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JUDITH LUMLEY CENTREformerly Mother and Child Health Research

ANNUAL REPORT

2013

latrobe.edu.au/jlc

Judith Lumley Centre

La Trobe University 215 Franklin Street

Melbourne Vic 3000

T: +61 3 9479 8800 E: [email protected]

The Judith Lumley Centre is a multidisciplinary public health research centre in the Faculty of Health Sciences at La Trobe University. Established in 1991, it has built a strong program of research addressing issues of major public health importance for mothers and infants and is now expanding to include research on the transition to contemporary parenthood.

The research focus areas at the Judith Lumley Centre include

Mother and infant health Transition to contemporary parenthood Maternity care and family services in the early years Sexual and reproductive health Breastfeeding Reducing violence against women and children.

The Judith Lumley Centre aims to

Undertake and interpret research in our research focus areas Contribute to policy and practice development Be involved in postgraduate and continuing education Provide advice and resources to researchers in related fields.

We have a broad public health and population focus and an inclusive approach to the social and medical aspects of health and care for parents and infants. A wide range of disciplines contribute to our research.

We emphasise the need for research, service development, evaluation and policy to be linked. We support testing interventions in randomised trials, research translation into clinical practice, and implementation of effective and cost‐effective interventions.

RUBY volunteer training (project description p. 18)

Lisa Amir, Miranda Buck with new parents at RWH

At the launch of the new name and program for the Centre

ANNUAL REPORT 2013

Table of contents

DIRECTOR’S REPORT 4

RESEARCH PROGRAM 2013 5

Healthy Motherhood Program 5

Mother and infant health 6 Diabetes and antenatal milk expressing (DAME): a randomised controlled trial 6 Evaluation of the PANDA national perinatal depression helpline 6 Obstetric outcomes for immigrant women 6 Risk factors and trends in postpartum haemorrhage (PPH) in Victoria 2003–2011: health policy implications 7

Systematic reviews 7 Antenatal breast milk expression by women with diabetes for improving infant outcomes 7 Interventions for supporting pregnant women's decision‐making about mode of birth after a caesarean 7

Collaborative work 7 Expectations, fears and pain experience: identifying external and internal threats to perceived safety for women in two birthing environments 7 Fetal lactate measurement to reduce caesarean sections during labour: a randomised trial (FLAMINGO) 8 Impact of risk‐reducing bilateral salpingo‐oophorectomy on non‐cancer outcomes in young high‐risk women: a multicentre prospective study (WHAM) 8

Transition to contemporary parenthood 8 Birth cohort pilot study 8 Labour Companion Education (LaCE): a feasibility study for a randomised trial 8

Collaborative work 9 Health promotion in pregnancy and early parenthood: the challenge of innovation, implementation and change 9

Maternity care and family services in the early years 10 COmparing standard maternity care with one to one midwifery support (COSMOS): a randomised trial 10 Enhanced care and support in early labour (ecsel pilot study) 10 Evaluation of Victorian Homebirthing Pilots 10 ECO – Exploring the introduction, expansion and sustainability of caseload midwifery in Australia 11 Implementing and evaluating changes to postnatal care at the Royal Women’s Hospital: a before and after study 11 Improving the reporting and collection of rural obstetrics data 12 A review of home‐based postnatal care in Victoria 12 Validation study of data in the 2011 Victorian Perinatal Data Collection 13 Women’s and staff views: an evaluation of maternity care at Barwon Health (WAVE) 13

Judith Lumley Centre

Collaborative work 14 Birthplace in Australia: a prospective cohort study 14 Maternal and fetal role and rights in relation to use of obstetric ultrasound examinations 14 Reproductive Outcomes And Migration (ROAM): an international collaboration 14

Sexual and reproductive health 15 An evaluation of access and equity in the provision of medical abortion following the introduction of mifepristone on the Australian Pharmaceutical Benefits Scheme 15 Exploring the antecedents and predictors of termination of pregnancy in the 1973–78 cohort of the Australian Longitudinal Study of Women’s Health 16

Breastfeeding 16 Delphi study of pharmacology experts to derive international recommendations for medicine use in lactation 16 Improving maternity care and breastfeeding outcomes for Aboriginal mothers and babies in Victoria 17 MILC (Mothers and Infants Lactation Cohort): a multi‐site study 17 Ringing Up about Breastfeeding – a randomised controlled trial exploring early telephone peer support for breastfeeding (RUBY) 18 The role of micro‐organisms (S. aureus & C. albicans) in the pathogenesis of breast pain and infection in lactating women (CASTLE Study) 18 Supporting breastfeeding In Local Communities (SILC) 19

Reducing violence against women and children 20 Harmony: a cluster randomised trial to prevent and reduce family violence in Vietnamese and Indian migrant communities 20 Improving maternal and child health care for vulnerable mothers (MOVE) 20 Violence against women in Timor‐Leste: secondary analysis of the 2009‐10 Demographic and Health Survey 21

Systematic reviews 21 Screening women for intimate partner violence in health care settings 21

Collaborative work 21 Disclosure of violence: women’s experiences of self, social identity and seeking help in the context of intimate partner violence (The DOVE study) 21 I‐DECIDE: an internet‐based safety decision aid for women experiencing intimate partner violence: a randomised controlled trial 22 Women’s experience of abuse and violence care in general practice: Long term outcomes and process evaluation (WEAVE) 22

EDUCATION & CAPACITY BUILDING 23

Postgraduate study 2013 23 Postgraduate projects 23

Seminars and workshops 25 Lunchtime Seminars 25 Journal Club 25 Methods Journal Club 26 Teaching 26 Visiting academics 26

ANNUAL REPORT 2013

PUBLICATIONS 2013 27

Articles in refereed journals 27

Articles in press 28

Articles submitted 28

Annotations, commentaries, editorials and other invited contributions in refereed journals 29

Books / book chapters 29

Books reviews 29

Conference abstracts 30

ADVOCACY & OTHER ACTIVITIES 33

Public health advocacy 33

Talks and lectures 33

Reference groups 33

Conferences and workshops attended 34

Committees and advisory groups 35

Reviewing papers 36

Membership of editorial boards 36

Assessing research grants 36

Thesis examination 36

PEOPLE 37

Staff 37

Higher degree students 37

Administrative staff 37

Honorary associates 37

Research associates and collaborators 38

CURRENT GRANTS, SCHOLARSHIPS & AWARDS 44

Grants 44

Scholarships 45

Awards 45

FUNDS 2013 46

Funds 46

DONATION 47

Director’s report

4 Judith Lumley Centre

Dire c to r ’ s r epo r t

The photos on this page portray two very exciting events in the Centre’s history at the end of 2013. First, the renaming of Mother and Child Health Research to the Judith Lumley Centre in honour of the Centre’s eminent founding Director, Professor Emerita Judith Lumley. This renaming responds to a recommendation made in our 2012 Centre Review, gives us a new constitution and the support of the Strategic Advisory Committee, which will meet for the first time in March 2014. The second celebrates the great generosity of Mrs Roberta Holmes, who has made a large donation to the Centre to establish a new research program to improve the lives of parents—the Transition to Contemporary Parenthood Program. This donation, which covers the first five years of the program, establishes a new Inaugural Professorial Chair to lead the research, a postdoctoral fellow, two PhD scholars, administrative support and additional funds. La Trobe University has guaranteed the continuity of the professorial position and also contributed two further PhD scholarships and funds. The new Parenting Program extends the current focus of the Judith Lumley Centre on the welfare of mothers and infants to include recognition of the importance of partners and grandparents, the challenges of work–life balance, new technologies, older motherhood, and the diversity of families on parenting transitions in the new millennium.

Another significant change for the Judith Lumley Centre is the transition in leadership of the Centre as Professor Rhonda Small steps sideways from the Director’s role after five years to focus her very considerable research skills on her own studies. Rhonda was a founding scholar in the then Centre for the Study of Mothers’ and Children’s Health, established by Judith Lumley in the early nineties. She has been pivotal in the successful stability and continuing achievements of this centre following Judith’s retirement. Rhonda’s leadership has been characterised by the emotional intelligence she brought to staff and student support; in the strategic wisdom she brought to negotiations with the wider university and faculty management; her unwavering commitment to the Centre; and her own achievements in research into the needs of mothers and infants, especially those of migrant and refugee backgrounds. It is her desire to have more time to devote to these studies that she has decided to step aside. We are grateful to her for her work and very pleased that she will stay to continue to contribute to the research successes at the centre. It is with a sense of privilege, wonderful pride and humility that I have accepted a leadership role at the centre at a time of great opportunity in the Judith Lumley Centre and challenges in the wider university sector.

These are the larger shifts on our horizon, but we continue to celebrate our other quieter achievements. These include the successful completion and 2013 publication in BMJ Open of

the CASTLE study outcomes, a cohort study of the role of Candida albicans (‘thrush’) and Staphylococcus aureus in breast and nipple pain led by Associate Professor Lisa Amir. This firmly established the central role of thrush in nipple and breast pain which can deter many women from continuing to breastfeed.

Other highlights include an expansion (across Australia) of the COSMOS one‐to‐one midwifery model, so successfully trialed by Associate Professor Helen McLachlan and her team and published in the British Journal of Obstetrics and Gynaecology in 2012. Helen and her group have commenced partnerships with VACCHO to develop a caseload model that would be acceptable and effective for Aboriginal mothers and continue to explore the sustainability needs of the caseload midwifery model. Further expansion and support for the public hospital homebirth model was incorporated into a successfully passed motion in the Victorian state parliament citing results of the pilot evaluation undertaken at the Judith Lumley Centre.

In 2013, we congratulated Jane Morrow, Kristina Edvardsson and Natasha Maharaj who celebrated their PhD graduation and Michelle Newton, Zaharah Suleiman and Ellie McDonald who successfully submitted theirs. We welcomed six new PhD scholars and enjoyed the company of Associate Professor Kenji Nashiro from Okinawa, Japan and Dr Nayana Samaraweera from Sri Lanka. Staff, students and visitors’ contributions, the launch and renaming of the Judith Lumley Centre and the promise and opportunities offered by Roberta Holmes’ generosity all made the closing weeks of 2013 a window to exciting horizons for the Judith Lumley Centre in 2014.

Angela Taft Director February 2014

John Dewar, VC; Natasha Stott Despoja; Roberta Holmes; Rhonda Small; Angela Taft

Research program 2013

ANNUAL REPORT 2013 5

Resear ch prog r am 2013

HEALTHY MOTHERHOOD PROGRAM

A RESEARCH STRENGTH AREA IN THE FACULTY OF HEALTH SCIENCES

Achieving healthy motherhood – and a healthy start to life for children – is increasingly compromised in Australia, as in many other developed nations, by concerning rates of unwanted pregnancy, high rates of caesarean section, new complexities in relation to maternal and infant morbidity and inadequate duration of breastfeeding. Inequities in health and care also occur, arising from the social contexts of women’s lives and the ways in which health services are provided. Intimate partner violence, socio‐economic disadvantage, migration and indigeneity have important impacts on the achievement of healthy motherhood, but are often neglected in research.

The overall purpose of this program, started in 2012 as a Faculty of Health Sciences project, is to improve the health and experiences of women giving birth in Australia.

This program of research addresses four key areas affecting the achievement of healthy motherhood:

1. Prevention and reduction of unwanted pregnancy

2. Promotion of normal birth and reduction of high rates of caesarean section

3. Improvement in breastfeeding rates and experiences

4. Promotion of healthy motherhood in the context of maternal and infant morbidity.

Within these four areas we also address key contextual issues, including socio‐economic disparities, violence against women, migration and indigeneity.

These 2013 projects were supported (at least in part) by Healthy Motherhood Research Strength funding from the Faculty of Health Sciences:

Access and equity in the provision of medical termination on the PBS in Australia – Angela Taft, Judith Lumley Centre

Attitudes and decision‐making associated with intervention during labour, birth and breastfeeding – Mary‐Ann Davey and Rhonda Small, Judith Lumley Centre

Classification of medicines used in breastfeeding women: a Delphi study aimed at consensus – Kath Ryan, School of Nursing and Midwifery and Lisa Amir, Judith Lumley Centre

Data analyses of depression outcomes for women’s responses within PRISM trial – Rhonda Small, Judith Lumley Centre

The ECO study ‐ a national study exploring the expansion and sustainabiility of the caselaod midwifery model – Kate Dawson, Michelle Newton, Della Forster, Helen McLachlan, Judith Lumley Centre

Exploring complex birth – Wendy Pollock, Department of Midwifery

Food and dietary habits of women of gestational age in Ooty, India – Catherine Itsiopoulos, Department of Dietetics

Infant feeding practices in families with children at increased risk of coeliac disease – Susannah King and Sue Shepherd, Department of Dietetics

Nipple and breast pain in breastfeeding women – Lisa Amir, Judith Lumley Centre

Optimising maternity care and breastfeeding outcomes of Aboriginal women in Victoria – Helen McLachlan and Della Forster, Judith Lumley Centre

Peer support training for breastfeeding: what is it and how does it happen? An international survey – Kath Ryan, School of Nursing and Midwifery

Postnatal use of maternal medications and breastfeeding outcomes (MoBa study) – Lisa Amir and Moni Rani Saha, Judith Lumley Centre; Kath Ryan, School of Nursing and Midwifery

Preventing unwanted pregnancy and reducing intimate partner/family violence – Angela Taft, Judith Lumley Centre

Validation study of postpartum haemorrhage items in the Victorian Perinatal Data Collection – Sue McDonald and Wendy Pollock, Department of Midwifery; Mary‐Ann Davey and Maggie Flood, Judith Lumley Centre



MOTHER AND INFANT HEALTH

DIABETES AND ANTENATAL MILK EXPRESSING (DAME): A RANDOMISED CONTROLLED TRIAL

Della Forster, Lisa Amir, Anita Moorhead; in collaboration with Susan Jacobs and Peter Davis, Royal Women’s Hospital; Susan Walker, Kerri McEgan and Gillian Opie, Mercy Hospital for Women; Susan Donath, Murdoch Childrens Research Institute; Rachael Ford, Royal Women’s Hospital; Catherine McNamara, Mercy Hospital for Women; Amanda Aylward, Royal Women’s Hospital; Christine East, Monash Medical Centre; Lisa Gold, Deakin University

Diabetes is increasing globally and occurs in 8% of pregnancies. These pregnancies are considered to be at high risk of perinatal complications. Infants of women with diabetes in pregnancy have an increased risk of developing diabetes and being obese later in life. They are highly likely to be exposed to cow’s milk protein early, also increasing the risk of diabetes. Many maternity providers encourage these ‘high‐risk’ women to express colostrum before birth to have breast milk available should the infant need supplementary feeding to treat hypoglycaemia.

Pilot data from our group and another small study in the United Kingdom found increased special care nursery (SCN) admissions in infants of mothers who expressed antenatally, and the UK study found a one‐week reduction in pregnancy gestation. Evidence for this practice is lacking so we are undertaking a multi‐site, two‐arm randomised controlled trial (RCT) of antenatal expression of colostrum in late pregnancy for women with diabetes in pregnancy to explore the safety and efficacy for mother, fetus and infant. Trial sites are the Mercy Hospital for Women, the Royal Women’s Hospital, Monash Medical Centre and Geelong Hospital, Barwon Health.

The primary hypothesis of this study is that infants of women with diabetes in pregnancy, who commence antenatal expressing of colostrum from 36 weeks’ gestation, will be more likely to be admitted to the SCN/NICU after birth compared with infants of women with diabetes in pregnancy who receive standard care. We will also test whether antenatal expressing increases the proportion of infants receiving exclusive breast milk during the hospital stay after the birth and at three months of age, and whether it decreases duration of pregnancy. We are in the process of recruiting 658 women to the study.

FUNDING: NHMRC project grant 2011–2014

STATUS: Recruitment underway (330 women recruited)

DAME website

EVALUATION OF THE PANDA NATIONAL PERINATAL DEPRESSION HELPLINE

Helen McLachlan, Della Forster, Rhonda Small, Touran Shafiei, Laura Biggs

The Post and Antenatal Depression Association (PANDA) is a national, not‐for‐profit organisation established in Victoria in 1985. The PANDA Helpline is a telephone information, support and referral service, staffed by trained volunteers and professional counsellors. PANDA’s mission is to support and inform women, men and their families who are concerned about or affected by childbirth‐related depression and anxiety.

In January 2013, the Judith Lumley Centre was engaged by PANDA to undertake an independent evaluation of the PANDA National Perinatal Depression Helpline.

The evaluation comprised a number of components including:

A description of the PANDA caller profile Demand and referral pathways using routinely collected

data An exploration of the views and experiences of callers to

PANDA via an online survey A hard copy survey or a telephone interview.

It also included:

Key informant consultations with PANDA volunteers, PANDA counsellors and key stakeholders via online surveys

Focus groups Face‐to‐face interviews.

FUNDING: PANDA

STATUS: Data analysis completed, report drafted

OBSTETRIC OUTCOMES FOR IMMIGRANT WOMEN

Rhonda Small, Mary‐Ann Davey; in collaboration with the Victorian Perinatal Data Collection Unit and Paul Agius, Burnet Institute

This project continues earlier work investigating identified problems of public health importance in relation to obstetric outcomes and experiences of maternity care for immigrant women of non‐English speaking backgrounds in Australia.

These include a range of unexplained variations by:

Maternal country of birth (e.g. in caesarean section and other obstetric procedures)



Evidence for higher standardised perinatal mortality ratios among well‐grown term infants of women born in NES‐countries (suggesting possible cause for concern about the role of communication difficulties in decision‐making during labour and birth in these poorer outcomes)

Consistently poorer ratings of maternity care by immigrant women from NES‐countries.

Analyses investigating mode of birth outcomes for Vietnamese‐born women over time (1984–2007) have been completed and findings presented at two conferences.

FUNDING: none

STATUS: paper being finalised for submission in 2014

RISK FACTORS AND TRENDS IN POSTPARTUM HAEMORRHAGE (PPH) IN VICTORIA 2003–2011: HEALTH POLICY IMPLICATIONS

Mary‐Ann Davey, Maggie Flood; in collaboration with Susan McDonald and Wendy Pollock, School of Nursing and Midwifery, La Trobe University; Fiona Cullinane, Royal Women’s Hospital

This study analyses trends in postpartum haemorrhage (PPH) and associated morbidities using data from the Perinatal Data Collection for all births in Victoria, 2003–2011. The frequency and severity of postpartum haemorrhage are increasing, as are rates of known risk factors. Small increases in rates of postpartum haemorrhage—a continuing major cause of maternal morbidity—may impact heavily on women and their families.

This study will provide up‐to‐date local information on postpartum haemorrhage incidence and risk factors, enabling insights into strategies to reduce these and to inform policy and practice in maternity services to benefit the women of Victoria.

FUNDING: none

STATUS: awaiting data from the Consultative Council for Obstetric and Perinatal Mortality and Morbidity for analysis

COSMOS trial participant; Image courtesy of K Booth

Systematic reviews

ANTENATAL BREAST MILK EXPRESSION BY WOMEN WITH DIABETES FOR IMPROVING INFANT OUTCOMES

Christine East, Willie Dolan, Della Forster

FUNDING: none

STATUS: protocol published

PUBLICATION: East CE, Dolan WJ, Forster DA. Antenatal breast milk expression by women with diabetes for improving infant outcomes [Protocol]. Cochrane Database Syst Rev 2013; Issue 3: Art.No.: CD010408

INTERVENTIONS FOR SUPPORTING PREGNANT WOMEN'S DECISION‐MAKING ABOUT MODE OF BIRTH AFTER A CAESAREAN

Dell Horey, Michelle Kealy, Mary‐Ann Davey, Rhonda Small, Caroline A Crowther

FUNDING: none

STATUS: review published

PUBLICATION: Horey D, Kealy M, Davey M‐A, Small R, Crowther CA. Interventions for supporting pregnant women's decision‐making about mode of birth after a caesarean [Review]. Cochrane Database Syst Rev 2013; Issue: 7: Art.No.: CD010041

Collaborative work

EXPECTATIONS, FEARS AND PAIN EXPERIENCE: IDENTIFYING EXTERNAL AND INTERNAL THREATS TO PERCEIVED SAFETY FOR WOMEN IN TWO BIRTHING ENVIRONMENTS

Lester Jones, Department of Physiotherapy, La Trobe University; Rhonda Small, Mary‐Ann Davey, Laura Whitburn

This exploratory study involving 20 participants recruited from the Mercy Hospital for Women commenced in 2011. The aim of the project is to examine women’s experience of labour pain within the perspective of modern pain science.

Preliminary findings highlight a range of social needs during labour identified as advocacy, expertise, reassurance, encouragement, information, empathy, positivity and an agent to act on the woman’s preferences and desires. Key observations relating to the focus of women’s attention during labour suggest better coping may be determined by a woman’s undistracted attention on the moment and acceptance of the adversity of labour.

FUNDING: La Trobe University Faculty of Health Sciences Research Grant 2011

STATUS: Data collection completed; analysis ongoing; one paper published, one manuscript submitted for publication, one manuscript



in development; two poster presentations in 2013 (Mindfulness, Science and Practice 2013; PainAdelaide 2013)

PUBLICATION: Whitburn L. Labour pain: from the physical brain to the conscious mind. J Psychosom Obstet Gynaecol 2013; 34(3):139–43

FETAL LACTATE MEASUREMENT TO REDUCE CAESAREAN SECTIONS DURING LABOUR: A RANDOMISED TRIAL (FLAMINGO)

Christine East and Shaun Brennecke, Royal Women’s Hospital; Mary‐Ann Davey; Omar Kamlin, Royal Women’s Hospital

There is currently an epidemic of caesarean sections performed in Australia and overseas. Although many caesarean sections are performed for concerns about fetal welfare, the majority of babies are shown to be well at birth, meaning that the operation, with its inherent short‐ and long‐term risks, could have been avoided, without compromising the baby’s health.

In this study, half the babies with a non‐reassuring heart rate recording during labour will have a blood test to measure lactate and the other half will not. We will then determine whether having a lactate test makes a difference in the number women having caesarean births.

FUNDING: NHMRC Project Grant 2012–2015, University of Melbourne

STATUS: recruitment underway

IMPACT OF RISK‐REDUCING BILATERAL SALPINGO‐OOPHORECTOMY ON NON‐CANCER OUTCOMES IN YOUNG HIGH‐RISK WOMEN: A MULTICENTRE PROSPECTIVE STUDY (WHAM)

Martha Hickey, Royal Women’s Hospital; Gillian Mitchell, Peter MacCallum Cancer Centre; Bettina Meiser, University of New South Wales; John Wark, Royal Melbourne Hospital; Mary‐Ann Davey

This study is looking at menopause symptoms, sexual function, bone health and risk factors for cardiovascular disease in women who choose to have surgery to remove their ovaries and fallopian tubes because they are considered high risk for developing ovarian cancer.

They will be asked to invite an age‐matched friend to take part in the study as part of the “low risk” control group.

FUNDING: NHMRC Project Grant 2013–2015, University of Melbourne

STATUS: recruitment underway

TRANSITION TO CONTEMPORARY PARENTHOOD

BIRTH COHORT PILOT STUDY

Mary‐Ann Davey, Rhonda Small, Lester Jones, Laura Whitburn

Forty women are being recruited from the Mercy Hospital for Women and Sunshine Hospital to take part in this pilot study about the factors that shape women’s expectations and experience of care during labour and birth, breastfeeding and transition to parenthood. It is a longitudinal cohort study and will inform the development of a definitive study. It involves completion of questionnaires during pregnancy and in the postnatal period. Half the women will also take part in in‐depth interviews before and after birth exploring pain in labour.

FUNDING: Healthy Motherhood Program Grant

STATUS: recruitment underway; questionnaires developed; interview schedule developed

LABOUR COMPANION EDUCATION (LACE): A FEASIBILITY STUDY FOR A RANDOMISED TRIAL

Rhonda Small, Della Forster, Touran Shafiei; in collaboration with Tanya Farrell, Royal Women’s Hospital; Chris East, Monash Health; Sue McDonald, Mercy Hospital for Women / La Trobe University

Caesarean section rates have climbed to more than 30% in Australia, and are even higher in some groups of immigrant women, suggesting urgent action is required. Continuous support in labour from a trained labour companion has been shown to reduce rates of caesarean section, but testing this evidence in a population‐representative sample, inclusive of culturally and linguistically diverse first‐time mothers, has not been attempted nor its feasibility investigated.



This project explored the feasibility of conducting a randomised trial of labour companion education at the Royal Women’s Hospital in Melbourne.

Interviews and focus groups explored acceptability and feasibility issues with maternity services staff, with women and with immigrant community representatives.

During the feasibility study, other maternity hospitals expressed interest in involvement in the proposed trial and a small group of midwives from The Royal Women’s Hospital, Monash Health and The Mercy Hospital for Women participated in a workshop in October 2012 to develop the education module, which was then successfully piloted with 19 women and their labour companions in 2013.

An application for funding for the main trial will be submitted in 2014.

FUNDING: Faculty of Health Sciences Research Grant 2011

STATUS: Interviews and focus groups conducted; education module developed and piloted; paper in preparation; project grant application to NHMRC in preparation

Collaborative work

HEALTH PROMOTION IN PREGNANCY AND EARLY PARENTHOOD: THE CHALLENGE OF INNOVATION, IMPLEMENTATION AND CHANGE

Kristina Edvardsson, Rhonda Small; in collaboration with Anneli Ivarsson, Eva Eurenius, Marie Lindkvist and Ingrid Mogren, Umeå University, Sweden; Rickard Garvare, Luleå University of Technology, Sweden; Monica Nyström, Karolinska Institute, Sweden

Kristina came to the Judith Lumley Centre as a visiting PhD‐candidate in February 2011. During her PhD studies she was employed by the Department of Public Health and Clinical Medicine, Epidemiology and Global Health at Umeå University in Sweden. Kristina left the Centre in March 2013 and graduated at Umeå University in Sweden in May the same year.

The aim of the research visit was to gain international experience and add international research collaboration to the study into the implementation of a Swedish multisectoral child health promotion programme (the Salut Programme).

All papers resulting from the thesis have been published. The papers aimed to:

Explore the prevalence and socio‐demographic patterns of overweight and obesity in Swedish expectant parents, and to assess within‐couple associations

Explore first‐time parents’ experiences of health promotion and lifestyle change during pregnancy and early parenthood

Explore facilitators, barriers, and requirements for sustainability as experienced by professionals two years after finalising the development and implementation of the Salut Programme

Examine outcomes of the Salut Programme on professionals’ self‐reported health promotion practices, and to investigate perceived facilitators and barriers for programme implementation.

Results from the thesis were presented at the 21st International Conference on Health Promoting Hospitals and Health Services, Gothenburg, Sweden, in May 2013 (two abstracts).

FUNDING: The Faculty of Medicine and FAS Centre of Global Health Research at Umeå University in Sweden (2009–2012); Swedish Research Council for Health, Working Life and Welfare (FORTE) (2012)

STATUS: Four papers published, of which one published in 2013

PUBLICATIONS: Edvardsson K, Lindkvist M, Eurenius E, Mogren I, Small R, Ivarsson A. A population‐based study of overweight and obesity in expectant parents: socio‐demographic patterns and within‐couple associations. BMC Public Health 2013; 13:923.

Image courtesy of Arifur Rahman



MATERNITY CARE AND FAMILY SERVICES IN THE EARLY YEARS

COMPARING STANDARD MATERNITY CARE WITH ONE TO ONE MIDWIFERY SUPPORT (COSMOS): A RANDOMISED TRIAL

Helen McLachlan, Della Forster, Mary‐Ann Davey, Michelle Newton; in collaboration with Lisa Gold, Deakin University; Mary Anne Biro, Monash University; Tanya Farrell and Jeremy Oats, Royal Women’s Hospital; Ulla Waldenström, Karolinska Institute; Leah Albers, University of New Mexico

Continuity of carer in the provision of maternity care has been strongly recommended and encouraged in Victoria and throughout Australia. Many hospitals have responded by introducing caseload midwifery, a one to one midwifery model of care in which women are cared for by a primary midwife throughout pregnancy, birth and the early postnatal period. However, this model of care had not been subjected to rigorous evaluation. The COSMOS trial compared caseload midwifery care with the standard options of care for women at low risk of medical complications at the Royal Women’s Hospital in Melbourne.

The trial, which recruited over 2,300 women, found that women who were randomly allocated to receive caseload midwifery care (compared with women allocated to standard care), were less likely to have a caesarean birth, more likely to have a normal birth, and less likely to have epidural pain relief during labour. The study also found that babies of women who had caseload midwifery care were less likely to be admitted to the special care nursery or neonatal intensive care. Women allocated to caseload midwifery were also more satisfied with their care during pregnancy, birth, and after the birth in hospital and at home and had more positive experiences of labour and birth. Moreover, the reduction in caesarean births and associated reduction in length of stay may yield some cost savings. A full cost analysis and cost‐effectiveness analysis will be completed based on these birth outcomes and data on service use and costs over the first six months after birth.

The study is the first randomised controlled trial of caseload midwifery in Australia and only the third internationally. It is also the largest study of its kind in the world. The results assist policy‐makers and maternity services in planning for future models of maternity care in Australia and internationally.

FUNDING: NHMRC project grant 2007–2010

STATUS: Three papers published – one in 2013; three in preparation

PUBLICATION: Davey M‐A, McLachlan H, Forster D, Flood M. Influence of timing of admission in labour and management of labour on method of birth: results from a randomised controlled trial of caseload midwifery (COSMOS trial). Midwifery 2013; 29(12):1297–302.

COSMOS website

ENHANCED CARE AND SUPPORT IN EARLY LABOUR (ECSEL PILOT STUDY)

Mary‐Ann Davey, Rhonda Small, Maggie Flood

This project undertook feasibility work for a proposed randomised controlled trial of modified care in early labour. Women attending the proposed study hospitals for maternity care completed questionnaires regarding their willingness to take part in a study like the one described to them. Key clinical staff were interviewed to identify facilitators and barriers to the introduction of the trial.

FUNDING: Healthy Motherhood Program Grant 2012

STATUS: data collection complete; analysis underway

EVALUATION OF VICTORIAN HOMEBIRTHING PILOTS

Helen McLachlan, Della Forster, Heather McKay, Rhonda Small, Mary‐Ann Davey, Ya‐Seng (Arthur) Hsueh, and Michelle Newton; in collaboration with Fiona Cullinane, Royal Women’s Hospital, Colleen White, Southern Health, and Susan Gannon, Western Health

In most developed countries, including Australia, women usually give birth in hospital. Until recently, women in Australia who wanted to choose homebirth could only access this option privately, with most having care provided by midwives in private practice. In recent years, however, a small number of publicly‐funded homebirth models were set up across the country. In Victoria, following consultation with key stakeholder groups, the Department of Health identified an opportunity to provide women with greater choice in place of birth through the introduction of a publicly funded homebirth model of maternity care. This led to the establishment of a homebirthing pilot program offering midwife‐led homebirths through two Melbourne metropolitan hospitals – Sunshine Hospital and Casey Hospital.

This project aimed to evaluate the two homebirthing pilot programs. At each pilot/program site (hospital) we conducted a survey of new mothers who participated in the homebirth program, surveys of midwives and obstetric medical staff, consultation with key stakeholders, an audit of relevant medical record data, an economic evaluation, and a review of relevant policies and procedures.

The evaluation was conducted on behalf of the Hospital and Health Service Performance Division, Department of Health (Victoria). It commenced in March 2011 and was completed in June 2012. The results of the evaluation formed a report



submitted to the Department of Health, used by government in decision‐making about the future operation and possible expansion of the homebirthing option in Victoria.

In November 2013, the report findings were used to inform a motion passed in the Victorian Parliament to expand public hospital homebirth services, including committing to fund start‐up costs of homebirth programs to hospitals providing maternity services in the next state budget; developing state‐wide guidelines and information for health services implementing homebirth services; developing systems to prospectively collect costing data; and supporting further research into the safety of homebirth programs and research to compare clinical outcome data associated with low risk births in different birth settings.

FUNDING: Victorian Department of Health

STATUS: Report completed; papers in preparation

ECO – EXPLORING THE INTRODUCTION, EXPANSION AND SUSTAINABILITY OF CASELOAD MIDWIFERY IN AUSTRALIA

Kate Dawson, Michelle Newton, Della Forster, Helen McLachlan

Caseload midwifery is a maternity model of care which aims to provide women with continuity of carer from a known midwife. There is strong evidence that caseload care decreases interventions (e.g. caesarean births, analgesia in labour) as well as increasing women’s satisfaction with care. Infant outcomes are also improved – our recent randomised controlled trial of caseload care compared with standard care found infants whose mothers were allocated to caseload were less likely to be admitted to the special care nursery and be of low birthweight, and more likely to commence breastfeeding (McLachlan 2012). In the caseload model women have a primary midwife, and each midwife carries a ‘caseload’ of women, to whom she provides care throughout the antenatal, intrapartum and postnatal periods. When a woman is in labour she is looked after by the primary midwife, unless she is on leave, on a scheduled day off, or she has already worked the maximum hours in a 24‐hour period. The midwife usually works with two or three other midwives in a small group, with each providing back‐up care for the others, to maintain care by known care givers. A study we undertook in Victoria found that midwives working in caseload were more satisfied and less burnt out than their standard care counterparts, (Newton, Australian Midwifery Models of Care conference, Adelaide 2012); however, there was some evidence that not all midwives want to work in this way, suggesting that the sustainability of the model needs exploration.

The ECO study commenced in 2012 and aims to explore the sustainability of caseload midwifery in Australia. This model of

care is being promoted by many levels of government throughout Australia and an increasing number of hospitals are introducing the model. However, very little is known about the workforce implications of the model and therefore the possible scale and sustainability of this style of care.

This cross‐sectional study involved contacting all public maternity hospitals in Australia to invite management and midwives to participate. An online survey was sent to maternity managers of participating hospitals. Online or hard copy surveys were supplied to midwives around Australia. We also conducted a survey of Victorian graduating midwifery students to elicit their intent to work in a caseload model.

FUNDING: None

STATUS: Data collection complete; papers in preparation

IMPLEMENTING AND EVALUATING CHANGES TO POSTNATAL CARE AT THE ROYAL WOMEN’S HOSPITAL: A BEFORE AND AFTER STUDY

Della Forster, Michelle Newton, Helen McLachlan; in collaboration with Fiona McLardie‐Hore and Tanya Farrell, Royal Women’s Hospital; Heather Grimes, School of Nursing and Midwifery, La Trobe University

Women have consistently rated the care they receive in hospital after the birth of their baby less favourably than other episodes of maternity care. Likewise, midwives (who are the main providers of very early postnatal care in Victoria) have expressed concerns about postnatal care provision; while they have a commitment to providing high quality care they often feel constrained by the barriers to care provision, such as the busy environment, the increasing acuity of the women and infants they care for, and challenges related to documenting care. A 2007 review of the documentation used in postnatal care across Victoria found extensive duplication of postnatal documentation, and sometimes contradictory advice and incorrect information. No clinical pathways met recommended quality criteria and, almost universally, different professional care providers documented in different places in the women’s medical record, increasing duplication and the risk of errors. We therefore aimed to achieve a simple but effective documentation and care strategy at the Royal Women’s Hospital that was evidence based, worked well for new mothers and for midwives, and reduced clinical risk.

Various hospital charts (e.g. the maternal and newborn observation documents) used in the postnatal environment were revised, rationalised, piloted and implemented. A baseline survey of midwives’ views was completed, with the main concerns raised about clinical pathways (care maps) being that they did not allow care to be individualised, and that the pathways were repetitious.



The next step was to replace the postnatal care maps allowing more streamlined documentation of care; reducing excessive repetition and duplication in documentation, and allowing more flexibility of care, with the aim of increasing individuallised care tailored to each woman’s needs. A guide to documentation and care of the mother and baby was compiled to ensure all staff were aware of normal ranges of observations, care provision and documentation require‐ments, from birth to discharge from the home visiting service.

An education tool was developed to ascertain each woman’s individual education needs in the postnatal period, and an information checklist of postnatal topics introduced to women between 26‐30 weeks, for them to consider, prior to the birth, what their needs may be in relation to the postnatal period.

We undertook two cross‐sectional surveys of women who were four months postpartum (752 at each time point) – one prior to the changes and one after the changes. Our aim was to explore the views, experiences and health outcomes of these two groups, with primary outcomes of interest being breastfeeding and satisfaction with care.

FUNDING: Faculty of Health Sciences Research Grant

STATUS: Data collection complete, analysis underway, minor thesis passed (HG), final report complete, one paper in preparation

PUBLICATION: Grimes HA, Forster DA, Newton MS. Sources of information used by women during pregnancy to meet their information needs. Midwifery 2013 (in press). Epub 2013 Oct 17

IMPROVING THE REPORTING AND COLLECTION OF RURAL OBSTETRICS DATA

Mary‐Ann Davey, Angela Taft, Rosemary Warren

The Judith Lumley Centre was successful in winning the tender to complete this project for the Department of Health.

It covers a number of areas:

Exploration of the extent and quality of data collected around maternity care in rural areas

Identification of gaps in data or its use Analysis of characteristics of women accessing maternity

care in rural areas and their outcomes Suggestions regarding modifications to data items

collected and Performance Indicators relating to maternity care

Recommendations related to rural obstetrics data.

FUNDING: Department of Health

STATUS: Data collection and analysis complete; two reports submitted; final report in preparation

A REVIEW OF HOME‐BASED POSTNATAL CARE IN VICTORIA

Helen McLachlan, Della Forster, Heather McKay; in collaboration with Rachael Ford, The Royal Women’s Hospital; Harriet Morton, Jen Hocking, School of Nursing and Midwifery, La Trobe University; Tanya Farrell, Royal Women’s Hospital

The care women receive after having a baby is likely to have a significant impact on their health and well‐being. With the rising number of births, many health services in Victoria (including tertiary referral hospitals), have had to respond by discharging women much earlier than planned or expected. Women receive one or two home visits by a hospital midwife, yet there has been very little evaluation of the provision of home‐based postnatal care in Victoria, and there is very little evidence to guide care.

The aim of the project was to explore home‐based postnatal care in terms of what is currently provided, what women expect and how prepared midwives are to provide home‐based postnatal care. This project included three components: focus groups (with midwives); semi‐structured interviews with postpartum women; and a survey of public hospital managers of maternity services.

The project is the first to provide urgently needed information regarding the structure and content of home‐based postnatal care. It is our intention for this study to provide valuable data to inform clinical practice as well as policy. It also guides future research and, if appropriate, may inform a future randomised controlled trial to explore the association between different types of postnatal care provision and clinical outcomes.


STATUS: Masters thesis completed (JH); two papers in preparation

SILC project, drop‐in centre (project description p. 19)



VALIDATION STUDY OF DATA IN THE 2011 VICTORIAN PERINATAL DATA COLLECTION

Mary‐Ann Davey, Maggie Flood; Sue McDonald, Mercy Hospital for Women/La Trobe University; Wendy Pollock, School of Nursing and Midwifery, La Trobe University; Rosemary Warren, Sonia Palma

This program of research includes a project based on data in the Victorian Perinatal Data Collection. In order to quantify the accuracy of the data, we are also conducting a validation study of the 2011 Perinatal Data, in collaboration with the Clinical Councils Unit, Victorian Department of Health, and the Consultative Council on Obstetric and Paediatric Mortality and Morbidity.

The study of a random sample of 1% of births in Victoria commenced late in October 2013 when necessary approvals had been received; 737 mother/baby pairs of records at three tertiary hospitals and a random sample of other hospitals will be checked and validated.

The audit will include 15 hospitals and two homebirths at seven rural sites, four inner metropolitan and four outer metropolitan sites.

Progress is slower than had been anticipated based on the 2003 audit rate because many hospitals have introduced electronic methods of reporting, as well as electronic systems for the medical records themselves or combinations of paper and electronic systems. Auditing scanned paper records, which must be opened page by page, or electronic records takes longer than auditing paper records.

The audit of the remaining records resumes in January.

FUNDING: La Trobe University Faculty of Health Sciences Research Grant 2013, Australian College of Midwives Victorian Branch Higher Degree Research Scholarship

STATUS: records validation and audit ongoing

SILC project, drop‐in centre (project description p. 19)

WOMEN’S AND STAFF VIEWS: AN EVALUATION OF MATERNITY CARE AT BARWON HEALTH (WAVE)

Helen McLachlan, Della Forster, Mary‐Ann Davey, Jane Morrow; in collaboration with Michelle Newton, School of Nursing and Midwifery, La Trobe University; Therese Cotter, Kim Layton, Barwon Health

In 2008 Barwon Health implemented two major changes to its maternity service provision: a re‐organisation of postnatal care and the implementation of a caseload midwifery model of maternity care. Postnatal care provision was altered to be a more flexible, individualised model of care focused on promoting the normalisation of the postnatal period.

Changes commenced in January 2008 and included:

Encouraging women to self‐cater for breakfast Independently care for themselves and their baby where

appropriate Promote rest Provide communal space for socialisation Encourage and provide group education Cease the use of maternal and neonatal clinical pathways

to guide care for women who have had a vaginal birth Implement a focused time where midwives specifically sit

and discuss the education and support needs identified by women themselves instead of undertaking routine postnatal observations.

Caseload midwifery (called Midwifery Group Practice or MGP) was implemented in July 2008. Women receiving caseload care receive antenatal, intrapartum and postpartum care from a primary MGP midwife with one or two antenatal visits (and other care as required) by a ‘back‐up’ midwife.

MGP midwives collaborate with obstetricians and other health professionals as necessary, provide care until after the birth of the baby and attend for some postnatal and domiciliary care following discharge from hospital.

An evaluation of the changes included three cross‐sectional surveys of women (550 at each time point); two cross‐sectional surveys of midwives (all midwives in maternity services at each time point); key informant interviews with women, midwives and other key stakeholders; and two focus groups with midwives. Specific aims were to:

Explore the views, experiences and health outcomes of women who gave birth at Barwon Health following implementation of changes to postnatal care and introduction of caseload midwifery, and to compare these to the views, experiences and health outcomes of women who gave birth prior to the changes



Explore the views and experiences of clinicians and other key stakeholders involved in the provision of postnatal care and caseload midwifery.

FUNDING: Department of Human Services Victoria and Barwon Health

STATUS: Final report completed in 2011, one paper published, three papers in preparation; PhD passed (JM), PhD submitted (MN)

PUBLICATION:

Morrow J, Forster D, McLachlan H, Davey M‐A, Newton M. Redesigning postnatal care: exploring the views and experiences of midwives. Midwifery 2013; 29(2):159–66

Collaborative work

BIRTHPLACE IN AUSTRALIA: A PROSPECTIVE COHORT STUDY

Caroline Homer, University of Technology Sydney; David Elwood, Canberra Hospital; Jeremy Oats, Royal Women’s Hospital; Maralyn Foureur, University of Technology Sydney; David Sibbritt, University of Technology Sydney; Helen McLachlan and Della Forster; Hannah Dahlen, University of Technology Sydney

In Australia, each year, more than 7,500 babies are born outside conventional labour wards, either in birth centres or at home. However, evidence on the safety of these alternative settings is limited, with concerns being raised about increased risk of stillbirth, early neonatal death, neonatal encephalopathy, meconium aspiration, brachial plexus injury, and fractured humerus or clavicle. High quality evidence about the risks and benefits associated with giving birth in different settings should be available to women, policy‐makers and those responsible for service provision.

Birthplace in Australia is a prospective cohort study which aims to compare the safety of planned birth at home, in birth centres and in stand‐alone midwifery units with standard labour wards in Australia, for women at ‘low risk’ of complications at labour onset.

FUNDING: NHMRC Project Grant 2012–2015

STATUS: Data collection in progress

MATERNAL AND FETAL ROLE AND RIGHTS IN RELATION TO USE OF OBSTETRIC ULTRASOUND EXAMINATIONS

Ingrid Mogren, Ann Lalos, Kristina Edvardsson, Umeå University, Sweden; Margareta Persson, Dalarna University, Sweden; Sophie Graner, Karolinska Insitute, Sweden; in collaboration with Rhonda Small

Obstetric ultrasound examinations have come to play an increasingly significant role in obstetrics, and advances in

obstetric ultrasound have led to improvements in pregnancy outcomes. However, at the same time it has been argued that the continuing medico‐technical progress has led to an increased medicalisation of pregnancy.

The increasing use of obstetric ultrasound has also raised many ethical challenges, especially in relation to its non‐medical use, but the ethical discussions and research in this area are still limited. The overall aim of this project is to explore midwives’ and obstetricians’ views and experiences on the use of obstetric ultrasound in relation to clinical management and care, and maternal and fetal roles and rights, in low‐income and high‐income countries. The project commenced in 2012, and the participating countries are Australia, Norway, Sweden, Rwanda, Tanzania and Vietnam.

Qualitative data collection has been completed in Australia, Vietnam and Sweden. In total, seven focus group discussions (FGDs) and 15 interviews were performed in Australia (n=52), five FGDs and 17 interviews (n=48) in Vietnam, and 5 FGDs and 12 interviews in Sweden (n=38). Data has been analysed using qualitative content analysis. The first paper was submitted for publication. Further data collection (Rwanda), data analysis and reporting will be undertaken in 2014.

Dr Kristina Edvardsson, Umeå University, Sweden, was granted a three‐year international Postdoc Fellowship from the Swedish Research Council for Health, Working Life and Welfare (FORTE) in December 2013. She will be based at the Judith Lumley Centre during the first two years and act as the international project coordinator. The project is subject to further applications for research funding.

FUNDING: Grant for professorship Umeå University, Sweden (Prof Ingrid Mogren); three‐year Postdoc Fellowship funded by the Swedish Research Council for Health, Working Life and Welfare (FORTE) (KE)

STATUS: One paper based on the Australian data submitted, further data analysis ongoing

REPRODUCTIVE OUTCOMES AND MIGRATION (ROAM): AN INTERNATIONAL COLLABORATION

Rhonda Small, Mary‐Ann Davey, Touran Shafiei ROAM Steering Group: Rhonda Small; Anita Gagnon, McGill University, Canada; Mika Gissler, Institute of Health, Finland; Carolyn Roth, University of Keele, UK; Jennifer Zeitlin, INSERM, France and EURO‐PERISTAT

The collaboration aims to undertake comparative work on migrant, refugee and asylum‐seeking women’s reproductive health outcomes and their views of maternity care in Europe, North America and Australia. The collaboration began with an initial grant awarded from the Canadian Institutes of Health Research (CIHR) International Opportunity Development Grant Scheme to establish research links between Canada and



Australia for comparing reproductive health outcomes of immigrant and refugee women. The first meeting of a wider collaborative network with researchers from the UK, Italy, France, Belgium and Finland was held at the European Congress of Epidemiology in Porto, Portugal in September 2004. Since then, collaborators from a range of other countries have joined the collaborative network and annual meetings have been held.

ROAM collaborators met in Copenhagen from 15–16 August 2013, following the Annual European Epidemiology Association Conference in Aarhus, Denmark. Completed work was presented and further collaborative research was discussed. Projects with involvement from the Judith Lumley Centre include:

A cross‐country comparative study of migration and severe maternal morbidity

Migrant friendly maternity care questionnaire project Usefulness of the migration integration policy index

(MIPeX) for understanding variations in birth outcomes for migrant populations

Migrant women’s experiences of maternity care: a focused review.

FUNDING: Canadian Institutes of Health Research International Collaboration Grant 2007–2008 and Systematic Review Grant 2010

STATUS: ten papers published (one in 2013); five submitted; several in preparation

PUBLICATION:

Merry L, Small R, Blondel B, Gagnon A. International migration and caesarean birth: a systematic review and meta‐analysis. BMC Pregnancy Childbirth 2013; 13: 27

ROAM website

RUBY volunteer training (project description p. 18)

SEXUAL AND REPRODUCTIVE HEALTH

AN EVALUATION OF ACCESS AND EQUITY IN THE PROVISION OF MEDICAL ABORTION FOLLOWING THE INTRODUCTION OF MIFEPRISTONE ON THE AUSTRALIAN PHARMACEUTICAL BENEFITS SCHEME

Angela Taft; in collaboration with Jayne Lucke, Kerry Petersen and Julia Shelley, Deakin University; Danielle Mazza, Monash University; Kirsten Black, University of Sydney; Philip Goldstone, MSH; Safeera Hussainy, Monash University

Approximately one in four pregnancies is terminated in Australia. Termination of pregnancy (TOP) is best prevented, In Australia, TOP is more prevalent among socioeconomically disadvantaged women. When unwanted pregnancy does occur, Australia has only recently been able to offer women a choice of termination methods. In 2013, mifepristone—the most effective and safe pharmaceutical abortifacient—was made available on the PBS.

This study – a collaboration with Marie Stopes Australia – seeks to ask the following questions:

How does the inclusion of mifepristone on the PBS impact on access to abortion services in Australia?

Does mifepristone on the PBS increase the number and locations of abortion providers in rural and urban Australia?

Does mifepristone on the PBS allow more women to choose their preferred abortion method and location?

Does mifepristone on the PBS reduce women’s direct and indirect out‐of‐pocket costs when accessing abortion services?

Does mifepristone on the PBS alter the abortion rate?

This study will use an anonymous online survey with providers, combined with a national random computer‐assisted telephone interview with 2000 women aged between 16 and 50 to establish a baseline rate of TOP methods and geographic distribution in 2014 and then seek to repeat this in 2016 to assess any changes.

FUNDING: Building Healthy Communities RFA and MSHealth

STATUS: Ethics approval granted for baseline survey and CATI methods outlined



EXPLORING THE ANTECEDENTS AND PREDICTORS OF TERMINATION OF PREGNANCY IN THE 1973–78 COHORT OF THE AUSTRALIAN LONGITUDINAL STUDY OF WOMEN’S HEALTH

Angela Taft, Lyn Watson, Melissa Hobbs; in collaboration with Jayne Lucke, University of Queensland; Danielle Mazza, Safeera Hussainy, Kay Stewart and Kathy McNamee, Monash University

The aim of this study was to examine what factors predicted Termination of pregnancy (TOP) among diverse groups of women. We investigated how antecedents and predictors of TOP might change over time. We undertook three sets of analyses:

all new terminations between surveys from S1‐S5 all new terminations between surveys from S1‐S3 all new terminations between surveys from S3‐S5.

Participants were 5790 women who responded to all five surveys. Explanatory variables included:

contraceptive use socio‐demographic variables parity childhood sexual abuse intimate partner violence alcohol and other drug use depression BMI aspirations at age 35.

The analysis was conducted with regression analysis using STATA 11.


STATUS: Analysis complete, paper drafted

BREASTFEEDING

DELPHI STUDY OF PHARMACOLOGY EXPERTS TO DERIVE INTERNATIONAL RECOMMENDATIONS FOR MEDICINE USE IN LACTATION

Lisa Amir, Clare Barnett; Kath Ryan, School of Nursing and Midwifery

Although most medicines are compatible with breastfeeding, pharmaceutical companies often state that a medicine is not recommended during lactation, leading to confusion amongst prescribing clinicians.

Our objective was to gain international consensus on the key parameters experts use to inform decisions and to develop a user‐friendly, evidence‐based safety hierarchy for medicine use during breastfeeding.

We used a three‐round web‐based Delphi research design. Sixteen experts were identified based on their international prominence in the field, with a further 12 recruited through snowballing. Questionnaires were distributed electronically by a secure program (Qualtrics).

Round 1 explored experts’ opinions of current medicines and breastfeeding classification systems and identified key clinical, social and pharmacological parameters used to inform decisions.

Rounds 2 and 3 built consensus around these parameters using a five‐point Likert scale and prioritisation.

FUNDING: School of Nursing and Midwifery, La Trobe University; Healthy Motherhood Program Grant

STATUS: Data collection and analysis

Image courtesy of R Thombros



IMPROVING MATERNITY CARE AND BREASTFEEDING OUTCOMES FOR ABORIGINAL MOTHERS AND BABIES IN VICTORIA

Helen McLachlan, Lisa Amir, Della Forster, Michelle Newton, Kate Dawson, Touran Shafiei; in collaboration with Karen Adams, Victorian Aboriginal Community Controlled Health Organisation (VACCHO); Helena Maher, Teagan Cornelissen, Royal Women's Hospital

Partners: Victorian Aboriginal Community Controlled Health Organisation (VACCHO); The Royal Women’s Hospital

Breastfeeding provides many benefits for babies and children. Aboriginal women in urban areas are less likely to initiate breastfeeding compared with non‐Aboriginal women and the proportion of Aboriginal babies being predominantly breastfed at six months is half the rate of non‐Indigenous babies (17% vs 35%). These data point to the need for further research on why Aboriginal women stop breastfeeding (or do not start), and how they can be supported to continue.

A recent report by the Victorian Aboriginal Community Controlled Health Organisation (VACCHO) identified breastfeeding as a key concern and recommended planning, implementing and evaluating strategies to improve breastfeeding rates for Aboriginal women. The recommendation is consistent with a number of government inquiries and reviews.

In partnership with VACCHO, we are exploring a number of strategies that may help increase breastfeeding rates among Aboriginal women in Victoria; including gaining an understanding of the breastfeeding rates in different parts of Victoria using routinely collected data and exploring the feasibility of implementing models of maternity care that provide continuity of midwife care.

FUNDING: Building Healthy Communities RFA Grant; Healthy Motherhood Program Grant

STATUS: Data collection in progress, paper drafted

Image courtesy of David McLachlan, Merralyn Power

MILC (MOTHERS AND INFANTS LACTATION COHORT): A MULTI‐SITE STUDY

Della Forster, Lisa Amir, Helen McLachlan, Anita Moorhead, Helene Johns; in collaboration with Rachael Ford, Royal Women’s Hospital; Kerri McEgan, Mercy Hospital for Women; Chris Scott, Frances Perry House

A high proportion of women in Australia initiate breastfeeding but many stop in the early months. Anecdotally, more women are leaving hospital feeding their babies expressed breast milk and continue to do so at home.

Little is known about the effect of expressing breast milk on a longer term basis in relation to breastfeeding outcomes and other factors such as maternal fatigue, stress and anxiety.

In this prospective cohort study exploring the frequency of breast milk expressing and the effect of expressing on breastfeeding outcomes and other factors, 1000 mothers of healthy term infants who planned to breastfeed were recruited from three hospitals (Mercy Hospital for Women, Frances Perry House and Royal Women’s Hospital) before discharge home postnatally.

The study involved completion of an initial structured interview to collect demographic details, breastfeeding intentions and current feeding details. Other relevant information was collected from medical records with the women’s consent. Structured telephone interviews were conducted at three and six months postpartum.

The primary outcome for comparison is feeding any breast milk at six months. Secondary outcomes included exclusive breastfeeding, maternal confidence and satisfaction with infant feeding.

Almost half of the primiparous women owned a breast pump at recruitment and less than half of the whole group had been fully breastfeeding at the breast. A high proportion of women reported very early breastfeeding problems and less than half of the infants had fed only at the breast in the first days of life.

FUNDING: Faculty of Health Sciences Research Grant; PhD scholarship

STATUS: further analysis and writing‐up underway, two papers published, two in draft, four conference presentations in 2013

PUBLICATIONS:

Johns H, Forster D, Amir LH, McLachlan H. Prevalence and outcomes of breast milk expressing in women with healthy term infants: a systematic review. BMC Pregnancy Childbirth 2013; 13: 212

Johns HM, Forster DA, Amir LH, Moorhead AM, McEgan KM, McLachlan HL. Infant feeding practices in the first 24–48 h of life in healthy term infants. Acta Paediatrica 2013; 102(7):e315‐e20



RINGING UP ABOUT BREASTFEEDING – A RANDOMISED CONTROLLED TRIAL EXPLORING EARLY TELEPHONE PEER SUPPORT FOR BREASTFEEDING (RUBY)

Della Forster, Helen McLachlan, Mary‐Ann Davey, Lisa Amir, Rhonda Small, Heather Grimes; in collaboration with Lisa Gold, Deakin University; Anita Moorhead and Fiona McLardie‐Hore, Royal Women’s Hospital; Chris East, Monash Medical Centre; Patrice Hickey, Sunshine Hospital; Nanette Shone and Kate Mortensen, Australian Breastfeeding Association; Cindy‐Lee Dennis, University of Toronto, Canada;

In Australia, although most women initiate breastfeeding, only about 60% are giving their infant any breast milk by six months. Furthermore, the gap in rates of breastfeeding between socially disadvantaged and advantaged infants has increased: less advantaged infants are much less likely to continue to be breastfed. Very few interventions have shown to increase breastfeeding maintenance in countries with high initiation of breastfeeding – peer support is one intervention that has shown some promise, but randomised trials have had mixed findings. The only one relevant to the Australian context demonstrated a positive outcome – a Canadian trial by Cindy‐Lee Dennis – and it was this trial that formed the basis of our intervention. We received funding to conduct a trial of telephone support for breastfeeding provided by volunteer mothers who have themselves breastfed.

The trial is led jointly by a team from the Judith Lumley Centre and the Royal Women’s Hospital, in collaboration with the Australian Breastfeeding Association, Monash Medical Centre and Sunshine Hospital. We use a two‐arm randomised controlled trial to determine whether peer support, provided by telephone during the postnatal period using a proactive approach, increases the proportion of infants who are breastfed for at least six months. We are recruiting first‐time mothers from postnatal wards of three Victorian hospitals whose catchments include areas with some of the lowest breastfeeding rates in the state.

Women randomised to the non‐intervention arm receive usual hospital postnatal care and infant feeding support.

Women randomised to the intervention arm receive usual hospital postnatal care and infant feeding support as well as proactive peer support provided by telephone from a trained volunteer mother (who has breastfed for six months or more).

Training for the volunteer mothers is being conducted in conjunction with the Australian Breastfeeding Association. The peer support mothers are encouraged to provide most of the contact in the important early weeks, when many women cease breastfeeding, with continued contact tapering off up to

six months postpartum. Outcome data will be collected at six months by telephone interview.

FUNDING: Felton Bequest; PhD Scholarship

STATUS: Training of volunteer mothers ongoing (115 trained to date); recruitment of participants began February 2013 (266 women to date); trial protocol paper submitted

RUBY website

THE ROLE OF MICRO‐ORGANISMS (S. AUREUS & C. ALBICANS) IN THE PATHOGENESIS OF BREAST PAIN AND INFECTION IN LACTATING WOMEN (CASTLE STUDY)

Lisa Amir and Méabh Cullinane; in collaboration with Suzanne Garland and Sepehr Tabrizi, University of Melbourne; Susan Donath, Murdoch Childrens Research Institute; Catherine Bennett, Deakin University

This project is a descriptive study of 360 breastfeeding women, recruited from the Royal Women’s Hospital and Frances Perry House. The aim of the study was to investigate the role of microorganisms in nipple and breast pain in breastfeeding women. At present, there is controversy about whether burning nipple pain associated with radiating breast pain is caused by fungal infection (Candida albicans, known as “thrush”) or bacterial infection (Staphylococcus aureus, known as “golden staph”).

For this study, at the time of recruitment, swabs were collected from mothers’ noses, nipples and vagina and a questionnaire asking about previous staphylococcal and candida infections was completed. Following birth, the participating mothers were followed up six times: while still in hospital and then weekly at home until four weeks postpartum.

At each of these follow‐up meetings participants filled out a questionnaire and swabs were taken from the mother’s nose and nipple as well as the baby’s nose and mouth. Breast milk samples were also taken.

At eight weeks postpartum a final telephone interview was held, collecting further information about breastfeeding problems such as nipple and breast pain.

The main outcomes paper was published in 2013 in BMJ Open. There was strong evidence of an association between the presence of Candida and nipple and breast pain, while Staphylococcus aureus was present in both women with and without pain.

FUNDING: NHMRC Health Professional Research Fellowship 2006–2010 (LA); NHMRC Project Grant 2009–2010; NHMRC Equipment Grant 2009–2010; Helen Macpherson Smith 2011–2012



STATUS: Recruiting completed; protocol published; main outcomes paper published; further analysis and dissemination underway

PUBLICATION:

Amir LH, Donath SM, Garland SM, Tabrizi SN, Bennett CM, Cullinane M, Payne MS. Does Candida and/or Staphylococcus play a role in nipple and breast pain in lactation? A cohort study in Melbourne, Australia. BMJ Open 2013; 3(3): e002351

CASTLE website

SILC project, drop‐in centre

SUPPORTING BREASTFEEDING IN LOCAL COMMUNITIES (SILC)

Helen McLachlan, Della Forster, Lisa Amir, Rhonda Small, Méabh Cullinane, Touran Shafiei, Rhian Cramer, Heather McKay; in collaboration with Lael Ridgway, School of Nursing and Midwifery, La Trobe University

Breastfeeding provides infants with the optimal start to life, yet despite recommendations from the World Health Organization and high rates of breastfeeding initiation, exclusive breastfeeding for six months is uncommon in Australia. Increased breastfeeding support early in the postpartum period may improve breastfeeding maintenance. The Department of Education and Early Childhood Development (DEECD) provided funding to trial interventions aimed at increasing breastfeeding duration in Local Government Areas (LGAs) in Victoria.

This trial is a three‐arm cluster randomised controlled trial evaluating whether two specific community‐based interventions increase breastfeeding maintenance in Victorian LGAs. Ten LGAs with a lower‐than‐average rate of any breastfeeding at hospital discharge and more than 450 births

per year agreed to participate and were randomly allocated to one of three trial arms:

Standard care Early postnatal home‐based breastfeeding support visits

to women at risk of breastfeeding cessation Home‐based breastfeeding support visits plus access to

community‐based breastfeeding drop‐in centres.

Home visits were conducted by experienced Maternal and Child Health Nurses (SILC‐MCHNs). Breastfeeding drop‐in centres were staffed by SILC‐MCHNs. The interventions ran for nine months from July 2012 to March 2013. The primary outcome is the proportion of infants receiving any breast milk at four months of age. Secondary outcomes are the proportion of infants receiving any breast milk at three months and six months; the exploration of early breastfeeding problems and women’s satisfaction with breastfeeding support; the investigation of SILC‐MCHN and MCH co‐ordinator satisfaction with SILC; and the comparison of pre‐intervention and post‐intervention breastfeeding rates in each LGA. Breastfeeding outcomes were obtained from routinely collected Maternal and Child Health (MCH) centre data, including a new question collecting infant feeding ‘in the last 24 hours’. Information was also obtained directly from women via a postal survey when their infants were six months of age.

FUNDING: Department of Education and Early Childhood Development, 2011–2014

STATUS: Data analysis in progress, final results expected in June 2014

SILC website

SILC workshop March 2013



REDUCING VIOLENCE AGAINST WOMEN AND CHILDREN

HARMONY: A CLUSTER RANDOMISED TRIAL TO PREVENT AND REDUCE FAMILY VIOLENCE IN VIETNAMESE AND INDIAN MIGRANT COMMUNITIES

Angela Taft, Rhonda Small; in collaboration with Kelsey Hegarty and Ruth McNair, University of Melbourne; Mridula Bandyopadhay, Victoria University; Gene Feder, Bristol University, UK; Lisa Gold, Deakin University; Trang Vu, Monash University; Douglas Boyle, University of Melbourne; Janette Collier, AIPCA, La Trobe University

Domestic or family violence (FV) is prevalent globally, including the home countries of immigrant and refugee communities seeking a new life in Australia. FV causes significant mental and physical harm not only to victims, but to children and their wider family and community and to the economy. FV is the leading contributor to death, disability and illness for Victorian women of childbearing age.

Immigrant and refugee families face significant hurdles to good mental health and safety: from racism, lack of knowledge about Australian systems and services and the broader challenges of acculturation. Preventing and reducing FV in these communities requires culturally safe strategies involving community institutions and opinion leaders. Increasingly, Australia’s health care system includes bilingual GPs who may be immigrant doctors or those born and educated here. Doctors are highly regarded authority figures in migrant and refugee communities and could play a vital role in prevention and early intervention in their own communities if they were well‐trained and supported. This study adapts a recent successful UK trial published in the Lancet (Feder et al, 2011),

Documents

ANNUAL REPORT - La Trobe University€¦ · This program of research addresses four key areas affecting the achievement of healthy motherhood: 1. Prevention and reduction of unwanted