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Abstract Background Australian Aboriginal and Torres Strait Islander women with diabetes in pregnancy (DIP) are more likely to have glycaemic levels above the target range, and their babies are thus at higher risk of excessive fetal growth. Shoulder dystocia, defined by failure of spontaneous birth of fetal shoulder after birth of the head requiring obstetric maneuvers, is an obstetric emergency that is strongly associated with DIP and fetal size. The aim of this study was to investigate the epidemiology of shoulder dystocia in Aboriginal babies born to mothers with DIP. Methods Stratifying by Aboriginal status, characteristics of births complicated by shoulder dystocia in women with and without DIP were compared and incidence and time-trends of shoulder dystocia were described. Compliance with guidelines aiming at preventing shoulder dystocia in women with DIP were compared. Post-logistic regression estimation was used to calculate the population attributable fractions (PAFs) for shoulder dystocia associated with DIP and to estimate probabilities of shoulder dystocia in babies born to mothers with DIP at birthweights > 3 kg. Results Rates of shoulder dystocia from vaginal births in Aboriginal babies born to mothers with DIP were double that of their non-Aboriginal counterparts (6.3% vs 3.2%, p 4.5 kg were lower in the Aboriginal women (28.6% vs 43.1%, p = 0.004). PAFs indicated that 13.4% (95% CI: 9.7%-16.9%) of shoulder dystocia cases in Aboriginal (2.7% (95% CI: 2.1%-3.4%) in non-Aboriginal) women were attributable to DIP. Probability of shoulder dystocia among babies born to Aboriginal mothers with DIP was higher at birthweights > 3 kg. Conclusions Aboriginal mothers with DIP had a higher risk of shoulder dystocia and a stronger association between birthweight and shoulder dystocia. Many cases were recurrent. These factors should be considered in clinical practice and when counselling women.

Abstract Background Diabetes in pregnancy (DIP), which includes pre-gestational and gestational diabetes, is more prevalent among Aboriginal women. DIP and its adverse neonatal outcomes are associated with diabetes and cardiovascular disease in the offspring. This study investigated the impact of DIP on trends of large for gestational age (LGA) in Aboriginal and non-Aboriginal populations, and added to the limited evidence on temporal trends of DIP burden in these populations. Methods We conducted a retrospective cohort study that included all births in Western Australia between 1998 and 2015 using linked population health datasets. Time trends of age-standardised and crude rates of pre-gestational and gestational diabetes were estimated in Aboriginal and non-Aboriginal mothers. Mixed-effects multivariable logistic regression was used to estimate the association between DIP and population LGA trends over time. Results Over the study period, there were 526,319 births in Western Australia, of which 6.4% were to Aboriginal mothers. The age-standardised annual rates of pre-gestational diabetes among Aboriginal mothers rose from 4.3% in 1998 to 5.4% in 2015 and remained below 1% in non-Aboriginal women. The comparable rates for gestational diabetes increased from 6.7 to 11.5% over the study period in Aboriginal women, and from 3.5 to 10.2% among non-Aboriginal mothers. LGA rates in Aboriginal babies remained high with inconsistent and no improvement in pregnancies complicated by gestational diabetes and pre-gestational diabetes, respectively. Regression analyses showed that DIP explained a large part of the increasing LGA rates over time in Aboriginal babies. Conclusions There has been a substantial increase in the burden of pre-gestational diabetes (Aboriginal women) and gestational diabetes (Aboriginal and non-Aboriginal) in recent decades. DIP appears to substantially contribute to increasing trends in LGA among Aboriginal babies.

Abstract Background Increased allostatic load is linked with racial discrimination exposure, providing a mechanism for the biological embedding of racism as a psychosocial stressor. We undertook an examination of how racial discrimination interacts with socioecological, environmental, and health conditions to affect multisystem dysregulation in a First Nations population. Methods We conducted latent class analysis (LCA) using indicators of life stress, socioeconomic background, and physical and mental health from a nationally representative sample of Australian Aboriginal adults (N = 2056). We used LCA with distal outcomes to estimate the effect of the latent class variable on our derived allostatic load index and conducted a stratified analysis to test whether allostatic load varied based on exposure to racial discrimination across latent classes. Results Our psychosocial, environmental, and health measures informed a four-class structure; ‘Low risk’, ‘Challenged but healthy’, ‘Mental health risk’ and ‘Multiple challenges’. Mean allostatic load was highest in ‘Multiple challenges’ compared to all other classes, both in those exposed (4.5; 95% CI: 3.9, 5.0) and not exposed (3.9; 95% CI: 3.7, 4.2) to racial discrimination. Allostatic load was significantly higher for those with exposure to racial discrimination in the ‘Multiple challenges’ class (t = 1.74, p = .04) and significantly lower in the ‘Mental health risk’ class (t = − 1.67, p = .05). Conclusions Racial discrimination may not always modify physiological vulnerability to disease. Social and economic contexts must be considered when addressing the impact of racism, with a focus on individuals and sub-populations experiencing co-occurring life challenges.

Abstract Background Racial discrimination is acknowledged as a central social determinant of Australian Aboriginal and Torres Strait Islander (hereafter referred to as Aboriginal) health, although quantitative empirical literature on the impacts of racism on Aboriginal children remains sparse. We use a novel, longitudinal dataset to explore the relationship between caregiver-perceived racism exposure and a range of mental health and related behavioural and physiological outcomes in childhood. Method The study cohort comprised 1759 Aboriginal children aged 4–12 years from waves 2–8 (2009–2015) of the Footprints in Time: The Longitudinal Study of Indigenous Children (LSIC) dataset. We examined exposure to caregiver-perceived racism between 4 and 11 years as a predictor for mental health and related outcomes at ages 7–12 and substance use at 10–12 years. Unadjusted models and models adjusted for remoteness, community-level and family-level socio-economic status, child age and gender were used in analysis. Multilevel logistic regression was used in all analysis. Results In fully adjusted models, perceived exposure to racism at ages 4–11 was associated with twice the risk of negative mental health (95% CI: 1.3–3.0), sleep difficulties (95% CI: 1.4–3.0), and behaviour issues at school (95% CI: 1.2–2.9), 1.7 times the risk of obesity (95% CI: 1.1–2.5), and nearly 7 times the risk of trying cigarettes (95% CI: 1.1–43.9). Increased risks were also found for being underweight and trying alcohol though estimates did not reach statistical significance. There was no evidence that racism was associated with poorer general health. Conclusion Exposure to racial discrimination in Aboriginal children increased the risk for a spectrum of interrelated psychological, behavioural and physiological factors linked to negative mental health. Our results further affirm the importance of interventions aimed at reducing the prevalence of racial discrimination for the benefits of population health and health inequalities. The services and institutions which aim to support the mental health and wellbeing of Aboriginal children should also support interventions to reduce racism and implement accountable policies which prioritise this goal.

This study examined the extent to which the association between increased student absence and lower achievement outcomes varied by student and school-level socioeconomic characteristics. Analyses were based on the enrolment, absence and achievement records of 89,365 Year 5, 7 and 9 students attending government schools in Western Australian between 2008 and 2012. Multivariate multi-level modelling methods were used to estimate numeracy, writing and reading outcomes based on school absence, and interactions between levels of absence and school socioeconomic index (SEI), prior achievement, gender, ethnicity, language background, parent education and occupation status. While the effects of absence on achievement were greater for previously high-achieving students, there were few significant interactions between absence and any of the socioeconomic measures on achievement outcomes. The results of first-difference regression models indicated that the negative effect of an increase in absence was marginally larger for students attending more advantaged schools, though most effects were very small. While students from disadvantaged schools have, on average, more absences than their advantaged peers, there is very little evidence to suggest that the effects of absence are greater for those attending lower-SEI schools. School attendance should therefore be a priority for all schools, and not just those with high rates of absence or low average achievement.

Objectives To assess the scale of ethnic inequalities in severe maternal morbidity (SMM) rates and quantify the contribution of maternal characteristics to these disparities.Design Retrospective cohort study.Setting Whole-of-population linked administrative data from 2002 to 2015 in Western Australia.Participants Women with 410 043 birth events (includes all births from the same pregnancy) of 20 weeks’ or more gestation, including terminations for congenital anomalies.Primary and secondary outcome measures Women with SMM were identified based on a composite indicator of SMM using diagnosis and procedure codes developed for use in routinely collected data. Mothers were classified into seven ethnic groups, based on their reported ethnic origin. The associations between maternal ethnic origin and SMM were examined using a log-binomial model, which estimates risk ratios (RRs) and 95% CIs. The Blinder-Oaxaca decomposition technique was employed to partition the disparity in SMM between Aboriginal and Caucasian populations into ‘explained’ and ‘unexplained’ components.Results During the study period, 9378 SMM cases were documented. In the adjusted model, Aboriginal (RR 1.73, 95% CI 1.59 to 1.87), African (RR 1.64, 95% CI 1.43 to 1.89) and ‘other’ ethnicity (RR 1.49, 95% CI 1.37 to 1.63) women were at significantly higher risk of SMM compared with Caucasian women. Teenage and older mothers and socioeconomically disadvantaged women were also at greater risk of SMM. Differences in sociodemographic characteristics explained 33.2% of the disparity in SMM between Aboriginal and Caucasian women.Conclusions There are distinct disparities in SMM by ethnicity in Western Australia, with a greater risk among Aboriginal and African women. While improvements in SES and a reduction in teenage pregnancy can potentially support a sizeable reduction in SMM rate inequalities, future research should investigate other potential pathways and targeted interventions to close the ethnicity disparity.

BACKGROUND:The preterm birth rate is rising in high-income countries and is associated with increased mortality and morbidity. Although the risks increase with greater prematurity and risk factors have been found to vary with gestational age and labour onset, few studies have focused on the myriad pathways to extreme preterm birth (20-27 weeks' gestation). The current study investigated trends in extreme preterm birth by labour onset type and examined the antecedent risks to further our understanding around the identification of high-risk pregnancies. METHODS:Retrospective cohort study including all singleton extreme preterm births in Western Australia between 1986 and 2010. De-identified data from six core population health datasets were linked and used to ascertain extreme preterm births (excluding medical terminations and birth defects) after spontaneous onset of labour, preterm pre-labour rupture of membranes, and medically indicated labour onset. Trends over time in extreme preterm birth were analysed using linear regression. Multivariable regression techniques were used to assess the relative risks associated with each salient, independent risk factor and to calculate Population Attributable Risks (PARs). RESULTS:The extreme preterm birth rate including medical terminations and birth defects significantly increased over time whereas the extreme preterm birth rate excluding medical terminations and birth defects did not change. After medical terminations and birth defects were excluded, the rate of medically indicated extreme preterm births significantly increased over time whereas the rate of preterm pre-labour rupture of membranes extreme preterm births significantly reduced, and the rate of spontaneous extreme preterm births did not significantly change. In the multivariate analyses, factors associated with placental dysfunction accounted for >10% of the population attributable risk within each labour onset type. CONCLUSIONS:First study to show that the increase in extreme preterm birth in high-income jurisdiction is no longer evident after medical terminations and birth defects are excluded. Interventions that identify and target women at risk of placental dysfunction presents the greatest opportunity to reduce extreme preterm births.

Purpose: There is scant literature about the management of stillbirth and the subsequent risk of severe maternal morbidity (SMM). We aimed to assess the risk of SMM associated with stillbirths compared with live births and whether this differed by the presence of maternal comorbidities. Methods: In this retrospective cohort study, we used a population-based dataset of all stillbirths and live births ≥ 20 weeks' gestation in Western Australia between 2000 and 2015. SMM was identified using a published Australian composite for use with routinely collected hospital morbidity data. Maternal comorbidities were identified in the Hospital Morbidity Data Collection or the Midwives Notification System using a modified Australian chronic disease composite. Multivariable Poisson regression was used to estimate relative risks (RRs) and 95% confidence intervals (CIs) for factors associated with SMM in analyses stratified by the presence of maternal comorbidities. Singleton and multiple pregnancies were examined separately. Results: This study included 458,639 singleton births (2319 stillbirths and 456,320 live births). The adjusted RRs for SMM among stillbirths were 2.30 (95% CI 1.77, 3.00) for those without comorbidities and 4.80 (95% CI 4.11, 5.59) (Interaction P value < 0.0001) for those with comorbidities compared to live births without and with comorbidities, respectively. Conclusion: In Western Australia between 2000 and 2015, mothers of stillbirths both with and without any maternal comorbidities had an increased risk of SMM compared with live births. Further investigation into why women who have had a stillbirth without any existing conditions or pregnancy complications develop SMM is warranted. [ABSTRACT FROM AUTHOR]

Background Aboriginal and Torres Strait Islander (hereafter Aboriginal) women have a high prevalence of diabetes in pregnancy (DIP), which includes pre-gestational diabetes mellitus (PGDM) and gestational diabetes mellitus (GDM). We aimed to characterize the impact of DIP in babies born to Aboriginal mothers. Methods A retrospective cohort study, using routinely collected linked health data that included all singleton births (N  = 510 761) in Western Australia between 1998 and 2015. Stratified by Aboriginal status, generalized linear mixed models quantified the impact of DIP on neonatal outcomes, estimating relative risks (RRs) with 95% CIs. Ratio of RRs (RRRs) examined whether RRs differed between Aboriginal and non-Aboriginal populations. Results Exposure to DIP increased the risk of adverse outcomes to a greater extent in Aboriginal babies. PGDM heightened the risk of large for gestational age (LGA) (RR: 4.10, 95% CI: 3.56–4.72; RRR: 1.25, 95% CI: 1.09–1.43), macrosomia (RR: 2.03, 95% CI: 1.67–2.48; RRR: 1.39, 95% CI: 1.14–1.69), shoulder dystocia (RR: 4.51, 95% CI: 3.14–6.49; RRR: 2.19, 95% CI: 1.44–3.33) and major congenital anomalies (RR: 2.14, 95% CI: 1.68–2.74; RRR: 1.62, 95% CI: 1.24–2.10). GDM increased the risk of LGA (RR: 2.63, 95% CI: 2.36–2.94; RRR: 2.00, 95% CI: 1.80–2.22), macrosomia (RR: 1.95, 95% CI: 1.72–2.21; RRR: 2.27, 95% CI: 2.01–2.56) and shoulder dystocia (RR: 2.78, 95% CI: 2.12–3.63; RRR: 2.11, 95% CI: 1.61–2.77). Birthweight mediated about half of the DIP effect on shoulder dystocia only in the Aboriginal babies. Conclusions DIP differentially increased the risks of fetal overgrowth, shoulder dystocia and congenital anomalies in Aboriginal babies. Improving care for Aboriginal women with diabetes and further research on preventing shoulder dystocia among these women can reduce the disparities. [ABSTRACT FROM AUTHOR]

Elder- and community-led research processes are increasingly being acknowledged as critical for successful Aboriginal health and wellbeing research. This article provides an overview of the methodologies, methods and progress of the Ngulluk Koolunga Ngulluk Koort (Our Children, Our Heart) project—an Elder- and community-led research and research-translation project focused on the early childhood development of Australian Aboriginal children in an urban context (Perth, Western Australia). We describe the application of a participatory action research methodology that is grounded in Aboriginal worldview(s), from the collaborative development of the original idea to the post-funding processes of co-design and implementation, data collection, analysis, interpretation and translation.

Objectives: To examine factors that impact on breastfeeding duration among Western Australian Aboriginal children. We hypothesised that Aboriginal children living in remote locations in Western Australia were breastfed for longer than those living in metropolitan locations. Methods: A population-based cross-sectional survey was conducted from 2000 to 2002 in urban, rural and remote settings across Western Australia. Cross-tabulations and multivariate logistic regression analyses were performed, using survey weights to produce unbiased estimates for the population of Aboriginal children. Data on demographic, maternal and infant characteristics were collected from 3932 Aboriginal birth mothers about their children aged 0–17 years (representing 22,100 Aboriginal children in Western Australia). Results: 71% of Aboriginal children were breastfed for three months or more. Accounting for other factors, there was a strong gradient for breastfeeding duration by remoteness, with Aboriginal children living in areas of moderate isolation being 3.2 times more likely to be breastfed for three months or more (p < 0.001) compared to children in metropolitan Perth. Those in areas of extreme isolation were 8.6 times more likely to be breastfed for three months or longer (p < 0.001). Conclusions: Greater residential isolation a protective factor linked to longer breastfeeding duration for Aboriginal children in our West Australian cohort.