Open Access

Stressful events, social health issues and psychological distress in Aboriginal women having a baby in South Australia: implications for antenatal care

  • Donna Weetra1,
  • Karen Glover2,
  • Mary Buckskin3,
  • Jackie Ah Kit4,
  • Cathy Leane4,
  • Amanda Mitchell3,
  • Deanna Stuart-Butler4,
  • May Turner5,
  • Jane Yelland1, 6,
  • Deirdre Gartland1 and
  • Stephanie J Brown1, 2, 7Email author
BMC Pregnancy and ChildbirthBMC series – open, inclusive and trusted201616:88

https://doi.org/10.1186/s12884-016-0867-2

Received: 21 February 2015

Accepted: 8 April 2016

Published: 26 April 2016

Abstract

Background

Around 6 % of births in Australia are to Aboriginal and Torres Strait Islander families. Aboriginal and Torres Strait Islander women are 2–3 times more likely to experience adverse maternal and perinatal outcomes than non-Aboriginal women in Australia.

Methods

Population-based study of mothers of Aboriginal babies born in South Australia, July 2011 to June 2013.

Mothers completed a structured questionnaire at a mean of 7 months postpartum. The questionnaire included measures of stressful events and social health issues during pregnancy and maternal psychological distress assessed using the Kessler-5 scale.

Results

Three hundred forty-four women took part in the study, with a mean age of 25 years (range 15–43). Over half (56.1 %) experienced three or more social health issues during pregnancy; one in four (27 %) experienced 5–12 issues. The six most commonly reported issues were: being upset by family arguments (55 %), housing problems (43 %), family member/friend passing away (41 %), being scared by others people’s behavior (31 %), being pestered for money (31 %) and having to leave home because of family arguments (27 %). More than a third of women reporting three or more social health issues in pregnancy experienced high/very high postpartum psychological distress (35.6 % versus 11.1 % of women reporting no issues in pregnancy, Adjusted Odds Ratio = 5.4, 95 % confidence interval 1.9–14.9).

Conclusions

The findings highlight unacceptably high rates of social health issues affecting Aboriginal women and families during pregnancy and high levels of associated postpartum psychological distress. In order to improve Aboriginal maternal and child health outcomes, there is an urgent need to combine high quality clinical care with a public health approach that gives priority to addressing modifiable social risk factors for poor health outcomes.

Background

Disparities in health outcomes for Aboriginal and Torres Strait Islander Australians have a long history. As a legacy of colonisation, Aboriginal and Torres Strait Islanders have been dispossessed of land and culture in ways that have profound implications for health and well-being [1]. Aboriginal Australians are more likely to experience poor physical and mental health; have higher rates of suicide, self-harm and substance abuse; and experience earlier onset of chronic disease and associated mortality compared with other Australians [2]. National data show that over half of Aboriginal first time mothers are under 20 years of age [3]. Despite the younger age at which Aboriginal women commence childbearing, they experience higher rates of medical complications in pregnancy [4], and are two to five times more likely to die from pregnancy related complications as non-Aboriginal women [5]. Aboriginal women also experience higher rates of perinatal deaths compared with non-Aboriginal women (17.1 versus 8.8 per 1000 births), and are twice as likely to have a preterm birth (13.5 % versus 8.0 %) and/or baby with a low birthweight (12.0 % versus 6.0 %) [3].

It is estimated that around 6 % of births in Australia are to Aboriginal and Torres Strait Islander families [3]. Individual states and territories within Australia have adopted different policy and service approaches to addressing disparities in Aboriginal maternal and child health outcomes. In South Australia, the state government has implemented the Aboriginal Family Birthing Program (AFBP) building on the success of two small scale regional birthing programs established in the early 1990s [6]. Scaling up of the program commenced in 2009 and it currently operates in six regional areas and in the capital city of Adelaide. Women participating in the program are cared for by Aboriginal Maternal Infant Care (AMIC) workers that work in partnership with midwives and doctors to provide antenatal, intrapartum and early postnatal care up to 8 weeks after the birth. The Aboriginal Family Birthing Program services aim to provide culturally responsive holistic care that combines high quality clinical care with attention to broader social determinants of health, consistent with the principles of comprehensive primary health care [7]. As South Australia covers a geographic area four times the size of the UK, one of the major challenges for the program is how to provide continuity of care for Aboriginal women living in regional or remote areas of South Australia needing to access specialist services only available in the major capital city of Adelaide.

This paper reports data from a population-based study, called the Aboriginal Families Study, which investigated the views and experiences of mothers having an Aboriginal baby in South Australia between July 2011 and June 2013. The study was conducted in partnership with the Aboriginal Health Council of South Australia and was designed in part to assess the views and experiences of Aboriginal women accessing different models of maternity care, including the Aboriginal Family Birthing Program services. An earlier paper from the study focusing on antenatal care compares the experiences of women attending Aboriginal Family Birthing Program services with those of women attending mainstream public maternity services [8]. In addition to assessing women’s views and experiences in different models of care, the study aimed to investigate stressful events and social health issues affecting women’s health in pregnancy and the first 6 months after giving birth. The aims of this paper are to: (i) describe the frequency and types of stressful events and social health issues experienced by Aboriginal women and families during pregnancy, (ii) to examine the relationship between the number and types of stressful events and social health issues experienced by families during pregnancy and maternal postpartum psychological distress, and (iii) consider implications for policy and health services.

Method

The Aboriginal Families Study was conducted as a partnership between academic researchers at the Murdoch Childrens Research Institute, the University of Adelaide and the Aboriginal Health Council of South Australia Inc. The first stage of the study involved community consultations undertaken in urban, regional and remote areas of South Australia in 2008-2009 [9]. An Aboriginal Advisory Group has guided the development and conduct of the study since its inception in 2007. The community consultations highlighted the importance of women’s ‘social and emotional well-being’, and ‘knowing what’s happening in women’s lives during pregnancy’. Based on feedback from the community consultations, it was decided that to include questions in the study that: (i) asked about stressful events and social health issues experienced by Aboriginal women and families in pregnancy, (ii) inquired about women’s social and emotional well-being, and (iii) asked women about what helped them to stay ‘positive and strong’.

Study population

Women were recruited to the study via public maternity hospitals, Aboriginal community controlled health services, community organisations and community events, the interviewers’ own community networks, and through study participants referring women to the study. Information about the study was circulated via community newsletters, information brochures and posters in community agencies, and by community radio. To be eligible to take part women needed to be aged ≥ 14 years, and to have given birth to an Aboriginal baby in the study period. Women consenting to participate were invited to complete a structured interview when their baby was between 4 to 12 months old. A team of 12 Aboriginal research interviewers and one non-Aboriginal research interviewer recruited eligible women living in urban, regional and remote areas of South Australia over a 2-year period. Interviewers were based in Adelaide and in regional areas, including Port Augusta, Murray Bridge and Port Lincoln. Interviewers made regular visits to other communities, including Ceduna, Yalata, Whyalla, Coober Pedy and Mount Gambier.

Women recruited via public hospitals were mostly approached on postnatal wards in the first few days after giving birth. Aboriginal researchers made regular visits to the postnatal ward of the largest tertiary maternity hospital in Adelaide to provide information about the study to Aboriginal women and their families. This included verbal and written information about the study. Women who expressed interest in participating in the study were asked to provide contact details, and were then followed up 3–6 months later. Women recruited via other agencies, including other metropolitan and regional hospitals and health services, mostly heard about the study from staff working in the agency that gave out information about the study on our behalf. Women’s contact details were only passed on to study staff if women expressed interest in hearing more about the study. Once a community referral was received, women were initially followed up by phone, and then an appointment was made to meet with the woman either at the community based agency making the referral, or in her own home if she preferred. Women also heard about the study via community networks, and at community events. In addition, the Aboriginal researchers drew on their own community networks to distribute information and recruit women to the study.

Women were offered the option of completing the questionnaire with an interviewer or completing the questionnaire themselves. Women were able to provide written or verbal consent to participate. Women aged 14–17 were encouraged to discuss the project with another family member, parent or legal guardian before deciding to take part. However, parental or guardian consent was not a requirement for participation. After completing the questionnaire, women were given a gift voucher in appreciation of their participation. Further details about the study, including information about the community consultations that informed the study protocol and methods are available in a previous paper [9].

Questionnaire

The 44 page questionnaire included sections which asked about: ‘you and your family’, ‘about your pregnancy care’, ‘about your life when you were pregnant’, ‘the first few months after the baby’s birth’ and ‘support for you and staying on track’. Information was collected on a range of social and maternal characteristics, including the participant’s age, educational qualifications, place of residence, and number of adults and children living in the household. Pilot testing of the questionnaire resulted in modifications to ensure that questions were acceptable to women of all ages and backgrounds.

Measures and definitions

Assessment of stressful events and social health issues drew on items included in a measure developed for a population-based study of women giving birth in South Australia and Victoria (broadly based on the PRAMS study), with additional items incorporated based on consultations with Aboriginal community organisations and communities in South Australia and Victoria (10). In the section of the questionnaire that asked about ‘your life when you were pregnant’, women were asked to indicate whether or not 12 stressful events and social health issues had happened to them during their pregnancy. Stressful events included: death of a family member; serious illness or injury; and having to stop work or study, not because of the pregnancy. Social health issues included: housing problems, trouble with police or having to go to court; leaving home because of a family argument or fight; being scared by other people’s behaviour; being pestered for money; being pushed, shoved or assaulted; having drug and alcohol problems; and having a partner with drug and alcohol problems. Pre-given response categories were ‘yes’, ‘no’ or ‘prefer not to answer’. The final set of items included in this measure was determined in consultation with the Aboriginal Advisory Group and pilot-tested with Aboriginal women living in urban, regional and remote areas of South Australia to assess acceptability and ease of completion. As a result of piloting minor changes were made to wording of some items, and some items originally included in the pilot version were omitted from the final version. A copy of the questionnaire containing this measure is available via the study website [11].

The questionnaire also included the 5-item version of the Kessler Psychological Distress Scale (K-5) [12]. The longer 10 item (K-10) and 6 item (K-6) versions of this scale were designed to measure non-specific psychological distress encompassing both anxiety and depression, and have been extensively validated and shown to perform well in population-based studies [1214]. The K-5 was devised for use in the National Aboriginal and Torres Strait Islander Health Survey (NATSIHS), after concerns were raised about the wording of some items in the K-6 and K-10 with respect to their acceptability to Aboriginal people [12]. The 5-item version includes the following questions: “During the past 4 weeks, about how often did you feel … (i) nervous?, (ii) without hope?, (iii) restless or jumpy?, (iv) everything was an effort?, and (v) so sad nothing could cheer you up?. Response options for each item were: ‘none of the time’, ‘a little of the time’, ‘some of the time’, ‘most of the time’ and ‘all of the time’ were scored from 1 to 5 to produce a possible range of 5-25, with higher scores indicating higher psychological distress. Scores were calculated using the framework devised for the NATSIHS, with a score of 5–7.99 categorised as low, 8–11.99 categorised as moderate, 12–14.99 categorised as high, and 15–25 categorised as very high psychological distress [12]. The K-5 was selected for use in the current study in preference to other measures of social and emotional wellbeing that have been used in Aboriginal populations such as the Edinburgh Postnatal Depression Scale [15, 16] and Strong Souls Checklist [17] based on positive feedback about the acceptability of the K-5 from women who participated in the pilot study. The K-5 questions were located towards the end of the interview booklet, and were immediately followed by questions asking whether women had someone to talk to about things happening in their lives. Training and guidelines were providing for research interviewers regarding provision of support, information and referral to local services for women identified through the research as potentially needing additional support.

Data analysis

Quantitative data were analysed using Stata version 13 (StataCorp) [18]. We calculated the proportion of women reporting individual stressful life events and social health issues during pregnancy, and the proportions of women reporting no issues, one to two issues, and three or more issues, consistent with the approach taken in population based study of women giving birth in South Australia and Victoria conducted in 2008 [10]. Univariable logistic regression was used to assess associations between participant characteristics and (i) number of social health issues (<3/≥3), and (ii) level of psychological distress according to scores on the K-5. Results on the K-5 were dichotomised (<12/≥12) with a cut off score of ≥12 reflecting ‘caseness’ for psychological distress. Multivariable logistic regression was used to assess the relationship between number of social health issues reported (none/1-2/3 or more) and postpartum psychological distress (K-5 score of ≥12), taking into account maternal social characteristics as potential confounders. Sample size estimates reported in the study protocol were based on the primary outcome measure for the study, which is not the subject of this paper [8]. Posthoc power calculations showed that with a sample of 344, the study had 80 % power with alpha of 0.05 to detect an odds ratio of 3 for the outcome of high/very high psychological distress (K-5 score of ≥12), on the K-5 comparing women experiencing no social health issues with women reporting three or more stressful events and social health issues.

Open-ended responses to a question that asked women to comment on ‘what keeps them positive and strong’ were analysed thematically by two members of the research team (DW, SB). Any discrepancies in coding were discussed and resolved by agreement.

Ethics approval, including specific provisions for recruiting women aged 14–17 years, and offering women the option of verbal consent, was obtained from the Aboriginal Human Research Ethics Committee of South Australia, the South Australian Department of Health, the Women’s and Children’s Health Network, the Lyell McEwin Hospital, Adelaide, and the Royal Children’s Hospital, Melbourne. The study was adherent to the STROBE criteria as outlined in Additional file 1.

Results

Of 418 women who expressed interest in the study, 348 completed the interview booklet (83 %). One woman was excluded because she had all of her pregnancy care outside South Australia, and a further three women because of incomplete consent forms. The final sample included 344 women: 178 (52 %) were interviewed by an Aboriginal research interviewer, and 166 (48 %) chose to self-complete the questionnaire. The approximate time taken to complete the questionnaire was 45 min (range 30–90 min). The average age of the index child at the time women completed the interview booklet was 7 months (SD 3, range 1–17 months).

Social characteristics of participants are shown in Table 1. Most participants (90 %) were Aboriginal, a small number of participants identified as Torres Strait Islander or both Aboriginal and Torres Strait Islander (8 women, 2 %), and 7 % were non-Aboriginal. The mean age of study participants was 25 years (SD 6, range 15–43 years), with 16 % aged under 20, and 57 % aged less than 25 consistent with the age distribution for births to Aboriginal women recorded in South Australian routinely collected perinatal data [8]. Household size ranged from one to 14 people, and the number of children in households from one to 10 children. 39 % of study participants were living in Adelaide at the time of completing the interview booklet and 61 % were living in regional or remote areas of South Australia. One in four women lived in a remote area. 52 % of study participants had completed a post-secondary qualification and over half (52.3 %) reported that they were not smoking cigarettes in pregnancy.
Table 1

Social characteristics of study participants stratified by frequency of stressful events and social health issues during pregnancya

   

Number of social health issues

 
 

Total

None

1-2 issues

3-11 issues

Chi2

n

Col %

n

%

n

%

n

%

p-value

Mother’s age when baby born

 15–19 years

55

16.0

9

16.4

13

23.6

33

60.0

0.09

 20–24 years

140

40.7

22

15.7

41

29.3

77

55.0

 

 25–29 years

91

26.5

10

11.0

24

26.4

57

62.6

 

 30+ years

58

16.9

5

8.6

27

46.6

26

44.8

 

Aboriginal or Torres Strait Islander

 Aboriginal &/or Torres Strait Islander

319

92.7

45

14.1

93

29.2

181

56.7

0.09

 Non-Aboriginal

25

7.3

1

4.0

12

48.0

12

48.0

 

Place of residence

 Major city

134

39.0

11

8.2

40

29.9

83

61.9

0.09

 Regional

123

35.8

19

15.4

43

35.0

61

49.6

 

 Remote

87

25.3

16

18.4

22

25.3

49

56.3

 

Number of children in family

 One child

145

42.2

23

15.9

42

29.0

80

55.2

0.45

 2-3 children

127

36.9

17

13.4

36

28.3

74

58.3

 

 4–10 children

72

20.9

6

8.3

27

37.5

39

54.2

 

Total number of people (adults & children) in household

 1-2 people

19

5.8

0

0.0

6

31.6

13

68.4

0.44

 3-4 people

141

42.9

21

14.9

37

26.2

83

58.9

 

 4-5 people

59

17.9

10

16.9

19

32.2

30

50.8

 

 5–14 people

110

33.4

13

11.8

37

33.6

60

54.5

 

Highest educational qualification

 Less than year 12

134

39.0

20

14.9

33

24.6

81

60.4

0.011

 Year 12

33

9.6

4

12.1

18

54.5

11

33.3

 

 Certificate/Traineeship

155

45.1

17

11.0

45

29.0

93

60.0

 

 Diploma/Degree

22

6.4

5

22.7

9

40.9

8

36.4

 

Health care concession card

 Yes

296

87.1

36

12.2

85

28.7

175

59.1

0.006

 No

44

12.9

10

22.7

19

43.2

15

34.1

 

Smoked cigarettes in pregnancy

 No

175

51.6

30

17.1

64

36.6

81

46.3

0.001

 Yes

164

48.4

15

9.1

40

24.4

109

66.5

 

Total

344

100.0

46

13.4

105

30.5

193

56.1

 

aDenominators vary due to missing values

In order to assess the representativeness of the sample, we compared participant characteristics with data collected by the South Australian Pregnancy Outcome Unit for all births to Aboriginal mothers in 2011 [8]. This showed that participants were largely representative in relation to maternal age, gestation and infant birthweight. Women having their first baby appeared to be slightly over-represented (42 % of participants versus 34.3 % of recorded births to Aboriginal mothers in 2011 data), and women giving birth at metropolitan hospitals slightly under-represented (53 % of participants versus 59 % of recorded births to Aboriginal mothers in 2011 data).

Just over half (56 %) of women in the study had experienced three or more stressful events and social health issues during pregnancy, and one in four (27 %) had experienced between five to 12 issues. There were no differences in reported exposure to stressful events and social health issues related to maternal age, number of children and adults in the household or place of residence. Women who reported smoking cigarettes in pregnancy and women who had a health care concession card were more likely to report three or more social health issues, and women who had completed a degree or diploma were less likely to report multiple issues.

Reported frequencies of stressful events and social health issues are shown in Table 2, stratified by maternal age. The six most commonly reported social issues were: being upset by family arguments, housing problems, family member or friend passing away, being scared by others people’s behavior, being pestered for money and having to leave home because of family arguments. There were some issues that appeared to be less common amongst younger women (e.g. problems with drugs and alcohol), and some that appeared to be less common amongst older women (e.g. problems with the police or having to go to court). However, the study had limited power to assess differences between subgroups.
Table 2

Frequency of stressful events and social health issues by maternal age*

   

Maternal age at birth of index child

 
 

Total

15–19 years

20–24 years

25–29 years

30+ years

Chi2

n

%

n

%

n

%

n

%

n

%

p-value

Upset by family arguments

187

55.3

28

51.9

72

52.6

57

64.0

30

51.7

0.29

Housing problems/moved house

144

42.6

23

43.4

66

48.5

38

41.8

17

29.3

0.10

Family member or a friend passed away

137

40.9

20

38.5

51

37.8

42

46.7

24

41.4

0.59

Pestered for money

106

31.3

12

22.2

43

31.4

27

29.7

24

42.1

0.15

Scared by other people’s behaviour

103

30.7

15

27.8

38

28.1

26

28.9

24

42.1

0.24

Left home because of a family argument

90

26.6

17

32.1

38

27.5

24

26.4

11

19.6

0.51

Very sick or badly injured (not related to pregnancy)

81

24.3

12

22.2

30

22.1

22

24.7

17

31.5

0.57

Partner had problems with drugs or alcohol

70

21.8

12

24.0

24

18.0

19

22.4

15

28.3

0.46

Had to stop working or studying (not related to pregnancy)

53

16.1

3

6.0

26

19.3

16

17.8

8

14.5

0.17

Pushed, shoved or assaulted

53

15.9

8

15.1

19

14.2

15

16.9

11

19.3

0.83

Problems with the police or need to go to court

42

12.5

6

11.1

18

13.1

14

15.7

4

7.0

0.46

Mother had problems with drugs or alcohol

30

8.9

2

3.7

16

11.7

6

6.7

6

10.7

0.27

Total

  

55

100.0

140

100.0

91

100.0

58

100.0

 

*Denominators vary due to missing values

Table 3 reports data on psychological distress experienced by women in the study according to scores on the K-5. Seven women (2 %) had missing data on the K-5 and were excluded from further analyses. The mean score on the K-5 was 9.4, standard deviation = 3.9, range 5–25. The proportion of women in the study experiencing high to very high levels of psychological distress (K-5 score of ≥12) was 24.7 % (95 % CI 20.1–29.6) Women experiencing a greater number of stressful events and social health issues reported higher levels of psychological distress. Among women experiencing 3–12 issues during pregnancy, 35.6 % (95 % CI 28.8–42.9) reported high to very high levels of psychological distress.
Table 3

Level of maternal postpartum psychological distress by number of stressful events and social health issues in pregnancy (n = 337)a

Psychological

  

Stressful events/social health issues

Distress (K-5)

Total

None

1-2 issues

3–11 issues

 

n

%

n

%

n

%

n

%

Low

133

39.5

25

55.6

50

48.1

58

30.9

Moderate

121

35.9

15

33.3

43

41.3

63

33.5

High

42

12.5

2

4.4

6

5.8

34

18.1

Very High

41

12.2

3

6.7

5

4.8

33

17.6

aDenominators vary due to missing values

The social characteristics of women reporting low/moderate psychological distress (K-5 score of <12) and high/very high psychological distress (K-5 score of ≥12) are shown in Table 4. Compared to women living in urban areas, women living in remote parts of South Australia had higher odds of scoring above 12 on the K-5. Other characteristics associated with higher scores on the K-5 (score of ≥12) were: having a health care concession card, having more than three children, not completing year 12, and smoking during pregnancy. Compared to women aged 20–24 years, younger women (under 20) and women aged 25–30 years had slightly raised odds of scoring above the cut off score of ≥12, with results only bordering on statistical significance.
Table 4

Relationship between maternal social characteristics and psychological distress

   

Psychological Distress

 

Total

Low/Moderate

High/Very high

  

n

Col %

n

%

n

%

OR

95 % CI

Mother’s age when baby born

 15–19 years

54

16.0

37

68.5

17

31.5

1.8

[0.9,3.7]

 20–24 years

135

40.1

108

80.0

27

20.0

1.0

[ref]

 25–29 years

91

27.0

63

69.2

28

30.8

1.8

[1.0,3.3]

 30+ years

57

16.9

46

80.7

11

19.3

1.0

[0.4,2.1]

Aboriginal or Torres Strait Islander

 Aboriginal &/or Torres Strait Islander

312

92.6

231

74.0

81

26.0

1.0

[ref]

 Non-Aboriginal

25

7.4

23

92.0

2

8.0

0.2

[0.1,1.1]

Place of residence

 Major city

130

38.6

102

78.5

28

21.5

1.0

[ref]

 Regional

121

35.9

96

79.3

25

20.7

0.9

[0.5,1.7]

 Remote

86

25.5

56

65.1

30

34.9

2.0*

[1.1,3.6]

Number of children in family

 One child

141

41.8

110

78.0

31

22.0

1.0

[ref]

 2-3 children

125

37.1

97

77.6

28

22.4

1.0

[0.6,1.8]

 4–10 children

71

21.1

47

66.2

24

33.8

1.8

[1.0,3.4]

Total number of people (adults & children) in household

 1-2 people

18

5.6

16

88.9

2

11.1

1.0

[ref]

 3-4 people

140

43.3

108

77.1

32

22.9

2.4

[0.5,10.9]

 4-5 people

59

18.3

46

78.0

13

22.0

2.3

[0.5,11.1]

 5–14 people

106

32.8

75

70.8

31

29.2

3.3

[0.7,15.2]

Highest educational qualification

 Less than year 12

131

38.9

83

63.4

48

36.6

2.8***

[1.6,4.9]

 Year 12

32

9.5

23

71.9

9

28.1

1.0

[ref]

 Certificate/Traineeship

152

45.1

126

82.9

26

17.1

1.9

[0.8,4.6]

 Diploma/Degree

22

6.5

22

100.0

0

0.0

1.0

[1.0,1.0]

Health care concession card

 No

44

13.2

41

93.2

3

6.8

1.0

[ref]

 Yes

289

86.8

211

73.0

78

27.0

5.1**

[1.5,16.8]

Smoked cigarettes in pregnancy

 No

171

51.2

144

84.2

27

15.8

1.0

[ref]

 Yes

163

48.8

108

66.3

55

33.7

2.7***

[1.6,4.6]

Someone to talk to in pregnancy

 Sometimes/No/Didn’t want to talk

103

30.8

65

63.1

38

36.9

1.0

[ref]

 Always

232

69.3

188

81.0

44

19.0

0.4***

[0.2,0.7]

Total

337

100.0

254

75.4

83

24.6

  

Denominators vary due to missing values

*p < 0.05

**p < 0.01

***p < 0.001)

Table 5 shows; (i) the proportions of women experiencing specific events and social health issues in pregnancy that reported high or very high psychological distress in the postpartum period (K-5 score of ≥12), and (ii) odds ratios and 95 % confidence intervals for the association between each issue and scores above the cut-off for high to very high distress on the K-5. Five out of the 12 issues were associated with greater than three fold increases in odds of high to very high psychological distress. These were: ‘being scared by other people’s behaviour’, ‘being pushed, shoved or assaulted in pregnancy’, ‘having problems with drugs or alcohol’, ‘partner having problems with drugs or alcohol’, and ‘being upset by family arguments’.
Table 5

Relationship between stressful events and social health issues during pregnancy and maternal psychological distress during first 12 months postpartum (n = 331)

  

High/very high psychological distress(K5 score ≥12)

Odds Ratio

95 % CI

 

n

n

%

  

Housing problems/had to move house

140

40

28.6

1.5

[0.9,2.4]

Very sick or badly hurt

78

27

34.6

1.9*

[1.1,3.3]

Problems with the police/needing to go to court

42

14

33.3

1.7

[0.8,3.3]

Problems with drugs or alcohol

30

15

50.0

3.6***

[1.7,7.8]

Partner had problems with drugs or alcohol

70

28

40.0

3.1***

[1.8,5.6]

Scared by other people’s behaviour

100

42

42.0

3.8***

[2.2,6.4]

Pestered for money

104

41

39.4

2.9***

[1.7,4.9]

Upset by family arguments

183

62

33.9

3.3***

[1.9,5.8]

Family member or a friend passed away

134

41

30.6

1.7*

[1.0,2.7]

Left home because of a family argument

87

31

35.6

2.2**

[1.3,3.7]

Had to stop working or studying

52

9

17.3

0.6

[0.3,1.4]

Pushed, shoved or assaulted

53

25

47.2

3.6***

[1.9,6.6]

*p < 0.05

**p < 0.01

***p < 0.001

Multivariable logistic regression analyses were undertaken to obtain a more precise estimate of the association between exposure to stressful events and social health issues during pregnancy and maternal postpartum psychological distress taking into account social characteristics. Variables included in the model shown in Table 6 were: number of stressful events and social health issues as the exposure of main interest (3 levels), maternal age, maternal education and place of residence (urban, regional, remote). These factors were selected based on associations evident in univariable analyses, and the advice of the study’s Aboriginal Advisory Group with regard to factors most salient to the community. The adjusted odds of women reporting high to very high psychological distress (K-5 score of ≥12) were five times higher among women reporting 3–12 stressful events or social health issues during pregnancy, compared with women reporting no issues. Women who had completed post-secondary education had lower odds of reporting high to very high psychological distress that remained statistically significant in the adjusted model. In contrast, women living in remote areas were more likely to report high to very high distress.
Table 6

Association between number of stressful events and social health issues during pregnancy and maternal postpartum psychological distress (K5 score of ≥12) (n = 331)

 

Total

High/very high psychological distress

Unadjusted Odds Ratio

95 % CI

Adjusted Odds Ratio

95 % CI

 

n

n

%

    

Social health issues

 None

45

5

11.1

1.0

[ref]

1.0

[ref]

 1-2 issues

104

11

10.6

0.9

[0.3,2.9]

1.1

[0.3,3.4]

 3–11 issues

188

67

35.6

4.4**

[1.7,11.8]

5.4**

[1.9,14.9]

Mothers’ age when baby born

 15–19 years

54

17

31.5

1.8

[0.9,3.7]

1.6

[0.7,3.5]

 20–24 years

135

27

20.0

1.0

[ref]

1.0

[ref]

 25–29 years

91

28

30.8

1.8

[1.0,3.3]

2.0

[1.0,3.9]

 30+ years

57

11

19.3

1.0

[0.4,2.1]

1.2

[0.5,2.9]

Maternal education

Post-secondary education

174

26

14.9

1.0

[ref]

1.0

[ref]

Year 12 or less

163

57

35.0

3.1***

[1.8,5.2]

3.6***

[2.0,6.4]

Place of residence

 Major City

130

28

21.5

1.0

[ref]

1.0

[ref]

 Regional

121

25

20.7

0.9

[0.5,1.7]

0.9

[0.5,1.8]

 Remote

86

30

34.9

2.0*

[1.1,3.6]

1.8

[0.9,3.6]

Total

331

81

24.5

    

*p < 0.05

**p < 0.01

***p < 0.001

Two-thirds of women (235/341, 69 %) said that they always had someone to talk to about things happening in their lives. One in five (72/341, 21 %) only sometimes had someone to talk to, 5 % (17/341) had no-one to talk to and 5 % (17/341) did not want to ‘talk about personal stuff’. There was a trend for older women to be more likely to have someone to talk to and younger women under 25 appeared to be more likely not to want to talk about personal things happening in their lives. Including this measure of social support in the multivariable model described above did not change the conclusion that women exposed to three or more stressful events or social health issues during pregnancy are at greater risk of postpartum psychological distress (adjusted odds ratio = 4.6, 95 % Confidence Interval 1.6–13.2).

Almost all women who took part in the study commented on what helped them to stay positive and strong. Common themes in their responses were: having happy, healthy children; the support of their families, and the support of their partners. Women also spoke about being a role model for their children, and believing in themselves and their capacity to be a ‘strong mother’. Other themes in women’s comments about what helped them stay strong included: study, education and work; life experiences; doing things to stay healthy and look after themselves; and support from services.

Discussion

Evidence that Aboriginal families in Australia experience a disproportionate burden of social health issues is not new [19, 20]. However, to our knowledge the Aboriginal Families Studies is the first population-based study to collect and report information about the extent and nature of social health issues experienced by Aboriginal women and families during pregnancy.

The research highlights unacceptably high rates of housing stress affecting Aboriginal women and families. This undoubtedly has an impact on where and how women access antenatal care, and the extent to which they are able to make healthy lifestyle choices to eat well, exercise, and modify smoking and alcohol consumption during pregnancy. Many women (over 40 %) reported that they had experienced the loss of a family member or friend during their pregnancy. The strong connections in families, larger family size and shorter life expectancy of Aboriginal people make it a common experience for Aboriginal families to be grieving while preparing for the birth of a new baby. Although a very common experience for Aboriginal families, the impact of this on women’s physical and emotional wellbeing during and after pregnancy is poorly understood.

A large number of women reported experiences of family or community conflict. One in three had been scared by other people’s behavior while they were pregnant, one in five had left home because of a family argument, and one in six had been physically assaulted. There is an accumulating evidence of the negative impact of family violence and other kinds of social adversity on rates of miscarriage, preterm birth and low birthweight, as well as other long term health consequences for women and children [2127].

One in four women in the study (24.7 %) reported high to very high psychological distress in the postpartum period. This is markedly higher than estimates of maternal psychological distress among general population samples [28, 29], and estimates using the same measure (K-5) to assess psychological distress among similar aged non-Aboriginal Australian women [30]. While attributing causation is problematic in observational studies, the 2-3-fold increase in odds of high to very high psychological distress associated with individual social health issues and stressful events in pregnancy, and the evidence of cumulative impact of multiple social health issues (5-fold increase in odds for women experiencing three or more social health issues) are strongly suggestive of a causal relationship.

When we were designing the study, community members told us it was important for the study to collect information on these issues, and for this information to be used to inform changes to services to improve outcomes for Aboriginal families. A major strength of the study is the partnership with the Aboriginal Health Council of South Australia, and the processes that were used to engage Aboriginal community organisations and communities throughout the planning and evolution of the study [9]. The Aboriginal Advisory Group worked closely with the research team to guide the way that the interviewers worked with communities and families, and to assist with interpreting the findings. Approximately a quarter of all Aboriginal women who gave birth in South Australia over a 2-year period took part in the study. The high level of participation in regional and remote communities, and engagement of so many younger women, is a testament to the Aboriginal research interviewers’ skills working with communities across South Australia. It is extremely rare in epidemiological studies to achieve a population-based sample that is representative in relation to maternal age. This feature of the sample greatly strengthens the generalisability of the findings.

Notwithstanding these strengths, the study also has a number of limitations. The K-5, while highly acceptable to participants, has not been validated against diagnostic interview in an Indigenous population. No interviews were conducted with fathers, or with other family members. This was a decision based on funding constraints. Although the interviewers travelled to many areas of South Australia, we were unable to visit all regions of the state. Other limitations include the decisions not to collect data on income, relationship status, intimate partner abuse or alcohol use in pregnancy: all of which were seen as potentially intrusive questions for the interviewers to ask, that may have resulted in lower overall participation. While it is not possible to determine whether this would have been the case, respecting community advice was an important principle underpinning the way that the researchers and the Aboriginal Health Council of South Australia worked together to undertake the study. The questions that asked about stressful events and social health issues and symptoms of psychological distress might also be considered sensitive. The fact that these questions were so well answered, with very few women opting to skip individual items, demonstrates the benefits of engaging Aboriginal communities in the design of research, and of careful pre-testing of study instruments and study methods. The role of the small team of Aboriginal interviewers in facilitating women’s involvement in the study is also an important aspect of the way the study was conducted and likely to have contributed to the low level of missing data. Other studies using the K-10 and K-5 with Aboriginal and Torres Strait Islander populations, but not involving the same degree of community consultation and engagement or involvement of Aboriginal researchers in data collection, have reported higher levels of missing data (>14 % for the K-5, and 16 % for the K-10) [30, 31].

Women were very open about things that were happening in their lives, and the high level of stressful events and social health issues in urban, regional and remote communities shocked even members of the Aboriginal Advisory Group. Non-Aboriginal women in Australia are much less likely to experience cumulative stresses and social health issues in pregnancy. Eighteen percent of non Aboriginal women participating in a population-based survey of women giving birth in South Australia and Victoria in 2008 reported three or more stressful events and social health issues, compared with 56 % of women in the Aboriginal Families Study [10, 28]. Acting on this information is a priority. Women themselves identified that what helped them stay healthy and strong during pregnancy was their children, families and community. Antenatal care provides a window of opportunity to support women and families coping with multiple social health issues. However, public maternity services are often under resourced and lack systems to address social determinants of poor maternal and child health outcomes [10]. In order to improve outcomes, there is a pressing need to re-frame current models of care to combine high quality clinical care with a public health approach that gives priority to addressing modifiable social health risk factors for poor health outcomes [3234].

Central to this is the need for better integration of systems to support women and families experiencing housing problems, family violence, problems with drugs and alcohol and other social health issues as a core component of pregnancy care. There is evidence that strengthening cross-sector collaboration and multi-disciplinary team-based approaches to antenatal care, involving Aboriginal primary care and community controlled health services in flexible program delivery, providing outreach and transport, and tailoring programs to local community needs are likely to improve maternal and child health outcomes [3539].

However, few programs and initiatives specifically designed to address the needs of Aboriginal women and families have been subject to rigorous evaluation, limiting conclusions that can be drawn from these studies [39, 40].

Looking beyond this literature, there is increasing recognition of the need for maternity services in high income countries to take steps to address the needs of disadvantaged and vulnerable populations, such as families of refugee background, women experiencing family violence, adolescent mothers and women with substance abuse problems [4145]. A systematic review of RCTs and observational studies examining antenatal care programs focusing on disadvantaged populations in high income countries found limited evidence of improved perinatal outcomes, but noted a number of ‘promising’ intervention strategies requiring further evaluation [46]. These include: group antenatal care, multi-faceted antenatal care programs targeting a range of risk factors for poor outcomes, and financial incentives for health services to tailor care to specific populations [46]. Few studies have examined the impact of antenatal programs on a broader range of longer term maternal and child health outcomes in disadvantaged populations.

Conclusion

Our findings highlight unacceptably high rates of social health issues affecting Aboriginal women and families during pregnancy, and high levels of associated postpartum psychological distress. In order to improve Aboriginal maternal and child health outcomes, there is an urgent need to combine high quality clinical care with a public health approach to antenatal care that gives priority to addressing modifiable social risk factors for poor maternal and child health outcomes. Attention to the circumstances of women’s lives—including housing problems, family violence, drug and alcohol problems and other consequences of social disadvantage—should be an integral and core component of antenatal care for Aboriginal families and other socially disadvantaged populations. Implementation studies with longer term follow up of mothers and children are needed to refine approaches, and demonstrate benefits.

Notes

Declarations

Acknowledgements

The authors respectfully acknowledge the Aboriginal Custodians of the Lands and Waters of Australia. We thank the many Aboriginal families who have played a role in development of the Aboriginal Families Study through the community consultation and development of the questionnaire; the women who have taken part; their communities and the staff in the many agencies that have supported the study. We would also like to thank members of the Aboriginal Advisory Group for the study and members of the fieldwork team: Eunice Aston, Deborah Fuschtei, Jessie King, Rosie King, Emily Jaworek, Karen McCue, Roxanne Miller, Jess Reid, Deelia Richards, Denise Thomas, Jan Wiebe, Hayley Wilson, Jannaya Wilson, Rikki Wilson.

The Aboriginal Families Study is funded by the National Health and Medical Research Council (project grant ID1004395, 2011-2013), the Rio Tinto Aboriginal Fund, and SA Health, and supported by the Victorian Government’s Operational Infrastructure Support Program. SB was supported by a National Health and Medical Research Council Career Development Fellowship (ID491205, 2008-2011), an Australian Research Council Future Fellowship (2012-2015) and a National Health and Medical Research Council Research Fellowship (ID1103976, 2016-2020).

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Healthy Mothers Healthy Families Research Group, Murdoch Childrens Research Institute
(2)
South Australian Health and Medical Research Institute
(3)
Aboriginal Health Council of South Australia Inc
(4)
Women’s and Children’s Health Network
(5)
Council of Aboriginal Elders Inc
(6)
General Practice and Primary Health Care Academic Centre, The University of Melbourne
(7)
School of Population and Global Health, General Practice and Primary Health Care Academic Centre, The University of Melbourne

References

  1. Australian Government. Aboriginal Torres Strait Islander Health Plan 2013-2023. http://www.health.gov.au/natsihp (Accessed April 2016)
  2. Vos T, Barker B, Begg S, Stanley L, Lopez AD. Burden of disease and injury in Aboriginal and Torres Strait Islander Peoples: the Indigenous health gap. Int J Epidemiol. 2009;38(2):470–7.View ArticlePubMedGoogle Scholar
  3. Li Z, Zeki R, Hilder L, Sullivan EA. Australia's mothers and babies 2010. Perinatal statistics series no. 27. Cat. no. PER 57. Canberra: AIHW; 2012.Google Scholar
  4. Eades S, Read AW, Stanley FJ, Eades FN, McCaullay D, Williamson A. Bibbulung Gnarneep (‘solid kid’): causal pathways to poor birth outcomes in an urban Aboriginal birth cohort. J Paediatr Child Health. 2008;44(6):342–6.View ArticlePubMedGoogle Scholar
  5. Sullivan EA, Hall B, King JF. Maternal deaths in Australia 2003–2005. Maternal deaths series no. 3. Cat. no. PER 42. Sydney: AIHW National Perinatal Statistics Unit; 2007.Google Scholar
  6. Stamp G, Champion S, Anderson G, Warren B, Stuart-Butler D, Doolan J, Boles C, Callaghan L, Foale A, Muyambi C. Aboriginal maternal and infant care workers: partners in caring for Aboriginal mothers and babies. Rural Remote Health. 2008;8:883.Google Scholar
  7. Middleton P, Glover K, Weetra D, Bubner T, Crowther C, Rumbold A, Brown SJ. Evaluation of the Aboriginal Family Birthing Program. Adelaide: RANZCOG 2014 Indigenous women’s health meeting; 2014.Google Scholar
  8. Brown SJ, Weetra D, Glover K, Buckskin M, Ah Kit J, Leane C, Mitchell A, Stuart-Butler D, Turner M, Gartland D, Yelland J. Improving Aboriginal women’s experiences of maternity care: results of the Aboriginal Families Study. Birth. 2015;42(1):27–37.Google Scholar
  9. Buckskin M, Ah Kit J, Glover K, Mitchell A, Miller R, Weetra D, Wiebe J, Yelland J, Newbury J, Robinson J, Brown SJ. Aboriginal Families Study: a population-based study keeping community and policy goals in mind right from the start. Int J Equity Health Care. 2013;12:41.Google Scholar
  10. Brown SJ, Yelland JS, Sutherland GA, Baghurst PA, Robinson JS. Stressful life events, social health issues and low birthweight in an Australian population-based birth cohort: challenges and opportunities in antenatal care. BMC Public Health. 2011;11:196.View ArticlePubMedPubMed CentralGoogle Scholar
  11. https://www.mcri.edu.au/research/projects/aboriginal-families-study (Accessed April 2016)
  12. Australian Institute of Health and Welfare. Measuring the social and emotional well-being of Aboriginal and Torres Strait Islander Health Survey 2004-05. Canberra: Australian Bureau of Statistics; 2006, ABS Cat. No. 4715.0.Google Scholar
  13. Kessler RC, Andrews G, Colpe LJ, Hirilpi E, Mroczek DK, Normand SLT, Walters EE, Zaslav AM. Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychol Med. 2002;32:959–76.Google Scholar
  14. Kessler RC, Barker PR, Colpe LJ, Epstein JF, Gfoerer JC, Hiripi E, Howes MJ, Normand SLT, Mandersheid RW, Walters EE, Zalavsky AM. Screening for serious mental illness in the general population. Arch Gen Psychiatry. 2003;60:184–9.Google Scholar
  15. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression: development of the 10-item Edinburgh Postnatal Depression Scale. British J Psychiatr. 1987;150:782–6.View ArticleGoogle Scholar
  16. Campbell A, Hayes B, Buckby B. Aboriginal and Torres Strait Islander women’s experience when interacting with the Edinburgh Postnatal Depression Scale: a brief note. Aust J Rural Health. 2008;16(3):124–31.View ArticlePubMedGoogle Scholar
  17. Thomas A, Cairney S, Gunthorpe W, Paradies Y, Sayers S. Strong Souls: development and validation of a culturally appropriate tool for assessment of social and emotional well-being in Indigenous youth. Aust NZ J Psychiatry. 2010;44(1):40–8.View ArticleGoogle Scholar
  18. StataCorp. Stata Statistical Software Release 13. College Station. TX: StataCorp LP; 2013.Google Scholar
  19. De Maio JA, Zubrick SR, Silburn SR, Lawrence DM, Mitrou FG, Dalby RB, Blair RM, Griffin J, Milroy H, Cox A. The Western Australian Aboriginal Child Health Survey: Measuring the Social and Emotional Wellbeing of Aboriginal Children and Intergenerational Effects of Forced Separation. Perth: Curtin University of Technology and Telethon Institute for Child Health Research, 2005.Google Scholar
  20. Askew DA, Schluter PJ, Spurling GKP, Bond CJR, Brown ADH. Urban Aboriginal and Torres Strait Islander children’s exposure to stressful events: a cross-sectional study. MJA. 2013;199:42–5.PubMedGoogle Scholar
  21. Holt S, Buckley H, Whelan S. The impact of exposure to domestic violence on children and young people: a review of the literature. Child Abuse Negl. 2008;32:797–810.View ArticlePubMedGoogle Scholar
  22. Shonkoff J, Garner A. The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012;129:e232–46.View ArticlePubMedGoogle Scholar
  23. Glover V. Annual Research Review: Prenatal stress and the origins of psychopathology: an evolutionary perspective. J Child Psychol Psychiatr. 2011;52(4):356–67.View ArticleGoogle Scholar
  24. Cker AL, Sanderson M, Dong B. Partner violence during pregnancy and risk of adverse pregnancy outcomes. Paediatr Perinat Epidemiol. 2004;18:260–9.View ArticleGoogle Scholar
  25. Silverman JG, Decker MR, Reed E, Raj A. Intimate partner violence victimization prior to and during pregnancy among women residing in 26 US states: associations with maternal and neonatal health. Am J Obstet Gynecol. 2006;195(1):140–8.View ArticlePubMedGoogle Scholar
  26. Sanchez SE, Alva AV, Diez Chang G, Qui C, Yanez D, Gelaye B, Williams MA. Risk of spontaneous preterm birth in relation to maternal exposure to intimate partner violence during pregnancy in Peru. Matern Child Health J. 2013;17(3):485–92.Google Scholar
  27. Shepherd CCJ, Li J, Mitrou F, Zubrick SR. Socio-economic disparities in the mental health of Indigenous children in Western Australia. BMC Public Health. 2012;12:756.View ArticlePubMedPubMed CentralGoogle Scholar
  28. Yelland J, Sutherland G, Brown SJ. Postpartum anxiety, depression and social health: findings from a population-based survey of Australian women. BMC Public Health. 2010;10:771.View ArticlePubMedPubMed CentralGoogle Scholar
  29. Buist AE, Austin MP, Hayes BA, Speelman C, Biliszta JL, Gemmill AW, rooks J, Ellwood D, Milgrom J. Postnatal mental health of women giving birth in Australia 2002-2004: findings from the beyondblue National Postnatal Depression Program. Aust NZ J Psychiatry. 2008;42(1):66–73.Google Scholar
  30. Cunningham J, Paradies Y. Socio-demographic factors and psychological distress in Indigenous and non-Indigenous Australian adults aged 18-64 years: analysis of national survey data. BMC Public Health. 2012;12:95.View ArticlePubMedPubMed CentralGoogle Scholar
  31. McNamara BJ, Banks E, Gubhaju L, Williamson A, Joshy G, Raphael B, Eades SJ. Measuring psychological distress in older Aboriginal and Torres Strait Islander Australians: a comparison of the K-10 and K-5. Aust NZ J Public Health 2014;online; doi:https://doi.org/10.1111/1753-6405.12271
  32. Ekman B, Pathmanathan I, Liljestrand J. Integrating health interventions for women, newborn babies and children; a framework for action. Lancet. 2008;372:990–1000.View ArticlePubMedGoogle Scholar
  33. Frenk J. Reinventing primary health care: the need for systems integration. Lancet. 2009;374:170–3.View ArticlePubMedGoogle Scholar
  34. Wong R, Herceg A, Patterson C, Freebairn L, Baker A, Sharp P, Pinnington P, Tongs J. Positive impact of a long-running urban Aboriginal medical service midwifery program. Aust NZ J Obstet Gynaecol. 2011;51:518–22.Google Scholar
  35. Homer CSE, Foureur M, Allende T, Pekin F, Caplice S, Catling-Paull C. ‘It’s more than just having a baby’ women’s experience of a maternity service for Australian Aboriginal and Torres Strait Islander families. Midwifery. 2012;28:e509–15.View ArticleGoogle Scholar
  36. Murphy E, Best E. The Aboriginal Maternal and Infant Health Service: a decade of achievement in the health of women and babies in NSW. NSW Public Health Bull. 2012;23(3-4):68–72.View ArticleGoogle Scholar
  37. Barclay L, Kruske S, Bar-Zeev S, Steenkamp M, Josif C, Narjic CW, Wardaguga M, Belton S, Gao U, 497 Dunbar T, Kildea S. Improving Aboriginal maternal and infant health services in the ‘Top End’ of Australia; synthesis of the findings of a health services research program aimed at engaging stakeholders, developing research capacity and embedding change. BMC Health Serv Res. 2014;14:241.Google Scholar
  38. Di Lallo S. Prenatal care through the eyes of Canadian Aboriginal women. Nurs Womens Health. 2014;18(1):40–6.View ArticleGoogle Scholar
  39. Rumbold AR, Cunningham J. A review of the impact of antenatal care for Australian Indigenous women and attempts to strengthen these services. Matern Child Health J. 2008;12(1):83–100.View ArticlePubMedGoogle Scholar
  40. Jongen C, McCalman J, Bainbridge R, Tsey K. Aboriginal and Torres Strait Islander maternal and child health and wellbeing: a systematic search of programs and services in Australian primary health care settings. BMC Pregnancy Childbirth. 2014;14:251.View ArticlePubMedPubMed CentralGoogle Scholar
  41. Kramer MS, Séguin L, Lydon J, Goulet L. Socio-economic disparities in pregnancy outcome: why do the poor fare so poorly? Paediatr Perinatal Epidemiol. 2000;14(3):194–210.View ArticleGoogle Scholar
  42. National Insitute of Clinical Excellence. Pregnancy and complex social factors: A model for service provision for pregnant women with complex social factors. London: NICE; 2010.Google Scholar
  43. Centre for Maternal and Child Enquiries (CMACE). Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer: 2006–08. The Eighth Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG. 2011;118(1):1–203.View ArticleGoogle Scholar
  44. Rayment-Jones H, Murrells T, Sandall J. An investigation of the relationship between the caseload model of midwifery for socially disadvantaged women and childbirth outcomes using routine data – a retrospective, observational study. Midwifery 2015; http://dx.doi.org/https://doi.org/10.1016/j.midw.2015.01.003
  45. Mezey G, Bacchus L, Bewley S, White S. Domestic violence, lifetime trauma and psychological health of childbearing women. BJOG. 2005;112(2):197–204.View ArticlePubMedGoogle Scholar
  46. Hollowell J, Oakley L, Kurinczuk JJ, Brocklehurst P, Gray R. The effectiveness of antenatal care programmes to reduce infant mortality and preterm birth in socially disadvantaged and vulnerable women in high-income countries: a systematic review. BMC Pregnancy Childbirth. 2011;11:13.View ArticlePubMedPubMed CentralGoogle Scholar

Copyright

© Weetra et al. 2016