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Objective This study explored the risk of antenatal psychosocial distress (APD) and associated potential factors and examined management aspects of risk of APD in women attending Aboriginal primary health care services in Australia. Method Audits of medical records of 797 pregnant women from 36 primary health centres in five jurisdictions (NSW, QLD, SA, WA and NT) were undertaken as part of a quality improvement programme. Information collected included mental health assessed by a standard screening tools, enquiry regarding social and emotional well-being (SEWB), depression management (including antidepressant medications) and referral. Results Around 18% ( n = 141) of women were at risk of APD based on assessment using a standard screening tool or by SEWB enquiry. There was a significant association between risk of distress and women’s life style behaviours (e.g., alcohol, illicit drug use) and health centre characteristics. Of the 141 women, 16% ( n = 22) were prescribed antidepressant drugs during pregnancy. A range of nonpharmaceutical mental health interventions were also recorded, including brief intervention of 61% ( n = 86), counselling of 57% ( n = 80) and cognitive behaviour therapy of 5% ( n = 7). About 39% ( n = 55) of women with APD were referred to external services for consultations with a psychiatrist, psychologist or social worker or to a women’s refuge centre. Conclusions The higher risk of APD associated with women’s life style behaviour indicates that the better understanding of mental health in its cultural context is essential. [ABSTRACT FROM AUTHOR]