Policy Document

Maternal and Infant Health BACKGROUND

The Australian Medical Students’ Association (AMSA) is the peak representative body of Australia’s medical students. AMSA believes that all people have the right to the best attainable health - regardless of age, sex, racial background or disability. Accordingly, AMSA actively seeks to advocate on issues that may impact health outcomes. As medical students and future health practitioners, AMSA also believes that we are in unique position to advocate for populations that are vulnerable to ill health such as mothers and infants. According to the World Health Organisation, maternal health refers to the “health of women during pregnancy, childbirth and the postpartum period” [1]. Infant health when defined has specific focuses on appropriate feeding and care from 28 days to the first year of life, where the child is at significant risk of death [2]. In 2016, the then Secretary General of the United Nations, Ban Ki Moon, launched the updated Global Strategy for Women’s, Children’s and Adolescents’ Health. This new evidence-based initiative reinvigorates the goal of seeing a world where every woman and every child realise their right to good mental and physical health and wellbeing. It is a hallmark document that also emphasises the importance of promoting and sustaining agency and social and economic opportunities for women and children. The attainment of these goals will see the development of healthy and prosperous societies for now and the future [3]. Overall, Australia ranks highly on international tables for life expectancy, health outcomes and system performance [4, 5]. With respect to maternal and infant health in Australia, measures of health outcomes have improved in recent years. However, there are significant inequities between different population groups [6, 7], and gaps exist in accessing health-care that continue to perpetuate these gross health inequities. This is despite the implementation of national strategies covering early childhood development [8] to breastfeeding [9]. Maternal and infant health are universally recognised as being strong indicators of health status and wellbeing [10]. There is a wealth of evidence demonstrating the positive impacts of maintaining a healthy weight and normoglycemia during pregnancy for both mothers and infants. However, the increasing prevalence of overweight and obese women in Australia makes this a significant challenge for obstetric care [11]. Implications for high risk pregnancies and increased susceptibility to develop type II diabetes in later life also hold significant public health concerns for the Australian people. The Importance of “The Life Course Approach” to Health The life course approach recognises that social, economic and cultural factors shape people’s health experiences, and thus provides health-based organisations a framework by which to deliver appropriate interventions, with aims at increasing the effectiveness of these interventions throughout a person’s life [12]. As described by the World Health Organisation, it focuses on a healthy start to life and targets the needs of people at critical periods throughout their lifetime [13]. Groups, from researchers to policy makers, can use the life course approach to design their work so that it acknowledges the physical and social hazards that can affect critical periods in someone’s life, such us during gestation and early childhood. In doing so, it understands the

risk of chronic disease and other adverse health outcomes later in life that arise directly due to exposure to these hazards [12]. AMSA’s Maternal and Infant Health policy takes into the account the importance of the life course approach when addressing the deficits in maternal and child health in Australia. Maternal and Infant Health in Australia As per the 2016 Census results published by the Australian Bureau of Statistics, women make up 12.2 million people of our population [14]. The maternal mortality rate in Australia in 2012–2014 was 6.8 deaths per 100,000 women giving birth, which is among the lowest rates in the world [15]. However, there continues to be a higher incidence of maternal death in Aboriginal and Torres Strait Islander women, with the maternal mortality rate within this population being 3 times that of other Australian women [15]. Rural and remote populations experience higher rates of maternal death, with rural women experiencing significantly higher rates of neonatal death and remote women experiencing higher rates of intrauterine fetal deaths [16]. In 2016, the Australian infant mortality rate was the lowest on record at 3.1 infant deaths per 1,000 live births [17]. However, infant mortality was 1.9 times higher in Indigenous populations compared with non-Indigenous populations in Australia [18]. A study conducted in Dandenong, Victoria found that women from refugee backgrounds are more likely to be discharged from regional public hospitals with diagnoses related to obstetric complications (e.g. female genital mutilation, fetal death in utero and stillbirths) [19]. African women of refugee background living in Australia also appear to be at increased risk of adverse pregnancy outcomes compared to migrant women without a refugee background [20]. Currently, there is a lack of significant statistics pertaining to the mothers and children of refugee background, and more research is needed to understand the context of maternal and infant health within this population. Access to Health Services Maternal and Perinatal Health Services Access to safe and effective family planning, antenatal, postnatal and child healthcare services is essential to decreasing morbidity and mortality rates in women and infants [21]. In Australia, three levels of government are involved in the provision of maternal and child health services and each level of government has distinct roles [22]. At a national level, the Federal Government funds free or subsidised primary and tertiary healthcare services through the Medicare Benefits Scheme. However, the majority of the planning and delivery of these services are managed by State, Territory and local governments [22]. Consequently, the variety, quantity and distribution of these services vary considerably throughout the country [23]. Under Medicare, there is free healthcare available throughout the antenatal, perinatal, postnatal and newborn periods delivered by midwives, obstetricians in public hospitals, birth centres or the publicly funded homebirth program. There are also rebates for screening, ultrasound scans and for new mothers seeking counselling [24]. However, maternal and infant health care also occurs across private settings in Australia [25]. According to the The Maternity Services Review, a majority of Australian women receive antenatal care from obstetricians at private clinics, public hospital outpatient clinics or birth care centres [26]. In 2013, 97% of births in Australia were in hospitals, while 2% were in birth centres and 0.3% were at home [27]. In 2007, there were approximately 300 maternity units throughout Australia. These range from large referral centres in metropolitan areas to smaller units in rural settings [28]. The number and distribution of these services reflects population size and geographic location [28].

Routine antenatal healthcare is known to improve health outcomes for both mother and infant [27]. The Pregnancy Care Guidelines state that during a woman’s first pregnancy, women should have ten antenatal visits with a health professional, with the first visit before 10 weeks gestation [29]. However, in 2013 only 62% of pregnant women visited a health care provider in the first trimester [27]. This rate varied among different populations, based on remoteness, socioeconomic position, indigenous status and country of birth [27]. These variations reflect systemic issues regarding access to and knowledge about local and culturally appropriate health care services, and language barriers. Access to Sexual and Reproductive Health Services Sexual and reproductive health is an internationally agreed upon human right, with safe and equitable access to these services being a vital factor [30, 31]. The importance of extensive sexual and reproductive health services has been covered previously in AMSA’s ‘Access to Safe Termination of Pregnancy Policy’ [30]. The scope of reproductive services includes, but is not limited to, access to contraception, infertility support and access to termination of pregnancy services. It is evident that the provision of sexual and reproductive health services is important in achieving overall positive health outcomes for the population and accelerating the achievement of sustainable health outcomes [31, 32]. Moreover, the evidence demonstrates that equitable access to reproductive health services significantly decreases the health burden on healthcare resources that are usually associated with a lack of access [31, 32]. If preemptive policies are put in place to ensure safe and equitable access, the need to implement emergency curative strategies is reduced. Access to Contraception In Australia, the main form of contraception for women is the oral contraceptive pill [33]. This encompasses both preventative and emergency contraceptive pills. In some populations, women for a variety of reasons lack adequate access to the emergency contraceptive pills and as such are placed at an increased risk of unwanted pregnancies [33]. It is estimated that half of Australian pregnancies are unplanned [33]. Whilst not every unplanned pregnancy is unwanted, the relatively high rates of unplanned pregnancies suggests that although there is a vast array of contraceptive options available, not everyone has appropriate access to them or the knowledge on how to utilise them effectively [33]. Access to Safe Termination of Pregnancy Services Currently, there are discrepancies in the legislation regarding access to pregnancy termination services between Australian states and territories [34]. It is important that the legislation is consistent across all states and territories so that all women have equal access to pregnancy termination, regardless of where they live. Furthermore, consistent legislation may provide healthcare professionals with more confidence when administering these services. An in depth review of these discrepancies is highlighted in the AMSA Safe Termination of Pregnancy Services policy. Reproductive choices empower women and gives them control over their own bodies. When women are put at the forefront of their health decisions, better and safer health outcomes are recorded for all parties involved. [32, 35]. Furthermore, the decriminalisation of abortion signals to the community that these services are a normal part of gynaecological care and should be treated as such. By doing so, the stigma associated with abortion in certain community groups can be reduced allowing women to seek reproductive health services when needed [32, 35]. As part of a reproductive health service, it is important to ensure that women who do seek these services are able to do so in a safe and supportive environment. This will go a long way in ensuring that women are more likely to seek the services that they require.The presence of

exclusion zones around reproductive health centers and clinics (such as those adopted in Tasmania and more recently, New South Wales) ensures that women seeking these services are able to do so in a safe environment and are not harassed for their choices [35]. Safe access zones protect women and staff from harassment, obstruction and invasion of privacy [35]. Maternal and Infant Nutrition Nutrition, obesity and diabetes during pregnancy The Australian Dietary Guidelines provide national advice for adequate nutrition during pregnancy [36]. They include advice on choosing nutritious foods, limiting discretionary foods, and safe food preparation and choices [36]. While these national guidelines are publicised, adherence is poor. In a survey of 857 pregnant women across Australia in 2015, none of the women adhered to the guidelines for all food groups [37]. Only 56% met the fruit recommendations, 29% met the dairy recommendations, and 10% met the recommendations for other core food groups [37]. However, 61% believed they had a healthy diet during their pregnancy [37].

In Australia, 2 in 3 adults now are overweight or obese, putting them at risk of chronic health conditions such as high blood pressure and type II diabetes [38]. The greatest risk factor for childhood overweight and obesity is high parental Body Mass Index (BMI) [39]. Data from South Australia estimates that more than half of women beginning their pregnancy are overweight or obese [40]. The child of an overweight or obese parent is more than twice as likely to be overweight or obese themselves at age 3 [41], increasing to three to four fold at 9 to 10 years [39] when compared with individuals whose parents have a BMI in the normal weight range.

A cross-sectional survey of Australian women beginning their pregnancy showed that 75% of women were aware that being obese during pregnancy carried an increased overall risk of complications, and that this knowledge was similar across all BMI categories [42]. However, surveys of pregnant women who are obese have shown that 74% underestimate their own BMI category, and that the majority of women who are overweight or obese overestimate how much weight they should gain during pregnancy [43]. This knowledge gap represents a significant health risk for women who are overweight or obese and planning a pregnancy.

Increased obesity in Australia has led to a rise in glucose tolerance abnormalities. Many women are having this detected for the first time as gestational diabetes [44], which affects around 10% of Australian pregnancies [45]. While gestational diabetes is screened for nationally during pregnancy, these screening programs and diagnostic criteria are not consistent. A Cochrane review found that there was not enough evidence that current screening and management leads to any improvement in maternal or infant health outcomes [46].

Breastfeeding

The numerous benefits of breastfeeding on both maternal and child health have been well-documented. Breastfed children have higher intelligence and lower infectious morbidity and mortality than those who are not breastfed, or those who are breastfed for shorter periods [47]. Breastfeeding also lowers the risk of chronic conditions later in life, including hypertension, childhood asthma and obesity [48]. It is also thought to have numerous benefits for maternal health, including reducing the risk of post-partum haemorrhage, type II diabetes and breast, uterine and ovarian cancers [47, 48]. According to the National Health and Medical Research Council (NHMRC) dietary guidelines, exclusive breastfeeding of infants should be encouraged until six months of age, with combined solid food and breastfeeding until 12 months of age [49]. In Australia, only 11.3% of children aged 12 months to 3 years met this standard in their first 12 months [50]. This low adherence is typical of most high income countries, which have been found to have shorter breastfeeding durations than middle-income and low-income countries [47]. In addition, there is a lack of

reliable, standardised indicators of breastfeeding compliance, data collection and reporting, which creates difficulties in the monitoring and evaluation of health outcomes from breastfeeding [47, 51]. There are numerous factors influencing Australia’s low rate of breastfeeding. Societal attitudes towards breastfeeding play a significant role in the decision to not continue breastfeeding for Australian mothers, as many feel that it is not the societal norm [52, 53]. In a large survey of South Australian adults, over 80% of respondents agreed that bottle-feeding was more acceptable in public places, and 70% agreed that there wasn’t always a place to breastfeed when outside the home [53]. In addition, mothers’ return to work also plays a role in the low duration of breastfeeding. Barriers for mothers at work include the lack of support and difficulty maintaining a breastfeeding relationship with their infants [54, 55]. Breastfeeding supports, such as breastfeeding breaks and lactation spaces, have been implemented in a variety of workplaces across the world, including large and small organizations, and both male-dominated and more mixed-gender environments [56]. They have been associated with increasing rates of breastfeeding initiation, duration, and exclusivity among working mothers [56]. It is also important to acknowledge that certain mothers experience delayed, reduced and/or a complete lack of lactation [57]. This can be due to various factors, including primiparity, stress, maternal obesity and gestational diabetes [57, 58]. Several strategies for recognising and managing this have been identified, including early post-natal follow-up (during the first week post-birth), mechanical breast pumping, and maternal reassurance [59]. Although delayed and failed lactogenesis are known phenomena, there is a lack of research into how much they affect Australian breastfeeding inititation and exclusivity rates, as well as the extent to which interventions such as the aforementioned are implemented. The Baby Friendly Health Initiative (BFHI) is a joint World Health Organisation (WHO) and United Nations Children’s Fund (UNICEF) project, aiming to create healthcare environments where breastfeeding is encouraged [60]. Healthcare facilities can apply for ‘Baby Friendly’ accreditation, which is contingent on compliance with and promotion of the ‘Ten Steps to Successful Breastfeeding’ [60, 61]. These steps include having a written breastfeeding policy that is routinely communicated to all staff and informing all pregnant women about the benefits and management of breastfeeding [60]. In Belarus, the implementation of BFHI-associated measures was shown to increase the duration and degree (exclusivity) of breastfeeding, as well as decrease the risk of gastrointestinal tract infection and atopic eczema in the first year of life [62]. According to UNICEF, only about 20% of births in Australia currently occur in BFHI-accredited facilities [63]. Implementation of the BFHI in Australia is limited and there has been no formal Commonwealth support provided to encourage healthcare facilities to acquire ‘Baby Friendly’ accreditation [60]. In 1981, The World Health Assembly adopted the International Code of Marketing of Breast-milk Substitutes to promote breastfeeding, through the provision of adequate information on appropriate infant feeding and the regulation of the marketing of breastmilk substitutes [63, 64]. Australia’s response to this code is the Marketing of Infant Formulas (MAIF) Agreement, a voluntary, self-regulatory code of conduct between manufacturers and importers of infant formula - it currently falls short of the WHO Code on the marketing of Breastmilk Substitutes in various areas [66, 67]. For example, the MAIF only refers to infant formulas, and thus does not cover the entire range of products covered by the WHO Code, such as all breastmilk substitutes, bottle-fed complementary foods and baby teas [52]. The Australian Federal Department of Health is currently developing a new Australian National Breastfeeding Strategy, of which a key focus will be addressing barriers to women establishing and maintaining breastfeeding [51, 68]. Numerous key themes emerged from early consultations with stakeholders involved in developing the strategy, including the need for a national campaign to promote breastfeeding, the strengthening of implementation of the WHO International Code on the Marketing of Breast Milk Substitutes in Australia, and the inclusion of evidence-based breastfeeding education in the teaching curricula for midwives, nurses, neonatologists, and doctors [68].

Maternal and Infant Health of Vulnerable Populations

Aboriginal and Torres Strait Islanders

There is an evident gap between Indigenous and non-Indigenous health outcomes. Across 2012-2016, Indigenous infant mortality rate was 1.9 times that of the non-Indigenous rate [18]. The single largest cause of mortality in the 0-4 years age bracket was perinatal conditions, including pregnancy complications, foetal growth disorders and birth trauma [18]. Perinatal conditions also accounted for 42.7% of the child mortality gap between Indigenous and non-Indigenous populations [18].

The consequences of colonialism and subsequent loss of land, language, cultural and spiritual identity of Aboriginal and Torres Strait Islander people has led to intergenerational trauma and a number of social, economic and cultural determinants of the discrepancy between Indigenous and non-Indigenous populations [69]. With respect to maternal and infant health, these include factors such as alcohol, smoking and illicit drug use during pregnancy [70], inadequate access to and uptake of antenatal care services as well as maternal and infant malnutrition [71]. Indigenous children experienced 1.7 times higher levels of malnutrition in 2016 compared to non-Indigenous children [71].

Successful strategies recognised by both the RANZCOG and the Close the Gap campaign have a focus on cultural competency and community engagement. This involves a holistic approach that acknowledges Indigenous cultural and spiritual beliefs and practices as well as involving community controlled health services with trained Aboriginal and Torres Strait Islander staff [18, 72]. Indigenous health workers are employed throughout Australia in government and non-government health services to help support primary health care delivery for First Nations people [73]. In 2011 however, approximately 1.6% of the Aboriginal and Torres Strait Islander population were employed in health related areas. This was half the rate of the non-indigenous health workforce [74].

A number of key areas for intervention have been identified to improve the health of Aboriginal and Torres Strait Islander women and children and decrease rates of child mortality. Improving the accessibility of healthcare services for Aboriginal and Torres Strait Islanders is a priority for the Federal government [75]. Geographical distance, fear and discrimination are significant barriers to access [76, 77]. Improved access to antenatal care services and training of Aboriginal and Torres Strait Islander health workers will promote on Country births, thus helping to maintain connection to country [72]. It will also provide women with support during and after pregnancy and lower the associated risks of poor antenatal care such as having a preterm birth or low birth weight baby [72]. Furthermore, smoking and alcohol consumption during pregnancy are more prevalent amongst Aboriginal and Torres Strait Islander women [18] and are among the major risk factors for poor pregnancy outcomes such as foetal growth restriction [78]. RANZCOG identified that 45% of Aboriginal and Torres Strait Islander women smoked during pregnancy as compared to 13% of non- Aboriginal and Torres Strait Islanders [72]. Initiatives to improve health behaviours during pregnancy, such as smoking and drinking, are in place, however knowledge about the associated risks is ineffective in reducing these behaviours that are exacerbated by the stressful social environments experienced by Aboriginal and Torres Strait Islander women [78].

Although current initiatives to close the gap between Indigenous and non-Indigenous maternal and infant health outcomes have had a positive impact, there is still much room for improvement. This includes an increase in program funding, which is insufficient and often only short-term, as well as greater local community involvement and empowerment of Aboriginal and Torres Strait Islander people in addressing their own health needs [18, 72, 78]. Rural Populations

Women living in rural and remote Australia are more likely to experience adverse health outcomes compared to those in metropolitan areas [27]. This inequity is reflective of several factors, including a greater difficulty in accessing specialised maternity care [79]. In the absence

of local services, women may need to travel long distances or move away from home to receive the care they need. Due to a long standing shortage of general practitioners, obstetricians, and anesthetists in rural areas, this issue is worsening [28]. Over the past two decades, the number of rural maternity units has halved [80]. RANZCOG promotes shared care arrangements, early risk assessments and counselling to help women in rural areas make informed decisions about their ongoing care [81]. The Royal Flying Doctor Service is integral in providing antenatal care for women in rural Australia [82]. The service includes home visits with doctors and midwives and teleconsultations with medical professionals [82]. However, this service cannot fully replace specialised maternity clinics in rural areas. Refugees and Asylum Seekers

The burden of poor health outcomes in refugee and asylum-seeker populations is carried most heavily by women and children [83]. Women of refugee background in Australia are more likely to have suffered injuries as a consequence of torture, assault and rape, as well as associated physical and psychological consequences and gynaecological problems [84]. Exposure to conflict, trauma, and torture is common for asylum seeker populations [84]. Women may have been exposed to varying degrees of information regarding contraception in their home countries or in other places they have lived [85]. Previous deliveries may have taken place at home, often with the assistance of a traditional birthing assistant [83, 84]. Many refugee women may not be familiar with options for antenatal care and birth available in Australia, such as birthing centres and shared care [86]. Health and settlement workers have an important role in supporting women from refugee backgrounds to access hospital antenatal care that is sensitive to their special needs [84]. Poorer health, racism, discrimination and illiteracy are concerns reported by women from a refugee background [87]. Additionally, during the perinatal period, separation from loved ones and from traditional cultural norms may result in feelings of isolation and vulnerability [88]. Gender Equity in the workplace

Discrimination on the basis of pregnancy or childbirth constitutes unlawful sex discrimination under Title VII of the Civil Rights Act of 1964. Women affected by pregnancy or related conditions must be treated in the same manner as other applicants or employees who are similar in their ability or inability to work [89]. However, one in two women in Australia report experiencing discrimination in the workplace during their pregnancy, parental leave, or on return to work [90]. This discrimination is in relation to pay, conditions and duties, worker health and safety, and job loss. One in five mothers reported that they were made redundant, restructured, dismissed or their contract was not renewed either during their pregnancy, when they requested or took parental leave or when they returned to work [90]. Furthermore, young mothers and single mothers were more likely to experience discrimination during pregnancy [91]. This discrimination impacts mothers’ health, finances, career and job opportunities, as well as their families and their engagement and attachment to the workforce [92]. Protection in this area is limited by the difficulty in enforcing, and the loopholes present in, Australian discrimination protection laws [93]. This highlights not only the lack of effective legislation, but the negative impact of societal views around the ability of pregnant women and mothers to work and have access to work. There currently is a lack of Australian research into the adverse health outcomes on both the mother and the child due to a mother’s inability to gain work. Results from a United States study showed that mothers having to rely on welfare due to the inability to enter the workforce resulted in poorer outcomes for the family [94]. A partner’s involvement in childbirth leads to better health for both mother and newborn, including lower maternal and neonatal mortality rate, reduced likelihood of prematurity and low birth weight, shorter labour period, and lower levels of maternal pain, anxiety, and fatigue during labour [95]. Partner support is also a protective factor against postnatal depression, and is linked to increased maternal well-being post-partum [96].

Research has shown that longer periods of paid paternity leave can increase gender equity at home and in the workplace [97]. Time off from work plays a significant role in developing a culture of active co-parenting [97]. Furthermore, increased paternity leave diminishes the incentive of employers to preference men over women at a childbearing age [97]. Given the potential for paternal leave to decrease pregnancy discrimination in the workplace, and increase the health and wellbeing of both mother and infant, more research into parental leave structures could provide considerable benefit to the health of the Australian population.

POSITION STATEMENT

AMSA believes that: Maternal Health Services

• Australian women need equitable and regular access to quality antenatal healthcare services that follow current guidelines to improve maternal health outcomes.

Sexual and Reproductive Health Services

• Safe and equitable access to reproductive services is imperative in improving health outcomes for all Australian women.

• Respecting a woman’s autonomy with regards to the decision to terminate a pregnancy contributes significantly to achieving positive outcomes for their health.

Maternal and Infant Nutrition

• National measures are needed to improve the nutrition of women during their pregnancy, in line with the Australian Dietary Guidelines. Particular attention needs to be paid to pre-pregnancy screening for overweight and obese patients.

• Measures need to be implemented that promote breastfeeding and increase the duration of breastfeeding in Australia, taking into account the social, cultural, and work-related barriers that prevent mothers from breastfeeding.

Vulnerable Populations

• Vulnerable groups, including Aboriginal and Torres Strait Islander, refugee and rural populations, experience significant maternal and infant health disparities that need to be addressed, taking into account the cultural, social and economic determinants of health.

Gender Equity In the Workplace

• Equitable parental leave for both mothers and their partners plays an important part in ensuring better health outcomes for both mother and infant, and is pivotal in promoting healthy family dynamics.

• Pregnant women and mothers should have the right to maternal leave and the right to return to their job without any discrimination against their maternal status.

POLICY

AMSA calls upon: The Federal and State Governments to: 1) With respect to maternal and infant health services:

a) Ensure that there is continuity and standardisation of maternal care in all states and territories.

b) Expand the number of public maternal and infant health services available for free under Medicare.

c) Increase access to services in rural areas by promoting policies that call for expansion of the rural healthcare workforce.

2) With respect to sexual and reproductive health services: a) Adhere to the recommendations outlined in AMSA’s Access to Safe Termination of

Pregnancy Policy. b) Provide safe and equitable access to termination of pregnancy services for all women

in Australia through the public health system and appropriately licensed private health facilities including: i) The adoption of safe access zones around termination of pregnancy facilities for

women seeking these services and staff rendering them. c) Improve affordability of, and access to all contraceptives, via the listing of newly-

available hormonal contraceptives (including those used for emergency contraception) on the Pharmaceutical Benefits Scheme.

d) Call for a review of the legislation that currently restricts the provision of the emergency oral contraceptive to women below the age of 16 in certain states and territories.

3) With respect to breastfeeding: a) Ensure that the new Australian National Breastfeeding Strategy is appropriately funded,

implemented and monitored. b) Provide funding for a national marketing campaign to promote breastfeeding and reduce

the social stigmas surrounding breastfeeding in public. c) Strengthen implementation of the WHO International Code on the Marketing of Breast

Milk Substitutes in Australia’s Marketing of Infant Formulas Agreement. d) Provide increased support and funding for the implementation of the Baby Friendly

Health Initiative (BFHI) at all healthcare providers offering maternity services. e) Provide increased support and funding for resources, tools and training on breastfeeding

for all health care providers. f) Ensure that women who are unable to breastfeed or decide not to breastfeed are

respected and not subject to stigmatisation for their circumstances or decisions. g) Provide funding for more research into the barriers that women from all backgrounds

face with regards to breastfeeding, as well as development of reliable, standardised indicators of breastfeeding compliance data collection and reporting.

h) Provide funding for more research into best practice for women unable to breastfeed 4. With respect to antenatal and perinatal nutrition:

a) Promote the Australian Dietary Guidelines for pregnancy, and develop strategies to improve adherence.

b) Develop standardised diagnostic and prognostic tools to identify women at risk of adverse outcomes during pregnancy linked to overweight and obesity.

c) Develop evidence-based national guidelines for pregnancy care in maternal obesity. d) Fund public education campaigns about the risks of obesity during pregnancy and

healthy gestational weight gain. e) Implement realistic and effective population-level interventions and campaigns to

improve pre-pregnancy and antenatal nutrition and lifestyle. f) Develop consistent, evidence-based guidelines for the diagnosis and management of

gestational diabetes.

5. With respect to Aboriginal and Torres Strait Islander maternal and infant health: a) Increase funding of accessible, culturally appropriate and sensitive Aboriginal and

Torres Strait Islander maternal and infant health initiatives that address the social, economic and cultural determinants of the health discrepancies between Indigenous and non-Indigenous populations.

b) Continue to re-evaluate and fund successful Aboriginal and Torres Strait Islander maternal and infant health services.

c) Address the ways in colonialism impacts on the gap between maternal and child health outcomes in Indigenous and non-Indigenous populations.

d) Promote active involvement of Indigenous communities in maternal and infant health program development.

e) Invest in training of more Aboriginal and Torres Strait Islander maternal and infant health workers.

f) Improve outreach services for Aboriginal and Torres Strait Islander women and infants

for increased access to maternal and infant health care, including quality antenatal care.

6. With respect to refugee populations: a) Adhere to the recommendations outlined in AMSA’s Refugee and Asylum Seeker

Health Policy. b) Increase investment into culturally appropriate and sensitive refugee maternal and child

health initiatives. 7. With respect to maternal and infant health in rural and remote populations:

a) Implement measures to address the shortage of maternal healthcare workers in rural and remote areas.

b) Implement strategies to improve access to antenatal care in rural and remote areas, including provision of telehealth services.

8. Fund research into parental leave programs, with the aim of establishing: a) The periods of paid maternal, paternal and partner leave that most benefit infants. b) The levels of pregnancy and maternal discrimination within Australian workplaces. c) The effect of pregnancy and maternal discrimination on women’s lifetime earning

power. d) Interventions that can prevent pregnancy and maternal discrimination, including the

implementation of equal, paid, non-transferrable parental leave. Private sector companies to:

1. Establish employer-based programs to support breastfeeding among working mothers. 2. Abide by anti-discrimination legislation that offers protections for pregnant women and

mothers. 3. Have appropriate avenues to report, and safeguards against, pregnancy and maternal

discrimination. 4. Support initiatives that increase paid parental leave and provide a safe and positive

culture around access to parental leave. Health professionals and healthcare providers, including hospitals, to:

1. Recognise the significant impact of obesity and diabetes on pregnancy, and provide adequate pre-pregnancy weight and nutrition counselling.

2. Require all health professionals involved in maternal care to undertake evidence-based breastfeeding education and training.

3. Provide holistic and culturally sensitive approaches to Aboriginal and Torres Strait Islander maternal and infant health services.

4. Provide outreach services to Aboriginal and Torres Strait Islander women and infants, particularly in rural and remote areas.

5. Employ Aboriginal and Torres Strait Islander staff in areas relating to maternal and infant health, in order to build and support culturally safe spaces.

6. Support women from refugee backgrounds to access hospital antenatal care that is sensitive to their needs.

7. Ensure there are easily accessible facilities in hospitals for mothers to breastfeed while ensuring that facilities are clean, culturally appropriate and respects privacy.

Medical schools, universities and educational institutions to: 1) Provide evidence-based education and training for medical students and young doctors with

respect to: a) Maternal nutritional guidelines, weight optimisation, and healthy physical activity; b) Social and cultural determinants of maternal and infant health; c) Breastfeeding; d) Aboriginal and Torres Strait Islander maternal and infant health; e) Asylum seeker and refugee maternal and infant health.

2) Ensure there are easily accessible facilities for mothers to breastfeed while ensuring that

facilities are clean, culturally appropriate and respect privacy.

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APPENDIX Australia’s pregnancy termination laws

STATE TERMINATION OF PREGNANCY LAWS

Queensland Any person who carries out, or assists with, an abortion may be liable to criminal prosecution, including the woman herself. “In exceptional cases” an abortion would not be unlawful where it was carried out in good faith to avoid “serious danger to the mother’s life or her physical or mental health (not merely the normal dangers of pregnancy and childbirth) which the continuation of the pregnancy would entail”.

New South Wales

NSW case law has established that in certain circumstances, similar to those in Queensland, an abortion would not be unlawful. It also allows for broader considerations of economic and social factors to determine whether continuing the pregnancy poses a serious danger to the woman’s mental health.

Australian Capital Territory

No complete decriminalisation

Tasmania Decriminalised up to 16 weeks Adoption of safe exclusion zones around reproductive service clinics

Western Australia

After 20 weeks, abortions can only be performed if two medical practitioners from a statutory panel of six agree that the woman or her fetus has a “severe medical condition” that justifies the procedure.

South Australia

No complete decriminalisation

Northern Territory

No complete decriminalisation

Fig Adapted from Abortion Law in Australia – Parliament of Australia [Internet]. Aph.gov.au. 2018 [cited 19 May 2018]. Available from: https://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/pubs/rp/rp9899/99rp01

POLICY DETAILS Name: Maternal and Infant Health Category: G- Global Health History: Adopted Council 2, 2018

D. Daudu, M. Batchelor, G. Chrisp, R. Clark, C. Harvey, T. Mojeed, R. Mahesh