In general, remote-dwelling Indigenous mothers had higher proportions of antenatal risk factors, as well as worse outcomes for some labour characteristics compared to non-Indigenous mothers living in remote areas. Indigenous infants also had worse outcomes than non-Indigenous infants. There were some notable differences between urban- and remote-dwelling Indigenous women. The latter were younger, seemed to receive less pain relief during labour, had higher CS rates and longer hospital stays for vaginal births (mainly due to the air service transporting these remote mothers not allowing newborns <8 days on the plane) than urban Indigenous mothers. There were important differences by region and remoteness for risk factors and outcomes seen amongst Indigenous mothers and newborns. TE Remote Indigenous women and newborns appeared to have worse outcomes in general. Our findings seem to suggest that remoteness appears to be an independent risk factor as differences persisted for normal birth, preterm birth and birthweight for TE Remote mothers and newborns, even after accounting for risk factors and access to care. Our analyses at community level revealed differences in the prevalence of smoking during pregnancy. In summary, we found that for mothers and newborns in the NT, there is a huge disadvantage in being Indigenous and that for a number of outcomes it is worse to be also living in a remote area, especially a remote area in the TE.
Most articles on inequalities focus only on neonatal outcomes, but we included maternal outcomes. Therefore, this paper expands current knowledge on outcomes for Indigenous newborns, as well as on maternal outcomes for Indigenous women. We also quantify the inequalities in health outcomes between groups of Indigenous women and newborns at a regional level and by remoteness and include analyses for communities. The data identify opportunities for health services and clinicians for targeted service delivery and interventions at the regional and local levels. Specific issues are: smoking during pregnancy, teenage motherhood, antenatal attendance and care, pain relief during labour, normal birth, preterm birth and birthweight.
Our findings reinforce the statement that “preventing Aboriginal mothers from smoking during pregnancy is the single most effective short-term intervention to improve Indigenous perinatal outcomes” (p474) . Also, although smoking during pregnancy seemed to be less of a problem in CA, the use of chewing tobacco and ‘bush’ tobacco (i.e., wild tobacco plants)  is more common in this region . Young Indigenous women in CA do not appear to consider these products as harmful during pregnancy . Prevention efforts must incorporate other forms of tobacco use, especially in CA in regard to making pregnant women aware of the adverse effects of smokeless tobacco [31, 32]. Local context need to be considered in the implementation of smoking interventions as suggested by our analyses for the two communities that showed a difference in prevalence.
In the NT, women become mothers at early ages . Few Australian studies report on whether outcomes for teenage Indigenous mothers differ from those for adult Indigenous mothers; if the majority of Indigenous teenage births occur before or after 17 years of age; and whether those who give birth before 17 years have worse outcomes. Similarly, it is unclear if the outcomes of teenage pregnancy amongst Indigenous women can largely be explained by the prevalence of preventable risk factors such as smoking, remoteness, poorer access to health services, and later presentation for antenatal care. These issues are currently being investigated and are the topic of a subsequent paper.
High-quality antenatal care has been identified as an important strategy to improve Indigenous maternal and neonatal outcomes and closing the gap between Indigenous and non-Indigenous child mortality . In this study, CA Remote Indigenous women more often had <4 antenatal visits than TE Remote Indigenous women and those in urban areas. However, TE Remote Indigenous women and their newborns were more likely to experience adverse outcomes (less ‘normal birth’, more emergency CS, more preterm birth and lower mean birthweight). This suggests that access to antenatal care is not the only important factor, but that the quality of such care matters too . Although strong evidence that the content, frequency and time of antenatal visits are effective is lacking , a recent review indicated that programs offering additional antenatal support to mothers at increased risk of having LBW babies may be helpful in reducing the likelihood of antenatal hospital admission and caesarean birth, even though these programs are unlikely to prevent LBW or preterm birth . A study of Indigenous primary health services across Australia identified clear areas for improvement in the delivery of antenatal care , For example, only less than 50% of the smokers identified in the study received smoking cessation advice/counselling and just more than half of all women received antenatal education. There were also regional differences in the standard of care, in particular, CA services made greater use of antenatal preventative interventions than services in the TE.
Although improvements in antenatal care are clearly needed, antenatal support by health professionals and others “is unlikely to be powerful enough to overcome the effects of a lifetime of poverty and disadvantage” . Social disadvantage, maternal socio-economic status (SES) and neighbourhood SES have all been linked to adverse birth outcomes [39–41]. Therefore, antenatal care should occur within an integrated primary care model that includes community-based programs, in conjunction with intersectoral interventions in education, housing, and employment [5, 16, 42].
Remoteness has been described as “a minor but significant factor associated” with poorer Indigenous neonatal outcomes . Our study is consistent with this earlier work, but also demonstrates that remoteness appears to influence maternal outcomes. It is possible that remoteness reflects other unmeasured factors associated with disadvantage. For example, our dataset did not include information on income, education, occupation, and housing circumstances, all of which are likely to be different amongst remote and urban-dwelling individuals, as well as between remote contexts. Also, the distress, social isolation, communication difficulties and practical problems concerning food and transport resulting from taking Indigenous women ‘off country’ to give birth in regional centres  are other unmeasured aspects of ‘remoteness’ that are likely to contribute to adverse birth outcomes, such as lower normal birth rates.
A major strength of this study is the data set used: the NT has the highest proportion of Indigenous births of all Australian jurisdictions and there is good identification of Indigenous status . A limitation was that, as the data was de-identified, we could not identify mothers who had multiple pregnancies during the study period. An analysis of a limited set of identifiable NTMC data for 2003–2005 indicated that 13.2% of individual Indigenous mothers had two or more pregnancies during the three-year period. Proportions of mothers who gave birth more than once were similar for the TE and CA. It was illustrated that this clustering has the potential to lead to incorrect conclusions if results from analyses that assumes independence (e.g., logistic regression) are marginally significant. For example, a p-value of 0.045 or an upper level 95% CI of 0.95 might no longer be significant if clustering was accounted for . High mobility of some mothers could have resulted in misclassification of residence . However, a recent audit of demographic data of NT hospitals showed 88% agreement for patients’ resident health district between hospital records and interview data suggesting that this may not be a major cause of bias in this study . Another limitation is that our definition of ‘remoteness’ differed slightly from the Australian Standard Geographical Classification (ASGC)  which do not specifically include birthing services as a consideration. Our study had adequate power to detect statistically significant differences by region and remotes, but small sample sizes impacted the size of effects that were detectable as significant in the community analyses.
Our findings illustrate that context (i.e., remoteness/region/community) should be considered when policy and service delivery decisions are made. This applies to other countries as well. For example, disparities are evident in perinatal care, birth outcomes, and infant health between rural American Indian and Alaska Native persons and rural Whites, despite significant improvements in antenatal care amongst American Indians and Alaska Natives, suggesting that additional measures are needed to close persistent health gaps for this group . Also, a South African study to determine the prevalence and predictors of alcohol exposure during pregnancy found high levels of risk, especially amongst rural women, indicating a need for location-specific prevention programmes . Another study in Northern India reported that community context influenced reproductive wellness . Community-level differences analyses may be useful in identifying important risk factors relevant for service planning and interventions. It is, however, more challenging to show differences in outcomes given the small numbers involved in community-level analysis in the NT.
Future research should concern investigations into whether remoteness is a proxy for particular social and environmental factors in the Australian context. Aspects to consider are summary measures of advantage, disadvantage, economic resources, education and occupation (e.g. the Australian Socio-Economic Indexes for Areas (SEIFA)) ; as well as environmental factors in communities (e.g., number of houses per community, state of houses, crowding) and social factors (e.g., community cohesion, level of community violence, level of domestic violence, substance abuse, etc.) . In particular, we suggest that NTMC data be analysed again after the inclusion of SEIFA measures while using ASGC to define remoteness. These investigations were out of scope for the study reported here. There is also an imperative need to explore the distress experienced by remote women giving birth in regional centres and its direct association with adverse birth outcomes.