Torres Strait Islander Women Research Articles

An intensive smoking intervention for pregnant Aboriginal and Torres Strait Islander women: a randomised controlled trial

[Extract] We comment on practical aspects of the approach to maternal Indigenous smoking raised in the study by Eades and colleagues. Pregnant smokers face barriers to quitting; however, we believe some additional barriers are systemic, including excessive caution in prescribing nicotine replacement therapy (NRT). Guidelines for maternal smoking cessation recommend an unassisted attempt before considering NRT. There is no agreed definition of a quit attempt, or for how long a pregnant woman should persist unaided before NRT is tried. In this study, two failed attempts were a prerequisite. In a practice setting, this may be overcautious; intermittent NRT is considered less hazardous than continued smoking in pregnancy. If a pregnant woman is unable to abstain for 2–3 days, an accelerated option of intermittent NRT should be considered, to keep up momentum with the quit attempt. The attendance rate dropped from 64% at 3–5 days to 35% at 7–10 days — perhaps lost opportunities for initiating pharmacotherapy. The article does not detail the type of NRT (oral or transdermal), dosage, duration of treatment, compliance rates, or the management of side effects. These aspects would be of interest to smoking cessation practitioners.

The Murri clinic: a comparative retrospective study of an antenatal clinic developed for Aboriginal and Torres Strait Islander women

BackgroundIndigenous Australians are a small, widely dispersed population. Regarding childbearing women and infants, inequities in service delivery and culturally unsafe services contribute to significantly poorer outcomes, with a lack of high-level research to guide service redesign. This paper reports on an Evaluation of a specialist (Murri) antenatal clinic for Australian Aboriginal and Torres Strait Islander women.MethodsA triangulated mixed method approach generated and analysed data from a range of sources: individual and focus group interviews; surveys; mother and infant audit data; and routinely collected data. A retrospective analysis compared clinical outcomes of women who attended the Murri clinic (n=367) with Indigenous women attending standard care (n=414) provided by the same hospital over the same period. Both services see women of all risk status.ResultsThe majority of women attending the Murri clinic reported high levels of satisfaction, specifically with continuity of carer antenatally. However, disappointment with the lack of continuity during labour/birth and postnatally left some women feeling abandoned and uncared for. Compared to Indigenous women attending standard care, those attending the Murri clinic were statistically less likely to be primiparous or partnered, to experience perineal trauma, to have an epidural and to have a baby admitted to the Neonatal Intensive Care Unit, and were more likely to have a non-instrumental vaginal birth. Multivariate analysis found higher normal birth (spontaneous onset of labour, no epidural, non-instrumental vaginal birth without episiotomy) rates amongst women attending the Murri clinic.ConclusionsSignificant benefits were associated with attending the Murri clinic. Recommendations for improvement included ongoing cultural competency training for all hospital staff, reducing duplication of services, improving co-ordination and communication between community and tertiary services, and working in partnership with community-based providers. Combining multi-agency resources to increase continuity of carer, culturally responsive care, and capacity building, including creating opportunities for Indigenous employment, education, and training is desirable, but challenging. Empirical evidence from our Evaluation provided the leverage for a multi-agency agreement to progress this goal within our catchment area.

Menopause and the influence of culture: another gap for Indigenous Australian women?

BackgroundThere is great variation in experience of menopause in women around the world. The purpose of this study was to review current understanding of Australian Aboriginal and Torres Strait Islander (Indigenous) women’s experiences of menopause. The literature pertaining to the perception, significance and experience of menopause from a number of cultural groups around the world has been included to provide context for why Indigenous women’s experience might be important for their health and differ from that reported in other studies of Australian women and menopause.MethodsA search of databases including Ovid Medline, Pubmed, Web of Science, AUSThealth, AMED, EMBASE, Global Health and PsychINFO was undertaken from January 2011 to April 2011 using the search terms menopause, Indigenous, Aboriginal, attitudes, and perceptions and repeated in September 2012.ResultsConsiderable research shows significant variation across cultures in the menopausal experience. Biological, psychological, social and cultural factors are associated with either positive or negative attitudes, perceptions or experiences of menopause in various cultures. Comparative international literature shows that neither biological nor social factors alone are sufficient to explain the variation in experiences of the menopausal transition. However, a strong influence of culture on the menopause experience can be found. The variation in women’s experience of menopause indicates that different cultural groups of women may have different understandings and needs during the menopausal transition. While considerable literature exists for Australian women as a whole, there has been little investigation of Australian Indigenous women, with only two research studies related to Indigenous women’s experiences of menopause identified.ConclusionsDifferences in biocultural experience of menopause around the world suggest the importance of biocultural research. For the Indigenous women of Australia, the relative contribution of culture, social disadvantage and poor general health compared with non-Indigenous women to the experience of menopause is unknown. As such, further research and understanding of the experience of Indigenous women around Australia is needed. This information could assist individuals, families, cultural groups and healthcare providers to enhance management and support for Indigenous Australian women.

Pragmatic randomised trial of a 12-week exercise and nutrition program for Aboriginal and Torres Strait Islander women: clinical results immediate post and 3 months follow-up

BackgroundAboriginal and Torres Strait Islander women experience higher rates of heart disease and type 2 diabetes than non-Indigenous Australian women. Increasing physical activity, improving diets and losing weight have been shown to reduce cardio metabolic risk. The primary aim was to evaluate the effectiveness of a 12-week structured exercise and nutrition program in a cohort of urban Indigenous Australian women on waist circumference, weight and biomedical markers of metabolic functioning from baseline (T1) to program completion (T2). The secondary aim assessed whether these outcomes were maintained at 3-month follow-up.MethodsOne hundred Aboriginal and/or Torres Strait Islander women aged 18–64 years living in the Adelaide metropolitan area were recruited. The program included two 60-minute group cardiovascular and resistance training classes per week, and four nutrition education workshops. Participants were randomly assigned to an ‘active’ group or ‘waitlisted’ control group. Body weight, height, waist and hip circumference, blood pressure, fasting glucose, fasting insulin, glycated haemoglobin (HbA1C), lipid profile and C-reactive protein (CRP) were assessed at baseline (T1), immediately after the program (T2) and three months post program (T3).ResultsThe active group showed modest reductions in weight and body mass index (BMI). Compared to the waitlisted group, the active group had a statistically significantly change in weight and BMI from baseline assessments; at T2, -1.65 kg and -0.66 kg/m2 and at T3, -2.50 kg and -1.03 kg/m2, respectively. Systolic and diastolic blood pressure also had a statistically significant difference from baseline in the active group compared to the waitlisted group at T2, -1.24 mmHg and -2.46 mmHg and at T3, -4.09 mmHg and -2.17 mmHg, respectively. The findings were independent of the baseline measure of the outcome variable, age, households with children and employment status. Changes in waist circumference and other clinical measures were not significant at T2 or T3. The primary outcome measure, waist circumference, proved problematic to assess reliably. Missing data and participants lost to follow-up were significant.ConclusionsThis 12-week exercise program demonstrated modest reductions in weight, BMI and blood pressure at T2, which improved further at 3-month follow-up (T3). Positive intervention effects were observed despite low attendance at exercise classes. Structured exercise programs implemented in community settings require attention to understanding the barriers to participation for this high risk group.Trial registrationAustralian New Zealand Clinical Trials Registry ACTRN12610000224022

Knowledge and Views About Maternal Tobacco Smoking and Barriers for Cessation in Aboriginal and Torres Strait Islanders: A Systematic Review and Meta-ethnography

Maternal smoking rates in Australian Aboriginal women are triple that of the general population, with little evidence for successful interventions. We reviewed the literature to understand smoking and cessation in Aboriginal and Torres Strait Islander women and provide recommendations for targeted interventions. Six databases were searched using terms related to smoking, pregnancy, and Aboriginal Australians. Two reviewers independently assessed papers for inclusion and quality. Meta-ethnography synthesized first- and second-order constructs from included studies and constructed a line of argument. Seven relevant studies were analyzed. The synthesis illustrates 11 third-order constructs operating on the levels of self, family, and social networks, the wider Aboriginal community, and broader external influences. Highlighted are social norms and stressors within the Aboriginal community perpetuating tobacco use; insufficient knowledge of smoking harms; inadequate saliency of antismoking messages; and lack of awareness and use of pharmacotherapy. Indigenous Health Workers have a challenging role, not yet fulfilling its potential. Pregnancy is an opportunity to encourage positive change where a sense of a "protector role" is expressed. This review gives strength to evidence from individual studies across diverse Indigenous cultures. Pregnant Aboriginal and Torres Strait Islander smokers require comprehensive approaches, which consider the environmental context, increase knowledge of smoking harms and cessation methods, and provide culturally targeted support. Long term, broad strategies should de-normalize smoking in Aboriginal and Torres Strait Islander communities. Further research needs to examine causes of resistance to antitobacco messages, clarify contributing roles of stress and depression, and attitudes to pharmacotherapy.

An intensive smoking intervention for pregnant Aboriginal and Torres Strait Islander women: a randomised controlled trial

To determine the effectiveness of an intensive quit-smoking intervention on smoking rates at 36 weeks' gestation among pregnant Aboriginal and Torres Strait Islander women. Randomised controlled trial. Pregnant Aboriginal and Torres Strait Islander women (n = 263) attending their first antenatal visit at one of three Aboriginal community-controlled health services between June 2005 and December 2009. A general practitioner and other health care workers delivered tailored advice and support to quit smoking to women at their first antenatal visit, using evidence-based communication skills and engaging the woman's partner and other adults in supporting the quit attempts. Nicotine replacement therapy was offered after two failed attempts to quit. The control ("usual care") group received advice to quit smoking and further support and advice by the GP at scheduled antenatal visits. Self-reported smoking status (validated with a urine cotinine measurement) between 36 weeks' gestation and delivery. Participants in the intervention group (n = 148) and usual care group (n = 115) were similar in baseline characteristics, except that there were more women who had recently quit smoking in the intervention group than the control group. At 36 weeks, there was no significant difference between smoking rates in the intervention group (89%) and the usual care group (95%) (risk ratio for smoking in the intervention group relative to usual care group, 0.93 [95% CI, 0.86-1.08]; P = 0.212). Smoking rates in the two groups remained similar when baseline recent quitters were excluded from the analysis. An intensive quit-smoking intervention was no more effective than usual care in assisting pregnant Aboriginal and Torres Strait Islander women to quit smoking during pregnancy. Contamination of the intervention across groups, or the nature of the intervention itself, may have contributed to this result. Australian New Zealand Clinical Trials Registry ACTRN12609000929202.

Factors associated with antenatal smoking among Aboriginal and Torres Strait Islander women in two jurisdictions

Smoking rates are three times as high for pregnant Indigenous women relative to non-Indigenous women, in Australia. This paper describes Indigenous women's self-reported antenatal smoking behaviour and compares knowledge and attitudes of those who: (i) smoke and don't smoke during pregnancy; and (ii) quit or continued to smoke since the beginning of pregnancy. Cross-sectional surveys with 264 pregnant Indigenous women in two states collected data on smoking status, antenatal changes, risk knowledge, attitudes to smoking and sociodemographic characteristics. Multivariable logistic regression analyses assessed associations between knowledge and attitude variables and smoking status and antenatal changes in smoking status. Forty-six per cent of the women (n = 121) reported currently smoking. The majority (68%) who smoked at the beginning of pregnancy reported quitting (21%) or reducing (47%). Relative to smokers, non-smokers had more schooling (P = 0.002), more post-secondary education (P = 0.023), lower parity (P = 0.003), better understanding of smoking-related risks (miscarriage P = 0.01; low birth weight P = 0.003; infant illness P < 0.001; childhood behavioural problems P = 0.007), and less frequently expressed attitudes indicating that quitting was very difficult given other problems they faced. Similar patterns were found for women who quit during pregnancy compared to those who continued smoking. Increasing awareness of antenatal smoking risks and the benefits of quitting may motivate women to attempt to quit. However, knowledge alone is unlikely to be sufficient considering the life circumstances of many Indigenous women. Addressing the social environment and daily stressors, particularly those exacerbated by pregnancy, may be critical to supporting quit attempts.

Breast Screening and Breast Cancer Survival in Aboriginal and Torres Strait Islander Women of Australia

Aboriginal and Torres Strait Islander people comprise about 2.5% of the Australian population. Cancer registry data indicate that their breast cancer survivals are lower than for other women but the completeness and accuracy of Indigenous descriptors on registries are uncertain. We followed women receiving mammography screening in BreastScreen to determine differences in screening experiences and survivals from breast cancer by Aboriginal and Torres Strait Islander status, as recorded by BreastScreen. This status is self-reported and used in BreastScreen accreditation, and is considered to be more accurate. The study included breast cancers diagnosed during the period of screening and after leaving the screening program. Least square regression models were used to compare screening experiences and outcomes adjusted for age, geographic remoteness, socio-economic disadvantage, screening period and round during 1996-2005. Survival of breast cancer patients from all causes and from breast cancer specifically was compared for the 1991-2006 diagnostic period using linked cancer-registry data. Cox proportional hazards regression was used to adjust for socio-demographic differences, screening period, and where available, tumour size, nodal status and proximity of diagnosis to time of screen. After adjustment for socio-demographic differences and screening period, Aboriginal and Torres Strait Islander women participated less frequently than other women in screening and re-screening although this difference appeared to be diminishing; were less likely to attend post-screening assessment within the recommended 28 days if recalled for assessment; had an elevated ductal carcinoma in situ but not invasive cancer detection rate; had larger breast cancers; and were more likely than other women to be treated by mastectomy than complete local excision. Linked cancer registry data indicated that five-year year survivals of breast cancer cases from all causes of death were 81% for Aboriginal and Torres Strait Islander women, compared with 90% for other women, and that the former had larger breast cancers that were more likely to have nodal spread at diagnosis. After adjusting for socio-demographic factors, tumour size, nodal spread and time from last screen to diagnosis, Aboriginal and Torres Strait Islander women had approximately twice the risk of death from breast cancer as other women. Aboriginal and Torres Strait Islander women have less favourable screening experiences and those diagnosed with breast cancer (either during the screening period or after leaving the screening program) have lower survivals that persist after adjustment for socio-demographic differences, tumour size and nodal status.

National trends in Aboriginal and Torres Strait Islander smoking and quitting, 1994–2008

To describe the trends in the prevalence of smoking, quitting and initiation among Aboriginal and Torres Strait Islander men and women aged 18 years and over. Analysis of responses to smoking questions in national Indigenous surveys in 1994, 2002, 2004 and 2008. Male Indigenous smoking prevalence fell significantly from 58.5% in 1994 to 52.6% in 2008, an absolute decrease of 0.4 (CI 0.1-0.7)% per year, with the same decline in remote and non-remote areas. Female smoking fell from 51.0% to 47.4%, with markedly different changes in remote and non-remote areas. In non-remote areas, there was an absolute decrease in female smoking of 0.5 (CI 0.2-0.9)% per year, but in remote areas, female smoking increased by 0.4 (CI 0.0-0.8)% per year. From 2002 to 2008, the percentage of ever-smokers who had quit (quit ratio) increased absolutely by 1% per year in both men and women, remote and non-remote areas. Results about trends in initiation were inconclusive. Health Minister Roxon has committed to halving the Indigenous smoking prevalence by 2018, and has dramatically increased Indigenous-specific funding and activity in tobacco control. The reported historical trends in this paper are encouraging as they occurred at a time when there was little such tobacco control activity focused on Aboriginal and Torres Strait Islander people. However, to meet the Minister's goal, Indigenous smoking prevalence will need to fall more than six times as quickly as occurred from 1994 to 2008.

Indigenous Australian-Indonesian intermarriage: negotiating citizenship rights in twentieth-century Australia

This story of Indigenous Australian-Indonesian intermarriage is one that sheds light on the changes to citizenship entitlement in Australia and the struggles of Aboriginal, Torres Strait Islander and Asian peoples to lead their lives free from government intervention. Indonesian-Australian contacts remain relatively unknown in Australian history. Early Macassan relations with the peoples of Northern Australia, brought to light by Campbell Macknight, stands out in Australian history as a significant first contact with Asia. More recently Regina Ganter has continued the Macassan story into the twentieth century exploring encounters with northern communities across Australia. But the story of wartime disruption faced by the families of Indonesian men and Aboriginal and Torres Strait Islander women and their long wait for citizenship rights has yet to be told.

Plenary 9: Maternity monologues: Stories from Aboriginal and Torres Strait Islander women in the Northern Territory, Australia and their relationship to research and policy

Rachael Lockeya, Leshay Maidmentb, Margaret O’Brienc,d a Midwifery Co-Director Integrated Maternity Services, NT Department of Health and Families, Australia b Deputy CEO of the Central Australian Aboriginal Congress Inc., Alice Springs, Australia c Recall Support Officer, Danila Dilba Health Service, NT, Australia d Indigenous consumer representative on the NT Integrated Maternity Services Clinical Reference Group

Pre-Pregnancy Predictors of Diabetes in Pregnancy Among Aboriginal and Torres Strait Islander Women in North Queensland, Australia

To identify pre-pregnancy risk factors for diabetes in pregnancy among a cohort of Australian Indigenous women. Data on 1,009 Indigenous women of childbearing age who participated in a 1998-2000 health screening program in far north Queensland were linked to Queensland hospitalisations data. Women who attended hospital after their health check for a pregnancy-related condition were identified. The data on women who were hospitalised for birth were also linked to Queensland perinatal data. Of 220 women who gave birth, 23 had diabetes in the pregnancy following their health check. A strong predictor of having a subsequent pregnancy affected by diabetes was suboptimal glucose control before conception. The presence of the metabolic syndrome predicted over a threefold increase in risk among non-diabetic women after adjustment for age and ethnicity (PR, 3.50; 95% CI, 1.54-8.00). For each 1-cm increase in waist circumference, there was an age-adjusted increase in risk of 4% for diabetes in pregnancy (1.04; 1.01-1.06). For each 1-mmHg increase in blood pressure (systolic and diastolic), there was an age-adjusted increase in risk of 3% (1.03; 1.01-1.05 and 1.03; 1.00-1.07, respectively). Associations between hypercholesterolaemia and dyslipidaemia and diabetes in the subsequent pregnancy were diminished after adjustment for age and ethnicity. The risk for women with "hyper-triglyceridaemic waist" phenotype before pregnancy was diminished by adjustment for age, ethnicity and baseline fasting glucose. Alcohol intake, smoking, level of physical activity and red cell folate showed little effect. Identification of women at particularly high risk for future diabetes in pregnancy, given their pre-pregnancy health, is important so that they can manage their risks and where overweight or obesity is a factor, interventions aimed at weight management should be implemented.

Study protocol: a pragmatic randomised controlled trial of a 12-week physical activity and nutritional education program for overweight Aboriginal and Torres Strait Islander women

BackgroundAboriginal and Torres Strait Islander women have a higher prevalence and incidence of obesity and type 2 diabetes than non-Indigenous Australian women. Physical inactivity is a key modifiable risk factor for obesity and evidence shows that even modest reductions in waist circumference (WC) have significant health benefits. Trialing physical activity programs in difficult-to-reach high risk groups, especially urban Indigenous Australians poses distinct implementation challenges.Methods/DesignThe trial objective is to evaluate the effectiveness of a structured 12-week physical activity group program with nutritional advice. The design is a pragmatic randomised controlled trial. This study protocol describes the implementation and evaluation of the program. Participants are randomised into either an intervention or waitlisted group. The waitlisted group have a 12 month waiting period before commencing the 12-week program. Participant data is collected at baseline, 12, 24 and 52 weeks. Participants are Aboriginal and Torres Strait Islander women, aged 18-64 years with a waist circumference greater than 80 centimetres residing in Adelaide. The primary outcome measure is WC change immediately post program from baseline. Secondary outcomes include short term and long term changes in WC, weight, blood pressure, fasting blood glucose, insulin, insulin resistance (calculated HOMA), haemoglobin A1C (HbA1C), triglycerides and C-reactive protein (CRP). Behavioural and psychosocial surveys are administered to assess physical activity, dietary intake and the participant's motivation, self-efficacy and perceived social support for physical activity. Qualitative interviews focusing on participants' motivation, enablers and barriers to healthy eating and physical activity will be undertaken. Implementation fidelity and participation are also assessed.DiscussionThe Aboriginal and Torres Strait Islander Women's Fitness Program (WFP) is designed to provide a rigorous physiological and client-based evaluation of a structured 12-week program aimed to increase metabolic fitness and reduce WC in this high risk population. Evaluation results aim to provide the support necessary to design programs that are accessible, affordable and effective at reducing WC, while also improving the metabolic profile of overweight Aboriginal and Torres Strait Islander women.Trial registrationAustralian New Zealand Clinical Trials Registry ACTRN12610000224022

‘It's more than just having a baby’ women's experiences of a maternity service for Australian Aboriginal and Torres Strait Islander families

Objectivethe Malabar Community Midwifery Link Service was developed to meet the needs of women from Aboriginal and Torres Strait Islander communities in suburban Sydney, Australia. This paper reports the evaluation from the perspective of the Aboriginal and Torres Strait Islander women who accessed the service. Methodsa descriptive study using quantitative and qualitative approaches was undertaken for the first two years of the service. Clinical outcomes for women who gave birth in 2007 and 2008 were collected prospectively. A focus group with Aboriginal and Torres Strait Islander women was conducted, then tape recorded, transcribed verbatim and analysed qualitatively. Findings353 women gave birth through the Malabar service during 2007 and 2008. Over 40% of the babies born were identified as Aboriginal and Torres Strait Islander. Almost all the women had their first antenatal visit before 20 weeks of pregnancy. The service was successful in reducing the number of women smoking cigarettes during pregnancy. Women felt the service provided ease of access, continuity of care and caregiver, trust and trusting relationships. Conclusionsthe Malabar service is an excellent example of a primary health care model of care that is meeting the needs of the community. Improving maternal and neonatal outcomes takes considerable time as the underlying causes of the disparities are complex. Implicationsfurther research into ways to ensure that services like Malabar can address issues like smoking in pregnancy and the range of social and emotional issues faced by Australian Aboriginal and Torres Strait Islander women and families needs to be undertaken. More community-based appropriate services should be developed for these families.

Pre‐pregnancy predictors linked to miscarriage among Aboriginal and Torres Strait Islander women in North Queensland

Identify preventable pre-pregnancy risk factors that may affect the prevalence of miscarriage among a cohort of Australian Indigenous women. Data from 1,009 Indigenous women of childbearing age who participated in a 1999-2000 health screening program in far-north Queensland were linked to Queensland hospitalisation data. Women who attended hospital after their health check (censor date: March 2008) for a pregnancy-related condition were identified. Characteristics associated with becoming pregnant and subsequent miscarriage were analysed using generalised linear models. After adjusting for age and ethnicity, women who became pregnant were more likely to be smokers and to have low red cell folate at baseline. The risk of miscarriage increased with age. Women who reported risky drinking or had elevated gamma-glutamyl transferase were also at higher risk. After further adjustment for risky drinking, the presence of chlamydia or gonorrhoea before pregnancy was associated with miscarriage. The presence of both infections at baseline compared with women who had no infection, again after further adjustment for risky drinking, was strongly associated with miscarriage; these women had more than a four-fold increase in risk (PR: 4.57 [2.21-9.46]). Elevated body mass index, high blood pressure and smoking were not statistically significantly associated with risk of miscarriage. A high prevalence of pre-pregnancy sexually transmitted infections and high rates of risky drinking are associated with miscarriage among young Indigenous women in rural and remote communities in north Queensland.

Setting a New Agenda

The Australian National Aboriginal and Torres Strait Islander Women’s Health Strategy was developed to reflect the health priorities of Aboriginal and Torres Strait Islander women, as identified by Aboriginal and Torres Strait Islander women themselves. This article describes the process used by the Australian Women’s Health Network to develop the strategy. The women involved in the research used the talking circle method and engaged with Aboriginal and Torres Strait Islander women through a process referred to as ‘talkin’ up’, where women ‘talk back’ to one another about issues that matter to them. In this article, we describe the power of the talkin’ up process, as a way for Aboriginal and Torres Strait Islander women to identify their own issues, discuss them in context and talk in a culturally safe environment. The strategy which emerged from this process is an accurate reflection of the issues that are important to Australian Indigenous women and highlights the improvements needed in Aboriginal and Torres Strait Islander women’s health to strengthen and underpin women’s health, Indigeneity and their sense of well-being as Aboriginal and Torres Strait Islander women.

Jumping the Hurdles for Smoking Cessation in Pregnant Aboriginal and Torres Strait Islander Women in Australia

AbstractTobacco smoking perpetuates the disadvantages experienced by Aboriginal and Torres Strait Islander people in Australia. Tobacco smoking is a risk factor for poor maternal and infant outcomes in pregnancy. Over half of Aboriginal and Torres Strait Islander women smoke during pregnancy and few successfully quit. Aboriginal and Torres Strait Islander women face many intrinsic barriers to quitting such as low socioeconomic disadvantage and patterns of use in family networks. There are also several extrinsic hurdles surrounding current practice guidelines and policy that may limit success in reducing smoking rates among Aboriginal and Torres Strait Islander women during pregnancy: the use of the Stages of Change (SOC) model; delay in the use of nicotine replacement therapy (NRT); and the absence of subsidised intermittent NRT. A more proactive approach towards smoking cessation for pregnant Aboriginal and Torres Strait Islander women may be necessary, including moving away from the SOC model approach and subsidised provision of intermittent NRT. Comprehensive programs that take into account the family network and wider social context are also recommended.

The transformative potential of young motherhood for disadvantaged Aboriginal and Torres Strait Islander women in Townsville, Australia

To explore attitudes to pregnancy and parenthood among a group of Indigenous young people in Townsville, Australia. Mixed methods and a cross-sectional design involving Indigenous women from a Young Mums Group designing the research instruments and acting as peer interviewers. Data were collected in 2004 from young Indigenous people who had never been pregnant (171 students at three high schools and 15 people at a homeless youth shelter) using a computer-assisted self-administered survey; from 59 of this group who also participated in single sex focus group discussions; and from 10 pregnant and parenting young women in individual semi-structured interviews. Self-reported attitudes and behaviour about aspirations, pregnancy and parenthood. Only eight of 186 young Indigenous people who had never been pregnant reported wanting to have a child as a teenager. Large proportions of this group of 186 reported idealised views about pregnancy, particularly young men, with 50.5% reporting that being a parent would always be enjoyable, and 62.6% reporting that being a mother or a father would not change their lives. Idealised views were associated with earlier sexual initiation (P = 0.001). Issues identified in the narratives of young mothers related to difficult backgrounds, pregnancy "just happening" to them, and the transformative impact of having a child on their lives and aspirations. Accurate parenting information may be necessary to address unrealistic views about parenting among Indigenous young people. Young Indigenous parents often come from extremely disadvantaged backgrounds, and becoming a parent may be the impetus for positive change.

Smoking and Aboriginal and Torres Strait Islander and Māori children

Smoking and the deaths and suffering it causes are more common among Aboriginal and Torres Strait Islander peoples and Māori than other Australians and New Zealanders. While, many tobacco control activities that are not specifically targeted at children will have a positive impact on child health, this review concentrates on recent tobacco control research on pregnant women and children. The important tasks are to reduce smoking by pregnant Māori and Aboriginal and Torres Strait Islander women to reduce infant and child exposure to second-hand smoke and to reduce smoking initiation of children and adolescents. Health professionals who want to reduce the suffering caused by smoking among Māori and Aboriginal and Torres Strait Islander children can be guided by much new relevant research evidence and clear frameworks about how to approach tobacco control in these communities.

'Closing the Gap': How maternity services can contribute to reducing poor maternal infant health outcomes for Aboriginal and Torres Strait Islander women

The reproductive health outcomes for Aboriginal and Torres Strait Islander mothers and infants are significantly poorer than they are for other Australians; they worsen with increasing remoteness where the provision of services becomes more challenging. Australia has committed to 'Overcoming Indigenous Disadvantage' and 'Closing the Gap' in health outcomes. Fifty-five per cent of Aboriginal and Torres Strait Islander birthing women live in outer regional and remote areas and suffer some of the worst health outcomes in the country. Not all of these women are receiving care from a skilled provider, antenatally, in birth or postnatally while the role of midwives in reducing maternal and newborn mortality and morbidity is under-utilised. The practice of relocating women for birth does not address their cultural needs or self-identified risks and is contributing to these outcomes. An evidence based approach for the provision of maternity services in these areas is required. Australian maternal mortality data collection, analysis and reporting is currently insufficient to measure progress yet it should be used as an indicator for 'Closing the Gap' in Australia. A more intensive, coordinated strategy to improve maternal infant health in rural and remote Australia must be adopted. Care needs to address social, emotional and cultural health needs, and be as close to home as possible. The role of midwives can be enabled to provide comprehensive, quality care within a collaborative team that includes women, community and medical colleagues. Service provision should be reorganised to match activity to need through the provision of caseload midwives and midwifery group practices across the country. Funding to embed student midwives and support Aboriginal and Torres Strait Islander women in this role must be realised. An evidence base must be developed to inform the provision of services in these areas; this could be through the testing of the Rural Birth Index in Australia. The provision of primary birthing services in remote areas, as has occurred in some Inuit and New Zealand settings, should be established. 'Birthing on Country' that incorporates local knowledge, on-site midwifery training and a research and evaluation framework, must be supported.