Marginalised individuals in Australia, including Aboriginal, Torres-Strait Islander, First Nations (respectfully referred to as Indigenous Australians hereafter) and Culturally and Linguistically Diverse (CALD) women and infants have long had different experiences of health and healthcare in Australia compared to their non-marginalised counterparts. Indigenous infants make up approximately 5.2% of births each year in Australia (1 in 19 births) [1]. Low birthweight and prematurity are more prevalent among Indigenous infants compared with non-Indigenous infants [2]. Infants born to CALD women account for one-third of Australia’s births, and they too are among the most likely to experience low birthweight and prematurity [3]. Social determinants of health that differ for Indigenous Australians, including cultural identity, family support, participation in cultural activities and access to traditional lands, can contribute to differences in health outcomes such as low birthweight and prematurity, as well as quality of life within the Indigenous population [4].

Disadvantages and social determinants to CALD women that act as barriers to accessing care, and in turn contribute to poor birth outcomes include cultural differences, language barriers, limited health literacy, insufficient support, transport issues and limited financial capacity [3]. Additionally, marginalised women in Australia are at an increased risk of low birthweight and premature births secondary to factors that include intergenerational trauma, colonisation, and stigma and racism [5].

Extensive research has identified that individual-level risk factors for adverse pregnancy outcomes amongst Indigenous women may include smoking, excessive alcohol consumption, substance use, obesity, poor nutrition and gestational diabetes [6]. Additionally, there is little information regarding the individual level factors that may contribute to poor birth outcomes for CALD women, however the structural, organizational, and cultural barriers are evident [7]. There may be wider systematic factors that also contribute to these poorer outcomes, including low birthweight, and prematurity, for both Indigenous and CALD women.

The political structure of Australia’s healthcare system and the way healthcare is delivered and made available in Australia is not appropriate for all, particularly Indigenous and CALD women [8, 9]. Indigenous women identify that the delivery of health services in Australia is heavily underpinned by ‘white’ culture, which does not reflect the same values, beliefs and practices of Indigenous culture [9]. Further, current health policy and practices favor care that suppresses the voice of marginalized individuals, and identifies Indigenous people as the ‘problem’ [9]. This is a discourse that needs to be adjusted to recognise health system, social and policy factors that may also contribute to poorer health outcomes [9]. Such issues are likely to extend to CALD women and infants on the basis of race inequity [7]. Currently, inequities are attributed to socio-economic status or ethnicity, instead of the political choices about how to design, finance and deliver healthcare.

The social-ecological model is a multi-level public health approach to prevention that considers broad social and political factors; not just individual ones [10]. The model consists of five levels, each encompassed within the next, beginning with the individual level, then interpersonal, organizational, community and policy levels, respectively (see Fig. 1). To obtain the greatest impact from public health interventions, it is recommended that interventions be applied at all levels of the model [10], as changes in broader levels are likely to impact on the levels nested within (e.g., individual factors such as smoking or alcohol consumption can be influenced by interpersonal, organizational, community and policy levels). Further, the social-ecological model has previously demonstrated impact for Indigenous Australians in interventions related to nutrition, physical activity, diabetes, men’s health, and substance use [11].

Fig. 1

The Social-Ecological Model

The Australian government recognizes that poorer individual level outcomes for Indigenous women are strongly associated with poorer socio-economic determinants [12]. However, disproportionate emphasis has been placed on the behavior of individuals, as opposed to wider societal and system factors that also contribute to poorer health outcomes [8]. Improvements made to Indigenous women’s access to antenatal care has resulted in an increase in the proportion of Indigenous mothers attending the first antenatal visit within 12 weeks of pregnancy, and an increase in the proportion of Indigenous mothers attending five or more antenatal visits [12]. There was also a decrease in the proportion of Indigenous mothers who reported smoking during pregnancy [12]. Despite these individual-level improvements, Indigenous mothers are still twice as likely to deliver infants of low birthweight compared to non-Indigenous mothers, and to deliver prematurely [2]. CALD women in Australia are also at an increased risk of delivering infants prematurely and with low birthweight, and it has been found that health service utilization by these women differs from those who are not marginalised [3].

Australia has a number of policies to improve the birth outcomes of women and infants in Australia, including some targeted specifically for Indigenous women and infants. The National Aboriginal and Torres Strait Islander Health Plan 2013–2023 is an evidence-based policy framework designed to guide policies and programs to improve Aboriginal and Torres Strait Islander Health [13]. Additionally, the National Maternity Services Plan aimed to provide culturally competent maternity care for Aboriginal and Torres Strait Islander women in an effort to reduce poor pregnancy and birth outcomes [14]. The plan identified three priority areas to improve services for Indigenous women; 1) developing and expanding culturally competent maternity care; 2) developing and supporting an Aboriginal workforce; and 3) developing dedicated programs for ‘Birthing on Country’ – best practice and culturally responsive maternal and infant healthcare for Indigenous women [15, 16]. Examples of culturally appropriate community-centred models of care include the Ngua Gundi Mother Child Project, Aboriginal Maternal and Infant Health Strategy (AMIHS), and Strong Women Strong Babies Strong Culture program [17]. In 2009, the report of the maternity services review for improving maternity services in Australia identified that Indigenous women have poorer maternal and perinatal outcomes. This report highlighted the need for culturally safe and community-centred models of care for these women. It is notable too that in Australia, there is an absence of policy focusing on reducing poor birth outcomes experienced by CALD women.

As such, there is an urgent need to address the poorer outcomes, particularly low birthweight, and prematurity, of infants born within marginalised groups living in Australia. The purpose of this systematic review was to identify interventions that aimed to reduce the incidence of preterm birth and low birthweight births in Indigenous and CALD mothers and infants, and examine which levels of the social-ecological model were addressed.

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