identified as the mainintervention types in 14 (61%) of the search documents[15,17,18,20-22,25,27,29,31-33]. Another 4 (17%) publi-cations identified an integrated or continuum model ofmaternity care as the main intervention [19,23,24,28].One publication documenting a service targeting mothersand infants identified health promotion and education asthe primary intervention [36], another identified advocacy,support and psychotherapy as the main interventions [30]and two did not state a main intervention type [16,37].The most common component of interventions cited in

the literature documenting MCH was health promotion/education and advice/support (16/23, 70%) [15,16,19,20,22,23,25,26,29,30,32,33,36,37]. Health promotion topics doc-umented included nutrition [23,25,32,33,36], breastfeeding[23,33], immunisation [33], infant care [33] and accessinggroups and services [33]. Publications that described orevaluated these health promotion/education and advice/support activities focused on the health issues of smokingcessation [23], sexual and reproductive health [32], sub-stance misuse [25,36], early warning signs of complica-tions [19] and Sudden Infant Death Syndrome (SIDS)[23]. Other common intervention components docu-mented in the literature include home visitation (8/23,35%) [15,26,29,31-33,36,37], antenatal and postnatalcheckups and support (5/23, 22%) [19,22,31,33,36], transport

services (4/23, 17%) [20,23,31,36], labor/birth support (3/23, 13%) [22,31,36], assistance making or attending ap-pointments and hospital bookings (3/23, 13%) [21,31,32],pregnancy screening (2/23, 9%) [22,29], counseling/psy-chotherapy (2/23, 9%) [16,30], referrals (2/23, 9%) [15,26]and training and support for midwives and AboriginalHealth Workers (2/23, 9%) [20,27].

Outcomes and effectsOf the 23 publications, 14(61%) reported program out-comes and/or effects. These included the 12 interventionstudies plus two program descriptions (one was basedon an evaluation report [27] and the other simply claimedoutcomes without providing evidence [32]). The outcomesand effects described in the literature on maternal and in-fant health services included an increase in antenatal at-tendance (6/23, 26%) [20,21,23,24,26,27], an increase ininfant birth weights (5/23, 22%) [17,20,25-27], a decreasein, or lower proportion of, pre-term births (4/23, 17%)[24,26,27,31], earlier antenatal attendance (4/23, 17%)[18,20,21,26] and a decrease in, or lower proportion of,low birth weight babies [18,26,31]. Decreased perinatalmortality [18,23,27], reports of positive views and/or expe-riences of the service from service users [21,22], improvedbreastfeeding rates [18,27] and improved nutritional statussuch as decreased rates of stunting and malnutrition[26,32] were also reported. Other outcomes includedhigher rates of childhood immunisation coverage, im-provements in care planning [23], lower caesarean rates[31] and changes in birth weight associated with changesin maternal weight [17]. Completion of cycle of care [23]and reduction in overdue immunisations [32] were eachcited as outcomes along with an increase in infant weightafter six months [16]. One study reported the outcomes ofall women having an antenatal plan, women having suc-cessfully engaged with the service, all women havingbirthed at their local maternity service and an increasein referrals to appropriate support services [28]. Oneevaluation study described no changes in the proportionof women smoking during pregnancy [18].

Methodological quality of intervention studiesThe 12 intervention studies were assessed for studyquality. All 6 studies which employed solely quantitativemethods were rated as weak. There were four mixed-method studies, three of which were rated as weak forthe quantitative aspect, and the other moderate. Quanti-tative studies most commonly received weak ratings forconfounders, data collection methods and withdrawalsand drop outs (see Tables 2 and 3 for further details onstudy quality assessments). For the qualitative componentof mixed-method evaluations, two were rated moderate,one weak, and the other strong. There was a further quali-tative study which was rated strong, and one study that

Table 2 Effective Public Health Practice Project (EPHPP) quality assessment of quantitative studies

Publication Selectionbias

Studydesign

Confounders Blinding Datacollectionmethods

Withdrawalsand dropouts

Interventionintegrity*

Analyses** Totalscore

Jan, S., et. al.(2004) [21]

Moderate Moderate Weak Moderate Weak Not applicable (Q1) Can’t tell (Q1) Individual Moderate

(Q2) Can’t tell (Q2)Organisation

(Q3) Can’t tell(Q3) Yes

(Q4) No

Carter, E. et al.(2004) [20]

Moderate Moderate Weak Weak Weak Not applicable (Q1) Can’t tell (Q1) Individual Weak

(Q2) Can’t tell (Q2)Organisation

(Q3) Can’t tell(Q3) Yes

(Q4) No

NSW Health(2005) [18]

Moderate Moderate Weak Weak Weak Weak (Q1) 80-100% (Q1) Individual Weak

(Q2) Can’t tell (Q2) Individual

(Q3) Can’t tell (Q3) Yes

(Q4) No

Power, C. et al.(2008) [28]

Weak Weak Weak Weak Weak Weak (Q1) 80-100% (Q1) Individual Weak

(Q2) Can’t tell (Q2) Individual

(Q3) Can’t tell (Q3) Yes

(Q4) No

Panaretto, K. S.et al. (2007) [23]

Moderate Moderate Weak Moderate Weak Weak (Q1) 80-100% (Q1) Individual Weak

(Q2) No (Q2) Individual

(Q3) Can’t tell (Q3) Yes

(Q4) No

Panaretto, K.et al. (2005) [24]

Moderate Moderate Weak Moderate Weak Weak (Q1) 80-100% (Q1) Individual Weak

(Q2) No (Q2) Individual

(Q3) Yes

(Q3) Can’t tell

(Q4) No

Smith, R. M.et al. (2000) [16]

Moderate Moderate Weak Moderate Weak Weak (Q1) 80-100%(Q2) Can’t tell

(Q1)Community

Weak

(Q3) Can’t tell (Q2) Individual

(Q3) Yes

(Q4) No

Mackerras, D.(2001) [17]

Moderate Moderate Weak Moderate Weak Weak (Q1) Can’t tell (Q1) Community Weak

(Q2) No

(Q3) Can’t tell (Q2) Individual

(Q3) Yes

(Q4) No

Tursan d’Espaignet, E.et al. (2003) [25]

Moderate Moderate Weak Moderate Weak Weak (Q1) Can’t tell (Q1)Community

Weak

(Q2) Can’t tell

(Q3) Can’t tell (Q2) Individual

(Q3) Yes

(Q4) No

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Table 2 Effective Public Health Practice Project (EPHPP) quality assessment of quantitative studies (Continued)

Wong, R. et al.(2011) [31]

Moderate Moderate Weak Moderate Weak Weak (Q1) Can’t tell (Q1) Individual Weak

(Q2) Can’t tell (Q2) Individual

(Q3) Can’t tell (Q3) Can’t tell

(Q4) No

*Intervention Integrity.Q1) What percentage of participants received the allocated intervention or exposure of interest.Q2) Was the consistency of the intervention measured?Q3) Is it likely that participants received an unintended intervention (contamination or co-intervention) that may influence the result?**Analyses.Q1) Unit of allocation.Q2) Unit of analyses.Q3) Are the statistical methods appropriate for the study design?Q4) Is the analyses performed by intervention allocation status (i.e. intention to treat) rather than the actual intervention received?

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was rated weak due to lack of information regarding thestudy design and methods used.

DiscussionThis systematic literature review contributes detailed in-formation about the characteristics of programs and ser-vices for Aboriginal and Torres Strait Islander MCH.Results pertaining to the reported outcomes or effectsand the lack of high quality evaluations mirror the find-ings of previous reviews of Aboriginal and Torres StraitIslander MCH programs and services. This paper ex-tends the existing knowledge base by updating the litera-ture search and contributing new findings about theorganisational settings, program content and compo-nents, and reported outcomes of MCH programs andservices. As well, our review of study quality draws at-tention to the gaps in evidence. Building on the know-ledge presented in previous reviews, the conclusionsdrawn here contribute to the broader understanding ofwhat is required to improve the health and wellbeing ofAboriginal and Torres Strait Islander mothers andinfants.

Organisation settingThe finding that over half of publications reviewed(52%) reported on MCH programs operating out ofACCHO’s is significant considering the connection be-tween the need for self-determination and Aboriginaland Torres Strait Islander health and wellbeing. A lackof power and control has long been recognised as con-tributing to the health inequality experienced by Abori-ginal and Torres Strait Islander peoples, hence thesignificance and continuing use of community control ofdecision-making processes and resources as a health im-provement strategy [38]. Along with the prevalence ofcommunity controlled MCH care programs, a furthertwo studies reviewed documented a community-basedprogram developed by the NT government in conjunctionwith Aboriginal people [17,25] and another one on a com-munity initiated program developed and administered by

the government [16]. These findings supports that ofHerceg [7] which found that being community basedand/or community controlled is one factor important insuccessful Aboriginal and Torres Strait Islander MCHprograms around Australia. This strong presence of com-munity controlled and community-based or initiated pro-grams is a positive indicator of efforts to enhance theoverall wellbeing, not only of Aboriginal and Torres StraitIslander women and their babies, but also of the commu-nities in which they live. It is important to note, however,that 22% of publications being on government programsand services and 13% on programs operating out of main-stream community health services demonstrates the im-portant role that the mainstream primary health sectorhas an to play in addressing the health needs of Aboriginaland Torres Strait Islander mothers and infants.

Program content and componentsIn regards to the types of responses outlined, the mainintervention type reported in the publications was ante-natal and postnatal care (61%), however details of whatthis care entailed were not provided. There are currentlyno Australian national guidelines for the provision ofantenatal care and research has found that, althoughprotocols used in different antenatal care settings havecommon areas, there is significant variation in coverageand recommendations about schedules and tests [39]. Inthe absence of thorough documentation of tests, screen-ing procedures and treatments undertaken in the studiesreviewed, it was impossible to assess quality of antenataland postnatal care for Aboriginal and Torres Strait Is-lander women and infants. A further 17% of publicationsidentified an integrated or continuum of care model asthe main intervention type. A lack of continuity of carehas been identified as a common issue affecting commu-nication and quality of care in antenatal and postnatalservices for Aboriginal and Torres Strait Islander women[39]. Research shows that fragmented maternity care canincrease medical risks and compromise patient safety,

Table 3 Critical Appraisal Skills Program (CASP) quality assessment of qualitative studies

Publication Clearstatementofresearch?

Qualitativemethodologyappropriate?

Researchdesignappropriate foraims?

Recruitmentstrategyappropriate foraims?

Data collectionaddressesresearch issue?

Relationship betweenresearcher andparticipant considered?

Ethicalconsiderationsaccounted for?

Rigorousdataanalysis?

Clearstatementof findings?

Research isvaluable?

Totalscore

Jan, S., et. al.(2004) [21]

Yes Yes Can't tell Yes Yes No No Yes Yes Yes Moderate

Carter, E.et al. (2004)[20]

Yes Yes Yes Yes Yes Yes Can't tell Yes Yes Can't tell Moderate

Campbell, S.et al. (2004)

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Strong

NSW Health(2005) [18]

Yes Yes No No No No Yes No Yes Yes Weak

Power, C.et al. (2008)[28]

Yes Yes Yes Yes Yes No Yes Yes Yes Yes Strong

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causing adverse outcomes for women and infants [40-42].This focus on models of continuity of care demonstratesthe efforts of several Aboriginal and Torres Strait IslanderMCH programs to address these concerns and ensurequality care that meets the needs of the women usingthese services.The most common component of MCH interventions,

documented in 70% of the literature reviewed, was healthpromotion/education and advice/support, a finding notidentified in previous reviews. Education and health pro-motion is a prominent MCH care strategy, particularlyused by midwives who emphasise their role in promotingthe health and wellbeing of pregnant women [43]. Briefhealth education interventions have been shown to reducealcohol [44] and tobacco [45] consumption during preg-nancy and nutritional education and counseling has beenassociated with improved gestational weight gain, a re-duced risk of anaemia, an increase in infant birth weightand a decreased risk of pre-term birth [46]. Research hasfound that the provision of additional support for at-riskpregnant women reduced the likelihood of caesareanbirths and hospital admissions, however no impact wasshown on the incidence of babies born with low birthweight, pre-term birth, perinatal deaths, maternal satisfac-tion with care or depression [47]. While there appears tobe a lack of evidence documenting the effectiveness ofhealth education/promotion and advice/support for preg-nant Aboriginal and Torres Strait Islander women, it hasbeen suggested that, embedded within a broader antenatalprogram, these approaches can contribute to better birthoutcomes by improving cultural safety and engagement [48].Home visitation and transport services were other inter-

vention components commonly found in the literature,consistent with the findings of Herceg [7]. However, whilethere were common program components seen acrossmultiple studies, more apparent was the diversity of re-sponses in MCH programs. This may be a reflection ofthe focus of primary health care in Aboriginal and TorresStrait Islander contexts, which is on providing appropri-ate, holistic care to meet the unique health needs of eachcommunity [49]. However, this lack of consistency betweenAboriginal and Torres Strait Islander MCH programsmeans it is difficult to assess the effects of particular com-ponents or combinations of components on the pregnancyand birth outcomes of mothers and infants. More rigorousevaluations which study the impact of specific programcomponents would be needed to further explore this issue.This review also identified some significant gaps in the

literature. Consistent with previous research indicatingthe underutilisation of smoking cessation interventionswith Aboriginal and Torres Strait Islander women whosmoked during pregnancy [39], this review found docu-mentation of interventions targeting smoking during preg-nancy in only two publications reviewed [23,25]. While

there is evidence that smoking cessation interventionscannot only help women reduce or stop smoking but alsohave an impact on birth weight and pre-term birth [45], arecent systematic review found that there is currently noevidence for effective smoking cessation interventions forpregnant Aboriginal and Torres Strait Islander women[50]. Given the current lack of evidence, there is a needfor high quality evaluations of approaches to smoking ces-sation among pregnant Aboriginal and Torres Strait Is-lander women [50].Another important factor found to be lacking in evalu-

ations was women’s subjective views and experiences oftheir health care, with only two publications reportingon this [21,22]. The need to consider and prioritise thefeelings, experiences and preferences of Aboriginal andTorres Strait Islander women regarding their pregnancyis consistently reiterated in the literature [39,51,52] andis something that needs to be addressed in future evalua-tions. There was also a lack of documentation on pro-grams which linked women’s pre-conception health topregnancy and birth outcomes. Only three publicationsexplicitly stated that the service was available for non-pregnant women [17,25,29], with only one program stat-ing goals to improve the pre-conception health of womenand increase pre-conception immunisation [37]. This find-ing supports that of previous research which has shownthat many women to do not receive pre-conception advicefrom health care professionals and that most women havelow levels of knowledge about pre-conception health care,despite the strength of evidence on the positive benefits ofthis for MCH outcomes [53]. There is a strong imperativeto enhance the pre-conception health of Aboriginal andTorres Strait Islander women given that many factorswhich contribute to the poor birth outcomes of Aboriginaland Torres Strait Islander are preventable, especially whenaddressed before pregnancy [54].

Outcomes and study qualitySimilar to those reported by Eades [8] and Herceg [7],many of the publications reviewed reported positive out-comes. The main outcome identified across the studieson MCH programs was an increase in antenatal attend-ance (26%), with earlier antenatal attendance also reportedin several evaluations (17%). This is an important outcomeconsidering the late and low antenatal attendance ratestypical of Aboriginal and Torres Strait Islander women[9,39] and concerns around poor management of compli-cations resulting in increased morbidity and mortality[27]. However, while equity in antenatal care utilisation isimportant, it should not be assumed that increased ante-natal coverage will necessarily impact on other maternaland infant health outcomes [55]. Hunt [39] demonstratedthat when programs of enhanced antenatal attendancehave been rigorously evaluated, controlling for confounding

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factors such as socio-economic status, earlier and more fre-quent antennal care did not improve perinatal outcomes,such as low birth weight [39]. Equally important to ante-natal utilisation was a focus on aspects of quality care, suchas ensuring that recommended brief interventions, ad-vice, screening procedures and treatments were ad-hered to [56].Other key outcomes reported includedan increase in

infant birth weights after birth (22%) and a decrease in,or lower proportion of, infants born with low birthweight (13%). Although birth weight is a crucial measureof maternal and infant health being associated with arange of poor health outcomes throughout the lifetime[48,57], it is also a measure that requires further investi-gation. While pregnancy is important in determining thebirth weight of babies, there are many other influencingfactors, such as socio-economic status, generational ma-ternal nutrition, health risk behaviours, maternal age andsize, and medical conditions during pregnancy [52,55]. Notdiscounting the importance of these key indicators, it isnecessary to critically examine the primary MCH mea-sures used to assess the effectiveness of MCH programsfor enhancing the health and wellbeing of Aboriginal andTorres Strait Islander women and infants.The outcomes reported in the literature reviewed paint

a positive picture for progress in improving the health out-comes of Aboriginal and Torres Strait Islander mothersand infants. However it is impossible to conclusively stateany cause and effect relationships between these andMCH programs due to issues of study quality. Themethodological quality of intervention studies varied con-siderably, with quantitative evaluations and the quantita-tive components of mixed-method studies overwhelminglyrated as weak. Cluster Randomised Control Trials are anappropriate design for evaluations of interventions thatnaturally occur in groups of individuals [58] and should beexplored further for use in evaluations of primary healthcare interventions. Multiple Baseline research designs havealso been recommended as an alternative to RandomisedControl Trials for methodologically rigorous and practicalevaluations of population-based health interventions [59].However we found no studies that utilised these higherlevel designs. As found in previous reviews of Aboriginaland Torres Strait Islander MCH care programs, good qual-ity longitudinal data on MCH care is needed to demon-strate clinically significant perinatal outcomes [9]. It is alsoimportant to consider that, given the disparities in healthoutcomes faced by Aboriginal and Torres Strait Islanderwomen and children compared to non-Indigenous womenand infants, significant improvements in MCH outcomesare unlikely to be achieved over a short period of time.For this reason, it is critical that a long term vision is takenfor assessing the impact of antenatal care programs andservices.

LimitationsAlthough a rigorous and thorough search strategy wasemployed, limitations include the possibility that thesearch did not locate all relevant studies. There is also arisk for publication bias in that programs and serviceswhich resulted in no overall benefit, or harmful effectsmay not have been reported on or published, and wouldtherefore would not be included in this search. Otherprograms and services are likely to exist but were notincluded in this review because there was no publiclyavailable literature concerning them. Since evaluationswith statistically significant findings are more likely tobe published, it is also possible that the published evalu-ations reviewed may over-estimate the true effectivenessof interventions [60]. The general weakness of quantita-tive studies is consistent with previous reviews of Indi-genous intervention research [12]. While this weakensthe evidence base of reported outcomes, it also providesan opportunity for researchers to improve the quality ofevaluations of Indigenous health and wellbeing pro-grams and services through the application of morerigorous study designs.

ConclusionThere has been a substantial increase in publications doc-umenting Aboriginal and Torres Strait Islander child andmaternal health programs and services over the past dec-ade. These publications outline responses to a range ofhealth and wellbeing issues relevant to Aboriginal andTorres Strait Islander mothers, infants and children, withthe majority of studies documenting programs targetingmothers and their babies through antenatal and postnatalcare. There was a significant difference in the componentsof programs and services outlined in the literature, withhealth promotion/education and advice/support reportedacross a majority of maternal and infant health publica-tions. The literature documents a serious underutilisationof tobacco smoking cessation interventions in antenatalcare. Some improvements in health outcomes were re-ported on, however the true effectiveness of interventionsdocumented in the quantitative studies is unclear due topoor study quality. Considering that it is unlikely that sig-nificant improvements in health outcomes will be achievedin the short term, research efforts need to focus on devel-oping good quality longitudinal data to assess the impact ofAboriginal and Torres Strait Islander child and maternalhealth programs and services over several decades.

Competing interestsThe authors declare that they have no competing interests.

Authors’ contributionsJM, RB and KT contributed to the search strategy. CJ took the lead role inthe classification of studies, data extraction, study quality assessment draftingof the paper. All authors edited and revised the draft paper and approvedthe final manuscript.

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AcknowledgementsThis review was funded by the Queensland Centre for Social ScienceInnovation. The authors gratefully acknowledge Kathy Fowler for conductingthe search of electronic databases.

Received: 19 December 2013 Accepted: 27 June 2014Published: 30 July 2014

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doi:10.1186/1471-2393-14-251Cite this article as: Jongen et al.: Aboriginal and Torres Strait Islandermaternal and child health and wellbeing: a systematic search ofprograms and services in Australian primary health care settings. BMCPregnancy and Childbirth 2014 14:251.

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