Group Pregnancy Care for refugee background women: a codesigned, multimethod evaluation protocol applying a community engagement framework and an interrupted time series design.

INTRODUCTION: Pregnancy and early parenthood are key opportunities for interaction with health services and connecting to other families at the same life stage. Public antenatal care should be accessible to all, however barriers persist for families from refugee communities to access, navigate and optimise healthcare during pregnancy. Group Pregnancy Care is an innovative model of care codesigned with a community from a refugee background and other key stakeholders in Melbourne, Australia. Group Pregnancy Care aims to provide a culturally safe and supportive environment for women to participate in antenatal care in a language they understand, to improve health literacy and promote social connections and inclusion. This paper outlines Froup Pregnancy Care and provides details of the evaluation framework. METHODS AND ANALYSIS: The evaluation uses community-based participatory research methods to engage stakeholders in codesign of evaluation methods. The study is being conducted across multiple sites and involves multiple phases, use of quantitative and qualitative methods, and an interrupted time series design. Process and cost-effectiveness measures will be incorporated into quality improvement cycles. Evaluation measures will be developed using codesign and participatory principles informed by community and stakeholder engagement and will be piloted prior to implementation. ETHICS AND DISSEMINATION: Ethics approvals have been provided by all six relevant authorities. Study findings will be shared with communities and stakeholders via agreed pathways including community forums, partnership meetings, conferences, policy and practice briefs and journal articles. Dissemination activities will be developed using codesign and participatory principles.

Urinary incontinence in nulliparous women before and during pregnancy: prevalence, incidence, and associated risk factors.

INTRODUCTION: Few studies have examined associations of prepregnancy urinary incontinence (UI). METHODS: Multicentre prospective pregnancy cohort study (n = 1,507) using standardised measures to assess frequency and severity of UI. RESULTS: Prevalence of UI increased from 10.8% in the 12 months before the index pregnancy to 55.9% in the third trimester. Stress incontinence (36.9%) and mixed incontinence (13.1%) were more common during pregnancy than urge incontinence alone (5.9%). UI before pregnancy was associated with childhood enuresis (adjusted odds ratio (AdjOR) = 2.4, 95% confidence interval (CI) 1.6-3.4), higher maternal body mass index (AdjOR = 2.3, 95% CI 1.4-3.8), and previous miscarriages or terminations (AdjOR = 1.6, 95% CI 1.1-2.3). The strongest predictor of incident UI in pregnancy was occasional leakage (less than once a month) before pregnancy (AdjOR = 3.6, 95% CI 2.8-4.7). CONCLUSIONS: Further research is needed to elucidate the complex interplay of prepregnancy and pregnancy-related factors in the aetiology of UI in nulliparous women.

Seeking help for anxiety and depression after childbirth: results of the Maternal Health Study.

Access to treatment for postnatal anxiety and depression is dependant on women seeking help for psychological symptoms. The aim of this paper was to investigate what women themselves say about seeking help for emotional difficulties after childbirth. The Maternal Health Study is a prospective pregnancy cohort study investigating the physical and psychological health of 1,507 nulliparous women during pregnancy and after birth. One thousand, three hundred eighty-five women completed a computer-assisted telephone interview at 9 months postpartum; 8.5% of women reported intense anxiety or panic attacks occasionally or often, and 9.5% reported depressed mood, between 6 and 9 months postpartum. Of those experiencing anxiety symptoms alone 44.4% had spoken to a health professional, compared with 65.5% of women experiencing depressive symptoms alone (RR = 0.68, 95% CI-0.5 to 0.9). Measures of anxiety and depressive symptoms at 9 months postpartum were not validated against diagnostic criteria. Anxiety is a common experience in the perinatal period. More research is needed into this area to determine what levels of anxiety are 'normal' and acceptable to women during this period. Public health campaigns may have been more effective in encouraging women to seek help for depression than anxiety.

Fear of an intimate partner and women's health in early pregnancy: findings from the Maternal Health Study.

BACKGROUND: Intimate partner violence affects 1 in 4 women at some stage in their lives. Exposure to violence has short- and long-term consequences for women themselves and their children. The objective of this study was to examine associations between fear of an intimate partner and maternal physical and psychological morbidity in early pregnancy. METHOD: This paper reports baseline measures from a prospective pregnancy cohort study of 1,507 nulliparous women recruited at six public hospitals in Melbourne, Australia. RESULTS: The study showed that 18.7 percent (280/1,497) of women reported being afraid of an intimate partner at some stage in their lives; 3.1 percent (47/1,497) were afraid in early pregnancy and 15.6 percent (233/1,497) had been afraid before but not during the current pregnancy. Compared with women who had never been afraid of an intimate partner, women who reported being afraid of an intimate partner in early pregnancy (< or = 24 wk gestation) were at increased risk of urinary incontinence (adjusted OR = 1.64, 95% CI 0.9-3.1), fecal incontinence (adjusted OR = 3.32, 95% CI 1.2-9.2), vaginal bleeding (adjusted OR = 2.84, 95% CI 1.5-5.5), anxiety (adjusted OR = 10.22, 95% CI 5.0-21.2), and depression (adjusted OR = 4.43, 95% CI 2.1-9.7). Women afraid of an intimate partner before but not during pregnancy experienced a similar pattern of morbidity. CONCLUSIONS: Women afraid of an intimate partner both before and during pregnancy have poorer physical and psychological health in early pregnancy.

Maternal health study: a prospective cohort study of nulliparous women recruited in early pregnancy.

BACKGROUND: In the first year after childbirth, 94% of women experience one or more major health problems (urinary incontinence, faecal incontinence, perineal pain, back pain). Difficulties in intimate partner relationships and changes affecting sexual health are also common. The aim of this study is to investigate changes in women's health from early pregnancy until four years after the birth of a first child. METHODS/DESIGN: The Maternal Health Study is a longitudinal study designed to fill in some of the gaps in current research evidence regarding women's physical and psychological health and recovery after childbirth. A prospective pregnancy cohort of >1500 nulliparous women has been recruited in early pregnancy at six metropolitan public hospitals in Melbourne, Australia between April 2003 and December 2005. In the first phase of the study participants are being followed up at 30-32 weeks gestation in pregnancy, and at three, six, nine, 12 and 18 months postpartum using a combination of self-administered questionnaires and telephone interviews. Women consenting to extended follow-up (phase 2) will be followed up six and 12 months after any subsequent births and when their first child is four years old. Study instruments incorporate assessment of the frequency and severity of urinary and bowel symptoms, sexual health issues, perineal and abdominal pain, depression and intimate partner violence. Pregnancy and birth outcome data will be obtained by review of hospital case notes. DISCUSSION: Features of the study which distinguish it from prior research include: the capacity to identify incident cases of morbidity and clustering of health problems; a large enough sample to detect clinically important differences in maternal health outcomes associated with the method of birth; careful exposure measurement involving manual abstraction of data from medical records in order to explore mediating factors and possible causal pathways; and use of a variety of strategies to improve ascertainment of health outcomes.

Enhancing early postnatal care: findings from a major reform of maternity care in three Australian hospitals.

BACKGROUND: four hospitals comprising a health network in Melbourne, Australia, implemented a range of initiatives aimed at enhancing women's experiences of postnatal maternity care. OBJECTIVE: to compare women's views and experiences of early postnatal care before and after implementation of maternity enhancement initiatives. DESIGN: 'before and after' study design incorporating two postal surveys of recent mothers (baseline and post-implementation). SETTING: four hospitals in Melbourne, Australia. Analysis of postnatal outcomes was confined to three hospitals where the initiatives were fully operational. PARTICIPANTS: 1256 women participated in the baseline survey in 1999 (before implementing the initiative) and 1050 women responded to the post-implementation survey in 2001. FINDINGS: the response to the 1999 baseline survey was 65.3% (1256/1922) and to the 2001 post-implementation survey 57.4% (1050/1829). Comparative analysis revealed a statistically significant improvement in overall ratings of hospital postnatal care; the level of advice and support received in relation to discharge and going home; the sensitivity of caregivers; and the proportion of women receiving domiciliary care after discharge. There was little change in the time women spent in hospital after birth between the two survey time-points. Over 90% of women reported one or more health problems in the first 3 months postpartum. The proportion of women reporting physical or emotional health problems between the two surveys did not change. KEY CONCLUSION: mainstream maternity care can be restructured to improve women's experiences of early postnatal care. IMPLICATIONS FOR PRACTICE: maternity service providers should consider a multi-faceted approach to reorienting postnatal services and improving women's experiences of care. Approaches worthy of consideration include attempts to ensure consistency and continuity of care through staffing arrangements, guidelines and protocols; an emphasis on planning for postnatal care during pregnancy; the use of evidence to inform both consumer information and advice and in the practice of caring; and skill-enhancement opportunities for care providers in managing postnatal issues and in effective communication.

Evaluating innovations in maternity care: methodological approaches to a baseline postal survey.

BACKGROUND: A network of four public maternity hospitals in Melbourne, Australia, has implemented a range of initiatives aimed at improving maternity care. Comprehensive evaluation aims to determine whether or not the maternity service enhancement strategies have led to improvements in women's views and experiences of care. This paper discusses the baseline survey study design and methodological issues associated with the recruitment and reminder processes. METHOD: All women who gave birth over a 14-week period in 1999 at one of the four maternity units, except those who had a stillbirth or neonatal death, were invited to participate in the baseline postal survey. Questionnaires were sent to women at 3 months postpartum. A system of written and telephone reminders was instituted. RESULTS: The overall response fraction to the baseline survey was 65.2 percent (1256/1922). The sample was representative in terms of maternal age, method of birth, and infant birthweight. Women born overseas of non-English speaking background, single women, and women having their second or subsequent baby were underrepresented. CONCLUSIONS: The pleasing response fraction in part may be attributed to the method of recruitment and the reminder processes. Rigorous and careful approaches to methodology enhance study integrity and provide context to the interpretation of study findings.