Ultrahigh-pressure disordered eight-coordinated phase of Mg2GeO4: Analogue for super-Earth mantles.

Mg2GeO4 is important as an analog for the ultrahigh-pressure behavior of Mg2SiO4, a major component of planetary interiors. In this study, we have investigated magnesium germanate to 275 GPa and over 2,000 K using a laser-heated diamond anvil cell combined with in situ synchrotron X-ray diffraction and density functional theory (DFT) computations. The experimental results are consistent with the formation of a phase with disordered Mg and Ge, in which germanium adopts eightfold coordination with oxygen: the cubic, Th3P4-type structure. DFT computations suggest partial Mg-Ge order, resulting in a tetragonal [Formula: see text] structure indistinguishable from [Formula: see text] Th3P4 in our experiments. If applicable to silicates, the formation of this highly coordinated and intrinsically disordered phase may have important implications for the interior mineralogy of large, rocky extrasolar planets.

Developing and evaluating Birthing on Country services for First Nations Australians: the Building On Our Strengths (BOOSt) prospective mixed methods birth cohort study protocol.

BACKGROUND: With the impact of over two centuries of colonisation in Australia, First Nations families experience a disproportionate burden of adverse pregnancy and birthing outcomes. First Nations mothers are 3-5 times more likely than other mothers to experience maternal mortality; babies are 2-3 times more likely to be born preterm, low birth weight or not to survive their first year. 'Birthing on Country' incorporates a multiplicity of interpretations but conveys a resumption of maternity services in First Nations Communities with Community governance for the best start to life. Redesigned services offer women and families integrated, holistic care, including carer continuity from primary through tertiary services; services coordination and quality care including safe and supportive spaces. The overall aim of Building On Our Strengths (BOOSt) is to facilitate and assess Birthing on Country expansion into two settings - urban and rural; with scale-up to include First Nations-operated birth centres. This study will build on our team's earlier work - a Birthing on Country service established and evaluated in an urban setting, that reported significant perinatal (and organisational) benefits, including a 37% reduction in preterm births, among other improvements. METHODS: Using community-based, participatory action research, we will collaborate to develop, implement and evaluate new Birthing on Country care models. We will conduct a mixed-methods, prospective birth cohort study in two settings, comparing outcomes for women having First Nations babies with historical controls. Our analysis of feasibility, acceptability, clinical and cultural safety, effectiveness and cost, will use data including (i) women's experiences collected through longitudinal surveys (three timepoints) and yarning interviews; (ii) clinical records; (iii) staff and stakeholder views and experiences; (iv) field notes and meeting minutes; and (v) costs data. The study includes a process, impact and outcome evaluation of this complex health services innovation. DISCUSSION: Birthing on Country applies First Nations governance and cultural safety strategies to support optimum maternal, infant, and family health and wellbeing. Women's experiences, perinatal outcomes, costs and other operational implications will be reported for Communities, service providers, policy advisors, and for future scale-up. TRIAL REGISTRATION: Australia & New Zealand Clinical Trial Registry # ACTRN12620000874910 (2 September 2020).

An exploration of potential output measures to assess efficiency and productivity for labour and birth in Australia.

BACKGROUND: In maternity services, as in other areas of healthcare, increasing emphasis is placed on improving "efficiency" or "productivity". The first step in any efficiency and productivity analysis is the selection of relevant input and output measures. Within healthcare quantifying what is produced (outputs) can be difficult. The aim of this paper is to identify a potential output measure, that can be used in an assessment of the efficiency and productivity of labour and birth in-hospital care in Australia and to assess the extent to which it reflects the principles of woman-centred care. METHODS: This paper will survey available perinatal and maternal datasets in Australia to identify potential output measures; map identified output variables against the principles of woman-centred care outlined in Australia's national maternity strategy; and based on this, create a preliminary composite outcome measure for use in assessing the efficiency and productivity of Australian maternity services. RESULTS: There are significant gaps in Australia's maternity data collections with regard to measuring how well a maternity service is performing against the values of respect, choice and access; however safety is well measured. Our proposed composite measure identified that of the 63,215 births in Queensland in 2014, 67% met the criteria of quality outlined in our composite measure. CONCLUSIONS: Adoption in Australia of the collection of woman-reported maternity outcomes would substantially strengthen Australia's national maternity data collections and provide a more holistic view of pregnancy and childbirth in Australia beyond traditional measure of maternal and neonate morbidity and mortality. Such measures to capture respect, choice and access could complement existing safety measures to inform the assessment of productivity and efficiency in maternity care.

Modelling the cost of place of birth: a pathway analysis.

BACKGROUND: In New South Wales (NSW), Australia there are three settings available for women at low risk of complications to give birth: home, birth centre and hospital. Between 2000 and 2012, 93.6% of babies were planned to be born in hospital, 6.0% in a birth centre and 0.4% at home. Availability of alternative birth settings is limited and the cost of providing birth at home or in a birth centre from the perspective of the health system is unknown. OBJECTIVES: The objective of this study was to model the cost of the trajectories of women who planned to give birth at home, in a birth centre or in a hospital from the public sector perspective. METHODS: This was a population-based study using linked datasets from NSW, Australia. Women included met the following selection criteria: 37-41 completed weeks of pregnancy, spontaneous onset of labour, and singleton pregnancy at low risk of complications. We used a decision tree framework to depict the trajectories of these women and Australian Refined-Diagnosis Related Groups (AR-DRGs) were applied to each trajectory to estimate the cost of birth. A scenario analysis was undertaken to model the cost for 30 000 women in one year. FINDINGS: 496 387 women were included in the dataset. Twelve potential outcome pathways were identified and each pathway was costed using AR-DRGs. An overall cost was also calculated by place of birth: $AUD4802 for homebirth, $AUD4979 for a birth centre birth and $AUD5463 for a hospital birth. CONCLUSION: The findings from this study provides some clarity into the financial saving of offering more options to women seeking an alternative to giving birth in hospital. Given the relatively lower rates of complex intervention and neonatal outcomes associated with women at low risk of complications, we can assume the cost of providing them with homebirth and birth centre options could be cost-effective.

The impact of caseload midwifery, compared with standard care, on women's perceptions of antenatal care quality: Survey results from the M@NGO randomized controlled trial for women of any risk.

BACKGROUND: The measurement and interpretation of patient experience is a distinct dimension of health care quality. The Midwives @ New Group practice Options (M@NGO) randomized control trial of caseload midwifery compared with standard care among women regardless of risk reported both clinical and cost benefits. This study reports participants' perceptions of the quality of antenatal care within caseload midwifery, compared with standard care for women of any risk within that trial. METHODS: A trial conducted at two Australian tertiary hospitals randomly assigned participants (1:1) to caseload midwifery or standard care regardless of risk. Women were sent an 89-question survey at 6 weeks postpartum that included 12 questions relating to pregnancy care. Ten survey questions (including 7-point Likert scales) were analyzed by intention to treat and illustrated by participant quotes from two free-text open-response items. RESULTS: From the 1748 women recruited to the trial, 58% (n = 1017) completed the 6-week survey. Of those allocated to caseload midwifery, 66% (n = 573) responded, compared with 51% (n = 444) of those allocated to standard care. The survey found women allocated to caseload midwifery perceived a higher level of quality care across every antenatal measure. Notably, those women with identified risk factors reported higher levels of emotional support (aOR 2.52 [95% CI 1.87-3.39]), quality care (2.94 [2.28-3.79]), and feeling actively involved in decision-making (3.21 [2.35-4.37]). CONCLUSIONS: Results from the study show that in addition to the benefits to clinical care and cost demonstrated in the M@NGO trial, caseload midwifery outperforms standard care in perceived quality of pregnancy care regardless of risk.

How well do women understand and remember information in labour versus in late pregnancy? A pilot randomised study.

Medical informed consent is the process by which a 'competent', non-coerced individual receives sufficient information including risks of a medical procedure and gives permission for it to occur. The capacity to give an informed consent might be impaired during labour. This study aimed to examine women's abilities to understand and remember during labour. Women were prospectively recruited at 36 weeks of gestation and randomised to undertake questionnaires which assessed their ability to understand and remember information. They were randomised to: (1) information given in labour only, written format (2) information in labour, verbal (3) information at 36 weeks plus labour, written (4) information at 36 weeks plus labour, verbal. Immediate comprehension and retention was assessed at 36 weeks, in labour, and 24-72 hours after birth. Forty-nine women completed the questionnaires regarding understanding and retention of information at 36 weeks, six intrapartum, and five postpartum (90% attrition). Women receiving information at 36 weeks and in labour versus in labour had a higher comprehension of pregnancy-related information, its retention, and total score. Women receiving information in late pregnancy and labour may comprehend and retain it better than women only receiving information during labour. Given small sample size, further research is needed to support these preliminary findings. Impact statement What is already known on this subject? The evidence regarding the capacity of labouring women to give informed consent is largely based on women's self-reported experiences or expert opinions and has mixed findings. Existing guidelines recommend that an informed consent should be given antenatally for both clinical practice and research. Studies show that obtaining an informed consent antenatally is neither feasible nor widely implemented. What do the results of this study add? A novel approach to providing empirical evidence regarding women's capacity to comprehend and retain information during labour. Our study confirms the difficulty with antenatal recruitment for intrapartum research. What are the implications of these findings for clinical practice and/further research? This raises ethical concerns regarding the current intrapartum research in which consent is largely sought at the time of the study. Emphasises the need to explore the question 'Do labouring women have the capacity to consent to research?' in order to ensure that women are protected during labour.

In situ X-Ray Diffraction of Shock-Compressed Fused Silica.

Because of its widespread applications in materials science and geophysics, SiO_{2} has been extensively examined under shock compression. Both quartz and fused silica transform through a so-called "mixed-phase region" to a dense, low compressibility high-pressure phase. For decades, the nature of this phase has been a subject of debate. Proposed structures include crystalline stishovite, another high-pressure crystalline phase, or a dense amorphous phase. Here we use plate-impact experiments and pulsed synchrotron x-ray diffraction to examine the structure of fused silica shock compressed to 63 GPa. In contrast to recent laser-driven compression experiments, we find that fused silica adopts a dense amorphous structure at 34 GPa and below. When compressed above 34 GPa, fused silica transforms to untextured polycrystalline stishovite. Our results can explain previously ambiguous features of the shock-compression behavior of fused silica and are consistent with recent molecular dynamics simulations. Stishovite grain sizes are estimated to be ∼5-30 nm for compression over a few hundred nanosecond time scale.

The Indigenous Birthing in an Urban Setting study: the IBUS study : A prospective birth cohort study comparing different models of care for women having Aboriginal and Torres Strait Islander babies at two major maternity hospitals in urban South East Queensland, Australia.

BACKGROUND: With persisting maternal and infant health disparities, new models of maternity care are needed to meet the needs of Aboriginal and Torres Strait Islander people in Australia. To date, there is limited evidence of successful and sustainable programs. Birthing on Country is a term used to describe an emerging evidence-based and community-led model of maternity care for Indigenous families; its impact requires evaluation. METHODS: Mixed-methods prospective birth cohort study comparing different models of care for women having Aboriginal and Torres Strait Islander babies at two major maternity hospitals in urban South East Queensland (2015-2019). Includes women's surveys (approximately 20 weeks gestation, 36 weeks gestation, two and six months postnatal) and infant assessments (six months postnatal), clinical outcomes and cost comparison, and qualitative interviews with women and staff. DISCUSSION: This study aims to evaluate the feasibility, acceptability, sustainability, clinical and cost-effectiveness of a Birthing on Country model of care for Aboriginal and Torres Strait Islander families in an urban setting. If successful, findings will inform implementation of the model with similar communities. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry # ACTRN12618001365257 . Registered 14 August 2018 (retrospectively registered).

Continuity of midwifery carer moderates the effects of prenatal maternal stress on postnatal maternal wellbeing: the Queensland flood study.

Poor postnatal mental health is a major public health issue, and risk factors include experiencing adverse life events during pregnancy. We assessed whether midwifery group practice, compared to standard hospital care, would protect women from the negative impact of a sudden-onset flood on postnatal depression and anxiety. Women either received midwifery group practice care in pregnancy, in which they were allocated a primary midwife who provided continuity of care, or they received standard hospital care provided by various on-call and rostered medical staff. Women were pregnant when a sudden-onset flood severely affected Queensland, Australia, in January 2011. Women completed questionnaires on their flood-related hardship (objective stress), emotional reactions (subjective stress), and cognitive appraisal of the impact of the flood. Self-report assessments of the women's depression and anxiety were obtained during pregnancy, at 6 weeks and 6 months postnatally. Controlling for all main effects, regression analyses at 6 weeks postpartum showed a significant interaction between maternity care type and objective flood-related hardship and subjective stress, such that depression scores increased with increasing objective and subjective stress with standard care, but not with midwifery group practice (continuity), indicating a buffering effect of continuity of midwifery carer. Similar results were found for anxiety scores at 6 weeks, but only with subjective stress. The benefits of midwifery continuity of carer in pregnancy extend beyond a more positive birth experience and better birthing and infant outcomes, to mitigating the effects of high levels of stress experienced by women in the context of a natural disaster on postnatal mental health.

Birthing on Country (in Our Community): a case study of engaging stakeholders and developing a best-practice Indigenous maternity service in an urban setting.

Developing high-quality and culturally responsive maternal and infant health services is a critical part of 'closing the gap' in health disparities between Aboriginal and Torres Strait Islander people and other Australians. The National Maternity Services Plan led work that describes and recommends Birthing on Country best-practice maternity care adaptable from urban to very remote settings, yet few examples exist in Australia. This paper demonstrates Birthing on Country principles can be applied in the urban setting, presenting our experience establishing and developing a Birthing on Country partnership service model in Brisbane, Australia. An initial World Café workshop effectively engaged stakeholders, consumers and community members in service planning, resulting in a multiagency partnership program between a large inner city hospital and two local Aboriginal Community-Controlled Health Services (ACCHS). The Birthing in Our Community program includes: 24/7 midwifery care in pregnancy to six weeks postnatal by a named midwife, supported by Indigenous health workers and a team coordinator; partnership with the ACCHS; oversight from a steering committee, including Indigenous governance; clinical and cultural supervision; monthly cultural education days; and support for Indigenous student midwives through cadetships and placement within the partnership. Three years in, the partnership program is proving successful with clients, as well as showing early signs of improved maternal and infant health outcomes.

The presence of vaginal Lactobacillus species does not contribute to a measureable difference in amniotic fluid lactate levels collected from the vaginal tract of laboring women.

INTRODUCTION: Amniotic fluid lactate research is based on the hypothesis that a relationship exists between fatigued uterine muscles and raised concentrations of the metabolite lactate, which is excreted into the amniotic fluid during labor. To assess potentially confounding effects of lactate-producing organisms on amniotic fluid lactate measurements, we aimed to determine if the presence of vaginal Lactobacillus species was associated with elevated levels of amniotic fluid lactate, measured from the vaginal tract of women in labor. MATERIAL AND METHODS: Results from this study contribute to a large prospective longitudinal study of amniotic fluid lactate at a teaching hospital in Sydney, Australia. Amniotic fluid lactate measurement was assessed at the time of routine vaginal examination, after membranes had ruptured, using a hand-held lactate meter StatStripXPress (Nova Biomedical). Vaginal swab samples were collected at the time of the first amniotic fluid lactate measurement and stored for later detection and quantification of Lactobacillus species using a TaqMan real-time PCR assay. Swab sample and amniotic fluid lactate results were paired and analyzed. RESULTS: The PCR assay detected Lactobacillus species in 48 of 388 (12%) vaginal swab specimens (8% positive, 4% low positive) collected from women in labor after membranes had ruptured. There was no significant difference in median and mean (respectively) amniotic fluid lactate levels with (8.35 mmol/L; 8.95 mmol/L) or without (8.5 mmol/L; 9.08 mmol/L) Lactobacillus species detected. CONCLUSION: There was no association between the presence or level of vaginal Lactobacillus species and the measurement of amniotic fluid lactate collected from the vaginal tract of women during labor.

Improving maternity services for Indigenous women in Australia: moving from policy to practice.

The well established disparities in health outcomes between Indigenous and non-Indigenous Australians include a significant and concerning higher incidence of preterm birth, low birth weight and newborn mortality. Chronic diseases (eg, diabetes, hypertension, cardiovascular and renal disease) that are prevalent in Indigenous Australian adults have their genesis in utero and in early life. Applying interventions during pregnancy and early life that aim to improve maternal and infant health is likely to have long lasting consequences, as recognised by Australia's National Maternity Services Plan (NMSP), which set out a 5-year vision for 2010-2015 that was endorsed by all governments (federal and state and territory). We report on the actions targeting Indigenous women, and the progress that has been achieved in three priority areas: The Indigenous maternity workforce; Culturally competent maternity care; and; Developing dedicated programs for "Birthing on Country". The timeframe for the NMSP has expired without notable results in these priority areas. More urgent leadership is required from the Australian government. Funding needs to be allocated to the priority areas, including for scholarships and support to train and retain Indigenous midwives, greater commitment to culturally competent maternity care and the development and evaluation of Birthing on Country sites in urban, rural and particularly in remote and very remote communities. Tools such as the Australian Rural Birth Index and the National Maternity Services Capability Framework can help guide this work.

Women's experiences of transfer from primary maternity unit to tertiary hospital in New Zealand: part of the prospective cohort Evaluating Maternity Units study.

BACKGROUND: There is worldwide debate regarding the appropriateness and safety of different birthplaces for well women. The Evaluating Maternity Units (EMU) study's primary objective was to compare clinical outcomes for well women intending to give birth in either a tertiary level maternity hospital or a freestanding primary level maternity unit. Little is known about how women experience having to change their birthplace plans during the antenatal period or before admission to a primary unit, or transfer following admission. This paper describes and explores women's experience of these changes-a secondary aim of the EMU study. METHODS: This paper utilised the six week postpartum survey data, from the 174 women from the primary unit cohort affected by birthplace plan change or transfer (response rate 73%). Data were analysed using descriptive statistics and thematic analysis. The study was undertaken in Christchurch, New Zealand, which has an obstetric-led tertiary maternity hospital and four freestanding midwife-led primary maternity units (2010-2012). The 702 study participants were well, pregnant women booked to give birth in one of these facilities, all of whom received continuity of midwifery care, regardless of their intended or actual birthplace. RESULTS: Of the women who had to change their planned place of birth or transfer the greatest proportion of women rated themselves on a Likert scale as unbothered by the move (38.6%); 8.8% were 'very unhappy' and 7.6% 'very happy' (quantitative analysis). Four themes were identified, using thematic analysis, from the open ended survey responses of those who experienced transfer: 'not to plan', control, communication and 'my midwife'. An interplay between the themes created a cumulatively positive or negative effect on their experience. Women's experience of transfer in labour was generally positive, and none expressed stress or trauma with transfer. CONCLUSIONS: The women knew of the potential for change or transfer, although it was not wanted or planned. When they maintained a sense control, experienced effective communication with caregivers, and support and information from their midwife, the transfer did not appear to be experienced negatively. The model of continuity of midwifery care in New Zealand appeared to mitigate the negative aspects of women's experience of transfer and facilitate positive birth experiences.

QF2011: a protocol to study the effects of the Queensland flood on pregnant women, their pregnancies, and their children's early development.

BACKGROUND: Retrospective studies suggest that maternal exposure to a severe stressor during pregnancy increases the fetus' risk for a variety of disorders in adulthood. Animal studies testing the fetal programming hypothesis find that maternal glucocorticoids pass through the placenta and alter fetal brain development, particularly the hypothalamic-pituitary-adrenal axis. However, there are no prospective studies of pregnant women exposed to a sudden-onset independent stressor that elucidate the biopsychosocial mechanisms responsible for the wide variety of consequences of prenatal stress seen in human offspring. The aim of the QF2011 Queensland Flood Study is to fill this gap, and to test the buffering effects of Midwifery Group Practice, a form of continuity of maternity care. METHODS/DESIGN: In January 2011 Queensland, Australia had its worst flooding in 30 years. Simultaneously, researchers in Brisbane were collecting psychosocial data on pregnant women for a randomized control trial (the M@NGO Trial) comparing Midwifery Group Practice to standard care. We invited these and other pregnant women to participate in a prospective, longitudinal study of the effects of prenatal maternal stress from the floods on maternal, perinatal and early childhood outcomes. Data collection included assessment of objective hardship and subjective distress from the floods at recruitment and again 12 months post-flood. Biological samples included maternal bloods at 36 weeks pregnancy, umbilical cord, cord blood, and placental tissues at birth. Questionnaires assessing maternal and child outcomes were sent to women at 6 weeks and 6 months postpartum. The protocol includes assessments at 16 months, 2½ and 4 years. Outcomes include maternal psychopathology, and the child's cognitive, behavioral, motor and physical development. Additional biological samples include maternal and child DNA, as well as child testosterone, diurnal and reactive cortisol. DISCUSSION: This prenatal stress study is the first of its kind, and will fill important gaps in the literature. Analyses will determine the extent to which flood exposure influences the maternal biological stress response which may then affect the maternal-placental-fetal axis at the biological, biochemical, and molecular levels, altering fetal development and influencing outcomes in the offspring. The role of Midwifery Group Practice in moderating effects of maternal stress will be tested.

Caseload midwifery care versus standard maternity care for women of any risk: M@NGO, a randomised controlled trial.

BACKGROUND: Women at low risk of pregnancy complications benefit from continuity of midwifery care, but no trial evidence exists for women with identified risk factors. We aimed to assess the clinical and cost outcomes of caseload midwifery care for women irrespective of risk factors. METHODS: In this unblinded, randomised, controlled, parallel-group trial, pregnant women at two metropolitan teaching hospitals in Australia were randomly assigned to either caseload midwifery care or standard maternity care by a telephone-based computer randomisation service. Women aged 18 years and older were eligible if they were less than 24 weeks pregnant at the first booking visit. Those who booked with another care provider, had a multiple pregnancy, or planned to have an elective caesarean section were excluded. Women allocated to caseload care received antenatal, intrapartum, and postnatal care from a named caseload midwife (or back-up caseload midwife). Controls received standard care with rostered midwives in discrete wards or clinics. The participant and the clinician were not masked to assignment. The main primary outcome was the proportion of women who had a caesarean section. The other primary maternal outcomes were the proportions who had an instrumental or unassisted vaginal birth, and the proportion who had epidural analgesia during labour. Primary neonatal outcomes were Apgar scores, preterm birth, and admission to neonatal intensive care. We analysed all outcomes by intention to treat. The trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12609000349246. FINDINGS: Publicly insured women were screened at the participating hospitals between Dec 8, 2008, and May 31, 2011. 1748 pregnant women were randomly assigned, 871 to caseload and 877 to standard care. The proportion of caesarean sections did not differ between the groups (183 [21%] in the caseload group vs 204 [23%] in the standard care group; odds ratio [OR] 0·88, 95% CI 0·70-1·10; p=0·26). The proportion of women who had elective caesarean sections (before onset of labour) differed significantly between caseload and standard care (69 [8%] vs 94 [11%]; OR 0·72, 95% CI 0·52-0·99; p=0·05). Proportions of instrumental birth were similar (172 [20%] vs 171 [19%]; p=0·90), as were the proportions of unassisted vaginal births (487 [56%] vs 454 [52%]; p=0·08) and epidural use (314 [36%] vs 304 [35%]; p=0·54). Neonatal outcomes did not differ between the groups. Total cost of care per woman was AUS$566·74 (95% 106·17-1027·30; p=0·02) less for caseload midwifery than for standard maternity care. INTERPRETATION: Our results show that for women of any risk, caseload midwifery is safe and cost effective. FUNDING: National Health and Medical Research Council (Australia).

An exploration of influences on women's birthplace decision-making in New Zealand: a mixed methods prospective cohort within the Evaluating Maternity Units study.

BACKGROUND: There is worldwide debate surrounding the safety and appropriateness of different birthplaces for well women. One of the primary objectives of the Evaluating Maternity Units prospective cohort study was to compare the clinical outcomes for well women, intending to give birth in either an obstetric-led tertiary hospital or a free-standing midwifery-led primary maternity unit. This paper addresses a secondary aim of the study--to describe and explore the influences on women's birthplace decision-making in New Zealand, which has a publicly funded, midwifery-led continuity of care maternity system. METHODS: This mixed method study utilised data from the six week postpartum survey and focus groups undertaken in the Christchurch area in New Zealand (2010-2012). Christchurch has a tertiary hospital and four primary maternity units. The survey was completed by 82% of the 702 study participants, who were well, pregnant women booked to give birth in one of these places. All women received midwifery-led continuity of care, regardless of their intended or actual birthplace. RESULTS: Almost all the respondents perceived themselves as the main birthplace decision-makers. Accessing a 'specialist facility' was the most important factor for the tertiary hospital group. The primary unit group identified several factors, including 'closeness to home', 'ease of access', the 'atmosphere' of the unit and avoidance of 'unnecessary intervention' as important. Both groups believed their chosen birthplace was the right and 'safe' place for them. The concept of 'safety' was integral and based on the participants' differing perception of safety in childbirth. CONCLUSIONS: Birthplace is a profoundly important aspect of women's experience of childbirth. This is the first published study reporting New Zealand women's perspectives on their birthplace decision-making. The groups' responses expressed different ideologies about childbirth. The tertiary hospital group identified with the 'medical model' of birth, and the primary unit group identified with the 'midwifery model' of birth. Research evidence affirming the 'clinical safety' of primary units addresses only one aspect of the beliefs influencing women's birthplace decision-making. In order for more women to give birth at a primary unit other aspects of women's beliefs need addressing, and much wider socio-political change is required.

Caseload midwifery compared to standard or private obstetric care for first time mothers in a public teaching hospital in Australia: a cross sectional study of cost and birth outcomes.

BACKGROUND: In many countries midwives act as the main providers of care for women throughout pregnancy, labour and birth. In our large public teaching hospital in Australia we restructured the way midwifery care is offered and introduced caseload midwifery for one third of women booked at the hospital. We then compared the costs and birth outcomes associated with caseload midwifery compared to the two existing models of care, standard hospital care and private obstetric care. METHODS: We undertook a cross sectional study examining the risk profile, birth outcomes and cost of care for women booked into one of the three available models of care in a tertiary teaching hospital in Australia between July 1st 2009 December 31st 2010. To control for differences in population or case mix we described the outcomes for a cohort of low risk first time mothers known as the 'standard primipara'. RESULTS: Amongst the 1,379 women defined as 'standard primipara' there were significant differences in birth outcome. These first time 'low risk' mothers who received caseload care were more likely to have a spontaneous onset of labour and an unassisted vaginal birth 58.5% in MGP compared to 48.2% for Standard hospital care and 30.8% with Private obstetric care (p < 0.001). They were also significantly less likely to have an elective caesarean section 1.6% with MGP versus 5.3% with Standard care and 17.2% with private obstetric care (p < 0.001). From the public hospital perspective, over one financial year the average cost of care for the standard primipara in MGP was $3903.78 per woman. This was $1375.45 less per woman than those receiving Private obstetric care and $1590.91 less than Standard hospital care per woman (p < 0.001). Similar differences in cost were found in favour of MGP for all women in the study who received caseload care. CONCLUSIONS: Cost reduction appears to be achieved through reorganising the way care is delivered in the public hospital system with the introduction of Midwifery Group Practice or caseload care. The study also highlights the unexplained clinical variation that exists between the three models of care in Australia.

Maternal morbidity of women receiving birth center care in New South Wales: a matched-pair analysis using linked health data.

BACKGROUND: Around 2 percent of women who give birth in Australia each year do so in a birth center. New South Wales, Australia's largest state, accounts for almost half of these births. Previous studies have highlighted the need for better quality data on maternal morbidity and mortality, to fully evaluate the safety of birth center care. AIMS: This study aimed to examine maternal morbidity related to birth center care for women in New South Wales. METHODS: A retrospective cohort study with matched-pairs was conducted using linked health data for New South Wales. Maternal outcomes were compared for women who intended to give birth in a birth center, matched with women who intended to give birth in the co-located hospital labor ward. RESULTS: Rates of maternal outcomes, including postpartum hemorrhage, retained placenta, and postpartum infection, were significantly lower in the birth center group, after controlling for demographic and institutional factors. Interventions such as cesarean section and episiotomy were also significantly lower in these women, and the rate of breastfeeding at discharge was higher. There existed no difference in length of stay, admission to ICU, or maternal mortality. CONCLUSIONS: Birth centers are a safe option for low-risk women; however, further research is required for some rare maternal outcomes.

Recruitment difficulties in obstetric trials: a case study and review.

BACKGROUND: The CONSORT statement calls for complete data on flow of participants, including all losses and exclusions. Incomplete reporting of flow into trials versus flow through trials is not uncommon. Where complete data exist in obstetric trials, poor recruitment seems a recurring theme. AIMS: To explore difficulties in recruitment and differences between assessed-but-not-recruited and included women to improve future trial participation, using a case study of a recently published randomised trial of outpatient Foley catheter versus inpatient PGE2 gel for cervical ripening. MATERIALS & METHODS: The assessed-but-not-recruited population of an obstetric trial (ACTRN:12609000420246) was prospectively studied for reasons for noninclusion, demographic data and pregnancy outcome. Women assessed-but-not-recruited due to declined consent or obstetrician declined participation were compared to included women. Main outcome measures included demographic and outcome differences associated with trial participation. RESULTS: Of 468 assessed participants, 220 (47%) were not eligible by exclusion criteria (potential 'trial factor' recruitment difficulties), 147 (31%) declined consent (n = 100, 'participant factor') or their obstetrician declined participation (n = 47, 'clinician factor') and 101 (22%) were included. Declining women were more likely than participants to be parous (24 vs 10%, P < 0.05), induced for nonmedical reasons (18 vs 4%, P < 0.001), privately admitted (31 vs 3%, P < 0.001) and have longer inpatient stay (4.9 vs 4.2 days, P < 0.05). CONCLUSION: The high assessed-but-not-recruited rate highlights important issues with external validity and feasibility when conducting obstetric trials, including recruitment difficulties related to participant, clinician and trial factors. Assessed: recruited ratios and demographic and outcome differences need consideration in planning and interpretation of randomised trials.

Is a randomised controlled trial of a maternity care intervention for pregnant adolescents possible? An Australian feasibility study.

BACKGROUND: The way in which maternity care is provided affects perinatal outcomes for pregnant adolescents; including the likelihood of preterm birth. The study purpose was to assess the feasibility of recruiting pregnant adolescents into a randomised controlled trial, in order to inform the design of an adequately powered trial which could test the effect of caseload midwifery on preterm birth for pregnant adolescents. METHODS: We recruited pregnant adolescents into a feasibility study of a prospective, un-blinded, two-arm, randomised controlled trial of caseload midwifery compared to standard care. We recorded and analysed recruitment data in order to provide estimates to be used in the design of a larger study. RESULTS: The proportion of women aged 15-17 years who were eligible for the study was 34% (n=10), however the proportion who agreed to be randomised was only 11% (n = 1). Barriers to recruitment were restrictive eligibility criteria, unwillingness of hospital staff to assist with recruitment, and unwillingness of pregnant adolescents to have their choice of maternity carer removed through randomisation. CONCLUSIONS: A randomised controlled trial of caseload midwifery care for pregnant adolescents would not be feasible in this setting without modifications to the research protocol. The recruitment plan should maximise opportunities for participation by increasing the upper age limit and enabling women to be recruited at a later gestation. Strategies to engage the support of hospital-employed staff are essential and would require substantial, and ongoing, work. A Zelen method of post-randomisation consent, monetary incentives and 'peer recruiters' could also be considered.