Association between maternal mental health-related hospitalisation in the 5 years prior to or during pregnancy and adverse birth outcomes: a population-based retrospective cohort data linkage study in the Northern Territory of Australia

Background

Mental health conditions prior to or during pregnancy that are not addressed can have adverse consequences for pregnancy and birth outcomes. This study aimed to determine the extent to which women's mental health-related hospitalisation (MHrH) prior to or during pregnancy was associated with a risk of adverse birth outcomes.

Methods

We linked the perinatal data register for all births in the Northern Territory, Australia, from the year 1999 to 2017, to hospital admissions records to create a cohort of births to women aged 15-44 years with and without MHrH prior to or during pregnancy. We used Modified Poisson Regression and Latent Class Analysis to assess the association between maternal MHrH and adverse birth outcomes (i.e., stillbirth, preterm birth, low birth weight, and short birth length). We explored a mediation effect of covariates on theoretical causal paths. We calculated the adjusted Population Attributable Fraction (PAF) and Preventive Fractions for the Population (PFP) for valid associations.

Findings

From 72,518 births, 70,425 births (36.4% for Aboriginal women) were included in the analysis. The Latent Class Analys identified two classes: high (membership probability of 10.5%) and low adverse birth outcomes. Births to Aboriginal women with MHrH were around two times more likely to be in the class of high adverse birth outcomes. MHrH prior to or during pregnancy increased the risk of all adverse birth outcomes in both populations with risk ranging from 1.19 (95% CI: 1.05, 1.35) to 7.89 (1.17, 53.37). Eight or more antenatal care visits and intrauterine growth restriction mostly played a significant mediation role between maternal MHrH and adverse birth outcomes with mediation effects ranging from 1.04 (1.01, 1.08) to 1.39 (1.14, 1.69). MHrH had a low to high population impact with a PAF ranging from 16.1% (5.1%, 25.7%) to 87.3% (14.3%, 98.1%). Eight or above antenatal care visits avert extra adverse birth outcomes that range from 723 (332-765) stillbirths to 3003 (1972-4434) preterm births.

Interpretation

Maternal MHrH is a modifiable risk factor that explained a low to moderate risk of adverse birth outcomes in the Northern Territory. The knowledge highlights the need for the development and implementation of preconception mental health care into routine health services.

Funding

The Child and Youth Development Research Partnership (CYDRP) data repository is supported by a grant from the Northern Territory Government.

Looking after bubba for all our mob: Aboriginal and Torres Strait Islander community experiences and perceptions of stillbirth

The stillbirth rate among Aboriginal and Torres Strait Islander women and communities in Australia is around double that of non-Indigenous women. While the development of effective prevention strategies during pregnancy and improving care following stillbirth for women and families in communities has become a national priority, there has been limited progress in stillbirth disparities. With community permission, this study aimed to gain a better understanding of community experiences, perceptions, and priorities around stillbirth. We undertook an Indigenous researcher-led, qualitative study, with community consultations guided by a cultural protection protocol and within an unstructured research framework. A total of 18 communities were consulted face-to-face through yarning interviews, focus groups and workshops. This included 54 community member and 159 health professional participants across remote, regional, and urban areas of Queensland, Western Australia, Victoria, South Australia, and Northern Territory. Thematic analysis of consultation data identified common themes across five focus/priority areas to address stillbirth: Stillbirth or Sorry Business Baby care needs to be family-centered; using Indigenous "ways of knowing, being, and doing" to ensure cultural safety; application of Birthing on Country principles to maternal and perinatal care; and yarning approaches to improve communication and learning or education. The results underscore the critical need to co-design evidence-based, culturally appropriate, and community-acceptable resources to help reduce existing disparities in stillbirth rates.

Barriers and facilitators for recruiting and retaining male participants into longitudinal health research: a systematic review

BACKGROUND

Successfully recruiting male participants to complete a healthcare related study is important for healthcare study completion and to advance our clinical knowledgebase. To date, most research studies have examined the barriers and facilitators of female participants in longitudinal healthcare-related studies with limited information available about the needs of males in longitudinal research. This systematic review examines the unique barriers and facilitators to male recruitment across longitudinal healthcare-related research studies.

METHODS

Following PRIMSA guidelines, MEDLINE, Embase, CINAHL and Web of Science databases were systematically searched using the terms recruitment and/or retention, facilitators and/or barriers and longitudinal studies from 1900 to 2023 which contained separate data on males aged 17-59 years. Health studies or interventions were defined longitudinal if they were greater than or equal to 12 weeks in duration with 3 separate data collection visits.

RESULTS

Twenty-four articles published from 1976-2023 met the criteria. One-third of the studies had a predominantly male sample and four studies recruited only male participants. Males appear disinterested towards participation in health research, however this lack of enthusiasm can be overcome by clear, non-directive communication, and studies that support the participants interests. Facilitating factors are diverse and may require substantial time from research teams.

CONCLUSIONS

Future research should focus on the specific impact of these factors across the spectrum of longitudinal health-related studies. Based on the findings of this systematic review, researchers from longitudinal health-related clinical trials are encouraged to consider male-specific recruitment strategies to ensure successful recruitment and retention in their studies.

REGISTRATION

This systemic review is registered with the PROSPERO database (CRD42021254696).

"It's research, our input can grow": identifying health research priorities with Aboriginal and Torres Strait Islander communities-study protocol

BACKGROUND

In Australia, Aboriginal and Torres Strait Islander (Indigenous) families have strong, cohesive, and nurturing cultural practices that contribute to effective family functioning and child rearing. These practices can lead to positive effects on children and communities, and include kinship relations, traditional knowledge systems, collective community focus, respect for Elders contributions, and spirituality. However, poor health and wellbeing outcomes exist across the lifespan for Indigenous Australians. Health programs, services and research that support Indigenous women, babies and their families are a critical investment to improve birthing and health outcomes and impact the life trajectories of Indigenous Australians.

AIM

The Indigenous Health Research Priorities study aims to identify the research priorities for families during the perinatal and early childhood period through a co-designed and collaborative process. This has been led by communities to determine the priorities identified with and for local Indigenous families in Queensland. This paper aims to report on engagement and involvement with Indigenous communities to identity health research priorities for families and presents preliminary findings of the research process including participants' demographic information and feedback on the yarning sessions, as part of the study protocol.

METHODS

The study protocol showcases the Participatory Action Research approach, yarning sessions with clients and staff of three community-controlled health services to date, and Delphi workshop methods to prioritise the health issues identified during the yarns with corresponding communities. The study will undertake qualitative data collection and analysis to identify and report on community and health service research priorities for Indigenous families in Queensland. A short survey was conducted to collect participants' demographic information. A feedback form with five open-ended questions was also administered to collect data on participants' views and satisfaction with the research process.

PRELIMINARY RESULTS

This protocol paper reports on the participant demographic information and feedback on the research process and reactions to participating in the yarning sessions. There have been 12 yarning sessions in Far North Queensland to date. The qualitative analysis of these will be reported on in future, with South East Queensland and further sites to follow. Feedback from 61 community members and health professionals has highlighted they valued sharing stories, being heard, and feeling hopeful. Preliminary findings will be reported.

DISCUSSION

Identification of health research priorities will allow each organisation and region of Queensland to develop research initiatives and the translational outcomes that are a focus for their community members.

Indigenous women and their nutrition during pregnancy: Study Protocol for co-designed m-health resource for the 'Mums and Bubs Deadly Diets' project

BACKGROUND

Nutrition in pregnancy is pivotal to optimising infant growth and maternal wellbeing. The factors affecting Indigenous people's food and nutrition intake are complex, with a history of colonisation impacting the disproportionate effect of social determinants to this day. Literature regarding the dietary intake or priorities of Indigenous women in Australia is scarce with supportive, culturally appropriate resources developing for and with this group rare. Research suggests mHealth tools are effective in supporting health knowledge of Indigenous people and positive health behaviour changes when designed and developed with the expertise of Indigenous communities.

OBJECTIVE

This study seeks to build the body of knowledge related to nutrition needs and priorities for Indigenous women in Australia during pregnancy. Further this project team and its participants will co-design an mHealth digital tool to support these nutrition needs.

METHODS

The Mums and Bubs Deadly Diets study recruits Indigenous women and healthcare professionals who support Indigenous women during pregnancy into two phases. Phase One (pre-design) utilises a mixed methods convergent design utilising a biographical questionnaire and social/focus groups to inform Phase Two (generative). Phase Two will use a participatory action research process during co-design workshops to iteratively develop the digital tool, the exact actions within a workshop will evolve according to the participant group decisions.

RESULTS

To date, this project has undertaken Phase One focus groups at all Queensland sites with New South Wales and Western Australia to begin in early to mid 2023. We have recruited 12 participants from Galangoor Duwalami, 18 participants from Carbal in Toowoomba and 18 participants from Carbal in Warwick. We are expecting similar numbers of recruits in Western Australia and New South Wales. Participants have been both community members and health care professionals.

CONCLUSIONS

This study is an iterative and adaptive research program that endeavours to develop real world, impactful resources to support the nutrition needs and priorities of pregnant Indigenous women in Australia. This comprehensive project requires a combination of methods and methodologies to ensure Indigenous voices are heard at each stage and in all aspects of research output. The development of an mHealth resource for this cohort will provide a necessary bridge where there is often a gap in access to nutrition resources for women in pregnancy in Indigenous communities.

CLINICALTRIAL

Not applicable.

Omega-3 Fatty Acids during Pregnancy in Indigenous Australian Women of the Gomeroi Gaaynggal Cohort

Higher dietary intakes of Omega-3 long-chain polyunsaturated fatty acids (n-3 LC-PUFAs) have been linked to lower rates of preterm birth and preeclampsia. The aim of this analysis was to describe dietary intake and fractions of red blood cell (RBC) membrane LC-PUFAs during pregnancy in a cohort of Indigenous Australian women. Maternal dietary intake was assessed using two validated dietary assessment tools and quantified using the AUSNUT (Australian Food and Nutrient) 2011-2013 database. Analysis from a 3-month food frequency questionnaire indicated that 83% of this cohort met national n-3 LC-PUFA recommendations, with 59% meeting alpha-linolenic acid (ALA) recommendations. No nutritional supplements used by the women contained n-3 LC-PUFAs. Over 90% of women had no detectable level of ALA in their RBC membranes, and the median Omega-3 Index was 5.5%. This analysis appears to illustrate a decline in concentrations of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) across gestation in women who had preterm birth. However, there was no visible trend in LC-PUFA fractions in women who experienced hypertension during pregnancy. Further research is needed to better understand the link between dietary intake of n-3 LC-PUFA-rich foods and the role of fatty acids in preterm birth and preeclampsia.

Insufficient Evidence of a Breastmilk Microbiota at Six-Weeks Postpartum: A Pilot Study

Breastmilk is thought to influence the infant gut by supplying prebiotics in the form of human milk oligosaccharides and potentially seeding the gut with breastmilk microbes. However, the presence of a breastmilk microbiota and origins of these microbes are still debated. As a pilot study, we assessed the microbes present in expressed breastmilk at six-weeks postpartum using shotgun metagenomic sequencing in a heterogenous cohort of women who delivered by vaginal (n = 8) and caesarean delivery (n = 8). In addition, we estimated the microbial load of breastmilk at six-weeks post-partum with quantitative PCR targeting the 16S rRNA gene. Breastmilk at six-weeks postpartum had a low microbial mass, comparable with PCR no-template and extraction controls. Microbes identified through metagenomic sequencing were largely consistent with skin and oral microbes, with four samples returning no identifiable bacterial sequences. Our results do not provide convincing evidence for the existence of a breastmilk microbiota at six-weeks postpartum. It is more likely that microbes present in breastmilk are sourced by ejection from the infant's mouth and from surrounding skin, as well as contamination during sampling and processing.

Associations between COVID-19 lockdown and post-lockdown on the mental health of pregnant women, postpartum women and their partners from the Queensland family cohort prospective study

Background

There are very few developed countries where physical isolation and low community transmission has been reported for COVID-19 but this has been the experience of Australia. The impact of physical isolation combined with low disease transmission on the mental health of pregnant women is currently unknown and there have been no studies examining the psychological experience for partners of pregnant women during lockdown. The aim of the current study was to examine the impact of the first COVID-19 lockdown in March 2020 and post lockdown from August 2020 on the mental health of pregnant women or postpartum women and their partners.

Methods

Pregnant women and their partners were prospectively recruited to the study before 24 weeks gestation and completed various questionnaires related to mental health and general wellbeing at 24 weeks gestation and then again at 6 weeks postpartum. The Depression, Anxiety and Stress Scale (DASS-21) and the Edinburgh Postnatal Depression Scale (EPDS) were used as outcome measures for the assessment of mental health in women and DASS-21 was administered to their partners. This analysis encompasses 3 time points where families were recruited; before the pandemic (Aug 2018-Feb 2020), during lockdown (Mar-Aug 2020) and after the first lockdown was over (Sept-Dec 2020).

Results

There was no significant effect of COVID-19 lockdown and post lockdown on depression or postnatal depression in women when compared to a pre-COVID-19 subgroup. The odds of pregnant women or postpartum women experiencing severe anxiety was more than halved in women during lockdown relative to women in the pre-COVID-19 period (OR = 0.47; 95%CI: 0.27–0.81; P = 0.006). Following lockdown severe anxiety was comparable to the pre-COVID-19 women. Lockdown did not have any substantial effects on stress scores for pregnant and postpartum women. However, a substantial decrease of over 70% in the odds of severe stress was observed post-lockdown relative to pre-COVID-19 levels. Partner’s depression, anxiety and stress did not change significantly with lockdown or post lockdown.

Conclusion

A reproductive age population appear to be able to manage the impact of lockdown and the pandemic with some benefits related to reduced anxiety.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04795-9.

Dietary intake of Indigenous Australian infants and young children in the Gomeroi gaaynggal cohort

AIM

The nutritional quality of foods consumed by infants and young children to complement breastfeeding or formula feeding influences growth and development. The aim of this study was to identify the dietary intake of Indigenous infants and young children in the Gomeroi gaaynggal cohort, and evaluate the nutritional adequacy of their intake compared with Australian recommendations.

METHODS

Dietary intake was assessed using diet recalls at approximately 9-, 12- and 24-month visits. Nutrient values of foods were obtained from AUSNUT 2011-13 and nutrient intake compared to the Australian Nutrient Reference Values. Foods were categorised into food groups and intakes compared to the Australian Guide to Healthy Eating.

RESULTS

A total of 206 infants and young children were included in the study. Of these, 95 individual children had dietary data collected between 7.6 and 24.7 months. Infant formula and breastfeeding rates were highest among infants (70% and 20%, respectively). Cow's milk intake was highest among young children (75%). Infants and young children in the cohort met most macro- and micronutrient intake recommendations. Few young children met recommendation for iron (42%), no infant met recommendation for omega-3 fatty acids and almost all exceeded recommendation for sodium. Most young children met daily dairy and fruit recommendations although intake of discretionary foods was high.

CONCLUSIONS

This study found that diets of Indigenous infants and young children met most key nutrient reference targets. Potential target areas that require dietary optimisation have been identified and will be the focus of community-led strategies in adequate infant nutrition promotion.

Factors influencing contraceptive use or non-use among Aboriginal and Torres Strait Islander people: a systematic review and narrative synthesis

Background

The Australian population has an unmet need for contraception. However, evidence suggests contraceptive patterns of Aboriginal and Torres Strait Islander populations are unique. To tailor contraceptive services and meet the contraceptive needs of Aboriginal and Torres Strait Islander people, it is important to understand the contributing factors to contraceptive use and non-use.

Methods

This study aimed to systematically review and narratively synthesise the evidence exploring the factors influencing contraceptive use among Aboriginal and Torres Strait Islander people. A systematic literature search was initially run in September 2016 and was updated again in April and August of 2018. A qualitative narrative synthesis was conducted from 2018 to 2019. Factors influencing contraceptive use or non-use were explored using a Social Ecological Model.

Results

The review identified 17 studies meeting the inclusion criteria published between 1972 and 2018. Most of the included studies were qualitative (n = 11), with the remaining studies being mixed methods (n = 3) or quantitative (n = 3). The majority focused on either a localised geographic area or specific Aboriginal or Torres Strait Islander community (n = 11). One study specifically focused on factors influencing contraceptive use, albeit among postpartum women. The remaining studies discussed factors influencing contraceptive use within the context of risky behaviour, sexual transmitted infections, or contraceptive practices more generally. Factors unique to individual communities included community attitudes (e.g. importance of not being too young to have a baby), specific cultural norms (e.g. subincising the penis as part of transition to manhood), and access to culturally appropriate health services. Other factors, including contraceptive characteristics (e.g. discomfort of condoms) and reproductive coercion (e.g. partner wants a baby), were similar to those found in the broader population of Australia and internationally. Most studies were lacking in quality, warranting more methodologically sound studies in the future to further assess the factors contributing to contraceptive use or non-use among Aboriginal and Torres Strait Islander people.

Conclusions

Identifying community specific facilitators, as well as understanding the more broadly applicable factors contributing to contraceptive use or non-use, is essential if wanting to offer appropriate contraceptive services within an Aboriginal or Torres Strait Islander community.

Contraception usage and the desired number of offspring of Indigenous women from the Gomeroi lands

OBJECTIVES

To describe the current contraception usage patterns from a cohort of Australian Indigenous women, including their ideal family size and spacing between children.

DESIGN

Cross-sectional analysis of data (2012-2019).

SETTING

Data are from a longitudinal study, the Gomeroi gaaynggal (babies from Gomeroi lands) program, based in rural and remote Gomeroi lands in New South Wales.

PARTICIPANTS

Women carrying an Indigenous baby who enrolled during pregnancy were eligible for the study. The mother and child are then followed for up to 10 years.

MAIN OUTCOME MEASURES

Contraception usage in the postnatal period was recorded, as well as whether they were sexually active, whether they wanted more children and their preferred spacing between children. Medical, social and demographic information was also collected. These measures were self-reported via an online tool (Survey Monkey® ) at their first visit to the study following the birth of their child.

RESULTS

Ninety-nine women were included in the analysis. Most women reported that they were sexually active at the time they were questioned about their contraceptive usage. The most popular contraception choices were condoms, the oral contraceptive pill and implant rods. Those answering that they did not want more children had a median of three children already. Those who wanted more children had a median of one child. The majority of the women stated that 2-3 years between babies was ideal.

CONCLUSION

The sampled women had clear beliefs about their ideal family size, in which contraceptive usage played an important part.

The role of socio-economic status and energy-density in Australian women of child-bearing age

INTRODUCTION

An optimal diet is imperative in preparing women for pregnancy and this may be influenced by socio-economic status (SES). This research aims to investigate the role of SES on the dietary energy density (ED) in Australian women of preconception age.

METHODS

A secondary analysis of the Australian National Nutrition and Physical Activity Survey 2011-12 for females aged 18-39 years (n = 1617) was conducted. Dietary intake was assessed by 24-hr recalls and dietary ED by dietary energy per weight (kJ.g^-1 ). ED was further categorised as ED of foods and beverages separately. SES was assessed by three variables: Socio-Economic Indexes for Areas (SEIFA), developed by the Australian Bureau of Statistics; income decile; and level of education. Linear mixed model regressions were used to identify associations between ED and SES.

RESULTS

The median ED for food, beverages and combined food and beverages was 9.38 kJ g^-1 , 1.02 kJ g^-1 and 7.11 kJ g^-1 , respectively. No significant variation was explained by SES variables when analysing combined ED in the adjusted model or ED from foods. Income decile reduced ED of beverages, although with little effect (coefficient: -0.04, P = 0.002). Significant confounders included inactivity, which increased ED in both combined ED and ED foods (coefficient: 0.51, P = 0.001 and coefficient: 0.78, P < 0.001).

CONCLUSIONS

SES explained little variation in dietary ED in women of childbearing age. A large proportion of women had high energy-dense diets regardless of their SES. These findings suggest that a large proportion of women, who may become pregnant, have diets that exceed the international recommendations for dietary energy density.

The relationship between maternal adiposity during pregnancy and fetal kidney development and kidney function in infants: the Gomeroi gaaynggal study

Maternal obesity during pregnancy has a detrimental impact on offspring renal development and function. This is pertinent to Indigenous Australians as they are twice as likely as non-Indigenous Australians to develop chronic kidney disease (CKD). The aim of this study was to examine whether there was an association between maternal adiposity and fetal kidney growth in late gestation (>28 weeks) and kidney function in infants, <2.5 years of age, from the Gomeroi gaaynggal cohort. Pre-pregnancy body mass index (BMI) was recorded at the first prenatal visit and maternal adiposity indicators (percent body fat and visceral fat area) measured at >28 weeks gestation by bioelectrical impedance analysis. Fetal kidney structure was assessed by ultrasound. Renal function indicators (urinary albumin:creatinine and protein:creatinine) were measured in infants from a spot urine collection from nappies. Multiple linear regression and multi-level mixed effects linear regression models with clustering were used to account for repeated measures of urine. 147 mother-child pairs were examined. Estimated fetal weight (EFW), but not fetal kidney size, was positively associated with maternal adiposity and pre-pregnancy BMI. When adjusted for smoking, combined kidney volume relative to EFW was negatively associated with maternal percentage body fat. Infant kidney function was not influenced by maternal adiposity and pre-pregnancy BMI (n = 84 observations). Current findings show that Indigenous babies born to obese mothers have reduced kidney size relative to EFW. We suggest that these babies are experiencing a degree of glomerular hyperfiltration in utero, and therefore are at risk of developing CKD in later life, especially if their propensity for obesity is maintained. Although no impact on renal function was observed at <2.5 years of age, long-term follow-up of offspring is required to evaluate potential later life impacts.

Relationship between maternal global nutrient restriction during pregnancy and offspring kidney structure and function: a systematic review of animal studies

Maternal undernutrition during pregnancy is prevalent across the globe, and the origins of many chronic diseases can be traced back to in utero conditions. This systematic review considers the current evidence in animal models regarding the relationship between maternal global nutrient restriction during pregnancy and offspring kidney structure and function. CINAHL, Cochrane, EMBASE, MEDLINE, and Scopus were searched to November 2017. Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines were followed, and articles were screened by two independent reviewers. Twenty-eight studies met the inclusion criteria: 16 studies were on rats, 9 on sheep, 2 on baboons, and 1 on goats. The majority of the rat studies had maternal global nutrient restriction during pregnancy at 50% of ad libitum while restriction for sheep and baboon studies ranged from 50% to 75%. Because of the heterogeneity of outcome measures and the large variation in the age of offspring at followup, no meta-analysis was possible. Common outcome measures included kidney weight, nephron number, glomerular size, glomerular filtration rate, and creatinine clearance. To date, there have been no studies assessing kidney function in large animal models. Most studies were rated as having a high or unknown risk of bias. The current body of evidence in animals suggests that exposure to maternal global nutrient restriction during pregnancy has detrimental effects on offspring kidney structure and function, such as lower kidney weight, lower nephron endowment, larger glomerular size, and lower glomerular filtration rate. Further long-term followup of studies in large animal models investigating kidney function through to adulthood are warranted.

Reprint of characterizing gestational weight gain in a cohort of indigenous Australian women

OBJECTIVE

to determine the adequacy of gestational weight gain for a cohort of Indigenous Australian women and investigate whether it is associated with pre-pregnancy body mass index.

DESIGN

analysis of observational data collected from a longitudinal cohort study that follows Indigenous Australian women through pregnancy.

SETTING

women recruited through antenatal clinics in regional and remote towns in NSW, Australia to the Gomeroi gaaynggal program.

PARTICIPANTS

110 pregnant women who either identified as being an Indigenous Australian or as carrying an Indigenous child.

MEASUREMENTS AND FINDINGS

measurements included weight and height, self-reported pre-pregnancy weight and smoking status, parity and health conditions that may contribute to gestational weight gain, such as hypertensive or diabetic disorders. Compared to the 2009 Institute of Medicine recommendations for gestational weight gain and based on pre-pregnancy body mass index, the rate of adequate gestational weight gain in this cohort was low (26%). 33% of women had inadequate weight gain and 41% had excessive weight gain. The highest rate of excessive gestational weight gain was found in overweight women (65%), with rates of 39% and 31% found in healthy and obese (all classes) categories, respectively. Parity (coefficient 4.2, p < 0.01) and hypertension (coefficient 4.3, p = 0.049) were found to be significantly associated with gestational weight gain in mixed model linear regression.

CONCLUSIONS

few women gained adequate gestational weight gain in this study. Culturally acceptable ways of addressing this issue are needed for this group of women, as inadequate and excessive rates of gestational weight gain have health implications for women and their offspring.

IMPLICATIONS FOR PRACTICE

a systematic approach to addressing gestational weight gain within antenatal care is required, including asking about diet and exercise, for all women identifying as Indigenous Australian.

Urinary angiotensinogen excretion in Australian Indigenous and non-Indigenous pregnant women

The intrarenal renin-angiotensin system (iRAS) is implicated in the pathogenesis of hypertension, chronic kidney disease and diabetic nephropathy. Urinary angiotensinogen (uAGT) levels reflect the activity of the iRAS and are altered in women with preeclampsia. Since Indigenous Australians suffer high rates and early onset of renal disease, we hypothesised that Indigenous Australian pregnant women, like non-Indigenous women with pregnancy complications, would have altered uAGT levels. The excretion of RAS proteins was measured in non-Indigenous and Indigenous Australian women with uncomplicated or complicated pregnancies (preeclampsia, diabetes/gestational diabetes, proteinuria/albuminuria, hypertension, small/large for gestational age, preterm birth), and in non-pregnant non-Indigenous women. Non-Indigenous pregnant women with uncomplicated pregnancies, had higher uAGT/creatinine levels than non-Indigenous non-pregnant women (P < 0.01), and levels increased as pregnancy progressed (P < 0.001). In non-Indigenous pregnant women with pregnancy complications, uAGT/creatinine was suppressed in the third trimester (P < 0.01). In Indigenous pregnant women with uncomplicated pregnancies, there was no change in uAGT/creatinine with gestational age and uAGT/creatinine was lower in the 2nd and 3rd trimesters than in non-Indigenous pregnant women with uncomplicated pregnancies (P < 0.03, P < 0.007, respectively). The uAGT/creatinine ratios of Indigenous women with uncomplicated or complicated pregnancies were the same. A decrease in uAGT/creatinine with advancing gestational age was associated with increased urinary albumin/creatinine, as is seen in preeclampsia, but it was not specific for this disorder. The reduced uAGT/creatinine in Indigenous pregnant women may reflect subclinical renal dysfunction which limits the ability of the kidney to maintain sodium balance and could indicate an increased risk of pregnancy complications and/or future renal disease.

The Relationship between Maternal Nutrition during Pregnancy and Offspring Kidney Structure and Function in Humans: A Systematic Review

The intrauterine environment is critical for fetal growth and organ development. Evidence from animal models indicates that the developing kidney is vulnerable to suboptimal maternal nutrition and changes in health status. However, evidence from human studies are yet to be synthesised. Therefore, the aim of the current study was to systematically review current research on the relationship between maternal nutrition during pregnancy and offspring kidney structure and function in humans. A search of five databases identified 9501 articles, of which three experimental and seven observational studies met the inclusion criteria. Nutrients reviewed to date included vitamin A (n = 3), folate and vitamin B12 (n = 2), iron (n = 1), vitamin D (n = 1), total energy (n = 2) and protein (n = 1). Seven studies were assessed as being of "positive" and three of "neutral" quality. A variety of populations were studied, with limited studies investigating maternal nutrition during pregnancy, while measurements of offspring kidney outcomes were diverse across studies. There was a lack of consistency in the timing of follow-up for offspring kidney structure and/or function assessments, thus limiting comparability between studies. Deficiencies in maternal folate, vitamin A, and total energy during pregnancy were associated with detrimental impacts on kidney structure and function, measured by kidney volume, proteinuria, eGFR_cystC and mean creatinine clearance in the offspring. Additional experimental and longitudinal prospective studies are warranted to confirm this relationship, especially in Indigenous populations where the risk of renal disease is greater.

Characterizing gestational weight gain in a cohort of Indigenous Australian women

OBJECTIVE

to determine the adequacy of gestational weight gain for a cohort of Indigenous Australian women and investigate whether it is associated with pre-pregnancy body mass index.

DESIGN

analysis of observational data collected from a longitudinal cohort study that follows Indigenous Australian women through pregnancy.

SETTING

women recruited through antenatal clinics in regional and remote towns in NSW, Australia to the Gomeroi gaaynggal program.

PARTICIPANTS

110 pregnant women who either identified as being an Indigenous Australian or as carrying an Indigenous child.

MEASUREMENTS AND FINDINGS

measurements included weight and height, self-reported pre-pregnancy weight and smoking status, parity and health conditions that may contribute to gestational weight gain, such as hypertensive or diabetic disorders. Compared to the 2009 Institute of Medicine recommendations for gestational weight gain and based on prepregnancy body mass index, the rate of adequate gestational weight gain in this cohort was very low (15%). 32% of women had inadequate weight gain and 54% had excessive weight gain. The highest rate of excessive gestational weight gain was found in overweight women (74%), with rates of 48% and 50% found in healthy and obese (all classes) categories, respectively. Parity (coefficient 4.5, p<0.01) and hypertension (coefficient 4.8, p = 0.04) were found to be significantly associated with gestational weight gain in mixed model linear regression.

CONCLUSIONS

few women gained adequate gestational weight gain in this study. Culturally acceptable ways of addressing this issue are needed for this group of women, as inadequate and excessive rates of gestational weight gain have health implications for women and their offspring.

IMPLICATIONS FOR PRACTICE

a systematic approach to addressing gestational weight gain within antenatal care is required, including asking about diet and exercise, for all women identifying as Indigenous Australian.

Assessment of Fetal Kidney Growth and Birth Weight in an Indigenous Australian Cohort

Introduction: Indigenous Australians experience higher rates of renal disease and hypertension than non-Indigenous Australians. Low birth weight is recognized as a contributing factor in chronic disease and has been shown to increase the risk of renal failure in adulthood. A smaller kidney volume with fewer nephrons places an individual at risk of hypertension and renal failure. Indigenous Australians have fewer nephrons than non-Indigenous Australians. In this study, intrauterine fetal and kidney growth were evaluated in 174 Indigenous Australian babies throughout gestation in order to record and evaluate fetal growth and kidney size, within a population that is at high risk for chronic illness. Methods: Pregnant women that identified as Indigenous, or non-Indigenous women that were pregnant with a partner who identified as an Indigenous Australian were eligible to participate. Maternal history, smoking status, blood and urine samples and fetal ultrasounds were collected throughout pregnancy. Fetal kidney measurements were collected using ultrasound. Statistical analysis was performed using the Stata 14.1 software package. Results: 15.2% of babies were born prematurely. 44% of the mothers reported smoking in pregnancy. The median birth weight of this cohort was 3,240 g. Male fetuses had higher kidney to body weight ratios than female fetuses (P = 0.02). The birth weights of term neonates whose mothers smoked during pregnancy were lower (327 g, P < 0.001) than the birth weights of term babies from non-smoking mothers. The kidney volumes of babies whose mothers smoked were also smaller (P = 0.02), but were in proportion to body weight. Conclusion: In this cohort of Indigenous women smoking was associated with both increased number of preterm births and with a reduction in birth weights, even of term infants. Since kidney volume is a surrogate measure of nephron number and nephrogenesis is complete at birth, babies whose mothers smoked during pregnancy must have fewer nephrons than those from non-smoking mothers. Previous studies have shown that glomerular filtration rate is not related to birth weight, thus infants with smaller kidney volumes are hyperfiltering from birth and therefore are likely to be more susceptible to early onset renal disease in later life.

Post-traumatic stress disorder symptoms in pregnant Australian Indigenous women residing in rural and remote New South Wales: A cross-sectional descriptive study

BACKGROUND

Pregnancy can be a stressful time for many women. There is ample evidence of numerous physical and mental health inequities for Indigenous Australians. For those Indigenous women who are pregnant, it is established that there is a higher incidence of poor physical perinatal outcomes when compared with non-Indigenous Australians. However, little evidence exists that examines stressful events and post-traumatic stress disorder (PTSD) symptoms in pregnant women who are members of this community.

AIMS

To quantify the rates of stressful events and PTSD symptoms in pregnant Indigenous women.

METHODS

One hundred and fifty rural and remote Indigenous women were invited to complete a survey during each trimester of their pregnancy. The survey measures were the stressful life events and the Impact of Events Scale.

RESULTS

Extremely high rates of PTSD symptoms were reported by participants. Approximately 40% of this group exhibited PTSD symptoms during their pregnancy with mean score 33.38 (SD = 14.37) significantly higher than a study of European victims of crisis, including terrorism attacks (20.6, SD = 18.5).

CONCLUSIONS

The extreme levels of PTSD symptoms found in the women participating in this study are likely to result in negative implications for both mother and infant. An urgent response must be mounted at government, health, community development and research levels to address these findings. Immediate attention needs to focus on the development of interventions to address the high levels of PTSD symptoms that pregnant Australian Indigenous women experience.

Validation of a Smartphone Image-Based Dietary Assessment Method for Pregnant Women

Image-based dietary records could lower participant burden associated with traditional prospective methods of dietary assessment. They have been used in children, adolescents and adults, but have not been evaluated in pregnant women. The current study evaluated relative validity of the DietBytes image-based dietary assessment method for assessing energy and nutrient intakes. Pregnant women collected image-based dietary records (via a smartphone application) of all food, drinks and supplements consumed over three non-consecutive days. Intakes from the image-based method were compared to intakes collected from three 24-h recalls, taken on random days; once per week, in the weeks following the image-based record. Data were analyzed using nutrient analysis software. Agreement between methods was ascertained using Pearson correlations and Bland-Altman plots. Twenty-five women (27 recruited, one withdrew, one incomplete), median age 29 years, 15 primiparas, eight Aboriginal Australians, completed image-based records for analysis. Significant correlations between the two methods were observed for energy, macronutrients and fiber (r = 0.58–0.84, all p < 0.05), and for micronutrients both including (r = 0.47–0.94, all p < 0.05) and excluding (r = 0.40–0.85, all p < 0.05) supplements in the analysis. Bland-Altman plots confirmed acceptable agreement with no systematic bias. The DietBytes method demonstrated acceptable relative validity for assessment of nutrient intakes of pregnant women.

Personalised Medicine: A New Approach to Improving Health in Indigenous Australian Populations

Personalised medicine is a newly emerging field with much to offer to all populations in improved clinical treatment options. Since the 1970s, clinicians and researchers have all been working towards improving the health of Indigenous Australians. However, there has been little research on the impact of genetics on Indigenous health, how genetic and environmental factors interact to contribute to poor health in Indigenous people, and how genetic factors specific to Indigenous people affect their responses to particular treatments. This short review highlights the urgent need for more genetic studies specific to Indigenous people in order to provide more appropriate care and to improve health outcomes. This paper explores why genetic work with Indigenous communities has been limited, how personalised medicine could benefit Indigenous communities, and highlights a number of specific instances in which personalised medicine has been critical for improving morbidity and mortality in other high-risk groups. In order to take the next step in advancing the health of Indigenous peoples, targeted research into the genetic factors behind chronic diseases is critically needed. This research may allow clinicians a better understanding of how genetic factors interact with environmental factors to influence an Indigenous Australian's individual risk of disease, prognosis, and response to therapies. It is hoped that this knowledge will produce clinical interventions that will help deliver clearly targeted, more appropriate care to this at-risk population.

A Brief Tool to Assess Image-Based Dietary Records and Guide Nutrition Counselling Among Pregnant Women: An Evaluation

Background

Dietitians ideally should provide personally tailored nutrition advice to pregnant women. Provision is hampered by a lack of appropriate tools for nutrition assessment and counselling in practice settings. Smartphone technology, through the use of image-based dietary records, can address limitations of traditional methods of recording dietary intake. Feedback on these records can then be provided by the dietitian via smartphone. Efficacy and validity of these methods requires examination.

Objective

The aims of the Australian Diet Bytes and Baby Bumps study, which used image-based dietary records and a purpose-built brief Selected Nutrient and Diet Quality (SNaQ) tool to provide tailored nutrition advice to pregnant women, were to assess relative validity of the SNaQ tool for analyzing dietary intake compared with nutrient analysis software, to describe the nutritional intake adequacy of pregnant participants, and to assess acceptability of dietary feedback via smartphone.

Methods

Eligible women used a smartphone app to record everything they consumed over 3 nonconsecutive days. Records consisted of an image of the food or drink item placed next to a fiducial marker, with a voice or text description, or both, providing additional detail. We used the SNaQ tool to analyze participants’ intake of daily food group servings and selected key micronutrients for pregnancy relative to Australian guideline recommendations. A visual reference guide consisting of images of foods and drinks in standard serving sizes assisted the dietitian with quantification. Feedback on participants’ diets was provided via 2 methods: (1) a short video summary sent to participants’ smartphones, and (2) a follow-up telephone consultation with a dietitian. Agreement between dietary intake assessment using the SNaQ tool and nutrient analysis software was evaluated using Spearman rank correlation and Cohen kappa.

Results

We enrolled 27 women (median age 28.8 years, 8 Indigenous Australians, 15 primiparas), of whom 25 completed the image-based dietary record. Median intakes of grains, vegetables, fruit, meat, and dairy were below recommendations. Median (interquartile range) intake of energy-dense, nutrient-poor foods was 3.5 (2.4-3.9) servings/day and exceeded recommendations (0-2.5 servings/day). Positive correlations between the SNaQ tool and nutrient analysis software were observed for energy (ρ=.898, P<.001) and all selected micronutrients (iron, calcium, zinc, folate, and iodine, ρ range .510-.955, all P<.05), both with and without vitamin and mineral supplements included in the analysis. Cohen kappa showed moderate to substantial agreement for selected micronutrients when supplements were included (kappa range .488-.803, all P ≤.001) and for calcium, iodine, and zinc when excluded (kappa range .554-.632, all P<.001). A total of 17 women reported changing their diet as a result of the personalized nutrition advice.

Conclusions

The SNaQ tool demonstrated acceptable validity for assessing adequacy of key pregnancy nutrient intakes and preliminary evidence of utility to support dietitians in providing women with personalized advice to optimize nutrition during pregnancy.

Using a grid framework to aid constructive thinking

A transitional route to the recording of specialist practice for community nurses was undertaken via portfolio development. A grid system was developed to give a concise framework to follow.