Characteristics and co-admissions of mothers and babies admitted to residential parenting services in the year following birth in NSW: a linked population data study (2000-2012).

BACKGROUND: There is a tiered healthcare system in Australia to support maternal and child health, including, non-psychiatric day stay and residential parenting services (RPS) such as Tresillian and Karitane (in New South Wales [NSW]). RPS are unique to Australia, and currently there is limited information regarding the healthcare trajectory of women accessing RPS and if they are more likely to have admissions to other health facilities within the first-year post-birth. This study aimed to examine differences in hospital co-admissions for women and babies admitted to RPS in NSW in the year following birth compared to non-RPS admitted women. METHODS: A linked population data study of all women giving birth in NSW 2000-2012. Statistical differences were calculated using chi-square and student t-tests. RESULTS: Over the 12-year timeframe, 32,071 women and 33,035 babies were admitted to RPS, with 5191 of these women also having one or more hospital admissions (7607 admissions). The comparator group comprised of 99,242 women not admitted to RPS but having hospital admissions over the same timeframe (136,771 admissions). Statistically significant differences between cohorts were observed for the following parameters (p ≤ .001). Based upon calculated percentages, women who were admitted to RPS were more often older, Australian born, socially advantaged, private patients, and having their first baby. RPS admitted women also had more multiple births and labour and birth interventions (induction, instrumental birth, caesarean section, epidural, episiotomy). Their infants were also more often male and admitted to Special Care Nursery/Neonatal Intensive Care. Additionally, RPS admitted women had more admissions for mental health and behavioural disorders, which appeared to increase over time. There was no statistical difference between cohorts regarding the number of women admitted to a psychiatric facility; however, women attending RPS were more likely to have mood affective, or behavioural and personality disorder diagnoses. CONCLUSION: Women accessing RPS in the year post-birth were more socially advantaged, had higher birth intervention and more co-admissions and treatment for mental health disorders than those not accessing RPS. More research is needed into the impact of birth intervention and mental health issues on subsequent parenting difficulties.

Probiotics for preventing and treating infant regurgitation: A systematic review and meta-analysis.

Infant regurgitation is common during infancy and can cause substantial parental distress. Regurgitation can lead to parental perception that their infant is in pain. Parents often present in general practitioner surgeries, community baby clinics and accident and emergency departments which can lead to financial burden on parents and the health care system. Probiotics are increasingly reported to have therapeutic effects for preventing and treating infant regurgitation. The objective of this systematic review and meta-analysis was to evaluate the efficacy of probiotic supplementation for the prevention and treatment of infant regurgitation. Literature searches were conducted using MEDLINE, CINAHL, and the Cochrane Central Register of Controlled trials. Only randomised controlled trials (RCTs) were included. A meta-analysis was performed using the Cochrane Collaboration methodology where possible. Six RCTs examined the prevention or treatment with probiotics on infant regurgitation. A meta-analysis of three studies showed a statistically significant reduction in regurgitation episodes for the probiotic group compared to the placebo group (mean difference [MD]: -1.79 episodes/day: 95% confidence interval [CI]: -3.30 to -0.27, N = 560), but there was high heterogeneity (96%). Meta-analysis of two studies found a statistically significant increased number of stools per day in the probiotic group compared to the placebo group at 1 month of age (MD: 1.36, 95% CI: 0.99 to 1.73, N = 488), with moderate heterogeneity (69%). Meta-analysis of two studies showed no statistical difference in body weight between the two groups (MD: -91.88 g, 95% CI: 258.40-74.63: I2 = 23%, N = 112) with minimal heterogeneity 23%. Probiotic therapy appears promising for infant regurgitation with some evidence of benefit, but most studies are small and there was relatively high heterogeneity. The use of probiotics could potentially be a noninvasive, safe, cost effective, and preventative positive health strategy for both women and their babies. Further robust, well controlled RCTs examining the effect of probiotics for infant regurgitation are warranted.

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.

Associations Between Mode of Birth and Neuropsychological Development in Children Aged 4 Years: Results from a Birth Cohort Study.

The aim of this prospective longitudinal study was to examine the association between Cesarean section (CS) and child development and behavior. The sample consisted of 256 children who were born at term without serious perinatal pathologies. Their development and behavior was assessed at the age of four using Ages and Stages Questionnaire (ASQ-3), Children's Behavior Questionnaire and Strength and Difficulties Questionnaire. Multivariate linear regression analyses were conducted to assess the association between CS and child outcomes. CS was associated with better scores in the Problem Solving domain of the ASQ in the whole sample. After stratifying by child sex, the positive association between CS and the Problem Solving domain was significant in boys, while no association was found in girls. Girls were rated less optimally in the Gross Motor domain of the ASQ when born via CS. Mode of birth was not associated with behavioral outcomes.

Creating the first national linked dataset on perinatal and maternal outcomes in Australia: Methods and challenges.

BACKGROUND: Data linkage offers a powerful mechanism for examining healthcare outcomes across populations and can generate substantial robust datasets using routinely collected electronic data. However, it presents methodological challenges, especially in Australia where eight separate states and territories maintain health datasets. This study used linked data to investigate perinatal and maternal outcomes in relation to place of birth. It examined data from all eight jurisdictions regarding births planned in hospitals, birth centres and at home. Data linkage enabled the first Australia-wide dataset on birth outcomes. However, jurisdictional differences in data collection created challenges in obtaining comparable cohorts of women with similar low-risk pregnancies in all birth settings. The objective of this paper is to describe the techniques for managing previously linked data, and specifically for ensuring the resulting dataset contained only low-risk pregnancies. METHODS: This paper indicates the procedures for preparing and merging linked perinatal, inpatient and mortality data from different sources, providing technical guidance to address challenges arising in linked data study designs. RESULTS: We combined data from eight jurisdictions linking four collections of administrative healthcare and civil registration data. The merging process ensured that variables were consistent, compatible and relevant to study aims. To generate comparable cohorts for all three birth settings, we developed increasingly complex strategies to ensure that the dataset eliminated women with pregnancies at risk of complications during labour and birth. It was then possible to compare birth outcomes for comparable samples, enabling specific examination of the impact of birth setting on maternal and infant safety across Australia. CONCLUSIONS: Data linkage is a valuable resource to enhance knowledge about birth outcomes from different settings, notwithstanding methodological challenges. Researchers can develop and share practical techniques to address these challenges. Study findings suggest that jurisdictions develop more consistent data collections to facilitate future data linkage.

Mapping the trajectories for women and their babies from births planned at home, in a birth centre or in a hospital in New South Wales, Australia, between 2000 and 2012.

BACKGROUND: In New South Wales (NSW) Australia, women at low risk of complications can choose from three birth settings: home, birth centre and hospital. Between 2000 and 2012, around 6.4% of pregnant women planned to give birth in a birth centre (6%) or at home (0.4%) and 93.6% of women planned to birth in a hospital. A proportion of the woman in the home and birth centre groups transferred to hospital. However, their pathways or trajectories are largely unknown. AIM: The aim was to map the trajectories and interventions experienced by women and their babies from births planned at home, in a birth centre or in a hospital over a 13-year period in NSW. METHODS: Using population-based linked datasets from NSW, women at low risk of complications, with singleton pregnancies, gestation 37-41 completed weeks and spontaneous onset of labour were included. We used a decision tree framework to depict the trajectories of these women and estimate the probabilities of the following: giving birth in their planned setting; being transferred; requiring interventions and neonatal admission to higher level hospital care. The trajectories were analysed by parity. RESULTS: Over a 13-year period, 23% of nulliparous and 0.8% of multiparous women planning a home birth were transferred to hospital. In the birth centre group, 34% of nulliparae and 12% of multiparas were transferred to a hospital. Normal vaginal birth rates were higher in multiparous women compared to nulliparous women in all settings. Neonatal admission to SCN/NICU was highest in the planned hospital group for nulliparous women (10.1%), 7.1% for nulliparous women planning a birth centre birth and 5.1% of nulliparous women planning a homebirth. Multiparas had lower admissions to SCN/NICU for all thee settings (hospital 6.3%, BC 3.6%, home 1.6%, respectively). CONCLUSIONS: Women who plan to give birth at home or in a birth centre have high rates of vaginal birth, even when transferred to hospital. Evidence on the trajectories of women who choose to give birth at home or in birth centres will assist the planning, costing and expansion of models of care in NSW.

The effect of medical and operative birth interventions on child health outcomes in the first 28 days and up to 5 years of age: A linked data population-based cohort study.

BACKGROUND: Spontaneous vaginal birth rates are decreasing worldwide, while cesarean delivery, instrumental births, and medical birth interventions are increasing. Emerging evidence suggests that birth interventions may have an effect on children's health. Therefore, the aim of our study was to examine the association between operative and medical birth interventions on the child's health during the first 28 days and up to 5 years of age. METHODS: In New South Wales (Australia), population-linked data sets were analyzed, including data on maternal characteristics, child characteristics, mode of birth, interventions during labor and birth, and adverse health outcomes of the children (ie, jaundice, feeding problems, hypothermia, asthma, respiratory infections, gastrointestinal disorders, other infections, metabolic disorder, and eczema) registered with the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification codes. Logistic regression analyses were performed for each adverse health outcome. RESULTS: Our analyses included 491 590 women and their children; of those 38% experienced a spontaneous vaginal birth. Infants who experienced an instrumental birth after induction or augmentation had the highest risk of jaundice, adjusted odds ratio (aOR) 2.75 (95% confidence interval [CI] 2.61-2.91) compared with spontaneous vaginal birth. Children born by cesarean delivery were particularly at statistically significantly increased risk for infections, eczema, and metabolic disorder, compared with spontaneous vaginal birth. Children born by emergency cesarean delivery showed the highest association for metabolic disorder, aOR 2.63 (95% CI 2.26-3.07). CONCLUSION: Children born by spontaneous vaginal birth had fewer short- and longer-term health problems, compared with those born after birth interventions.

Gastro-oesophageal reflux: a mixed methods study of infants admitted to hospital in the first 12 months following birth in NSW (2000-2011).

BACKGROUND: Gastro-oesophageal reflux (GOR) is common in infants. When the condition causes pathological symptoms and/or complications it is considered gastro-oesophageal reflux disease (GORD). It appears to be increasingly diagnosed and causes great distress in the first year of infancy. In New South Wales (NSW), residential parenting services support families with early parenting difficulties. These services report a large number of babies admitted with a label of GOR/GORD. The aim of this study was to explore the maternal and infant characteristics, obstetric interventions, and reasons for clinical reporting of GOR/GORD in NSW in the first 12 months following birth (2000-2011). METHODS: A three phase, mixed method sequential design was used. Phase 1 included a linked data population based study (n = 869,188 admitted babies). Phase 2 included a random audit of 326 medical records from admissions to residential parenting centres in NSW (2013). Phase 3 included eight focus groups undertaken with 45 nurses and doctors working in residential parenting centres in NSW. RESULTS: There were a total of 1,156,020 admissions recorded of babies in the first year following birth, with 11,513 containing a diagnostic code for GOR/GORD (1% of infants admitted to hospitals in the first 12 months following birth). Babies with GOR/GORD were also more likely to be admitted with other disorders such as feeding difficulties, sleep problems, and excessive crying. The mothers of babies admitted with a diagnostic code of GOR/GORD were more likely to be primiparous, Australian born, give birth in a private hospital and have: a psychiatric condition; a preterm or early term infant (37-or-38 weeks); a caesarean section; an admission of the baby to SCN/NICU; and a male infant. Thirty six percent of infants admitted to residential parenting centres in NSW had been given a diagnosis of GOR/GORD. Focus group data revealed two themes: "It is over diagnosed" and "A medical label is a quick fix, but what else could be going on?" CONCLUSIONS: Mothers with a mental health disorder are nearly five times as likely to have a baby admitted with GOR/GORD in the first year after birth. We propose a new way of approaching the GOR/GORD issue that considers the impact of early birth (immaturity), disturbance of the microbiome (caesarean section) and mental health (maternal anxiety in particular).

Characteristics and service needs of women and babies admitted to residential parenting units in New South Wales: A mixed-methods study.

AIMS AND OBJECTIVES: To examine the characteristics and service needs of women and babies admitted to residential parenting services (RPS) in the first year following birth in New South Wales, Australia. BACKGROUND: In Australia, there is a tiered system to support maternal, child and family health, which includes RPS. DESIGN: Sequential explanatory mixed-methods design. METHODS: Individual patient data were obtained from a random review of 10% of all medical records (n = 300 of 3,011 admissions) of women with an infant of <12 months of age who were admitted to RPS in 2013. Following review of the medical records, qualitative data were collected via interviews with eight women who accessed RPS. Chi-square analysis and Student's t test were used to analyse quantitative data. Qualitative data were analysed using a descriptive interpretive approach. An integrative approach was taken in reporting the findings. RESULTS: Women admitted to the RPS were on average 32 years of age, were Australian born (72%) and had a university qualification (40%), and most were employed. The majority of women were primiparous (60%) and had a vaginal birth (61%). Women with male infants were much more likely to be admitted to the RPS (58%) compared to the NSW male-to-female ratio (51.3% vs. 48.7%). Over 50% of women reported mental health issues with 27% having an Edinburgh Postnatal Depression Scale score ≥13 on admission. The primary reason women sought parenting support was for sleep and settling (83%). During their stay, services used by women included social workers (44%), psychologists (52%) and psychiatrists (4.5%). CONCLUSION: Women who access RPS report psychosocial and mental health issues. Services provided by RPS support women during this challenging early parenting period by providing multidisciplinary, holistic and peer support. RELEVANCE TO CLINICAL PRACTICE: A high prevalence of mental health issues identified in this study indicated a need for ongoing training and support for RPS staff. Ensuring clinicians have the appropriate skill sets to best support their clientele will maximise the outcomes for women and families who access RPS during the early parenting period.

A longitudinal analysis of angiotensin II type 1 receptor antibody and angiogenic markers in pregnancy.

BACKGROUND: Preeclampsia can be caused by shallow trophoblast invasion and results in endothelial dysfunction. Angiotensin II type 1 receptor antibodies may have a role in both processes. Other angiogenic markers (placental growth factor, soluble fms-like tyrosine kinase-1, and soluble endoglin) have been shown to alter before clinically evident preeclampsia. OBJECTIVE: The aim of this study is to assess the longitudinal changes and utility of biomarker angiotensin II type 1 receptor antibodies and angiogenic markers in hypertensive disorders of pregnancy, gestational hypertension, and preeclampsia. STUDY DESIGN: A longitudinal prospective cohort observational study of angiogenic markers and a secondary retrospective case-control study of angiotensin II type 1 receptor antibody changes were conducted. The studies were conducted in a large tertiary metropolitan teaching hospital (Sydney, Australia). Sequential recruitment of women with a singleton pregnancy (N = 351) was undertaken. Plasma concentrations of angiotensin II type 1 receptor antibodies, placental growth factor, soluble fms-like tyrosine kinase-1, and soluble endoglin were measured using validated enzyme-linked immunosorbent assays at 12, 18, 28, 36, and 40 weeks' gestation and 6 weeks' postpartum. Clinical, demographic, and pregnancy data were prospectively collected. Pregnancy outcomes were classified as normotensive, gestational hypertension, or preeclampsia. Analyses were carried out using software and significance set at P < .05. RESULTS: In all, 351 women were recruited, 17 developed gestational hypertension, and 18 developed preeclampsia. Women with preeclampsia at baseline were heavier (P = .015), were taller (P = .046), and had higher systolic (P = .029) and diastolic (P = .006) blood pressure. The preeclampsia group had higher soluble fms-like tyrosine kinase-1 from ≥28 weeks (P = .003) and lower placental growth factor from 18 weeks (P = .004). Soluble endoglin and angiotensin II type 1 receptor antibodies did not vary over time or between groups. Angiotensin II type 1 receptor antibody (12 weeks) was positively correlated with serum pregnancy associated plasma protein A (P = .008) and human chorionic gonadotrophin (P = .04). CONCLUSION: Angiogenic markers vary longitudinally during pregnancy and placental growth factor and soluble fms-like tyrosine kinase-1 have a role for predicting and diagnosing preeclampsia later in disease. Our data show that angiotensin II type 1 receptor antibodies are not sensitive for disease and hence not useful as a biomarker. Larger studies are required to describe the role and functionality of angiotensin II type 1 receptor antibodies in preeclampsia.

Hypertension in pregnancy and long-term cardiovascular mortality: a retrospective cohort study.

BACKGROUND: There is growing evidence that hypertensive disorders of pregnancy are associated with increased long-term cardiovascular mortality in the mother. Hypertension in pregnancy, until recently, however, has been ignored largely as a risk factor for future cardiovascular disease and mortality because the link between the 2 is not fully understood. OBJECTIVE: To determine the association between women with hypertension in pregnancy and long-term cardiovascular disease mortality. STUDY DESIGN: All women who delivered at a metropolitan hospital between the periods of January 1, 1980, and December 31, 1989, were identified by use of the International Statistical Classification of Diseases and Related Health Problems, 9th Revision, Australian Modification. RESULTS: The total number of deliveries in the given time period was 31,656, with 4387 (14%) of the women identified as having had hypertension in their pregnancy. Using information from the New South Wales Births, Deaths and Marriages Registry and the Australian Bureau of Statistics Death Registry, we identified a total of 651 deaths from this cohort (n = 31,656). There were 521 deaths among the women who remained normotensive in their pregnancy and 129 deaths for women who had hypertension during their pregnancy. Overall, the women with hypertensive disorders of pregnancy were at greater risk of death than the women who remained normotensive in their pregnancy (odds ratio 1.56; 95% confidence interval 1.28-1.89; P < .001). CONCLUSION: Women with a history of hypertension in their pregnancy are at an increased risk of future cardiovascular mortality, and this work identifies a group of women who may benefit from early screening and intervention strategies to help decrease their risk of future cardiovascular disease.

Obstetric and psychosocial risk factors for Australian-born and non-Australian born women and associated pregnancy and birth outcomes: a population based cohort study.

BACKGROUND: One in four Australians is born overseas and 47% are either born overseas or have a parent who was. Obstetric and psychosocial risk factors for these women may differ. METHOD: Data from one Sydney hospital (2012-2013) of all births recorded in the ObstetriX database were analysed (n = 3,092). Demographics, obstetric and psychosocial risk profile, obstetric interventions and complications and selected maternal and neonatal outcomes were examined for women born in Australia and overseas. RESULTS: Women born in Australia were younger, more likely to be primiparous (28.6 v 27.5%), be obese (32.0% v 21.4%), smoke (19.7 % v 3.0%), have an epidural (26.2% v 20.2%) and were less likely to have gestational diabetes mellitus (GDM) (6.8% v 13.7% when compared to non-Australian born women. The highest rates of GDM, Gestational Hypertension (GH) and maternal anaemia were seen in women born in China, the Philippines and Pakistan respectively. Differences were also seen in psychosocial screening between Australian and non-Australian women with Australian-born women more likely to smoke and report a mental health disorder. There was an association between having an Edinburgh Postnatal Depression Scale (EPDS) ≥ 13 and other psychosocial issues, such as thoughts of self-harm, domestic violence, childhood abuse etc. These women were also less likely to breastfeed. Women with an EPDS ≥ 13 at booking compared to women with EPDS ≤12 had a higher chance of being diagnosed with GDM (AOR 1.85 95% CI 1.14-3.0). CONCLUSIONS: There are significant differences in obstetric and psychosocial risk profiles and maternal and neonatal outcomes between Australian-born and non-Australian born women. In particular there appears to be an association between an EPDS of ≥13 and developing GDM, which warrants further investigation.

Birthplace in New South Wales, Australia: an analysis of perinatal outcomes using routinely collected data.

BACKGROUND: The outcomes for women who give birth in hospital compared with at home are the subject of ongoing debate. We aimed to determine whether a retrospective linked data study using routinely collected data was a viable means to compare perinatal and maternal outcomes and interventions in labour by planned place of birth at the onset of labour in one Australian state. METHODS: A population-based cohort study was undertaken using routinely collected linked data from the New South Wales Perinatal Data Collection, Admitted Patient Data Collection, Register of Congenital Conditions, Registry of Birth Deaths and Marriages and the Australian Bureau of Statistics. Eight years of data provided a sample size of 258,161 full-term women and their infants. The primary outcome was a composite outcome of neonatal mortality and morbidity as used in the Birthplace in England study. RESULTS: Women who planned to give birth in a birth centre or at home were significantly more likely to have a normal labour and birth compared with women in the labour ward group. There were no statistically significant differences in stillbirth and early neonatal deaths between the three groups, although we had insufficient statistical power to test reliably for these differences. CONCLUSION: This study provides information to assist the development and evaluation of different places of birth across Australia. It is feasible to examine perinatal and maternal outcomes by planned place of birth using routinely collected linked data, although very large data sets will be required to measure rare outcomes associated with place of birth in a low risk population, especially in countries like Australia where homebirth rates are low.

The incidence of preeclampsia and eclampsia and associated maternal mortality in Australia from population-linked datasets: 2000-2008.

OBJECTIVE: To determine the incidence of preeclampsia and eclampsia and associated mortality in Australia between 2000 and 2008. STUDY DESIGN: Analysis of statutorily collected datasets of singleton births in New South Wales using International Classification of Disease coding. Analyzed using cross tabulation, logistic regression, and means testing, where appropriate. RESULTS: The overall incidence of preeclampsia was 3.3% with a decrease from 4.6% to 2.3%. The overall rate of eclampsia was 8.6/10,000 births or 2.6% of preeclampsia cases, with an increase from 2.3% to 4.2%. The relative risk of eclampsia in preeclamptic women in 2008 was 1.9 (95% confidence interval, 1.28-2.92) when compared with the year 2000. The relative risk of a woman with preeclampsia/eclampsia dying in the first 12 months following birth compared with normotensive women is 5.1 (95% confidence interval, 3.07-8.60). CONCLUSION: Falling rates of preeclampsia have not equated to a decline in the incidence of eclampsia. An accurate rate of both preeclampsia and eclampsia is vital considering the considerable contribution that these diseases make to maternal mortality. The identification and treatment of eclampsia should remain a priority in the clinical setting.

Rates of obstetric intervention during birth and selected maternal and perinatal outcomes for low risk women born in Australia compared to those born overseas.

BACKGROUND: There are mixed reports in the literature about obstetric intervention and maternal and neonatal outcomes for migrant women born in resource rich countries. The aim of this study was to compare the risk profile, rates of obstetric intervention and selected maternal and perinatal outcomes for low risk women born in Australia compared to those born overseas. METHOD: A population-based descriptive study was undertaken in NSW of all singleton births recorded in the NSW Midwives Data Collection between 2000-2008 (n=691,738). Risk profile, obstetric intervention rates and selected maternal and perinatal outcomes were examined. RESULTS: Women born in Australia were slightly younger (30 vs 31 years), less likely to be primiparous (41% vs 43%), three times more likely to smoke (18% vs 6%) and more likely to give birth in a private hospital (26% vs 18%) compared to women not born in Australia. Among the seven most common migrant groups to Australia, women born in Lebanon were the youngest, least likely to be primiparous and least likely to give birth in a private hospital. Hypertension was lowest amongst Vietnamese women (3%) and gestational diabetes highest amongst women born in China (14%). The highest caesarean section (31%), instrumental birth rates (16%) and episiotomy rates (32%) were seen in Indian women, along with the highest rates of babies <10th centile (22%) and <3rd centile (8%). Lebanese women had the highest rates of stillbirth (7.2/1000). Similar trends were found in the different migrant groups when only low risk women were included. CONCLUSION: The results suggest there are significant differences in risk profiles, obstetric intervention rates and maternal and neonatal outcomes between Australian-born and women born overseas and these differences are seen overall and in low risk populations. The finding that Indian women (the leading migrant group to Australia) have the lowest normal birth rate and high rates of low birth weight babies is concerning, and attention needs to be focused on why there are disparities in outcomes and on effective models of care that might improve outcomes for this population.

Risk of recurrence, subsequent mode of birth and morbidity for women who experienced severe perineal trauma in a first birth in New South Wales between 2000-2008: a population based data linkage study.

BACKGROUND: Severe perineal trauma occurs in 0.5-10% of vaginal births and can result in significant morbidity including pain, dyspareunia and faecal incontinence. The aim of this study is to determine the risk of recurrence, subsequent mode of birth and morbidity for women who experienced severe perineal trauma during their first birth in New South Wales (NSW) between 2000 - 2008. METHOD: All singleton births recorded in the NSW Midwives Data Collection between 2000-2008 (n=510,006) linked to Admitted Patient Data were analysed. Determination of morbidity was based upon readmission to hospital within a 12 month time period following birth for a surgical procedure falling within four categories: 1. Vaginal repair, 2. Fistula repair, 3. Faecal and urinary incontinence repair, and 4. Rectal/anal repair. Women who experienced severe perineal trauma during their first birth were compared to women who did not. RESULTS: 2,784 (1.6%) primiparous women experienced severe perineal trauma during this period. Primiparous women experiencing severe perineal trauma were less likely to have a subsequent birth (56% vs 53%) compared to those not who did not (OR 0.9; CI 0.81-0.99), however there was no difference in the subsequent rate of elective caesarean section (OR 1.2; 0.95-1.54), vaginal birth (including instrumental birth) (OR 1.0; CI 0.81-1.17) or normal vaginal birth (excluding instrumental birth) (OR 1.0; CI 0.85-1.17). Women were no more likely to have a severe perineal tear in the second birth if they experienced this in the first (OR 0.9; CI 0.67-1.34). Women who had a severe perineal tear in their first birth were significantly more likely to have an 'associated surgical procedure' within the ≤12 months following birth (vaginal repair following primary repair, rectal/anal repair following primary repair, fistula repair and urinary/faecal incontinence repair) (OR 7.6; CI 6.21-9.22). Women who gave birth in a private hospital compared to a public hospital were more likely to have an 'associated surgical procedure' in the 12 months following the birth (OR 1.8; CI 1.54-1.97), regardless of parity, birth type and perineal status. CONCLUSION: Primiparous women who experience severe perineal trauma are less likely to have a subsequent baby, more likely to have a related surgical procedure in the 12 months following the birth and no more likely to have an operative birth or another severe perineal tear in a subsequent birth. Women giving birth in a private hospital are more likely to have an associated surgical procedure in the 12 months following birth.

The effectiveness and safety of complementary health approaches to managing postpartum pain: A systematic review and meta-analysis.

BACKGROUND: Women experience pain from a number of causes during the postpartum period. Although pharmacological pain relief has shown to be effective, the efficacy of non-pharmacological methods of pain relief will be of interest to breastfeeding women. The aim of this systematic review was to examine the efficacy and safety of complementary approaches to manage postpartum pain. METHODS: A search of English language databases from their inception to 2020 was undertaken for randomised controlled trials and included primiparous and multiparous women who experienced postpartum pain up to two weeks post birth. The primary outcome was pain. The risk of bias was assessed using the Cochrane risk of bias tool. RESULTS: Thirty trials were included in the review, 25 trials (2,413 women) were included in the meta-analysis. Two trials of massage found a reduction in pain following caesarean birth within the first 24 h post birth (MD -2.64, 95-2.82 to -2.46, 184 women, I2 0%), and at seven days postpartum (MD -1.91, 95%CI -2.42 to -1.40, 2 trials, 120 women I2 37%). Two trials conducted with women receiving an episiotomy found reduction in perineal pain from herbal ointments within 24 h (MD -1.33, 95% CI -.96 to -0.70, 221 women) and at 14 days postpartum (MD -0.74, 95% CI -1.02 to -0.47, 4 trials). Few trials reported on safety, few trials were at an overall low risk of bias, and overall the quality of evidence was very low. CONCLUSION: Further high quality trials are needed to determine the safety and effectiveness of herbal ointment and massage during the early postpartum period.

Urinary placental growth factor differentiates the hypertensive disorders of pregnancy.

AIMS: To evaluate the discriminating capacity of urinary placental growth factor (uPlGF) for different hypertensive diseases of pregnancy during the third trimester. METHODS: A prospective descriptive case-control study conducted in an urban tertiary referral hospital and district general hospital, Sydney South West Area Health Service, Australia. Inpatients and outpatients with and without hypertension in the third trimester were recruited. Eligible patients provided a urine sample for protein, creatinine and a uPlGF level by ELISA. Patients were categorised into clinical hypertensive groups based on the diagnostic criteria of SOMANZ. RESULTS: Eighty-eight women were evaluated; 41 had hypertension (15 pre-eclampsia; 13 gestational hypertension; eight chronic hypertension; five pre-eclampsia superimposed on chronic hypertension) and 47 women without hypertension as the control group. There was a significant difference in uPlGF levels between the pre-eclamptic group (median 2.56 IQR 1.12-4.51) and the normotensive controls (median 13.18 IQR 5.95-31.39) (P < 0.0001); the gestational hypertensive group (median 3.74 IQR 2.49-4.91) and the normotensive group (median 13.18 IQR 5.95-31.39) (P=0.002) and for a subgroup comparison of placental-mediated hypertension (median 2.75 IQR 1.38-4.82) versus non-placental-mediated hypertensives (median 6.96 IQR 3.87-12.54) (P=0.007). CONCLUSIONS: Urinary placental growth factor is a simple non-invasive test, which is discriminatory for pre-eclampsia in the third trimester of pregnancy. Results from this study indicate that it may be discriminatory for hypertension related to placental dysfunction (pre-eclampsia and gestational hypertension) when compared with hypertension unrelated to placental function. Further work is required to assess the ability to detect hypertensive diseases before they are clinically apparent.

An exploration of midwives' role in the promotion and provision of antenatal influenza immunisation: A mixed methods inquiry.

PROBLEM: No South Australian study has previously investigated the role of midwives in the promotion and provision of antenatal influenza immunisation. BACKGROUND: Influenza acquired in pregnancy can have serious sequalae for both mother and foetus. Recent studies have demonstrated that influenza vaccine in pregnancy is both safe and effective. Despite this, evidence suggests that vaccine uptake in pregnancy is suboptimal in both Australia and worldwide. AIM: The aim of this study was to investigate the role of midwives in the promotion and provision of antenatal influenza vaccine and, to provide a statistical and thematic description of the barriers and enablers midwives encounter. METHODS: This mixed method study incorporated a cross sectional on-line survey and in-depth interviews conducted with midwives, employed in urban and regional South Australia. FINDINGS: Quantitative data were available for 137 midwives and 10 midwives participated in the interviews. Recruitment for the interview phase was through the last question on the survey. Whilst all midwives indicated that education and vaccine promotion were part of their role, immunisation knowledge varied between Registered Nurse/Midwives (RM/RN) 80% and Registered Midwives (RM) 48.90% (p = 0.001). Quantitative data showed that only 43% of midwives felt sufficiently educated to provide the vaccine. Midwives who had received formal immunisation training were more likely to recommend the vaccine 93.7% (p = 0.001). Qualitative data confirmed these results and identified the lack of immunisation education as a barrier to practise. CONCLUSION: Midwives identified an immunisation knowledge deficit. Midwives who had received immunisation education were more likely to actively promote and provide the vaccine to pregnant women. These findings indicate the need for more immunisation education of midwives in both tertiary and practice settings.

Intrapartum interventions and outcomes for women and children following induction of labour at term in uncomplicated pregnancies: a 16-year population-based linked data study.

OBJECTIVES: We compared intrapartum interventions and outcomes for mothers, neonates and children up to 16 years, for induction of labour (IOL) versus spontaneous labour onset in uncomplicated term pregnancies with live births. DESIGN: We used population linked data from New South Wales, Australia (2001-2016) for healthy women giving birth at 37+0 to 41+6 weeks. Descriptive statistics and logistic regression were performed for intrapartum interventions, postnatal maternal and neonatal outcomes, and long-term child outcomes adjusted for maternal age, country of birth, socioeconomic status, parity and gestational age. RESULTS: Of 474 652 included births, 69 397 (15%) had an IOL for non-medical reasons. Primiparous women with IOL versus spontaneous onset differed significantly for: spontaneous vaginal birth (42.7% vs 62.3%), instrumental birth (28.0% vs 23.9%%), intrapartum caesarean section (29.3% vs 13.8%), epidural (71.0% vs 41.3%), episiotomy (41.2% vs 30.5%) and postpartum haemorrhage (2.4% vs 1.5%). There was a similar trend in outcomes for multiparous women, except for caesarean section which was lower (5.3% vs 6.2%). For both groups, third and fourth degree perineal tears were lower overall in the IOL group: primiparous women (4.2% vs 4.9%), multiparous women (0.7% vs 1.2%), though overall vaginal repair was higher (89.3% vs 84.3%). Following induction, incidences of neonatal birth trauma, resuscitation and respiratory disorders were higher, as were admissions to hospital for infections (ear, nose, throat, respiratory and sepsis) up to 16 years. There was no difference in hospitalisation for asthma or eczema, or for neonatal death (0.06% vs 0.08%), or in total deaths up to 16 years. CONCLUSION: IOL for non-medical reasons was associated with higher birth interventions, particularly in primiparous women, and more adverse maternal, neonatal and child outcomes for most variables assessed. The size of effect varied by parity and gestational age, making these important considerations when informing women about the risks and benefits of IOL.